Every finding on record at Westhaven Community

Based on clinical record review, police record review, resident interview, staff interview and policy review, the facility failed to protect the resident's right to be free from abuse in the manner of misappropriation of resident property/financial exploitation by a staff member for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 55 residents. Findings include;The Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had diagnoses to include heart failure and diabetes mellitus. The Care Plan for Resident #1, initiated 5/15/26, included a problem area which documented the resident needed help with his cares and required one staff assistance for bathing/showering and personal hygiene, set-up/supervision for dressing and verbal cues to toilet in the morning, at bedtime, before/after meals and as needed. The Care Plan further included a problem area for discharge planning, which documented the resident would be staying in the facility for 24 hour care, safety, health and well-being. During an interview 7/8/26 at 9:30 AM, Resident #1 stated his banking account was recently wiped out due to a staff member stealing his bank card from his wallet and depleting his account. He advised the staff member, Staff A, Certified Nursing Aide (CNA), stole around $400 dollars and used his bank card for her own purposes, until there were no more funds in his account. Resident #1 stated he did not give Staff A permission or consent to use his bank card. He said he always kept his wallet in the top drawer of his nightstand where supplies are also kept for his blood sugar monitoring for his diabetes, and always kept his bank card in his wallet. Staff A came into his room in the night to check on him, in May of this year, and removed his bank card from his wallet, without his knowledge or consent. Resident #1 stated he never would have thought any staff person would steal anything from him, especially his bank card. Resident #1 advised he was shocked when he found out Staff A stole his bank card and depleted his bank account. Review of the police record revealed on 5/20/26 Staff A arrived at the police department to report she had unlawfully used a debit card belonging to a resident (Resident #1) at the nursing home where she was employed. Staff A stated she took the debit card without Resident #1's knowledge on Monday, 5/18/26. She admitted to using the card at McDonalds, Quick Star and Walmart. On 5/21/26, an officer with the police department made contact with Staff A. Staff A stated she works the overnight shift, 10:00 PM to 6:00 AM, at the facility. During her night shift beginning on 5/17/26, going into the morning hours of 5/18/26, she stated she observed Resident #1's debit card sitting on his nightstand. Staff A admitted to taking the debit card without Resident #1 knowing. Staff A stated after leaving work that Monday morning, she spent the debit card at a gas station for fuel, then another gas station for more fuel and food, and then at Walmart for groceries. Staff A stated she did not keep receipts and does not recall the exact amount that she spent, but estimated it was around $400. Review of Staff A's timesheet revealed Staff A worked on Sunday, 5/17/26, from 12:00 AM to 6:09 AM and then again from 10:02 PM to 12:00 AM. Staff A continued to work on Monday, 5/18/26, from 12:00 AM to 6:12 AM. During an interview 7/8/26 at 10:45 AM, the Administrator and the Director of Nursing (DON), both stated an expectation that staff employed at the facility not steal from any residents or use a resident's financial resources for their own personal gain.Review of the facility Abuse Policy, with a revision date 10/14/22, documented the resident has the right to be free from verbal, physical, sexual, or mental abuse, neglect, misappropriation of resident property, and exploitation. The facility prohibits the abuse, neglect, personal degradation, exploitation of residents, and mistreatment of residents and/or misappropriation of resident property by anyone, including staff. The policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.

Based on observations, staff interviews, and policy review, the facility failed to properly wear and change out gloves during meal services for 2 of 2 dining rooms observed. The facility reported a census of 59. Findings include:During a continuous observation on 4/30/26 at 12:15 PM, Staff I, Culinary Assistant, wore a glove on one hand (right) while preparing resident lunch plates in the Westown independent resident dining room. They touched the refrigerator door, cabinet door, counter top, and scoop handles with the gloved hand. The same glove was also worn as Staff I prepped and placed buns on resident plates. During a continuous observation on 4/20/26 at 12:00 PM, Staff H, Culinary Assistant, prepared resident lunch plates in the Bistro resident assist dining room. Upon the start of service, Staff H noted there were no tongs to use for the philly steak sandwich buns. Before preparing each plate, Staff H washed hands and put on new gloves. They then touched scoop handles, dietary cards, menus, and food packaging before handling the bread. Staff H delivered plates and assisted the resident with meal set-up. They touched condiment packets (from a bowl of packets), silverware, and resident arms/shoulders with the gloved hands and then touched sandwiches to cut or prepare as requested.In an interview on 4/29/26 at 1:15 PM, the Registered Dietitian (RD) noted the above observations were inappropriate glove use. Staff should not be touching other objects with gloved hands and then resident food.The policy Employee Health and Hygiene, Food and Nutrition Services (revised 1/12/24) noted the following: A. Food service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness B. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper hand washing.

