Every finding on record at Wapello Specialty Care

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to use Enhanced Barrier Precautions (EBP) precautions during wound care in an effort to prevent the transfer of multidrug-resistant organisms (MDROs) for 1 of 1 residents (Resident #3) reviewed for EBP precautions. The facility reported a census of 41 residents. Findings include:The Minimum Data Set (MDS) for Resident #3, dated 10/15/25, documented a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating intact cognition. The resident diagnoses listed included medically complex conditions, hypertension, neurogenic bladder, obstructive uropathy. multidrug-resistant organism (MDRO), non-pressure chronic ulcer of buttock with fat layer exposed and a urinary tract infection (UTI, in the last 30 days). The MDS documented the resident had one or more unhealed pressure ulcers/injuries and had a indwelling catheter. The Care Plan, with a revision date 10/10/25, documented Resident #3 had a stage 3 pressure ulcer on her sacrum and further documented the resident was at risk for potential infection related to indwelling foley catheter and instructed staff to use Enhanced Barrier Precautions (EBP) when performing high-contact care activities. During an observation 11/19/25 at 9:25 AM, Staff A, Assistant Director of Nursing (ADON) and Staff B, Registered Nurse (RN), performed wound care for Resident #3. Both Staff A and Staff B washed their hands, sanitized the surface of the tray table, placed a barrier down on the table and then the supplies on top of the barrier. Both staff then put on gloves. Staff B assisted the resident to roll over onto her side while in bed and Staff A performed perineal care (washing and cleaning of the genitals and anal area) of bowel movement with cleaning wipes and then removed her gloves, sanitized hands and put on fresh gloves. After cleaning the resident of bowel movement, Staff A used a saline wash to clean the wound, removed gloves and sanitized hands, put on new gloves and then used a cotton tip to apply the medicated ointment to the wound and placed a bandage over the wound. Staff A then removed her gloves, sanitized her hands and placed new gloves and cleaned the resident's perineal area with a wipe. Staff B assisted with rolling the resident and holding the resident. Neither Staff A nor Staff B wore a gown during the wound care or perineal care. During an interview 11/19/2025 at 12:20 PM, Staff A (ADON) acknowledged she should have worn a gown to be in compliance with EBP and acknowledged Resident #3 required EBP due to her chronic wound and indwelling catheter. Staff A stated an expectation that EBP are utilized when a resident has a chronic or open wound and wound care is performed, and when a resident has a catheter and high contact care activities are performed. During an interview 11/19/2025 at 12:35 PM, the Administrator acknowledged EBP should have been used during the wound care and high care activity for Resident #3. Review of the facility policy Enhanced Barrier Precautions, with a revision date 3/28/24, documented it is the policy of this facility to implement Enhanced Barrier Precautions for the prevention of transmission of multidrug-resistant organisms. An order for EBP will be initiated for residents with wounds and/or indwelling medical devices. The facility will make gowns and gloves available immediately near or outside of the resident's room.

Based on observations, staff interviews, Food Code review, and facility policy review the facility failed to ensure foods were appropriately labeled and dated and failed to ensure meal service conducted in a sanitary manner for all residents who received food from the kitchen. The facility reported a census of 44 residents. Findings include: On 9/30/24 at approximately 10:20 AM during an initial tour of the kitchen, the following was observed: a. One package of cheddar cheese open and undated. b. Open smoked ham dated 9/22. c. One 5 pound container homestyle chicken salad dated 9/22. d. One bag of chicken fried steak in the reach in freezer with no date visible on the bag. Observation of the lunch meal service conducted on 10/1/24 revealed the following: a. On 10/1/24 at 11:28 AM Staff B, [NAME] picked up a key from the floor and then went back to preparing drinks. b. On 10/1/24 at 11:43 AM Staff B picked up an ice scoop that was present on top of the milk cooler and used it to fill drinks with ice. c. During the lunch meal service, the handwashing sink observed to be used to fill drinks. d. On 10/1/24 at 11:40 AM, Staff B observed wiping hands on shirt then touching drink. e. On 10/1/24 at 11:56 AM Staff B picked something up from the floor. Another staff member utilizing the hand sink at the time. Staff B then observed working with drinks in the kitchen. f. On 10/1/24 at 12:10 PM, Staff B brushed off a tray that Staff B held over the hand washing sink. On 10/3/24 at 1:55 PM during an interview with Staff A, [NAME] who was covering during the Manager's absence, Staff A explained the following about label/dating: No matter what comes on the truck is first date, with freezer has pull date, and for other items has open date. Staff A explained everything should have two dates, delivery and opened or sticky pull date (date when pulled out of freezer). When queried about using the hand sink to fill water pitchers, Staff A acknowledged was 50/50 if used the hand sink. Staff A acknowledged if staff dropped item on ground should wash hands, and also explained tried to keep the ice scoop with the ice. Review of the 2022 Food Code revealed, 5-205 Operation and Maintenance 5-205.11 Using a Handwashing Sink. (A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use. Pf (B) A HANDWASHING SINK may not be used for purposes other than handwashing. On 10/3/24 at approximately 3:20 PM, the Administrator explained the other sink in the kitchen was the handwashing sink. Review of the Facility Policy titled Sanitation, dated 2001 and revised 10/2008, revealed the following: The food service area shall be maintained in a clean and sanitary manner.

Based on observations, clinical record review, facility policy review and staff interviews the facility failed to update care plans to address one residents wandering, and to address another resident taking the property of others while wandering in the building for 2 of 2 residents (Resident #39 and Resident #6) reviewed for wandering. The facility reported a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 8/16/24, for Resident #39 included a Brief Interview for Mental Status (BIMS) score 00 out of 15 indicating a severe cognitive impairment. The MDS revealed the resident displayed wandering behavior daily. The MDS documented the resident used a wheelchair and dependent with chair/bed to chair transfers. The MDS listed diagnoses included: non-Alzheimer's dementia, amnesic disorder due to known physiological condition, and delirium due to known physiological condition. The Care Plan did not included a Focus area or Interventions for wandering behavior. The Progress Notes dated 9/19/24 at 7:17 AM, revealed the resident attempted to leave the front door when someone left for an appointment and had to be stopped. He had been wandering up and down halls going into other residents room this am. During an observation on 9/30/24 at 12:45 PM, the resident propelled self into another resident's room. The staff intervened and the resident self propelled himself back into the hallway. During an observation on 9/30/24 at 1:05 PM, the resident propelled self throughout the building (opposite hallway of his room), and sat at the exit door. During an observation on 10/2/24 at 1:00 PM, the resident wandered in the hall and attempted to go into another resident's room. Two staff intervened asking the resident to not go into the room. The resident moved out of the doorway to the room. During an interview on 10/2/24 at 3:04 PM, Staff D, Certified Nursing Assistant, (CNA) stated Resident #39 wandered into other resident's room. During an interview on 10/3/24 at 2:14 PM, Staff C, LPN (Licensed Practical Nurse) stated the resident wandered into other resident's rooms. During an interview on 10/3/24 at 2:48 PM, the Director of Nursing (DON) stated Resident #39 wandered into other resident's rooms. She stated she put out education for staff to redirect him to the front area. The DON stated the wandering needed to be care planned. 2. The MDS assessment, dated 9/6/24, for Resident #6 included a BIMS score of 4 out of 15, indicating a severe cognitive impairment. The MDS revealed the resident displayed wandering behavior daily. The MDS indicated the resident displayed behavior of significantly intrusion on the privacy or activity of others. The MDS listed diagnoses included: schizophrenia, restlessness and agitation, and obsessive-compulsive behavior. The Care Plan included a Focus area, dated 2/24/24, to address the risk for elopement related to safety awareness. Interventions included: Alert staff to my wandering behavior; I like activities that involve food and 1:1 conversation; and Provide divisional activities for me. The Care Plan included a Focus area, revised on 4/17/23, to address My wandering intrudes on other's privacy. Interventions included: Alert staff to my wandering behavior; Approach me positively and in calm, accepting manner; If I wander away from unit, instruct staff to stay with me, converse and gently persuaded me to walk back to designated area with them; Redirect me when I wander into other's rooms. The Care Plan did not address Resident #6 taking another residents property when wandering into rooms. A Behavior Note, dated 6/28/24 at 1:11 PM documented He [Resident #6] has been entering residents rooms and taking items from their rooms today. He has been re-directed multiple times and staff found he had taken a residents tablet and hid it in his shirt, Nurse is shutting doors when residents leave the rooms to keep him from coming in but he is entering the rooms in spite of doors being closed. The Behavior Note, dated 7/29/24 at 9:40 AM, documented He [Resident #6] sent into a residents room and took her phone from her room. Nurse wiped it down and gave it back to the resident since he had it inside his clothing. Nurse will let the ADON (Assistant Director of Nursing) know of his behavior. The resident told him she had an agreement and he was to stay out of her room and he stated ok. The Behavior Note, dated 8/17/24 at 10:31 AM, documented He [Resident #6] had taken two separate phones that did not belong to him and nurse had to return them. The CNA reported he yelled and became agitated with cares and hit at her during his shower. During an observation on 9/30/24 at 4:03 PM, Resident #6 self propelled himself in his wheelchair into a resident's room, under her stop sign, staff noticed and instructed him to back up and he was easily redirected and backed up from the room. During an interview on 10/2/24 at 3:07 PM, Staff D, CNA stated Resident #6 wandered into other resident's rooms and took things. Staff D stated if something came up missing they looked in his room or asked him to change his clothes to see if he hide the items on his person. Staff D stated they usually found the missing items within a couple of hours. During an interview on 10/3/24 at 10:00 AM, Staff E, CNA stated Resident #6 got into everything and everybody's rooms. Staff E stated the women shooed him from their hallway because they knew he would go into their rooms. Staff E stated they eventually get the items back from the resident. Staff E stated room [ROOM NUMBER] had a stop sign to prevent him from going into her room. During an interview on 10/3/24 at 10:51 AM, Staff G, CNA stated Resident #6 went into other resident's room and took things and sometimes they got them back. Staff G stated she knew the residents got quite upset and they knew he took their items. Staff G stated he went into [name redacted] room and took his billfold and flashlight, but the items were returned. During an interview on 10/3/24 at 2:11 PM, Staff C, LPN stated Resident #6 wandered and took other resident's things. Staff C stated the staff did a better job at keeping him on the men's hall and he been doing better the last few months. During an interview on 10/3/24 at 2:50 PM, the DON confirmed Resident #6 went into other resident's room and if he had something that didn't belong to him, he gave it back. The DON stated she felt his behavior improved since she returned to the facility. The DON confirmed his behavior for taking resident's property needed addressed on the care plan. The DON stated she had family in the past that were no longer here that complained about Resident #6 going into their family member's room and they put a stop sign in their door. The Facility Care Plans, Comprehensive Person-Centered Policy revised December 2016 revealed the following: a. The comprehensive, person centered care plan would: 1. Incorporate identified problem areas b. Areas of concern that were identified during the resident assessment would be evaluated before interventions were added to the care plan. c. Identified problems areas and their causes, and developed interventions that were targeted and meaningful to the resident, and were the endpoint of an interdisciplinary process.

Based on observation, interview, clinical record review, and facility policy review the facility failed to ensure medication was available and administered per physician order for one of six residents reviewed for medications (Resident #18). The facility reported a census of 44 residents. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 7/4/24, for Resident #18 revealed the resident scored 12 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. Per this assessment, the resident did not take antipsychotic medication. Review of Resident #18's Care Plan dated 8/21/24 revealed, I have a psychosocial well-being problem (actual or potential) related to lack of acceptance to current condition, lack of motivation, social isolation. The Physician Order for Resident #18 dated 7/16/24 revealed, Aripiprazole Oral Tablet 10 MG (milligram), an antipsychotic medication, with instructions to give 1 tablet by mouth at bedtime related to Borderline Personality Disorder. Review of Resident #18's Progress Notes documented the following in regards to the order for: a. 7/16/2024 at 8:49 PM: has not arrived from the pharmacy. b. 7/17/24 at 7:12 PM: Medication is not available. c. 7/21/24 at 7:44 PM: On order. d. 7/22/24 at 7:27 PM: waiting for pharmacy to send. e. 7/28/24 at 7:55 PM: ordered. f. 7/29/24 at 7:35 PM: no card found, ordered from pharmacy. Review of the resident's Medication Administration Record (MAR) dated July 2024 for 7/16/24 through 7/29/24 documented the medication administered on the following dates: a. 7/18/24 through 7/20/24 b. 7/23/24 through 7/27/24 Review of a Packing Slip dated 7/24/24 revealed 31 tablets of aripiprazole 10 MG for Resident #18 was included in the delivery. A Packing Slip dated 7/29/24 revealed 3 tablets of aripiprazole 10 MG for Resident #18 was included in the delivery. Observation conducted on 10/02/24 at 10:22 AM revealed Resident #18 present in the activity room with other residents. Resident #18 had red gripper socks to their feet. On 10/3/24 at 12:28 PM, the Assistant Director of Nursing (ADON) explained pharmacy delivered every night except Sunday. Per the ADON, the pharmacy closed at noon on Saturday, so if an order did not get in before noon on Saturday would get it [medication] Monday night, and resident wouldn't have the med until Tuesday morning. Per the ADON, the pharmacy did not come in until 9:30 PM/11:00 PM, and third shift nurse would address. The ADON further explained sometimes the pharmacy did not have Abilify (brand name for aripiprazole) in stock. The ADON confirmed the facility did not have Abilify in back-up supply. On 10/3/24 at 12:42 PM when queried about the above timeline for the residents aripiprazole, the Director of Nursing (DON) explained she would call the pharmacy. Per the DON, the pharmacy came in the evening and night shift nurse received medications. The DON explained when got 31 tabs would be for the next month, for the month change over. On 10/03/24 at 1:41 PM, the DON explained she reached out to the nurses, and they did not remember. The DON explained she was still waiting on the pharmacy to send their delivery slips, and staff were not aware of additional information. Review of the facility policy titled Administering Medications, dated 2001 and revised 4/2019, revealed the following: Medications are administered in a safe and timely manner, and as prescribed.

Based on clinical record review, facility policy review and staff interviews the facility failed to follow Care Plan fall risk interventions, leading to a fall for one of four residents (Resident #36) reviewed for falls. The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 5/14/24, revealed Resident #36 scored a 15 out 15 on the Brief Interview for Mental Status (BIMS) exam, indicating intact cognition. The MDS listed an impairment on both lower extremities. The MDS assessed the resident needed maximal/substantial assistance with upper and lower body dressing, and dependent on staff for sit to stand transfers, and chair/bed to bed transfers. The MDS listed diagnoses included: heart failure, lack of coordination, and reduced mobility. The MDS assessment did not indicate the residents fall history prior to or since admission on 3/5/24. The Care Plan Focus area, dated 3/5/24, addressed Activities of Daily Living (ADLs). Interventions included, in part: Transfer-I require 1 assist using bariatric walker and gait belt; Upper Body Dressing - I require 1 assist; Lower Body Dressing - I require one assist. The Care Plan Focus area, dated 7/23/24, addressed I am at risk for falls. Interventions included, in part: Staff will assist me with dressing and undressing while sitting down. A Nurses Note, dated 7/22/24 at 10:00 PM, documented CNA (Certified Nurse Aide) was dressing resident for bed and resident lost balance and fell backward into closet hitting his ear on the door frame. Acquired 2 skin tears to right wrist, a skin tear between left thumb, and first finger, and a skin tear to his left ear. Also has abrasion to middle of his back. Wife notified and ADON (Assistant Director of Nursing) notified and Dr. faxed. I just lost my balance and went backwards. Assist of 3 to get up to walker and into bed. The Incident report #1351 revealed a witnessed fall dated 7/22/24 at 10:00 PM with the following information: a. Nursing description: CNA was dressing the resident for bed and resident lost his balance and fell backward into closet hitting his ear on the door frame. acquired 2 skin tears to right wrist, a skin tear to left thumb, a skin tear between left thumb and first finger, and a skin tear to his left ear. Also had abrasion to middle of his back. Wife notified and ADON notified and doctor faxed. b. Resident description: I just lost my balance and went backwards. c. Immediate Action Taken: Assist of 3 to get up to walker and into bed. e. Injuries: abrasion to the right scapula; skin tear to right hand, left ear, left finger(s), and right wrist. f. Mobility: ambulatory with assistance g: No predisposing environmental or physiological factors h: Predisposing situation factors: ambulating with assist I: Statements: Staff D stated the resident held onto the walker and while she put his gown on for bed, the resident went backwards and fell into the closet hitting his ear on the doorframe. DJ: Notes: dated 7/23/24: staff assisted resident with dressing and undressing while sitting down. During an interview on 9/30/24 at 12:11 PM, Resident #36 stated he fell twice since being at the facility and the first time was the staff's fault. He stated the staff member got him up to go to bed and when she let go of him, he fell into the closet and onto the floor. He stated he didn't get hurt, but was bruised and scratched up. Resident #36 stated the staff member didn't use a gait belt. Resident #36 stated the staff member took off his shirt when he stood up and they normally did it when he sat in the chair or on the bed, and when she took off his shirt he lost his balance and fell . Resident #36 stated he didn't recall what the staff member's name was. During an interview on 10/2/24 at 2:54 PM, Staff D, CAN (Certified Nurse Aide) stated she recalled the incident with she helped Resident #36 and he fell backwards. She stated he fell into the closet and she tried to catch him and he bumped his ear. She stated she was transferring him to change him. She stated she had a gait belt on the resident and she wasn't going to change him until she got him to bed. Staff D stated the resident a one assist with a gait belt and would lose his balance out of nowhere. She stated she was moving to the other side of him and she let go of the gait belt to get to the other side and within a second he lost his balance. Staff D stated now, she holds on to the gait belt with a death grip because she doesn't want that to happened again. During an interview on 10/3/24 at 10:20 AM, Staff E, CAN queried if she changed Resident #36 while standing and she stated no and the only time would be if he sat on the toilet and when he stood up, she would pull his pants up. Staff E stated she would never change a resident's shirt while standing up because they were unsteady and didn't have the balance and she didn't feel safe to do it. Staff E queried if you could ever take your hand off the gait belt when transferring and she stated no. During an interview on 10/3/24 at 2:04 PM, Staff HO, LP (Licensed Practical Nurse) stated she recalled the incident with Resident #36 falling into the closet and she stated the resident fell backwards because the CAN stood in front of him. Staff HO stated the CAN did use a gait belt and the CAN told her, she was changing his bottoms and he fell backwards when he lifted his feet. Staff HO stated she wouldn't change a resident's clothing standing up because they were unsteady as it was and she would sit him down and change him. During an interview on 10/3/24 at 3:00 PM, the DON (Director of Nursing) stated she didn't recall the incident and needed to go back and look. The DON queried if a resident should have his pants and shirt changed while standing up and the DON stated socks and a shirt could be put on before the resident stood up and no, they shouldn't change him while standing. The facility policy, revised March 2018, titled Assessing Falls and Their Causes, Preparation section directed staff to: 1. Review the resident's care plan to assess for any special needs of the resident.

