Every finding on record at West Ridge Specialty Care

Based on electronic record review, resident interviews, staff interviews, and policy review, the facility failed to provide restorative programs as care planned for 3 of 4 residents reviewed for restorative care (Residents #2, #7, and #8). The facility reported a census of 71. Findings include: 1. Resident #7's Minimum Data Set (MDS) Assessment completed on 10/2/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Diagnoses included a right femur (thigh bone) fracture, lack of coordination, history of falling, and cognitive communication deficit (difficulty speaking or understanding). The MDS documented limited range of motion on one side of the lower extremity including the hip, knee, ankle, and foot, and noted the use of a manual wheelchair for mobility. Resident #7 received Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) services in the seven days lookback period. On 4/21/26 at 12:42 PM Resident #7 reported he hadn't received his restorative programs recently for at least the past two weeks and he didn't know why. The SPN - Nursing/Therapy Communication note dated 12/1/25 at 10:51 AM documented communication from therapy to nursing. Occupational Therapy (OT) recommended a restorative nursing program (RNP) (nursing interventions that promote the resident's ability to live as independently as possible) 2 to 7 times per week. The program included static standing (standing still) using the parallel bars as tolerated. Staff should donn (put on) a dynamic left (L) lower extremity (LE) knee brace in the morning (AM) and doff (take off) at hour of sleep (HS) (bedtime) or as requested. Staff must ensure skin checks. A right (R) elevating leg rest and Left standard leg rest with a heel strap needs to be on the wheelchair (w/c) for both lower extremity (BLE) positioning. The SPN - Nursing/Therapy Communication note dated 12/1/25 at 12:42 PM documented communication from therapy to nursing. Physical Therapy (PT) recommended a RNP 2 to 6 times per week. The program includes seated lower extremity (LE) (leg) strengthening and reaching activities.The Restorative Note: Restorative Monthly Summary note dated 12/30/25 at 10:49 AM documented Resident #7 participated in the RNP with encouragement. The goal to maintain current strength and mobility remained ongoing. He required the assistance of one staff member for transfers and activities of daily living (ADLs). He moves throughout the facility independently with his wheelchair (w/c) and wears a knee brace to assist with a contracture (permanent tightening of muscles or joints) to his knee. He ate independently in the dining room. No decline occurred. The restorative program continued with the current plan of care.A progress note on 2/2/26 indicated Resident #7 received physical and occupational therapies and his restorative program resolved. The SPN - Nursing/Therapy Communication note dated 3/6/26 at 12:32 PM documented communication from therapy to nursing. PT recommended a RNP 2 to 6 times per week. The program included LE strengthening activities. The Restorative Note: Restorative Monthly Summary note dated 3/9/26 at 3:00 PM documented Resident #7 participated in the RNP with encouragement. The goal to maintain current strength and mobility remains ongoing. He required the assistance of one staff member for transfers and ADLs.The SPN - Nursing/Therapy Communication note dated 4/1/26 at 8:36 AM documented communication from therapy to nursing. Therapy recommended changes to the existing RNP 2 to 6 times per week. The changes included an omnicycle (exercise bicycle) for the LE, passive range of motion (PROM) (exercises where staff move the resident's joints) to both knees to work on extension (straightening the joint), standing tolerance in the parallel bars with a gait belt, and working on leaning forward in the wheelchair to improve trunk flexion (bending of the torso). The Care Plan Focus revised 4/1/26, identified Resident #7 had a restorative program which included exercises of included an omnicycle for the LE, PROM to both knees to work on extension, standing tolerance in the parallel bars with a gait belt, and working on leaning forward in the wheelchair to improve trunk flexion 2 to 6 days a week for up to 15 minutes as tolerated. 2. Resident #8's MDS Assessment completed on 10/2/25 revealed a BIMS score of 14, indicating intact cognition. The MDS documented limited range of motion on one side of the upper extremity including the shoulder, elbow, wrist, and hand, and noted the use of a manual wheelchair for mobility. The MDS included diagnoses of muscle weakness, lack of coordination, reduced mobility, history of falling, and cognitive communication deficit. Resident #8 received restorative programs including PROM 2 days in the 7 day in the lookback period. On 4/21/26 at 11:30 AM Resident #8 reported he hadn't received his restorative programs recently. The Care Plan Focus revised 4/1/26, indicated Resident #8 had a Restorative: PROM program. The Interventions directed the following:a. Omni cycle for both lower extremitiesb. PROM to the left knee and anklec. General lower extremity exercises with a three-pound weight on the right leg for up to 15 minutes for 2 to 6 days a week as tolerated. The Restorative Note: Restorative Monthly Review note dated 4/3/26 at 11:24 AM documented Resident #8 participated in the restorative program (nursing interventions that promote the resident's ability to live as independently as possible) as offered most days. The goal to maintain current strength and range of motion (the distance a joint can move) remained met and ongoing. Resident #8's Point of Care (POC) Documentation Report reviewed on 4/23/26 for the lookback period of 30 days listed not applicable for 4/18/26 with no other documentation. On 4/22/26 at 11:20 AM the Restorative Nurse, Registered Nurse (RN), reported she coordinated restorative programs for approximately 26 residents. She acknowledged the facility hasn't done restorative programs for about a month. She stated the facility employed a restorative aide, but she no longer worked at the facility and since she left, they haven't done the programs. She stated staff documented participation in the EMR under POC tasks. On 4/23/26 at 11:14 AM Staff E, Certified Nursing Assistant (CNA)/CMA, stated that over the last three months, the restorative aide routinely moved from completing restorative programs to help on the floor with resident cares. She stated residents complained to her about not getting their programs, but she couldn't recall specific names. On 4/23/26 at 11:30 AM Staff D, CNA, acknowledged there's currently no restorative aide working at the facility. She stated January 2026 was when the staffing worsened. She stated she hasn't completed any restorative programs with the residents. On 4/23/26 at 11:36 AM the Director of Nursing (DON) acknowledged staffing definitely remained a challenge and caused problems with residents receiving restorative programs. She stated the restorative aide voluntarily left employment on 3/24/26 because she was pulled to the floor to work as a CNA. 3. Resident #2's MDS assessment completed on 3/18/26 identified a BIMS score of 3, indicating severely cognitively impaired. The MDS documented Resident #2 used a wheelchair and required staff dependence for all motion except eating. The MDS included diagnoses of non-Alzheimer's dementia (brain disorder that causes a decline in thinking skills), arthritis (joint inflammation), pain in the left shoulder, muscle weakness, and a history of falls. The MDS noted Resident #2 participated in at least 15 minutes of active range of motion (exercises where the resident moves their own joints) through a restorative program in the 7-day lookback period. The Care Plan Focus revised 3/31/26, indicated Resident #2 had a RNP to maintain strength and the current ability to transfer. The plan instructed staff to document refusals of the RNP.The Restorative Note: Restorative Monthly Summary note dated 4/1/26 at 1:39 PM documented Resident #2 participates in the restorative program (nursing interventions that promote the resident's ability to live as independently as possible) with encouragement. The goal to maintain her current strength and transfer abilities remained ongoing. The restorative program continued with the current plan of care.Resident #2's April 2026 Documentation Survey Report reviewed 4/22/26 directed staff to complete forward leans using a basketball hoop for 3 sets of 10 repetitions to increase upper body and core strength. The plan directed staff to perform 2 to 6 times per week. The reported reflected a schedule of Monday and Thursdays. On 4/6/26, the documentation reflected Resident #2 refused to participate. The report lacked any other documentation. A review of Resident #2's nursing progress notes since April 2025 lacked documentation of restorative care refusals. On 4/21/26 at 12:22 PM Staff G, Licensed Practical Nurse (LPN), stated staffing felt worse in the last few months. She knew restorative therapy didn't occurred due to a direct result of staffing issues. She stated restorative aides are the first staff pulled to the floor when they require additional staff. The facility hasn't had a dedicated restorative aide for some time. On 4/21/26 at 1:32 PM Staff H, RN, stated it's been a struggle to get bathing and restorative care covered because of the facility's lack of staff. She believed it began in January or February. On 4/23/26 at 11:14 AM Staff E, CNA, stated she's aware restorative care wasn't occurring. She stated it's because restorative aides are the first pulled to the floor when the facility has low staffing. She stated this has been ongoing for the last three months. She stated residents complained to her about the lack of restorative services. On 4/23/26 at 11:30 AM Staff D stated the lack of staffing impacted showers and restorative care. She stated they weren't occurring. On 4/23/26 at 11:37 AM the Director of Nursing (DON) acknowledged staffing remains an ongoing issue and she knew it caused issues with bathing and restorative services. She stated she expected staff to follow the Care Plan regarding restorative services. A request occurred for a policy regarding restorative services, but the facility didn't provide one.

Based on electronic record review, resident interviews, staff interviews, and policy review, the facility failed to provide resident showers as scheduled for 5 of 5 residents reviewed for activities of daily living (Residents #1, #2, #4, #5, and #7). The facility reported a census of 71. Findings include: 1. Resident #3's Minimum Data Set (MDS) Assessment completed on 3/18/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The DMS included diagnoses of arthritis (joint inflammation), low back pain, malnutrition (lack of proper nutrition), and osteoporosis (brittle bones). The MDS noted the use of a motorized wheelchair for mobility. Resident #3 required maximum staff assistance for bathing and transfers to and from the bed to the wheelchair. The Care Plan, revised 3/31/26, outlined Resident #3 required staff assistance for bathing. The Documentation Survey Report v2 outlined Resident #3 scheduled for bathing two times per week on Tuesdays and Fridays. Review of monthly reports revealed the following: a. January 2026, 9 out of 9 showers occurred. b. February 2026, 6 out of 8 showers occurred. - No documentation identified why 1 of the 2 missed showers didn't occur.c. March 2026, 7 out of 9 showers occurred. - No further documentation identified why the 2 showers didn't occur. d. April 2026, 5 out of 6 showers occurred. - No documentation identified why the 1 shower didn't occur. On 4/21/26 at 11:45 AM Resident #3 reported they didn't receive a shower last Friday, 4/17/26. Resident #3 stated no one came to give the shower. On 4/21/26 at 1:30 PM Staff A, Certified Medication Aide (CMA), acknowledged some residents don't receive or aren't offered showers as scheduled. Staff A noted residents on the 300 and 400 halls experience the most impact and receive a shower one time per week. Staff A explained there isn't a specific bath aide scheduled for that side of the facility. Residents on the other halls most likely receive two showers per week, as scheduled. Staff A stated they'd lost count and couldn't estimate how long this went on. On 4/21/26 at 2:55 PM Staff C, Certified Nursing Assistant (CNA), stated there's no extra staff to assist with showers on the weekends as there's no scheduled bath aide. Staff working weekends can't help catch up with showers from the past week. On 4/22/26 at 8:30 AM Staff B, CNA, acknowledged some residents don't receive or aren't offered scheduled showers. Residents on the 300 and 400 halls experience the most impact. Staff B explained two full-time bath aides remained scheduled during weekdays until early December 2025. One bath aide worked for each side of the building with the primary responsibility to provide resident showers and bathing. After this, the facility only had 1 full-time bath aide and attempted to fill the other open position with facility staff or agency staff. However, the position remained unfilled. On 4/22/26 at 10:35 AM Staff D, CNA, acknowledged some residents don't receive or aren't offered showers as scheduled. Residents on the 300 and 400 halls experience the most impact. Staff D noted there's one full time bath aide. 2. Resident #7's MDS assessment dated [DATE] identified a BIMS score of 13, indicating intact cognition. The MDS included diagnoses of a right femur (thigh bone) fracture, lack of coordination, history of falling, and cognitive communication deficit (difficulty with speaking or understanding). The MDS documented limited range of motion on one side of the lower extremity including the hip, knee, ankle, and foot. The MDS indicated Resident #7 used a manual wheelchair for mobility. Resident #7 required moderate staff assistance for bathing. The Care Plan, revised 3/31/26, outlined Resident #7 required staff assistance for bathing. The Documentation Survey Report v2 outlined Resident #7 scheduled for bathing two times per week on Tuesdays and Fridays. Review of monthly reports revealed the following: a. January 2026, 9 out of 9 showers occurred. b. February 2026, 5 out of 8 showers occurred. - No documentation identified why the 3 showers didn't occur. c. March 2026, 6 out of 9 showers occurred. - 3/27/26, the report indicated Resident #7 refused. - No additional documentation identified why the other 2 showers didn't occur. d. April 2026 up to 4/23/26, 3 out of 6 showers occurred. - 4/7/26 and 4/14/26, the report indicated Resident #7 refused. - No additional documentation identified why the 1 other shower didn't occur. On 4/21/26 at 12:42 PM Resident #7 stated he's supposed to get a shower twice a week, on Tuesdays and Fridays. He stated he felt he needed two showers a week and he'd only refused a shower on a Saturday when he'd received a shower the previous day, on Friday. On 4/22/26 at 2:15 PM Staff F, CNA, acknowledged some residents felt upset and complained about not receiving or being offered showers on their scheduled day. She stated residents remain scheduled for showers either on Mondays and Thursdays or Tuesdays and Fridays. Staff try to get residents showered at least once every week as staffing remained challenging and the facility used a lot of agency staff. On 4/23/26 at 11:14 AM Staff E, CNA/CMA, stated staffing felt a little rough and the facility definitely had a shortage of CNA staff. She acknowledged the shower aide and restorative aide (aide assisting with exercise) moved from their positions to help on the floor with resident care. She stated she's aware resident showers haven't occurred as scheduled due to staffing challenges. She stated the last three months remained the most challenging for CNA staffing. She stated residents complained about not getting showers but couldn't recall specific individuals. On 4/23/26 at 11:30 AM Staff D stated staffing wasn't great, we are short a lot. She acknowledged some residents don't receive or aren't offered showers as scheduled. Residents on the 300 and 400 halls experience the most impact as there's no shower aide for that hallway. The facility attempted to fill the open position with facility staff or agency staff. On 4/23/26 at 11:36 AM the Director of Nursing (DON) acknowledged staffing definitely remained a challenge and caused problems with residents receiving showers as scheduled. 3. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 10, indicating moderately impaired cognition. The MDS documented Resident #1 remained dependent on staff for personal hygiene. The MDS included diagnoses of anemia (low red blood cell count), heart failure, hypertension (high blood pressure), gastric reflux disease (acid reflux), renal failure (kidney failure), obstructive uropathy (urine flow blockage), cerebrovascular accident (stroke), respiratory failure, Parkinson's disease (nervous system disorder affecting movement), and a cognitive communications defect (difficulty speaking or understanding). On 4/20/26 at 3:26 PM Resident #1 stated she believed the facility had staffing issues. She stated she recently missed numerous baths and noted she'd complained about it. The Care Plan Focus revised 4/14/26 indicated Resident #1 as an assist of one for oral cares and bathing. Resident #1's January 2026 Documentation Survey Report v2 outlined Resident #1's bath scheduled as Fridays and Sundays. The report lacked documentation for baths from 1/16/26 until 1/26/26, a period of 10 days. 4. Resident #2's MDS assessment dated [DATE] identified a BIMS score of 3, indicating severely cognitively impaired. The MDS documented her reliance on staff for bathing. The MDS included diagnoses of non-Alzheimer's dementia (brain disorder that causes a decline in thinking skills), diabetes mellitus (high blood sugar), arthritis (joint inflammation), pain in the left shoulder, muscle weakness, and a history of falls. The MDS noted Resident #2 participated in at least 15 minutes of active range of motion (exercises where the resident moves their own joints) through a restorative program (nursing interventions that promote the resident's ability to live as independently as possible) in the 7-day lookback period. The Care Plan revised 3/31/26, indicated Resident #2 she required assistance from one staff for bathing. Resident #2's January 2026 Documentation Survey Report v2 listed their bath schedule as Mondays and Thursdays. The report lacked documentation of a bath or refusal from 1/20/26 until 1/29/26. Resident #2's February 2026, Documentation Survey Report v2 listed their bath schedule as Mondays and Thursdays. The facility failed to document a bath or refusal from 2/6/26 until 2/12/26. Resident #2's March 2026 Documentation Survey Report v2 listed their bath schedule as Mondays and Thursdays. The facility failed to document a bath or refusal from 3/27/26 until the following month. 5. Resident #4's MDS Assessment completed on 3/18/26 revealed a BIMS score of 15, indicating intact cognition. The MDS documented Resident #4 remained dependent on staff for bathing. The MDS included diagnoses of anemia, atrial fibrillation (irregular heartbeat), coronary artery disease (clogged heart arteries), hypertension, peripheral vascular disease (poor circulation), gastroesophageal reflux disease (acid reflux), renal insufficiency (kidney failure), arthritis, and osteoporosis (brittle bones). The Care Plan revised 3/31/26, documented Resident #4 required an assist of one person with bathing. Resident #4's January 2026 Documentation Survey Report v2 listed their bath schedule as Tuesdays and Fridays. The facility failed to document a bath or refusal from 1/28/26 until 2/2/26. Resident #4's March 2026, Documentation Survey Report v2 listed their bath schedule as Tuesdays and Fridays. The facility failed to document a bath or refusal from 3/11/26 until 3/17/26, and again from 3/21/26 until 4/3/26. On 4/21/26 at 1:32 PM Staff H, Registered Nurse (RN), stated it's been a struggle to get bathing and restorative care covered because of the facility's lack of staff. She believed this began in January or February. On 4/23/26 at 11:14 AM Staff E, Certified Nursing Assistant (CNA), stated she's aware restorative care wasn't occurring. She stated it's because restorative aides and bath aides are the first pulled to the floor when the facility has low staffing. She stated this has been ongoing for the last three months. She stated residents complained to her about the lack of consistent baths. On 4/23/26 at 11:30 AM Staff D stated the lack of staffing impacted showers and restorative care. She stated they weren't occurring. On 4/23/26 at 11:37 AM the Director of Nursing (DON) acknowledged staffing remained an ongoing issue and she knew it caused issues with bathing and restorative services. She stated her expectation for staff is to follow the Care Plan. The Activities of Daily Living (ADLs), Support policy dated March 2018 directed appropriate care and services will be provided for residents who are unable to carry out ADLs (activities of daily living) independently, with the consent of the resident and in accordance with the Care Plan, including appropriate assistance with hygiene and bathing.

Based on clinical record review, staff interview, policy review, and resident interviews, the facility failed to protect the resident's right to a dignified existence by failing to carry out perineal cares in a timely manner after incontinence episodes for 1 of 1 residents reviewed for incontinence care assistance (Resident #1) and for multiple, random residents affected, as reported by multiple staff members. The facility reported a census of 74 residents. Findings: 1. The Minimum Data Set(MDS) assessment tool, dated 10/24/25, listed diagnoses for Resident #1 which included hemiplegia(one-sided paralysis), anxiety, and depression. The MDS stated the resident was frequently incontinent with bowel and bladder and stated the resident was dependent on staff assistance for toileting hygiene. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 14 out of 15, indicating intact cognition. The facility policy Dignity, revised February 2021, stated the facility would care for residents in a manner that promoted and enhanced well-being, satisfaction with life, and feelings of self-worth. The facility directed staff to treat residents with dignity and respect at all times and to promptly respond to a resident's request for toileting assistance. A 10/21/25 Care Plan entry stated the resident required the assistance of 2 staff for personal hygiene. A 7/22/24 Corrective Action Form for Staff A Certified Nursing Assistant(CNA) stated that a resident was found soaked in urine from his head to his knees and the incontinent brief was (wet) beyond the point of falling apart. The form directed Staff A to complete rounds every 2 hours and check and change residents assigned to her. A 10/25/25 Grievance/Concern Investigation Form for Staff A CNA stated Resident #1 required a complete bed strip and Staff A stated there was no point in changing his sheets if he's just going to do it again. The resident sat in saturated sheets until (other) staff assisted him. On 10/29/25 at 2:22 p.m., when queried as to if she had had problems with other staff members completing rounds on night shift, Staff B CNA stated she had problems with Staff A CNA for a really long time. Staff B filled out multiple grievances related to Staff A and her completion of rounds on the night shift. She stated the Director of Nursing(DON) or the Administrator were supposed to come in on the night shift to audit rounds but this did not happen.On 10/29/25 at 3:53 p.m , the Administrator stated she had allegations in the past that Staff A had left residents wet and she coached her. She stated she had no grievances in the last 6 months though related to Staff A. She stated she did not receive anything this week about Staff A. She stated she would start an investigation and would suspend her. On 11/4/25 at 8:40 a.m., Staff C CNA stated that when she followed Staff A on the day shift after she had worked overnight, the residents were wet. She stated residents had visibly soiled briefs which were dark in color because they were wet for several hours. She stated she talked to the DON about it approximately a month ago. She stated the resident rooms have odors and the bed pads have rings(of urine). She stated staff should change residents every 2 hours. On 11/4/25 at 8:49 a.m., Staff D CNA stated after Staff A worked the night shift, half of her residents were soaked, He stated she did not go room to room to complete rounds like they were supposed to but instead left the building. He stated at times he found a clean bed pad under residents but the layer under that was wet. He stated this happened for the last year and a half and he spoke to charge nurses about it. On 11/4/25 at 9:23 a.m., Staff F Registered Nurse(RN) stated staff reported to her that Staff A left residents wet in bed. Staff F stated she herself filled out a grievance form within the last couple of months related to this concern. On 11/4/25 at 9:28 a.m., Staff E Licensed Practical Nurse(LPN) stated staff found residents soaked in beds requiring a bed strip when they took over care for Staff A. She stated she filled out some grievances but she was not sure on the time frame. On 11/4/25 at 9:37 a.m., the Director of Nursing(DON) stated she had not had any encounters with Staff A since 2024 when Staff A ripped up a disciplinary action sheet she gave to her. The disciplinary action was regarding residents being left wet when day shift took over for her. The DON stated she was directed by the Administrator to let her(The Administrator) handle Staff A. She stated last week, Staff G CNA told her she had a complaint about Staff A doing the same thing again, leaving resident's wet. She stated because the Administrator handled Staff A, she didn't know what happened regarding this. She stated she did not come in on the night shift and was unsure if anyone else had. She stated she felt like there were grievances filled out regarding Staff A. On 11/4/25 at 9:55 a.m., the Regional Director of Clinical Services stated the facility located a grievance related to Staff A, dated 10/25/25. She stated they interviewed residents and educated staff related to denial of critical care. The facility implemented a new box to place grievances in and they conducted education related to rounding. The facility lacked documentation of follow-up to the 10/25/25 grievance from 10/25/25 to 10/29/25. The facility also lacked any additional documentation of grievances filled out by staff concerning Staff A.On 11/4/25 at 2:23 p.m., Regional Director of Clinical Services stated if there was an allegation that a staff member intentionally withheld care, they would report it to the state agency and complete an investigation. She stated the facility should review all grievances.On 11/4/25 at 2:47 p.m., the Director of Nursing(DON) stated staff should change residents every 2 hours.