Based on clinical record review, family interview, resident interview, staff interview, and policy review, the facility failed to offer or hold an admission care conference for 2 of 17 residents (Residents #1 and #30) reviewed for Care Plans. The facility reported a census of 59. Findings include:1.The Minimum Data Set (MDS) Assessment completed on 2/3/26 revealed Resident #1 with a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The Clinical Census section of the electronic health record (EHR) showed Resident #1 was admitted to the facility on [DATE]. The clinical record lacked documentation that a care conference was offered or held after the admission comprehensive assessments were completed. The first care conference documented was held on 2/11/26. This coincided with the quarterly comprehensive assessments completed by 2/3/26. The Care Plan Conference Summary sheet, dated 2/11/26, lacked documentation if Resident #1 attended the conference or if they declined to attend. During an interview on 4/30/26 at 11:00 AM, Resident #1 was unable to recall either way if they participated in a Care Plan meeting or not since admission.2. The MDS Assessment completed on 2/28/26 revealed Resident #30 with a BIMS score of 6, indicating severe cognitive impairment. The Clinical Census section of the EHR showed Resident #30 was admitted to the facility on [DATE] and discharged on 11/11/25. Resident #30 was readmitted on [DATE]. The MDS Assessment tab of the EHR showed an admission assessment was completed on 9/19/25 and 12/24/25. A quarterly assessment was completed 1/26/26. Review of the clinical record showed a care plan conference was held in September 2025 coinciding with Resident #30's previous admission. No documentation identified which indicate a care conference had been held or offered since the resident's readmission on [DATE].During an interview on 4/27/26 at 1:30 PM, Resident #30's family indicated they have not attended nor been invited to a care conference since December's readmission. During an interview on 4/29/26 at 8:15 AM, the MDS Coordinator acknowledged the lack of documented care conferences for Resident #30 since the December 2025 readmission. With no documentation, the MDS Coordinator noted a care conference was most likely not held. With regards to Resident #1, the MDS Coordinator reported an admission care conference was most likely not held as there is no documentation. The MDS Coordinator explained a resident's first care conference is typically held when the first quarterly assessments are completed and not with admission assessments. If a resident and/or resident representative is present, the Care Plan Conference Summary sheet is signed by them. However if the the resident declines to attend and a resident representative is not present, no further documentation is noted on the Care Plan Conference Summary sheet to reflect the non-attendance. The policy Care Plan and Baseline Care Plan, revised 10/14/22, outlined the following: a. A comprehensive care plan will be in the EHR by day 21 of the stay or 7 days after completion of the comprehensive initial MDS, whichever comes first. b. The resident care plan is reviewed for accuracy, updated with quarterly MDS review, and all other scheduled MDS assessments. c. The resident and their representative have the right to participate in the care planning process, including the right to be informed, in advance, of the care to be furnished. The resident also has the right to request meetings and the right to request revisions to the person-centered plan of care. If it is determined that the participation of the resident and their representative is not practical for the development of the care plan, this will be explained in the EHR.