Based on clinical record review, staff interview, and facility policy review the facility failed to ensure prompt treatment for a urinary tract infection (UTI) for one of two residents reviewed for UTI (Resident #30). The facility reported a census of 44 residents. Findings include: Review of Resident #30's Minimum Data Set (MDS) assessment revealed the resident scored 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident was severely cognitively impaired. Review of the Care Plan dated 9/27/23 revealed, Activities of Daily Living (ADL's). The Intervention most recently revised 12/11/23 revealed, Toileting - I require no assist. The Physician Order dated 6/3/24 revealed, UA (urinalysis), reflex to culture one time only for urgency and burning until 06/03/2024 23:59 (11:59 PM). Review of Progress Notes for Resident #30 dated 6/3/24 and 6/4/24 revealed the following: a. 6/3/24 at 11:31 AM: Resident has been complaining of urgency with urination, can hardly make it to the bathroom. And burning with urination, note to physician, coming today to see her. b. 6/3/24 at 12:58 PM: New order for UA (urinalysis) with culture, son aware of new order. c. 6/4/24 at 9:24 AM: Nurse will have her to give a fresh clean catch urine sample. d. 6/4/24 at 11:02 AM: She had reported discomfort with voiding the other day and her urine sample was collected and it will be sent to the lab to check for UTI (urinary tract infection). Review of Urinalysis Results for Resident #30 dated 6/4/24 revealed the resident had turbid urine with abnormal leuk esterase (screen for white blood cells and other signs of infection in urine), abnormal urine WBC (white blood cell), and abnormal urine RBC (red blood cell). Continued review of Resident #30's Progress Notes dated 6/5/24 to 6/6/24 revealed the following: e. 6/5/2024 at 8:34 AM: Awaiting results from UA. Resident states she is still having some discomfort upon urination. f. 6/5/24 at 8:25 PM: Waiting on UA results. Continues to urinate often with very little output. g. 6/6/24 at 9:46 AM: This nurse called [Hospital Name Redacted] for UA results lab states results are preliminary at this time. h. 6/6/24 at 10:53 AM: [Name Redacted] noted UA results with ABN awaiting C&S (culture and sensitivity) to guide Tx (treatment). Review of the Bacteriology Report with Verified Date and Time 6/7/24 at 7:11 AM revealed greater than 100,000 cfu/ml (colony forming unit per milliliter) Psuedomonas aeruginosa. The fax was dated 6/7/24. Continued review of Resident #30's Progress Notes dated 6/8/24 to 6/11/24 revealed the following: i. 6/8/24 at 2:59 PM: Awaiting provider to review UA results, no new orders at this time. Resident appears at baseline & able to make needs known to this nurse. VS (vital signs) WNL (within normal limits) with no S/S (signs/symptoms) of UTI at this time. j. 6/10/24 at 10:11 AM: Physician in today to look over ua results, resident has been out to meals without any symptoms of UTI at this time. k. 6/10/24 at 11:43 AM: New order for Cipro 500 mg (milligram), daily for 3 days for UTI. l. 6/11/24 at 10:24 AM: Resident started ATB (antibiotic) today 6/11 for a UTI. Resident tolerating first dose this morning well. Denies any pain or discomfort at this time. In room doing nebulizer treatment. Vitals stable, plan of care ongoing. The Physician Order dated 6/11/24 to 6/14/24 revealed, Cipro Oral Tablet 500 MG (milligram)(Ciprofloxacin HCl), an antibiotic medication, with instructions to give 500 mg (milligram) by mouth one time a day for UTI for 3 Days. Review of the resident's Medication Administration Record dated June 2024 revealed the resident received Cipro on 6/11/24, 6/12/24, and 6/13/24. On 10/3/24 at 1:42 PM, the Director of Nursing (DON) queried about UA and C&S results, and explained they would be faxed to the facility. When queried how results sent to the provider, the DON explained by fax. The DON explained the following about C&S: would get a response that day or would call. When queried if would wait for the provider to come in and look at C&S results, the DON responded no. When queried if nurses would chart if fax the doctor with results, DON responded, yeah. On 10/3/24 at approximately 2:25 PM, the Assistant Director of Nursing (ADON) queried about the provider (who was noted to sign the culture result for the resident), and explained it was a provider who had covered in a gap between other Providers. On 10/3/24 at 2:30 PM during an interview with Staff C, Licensed Practical Nurse (LPN), Staff C queried about how they got results from a urine culture from the lab. Staff C explained she would call the lab for culture results, then would call the doctor. Per Staff C, would call and have the results faxed to them so they had the paper. On 10/3/24 at 2:39 PM the ADON/Infection Preventionist queried if staff got urine culture back,what do they do? The ADON explained the following for providers noted to be current providers at the facility (not the provider who signed Resident #30's culture report): For one provider, would call and read results to them, and other provider would get them immediately. The ADON explained for provider who could see results, facility would call and explain that the results were in. Per the ADON, at time when providers were covering, there was an on-call phone that nurses could call. When queried if staff should have called, the ADON acknowledged should have called the on call phone, and if did call acknowledged staff needed to note it. On 10/3/24 at 3:05 PM, the DON explained once got the ua sent to lab, the DON always called the next day, and would call every single morning to see if the results back. Per the DON, if C&S indicated, took a few more days, and the DON would call and check until results received. The DON further explained the provider would be notified that day. Per the DON, sometimes the C&S took 2 to 3 days, and as soon as back like to get started on antibiotics as indicated. Review of the Facility Policy titled Antibiotic Stewardship dated 2001, revised 12/16, revealed the following: 11. When a culture and sensitivity (C&S) is ordered lab results and current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.

Based on interviews, record review, and the facility policy, the facility failed to prevent abuse from occurring between residents for 3 of 7 residents reviewed for abuse (Resident #1, Resident #2, and Resident #7). The facility reported a census of 33 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored a 00 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The Care Plan revealed a focus area initiated on 11/13/23 for resident displayed socially inappropriate sexual behavior and displayed untargeted touching at others. The interventions dated 11/13/23 revealed Resident #1 would be seated in the dining room away from female resident alleged incident. The interventions dated 11/14/23 revealed Resident #1 would eat meals in the lobby with male residents. The interventions dated 11/17/23 revealed resident had 1:1 supervision and the 1:1 supervision could be removed when no longer warranted due to resident not exhibiting untriggered behavior due to his confused/dementia state. The interventions dated 11/28/24 revealed placed on 1:1 and a pressure floor alarm in resident's room doorway to alert staff when exited the room. The Incident Report #1188 dated 11/12/23 at 11:20 AM revealed the following information: a. Nursing Description: The DON (Director of Nursing) became aware on 11/13 that there was an alleged resident to resident incident regarding Resident #1 and another female resident. The allegation was that Resident #1 touched a female resident's right breast. b. Resident Description: Resident Unable to give Description c. Immediate Action Taken: The residents separated, assessment of residents conducted today with no injuries. The residents will remain separated in the dining room for meals, as previously they were seated at the same dining room table. The Progress Note dated 11/13/23 at 6:33 PM revealed sexually inappropriate behavior observed and resident reassigned a new dining room seat due to alleged incident with female peer. The Progress Note dated 11/16/23 at 4:18 PM revealed resident witnessed attempting to put hand up a female resident's shirt. The nurse educated resident that was inappropriate to touch other people and moved resident to a different area. The Self Report with submission date of 11/17/23 at 3:50 PM revealed the following information: a. Reporting type: Allegation of Abuse b. Approximate date time occurred: 11/17/23 at 3:40 PM c. Location occurred: lobby d. date aware: 11/17/23 e. Incident Summary: During investigation of a previous incident Resident #5 reported to staff that she witnessed Resident #1 rubbing Resident #2 with his hand up her shirt. She stated she notified the nurse but unable to identify the nurse or the time or date of the alleged incident. f. Corrective action description: Resident #1 placed on 1:1 at this time. The Self Report revealed the following information: a. Submission Date: 11/17/23 at 7:55 PM b. Approximate date time occurred: 11/16/23 at 4:20 PM c. location occurred: lobby of facility d. Date aware: 11/17/23 e. Incident summary: Staff C, LPN (Licensed Practical Nurse) reported that Resident #1 observed in an untargeted act and touched Resident #2 stomach on top of her shirt. Nurse moved resident to another area of the lobby away from others and in line of sight of nursing staff. Resident #1 experienced a change of behavior and MD (Medical Director) notified. The Progress Note dated 11/28/23 at 12:18 PM revealed a left a voice message with the provider regarding incident with resident and a female resident this morning. Requested a call back if Nurse Practitioner had any questions or would need any further information. The Incident Report #1209 dated 11/28/23 at 9:55 AM revealed the following information: a. Nursing Description: Resident #1 approached female peer in the hallway outside dining area and started to lift her shirt. b. Immediate Action Taken: Residents separated immediately 2. The MDS assessment dated [DATE] revealed Resident #2 scored a 1 out of 15 on the BIMS exam, which indicated cognition severely impaired. The MDS revealed medical diagnosis of non-Alzheimer's Disease. The Progress Note dated 11/17/23 at 8:14 PM, revealed phone call placed to resident's family to inform him of the alleged incident between his mother and a male peer. The resident's family member verbalized understanding of allegation and asked that his mother and the male peer stay separated. The Progress Note dated 11/28/23 at 10:47 AM revealed resident's son in the building. This writer spoke with him regarding the incident that occurred this morning between his mom and another resident. The son assured that staff will be within arm's reach of resident. The son will contact staff with any questions and or concerns. The Incident Report #1208 dated 11/28/23 at 7:45 AM revealed the following information: a. Nursing Description: Resident #2 sat in the hallway outside dining room waiting for breakfast when male peer approached her and started to lift up her shirt. b. Immediate Action Taken: Residents separated immediately c. Agencies/People Notified: Family member (son) and physician 3. The MDS assessment dated [DATE] revealed Resident #7 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The Care Plan revealed a focus area initiated on 11/13/23 for resident displayed socially inappropriate behavior. The interventions dated 11/13/23 revealed removing resident from public area's when behavior disruptive and unacceptable. The interventions dated 11/14/23 Resident #7 sat in the dining room away from the alleged resident incident. The Incident Report #1189 dated 11/12/23 at 11:20 AM revealed the following information: a. Nursing Description: DON notified 11/13/23 that on 11/12/23 at lunch a male resident touched Resident #7 right breast and she had her shirt up allegedly. b. Resident Description: Per Witness statement Resident #7 denied her shirt up, she said the male resident tried to get fresh with her, she denied that he actually touched her and denied that her shirt lifted up. c. Immediate Action Taken: The residents separated in the dining room, the dining room seating updated so they sat on the opposite areas of the dining room during meals. Resident #7 reported she wasn't upset regarding alleged incident as he didn't actually touch her. The Witness Statement for Resident #7 on 11/13/23 for incident that occurred 11/12/23 revealed the following statement: The Regional Director of Clinical Services (RDCS) asked Resident #7 what happened yesterday at breakfast with the gentleman and she stated he tried to get fresh with me. The RDCS said did he touch you, and she stated No, he tried to. The RDCS asked if he pulled up her shirt or if her shirt was up and she said no. The RDCS asked her if she was upset and she stated no. The Witness Statement from Staff A, CNA (Certified Nurse Aide) on 11/13/23 for incident that occurred on 11/12/23 revealed the following information: On 11/12/23 at lunchtime approximately noonish, turned around and saw Resident #7 shirt lifted up. Resident #7 wore a clothing protector, and from the side she could see her exposed skin/bra. Resident #1 touched her right side of her breast. Staff A went over and pulled her shirt down and moved his arm away. Went to the door to start serving and then he tried to touch Resident #7 again, he reached towards her but didn ' t touch her. Staff A went back over and separated and moved Resident #1 to the opposite side of the table. After lunch service Resident #1 started scooching towards Resident #7. Staff A had Staff D, Cook report to Staff B, LPN. When noticed Resident #1 moved closer to Resident #7, Staff A assisted him to the lobby in his wheelchair. Staff A hasn ' t noticed Resident #7 in any similar situations. Staff A stated her and Staff D were the only staff in the dining room at time of incident. During an interview on 4/10/24 at 1:48 PM, Staff A, CNA stated she tried to stop the incident between Resident #1 and Resident #7. She stated Resident #7 raised her shirt for Resident #1 to fondle her breast. During an interview on 4/10/24 at 3:09 PM, Staff E, CMA (Certified Medication Aide) stated Resident #1 reached under Resident #2 shirt in the common area in front of the nurse's station and she believed it happened a few times. During an interview on 4/11/24 at 9:00 AM, Staff C, LPN stated she recalled an incident with Resident #1 and Resident #2 sitting in the lobby and Resident #2 wheeled himself over to Resident #1 and she stopped him before he got his hand up Resident #2 shirt. Staff C stated she separated the residents but Resident #1 tried to go back to Resident #2 so she brought Resident #2 over by her side. During an interview on 4/11/24 at 1:55 PM, the ADON (Assistant Director of Nursing) stated when residents known to have this type of behavior, they needed monitored the whole time. During an interview on 4/11/24 at 2:00 PM, the RDCS stated Resident #1 was sexually inappropriate and touched the front of one of the resident's shirt. She stated she knew at least one of the times Resident #1 made skin contact. The Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy dated 4/21 revealed the following information: a. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: 1. other residents b. Develop and implement policies and protocols to prevent and identify: 1. Abuse and mistreatment of residents 2. Protect residents from any further harm during investigations.

Based on interview, record review, and the facility policy, the facility failed to report an allegation of abuse within 2 hours after the incident occurred for 3 of 7 residents reviewed for allegations of abuse (Resident #1, Resident #2, and Resident #7). The facility reported a census of 33 residents. Findings include: The Self Report revealed the following information: a. Submission Date 11/13/23 at 3:45 PM b. Approximate Date Time Occurred: 11/12/23 at 12:00 PM c. Location Occurred: Resident Dining Room d. Date Aware: 11/13/23 e. Incident Summary: Regional Services Clinical Director notified there was an alleged resident to resident incident in the dining room involving Resident #1 and Resident #7. The allegation was that Resident #1 touched Resident #7 right breast. Corrective Action Description: Internal investigation initiated. Local Law enforcement notified. Residents assessed no injuries. Responsible party/MD (Medical Director) notified of incident. Residents will be moved in the dining room as they were previously table mates. They are now assigned to different sides of the dining room. The Self Report revealed the following information: a. Submission Date of 11/17/23 at 7:55 PM b. Approximate date time occurred: 11/16/23 at 4:20 PM c. Location occurred: lobby of facility d. Date aware: 11/17/23 e. Law Enforcement notified f. Incident summary: Staff C, LPN (Licensed Practical Nurse) reported that Resident #1 observed in an untargeted act and touched on Resident #2 stomach on top of her shirt. Nurse moved resident to another area of the lobby away from others and in line of sight of nursing staff. Resident #1 experienced a change of behavior and MD notified. During an interview on 4/10/24 at 1:48 PM, Staff A, CNA (Certified Nurse Aide) stated she and the nurse didn't realize they needed to report the incident with Resident #1 and Resident #7 when it happened. During an interview on 4/11/24 at 8:35 AM, Staff B, LPN (Licensed Practical Nurse) stated she did not report the incident with Resident #1 and Resident #7 in the appropriate time frame. During an interview on 4/11/24 at 2:02 PM, the ADON (Assistant Director of Nursing) confirmed allegations of abuse needed reported within 2 hours of the incident. The Facility Recognizing Signs and Symptoms of Abuse/Neglect Policy dated 4/21 revealed the following information: a. All personnel expected to report any signs and symptoms of abuse/neglect to their supervisor or to the director of nursing services immediately. The Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy dated 4/21 revealed the following information: a. Investigate and report any allegations within the timeframe required by federal requirements.

Based on interviews, record review, and the facility policy, the facility failed to adequately supervise a resident after an allegation of abuse with another resident. This resulted in another occurrence with a resident to resident allegation of abuse for 2 of 7 residents reviewed for allegation of abuse (Resident #1 and Resident #2). The facility reported a census of 33 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored a 00 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The Care Plan revealed a focus area initiated on 11/13/23 for resident displayed socially inappropriate sexual behavior and displayed untargeted touching at others. The interventions dated 11/13/23 revealed Resident #1 would be seated in the dining room away from female resident alleged incident. The interventions dated 11/14/23 revealed Resident #1 would eat meals in the lobby with male residents. The interventions dated 11/17/23 revealed resident had 1:1 supervision and the 1:1 supervision could be removed when no longer warranted due to resident not exhibiting untriggered behavior due to his confused/dementia state. The interventions dated 11/28/24 revealed placed on 1:1 and a pressure floor alarm in resident's room doorway to alert staff when exited the room. The Self Report with submission date of 11/17/23 at 3:50 PM revealed the following information: a. Reporting type: Allegation of Abuse b. Approximate date time occurred: 11/17/23 at 3:40 PM c. Location occurred: lobby d. date aware: 11/17/23 e. Incident Summary: During investigation of a previous incident Resident #5 reported to staff that she witnessed Resident #1 rubbing Resident #2 with his hand up her shirt. She stated she notified the nurse but unable to identify the nurse or the time or date of the alleged incident. f. Corrective action description: Resident #1 placed on 1:1 at this time. The Self Report revealed the following information: a. Submission Date: 11/17/23 at 7:55 PM b. Approximate date time occurred: 11/16/23 at 4:20 PM c. location occurred: lobby of facility d. Date aware: 11/17/23 e. Incident summary: Staff C, LPN (Licensed Practical Nurse) reported that Resident #1 observed in an untargeted act and touched on Resident #2 stomach on top of her shirt. Nurse moved resident to another area of the lobby away from others and in line of sight of nursing staff. Resident #1 experienced a change of behavior and MD (Medical Director) notified. The Investigative Report for the incident that occurred on 11/28/23 revealed the following information: a. Date of Incident: 11/28/23 b. Date of Investigation: 11/28/23-12/1/23 Summary of alleged incident: c. Resident #2 sat in the hallway outside of dining room and waited for breakfast when Resident #1 approached her and started to lift Resident #2 shirt. He was stopped by staff and redirected back to male table for breakfast. Both assessed with no injuries. d. People interviewed Staff E, CMA (Certified Medication Aide) on 11/28/23 and Staff F, CNA (Certified Nurse Aide) on 11/28/23 e. Incident occurred at approximately 7:45 AM in the common area in front of the dining room doors f. Action taken during investigation: Residents separated immediately and male residents placed on 1:1 awaiting placement for male memory unit bed at [name redacted]. At this time will transfer to [name redacted] on Monday 12/4. e. Conclusion: Root cause analysis: Resident #1 observed starting to lift Resident #2 shirt. The self report completed, internal investigation completed. Resident had increased incidence of untargeted touch, care plan interventions have included: separation from previous female in the dining room, placement at a dining room table with males only, placement in the lobby eating table with males and supervision of staff, evaluated by provider for any acute infections, sertraline started, psych referral requested and made by facility, and placed on 1:1 with floor alarm in place to alert staff if he exited his room when he was previously in bed. Referral made to [name redacted]for male bed memory unit, planned transfer on 12/4. f. Conclusion: Resident #1 will be transferred to all male unit at the earliest opening. 1:1 continued until that time. The Progress Note dated 11/27/23 at 9:32 PM revealed the following information: a. Reason for Evaluation: Incident/Accident/Unusual Occurrence Follow-up Charting b. History of inappropriate behavior, resident a 1:1 while outside room, resident assisted with supper in his room as he refused to get up and go to the living room area to eat. Appetite good, no contact with other residents, resting at this time, no new concerns. 2. The MDS assessment dated [DATE] revealed Resident #2 scored a 1 out of 15 on the BIMS exam, which indicated cognition severely impaired. The MDS revealed medical diagnosis of non-Alzheimer's Disease. The Progress Note dated 11/17/23 at 8:14 PM, revealed phone call placed to resident's family to inform him of the alleged incident between his mother and a male peer. The resident's family member verbalized understanding of allegation and asked that his mother and the male peer stay separated. The Progress Note dated 11/28/23 at 10:47 AM revealed resident's son in the building. This writer spoke with him regarding the incident that occurred this morning between his mom and another resident. The son assured that staff will be within arm's reach of resident. The son will contact staff with any questions and or concerns. The Incident Report #1208 dated 11/28/23 at 7:45 AM revealed the following information: a. Nursing Description: Resident #2 sat in the hallway outside dining room waiting for breakfast when male peer approached her and started to lift up her shirt. b. Immediate Action Taken: Residents separated immediately c. Agencies/People Notified: Family member (son) and physician The Witness Statement on 11/28/24 from Staff E revealed the following information: a. Staff F yelled Staff E name and asked her to come quick. Staff E ran over to find Resident #1 sitting next to Resident #2 and pulling his hand back. Staff F then stated to Staff E what she saw. Staff E took Resident #1 to his room and reported to the DON (Director of Nursing). The Witness Statement on 11/28/24 from Staff F revealed the following information: a. Resident #1 lifted Resident #2 shirt, when Staff F saw what was happening, the shirt lifted to bottom breast and Resident #1 tried to get his hand up under her shirt. Staff F yelled for Staff E and she removed Resident #1 from the situation and took him to his room. During an interview on 4/10/24 at 1:32 PM, Staff G, CMA stated after Resident #1 and Resident #2 incident, staff needed to keep Resident #1 on a 1:1 until Resident #1 transferred to another facility. She stated Resident #1 always had someone outside his room and someone in the dining room. During an interview on 4/10/24 at 1:48 PM, Staff A, CNA stated they did 1:1 supervision with Resident #1 and put a pressure device in front of his door and they usually had a person who sat outside of his room until he transferred to another facility. During an interview on 4/10/24 at 1:58 PM, Staff H, CNA stated he worked third shift when the incidents occurred with Resident #1 and he stated if Resident #1 came out of his room he needed to be a 1:1 and to keep eyes on the resident. During an interview on 4/10/24 at 3:09 PM, Staff E, CMA stated Resident #1 had 1:1 supervision but a lot of times the 1:1 staff disappeared or they didn't have the staff. Staff E stated they considered 1:1 supervision if the resident in the lobby area and staff at the nurse's station. She stated they preferred to sit at the table with him. During an interview on 4/11/24 at 1:55 PM, the ADON (Assistant Director of Nursing) queried on the expectation of 1:1 supervision and she stated staff to keep them in sight and not within reach of another resident. The Facility Safety and Supervision of Residents Policy dated July 2017 revealed the following information: a. Individualized, Resident-Centered Approach to Safety- Implementing interventions to reduce accident risks and hazards shall include 1. Communicating specific interventions to all relevant staff 2. Assigning responsibility for carrying out interventions 3. ensuring interventions implemented 4. documented interventions b. Systems's Approach to Safety 1. Resident supervision was a core component of the systems approach to safety. The type and frequency of residents supervision determined by the individual resident's assessed needs and identified hazards in the environment. The 1:1 Job Assignment Procedure (no date listed) revealed the following information: a. Goal: When assigned to 1:1 duty, the goal was to prevent the assigned resident access to strike out or engage in resident-to-resident behavior by staying between your assigned resident and other residents. b. Process: 1. Do not let assigned resident ambulate away from you. 2. Engage assigned resident in a 1:1 activity

