Every finding on record at Valley View Village

Based on observation, staff and resident interview, and clinical record review, the facility failed to ensure 1 of 4 residents (Resident #4) review for accidents/hazards, had the appropriate staff assistance for utilizing the elevator, as recommended by therapy. On 9/17/25 at approximately 9:30 AM, Chaplain Assistant supervised as Resident #4 attempted to turn an electric scooter around and exit the elevator independently. The Resident #4 sustained an injury to the lower left leg when the elevator door closed On 9/17/25 at 11:08 AM, following the incident, a Nursing Note revealed that Resident #4's leg was swollen with severe pain. The Resident #4 was transferred to the Emergency Department on 9/17/25 and was found to have a large hematoma to left lower leg. On 4/30/26, the left lower leg hematoma remained unhealed, and Resident #4 continued to complain of severe pain during observation of wound care. The facility reported a census of 76 residents. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 9/12/25, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated moderate cognitive impairment. The MDS indicated that Resident #4 was dependent on staff assistance for transfers and cares, Resident #4 was independent in a manual wheelchair for mobility.Review of an Occupational Therapy Note, dated 9/10/25, revealed the following entry: Patient demonstrates the ability to maneuver electric wheelchair with modified independence with the exception of the elevator. Recommendations to be provided upon discharge to upgrade patient to independent with electric wheelchair mobility in facility with assistance to operate the elevator. Review of the Occupational Therapy Discharge summary, dated for service between 8/29/25 and 9/12/25, revealed the goal that Resident #4, family, and/or caregivers would be educated on appropriate recommendations (example: assist levels, equipment) in order to maximize patient independence and safety with Activities of Daily Living (ADLs), mobility, and transfers upon discharge. The Discharge Summary identified that Resident #4 met the goal to be independent in electric wheelchair for mobility, with recommendation to assist with managing doors and buttons in elevator. Review of the Care Plan revealed the Focus area, initiated on 8/21/25 for Mobility: I have been cleared by therapy to be in my electric wheelchair. I have a history of bumping into things which could cause bruising or injury. It is recommended that I only have my electric wheelchair in manual mode for mobility. I am able to use the tilt mode independently with the goal that staff would educate Resident #4 on safe operating as needed through the next MDS assessment. The Care Plan listed an intervention directing nursing discipline to reassess mobility as needed. Review of a facility provided investigation of Resident #4 incident on 9/17/25, revealed the following timeline of events: a. Chaplain Assistant was upstairs guiding people to the chapel downstairs, assisting one person in their manual wheelchair. b. Resident #4 was going downstairs in the elevator. She drove her electric wheelchair into the elevator (car 2), facing the back of elevator. c. When they arrived on the first floor to exit the elevator, Resident #4 told Chaplain Assistant that she could not back up her wheelchair. d. Chaplain Assistant pushed the other resident out of the elevator, who was in a manual wheelchair, and stopped to hold the elevator door open on the side of the door entrance. e. Resident #4 started to turn around in the elevator car to exit, this took several minutes. Resident #4 then began exiting the elevator and Chaplain Assistant had to move out of the elevator cased opening to let Resident #4 out. In doing this, she removed her hand from the elevator door track opening. f. When Chaplain Assistant removed her hand, the door of the elevator went into nudging mode and began to close. The door came in contact with Resident #4's leg and then immediately began to retract (nudging mode), in normal operation of the elevator, recognizing an obstacle in it's pathway. g. Due to the way Resident #4's legs sit in her electric wheelchair with her knees slightly outward and bent, the door bumped at the top/medial part of the knee. h. Resident #4 verbalized pain and another staff member told Chaplain Assistant to have her nurse look at it. i. Chaplain Assistant noted that her left leg, which was bumped, did not shift and did not bump into her other leg or another object. Resident #4 was wearing pants and had ACE wrap (compression bandages) on. j. Chaplain Assistant brought Resident #4 back up to her hallway and told the nurse what happened. k. Nurse unwrapped Resident #4's ACE wrap that she had up the length of her leg to look at the area that Resident #4 and Chaplain Assistant told her was bumped, and did not see any marks, redness, or bruising, Nurse then rewrapped Resident #4's leg. l. Resident #4 decided she did not want to attend chapel and stayed upstairs on her hall. m. Resident #4 continued to state that her leg hurts. Nurse decided to reassess and unwrapped her ACE wraps. At this time, there was a hematoma that began to swell as the ACE wrap was removed. The ACE wraps were still on the bottom of her leg and on her thigh, which created more pressure at the mid-knee. n. Nurse obtained ice and offered a Per Required Need (PRN) Tramadol (opioid medication used to treat moderate to moderately severe pain in adults) to Resident #4 to help with pain, which Resident #4 accepted. She also asked provider, who was on-site, to look at Resident #4's leg. o. Provider assessed and stated that there was likely no fracture, but to send her out due to the size of the hematoma. p. 911 was called, and Resident #4 was transported to the Emergency Department (ED). Family was present at this time and kept stating that her mom's leg was crushed in the elevator. q. An X-Ray was taken in the ED and there is no fracture. r. Our contracted elevator maintenance is scheduled to evaluate the elevator today due to this incident. The elevator is closed until this occurs. Review of a Nursing Notes, dated 9/17/25, revealed the following entries: At 11:08 AM documented, while resident was going down to church around 9:50 AM, the elevator door closed on her. Resident sustained injury to her left leg. Upon assessment by nurse, resident's leg was swollen and complained of [pain rated] 9 out of 10. One time dose of Tramadol 50 milligrams (mg) given per provider order. Provider was in facility and assessed the resident. Provider gave written order to send out to ED around 10:50 AM of choice for [evaluation]. Resident sent to hospital ED. Family went with her. At 3:58 PM, Resident #4 returned to the facility via stretcher, accompanied by Emergency Medical Technician (EMT) staff with no new orders. Resident's level of pain rated 9 out of 10 on her left lower leg. ED recommended follow up with facility provider in 2 days. On 9/17/25 at 7:29 PM, provider gave telephone order to give Hydrocodone-Acetaminophen (opioid medication used to treat moderate to severe pain) 5-325, 1 tablet every 6 hours as needed for pain.Review of a Provider Visit Note, dated 9/17/25, revealed that Resident #4 was being seen for left leg injury, occurring 5 minutes ago. Patient used electric wheelchair for mobility, was getting onto elevator and elevator door closed onto her left leg. Facility staff were present and report that the door did not close completely but opened back up once it bumped her leg. Door contacted the lateral (side) aspect of the lower leg. The resident had immediate severe pain to the left lower leg, hematoma developed almost immediately. Provider Note documented patient in extreme pain, would not allow for much of an examination. There is a large, softball sized hematoma to left lower leg, just in front and medial to the knee. No open areas/wounds. no obvious bony deformities. Provider indicated that given the severity of pain, opted for evaluation in the ED as opposed to work up at the facility. Resident #4 was transferred via Emergency Medical Services (EMS). Tramadol 50mg x1 given prior to transport. Review of the Hospital ED Note, dated 9/17/25, revealed Chief Complaint for leg injury, Patient was on her scooter at her living facility and her leg got caught in the elevator door. Large hematoma noted on left lower extremity. An X-Ray performed of left tibia/fibula (bone in lower leg) identified no acute fracture or dislocation of left tibia or fibula is apparent. Round subcutaneous mass of the posteromedial (positioned at the back and towards the middle) upper calf, possibly hematoma. Review of additional Nursing Notes, revealed the following documentation, in part: a On 9/18/25 at 7:56 PM, Resident #4 left leg assessed with no new skin issues but remained swollen, hydrocodone 5-325 mg 1 tablet every 6 hours as needed for pain and ice pack administered. b. On 9/19/25 at 12:30 AM, left lower extremity remained swollen and bruised, complained of 10 out of 10 pain, stating that it hurts so bad, as needed pain medication given with bedtime medications and resident positioned in bed until comfortable. c. On 9/21/25 at 6:33 PM, Resident #4 had pain pill x2 today. Ice applied to the left leg and there is a large fluid filled blister. Legs elevated to help with swelling. d. On 9/22/25 at 6:39 PM, Resident #4 complained of pain in left lower extremity. Pain medication and ice pack applied but not effective. Provider notified of condition and telephone order received to send resident out to the ED for evaluation.Review of a Hospital Discharge summary, dated [DATE], revealed reason for hospitalization related to hematoma and acute metabolic encephalopathy (brain dysfunction caused by systemic illness, organ failure, or toxic substances that can disrupt normal metabolism, leading to altered mental status, confusion, and sometimes coma). Hospital Course indicated admission on [DATE] with acute metabolic encephalopathy and left lower extremity hematoma/pain following injury from an elevator on 9/17/25. Encephalopathy improved over 24-48 hours. Surgery consulted for evaluation of left lower extremity hematoma, discharge with orthopedics and receiving wound cares. Lower extremity venous ultrasound on 9/23/25 negative for Deep Vein Thrombosis (DVT or clot). Pain has improved and will require several more days of oxycodone (strong prescription opioid medication used to treat moderate to severe pain) 2.5 mg every 6 hours as needed. During an observation on 4/29/26 at 8:12 AM, Staff O, Certified Nursing Assistant (CNA), assisted Resident #4 onto the elevator by manually pushing the scooter from behind. Resident #4 asked Staff O if she would go with Resident #4, Staff O told Resident #4 yes, you do not go by yourself. Resident #4 stated that she got her leg struck and asked Staff O to watch her feet when entering the elevator. Resident #4 stated that her leg had hurt since September. During an interview on 4/30/26 at 9:40 AM, Resident #4 stated that she continued to have pain in left lower leg following the incident in which the elevator door bumped into her leg. During an observation on 4/30/26 at 9:44 AM, Staff C Registered Nurse (RN) performed wound cares to Resident #4's left lower leg wound. Staff C removed the old dressing that appeared to be heavily saturated and dripping serosanguineous (mixture of blood and serum, usually thin watery drainage that is pink or yellow in color) from the dressing onto the floor as Staff C disposed of it. The wound to left lower extremity appeared to be approximately the size of a softball, the wound bed appeared red in color and actively bleeding bright red blood following the dressing removal. Wound edges from approximately 2'o'clock to 6'o'clock were rolled under. Resident #4 winced, gasped, and said ow with touch to the wound throughout the procedure. Staff C cleansed the wound bed with normal saline, then patted dry with gauze, applied treatment and covered with new adhesive padded dressing. During an interview on 4/30/26 at 12:26 PM, Staff P, Physical Therapist (PT) stated that on 9/12/25 mobility recommendations indicated that Resident #4 would require nursing or CNA assistance to assist with elevator doors and buttons when traveling on elevator. Staff P reported that therapy department communicates recommendations to the nursing department via email for the floor nurses and CNA staff to update the resident's plan of care. Staff P identified that an email was sent out to nursing staff that this was the recommendation for Resident #4 on 9/12/25 and that the therapy department received communication from the Interdisciplinary Team (IDT) on 9/17/25 that Resident #4 was no longer allowed to drive electric scooter independently due to incident with injury and instruction to use manual mode. During an interview on 4/29/26 at 1:59 PM, Chaplain Assistant recalled that on 9/17/25 when assisting residents to the chapel for an activity, Resident #4 went into the elevator using electric scooter. The Chaplain Assistant stated Resident #4 didn't seem too comfortable using the electric scooter so she entered the elevator as well, while pushing another resident in a manual wheelchair. The Chaplain Assistant reported pushing the other resident's wheelchair out of the elevator upon arrival to the first floor, and due to being previously informed not to block the elevator for too long, stood outside of the elevator and waited for Resident #4 to exit the elevator. The Chaplain Assistant stated that Resident #4 took a long time to get electric wheelchair turned around in the elevator and as she was coming out, the elevator door shut and hit Resident #4's leg and Resident #4 immediately complained of pain to the leg. The Chaplain Assistant recalled taking Resident #4 back upstairs on the elevator to the nurse who assessed Resident #4's leg. During an interview on 4/30/26 at 3:25 PM, Staff Q, CNA, stated she had been employed by facility for approximately 5 years and was familiar with Resident #4. Staff Q recalled that Resident #4 would not be safe to maneuver her electric scooter independently in the elevator due to a history of bumping the scooter into things. Staff Q denied knowledge of any guidance received for who could help or how to assist Resident #4 with using the elevator but recalled that an incident with injury that involved the elevator is why Resident #4 was changed from independent to manual mode when using the electric scooter. During an interview on 4/30/25 at 4:54 PM, Staff F, Certified Medication Assistant (CMA)/CNA stated she had been employed by facility for approximately 2 years and was familiar with Resident #4. Staff F denied knowledge of guidance received for who could help or how to assist Resident #4 with using the elevator but recalled that following an incident with the elevator, Resident #4 was unable to use the electric scooter independently. During an interview on 4/29/26 at 12:34 PM, the Director of Nursing (DON) stated that the previous facility Administrator had investigated the incident. The DON reported that in response to the incident, the facility had an elevator technician come onsite to ensure proper elevator operation and Resident #4 no longer used her electric wheelchair independently. During an interview on 4/30/26 at 2:01 PM, the previous facility Administrator confirmed that therapy would send out an email of recommendations to the nursing staff, which would be put into a resident's plan of care. The previous Administrator stated that therapy had assessed Resident #4, and determined she could be independent in the electric scooter. The previous Administrator denied clarification with therapy on Resident #4's recommendations for elevator assistance, but said Resident #4 could not reach the buttons in the elevator, and stated that anyone could help with this. The previous Administrator confirmed that elevator technicians evaluated the elevator for safe operation as intervention following the incident involving Resident #4.