Based on clinical record review, staff and resident interview, and policy review, the facility failed to report suspected abuse to the proper state agency within two (2) hours. The facility reported a census of 72 residents. Findings include: A Facility Reported Incident (FRI) dated 7/29/24 indicated the facility reported to the State Agency (SA) on 7/24/24 at 10:58 am Resident #1 stated Staff A, Certified Nurse Aide (CNA) swore at her in the early morning of 7/24/24. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated completely intact cognition. It included diagnoses of anemia, Coronary Artery Disease (CAD), Heart Failure, renal failure, Diabetes Mellitus, thyroid disorder, and Chronic Obstructive Pulmonary Disease (COPD). It indicated the resident required set-up assistance with eating and oral hygiene and was dependent or required maximum assistance with all other areas of Activities of Daily Living (ADLs). A progress note dated 7/24/24 at 1:52 am revealed Resident #1 fell during the shift and required assistance to get up. The Care Plan dated 10/23/23 indicated the resident required one (1) person assistance with transfers. It directed staff to use a mechanical lift for resident transfers. On 8/29/24 at 4:36 PM, Staff B, CNA stated she and Staff A were assisting Resident #1 off of the floor in the early morning hours on 7/24/24 and heard Staff A curse at the resident but was unable to recall the specific words Staff A used. She stated she did not report this to the charge nurse. A progress note dated 7/24/24 at 8:55 am revealed Resident #1 told the Director of Nursing (DON) Staff A swore at her last evening. On 8/30/24 at 12:39 PM, the administrator stated the on-call administrator designee spoke with the staff nurse regarding the residents fall but not the report of suspected abuse. She stated the administrative team was made aware of it the next morning. An undated document titled Past Non-Compliance Checklist included the facility failed to investigate and report verbal abuse timely. It also included verbal allegation of abuse occurred on 7/24/24 and staff did not report it to management or the charge nurse timely to initiate an investigation. A document titled In-Service Form Education Description: Abuse and Neglect dated 7/24/24 directed staff that all allegations of resident abuse should be reported immediately to the charge nurse. On 8/30/24 at 4:30 pm, the DON stated staff should report situations if they are unsure whether or not it is abuse.

Based on clinical record review, policy review, and staff interview, the facility failed to notify the provider of a resident's low blood sugars for 1 of 3 residents reviewed for a change in condition (Resident#1). The facility reported a census of 74 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 8/15/23, listed diagnoses for Resident #1 which included diabetes, malnutrition, and anxiety disorder. The MDS stated the resident received insulin and listed the resident's Brief Interview for Mental Status(BIMS) score as 13 out of 15, indicating intact cognition. The facility policy Change in a Resident's Condition or Status, revised February 2021, stated the facility promptly notified the attending physician of changes in the resident's medial condition. The August 2023 Medication Administration Record(MAR) listed a 6/1/23 order to check blood sugars before meals and at bed time. The order directed staff to report to the primary care physician if below 60 milligrams per deciliter(mg/dl) or over 400 mg/dl. A 12/14/23 Care Plan entry stated the resident received insulin related to diabetes and a 12/28/23 entry directed staff to follow blood sugar reporting parameters. An 8/16/23 9:30 p.m. Nurses Note stated the resident's blood sugar was 43 mg/dl and the nurse gave the resident orange juice with sugar and a peanut butter sandwich. The resident's blood sugar rose to 100 mg/dl in about 10 minutes and to 205 mg/dl in about 20 minutes. A 2/15/24 11:47 p.m. Focused Evaluation Note stated the resident's blood sugar was 41 mg/dl this shift and the nurse gave the resident orange juice with sugar and snacks and the resident's blood sugar rose to 117 mg/dl. The facility lacked documentation of provider notification of the above occurrences of low blood sugars. On 3/12/24 at 11:14 a.m. via phone, Staff C Licensed Practical Nurse (LPN) stated the resident's blood sugar became low a couple of times She stated she gave him orange juice and sat with him and it raised within an hour. She stated she did not think that she notified the provider of his low blood sugars. On 3/13/24 at 9:37 a.m., Staff A Advanced Registered Nurse Practitioner (ARNP) stated she would want the facility to notify her of blood sugars in the 40's and stated if it was after 6:00 p.m., they should call the on-call provider. On 3/13/24 at 10:36 a.m., the Director of Nursing (DON) stated she would not have called the provider if she was in the situation of the low blood sugars either. She expected nurses to pass those things on in report. On 3/13/24 at 1:54 p.m. via phone, Staff B LPN stated they had parameters to follow regarding when to notify the provider of an abnormal blood sugar. She stated they would call the provider if a blood sugar was below 60 mg/dl or over 400 mg/dl. On 3/13/24 at 2:24 p.m., the DON stated she could not locate any documentation of provider notification of Resident #1's low blood sugars.

Based on clinical record review, policy review, and staff interviews, the facility failed to carry out an intervention to prevent a fall, and failed to ensure Care Plan entries based on root cause analysis were carried out and documented on the Care Plan for 2 of 3 residents reviewed for falls(Residents #3 and #6). The facility reported a census of 74 residents. Findings include: 1. An 11/17/14 Care Plan entry documented that Resident #3 was at risk for falls. A 2/23/23 Care Plan entry stated the resident had bolsters on her mattress(additional cushions placed on a mattress which can prevent rolling). The Quarterly Minimum Data Set (MDS) assessment tool, dated 3/30/23, listed diagnoses for Resident #3 which included dementia, osteoarthritis of the knee(inflammation of the knee bone) and muscle wasting. The MDS documented the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use, and personal hygiene, and depended completely on 1 staff for bathing. The MDS listed a Brief Interview for Mental Status(BIMS) score as 3 out of 15, indicating severely impaired cognition. A 3/30/23 Fall Risk Evaluation stated the resident was at high risk for falls. A 6/11/23 4:45 a.m., untitled Fall Incident Report documented that the resident was found face down next to her bed and her body pillow was not next to her side. The resident sustained bruises to her knees and skin tears to her right elbow and right forearm. On 3/14/24 at 8:39 a.m., the Director of Nursing(DON) stated that the intervention for Resident #3's 6/11/23 fall was a beveled mattress. She stated the resident should have already had the mattress. She stated beveled mattresses can prevent residents from falling out. She stated she located an email that the beveled mattress was ordered after the 6/11/23 fall. 2. A 10/15/23 hospital History and Physical stated the Resident #6 had a fracture of the hip. The 10/20/23 Admission MDS assessment tool, dated 10/20/23, listed diagnoses which included fracture, abnormalities of gait and mobility, and pain in the right hip. The MDS stated the resident required substantial/maximal assistance with toileting, rolling, sitting to lying, lying to sitting, sitting to standing, and transferring. The MDS stated the resident had one fall since admission and listed his BIMS score as 6 out of 15, indicating severely impaired cognition. A 10/22/23 SPN-Skilled Evaluation Note stated Resident #6 was post pelvic fracture with a history of multiple falls. A 10/23/23 untitled Fall Incident Report stated the resident was found on the floor, lying on his back and he sustained a skin tear to the scapula(shoulder blade). A Care Plan entry with an initiation date of 10/23/23 stated the physician would review the medication list and evaluate. The facility lacked documentation of a medication review which addressed the resident's falls. An 11/10/23 untitled Fall Incident Report documented the resident laid on his right side beside his roommate's bed. A Care Plan entry with the initiation dated of 11/10/23 stated the facility would refer the resident to Hospice. The Care Plan Changes Since Last Review report documented the intervention's created date was 3/12/24. A 12/7/23 untitled Fall Incident Report stated the resident was on his knees with his arms on his bed with no injuries noted. A Care Plan entry with the initiation date of 12/7/23, stated the facility would request an evaluation for Physical Therapy(PT). The Care Plan Changes Since Last Review report documented the intervention's created date was 3/12/24. A 1/3/24 untitled Fall Incident Report stated the resident laid on the floor with his legs stretched out and he wanted to see what the commotion was. A Care Plan entry with an initiation dated of 1/3/24 directed the staff to provide the resident with a calm environment where he could rest peacefully. The Care Plan Changes Since Last Review report documented the intervention's created date was 3/12/24. The facility policy Falls and Fall Risk, Managing, revised March 2018, stated staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling. The policy stated the facility would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk for falls. On 3/13/24 at 11:40 a.m., the Administrator stated Resident #6 did not receive therapy because it was not approved by Hospice. On 3/13/24 at 2:24 p.m., the DON stated they discussed root causes of falls and created interventions. She stated if there was a change, it would be on the Kardex(a pocket care plan). She stated with regard to Resident #6's intervention of a medication review, she did not see a review related to his fall. She stated they went through the Care Plan yesterday(3/12/24) and added everything they had carried out. When queried regarding why the calm environment intervention was not on the Care Plan until 3/12/24, she stated they would have talked about that in an inservice. She stated interventions should be on the Care Plan for all to see. She stated with regard to Resident #6 not being eligible for Physical Therapy, they should have come up with another intervention.

Based on observations, clinical record review, policy review, resident and staff interviews the facility failed to accommodate medication administration time preference for 1 of 2 residents (Resident #27) in the sample. The facility reported a census of 75. Findings included: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 4/19/23, listed diagnosis for Resident #27 included: high blood pressure, depression, and hypothyroidism. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, which indicated intact cognition. A record review revealed a 3/20/23 physician order for Levothyroxine (a medication to treat hypothyroidism) 25 mcg (micrograms) 1 tablet by mouth one time a day. During an interview on 5/2/23 at 8:25 AM, Resident #27 stated that she has requested to receive levothyroxine before breakfast as the medication is to be taken before eating. The resident stated she receives the medication with all her morning medications, often after she has had her breakfast. During an observation on 5/3/23 at 9:41 AM, Resident #27 ate breakfast in her room. At 9:42 AM, the resident stated she had yet to receive Levothyroxine or any morning medications. During a continual observation on 5/3/23 at 9:56 AM, Staff B, Certified Medication Assistant (CMA) started medication administration in the 200 hallway. At 10:36 AM, Staff B entered Resident#27's room with medications. At 10:37 AM, Resident#27 confirmed she received the Levothyroxine, with all morning medications. During an interview on 5/3/23 at 11:53 AM, the facility Nurse Practitioner stated she would expect Levothyroxine to be administered prior to a meal for proper absorption to occur. During an interview on 5/4/23 at 12:11 AM, the Director of Nursing (DON) stated she would expect staff to honor a request for a medication to be administered during a specific time frame. The DON stated Levothyroxine should be taken on an empty stomach, and she would expect the medication to be given prior to a meal. A facility policy, dated April 2007, titled Medication Therapy #2 indicated all decisions related to medications shall include appropriate elements of the care process, such as: e. Each resident;s wishes, values, goals, conditions and prognosis

Based on record review, policy review, resident and staff interviews the facility failed to administer pain medication in a timely manner for 1 of 1 residents (Resident #176) in the sample. The facility reported a census of 75 residents. Findings include: 1. TheAdmission Minimum Data Set (MDS) assessment tool, dated 4/11/22, listed diagnoses for Resident #176 which included: Cellulitis (skin infection) of right and left lower legs, peripheral venous insufficiency (veins not working effectively, making blood return difficult), and anxiety disorder. The MDS listed the Brief Interview for Mental Status) BIMS score as 3 out of 15, whcih indicated severely impaired cognition. During an interview on 5/1/23 at 2:06 PM, Resident #176 stated there have been times when she had to wait too long for pain medication. A record review revealed a 4/5/23 physician's order for hydrocodone-acetaminophen (tylenol) 7.5-325 mg (milligrams) 1 tablet every six hours as needed for pain (PRN). During an interview on 5/3/23 at 10:48 AM, the resident stated on 5/2/23 after receiving a noon dose of Buspar she reported she had pain and requested a PRN pain medication. The resident reported she had to wait several hours to get the medication. A record review revealed a 4/5/23 physician's order for Buspirone (commonly called Buspar) 5 mg 1 tablet by mouth three times a day. A record review of the May 2023 Electronic Medication Administration Record (EMAR) revealed the residents Buspar scheduled for AM, mid, and HS (bedtime). On 5/3/23, the EMAR documented the resident received a dose of Buspar at the mid time frame. A review May 5/2/23 2023 EMAR revealed the resident received a PRN dose of Hydrocodone-Acetaminophen (tylenol) 7.5-325 mg (milligrams) at 2:59 PM. During an interview on 5/4/23 at 9:41 PM, Staff F, Registered Nurse (RN) stated if a resident requested pain medication she would give it as soon as possible. [NAME] stated typically this would be in 5 to 10 minutes. Staff F stated more than a half hour is too long for a resident to wait. During an interview on 5/4/23 at 12:08 PM, the Director of Nursing (DON) stated she expects nursing staff to administer pain medication right away, if the order allows. The DON stated a resident waited too long if they requested pain medication at 12:30 PM, and did not get the medication until 2:59 PM. The facility policy, dated March 2020, titled Pain Assessment and Management Implementing Pain Management Strategies section #5 directed staff to implement the medication regimen as ordered, carefully documenting the results of the intervention.

Based on observations, clinical record review, and staff interviews the facility failed to support the behavior health needs in an effort to prevent self harm for 1 of 1 residents (Resident #27) in the sample. The facility reported a census of 75. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 4/19/23, listed diagnoses for Resident #27 included: Alzheimer's disease, depression, and hypothyroidism. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, which indicated intact cognition. The MDS Behavior Section documented no hallucinations or delusions during the review period. The assessment documented a 0, indicating behaviors such as scratching or picking self not exhibited. During an observation on 5/2/23 at 8:22 AM, Resident #27 noted to have a nickel size wound on her nose. The resident explained she had something on her nose and had to pick it off. A Skin & Wound note, dated 4/27/23 documented the wound as an abrasion, and acquired in house 12/13/22 with location documented as face. A review of the Electronic Health Record (EHR) revealed an addendum note, dated 2/14/23, from the residents outpatient provider. The note documented the provider contracted Staff G, Social Services asking for a medical work up/evaluation to rule out possible delirium as they [the facility] report this was more sudden in onset. Staff G reported this has been going off and on for the past six weeks or so. The provider expressed the importance of having an in-depth medical work up done as she [the resident] is experiencing changes to her mental status that is described as sudden and ongoing for approximately six weeks. The provider asked about the abrasion on the resident's nose. Staff G informed the provider the abrasion is from the resident picking at the side of her face and scratching it. An Incident, Accident, Unusual Occurrence note, dated 2/20/23, revealed the resident noted to have two open areas on her abdomen. A Primary Care Provider (PCP) progress note dated 2/21/23 documented the resident had picked her face, left ear and scalp. The note lacked documentation of the two open areas on abdomen discovered on 2/20/23. A Behavior note in the EHR, dated 2/25/23 at 1:01 PM, documented the resident picking scabs on her face stating blood is coming from my ear. I have something growing in my ear. Resident reassured drops were for wax in ears and would be flushed in a couple of days. A Nurses note, dated 4/29/23 at 6:36 AM, documented the resident had been up most of the night, extremely anxious and restless. The note revealed the resident rubbed and picked at her skin to the point of two new open areas, one on each thigh. An Orders-Administration Note, dated 4/29/23 at 1:32 PM , documented every shift the resident continues to pick at skin and asks the nurse to pick a booger out of her nose. Resident stated If I just rub this you can see the grains of sand that come out of my skin. A review of the Care Plan revealed a lack of focus and interventions for behavior management related to picking skin. During an interview on 5/4/23 at 8:57 AM, Staff D, Certified Nursing Assistant stated Resident #27 will say there is black fluid coming out of her body and then pick her skin. Staff D stated she stated the resident has picked her skin open on her ear, thigh and stomach due to believing there is something coming out of her skin. Staff D stated she does not recall a specific training on how to help the resident manage her behavior. During an interview on 5/4/23 at 9:17 AM, Staff C, Registered Nurse stated picking has caused most of Resident #27 wounds. She stated the resident picked her right forearm open to get the vein out. Staff C stated she is able to work well with the resident, but does not know of a behavior management plan to prevent the picking. During an interview on 5/4/23 at 12:15 PM, the Director of Nursing (DON) stated she would expect any resident who started a medication for behavior concerns, or receives psychiatric services to have a behavior management plan on their care plan. When asked if Resident #27 needed a goal with interventions for behavior management, the DON stated she probably should. The facility policy, dated March 2019, titled Behavior Assessment, Intervention and Monitoring revealed the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive and plan of care. The policy documented interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situation and environmental reasons for the behavior. The care plan will include, as a minimum: a. A description of the behavioral symptoms including 1. Frequency 2. Intensity 3. Duration 4. Outcomes 5. Locations 6. Environment and 7. Precipitating factors or situations b. Target and individualized interventions for the behavioral and/or psychosocial symptoms. c. The rationale for the interventions and approaches d. Specific and measurable goals for target behaviors; and e. How the staff will monitor for effectiveness of the interventions

Based on employee training list, facility policy and staff interviews the facility failed to provide behavior management training to staff to meet the behavioral health needs 1 of 1 residents (Resident #27) in the sample The facility reported a census of 75 residents. Findings Include 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 4/19/23, listed diagnosis for Resident #27 included: Alzheimer's disease, depression, and hypothyroidism. The MDS listed the resident ' s Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. A review of progress notes in the Electronic Health Record (EHR) revealed the resident acquired the following wounds from picking her skin: a. On 12/13/23 an abrasion on her face (nose) b On 2/11/23 a skin tear on her right forearm c. On 2/20/20 two abrasions on her abdomen d. On 4/29/23 an abrasion on her right, and left thighs A review of the residents care plan revealed a lack of focus and interventions for the behavior of picking skin. During an interview on 5/4/23 at 8:57 AM, Staff D, Certified Nursing Assistant (CNA) stated she has not had any behavior management training specific to Resident #27. She stated she remembers discussing the picking behavior with nurses, and has watched Relias videos. During an interview on 5/4/23 at 12:15 PM, the Director of Nursing (DON) stated she knows that staff training consists of a video on dementia, and then if there are any concerns they would be discussed at the 2:00 PM in services. During an interview on 5/4/23 at 1:18 PM, the Regional Nurse Consultant stated staff training for behavior management are addressed in the Relias training. A review of the Relias Training Plan Module list used for staff training revealed the following trainings: a. Using Personal Protective Equipment b. Affirmative Action in the Workplace c. Preventing, Recognizing and Reporting Abuse d. Management Elopement e. Clean Hands: Combat Covid-19 f. Harassment in the Workplace g. HIPPA Basics h Transmission -Based Precautions i. A Day in the LIfe of [NAME]: A Dementia Experience j. Hazardous Chemical: SDS and Labels k.Providing Customer Service l.Essential of Resident Rights The facility provided an additional Relias Course Enrollments list. This list included: a. 5 Signs and Symptoms of Anxiety and Panic Attacks b. Communication and People with Dementia c. The Meaning Behind Behaviors The facility policy, dated March 2019, titled Behavior Assessment, Intervention and Monitoring Management Section #11 documented the DON will evaluate whether the staffing needs have changed based on the acuity of the residents and their plans of care. Additional staff and/or staff training will be provided if it is determined that the needs of the residents cannot be met with the level of staff or staff training.

Based on observations, clinical record review, staff interview and facility policy review the facility failed to maintain appropriate care for 2 out of 2 resident's catheters (Resident #26 and #52). The facility reported a census of 75 residents. Findings included: 1. The Quarterly Minimum Data Set Assessment (MDS) for Resident # 52 dated 4/19/23, listed diagnoses of dementia, obstructive uropathy and benign prostate hyperplasia (BPH). The MDS included the Brief Interview for Mental Status score of 7 (sever cognitive impairments). The MDS listed Resident # 52 required extensive assist of 1 staff for transfers, toileting, and personal hygiene. The Care Plan for Resident # 52 dated 04/28/2023, revealed a urinary tract infection (UTI), treated with an antibiotic from 4/28/23 through 5/3/23. The Physician's note dated 4/21/23, reflected the Chief Complaint/Nature of Presenting Problem: New onset dysuria (painful or difficult urination) and urgency with indwelling catheter present. The progress note revealed Resident # 52 seen per facility request. Patient complained of dysuria and constant feeling of having to urinate. Staff reported Resident # 52, requested to go to the bathroom every couple of hours. The facility Matrix on 05/01/23, included Resident # 52 triggered for the catheter, an antibiotic and a UTI. The Order Audit Report dated 4/28/23, directed Bactrim 800-160 milligrams (MG) (Sulfamethoxazole-Trimethoprim) give 1 tablet by mouth two times a day for UTI for 5 Days. On 05/01/23 at 3:08 PM, Resident # 52 laid in his bed, the catheter sat in a dignity bag on the left of the bed. On 05/02/23 at 8:37 AM, Resident # 52 wheeled himself out of the dining room while 3 inches of the catheter tubing drug on the floor under the wheel chair. On 05/03/23 at 7:08 AM, Resident # 52's catheter tubing drug on the floor in the [NAME] pool room as Staff C, Registered Nurse (RN) pushed him in the room for wound care. The fluid in the catheter tubing appeared bright red. Staff C, reported the charge nurse knew of the discoloration. On 05/03/23 at 11:00 AM, Staff A, Certified Nurses Aid (CNA) reported he emptied about 200 cubic centimeters (cc) from Resident # 52's catheter bag in the morning. Staff A, revealed he saw several blood clots. On 05/03/23 11:23 AM, Staff A moved Resident # 52 to the wheel chair (w/c). Staff A placed Resident # 52 catheter bag on the floor as he moved to the back of the w/c, reached under the w/c and hooked catheter up under the w/c On 05/04/23 at 8:16 AM, Staff E, Nurses Aid (NA), reported the catheter bags are hooked on the side if the bed or the under the w/c. The Facility provided a policy titled Catheter Care, Urinary dated 2014, directed Infection Control, at point #2b, be sure the catheter tubing and drainage bag are kept off the floor. 45775 2. The Minimum Data Set (MDS) assessment tool, dated 2/27/23 , listed diagnosis for Resident #26 included type 2 diabetes, obstructive and reflux uropathy (urine flow obstructed), and anxiety disorder. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, which indicated intact cognition. A record review revealed a 10/24/22 physician order for a Foley catheter. During an observation on 5/2/23 at 9:23 AM, the resident's catheter bag hung from the side of a waste basket next to the residents bed. The catheter tubing rested on the floor. The waste basket contained used paper towels, paper cups, and various wrappers. During an observation on 5/3/23 at 9:59 AM, the resident's catheter bag hung from the side of the waste basket, with the tubing on the floor. At 10:01 AM, Staff B, Certified Medication Assistant (CMA) entered the residents room, and exited at 10:08 AM. At 10:08 AM, the catheter bag remained hooked on the side of the waste basket with the tubing resting on the floor. During an interview on 5/4/23 at 8:57 AM, Staff D, Certified Nursing Assistant (CNA) stated when in bed, a resident's catheter bag should be hooked on to the bedframe, with the tubing situated so it can drain into the bag. Asked if the bag can be hooked on to the side of a waste basket, Staff D stated no it should not. Staff D stated if she saw a bag hooked on to a waste basket with the tubing on the floor she would clean the bag and tubing, and hook it to the bed frame. During an interview on 5/4/23 at 9:44 AM, the Director of Nursing (DON) stated she would expect a catheter bag and tubing to be hooked on the residents bed frame so as not to touch the floor. The DON stated it is not acceptable to hook the catheter bag on the side of a waste basket, with the tubing on the floor due to the risk of infection. A facility policy, dated September 2014, Titled Catheter Care, Urinary directed staff in the Infection Control section #2. Maintain clean technique when handling and manipulating the catheter, tubing or drainage bag, and 2b. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on clinical record reviews and staff interview, the facility failed to ensure a resident with limited range of motion and mobility receive restorative services to maintain or increase range of motion and prevent further decline in mobility for 3 of 3 residents reviewed. (Residents #4, #5, #9) The facility reported census was 75. Findings include: 1. According to the Minimum Data Set (MDS) assessment with assessment reference date of 10/26/22, Resident #4 had a brief interview for mental status (BIMS) score of 4 which indicated a severely impaired cognitive status. Resident #4 required extensive assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. Resident #4's diagnosis included diabetes mellitus, coronary artery disease and Non-Alzheimer's dementia. According to Resident #4's restorative plan schedule, Resident #4 was to complete active range of motion (AROM) exercises to her upper extremities to include arm bike up to 10 minutes or ROM upper extremities, 3 times weekly and AROM exercises to her lower extremities to include Omni L2 up to 15 minutes or ROM to her lower extremities, 2-6 times per week. Review of Resident #4's restorative plan schedule for January 2023, noted no scheduled restorative activity on January 4, 9, 13, 16, 18, 20, 23, 25 and 27. 2. According to the Minimum Data Set (MDS) assessment with assessment reference date of 10/19/22, Resident #5 had a brief interview for mental status (BIMS) score of 13 which indicated an intact cognitive status. Resident #5 required extensive assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. Resident #5's diagnosis included cancer and morbid obesity. According to Resident #5's restorative plan schedule, Resident #5 was to complete active range of motion exercises to her upper extremities to include Omnicycle up to 15 minutes, L2/arm bike up to 15 minutes 2-6 days per week and AROM exercises to her lower extremities to include Omnivr for core ex picnic or exercises LAQ, hs, curls, hip abd, hip add, ankle pumps 2-6 days per week. Review of Resident #5's restorative plan schedule for January 2023, noted no scheduled restorative activity on January 4, 11, 13, 18, 20 and 27. 3. According to the Minimum Data Set (MDS) assessment with assessment reference date of 10/26/22, Resident #9 had a brief interview for mental status (BIMS) score of 13 indicating an intact cognitive status. Resident #9 required extensive assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. Resident #9's diagnosis included cerebrovascular accident (stroke), hemiplegia, diabetes mellitus and malnutrition. According to Resident #9's restorative plan schedule, Resident #9 was to complete passive/active range of motion (ROM) exercises to his lower extremities to include the Omnicycle L2-3 up to 15 minutes as tolerates, 2-6 days per week. Review of Resident #4's restorative plan schedule for January 2023, noted Resident #9 with positive COVID from January 8-18, but no scheduled restorative activity on January 19, 20, 23, 26 and 27. On 1/30/23 at 12:39 p.m. Staff G, Registered Nurse, stated she was the restorative nurse and responsible for providing the restorative program. Staff G stated when residents are finished with therapies, she gets a restorative plan which she implements. Staff G stated because of her current illness and the need to sometimes work on the floor, the restorative programs are not done. Staff G indicated there is no one else currently trained to do restorative in her absence.