Based on observation, interview, record review, and the facility policy review the facility failed to implement interventions to prevent worsening of a Stage II pressure ulcer on the right heel for 1 of 3 residents reviewed for pressure ulcers (Resident #17). The facility reported a census of 38. Findings include: The Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed Resident #17 with diagnoses of medically complex conditions and multiple sclerosis; three Stage 4 pressure ulcers present on admission and no unstageable pressure ulcers present. The Annual MDS assessment dated [DATE] revealed Resident #17 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed the resident required extensive assistance of 2 plus person physical assist with bed mobility and transfers. The MDS revealed diagnosis of progressive neurological condition and multiple sclerosis. The MDS revealed the resident had two Stage 4 pressure ulcers present on admission and one Unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar. not present on admission. The MDS revealed the resident received an opioid 2 out of 7 days. The Admission/Readmission Evaluation for Skin and Wound Initial Care Plan dated 2/15/23 at 1:15 PM revealed Resident # 17 had a history of pressure related injuries including a Stage 2 on right heel. The Care Plan revealed a focus area of self care deficit related to multiple sclerosis dated 7/19/21. The interventions dated 7/4/2018 revealed a rotating air mattress in place for assistance with pressure relief, but may need staff to assist with devices for my comfort with position changes; resident had minimal active movement with my BLE's (bilateral lower extremities), so please assure they are positioned comfortably and no pressure to areas; and pressure relieving boots on my bilateral feet to assist with pressure relief of my heels. The Care Plan revealed a focus area for Stage 4 pressure ulcers on resident's left buttock, right buttock, sacrum, and an unstageable pressure on the right heel initiated on 7/20/21 and revised on 5/3/23. The interventions dated 10/13/21 documented adjustment of the treatment plan if wound didn't heal within 2-4 weeks; weekly evaluation of wound healing; and monitored changes in skin status that indicated worsening of the pressure ulcer and notification to physician. The interventions dated 5/3/23 revealed assessment, recorded, and monitored wound healing (specific frequency) with measurement of length, width, and depth when possible and assessment of wound perimeter, wound bed, and healing progress with reported improvements/declines to physician. The interventions dated 9/18/23 revealed pressure relieving boots on bilateral feet. Braden Scale for Predicting Pressure Sore Risk dated 2/16/23 at 6:07 AM revealed a score of 15. A score of 15-18 indicated resident at risk for pressure sores. The Wound Evaluation dated 2/28/23 revealed a new in house acquired unstageable pressure ulcer due to slough and/or eschar to the right heel with the following measurements: a. area: 9.26 cm 2 (a unit of area measurement equal to a square measuring one centimeter on each side) b. length: 3.99 cm (centimeter) c. width: 3.08 cm The Wound Evaluation and Management Summary notes dated 3/1/23 revealed the following information: a. Unstageable DTI (deep tissue injury) of the right heel partial thickness b. Etiology (quality): Pressure c. MDS 3.0 Stage: Unstageable DTI with intact skin d. Duration: > 1 days e. Objective Healing, sustained in hospital f. Wound Size (L x W x D): 4.0 x 5.0 x Not Measurable cm g. Surface Area: 20.00 cm^2 h. Exudate: None i. Blister: Dry j. Expanded evaluation performed: The development of this wound and the context surrounding the development were considered in greater depth today. k. Dressing treatment plan: Primary Dressing(s); Skin prep apply once daily for 30 days l. Plan of Care reviewed and addressed: 1. Recommendations: Off-load wound Braden Scale for Predicting Pressure Sore Risk dated 3/2/23 at 9:02 AM revealed a score of 12. A score of 12 indicated resident high risk for pressure sores. The Wound Evaluation and Management Summary dated 3/8/23 revealed the following: a. Unstageable DTI of the right heel partial thickness b. Etiology (quality): Pressure c. MDS 3.0 Stage: Unstageable DTI with intact skin d. Duration: > 7 days e. Objective Healing, sustained in hospital f. Wound Size (L x W x D): 1.2 x 0.9 x Not Measurable cm g. Surface Area: 1.08 cm^2 h. Exudate: None i. Blister: Dry j. Wound progress: Improved k: Dressing treatment plan: 1. Primary Dressing(s) with Skin prep apply once daily for 23 days l: Plan of Care reviewed and addressed with the following recommendations: 1. Off-load wound The Wound Evaluation and Management Summary notes dated 3/15/23 revealed the following information: a. Unstageable DTI of the right heel partial thickness b. Etiology (quality): Pressure c. MDS 3.0 Stage: Unstageable DTI with intact skin d. Duration: > 13 days e. Objective Healing, sustained in hospital f. Wound Size (L x W x D): 4.0 x 3.0 x Not Measurable cm g. Surface Area: 12.00 cm^2 h. Exudate: None i. Blister: Fluid Filled j. Wound progress: No Change k. Additional wound detail: resident wore shoes when in his wheelchair l. Dressing treatment plan: 1. Primary Dressing(s) with Skin prep apply once daily for 16 days m. Plan of Care reviewed and addressed n. Recommendations: Off-load wound; Wear Prevalon boot on both feet. Wear boots when in wheelchair for protection Review of the March 2023 MAR/TAR (Medication Administration Record/Treatment Administration Record) lacked documentation for administration of skin prep on the right heel. The Wound Evaluation and Management Summary notes dated 3/22/23 revealed the following information: a. Unstageable DTI of the right heel full thickness b. Etiology (quality): Pressure c. MDS 3.0 Stage: Unstageable DTI within and around wound d. Duration: > 20 days e. Objective Healing, sustained in hospital f. Wound Size (L x W x D): 5.0 x 5.0 x Not Measurable cm g. Surface Area: 25.00 cm^2 h. Exudate: Moderate serosanguineous with thick adherent devitalized necrotic tissue: 50 % and other viable tissues: 50 % (Dermis) i. Wound progress: No Change j. Additional Wound Detail: blister erupted. Non viable skin debrided and a clean wound bed revealed with no non viable tissue left k. Dressing treatment plan: 1. Primary Dressing(s) with Alginate calcium with silver apply once daily for 30 days: or Iodosorb to the wound bed once daily 2. Secondary Dressing(s): Gauze island with border applied once daily for 30 days l. Plan of Care reviewed and addressed: 1. Recommendations: Off-load wound; Wear Prevalon boot on both feet. Wear boots when in wheelchair for protection m. Surgical excisional debridement procedure: Indication for procedure: 1. remove necrotic tissue and establish the margins of viable tissue The Physician Orders included the following medication orders: a. ordered 3/22/23 and discontinued on 8/1/23: Iodosorb External Gel 0.9 % (Cadexomer Iodine)- apply to right heel topically every day shift for open area and apply to wound bed and cover with an island dressing. The Mini Nutritional assessment dated [DATE] at 3:10 PM revealed a score of 12 which indicated normal nutritional status. The Progress note: Dietitian Nutritional Assessment revealed the multiple pressure wounds and no new recommendations and the Registered Dietician (RD) will continue to monitor and reassess as needed. The Wound Evaluation and Management Summary notes dated 4/19/23 revealed the following: a. Stage 4 pressure wound of the right heel full thickness b. Etiology (quality): Pressure c. MDS 3.0: Stage 4 d. Duration: > 47 days e. Objective Healing, sustained in hospital f. Wound Size (L x W x D): 2.5 x 4.0 x 0.1 cm g. Surface Area: 10.00 cm^2 h. Exudate: Heavy Serous i. Thick adherent devitalized necrotic tissue: 30 % j. Granulation tissue: 70 % k. Wound progress: Improved l. Dressing treatment plan: 1. Primary Dressing(s): Alginate calcium with silver apply once daily for 30 days: or Iodosorb to the wound bed once daily 2. Secondary Dressing(s): Gauze island with border apply once daily for 30 days m. Plan of Care reviewed and addressed with recommendations: 1. Off-load wound; Wear Prevalon boot on both feet. Wear boots when in wheelchair for protection The Wound Evaluation dated 4/21/23 revealed the following measurements for the right heel: a. area: 8.96 cm 2 b. length: 3.66 cm c. width 3.44 cm The Wound Evaluation dated 4/29/23 revealed the following measurements for the right heel: a. area: 64.15 cm2 b. length: 11.52 cm c. width: 7.08 cm The Physician Orders revealed the following orders: a. ordered 9/18/23 and discontinued on 9/18/23- Prafo boots to bilateral feet while in bed every shift b. ordered 9/18/23- Heel pressure relieving boots to bilateral feet while in bed During an interview on 9/11/23 at 1:37 PM, Resident #17 stated he developed new wounds on his heel and his bottom. Resident wore a sock on his right foot and sat in his wheelchair. During an observation on 9/13/23 at 2:34 PM, Resident #17 sat in his wheelchair in the common area. His right foot had a thickened bandage under the right heel under his sock. During an interview on 9/13/23 at 3:28 PM, Resident #17 stated he wore pressure boots at bedtime. During an observation on 9/14/23 at 3:59 PM, Resident #17 laid in bed and his heel pressure relieving boots laid on the bed next to him. During an interview on 9/14/23 at 11:58 AM, the Staff E, Wound Doctor queried on Resident #17 wounds and she spoke of his chronic wounds and stated the wounds in stable condition and she used to see him weekly for his wounds but that recently changed to monthly due to the stability of the wounds. Staff E asked when the resident needed to wear the Prevalon boots and she stated all the time even when he sat in the wheelchair. She stated they needed to be on all the time. During an interview on 9/14/23 at 1:10 PM, Staff A, Registered Nurse (RN) queried on the skin assessments and she stated if the resident develops a new wound the nurse got the IPAD and took a picture and conducted a risk management assessment. She stated the Nurse Practitioner (NP) did the staging for wounds. During an interview on 9/14/23 at 1:28 PM, Staff A queried about the pressure ulcer on Resident #17 right heel and she stated he wore moon boots when he laid in bed. She stated he didn't wear them when he sat in his wheelchair. She stated he didn't have a care plan for the boots to be worn in his chair and he sat in his chair 2 to 3 hours a day. Staff A asked if the Resident #17 had an order for Prevalon boots and she stated she didn't know but didn't think so. During an observation on 9/18/23 at 9:50 AM, Staff A, RN performed wound care on Resident #17 right heel. She removed a rolled gauze from the heel and cleaned the heel. The heel beefy red with necrotic tissue on the lateral side of the foot. Dressing completed as ordered. During an observation on 9/18/23 at 1:27 PM, Resident # 17 sat in his electric wheelchair sat in the hallway. His right foot crossed over his left foot. Resident # 17 stated his heel hurt and he stated he was making his way up to the nurse's station to get something stronger than acetaminophen for the pain. During an interview on 9/19/23 at 12:31 PM, Staff D, Certified Nurse Aide (CNA) queried on the interventions they used for Resident #17 heel and she stated they put boots on him when he laid in bed and he needed to wear them in the chair but didn't always wear them. She stated he used to wear a thin heel protector but didn't like it on and only wore the moon boots in his bed. Staff D asked if he wore boots in his chair prior to the wound and she stated she didn't remember. She stated when the wound developed they tried to get him to wear the boots in the chair and he didn't but she didn't remember any other interventions they tried and that would be the nurse's responsibility on what bandages they used to save the heel. During an interview on 9/19/23 at 12:59 PM, Staff C, CNA queried on the interventions used for Resident #17 heel and she stated he wore the moon boots when in bed and got up into his chair from 9:30 AM to around 1 PM. During an interview on 9/19/23 at 3:58 PM, Staff B, RN queried on Resident #17 right heel and she stated he had a wound since she been here and she believed it got worse. She states he wore the moon boots while in bed and he wore socks in the wheelchair and might wear shoes when he went into the public. Staff B asked if the resident used a pillow for a pressure reducing device for the right heel when he sat in the wheelchair and she stated not that she knew of and she stated she guessed she could of thought of that. During an interview on 9/18/23 at 10:08 AM, the Director of Nursing (DON) queried about Resident #17 right heel and she stated they found it after he came back from the hospital and it started out like a purple spot and deteriorated at the facility and now they got it back on track. She stated when he came back from the hospital they watched it and then it broke open and she thought the wound doctor staged it and marked it unstageable. The DON asked about interventions for the heel and she stated the resident wore Prafo boots, air mattress, and whatever the treatments the wound doctor ordered. She stated he didn't like wearing the boots in the wheelchair and he used to wear shoes but she convinced him not to wear shoes. The DON asked if she documented his refusal for the boots and she stated she needed to look. The DON asked if the wound was preventable and she stated yes. She stated the resident liked the thinner boots and she told him he needed a bigger boot and she thought the thin boot caused the wound because they didn't have cushion or a lift to keep the pressure off. During an interview on 9/18/23 at 11:04 AM, the Regional Director of Clinical Services stated Resident #17 never wore Prafo boots and he wore Prevalon boots since admission until the hospital gave a different pressure cushion boot that the resident prefers. She stated he didn't have an order for them but the boots placed on the care plan and the kardex. The Facility Pressure Ulcers/Skin Breakdown - Clinical Protocol dated April 2018 revealed the following information: a. Assessment and Recognition: The staff will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. b. Treatment/Management: The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. c. Monitoring: As needed, the physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. 1. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. 2. Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, were affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker.