Based on facility document and menu review, observations, and staff interview, the facility failed to ensure appropriate serving sizes for 5 of 6 residents receiving the puree lunch served on 4/29/26. The facility reported a census of 59. Findings include:Observation on 4/29/26 revealed the puree hot lunch items for the meal served consisted of a philly steak sandwich with peppers and onions and a hot dog on bun as the alternative. Beets were offered instead of baked beans as the beans were not available. On 4/29/26 at 9:00 AM, Staff E, Cook, prepped the puree hot lunch items. Four servings of puree philly steak sandwich (which measured out to 4 cups) and three servings of puree hot dog with bun (which measured out to 2.5 cups) were prepared to the correct consistency and set aside in separate measuring cups. Six servings of puree canned beets (measured out to 3 cups) were also prepared to the correct consistency and set aside in separate measuring cup.After preparing the puree items, Staff E referred to the Pureed Diet Portion Sizes/Scoops chart to determine scoop serving sizes. The puree philly steak sandwiches were remeasured and voiced at 4.5 cups, requiring a grey and a black scoop. Staff E transferred to entree to a serving pan, covered with foil and labeled it with #12 and blackThe pureed hot dogs with bun were initially remeasured as 3.5 cups. The process was stopped and Staff E was asked to verify the measurement. Staff E corrected it to 2.5 cups, voiced it required a #12 and #16. Staff E transferred the entree to a serving pan, covered with foil, and labeled it with grey and green. The pureed beets were remeasured at 3 cups, requiring a grey scoop. Staff E transferred the vegetable to a serving pan, covered with foil, and labeled with #12. On 4/29/26 at 11:30 AM, Staff E removed the pureed items from the oven and prepared them for delivery to the Central Bistro Dining Room. It was observed that the pan of philly steak sandwiches lacked the scoop size on the foil. Upon arrival to the dining room, Staff E placed the pureed items on the steam table with the following serving scoops on top of the lidded pans: Philly steak sandwiches a grey #8Hot dog with bun a grey #8 and green #12 Beets a grey #8 and black #30 During the lunch service, Staff H, Culinary Assistant, dished out the puree items, per resident choice, using the above scoop sizes for 5 of the 6 residents on a puree diet. For the items with two scoops, Staff H used both (1 serving from each scoop) for the plate. The Pureed Diet Portion Sizes/Scoops chart listed the following serving scoop sizes:Philly steak sandwiches: Total volume 4 cups for 4 servings would need 2 scoops from a grey #8 and 1 scoop from a black #30Hot dog on bun: Total volume 2.5 cups for 3 servings would need 1 scoop from grey #8 and 1 scoop form a green #12Beets: Total volume 3 cups for 6 servings would need 1 scoop from a grey #8In an interview on 4/29/26 at 1:15 PM, the Registered Dietitian (RD) explained staff should correctly measure out puree food items when utilizing the volume method for determining puree serving sizes. The RD would expect dietary staff to use the scoop size and the number of scoops as outlined on the Puree Diet Portion Sizes/Scoops chart. The facility did not have a specific policy which outlined the procedure used to determine appropriate puree food portions sizes.

Based on observations, staff and resident interviews, resident health record review, and policy review the facility failed to obtain an order for self administration of medication and allowed resident to consume her medications without observation for 1 of 5 residents reviewed. The facility reported a census of 59 residents. Findings include:The Minimum Data Set (MDS) for Resident #57, dated 1/6/26, included diagnoses of stroke, diabetes, and depression. A Brief Interview for Mental Status (BIMS) score of 12 indicated mild cognitive impairment. On 4/30/26 at 8:18 AM, observed Resident #57 sitting at the dining room (DR) table with several pills in a cup sitting on the table in front of her. On 4/30/26 at 8:22 AM, Staff D, Certified Medication Aide stated Staff A, Licensed Practical Nurse (LPN) prepared Resident #57's medications. On 4/30/26 from 8:22 AM - 8:28 AM, observed Resident #57 drinking fluids, covered her mouth and face turned red. Staff A propelled Resident #57 to her room with the pills remaining on the table. Staff D left the DR area with the cup of pills remaining on the table and no nursing staff in the DR. Staff A returned to the DR and removed the cup of pills and returned to Resident #57's room. Interview on 4/30/26 at 8:30 AM, Staff B, LPN stated Resident #57 does not have an order to self administer medications and the policy is to observe the residents take their medications. Interview on 4/30/26 at 8:40 AM, Staff A stated she prepared and placed Resident #57's medications on the table. Staff A stated the pills were the resident's morning pills and there were 13 pills in the cup. Staff A stated she does that for residents if she is in the DR passing medications and she will just keep an eye on the residents to make sure they take the pills. Staff A confirmed she left the medications on the table when she took the resident to her room due to the choking type episode. Interview at 04/30/2026 at 12:45 PM, Resident #57 stated the staff always leave her medications on the table because she doesn't want to take them until after she eats. Facility Medication Management, Oral Medications policy reviewed 9/30/25, revealed administer medications and stay with the resident until medications are swallowed unless the resident has an order to self- administer medications. Interview on 4/30/26 at 9:50 AM, the Director of Nursing stated an expectation for staff to observe the resident take the medication, not leave on the table unsupervised.