Based on record review, observations, resident and staff interviews and policy review the facility failed to provide adequate supervision to prevent an elopement for one of three wandering residents reviewed (Resident #79). The facility also failed to answer resident call lights within the allotted professional standard of 15 minutes for 3 of 5 residents reviewed (Resident #28, #83, and #84). The facility reported a census of 76 residents. Findings include: 1.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 had diagnoses of Alzheimer's Disease, bipolar disease and anxiety disorder. The MDS recorded the resident had a Brief Interview for Mental Status of 9, indicating moderately impaired cognition. The MDS documented the following related to walking; resident used walker, when walking 150 feet the helper provides verbal cues and/or touching/steadying and /or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. The MDS documented the resident exhibited no wandering behaviors. The Residents Care Plan had a start date of 2/11/26 and revealed Resident #79 had Alzheimer's Disease and dementia. The Care Plan identified that the resident had a risk for elopement due to wandering. The resident ambulated independently with a wheeled walker. The Care Plan directed staff to redirect the resident as he allowed and ensure his needs were met. An approach for staff was added on 3/14/26 to do frequent checks and monitor his whereabouts. Progress Notes revealed the following: a. On 3/6/26 at 9:40 PM, resident had agitation, aggression, and restlessness before dinner. Non-pharmacological alternatives such as redirection, explanation of situation such as dinner is on the way, and a calm approach were not effective. b. On 3/14/26 at 3:00 PM, after the AM meal, resident made the following speech in the dayroom: This is a place of refuge for slaves and criminals. This is a wonderful Christmas season for our refugees. Congratulations to this choir for singing beautiful Christmas songs with beauty and great expression. Thank you all. c. On 3/14/26 at 6:58 PM (recorded as a late entry on 3/16/26 at 1:44 PM), Staff G, Licensed Practical Nurse (LPN) documented that Staff H, Registered Nurse (RN), escorted the resident back onto the unit at 6:00 PM. It was discovered that the resident had left the unit through the back exit. The door alarm was sounding. A CNA returned to the alarming door. Resident was assessed. Family, physician and management was notified. Upon camera footage review, the resident was outside approximately 3 minutes and escorted back by staff. The weather was 52 degrees. The resident was dressed appropriately. Staff education was provided immediately and an elopement protocol was implemented. The Incident Summary revealed Resident #79 had a BIMS of 4, indicating severely impaired cognition. On 3/14/26 at approximately 5:55 PM, the back exit door alarmed on the Memory Care unit. Staff I, certified nursing assistant (CNA) responded. Five minutes later, at 6:00 PM, Staff H, RN, walked Resident #79 back onto the unit and stated the resident was in the back parking lot (which is located off the back exit door). The resident walked independently with a walker and appeared in good health. Resident was assisted to the recliner and assessed. Upon investigation, the resident left the dining room at approximately 5:53 PM, walked down the hallway and then later walked through the alarmed door to the back parking lot. Resident #79 was out of site for approximately five minutes. The Facility's Investigation revealed the following:a. The census on the Memory Care Unit was 17 residents. b. The weather was 52 degrees, the sun was out and there was no inclement weather.c. Resident #79 had long pants, a long sleeve t-shirt and grippy socks on. d. On the evening of 3/14/26, Staff J, CNA, Staff I, CNA, and Staff G, LPN, worked on the unit. Supper was served at approximately 5:15 pm. All residents were in the dining room with staff, and the TV was on. After Resident #79 finished eating his meal, he arose from his chair to walk the hall independently with his walker as he normally did. e. Resident #79 often demonstrated continuous pacing/wandering within the unit and had not previously shown any signs of exit seeking such as testing doors or approaching exit areas. Resident #79 went all the way down the hall and back several times, as shown by the video surveillance. At approximately 5:42 PM, Resident #79 was at the back of the hall at the furthest point from the dining room and went by the emergency exit door. The emergency exit door has a 15-second egress and an alarm, both of which were working. The staff could not hear the alarm due to the noise level in the dining room at the time. Resident #79 pushed the bar on the side of the door by the hinges, which also prohibited the door from opening, and in doing this, he held the bar on the door down for 15 seconds, releasing the 15-second egress. At this point, he pushed on the other side of the door and was able to push it open. Through this door is a floor-level exit door to the employee parking lot. At approximately 5:43 PM, Resident #79 was shown by video surveillance exiting the door on the walkway by the employee parking lot. As he is exited, Staff H arrived to work and was seen driving by the resident and then parked in the lot. Staff H immediately went over to talk to Resident #79 and helped escort him back into the building. Staff H and Resident #79 was seen walking together from another video camera at approximately 5:45 PM. Per video surveillance, at approximately 5:48 PM, Staff H and Resident #79 was seen entering the building together. They then walked together back to the Memory Care hall, where Resident #79 was assessed. His overall appearance was stable and in good condition. Immediate intervention included increased checks and redirection to activities. In an interview on 4/28/26 at 8:30 AM, Staff K, certified medication aide (CMA), reported Resident #79 was pleasantly confused, an intelligent man and very funny. He was independent and used a walker. Staff K reported she was not working on the day Resident #79 left the unit. Staff K reported there were alarms on all of the doors in the unit. Staff K reported they had to push on the bar on the door for 15 seconds before the door would open. There were alarms on all of the exit doors and required a code to be entered in order to go through the door or stop it from alarming. Staff K reported she had not ever seen Resident #79 try to push the exit doors open. In an interview on 4/28/26 at 4:51 PM, Staff I, CNA, reported she recalled the facility staff went over alarms and where the alarms were located during her orientation. The alarms were located at each exit door on the front, side and back hall exit door. Staff had to hold the door for 15 seconds and then the door could be opened. Each door had a different code that could be entered to stop the alarm. Staff I reported Resident #79 had behaviors and often wandered around the unit. Resident #79 ambulated with a walker. On the day Resident #79 left the unit, there were only 2 CNA's working on the unit and they were in the dining room feeding 6 to 7 residents. Resident #79 cannot sit for two seconds. Resident #68 was also having behaviors that day. Staff I told Resident #79 to sit down and he sat down in a chair. While Staff I assisted the residents in the dining room, Resident #31 had spilled her chocolate milk. Staff I got some towels and cleaned the milk up. When she got up from the floor, she did not see Resident #79. As she carried the soiled towels, she saw Staff G. Staff G told her they were looking for Resident #79. As they walked by the nurse's station they heard the alarm coming from the back hall exit door. Staff I went to the door and punched in the code to stop the alarm. They did a count of the residents and that was when Resident #79 was being brought into the building. Staff I reported it was within seconds from the time she noticed the resident not in the dining room to when she noticed the alarm going off and Resident #79 being brought into the unit by Staff H. In an interview on 4/29/26 at 7:28 AM, Staff L, RN, reported Resident #79 had not walked in weeks while he was at the hospital but when he got to the facility he started walking. Staff had to keep an eye on him. He was only oriented to self. Staff L reported she was not working on the day Resident #79 left the unit. Staff L reported she was aware that Resident #79 had set the alarm off, he got out the back door, and a nurse brought him back to the unit. The back door had an alarm but the alarm on the back door was hard to hear. Staff L reported since the incident they had a monitor, similar to a baby monitor, in the dining room and a monitor on the back door in the stairwell so they could hear the sounds from the back exit door over the monitor. On 4/29/26 at 7:32 AM, Staff L, RN, reported the back door was an exit for fire safety purposes and was not used as an entrance or exit to the facility routinely. The back door led to the stairwell and then to another exit door to exit the building. The outside exit door led to the parking lot. On 4/29/26 at 10:05 AM, the DON reported the facility had cameras located at the entrance to the facility, in the hallway (of the unit) by the exit doors, and another camera to the outdoor exit door. The DON provided video footage of the incident involving Resident #79 on 3/14/26. The surveyor viewed three different cameras: 1 in the unit by the DR and exit door, 1 by the back exit door to unit and 1 by the back exit door to the outside. Video #1 on 3/14/26 starting at 6 PM (video was 2 minutes long) revealed resident ambulated in the hallway with a four wheeled walker and went by the exit door. He stopped to look at the scale in an alcove, then proceeded to walk across the hall to the exit door. Camera footage revealed the resident stood by the door for a period of time and then breached the door to open it. He then proceeded to walk through the door, and the exit door closed. Video #2 on 3/14/26 at 5:42 PM (video was 1 minute long) revealed resident came through the back exit door to the outside and ambulated down the sidewalk to the driveway toward the parking lot with his walker. From the start of the video to the time the resident exited the back door was 41 seconds. A van was viewed pulling into the driveway and parking in the parking lot.Video #3 on 3/14/26 at 5:46 PM (lasting 1 minute, 21 seconds) revealed a female walked up to the resident as the resident walked with the walker, and then the female ambulated with the resident toward the sidewalk and into the building. The DON reported Resident #79 typically ambulated with a walker around the unit but this was the first time he had exited the unit. On that day, it was during mealtime, there was a lot of residents and staff in the dining room. There was a lot of noise with people talking and the TV was on. Staff did not hear the alarm sounding. Family was notified about the incident and staff increased their monitoring of the resident. The resident did not have any kind of injury or fall at that time. The DON reported since the incident, they put in a monitor by the back door and the dining area so staff could hear the alarm or anything going on by the back exit door. They also did an elopement drill with all of the staff. Elopement drills were unannounced and held quarterly on different shifts. In an interview on 4/30/26 at 7:29 AM, Staff J, CNA, reported she had worked at the facility three months. Resident #79 had dementia and had behaviors. He wandered all of the time and staff had difficulty getting him to sit down. Staff had to follow him around. On the day of the incident, Staff J reported she kept redirecting Resident #79 to sit in the dining room. It was suppertime and residents were eating. She had just sat him down in the dining room, and when she looked again, she saw Staff H bringing him into the unit. At that time, she wondered why or what was going on. Staff G and Staff I went down and found the alarm by the back exit door sounding. Staff J reported she did not hear the alarm going off. Staff J was in the dining room talking with residents and assisted residents with feeding. After Resident #79 was brought to the unit, she went and checked to make sure everyone was in the unit. Staff J reported the door the resident went out is not used as an entrance to get in and out of the building. Staff J felt the facility had enough staff on the unit but it also depended on the residents and what was going on, such as if residents were sundowning or had behaviors. In an interview on 4/29/26 at 10:58 AM, Staff G, LPN, reported she worked the evening shift on the day of the incident with Resident #79. They had enough staff but Resident #79 was very quick. In the Memory Care unit, a resident will be is one place one minute and the next minute they move. On that day, Resident #79 took off with his walker. Staff H came in the front door and had Resident #79 with her. Staff H brought Resident #79 to the unit. Staff G reported she checked him over. The resident had shoes on, and the weather was not too cold or too hot. Staff G explained that there was an alarm that went off. As the CNA walked toward the lobby, the alarm was faint from the day room. The CNA checked it over and cancelled the alarm. At the time, Staff G reported she was standing in the dining room assisting a resident with feeding. Resident #79 was in the dining room at that time. Staff G stated she may have turned her back when Resident #79 had just finished dinner. Resident #79 got through the stairwell door. Staff G acknowledges at that time, she thought there was only a door by the dayroom. She was not aware of the back door. She was new and did not know. Honestly, she had not realized he had left or he was somewhere. She realized it when Staff H brought the resident in the unit and Staff H told Staff G that he got out. Staff G reported she was not sure how long he was outside, but it was not much longer after the meal. She did not hear an alarm going off. She let the DON know they could not hear the alarm. The alarm was far enough away and if the staff were in the dining room they could not hear the alarm. Staff G reported since the incident she thought maintenance made the alarm louder, a monitor was installed in the dining room, and they increased hallway checks. Staff reported she did not know if Staff I checked to see if a resident or someone left the unit. This was an isolated event. They got education about the elopement and the need to get to the alarm right away. In an interview 4/29/26 at 6:40 PM, Staff H, RN, reported the staffing level on the 2 PM to 10 PM included 1 nurse, 1 CMA, and 2 CNA's on the Memory Care unit. The staffing ratio was fine when their routine and things went well, but when things happen such as a resident fall or a change in condition, then staffing was not so fine. The facility had alarms on the front door to the main area and exit door in the Memory Care unit. The exit doors required a code whenever someone entered or exited the area. The doors would unlock after 15 seconds when the door was pushed. The door alarmed but after 15 seconds you can push the door open and go outside. Staff H reported Resident #79 used a walker and ambulated around the unit a lot. He was very intense, anxious and very wandery. He talked about people dying in a plane crash and that he had to get to the airport. Staff H reported on the day of the incident, she was coming in from the parking lot and Resident #79 was right in front of her. Staff H did not know how he got there. He had grippy socks on but did not have shoes on. She did not know what was going on. She asked what he was doing. Resident #79 was confused. Staff H told him to come with her, she would keep him safe. Staff H took him through the door by the employee entrance and then took him back to the unit. Staff H told Staff G where she found Resident #79 in the parking lot. Staff L and Staff I were in the dining room feeding residents. The staff told Staff H that Resident #79 had just been in the dining room eating. Staff H thought it had only been a short moment that Resident #79 was out of the unit. After that happened, they put a baby monitor in so staff could hear on the other side of the unit. Staff H explained she did not even realize anyone could get to the back parking from the back door fire escape. In an interview on 4/29/26 at 1:01 PM, Staff F, CMA, reported the Memory Care unit needed at least three CNA's in the Memory Care unit due to the types of residents and their needs. Several residents required two staff assistance for transfers. When two staff were in a room providing cares or doing a transfer, the CNA's cannot watch the rest of the residents in the unit or know what is going on in the unit. In an interview on 4/30/26 at 9:50 AM, the Assistant Maintenance Supervisor reported doors were checked weekly to ensure they functioned properly. He reported the unit door, the door to the courtyard, and the South back fire exit door had an alarm. The South (back) Exit door led to another door (unalarmed) and this led to the outside employee parking lot. The Assistant Environmental Director reported a monitor was installed by the South Exit door so staff could hear the alarm. Staff are supposed to check the alarm when the alarm went off. In an interview on 4/30/26 at 10:10 AM, the Administrator reported they received a report for the fire system when the fire alarm went off but not the door alarms. The Administrator was unable to verify when a door alarm went off or when the exit door was breached. In an email on 4/30/26 at 10:21 AM, the Administrator wrote she double checked the documentation. The resident was shown exiting the door at approximately 5:43 PM, the RN walked with him back to the building at 5:45 PM, and entered the building at 5:48 PM. The total time of the incident was 5 minutes. In an interview on 4/30/26 at 10:55 AM, the surveyor asked what the facility had done to ensure a process was in place to prevent further incidents of elopement. The DON responded she had done random checks by setting off the alarm and waiting for staff to respond. She had also checked the monitors to make sure they were plugged in and worked. The DON stated she expected staff to check the alarms and respond to the door, then go through the door to check surroundings and make sure nobody was outside, and do a head count. A Wandering Resident policy reviewed 2/18/26 and revised 3/17/26 revealed the facility ensured that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and received care in accordance with their person-centered care plan. An elopement occurred when a resident left the premises or a safe area without authorization or without necessary supervision. Staff members are to be vigilant in responding to alarms in a timely manner. 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented the resident was substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) for toileting transfer and is dependent (helper does all of the effort. The resident does none of the effort to complete the activity or, the assistance of 2 or more helpers is required for the resident to complete the activity) for toileting hygiene. During an interview on 4/27/2026 at 2:23 PM Resident #5 reported during the meal hour it can take up to an hour for staff to answer the light and had an accident in her pants due to it. During an interview on 4/30/2026 at 11:10 AM the Director of Nursing (DON) reported that the expectation of staff is to answer the call light within the 15 minute time frame. The facility policy for call lights reviewed date 11/20/2025 directed staff it is the responsibility of all staff (from all departments) to respond to the call light and to either assist with the request, if able, or obtain assistance from the appropriate staff to meet the resident's need. 3.Resident #84's Care Plan documented he does not have any cognitive diagnoses, is alert and oriented to himself but occasionally tends to be forgetful. The Care Plan documented he was assisted by 2 staff for transfers. Observation on 4/29/2026 at 7:33 AM Resident #84's call light on. At 7:47 AM Resident #84 heard yelling out from his room for help and the call light was still on. At 7:54 AM Resident #84 yelling out for someone to please help him. Throughout the time staff have been walking the hallway but not answering the light. At 7:58 AM observed staff going into Resident #84's room and answered his light. During an interview on 4/29/2026 at 8:30 AM Resident #84 reported sometimes he waits a long time for his call light and will yell out. He reported it doesn't always happen just in the mornings at times it happens. 4. Resident #83's Care Plan documented he was assisted by 1 staff for transfers. During a continuous observation on 4/29/2026 at 12:54 PM to 1:11 PM noted Resident #83's call light on. At 1:11 PM a Certified Nurses Aide (CNA) walks into the room to answer the call light and assist the resident.

Based on observation, staff interview and policy review the facility failed to handle and serve food in a sanitary manner to prevent cross-contamination for 2 of 2 meals observed. The facility staff also failed to handle and transport contaminated linens in a manner to prevent contamination and the potential spread of infection for 1 of 4 units. The facility reported a census of 76 residents.Findings include: 1.During observation of dining on 4/28/26 starting at 8:39 AM, Staff D, certified nursing assistant (CNA) sat down at an assisted diners table with eight residents. Staff D offered a bite of food to one of the residents. Staff D placed her bare left hand over a croissant breakfast sandwich, took a knife, cut the sandwich in half and gave the sandwich to Resident # 64. Resident #64 held the sandwich in his hand and fed himself. Staff D then placed her bare hand over Resident #27's croissant sandwich, cut the sandwich in half and fed Resident #27. At 8:48 AM, Staff E, CNA, rubbed her fingers on her head then picked up a glass of chocolate milk and offered Resident #31 a drink. Staff E then picked up a glass of chocolate milk and offered the milk to Resident #33. During the meal service, Staff E rubbed her eye, then placed a fork full of food into Resident #33's mouth. The food stuck on the outside of the resident's lips. Staff E used her bare fingers, pulled the food out of Resident #33's mouth, then moved to the next resident at the table and gave the resident a bite of cereal. Staff E assisted three residents at the assisted diners table during this time. Staff E then picked up a croissant sandwich with her bare hand and placed the sandwich into the resident's mouth for the resident to take a bite. Staff D and Staff E did not sanitize their hands between residents during the meal service. In an interview on 4/30/26 at 10:55 AM, the Director of Nursing reported she expected staff not to touch food with their bare hands, and sanitize hands between each resident. A Food Preparation and Service policy reviewed 1/9/26 directed staff as follows; food shall be prepared and served in a manner that complies with safe food handling practices. Bare hand contact with food is prohibited. A fork, spoon or knife shall be used to serve food. 2. During an observation on 4/30/26 at 9:32 AM, Staff S, Housekeeping Supervisor and Staff T, Laundry Aide, transported a rolling rack of clean personal clothing through one of four hallways. The rolling rack had a single white sheet placed over the top of clothing, which covered the top half of the clean clothing, the bottom half remained uncovered and exposed during transport. Staff S and Staff T both observed removing the clean personal clothing from the rack, and held clothing close to the body, touching each staff's uniforms, as clothing was taken into the resident rooms. During an interview on 4/30/26 at 9:34 AM, Staff T confirmed that bottom half of clean personal clothing remained uncovered and exposed while passing clothing and denied using any other clean clothing racks or covers to transport the clean clothing through hallways. During an interview on 4/30/26 at 10:07 AM the Director of Nursing (DON)/Infection Preventionist, revealed an expectation that clean linen is fully covered when transported through the hallways and expected all staff to hold clean linen away from their bodies to prevent possible contamination or the risk to spread infection. Review of the facility policy titled, Handling of linen, revised on 4/12/24, directed staff as follows; that when clean linen is being passed on resident units, it should be covered.

Based on observation, resident interview, staff interview, clinical record review, and facility policy review, the facility failed to ensure a lap belt device, that may restrain a resident's movement, was assessed for safe use upon initiation and periodically following implementation for 1 of 4 residents reviewed for assessment and intervention. The facility reported a census of 76 residents. Findings include:During an observation on 4/27/26 at 1:15 PM, Resident #4 sat in electric wheelchair as staff pushed the chair from the dining room into the common room on her hallway, a lap belt fixed above the back wheel on both sides of the chair appeared secured at Resident #4's waist. Review of the Minimum Data Set (MDS) assessment, dated 4/01/26, revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated Resident #4 had moderate cognitive impairment. The list of diagnoses included Heart Failure, Peripheral Vascular Disease (PVD), diabetes mellitus, anxiety disorder, and depression. The MDS indicated that Resident #4 was dependent on staff assistance for all transfers, cares, and wheelchair mobility. The MDS revealed that Resident #4 did not use any restraints or alarms on bed, on chair, or outside of bed. Review of the Care Plan, revised 4/07/26, lacked identification of a lap belt utilized on Resident #4's electric wheelchair or interventions related to the device. Review of Resident #4's Electronic Health Records (EHR) lacked documentation of device assessment or indication for use by provider. During an interview on 4/30/26 at 9:40 AM, Resident #4 sat in wheelchair in her room with lap belt secured at her waist. When asked if Resident #4 could remove her lap belt, she denied ability to remove lap belt and said staff have to do it. During an interview on 4/30/26 at 9:36 AM, Staff C, Registered Nurse (RN) reported working at the facility for over 1 year and said that a lap belt was being used on Resident #4's electric wheelchair throughout that time. Staff C denied completing any assessments on Resident #4's lap belt and when queried if Resident #4 could remove the lap belt on her own, Staff C stated, I think so. During an interview on 4/30/26 at 1:37 PM, Staff R, Certified Nursing Assistant (CNA) reported working at the facility for over 1 year and said that a lap belt was being used on Resident #4's electric wheelchair throughout that time. Staff C reported that she would mostly remove the lap belt for Resident #4 because resident was usually too tired. During an interview on 4/30/26 at 10:57 AM, Director of Nursing (DON) reported inability to find an assessment or documented indication for use of Resident #4's lap belt. Review of the facility policy titled, Restraints, Physical, revised 10/14/22, revealed that facility would use restraints only under the following conditions: As a last resort measure after a trial period where less restrictive measures have been undertaken and proven unsuccessful. Restraints shall not be used for disciplinary purposes, for staff convenience, or to reduce the need for care of residents during periods of understaffing. With a physician order and only when necessary to prevent injury to the resident or others, based on a physical, functional, emotional, and medication assessment. With the consent of the resident or his/her representative. When the benefits of the restraint outweigh the risks. No restraints that require a tie will be used. Whenever restraints are used a call signal switch or similar device within reach or other appropriate method of communication shall be provided to the resident. The Section titled, Procedure directed the following, in part: Residents who would benefit from a device that matches the definition of a restraint will be thoroughly evaluated for the need for that device, the safe application and use of that device, and the life enhancement or safety it will provide for the resident.Nursing will complete the Device-Equipment Observation And Consent when a symptom exists for which the need to use a restraint has been identified and after alternative measures have proven unsuccessful. The Observation will be reviewed by the IDT for additional input as needed.No tie-type restraints will be used. Linen shall not be used as a restraint. If a restraint is deemed necessary, a physician's order that contains the following information will be obtained: Medical symptom for use of restraint; Type of restraint; Duration and circumstances under which the restraint is to be used, including intervals for release/monitoring.Device will be removed at meals or for certain activities as appropriate per assessment.Nursing will discuss the risks/benefits of physical restraints with resident or resident representative and document this in the progress notes.Nursing will update the plan of care with restraint order and interventions, initiate orders for scheduling of restraint interventions, and will update Nursing Assistant assignment sheet and/or Resident Profile. Nursing will obtain written consent for physical restraint from the resident or their resident representative. If nursing is unable to obtain written consent, verbal consent will be obtained while waiting for written consent.Nursing will assess restraint usage every shift and will record these assessments/checks in the electronic health record.Nursing will complete a Device-Equipment Observation quarterly for review by the IDT. Re-evaluation of the continued need for the restraint, symptom, duration, and a restraint reduction plan will be discussed by the IDT at that time with corresponding documentation by all disciplines.Residents with restraints are observed every 15 minutes and restraints are released every 2 hours and as needed for safety, comfort, exercise, and elimination needs for a minimum of 10 minutes and the activity shall be documented in the resident record.

Based on clinical record review, staff interview, and policy review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) evaluation as required for 1 of 3 reviewed (Resident #83). The facility reported a census of 76 residents. Findings include:Resident #83's Electronic Health Record (EHR) profile documented an admission date of 4/22/26. Resident #83's progress note dated 4/22/26 at 4:32 PM documented the resident admitted to the facility from the hospital. Review of #83's EHR lacked documentation of a PASRR completed.On 4/28/2026 at 8:55 AM Received Resident #83's PASRR from the Administrator. Review of the PASRR noted Staff A completed it on 4/27/26. During an interview on 4/28/2026 at 1:25 PM Staff A, Hospital Liaison/Admissions Coordinator reported the hospital usually does the PASRR. Staff A reported last night she received a phone call on Resident #83's PASRR not in the chart. Staff A reported she completed the PASRR last night Staff A reported she missed it prior to admission and it should have been done. During an interview on 4/28/2026 at 1:37 PM the Administrator reported the facility receives the PASRR from the hospital admission records and it is to be completed prior to admission to the facility. She reported Resident #83's PASRR was missed somehow and not complete prior to admission.