Based on observation, clinical record review and staff interview, the facility failed to provide routine perineal cares of incontinent residents for 1 of 3 residents who are unable to carry out the activity independently. (Resident #2) The facility reported census was 75. Findings include: According to the Minimum Data Set (MDS) assessment with assessment reference date of 11/9/22, Resident #2 had short and long term memory deficits and had a severely impaired cognitive status. Resident #2 required extensive assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. Resident #2's diagnosis includes Non-Alzheimer's Dementia and respiratory failure. According to Resident #2's plan of care, she is at risk for skin impairment with an intervention which directed staff to reposition as Resident #2 allows. The plan of care also indicated Resident #2 was in need of assistance with both toileting and personal hygiene. On 1/25/23, at 9:00 a.m. Resident #2 sat in her wheelchair at the corner of 300 hall near the nurse's station. Resident #2 remained at that location until 12:00 p.m. at which time she was propelled into the dining room for lunch. Resident #2 remained in the dining room until approximately 1:30 p.m. at which time she was propelled back to the corner of 300 hall. There was no observations of Resident #2 ever being off loaded from her wheelchair or provided any incontinence cares during the day shift. On 1/25/23 at 2:00 p.m. Staff D, Certified Nurse Aide, stated she worked the 6:00 a.m. to 2:00 p.m. shift and was responsible for the 300 hall. Staff D stated Resident #2 was provided incontinence cares when they got her up around 7:30 a.m. Resident #2 was brought to the dining room for breakfast and was then moved to the corner of 300 hall. Resident #2 remained there until lunch. After lunch, Resident #2 was returned to the corner nurse's station where she currently remains. Staff D stated Resident #2 had not been out of her wheelchair or provided incontinence cares since that morning. \

Based on observation, record review, and staff and physician interviews, the facility failed to obtain and clarify physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1). The failure resulted in Immediate Jeopardy to the health, safety, and security of the residents. The facility also failed to implement appropriate interventions in a timely manner for Resident #1, and Resident #6, when significant changes of condition that included pain level rated at 10 out of 10 on a 0 to 10 pain scale, with 10 assigned to the highest level of pain, and circulation changes that included the development of worsened pitting [CONDITION(S)] that weeped fluid, did not implement appropriate interventions, and did not notify the physician of Resident #1's and Resident #6's condition changes or seek direction to provide care consistent with the condition changes and resident needs. The facility reported a census of 74 residents. Findings include: 1. The [DATE] admission Minimum Data Set (MDS) assessment recorded that Resident #1 admitted to the facility [DATE], had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented she had severely impaired cognitive skills for daily decision-making, symptoms of [CONDITION(S)], she did not speak and rarely or never could make herself understood or understand others. Resident #1 required extensive assistance of at least 2 staff for transfers to and from bed and chair, dressing, eating, toilet use, bathing and personal hygiene. She was always incontinent of bowel and frequently incontinent of urine. Review of a hospital History and Physical form revealed that Resident #1 had an operation for open reduction and internal fixation (ORIF) of the right hip and olecranon (elbow area of the humerus, upper arm bone) completed on [DATE] by an orthopedic surgeon. Hospital Discharge Orders dated [DATE] directed the resident's admission to the facility at a skilled level of care, with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Schedule follow-up appointment with Orthopedic Surgeon within 2 weeks. b. Administer 2 Acetaminophen (Tylenol) 325 milligrams (mg) tablets (650 mg dose) orally 4 times daily. c. Resident #1 to wear sling to right arm. The Discharge Orders stated incisions were present on the right hip and right elbow, but did not direct what incision or wound care was required. A Cast or Splint Care, Adult Instruction Form, revised [DATE] and included with the resident's Hospital Discharge Orders, directed staff to contact the health care provider if the skin around the cast or splint got red or raw and/or the skin under the cast was extremely itchy or painful. The resident's ,d+[DATE], ,d+[DATE] and ,d+[DATE] Medication Administration Records (MARs) recorded that Resident #1 received 1 tablet of Acetaminophen, 325 mg orally 4 times daily from the time of admission on [DATE] until the time of her discharge on [DATE] and from the resident's return on [DATE] through [DATE] when reviewed. An Impaired Skin problem on the resident's Nursing Care Plan, initiated [DATE], documented the goal that Resident #1 would not have complications related to skin impairment, directed staff: a. Educate me, my family, and caregivers of causative factors and measures to prevent skin injury. b. Monitor for and document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Weekly treatment documentation to include, measurement of each area of skin breakdown, type of tissue and exudates, and any other notable changes or observations. The resident's record did not contain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's record lacked documentation of CMS (circulation, motor and sensory) assessments of the right arm at least every nursing shift, as directed by professional standards of practice. A Nursing Progress Note dated [DATE] at 11:25 a.m. and authored by Staff A, Licensed Practical Nurse (LPN) documented Resident #1 showed non verbal signs/symptoms of pain with movement, however, denied pain when asked. A Nurses Note on [DATE] at 10:42 a.m. by Staff A recorded that Resident #1 had post right hip and right elbow fractures with surgical intervention. The bandages to both were clean, dry and intact, and not to be removed until follow up appointments. Resident #1 continued to deny pain; however does show non verbal signs and symptoms of pain during transfers. A Nurses Note dated [DATE] at 3:05 p.m. recorded Staff B, Registered Nurse (RN) noted an abrasion to Resident #1's right inner wrist. The abrasion had an intact scab, and no odor, drainage or redness. Staff B cleansed the area and left it open to air at this time. The nurse notified the local general practice physician of the area. A fax (facsimile) to the same physician transcribed by Staff B on [DATE] at 3:06 p.m. recorded Noted abrasion to right wrist from soft cast rubbing. Area scab intact at this time. The physician returned the fax on [DATE] at 2:07 p.m., and directed staff monitor the area and update the physician with changes. A Skin/Wound Assessment form completed on [DATE] by Staff B described a scabbed abrasion that measured 0.8 centimeters (cm) by 1.5 cm by 0.8 cm, without drainage or symptoms of infection, and skin around scab normal. A Nurses Note dated [DATE] at 5:41 p.m. by Staff C, LPN and Assistant Director of Nursing (ADON) documented the local general practice physician noted the abrasion to the resident's right wrist where her cast rubbed without new orders. A Nurses Note dated [DATE] at 3:27 a.m. by Staff D, LPN recorded Resident #1 continued to show signs and symptoms of restlessness. PRN [MEDICATION(S)] utilized after non-pharmacological interventions exhausted, i.e. distraction, 1:1, repositioning, redirection. The Nurses Notes dated [DATE] at 9:36 a.m. by Staff A documented Resident #1 was alert and oriented to herself only. She continued to pick at the soft cast and an area to her wrist was warm to the touch. The local general practice physician rounded; he took a look at this and would come back to facility and recast the area with a shorter cast so we can treat the area. Staff placed a call to the resident's orthopedic surgeon and made a follow-up appointment. At 12:00 p.m., Staff A documented the local general practice physician returned to recast the resident's right arm. When the cast was removed there was an area about a quarter size opened with copious amounts of drainage noted. The doctor ordered the resident sent to the hospital emergency room (ER) for evaluation. A Hospital ER Physician Note dated [DATE] at 12:23 p.m. described that Resident #1 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The ER provider consulted with the orthopedic surgeon, and the resident transferred to another hospital under the care of the orthopedic surgeon on [DATE]. The Surgeon's Operative Report dated [DATE] documented Resident #1 received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The surgery required and completed on [DATE] included a rotational flap of the anconeus muscle to cover the right elbow skin defect; complex closure of secondary wound dehiscence, right elbow; removal of deep hardware, right elbow and excision of infected olecranon bursa, right elbow. The resident required treatment with intravenous antibiotics at the hospital, where she remained until [DATE]. During interview on [DATE] at 9:47 a.m., Staff B, RN, Restorative Nurse stated that on [DATE] she took a photo of the resident's wrist wound, could tell it was from the cast because it was located in the area that rubbed the resident's arm when she flexed at the wrist. It was an intact scab, no drainage and not reddened, and Staff B put it on the list for the Wound Nurse to follow, sent a fax to the physician's clinic for treatment orders because it was a skin issue. The floor nurse could have called the surgeon, she had just updated the primary physician and wasn't a regular staff nurse there, but did fill in when a nurse was off sometimes. Staff B couldn't recall if she was a staff nurse that day or just helping out to get the information to the doctor (facility records revealed Staff B was the nurse assigned to the resident on the [DATE] 6 a.m. to 6 p.m. shift.) On [DATE] 11:36 a.m. Staff E, RN stated there was an area on the resident's right wrist that became sore. On [DATE], one of the local general practice physicians came to change the cast, when the cast was removed, there was a large amount of thick, yellow drainage from the elbow and the doctor ordered the resident transferred to the ER. During an interview on [DATE] at 6:21 a.m. Staff A stated the resident developed a sore on their right wrist. They cleaned it, padded it with dressings, when she cleansed it on [DATE] it became red. She checked to see when the resident's ortho follow-up appointment was, discovered it had not been scheduled, called that day and scheduled it. One of the local doctors was at the facility that day and she asked if they would look at the resident's arm and change the cast. When the doctor removed the cast there was a lot of drainage from the elbow, Staff A saw metal where the incision opened, and the doctor ordered staff to transfer the resident to the ER. Prior to that day, the resident picked at the soft cast and acted like she was trying to take it off. Staff A stated she did not notify the orthopedic surgeon of the wrist skin condition and need to revise the cast because the general practice physician was at the facility and agreed to change it. During interview on [DATE] at 8:27 a.m. Staff F, LPN, the facility's Wound Nurse stated she looked at the resident's wrist wound with Staff B, she thought it was a scabbed area, maybe dime-sized. Staff F thought the resident picked at it, and wasn't necessarily from the cast. When asked how the staff could have known sooner there was a problem under the resident's cast, Staff F stated staff could have called the orthopedic office and asked for clarification, to see if they were supposed to check the dressing under the cast, but staff would need an order to remove the soft cast to check the dressing. On [DATE] at 10:15 a.m. the Director of Nursing (DON) stated she didn't expect staff to take the cast off to check the resident's CMS and dressing, the staff should have called the orthopedic office for clarification of cast care and wound care orders for the resident's arm, and they didn't do that; they should have. Staff B faxed a local general practice MD, not the orthopedic doctor, about the wound on her wrist, at that time staff padded the area with dressings to protect the skin. There was an order faxed back from the doctor, but this wasn't entered as an order because it hadn't been double noted, that staff were to monitor the wrist abrasion and notify the physician of changes. When asked why staff wouldn't have notified the orthopedic surgeon about that condition, the DON stated the general practice MD (Medical doctor) group are often at the facility, staff felt comfortable with them, and the resident was assigned to one of them for all general orders. On [DATE], one of the local general practice physicians came to the facility for another resident, looked at Resident #1's arm and agreed to change the cast. There should have been some clarification of what to do with the soft cast on the resident's admission. The facility identified this issue on [DATE], made a past non-compliance Plan of Correction and educated staff on neurovascular assessments (CMS) and orders that weren't recorded on the resident's [DATE] admission (follow-up doctor appointment, clarification of care). During interview on [DATE] at 4:28 p.m., Staff G, RN, Clinic Manager at the resident's orthopedic surgeon's office stated she verified their Cast/Splint Care follow-up instruction sheet was in Resident #1's electronic hospital record, and it should have been sent with the resident upon her discharge to the facility, along with her other discharge orders. The instruction sheet directed them to call the orthopedic doctor if there was pain or problems associated with the cast. The resident was to have a follow-up appointment with their surgeon within two weeks of her [DATE] hospital discharge. The first time they heard from anyone at the facility was on [DATE] at 9:06 a.m., when staff called to set up the resident's follow-up appointment and made no mention of any problems or skin conditions. Staff G stated the first notice the clinic had of condition concerns came on [DATE] at 1:09 p.m. when a nurse from the local hospital ER called and urgently wanted the cell phone number for the orthopedic surgeon. The ER nurse described the resident's elbow wound as dehisced and infected, and wanted directions from the surgeon for urgent care. The orthopedic surgeon directed the resident's transfer to another hospital and the resident required surgery the following morning. The facility should have called if there were any problems, should have clarified care orders if they were uncertain, and should have assessed the resident's CMS per professional standards and documented that. The facility should have called them, and not a general practice physician, of the need to revise the resident's cast due to the cast causing skin injury to the resident's wrist. The facility's Medication and Treatment Orders policy, revised ,d+[DATE], directed staff that medications shall be administered only upon the written order of a person licensed and authorized to prescribe such medications in this state; the orders must be recorded on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy did not specify or direct an expectation that staff follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Change in a Resident's Condition or Status policy, revised ,d+[DATE], directed staff: The nurse will notify the resident's attending physician or physician on call when there has been a (an) a. Discovery of injuries of an unknown source. b. Significant change in the resident's physical/emotional/mental condition. c. Need to alter the resident's medical treatment significantly. d. Specific instructions to notify the physician of changes in the resident's condition. The State Agency notified the facility of the Immediate Jeopardy on [DATE] at at 12:45 p.m. The Immediate Jeopardy situation started on [DATE]. The facility removed the Immediate Jeopardy on [DATE] through the following actions: Initiated staff education to all nurses that CMS assessments required when a resident has a cast or splint, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON or designee will be responsible to monitor that CMS checks are in place with accurate orders for removal or not removal of splint/cast; will complete audits of CMS checks, 4 audits per week for 4 weeks, then weekly for 2 months and will complete audits of surgeon notification with change in condition, 4 audits per week for 4 weeks, then weekly for 2 months. Residents admitted with splints/cast will be reviewed during their weekly SOC meeting for any changes observed and documented, and surgeon notification. The scope lowered from J to D at the time of the survey after ensuring the facility implemented staff education. 2. The [DATE] MDS assessment recorded Resident #6 entered the facility [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident scored 12 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, indicating moderate cognitive and memory impairment. Resident #6 did not walk and required the extensive assistance of 2 staff to reposition in bed, to transfer, and with toilet use. Resident #6 required the assistance of one staff member with locomotion on and off the unit and with personal hygiene. The MDS documented she'd not had any pain during the 5 days that preceded the assessment. The resident required renal [CONDITION(S)] treatments before and during facility residence. Wound assessments on [DATE] by Staff H, LPN documented: a. Open lesion of right lateral calf that measured 5.5 cm by 1.9 cm, no depth, scant serous (yellow liquid) drainage. b. Left heel deep tissue injury (DTI) that measured 1.9 cm by 1.2 cm, without depth, surrounding skin normal colored and without drainage. c. Stage 2 pressure sore of the coccyx (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) that measured 0.8 cm by 0.6 cm, no depth, light serosanguinous (pink and yellow colored) drainage. d. Another Stage 2 pressure sore of the coccyx that measured 0.9 cm by 0.7 cm, no depth with light serous drainage. e. Stage 2 pressure sore of right calf that measured 1.6 cm by 2.9 cm, without depth, light serosanguinous drainage. Resident #6's [DATE] Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Wound Care Orders dated directed staff to apply [MEDICATION(S)] to DTI on left heel daily, to cleanse area to right lower posterior leg with Normal Saline (NS), pat dry and cover with [MEDICATION(S)] (clear adhesive dressing), change every 3 days and PRN (as needed) and to cleanse areas to the left and right buttocks with NS, pat dry and cover with [MEDICATION(S)], change every 3 days and PRN. A pressure related skin injury problem initiated on [DATE] on the resident's Nursing Care Plan directed staff to assess, record and monitor wound healing; measure length, width and depth where possible; assess and document status of wound perimeter; to apply pressure reducing cushion to her wheelchair, a pressure relieving/reducing device on bed (low loss air mattress; place pressure reducing boots to bilateral feet (Prevalon Boots) and to monitor for pain related to pressure injury. The resident's ,d+[DATE] and ,d+[DATE] Treatment Administration Records (TARs) revealed the following pain assessments, with a 0 to 10 pain scale used, 10 assigned to the worst possible pain: ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] Day shift 3 0 0 7 0 0 0 0 4 0 X Night shift 3 3 0 0 0 0 0 0 4 0 0 A Nurses Note on [DATE] at 11:10 a.m. by Staff H, LPN recorded that Resident #6 denied cough or shortness of breath, lungs clear to auscultation (LCTA), resident alert, pleasant and able to make needs known. A Nurses Note dated [DATE] at 9:31 a.m. by Staff I, RN recorded the resident's LCTA, capillary refill quick, no complaints of shortness of breath or cough. Assist of one with EZ-Stand (for transfer assistance) and wheelchair propelled by staff. On [DATE] at 9:55 a.m. Staff E, RN documented Resident #6 continued with an occasional non productive dry cough. She denied any shortness of breath and continued with oxygen at 2 liters nasal cannula (NC). LCTA. Resident #6 refused to wear Prevalon boots to bilateral feet. The resident had a low air loss mattress to her bed and pressure relief cushion in the wheel chair. Staff encourage Resident #6 to reposition. A Nurses Note dated [DATE] at 9:29 a.m. by Staff J, RN recorded Resident #6 as pleasant and cooperative with cares, she denied any shortness of breath and continued with oxygen at 2 liters NC. LCTA, dressing changed to right calf per orders. Resident #6 refused to wear Prevalon boots to bilateral feet. The resident had pitting [CONDITION(S)] to bilateral lower extremities reported to this nurse, right lower extremity without [CONDITION(S)] this shift, left lower extremity (LLE) with 3+ pitting [CONDITION(S)] (when thumb pressed on the skin surface with moderate pressure applied, a pit of 4 millimeters (mm) to 6 mm deep lasts as long as 60 seconds before resolved), the resident's legs were elevated in recliner. Resident #6 got up with the EZ stand for transfer to [CONDITION(S)] this morning. A Nurses Note on [DATE] at 11:50 p.m. by Staff K, LPN documented Resident #6 continued with 4+ pitting [CONDITION(S)] (when thumb pressed on the skin surface with moderate pressure applied, a pit of 8 mm deep lasts 2 to 3 minutes before resolved) to right lower extremity (RLE) and 3+ [CONDITION(S)] to LLE. The resident's RLE was weeping, red and warm. Staff covered the area with ABD pads (thick absorbent gauze dressings that measure 5 inches by 9 inches by ,d+[DATE] inch thick) and wrapped. The resident's right foot had purple bruising all around it. Resident #6 denied shortness of breath. LCTA. The resident reported pain of 10 out of 10 on the pain scale and her scheduled Acetaminophen was not effective with pain relief; the resident continued to ask for more pain medication. Staff encouraged her to elevate her BLE as much as possible. The resident had one Prevalon boot on the left foot but won't wear one on the right foot due to pain. Staff K documented she would continue to monitor. A Nurses Note dated [DATE] at 11:42 a.m. documented Resident #6 was found unresponsive, had CPR (cardiopulmonary resuscitation) in progress and staff alerted 911. The [CONDITION(S)] Treatment Note dated [DATE] by Staff L, RN documented: [CONDITION(S)] start time 10:46 a.m., stop time 2:18 p.m. Weight pre treatment 204.4 pounds, post treatment 199.5 pounds. Pre treatment legs with 2+ pitting [CONDITION(S)], (when thumb pressed on skin with moderate pressure, a pit between 2 mm and 4 mm takes up to 15 seconds to rebound) no complaints of pain. Post treatment legs with 2+ pitting [CONDITION(S)], no complaints. The [CONDITION(S)] Treatment Note dated [DATE] Staff L, RN documented: [CONDITION(S)] start time 10:39 a.m., stop time 2:18 p.m. Weight pre treatment 197.3 pounds, post treatment 193.8 pounds. Pre treatment legs with 3+ pitting [CONDITION(S)], no complaints. Post treatment legs with 2+ pitting [CONDITION(S)], no complaints. On [DATE], the Administrator provided the resident's wound photos obtained [DATE] in the resident's electronic record, that revealed the left heel had a medium violet colored area approximately 3 cm in size and identified as the DTI, with a 1 to 2 cm border of dark pinkish-red skin, and normal pink skin color throughout the sole and heel area outside of the pinkish-red border. Another photo of one of the wounds on the resident's right leg showed a portion of the top of the right foot that was a normal pink color. When copies of the resident's [DATE] wound photos were requested on [DATE], the Administrator stated they were a part of the facility's Quality Assurance Program and would not be provided. The resident's Responsible Party/Power of Attorney (POA) submitted a photo of the resident's right lower leg and foot taken on [DATE] that revealed most (at least 90 percent) of the top portion of the resident's right foot was a deep purple-reddish color, similar to a [NAME], and the foot extremely edematous. Interview on [DATE] at 9:53 a.m. with Staff K, LPN revealed she remembered Resident #6's foot looked purple, the resident had a lot of [CONDITION(S)] in her legs and complained of severe pain when she worked on [DATE]. Staff K did not notify the physician of the findings, they can call the hospital ER doctor on nights/weekends or holidays but the only order they ever gave was to send the resident to ER, or not even that and no other orders. Staff K did not notify the DON about the change of condition either. The resident's right foot looked different on [DATE] and she had a lot more [CONDITION(S)], the resident couldn't say what happened to her foot and Staff K tried to figure out how her foot got bruised/purple. On [DATE] 11:36 a.m. Staff E, RN stated on the morning of [DATE] she heard a page for her to go to the resident's room STAT (as soon as possible). When she got there Staff F, LPN/Wound Nurse and the wound doctor had started CPR. When asked what she would do if a wound had worsened, or if a resident developed swelling, or warmth of skin and was new or worse, Staff E stated she would notify the physician. On weekends or evenings/nights, staff can call the hospital Hospitalist or the ER doctor for orders, that system has long been in place. On [DATE] at 8:27 a.m. Staff F stated she thought the resident's legs were edematous, and she initiated CPR on the resident one morning when she rounded with the Wound Doctor and found the resident had arrested. When asked what she would do if she thought a resident's legs were more edematous, or started weeping, she stated she would call the physician and that after hours they can call the ER doctor at the hospital for orders on any of the residents. During interview on [DATE] at 9:15 a.m., Staff L, RN, [CONDITION(S)] Nurse stated the resident had pitting [CONDITION(S)] that was improved slightly be the end of the [CONDITION(S)] treatment cycle, she never had weeping [CONDITION(S)] in her legs, and if that was a new finding, the nurse should have notified the doctor. Staff L reviewed a photo of the resident's feet that showed her right foot dark purple colored and extremely edematous and Staff L stated she had never saw the resident's foot look like that and staff should have notified the physician of that. On [DATE] at 3:54 p.m. Staff J, RN stated that on [DATE], when she documented the resident's [CONDITION(S)] was worse, it's because that is what the previous nurse reported to her, it wasn't a new condition that she had identified. If she had identified a new condition, she would have called the doctor. On the weekends they have to call the ER doctor at the hospital. Staff J stated if a resident complained of pain 10 out of 10 on the pain scale, and pain meds didn't help or if there wasn't a pain med to give, she would call the MD, would not fax, and doesn't matter if it's a holiday, or weekend, or night shift, staff are supposed to notify the physician. During interview on [DATE] at 10:46 p.m., Staff H, LPN, when asked if a resident had worsened [CONDITION(S)], or if their [CONDITION(S)] started weeping and the extremity warm to touch, or if a resident complained of pain 10 out of 10 on the pain scale that was new, Staff H stated those were all things that the physician should be notified of, and they called the ER doctor at the hospital on the evening/night shifts and on weekends for orders. On [DATE] at 10:15 a.m. the DON stated the physician group from the hospital were not on call, when there was a problem with a resident after 5 p.m. or on weekends/holidays, staff were supposed to call the ER doctor for orders and it's sort of a problem, the ER doctor doesn't know the resident, sometimes they don't give orders, other times they want the resident sent to the ER so they can assess them. When asked what she expected staff to do for the symptoms described in the Nursing Progress Notes by Staff K on [DATE], the DON stated the nurse should have notified the ER doctor for orders, and the nurse had not notified her of the resident's condition changes. The DON stated they just started and were monitoring for staff notifying physicians when changes in conditions were identified, on one of their Past Non Compliance Plans of Correction (POC). When asked what that POC was related to, the DON stated it was for Resident #6 and similar residents. When asked why that wasn't implemented sooner, if it was related to the resident's [CONDITION(S)] and death on the morning of [DATE], the DON stated they had just recently became aware of the situation. During interview on [DATE] at 1:05 p.m. the resident's POA stated Resident #6 was at the hospital for several weeks before she transferred to the nursing home, the POA visited her frequently and saw her legs while there, the resident complained of some pain in her legs at times, but it varied and managed with medication. When she transferred to the nursing home, the first couple of days were okay, then her leg sores and her pain got worse. She saw the resident at the facility [DATE], her feet were swollen but normal colored. On [DATE], the resident called and said her right leg really hurt, another family member visited the resident that day, noticed the resident's right foot was dark purple and took a picture of it. On [DATE], Resident #6 called and said they were in horrible pain, wanted the nurse to check on her, the POA called the nurse at the facility and asked her to check on the resident and call back with an update; the nurse never called back. The resident called and asked if they called the nurse because they hadn't come to assess her. Later that day the resident said 2 nurses came in to her room and asked her what happened. The POA didn't hear anything from the staff about the resident's pain or condition on [DATE], early the next morning the facility called and said they were doing CPR and sending her to the hospital. Resident #6 expired when they got to the hospital.