Based on interviews, observations and record review the facility failed to transport a Resident safely in the shower chair and failed to determine the root cause analysis for two recent falls for 2 of 3 residents reviewed for accidents. (Resident #13 and Resident #34). The deficient practice resulted in a fractured fibula, increased pain and hospitalization . The facility reported a census of 38. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #13 dated 08/18/2023 documented Resident #13 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognitively intact. The MDS assessment documented Resident #13 completely dependent on staff when transported. The Care Plan Initiated 07/20/2023 documented; I am unable to transfer independently. The Care Plan initiated 03/11/2023 with a target date of 11/16/2023 documented the resident had a fractured left fibula. Per the Care Plan the following goals and interventions were initiated on 03/16/2023 and revealed: 1. I will not develop complications or permanent loss of mobility related to fracture through review date. 2. I will be free from signs and symptoms of pain, or will express/exhibit relief of pain after administration of ordered meds, alt comfort measures. 3. Encourage use of affected limb as much as tolerated, to help maintain range of motion. 4. Give pain, anti-inflammatory medications as ordered. Monitor/document side effects and effectiveness. 5. If orthopedic fixation device or traction is present, follow physician's orders for monitoring, maintaining device, and providing skin care. 6. Monitor, document, and report as needed edema, bruising/discoloration of skin, skin temperature changes, loss of sensation distal to fracture, presence/absence of pulses distal to fracture. If cast is present, skin breakdown or trauma at cast edges and pad as recommended 5. PT, OT evaluate and treat as indicated. 7. Support injured area with pillows and immobilize part as appropriate. An Incident, Accident, Unusual Occurrence Note dated 3/2/2023 at 2:14 PM documented by the facility included; CNA was transporting resident in the shower chair from shower to her room. As they came around the corner, residents foot slipped under chair causing pain and bruising. Resident states My foot went under the shower chair Review of Nurse Progress Note documentation dated 3/2/2023 Incident, Accident, Unusual Occurrence; CNA transported Resident in the shower chair from shower to her room. As they came around the corner, residents foot slipped under chair causing pain and bruising. Resident states My foot went under the shower chair elevate foot, Ice pack administered, order for x-ray obtained and no fracture was determined. Will continue to elevate and ice as needed. Review of nursing note dated 3/6/23 revealed x-ray results no evidence of acute fracture or dislocation and No acute fracture dislocation seen. Osteoarthritis and Osteopenia Per Primary Care Physician (PCP) no acute fracture. No new orders. Power of Attorney (POA) notified and resident aware. Review of nursing note dated 3/6/23 advised the nurse called the Primary Care Provider (PCP) for concerns of residents left leg and foot. Calf and foot were swollen, red and had slight warmth to the touch. Resident stated some pain was present to the arch of the foot. Family was present in the room and also requested she be sent to Emergency Department (ED) and family all notified of transfer. The Nurses Note dated 3/11/23 at 11:54 AM documented, this nurse called PCP for concerns of residents left leg and foot. Calf and foot were swollen, red and had slight warmth to the touch. Resident stated some pain was present to the arch of the foot. Family was present in the room and also requested she be sent to ED. Review of nursing note dated 3/11/23 revealed Resident returned from ED with new orders. Minimal weight bearing for 2 weeks. Repeat left ankle x-ray in 2 weeks. Document dated 3/11/23 by the hospital reported; Ankle run over by shower chair now red and swollen possibly infection. X-rays completed, 3 views. Impression indicated a subacute oblique mildly fracture of the distal fibula with large amount of soft tissue swelling of the ankle. The Major Injury Determination Form dated 03/13/2923 reported the following; X-rays done on 3/1/23 showed no fracture. X-rays done 3/11/23 shows fibula fracture. Resident was transported in shower chair when foot caught under chair. Document narrated by the Physician and dated 4/8/23 advised the fibular fracture is healing, but the radiologist noticed a possible subtle fracture on the other side of the ankle. She had diffuse osteoporosis of her bones from being immobile. An interview with Resident #13 on 09/11/23 revealed Resident had broken her ankle earlier this year while at the facility. Resident was in the shower chair and was being transported to the shower room by a male staff member when her foot slid off the peddle and she scrapped her big toe and it hurt. Resident thought foot would be alright but it started swelling. The nurse on duty looked at the foot/ankle at the time of incident. On 09/13/23 at 10:51 AM Resident #13 was interviewed again and reported the morning of the incident a staff member transported her to the shower room. On the way there, Resident's foot hit the edge of the floor where the carpet and laminate come together and her foot twisted to the left. The worker stopped and looked at it. Resident indicated she did not see a nurse at this time. Resident had pain when it first happened. Resident advised she told staff she had pain. Staff looked at her foot and it was scraped. Resident was given a as needed (PRN) Tylenol 3 Resident's foot was x-rayed later in the day after a portable x-ray machine was brought in to the facility. The x-ray did not reveal a fracture or dislocation. Resident reported her foot was swollen and the back of her heal was bruised. Resident advised she continued to have pain and swelling to the left foot and ankle and several days after the incident she was sent to the Emergency Department at the request of a family member. Her foot and ankle were x-rayed again and a fracture was revealed. On 09/13/2023 at 6:46 PM A family member was interviewed and provided the following information. The family member was notified of the incident by the resident and not the facility. Reportedly Resident's foot was ran over when transported to the shower room. The foot pedals were not on. The staff member needed the Resident to hold her leg up while they pushed her down to the shower room. Resident reported it really hurt. Complainant observed the injury several hours later and advised it was swollen and black and blue. Does not think they iced her foot but may have given her a Tylenol 3. Complainant spoke to Staff Member I, Licensed Practical Nurse (LPN), who advised the foot did not look like that earlier. The Nurse claimed they had checked on the foot throughout the day. The foot was x-rayed that day and no fractures were indicated. Several days later the foot was the x-rayed again and it was determined there was a fracture. Resident not able to wear a shoe on that foot since the fracture. On 09/19/23 03:56 PM an in-person interview conducted with Staff B, Registered Nurse (RN), who reported the following. The injury to Resident #13's foot occurred prior to the start of her shift. During her shift a portable x-ray machine was brought in to the facility to x-ray the Resident's foot. The initial x-ray did not indicate there was a fracture. Several days later Resident #13's foot was x-rayed again after she was taken to the hospital. This x-ray revealed a fractured fibula. Staff B does not know how the injury was assessed or watched after the first x-ray. Staff B advised the foot was not hot to the touch. Staff B does not remember that the foot or ankle was hot or swollen but remembers the Resident had some pain. Resident had already been on Tylenol 3 PRN and that was provided. On 09/20/23 11:50 AM the Director of Nursing (DON), advised she was not at the facility when the incident occurred. The DON was not notified at the time of the incident. The DON reported Staff I, RN described to her how the injury occurred. Staff I advised Staff H CNA, was bringing the Resident back from the shower and the Resident's foot got caught underneath the shower chair. The Nurse that worked that shift completed an assessment. Later that day the doctor was notified and ordered a portable x-ray. The original x-ray did not indicate a fracture. The DON advised she assessed the Resident's foot the following morning and there no was bruising, redness or swelling. Resident always has had some edema plus 2 in her foot but nothing out of the ordinary for her. Resident was treated for pain. Resident had a previous order for Tylenol 3 PRN. Staff elevated and iced the Resident's foot. Prior to the incident Resident was not able to no ambulate on her own and was weak and couldn't pull herself up. Resident had had issues with transfers for a while. Staff H CNA had transported the Resident when the incident occurred. On 09/20/23 at 5:35 PM Accompanied by the DON the shower chair was observed. The DON indicated the large shower chair was likely the one used with the Resident the day of the incident. The PVC chair had a padded seat with hole along with six locking wheels and a mesh back. There was a pull-out platform foot rest. See pictures in file. On 09/21/23 09:11 AM Staff H provided the following interview. Staff H transported the Resident to the shower room. During the transport the area near the nurses station was congested with other residents. Staff H advised he was pulling the Resident backwards and then spun her around to navigate past the other residents and as he spun the shower chair it went over the slight slope between the laminate and carpet near the cafeteria and the Resident's toes caught on the carpet and the chair slid more than expected. The Resident had her shoes on. The Resident stated, my foot and Staff H immediately backed up the nurse Staff H was there. Staff H reportedly did not observe any redness to the foot. Staff H proceeded with the shower as Resident did not have pain. Staff H checked on the Resident before breakfast. Later that morning Staff H again checked resident who advised there was a little tenderness. Staff H then notified Staff I who reported they would monitor the Resident. The next time Staff H returned to work Staff H was advised the Resident had x-rays and there was no fracture. Staff H could not recall if the shower chair utilized had a platform for the Resident's feet on it or not. Staff H advised he had pulled the Resident backwards in the shower chair because there was no place for her feet. When the incident occurred the shower chairs, were older and Staff H advised the DON they needed replaced and shortly after facility got a new. Had a small, medium and large shower chair at that time. Staff H used the medium chair as it was shorter to the ground. Staff H could not recall if the medium chair had a foot platform on it. On 09/21/23 10:00 AM Staff I Licensed Practical Nurse (LPN) recalled the incident and explained what she could remember. Staff H CNA, was transporting Resident #13 backwards in the shower chair and when they approached the area was congested and Staff H turned the Resident around to better maneuver and her foot came down and got underneath the plastic PVC. The top of her foot just above her toes was scrapped. Reportedly the foot did not bend backwards. The chair sits high. Her feet were not on the floor because they didn't reach the floor. As soon as he realized he stopped quickly. Doesn't remember if the chair had footings or platform. Staff I looked at and noticed a slight rug abrasion on the top of the foot. Resident did not report pain. Staff I checked on her throughout my shift but didn't put anything in notes and called her family. Staff I indicated I know we had a portable x-ray technician come in and x-ray her and then the daughter took her to the ED and there were conflicting reports. Her next shift we were ace wrapping her. Went from sit to stand to Hoyer lift because it was getting to difficult for us as 3 staff. Per Staff I If there is any chance a resident's feet would hit the floor and I would think it would be safer to pull them backwards. 47336 2. The Quarterly MDS assessment dated [DATE] revealed Resident #34 scored 2 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely cognitively impaired. The MDS revealed the resident need extensive assistance with one- person physical assist with bed mobility, dressing, and toilet use. The MDS revealed the resident needed extensive assistance with two plus person physical assist with transfers. The MDS revealed the resident fell on ce since admission with no injury. The Care Plan revealed a focus area dated 1/16/23 of risk for falls related to the need for assistance and Parkinson's. The interventions dated 1/15/23 documented encouraged use of call light for assistance. The Care Plan lacked documentation for actual falls and interventions after resident's falls on 5/18/23 and 8/22/23. The Fall Risk Evaluation completed on 4/25/23 at 9:52 AM revealed a score of 8. The Incident Report #1111 revealed an unwitnessed fall on 5/18/23 at 11:20 AM with the following information. a. resident's description: resident stated he tried to close his blinds in his room and he tripped over his TV stand and TV and fell on to the floor. b. type of injury: no injury observed at the time of incident. c. mental status- oriented to person, situation, place and time d. no predisposing environmental factors. e. predisposing physiological factors: gait imbalance f. predisposing situation factors: ambulating without assist The Progress Note dated 5/18/2023 at 12:33 PM revealed the nurse and Certified Nurse Aide (CNA) ran down to see what they could find after they heard the yelling and found the resident laying on the floor face down. Resident stated he was not seriously hurt but did have some pain to his Left hip. This nurse did a head to toe assessment and found no major injuries. Vitals were taken and resident placed back into his wheelchair safely. The facility doctor in the building and also evaluated him. Resident stated he hit his head. This nurse called 911 and resident was sent to Emergency Department (ED) at the local hospital. The family, Primary Care Provider (PCP) and facility manger notified of incident. The Fall Risk Evaluation completed on 5/22/23 at 10:28 AM revealed Resident # 34 scored a 10 which indicated high risk for falls. The Fall Risk Evaluation completed on 7/19/23 at 3:33 PM revealed Resident # 34 scored a 8. The Incident report #1135 dated 8/22/23 at 3:00 AM revealed an unwitnessed fall with the following information: a. resident description: See what you did, where's my God Damn blanket? b. assist of 3 to get resident off of floor into WHEELCHAIR and then into bed. c. no injuries observed at time of incident. mental status: orient to person, situation, place and time. d. no predisposing environmental factors e. other predisposing physiological factors (resident agitated when tried to get out of bed by himself) f. predisposing situation factors: ambulating without assist The Progress Note dated 8/22/2023 at 3:43 AM revealed resident put self on floor due to not getting sheet fast enough. Resident laid on right side on floor beside bed. Assist of 3 to get resident off of floor into wheelchair and then into bed. No injuries noted. Resident denies pain/discomfort. Neuros Within normal limits (WNL). The Fall Risk Evaluation completed on 8/22/23 at 3:46 AM revealed Resident # 34 scored a 6. During an observation 09/14/23 10:27 AM Resident # 34 sat in his wheelchair in the dining room and played Bingo with other residents. During an interview on 9/14/23 at 1:10 PM, Staff A, Registered Nurse (RN) queried on the interventions after a fall and she stated most falls were unwitnessed and she went and got vital signs, a head to toe assessment, seen if resident hit their head, did neuros, and got them laid back in bed. She stated they did a risk management, notified the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) and informed the doctor and family and if the resident injured themselves, they went to the hospital and if the resident on a blood thinner they automatically went to the Emergency Department (ED) for a scan. During an interview on 9/20/23 at 10:10 AM, the ADON queried on how management found out about falls and he stated in the morning meeting they discussed risk management and if any falls happened since previous day meeting and what happened and the cause. The ADON asked if they looked at the root analysis for falls and he stated yeah, we discussed the circumstances of the fall and what went on and what time of day and the contributing factors. The ADON asked if they filled out a form or paperwork and he state they didn't use a form. The ADON asked if they looked at interventions and he stated yes, they looked at different interventions. The ADON asked how the staff knew of the new interventions and he stated they were usually done in the meeting and if the interventions would have been put in, they linked to the Kardex for staff to know them. During an interview on 9/20/23 at 11:25 AM, the DON queried on how she found out about a fall and she stated she staff notified her or the ADON and then every morning they looked at the risk management and seen if they got notified. The DON asked if they did root cause analysis with falls and she stated yeah, they just started doing them and a received a training on them. She stated they did a little investigation and found out what the resident did when they fell and the interventions in place when they fell . During an interview on 9/20/23 at 3:30 PM, the DON queried if a root cause analysis completed and documented for Resident #34 and she stated she would look. No documentation submitted for a root cause analysis for Resident #34 for falls. The Facility Falls - Clinical Protocol Policy dated March 2018 revealed the following information: a. The staff and practitioner will review each resident ' s risk factors for falling and document in the medical record. 1. Examples of risk factors for falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment. b. The physician will identify medical conditions affecting fall risk (for example, a recent stroke or medications that cause dizziness or hypotension) and the risk for significant complications of falls (for example, increased fracture risk in someone with osteoporosis or increased risk of bleeding in someone taking an anticoagulant). 1. Falls often have medical causes; they are not just a nursing issue.

Based on observation, interview, and record review, the facility failed to ensure prompt follow up on urinalysis and culture and sensitivity results, failed to document effectiveness of antibiotics, failed to ensure a catheter drainage bag remained positioned off of the floor, and failed to promptly address decreased urinary output for a resident who had a Foley catheter for three of four residents reviewed for catheter and/urinary tract infections (Resident #19, Resident #93, Resident #143). The facility reported a census of 38 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #143 dated 9/21/22 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, Resident #143 had an indwelling catheter. The Care Plan dated 10/1/22 documented, I have a chronic urinary tract infection which require prophylactic antibiotics. The Intervention dated 12/9/22 documented, give antibiotic therapy as ordered. Monitor for and document side effects and effectiveness. Another intervention also dated 12/9/22 documented, Monitor, document, and report to physician as needed any signs or symptoms of urinary tract infection: frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes. The Physician Order dated 11/7/22 to 11/9/22 documented, Urinalysis (UA) with Culture and Sensitivity (C& S) one time only for 2 Days. Review of a Bacteriology report from a urine culture, collection date 11/8/22 with final report verified date and time 11/13/22 at 11:43 AM, documented the following: 70-80,000 cfu/ml Escherichia coli Multi drug-resistant organism. Recommended isolation precautions. Extended spectrum Beta lactamase (ESBL) type organism. This organism should be considered resistant to all penicillin's, cephalosporins, and aztreonam. Organism is a Carbapenem-resistant Enterobacteriaceae. Consider using Contact Isolation precautions. Organism is not enzyme producing. > (greater than) 100,000 cfu/ml Pseudomonas aeruginosa. Review of documentation hand written on the bottom of the report revealed, please call me with current weight. Review of the resident's Progress Notes between 11/13/22 and 11/22/22 at 1:26 PM lacked documentation of follow up about the resident's weight, and lacked reference to further actions taken following the Bacteriology report results (dated 11/13/23). The Order Note dated 11/22/22 at 1:26 PM documented, Verbal order received to hold methenamine while on Bactrim and Cipro. Power of Attorney (POA) aware. Medication Administration Record (MAR) updated. The Physician Order, start date 11/23/22, documented, Cipro Tablet 500 MG (Ciprofloxacin HCl) Give 1 tablet by mouth two times a day for UTI for 7 Days. The Physician Order, start date 11/23/22, documented, Bactrim DS Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for UTI for 7 Days. On 9/20/23 during an interview with the Director of Nursing (DON), additional information was requested about what occurred for the resident between 11/13/22 until the antibiotics began. On 9/21/23 at 2:00 PM, the Director of Nursing explained the Nurse Practioner (NP) had been unable to find the culture and sensitivity. The eInteract Transfer Form dated 12/2/22 revealed the resident sent to [Hospital Name Redacted] on 12/2/22 per resident and family request. Blood pressure, pulse, respiration, temperature, and oxygen saturation vital signs for the resident were all dated 11/27/23. Review of an Infectious Disease Note from Hospital Records, date of service 12/3/22, documented, in part the following for Resident #143: presents with chief complaint (CC) of lower abdominal pain and lower back pain. Infectious Disease (ID) is consulted for Urinary Tract Infection (UTI) [Resident #143] was admitted to [Hospital Name Redacted] yesterday through the emergency department (ED) where she presented [illegible words] facility in [City Redacted] w/ (with)UTI concerns. She has been at [City Name]. CC of malodorous urine and abdominal pain worse over the past several days. The Assessment and Plan per Hospital Records documented, in part, the following: ID is consulted for UTI Isolated E faecalis from new Foley urine culture on 12/2 .She recently received treatment of cipro and tmp/smx for full duration for UTI that didn't improve likely because of current culture showing E faecalis. Recommend treatment of E faecalis with vancomycin until the susceptibilities come back, then can likely de-escalate. 2. The Admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #93 revealed the resident scored 12 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The assessment revealed Resident #93 as frequently incontinent of urine. The MDS documented that the resident had diagnoses including Multiple Sclerosis (MS), and kidney disease. The Care Plan initiated 8/28/23 revised 9/11/23 documented, I have a urinary tract infection. The Intervention dated 9/11/23 documented, give antibiotic therapy as ordered. Monitor for and document side effects and effectiveness. The Nurses Note dated 8/31/23 at 3:36 PM documented, Resident holding arm up complaining of (c/o) starting to have an MS flare-up and asking for Solumedrol. This RN called [Nurse Practitioner Name Redacted] and discussed residents MS and request for solumedrol; [Name Redacted] states that resident needs to follow up with Neurology, [Name Redacted] re; MS and she will not order solumedrol at this time. UA (urinalysis) was ordered stating infections may cause flare up. The Physician Order dated 8/31/23 to 9/2/23 documented, UA with C&S one time only for 2 Days possible MS flare up r/t UTI. Review of Resident #93's Medication Administration Record (MAR) dated August 2023 revealed the following, start date 8/31/23: UA (urinalysis) with C&S (culture and sensitivity) one time only for 2 Days possible MS (multiple sclerosis) flare up r/t (related to) UTI (urinary tract infection). Review of the resident's MAR for September 2023 revealed the order signed as completed on 9/1/23. The Provider Note dated 9/5/23 at 12:00 AM documented, in part, the following for Resident #93: She states that she thinks she is having an MS flare .A UA was obtained and results are pending. The Nurses Note dated 9/7/23 at 10:16 AM documented, UA from 9/1 results received on 9/6, PCP notified. New order for antibiotic. The Provider Note dated 9/7/23 at 12:00 AM documented, in part, the following for Resident #93: seen today for follow-up of urinalysis and urine culture. She had felt that she was having symptoms related to an MS flare. Due to this, a urinalysis was obtained. Urinalysis and culture returned today. The urinalysis showed leukocyte Estrace, negative nitrates. She had 11-20 WBCs (white blood cells) per high-power field. Urine culture was faxed to me today and shows 2 different organisms, a multidrug-resistant E. coli and Streptococcus group . Due to resistance pattern and allergy to cephalosporins, we are limited in what we can use for treatment. Discussed that ertapenem would be a good option that would cover both E. coli and strep. Discussed that this would need to be given intramuscularly. The Physician Order dated 9/8/23 to 9/15/23 revealed, Ertapenem Sodium Injection Solution Reconstituted 1 GM (Ertapenem Sodium)with directions to inject 1 gram intramuscularly one time a day for UTI for 7 Days. The MAR dated September 2023 for Resident #93 revealed Ertapenem administration daily from 9/8/23 through 9/14/23. Review of Progress Notes for Resident #93 lacked documentation of monitoring for antibiotic effectiveness or side effects. Review of Skilled Evaluation documentation dated 9/8/23 and 9/9/23 for Resident #93 lacked documentation the resident currently under treatment for a UTI, and lacked documentation of signs and symptoms of infection or antibiotic effectiveness. On 9/20/23 at 10:42 AM during an interview with the Assistant Director of Nursing (ADON), the ADON explained a UA would come back in 24 to 48 hours, and the C and S in 3 to 4 days sometimes. When queried if there was a certain timeframe when they would call, the ADON explained usually on labs they called the next day, and with the UA either the next day or the day after. On 9/20/23 at 12:26 PM, the Director of Nursing (DON) acknowledged issues with labs not faxed right away. The DON explained the nurse would need to follow up and make sure got results, then needed to notify the practitioner. The Facility Policy titled Antibiotic Stewardship dated 12/16 documented, 11. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. 47336 3. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 scored 12 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS documented extensive assistance with two plus person physical assist. The MDS revealed an indwelling catheter. The MDS lacked documentation of a diagnosis of an indwelling catheter. The MDS revealed the resident received an antibiotic 3 out of 7 days. The Admission/Readmission Evaluation dated 7/21/23 at 4:22 PM revealed a urinary catheter not present and Resident # 19 always incontinent. The Admission/Readmission Evaluation dated 8/1/23 at 1:24 PM revealed Resident #19 continent of bladder with a 16 French catheter Foley catheter in place. The Care Plan revealed a focus area for a urinary catheter related to a neurogenic bladder dated 8/1/23. The interventions dated 8/1/23 documented catheter care every shift and evaluation for removal of the catheter. The interventions dated 9/11/23 revealed a catheter size 18 French, 10 cc (milliliter) indwelling catheter and position catheter bag and tubing below the bladder and way from the entrance door. The interventions dated 9/11/23 documented monitored, documented and reported signs or symptoms of urinary tract infection as needed such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, pulse, increased temp., urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and eating patterns. The Progress Notes dated 8/7/2023 at 8:23 PM documented resident's Foley found out of bladder at approximately 7:00 PM, disposable underwear soaked with urine, bladder not distended, resident denied any distress. On call Medical Doctor (MD) notified, will watch overnight and MD will see in the morning. The Skilled Progress Note (SPN) dated 8/8/2023 at 2:02 PM revealed resident incontinent and used disposable underwear, Foley catheter found and discontinued yesterday. The Progress Note dated 8/9/2023 at 1:30 PM revealed an 18 French catheter inserted with 5 cc balloon. No return of urine, this nurse flushed catheter with still no return of urine. Resident tolerated well. Advanced Registered Nurse Practitioner (ARNP) notified and continued to monitor and draw complete metabolic panel (CMP) lab. The SPN dated 8/9/2023 at 6:28 PM revealed resident monitored for (cerebral vascular accident (CVA) and left sided weakness. Resident with a poor appetite, didn't eat supper this evening, he wanted to stay in bed due to being tired. Plan of care ongoing. The Orders Noted dated 8/10/2023 at 4:18 AM revealed monitored urine output every shift. The SPN dated 8/10/2023 at 6:12 PM revealed reason for evaluation: Hot Charting (Not related to incident/accident/unusual occurrence)- Resident evaluated for the insertion of a new catheter. Resident with adequate urine outflow at this time, and denies any discomfort in his abdomen. The Progress Note dated 8/11/2023 at 9:44 AM revealed the physician called with new orders for antibiotic Cephalexin to be started and given 4 times a day for 5 days. The EMR (Electronic Medical Record) revealed a diagnosis of retention of urine, unspecified dated 8/1/23 and creation date of 9/11/23. The Physician Order revealed the following orders: a. ordered 8/11/23- Cephalexin Oral Capsule 500 MG (Cephalexin)- Give 500 mg by mouth four times a day for UTI (urinary tract infection) for 5 Days b. ordered 9/11/23- type of Catheter: indwelling; size of catheter: 18 French; Bulb Size: 10 cc; How often to change: Monthly c. ordered 8/11/23- monitor urine output every shift d. ordered 8/1/23- Foley catheter, 18 French, 10 ml. Change monthly and PRN (as needed)- every evening shift every 1 month(s) starting on the 1st for 1 day(s) e. Start Date-08/10/2023 1330 Check Vital Signs every shift for 24 hrs for 1 Day -Start Date- 08/10/2023 1330- Monitor urine output every shift The August TAR (Treatment Administration Record) revealed Resident # 19 produced 0 ml (milliliters of urinary output on the evening shift of 8/9/23 and 5 ml of urinary output on the night shift of 8/9/23. The day shift of 8/10/23 Resident # 19 produced 1700 ml of urinary output. During an observation on 9/11/23 at 1:55 PM, the urinary catheter hooked to the side of the bed and laid on the floor. During an observation on 9/13/23 at 3:24 PM, the catheter bag laid on the floor hooked to the side of the bed. During an observation on 9/14/23 at 3:56 PM, Resident #19 laid in bed and catheter bag laid on the floor, not attached to the bed. During an observation on 9/18/23 at 8:24 AM, Resident # 19 transferred with the sit to stand and during the transfer the urinary catheter bag drug on the floor. During an interview on 9/14/23 at 1:28 PM, Staff Registered Nurse (RN) queried where the catheter bag needed to be located for good drainage and she stated the bag needed hooked to the frame of the bed and when in a wheelchair they needed a dignity bag and hooked to the bottom of the seat lower than the bladder. Staff A asked if the catheter bag can touch the floor and she stated no. During an interview 9/19/23 at 12:31 PM, Staff D, Certified Nurse Aide (CNA) queried on where the catheter bag is placed for proper drainage and she stated normally it hung on the bed frame. Staff D asked if the catheter bag could touch the floor and she stated no, it shouldn't touch the floor. Staff D asked where she placed the catheter when transferring a resident in a sit to stand and she stated the sit to stand had a hook the catheter bag hung it on. Staff D asked how often catheter care completed and she stated she checked it every 2 hours. Staff D asked when she would be concerned with low urine output and she stated normally less than 200 milliliter (ml) wasn't really a lot especially when not emptied out of the catheter and pushed fluids. She stated she told the nurse to make sure everything was okay. During an interview on 9/19/23 at 12:59 PM, Staff C, CNA queried on where the catheter bag needed placed for good drainage and she stated on the bed frame. Staff C asked if the catheter bag could touch the floor and she stated no and she stated when the resident laid far down in bed she hung it on the foot of the bed up high enough but not pulling the tube tight to keep the bag off the floor. She stated she used a two person assist with Resident #19 when she used the sit to stand and had the other CNA hold the catheter bag so it didn't get pulled out. Staff C asked how often catheter care completed and she stated completed it at the beginning and end of every shift and drain the bag in the morning and when she put them in bed and did catheter care as well. Staff C asked what she considered low urinary output and what she did and she stated actually they just had an incident and immediately told my charge nurse and the DON (Director of Nursing). She stated the incident happened with Resident #19 probably 3 or 4 weeks ago. She stated she went into his room and only had 25 ml in the catheter and she told the charge nurse and they called NP (Nurse Practitioner) and she came in and fixed it right up and drained the catheter. Staff C asked if she received report about the resident's urinary output and she stated she didn't get report he didn't have any urine. Staff C asked if urinary output should be reported and she stated yep it was something we should report. During an interview on 9/19/23 at 3:59 PM, Staff B, RN queried on what she considered a change of condition and she stated a major change in vitals, for example a pulse 60 normally and then today 110; a fever, any change in vital signs, pain, weight loss, fall, and look at people and see if something off were what she considered a change of condition. Staff B what she done for a change of condition and she stated if something not right she called the physician or called the ambulance. Staff B asked how nurses reported to each other on things like urinary catheter output and she stated she concerned about Resident #19 when he got here and monitored his urinary output. Staff B stated she informed all the nurse aides he needed 30 ml out an hour. She stated Resident #19 never produced less than 300 ml a shift for her and she gave him fluids every time she seen him. Staff B asked what interventions she did if a resident didn't produce any urinary output for a shift and she stated she would reposition the catheter and looked to see if draining, pushed fluids, palpated the bladder, and called the doctor for an order to flush the catheter or change the catheter. Staff B asked what interventions she did if a resident didn't produce urinary output for 2 shifts and she stated the same interventions and made sure the catheter tube not kinked. Staff B asked if she documented the interventions and she stated yes, she would and no urinary output would be a big concern. During an interview on 9/20/23 at 11:25 AM, the Director of Nursing (DON) queried on what she considered a change of condition and she stated it could be a cough or cold, decrease in Activities of Daily Living (ADL), and anything not in their normal baseline. The DON asked how nurses reported to each other on things like urinary catheter output and the CNA grabbed the amounts at the end of their shift and monitored it with cares and let them know when the resident had little to no output and even they didn't produce more than 300 ml. The DON asked she expected of the nursing staff if a resident didn't produce any urinary output in their catheter in a shift and she stated her as a nurse assessed the person, asked about pain, palpated bladder and advanced the catheter and seen output came out and called the on call or Primary Care Provider (PCP)and let them know the residents didn't produce output. She stated if no output for 8 hours, she called the doctor. Discussed the situation with documentation of Resident #19 of no production of urinary output for 2 shifts and then on the day shift produced 1700 ml and then the following day received orders for a UTI. The DON asked what she expected to happen in this situation and she stated she expected by the second shift for them to call the on call and the PCP to find out what to do next. The DON asked if this situation contributed to the UTI and she stated possibly. The DON stated the ARNP advanced the catheter that morning and informed them the catheter needed to go all the way to the split and then ordered a UA (urinalysis). During an interview on 9/20/23 at 12:38 PM, the DON queried asked if the catheter bag could touch the floor and she stated no, it shouldn't touch floor for any circumstance. The Catheter Care, Urinary Policy dated September 2014 revealed the following information: a. Input/Output 1. Observed the resident ' s urine level for noticeable increases or decreases. If the level stayed the same, or increased rapidly, report it to the physician or supervisor. b. Infection Control 1. Be sure the catheter tubing and drainage bag kept off the floor. c. Complications 1. Observed for other signs and symptoms of urinary tract infection or urinary retention. Reported findings to the physician or supervisor immediately. d. Managing Obstruction 1. If the catheter material contributed to obstruction, notified the physician and changed the catheter if instructed to do so. 2. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction.