Based on clinical record review, staff interviews and facility policy review the facility failed to promote the healing of a pressure injury and prevent futher deterioration of the pressure injury for 1 of 1 residents reviewed (Resident #2). The resident had a documented risk for pressure ulcers/injuries without interventions listed on the care plan, assessments were not complete and the treatments were not signed as complete. The facility reported a census of 59 residents. Findings include:The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers:Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister.Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar.Unstageable Ulcer: inability to see the wound bed.Other staging considerations include:Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The Minimum Data Set (MDS) assessment dated [DATE], for Resident #2 documented diagnoses that included depression, diabetes mellitus, and hypertension. The MDS showed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS identified the resident as at risk for pressure ulcers. The MDS also identified the facility had placed a pressure reducing device in the Resident #2's chair and bed. The MDS identified Resident #2 is partial/moderate assistance, (helper does less than half the effort. Helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort.) with rolling left and right in bed, sitting to lying on the bed and lying to sitting on the side of the bed, sit to stand, and with transfers. Resident #2's care plan with date initiated on 11/11/25 contained the following information:Resident #2 states I have skin problems, the care plan revealed:Will see foot doctor for routine diabetic foot careWeekly diabetic skin checksTreatments as orderedSkin protective mattress on bedSkin protective cushion in chairReport changes as neededEncourage good nutrition and hydration in order to promote healthier skinDiscourage scratching if notedCheck skin with cares and report changes as neededThe care plan lacked preventative interventions to prevent pressure areas The pocket care plan dated 2/24/26 lacked preventative interventions to prevent pressure areas. The facility provided Braden Scale dated 2/11/26 was incomplete.The facility provided Braden Scale dated 1/26/26 score was 18, which indicated at risk for pressure ulcers. Review of Resident #2's Progress Notes revealed the following:On 2/27/26 at 6:00 a.m. Resident #2 reported to staff his right heel was hurting, staff noted an area measuring 4.2 centimeters(cm) x 4.4cm area of redness that was blanchable. In the center of the red area was an area of black eschar and dried skin. Eschar measured 1.7cm x 1.3cm. New intervention was to apply a heel bonnet to the right foot at all times. According to the skin tear investigation the resident stated someone ran over his heel with the wheelchair leg. On 2/27/26 at 2:09 p.m. Advanced Registered Nurse Practitioner (ARNP) here to see resident: new order to paint area to right heel with betadine twice a day and leave open to air. Have a Physicians Assistant (PA-C) see next week. Area could be from trauma from bumping/rubbing with wheelchair wheel or could be pressure but unstageable at this time.On 3/3/26 at 5:52 p.m. Per PA-C, continue to the right heel with betadine and leave open to air, continue heel bonnet. The goal is to dry out so eschar comes off on its own. On 3/10/26 at 4:51 p.m. seen by PA-C with diagnosis unstageable heel injury. Continue current orders and hold compression socks until wound healed. Review of the Non-Pressure Skin Condition Report revealed measurements on the right heel: 2/27/26 - 4.2cm x 4.4cm redness with 1.7cm x 1.3cm eschar3/3/26 - 2.4cm x 2.0cm 100% eschar3/7/26 - 2.3cm x 3cm eschar - no change in progressReview of the wound/skin healing record revealed measurements on the right heel:3/10/26 - 2cm x 2cm unstageable eschar3/13/26 - 2.4cm x 2cm unstageable eschar3/21/26 - 2.4cm x 2cm unstageable eschar, deep tissue injury3/25/26 - 5.0cm x 4.9cm unstageable eschar3/28/26 - 5.0cm x 4.9cm unstageable eschar4/1/26 - 3.6cm x 4.0cm - nothing else completed on assessment4/15/26 - 3.6cm x 2.9cm - nothing else completed on assessment4/25/26 - 5.0cm x 4.0cm - escharReview of the March and April 2026 Treatment sheets revealed the order to paint betadine to the right heel twice a day and leave it open to air; the treatment sheets lacked many signatures indicating treatment was not completed. The facility provided a policy named Skin integrity and wound management with a date revised 3/3/26 revealed residents admitted without pressure injuries will remain free of pressure injuries unless clinically unavoidable. Care and services will align with professional