Based on record review, observation, staff interview and policy review, the facility failed to ensure a resident was properly positioned and placed in an upright position in order to facilitate consumption of beverages and food and to reduce the risk of choking and aspiration during 1 of 2 mealtime observations. (Resident #31) The facility reported a census of 76 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had diagnosis of Alzheimer's Disease. The resident had a Brief Interview for Mental Status score of 2, indicating severely impaired cognition. The MDS indicated the resident required partial to moderate assistance for eating. The Care Plan initiated on 4/18/25 revealed the resident had a nutrition and hydration risk related to an end-stage diagnosis, cognitive limitations and weakness. The Care Plan directed staff to provide a general diet and thin liquids, and provide assistance with eating. During dining observations on 4/28/26 starting at 8:22 AM in the Magnolia Unit revealed Resident #31 sat in a broda chair with the broda chair reclined back. At 8:41 AM, the dietary aide placed food on the table in front of Resident #31. At 8:43 AM, Staff D, certified nursing assistant (CNA), placed beverages and food on an overbed table for Resident #31and walked away. At 8:47 AM, Resident #31 continued to sit in a broda chair with her eyes closed and a plate of food in front of her that was untouched. At 8:48 AM, Staff E, CNA, picked up a glass of chocolate milk and offered Resident #31 the chocolate milk. The broda chair remained tilted backward. Resident #31 struggled to move her head up and forward to get her mouth up to the cup. Staff E then offered Resident #31 hot cereal but the resident said later. At 8:53 AM, Staff D, CNA, offered Resident #31 a drink of chocolate milk. The broda chair remained in the tilted back position. In an interview on 4/30/26 at 10:55 AM, the Director of Nursing reported the facility had no policy for positioning. The staff would get education about positioning during facility training and the CNA certification training. The DON reported she expected residents to be placed in an upright position whenever food or drink offered. A Feeding of Residents by Staff policy reviewed 2/18/26 revealed residents unable to feed themselves will be provided with assistance per their care plan. The resident shall be positioned comfortably in an upright position.

Based on observation, record review, manufacturer's instructions for use, resident representative and staff interview, and policy review the facility staff failed to administer medications and follow the doctor's order for one of six residents reviewed for medication administration (Resident #31). Facility staff gave morphine (an opioid pain medication) instead of lorazepam (an antianxiety medication), administered insulin to the wrong resident, and failed to administer insulin according to manufacturers' instructions for use for 1 for 2 residents reviewed for insulin use (Resident #5) The facility reported a census of 76 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had diagnoses of Alzheimer's Disease and anxiety disorder. The resident had impaired short-term and long-term memory and severely impaired decision-making skills. The MDS recorded the resident had no injections or insulin orders during the seven-day look-back period. The MDS did not indicate the resident had a diagnoses of diabetes.Resident #31's Care Plan initiated on 1/26/26 revealed a diagnoses list. The diagnoses list lacked a diagnosis of diabetes. The Care Plan revealed the resident had altered cognition related to dementia and pain, and took an antianxiety medication and pain medication. The Care Plan directed staff to administer medications per the doctor's order. A Physician Order Notification Request dated 2/4/26 revealed Resident #31 was given Lorazepam (anti-anxiety medication) 0.5 milligrams (mg) at noon instead of 0.25 mg of Oxycodone (medication used for moderate pain). On 3/23/26, Resident #31 got glargine (a long-acting) insulin 23 units by accident. The provider gave an order to check blood sugars every hour for 24 hours and as needed (PRN), and follow hypoglycemic (low blood sugar) protocol if needed. Review of the Event History revealed the following medication incidents: a. On 2/4/26 at 2:47 PM, resident was given 0.5 mg of Lorazepam instead of 0.25 mg of Oxycodone during the noon meal. At 2:53 PM, during the narcotic count with Staff M, Registered Nurse (RN), it was noted that Staff L, RN, signed out Resident #31's Oxycodone, but gave one of Resident #39's 0.5mg Lorazepam. That was the conclusion based on the narcotic book. b. On 3/23/26 at 9:09 AM, Resident #31 received Glargine insulin (lowers blood sugar for approximately 24 hours) 23 units but had no order for Glargine. Orders received to check Resident #31's blood sugar every hour for 24 hours to monitor for low blood sugar. c. On 4/19/26 at 2:30 PM, during a medication administration review it was noted that Resident #31 received Morphine (strong pain med) instead of scheduled Ativan (used to treat anxiety) for the noon dose. Staff F, Certified Medication Aide (CMA), reported she did not give Lorazepam from the refrigerator but gave Morphine from the cart for the AM and noon medication passes. Resident #31 had a documented allergy to the medication that was given. In a confidential interview on 4/28/26 at 1:00 PM, a family member reported the quality of care had declined since the staffing schedule got changed. A few weeks ago, a nurse (Staff B) gave the resident insulin but the resident was not diabetic. The resident had to get her finger poked to monitor the blood sugar for 24 hours after the insulin had been given. Another time, Staff M, RN, called her to report the resident had her head to the side and was drooling. When Staff M came on duty and during their medication count it was discovered that the resident got Morphine instead of Lorazepam for the AM and lunch dose. A CMA gave Morphine twice instead of Lorazepam.In an interview on 4/28/26 at 4:37 PM, Staff B, RN, reported he was not familiar with residents on the Memory Care unit. He had worked at the facility for awhile and had to cover for certain things on other units when a CMA worked on the other unit. Staff B reported there was a lot going on on the day he made the insulin medication error. A CMA worked in Memory Care and Staff B was told that insulin needed to be given. He was trying to side saddle on the medication cart with the CMA at the same time, and he tried to get what he needed out of the medication cart. It just did not work very well having the CMA in the cart at the same time. He made a medication error and he felt really bad about that. He had never made a medication error in 20 years. The resident was fine after the error happened. Staff B reported he was not use to sharing a medication cart when he prepared medications. In an interview on 4/29/26 at 1:01 PM, Staff F, CMA, reported she was supposed to check the five rights before she administered medications. She checked the MAR and medication card for the right resident, right medication, right dose and right time. She then popped the medication out and administered the medication to the resident, then documented the medication on the MAR. Staff F reported one day she gave morphine instead of lorazepam. On that day, she did not think. She saw morphine in the cart and did not think about the other medication stored in the refrigerator so she gave Morphine instead of Lorazepam. The resident did not have any issues but Staff F was upset that she made the error. Staff F reported she received education after the incident. In an interview on 4/30/26 at 10:55 AM, the DON reported she expected staff to follow the policy whenever they administered medications. She expected staff to check the resident's picture on the computer and ensured they had the right resident and checked the 6 rights. The DON reported education was provided to staff involved on the insulin medication error, as well as with the Lorazepam/Morphine error. A Medication Management Policy reviewed 9/30/25 revealed medications will be administered to residents as prescribed by the physician. Staff will follow the six rights of medication administration including the right resident, right medication, right dose, right dosage form, right frequency and right route. Resident photos are taken upon admission for the electronic health record and used as a method of identification for medication and treatment purposes.2. The Minimum Data Set (MDS) dated [DATE] identified Resident #5 had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The MDS documented the resident had a diagnosis of diabetes. The MDS documented that the resident received insulin 7 out of the last 7 days for the MDS history review.Observation on 4/29/2026 at 7:40 AM Staff B, Registered Nurse (RN) gather Resident #5's Insulin Glargine pen. Staff B turned the dosage selector on the pen to the 18 units then put the needle cap on prior to entering the room. The insulin pen was not primed prior nor clean the rubber seal prior to putting the needle cap on. Staff B washed his hands, applied gloves and used alcohol to wipe the area on the abdomen. Staff B gave the insulin in the abdomen and held it for 10 seconds. During an interview on 4/29/2026 at 7:45 AM Staff B, RN reported he did not clean nor prime the insulin pen prior to administering the insulin. Observation on 4/29/2026 at 7:43 AM noted no insulin instruction with the insulin pen in the cart for Resident #5. During an interview on 4/29/2026 at 3:20 PM Director of Nursing (DON) reported staff are to follow the manufacturer's guidelines for insulin pens. She reported the nursing staff is supposed to prime the insulin pens prior to giving. Review of the manufacturer's instructions for use for the Insulin Glargine pen provided by the Administrator documented to wipe the rubber seal prior to attaching the needle cap then to do the needle safety test to ensure the resident correct dosage of insulin. The needle safety test is to prime the pen by turning the dosage selector to 2 units then push the injection button and when insulin comes out it is ready. It can be primed up to 3 times to ensure insulin comes out. Then the pen is ready to select the dosage order to inject into the resident. The instructions documented to not turn the dose selector or press the injection button without a needle attached because it can cause damage to the pen. The facility policy for insulin pens revised 3/25/24 directs staff to clean the rubber seal with alcohol before attaching the needle cap. Once needle capped to dial 2 units of insulin on the dose selector, point the needle up and firmly press the plunger until a drop of insulin appears at the needle tip. Repeat this step if a droplet does not appear.

Based on observation, policy review, and staff interviews, the facility failed to date opened insulin for 1 of 2 medication carts inspected. The facility reported a census of 76 residents. Findings include: 0bervation on [DATE] at 10:18 AM with Staff C, Registered Nurse (RN) present, revealed the medication cart on Tulip Court noted the following insulins open and not dated: a. Resident #60 Lantus with a pharmacy delivery date of [DATE]. (Lantus expires 28 days after being opened) b Resident #1 Basaglar with a pharmacy delivery date of [DATE]. c .Resident #20 Novolog and Lantus with a pharmacy delivery date of [DATE]. (Novolog expires 28 after being opened) During an interview on [DATE] at 10:23 AM Staff C, RN reported the insulin should be dated when opened. Staff C reported if it is not then she goes by the delivery date from the pharmacy. During an interview on [DATE] at 3:21 PM the Director of Nursing (DON) reported staff are to label the insulin pens when opened. The DON reported Staff C reported to her about the expired insulin in the cart. The facility policy for insulin pens revised [DATE] directs staff to document the date open or use by date on the pen.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure resident preferences for end of life treatments were followed as indicated on their Iowa Physician Orders for Scope of Treatment (IPOST). for 1 of 1 resident reviewed for advance directives (Resident #2). The facility reported a census of 79 residents.Findings include:The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had diagnoses that included hypertension (high blood pressure), Type 2 diabetes, cerebral infarction, heart failure and cardiomyopathy.The Care Plan initiated [DATE] for Resident #2 lacked information on end of life treatment for a Full Code Cardiopulmonary Resuscitation (CPR) status with limited interventions.The electronic medical record (EHR) included an IPOST signed [DATE] that indicated Resident #2 wanted CPR attempted with limited additional interventions including do not use intubation or mechanical ventilation.In an interview on [DATE] at 1:29 PM Staff A, RN was very concerned that she should not talk with me as she no longer works there. She stated that Resident #2 was found unresponsive and they started CPR and called 911 as he was a full code. She stated they put on the AED and it did not advise shock as he was deceased . Staff A, RN then stated that Emergency Medical Services (EMS) arrived and took over CPR. Stated she does not remember if EMS intubated Resident #2 but they may have. She added that she did not remember if Resident #2 was a Do Not Intubate (DNI) as it was very chaotic.In an interview on [DATE] at 2:35 PM Staff B, Educational Nurse stated she was pulled into the room by a Certified Nursing Assistant (CNA) who said the resident was unresponsive and she assessed him he was still warm no pulse or respirations. She stated Staff A, RN initiated CPR and not sure who but someone called 911. Staff C, CNA was also present and was quite distressed as she had found Resident #2. Staff B, Educational Nurse then said that EMS arrived and Staff A, RN discussed Resident #2's code status verbally with EMS but did not present the IPOST. Confirmed EMS did intubate Resident #2. Staff B, Educational Nurse stated that no staff tried to stop EMS from intubating. The Power of Attorney (POA) was contacted and CPR was discontinued.In an interview on [DATE] at 2:45 PM the Director of Nursing (DON) confirmed that Resident #2 was a full code with DNI. The DON reported typically, if sending someone out, they present the IPOST but this was very chaotic and both aids were extremely distressed, and that they don't usually do CPR. The DON did state that the IPOST or wishes should have been presented to EMS.In a policy updated [DATE] titled IPOST-Advance directive form implementation it stated in the event of a crisis situation with a resident, staff will be instructed to look at the resident's order for code status and IPOST if the resident has one. It also indicated that upon discharge or transfer to another facility, the original IPOST form will be included in the discharge papers.

Based on resident record review, facility record review and staff interviews, the facility failed to submit the Minimum Data Set (MDS) in a timely manner for 2 of 3 residents reviewed (Resident #28 & #65). The facility reported a census of 70 residents. Findings include: 1. The MDS for Resident #28 dated 3/20/25 documented a quarterly review and was signed by Staff A, Registered Nurse (RN) on 5/1/25. The MDS 3.0 Final Report to verify assessment submission into the QIES ASAP System (Center for Medicare & Medicaid Network) revealed submission of the 3/20/25 quarterly assessment was submitted on 5/1/25. 2. The MDS for Resident #65 dated 3/20/25 documented annual review and was signed by Staff A, RN on 5/1/25. MDS 3.0 NH Final Validation Report to verify assessment submission into the QIES ASAP System revealed submission of the 3/20/25 Annual assessment was submitted on 5/2/25. During an interview on 05/07/25 04:36 PM the Administrator reported awareness there had been a gap in getting care plans updated and that MDS reporting was not in a timely manner and relayed staff that was responsible for MDS assessments and care plans was new. The Administrator stated prior to the new staff, the facility used remote staff that had gaps in reporting and struggled finding an MDS coordinator.

Based on record review, staff interview, and policy review the facility failed to code an anticoagulant drug accurately on the Minimum Data Set (MDS) for 1 of 4 residents reviewed (Resident #17). The facility reported a census of 70 residents. Findings include: The MDS dated [DATE] for Resident #17 documented a Brief Interview of Mental Status as 12 indicating moderate cognitive impairment. The MDS documented diagnosis of stroke. The MDS also documented the resident is taking an anticoagulant. The Orders in electronic health records for Resident #17 revealed an anticoagulant Eliquis, five milligram tablets, twice a day was discontinued on 2/6/25. During an interview on 05/07/25 at 4:36 PM, the Administrator reported awareness of MDS concerns due to staffing gaps, struggled finding an MDS coordinator, relayed current staff that is responsible for MDS assessments is new, 2-3 months, previously used remote staff and is working to correct MDS issues. The facility policy MDS assessments, last review date 3/28/24 documented assessments will be completed per the guidelines in the RAI Manual and include the Care Area Assessment (CAA) and care planning processes in compliance with Centers for Medicare and Medicaid Services (CMS) and any state regulations.

Based on record review, observation, and staff interviews and policy the facility failed to update Care Plans for 3 of 18 residents reviewed (#R17, R54, R195) did not include pertinent medications or side effects, pressure ulcer and transfer technique. The facility reported a census of 70 residents. Findings Include: 1. The Quarterly, Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 revealed a Brief Interview for Mental Status (BIMS) assessment scored 15 out of 15 indicating cognitive intact. Diagnosis included hypertension, peripheral vascular disease, mood disorder diagnoses included, non-Alzheimer's dementia, anxiety disorder. The MDS coded that antipsychotic medications were given on a routine basis. The MDS coded resident had pressure ulcers A Pharmacy Review, recommendation date 8/15/24 documented Resident #17 received an antipsychotic medication, Quetiapine 50 milligram (mg) at bedtime. A Pharmacy Review, recommendation date 3/25/24 documented Resident #17 received an antipsychotic medication 100 mg of Quetiapine 100 mg at bedtime. The Physician Order dated 4/28/25 documented a stage four pressure ulcer on the right ankle to use border gauze bandage The Care Plan focus last reviewed 5/7/25 documented behavior symptoms and mood and behavioral category included expressed feelings through inappropriate actions. The care plan did not include psychotropic or antipsychotic medication. The Care Plan did not include the pressure ulcer. The policy, Care Plan and Baseline Care Plan, last revised 10/14/22 documented, The care plan should include measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that are identified through the comprehensive assessment. Included: Problems and strengths, measurable, individualized goal related to the identified problem, intervention/approach: Specific instructions on how the goal will be met. 50500 2. The Annual MDS assessment, dated 4/15/25, revealed Resident #54 with a Brief Interview for Mental Status score of 3, indicating severe cognitive deficit. The primary medical condition listed on the MDS was non-traumatic brain dysfunction. The MDS documented the use of an antipsychotic medication. Active Physician Orders, obtained on 5/7/25, listed the use of an antipsychotic Quetiapine 12.5 mg two times daily. Review of the Medication Administration Record (MAR) confirmed the use and administration of Quetiapine at least since January 2025. Both the electronic Care Plan, obtained on 5/6/25, and the paper Pocket Care Plan, obtained on 5/8/25, lacked information regarding Resident #54's use of an antipsychotic medication. 3. The Admission MDS, dated [DATE], revealed Resident #195 with a BIMS of 15, indicating intact cognition. Diagnosis on the MDS include anemia, arthritis, diabetes, osteoporosis, and venous insufficiency (peripheral). The MDS noted a fall history prior to facility admission. The MDS reported Resident #195 requiring maximum to total staff assistance for transfers. Due to resident safety concerns, the resident's ability to walk 10 feet was not assessed. The New Admit Assessment Checklist, dated 4/25/25, listed Resident #195's diagnosis as a pubic rami fracture non-displaced. The checklist did not indicate which side the fracture occurred. The paper Admission Care Plan and the New Admit Assessment Checklist both documented transfer needs as a 2-person assistance with use of a standing mechanical lift. The Pocket Care Plan, obtained on 5/6/25, indicated Resident #195's transfer needs as a 1-person assistance with the use of a standing mechanical lift. During an interview on 5/6/25 at 12:45 PM Staff G, Physical Therapy, Staff H, Certified Occupational Assistant, and Staff I, Physical Therapy Assist, explained Resident #195's staff assist level as a 2-person as explained on the Admission Care Plan. Staff was not immediately aware of any changes. If therapy makes any new recommendations or updates, an email is sent to nursing staff. Therapy staff does not update or make any changes to a resident's Care Plan. This is completed by nursing. During an interview on 5/6/25 at 3:30 PM, Staff F, Registered Nurse, explained Pocket Care Plans are updated throughout the day by nursing staff and printed daily in the morning. The Pocket Care Plans are carried by floor staff for the most current information. Staff F reported an email from the therapy department, dated 4/28/25, changed the assistance level from a 2-person to 1-person. Staff F was unsure how or who would update the paper Admission Care Plan/New Admit Assessment Checklist so the two Care Plans would match. During an interview on 5/7/25 at 4:35 PM, the Administrator acknowledged a gap with updating Care Plans in a timely manner and should reflect current resident cares. The Administrator acknowledged that Pocket Care Plan information should come from the regular Care Plan. The Long-Term Care Facility Resident Assessment Instrument 3.0 (version 1.19.1 October 2024, pages N-5 and N-) identified antipsychotics as a high-risk drug. As such, the Care Plan should state the rationale for the medication initiation, non-pharmaological interventions, and possible adverse effects for staff to monitor.