Based on facility record review and staff interviews, the facility failed to ensure that each Certified Nursing Assistant (CNAs) received the required ongoing education, 12 hours annually or 4 hours since 7/1/22, for at least 5 of the 35 CNAs employed by the facility. The facility reported a census of 74 residents. Findings include: Records of CNA staff education since 7/1/22 revealed: 1. Staff P, CNA, hired 5/7/20, current P.R.N. status (she worked as-needed), last date worked 10/15/22, 0.65 hours of education completed on 11/10/22. 2. Staff Q, CNA, hired 10/25/21, current P.R.N. status, last date worked 11/6/22, no documented education. 3. Staff R, CNA, hired 5/25/18, current P.R.N. status, last date worked 9/11/22, no documented education. 4. Staff S, CNA, hired 11/29/21, current P.R.N. status, last date worked 10/22/22, 0.5 hours of education completed on 11/16/22. 5. Staff T, CNA and CMA (Certified Medication Aide), hired 8/10/16, current P.R.N. status, last date worked 8/31/22, no documented education. The facility's In-Service Training Program, Nurse Aide policy, dated revised 5/19, directed: 1. All nurse aide personnel participate in regularly scheduled in-service training classes. 2. In-service training is based on the outcome of annual performance reviews, addressing weaknesses identified in the reviews. 3. Annual in-services ensure the continuing competence of nurse aides, are no less than 12 hours per employment year, and address the special needs of the residents, as determined by the facility assessment. 4. Attendance of in-service training classes is considered working time for pay purposes. During interview on 11/16/22 at 4:19 p.m. Staff U, CNA stated that CNA are supposed to know to complete education modules in the computer quarterly. When staff log into the Relias computer program it says what modules are due, but staff have to login to see that. Staff are expected to come in on their own time to complete the required education, there really isn't time during the shift to be off the hall and unavailable for resident care. On 11/16/22 at 4:23 p.m. Staff V, CNA stated staff are required to complete continuing education on the computer through Relias. Staff have to login to the computer to see what courses are due, they are supposed to do that quarterly, can come in to work early or stay late while clocked in and report the extra hours were for Relias education. If staff don't complete the education, after a while they get reminders that they have to get caught up. During an interview 11/16/22 at 6:45 p.m., the Administrator stated P.R.N. employees that were not current on education requirements would not be permitted to work until their training requirements have been met. In the future, the Administrator or designee will review a report of education course completion weekly through the end of the calendar year to ensure education is completed. After that, a monthly report would be reviewed.

Based on clinical record review, and staff, physician and resident Responsible Party (RP) interviews and facility policy review, the facility failed to notify the physician of significant changes in resident condition for two of eight residents reviewed (Residents #1 and #6). The facility reported a census of 74 residents. Findings include: 1. The [DATE] admission Minimum Data Set (MDS) assessment recorded that Resident #1 admitted to the facility [DATE], had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented she had severely impaired cognitive skills for daily decision-making, symptoms of [CONDITION(S)], she did not speak and rarely or never could make herself understood or understand others. Resident #1 required extensive assistance of at least 2 staff for transfers to and from bed and chair, dressing, eating, toilet use, bathing and personal hygiene. She was always incontinent of bowel and frequently incontinent of urine. Review of a hospital History and Physical form revealed that Resident #1 had an operation for open reduction and internal fixation (ORIF) of the right hip and olecranon (elbow area of the humerus, upper arm bone) completed on [DATE] by an orthopedic surgeon. The Cast or Splint Care, Adult Instruction Form, included with the resident's Hospital Discharge Orders, directed staff to contact the health care provider if the skin around the cast or splint got red or raw and/or the skin under the cast is extremely itchy or painful. Resident #1 had an Impaired Skin problem initiated on [DATE] on her Nursing Care plan, with goal the resident would not have complications related to skin impairment. Interventions included: a. Educate me, my family, and caregivers of causative factors and measures to prevent skin injury. b. Monitor for and document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Weekly treatment documentation to include, measurement of each area of skin breakdown, type of tissue and exudates, and any other notable changes or observations. The resident's clinical record did not contain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] A Nursing Progress Note dated [DATE] at 3:05 p.m., recorded Staff B, Registered Nurse (RN) noted an abrasion to Resident #1's right inner wrist. The abrasion had an intact scab, and no odor, drainage or redness. Staff B cleansed the area and left it open to air at this time. The nurse notified the local general practice physician of the area. A fax (facsimile) to the same physician transcribed by Staff B on [DATE] at 3:06 p.m. recorded Noted abrasion to right wrist from soft cast rubbing. Area scab intact at this time. The physician returned the fax on [DATE] at 2:07 p.m., and directed staff monitor the area, update physician with changes. A Skin/Wound Assessment form completed on [DATE] by Staff B described a scabbed abrasion that measured 0.8 centimeters (cm) by 1.5 cm by 0.8 cm, without drainage or symptoms of infection, and skin around scab normal. A Nursing Progress Note dated [DATE] at 5:41 p.m., by Staff C, Licensed Practical Nurse (LPN) and Assistant Director of Nursing (ADON) documented the local general practice physician noted an abrasion to the resident's right wrist where her cast was rubbing, without new orders. The Nursing Progress Note dated [DATE] at 9:36 a.m. by Staff A, LPN documented Resident #1 was alert and oriented to herself only. She continued to pick at the soft cast and an area to her wrist was warm to the touch. The local general practice physician rounded; he took a look at this and would come back to facility and recast the area with a shorter cast so we can treat the area. Staff placed a call placed to the resident's orthopedic surgeon and made a follow-up appointment. At 12:00 p.m., Staff A documented the local general practice physician returned to recast the resident's right arm. When the cast was removed there was an area about a quarter size opened with copious amounts of drainage noted. The doctor ordered the resident sent to the hospital emergency room (ER) for evaluation. A Hospital ER Physician Note dated [DATE] at 12:23 p.m. described the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . An ulcerated area on the ulnar aspect of the right wrist, with [CONDITION(S)] (redness and swelling) and warmth, appeared as a pressure ulcer caused by the splint. The ER provider consulted with the orthopedic surgeon, and the resident transferred to another hospital under the care of the orthopedic surgeon on [DATE]. The facility's Change in a Resident's Condition or Status policy, dated as revised ,d+[DATE] directed staff: The nurse will notify the resident's attending physician or physician on-call when there has been a (an): 1. Discovery of injuries of an unknown source. 2. Significant change in the resident's physical/emotional/mental condition. 3. Need to alter the resident's medical treatment significantly. 4. Specific instructions to notify the physician of changes in the resident's condition. During interview on [DATE] at 9:47 a.m., Staff B, RN, Restorative Nurse, stated on [DATE], she took a photo of the resident's wrist wound. Staff B could tell it was from the cast because it was located in the area that rubbed the resident's arm when she flexed at the wrist. It was an intact scab, no drainage and not reddened. Staff B put it on the list for the Wound Nurse to follow, and sent a fax to the physician's clinic for treatment orders because it was a skin issue. The floor nurse could have called the surgeon, she had just updated the primary physician and wasn't a regular staff nurse there, but did fill in when a nurse was off sometimes. Staff B couldn't recall if she was a staff nurse that day or just helping out to get the information to the doctor. (Facility records revealed Staff B was the nurse assigned to the resident on the [DATE] 6 a.m. to 6 p.m. shift.) On [DATE] 11:36 a.m. Staff E, RN, stated there was an area on the resident's right wrist that became sore. On [DATE], one of the local general practice physicians came to change the cast, when the cast was removed, there was a large amount of thick, yellow drainage from the elbow and the doctor ordered the resident transferred to the ER. During interview on [DATE] at 6:21 a.m. Staff A, LPN, stated the resident developed a sore on their right wrist. They cleaned it, padded it with dressings, when she cleansed it on [DATE] it became red. She checked to see when the resident's ortho follow-up appointment was, discovered it had not been scheduled, called that day and scheduled it. One of the local doctors was at the facility that day and she asked if they would look at the resident's arm and change the cast. When the doctor removed the cast there was a lot of drainage from the elbow, Staff A saw metal where the incision opened, and the doctor ordered staff to transfer the resident to the ER. Prior to that day, the resident picked at the soft cast and acted like she was trying to take it off. Staff A stated she did not notify the orthopedic surgeon of the wrist skin condition and need to revise the cast because the general practice physician was at the facility and agreed to change it. On [DATE] at 10:15 a.m. the Director of Nursing (DON) stated staff should have called the orthopedic office for clarification of cast care and wound care orders for the resident's arm, and they didn't do that, they should have. During interview on [DATE] at 4:28 p.m., Staff G, RN, Clinic Manager at the resident's orthopedic surgeon's office stated she verified their Cast/Splint Care follow-up instruction sheet was in the resident's electronic hospital record, and it should have been sent with the resident upon her discharge to the facility, along with her other discharge orders. The instruction sheet directed them to call the ortho doctor if there was pain or problems associated with the cast. The first time they heard from anyone at the facility was on [DATE] at 9:06 a.m. when they called to set up her follow-up appointment. Staff who called made no mention of any problems or skin conditions. Staff G stated the first notice came on [DATE] at 1:09 p.m., when a nurse from the local hospital ER reported skin concerns that included an ulcerated pressure sore from the cast. The facility should have called them, and not a general practice physician, of the need to revise the resident's cast due to the cast causing skin injury to the resident's wrist. 2. The [DATE] MDS assessment recorded Resident #6 entered the facility [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident scored 12 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, indicating moderate cognitive and memory impairment. Resident #6 did not walk and required the extensive assistance of 2 staff to reposition in bed, to transfer, and with toilet use. Resident #6 required the assistance of one staff with locomotion on and off the unit and with personal hygiene. The MDS documented she'd not had any pain during the 5 days that preceded the assessment. The resident required renal [CONDITION(S)] treatments before and during facility residence. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Nursing Care Plan contained a pain problem initiated [DATE] with goal the resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain. The interventions included: a. Anticipate the need for pain relief and respond immediately to any complaint of pain (initiated [DATE]). b. Evaluate the effectiveness of pain interventions (initiated [DATE]). c. Review for compliance, alleviating of symptoms, dosing schedules and satisfaction with results, impact on functional ability and impact on cognition (initiated [DATE]). d. Monitor, document, and report any signs or symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing); Body (tense, rigid, rocking, curled up, thrashing) (initiated [DATE]). The June, 2022 and July, 2022 Treatment Administration Records (TARs) recorded the following pain assessments, with a 0 to 10 pain scale used, 10 assigned to the worst possible pain: ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] ,d+[DATE] Day shift 3 0 0 7 0 0 0 0 4 0 X Night shift 3 3 0 0 0 0 0 0 4 0 0 A Nursing Progress Note dated [DATE] at 11:10 a.m. by Staff H, LPN documented Resident #6 denied cough or shortness of breath, her lungs were clear to auscultation (LCTA), Resident #6 was alert, pleasant and able to make her needs known. A Nursing Progress Note dated [DATE] at 9:31 a.m. by Staff I, RN documented the resident's LCTA, capillary refill quick, no complaints of shortness of breath or cough. A Nursing Progress Note dated [DATE] at 9:55 a.m. by Staff E, RN documented Resident #6 continued with an occasional non productive dry cough. The resident denied any shortness of breath and continued with oxygen at 2 liters nasal cannula (NC). Her lungs were LCTA. Resident #6 refused to wear Prevalon boots to bilateral (both) feet. She had a low air loss mattress to the bed and a pressure relief cushion in her wheel chair. Staff encouraged Resident #6 to reposition. A Nursing Progress Note dated [DATE] at 9:29 a.m. by Staff J, RN recorded Resident #6 as pleasant and cooperative with cares. The resident denied any shortness of breath and continued with oxygen at 2 liters NC. Her lungs were LCTA. Staff changed the resident's dressing to right calf per orders. Resident #6 refused to wear Prevalon boots to bilateral feet. Staff J documented pitting [CONDITION(S)] to bilateral lower extremities; the resident's right lower extremity without [CONDITION(S)] this shift, her left lower extremity (LLE) with 3+ pitting [CONDITION(S)] (when thumb pressed on the skin surface with moderate pressure applied, a pit of 4 millimeters (mm) to 6 mm deep lasts as long as 60 seconds before resolved). Staff elevated the resident's legs in recliner. The resident got up with an EZ stand for transfer to [CONDITION(S)] this morning. A Nursing Progress Note dated [DATE] at 11:50 p.m. by Staff K, LPN documented Resident #6 continued with 4+ pitting [CONDITION(S)] (when thumb pressed on the skin surface with moderate pressure applied, a pit of 8 mm deep lasts 2 to 3 minutes before resolved) to the right lower extremity (RLE) and 3+ [CONDITION(S)] to LLE. The resident's RLE was weeping, red and warm. Staff wrapped the area with ABD pads (thick absorbent gauze dressings that measure 5 inches by 9 inches by ,d+[DATE] inch thick) and wrapped. The resident's right foot had purple bruising all around it. The resident denies shortness of breath and her LCTA. Resident #6 reported pain of 10 out of 10 on the pain scale. The resident's scheduled acetaminophen was not effective with pain relief and she continued to ask for more pain medication. Staff encouraged the resident to elevate BLE as much as possible. She had one Prevalon boot on the left foot but would not wear one on the right foot due to pain. Staff planned to continue to monitor. The record did not reveal, and the facility could not provide any documentation that the physician was notified of the resident's worsened [CONDITION(S)], or increased pain. The resident's Responsible Party/Power of Attorney (POA) submitted a photo of the resident's right lower leg and foot taken on [DATE] that revealed most (at least 90 percent) of the top portion of the resident's right foot was a deep purple-reddish color, similar to a [NAME], and the foot as extremely edematous. During interview on [DATE] at 9:53 a.m. Staff K, stated she remembered the resident's foot looked purple, she had a lot of [CONDITION(S)] in her legs and complained of severe pain when she worked on [DATE]. Staff K did not notify the physician of the findings, they can call the hospital ER doctor on nights/weekends or Holidays but the only order they ever gave was to send the resident to ER, or not even that and no other orders. Staff K did not notify the Director of Nursing (DON) about the change of condition either. The resident's right foot looked different on [DATE] and she had a lot more [CONDITION(S)], the resident couldn't say what happened to her foot and Staff K tried to figure out how her foot got bruised/purple. On [DATE] 11:36 a.m., when asked what she would do if a wound had worsened, or if a resident developed swelling, or warmth of skin and was new or worse, or if a resident complained of pain rated at 10 on a 0 to 10 pain scale, Staff E stated she would notify the physician. On weekends or evenings/nights staff can call the hospital Hospitalist or the ER doctor for orders; that system has long been in place. During interview on [DATE] at 8:27 a.m., when asked what she would do if she thought a resident's legs were more edematous, or started weeping, or if a resident complained of pain rated at 10 on a 0 to 10 pain scale, Staff F, Wound Nurse, stated she would call the physician, after hours they can call the ER doctor at the hospital for orders on any of the residents. On [DATE] at 9:15 a.m., Staff L, RN, [CONDITION(S)] Nurse stated the resident had pitting [CONDITION(S)] that was improved slightly by the end of the [CONDITION(S)] treatment cycle. The resident had never had weeping [CONDITION(S)] in her legs, and if that was a new finding, the nurse should have notified the doctor. Staff L reviewed a photo of the resident's feet that showed the resident's right foot dark purple colored and extremely edematous, and stated she had never saw the resident's foot look like that and staff should have notified the physician of that. On [DATE] at 3:54 p.m., Staff J stated if a resident complained of pain of 10 out of 10 on the pain scale, and pain meds didn't help or if there wasn't a pain med to give, she would call the MD, would not fax, and doesn't matter if it's a holiday, or weekend, or night shift, staff are supposed to notify the physician. On [DATE] at 10:46 p.m., Staff H when asked if a resident had worsened [CONDITION(S)], or if their [CONDITION(S)] started weeping and the extremity warm to touch, or if a resident complained of pain 10 out of 10 on the pain scale that was new, Staff H stated those were all things that the physician should be notified of, and they called the ER doctor at the hospital on the evening/night shifts and on weekends for orders. On [DATE] at 10:15 a.m. the DON stated the physician group from the hospital were not on call, when there was a problem with a resident after 5 p.m. or on weekends/holidays, staff were supposed to call the ER doctor for orders. When asked what she expected staff to do for the symptoms described in the Nursing Progress Notes by Staff K on [DATE], the DON stated the nurse should have notified the ER doctor for orders, and the nurse had not notified her of the resident's condition changes. The DON stated they just started and were monitoring for staff notifying physicians when changes in conditions were identified, on 1 of their Past Non Compliance Plans of Correction(POC). When asked what that POC was related to, the DON stated it was for Resident #6 and similar residents. When asked why that wasn't implemented sooner, if it was related to Resident #6 who expired on [DATE], the DON stated they had just recently became aware of the situation. During interview on [DATE] at 1:05 p.m., the resident's POA stated when Resident #6 transferred to the nursing home from the hospital the first couple of days were okay, then her leg sores and leg pain got worse. On [DATE], the resident said her right leg really hurt when they spoke to the resident on the phone. On [DATE] Resident #6 called and said they were in horrible pain and wanted the nurse to check on her. The POA called the nurse at the facility and asked her to check on the resident and call back with a condition update; the nurse never called back. The resident called the POA again and asked if they called the nurse because the nurse hadn't assessed her. Later that day, the resident called and said two nurses came into her room and asked her what happened. The POA didn't hear anything from the staff about the resident's pain or condition on [DATE]. Early the next morning ([DATE]), facility staff called and said they started CPR and were sending her to the hospital. The resident expired when they got to the hospital.