Based on observation, interview, and record review the facility failed to ensure care plans were updated to reflect a resident's toe amputation surgery, discontinuation of as needed (PRN) Lorazepam medication, discontinuation of hospice services, discontinuation of a catheter, updated to include receipt of prophylactic antibiotic medication, and updated to include fall interventions for four of fourteen residents reviewed for care plans (Resident #1, Resident #24, Resident #25, Resident #34). The facility reported a census of 38 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Review of the resident's Care Plan to address anti-anxiety medication use revealed the following intervention as part of the Care Plan: The Intervention dated 5/4/21 documented, I have prn Lorazepam that I may take if needed for comfort, please monitor my behaviors and if interventions such as pain medication, snack/drink, 1:1's do not help may give prn dose and monitor for side effects (SE's): dizziness, drowsiness, confusion, HA, anxiety, tremors orthostatic hypotension to report. The Intervention dated 5/4/21 documented, Monitor for effectiveness and SE's of Clonazepam and report concerns to Primary Care Provider (PCP) and Hospice; drowsiness, dizziness, confusion, headache, tremors, insomnia, slurred speech, suicidal tendencies ect. Review of Physician Orders for Lorazepam for Resident #24 revealed the most recent Lorazepam order discontinued in December 2022. The Encounter Note dated 5/25/23 documented, in part, That said she did recently graduate from hospice protocol for inoperable terminal gastrointestinal (GI) cancer and has advanced chronic obstructive pulmonary disease (COPD). On 9/19/23 at 10:03 AM, the date Resident #24 had hospice services discontinued was requested from the facility's Administrator via email. On 9/19/23 at 11:06 AM, the Administrator provided the response via email that hospice services were discontinued for the resident on 3/25/23. 2. The Admission MDS assessment for Resident #25 dated 11/23/22 documented Resident #25 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Medical diagnoses for Resident #25 included, in part, Diabetes Mellitus type 2 without complications and fusion of spine. Review of of Resident #25's Care Plan did not address the resident's recent amputation of the toes or receipt of prophylactic antibiotic medication. Review of notes from an outside provider for Resident #25 revealed the resident had a transmetatarsal amputation, right on 8/25/23. The Nurses Note dated 8/25/23 at 5:21 PM documented, Resident returned from [Hospital] s/p (status post) R foot amputation of toes via private vehicle with friend. Resident states she has no pain or discomfort at this time. Observation on 9/19/23 at 8:51 AM revealed Resident #25 in their wheelchair in the hallway. The resident had a black boot in their lap, and had a blue soft boot to their right foot. The resident self propelled herself down the hallway using her left foot. The resident had a tennis shoe to the left foot. Review of Physician Orders for Resident #25 revealed the following, active 7/7/23: Doxycycline Monohydrate Oral Capsule (Doxycycline (Monohydrate)) Give 100 mg (milligram) by mouth two times a day for prophylactic antibiotic (ATB) related to FUSION OF SPINE, LUMBAR REGION. On 9/20/23 at 10:09 AM, the Assistant Director of Nursing (ADON) explained he usually did the Care Plans. When queried how often they would be updated, the ADON explained any time and any change it should be updated and possibly reviewed with each MDS. When queried about Resident #25's amputation, the ADON explained he forgot and it should have been on the Care Plan for a surgical wound. When queried as to hospice and PRN Lorazepam use present on Resident #24's Care Plan, the ADON explained hospice should have been taken off, and acknowledged the resident was off the PRN anti-anxiety medication. When queried about Resident #25's antibiotic, the ADON acknowledged it should have been on the care plan, and he thought it was. Per the ADON, it had been on the Care Plan, and someone had resolved it on 9/12/23. The ADON explained he was going to unresolved it now. On 9/20/23 at 11:23 AM, the Director of Nursing (DON) explained a lot of the older nurses knew they could go in and out something in, interventions, things like that. The DON explained a lot of the nurses did not touch the care plans. The DON acknowledged the resident's amputation should be on the care plan, Ativan and hospice should be off, she believed the resident still took the antibiotic, and it would not be resolved until done. The Facility Policy revised 9/13 documented, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 47336 3. The MDS assessment dated [DATE] revealed Resident #1 didn't complete Brief Interview for Mental Status (BIMS) exam due to resident rarely understood. The MDS revealed an indwelling catheter and the resident needed extensive assistance with one person physical assist with toilet use. The MDS revealed the resident utilized a wheelchair. The MDS revealed medical diagnosis of obstructive uropathy and benign prostatic hyperplasia with lower urinary tract symptoms. The Care Plan revealed a focus area revised on 12/19/22 of self care deficit related to cognitive impaired associated with mental illness, urinary retention and need for indwelling catheter, occasional refusal of cares and bathing. The interventions dated 2/13/18 documented monitored for s/s (signs/symptoms) of urinary infection; increased o/p (output), change in mental status, odor to urine, flank pain to report to MD (medical doctor). The Progress Note dated 8/3/23 at 9:15 PM revealed the resident reported catheter out at approximately 2:00 PM, 3 attempts made to replace it but it would not insert. The Skilled Progress Note (SPN) dated 8/4/23 at 10:32 AM revealed resident pulled out catheter on 8/3/23. Resident incontinent with urine output. The SPN dated 8/5/23 at 6:48 PM revealed resident monitored for no longer having his catheter. The Advanced Registered Nurse Practitioner (ARNP) Encounter dated 8/8/2023 at 2:18 PM revealed the catheter inadvertently pulled out and resident wore incontinent briefs. The Orders Administration Note dated 9/5/23 at 11:29 PM revealed change catheter supplies and restock supplies. (basin, bags, ostomy drops, catheter plug, alcohol wipes) every night shift starting on the 5th and ending on the 5th every month with comment: NO CATHETER. During an observation on 9/11/23 at 3:12 PM, no catheter/tubing observed on the resident. During an observation on 9/14/23 at 3:57 PM, Resident # 1 observed in his wheelchair and self propelled to his room with no catheter/tubing observed. During an interview on 9/20/23 at 10:20 AM, the ADON/MDS Coordinator queried when orders and the care plan needed updated such as a resident no longer utilized a urinary catheter and he stated as soon as they happen. The ADON acknowledged the care plan should of been updated. During an interview on 9/20/23 at 11:25 AM, the DON queried if Resident #1 currently utilized a urinary catheter and she stated no, he didn't for 2 months now. The DON asked with the care plan focus area self deficit should be updated to reflect he no longer utilized the urinary catheter and she stated yes, she would of expected it taken out of the care plan. 4. The Quarterly MDS assessment dated [DATE] revealed Resident #34 scored 2 out of 15 on a BIMS exam, which indicated severely cognitively impaired. The MDS revealed the resident need extensive assistance with one person physical assist with bed mobility, dressing, and toilet use. The MDS revealed the resident needed extensive assistance with two plus person physical assist with transfers. The MDS revealed the resident fell on ce since admission with no injury. The Care Plan revealed a focus area dated 1/16/23 of risk for falls related to the need for assistance and Parkinson's. The interventions dated 1/15/23 documented encouraged use of call light for assistance. The Care Plan lacked documentation for actual falls and interventions after resident's falls on 5/18/23 and 8/22/23. The Progress Note dated 5/18/2023 at 12:33 PM revealed the nurse and Certified Nurse Aide (CNA) ran down to see what they could find after they heard the yelling and found the resident laying on the floor face down. Resident stated he was not seriously hurt but did have some pain to his Left hip. This nurse did a head to toe assessment and found no major injuries. Vitals were taken and resident placed back into his wheelchair safely. The facility doctor in the building and also evaluated him. Resident stated he hit his head. This nurse called 911 and resident was sent to Emergency Department (ED) at the local hospital. The family, Primary Care Provider (PCP) and facility manger notified of incident. The Progress Note dated 8/22/2023 at 3:43 AM revealed resident put self on floor due to not getting sheet fast enough. Resident laid on right side on floor beside bed. Assist of 3 to get resident off of floor into wheelchair and then into bed. No injuries noted. Resident denies pain/discomfort. Neuros Within normal limits (WNL's). During an observation 09/14/23 10:27 AM Resident # 34 sat in his wheelchair in the dining room and played Bingo with other residents. During an interview on 9/20/23 at 10:20 AM, the ADON queried if Resident #34 care plan needed updated for a focus area of falls and interventions updated after his falls and he stated yes with interventions. The ADON stated the care plan needed changed from risk to actual falls and interventions needed to be put in. During an interview on 9/20/23 at 11:25 AM, the DON queried if she expected the care plan updated from risk to fall to actual fall after a resident fell and she stated yes, and the interventions should be done.

Based on observation, interviews, and record review the facility failed to ensure Residents was treated in a dignified manner for 1 of 1 resident reviewed for dignity. (Resident #35). The facility reported a census of 38 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment for resident # 35 dated 07/25/23 documented the Resident scored 12 out of 15 on a Brief Interview for Mental Status (BIMS) exam which indicated the resident was moderately cognitively impaired. There is no evidence that resident had an acute change in mental status from the resident's baseline. Resident has clear speech and ability to express ideas and wants. The Care Plan documented a focus area with initiated date of 9/12/23 as follows; Resident#35 will receive specialized services to maintain my highest possible level of functioning in the least restrictive environment. The interventions and tasks included; a) Initiated: 09/12/2023 Resident will receive a functional assessment of maladaptive behaviors by a qualified behavior analyst or qualified behavior health professional with equivalent experience. b) Initiated: 09/12/2023 Psychological testing for differential diagnosis, resulting in appropriate treatment plan revisions and services will be implemented. c) Initiated: 09/12/2023A comprehensive Functional Analysis and work with staff to train them in how in how to develop strategies for addressing identified behaviors. d)Initiated: 09/12/2023 Mental Health Services Provider will complete psychological testing, staff member responsible for making appointment, date of appointment and timeline for delivery and implementation of treatment plan development or changes. e) Initiated: 09/14/23 Dr. (physician name redacted) provides psych services to the resident in the facility During an observation on 09/11/23 at 11:52 AM Surveyor observed a medical professional who identified themselves as the Nurse through their insurance talking to Resident #35 and advised I will be seeing you once a week. Listened to resident's heart in the dining room in front of the other residents. Looked at resident's legs and feet for swelling. Asked if she had skin concerns. Stated she has a rash under her breasts. Does it hurt or itch. Are they using a cream or anything on it.? Nurse then talking to resident about about constipation. During an interview on 09/19/2023 at 9:13 AM Resident #35 stated she doesn't know the name of her doctor but it is a female and she is new. Resident #35 advised the doctor meets with her all over the building. Resident occasionally has concerns about the practitioner meeting with her in open areas where other residents are present. Last week she met with me in the dining room. The practitioner talked with resident about if she is able to go to the bathroom or is having any problems with that. Practitioner also meets with her in her room. Resident advised it wasn't too tactful. During an interview on 09/20/2023 at 12:10 PM with the Director of Nursing (DON), if a doctor or medical practitioner is at the facility to meet with the resident they would meet with them in their room or another private area. The DON explained they have a Nurse Practitioner through the resident's insurance that comes to visit the resident every few weeks. The Facility Policy titled Dignity stated; staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interview, and record review the facility failed to ensure a resident was assessed for self administration of medications prior to the resident's inhaler present at bedside for one of one resident reviewed for self administration (Resident #24). The facility reported a census of 38 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Review of Resident #24's Care Plan did not address self administration of medication. The Physician Order dated 3/30/23 revealed, Ventolin HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) with directions for 1 puff inhale orally every 4 hours as needed for dyspnea. On 9/12/23 at approximately 2:00 PM, during an interview with Resident #24, a Ventolin inhaler was observed at the resident's bedside. On 9/13/23 at approximately 4:00 PM and 4:40 PM, observations were conducted from the hallway at the open door to the resident's room. On both observations, a blue inhaler was observed next to the resident's bed. On 9/13/23 at 4:43 PM when queried if there were residents who self administered medications, the Director of Nursing (DON) responded no. When notified of the inhaler at bedside, the DON followed up with the nurse. On 9/13/23 at 4:50 PM the DON explained she grabbed it, and further explained the resident could now take it out with her. The Facility Policy titled Self Administration of Medications, revised 2/21, documented, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.