standards of practice to prevent the development of new pressure injuries, promote healing of existing wounds, and prevent further deterioration. The facility recognizes that despite vigilant care, certain residents may develop or experience worsening skin injuries due to their medical condition. In these cases, the focus will be on risk reduction, prevention strategies, and effective wound management. Develop and implement individualized care plans and interventions based on current skin impairments and potential risk areas. Interventions will be communicated to certified nursing assistants (CNA) via assignment sheets or profiles. CNA's inspect the skin during care and report any new concerns immediately to the licensed nurse. Licensed nurses conduct visual body inspections, observation and document findings. Interview on 4/30/26 at 11:00 a.m. with the DON revealed that they go by the braden scale and anyone that scores an 18 they will put the interventions in place. DON stated it is an expectation that staff sign off when treatments are completed.

Based on observation, clinical record review, staff interviews, and policy review the facility failed to provide adequate supervision in the dining room at meal times for a resident with recommendations for full supervision during meals for 1 of 1 residents reviewed (Resident #57). The facility reported a census of 59 residents. Findings include: The Minimum Data Set (MDS) for Resident # 57, dated 1/6/26, included diagnoses of stroke, diabetes, and depression. A Brief Interview for Mental Status (BIMS) score of 12 indicated mild cognitive impairment. On 4/27/26 with continuous observation from 12:00 PM - 12:31 PM, observed 1 dietary staff and 19 residents in the Westown dining room (DR), with no nursing staff present in the DR. Resident #57 in the DR eating lunch with sign at table in front of her with documentation of Please chew and swallow food before taking a drink. Observation on 4/28/26 at 8:30 AM, Resident #57 in DR eating breakfast with no nursing staff present. Resident #57's Progress Notes revealed the following:a. 1/18/26 at 12:30PM - Dietary aide approached the nurse station to report that the resident seemed to be choking. Upon assessment, the resident was noted to be coughing, red in the face, was able to catch her breath but began coughing up mucus and had an emesis (vomit). Resident reports she has been having increasing difficulty chewing her meat at meals. Physician notified.b. 1/19/26 at 9:02 AM - Order received for speech therapy evaluation and treatment. c. 2/16/26 at 11:45 AM - this nurse was at the nurse's station when staff yelled that resident was choking. She was coughing and spit out a moderate amount of thin clear liquid.d. 4/14/26 at 12:05 PM - Resident red in the face, nurse approached, and resident was able to start coughing which brought up a pill. Resident had a large emesis. e. 4/29/26 at 12:31 PM - 2 nurses called upon by dietary aide due to resident choking on her lunch of egg salad and toast. Resident did cough up evidence of egg salad. Resident #57's MDS Nutrition assessment dated [DATE] revealed coughing or choking during meals or when swallowing medications in the past 7 days. Resident #57's Clinical Nutrition assessment dated [DATE] revealed resident is eating in the Westown DR or her room per her request. She is eating independently with set up. Resident to not consume fluids when food present in mouth. If resident agrees, recommend assist DR for additional supervision and encouragement during meals. Resident #57's physician notification form dated 4/14/26 revealed an episode of choking while taking pills with a new order written for speech therapy to evaluate and treat if needed. The Speech Therapy (ST) Evaluation and Plan of Treatment dated 4/20/26 documented resident presents with suspected esophageal dysphagia (difficulty swallowing) by reported episodes of emesis following intakes, complaints of heartburn, and sensation of food sticking. Recommendations for full supervision during meals. Interview on 4/30/26 at 9:25 AM, the Director of Rehab stated on 4/21/26 she sent an email to the Dietician, Director of Nursing, and MDS Coordinator for Resident #57 with the recommendations from the ST evaluation for supervision. Interview on 4/30/26 at 11:35 AM, the Dietician stated she received the email from the Director of Rehab for Resident #57 and the recommendations from the ST eval for supervision during meals. The Dietician stated she had completed an assessment herself prior and had recommended the assisted DR for additional supervision and those recommendations were provided in her weekly consultant report to the DON. Interview on 4/30/26 at 9:45 