Based on clinical record review, observation, and staff interviews, the facility failed to provide reasonable accommodations of need that included having a resident sleep in a comfortable bed, in a darkened area conducive to sleep, rest and comfort, and failed to provide for a resident's privacy and dignity when the resident slept and when intravenous medications were administered, for 1 of 8 residents reviewed (Resident #1). The facility reported a census of 74 residents. Findings include: The 10/3/22 admission Minimum Data Set (MDS) assessment recorded that Resident #1 admitted to the facility 9/27/22, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented she had severely impaired cognitive skills for daily decision-making, symptoms of [CONDITION(S)], she did not speak and rarely or never could make herself understood or understand others. Resident #1 required extensive assistance of at least 2 staff for transfers to and from bed and chair, dressing, eating, toilet use, bathing and personal hygiene. She was always incontinent of bowel and frequently incontinent of urine. A Fall Risk problem initiated 9/27/22 on the Nursing Care plan, with goal that Resident #1 would not have injuries from falls. The Nursing Care plan instructed to encourage the resident to use her call light for assistance, she needs a safe environment without clutter, to make sure the resident wears appropriate footwear, to monitor the resident for unsteady gait and to provide PT/OT (Physical Therapy/Occupational Therapy) evaluation and treatment as ordered. Resident #1's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . . When reviewed on 11/8/22 at 9:15 a.m., the resident's 11/22 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. 11/1/22 10:00 p.m. b. 11/2/22 2:13 p.m. c. 11/4/22 6:36 p.m. d. 11/5/22 7:50 p.m. e. 11/7/22 6:53 p.m. f. 11/8/22 2:45 a.m. Observation on 11/2/22 at 7:56 a.m. revealed the resident seated upright in a recliner chair by the Nurse's Station with all the lights on. Her legs were elevated on the footrest, covered with a blanket as a nurse sat beside the resident and administered medications with a spoon. The resident appeared tired. The nearby dining room was occupied by several residents with the breakfast meal served. Observation on 11/3/22 at 6:05 a.m. revealed Resident #1 seated upright in a recliner chair by the Nurse's Station with all the lights on (it was dark outside, with sunrise at 7:48 a.m.) and asleep with her head leaned towards her right shoulder and without a pillow for positioning. Her legs were elevated on the footrest and she was covered with a blanket. On 11/9/22 at 10:45 a.m., observation revealed the resident seated in a recliner chair by the Nurse's Station with all the lights on. The resident had slid down in the chair with her right foot and half of lower leg extended beyond the end of the elevated footrest. The resident was covered with a blanket and asleep without pillow for positioning or comfort. Observation on 11/9/22 at 11:37 a.m. revealed Resident #1 sat upright in a recliner chair by the Nurse's Station with all the lights on, both heels extended over the end of the elevated footrest, covered with a blanket. The resident's head had turned to her right side; she had a pillow was on the resident's right side but not used. The resident was asleep. At 2:13 p.m., she sat upright in a recliner chair by the Nurse's Station with all the lights on, immediately next to a resident hall and common pathway as her IV [MEDICATION(S)] medication infused via mechanical pump placed on an IV pole located behind the chair. The resident appeared asleep with her mouth open, head positioned to her right and without a pillow, her legs were elevated on a foot rest and she was covered with a blanket. Observation on 11/10/22 at 7:24 a.m. revealed the resident seated upright in a recliner chair by the Nurse's Station with all the lights on, immediately next to a resident hall and common pathway. The resident's head and upper chest leaned to her right side, without a pillow in place, her legs were elevated on a foot rest and covered with a blanket. The resident appeared asleep with her mouth open. During interview on 11/2/22 at 5:10 p.m. Staff M, Certified Nursing Assistant (CNA) stated they tried to keep the resident in a recliner in the common area; she does better there than in her room. On 11/2/22 at 5:50 p.m. Staff N, CNA stated the resident usually slept in a recliner in the common area. Staff took her to her room to use the toilet or check and change her, but then brought her back to the recliner in the common area and that's where she slept (not in her room). With interview on 11/2/22 at 5:58 p.m. Staff O, CNA stated the resident slept in a recliner in the common area because she's restless. If the resident was in her room she would try to get up; she's antsy. On 11/3/22 at 6:21 a.m. Staff A, Licensed Practical Nurse (LPN) stated prior to 10/12/22, Resident #1 kept picking at her soft cast and acted like she was trying to take it off, but she also kept trying to climb out of the chair; she was restless. The resident usually slept in a recliner chair by the Nurse's Station because she would climb out of bed. During interview on 11/3/22 at 10:15 a.m. the Director of Nursing (DON) stated Resident #1 was anxious and had [MEDICATION(S)] at the hospital to keep her in bed. The resident was more content when she knew there was someone there when she opened her eyes. The resident loved music and the DON played music to the resident from her cell phone. When asked if they had tried to play music for the resident in her room, the DON stated they had not, and again stated Resident #1 seemed more content when she could see people and she couldn't see people when she was in her room. On 11/4/22 at 3:15 p.m., Staff D, LPN stated the resident was anxious and restless, they tried multiple things such as 1 to 1 with staff, take her to the toilet, change her, and provided snacks and drinks Nothing seemed to help and why she medicated her with the anti-anxiety medication, that did seem to help the resident. The resident slept in a recliner chair near the Nurse's Station so they could keep a closer watch of her as she was a high fall risk. On 11/10/22 at 6:14 a.m., Staff D stated the resident had been restless that night, was up and down, they kept her in the recliner by the Nurse's Station, had taken her to the toilet her a few times, spent 1 to 1 time with her, and provided food and drinks. Staff D gave the resident anti-anxiety medication earlier in the shift; the resident stayed in the recliner for a few hours afterwards, her eyes were closed but she could tell the resident wasn't asleep. When asked if she had tried to play music for her, Staff D stated she didn't know the resident liked music, and didn't know how they would play music for her but was glad to know that might help the resident when she was restless. During interview on 11/9/22 at 9:47 a.m., Staff B, RN stated the resident was fidgety, a high fall risk and needed eyes on her at all times; that's why they kept her near the Nurse's Station. On 11/17/22 at 8:52 a.m., the Administrator stated the resident had fallen twice from the recliner chair located by the Nurse's station. At 11:00 a.m., the Administrator and DON stated nurses directed the CNAs to keep the resident in the recliner chair by the Nurse's Station, and not allow the resident to sleep in her room, so they could provide closer supervision of the resident.

Based on record review and staff interviews, the facility failed to consult a physician and notify the health care power of attorney for a resident experiencing a significant change in condition. (Resident #2) The facility reported a census of 74 residents. Findings include: The Minimum Data Set (MDS) with an assessment reference date of 3/23/22 indicated Resident #2 with a Brief Interview for Mental Status (BIMS) score of 13 indicating an intact cognitive status. Resident #2 required extensive assistance with transfers, mobility, dressing, eating, toilet use and personal hygiene needs. Resident #2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 8/9/22 at 11:00 a.m. Staff A, certified nurse aide, stated she worked the 6:00 a.m. to 2:00 p.m. shift on 5/28/22 and was responsible for the care of Resident #2. Resident #2 was not feeling well that day. Staff A stated she told the nurse, Staff B, several times if she would check on Resident #2, but she was too busy. Staff B finally checked on Resident #2 after lunch when Staff C asked her to. In an interview on 8/16/22 at 9:40 a.m. Staff C, certified nurse aide, stated she worked the 6:00 a.m. to 2:00 p.m. shift on 5/28/22 and was assigned to passing medications. Resident #2 was not feeling well that day and felt nauseous. Staff B and Staff D both checked on Resident #2. Resident #2 felt distended and they gave her milk of magnesia and she felt better. Staff B was pushing to have Resident #2 go to the emergency room , but Resident #2 adamantly refused. In an interview on 8/9/22 at 8:48 a.m. Staff B, licensed practical nurse, stated she worked the 6:00 a.m. to 6:00 p.m. shift on 5/28/22. Resident #2 was complaining of nausea earlier in the shift, then indicated she was ok. Later on that shift staff reported Resident #2 was again not feeling well. Staff B stated she assessed Resident #2, noting her abdomen was distended with minimal bowel sounds. Staff B stated she encouraged Resident #2 to go to the hospital several times, but Resident #2 refused. Resident #2 was given milk of magnesia and towards the end of her shift had a large bowel movement. Staff B stated Resident #2 is alert and her own person and she adamantly refused to go to the hospital. Staff B stated she did not consult a physician or notify the daughter, who was the health care power of attorney, of her concern. According to a progress note identified as a late entry and co-written by Staff B and Staff E (not present at the time of the event), an assessment was completed on 5/28/22 at 1:30 p.m. The assessment noted Resident #2 had general weakness, an oxygen saturation level of 87% on room air, a distended abdomen with decreased to absent bowel sounds. Resident #2 requested milk of magnesia and after two hours had a large bowel movement and reported feeling better. Resident #2 was asked if she felt she needed to go to the hospital and responded, no, I do not need to go and I do not want to go. I am feeling a lot better now. According to the facilities demographic sheet, a daughter is listed as the responsible party and specifically identified as the health care power of attorney.

Based on record review and staff interviews, the facility failed to provide the necessary care and services (assessment and intervention), to maintain the resident's optimal health and physical well-being. (Resident #2) The facility reported a census of 74 residents. Findings include: The Minimum Data Set (MDS) with an assessment reference date of [DATE] indicated Resident #2 with a Brief Interview for Mental Status (BIMS) score of 13 indicating an intact cognitive status. Resident #2 required extensive assistance with transfers, mobility, dressing, eating, toilet use and personal hygiene needs. Resident #2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on [DATE] at 11:00 a.m. Staff A, certified nurse aide, stated she worked the 6:00 a.m. to 2:00 p.m. shift on [DATE] and was responsible for the care of Resident #2. Resident #2 was not feeling well that day. Staff A stated she told the nurse, Staff B, several times if she would check on Resident #2, but she was too busy. Staff B finally checked on Resident #2 after lunch when Staff C asked her to. In an interview on [DATE] at 9:40 a.m. Staff C, certified nurse aide, stated she worked the 6:00 a.m. to 2:00 p.m. shift on [DATE] and was assigned to passing medications. Resident #2 was not feeling well that day and felt nauseous. Staff B and Staff D both checked on Resident #2. Resident #2 felt distended and they gave her milk of magnesia and she felt better. Staff B was pushing to have Resident #2 go to the emergency room , but Resident #2 adamantly refused. In an interview on [DATE] at 8:48 a.m. Staff B, licensed practical nurse, stated she worked the 6:00 a.m. to 6:00 p.m. shift on [DATE]. Resident #2 was complaining of nausea earlier in the shift, then indicated she was ok. Later on that shift staff reported Resident #2 was again not feeling well. Staff B stated she assessed Resident #2, noting her abdomen was distended with minimal bowel sounds. Staff B stated she encouraged Resident #2 to go to the hospital several times, but Resident #2 refused. Resident #2 was given milk of magnesia and towards the end of her shift had a large bowel movement. Staff B stated Resident #2 is alert and her own person and she adamantly refused to go to the hospital. Staff B stated she did not consult a physician or notify the daughter, who was the health care power of attorney, of her concern. In an interview on [DATE] at 3:24 p.m. Staff F, certified nurse aide, stated on the evening of [DATE], she had been told Resident #2 was not feeling well. Staff F stated it was only her second shift working at the facility and she was not familiar with the residents. Staff F stated at 6:00 p.m. Resident #2 refused supper and at 7:00 p.m. she checked and changed her. Resident #2 had had a medium bowel movement and seemed out of breath and out of it. Staff F stated she informed the nurse, Staff H who put it off as the resident just not feeling well. Staff F stated to her knowledge the nurse never checked on Resident #2. At around 8:00 p.m. there was a strong stool odor in the hallway. It was near the soiled linen barrel and across from Resident #2's room. At 8:30 p.m. Staff G entered Resident #2's room and found her deceased . Resident #2 had vomited and the stomach contents had blood in it and smelled like stool. The nurse, Staff H told her the feces may have came up through the stomach and esophagus. Staff F stated she was involved in cleaning up Resident #2 by herself and noted the float had called in that evening and she was the only aide working that hall that evening. In an interview on [DATE] at 10:15 a.m. Staff G, certified medication aide, stated she was working from 4:00 p.m. to 10:00 p.m. on [DATE] and was assigned to pass medications. Staff G stated she was unaware of any issues involving Resident #2's condition. Staff G stated Resident #2 did not get any medications until after supper and at 8:30 p.m. when Staff G entered Resident #2's room to give her her evening medications, Resident #2 was found deceased . Staff G stated that was the only contact she had with Resident #2 that evening. In an interview on [DATE] at 8:37 a.m. Staff H, registered nurse, stated she worked the 6:00 p.m. to 6:00 a.m. shift on [DATE]. During shift change report at around 6:00 p.m. she was informed by the off going nurse that Resident #2 had not felt well earlier that day, but had had a large and medium bowel movement and her discomfort had resolved. Staff H stated she was informed Resident #2 had refused supper, but denies being informed of Resident #2 ever being in distress. Staff H stated she did not see or assess Resident #2 until being informed at 8:30 p.m. she was found deceased .

Based on clinical record review, staff interview, and policy review, the facility failed to report an injury of unknown origin for 1 of 1 sampled (Resident #117) to the Department. The facility reported a census of 65 residents. Findings include: 1. The Minimum Data Set assessment dated [DATE] documented Resident #117 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #117 had a Brief Interview for Mental Status score of 8, indicating moderately impaired cognition. An Incident Report dated 7/11/21 documented Resident #117 had a bruise on the left medial thigh measuring 9.72 centimeters (cm) by 6.15 cm of unknown origin. The facility lacked documentation they reported the injury to the State Agency. The Dependent Adult Abuse policy dated November 2019 directed staff to report all injuries of unknown origin to the Administrator or designated representative and the facility would report this to the State Agency no later than 24 hours. During an interview on 7/22/21 at 7:16 a.m., the Director of Nursing stated staff did not report to her the resident had a bruise prior to his fall. She stated the facility did not complete an investigation of the bruise. During an interview on 7/22/21 at 7:59 a.m. the Administrator stated staff did not inform her of an injury of unknown origin. She stated if they had, they would have had a conversation about it to discuss a possible cause.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision to prevent an elopements for 1 of 4 residents sampled (Resident #1) for falls. The Wander Guard system failed to sound on [DATE], allowing Resident #1 to exit the facility without staff knowledge. Despite knowledge of the wander guard system not alarming, the facility continued to use it as a means to alert staff when at risk residents breech an exit door. The facility failed to implement additional interventions to mitigate Resident #1's risk for elopement. On [DATE], the staff again discover Resident #1 outside unattended. The wander guard system failed to alarm. The nurse on duty failed to report the incident and no action taken to address the resident's risk for elopement. This resulted in Immediate Jeopardy. The facility reported a census of 69 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated of [DATE], Resident #1 has a Brief Interview for Mental Status (BIMS) score of 4 indicating a severely impaired cognitive status. Resident #1 ambulated independently, required limited assistance with dressing, toilet use and personal hygiene needs. Resident #1 had diagnoses of Non-Alzheimer's dementia, anxiety and depression. The Care Plan initiated [DATE] revealed Resident #1 had an elopement risk and attempts to leave the facility unattended due to impaired safety awareness. The Care Plan directed staff to alert staff to wandering behavior, approach positively and in a calm, accepting manner, place in an area of frequent observation, place monitoring device that sounds alarms when leaving the building. The #1450 Elopement sheet dated [DATE] at 10:50 a.m. revealed the staff found Resident #1 outside of the building with a four wheeled walker unwitnessed. The wander guard alarm failed to sound. The staff assisted Resident #1 back into the building and no injuries noted. Resident #1 had increased agitation and anxiety this morning. The sheet revealed an immediate action of resident and facility wander guards checked. The Care Plan updated [DATE] revealed the staff replaced the wander guard bracelet, bracelet and all door alarms rechecked for proper function, maintenance notified for the malfunction and trouble shoot what may have caused the alarm not to sound, placed on 15 minute checks, staff provided education regarding residents at risk for elopement and how to properly respond when this occurs. The #1509 Elopement sheet dated [DATE] at 7:15 p.m. revealed a visitor informed the Staff D (Registered Nurse) at the Nurse's Station that Resident #1 was outside. Staff D went in the direction the visitor pointed and observed a Nurse Aide already assisting Resident #1 back inside the facility. Resident #1 kept going to the lobby looking for her husband. Staff D told the staff to keep a closer eye on Resident #1 in case the alarm did not operate properly. The Care Plan updated on [DATE] revealed staff visualized Resident #1 sitting on a bench outside of the front door of the facility. The facility implemented 15 minute checks, second wander guard alarm bracelet added to ankle, secondary stop sign alarm added to exit doors. Families educated on not assisting others out of the facility, and a referral made for alternative placement. During an interview on [DATE] at 2:14 p.m. Staff A (Registered Nurse) stated on the morning of [DATE], Resident #1 has just had her hair done and she is ready to go. Staff A stated Resident #1 is at the front entrance, exit seeking, and is redirected towards the nurse's station and starts down hall one, as Staff A grabs the bathroom keys and goes to the bathroom. Moments later, as Staff A exits the bathroom, Staff A hears the front door bell and responds. Staff A states she sees Staff B outside standing with Resident #1. Staff B states Resident #1 was observed walking down the sidewalk. Staff A states the Wander Guard alarm is not sounding and Resident #1 is wearing her Wander Guard bracelet. Staff A states the Wander Guard door alarm and bracelet were checked earlier that morning and working fine. Following the elopement, Staff A states she checked Resident #1's Wander Guard bracelet and it is working fine. Maintenance checks the Wander Guard door monitors and door alarms and they were also working properly During an interview on [DATE] at 11:00 a.m. Staff B (Certified Nurse Aide) stated on [DATE], she has just returned from her lunch break and is pulling into the front parking lot, when she sees Resident #1 walking East on the sidewalk. Staff B states she parks her car and escorts Resident #1 back to the front door and rang the doorbell. Staff A promptly answers and lets Staff B and Resident #1 back into the facility. Staff A asks Staff B how Resident #1 got out and Staff B responds, I don't know. During an interview on [DATE] at 3:00 p.m. Staff C (Licensed Practical Nurse) stated she checked Wander Guard bracelets every morning when doing treatments, usually around 9:00 a.m. Staff C stated she uses a device, that when activated next to a Wander Guard bracelet, will light up green, indicating it is functioning properly. Staff C states she was involved with checking Resident #1's bracelet on the morning of [DATE] and [DATE] (elopement dates) and both dates they were working fine. Staff C states on [DATE] she is informed Resident #1 eloped and neither the front door alarm or Wander Guard monitor sounded. The Wander Guard and door alarms were again checked after the elopement and were functioning properly. During the interview Staff C demonstrated the alarm system. The front door had an alarm which activated when the door opened. The alarm can be deactivated at the door by pressing a door bell switch within the foyer or by coding a box within the facility. The alarm can also be manually deactivated from a panel at the nurse's station. There is a 30 second delay from when the button is pushed or code entered for the alarm to reset. There is also a Wander Guard monitor at the front entryway, dining room door, 100 hall and 200 hall exits. The Wander Guard is designed to activate and alarm when a resident wearing a Wander Guard bracelet gets too close to the monitors mounted at the exits. The Wander Guard alarms, once activated, require a manual code to deactivate. Staff C states she understands the Wander Guard system failing, but doe not know how Resident #1 was able to exit without the door alarms sounding. During an interview on [DATE] at 11:25 a.m. the Administrator stated on [DATE] at around 10:50 a.m. the staff observed Resident #1 walking East on the sidewalk. They suspected Resident #1 exited through the front entrance, but the Wander Guard system does not activate. The Administrator stated the Wander Guard bracelets, monitors and door alarms are checked and functioning properly. The Administrator stated one resident with a Wander Guard bracelet is walked by the 200 hall exit and front entrance and in both instances activates the Wander Guard alarm. The Wander Guard bracelet on Resident #1 is replaced with a new one. The Administrator states the Director of Nursing makes inquiry into the Wander Guard system and is told it could be several things, but likely given the age of the system it, the whole system should be replaced. The Administrator states she pursues getting a new system installed and gets approval, but installation is 6 to 8 weeks out. The Administrator stated on [DATE] she is made aware, by a family member, of Resident #1's elopement on [DATE] at around 7:15 p.m. The Administrator stated they initiated an investigation and found with the previous elopement, the Wander Guard system failed. The Administrator stated she educated her staff on reporting protocols, they added a key lock door alarm system, placed Resident #1 on 15 minute checks, educated staff and family and posted signage of their new alarm system During an interview on [DATE] at 2:47 p.m. Staff D (Certified Nurse Aide) stated on the evening of [DATE], she heard the front door bell ring and responded. The front door requires a key to allow someone in and there was a visitor at the door. As the family member entered, she asked if it was okay for Resident #1 to be outside, unsupervised. Staff D states she sees Resident #1 sitting on the bench outside the front entrance with her feet resting on her wheel walker. Staff D states she went and got the nurse, Staff E, while the visitor remained with the resident. Staff D states she asked Staff E if someone had let Resident #1 outside. Staff E states no and both proceed to the front door. By then Resident #1 is walking away. Resident #1 is confused, stating husband (deceased ) is going to pick her up. Resident #1 is escorted back into the facility. Staff D states as they walk back in the Wander Guard alarm system sounds. Staff D states the Wander Guard alarm system was not sounding earlier. Staff D states it takes a code to deactivate the Wander Guard alarm. Staff D states she is not certain how long Resident #1 was outside, but she took her lunch break (6:12 p.m. to 6:41 p.m. according to time sheet) and walked through the front entrance, noting Resident #1 was not outside at that time. During an interview on [DATE] at 2:53 p.m. Staff E (Registered Nurse) stated on the evening of [DATE], Resident #1 is very confused and talking about her husband (deceased ) in the present tense. Resident #1 is exit seeking that evening and setting off her Wander Guard alarm several times at the front entrance. Staff E states this behavior is not uncommon for Resident #1 and she instructs her staff to keep a close eye on her. Staff E states they are one aide short that evening and it is very busy. Staff E states while passing medications on 100 hall, she goes to the nurse's station for something. A family member points towards the front entrance. Staff E walks to the front entrance and an aide is bringing Resident #1 in from outside. Staff E states at the time she does not think this is a big deal and admits she does not notify the Director of Nursing or the Administrator. Staff E states she does not recall the door alarm sounding and notes the Wander Guard alarm is not sounding. Staff E states she is able to get Resident #1 distracted from wanting to leave and provided her some whisky. The drink seemed to calm her and she returned to her hall and eventually went to bed. After reviewing video of Staff E accessing Resident #1's whisky at 6:42 p.m. Staff E recanted her earlier statement regarding when she gave Resident #1 whisky, noting it may have been given prior to her elopement. Staff E states Resident #1 is not placed on any monitoring schedule or increased level of supervision following the elopement. The facility is located 0.3 miles from Highway 14, a four lane heavily travelled highway. The State Agency informed the facility of the Immediate Jeopardy at 10:00 a.m. on [DATE]. After the Administration learned of the incident on [DATE], Exit Stopper alarms were implemented to all doors with a wander guard alarm. The alarms require a key to turn the alarm on and off. The facility provided staff education on [DATE] on the use of alarms. The education included to notify the nurse immediately of any resident that exits the facility unwitnessed. The facility contacted the manufacturer on [DATE] to install a new wander guard system and ordered a new system with a ,d+[DATE] week wait time. The facility provided adequate evidence to show they identified the deficient practice, and developed and implemented a corrective action plan following the incident. The facility corrected the deficient practice on [DATE] prior to the survey. Past noncompliance effectuated.