Based on record review and staff interviews, the facility failed to ensure that the consent was properly obtained when they required a resident with severe cognitive deficits, documented dementia and delusional disorder diagnoses, and history of suicidal ideation, to execute an Advanced Directive, instead of establishing a Power of Attorney (POA) as mandated by the resident's Level II PASARR requirements (Pre Admission Screening and Resident Review), for 1 of 4 residents reviewed with Level II PASARR's (Resident #34). The facility reported a census of 39 residents. Findings include: The Admission Minimum Data Set (MDS) Assessment tool dated [DATE] revealed resident #34 admitted to the facility [DATE] with diagnoses that included Post Traumatic Stress Disorder (PTSD), psychotic disorder, anxiety,Parkinson's disease and mild cognitive impairment, with a Level II PASARR that specified specialized services were required for other related conditions. The [DATE] Quarterly MDS Assessment tool revealed the resident scored 2 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated severe cognitive impairment, with symptoms of delirium always present that did not fluctuate. The resident's [DATE] Quarterly MDS Assessment tool revealed the resident scored 2 out of 15 points possible on the BIMS assessment, that indicated severe cognitive impairment, with symptoms of delirium present that fluctuated in severity. The resident's [DATE] and [DATE] Level II PASARR assessments stated: Resident diagnoses included Major depression, Delusional Disorder, Adjustment Disorder with Depressed Mood, Post Traumatic Stress Disorder (PTSD), Mood disorder due to general medical condition, and generalized anxiety disorder. Further details in the assessment described the resident: 1. diagnosed with Mild Neurocognitive Disorder and sometimes has trouble with memory. 2. Sometimes confused to who he is, where he is at, time, date and what is going on. 3. Due to conflicting cognitive reports, it appears that memory may fluctuate and at times the resident may have a poor awareness to his needs and not always capable of making decisions based on health, safety, and best interests. Resident will benefit from having the support of a substitute decision maker to help with decision making. The resident's Level II PASARR requirements stated: 1. If admitted to a Medicaid Certified Nursing Facility, the Nursing Facility staff are required to: a. Designate or establish a Power of Attorney (POA) for healthcare and financial matters in order to serve as a substitute decision maker in the event of incapacity, assist with decision making and support the resident's health, resource management, and/or safety. The resident's Nursing Care Plan included the following problems and staff directives: 1. Pre-Admission Screening & Resident Review (PASRR) problem, initiated [DATE], has been completed prior to the resident's admission to the facility, with 180 day approval that expired [DATE], and a non-limited PASRR on [DATE], directed staff: a. The facility will ensure that the nursing home is proper placement for the resident, initiated [DATE]. b. Facility administrator/designee will assist with formulating advanced directives, initiated [DATE], c. Facility administrator/designee will assist with obtaining guardianship/POA decision maker, imitated [DATE]. 2. PASRR has identified the following community placement supports, which resident may wish to explore as part of preparation for movement to the community, if and when the resident's return to home or community is determined problem, initiated [DATE], directed staff: a. Develop a healthcare advanced directive. b. Resident in need of a guardian, conservator, and/or Power of Attorney for Healthcare. Assistance required for the designation of such a person to help the resident for purposes of support with decisions about care needs, health and safety. c. Resident refuses to allow family member to obtain POA for decision making at this time d. Social services/designee contacted a Fiduciary Services to inquire guardianship services, initiated [DATE]. e. Social services/designee contacted the County Community Services to obtain guardianship-no services in the County, initiated [DATE]. 3. An impaired cognitive function/dementia or impaired thought processes related to Parkinson's, recent hospitalization problem, initiated [DATE] directed staff: a. Use resident's preferred name. Identify yourself at each interaction. Face resident when speaking and make eye contact. Reduce any distractions - turn off TV, radio, close door etc. Resident understands consistent, simple, directive sentences. Provide resident with necessary cues. Stop and return if I resident agitated. b. Keep resident routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. c. Monitor, document, and report as needed any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. An Advanced Directive Assessment form in the resident's electronic medical record, dated [DATE], completed by the facility's Social Worker (SW) stated the resident participated in the Advanced Directive and did not want to execute an Advanced Directive. A progress note dated [DATE], transcribed by the resident's psychiatric specialist provider, described the resident seen and treated for depression, anxiety, irritability, isolation, withdrawal, confusion, memory loss, short term memory problems, long term memory problems and adjustment disorder, assessments completed during the visit included a SLUMS assessment (St. Louis University Mental Status Examination, a screening test for Alzheimer's disease and other kinds of dementia), the resident scored 18, a score of 1 to 19 indicated dementia. A Nursing Progress Note dated [DATE] at 12:39 p.m., transcribed by the facility Administrator, revealed a BIM's cognitive assessment completed with the following results: Number of words repeated after first attempt: Three. Able to report correct year. Able to report correct month: Accurate within 5 days. Able to report correct day of the week: Incorrect or no answer. Record response (day): Wednesday Able to recall sock: Yes, no cue required. Able to recall bed: No, could not recall. Able to recall blue: Yes, no cue required. CSC - BIMS Summary score: 12.0 An email received from the facility Administrator dated [DATE] at 11:59 a.m., addressed to the Surveyor, stated the resident agreed to allow their family member to be his POA. Staff interviews revealed: [DATE] at 11:32 a.m., the Regional Director of Clinical Services (RDCS) stated the facility had not established a Guardian or POA for the resident, as directed in the resident's Level II PASARR. [DATE] at 11:47 a.m., the SW stated he reached out to the resident's family member that is designated as his Emergency Contact several times, they said they didn't know him/had no contact with him until recently and did not want to be responsible as his decision maker. The SW stated he called the county attorney a couple of months ago, asked about establishing a Guardianship for him, they said they would look it up, but hasn't gotten back to him and he would contact them again. [DATE] at 12:20 p.m., the RDCS stated she called the county attorney, they will do paperwork for someone to be the Guardian but will not be a Guardian, she contacted the County's community services who can't provide that support, and she has left a message with a Fiduciary company and awaited a return call from the company in reference to establishing a Guardian for the resident. [DATE] at 1:05 p.m., the facility Administrator stated she was surprised that the resident's BIM's score was 2 on his last 2 Quarterly MDS Assessments, that it depended on the resident's mood, willingness to participate in the Assessment, and the person that conducted the Assessment. She administered the BIM's Assessment test that day and obtained a score of 12 (that indicated mid cognitive impairment).

Based on record review and staff interviews, the facility failed to ensure that the consent was properly obtained when they required a resident with severe cognitive deficits, documented dementia and delusional disorder diagnoses, and history of suicidal ideation, to execute an Advanced Directive, instead of establishing a Power of Attorney (POA) as mandated by the resident's Level II PASARR requirements (Pre admission Screening and Resident Review), for 1 of 4 residents reviewed with Level II PASARR's (Resident #34). The facility reported a census of 39 residents. Findings include: The admission Minimum Data Set (MDS) Assessment tool dated [DATE] revealed resident #34 admitted to the facility [DATE] with diagnoses that included Post Traumatic Stress Disorder (PTSD), psychotic disorder, anxiety,Parkinson's disease and mild cognitive impairment, with a Level II PASARR that specified specialized services were required for other related conditions. The [DATE] Quarterly MDS Assessment tool revealed the resident scored 2 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated severe cognitive impairment, with symptoms of delirium always present that did not fluctuate. The resident's [DATE] Quarterly MDS Assessment tool revealed the resident scored 2 out of 15 points possible on the BIMS assessment, that indicated severe cognitive impairment, with symptoms of delirium present that fluctuated in severity. The resident's [DATE] and [DATE] Level II PASARR assessments stated: Resident diagnoses included Major depression, Delusional Disorder, Adjustment Disorder with Depressed Mood, Post Traumatic Stress Disorder (PTSD), Mood disorder due to general medical condition, and generalized anxiety disorder. Further details in the assessment described the resident: 1. Diagnosed with Mild Neurocognitive Disorder and sometimes has trouble with memory. 2. Sometimes confused to who he is, where he is at, time, date and what is going on. 3. Due to conflicting cognitive reports, it appears that memory may fluctuate and at times the resident may have a poor awareness to his needs and not always capable of making decisions based on health, safety, and best interests. Resident will benefit from having the support of a substitute decision maker to help with decision making. The resident's Level II PASARR requirements stated: 1. If admitted to a Medicaid Certified Nursing Facility, the Nursing Facility staff are required to: a. Designate or establish a Power of Attorney (POA) for healthcare and financial matters in order to serve as a substitute decision maker in the event of incapacity, assist with decision making and support the resident's health, resource management, and/or safety. The resident's Nursing Care Plan included the following problems and staff directives: 1. Pre-admission Screening & Resident Review (PASRR) problem, initiated [DATE], has been completed prior to the resident's admission to the facility, with 180 day approval that expired [DATE], and a non-limited PASRR on [DATE], directed staff: a. The facility will ensure that the nursing home is proper placement for the resident, initiated [DATE]. b. Facility administrator/designee will assist with formulating advanced directives, initiated [DATE], c. Facility administrator/designee will assist with obtaining guardianship/POA decision maker, imitated [DATE]. 2. PASRR has identified the following community placement supports, which resident may wish to explore as part of preparation for movement to the community, if and when the resident's return to home or community is determined problem, initiated [DATE], directed staff: a. Develop a healthcare advanced directive. b. Resident in need of a guardian, conservator, and/or Power of Attorney for Healthcare. Assistance required for the designation of such a person to help the resident for purposes of support with decisions about care needs, health and safety. c. Resident refuses to allow family member to obtain POA for decision making at this time d. Social services/designee contacted a Fiduciary Services to inquire guardianship services, initiated [DATE]. e. Social services/designee contacted the County Community Services to obtain guardianship-no services in the County, initiated [DATE]. 3. An impaired cognitive function/dementia or impaired thought processes related to Parkinson's, recent hospitalization problem, initiated [DATE] directed staff: a. Use resident's preferred name. Identify yourself at each interaction. Face resident when speaking and make eye contact. Reduce any distractions - turn off TV, radio, close door etc. Resident understands consistent, simple, directive sentences. Provide resident with necessary cues. Stop and return if I resident agitated. b. Keep resident routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. c. Monitor, document, and report as needed any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. An Advanced Directive Assessment form in the resident's electronic medical record, dated [DATE], completed by the facility's Social Worker (SW) stated the resident participated in the Advanced Directive and did not want to execute an Advanced Directive. A progress note dated [DATE], transcribed by the resident's psychiatric specialist provider, described the resident seen and treated for depression, anxiety, irritability, isolation, withdrawal, confusion, memory loss, short term memory problems, long term memory problems and adjustment disorder, assessments completed during the visit included a SLUMS assessment (St. Louis University Mental Status Examination, a screening test for Alzheimer's disease and other kinds of dementia), the resident scored 18, a score of 1 to 19 indicated dementia. A Nursing Progress Note dated [DATE] at 12:39 p.m., transcribed by the facility Administrator, revealed a BIM's cognitive assessment completed with the following results: Number of words repeated after first attempt: Three. Able to report correct year. Able to report correct month: Accurate within 5 days. Able to report correct day of the week: Incorrect or no answer. Record response (day): Wednesday Able to recall sock: Yes, no cue required. Able to recall bed: No, could not recall. Able to recall blue: Yes, no cue required. CSC - BIMS Summary score: 12.0 An email received from the facility Administrator dated [DATE] at 11:59 a.m., addressed to the Surveyor, stated the resident agreed to allow their family member to be his POA. Staff interviews revealed: [DATE] at 11:32 a.m., the Regional Director of Clinical Services (RDCS) stated the facility had not established a Guardian or POA for the resident, as directed in the resident's Level II PASARR. [DATE] at 11:47 a.m., the SW stated he reached out to the resident's family member that is designated as his Emergency Contact several times, they said they didn't know him/had no contact with him until recently and did not want to be responsible as his decision maker. The SW stated he called the county attorney a couple of months ago, asked about establishing a Guardianship for him, they said they would look it up, but hasn't gotten back to him and he would contact them again. [DATE] at 12:20 p.m., the RDCS stated she called the county attorney, they will do paperwork for someone to be the Guardian but will not be a Guardian, she contacted the County's community services who can't provide that support, and she has left a message with a Fiduciary company and awaited a return call from the company in reference to establishing a Guardian for the resident. [DATE] at 1:05 p.m., the facility Administrator stated she was surprised that the resident's BIM's score was 2 on his last 2 Quarterly MDS Assessments, that it depended on the resident's mood, willingness to participate in the Assessment, and the person that conducted the Assessment. She administered the BIM's Assessment test that day and obtained a score of 12 (that indicated mid cognitive impairment).

Based on interview, record review, and facility policy the facility failed to notify the provider with a low blood pressure for 1 of 1 residents reviewed for notification to providers (Resident #17). The facility reported a census of 38. Findings include: The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed diagnosis of progressive neurological condition and multiple sclerosis. The Care Plan with a focus area dated 11/23/18 revealed resident on diuretic therapy (Furosemide). The interventions dated 2/28/20 monitored, documented, and reported as needed any adverse reactions to diuretic therapy such as dizziness, postural hypotension, fatigue, and an increased risk for falls. The Clinical Weights and Vitals document revealed the following vital measurements: a. 9/13/23 at 8:30 PM: Blood pressure 81/48 mmHg (millimeters of Mercury) b. 9/13/23 at 8:30 PM: Temperature 97.8 F (Fahrenheit) c. 9/13/23 at 8:30 PM: O2 saturation: 91% The Progress Note dated 9/13/23 at 9:27 PM, revealed Resident #17 not feeling well this evening, his face rather red and he said he just felt exhausted and worn out. Vitals taken by this nurse and charted. Plan of care ongoing. During an interview on 9/14/23 at 3:59 PM, Resident #17 stated he didn't feel good and laid in bed all day. He stated he didn't feel good since last night. During an interview on 9/18/23 at 8:51 AM, Resident # 17 stated he felt better than he did on Thursday and he stayed in bed for 2 days and and then he got up and played Jenga with his friend. On 9/19/23 at 3:58 PM, Staff B, Registered Nurse (RN) queried on what she considered the range for a normal blood pressure and she stated between 90/50 and 150/90. She stated she looked at symptoms. Staff B asked what she did for a blood pressure reading of 81/48 and she stated she been surprised and would check it again with a different cuff, call the doctor, and send to the hospital. During an interview on 9/20/23 at 11:25 AM, the (Director of Nursing (DON) queried on what she considered a normal range for a blood pressure and she stated she thought it triggered at 120/80 and at 140/90 and 80 or 90 systolic for low and 50 or 60 diastolic for low. The DON asked what she expected for a blood pressure reading of 81/48 and she stated she would check it again and seen what the resident's normal blood pressure normally read and let the doctor know. She stated the nurse called her about this situation with Resident #17 and she told her to call the on call and do whatever the doctor ordered and she expected her to call the doctor. During an interview on 9/20/23 at 4:29 PM, Staff G, RN queried if she remembered last week when Resident #17 didn't feel well and she stated that was a week ago and she didn't know. Staff G asked what a normal blood pressure for him would be and she stated 90 to 110 systolic. Staff G asked if she thought a blood pressure of 81/48 would be considered low and she stated yeah for anyone. She stated she didn't remember taking his blood pressure and reviewed the chart and stated she charted it and couldn't think of the situation and then stated unless it occurred when his face red and he felt feverish. Staff G asked what interventions she did with a low blood pressure and she stated looking back now, she should of retaken it and if still low, she should of called the doctor. She stated she couldn't think of why she didn't take it again. The Facility Acute Condition Changes - Clinical Protocol Policy dated March 2018 revealed the following information: a. Assessment and Recognition 1. The physician will help identify individuals with a significant risk for having acute changes of condition during their stay; for example, someone with unstable vital signs. 2. The nursing staff contacted the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less).

Based on clinical record review, staff interview, and facility policy review the facility failed to ensure thorough documentation in the clinical record for why resident was sent to the hospital for one of two residents reviewed for transfer/discharge (Resident #143). The facility reported a census of 38 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment for Resident #143 dated 9/21/22 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, Resident #143 had an indwelling catheter. Review of Progress Notes dated 12/2/22 revealed the first reference of the resident's hospitalization included as part of a medication order note. The Orders-Administration Note dated 12/2/22 at 9:55 AM documented, Hydromorphone HCl Tablet 2 MG (milligram) Give 1 tablet by mouth every 4 hours as needed for Pain - Severe related to MULTIPLE SCLEROSIS .PRN (as needed) Administration was: Unknown patient sent to ED (emergency department). Progress Notes for Resident #143 lacked additional information as to why Resident #143 was sent to the hospital. The eInteract Transfer Form dated 12/2/22 revealed the resident sent to [Hospital Name Redacted] on 12/2/22 per resident and family request. Blood pressure, pulse, respiration, temperature, and oxygen saturation vital signs for the resident were all dated 11/27/23. Review of an Infectious Disease Note from Hospital Records, date of service 12/3/22, documented, in part the following for Resident #143: presents with CC (chief complaint) of lower abdominal pain and lower back pain. ID (Infectious Disease) is consulted for UTI (Urinary Tract Infection) [Resident #143] was admitted to [Hospital Name Redacted] yesterday through the ED (emergency department) where she presented [illegible words] facility in [City Redacted] w/ (with)UTI concerns. She has been at [City Name]. CC of malodorous urine and abd pain worse over the past several days. The Assessment and Plan per Hospital Records documented, in part, the following: ID is consulted for UTI Isolated E faecalis from new Foley urine culture on 12/2 .She recently received treatment of cipro and tmp/smx for full duration for UTI that didn't improve likely because of current culture showing E faecalis. Recommend treatment of E faecalis with Vancomycin until the susceptibilities come back, then can likely de-escalate. On 9/20/23 at 9:42 AM, when queried about documentation if a resident sent to the hospital, Staff A, Registered Nurse (RN) explained if someone was sent to the hospital, there was a whole list of stuff, including the eInteract transfer form and questions on that, face sheet, code status, bed hold form, orders summary, and she would make a progress note of why they went. When queried if she would input current vitals on the form, Staff A explained usually the system would pull them over or she could enter them. When queried as to documentation if a resident requested to be sent out, Staff A explained usually they would call the doctor and say what was going on. On 9/20/23 at 10:42 AM, when queried about documentation when a resident was sent out, the Assistant Director of Nursing (ADON) explained staff should chart change of condition and transfer, should be at least doing a progress note of what they observed, what happened, why the resident was sent out, should include Doctor notification, emergency contact notification, and report called to the ER (emergency room ). On 9/20/23 at 11:12 AM when queried if the nurse should do a progress note, the Director of Nursing (DON) said yes. The DON acknowledged vital signs should be current. The DON explained the resident had a PRN (as needed) order for an antibiotic when she felt like having symptoms of a UTI the resident would tell them and would get an extra tablet per doctors orders. The DON explained sometimes the resident would tell that she needed to go to the hospital, and she thought one of the times she felt she needed more than the extra antibiotics. The DON explained the resident was off and on antibiotics all throughout her stay. The Facility Policy titled Transfer or Discharge, Emergency revised 12/16 documented, 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident

Based on record review, staff interview, and facility policy review, the facility failed to ensure a significant change assessment completed following entry to hospice services and following discontinuation of hospice services for two of two residents reviewed for significant change assessments (Resident #12, Resident #24). The facility reported a census of 38 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The Care Plan in the electronic medical record for Resident #24 did not address hospice services. The Encounter Note dated 5/25/23 documented, in part, That said she did recently graduate from hospice protocol for inoperable terminal GI gastrointestinal (GI) cancer and has advanced Chronic Obstructive Pulmonary Disease (COPD). On 9/19/23 at 10:03 AM, the date Resident #24 had hospice services discontinued was requested from the facility's Administrator via email. On 9/19/23 at 11:06 AM, the Administrator provided the response via email that hospice services were discontinued for the resident on 3/25/23. Review of Hospice Documentation provided by the facility documented a discharge summary from hospice dated 3/25/23. On 9/20/23 at 10:07 AM, the Assistant Director of Nursing (ADON) explained he partly did MDS with the assistance or corporate. The ADON acknowledged a resident should have a significant change MDS done, and explained there was up to 14 days to do so. The Facility Policy titled Resident Assessments dated 12/19 documented, 3. A Significant Change in Status Assessment (SCSA) is completed within 14 days of the interdisciplinary team determining that the resident meets the guidelines for major improvement or decline. 48374 2. The quarterly Minimum Data Set (MDS) dated [DATE] documented the resident scored 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident was significantly cognitively impaired. The clinical record for Resident #12 revealed diagnoses which included Unspecified Atrial Fibrillation Cardiovascular and Coagulations-Principle diagnosis, Chronic Obstructive Pulmonary Disease Unspecified, Chronic Respiratory Failure with Hypercapnia, and Type 2 Diabetes Mellitus without complications. The Care Plan for Resident #12 revealed; I have chosen to receive Hospice Care on 09/11/2023 through the target review date of 10/26/2023. I will remain comfortable throughout Hospice Care. a) Initiated: 09/11/2023: Assist me with setting up hospice services. b) Initiated: 09/11/2023: Coordinate my care with my hospice team. c) Initiated: 09/11/2023: Coordinate with the hospice team to assure I experience as little pain as possible. d) Initiated: 09/11/2023: Provide me and my family with grief and spiritual counseling if desired. On 09/2023 Medical orders were reviewed and documented Resident #12 started Hospice Services through Every Step Hospice for respiratory failure effective 6/22/23 Physician Assistant. No directions specified for order During an interview on 09/20/23 11:21 AM with the Director of Nursing (DON) Staff C, advised she does not do revisions on Care Plans or MDS. The more experienced nurses may make changes. Wil does the Care Plans/MDS. The DON is not familiar with how and when to complete a Significant Change Assessment.