Based on observation, staff interview, and policy review, the facility failed to follow Enhanced Barrier Protection (EBP) practices for residents with an indwelling medical device and an open pressure injury for 2 of 2 residents reviewed for infection control (Residents #77 and #195). The facility reported a census of 70. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment, dated 4/8/25, revealed Resident #77 had diagnoses which include diabetes, obstructive uropathy, and septicemia. The MDS documented the presence of an indwelling catheter. The electronic Care Plan, last revised on 4/23/25, documented Resident #77 with an indwelling catheter related to the diagnoses of obstructive and reflux uropathy. The Pocket Care Plan, obtained on 5/7/25, alerted staff Resident #77 with a Foley and the abbreviations of EBP. During an observation on 5/7/25 at 1:25 PM, Staff B, Certified Nursing Assistant (CNA) and Staff C, CNA, washed their hands and donned gloves upon entering Resident #77's room to complete catheter and peri-cares. Once the resident was situated in bed, Staff B cleansed the catheter port with an alcohol swab, emptied the catheter bag, and cleansed the catheter port with a new alcohol swab. Staff B emptied the drainage graduate, threw away the used supplies, washed their hands, and donned a new pair of gloves. Staff B then proceeded to clean Resident #77's catheter tubing. Staff B held onto the urinary catheter, at the point where it entered the penis, and with a new peri-wipe, cleansed the tubing by wiping away from the body. Once this was done, Staff B and Staff C both proceeded to complete the rest of pericares. After all resident cares completed, Staff B and Staff C removed gloves and washed their hands. Neither staff member wore gowns during catheter cares. The resident's room door had signage which alerted staff the need for additional EBP or personal protective equipment (PPE). Gowns were stored in a small multi-drawer storage unit outside of the room. 2. The Admission MDS assessment, dated 4/30/25, revealed Resident #195 had a one stage 3 pressure ulcer upon facility admission on 4/25/25. Medical diagnoses listed on the MDS include anemia, chronic kidney disease-stage 4, diabetes, and peripheral venous insufficiency. Resident #195's Face Sheet also listed a diagnosis of influenza, which required the use of transmission based PPE upon facility admission. The paper Admission Care Plan, initiated on 4/25/25, documented Resident #195 with a pressure ulcer and listed interventions. The Pocket Care Plan, obtained on 5/6/25, did not list the pressure ulcer. Neither Care Plan addressed the use of EBP. During an observation 5/7/25 at 10:15 AM, Staff D, Registered Nurse, washed their hands and donned a new pair gloves upon entering Resident #195's room. Staff E, Assistant Director of Nursing and Infection Preventionist, was present during cares to observe. After the resident was positioned in their bed and gloves changed, Staff D proceeded to complete wound cares. After this was completed, Staff D gathered used supplies, threw them away, removed gloves, and washed hands before exiting the room. Staff D did not wear a gown during wound cares. The resident's room lacked signage regarding the use of EBP or PPE required. During an interview on 5/7/25 at 10:30 AM, Staff E, Registered Nurse stated EBP precautions were not needed during Resident 195's wound care as the wound is considered acute. EBP are initiated with chronic wounds. Staff E unable to provide a specific timeframe when a wound is considered chronic. During an interview on 5/7/25 at 2:00 PM, Staff C, Certified Nurse Aide (CNA) voiced they typically wear gowns for cares which involve catheter or open wounds. During an interview on 5/7/25 at 4:35 PM, the Administrator explained the facility initiates EBP with chronic wounds, which is defined as 3 months per the National Institute of Health. The Administrator acknowledged EBP not followed for Resident #195 since assessed as an acute wound (present less than 3 months). The policy Transmission-based Precautions and Enhanced Barrier Precautions, last reviewed 7/3/24, outlined EBP are recommended for residents with a chronic wound regardless of MDRO (multi-drug resistant organism) status and does not include small or short term wound and residents with an indwelling medical device. The Center for Disease Control and Prevention (CDC) directs nursing facility staff to implement EBP for residents with wounds and/or indwelling medical devices, regardless of MDRO status, during high contact resident care activities to include wound cares and device care or use (https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html)

Based on observation, clinical record review, staff interview, and facility policy review, the facility failed to ensure the safety for 1 of 5 residents (Resident #2) reviewed. This failure caused harm when Resident #2 was improperly transferred and needed to be lowered to the floor. This transfer resulted in a ligament injury. The facility reported a census of 72 residents. Findings include: The Annual Minimum Data Set (MDS) of Resident #2, dated 11/18/24, identified a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The MDS revealed the resident required substantial/maximal assistance for sit to stand, chair/bed-to-chair transfers and toilet transfer. The MDS documented diagnoses that included osteoporosis and Alzheimer's Disease. The MDS recorded the resident had not received any scheduled or as needed pain medication during the prior five days, and denied having any pain. The resident denied having had any pain during the prior 5 days of the look back period. The following Significant Change MDS Assessment for Resident #2, dated 1/23/25, revealed the resident was now totally dependent on staff for sit to stand, chair/bed-to-chair transfers and toilet transfer. The MDS documented the resident received scheduled pain medication and non-medication interventions for pain. The resident reported she had pain during the prior 5 days of the look back period. The Care Plan of Resident #2 identified a problem area needing assistance with daily needs. It directed staff the resident required two staff members for transfers, dated 8/12/24. On 1/6/25, the Care Plan was updated to require the resident to transfer with a standing mechanical lift from her bed to her wheelchair only. The Care Plan was updated again on 2/7/25 directing the staff to use two staff members using a full body mechanical lift for transfers. The resident was receiving Physical Therapy at the facility and was seen on 11/18/24. The Physical Therapy Treatment Encounter note documented the following; Patient completes sit to stand transfers from wheelchair to four wheeled walker with minimal to moderate assist each time. Patient requires extensive cues for upright posture and full bilateral knee extension. The note did not detail the resident experiencing any pain in either leg. The Progress Note dated 11/19/24 documented staff reported to the Registered Nurse the resident had fallen. Upon assessment, the resident was found to be in a sitting position on the floor with her legs stretched. Staff reported the resident had started to fall and was lowered to the floor, and during the lowering, her right knee had bent. The resident was complaining of severe pain, and was unable to move or bend her right leg. The medical provider was notified and the facility received orders to send the resident to the emergency room (ER) for evaluation. The ER notes documented the following: Musculoskeletal exam: Swelling, tenderness, and signs of injury present. Right upper knee: Swelling and bony tenderness present. Decreased range of motion. Tenderness present over the medial joint line. Right upper leg: Tenderness present. No swelling, deformity or bony tenderness. Comments: Limited range of motion right lower extremity. - Findings: Ligamentous injury versus knee sprain. Knee immobilizer was avoided due to risk of pressure induced soft tissue injury due to age and lack of subcutaneous tissue. Placed in an ACE wrap. Non weight bearing at baseline. The Event Report dated 11/19/24 documented the resident received an injury to her right lower extremity, experiencing painful/limited range of motion. Her left lower extremity was documented as strong movement, and her right lower extremity was documented as weak movement. The Report documented the operational factors which led to the fall as Students transferred resident without gait belt and proper transfer. Lowered to floor. The written statement from Student #1 documented the Student went to answer the resident's call light and the resident stated she needed to use the restroom. The student retrieved the wheelchair and moved it next to the recliner. The statement documented the resident told the student that she could do it (stand up) on her own, but the student offered help by holding her hands, then moving into a hug position to lift the resident but she was unable to lift her alone. The student documented that she then called for a second person (Student #2). She wrote they tried to move the resident to her wheelchair but the resident had started calling out about her leg, so she attempted to move the resident back to her recliner and for extra help. She documented the resident was still complaining of her leg and she then noticed the resident's right leg was caught by the wheel of the wheelchair. At that time, the students lowered the resident to the ground, writing that because of the position of her right leg behind her bent at the knee, they were not able to lower her fully to the ground. Staff A, Certified Nurse Aide (CNA) entered the room to help support the resident to a safe position. The statement ended with noting the resident was complaining of right knee pain. The written statement from Student #2 documented she was in the hallway and heard Student #1 calling for help. Her statement noted the resident was unbalanced and leaning forward almost off of the recliner, so she and Student #1 attempted to move the resident to the wheelchair. The resident's right foot was caught on the wheelchair wheel and she was unable to stand. She wrote they then lowered her to the ground and her right knee was under the resident's buttocks. The two students called for help and Staff A, CNA came to assist. The written statement from Staff A, CNA documented she was alerted by students of needing help in Resident #2's room, and heard Resident #2 calling out before she got to the room. She wrote the students had attempted to transfer Resident #2 and had not used a gait belt. The students were attempting to hold the resident up and she instructed them to lower her to the floor. She stated when she asked the students what happened, they told her the resident needed to use the restroom, and they had positioned the wheelchair close to the resident and attempted to assist her due to the resident stating she could do it herself. The Medication Administration Record (MAR) of Resident #2 for November of 2024 documented an order for Hydrocodone-Acetaminophen 5/325 mg (a narcotic pain reliever mixed with acetaminophen/Tylenol) ordered to be given one tablet three times a day beginning 11/20/24. The MAR reflected the order was changed on 11/25/24 to a half tablet three times a day. The MAR reflected additional orders for an ice pack to the right knee for 20 minutes at a time as a non pharmacological pain intervention. The MAR for March of 2025 revealed the current pain medication order to be Hydrocodone-Acetaminophen 5/325 mg, half a tablet, four times a day. Review of Progress Notes of Resident #2 identified the following: 11/20/24: Returned to facility on a stretcher via ambulance accompanied by two male staff. Transferred into her bed with assist x 4 without difficulty. Resident wakened during transfer from stretcher to bed and began crying out: Please leave me alone, please don't touch my leg it hurts. 11/20/24: Lying in bed resting soundly with eyes closed, no further crying out in pain after PRN Tramadol. She did refuse the scheduled ice pack to right knee yelling: stop it, no, I don't want it, leave me alone! 11/21/24: Resident has been resting quietly this shift without complaints voiced when lying still. Nurse placed pillow under legs to float heels which resident did wince at. Routine Norco (Hydrocodone/Acetaminophen) initiated with resident sleepy. 11/21/24: Patient has been in bed all shift again today. Did drink and eat better and her pain seems to be in better control. Cold pack applied several times to her right knee, patient tolerated well. Therapy was in and stated to use the Hoyer (full body mechanical) lift for resident when she gets up. 11/26/24: Removed ace wrap and floated heels on pillow. Ice three times a day continues. Right lower extremity remains edematous and resident has pain with movement and repositioning. 11/27/24: Continues to use Hoyer lift assist of two for transfers 11/30/24: Resident up in wheelchair this evening. Voiced no complaints of pain but did show symptoms during transfer to bed via Hoyer lift. 12/2/24: Hospice referral sent. 12/5/24: Resident denies complaints of pain unless she is moving. Assist of two with Hoyer lift for transfers. Ice, norco and ace wrap continue for swelling and pain issues. 12/13/24: Family requested decrease in pain medication due to resident being too sleepy 12/15/24: Edema remains to bilateral lower extremities, right greater than left. Assist of two via Hoyer lift for transfers 12/16/24: Staff requested to reinstate order for ice pack as an as needed order. Resident remains on scheduled narcotic pain medication four times a day which appears to manage pain at this time. Remains as a two person assist with a full body mechanical lift for transfers. Resident #2 was observed on 3/4/25 at 12:17 being transferred from her bed to her wheelchair by Staff B, CNA and Staff C, CNA. The full body mechanical lift sling was in place under the resident as she laid in bed. Staff B and Staff C secured the loops of the sling to the mechanical lift, verified placement and safety, and appropriately transferred Resident #2 from the bed to her wheelchair. Resident #2 stated during the transfer this leg hurts and indicated with her hand it was her right leg hurting. Observation ended after the resident was safely in her wheelchair, foot pedals were put in place, and staff was fixing her hair prior to taking her to lunch. On 3/4/25 at 4:57 pm, the Administrator stated the CNA students had been provided with pocket care guides. She said the students were eager to help and the resident told them it was fine. The Administrator verified the resident was care planned as a two staff assist but the students failed to use a gait belt. On 3/5/25 at 8:42 am, the Assistant Director of Nursing stated the resident only had the single injury to her knee in November of 2024 but has always had pain in her knee. On 3/5/25 at 9:29 am, the Physician Assistant from the facility stated the injury was a potential ligament injury. She stated due to the resident continuing to complain of pain, she did order a second x-ray (results were negative for any fractures). She stated the family ultimately chose to pursue hospice care as she had been declining prior to the injury related to advanced age and her diagnosis of Alzheimer's Disease. She stated she feels the resident's right leg pain will always be chronic and they are treating it as much as possible to keep her comfortable. Her pain management regimen has changed a couple of times to try to give the most pain relief without causing sedation or other side effects. On 3/5/25 at 1:17 pm, Staff A stated when she entered the room, the resident was not yet lowered to the floor. She described the resident's left leg as being extended forward and her right leg was bent. Staff A stated she instructed the students the resident needed to be lowered to the floor. When she was lowered, due to her leg being bent, her right leg was going out to the side but underneath the resident as she was gently lowered. She stated the resident was either wearing tennis shoes or slippers with non slip grippers on them. She stated the students were not using a gait belt during the transfer. The facility policy Transfer/ambulation assist using gait/transfer belt, review date 3/25/24 documented the following: Policy: Gait/transfer belts will be used for all residents who require physical support for mobility or safety in transfers. The residents will be assessed for appropriate transfer status by PT, OT, or a nurse. Gait/transfer belt will be removed upon completion of transfer/ambulation. Follow care plan for number of staff assistance required. Procedure: Assist to stand 1. Identify resident. 2. Verify in care plan the number of staff required for transfer assistance. 3. Explain procedure as needed. 4. Provide privacy as needed. 5. Apply the gait/transfer belt snugly around the waist, over the clothing. Apply the belt snugly enough so it will not ride up or down on the resident's body. 6. Fasten the safety buckle in the front, slightly off center. 7. Bring the resident to a standing position, using one or two hands on the gait/transfer belt. Do not lift resident under their arms during transfers. If the belt loosens, tighten it again after the resident is standing.

Based on direct observation, clinical record review, staff interviews, family interviews, and policy review, the facility failed to provide sufficient amount of properly trained staff to implement care plan interventions for 1 of 1 residents with self-injurious behavior. (Resident#37). The facility staff also failed to intervene when the resident displayed behaviors. This resulted in harm to the resident in the form of three occurrences of cellulitis and loss of the distal portion of the left index finger - the tip of the left index finger to the first finger joint. She was placed on antibiotics for the treatment of the cellulitis. The facility reported a census of 75. Findings include: Record review of Resident #37's Minimum Data Set (MDS) assessment dated [DATE] documented that a Brief Interview of Mental Status (BIMS) could not be completed due to the resident being rarely or never understood. The MDS also documented the need for significant assistance for transfers, dressing and toileting, supervision at meals with set up assistance, and assistance for bed mobility. The resident's diagnoses included, non-traumatic brain dysfunction, Alzheimer's disease, Non-Alzheimer's Dementia, diabetes, anxiety, depression, and pain. Record review of Resident #37's Care Plan last revised on 05/17/24 indicated staff should redirect self-harm behaviors by handing Resident #37 something to eat or giving her a stuffed dog. It indicated dependent care for oral hygiene. Review of oral hygiene charting revealed that oral cares were only recorded as completed on the following dates and times: 1. 04/29/24 at 10:52 AM 2. 04/30/24 at 12:24 AM 3. 05/07/24 at 02:48 PM 4. 05/08/24 at 09:23 AM 5. 05/09/24 at 04:25 AM 6. 05/10/24 at 12:35 PM 7. 05/11/24 at 03:55 PM 8. 05/12/24 at 10:21 AM 9. 05/13/24 at an undocumented time. Review of a Physician's Progress Note dated 04/15/24 revealed the following: 1. Resident #37 had a diagnosed history of advanced dementia. 2. She was placed on hospice services. 3. She had been persistently biting at her nails and fingers, ongoing for approximately two months as of the date of this progress note. 4. It began as minor wounds, but the patient had now chewed off the distal part of the left index finger near the distal interphalangeal (DIP) joint. 5. She had dementia related agitation, anxiety, and hallucinations. 6. The care team added Divalproex Sprinkles 125mg twice daily on 03/25/24. 7. This was reported to have slowed her behaviors, but staff reported finger chewing worsened as of the writing of this progress note. 8. Other measures have failed to stop chewing, included bandages and gloves. The Progress Notes for the resident documented the following: a. On 02/07/24 at 05:24 AM the resident was agitated, yelling, and biting an open area on the middle finger of the left hand. The area appeared swollen, red, and painful. The area was cleansed and covered. b.On 02/07/24 at 12:45 PM the resident was seen by the physician's assistant (PA) for an acute visit in which the resident presented with a swollen finger. The resident was prescribed Keflex 500mg two times daily for ten days, the wound to be covered, and triple antibiotic ointment to be applied to the left middle finger. c.On 02/12/24 at 07:31 AM the resident remained on antibiotics for cellulitis of the left middle finger. Resident #37 continued to bite at the area, and had removed the bandages, but fresh bandages were applied. It noted a scant amount of serosanguinous drainage present on the dressing. d.On 02/24/24 at 05:48 PM The resident continued to bite at her left index finger. e.On 02/25/24 at 06:23 AM The resident bit her left index finger nail causing mild bleeding. f.On 02/25/24 at 03:48 PM The resident had new wounds on left index and middle fingers. It noted the resident had been chewing on fingers, staff covered wounds with dressings, and resident continued to remove dressings and chew on fingers. g.On 02/29/24 at 01:45 PM Nursing staff dressed the left index finger and lower left extremities, at this time it was noted the left index finger nail had nearly fallen off. h.On 03/01/24 at 05:10 PM The resident continued to chew on her fingers. i.On 03/04/24 at 02:37 PM noted the resident had gloves added as an intervention which successfully prevented chewing behavior. j.On 03/05/24 at 06:19 AM the resident continued biting behavior and refused to allow staff to apply gloves or dressing. k.On 03/10/24 at 06:28 AM Noted the resident had bitten off nails on left index and middle fingers. A geri sleeve was placed over the dressing as a deterrent, which proved effective. l.On 03/15/24 at 03:13 PM The resident removed the dressing from her fingers. Nursing staff noted the fingers were red and warm to the touch. At 05:13 PM an order for Augmentin was clarified and changed to Doxycycline 100mg two times a day for ten days related to a second occurrence of cellulitis in the left fingers. m.On 04/12/2024 at 05:56 AM Noted that the resident had bitten her left index finger down to the distal interphalangeal joint and had bitten the fingernail off of her left middle finger. n.On 04/19/2024 at 03:43 PM Noted resident was placed on Bactrim for ten days due to another occurrence of cellulitis in the left finger. o.On 04/28/2024 at 10:42 AM Noted the resident continued to chew on fingers and is quickly removing bandages and dressings. Review of a Provider Progress Note dated 04/15/24 recorded Resident #37 had been persistently biting at her nails and fingers; ongoing for approximately two months. These began has minor wounds, but patient had since chewed off distal part of the left index finger, nearly to the distal interphalangeal joint. Divalproex sprinkles 125mg twice daily was added at 03/25/24, which first appeared to have slowed the chewing behavior, but was reported to have failed as of the writing of this note. A direct observation on 05/28/24 at 01:00 PM revealed wounds on Resident #37's legs and bandages on her left hand with no blood visible on the bandages at the time of this observation. A continuous direct observation on 05/29/24 from 12:12 PM to 12:40 PM revealed the following: 1. At 12:12 PM, Resident #37 in the dining room attempting to free herself from her wheelchair. When attempts failed to free herself from her wheelchair she began to bite the bandage on her left middle finger. A red mark on the bandage was present. 2. At 12:14 PM, Staff B, Therapeutic Activities Coordinator, walked past Resident #37. No attempts were made at redirection and the nurse was not notified. Resident continued to chew the bandage on her left middle finger. 3. At 12:17 PM, Staff C, CNA, seated another resident next to Resident #37, then placed a clothing protector on Resident #37. No attempts were made to redirect the resident from chewing. Nurse was not notified. Resident continued to chew on the bandage on her left middle finger. 4. At 12:19 PM, Staff D, CNA, walked past Resident #37 as she freed her finger from the bandage. Staff D commented That didn't last long and continued to seat residents at the dining tables. No attempts were made to redirect at this time. The nurse was not notified. Resident #37 began to chew on the proximal interphalangeal joint of her left middle finger - the middle joint of her middle finger. 5. At 12:25 PM, Resident #37 continued to chew on the proximal interphalangeal joint of her middle finger, but asked for help from Staff F, Culinary Assistant. Staff F did not acknowledge Resident #37. Staff F left the dining room without informing nursing staff. 6. At 12:27 PM, The Director of Food and Nutrition Services offered Resident #37 a glass of water. Resident #37 accepted the drink and stopped chewing. The chewing did not resume until the glass of water had been consumed. At 12:32 PM Resident #37 resumed chewing on the proximal interphalangeal joint of her left middle finger. Redness is noted on the finger at this time. 7. At 12:32 PM, Resident #37 had a dessert placed just out of her reach by the Director of Food and Nutrition Services. She continued chewing behavior in clear sight of Staff C and Staff D. No attempts to redirect were made. 8. At 12:40 PM, Staff G, RN noted resident was actively engaged in chewing behavior. Staff G placed the dessert in reach of Resident #37. Resident immediately ceased chewing behavior and began eating the dessert. In an interview on 05/29/24 at 03:23, PM Staff C stated they do not feel they have enough staff to handle the needs of residents in the Memory Care unit. She noted that several residents require a mechanical lift with an assist of two, leaving only on person on the floor to monitor all residents in Memory Care. She acknowledged the biting behavior but noted it happens so frequently it fades into the background. She acknowledged that staff should attempt to redirect when they notice. In an interview on 05/30/24 at 09:28 AM, Staff D noted staff are to attempt to redirect Resident #37 when they notice her biting or attempting to free herself from her wheelchair. She noted that interventions are not always successful, but staff are still supposed to attempt to distract or redirect the resident. She stated she feels they need more staff in Memory Care. She stated that it is hard to tend to resident needs when they are dealing with a two person assist. She noted it leaves only one staff member to monitor the rest of the floor. In an interview on 05/30/24 at 09:06 AM A family member of Resident #37 stated he feels the facility does not have enough staff to adequately care for all of the residents in the Memory Care Unit. He noted when a resident is being assisted it often leaves only one person to watch the entire floor. He noted he visits every morning and most evenings. The family member gave permission to take pictures of Resident #37's fingers. These pictures were taken on 05/30/24 at 01:05 PM. They revealed scabs on the distal phalangeal joint, with a finger missing above that point on the left index finger. The fingernail of the middle left finger had been removed and there was an open wound with a small white area protruding from the nail bed. There was recent trauma to the proximal phalangeal joint present with some scabbing noted. In an interview on 05/29/24 at 4:46 PM The Director of Nursing (DON) acknowledged the expectation is for nursing staff to attempt redirection as soon as they witnessed the self-injurious behavior. She noted kitchen and activities staff are expected to say something to nursing staff when they witness the behavior so that nursing staff can attempt to implement interventions in accordance with Resident #37's care plan. She stated she did not believe the facility could provide one on one care for Resident #37 at this time. Review of a visual body inspection dated 05/24/24 documented that the resident had no new injuries or damaged skin present. Review of a facility document titled Behavioral Health Services last reviewed on 03/18/24, documented the facility's interdisciplinary team (IDT) will evaluate behavior health symptoms to determine the degree of severity, distress and potential safety risk to the resident and effectiveness of interventions. If necessary, safety strategies will be implemented immediately to protect the resident or others from harm. If a resident is having behaviors that are not responding to current interventions, staff will complete a behavioral expression-elevated event and this will be reviewed by the IDT. Facility staff will receive education to ensure competency in meeting the behavioral health needs of residents. Review of a facility document titled Dementia Care last reviewed on 03/28/24, documented the facility will use consulting psychologists as needed for assessment and intervention, and should it be deemed necessary for the well-being of the resident, safety of other residents, and/or staff, the use of geriatric inpatient mental health units. The facility did not provide evidence that this occurred.