The following deficiency relates to complaint # and abuse allegation # . Based on clinical record review and interviews, the facility failed to follow the plan of care and failed to implement interventions to prevent falls for 2 of 2 sampled (Residents #2, #7). Resident #2 sustained a fractured right femur during an improper transfer. Resident #7 had repeated falls and sustained a fractured jaw and broken teeth. The facility made a therapy referral for wheelchair positioning but failed to implement interventions to keep Resident #7 safe in the interim. The facility reported a census of 72. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 had a [DIAGNOSES REDACTED].#2 had moderately impaired decision-making. The MDS dated [DATE] documented Resident #2 required extensive assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. The Care Plan identified Resident #2 had decreased mobility secondary to spinal stenosis and status [REDACTED]. The Care Plan directed the staff to transfer Resident #2 with a total mechanical lift with two staff for safety. During an interview on 6/10/19 at 12:29 p.m., Staff A (Nurse Aide) reported the morning of 5/16/19 Resident #2 required two staff to roll her over in bed and had increased pain with her leg turned inward. Staff A summoned the Staff B (Charge Nurse) to assess Resident #2. Staff A stated Resident #2 often had pain related to arthritis but didn't recall her having any pain issues on 5/13/19 or 5/14/19. Staff A stated she worked the day shifts on 5/13/19 to 5/16/19 and Resident #2 had complained of leg and right knee pain with transfers. During an interview on 6/10/19 at 3:10 p.m., Staff B (Licensed Practical Nurse) stated on the morning of 5/16/19 Staff A asked her to look at Resident #2. Staff B noticed Resident #2's right leg and knee had internally rotated. Resident #2 yelled out in pain when she touched the right knee. Staff B arranged for an x-ray outside of the facility. Resident #2's roommate (Resident #3) told Staff B a male nurse aide assisted Resident #2 into bed a couple of nights ago and the roommate heard Resident #2 yelled out ow, that hurts. Resident #3 as not able to identify the aide by name, but later that day identified Staff C, as the aide that assisted Resident #2 into bed when she yelled out in pain. The radiology report dated 5/16/19 revealed Resident #2 sustained a markedly displaced/impacted supracondylar [MEDICAL CONDITION] distal femur with resultant valgus angulation and severe [MEDICAL CONDITION] change in the knee joint. Resident #2 had severe bony demineralization in her pelvis. According to the MDS assessment dated of 3/27/19, Resident #3 had no cognitive impairments. During an interview on 6/10/19 at 1:55 p.m., Resident #3 reported Staff C transferred Resident #2 by himself from the wheelchair to the bed with a total mechanical lift. Resident #3 reported Staff C had the privacy curtain pulled between them, but she heard Resident #2 yell oh no, oh no, oh no. Resident #3 asked what was going on and Staff C stated Resident #2's foot slipped. During an interview on 6/13/19 at 12:00 p.m., Staff C (Nurse aide) stated he transferred Resident #2 into bed on the evening of 5/11/19 and Staff D (Agency Aide) assisted with the total mechanical lift transfer. Staff C stated the transfer was uneventful and recalled Resident #2 asking about his kids. Staff C stated Resident #2 never complained of any pain or discomfort. The Surveyor informed Staff C the other staff denied being involved in Resident #2's transfer the evening of 5/11/19. Staff C reiterated Staff D (Agency Aide) helped with the transfer. During an interview on 6/10/19 at 2:43 p.m., Staff D (Agency Aide) stated she worked the evening shift on 5/11/19. Staff D stated she assisted Staff C with a total mechanical lift transfer of Resident #2 around suppertime. Resident #2 had no complaints. Staff D reported she had no further contact with Resident #2 after 6:00 p.m. During an interview on 6/11/19 at 2:09 p.m., Staff [NAME] (Nurse Aide) stated she worked the overnight shift on 5/11/19. Staff [NAME] stated she assisted Staff C with some two-person transfers, but never with Resident #2. Staff [NAME] stated she went into Resident #2's room around 9:30 p.m. to help transfer Resident #2 into bed but Resident #2 was already in bed. Staff [NAME] stated she was not involved with transferring Resident #2 into bed and did not know who may have helped Staff C with the transfer. During an interview on 6/11/19 at 9:43 a.m., Resident #2's son stated he and other family visited his mother on 5/12/19. Resident #2 complained of right knee pain but he did not think much of it because she had arthritis. He visited again on 5/13/19 and she complained again of right knee pain. Her daughter attempted to place a rolled towel underneath her knee she cried out in pain. Resident #2's son stated the surgeon who repaired the fracture questioned how she sustained the fracture as she was nonweight bearing, and unlikely to fracture during a lift. In an interview on 6/10/19 at 11:45 a.m., Staff F (Nurse Aide) stated she worked during the day on 5/12/19 and Resident #2 complained of leg pain that morning. Staff F recalled Staff [NAME] (Nurse Aide) reported Resident #2 yelled out in pain when transferred the prior evening. During an interview on 6/10/19 at 12:55 a.m., Staff G (Nurse Aide) reported she worked the afternoon and overnight of 5/12/19 and recalled the off going staff reported Resident #2 had knee pain and the staff informed the charge nurse. Staff G stated the staff used a total mechanical lift to transfer Resident #2 for as long as she could recall. Staff G reported Resident #2 had stiff legs, unable to bear weight and unwilling to move legs apart during cares. During an interview on 6/10/19 at 2:20 p.m., Staff H (Nurse Aide) stated she worked the evening shift on 5/13/19, 5/14/19 and 5/15/19 and cared for Resident #2. On 5/14/19, Staff H and Staff I transferred Resident #2 with the total mechanical lift. Resident #2 complained of right knee pain. Staff H reported this was new and she reported this to the charge nurse. Staff H reported the nurse looked at Resident #2's knee and it had swelling. During an interview on 6/10/19 at 11:05 a.m., Staff I (Nurse Aide) reported she helped transfer Resident #2 into bed the evening of 5/14/19. Resident #2 complained of right knee pain. Staff H reported the complaint to the charge nurse. Staff I stated a couple days earlier, Resident #2 complained of right knee pain and the staff informed the charge nurse. Staff I reported Resident #2 required a total mechanical lift for transfers, which required the use of two staff. Staff I reported after Resident #2's fracture the staff switched to a from a cross leg sling to a full body sling to decrease the pressure around her knees. During an interview on 6/11/19 at 12:37 p.m., Resident #2's Primary Care Physician (PCP) stated Resident #2 had severe bony demineralization and inactivity, which made her susceptible to fractures. The PCP reviewed the radiology report and stated the fracture and deformity Resident #2 sustained was likely due to trauma, possibly a fall or some torsion at the knee. 2. According to the MDS assessment dated [DATE] Resident #7 had [DIAGNOSES REDACTED]. Resident #7 had severe cognitive impairments. The MDS dated [DATE] revealed Resident #7 required limited assistance with transfers and dressing and extensive assistance with mobility, toilet use and personal hygiene needs. The Care Plan revealed Resident #7 had a potential for injury from falls and had six falls in two months. The Care Plan directed the staff to place dycem above and below wheelchair cushion, do not leave alone in room when in wheelchair, gripper socks, sign in room to remind resident to use call light, ensure wheelchair next to bed at night with brakes locked, remove wheelchair pedals to allow safe self-propelling before and after meals. The Care Plan revealed the following updates: a. On 4/22/19, implement a table tent for dining room table to remind staff not leave resident unattended during meals. b. On 5/20/19, continue with occupational therapy to evaluate for wheelchair positioning. c. On 5/25/19, continue with occupational therapy evaluation for positioning. d. On 5/28/19, education review completed. e. On 5/30/19, placed pummel cushion in recliner. The Incident Report dated 4/20/19 at 4:15 a.m., revealed the staff heard someone yell out and found Resident #7 sitting on the floor. Resident #7 attempted to self-transfer from bed to the locked wheelchair and then attempted transfer to the recliner. Resident #7 had no injuries noted. The report revealed no fall interventions. The Incident Report dated 4/22/19 at 1:45 p.m., revealed Resident #7 sitting in wheelchair in dining room following meal. The staff found Resident #7 on her knees next to the dining room table. Resident #7 had injuries noted. The reported revealed an intervention for one on one supervision and table tent on dining room table to remind staff not to leave unattended at the dining room table. The Occupational Therapy note dated 5/15/19, revealed Resident #7 evaluated for wheelchair positioning. The wheelchair had a proper fit but may need a wedge cushion with dycem and positioners on her feet to discourage attempts to get up and prevent sliding. The Care Plan failed to address the Occupational Therapy recommendations. The Incident Report dated 5/16/19 at 8:25 p.m., revealed the staff found Resident #7 sitting on the dining room floor in front of wheelchair. Resident #7 had no injuries noted. The report had no interventions documented. The Incident Report dated 5/18/19 at 9:10 p.m., revealed the staff observed Resident #7 reaching for clothing protectors and fell out of her wheelchair. Resident #7 had removed her shoes. Resident #7 had redness to her forehead and a superficial abrasion to left elbow. The reported had an intervention to continue with occupational therapy to evaluate for wheelchair positioning. According to Occupational Therapy note dated 5/22/19, the therapist trialed a pummel cushion in the wheelchair. The Care Plan failed to reflect the trial of the pummel cushion. The Incident Report dated 5/25/19 at 3:44 p.m., revealed another resident witnessed Resident #7 leaning forward in her wheelchair. Resident #7 fell forward and struck another resident's wheelchair. Resident #7 had bleeding from her mouth and found on her left side. Resident #7 had an x-ray completed at the hospital. Resident #7 sustained a fractured jaw and had broken teeth. The report revealed an intervention to continue with occupational therapy for positioning. According to Occupational Therapy note dated 5/28/19, Resident #7 had a pummel cushion in place to help decrease the risk for falls. The Therapist adjusted Resident #7's wheelchair alignment for safety. The Incident Report dated 5/30/19 at 4:08 p.m., revealed Resident #7 sitting in a recliner in the lobby. Resident #7 leaned forward and tipped the recliner. She rolled out of the recliner onto her right side and sustained an abrasion to her right knee. The report revealed an intervention for a pummel cushion in recliner.

Based on record review, policy review and staff interviews, the facility failed to ensure one of eleven residents were free from abuse. Concerns were identified with Resident #5 placing hands on the breast of Resident #6. The facility reported a census of 72 residents. Findings include: The abuse protocols revised May 2016 documented a policy that all residents had the right to be free from verbal, sexual and mental abuse. The policy indicated residents must not be subject to abuse by anyone including but not limited to other residents. According to the Face Sheet, Resident #6 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] revealed Resident #6 had a BIMS (Brief Interview for Mental Status) score of 13 out of 15, revealing intact cognitive skills for daily decision making skills. Resident #6 required one staff assistance with bed mobility, dressing, transfers, toilet use and personal hygiene. According to the MDS, Resident #6 used a wheelchair/walker for mobility. According to the Face Sheet, Resident #5 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] revealed Resident #5 had a BIMS (Brief Interview for Mental Status) score of 15 out of 15, revealing intact cognation. Resident #5 required limited assist of one staff member with bed mobility, dressing, and personal hygiene, and assist of two for transfer, and toilet use. 1.Review of the Incident/Accident/Unusual Occurrences Form dated 8/13/16 at 3:45 p.m. revealed staff found Resident #5 in Resident #6 room telling Resident #6 I like your breast and staff witnessed Resident #5's hand on Resident's #6 breast. Staff members separated the two residents. Resident #6 reported Resident #5 wanting to play with his/her breast and touching his/her breast. Resident #6 tearful and staff assured his/her safety. Resident #6 family and physician notified of incident, and police notified. Staff D and Staff E were listed as witnesses to the incident. Review of the Police report dated 8/13/16 at 4:02 p.m. revealed Resident #5 as the offender and Resident #6 as a victim of a sexual assault. Resident #5 according to staff caught with hand on Resident #6 right breasts while in Resident #6 room. Resident #5 admitted to touching Resident #6 breasts. Resident #5 reported asking Resident #6 if he/she could massage his/her breast approximately a week prior to this incident. Resident #5 reported following Resident #6 to his/her room and touched his/her breast without asking again if he/she could do that. Resident #5 reported him/her thinking of touching Resident #6 breasts for approximately one week prior and gave his/her rational. Resident #6 reported that Resident #5 did follow him/her to room and did touch his/her breast. Resident #6 reported he/she did not want Resident #5 prosecuted or penalized and wished for Resident #5 to leave him/her alone and never touch him/her again. Staff D and Staff E were listed as witness to the incident. During an interview with Staff D, certified nurse aide (CNA) on 8/18/16 at 2:11 p.m., she reported on 8/13/16 at 3:30 p.m. she walked by Resident #6' s room when she heard something inappropriate being said and entered Resident #6's room. Staff D reported Resident #5 had his/her hand on Resident #6's breast. Resident #6 reported he/she did not like it. Staff D told Resident #5 to return to his/her room. Staff D reported Resident #6 was very upset and she had not seen Resident #6 that upset before. Staff D reported she notified the nurse and she had never seen Resident #5 in Resident #6's room before. Interview was conducted on 8/18/16 at 1:55 p.m. with Staff C (Charge Nurse). Staff C stated she assigned to care for Resident #6 on 8/13/16. Staff C stated around 3:45 p.m. she was alerted by staff of Resident #5 touching Resident #6 breasts and staff had immediately separated them. Staff C stated Resident #6 had been very upset over incident and was teary eyed as he/she explained Resident #5 touching his/her breast. Staff C indicated both residents were fully dressed and the touching occurred over the top of Resident #6 shirt. During an interview on 8/17/16 at 2:50 p.m., Resident #6 reported Resident #5 had touched him/her one time and the police were contacted. Resident #6 reported Resident #5 had been in his/her room [ROOM NUMBER] times, talking inappropriately. Resident #6 had been visibility upset when talking about the incident. A typed documented (untitled) dated as 8/15/16 documented statements by Resident #6, Resident #5 and Staff G and included the following: Resident #6's statement: Resident #5 had not talked with him/her prior to Saturday (8/13/6); it was in the dining room after lunch. Resident #5 approached Resident #6 and wanted to touch his/her breast. Resident #6 talked with Staff G after the incident. Resident #6 reported Staff G said that was inappropriate. Resident #6 returned to his/her room and Resident #5 followed and never changed the subject (talking about his/her breast). Resident #6 reported then Resident #5 grabbed his/her breasts and left. Resident #5's statement reported: On Saturday (8/13/16) at the end of the music, Resident #5 gave Resident #6 a diet coke and then pushed Resident #6 ' s back to his/her room {using his/her electric wheelchair}. Resident #5 reported going into Resident #6 ' s room and asked Resident #6 if he/she could touch his/her breast. Resident #5 noted Resident #6 decided he/she did not like it and Resident #5 left the room passing a couple of aides standing in the door. On Monday (8/15/16) or Tuesday last week Resident #5 asked again if he/she could touch Resident #6 ' s breast and according to Resident #5 he/she pushed Resident #6 ' s wheelchair halfway and then Resident #6 decided he/she did not feel so good and Resident #5 left. The facility statement by Staff G reported on 8/15/16 at 11:58 a.m., she talked with Resident #6 on Saturday the 13th (August 2016) at lunch and could not recall what they talked about. Staff G reported Resident #6 had been going downhill and was very confused; and had shaking his/her fingers at other residents. Interview conducted on 8/18/16 at 10:37 a.m. with Staff A, CNA. Staff A stated, she believes, on 8/15/16 sometime after breakfast and before lunch, she was checking on Resident #6 and found him/her in recliner in room and Resident #5 in room with Resident #6. Staff A stated she could tell Resident #6 was very upset and Staff indicated never seeing Resident #6 that upset before. Staff A stated Resident #6 needed her help to get Resident #5 out of his/her room. Staff A stated she asked Resident #5 to leave and Resident #5 remained at Resident #6 doorway in electric wheelchair, facing Resident #6. Staff A stated she spent about 10 minutes with Resident #6 due to being so upset and he/she reported to Staff A that Resident #5 is making comments about his/her breast and that he/she felt trapped in their room by Resident #5. Staff A stated Resident #5 remained at Resident's 6 doorways and did not leave. Staff A stated she walked away and Resident #5 still at doorway. Staff A stated she does not know how long Resident #5 remained at Resident #6 doorway, but not there when she assisted Resident #6 to lunch around 11:30 a.m. Staff A stated she never reported this to no one as she did not know who to report this to. Interview was conducted on 8/18/16 at 11:13 a.m. with Staff B, CNA. Staff B stated Resident #6 told her and Staff A prior to the incident of 8/13/16, that he/she did not want Resident #5 coming into his/her room. Staff B stated before that she seen Resident #5 in Resident #6 room before. Staff B stated Resident #5 had an electric wheelchair and before he/she got the electric wheelchair he/she would propel self over to Resident #6 table in the dining room. Staff B stated she thought Staff A informed the nursing staff of Resident #6 not wanting Resident #5 coming into his/her room anymore.

The following information relates to investigation of facility self-report # -I. Based on record review and staff interviews, the facility failed to ensure two of eleven residents received adequate supervision. Concerns were identified with Resident #5 placing hands on the breast of Resident #6 on 8/13/16. Staff reported finding Resident #5 in Resident #6's room after the 8/13/16 incident, and when asked to leave, Resident #5 remained at Resident #6's doorway,inappropriately talking about wanting to touch Resident #6. The facility reported a census of 72 residents. Findings include: According to the Face Sheet, Resident #6 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] revealed Resident #6 had a BIMS (Brief Interview for Mental Status) score of 13 out of 15, revealing intact cognitive skills for daily decision making skills. Resident #6 required one staff assistance with bed mobility, dressing, transfers, toilet use and personal hygiene. According to the MDS, Resident #6 used a wheelchair/walker for mobility. The Plan of Care dated 8/10/16 revealed Resident #6 had a history of [REDACTED]. Resident #6's care plan update on 8/15/16 revealed Resident #5 had inappropriately touched the resident without permission. Staff would follow-up with Resident #6 to evaluate his/her emotional state and that Resident #6 would remain separate from Resident #5 at all times. According to the Face Sheet, Resident #5 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] revealed Resident #5 had a BIMS (Brief Interview for Mental Status) score of 15 out of 15, revealing intact cognation. Resident #5 required limited assist of one staff member with bed mobility, dressing, and personal hygiene, and assist of two for transfer, and toilet use. The Plan of Care dated 8/15/16 revealed a problem/need area of Resident #5 inappropriately touched another resident's breast without permission from the resident (Resident #6). Staff will separate Resident #5 from Resident #6 at all times. 1.Review of the Incident/Accident/Unusual Occurrences Form dated 8/13/16 at 3:45 p.m. revealed staff found Resident #5 in Resident #6 room telling Resident #6 I like your breast and staff witnessed Resident #5's hand on Resident's #6 breast. Staff members separated the two residents. Resident #6 reported Resident #5 wanting to play with his/her breast and touching his/her breast. Resident #6 tearful and staff assured his/her safety and staff frequently checking Resident #6 in their room. Resident #5 and #6 family and physicians notified of incident and police notified. Resident #5 had been placed on 15 minute checks by staff. Staff D and Staff E were listed as witnesses to the incident. Review of the Police report dated 8/13/16 at 4:02 p.m. revealed Resident #5 as the offender and Resident #6 as a victim of a sexual assault. Resident #5 according to staff caught with hand on Resident #6 right breasts while in Resident #6 room. Resident #5 admitted to touching Resident #6 breasts. Resident #5 reported asking Resident #6 if he/she could massage his/her breast approximately a week prior to this incident. Resident #5 reported following Resident #6 to his/her room and touched his/her breast without asking again if he/she could do that. Resident #5 reported him/her thinking of touching Resident #6 breasts for approximately one week prior and gave his/her rational. Resident #6 reported that Resident #5 did follow him/her to room and did touch his/her breast. Resident #6 reported he/she did not want Resident #5 prosecuted or penalized and wished for Resident #5 to leave him/her alone and never touch him/her again. Resident #5 advised of this. No charges filed. Staff D and Staff E were listed as witness to the incident. During an interview with Staff D, certified nurse aide (CNA) on 8/18/16 at 2:11 p.m., she reported on 8/13/16 at 3:30 p.m. she walked by Resident #6's room when she heard something inappropriate being said and entered Resident #6's room. Staff D reported Resident #5 had his/her hand on Resident #6's breast. Resident #6 reported he/she did not like it. Staff D told Resident #5 to return to his/her room. Staff D reported Resident #6 was very upset and she had not seen Resident #6 that upset before. Staff D reported she notified the nurse and she had never seen Resident #5 in Resident #6's room before. Staff D reported Resident #5 stayed in his/her room for supper and completed 15 minute checks on him/her. Interview was conducted on 8/18/16 at 1:55 p.m. with Staff C (Charge Nurse). Staff C stated she assigned to care for Resident #6 on 8/13/16. Staff C stated around 3:45 p.m. she was alerted by staff of Resident #5 touching Resident #6 breasts and staff had immediately separated them. Staff C stated Resident #6 had been very upset over incident and was teary eyed as he/she explained Resident #5 touching his/her breast. Staff C indicated both residents were fully dressed and the touching occurred over the top of Resident #6 shirt. A typed documented (untitled) dated as 8/15/16 documented statements by Resident #6, Resident #5 and Staff G and included the following: Resident #6's statement: Resident #5 had not talked with him/her prior to Saturday (8/13/6); it was in the dining room after lunch. Resident #5 approached Resident #6 and wanted to touch his/her breast. Resident #6 talked with Staff G after the incident. Resident #6 reported Staff G said that was inappropriate. Resident #6 returned to his/her room and Resident #5 followed and never changed the subject (talking about his/her breast). Resident #6 reported then Resident #5 grabbed his/her breasts and left. Resident #5 ' s statement reported : On Saturday (8/13/16) at the end of the music, Resident #5 gave Resident #6 a diet coke and then pushed Resident #6 ' s back to his/her room {using his/her electric wheelchair}. Resident #5 reported going into Resident #6 ' s room and asked Resident #6 if he/she could touch his/her breast. Resident #5 noted Resident #6 decided he/she did not like it and Resident #5 left the room passing a couple of aides standing in the door. On Monday (8/15/16) or Tuesday last week Resident #5 asked again if he/she could touch Resident #6 ' s breast and according to Resident #5 he/she pushed Resident #6 ' s wheelchair halfway and then Resident #6 decided he/she did not feel so good and Resident #5 left. The facility statement by Staff G reported on 8/15/16 at 11:58 a.m., she talked with Resident #6 on Saturday the 13th (August 2016) at lunch and could not recall what they talked about. Staff G reported Resident #6 had been going downhill and was very confused; and had shaking his/her fingers at other residents. During an interview on 8/17/16 at 2:50 p.m., Resident #6 reported Resident #5 had touched him/her one time and the police were contacted. Resident #6 reported Resident #5 had been in his/her room 2 times, talking inappropriately. Resident #6 had been visibility upset when talking about the incident. During an interview with Staff F, CNA on 8/18/16 at 9:21 p.m., she reported assisting Resident #5 in the shower and the resident always grabbed her body parts. Staff F redirected Resident #5 and told him/her not to touch her. Staff F reported she had given Resident #5 two showers and the other shower aide did not have any problems with the resident. Staff F reported she was not aware of Resident #5 touching others (residents or staff). Staff F reported she told the charge nurse and the Administrator talked with Resident #5 afterwards. Interview conducted on 8/18/16 at 10:37 a.m. with Staff A, CNA. Staff A stated, she believes, on 8/15/16 sometime after breakfast and before lunch, she was checking on Resident #6 and found him/her in recliner in room and Resident #5 in room with Resident #6. Staff A stated she could tell Resident #6 was very upset and Staff indicated never seeing Resident #6 that upset before. Staff A stated Resident #6 needed her help to get Resident #5 out of his/her room. Staff A stated she asked Resident #5 to leave and Resident #5 remained at Resident #6 doorway in electric wheelchair, facing Resident #6. Staff A stated she spent about 10 minutes with Resident #6 due to being so upset and he/she reported to Staff A that Resident #5 is making comments about his/her breast and that he/she felt trapped in their room by Resident #5. Staff A stated Resident #5 remained at Resident's 6 doorways and did not leave. Staff A stated she walked away and Resident #5 still at doorway. Staff A stated she does not know how long Resident #5 remained at Resident #6 doorway, but not there when she assisted Resident #6 to lunch around 11:30 a.m. Staff A stated she never reported this to no one as she did not know who to report this to. Interview was conducted on 8/18/16 at 11:13 a.m. with Staff B, CNA. Staff B stated Resident #6 told her and Staff A prior to the incident of 8/13/16, that he/she did not want Resident #5 coming into his/her room. Staff B stated before that she seen Resident #5 in Resident #6 room before. Staff B stated Resident #5 had an electric wheelchair and before he/she got the electric wheelchair he/she would propel self over to Resident #6 table in the dining room. Staff B stated she thought Staff A informed the nursing staff of Resident #6 not wanting Resident #5 coming into his/her room anymore.