Based on clinical record review, staff interviews, facility investigation review, and observation, the facility failed to provide adequate supervision for 1 of 3 residents sampled for elopement (Resident #1). The facility failed to ensure all exit door alarms audible throughout the facility and failed to respond promptly to a door alarm when Resident #1 eloped. Resident #1 transferred to the hospital and returned to the facility two days later. Resident #1 required 14 stitches for a forehead laceration as well as a cervical collar for fractures of C1 and C2. The failure resulted in Immediate Jeopardy to the health, safety, and security of the residents. The facility reported 8 residents as independently mobile with cognitive impairment. The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of dementia and [CONDITION(S)]. Resident #1 scored 0 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The resident walked with supervision and wandered 4-6 days in the 7-day look-back period. The Care Plan failed to identify Resident #1's wandering or elopement risk prior to the 2/22/22 elopement. The Care Plan recorded the resident at risk for falls on 6/25/21 with an intervention on 2/9/22 to cue/encourage use of walker with ambulation. Review of Resident #1's most current wandering evaluation showed the resident scored low risk for wandering on 6/25/21. The Order Summary Report dated 2/21/22 revealed an order on 11/17/21 to check wander guard (a device which can trigger equipped exit doors to alarm and/or lock when nearby) every shift. Nurses Notes documented Resident #1 wandering: a. 11/15/21 1:03 p.m. wandered around facility, left through the front door. Staff assisted back in to the facility and placed a wander guard on her left wrist b. 11/28/21 9:31 p.m. wandered, opened the front door but did not exit c. 2/13/22 10:24 p.m. made multiple attempts to go out the front door d. 2/15/22 9:27 p.m. opened the patio door multiple times and also opened Hall 1 door e. 2/16/22 11:46 p.m. wandered in/out of rooms and attempted to go out exit doors twice f. 2/17/22 4:00 a.m. opened Hall 1 exit door and made it outside a few steps g. 2/18/22 12:05 a.m. attempted to go out the front door and Hall 1 exit door h. 2/20/22 10:48 a.m. went out the exit door a couple of times and staff redirected i. 2/21/22 1:17 p.m. wandered in the facility the whole shift j. 2/21/22 at 6:33 p.m. wandered the whole shift and exited the building one time. k. 2/21/22 at 8:45 p.m. Staff A, Licensed Practical Nurse (LPN), heard the door alarms go off on Hall 1 at 8:05 p.m. Staff A ran to the front and noticed Resident #1's walker by the nurses' station. Staff A checked all rooms and could not find Resident #1. Staff A ran out of the building through the Hall 1 door to find the resident around the corner lying on the ground, face down, at 8:07 p.m. Staff A turned Resident #1 over to assess. Staff A noted the resident to be unconscious but responsive to stimuli on feet and face, with an open lesion on her forehead. Another staff called 911 while Staff A stayed with the resident. A facility Incident Report dated 2/21/22 documented Staff A, LPN, heard an alarm going off on the Hall 1 exit door, ran down the hall and checked every room then looked outside to find Resident #1 lying on the ground, unconscious. Staff A stayed with Resident #1 while another staff called 911. On 5/17/22 at 10:10 a.m., Staff A, LPN, reported being at the end of the opposite hall (Hall 3) in a resident's room on 2/21/22 when Resident #1 exited the Hall 1 exit door. Staff A stated she could not hear the door alarm in the room so could not say how long it alarmed. Staff A heard the alarm upon exiting the room. Staff A reported being in the room on Hall 3 around 5 minutes. Staff A went to the Nurses Station where the door alarm box sounded and indicated the Hall 1 exit door had opened. Staff A noticed Resident #1's walker in the lobby area by the Nurses Station without Resident #1. Staff A proceeded to the alarming Hall 1 exit door, and went outside through it, around the building to the left approximately 30 feet to where Staff A found Resident #1 lying face down next to the building in the dirt. Staff A reported yelling to Staff B, Cook, who had followed Staff A to the exit door, to call 911. On 5/17/22 at 1:33 p.m., Staff B, Cook, reported Resident #1 had been more agitated for a couple of weeks prior to the elopement, wandering and not sitting still. On the evening of 2/21/22, Staff B reported rolling silverware in the dining room with the dining room door, on Hall 1 by the Nurses Station, closed, when Resident #1 exited the facility. Another cook washed dishes in the kitchen, adjacent to the dining room. Staff B reported she heard an alarm and walked to the hallway when it continued to sound. Staff B stated door alarms sound routinely, but staff typically shut them off within in 15-20 seconds. Dietary staff working in the kitchen/dining room areas often do not know why the doors alarms sound. People come and go, setting off alarms. When the alarm went off longer than usual, Staff B went to the dining room door and saw Staff A, LPN, headed down Hall 1 to the exit door. Staff A instructed Staff B to follow her to the door so Staff A would not be locked out when exiting the facility. Staff A then yelled in from outside for Staff B to call 911. On 5/17/22 at 3:49 p.m., Staff C, Certified Nurse Aide (CNA), reported being in a resident's room at the end of Hall 3 when Resident #1 walked out the Hall 1 exit. Staff C had not heard the door alarm in the room and did not hear it in the hall until walking further down the hall. Staff C reported the alarm sounded at the Nurses Station and continued to sound from the Hall 1 exit door as well. When Staff C arrived to the Hall 1 exit door, Staff A and Staff B had already arrived. Staff C stated Resident #1 would go to the front door or the Hall 1 exit door and push them. Resident #1 had walked out a door in the past, but Staff C did not recall the resident attempting to open doors earlier in the shift before going out. Staff C would distract Resident #1, usually with a [NAME] movie, when wandering. Staff C had last seen Resident #1 napping in her bed around supper-time. On 5/17/22 at 4:00 p.m., Staff D, Non-Certified Nurse Aide (NCNA), stated she had been assisting Staff C in a room on Hall 3 when Resident #1 exited the facility and had not heard any door alarms until leaving the room. Staff D jogged to Hall 1 to find Staff A and Staff B had responded to the alarms. Staff D reported she gave Resident #1 a shower that evening and dressed her in short-sleeved pajama top and capri-length pajama bottoms and non-skid socks, which the resident wore when she fell outside. Staff D had laid Resident #1 in bed 20-30 minutes prior to her being found outside. Staff D said Resident #1 went to doors all the time and pushed them open but then would back away because of the cold air. The day she went out was warmer. Resident #1 had pushed on doors like usual earlier that night; she usually went to either the front door or Hall 1 door. Staff tried to watch and distract her as much as possible. On 5/18/22 at 2:47 p.m., Staff E, Cook, reported washing dishes in the kitchen when the door alarms went off on 2/21/22. Staff E could not tell the alarms sounded with the noise of the dishwasher until her co-worker, Staff B, opened the door. Staff B then called to Staff E who went to the Hall 1 exit door. On 5/18/22 at 3:15 p.m., the Assistant Director of Nursing (ADON), recalled working the day shift on 2/21/22. The ADON could not recall Resident #1 opening any doors while the ADON worked but did recall the resident going in and out of resident rooms. The wander guard bands work only with the front door, causing a very loud alarm to sound throughout the building. On 5/19/22 at 2:40 p.m., Staff F, CNA, stated she had been in a resident's room on Hall 3 and had not heard the door alarm. She heard of the situation through the walkie-talkie. Hospital Discharge Summaries for 2/22/22 to 2/23/22 document Resident #1 transferred from the local emergency department to the hospital for a fall resulting in a type 2 dens (second vertebra) and C1 (first vertebra) fractures and a forehead laceration. Instructions stated Resident #1 should wear the Miami J (cervical) collar at all times. Hospital Discharge Summaries for admission 2/26/22 stated Resident #1 admitted from the nursing facility for unresponsiveness. The resident passed away on 2/26/22 due to cardiopulmonary arrest related to acute respiratory failure with [CONDITION(S)] and multi-organ failure. On 5/18/22 at 3:40 p.m., the Director of Nursing (DON) reported she worked until around 7:00 p.m. on 2/21/22. Resident #1 tended to be more active starting mid-afternoon and would often walk/pace in the hall and push on doors. Resident #1 had opened doors a few times and been observed by staff to walk out. Resident #1 acted no differently on 2/21/21; she walked back and forth on Hall 1 and the lobby area. Staff distracted her with TV, crossword puzzle books, or music, depending on her mood. The DON expected all staff, regardless of department, to respond to door alarms by going to the door and checking the area. The DON expected wandering to be on the Care Plan. The facility placed an additional alarm as well as stop signs across the exit doors, excluding the front door, after the elopement for an extra visual and sound. On 5/19/22 at 12:35 p.m., the Regional Director of Clinical Services opened Hall 1 exit door, and the door alarm sounded. The door alarm sounded down Hall 1 and part of Hall 2 but was not audible on Hall 3. The door alarm box at the Nurses Station sounded and could be heard on Halls 1 and 2 and outside the first six rooms of Hall 3 but not in any rooms on Hall 3, except the first 2, with the doors closed. The additional magnetic alarm attached to the stop sign banner sounded in the same areas as the door alarm box. The facility's Wandering and Elopements Policy, revised March 2019, stated if the facility identified a resident as at risk for wandering, elopement, or other safety issues, the resident's care plan would include strategies and interventions to maintain the resident's safety. The State Agency notified the facility of the Immediate Jeopardy on 5/19/22 at 2:30 p.m. The Immediate Jeopardy situation started on 2/21/22. The facility removed the Immediate Jeopardy on 5/20/22 by: a. On 5/19/22 at 3:00 p.m. the alarm company came to the facility and stated the alarm system functioned at its maximum capacity with no way to amplify the volume. b. On 5/19/22 implemented staff education to all staff to include door alarm response, checking outside, reporting to the charge nurse, conducting a head count, and initiated an outside facility search. c. Educated staff to keep the resident room doors ajar a few inches, and use privacy curtains, while providing cares to assure the alarms are audible. d. Evaluated all residents and care planned those displaying exit seeking or wandering behaviors with specific interventions to minimize the behaviors to include 1:1 monitoring and the potential for discharge to a secured unit I possible. e. Completed a mock elopement drill and will complete weekly times four weeks on various shifts including the weekend then once per quarter. The scope lowered from J to D at the time of the survey after ensuring the facility implemented staff education.

Based on clinical record review, hospital record review, staff interview and Nurse Practitioner interview, the facility failed to follow-up on a urinalysis (test to check urine for infection) which delayed timely treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident transferred to the hospital with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #4 had short and long term memory impairments and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had an indwelling urinary catheter. The Care Plan documented use of an indwelling catheter related to [CONDITION(S)], dated 2/13/20 and directed staff to monitor and document for pain and discomfort and monitor, document, and report any signs or symptoms of infection. A Progress Note dated 8/27/21 documented Resident #4 reported abdominal distension and pain, which resolved following a catheter change. A facsimile dated 8/27/21 documented the resident complained of low abdominal pain with amber, cloudy urine. The Physician responded on 8/30/21 and ordered a urinalysis (UA). The facility noted the order and documented they collected the UA specimen on 8/31/21. A Progress Note dated 8/31/21 documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note dated 9/4/21 noted the resident appeared pale and reported dizziness following an outing. The facility obtained vital signs and updated the Nurse Practitioner via phone. A different Nurse Practitioner (not Staff H) responded to monitor, push fluids, and call back if any changes. A Progress Note dated 9/6/21 at 5:21 PM documented the resident returned from an outing and had a temperature of 101.8 degrees Fahrenheit, lethargy, and slurred speech. The administered Tylenol. A Progress Note dated 9/6/21 at 8:45 PM documented the resident very drowsy and aroused with stimulation. His speech remained slurred, and he complained of hurting all over. His heart beat regularly but faster than normal. The resident tested negative for COVID-19. Temperature down to 98.7 after Tylenol administered. The nurse faxed Staff H (Nurse Practitioner) regarding the resident's condition. A Progress Note dated 9/7/21 documented the resident transferred to the hospital following [CONDITION(S)]-like activity and abnormal vital signs just before 1:00 PM. The Progress Notes failed reflect documentation of follow-up of the UA obtained on 8/31/21. A Laboratory Report dated 8/31/21 revealed the urinalysis indicated turbid urine, positive for bacteria (2+), with a urine culture indicated. An Emergency Department (ED) Note Physician dated 9/7/21 documented review of a urine culture from about a week prior growing greater than 100,000 colony-forming bacteria (indicating infection) of two types of bacteria. The ED Physician reported evidence of multidrug-resistant urinary tract infection from the urine culture a week prior. The physician admitted the resident to the hospital. A Urinalysis report dated 9/7/21 revealed turbid urine, positive for bacteria (4+) with >100,000 colony forming units per milliliter of each of three types of bacteria. A Hospital Progress Note dated 9/8/21 indicated an admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Discharge Summary revealed Resident #4 discharged from the hospital on 9/15/21 with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital placed a peripherally inserted central catheter (PICC) line and discharged the resident back to the nursing home on an intravenous (IV) antibiotic. During an interview on 9/15/21 at 10:25 AM, Staff B (Licensed Practical Nurse) reported when staff sends out lab work, they keep a copy of the lab slip at the desk for follow-up. Staff B did not recall a UA for Resident #4. The resident had abdominal pain days prior to the hospitalization , but it resolved with a catheter change. The resident had likely been worn out after the two outings. During an interview on 9/20/21 at 10:13 AM, Staff A (Registered Nurse) described Resident #4 as very drowsy but aroused on the evening of 9/6/21. He had slurred speech and a fever. He had been out of the facility, and appeared worn out. A previous outing had worn him out, but then he improved. She monitored him, gave him Tylenol, and reported to the next shift to keep an eye on him. She faxed the Nurse Practitioner instead of calling because his temperature decreased with the Tylenol, and she did not feel the call necessary. She could not recall if a UA was done on 8/31/21. She reported working part time and did not recall passing it on in report. During an interview on 9/16/21 at 3:00 PM, Staff H (Nurse Practitioner) reported the delay in addressing the UA results could have caused the resident's condition to worsen. She considered the resident already colonized; however, and so unless he had symptoms, she wanted to review the culture results before prescribing an antibiotic. The culture did not come in until 9/7/21. Staff H updated on 9/4/21 had likely not been at the clinic to see the pending urinalysis on her computer when she received the update via a phone call. Staff H reported staff should have called in the resident's symptoms on 9/6/21. She did not see the fax until the resident had admitted to the hospital. She would have had the facility send him to the hospital for treatment on 9/6/21. During an interview on 9/15/21 at 12:00 PM, the Director of Nursing stated an expectation of staff to update the Physician with lab results. The facility used a tracking log to ensure follow-up on labs. She had found no documentation of nursing discussing the resident's UA results with his Physician.

Based on record review and staff interviews the facility failed to ensure the environment remained free of accident hazards for 1 of 4 sampled (Resident #1). Resident #1 had a history of [REDACTED]. The staff found Resident #1 face down between the bed and wall with her arm on the baseboard heater. Resident #1 sustained a burn to the right upper arm. The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had [DIAGNOSES REDACTED]. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairments. Resident #1 required extensive assistance of two staff with bed mobility and transfers. Review of the Incident Reports dated 7/25/20, 8/12/20, and 12/20/20 revealed the staff found Resident #1 sitting on the floor beside the bed without injury. The Care Plan directed the staff to check on Resident #1 frequently and offer 1:1 if necessary, winged mattress on the bed, bed lowered close to floor, floor mat for safety, upper transfer rails to assist with bed positioning. The update on 7/25/20, directed staff to frequently remind Resident #1 to use the call light when wanting to get up. The update on 12/20/20, directed staff to move Resident #1 if restless for closer supervision. The Progress Note dated 12/26/20 5:28 a.m., revealed the staff found Resident #1 face down on the floor between the bed and wall. The staff noted the bed in lowest position and a floor mat on the other side of the bed. Resident #1 sustained a burn on the right upper arm, a skin tear to the left arm, and the right elbow deformed. Resident #1 had pain when the area touched. The staff notified the Physician's Assistant and received an order to apply a wet to dry dressing over the burn and transfer Resident #1 to the Emergency Department. According to the #604 Un-Witnessed sheet dated 12/26/20, the staff found Resident #1 lying face down with her arm against the baseboard heater. The right upper arm that had contact with the baseboard heater measured 1.5 centimeters (cm) by 5 cm. When Resident #1 returned from the hospital the staff moved Resident #1 to bed against a wall without a baseboard heater. During an interview on 1/6/21 at 12:18 p.m., Staff A (Nurse Aide) reported finding Resident #1 face down on the floor between the bed and wall. The wall beside Resident #1's bed contained a baseboard heater. Resident #1's right upper arm rested on the heater. Resident #1's feet remained in bed, shoulders back and elbows bent. A piece of wood on the floor held the bed back 8 inches from the heater. Staff A reported she last observed Resident #1 at 2:30 a.m. with the bed in the lowest position, and a floor mat on the open side of the bed. According to the ED Note Physician sheet dated 12/26/20 Resident #1 reported moderate to severe right upper arm pain and pain worse with movement. Resident #1 had a superficial partial-thickness burn to the right upper arm and a fractured right distal humerus. During an interview on 1/11/21 at 2:30 p.m., Staff D (Corporate Nurse Consultant) stated two to three years the facility installed pieces of wood to keep the bedding away from the baseboard heaters. Staff D reported prior to Resident #1's fall, the facility did not conduct temperature audits or address a need for safety covers for the baseboard heaters. During an interview on 1/12/21 at 10:30 a.m., Staff B (Maintenance) confirmed the facility did not complete audits of the baseboard heaters to assess safety prior to 12/26/20. The Past Non-Compliance Checklist provided by the facility revealed the following corrections as of 12/30/20: a. Audited all beds for proper placement and safety. b. Audited heat source in all rooms and identified 4 that required repairs. c. Reviewed all residents to determine high fall risk and relocated to bed away from baseboard heaters. d. Educated staff on bed placement. e. Ordered baseboard safety cover to test on current heat system for additional safety. The Surveyor confirmed past non-compliance achieved during the survey through record review and interviews.