AM, the MDS Coordinator stated she didn't recall receiving recommendations from therapy from the ST evaluation for Resident #57. The MDS Coordinator stated her process is to put the recommendations on the care plan and then direct therapy who else they need to advise of recommendations. The MDS Coordinator proceeded to review her emails and found an email from the Director of Rehab in her deleted folder and confirmed she had not addressed the recommendations. Interview on 4/30/26 at 12:40 PM, Staff C, Dietary Aide stated nursing staff are only in the Westown DR during meals times when they are passing medications. Staff C stated nursing staff do not stay in the DR the whole time the residents are eating, only in the assisted DR. Staff C stated she tries to keep an eye on the residents and if a resident starts coughing, she goes and checks on them and would go find a nursing staff if needed to. Interview on 4/30/26 at 11:40 AM, the DON stated Resident #57 doesn't want to go to the assisted DR and in a choking/coughing situation the Dietary Aide is to alert the nurse. The DON stated they have attempted to move Resident #57 to the assisted DR and she refused. Quiered about providing recommended supervision to Resident #57 during meal times and the DON stated she didn't have enough staff to sit 1:1 with the residents in the independent DR and residents are to go the assisted DR if need supervision/assistance. Interview on 4/30/26 at 12:45 PM, Resident #57 stated she is having choking and coughing problems, feels it is more in the morning when she is dry and then starts drinking at breakfast. The resident stated she had an episode this morning at breakfast and yesterday at lunch. The resident further stated no staff had spoken with her about going to the assisted DR to be supervised and that she was willing to try it because she gets worried about the choking. The Facility Dining Room Service policy revised 11/24/25 revealed staff will provide appropriate supervision in the DR to help ensure a safe and supportive mealtime environment for all residents. Interview on 4/30/26 at 2 PM - the Administrator stated expectation to follow recommendations from therapy.

Based on observation, clinical record review, document review and staff interviews the facility failed to provide appropriate infection prevention practices by not following guidelines for enhanced barrier precautions (EBP) for 1 out of 1 resident reviewed (Resident #8). The facility reported a census of 59 residents. Finding include:The Minimum Data Set (MDS) dated [DATE] for Resident #8, documented the Brief Interview for Mental Status (BIMS) scored a 14 indicating intact cognition. The MDS identified diagnosis as a renal insufficiency, urinary tract infection, diabetes mellitus. The MDS also documented that the resident has an indwelling catheter. Review of Resident #8's Care Plan with a date of 4/9/26 failed to mention Enhanced Barrier Precautions (EBP) due to an indwelling catheter. Observation completed on 4/29/26 at 12:05 pm with Staff F, Certified Nursing Assistant (CNA) and Staff G, CNA failed to wear EBPs while providing catheter care. Interview on 4/29/26 at 1:26 pm with Staff F and Staff G acknowledged that they should have worn the EBP while providing catheter care. The facility policy named Enhanced Barrier Precautions with a revised date of 9/29/25 stated If contact precautions do not otherwise apply enhanced barrier precautions are recommended for residents with any of the below criteria: Residence with an indwelling medical device, even if the resident is not known to be infected or colonized with an Multidrug-Resistant Organisms (MDRO). Examples of indwelling medical devices include but are not limited to central vascular lines, Peripherally Inserted Central Catheter (PICC) or mid-line catheters indwelling urinary catheter, nephrostomy tube, feeding tube, tracheostomy tubes. Dialysis shunts, ports that are not currently accessed, peripheral intravenous (IV) lines do not qualify as indwelling medical devices.Examples of high-contact resident care activities requiring gown and gloves used for EBP include (our goal is to keep our skin and uniform from touching the resident during high contact activities so that we can avoid potential transfer of organisms to other residents).These activities included:Bathing/showeringTransferringProviding hygieneChanging linensChanging briefs or assisting with toiletingDevice care or use: central line, urinary catheter, feeding tube, tracheotomy/ventilatorWound care: any skin opening requiring a dressingInterview on 4/29/26 at 1:47 pm with the Director of Nursing (DON) stated the expectation for the staff is to wear the EPB for residents catheters.