Based on record review and staff interviews, the facility failed to provide adequate supervision to protect against hazards from self. The facility left Resident #3 alone and unsupervised in a chair without a seat belt alarm secured. Resident #3 stood, fell and was found by a nurse. The x-rays identified Resident #3 had a fractured hip. Six residents with falls were reviewed. The facility identified a census of 73 residents. Findings include: 1. Resident #3 had a quarterly Minimum Data Set (MDS) assessment with a reference date of 5/21/14. The MDS reflected the resident with a BIMS (Brief Interview for Mental Status) score of 3. A score of 3 identified the resident with a severe cognitive impairment. Resident #3 required extensive assistance of two staff members for bed mobility, transfers, and toileting. The MDS noted the resident was non-ambulatory and used a wheelchair for mobility. The [DIAGNOSES REDACTED]. The MDS revealed the resident had not had any falls in the three month period and did not have any functional limitations of the upper or lower extremities. The Care Plan with a revision date of 6/5/14 identified Resident #3 at risk for injury from falls secondary to poor safety awareness, decreased mobility, and a history of falls. The approaches directed staff to transfer the resident from surface to surface with an EZ (mechanical device) stand. The approach reflected the resident as not ambulatory at this time and a tilt and space chair. The resident was to have an alarmed seat belt in place while in a wheelchair to alert staff to attempts of getting out of the wheelchair independently. Additional safety interventions on the care plan included an alarmed floor mat by the low bed, non-skid socks on at bedtime, dycem (non-slip plastic sheeting) on the wheelchair seat, and to put the resident to bed shortly after the spouse left at bedtime. The seatbelt was not identified as a restraint because the Care Plan identified the resident was able to self-release the seatbelt. A Fall Risk assessment dated [DATE] identified Resident #3 as high risk for falling with a score of 12 (10 or greater indicates high risk for falling). The resident's parameter assessment of contributing factors were: resident was chair bound, had intermittent confusion, and took three medications and had two [DIAGNOSES REDACTED]. The facility assessed the resident monthly for the need of an alarmed seat belt. The current Monthly Positioning Device assessment dated [DATE] revealed the positioning device was required due to the resident ' s confusion and balance as demonstrated by the inability of Resident #3 to position him/herself in the chair, maintain proper positioning, and keep from leaning forward in the chair. The assessment documented the facility had tried a chair alarm initially without success. Review of a facility Accident/Incident Report dated 8/12/14, completed by Staff A, Licensed Practical Nurse (LPN), revealed the resident was found by staff on the floor in the bedroom by the wheelchair. The document noted the resident had pain in the right hip area and could not extend the right leg. The resident ' s vital signs were normal except for a temperature of 99.3 (normal 98.6) and the resident was transferred to the emergency room for an assessment after the physician and family were notified. Review of a facility Investigation For CNAs (Certified Nursing Assistants) Report dated 8/12/14 and completed by Staff B, CNA, revealed she had been in the room with the resident five minutes prior to the fall. At the time of the fall, Staff B documented the resident had been in his/her room waiting for Staff B and a second CNA to assist him/her to bed. Staff B documented not all interventions were in place at the time of the fall. Review of the hospital radiology report for Resident #3 dated 8/12/14 revealed the resident had a mildly impacted right subcapital femoral head fracture (hip fracture). Hospital Patient Discharge and Transfer Form dated 8/13/14 revealed the resident was transferred back to the facility after an overnight stay in the hospital as a non-surgical skilled resident. The Nurse ' s Notes dated 8/14/14 at 2:15 p.m. revealed the resident voiced complaints of pain after breakfast and pain medication was given by the nurse. A note on 8/15/14 at 3:05 a.m. revealed the resident yelled out in pain when transferred with a Hoyer lift and 2 staff person assistance. The resident expressed pain relief when laid down in bed and given Tylenol #3 (analgesic) at bedtime. The note reflected on 8/15/14 at 1:44 p.m. the resident grimaced when transferring or repositioned. The resident was given Tylenol #3 in the morning for pain in the right hip. During an interview with Staff B, CNA, on 8/18/14 at 9:30 a.m. she stated she had taken Resident #3 into the bedroom after supper and unfastened the resident ' s alarmed seat belt so she could remove the resident ' s shirt and assist the resident to put on a pajama top. Staff B stated she left the room to go get Staff C, CNA, to assist her in to put the resident into the bed. She stated before leaving the room she told the resident she would be back with help to put him/her into bed and the resident replied " yes " . Staff C was busy with another resident so Staff B instead went to help a different resident prepare for bed. A few minutes later Staff B heard a nurse in the hallway say Resident #3 had fallen. Staff B stated at this point she realized she had neglected to refasten the resident ' s seatbelt before leaving the resident alone and seated in the wheelchair in the room. Staff B denied during the interview that she had forgotten any other safety measures for Resident #3 or any other residents prior to this incident. She stated she was very busy that evening because the facility was short a float aide and this might have contributed to her being forgetful. . On 8/18/14 at 1:05 p.m. Staff A, Licensed Practical Nurse (LPN), was interviewed and stated she was walking down the hall at 6:30 or 7:00 p.m. on 8/12/14 when she heard a resident calling for help. Staff A stated she found Resident #3 on the floor of the bedroom by the wheelchair and noted no alarms sounding at the time. Staff A stated she did a head to toe assessment of the resident and took vital signs. The resident voiced complaints of pain in the right hip area and exhibited decreased range of motion of the extremity. The physician and family were notified and the resident was sent to the emergency room for evaluation and was subsequently diagnosed with [REDACTED]. She stated the shift was short a CNA that evening and only had five CNAs working partial and full shifts. She stated the shift was less hectic when there were six CNAs working on the evening shift but this was not always possible due to call-ins from staff. On 8/14/14 at 1:00 p.m. Staff C, certified nursing assistant, was interviewed and stated she assisted to care for Resident #3 after the fall occurred. She stated she asked Staff B how the fall happened and Staff B replied she had forgotten to put the alarmed seat belt on the resident before she left the room. Staff C stated she worked frequently with Staff B before she became PRN (as needed) status, Staff C stated she had never known Staff B to forget safety interventions before and thought it was accidental. Staff C stated there is usually enough staff for her to get her work done and to safely supervise the residents. However she stated things often got hectic when evening shift only had five CNAs instead of six. Staff C stated the routine is for the resident to be kept up front until ready to be put to bed by 2 available nursing assistants. During an interview with Staff D, CNA, on 8/14/14 at 2:00 p.m. she stated she worked the evening shift on 8/12/14 but was on a different hall and did not know the resident fell until about 8:30-9:00 p.m. She stated when there are 6 CNAs working evening shift things seem to run more smoothly and she feels all residents are supervised safely. She stated it is not as easy to do when there are only 5 CNAs working however she feels she can do her job safely and timely and supervise her assigned residents. She stated she can answer the call lights within 15 minutes. During an interview the Director of Nursing (DON), on 8/14/14 at 12:15 p.m. she stated Staff B, CNA, was a wonderful employee and did a great job. The DON stated when she interviewed Staff B after the incident Staff B stated she had forgotten to put the alarmed seatbelt back on the resident and she felt very badly about the resident getting hurt. The DON stated optimal staffing is to have six CNAs working the evening shift along with two nurses. The DON stated she attempts to staff the evening shift with six CNAs but sometimes when staff calls in sick it is not possible to have six CNAs on the evening shift. Review of facility Safety Interventions check list carried by CNAs for shift rounds revealed Resident #3 was to have an alarmed seat belt, Dycem in the wheelchair, gripper socks, and low bed with mat on the floor, put to bed when spouse leaves, and to toilet the resident per facility schedule. Review of Daily Nursing Staff Assignments from 8/1/14 through 8/14/14 revealed out of 14 evening shifts half of the shifts were staffed with 5 CNAs and the other half were staffed with 6 CNAs.

Based on record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and failed to implement the Care Plan as written (Resident #1). The facility identified a census of 65 residents and the sample consisted of 4 residents. On 4/9/14, Resident #1 received an anti-anxiety injection medication and was left unattended in bed. The resident fell from the bed and fractured 2 ribs and a hip. The resident had a history of [REDACTED]. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 5/9/14, which identified the resident had impaired long and short term memory deficits and severely impaired cognitive skills for daily decision making. Resident #1 required extensive assistance with physical assistance of two staff with transfers, dressing, toilet use, bathing and personal hygiene. Resident #1's [DIAGNOSES REDACTED]. Resident #1's Care Plan dated 3/20/14 identified the resident at a potential for injury from falls related to a history of falls, poor decision making and poor safety awareness. The facility made a goal that Resident #1 would have no injuries related to falls. The approaches directed the staff to: a. Monitor side effects of medications. b. Keep area free of clutter and other hazards. c. 1/2 side rails up for assistance. d. Resident #1 is not to be left alone in his/her bedroom unless in bed because of confusion, Resident #1 should be in areas of increased supervision when awake. (3/29/14). e. Wheel chair is to be left in bathroom (out of sight) when in bed. (3/31/14). The Incident/Accident/Unusual Occurrences Form dated 3/29/14 at 5:00 p.m. indicated Resident #1 was found lying on his/her left side in the activity room. Resident #1 was found without injury. The Incident/Accident/Unusual Occurrences Form dated 3/31/14 at 1:10 a.m. identified Resident #1 was found kneeling on the floor next to his/her bed and pulling linens off. Resident #1 was found without injury. The Incident/Accident/Unusual Occurrences Form dated 4/4/14 at 5:30 a.m. reflected Resident #1 was found lying on the floor next to his/her bed. Resident #1 was found without injury. The Incident/Accident/Unusual Occurrences Form dated 4/9/14 at 3:15 a.m. identified Resident #1 was found lying on the floor next to his/her bed. Resident #1 was found with an abrasion on his/her left side and winced in pain when assisted up into bed. The Incident/Accident/Unusual Occurrences Form dated 4/9/14 at 4:45 a.m. reflected Resident #1 was found lying on the floor. Resident #1 complained of hip pain and was unable to extend left leg. A radiology report dated 4/9/14 at 6:13 a.m. identified posterolateral 9th and 10th rib fractures and intertrochanteric left femoral neck fracture (fractured hip). On 5/15/14 at 6:15 a.m. Staff A (Certified Nursing Assistant) was interviewed and stated she was working the overnight shift (10:00 p.m. to 6:00 a.m.) on 4/8/14 and was assigned to the 100 hall with a new hire, Staff B (Certified Nurse Assistant). Resident #1 resided in the 100 hall. Staff A stated Resident #1 was often restless during the overnight and staff would usually have Resident #1 brought to the nurse's station where he/she could be monitored more closely. Staff A stated on the evening of 4/8/14 at 10:00 p.m. Resident #1 was in bed asleep. It was sometime after that, that Staff A saw Resident #1 at the nurse's station and assumed one of the nurse's must have gotten him/her up. During the 1:00 a.m. rounds Resident #1 was back in bed asleep. During the 3:00 a.m. rounds Staff A discovered Resident #1 on the floor (3:15 a.m.). Resident #1 was assessed by the nurse and Staff D assisted the resident back into bed. Resident #1 had been incontinent and was provided perineal cares and a fresh brief before being positioned in bed with pillows. Resident #1 remained anxious and was given an intramuscular medication by Staff D (3:30 a.m.). Staff A stated she finished her rounds (20 minutes) and before leaving the 100 hall checked on Resident #1 and noted he/she was still in bed. Staff A stated she completed rounds on the 200 hall and returned to Resident #1's room and discovered Resident #1 on the floor (4:45 a.m.). Resident #1 was assessed and sent by ambulance to the hospital. The Psychotropic Report dated 4/9/14 revealed the resident received 2 milligrams of Ativan (anti-anxiety medication) per injection. In an interview on 5/15/14 at 6:05 a.m. Staff B (Certified Nursing Assistant) stated she was orientating on the overnight shift (10:00 p.m. to 6:00 a.m.) on 4/8/14 and was assigned with Staff A on the 100 hall. Staff B stated she could not recall specific times, but at some time mid-morning Staff A heard Resident #1 and discovered him/her on the floor. The nurses were summoned and Resident #1 was assessed. Staff B stated they assisted Resident #1 back into bed and positioned him/her with pillows. Resident #1 seemed settled, but remained awake. Staff B stated Resident #1 was checked on again about 20 minutes later and was in bed. Staff B and Staff A then completed rounds on the 200 hall and when finished returned to Resident #1's room and found him/her on the floor. In a follow up interview on 5/20/14 at 7:50 a.m. Staff B stated she was not in Resident #1's room when a medication was given. Staff B noted Resident #1 was restless when he/she was assisted back into bed, following the first fall, but was not attempting to get up. In an interview on 5/15/14 at 7:19 a.m. Staff C (Licensed Practical Nurse) stated she was working the overnight shift (6:00 p.m. to 6:00 a.m.) on 4/8/14 and was assigned to the 300-400 halls. Staff C stated Resident #1 went to bed after supper that evening. At around 10:30 p.m. the nurse assigned to Resident #1's hall (Staff D) was having difficulty getting Resident #1 to take his/her medication. Resident #1 was also complaining of back pain and was given pain medication. Because of Resident #1 being restless, Staff C brought Resident #1 to the nurse's station where he/she was provided nail care and hot chocolate. At 11:30 p.m. Resident #1 stated he/she was ready to go back to bed. Resident #1 was taken to his/her room, provided peri care, a new brief and laid down. Staff C stated Resident #1 slept for a few hours and during 3:00 a.m. rounds was discovered on the floor. Resident #1 was assessed by his/her nurse, Staff D and reportedly without complaint of pain. Resident #1 was returned to bed. Staff C stated she was not aware of any additional supervision provided. Staff C stated Resident #1 was often restless and brought to the nurse's station or provided 1:1 supervision during those times. In an interview on 5/15/14 at 10:29 a.m. Staff D (Licensed Practical Nurse) stated she was working the overnight shift (6:00 p.m. to 6:00 a.m.) on 4/8/14 and was assigned to the 100-200 halls. Staff D stated in report it was mentioned Resident #1 had been agitated and confused earlier in the day. At around 7:30 p.m. Resident #1 was taken to bed. Staff D was unsuccessful at getting Resident #1 to take his/her medications which included a psychotropic and pain medication. At around 10:30 p.m. Staff D consulted with Staff C regarding Resident #1's refusal to take his/her medications. Staff D accompanied Staff C to Resident #1's room and discovered him/her sitting up at his/her bedside. Staff C was able to get Resident #1 to take his/her medication and decided to bring him/her up to the nurse's station for closer monitoring. Resident #1 was provided 1 to 1 attention, snacks and a drink. At around 11:30 p.m. Resident #1 was ready to lie down and was taken to his/her room. During 1:30 rounds Resident #1 was reportedly sleeping. During rounds, at 3:15 a.m. Resident #1 was discovered on the floor. Resident #1 complained of left sided pain and had an abrasion on his/her mid back. Resident #1 remained restless. Staff provided peri care, a new brief and positioned him/her into bed. Staff D stated Resident #1 seemed a little agitated and restless, but seemed okay to be in bed. Staff D decided to give Resident #1 an injection of an antianxiety medication to help calm him/her (3:30 a.m.). Staff D stated in hindsight she probably should have brought him/her up to the nurse's station. Resident #1 was checked on by the aides and at 4:45 a.m. was found on the floor again, this time complaining of left hip pain. Staff D made arrangements to have Resident #1 sent to the hospital where a hip fracture was diagnosed . In a follow up interview on 5/20/14 at 9:58 a.m. Staff D indicated that following the first fall Resident #1 was restless, moaning and talking nonsensical when she decided to give the antianxiety medication. Staff D stated she had instructed staff to keep an eye on him/her, but did not give any formal timeline on checks and did not return to Resident #1's room to assess the effectiveness of the antianxiety medication. The Director of Nursing (DON) was interviewed on 5/15/14 at 7:30 a.m. The DON stated the resident would often up late and when anxious or agitated, would be brought out to the nurses ' station until the resident would get tired. The DON stated on 4/8/14 she assessed the resident because he complained of pain in his/her knees when the legs were moved. The DON stated she encouraged the nursing staff to be more assertive with as needed pain medication as she felt the resident ' s behaviors may possibly be connected to the pain. On 4/9/14 at 3:15 a.m. the resident was noted to have a small abrasion to the left side but no other injuries noted. An hour later the resident was found again on the floor by the bed and complained of hip pain. The resident was sent to the emergency room for an evaluation. The family did not wish to pursue surgery and wanted the resident returned to the facility with Hospice intervention. The family refused to have pneumonia treated. On 4/10/14 at 6:45 a.m., the resident ' s spouse requested the resident evaluated. The resident was returned a few hours later and Hospice was at the facility to admit the resident per the family ' s request.