Based on observation, interview, and facility policy the staff failed to perform hand hygiene to prevent the spread of possible food borne illness for one of one meal observation. The facility reported a census of 75 residents. Findings include: Observation on 05/29/24 at 12:38 PM revealed Staff F, Culinary Assistant (CA) did not perform hand hygiene at the hand washing station before beginning to serve lunch plates. While serving plates of food, Staff F continually touched the top of the resident's plates, and on two occasions used his thumb to hold food in place. Observation on 05/29/24 at 12:41 PM revealed Staff F pick up and handle paperwork to a coworker, then continue to serve food. No hand sanitation was completed at this time. In an interview on 05/30/24 at 02:20 PM the Director of Food and Nutrition services acknowledged Staff F should not have used his fingers to hold food in place and should have washed hands after handling other objects. She agreed that Staff F required more training. Review of a facility policy titled Food Preparation and Services, last reviewed on 01/12/24, documented facility staff should wash their hands before serving food to residents. It further documented bare hand contact with food is prohibited.

Based on observation, staff interview, and facility policy review, the facility failed to place a barrier prior to performing blood glucose monitoring for 3 of 3 residents reviewed (Residents #13, #26, #55), additionally the facility failed to have a sharp container when needed by staff for 3 of 3 residents (Residents #13, #26, #55), and the facility failed to properly locate the accu monitor while being cleansed by disinfecting wipe while using the same monitor for 3 of 3 residents (Residents #13, #26, #55). The facility also failed to follow infection control during dining service. The facility reported a census of 75 residents. Findings include: Observations revealed the following: a. On 5/28/24 at 11:25 AM, staff placed blood glucose items on surface without barrier, staff did not place lancet in sharp container after use, and staff wrapped blood glucose monitor with disinfecting wipe and placed it in the tray with clean blood glucose items. b. On 5/28/24 at 11:28 AM, staff placed blood glucose items on surface without barrier, staff did not place lancet in sharp container after used, and staff wrapped blood glucose monitor with disinfecting wipe and placed it in the tray with clean blood glucose items, used the same monitor from previous resident. c.On 5/28/24 at 11:33 AM, staff placed blood glucose items on surface without barrier, staff did not place lancet in sharp container after used, and staff wrapped blood glucose monitor with disinfecting wipe and placed it in the tray with clean blood glucose items, used the same monitor from previous resident. On 5/30/24 3:11 PM, The Director of Nursing (DON) reported staff should be using a paper towel or a barrier, sharp container is located on the medication cart, each resident has their own monitor that is stored in their own bag, and monitor should be on a barrier on the med cart to allow to dry. The facility policy title Blood Glucose Monitoring-Assure Prism revised 3/28/24 included the following documentation: Number 2- Gather the following equipment: test strips, glucose monitor, lancets, cotton balls, sharps container. Number 3- Place equipment on a clean barrier. The facility policy titled Clean-disinfect glucometer revised 7/24/23 included the following documentation: Policy statement- This glucometer is disinfected after use and stored in designated location. Number 1- Each resident's glucometer will be stored individually. Number 2- Clean per manufacturer's instructions. Number 3- Store individual glucometers in Ziploc bag or similar to keep separated from other machines.

Based on observation, clinical record review, resident interview, staff interviews and facility policy review, the facility failed to follow physician orders for 3 of 18 residents reviewed (Residents #20, #30 & #67). Resident #20 consistently received medications significantly past the ordered time, Resident #30 was administered a treatment that had been previously discontinued, and the facility failed to obtain ordered daily weights for Resident #67. The facility reported a census of 75. Findings include: 1. The Quarterly Minimum Data Set (MDS) Assessment of Resident #20, dated 4/22/24 identified a Brief Interview of Mental Status (BIMS) score of 15 which indicated cognition intact. The Care Plan of Resident #20 documented a Focus Area of Preferences dated 9/12/23. The Care Plan identified the goal, with a target date of 7/17/24 to be My preferences will be respected to the extent able, provided consideration of mine and other's safety. The Care Plan additionally documented a Focus Area of Cognition/Communication dated 5/16/23 which stated I am alert and oriented. I am able to make needs known to staff, though I can be forgetful at times. On 5/28/24 at 12:08 pm, Resident #20 stated that his bedtime medications are sometimes administered as late at 1:00 am. He stated he wishes to go to sleep earlier in the night and does not want to be woken up for medications after he goes to sleep. He voiced that there are two regular night shift nurses, and one of the two usually brought his medications before 9:30 pm but the other nurse was consistently late in administering the medicines. The undated document titled Medication Pass times provided by the facility during the survey documented HS (hour of sleep/bedtime) medications are to be administered between 7:00 pm and 10:00 pm. The Medication Administration Record of Resident #20 for the month of May, 2024 revealed the following seven medications were ordered for HS, 7:00-10:00 pm which were administered significantly late multiple times throughout the month: Donepezil, 10 milligrams (mg) ( treat memory loss and mental changes) Doxazosin 4 mg (for high blood pressure) Memantine 10 mg (treat memory loss) Omeprazole, 20 mg (for increased acid in stomach) Quetiapine 50 mg (for depression) Simvastatin 20 mg (for high cholesterol and triglycerides) Venlafaxine 75 mg (for depression) The MAR documented the following information: On 5/2/24 the HS meds were administered on 5/3/24 at 12:01 am. On 5/7/24, the HS meds were not administered due to resident being asleep, documented at 11:56 pm. On 5/10/24 the HS meds were administered at 11:15 pm. On 5/11/24 the HS meds were administered at 11:14 pm. On 5/21/24 the HS meds were administered at 10:52 pm. On 5/26/24, the HS meds were administered at 11:20 pm. On 5/30/24, at 11:25 am, the Director of Nursing (DON) stated that she is aware of the situation and that Resident #20 had previously expressed his concerns regarding this to her. She stated she has provided education to the nurse and is continuing to work with her. The orders of Resident #20 revealed an order dated 8/8/23 which stated Facility May Use Liberal Med Pass Times The facility policy Medication Management, review date of March 4, 2024 documented: Point 12 - Medications may be given 1 hour before or 1 hour after scheduled administration time unless there is a specific order or indication otherwise. Facilities using liberalized medication pass times will administer meds during the ranges given in the liberalized medication pass times and will not have an additional hour before or after those times. 48886 2. The Significant Change MDS dated [DATE] documented Resident #67 had a Brief Interview for Mental Status (BIMS) of 14, which indicated intact cognition. The MDS further documented the resident had diagnoses to include medically complex conditions, diabetes mellitus, hip fracture and respiratory failure. The Care Plan for Resident #67, with a start date of 2/21/24, documented nutritional status under a problem area with a goal no significant weight changes will be observed and an approach weights and medications per doctor of medicine (MD) order. Review of the Electronic Health Record (EHR) for Resident #67 showed a Physician Order with a start date 5/10/24 with an order for daily weights and to notify the physician if weight gain of 3 pounds in between weights or weight gain of 5 pounds in 1 week. Review of the EHR for Resident #67 revealed no weights recorded for the dates of 5/16/24 and 5/17/24 and no explanation as to why weights were not recorded. The resident's weight on 5/15/24 was recorded as 276.5 pounds, the resident's weight on 5/18/24 was recorded as 281.2 pounds, a weight gain of 4.7 pounds in between weights. Review of the EHR for Resident #67 revealed lack of documentation of notification to the physician of the 4.7 pound weight gain on 5/18/24. During an interview 5/29/24 at 2:00 PM, the Administrator advised the weight for Resident #67 was not recorded 5/16/24 or 5/17/24. Review of email documentation on 5/29/24 at 2:53 PM from the Administrator. The Administrator documented in email the nurse on 5/16/24 was contacted and recalls Resident #67 refused weight and will make a late entry. At this point, we are unable to reach the nurse from 5/17/24 but messages have been left. The Administrator documented our expectation would be that we would notify the doctor if the resident refused his weights and was showing symptoms of increased fluid retention. During an interview 5/29/24 at 03:10 PM, the Director of Nursing (DON) stated an expectation physician orders are followed and Resident #67's weight would be taken every day, and if not, a reason why should be documented. The DON acknowledged weights were not obtained on the 16th and 17th of May, and no documentation is present as to why. The DON stated an expectation staff contact the physician on the 18th of May to inform the physician of the weight gain. The DON acknowledged the physician was not contacted on 5/18/24. 50500 3. The Comprehensive Skin Risk assessment dated , of Resident #30, reflected a Braden score of 14, which indicates a moderate risk of pressure wound development. The Care Plan revision date of 5/13/24 indicated Resident #30 to be at risk for alteration of skin integrity related to poor skin turgor, poor safety awareness, impulsivity, and Foley catheter. Resident #30 had a prior treatment order to the left buttock/gluteal fold wound which read: Apply Calmoseptine to pressure ulcer on Left buttock every shift until healed. This treatment was initiated on 4/17/24 and discontinued on 5/11/23 as the site had healed. Resident #30 has an active wound care orders for the right buttock initiated on 5/20/24 which reads: Cleanse wound on right buttock with wound cleanser of choice. Pat dry. Cover with bordered foam dressing. Change 2 times weekly until healed. Check Placement of dressing every shift. Progress note entries from 5/26/24 and 5/27/24 document that Resident refused turns, Calmoseptine treatment during the night. Wound care observation completed on 5/28/24 at approximately 3:15 pm for Resident #30 with Staff A, Registered Nurse (RN), and the Assistant Director of Nursing (ADON). Wound care to the right buttock started after cares to the calf and heel completed. Staff A, RN and the ADON wore personal protection as per Enhanced Barrier Protection. Supplies were set up on a barrier on bedside table which include Calmoseptine and wound cleanser. No copy of treatment administration record observed in room for staff to compare and verify treatments. When Staff A, RN began treatment on the right buttock, Staff A, RN noted a dressing on the wound and asked the ADON about it. The ADON ungowned and went to verify the wound care order. The ADON returned with the ordered dressing as this was not brought into the room prior to cares. Resident #30 had a large bowel movement with incontinent care completes. A reddened wound bed observed. The wound was cleansed with normal saline; No wiping observed. Staff A, RN applied Calmoseptine followed by the dressing. Staff A, RN then dated the dressing.

Based on observation, resident interview, staff interview, record review and policy review, the facility failed to provide necessary services to maintain grooming for nail care for 1 of 1 residents (Resident #67) reviewed for Activities of Daily Living (ADL). The facility reported a census of 75 residents. Findings include: The Significant Change Minimum Data Set (MDS) dated [DATE] documented Resident #67 had a Brief Interview for Mental Status (BIMS) of 14, which indicated intact cognition. The MDS further documented the resident had diagnoses to include medically complex conditions, diabetes mellitus, hip fracture and respiratory failure. The Care Plan for Resident #67, dated 4/26/24, with a problem area for ADL, documented resident admitted to facility for skilled services, had a hospitalization after a fall with femur fracture and surgery. Resident needed assistance with ADL's, unable to complete them without assistance. The approach section of the Care Plan documented staff to provide assist with grooming. During an observation 5/28/24 at 2:11 PM, Resident #67's fingernails were long and jagged, they were brown in color and dirty under the nails. During an interview 5/28/24 at 2:11 PM, Resident #67 advised the facility has not trimmed his nails in a while and stated he relies on the facility to trim his fingernails, especially due to his diagnosis of diabetes mellitus. During an observation 5/29/24 at 1:50 PM, Resident #67's fingernails were long and jagged, brown in color with dirt under the nails. Review of the Electronic Health Record (EHR) for Resident #67, under the observation section, a skin inspection form was completed on 5/23/24 and 5/16/24, the form directed staff to observe resident nails and provide nail care as indicated. The form did not contain documentation nail care was completed. Review of the progress notes section of the EHR did not contain documentation regarding nail care. During an interview 5/29/24 at 2:30 PM, the Administrator advised she is not aware of other documentation regarding nail care for Resident #67 being completed. During an interview 5/29/24 at 3:15 PM, the Director of Nursing (DON) advised Resident #67's fingernails were just observed by her to be long and dirty. The DON stated the resident's fingernails should have been trimmed prior to this date given their length and appearance. The DON stated an expectation the resident's nails are observed weekly during the skin assessment, and trimmed regularly. The DON stated there is no documentation regarding the resident refusing to have his nails trimmed. The resident has diabetes mellitus and requires assistance with trimming fingernails. Review of facility policy titled Nail Care, with a revision date of 3/27/24, documented all residents will receive medically indicated nail care as required. Nails will be maintained in a clean and neat manner to support resident dignity and to avoid problems associated with rough, cracked, overly long, or broken nails. Nail care will be provided with the resident's weekly bath and/or as needed.

Based on clinical record, provider interview, and policy review, the facility failed to document a reason for declining a Gradual Dose Reduction (GDR) for 1 of 5 residents reviewed (Resident #42). The facility reported a census of 75. Findings include: The Significant Change Minimum Data Set (MDS) dated [DATE] shows a Brief Interview for Mental Status (BIMS) score of 4, which indicated a severe cognitive impairment. Active diagnoses include Huntington's Disease, anxiety disorder, and cognitive-communication deficit. The MDS documents improved behaviors since the last submitted MDS on 2/12/24. The Care Plan documented a Problem with the start date of 3/30/21 as follows; I receive an antipsychotic medication for my diagnosis of Huntington's disease with a goal of I will not require an increase in my antipsychotic mediations during my stay at this facility Interventions include attempt at dose reduction per regulatory guidelines as condition warrants, per physician/nurse practitioner (NP) order, pharmacy review monthly and as needed. Clinical record review documented a GDR recommendation on 10/5/24 with the primary care provider PCP) responding on 10/25/23. The PCP agreed to a dose reduction for Lorazepam but failed to address the request for a dose reduction for Risperidone. A second documented GDR recommendation for Risperidone noted on 4/2/24 with the primary care provider PCP) responding on 4/15/24. The PCP agreed to a dose reduction for Sertraline but failed to address the request for a dose reduction for Risperidone. An email received from the PCP on 5/30/24, provided rationale for not addressing the Risperidone. This was not documented in the clinical medical record or on the Pharmacist's Recommendation to Prescriber forms. No further documented attempt by the nursing staff identified. The policy Psychotropic Medication Monitoring, review date 3/4/24, documented As part of routine medication regimen reviews, the consultant pharmacist will review all psychotropic medications for appropriate indications of use, monitoring for efficacy, potential adverse effects and potential for dose reduction. The policy Medication Review Management, reviewed on 3/4/24, outlines the produce for regulatory compliance: 1. For documentation of non-clinical related concerns related to regulatory compliance, the consultant pharmacist may use a supplemental medication regimen review communication form to alert the director of nursing of issues requiring clarification or follow-up. 2. The attending physician will document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. These non-urgent recommendations should be reviewed and acted upon during the next scheduled physician visit (within 60 days). 3. If the attending physician has not responded to the medication regimen review within 75 days the Director of Nursing (or designee) will notify the Medical Director to respond to the pending medication regimen review reports. If the attending physician is also the medical director, the DON (or designee) will escalate the issue to the facility administrator. 4. If there is potential for serious harm and the attending physician does not concur with the recommendation, or the attending physician refuses to document an explanation for disagreement, the director of nursing and/or consultant pharmacist will contact the medical director for review. 5. If the attending physician disagrees with the consultant pharmacist and is also the medical director, the consultant pharmacist and the director of nursing will arrange a meeting with the medical director to discuss the identified irregularities. All parties must come to an agreement or a formal complaint should be initiated according to facility policy. If there is potential for serious harm to the resident, this process must be completed in a manner to ensure no actual harm occurs.