Based on clinical record review, observations, staff interviews, and policy review, the facility failed to disinfect equipment after resident use and failed to ensure staff changed gloves and sanitized hands in accordance with proper infection control techniques when contaminated to protect against cross contamination and potential infection for 4 of 8 residents observed during medication administration and for 2 of 3 residents observed for cares. The facility reported a census of 47 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had diagnosis of chronic obstructive pulmonary disease (COPD) and heart failure. The Care Plan initiated 1/16/25 revealed the resident had lung cancer. The Care Plan directed staff to use a spacer whenever inhalers administered. During observation on 4/2/25 at 11:13 AM, Staff B, Licensed Practical Nurse (LPN), attached a Combivent inhaler to a spacer with a mask attached to it. Staff B placed the mask on Resident #3's face covering the resident's nose and mouth. Staff B then administered the inhaler to the resident and had the resident inhale the medication. After Staff B administered the medication and had the resident rinse her mouth with water, Staff B placed the spacer and mask back in the bottom drawer of the medication cart without cleaning or disinfecting the mask. During an interview 4/3/25 at 10:20 AM, Staff D, Co-Director of Nursing (DON) reported she expected staff to rinse the mask used with the inhaler for the resident with water and air dried. An Administration of Metered Dose Inhalers revised 4/2012 revealed to replace the inhaler in a proper storage area. The policy lacked information related to care of the inhaler administration device after the medication administered. A Standard Precautions policy reviewed 6/10/21 revealed resident care equipment disinfected before resident use. 2. During observation on 4/1/25 at 2:40 PM, Staff G, certified nursing assistant (CNA), removed Resident #3's pants and brief. Staff H, CNA, handed disposable wipes to Staff G. Staff G provided pericare to Resident #3. Staff G continued to wear the same gloves after pericare provided and transferred the resident from the bed to the commode. Staff G donned the resident's shoes, then placed a sling under the resident. Staff touched the mechanical lift and the commode, then transferred the resident from the bed to the commode wearing the same gloves. Staff G then removed her gloves and sanitized her hands. Staff bagged up the trash, and placed the soiled clothes and sling into a plastic bag. Staff moved the mechanical lift into the hall/common area but did not disinfect the mechanical lift after use. At 3:05 PM, Staff G and Staff H returned to the resident's room. Staff G and Staff H moved the resident from the commode to the bed. Staff H provided disposable wipes to Staff G. Staff G continued to wear the same gloves and provided pericare to Resident #3. Staff G did not change gloves or sanitize her hands after she transferred the resident and after she performed pericare for the resident. Staff G touched the overhead trapeze and provided the trapeze to the resident to use as she turned side to side in bed. Staff G donned a clean brief on the resident, touched the bed sheets and blankets, the call light, and the bed control, then removed her gloves. At 3:25 PM, staff took the mechanical lift from the resident's room and placed it in a common area. Staff did not disinfect the mechanical lift after use. At 3:30 PM, Staff G, CNA, reported she asked nursing about wipes but did not get a response on where she could obtain the wipes. Staff G placed the used commode back into the bathroom that was shared with another resident. Staff G used a personal care wipe to wipe off the commode. Staff G stated Resident #3 was the only resident who utilized the commode. A Hand Washing Techniques dates 1/28/20 revealed hand washing reduced the spread of potential pathogens on the hands and prevent nosocomial infections. Hands washed before and after resident contact, after contact with body fluids, inanimate objects that are likely to be contaminated and after gloves removed. Hands sanitized with an alcohol-based handrub when persistent antimicrobial activity on the hands is desired or before an invasive procedure performed. Hands much be washed thoroughly with soap and water when visibly soiled. Gloves should be removed and hands washed whenever staff performed hand-contaminating activities. Gloves changed whenever moved from one procedure to another. 