Based on observation, record review and staff interviews, the facility failed to appropriately assess and implement interventions for Resident #2, following a fall. The facility reported a census of 33 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool for Resident #2, dated 07/22/13, revealed the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMS (Brief Interview for Mental Status) score of 3 of 15, indicating the resident had long and short term memory problems and impaired cognitive skills for daily decision making. The MDS indicated that the resident was extensive assist of one staff for all activities of daily living (ADLs) except eating. The MDS indicated the resident frequently incontinent of urine and always continent of bowel. The MDS revealed the resident receives a schedule pain medication regimen, received no PRN (as needed) additional pain medication and reported had no pain. The resident's plan of care with problem onset date 10/15/12, informed staff that Resident #2 listed a Problem that included self-care deficit related to fall at home resulting in a right [MEDICAL CONDITION]. The care plan instructed staff to transfer and ambulate resident with assist of one staff member, gait belt and front wheeled walker. Review of the Resident Incident Report dated 8/14/13 at 6:40 a.m. indicated Resident #2 found on floor in room incontinent of stool and urine. Alarms sounding. Moves all extremities well and no complaints of pain. The fall not witnessed and no medical care received and the status of the resident is OK. Review of the Nurse's Notes dated 8/14/13 at 6:40 a.m. indicated the resident found on floor in room beside bed incontinent of large bowel movement and urine. Resident able to move all extremities well and no complaints of pain. Resident assisted up and taken to shower. Resident's vital signs temperature of 97 degrees, respirations 18, oxygen saturation 92%, lying blood pressure 166/82 and pulse 69, sitting blood pressure 105/40 and pulse 66. Physician Assistant and family notified of fall and blood pressure. The note lacked indication that a full body assessment had been completed and documented or that a neurological assessment had been done at this time after resident's fall. Review of a fax sent to the resident's physician dated 8/14/12 indicated the physician had been contacted by staff and notified the physician of the resident being found on the floor and resident moves all extremities well, no complaints of pain. The physician orders [REDACTED]. Review of the Nurse's Notes dated 8/14/13 at 12:30 p.m. revealed the resident had an emesis after lunch and complained of general discomfort. Tylenol administered and relief of pain obtained. Resident continues to have good movement of legs. The note lacked indication that any further assessments completed at this time. Review of the next Nurse's Notes dated 8/14/13 at 9:00 p.m. revealed the resident had a temperature and Tylenol administered at this time. Resident has been assist of two staff members this evening and has been sleepy. Resident denies pain and neurological checks were performed. Review of the next entry dated 8/14/13 at 10:15 p.m. revealed the on call physician was called and informed of the resident's temperature. New orders received for a clear liquid diet for tonight and to call with a progress report in the morning. The Nurse's Notes lacked indication of assessment of resident change of status of requiring assist of two staff members or that the physician was notified of the change of resident's status of increase assist following the fall. Review of the Nurse's Notes dated 8/15/13 at 1:30 p.m. revealed resident denies pain, remained in wheel chair this shift and refusing to ambulate. Family member present and requesting an X-ray of resident ' s hips. Resident's urine noted as dark with odor and sediment present. The noted identified the physician had been faxed. Review of a fax sent to the resident's physician dated 8/15/13, revealed the resident's family requesting an X-ray of resident's hips as the resident would not walk. Resident's urine noted as dark in color with a very strong odor. The physician orders [REDACTED]. Review of the next entry of the Nurse's Notes dated 8/15/13 at 5:20 p.m. revealed resident does not appear in pain and does not express any pain. New orders received from the physician to X-ray hips and to obtain a urine specimen and send to the laboratory. Review of the Nurse's Notes dated 8/16/13 at 1:15 a.m. revealed resident's left foot cold to the touch, resident incontinent of urine. Resident difficult to roll side to side and required two assist. The resident ' s left thigh noted as larger than the right, no bruising noted. The left lower extremity noted as outward rotation, shorting of left leg noted, and resident moaning with movement. Resident temperature of 100.3 and Tylenol given. Resident not responding to questions. At 1:45 a.m. the physician notified of new findings and new orders received to transfer the resident to the emergency room for further evaluation and treatment. At 5:30 a.m. staff called the hospital and was informed the resident admitted to the hospital. Review of the resident's History and Physical dated 8/16/13 revealed the resident fell two days ago and suffered a left [MEDICAL CONDITION]. Family member present and reports the resident prior to the fall he/she usually walks with a walker and with some assistance. After the fall she required even more help it was decided to have the resident evaluated also reported to have fevers and is found to have a urinary tract infection. Review of the resident's hospital Consultant's Record dated 8/16/13, revealed the resident seen in the emergency room in early hours of 8/16/13. The resident was diagnosed with [REDACTED]. Apparently on 8/14/13 the resident fell at the facility and because of the pain the resident in the left femur the resident had been taken to the emergency room . The resident fractured occurred on 8/14/13. Interview on 8/27/13 at 11:33 a.m., Staff A C.N.A. (Certified Nurse Aide) revealed he/she was assigned to the resident on 8/14/13 on the day shift. Staff A stated she/he first seen the resident around 6:20 a.m. and the resident in bed sleeping. Staff A indicated that he/she heard the resident's alarm sounding around 6:40 a.m. and responded to the alarm. Staff A reported he/she found the resident in the room lying on left side with legs crossed and left shoulder on floor by the recliner, approximately 5-7 feet away from the bed. Staff A indicated the resident had apparently taken a few steps with the walker and the resident still had ahold of the walker while on the floor. Staff A stated the resident had been incontinent a large amount of bowel and urine on the floor and had a trail of it leading from the bed to where the resident fell . Staff A indicated the resident just had a gown on, no incontinent briefs and no shoes. Staff A reported the resident holding head up and Staff A placed a pillow under his/her head and summoned for help. Staff A reported that two other C.N.A.'s responded along with Staff B, nurse, and Staff C nurse, also responded. Staff A indicated the two nurses, Staff B and Staff C, asked her if the resident hit his/her head and Staff A responded that it did not appear so. Staff A stated that neither Staff B nor Staff C did not get close to the resident and did no assessment of the resident. Staff A indicated that nurse Staff C directed Staff A to get the resident up off the floor and take resident to the shower room to get the resident cleaned up. Staff A reported that nurse Staff B and Staff C left the resident's room and it took the assist of three to get resident up off the floor into the shower chair. Staff stated the resident never voiced any complaints to her but the resident doesn't communicate that well to make his/her need and wants known. Staff A stated he/she gave the resident a shower and transferred him/her to a wheelchair from the shower chair and had no problems with transfer at that time. Staff A indicated the resident remained in the wheelchair until after lunch. Staff A indicated that is unusual for resident to use a wheelchair for transportation as the resident prior to fall would ambulate with a walker and assist of one staff member for mobility in the facility. Staff A reported that after lunch he/she went to transfer the resident to the toilet but could not because the resident would not bear weight. Staff A indicated he/she called for assistance and another C.N.A. came to assist but even with two staff members they could not transfer the resident to the toilet. Staff A stated at that time another C.N.A. came into the resident's room to see if Staff A needed help and then nurse Staff C came in at that time also. Staff A indicated nurse Staff C watched while Staff A and the other two C.N.A.'s transferred the resident to the toilet. Staff A indicated the resident did not bear weight on left leg and they basically had to lift the resident onto the toilet. Staff A stated that nurse Staff B instructed them to put the resident to bed and that Staff B would be back. Staff A stated that this is very unusual for the resident to not bear weight and to take the assist of three staff for transfer. Staff A reported that the resident's behaviors were not his/her normal behaviors; just not interacting with Staff A as per the resident's normal. Staff A stated he/she left work at 12:00 noon and returned at 3:30 p.m. to work the second shift. Staff A indicated when he/she arrived back to the facility the resident in bed and that the staff reported to her that it took two staff members to transfer the resident. Staff A stated again it took two staff members to assist with transferring the resident from the bed to the wheelchair for supper. Staff A indicated the resident did not eat anything for supper that evening and his/her family member in to visit and requested to sit with the resident in the common area. Staff A stated she reported to nurse Staff D that the resident remained in the wheel chair, not bearing weight, did not eat anything for supper, and the resident felt warm to the touch. Staff A stated he/she also reported to nurse Staff D and the oncoming 3rd shift nurse the resident's condition of not bearing weight with transfers, not walking, and warm to the touch. Staff A reported he/she came into work the next morning and prior to coming to work she spoke with the DON (Director of Nursing) via phone and voiced her/his concerns of the resident's condition and no assessment done at time of fall. Staff A stated when he/she came into work the next morning at 10:00 a.m. the resident's condition remained unchanged, the resident still in wheel chair, not bearing weight, and still behavior changes. Staff A further indicated that at the time of the fall while the resident is on the floor, nurse Staff C told Staff B that he/she would take over passing medications and Staff B told Staff C that no he/she is passing the medications and both left the resident's room. Staff A stated he/she is upset that no assessment of resident had been done after fall, resident had not been acting per his/her normal behaviors, and that Staff A felt that the resident had been injured after fall. Staff A stated he/she had been very upset when Staff A found out that the resident in the hospital for a fracture to the left hip. Staff A stated she/he had never seen a nurse not assess a resident right after a fall. Staff A reported that the resident uses incontinent pads on the bed at night and the resident is basically a check and change on rounds. Interview on 8/27/13 at 12:45 p.m., Staff E, C.N.A., reported that she/he took care of the resident on 8/14/13 on second shift. Staff E stated the resident had been assist of one staff member for transfers and ambulation prior to the fall and after the fall the resident required the assist of two to transfer from bed to wheelchair and from wheelchair to toilet and the resident could not ambulate. Staff E reported this was unusual for the resident and she reported this to the nurse, Staff D. Interview on 8/27/13 at 10:42 a.m., Staff C, L.P.N. (Licensed Practical Nurse) stated he/she was the charge nurse on 8/14/13 when the resident fell . Staff C stated she/he and Staff B responded to the summons to the resident's room. Staff C indicated the resident on the floor and incontinent of bowel and bladder on the floor. Staff C stated he/she thought nurse Staff B said the resident was ok and thought Staff B was going to do assessment of resident and Staff C walked out of the room. Staff C stated she/he did not know if Staff B walked out of the resident's room after Staff C did. Staff C indicated he/she did the incident report of resident's fall, documented it in the Nurse's Notes and notified the resident's physician of fall. Staff C indicated she documented the resident able to move all extremities well and voiced no complaints of pain as Staff C thought Staff B reported this to him/her. Staff C reported no full assessment done on resident after fall and the facility protocol of an unwitnessed fall had not been followed by Staff C as it should have. Staff C indicated it had been a misunderstanding and lack of communication between him/her and Staff B regarding the care of the resident after the fall. Staff C reported he/she did do an assessment of the resident after the resident had an emesis after lunch on 8/14/13 but failed to document until 8/16/13. Staff C stated he/she knew the resident required more assist for transfers and using the wheel chair for mobility. Staff C stated he/she watched staff transfer the resident after the resident brought back to the room after having an emesis at lunch. Staff C stated he/she watched the resident being transferred from the wheelchair to the toilet and thought that the resident's right knee to be giving out. Staff C indicated the resident had been ambulating in facility and to and from meals, however after the fall the resident required a wheel chair and assist of two staff members for transfers. Staff C stated she did not think this to be unusual because as the resident had an elevated temperature and Staff C thought the resident may have a urinary tract infection. Staff C indicated that he/she had been disciplined by the facility for not following the fall protocol for the resident. Interview on 8/27/13 at 10:05 a.m., Staff B, RN (Registered Nurse) reported on 8/14/13 he/she worked as a medication aide. Staff B indicated he/she had been in the dining room passing medications when the resident fell . Staff B reported he/she had seen the resident around 6:15 a.m. lying in bed, resident not incontinent and the resident made no request at that time prior to the fall. Staff B stated he/she was called to the resident's room by Staff A via head set radio around 6:40 a.m. Staff B reported he/she had been the first nurse to enter the room and found the resident lying on the floor on his/her back, with knees bent up, a pillow under the resident's head, and resident incontinent of bowel and bladder on the floor. Staff B reported Staff C arrived in the resident ' s room right after him/her. Staff B stated he/she reported no obvious injuries after a visual assessment done. Staff B stated he/she then left room and went back to passing the residents ' medication. Staff B stated that Staff C was the charge nurse that day and thought Staff C would do the assessment of the resident. Staff B indicated the resident ambulated with assist of one and a walker prior to fall, but after the fall the resident in wheel chair, which is unusual for the resident. Staff B indicated that after the fall the resident required two assist for transfers and refusing and the resident refused to walk. Staff B stated she/he had taken care of the resident on 8/15/13 and assessed the resident that day in while the resident set in the wheel chair. Staff B reported that the resident's family came in and requested an X-ray to be done on resident's hips. Staff B stated he/she did do a full body assessment on the resident later when the resident lying in bed but did not document this assessment anywhere. Staff B stated after the family member requested an X-ray and the resident continued to not want to ambulate; Staff B faxed the resident's physician for the order and also to request an order for [REDACTED]. Interview on 8/27/13 at 3:40 p.m., Staff D stated he/she worked 2nd shift on 8/14/13 and was assigned to care for the resident. Staff D reported prior to the resident's fall that day, the resident had been assist of one for transfers and ambulation. Staff D indicated that the evening of 8/14/13 the resident using a wheel chair and required assist of two staff members for transfers and that the C.N.A.'s reported to him/her that the resident not transferring per usual. Staff D stated the resident is hard to assess and has a hard time of making his/her needs and wants known at times. Interview on 8/27/13 at 1:15 p.m., the DON (Director of Nursing) stated she thinks the assessment of the resident not done after fall due to a miscommunication between the nurses. The DON further stated she did not do an assessment on the resident and she thought the resident may have a urinary tract infection. The DON indicated that any fall of a resident she expects staff to do a complete head to toe assessment on resident and if it is an unwitnessed fall then staff should perform a neurological assessment per the facility policy and this had not been done after the resident fell . Review of the facility's Incident/Accident/Unusual Occurrence Form dated March 2007 included Procedure of Charge Nurse to complete a head to toe assessment and to write a description of the outcome of the assessment. Review of the Facility's Neurological assessment dated [DATE] included a Purpose of to provide documentation of neurological assessment for a resident who had fallen unwitnessed or had hit his/her head, or conditions warrants. The Procedure included the Neurological Assessment is completed for residents per the following schedule: every 15 minutes for an hour, then every hour for 4 hours, and then every four hours for 16 hours, and then every 8 hours for 16 hours.

Based on record review, resident and staff interviews, the facility failed to implement services to ensure Resident #1 received adequate supervision against hazards in the environment for one(1) of four (4) residents. A staff left Resident #1 unattended in a shower room, sitting in a shower chair without any alarms or the call light in place. The resident reached for the handrail and tipped his/her shower chair over, sustaining a fractured right hip. The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) with an assessment reference date of 7/26/13, revealed Resident #1 had scored 14 out of 15 on the BIMS (Brief Interview for Mental Status) test. A BIMS score of 14 revealed the resident had intact cognition. The MDS indicated the resident required one person to physically assist with the following: bed mobility, transfers, when walking in room, when dressing, for toilet use and with personal hygiene. The MDS indicated the resident had [DIAGNOSES REDACTED]. Review of the resident's Fall Risk assessment dated [DATE] revealed the resident had a history of [REDACTED]. 10 or above represents high risk for falls. Review of the resident's Care Plan with an on-set date of 4/22/13 revealed a Problem that included self-care deficit related to history of falls. The care plan directed staff that the resident does not always remember to use call light, assist of one and walker for transfers and ambulation, and the resident need a chair alarm in place for safety. The care plan noted the resident had a fall on 6/5/13 which resulted in a prior right hip fracture. Review of the Incident/Accident/Unusual Occurrence Form dated 8/1/13 at 8:30 a.m. revealed the nurse and the DON (Director of Nursing) had been called to Hall #1 whirlpool room by a C.N.A. (Certified Nurse Aide). Resident #1 was found lying on the floor on his/her back with his/her head against the stall wall. The shower chair had tipped over on its side and was beside resident. The resident had no clothes on, no shoes or socks. Resident stated he/she had been sitting in the shower chair and tried to scoot him/her (self) to reach the hand rail on the wall when the (shower) chair tipped over and landed on the floor. The assessment identified the resident ' s right hip protruding and the right leg shorter than the left leg. The resident complained of right hip pain. Resident assessed on the floor for other injuries. Resident admits he/she hit the back of his/her head, no bump or injury noted to back of head. The resident was transferred to the hospital. Review of the Nurse's Notes dated 8/1/13 at 8:30 a.m. indicated the resident had been found lying on his/her back in the shower stall. The resident ' s head rested on back of the shower stall wall. The shower chair had tipped over on its side beside him/her. The resident reported he/she had been sitting in shower and tried to scoot forward to grab hold of the grab bar on the wall, when the shower chair tipped over causing him/her to fall on the floor. The assessment revealed the resident ' s right hip protruding and resident immediately complained of pain. Resident reported he/she did hit head, no injury noted to head. Resident sent to the hospital and family and physician notified. Facility received a phone call at 2:24 p.m. reporting the resident had a right hip fracture and was scheduled for surgery later today. Review of the resident's History and Physical dated 8/1/13 revealed the resident fell today, immediate pain and deformity in his/her right hip and thigh, unable to bear weight. The X-ray showed a right periprosthetic femur fracture and the fracture was below this. Resident admitted for surgical treatment of [REDACTED]. Review of resident's Discharge Summary dated 8/7/13 revealed resident discharged to skilled care and physical therapy later when he/she developed some healing. Interview on 9/3/13 at 1:00 p.m., Staff F stated he/she had been assigned to care for the resident on 8/1/13. Staff F indicated that after the resident ate breakfast she assisted the resident to the shower room. Staff F stated she assisted the resident with taking a shower as the resident sat in the shower chair. Staff F reported after the shower Staff F assisted in drying the resident off. Staff F indicated she was going to put the resident's clothes back on him/her but the resident wanted the clothes that were on his/her recliner in the resident's room. Staff F stated he/she then radioed another staff member to bring the resident's clothes to the shower room. Staff F stated the other staff member indicated they were busy at the moment but would bring the clothes as soon as able to. Staff F stated the resident started to get anxious and cold. Staff F reported while the resident remained in the shower chair she covered the resident with a towel and pushed the shower chair out of the shower stall and pushed the back of the shower chair up against the shower room wall, and locked the shower chair wheels. Staff F stated she asked what clothes the resident wanted and the resident told Staff F the clothes were in his/her recliner. Staff F instructed the resident she would go get the clothes and that the resident was not to get up. Staff F stated the resident promised Staff F he/she would not attempt to get up out of the shower chair. Staff F stated he/she then left the resident unattended with no call light or alarms in the shower room and went to get the resident's clothes and returned immediately to the shower room and found him/her on the floor. Staff F then immediately summoned the nurse. Staff F stated she had been trained to never leave a resident alone in the shower room and had never done so before. Staff F indicated she ' s aware the resident was at risk for falls and had alarms in place. Staff F reported the resident was non-compliant with getting up on their own. Staff F stated she should had never left the resident alone in the shower room and that he/she knew better then to do so but felt since the resident said he/she would not attempt to get up, Staff F felt the resident would not. Staff F further stated she never radioed for any other staff member to retrieve the resident's clothes or to come to the shower room prior to leaving the resident unattended in the shower room. During an interview with Resident #1 on 8/27/13 at 12:35 p.m., he/she recalled the shower room incident. The resident stated his/her butt was getting stuck to the chair and he/she reached for the handrail. The resident reported yes the staff had left him/her alone and she did not want to get the staff in trouble. The surveyor noticed the resident seated in his/her recliner with a call light in reach and chair alarm in place. In a typed documented dated 8/1/13 at 10:00 (a.m.) by the DON she reported Staff F left Resident #1 in the whirlpool (shower) room seated in the shower chair. The resident had no fall alarms in place when Staff F left the whirlpool (shower) room. Interview on 8/21/13, DON (Director of Nursing), stated that it is a facility practice that no resident to be left unattended in the shower room. The DON stated that staff are trained on this facility practice.