Based on clinical record review, facility policy review and staff interviews, the facility failed to ensure fall interventions planned were implemented in order to prevent accidents for two of five residents reviewed. (Resident #1 & #2) The facility census was 69 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident used mobility devices of a wheelchair and walker. The care plan dated 5/3/18, identified the resident at risk for falls and safety risk related to falls. The care plan included the following approaches/interventions: a. 5/03/18 staff to use orthostatic [MEDICAL CONDITION] precautions. b. 5/03/18 staff to place resident's personal belongings within easy reach. c. 5/03/18 staff to keep resident's room free of clutter. d. 5/03/18 staff to keep call light within reach for resident and encourage use of call light. e. 5/3/18 staff to assure the resident has proper fit and non-skid soles. f. After fall of 5/13/18 staff to place Dycem in resident's wheelchair. g. After fall of 5/16/18 staff to ensure resident is wearing gripper socks at bedtime. h. After fall of 7/17/18 staff to have physician do a medication review. i. After fall of 7/21/18 staff obtained x-ray's and resident sent to the hospital. An Event Report form dated 5/13/18 at 3:10 p.m., indicated the resident was found on the floor in front of the wheel chair when attempting to get up and slid out of the wheel chair. No sign or symptoms of injury. Fall was not witnessed. An Event Report form dated 5/16/18 at 12:30 a.m., indicated the resident was found sitting on the floor next to the bed and was incontinent of stool. No apparent injury observed. Fall was not witnessed. Resident noted to have socks on and last time resident toileted at 10:30 p.m. Initial interventions to prevent another fall: gripper socks placed on resident. An Event Report form dated 5/23/18 at 5:40 a.m., indicated the resident was found lying on the floor in her room, fall was unwitnessed. Progress Notes dated 5/23/18 at 5:44 a.m., indicated the nurse overheard falling sound in resident's room, went immediately and found the resident lying on right lateral side on the floor with bleeding on the forehead. Nurse applied pressure using gauze and notify nursing staff for assistance. The physician was notified and ordered the resident to be transported to the emergency room for evaluation and treatment. At 2:35 p.m., facility received call from the emergency room reporting the resident would be transported back to the facility with stitches to the forehead and antibiotics [MEDICATION NAME]. Initial interventions to prevent another fall: will consult physician regarding [MEDICAL CONDITION] in bilateral feet. An Event Report form dated 6/1/2018 at 8:58 p.m., indicated the resident was sitting on the edge of her wheel chair and slid out and fell to the floor in the dining room, fall was witnessed by staff. No injury noted. Initial interventions to prevent another fall: Dycem applied to the seat of resident's wheel chair and would have therapy for proper wheel chair. An Event Report form dated 7/17/18 at 11:00 a.m., indicated the resident was in the activity area and attempted to stand up and reach for an object when she fell to the floor, hitting her head on the table, fall was witnessed. Progress Note dated 7/17/18 at 9:55 a.m., indicated bleeding noted from the residents forehead where bruise noted from previous fall, band aide applied, assessment completed and physician notified. Initial intervention to prevent another fall: would have resident's physician do a medication review. Contributing factors to help identify root cause of fall: staff reported to nurse of resident attempting to get up on own more frequently and being agitated towards staff and spouse. An Event Report form dated 7/21/18 at 2:00 p.m., indicated the resident was found on the floor in the common area, unwitnessed fall, resident at that time was all alone and unattended. No injury noted after fall. Resident had lunch and assisted with toileting after lunch and placed in the common area watching television What appears to be root cause of fall? Resident displaying increased fidgety behavior. Initial interventions to prevent another fall: x-ray obtained and sent to the hospital due to x-ray results. Progress Note dated 7/21/18 at 3:15 p.m., on call physician notified and received new order for x-ray. At 10:56 p.m., received order from physician to send emergency room . At 11:18 p.m., resident transferred to emergency room . A History of Physical dated 7/22/18, indicated assessment and plan for the resident included [DIAGNOSES REDACTED]. Orthopaedic Progress Note dated 7/23/18, indicated the resident was not cleared for surgery and may never be a surgical candidate. Plan was for palliative care consult. Progress Note dated 7/24/18, indicated the resident was readmitted to the facility with Hospice care. The resident had a fracture that will not be surgically corrected. During interview on 8/7/18 at 9:35 a.m., Staff A, Certified Nurse Aide, CNA stated she worked 7 a.m. to 7 p.m. and was assigned to care for the resident. Staff A stated the night shift reported the resident was anxious most of the night and required 1 to 1 supervision to keep her from falling. Staff A indicated the resident was anxious and attempting several times to get up on her own throughout the day. Staff A reported the resident had been more anxious and attempting to get up on her own over the last couple weeks. Staff A stated she toileted the resident before lunch and around 2 p.m., took the resident to the common area and placed her at the table with another resident and they were watching television. Staff A stated the other CNA was on break at that time and Staff B, licensed practical nurse, LPN, was at the nurses station. Staff A indicated Staff B was aware the resident was sitting in the common area but did not recall if she said anything to her. Staff A stated the resident usually does better if she was sitting with other residents or staff in common area, less anxious. Staff A stated another resident needed assist to go to the bathroom right away and she left the common area and to assist resident. Staff A stated she was gone 3 to 4 minutes when she heard Staff B yell out and Staff A responded and observed the resident on the floor in the common area about 2 feet away from her wheelchair. Staff A indicated after Staff B assessed the resident they assisted the resident up to her wheelchair. Staff A stated it was obvious the resident had pain as she was not bearing weight very well. Staff A stated she felt it would have been helpful if the resident was on one to one supervision. During interview on 8/16/17 at 8:37 a.m., Staff B, Licensed Practical Nurse, LPN indicated she worked 7 a.m. to 3 p.m., on 7/21/18 and was assigned to care for the resident. Staff B stated the resident was on one to one supervision most of the day and they kept the resident in sight. Staff B stated they try to have 3 CNA's and one nurse in the memory unit but were short and they pulled one of the CNA's to another area of the facility to work. Staff B stated she called her nurse manager and asked for additional staff due to resident's behaviors that day but was told they had no other staff to send to memory unit. Staff B indicated with only 3 staff members in memory unit it was hard to monitor the residents. Staff B stated around 2:00 p.m., the resident was sitting in the wheel chair in the common area, one CNA was on break, Staff A was assisting another resident and Staff B was at the nurses station. Staff B stated you cannot see the common area at the nurses station. Staff B stated she heard a resident yell out from the common area and immediately responded and found the resident lying on the floor of the common area. Staff B indicated she assessed the resident and initially did not note any injury, but after toileting the resident she noted the resident was having difficulty walking. Staff B stated she called the physician and received new orders for x-rays. During interview on 8/22/18 at 9:38 a.m., Staff E, Registered Nurse, RN stated on 7/21/18 she pulled a CNA from the memory unit to cover another area of the facility due to a call in and it did leave the memory unit short staffed. 2. The MDS assessment dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED]. assistance of two staff for transfers. Ambulation did not occur during the assessment period. The MDS documented the resident used mobility devices of a wheelchair and walker. The care plan dated 10/10/16, identified the resident had injuries related to falls, non-compliant at times with waiting for staff assistance and will transfer self. Approaches/interventions included: a. Staff to keep call light in reach at all times and personal items close within reach, and keep room free of clutter. b. Staff to educate me to use call light for staff assistance when need to go to bathroom; verbalize understanding. c. Staff to encourage me to use call light or bell for staff to pick up items on the floor. d. Staff to check bed to ensure appropriate height. e. Staff to assist with cares in am. f. Staff to assess footwear to ensure that they are appropriate. g. Staff to ensure resident is wearing gripper socks at bedtime. h. Staff to ask resident when she prefers to get up in the morning and educate staff to get up when she wants to. i. After fall of 6/21/18 staff to transfer resident to shower and resident to have non-skid socks on, do not place a towel under feet. j. Staff to transfer resident with Hoyer lift and assist of two staff members until seen by physician. A Physical Therapy Note dated 3/7/18, indicated the resident was assessed to be at prior level of function consistent. Resident was safe to perform transfers with assistance of one. Resident can ambulate short distances with four wheeled walker and with assistance of one. Recommending wheelchair for other mobility, no physical therapy treatment not indicated at this time. An Event Report form dated 6/21/18 at 2:45 p.m., indicated the resident was found on the floor of the shower stall sitting on their buttocks with legs extended out and feet up against the shower stall wall and back resting on shower seat with towel on it which also slid down behind the resident preventing her back from getting scraped by the shower seat. A certified nurse aide, CNA was in the shower room with the resident and reported the resident's feet slid slowly out from underneath her, but the resident did not hit her head. Resident had been standing on a towel bare footed getting ready for a shower. Root cause of this fall: footwear. Initial intervention to prevent another fall: not to use towel underneath feet during shower, transfer resident with shoes on then take shoes off when resident is sitting on shower chair. Progress Notes dated 6/21/18 at 2:45 p.m., indicated the resident was found on the floor in the shower stall in the room, CNA assisting the resident to take a shower, had towel underneath the resident's feet and feet started to slide out from underneath her, floor dry had not started shower, feet were up against the shower wall, did not hit head per CNA, resident denies dizziness/lightheadedness, resident assessed and head to toe assessment completed. Assist of 4 staff and gait belt to stand resident up on her feet, staff put tennis shoes on resident before standing resident, able to bear full weight with no problem, then assisted resident to wheel chair as resident no longer wanted to take a shower, assisted resident to dress. At 3:10 p.m., resident's family and physician notified. At 3:50 p.m., resident complained of pain to right ankle, slight swelling noted to area and slightly tender upon touch, Tylenol given as ordered for discomfort. At 4:05 p.m., new order received for x-ray of right ankle. Review of x-ray results dated 6/21/18, indicated the resident with an acute oblique distal fibula metadiaphysis fracture with one third shaft width lateral displacement the distal fibula. Progress Notes dated 6/21/18 at 9:10 p.m., indicated staff notified on call physician of the residents x-ray results and orders received to keep resident non-weight bearing and to call resident's physician in am to collaborate with orthopedics treatment plan. Progress Notes dated 6/22/18 at 4:59 p.m., indicated the resident returned from orthopedic appointment. Resident to be non-weight bearing of right leg, cast in place to right lower leg, return for follow-up in 3 weeks. During interview on 8/16/18 at 11:07 a.m., Staff C, Certified Nurse Aide, CNA stated on 6/21/18 around 2:00 to 3:00 p.m., she was assisting the resident to take a shower. Staff C stated she took the resident to the shower room and resident always requested a towel to be placed on the floor for her to stand on. Staff C stated she placed the towel on the dry floor and assisted the resident to stand, using a gait belt and resident holding on to the safety rail in the shower, removed her clothing, when the resident started to slip on the towel. Staff C stated she lowered the resident to the floor and called the nurse for help. Staff C stated the nurse responded immediately and assessed resident and we assisted resident up and into wheel chair. Staff C stated the resident complained of a little pain, assisted resident to dress as she did not want to take shower. During interview on 8/16 & 8/22/18, Staff D, Registered Nurse, RN stated she was assigned to the resident on 6/21/18. Staff D stated she was summoned and found resident sitting on the shower floor with her back against the built in shower bench and feet out in front of her with feet up against the shower wall. Staff D stated the resident had no clothes on, no shoes on and no gait belt on. Staff D indicated the floor was dry as the shower was not started. Staff D indicated Staff C should have had shoes on resident and a gait belt before transfer. Staff D stated they had to apply a gait belt to the resident to assist her up off the floor with assistance of 4 staff member. Staff D stated she assessed the resident prior to assisting her up off the floor and noted no injury initially until shortly after she complained of right ankle pain, tender to touch, and some swelling noted. Staff D reported she called physician and received order for x-rays. During interview on 8/22/18 at 9:38 a.m., Staff E, RN stated when staff transfer a resident that was an assist of one to two staff they are to always use a gait belt, even to transfer in shower. During interview on 8/22/18 at 9:51 a.m., Staff F, CNA stated she has given showers to the resident before and she always requested to have a towel placed on the floor for her to stand and transfer on and she would do this for the resident. Staff F stated the resident would refuse to wear her shoes to the shower room. Review of the facility's Transfer assist using transfer belt dated 8/14/18 indicated transfer belts will be used for all residents who require physical support for mobility or safety in transfers.

Based on observation, clinical record review, facility policy review and staff and physician interviews, the facility failed to provide the necessary care to maintain the highest physical well being for one of four residents reviewed and on two separate incidents. (Resident #1) The facility reported a census of 66. Findings include: A Minimum Data Set (MDS) assessment form dated 11/16/16, indicated Resident #1 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, had fluctuating inattention and disorganized thinking, required limited assistance of staff for transfers, ambulation in the room and corridor, locomotion on and off the unit, dressing and toilet use, with one fall without injury and no skin issues. A Care Plan with the last care conference dated 10/26/16, indicated the resident had [MEDICAL CONDITION] to his/her bilateral lower extremities, at a mild risk for skin breakdown due to limited mobility, occasional incontinence and a [DIAGNOSES REDACTED]. The approaches included the following: a. Encourage to elevate his/her legs when sitting in the recliner. (created 10/26/16) b. Remind him/her to wear ted hose as he/she failed to wear them at times per physician's orders [REDACTED]. c. Assist him/her with putting on the ted hose and removing them at night. (created 10/26/16) d. Inspect his/her skin every day during cares and perform systemic weekly skin inspection and skin checks with baths. (edited 5/9/16) e. He/she required assistance of 1 staff with supervision for all mobility and transfers. (edited 1/9/17) f. He she required assistance with activities of daily living (ADL'S), toileting, dressing and bathing. (edited 1/9/17) g. Ambulate partway to and from meals as tolerated wit a 4 wheeled walker and staff having pushed the wheel chair behind the him/her. (created 11/28/16) h. Recommend staff assistance with all transfers and mobility. (created 11/28/16) An Event Report dated 12/3/16 at 9:30 a.m., indicated no actual fall occurred, the resident stated he/she got his/her arm stuck in the grab bar when he/she tried to get off of the toilet which made him/her loose his/her balance so he/she leaned against the wall, put on the call light and waited until help arrived. No injury had been noted at that time. The resident stated he/she originally got up unassisted and took himself/herself to the bathroom. The Event Report Notes and the Resident Progress Notes dated 12/2/16 failed to address the above stated event and/or any assessment or intervention. The Event Report Notes dated 12/3/16 at 9:22 a.m., documented the following: The nurse had been told earlier that morning by a Certified Nursing Assistant (CNA) the resident had not wanted to go to breakfast and wanted a room tray due to not feeling well. The nurse asked the CNA what had been wrong and he stated the resident's arm hurt. The nurse thought to herself the resident had slept on his/her arm wrong. At the time stated above the nurse had been called to the resident's room due the CNA stated the resident told him he/she had fallen the night previous and his/her right wrist had been swollen. The resident called his/her family and the nurse had been suppose to return their call. After the assessment the nurse found the resident's right wrist [MEDICAL CONDITION], slightly deformed, with a pain level of 10 out of 10 but the vital signs and neurological checks had been within normal limits (WNL). The physician had been called with an order received to send the resident to the emergency room (ER) via the ambulance service. During an interview 1/14/17 at 8:13 p.m., Staff E, CNA confirmed she answered the resident's bathroom call light on 12/2/16 and found him/her standing beside the toilet, leaned up against the wall but she could not recall where the resident's hands had been positioned but said they had not been caught in the rails beside the toilet. The staff member then called for the assistance of Staff B. The resident told the staff member he/she had fallen earlier and was upset because he/she fell all of the time. The staff member looked at the resident's hand and noted it had been swollen with no deformity. The staff member confirmed she heard Staff B inform Staff D, Licensed Practical Nurse (LPN) about the resident's hand sometime after supper and before midnight. During an interview 11/12/17 at 9:33 a.m., Staff B, CNA confirmed on 12/2/16 he answered the resident's bathroom call light and observed another CNA as she assisted the resident off of the toilet when the resident became unsteady and leaned back against the wall and placed his/her right wrist on the upper bar beside the toilet to steady himself/herself. Staff B then assisted the resident to bed with the use of a walker. The staff member indicated although the resident placed his/her hand on the walker he/she failed to bare weight on the wrist however he had not noticed any deformity to the area. The staff member indicated he reported the entire situation to Staff D who had not been present during the incident. During an interview 1/11/17 at 3:31 p.m., Staff D indicated around 8:30 p.m. as she had been doing rounds she observed Staff B and another CNA with the resident who had been standing up against the wall in the bathroom with his/her hand on a rail with no noted deformity. Staff D asked the staff members if the resident had fallen and they said no so no assessment had been completed. During an interview 1/12/17 at 1:15 p.m., Staff D first stated Staff B failed to report any issues to her and that she had been standing right there during the incident. Then the staff member stated she could not remember if he told her anything. The staff member then stated she could not say one way or another if Staff B reported anything to her or not. During an interview 1/10/16 at 4:56 p.m., Staff F, LPN confirmed during report on 12/3/16 nothing had been reported to her about the resident's injury. Around 7:45 a.m. to 8:15 a.m. she asked Staff G, environmental aide where the resident had been and he stated the resident refused to eat in the dining room because he/she had not felt well. Staff F continued to assist the residents in the dining area when Staff H, CNA told her the resident's family member wanted her to call him/her. Staff F entered the resident's room, looked at the resident's right wrist and noted an obvious broken bone as the wrist had been deformed and [MEDICAL CONDITION]. The staff member asked the resident what happened and the resident stated he/she had fallen the night before. Staff F called the resident's family and physician and sent the resident to the ER via the local ambulance service. During an interview 1/13/17 at 9:35 a.m. Staff F indicated Staff G told her the resident refused to eat in the dining area on 12/3/16 because his/her arm hurt but he did not act like the situation had been emergent so she just thought the resident slept on his/her arm incorrectly. A written statement provided by Staff G (not dated) documented the following: I walked in to see if the resident wanted to get up for breakfast. He/she said no because he/she did not feel good and that his/her arm hurt so he went and told Staff F about it. He then went back in to check on the resident after she received his/her room tray and Staff H had been in the bathroom. Both of the staff members agreed the resident's arm looked swollen so they told Staff F who went to the resident's room. A written statement provided by Staff H dated 12/3/16 documented the following: I had been informed by Staff G the resident refused to get up for breakfast because his/he arm hurt so she informed the dining room to get the resident a room tray for breakfast. Staff H entered the resident's room after breakfast, turned on his he light, went into the room and the resident stated right away that he/she needed to go to the hospital and to call her family. The staff member asked why and the resident showed the staff member his/her arm and told the staff member he/she had fallen the night before after shift change. The staff member called the resident's family who then requested to speak the nurse. Staff G informed Staff F who followed through accordingly. During an interview 1/13/17 at 6:55 p.m., Staff I, Certified Medication Aide (CMA) confirmed she administered the resident's 8 p.m. medications on 12/2/16 while he/she had been positioned in the recliner and he/she had no complaints. At 6 a.m. on 12/3/16 she entered the resident's room to administer his/her morning medication, raised the head of the bed (HOB) and noticed the resident's arm/wrist as swollen and reddish. She asked Staff B if he thought the area had been swollen and he agreed it had been. The staff member had no further follow through. During an interview 1/12/17 at 12 p.m., the Director of Nursing (DON) confirmed she would have expected the nurses to properly assess and document the resident's complaint of arm discomfort. An Event Report dated 12/23/16 at 8:30 p.m., indicated the resident had a large round shaped blister on the inner aspect of his/her left foot. The resident wore ted hose which at times wrinkled at the foot and heel area which could have possibly contributed to the blister. The Event Report Notes read as follows: a. 12/23/16 at 8:30 p.m. - The left inner aspect of the heal with a large fluid filled blister approximately 4 centimeters (cm) wide x (by) 3.5 cm long and round. The resident stated he/she had pain when bore weight on that foot. b. 12/30/16 at 2:47 p.m. - The blister on the left heel remained intact. The area measured 3.5 cm x 3.0 cm filled with clear fluid, no drainage redness, swelling or warmth around the area and the resident had no complaints of pain. c. 1/2/17 at 1:49 p.m. - The blister on the left foot remained intact however it appeared to have been blood filled, tender to the touch with no redness surrounding the area however he/she had 2-3 plus [MEDICAL CONDITION] to the left leg and foot. The resident complained of increased pain to the blister area itself and requested a pain pill which had been given. The nurse failed to inform the physician and/or family related to the change of condition. d. 1/4/17 at 8:53 a.m. - New orders received from the Nurse Practitioner (NP) to discontinue the cling to the left heel and to wear a protective boot on the heel until another specialized boot arrived at the facility. An observation 1/11/17 at 5:02 p.m., revealed the resident wearing a ted hose stocking on his/her right foot/leg with the hole to the outer aspect of the foot which exposed 3 toes and wrinkled around the ankle area. (the hole belonged on the bottom of the foot) During an interview 1/10/17 at 1:55 p.m., a Physician indicated he/she could not say one way or another if the resident's blistered area had been unavoidable. The Physician indicated the area could have been caused from the resident's ted hose but he/she did not know.