I. Based on observation, clinical record review, staff and resident interview, the facility failed to provide adequate supervision and failed to monitor provisions of treatment to ensure against injury for one of four residents reviewed. Resident #2 sustained a second degree burn when staff placed a heating source on the resident's back without monitoring the treatment. Staff interviews identified multiple heating sources were being used by staff without consistent safety provisions. The findings constitute an immediate jeopardy to the resident's health and safety. The facility identified a census of 73 residents. Findings include: 1. According to the face sheet, Resident #2 had [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified the resident complete a cognitive test, Brief Interview for Mental Status (BIMS) and scored of 13 of 15, indicating he/she had no cognitive impairments. The MDS indicated he/she needed extensive assistance of one staff member to reposition in bed. The resident was at risk for developing pressure ulcers. Resident # 2's care plan dated 2/6/13 documented he/she was at risk for skin breakdown related to a decrease mobility and sensation from the waist down. The care plan also mentioned the resident had a [DIAGNOSES REDACTED]. The 10/31/13 5:54 p.m. nurse's notes documented a fax had been sent to the physician for a heat for Resident #2's back. The fax to the physician dated 10/31/12 identified staff requested a heating pad be applied to the resident's back/shoulder as the resident had complained of pain. The staff requested an order for [REDACTED]. The on 11/1/13 physician's response was "ok". The 11/2/13 2:10 p. m. nurse's notes, staff received the order and notified the resident's family. The incident/accident/unusual occurrences form dated 11/4/13 11:00 a. m. indicated Resident # 2 had blisters to the lower back due to a heating pad applied at an unknown hour. The resident reported he/she could not feel anything. The nurse's notes dated 11/4/13 at 12:44 p. m. identified the resident had blisters on their back due to a heat pad put on (the resident) at an unknown hour. The entire area measured 14 centimeters (cm) by 7.2 centimeters (cm). The open area measured 2.8 cm by 2.5 cm. The area was cleansed with normal saline (NS, a salt solution), covered with Aquacel Ag (wound care dressing) and Duoderm extra thin (protective bandage). The dressing would be changed every three days and as needed (prn). The physician was notified. The nurse's notes dated 11/6/13 at 1:30 a. m. the doctor acknowledged the fax related to the blisters on the lower back. There was also an order [REDACTED]. A Physician's Telephone order dated 11/12/13 the wound care order was changed. The new order was to: apply Silvadene cream 1% after cleansing with wound cleaner twice daily; cover with an Aquacel foam pad; and secure with Medifix. The treatment could be done as needed if the area were soiled. Resident # 2 was seen by the physician on 11/12/13. The clinic report dated 11/12/13 documented: the resident had a burn on the lower back. The resident apparently laid against a heating source for an extended period which resulted in the burn. The resident had Devic's disease and did not have sensation in the lower back. The resident had ulcerations on their back with necrotic areas. The was consistent with a contact burn. The area of the mid lower back was a contact second-degree burn. The non-pressure skin condition report, on 11/4/13, the entire area measured 14 cm by 7.2 cm. The area was a burn. The open area was 2.8 cm by 2.0 cm. On 11/11/13, the size of the burn had decreased to 7.2 cm by 11.2 cm. The skin around the burn area was reddened, and the entire area of reddened skin measured 16 cm by 20 cm. The depth of the area was 0.1 cm in places. The exudate/drainage was serosanguineous (bloody), and a moderate to large amount. The area had loose skin, and two areas of eschar (dead tissue). The resident denied pain. On 11/18/13, the burn measured 5.4 cm by 10.2 cm, 80 % of the areas was eschar, and the area had improved. On 11/8/13 at 9:35 a.m., with the DON observing, Staff A did Resident # 2's wound care. The resident had black, leathery looking tissue on either side of their backbone to the mid back. The edges of the black tissue were whitish yellow. The skin around the blackened areas was red/purple. There was brownish drainage to the old dressing and the drainage pads on the resident's bed. Staff A and the DON both asked the resident if they had pain, which the resident denied. Staff A cleaned the areas with wound cleaner and gauze, then measured the entire area as 5.4 cm top to bottom by 10.2 cm wide. Staff A stated the area was 80% eschar (dead tissue that is often the result of a burn). After measuring the area, Staff A applied Silvadene to the burned area, then applied an Aquacel foam pad, and affixed the pad in place with Medifix tape. Staff A said the area had no odor, and looked better - the redness had decreased. The untitled internal facility investigation documented the following: Resident # 2 complained of back and shoulder pain, so the staff faxed the physician 10/31/13 for an order for [REDACTED]. The facility staff reported the following: a.)The 11/3/13 evening certified nurse's aide (CNA), Staff E, reported Resident # 2 was still in bed when the CNA reported to duty. After Staff E helped the resident to get up to the wheelchair, the resident complained of pain to the lower back. The resident was out at the nurse's station at the time. The resident wanted a rice pack warmed up, so Staff E got a rice pack from the nurse. According to Staff E, the nurse also instructed Staff E to warm the rice pack for a minute and a half. Staff E gave the warmed rice pack to the resident around 3:30 p. m. The resident put the rice pack on his/her lap. Approximately 6:30 p. m., the resident wanted the still warm rice pack placed to the back of their neck. Staff E helped Resident # 2 to bed around 8:00 p. m., which was early for the resident. Staff E checked the resident's skin as the resident had decreased feeling and Staff E wanted to make sure that the rice bag had never gotten too hot. Staff E straightened out the resident's bed, and didn't see anything in the bed. Staff E reported she didn't see anything on the resident's neck or back at that time. b.) According to the facility investigation, the night shift Staff D said she had worked on 11/1/13 and 11/2/13, but not on 11/3/13. The resident complained of pain in their neck and shoulders. Staff D told the resident the Therma Care patches weren't in. So, Staff D put a wet hand towel into a plastic bag, and then into a pillow case. Staff D microwaved the wet towel for only 30 seconds. The pack was not to warm when Staff D applied it 11/1/13 and 11/2/13. The resident had some sensation in those areas and it was not to warm when Staff D applied the warm packs both nights. c.) According to the facility investigation Staff F worked on 11/3/13 as the day shift nurse and reported Resident # 2 had complained of pain on 11/3/13. The resident also said to Staff F that Staff D had made the resident a rice warm pack that had helped. Staff F reported she told Resident #2 she did not have an (physician's) order for the rice pack. Staff F reported seeing a rice pack on top of the medication cart, but didn't remember giving any of the CNAs a rice pack. d.) The facility investigation revealed, Staff I reported that Resident # 2 had requested the staff member warm up the rice pack, so the staff member did. On 11/3/13, Staff I observed Resident # 2 asking for a rice pack and sometime between 6-9 pm., seeing the resident wheeling themselves down the hall. The resident had a rice bag tucked underneath their clothes and looked like a hunchback. e.) The facility investigation revealed Staff G, the night CNA, reported not noticing anything. The resident frequently refused to turn (in bed). Staff H, the 11/3 night nurse, reported not knowing how to make a warm pack, and denied putting one on Resident # 2. f.) The facility investigation revealed on 11/4/13, the resident had an opened blister and non-opened blisters. On 11/4/13, the day shift CNA Staff B, found a wet hand towel in a plastic bag covered with a pillow case underneath the resident. The resident had refused repositioning earlier that morning. Staff B notified the 11/4/13 day nurse, Staff C. The resident told Staff C that the night nurse (Staff D) had put the pack on the resident. Staff C cleaned and covered the burn. The facility determined that the incident had happened after 10:00 p. m. Sunday night. On 11/4/13 according to the Five Minute Meeting for Employees, the only approved heat source for residents were the rice bags, and those were for nurse use only. The nurses and the CNAs were to closely monitor residents with a rice heating pack in place. Diabetic and/or residents, who had a decrease in feelings, etc., were to be monitored closely. A document identified the nature of the problem as follows: on 11/11/13, a resident was found on 11/4/13 with a washcloth under his/her lower back. The washcloth had been heated as the resident had a burn appearance to the skin with an open area in the center of their lower back. The resident had decreased sensation to their lower areas. The resident had an order for [REDACTED]. The subsequent investigation revealed that a compress was used without an order, and contrary to facility policy. On 11/11/13, the facility also determined that staff were using microwavable rice packs which were also not allowed by facility policy. Review of the facility's march 2007 Compresses, Warm, revealed that Staff were to check the physician's orders [REDACTED]. The compress solution was to be no more than 110 degrees Fahrenheit (F). Staff were to check the resident's skin under the compress for blanching, [DIAGNOSES REDACTED], and stop the treatment/notify the physician if this occurred. At the bottom of the policy was the notation in all caps: Note: Nursing department shall not apply microwavable heat modalities. Resident # 2's physician was contacted for additional information by the Department. The physician sent a fax on 11/26/13 at 8:02 a.m. with the flowing information: The resident's injury was consistent with the account given by the facility. A "homemade" pack of washcloths covered in linen could have caused the burn. Blisters such as Resident # 2 sustained could occur either instantly, or up to 24-48 hours later. The resident could not feel at the level of the burn. It was an expectation that heating packs would have controlled temperature adjustments. If the resident or facility requested alternative treatment(s), there would need to be additional parameters for application. These parameters included checking the treatment's temperature prior to placement, and not tolerated after 30 seconds of treatment it should not be applied to the resident's skin. Certain unnamed heating treatments should not be applied in direct contact with skin, and should not be applied for longer than 20 minutes in an hour time period. If the resident did not have sensation, the checks should be more often. If the treatment was not FDA (Food and Drug Administration) approved, there needed to be additional parameters to prevent injury. Since Resident # 2 did not feel temperature at that level, the heating treatment temperature needed to be check prior to applying it to the resident. Even heating devices with temperature controls needed to be checked before applying to the resident. The physician did not think the resident would suffer any permanent sequel from the injury as long as the resident continued to heal appropriately. Interviews: The 11/6/13 Room Assignments sheet revealed Resident # 2 could be interviewed. On 11/20/13, at 10:50 a.m., Resident # 2 discussed the incident with the surveyor and reported he/she did not know what was on his/her back and had not seen the heating source. The resident reported he/she did not know who had put something on his/her back. The resident did not feel well, so the interview was stopped. During an interview on 11/18/13 at 2:36 p. m., day shift Staff B reported Resident # 2 often refused to reposition until around 10:30 a. m. or so. The resident didn't fabricate things, was usually reliable, but did have some confusion. On 11/4/13, the resident had refused to reposition until around 10:30 - 10:45 a. m. When Staff B rolled Resident # 2 onto their side, Staff B noted that the pad underneath the resident was wet. Staff B also noted blisters on the resident ' s back. The resident didn't feel anything according to Staff B. Staff B found a hand towel in a plastic bag, inside of a pillow case in the resident's bed. Staff B didn't expect to see something such as this, and never placed a device such as this on a resident. Staff B had seen/placed only Kpads and Therma Care packs that cooled off. Staff B didn't know if there was an order for [REDACTED]. When Staff B asked the resident who had placed the heating device on the resident, the resident said that Staff D had last placed the device. However, Staff D had placed the device on the resident's legs. Staff B told the nurse (Staff C). Staff B reported Staff C cleaned, measured, treated, and covered the area. Staff B then changed the resident's bed and shirt. When asked to describe the area, Staff B reported that the resident had 2-3 blisters, with another blister had broken open to the far right of the resident's back. Staff B didn't think that Resident # 2 could prepare or place the heating device by him/her (self). Additionally the resident didn't have much feeling below the breast line. On 11/18/13 at 2:05 p.m. Staff C, an LPN reported she was the nurse on duty on 11/4/13 and found Resident # 2's injury. Staff C confirmed Resident # 2 often refused repositioning, preferring to lay on their back. The resident often didn't get out of bed until noon. On 11/4/13, Staff B reported that Resident # 2 had blisters on their back. Staff C saw 1 open blister, with red skin around it. The area was in the resident's mid back. Staff C reported Resident #2 had 2 different accounts of how the injury occurred. The first account was that unknown staff had put a rice back on the resident. The second account was that a different nurse, Staff D, the previous day had placed a wash cloth in a bag, then in a pillow case. Staff C stated another staff member, later identified as Staff I, had taken a warm rice pack, touched it to the resident's leg, and asked if the rice pack was too hot. The resident reported telling Staff I that the resident couldn't feel their legs. Staff C didn't apply heat devices to residents without a physician's orders [REDACTED]. Staff C didn't know if Resident # 2 had orders for Therma Care, but reported the linen/bag device wasn't an acceptable substitute. Staff C had no idea who placed the hot pack on Resident # 2. However, it was an isolated incident. Staff C consulted Staff A, who did wound care, prior to treating the area on Resident # 2's back. Additionally, Staff C reported that Resident # 2 was alert and oriented for the most part, but sometimes got things mixed up. The resident had been talking about the incident, but couldn't report what had happened. The resident couldn't move their legs, and couldn't feel when Staff C treated the burn area. Staff D, an LPN was interviewed on 11/19/13 at 11:36 a.m. per telephone. Staff D worked nights, but not the 11/3 into 11/4/13 shift. Staff D worked 6 p.m. to 6 a.m. Friday and Saturday nights. Staff D reported that Resident # 2 remembered events, but didn't always know who all was involved. The resident needed assistance with repositioning. Staff D didn't think the resident could feel with their legs, and couldn't feel when Staff D did wound care to the burned area. Staff D reported not knowing how Resident # 2 was burned. On Saturday night 11/3/13, after 10:00 p. m. Staff D took a small face towel wet it, put the small face towel in a plastic bag, and microwaved it. When Staff D removed the wet towel from the microwave, it was warm not hot. Staff D put the towel and plastic back in a pillow case. The pack measured perhaps 5 inches by 10-12 inches. Staff D then laid the pack across Resident # 2's neck and shoulders, and had the resident lay against it. The resident usually laid on his/her back, and didn't move. After about 45-60 minutes, the back was ice cold. Staff D didn't work on Sunday,11/3/13, and didn't place the pack on the resident. Staff D didn't know if they had placed any sort of heating device on Resident # 2 on 11/1/13, Friday night. The rice packs were too bulky, and too hard to keep in place. Staff D didn't know what the facility policy was on heating devices. Staff D had told the Director of Nursing (DON) that Staff D didn't let the CNAs place heating devices on the residents, as Staff D worried the devices might get too hot. Staff E a CNA was interviewed on 11/20/13 at 3:52 p. m., and reported working the 2-10 (PM) shift on Sunday, 11/13/13. When Staff E came to work at 2:00 p. m., Resident # 2 was still in bed. Staff K (the day aide), reported Resident # 2 had not wanted to get out of bed. Early in the shift, Resident # 2 asked Staff E to take the rice pack out of a drawer and heat it. (Staff E assumed that "everyone" knew the rice pack was in the resident's room.) The resident told Staff E to heat the pack for a minute. Staff E did so and reported the pack felt "really warm" to Staff E. However, Staff E also reported having "sensitive skin". Staff E put the heated rice pack on Resident # 2's lap. Resident #2 said the pack's temperature was "ok". Staff E checked the resident's lap a couple of times, and there was no redness to the resident's lap. According to Staff E, the rice pack was still slightly warm after the 6 PM nurse came on duty. The resident then asked for the rice pack to be put on the arch of his/her back. Staff E helped Resident # 2 to bed around 8:00 p.m. which was very early for the resident. The resident reported not feeling well. When Staff E helped Resident # 2 to bed, the rice pack was cold and Staff E put it in the drawer. Staff E saw the resident's entire back above the incontinency brief, the resident's back was intact without redness. Staff E also straightened the resident's bed, and didn't see any linen in a plastic bag in the resident's bed. Staff E didn't know who had placed the heating pack in Resident # 2's bed. Staff E had never been told to not use heated rice packs on residents. Staff F, an RN was interviewed on 11/18/13 at 1:40 p. m. and reported working 6 a.m. to 6 p.m. on Sunday, 11/3/13. Staff F had heard that Resident # 2 had received an injury from a wet cloth in a plastic bag placed in a pillow case. Staff F didn't know who had placed the device, nor any other information. Staff F reported Resident # 2 was usually at the nursing station before supper. Staff F reported the resident often refused repositioning. On 11/3/13, the resident had requested a heating device. Staff F stated the resident also reported the night nurse (from the previous night) had made the resident a rice pack which helped with the resident's shoulder pain. Staff R told the resident that there wasn't an order for [REDACTED]. Staff F reported the resident was able to express needs, but often got staff (names) mixed up. The resident had decreased sensation from their ribcage down, and couldn't feel their legs. The resident's pain was usually in the mid shoulder area. Staff F knew the facility didn't like heat packs, as they couldn't be regulated. At one point, Staff could use both rice bags and/or Kpads. As a result of this incident, now the Staff could use only Kpads. Staff F had never heard of using a wet warm cloth in plastic, and had since been told that this was an old treatment. Staff F reported being shocked that a wash cloth could do that. Staff G, a night shift CNA was interviewed on 11/20/13 at 10:25 a.m., and reported Resident # 2 usually refused to reposition most of the night shift, even though the staff offered repositioning every 2 hours. The resident was paralyzed from the waist down, and had no sensation to the same area. The resident could give accurate information. On 11/3/13, Staff G came to work at 10:00 p.m. The resident was in bed. The resident let Staff G reposition them once between 1 and 4:00 a. m. Staff G didn't recall seeing anything in the resident's bed. Staff G also didn't recall seeing the resident's back directly, as Staff G used the pad to reposition the resident. The resident had a urinary catheter, as well as an incontinency brief. Staff G didn't put any sort of heating device on Resident # 2. Staff G reported Staff E hadn't mentioned anything regarding the resident wanting a heating device. Staff G reported the staff usually used rice packs for heating devices. Staff H, a night shift LPN was interviewed on 11/20/13 at 7:21 a. m. Staff H reported to work on 11/3/13 at 6:00 p. m. Resident # 2 was out at the nursing station per their usual routine. The resident had a rice pack and asked to have it put on the resident's back. The pack wasn't warm, but the resident wanted the pack put in place anyway. So, Staff H put the not warm rice pack on the resident's upper back. Staff H didn't do any treatments to the resident's back, and so didn't look at it that shift. Resident # 2 was alert and oriented and couldn't feel, but would sometimes complain of his/her legs hurting. Staff H thought they had eventually removed the unheated rice pack from the resident. Staff H reported staff need a doctor's order to apply any sort of a heating device to a resident. Staff H hadn't placed a heated rice pack on a resident, and didn't feel comfortable so doing. Staff H didn't give, or place, any sort of a heating device on Resident # 2. Staff H also didn't tell any of the aides to place any sort of heating device on resident # 2. The aides knew to go through Staff H before placing any sort of heat on the resident. None of the aides had reported that Resident # 2 wanted any sort of a heating device, and Staff H usually spent a lot of time on that hall from 6:30 until 8:3- p. m. Staff K was interviewed on 11/20/13 at 9:42 a.m. Staff K reported working part time on the 6 a.m. to 6 p.m. day shift. Staff K was assigned to care for Resident # 2 on 11/3/13. Staff K reported Resident # 2 could wiggle their top half, but was numb from the mid chest down. The resident couldn't place any heating device on their back. The resident hadn't asked Staff K for any sort of a heating device at any time. Staff K didn't remember anything specifically about 11/3/13, and didn't know if Staff K saw Resident # 2's back at all that day. Staff K probably hadn't gotten Resident # 2 out of bed that day. Staff K reported Resident # 2 often refused repositioning. Staff I was interviewed per telephone on 11/25/13 at 1:08 p. m. per telephone. Staff I worked the evening shift, and had been at the facility about 2.5 years. Staff I reported seeing a resident on 11/3/13, after supper, wheeling down the hall with a rice pack between their shoulder blades. The resident looked like a hunch back. Staff I later realized this was Resident #2. Staff I member didn't know what happened after that. Staff I also didn't touch the pack. Staff I reported over hearing Resident # 2, after supper, at the nursing station, ask for a hot pack for his/her back pain. Staff I reported using rice bags as heat packs on occasion over the past few months. Some of the nurses would tell Staff I to microwave a heat pack for 60-90 seconds. Staff I would usually place the pack for 15 minutes, and check the resident's skin underneath after approximately 5 minutes. Staff I, several days prior to the incident, heated a rice bag and placed it on Resident # 2's legs. An unknown nurse was present at the time. The resident was having leg spasms and their legs were kicking themselves off of the pedals. This caused the resident discomfort. Staff I reported using a heated rice pack on another resident (not identified by the facility) without incident. The heated rice pack was placed to the resident's groin. Staff I reported not knowing who placed a hot pack on Resident # 2. Staff I reported using a wet hand towel in a plastic bag, and then microwaving it for approximately a minute. Staff I would then place the warmed towel in another towel before placing it on a resident. Staff I did this when first at the facility, but hadn't so done in a while. During an interview on 11/20/15, at 3:05 p. m., Staff J, the nurse consultant, reported that a total of 5 Staff members were using rice packs on two different residents, one of who was Resident # 2. Neither resident had orders for rice packs. The DON reported that no residents had been harmed by the rice packs. The DON was interviewed on 11/20/13 at 11:18 a. m. The DON reported that Resident # 2 had decreased sensation from the mid back down. The resident's top half "worked ok". The resident often refused repositioning. Resident # 2 could partially roll themselves over in bed. The DON reported staff shouldn't place any heating device without a physician's orders [REDACTED]. During the investigation of this incident, the facility had originally approved using heated rice packs. However, upon further investigation, the facility prohibited the use of rice packs. The staff were heating the rice pack for approximately a minute. Prior to this incident, the DON was unaware that Staff were using the rice packs. However, there had been no known negative outcomes related to the rice packs. The DON also didn't know any staff were using wet linen in plastic bags until this incident. The DON had spoken to Staff D about this. The use of wet linen in plastic bags was against facility policy. The use was poor judgment. The DON didn't know who placed the heating device that caused Resident # 2's burns. The DON thought the injury had occurred between 8:00 p. m. on Sunday, and 10:00 a. m. on Monday. The DON thought that the injury was from heated linen placed in a plastic bag, similar to what was found under Resident # 2 on 11/4/13. Resident # 2 reported that Staff D had placed such a pack on her, but Staff D hadn't worked the night of 11/3/13. The resident reported the pack was placed on their upper back/neck area. Staff G reported repositioning Resident # 2 approximately 3:45 a. m. on 11/4/13, but using the pad and not seeing the resident's back. The resident had reported that Staff F had thrown a rice pack at either Staff E or Staff I and told them to heat it. Both staff had reported taking a rice pack out of the resident's drawer and warming it for the resident. As part of the investigation, the facility tried heating both a rice bag and a small piece of wet linen in a plastic bag for approximately 1.5 minutes. The facility picked this length of time as it was the heating duration indicated by the staff. The heated rice pack was comfortably warm, but the heated linen device was so hot that it couldn't be held. The DON indicated that a rectangular fabric covered bag approximately one 1 thick, and the size of a regular piece of paper folded top to bottom was one of the homemade rice bags made by the Staff. The bag was filled with what felt like rice. The DON reported that one of the CNAs reported finding something wrapped in a plastic bag in Resident # 2's bed. The Staff member removed the wrapped item and placed it in the night stand. The facility abated the IJ on 11/11/13 when they implemented the following: On 11/11/13 the DON directed staff that they could not use rice bags, warm moist packs or any other heating devices with the exception of a physician ordered Therma Care or therapist direct supervision. The DON held an employee in-service on 11/11/13 for all nursing staff to explain the prior directive. The facility removed all rice packs on 11/11/13. On 11/14/13, the facility educated all professional staff on their guidelines and policy review on 11/14/13. According to the Five Minute Meeting for Employees, there was no further use of Rice bags, or warm moist pack by staff. There could be no further use of any heating devices with the exception of a physician ordered Therma Care or under Therapy's direct supervision. These actions lowered the deficiency from a scope and severity of J to D, with the need for ongoing monitoring of heating devices according to safety provisions. II. Based on record review, observation and staff interview, the facility failed to ensure a resident cognitive impairments received supervision and/or assistance devices to prevent the spillage of hot beverages and skin burns. The investigation sample included 4 residents, concern noted for one, Resident #4. 1. Resident # 4 had [DIAGNOSES REDACTED]. Per the 08/15/13 MDS, the resident's BIMS score was 6, indicating the resident was cognitively impaired. (The BIMS scale for cognitive impairment rates a score of 0-7 as severe impairment, 8-12 moderate impairment , and 13-15 the resident is not cognitively impaired). A problem dated 10/29/13 identified alteration in nutrition indicated the resident tended to play with food while eating meals. The resident would not accept help on a regular basis. The description indicated the [DIAGNOSES REDACTED]. A review of the Nurse's Notes dated 10/17/13 at 3:00 P.M. revealed Resident #4 sustained a burn to his/her right inner thigh when the resident spilled hot coffee. The incident was witnessed by the resident's family. The resident denied pain. The staff notified the physician by facsimile (fax). The inner thigh was reddened without blisters. An entry in the Nurse's Notes on 10/22/13 at 1:15 a.m. revealed there was no redness to the resident's right inner thigh. The care plan dated 10/29/13 indicated the resident needed the assistance of one staff to eat. Resident # 4 often refused assistance from staff when they performed the resident's cares. Staff were to assist the resident as needed at meals. The resident was to use adaptive equipment as recommended/needed. The resident sat at an assisted table to receive cueing and assistance as needed. The care plan did not include an intervention for protecting the resident from hot beverage spills even though he/she sustained the burn on 10/17/13. On 10/17/13 at 2:20 p. m., the incident/accident/unusual occurrences form, noted Resident # 4 spilled coffee on his/her lap. The resident had no blisters, and the right inner thigh was inflamed. The resident denied pain. Per the 10/17/20/13 Physician Notification, the physician was notified of the incident. There were no new orders. On 11/20/13 at 8:10 a.m., Resident #4 sat a dining room table in a wheelchair. There was an empty, regular coffee cup next to the resident. An unidentified staff member told resident # 4 he/she could have more coffee. The staff member took the resident's coffee cup, and filled it with coffee from a coffee dispenser in an adjacent room. The staff member gave Resident #4 the filled regular open coffee cup. The staff member told the resident to be careful, as the coffee was hot. At 8;12 a.m., Staff K said that Resident #4 sometimes had milk in their coffee. However, the coffee wasn't that hot. At 8:27 a. m., Resident # 4 held t

Based on record review and staff interview the facility failed to provide adequate supervision to ensure against hazards and failed to supervise the implementation of the written health care plan (Resident #1). The sample consisted of 4 residents and the facility identified a census of 69 residents. Findings include: 1. The MDS ( Minimum Data Set) assessment, with a reference date of 1/18/12, reflected Resident #1 had a brief interview for mental status score of 5 indicating short and long term memory deficits with moderately impaired cognitive skills for daily decision making. Resident #1 required extensive assistance with physical assist of one staff with transfers, ambulation, dressing, toilet use, bathing and personal hygiene. Resident #1's balance was determined as not steady. Resident #1's [DIAGNOSES REDACTED]. The Care Plan dated 12/3/06 for Resident #1 identified a problem for the potential for injury due to falls related to history of dizziness. The approaches directed staff to: a. Assist the resident with one staff and a gait belt during transfers. b. Non skid strips in front of recliner (9/26/11). c. Ensure the recliner is in down position and unobstructed (10/18/11). d. Move wheel chair out of reach and sight of resident to discourage resident from getting up unassisted (10/27/11). e. Pressure alarm in chair (11/16/11). Discontinued 12/27/11. The nurse's notes dated 11/16/11 indicated Resident #1 was noted and verbalized he/she had self transferred from the wheel chair into a recliner despite also indicating the understanding he/she is to use the call light to get assistance due to history of falls. Staff placed a pressure alarm in Resident #1's chair to cue/remind the resident to use the call light when transferring. On 3/15/2012 at 9:30 a.m. the DON (Director of Nursing) was interviewed and questioned as to why the pressure alarm initiated on 11/16/11 was discontinued on 12/27/11. The DON stated the pressure alarm was added as a fall intervention for Resident #1 on 11/16/11 after the nurse noted Resident #1 self transferring. The DON stated the pressure alarm was discontinued on 12/27/2011 after a 72 hour evaluation period in which it was reported to her, Resident #1 was no longer attempting to self transfer and had no falls in the last 30 days. The DON noted the facility goal is for residents to live in the least restrictive environment and safety alarms are regularly reviewed for continued appropriateness. Residents with no falls in the past 30 days or with no observed unsafe behavior have alarms reduced or modified. Following the fall on 12/27/11, The DON believed the contributing factor was having the wheel chair in site of Resident #1. The DON noted when the wheel chair was not in site, Resident #1 was much better about using the call light to get assistance. Facilities 3 Day Alarm Reduction Tracker indicated: 12/22/11 7-3 shift Resident #1 was up unassisted that morning. 12/22/11 11-7 shift Resident #1 was up on his/her own to the bathroom. 12/24/11 11-7 shift Resident #1 was to the bathroom one time without assistance and transferred him/herself to his/her chair one time. In an interview on 3/5/12 at 2:31 p.m. by phone, Staff B (Registered Nurse) stated she recorded the 12/22/11 7-3 entry on the 3 Day Alarm Reduction Tracker Form following an aide reporting the observation. Staff B stated it was common for Resident #1 to get up unsupervised. In an interview on 3/5/12 at 10:17 a.m. by phone, Staff C (Registered Nurse) stated she recorded the 12/22/11 11-7 entry on the 3 Day Alarm Reduction Tracker Form. Staff C indicated she recalled Resident #1 getting up to the bathroom unassisted. In an interview on 3/5/12 at 10:14 a.m. by phone, Staff D (Registered Nurse) stated she recorded the 12/24/11 11-7 entry on the 3 Day Alarm Reduction Tracker Form. Staff D indicated she had witnessed Resident #1 ambulating to the bathroom and transferring into his/her wheel chair unassisted and typically sat off the pressure alarm. Facilities Incident/Accident/Unusual Occurrences Form identified the following falls: ? On 9/25/11 at 1:00 a.m. Resident #1 was found sitting on the floor in front of his/her recliner. Resident #1 denies any pain or injuries. Facility added non skid strips to the floor in front of the recliner. (CP 9/26/11). ? On 10/18/11 at 5:00 a.m. Resident #1 was found on the floor. Resident #1 indicated he/she slid out of his/her chair. Resident #1 sustained minor cut to leg. Edge of recliner was on the bedside table leg. Facility educated staff to ensure recliner is in down position and unobstructed. (CP 10/18/11). ? On 10/26/11 at 5:15 p.m. Resident #1 was found sitting on the floor. Resident #1 indicated he/she was reaching for his/her wheel chair and slid out of the recliner. Resident #1 sustained no injuries. The facility added intervention to keep the wheel chair out of reach and out of sight of resident to discourage resident from getting up unassisted. (CP 10/27/11). ? On 12/30/11 at 4:45 p.m. Resident #1 was found sitting next to his/her recliner. Resident #1 stated he/she slid out of the recliner. The wheel chair was positioned in front of the recliner and it appeared Resident #1 had attempted to self transfer from the recliner to the wheelchair. Resident #1 sustained no injuries. The facility re-educated the staff to keep the wheel chair out of reach to prevent self transfers. (Internal quality assurance investigation form). ? On 2/13/12 at 11:10 a.m. Resident #1 was found on floor in front of his/her recliner. The wheel chair was found at end of the bed and suspected Resident #1 was attempting to self transfer.(Internal quality assurance investigation form). Resident #1 sustained a fractured right distal femur which was surgically repaired. In an interview on 3/5/12 at 9:59 a.m., Staff E (Certified Nursing Assistant) stated she was assigned Resident #1 on the morning of 2/13/12. Staff E stated at around 9:00 a.m. to 9:30 a.m. she assisted Resident #1 into her recliner and placed the wheel chair between the bed and dresser out of Resident #1's reach. Staff E noted she last saw Resident #1 sitting in his/her recliner at 10:30 a.m. Staff E indicated she believed Resident #1 was good about using his/her call light and didn't attempt to transfer unassisted unless she could actually touch his/her wheel chair.