Based on record review and staff interviews, the facility failed to ensure one of four residents received the assistance for safe transfers in accordance with Resident #1's care plan and had been free from possible abuse. Record review and staff interviews revealed Resident #1 required 2 staff and a mechanical lift (Hoyer) for safe transfers. Resident #1 sustained a fracture to his/her left shoulder after being transferred to his/her bed by one staff. The facility reported a census of 52 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 recorded the resident usually understood others and could usually make self-understood. The MDS identified a Brief Interview for Mental Status (BIMS) score of 6 indicative of severe cognitive impairment. The assessment documented the presence of delusions and revealed the resident totally dependent on 2 persons for bed mobility and transfers. The MDS documented [DIAGNOSES REDACTED]. The care plan start date of 4/30/15 identified Resident #1 required the use of a Hoyer Lift for all transfers with 2 staff at all times. The Progress Notes dated 7/7/16 at 4:01 p.m. documented the resident reported complaints of pain to his/her left shoulder for the first time that shift. The note recorded an assessment of the resident revealed a lack of ROM (range of motion), more severe complaints of pain with movements, and order obtained for portable x-ray of the left shoulder. The Patient Report for the Left Shoulder x-ray procedure signed on 7/7/16 at 5:59 p.m. documented findings of an acute non-displaced fracture. The Progress Notes dated 7/7/16 at 7:03 p.m. documented the x-ray results showed an acute non-displaced [MEDICAL CONDITION] shoulder with orders received not to send to the hospital. The (Doctor of Nursing Practice) DNP progress note dated 7/8/16 documented the DNP saw the resident to address acute pain status/post (after) a left great trochanter fracture (left shoulder). The note recorded the resident reportedly suffered trauma to his/her left shoulder during transfer on 7/6/16. The note documented the resident reported his/her left shoulder started hurting the next day. The Progress Notes dated 7/8/16 at 10:05 a.m. documented new orders received from the DNP for sling, ice, and DNP to re-assess the next Friday. The Event Report recorded on 7/12/16 at 2:10 p.m. documented an event occurred on 7/7/16 at 5:00 p.m. with the resident experiencing a major injury. The report summarized the resident informed the nurse on 7/7/16 at 5 p.m. that his/her left shoulder hurt and on 7/6/16 a CNA (certified nurse aide), put him/her to bed without the Hoyer (mechanical, full body lift). The report documented an investigation initiated to determine the details of the allegation by the resident. The report recorded the Administrator and the Director of Nursing (DON), notified on 7/7/16 at 5:00 p.m. The facility investigation dated 7/7/16 identified Resident #1 required the assistance of two staff members and the use of the Hoyer for transfers. Upon investigation, an agency staff was assigned to the resident on 7/6/16. The agency staff had been assigned to the resident multiple times and had always used a Hoyer for transfers as assigned. There had never been any complaint from residents or staff regarding the care the agency staff provided to staff. The agency staff (Staff B) had been assigned with Resident #1 cares on 7 am to 7 p.m. The resident was in bed when the 7 p.m. staff arrived on 7/6/16. The nurse (Staff C) completed a treatment to the resident before he/she fell asleep (on7/6/16), rolling Resident #1 to his/her sides and he/she did not complain of pain. The next shift (7/7/16) the resident was out to breakfast, and then later lunch, received Range Of Motion exercise by the restorative aide to his/her upper extremities and did not complain of pain. The report documented it was not until 5 p.m., that same day when the resident complain of pain to his/her left shoulder. Statements were received from all males of color that worked 7:00 p.m. or 7:00 a.m. on 7/6/16 and no (one) assisted Staff B with cares. Statements were received from other staff and no one put Resident #1 to bed. The facility investigation documented Resident #1 did not complain of pain until 7/7/16 at 5 p.m., 23 hours after the resident reported two males put him/her to bed without the machine (mechanical lift/Hoyer). The facility investigation revealed the agency staff (Staff B) had been the staff assigned to Resident #7 and would have been the only one who put Resident #7 to bed on 7/6/16. The facility investigation revealed the resident's care plan had not been followed by an agency staff. The facility investigation revealed when the resident received cares normally he/she yells out and no one heard Resident #1 yelling during any cares on 7/6/16 or 7/7/16. In an interview on 7/26/16 at 3:12 p.m., Staff A, certified medication aide (CMA), stated Resident #1 complained to her in the past of someone being rough. Staff A said the resident reported his/her shoulder hurt and 2 big men picked him/her up and put into bed without the use of the Hoyer. Staff A commented she thought she told the charge nurse a little after 7:00 a.m. the day the resident got an x-ray. In an interview with Staff B on 7/27/16 at 1:32 p.m., the agency staff reported the resident does call out when staff transfer him/her. Staff B reported Resident # 1 required a Hoyer and two staff to assist with transfers. Staff B reported he did not put Resident # 1 to bed, the day shift had put the resident to bed. Staff B reported he did not recall who went with him on rounds. Staff B reported the DON called and said 2 staff put resident to bed and asked if he remembered (doing so)? Staff B reported Resident #1 is heavy and it's not possible for 1 person to lift him/her. Staff B reported why he would put Resident #1 to bed around 4 or 5 p.m., when he already had plenty of work to do. During an interview on 7/27/16 at 7:30 p.m. Staff D, certified nurse aide (CNA) reported worked 7 p.m. shift and Resident #1 was already in bed when he came into work on 7/6/16. Staff D reported the nurse (Staff C) wanted him to relieve an aide and put a resident to bed but told the nurse he still had work to do with his group. Staff C told Staff D he had to do this first and followed him and said never turn your back on her. Staff D reported he went into another resident's room to assist and Staff C pounded on that resident's door. Staff D reported no other concerns with staff's behavior. Staff D reported there are times when staff trade the group they are assigned to work with. Staff D reported there have been times when staff are not available to help assist. During an interview with Staff C, Register Nurse on 7/27/16 at 6:54 p.m. she reported she had worked as the nurse on the blue group that night and had worked at the facility for a couple of months. Staff C reported one person alone could not pick up Resident #1, that he/she ' s dead weight. Staff C reported nothing memorable occurred that night and the resident did not have any reports of pain that night. In an interview on 7/26/16 at 3:40 p.m., Staff E, certified nurse aide (CNA) reported Resident #1 usually get'up easily and did not like to go to bed. Staff E reported Resident #1 had reported someone had been rough with him/her in the past (prior to this incident). During an interview with Staff F, Registered Nurse on 7/27/16 at 7:10 a.m. the staff reported they had not worked with Resident #1 in the past, and had not transferred him/her before. Staff F reported no knowledge of abuse. Staff F reported staff there's not enough staff and they need more help. Staff F reported working weekends and there's only three aides for the whole building and worst time was between 5:30 p.m. to 8 p.m., and describe it as turmoil.

Based on observation, record review and staff interviews, the facility failed to adequately supervise a resident and ensure that the environment remained free of hazards and the facility failed to direct the nursing care so the resident ' s needs are met with the use of assistive devices for 6 of 9 residents reviewed for supervision concerns. Resident # 6 removed his/her alarm and fell sustaining a pelvic fracture. Prior to the fall staff knew the resident removed alarms and did not alter interventions until after the fall. Resident #13 fell on [DATE]. The intervention following the fall was to obtain a physical therapy screen. Staff failed to obtain the screen and the resident fell again on [DATE] sustaining a pneumothorax injury. The resident was transported to the hospital and then the hospice house where the resident expired. Resident #4's care plan directed staff to use a floor mat at the bedside. Observation revealed no floor mat in place. Resident #3 sustained a laceration to the leg which required emergency room treatment following staff rapidly "swooping" the resident to the bedside via an EZ stand. An event form identified staff moved the resident too fast. Following the injury the care plan directed the resident to use gerilegs for covering of the legs. Observation revealed no gerilegs in place. A care plan and physical therapy directive directed staff to transfer Resident #11 with a slide board. Staff failed to use a slide board and the resident sustained [REDACTED]. Facility policy directed staff to transfer Resident #16 with a gaitbelt. The resident's care plan failed to direct staff to use a gait belt with transfers. Staff failed to transfer Resident #16 with a gait belt. The resident became unable to stand during a transfer and was lowered to the floor. The resident complained of right leg and hip pain and was transferred to the emergency room . The resident sustained [REDACTED]. The facility reported a census of 66 residents. Findings include: 1. A Minimum Data Set (MDS) assessment date of [DATE] identified Resident #6 with a brief interview for mental status score of "8" (moderate cognitive impairment). The resident entered the facility on [DATE]. The MDS documented the following signs and symptoms of delirium: inattention, disorganized thinking and psychomotor retardation. The MDS identified an acute change in mental status. The MDS documented the resident required extensive assistance of one staff with bed mobility, transfers, ambulation, dressing, toileting, personal hygiene and bathing. A "balance during transitions and walking" test identified the resident as not steady and only able to stabilize with human assistance when moving from seated standing position and with surface to surface transfers (transfer between bed and chair or wheelchair). The resident had functional limitations on both lower extremities. The resident had [DIAGNOSES REDACTED]. The MDS documented the resident had a history of [REDACTED]. An event report dated [DATE] at 4:15 a.m., identified staff found the resident on the floor following an fall not witnessed. The resident utilized an alarm but it did not sound. A major injury determination form dated [DATE] at 2:40 a.m. identified the resident with a minimally displaced fracture through the mid to distal portion of the left inferior pubic ramus. The report indicated the resident removed the bed alarm and the resident crawled out of bed. Staff heard the resident yell "help" and found the resident on the floor near the bathroom. The facility listed the resident's previous functional ability as ambulate/transfer with assist of one and gait belt. The Physician Assistant reviewed the circumstances, injury and prognosis of the resident and concluded the injury was not a major injury. An emergency treatment, dated [DATE] at 3:36 p.m. indicated the resident fell with a resulting pubic rami (pelvis) fracture. The hospital discharged the resident back to the facility with instructions for the primary physician to address pain control. The Progress Notes dated [DATE] at 2:13 p.m., documented the Physician Assistant saw the resident. A Progress Note, dated [DATE], identified the resident with a pelvic fracture and acute pain. A narrative, dated [DATE] and written by the charge nurse on duty when the incident occurred (Staff G) stated the alarm did not sound when the resident fell . Observation revealed the alarm as disconnected. Staff G asked the 2 CNAs (Certified Nursing Assistants) why the alarm was not connected. Staff F stated she observed the alarm connected at 4 a.m. Staff E stated the resident can reach over the bed and disconnect the alarm and staff observed this in the past. A care plan dated [DATE] identified the resident with a history of falls related to mobility/balance. The care plan identified the resident used alarms at all times, bed in low position and floor mat in place. The care plan did not contain an intervention to keep the alarm out of the resident's reach until [DATE] (after the incident). Staff Interviews: On [DATE] at 7:45 p.m. E (nurse aide) stated the night the resident fell , he/she tried multiple times to get up from bed so staff toileted the resident. Staff toileted the resident about 30 minutes prior to the fall. Staff E stated they caught the resident unplugging the alarm and trying to get up on occasions prior to the incident. The resident did not like the noise of the alarm so the resident would unplug it. On 1/ ,[DATE] at 7:30 p.m., Staff F (nurse aide) stated they toileted the resident 15 minutes prior to the fall. Upon entering the room following the incident, observation showed the bed in thigh high position and the alarm unplugged. The floor mat in place. Staff F stated she witnessed the resident unplug the alarm previous to the incident. On [DATE] at 7:05 p.m., Staff G (Registered Nurse) stated the night of the incident, the resident unhooked the alarm, crawled out of bed and attempted to self ambulate to the rest room. Staff G stated when the incident occurred, the bed was in thigh high position. Staff G stated she observed the resident unplug the alarm on previous shifts of work. Observation: Observation, on [DATE] at 1:30 p.m., revealed the resident in bed with the floor mat by the bed and the bed in low position. Observation revealed the alarm at the foot of the bed out of the resident's reach. 2. An MDS assessment with a reference date of [DATE] identified Resident #13 with a brief interview for mental status score of "4" (severe cognitive impairment). The MDS identified the resident as independent with transfers and ambulation. The resident used a walker. A balance during transitions and walking test identified the resident as not steady but able to stabilize without human assistance when moving from seated to standing position, walking (when assistive device used), turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. The resident had one fall since the prior assessment. The Resident Progress Notes dated [DATE] at 8 a.m. indicated staff found Resident #13 sitting on the floor of the memory care dining room. The Resident Progress Notes dated [DATE] stated staff would have a physical therapy (PT) screen performed due to a fall. The record lacked evidence the resident received the PT screen. The Resident Progress Notes dated [DATE] at 3:23 p.m. stated staff heard the resident call out, looked in room and found resident laying on the floor on back. The resident stated he/she felt "fine" and then laid down. On the same date at 4:33 p.m. the resident hollered in pain pointing to sternum and ribs. The resident complained of pain on the right upper rib area, and midline. The facility received an order for [REDACTED]. On the same date at 6:14 p.m. x-ray arrived and took x-rays. At 7:47 p.m. x-ray called and informed the facility the resident had a right pneumothorax. At 8:16 p.m., the resident was transported to the hospital . On [DATE] at 12:45 p.m., the resident's family picked up the resident ' s belongings and identified the resident as at the Taylor House. On [DATE] at 2:50 p.m. the ADON (Assistant Director of Nursing) stated the issue of the resident needing a PT screen was discussed at a meeting on [DATE] but she could find no evidence it was performed. The ADON stated she would keep looking. On [DATE] at 11:30 a.m., the Director of Nursing identified the facility could not find a PT screen had been performed. 3. An MDS assessment with a reference date of [DATE] reflected Resident #4 had a BIMS (Brief Interview For Mental Status) score of 10 (moderate cognitive impairment). The MDS identified the resident to require extensive assistance of one staff with bed mobility and transfers. The resident was nonambulatory. The resident utilized a wheelchair for mobility. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident with falls since the previous assessment. A care plan dated [DATE] identified Resident #4 with a history of falls related to confusion, weakness and an unsteady gait. The care plan directed staff to provide a floor mat next to the resident's bed when the resident is in bed. On [DATE] at 4:55 a.m., observation revealed the resident in bed with no floor mat in place. 4. An MDS with a date of reference of [DATE] identified a BIMS of 7 (severe cognitive impairment). The MDS documented the resident required extensive assistance with transfers and was nonambulatory. A facsimile to the physician dated [DATE] at 1 a.m. indicated staff transferred the resident with the EZ stand on [DATE] at 4:15 p.m. The facility is not sure how but the resident received a laceration to the left leg which bled quite a bit. The facility transferred the resident to the emergency room and 8 sutures was required to close the laceration. An event report concerning the incident, dated [DATE] at 7:36 p.m. stated Staff X transferred the resident from the wheelchair to the bed with the EZ stand moving too fast and the resident hit the leg on the side of the bed. The resident complained of pain with the use of the EZ stand and pulled his/her feet up. The report indicated the resident did not like to use the EZ stand. The Resident Progress Notes dated [DATE] at 8:58 p.m. indicated the staff would use a Hoyer lift from now on and the resident would wear geri legs. A weekly skin assessment form dated [DATE] measured the laceration as 7 centimeters (cm.) long, 1.5 cm. wide and closed with sutures. The most recent measurement on [DATE] measured the length of the laceration as 2 cm. and width 0.5 cm. superficial and improving. On [DATE] at 2:45 p.m., Staff X (Certified Nursing Assistant) stated the resident started to sit down during the EZ stand transfer so Staff X "swooped" the resident around to the side of the bed. The resident laid down for 2 hours and when Staff X returned to get the resident up from bed she observed blood on the blanket. Staff X stated she did not notice anything sharp to cause the laceration. A physician encounter form dated [DATE] at 3:05 p.m. stated the resident sustained [REDACTED]. The injury resulted from sharp laceration. Observation revealed on [DATE] at 2:20 p.m., the resident in bed and covered with a sheet. The resident complained of feeling cold. Observation revealed no gerilegs in place on the resident and the legs bare. On [DATE] at 2:50 p.m. Staff A (Assistant Director of Nursing) stated the resident just received a shower and the bath aide identified no gerilegs on prior to the shower. Staff A then questioned Staff B, the resident's nurse aide for the day; Staff B could not recall if the geri legs were on that shift. 5 . An MDS with an assessment reference date of [DATE], identified Resident #11 with a BIMS score of "13" (cognitively intact) The resident had "delusions" identified as occurring in the previous 2 weeks. The resident required extensive assistance of one staff with bed mobility, transfers and toileting. The resident was nonambulatory. The resident utilized a wheelchair for mobility. The resident had [DIAGNOSES REDACTED]. The Resident Progress Notes dated [DATE] at 2:02 p.m. identified the resident with a large bruise over the left knee cap. The bruise covered the entire knee cap and extended past the knee cap. Observation revealed swelling to the femur. Staff notified the physician who ordered an x-ray. The portable x-ray results dated [DATE] did not identify acute injury. A skin injury events/ injury of unknown origin form did not identify a cause of the bruising. The Resident Progress Notes dated [DATE] at 2:22 p.m. identified the resident obtained a skin tear to the right lower extremity during a transfer into bed. Progress notes dated [DATE] at 1:31 a.m. identified continuous oozing of serous drainage from the right lower extremity skin tear site. On the same date at 12:47 p.m., progress notes documented that staff is having more difficulty transferring the resident with the slide board. Staff will now use a Hoyer and 2 staff for transfers. A skin integrity/skin injury report dated [DATE] at 1:59 p.m. and documented by Staff M (Registered Nurse) stated the resident received a 5 centimeter (cm.) by 1 cm. by 0.3 cm. skin tear to the right lateral lower extremity while transferring into bed. A physical therapy (PT) documentation sheet dated [DATE] indicated PT recommended staff use a slide board for transfers. The CNA assignment sheet #1 directed staff to use a slide board when transferring the resident. A care plan dated [DATE] contained an addendum dated [DATE] for staff to use a Hoyer (mechanical lift) for all transfers. Staff Interviews: On [DATE] at 3:10 p.m., Staff M (Registered Nurse) stated an incident occurred while transferring Resident #11 when Staff L (nurse aide) did not follow the care assignment sheet and staff did not use the slide board. Staff M stated Staff L informed her she did not receive training on the slide board. On [DATE] at 4;25 p.m. Staff L stated she received training to use the slide board. Staff L stated she did not have the care sheet for the resident that day because Resident #11's nurse aide took a break and Staff L took over Resident #11's care during that time period. 6. The Minimum Data Set Assessment tool dated identified Resident #16 with [DIAGNOSES REDACTED]. The MDS revealed the resident demonstrated intact cognition. The MDS indicated the resident required extensive assist of one staff for surface to surface transfers and did not walk in his/her room or the hallway. The facility policy, "Gait Belts for Transfer," directed staff to utilize gait belts as provided to assist staff to safely transfer or ambulate (walk) residents who are unable to transfer without assistance. The CNA Assignment Sheet #4 dated [DATE] directed staff to transfer the resident with one staff and also directed staff not to utilize the EZ Stand (a type of mechanical lift). The form contained no information to advise staff of whether or not to use a gaitbelt with resident transfers. The Nurse's Notes dated [DATE] at 5:17 p.m. revealed the nurse documented CNA came to her and reported she attempted to transfer the resident off the toilet and the resident's knees began to buckle, so she lowered the resident to the floor. The nurse documented the resident did not complain of pain when she checked his/her range of motion, so 2 CNAs used a gaitbelt to transfer the resident from the floor back to the wheelchair. Staff then took the resident to dinner per his/her request. On [DATE] at 8:15 p.m., another nurse documented the resident sat in his/her wheelchair at the onset of the shift and complained of pain in right hip and leg. The leg presented as significantly swollen and hard. The nurse also documented she notified the physician of the resident's condition and received an order to transfer the resident to the ER for evaluation. An X-Ray dated [DATE] at 11:25 p.m. revealed the resident sustained [REDACTED]. During an interview on [DATE], Resident #16 told the surveyor he/she had surgery on his/her leg for a compound fracture with 5 breaks. When asked what happened, the resident reported a new girl helped him/her to the bathroom, told the resident to stand, could not hold on and he/she (resident) fell flat. Resident #16 said he/she did not think the staff used a gait belt with the transfer. On [DATE] at 1 PM, Staff B, CNA reported the evening of Resident #16's fall, Staff A, CNA approached her at the nurses station and requested assistance with Resident #16, because she (Staff A) lowered the resident to the floor while transferring him/her. Staff B stated she, Staff A and Staff K, LPN went to the resident's room and lifted him/her from the floor to the wheelchair using her (Staff B) gaitbelt. Staff B reported they used her gaitbelt because the resident did not have one around him/her, nor was there a gaitbelt in the room. On [DATE] at 10:37 a.m., Staff K, LPN reported on the evening of the resident's fall, Staff B told her Staff A lowered Resident #16 to the floor. The nurse went to the room with the CNAs and completed range of motion without resident complaints of pain. The LPN reported the three staff transferred the resident back to the wheelchair with Staff B's gaitbelt, because there was no gaitbelt on the resident or in the room. On [DATE] at 4:30 p.m., Staff A, CNA reported on [DATE] at about 5:00 p.m., she assisted Resident #16 from the toilet and was in the process of walking with the resident back to the resident's wheelchair. Staff A reported the resident told her he/she couldn't make it, so Staff A told the resident she would have to lower him/her to the floor. Staff A then summoned the other 2 staff to the room for assist. Staff said she did not use a gait belt to assist the resident back to his/her wheelchair because the resident refused it. On [DATE] at 11:50 a.m., Staff N, CNA reported Resident #16 transferred with assist of 1 staff and a gaitbelt. On [DATE], Staff W, CNA reported Resident #16 transferred with assist of 1 staff and a gaitbelt. On [DATE], Staff X, CNA reported Resident #16 transferred with contact guard assist of 1 staff. On [DATE] at 3:57 p.m., Staff AA, CNA reported Resident #16 transferred with stand by assist of 1 staff as he/she liked to self-transfer, but with someone there. Staff AA stated the resident tells staff what he/she needs and wants. During an interview on [DATE] at 1:30 p.m., the resident's surgeon confirmed the staff's account of the events that led to the fracture were consistent with the X-ray of the damage to the resident's leg. The physician reported the resident had very thin bones and did not walk, therefore the resident was susceptible to fractures.

Based on observation, record review and staff, resident and family interviews, the facility failed to ensure that residents receive proper respiratory treatment and care for 6 of 9 residents reviewed (Resident #9, Resident #17, Resident #12, Resident #15, Resident #1, Resident #14) Observation revealed Resident #9 did not receive oxygen at 4 liters as ordered. Resident #12 had an empty tank in use in the dining room. The tank was changed after the surveyor alerted staff. Resident #17 did not receive oxygen at 3 liters as the physician ordered or maintain oxygen levels above 92% as ordered. The resident removed his/her oxygen and the care plan did not contain interventions that addressed the issue. Staff found the resident without oxygen at 7:30 a.m. Following this the resident experienced a change of condition and admitted to the hospital with [REDACTED]. Resident #15's family identified the resident's tank as empty a few weeks ago and they notified staff to change the tank. Resident #1 removed his/her own oxygen. The care plan did not contain information that addressed this. Observation revealed the resident without oxygen. Resident #14 utilized oxygen continuously and was identified he/she ran out of oxygen at times and the facility "needs to watch it closer". The facility reported a census of 66 residents. Findings include: 1. Physician admission orders [REDACTED]. Observation revealed on [DATE] at 5:52 p.m., Resident #9 in the dining room receiving oxygen via small tank on the back of the wheelchair at 3 liters via nasal cannula. On the same date at 6:08 p.m., Staff S (Licensed Practical Nurse) adjusted the oxygen level to 4 liters after checking the resident's treatment sheet which identified the resident should receive oxygen at 4 liters. On [DATE] at 10:22 a.m., Resident #9 stated he/she had problems with oxygen delivery. The resident stated he/she went without oxygen when the small tank ran out in the past and that it ran out more than once. The facility identified the resident with a BIMS (Brief Interview For Mental Status) score of 13 (cognitively intact). 2. A care plan dated [DATE] identified Resident #12 with a problem of using oxygen at all times related to [MEDICAL CONDITION]. Observation revealed on [DATE] at 5:20 p.m., Resident # 12 in the dining room with a small oxygen tank at the back of the wheelchair. The oxygen tank showed the gauge in the middle of the red area indicating the tank was empty and/or approaching empty. At that time, the surveyor asked the resident if he/she was getting any oxygen. The resident stated, "No". The surveyor then summoned Staff Y (licensed practical nurse) to check the situation. Staff Y identified "barely" any oxygen coming through the tubing for the resident. Staff Y then took the resident from the dining room and the resident received a new tank for the wheelchair. Review of the resident's treatment record identified the resident should receive 2 to 4 liters of oxygen continuously to maintain oxygen levels above 90%. 3. Physician admission orders [REDACTED]%. On [DATE] at 9:45 a.m., a physician telephone order directed staff to administer 3 liters of oxygen. Resident progress notes dated [DATE] at 2:40 p.m. identified the resident's oxygen saturation level as 75% . A vitals report identified the following oxygen saturation levels: [DATE] at 2:15 p.m. 83% [DATE] at 8 p.m. 91% [DATE] at 2:23 p.m. 87% [DATE] at 7:59 p.m. 90% [DATE] 87% The facility failed to maintain oxygen levels above 92 % or notify the physician that the resident was not maintaining a oxygen level reading above 92%. Resident #17's treatment record did not identify the facility followed the new order for resident to receive 3 liters of oxygen instead of 2 liters. According to the treatment record, the resident continued to receive 2 liters throughout his/her stay. On [DATE] at 8:46 a.m., staff brought the resident to the nurses station. The resident appeared pale and somnolent with eyes closed and no verbal response. Nurse aide stated she found the resident with oxygen off. The resident's color improved once staff initiated oxygen. Staff laid the resident down and the resident remained very sleepy. Assessment showed lungs clear and no [MEDICAL CONDITION] present. Active bowel sounds. Speech therapy evaluated the resident and determined the resident required puree texture diet. Staff placed multiple calls to the physician assistant (PA) regarding the resident's condition change. The resident's family arrived as staff fed the resident. On [DATE] at 4 p.m. the resident transported to the hospital. Hospital records identified the resident admitted to the hospital with [REDACTED]. On [DATE] at 4:22 p.m., the cardiologist stated he could not comment on the question whether the resident was deprived of oxygen during the nursing home stay because "how do you know ?". When asked if the resident would have expired in a few hours if he/she did not transport to the hospital, the cardiologist stated it was "unknown but doubtful". When asked if the facility should have transported the resident to the hospital sooner, the physician stated "not necessarily". On [DATE] at 10:44 a.m., the PA stated the facility contacted her 4 times on [DATE]. However, they assured her the resident was stable and there were no concerns with the resident's physical examination. She stated the facility did not communicate the resident's past history of acute [MEDICAL CONDITION] infarction during any of the phone calls and if she knew of this she may have sent the resident to the emergency room sooner or had a higher suspicion of something going on with the resident. On [DATE] at 12:20 p.m., Staff P stated she informed the PA of the resident's past history of [MEDICAL CONDITION] and heart failure. She stated she did not specifically know if she informed the PA of a recent MI. On [DATE] at 12:05 p.m. Staff I stated she spoke with the PA and spoke with her about lab work. Staff Interviews: On [DATE] at 12:47 p.m., Staff C (medication aide) stated on [DATE] she observed the resident in the dining room and the resident did not have his/her oxygen on. The tank was on the back of the wheelchair and the oxygen tubing appeared twisted. Staff asked the resident why he/she did not have the oxygen on. Staff C reminded the resident to keep the oxygen on. The resident said Ok. At that time, the resident's family informed Staff C the resident has a tendency to take the oxygen off. On [DATE] Staff BB brought the resident to the nurse station and told Staff C the resident needed a new tank because the tank she had was empty. Staff C changed the tank and observation showed the resident was pale and lethargic. On [DATE] at 3:55 p.m., Staff U (nurse aide) stated when she cared for Resident #17 the resident kept taking the oxygen off. Staff U reminded the resident to keep it on. Staff U told Staff M (registered nurse). On [DATE] at 12:37 p.m., Staff HH (medication aide) stated on at least 2 occasions she entered Resident #17's room due to the resident taking the oxygen off. Staff HH reminded the resident to keep the oxygen on. On [DATE] at 10:05 a.m., Staff J (licensed practical nurse) stated she noticed the resident removing the oxygen in the hallway. Staff J explained the importance of oxygen to the resident and replaced the nasal cannula. On [DATE] at 3:10 p.m., Staff M (registered nurse) stated she observed the resident removing his/her oxygen multiple times and staff replaced it. Review of Resident #17's care plan did not identify that the resident removed oxygen or make staff aware of such. The intervention of reminding the resident to keep the oxygen on was not an effective intervention. According to the resident's admission record and physician admission orders [REDACTED]. On [DATE] at 12:05 p.m. Staff I (Director of Nursing) identified the facility could have implemented measures to keep the oxygen in place such as tape to keep in place and hourly checks to ensure the oxygen remained on. The facility did not know the resident removed oxygen per self on admission. 4. A care plan, dated [DATE] identified Resident # 15's admitted as [DATE] and with [DIAGNOSES REDACTED]. On [DATE] a facsimile to the physician indicated the physician ordered oxygen at 2 liters per nasal cannula as needed. Observation showed, on [DATE] at 9:55 a.m., the resident in bed with oxygen on per oxygen concentrator at 2 liters. At that time, the resident's daughter stated the resident uses a tank on the back of the wheelchair when out of bed. The daughter stated a few weeks ago the tank was empty so she told the nurse who replaced the tank. Observation showed, on the same date at 12:05 p.m., the resident wheeling back from the dining room in the wheelchair with a small oxygen tank at the back of the wheelchair supplying oxygen at 2 liters via nasal cannula. 5. A care plan ,dated [DATE] identified Resident #1 with a problem of requiring oxygen therapy due to a [DIAGNOSES REDACTED]. The care plan did not identify that the resident removed his/her own oxygen frequently. A physician order [REDACTED]. Observation showed, on [DATE] at 8:55 a.m., the resident in a wheelchair at the entrance of his/her bathroom without oxygen on. An oxygen concentrator ran at the bedside but the resident was not connected to it. The surveyor alerted Staff I (Director of Nursing) who was passing by the room at the time. Staff I reconnected the resident to the oxygen. Following the incident, Staff I supplied the surveyor with a written statement from Staff II (medication aide) which identified the resident leaving the dining room around 8:30 a.m. due to nausea. Staff II assisted the resident to his/her room and applying the oxygen at that time via concentrator. Staff Interviews: On [DATE] at 5 a.m., Staff DD (licensed practical nurse) stated Resident #1 removes oxygen frequently. The resident will state his/her ears hurt or nose itches. On [DATE] at 12:37 p.m., Staff HH (medication aide) stated the resident removes his/her oxygen "all the time". Staff HH stated she entered the resident's room today before lunch and the resident had the oxygen tubing around his/her neck like a necklace. 6. A care plan dated [DATE] identified Resident #14 with a problem of requiring oxygen therapy related to end stage [MEDICAL CONDITION]. The resident had a current physician order [REDACTED].'t have oxygen. They need to watch it closer". Observation showed the resident receiving oxygen at 2 liters via nasal cannula and oxygen concentrator at the time

Based on clinical record review, observation, facility policy review, staff and physician interviews, the facility failed to identify, assess, and provide timely interventions for one of five residents reviewed (Resident #11) who had an infected Stage III pressure sore when first identified. The facility reported a census of 70 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #11 had [DIAGNOSES REDACTED]. The MDS documented the resident as severely cognitively impaired, as non-ambulatory, and required extensive assistance of one staff with bed mobility, transfers, and personal hygiene. The MDS documented the resident had no pressure sores at the time of the assessment, but at risk for pressure sore development. The assessment further indicated the resident weighed only 86 pounds (lbs). A progress note dated 9/23/11 indicated the resident now weighted 80 lbs, down from 102 lbs in March 2011. The care plan dated initially dated 3/23/11, and last edited on 8/30/11 identified the resident as at risk for skin breakdown related to limited mobility. Interventions included directions for staff to conduct a systematic skin inspection weekly, with particular attention to bony prominences, and to report any signs of skin breakdown. The care plan indicated the resident had a pressure relieving mattress and chair pad. The care plan did not include a turning and repositioning program. On 9/19/11, staff documented the resident had a fluid filled area located next to the spine. The care plan directed staff to have the physician's assistant evaluate and treat the area. The care plan directed staff to assess and document every week. The care plan dated 9/26/11 indicated the resident had been placed on hospice care due to a general decline in condition. The computerized nursing progress notes dated 9/16/11 documented the resident had an open area to the mid-spine that measured 1 cm x 1 cm x .3 cm (centimeters). The area had black eschar and green drainage. The progress notes lacked documentation staff notified the physician of the area and signs of infection. The resident's treatment administration record for September 2011 documented staff applied a bandage to the open area on the mid-spine after cleansing with normal saline. The treatment started September 19, or three day after the discovery of the open area. The resident's Pressure Ulcer Record dated 9/16/11 documented the resident had a Stage III pressure ulcer that measured 1 x 1 x .3 cm with green drainage. A Stage III pressure ulcer is described as a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. The record documented staff sent a facsimile to the physician. A facsimile dated 9/16/11 documented the resident had an open area to the mid-spine. The facsimile documented staff described the area as a possible abscess with green drainage. The physician's assistant responded to the facsimile on 9/19/11, three days after the discovery of the pressure area. A progress note from the physician's assistant dated 9/19/11 documented his/her assessment of the wound. The physician's assistant documented the skin around the wound as yellow with thick yellow pus coming from the wound. The physician's assistant used a cotton tipped applicator and discovered the wound tunneled about 1 cm beyond the edges of the wound. The physician's assistant ordered staff to set up an appointment with the wound care center and treatment orders to cover the wound with [MEDICATION NAME] soaked gauze. The physician's assistant also directed staff to place a low air loss mattress to the resident's bed. The weekly skin assessment dated [DATE] documented an area to the mid-spine that measured 1 x 1 x .3 cm. and describe the area as an abscess. The weekly skin assessment dated [DATE] documented the area measured 1 x 1 x .3 cm with exudate. The weekly skin assessment dated [DATE] documented the area measured 2.5 x 1 x .3 cm. The physician's orders [REDACTED]. The physician changed the wound treatment and ordered antibiotics for the resident. During an interview on 9/27/11 at 4:18 p.m., Staff K, registered nurse, stated she completed weekly skin assessments. Staff K stated the nurse that observed the skin alteration needed to complete the assessment, fill out applicable forms, and obtain treatment orders for the resident. Observation of the resident's wound on 9/29/11 at 9:15 a.m. revealed an approximately quarter-sized open area to the resident's left back. The wound contained yellow slough to the outer right side, and a piece of hard steel protruded from the wound. During an interview on 9/29/11 at 2:45 p.m., the director of nursing stated the nurse that assessed the wound needed to call the physician instead of sending a facsimile, especially since the wound had signs of infection. During an interview on 10/4/11 at 5:40 p.m., the resident's family stated the resident had a rod placed in his/her back two years ago due to compression fractures. The surgeon had advised the resident's family that the resident's condition was unstable making surgery to remove the hardware too great of a risk (to the resident). During an interview on 10/14/11 at 2:39 p.m., the resident's physician stated she was not aware the resident had this wound until yesterday, when she spoke to her physician's assistant. The physician indicated her assistant stated when she assessed the wound, she thought it was an abscess and directed staff to obtain a wound consult at the wound care center. The physician would not provide any further information stating she had no knowledge of the wound until 10/14/11. During an interview on 10/17/11 at 8:56 a.m., the wound care physician that examined the resident on 9/26/11, stated the resident had a Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer with infected hardware. The physician estimated the wound had developed over thirty days. The physician stated upon discovery of the wound, the facility staff needed to obtain treatment orders immediately that would include an antiseptic application to the wound with a padded dressing. On 9/26/11, he ordered the resident's wound be treated with Iodosorb (wound gel that inhibits bacterial growth as it absorbs exudate. Specially formulated for use on wet, exudating ulcers, diabetic and venous ulcers, pressure sores and infected wounds), and covered with a padded dressing. The physician also stated the facility needed to provide pressure relieving devices to keep pressure off the wound. The physician stated the resident had a follow-up appointment that day. The facility policy's skin care protocol, dated June 2009, directed staff upon identification of a skin issue, to document odor, inflammation, pain, purulent drainage, redness, and swelling. The nurse will then complete the weekly skin assessment and notify the physician for appropriate treatment. The facility's skin integrity management policy dated August 2009, directed staff to document the assessment and management of skin issues using the Skin Event Form, and those resident's with pressure sores, document on the Pressure Ulcer/Stasis Ulcer Event form.