3. The MDS assessment dated [DATE] revealed Resident #30 had diagnosis of dementia. The MDS recorded the resident had incontinence and dependent on staff for toileting hygiene and lower body dressing. The Care Plan initiated 1/22/25 revealed the resident had memory loss and urinary infections, and required assistance with cares. The Care Plan directed staff to toilet the resident as needed and provide assistance of one staff for hygiene and dressing. During observation on 4/2/25 at 1:35 PM, Staff I, CNA, provided incontinence care for Resident #30 while he stood by a grab bar in the bathroom. Staff I took disposable wipes and cleansed the resident's buttocks area, then pulled the resident's pants up. Staff I continued to wear the same gloves, bagged up the trash, and walked down the hall to the utility room. Staff I entered a code on the utility room door, turned the knob on the door with her gloved hand, placed the bag of trash in a barrel, placed the lid over the barrel, and then removed one glove. Staff I walked back to the resident's room, closed the bathroom door and activated the alarm by the bathroom door. Staff I walked to the nurse's station across from the resident's room and removed the glove on her other hand. During an interview 4/3/25 at 10:30 AM, Staff E, Co-DON, reported she expected gloves changed whenever going from a dirty task or area to a clean task or area. Staff E reported she expected staff performed hand hygiene and removed gloves and wash hands when visibly contaminated. She also expected staff washed hands after tasks completed such as after resident cares. A Standard Precautions policy reviewed 6/10/21 revealed hands washed after touching body fluids and contaminated items regardless of whether gloves are worn, after gloves removed. Hands washed or hand sanitized between tasks and procedures on the same resident to prevent cross contamination. Gloves changed after contact with material that may contain high concentrations of microorganisms. Resident care equipment disinfected before resident use. 4. During observation on 4/2/25 at 11:01 AM, Staff B, LPN, administered insulin to Resident #31. Staff B recapped the end of the flexpen, then removed the needle from the pen, and disposed of the needle device into a sharps container by the medication cart. During an interview on 4/2/25 at 1:40 PM, Staff F, Registered Nurse (RN), reported the needles used and attached to the insulin flexpens do not automatically retract whenever an injection given. During an interview 4/3/25 at 10:20 AM, Staff D, Co-DON reported staff should never recap needles. On 4/3/25 at 11:15 AM, Staff D and Staff E requested the surveyor to look at the needle devices used on their insulin pens. Staff D explained they used a drop safe needle for insulin injections. The needles were obtained from their supplier. At the time, Staff D had Staff B demonstrate application of the needle device onto an insulin pen and then Staff B administered the insulin into a cotton ball. A bent needle was observed inside the plastic chamber. On 4/3/25 at 12:50 PM, Staff D confirmed they facility did not have a policy or procedure for insulin flexpen use. The facility's Injections Subcutaneous policy revealed using the safety syringe device cover the exposed needle. Dispose of the syringe and needle in the designated container. DO NOT RECAP NEEDLE! According to the Novolog Manufacturer instructions revised 2/2023 revealed do not recap the needle. Recapping can lead to a needle stick injury. Carefully slip the needle into the outer needle cap. Safely remove the needle and throw it away into a sharps disposal container after use. 5. The MDS assessment dated [DATE] revealed Resident #36 had a cardiorespiratory condition. During observation on 4/2/25 at 10:00 AM, Staff B, LPN, pushed a cart with a stethoscope, pulse oximeter machine, and blood pressure cuff on the top shelf, and three boxes of gloves on the middle shelf into Resident #36's room. Staff B placed an albuterol solution into a nebulizer chamber, attached the mask, and connected the tubing to the nebulizer machine. Staff B placed the nebulizer machine on top of the cart that she brought into the resident's room, then administered the nebulizer treatment to the resident. At 10:22 AM, Staff B removed the nebulizer mask from the resident's face then provided a washcloth for the resident to wash her face. Staff B moved the nebulizer machine to a bedside table, then placed the soiled washcloth on top of the cart. At 10:30 AM, Staff B pushed the cart with the soiled washcloth, blood pressure cuff, stethoscope, and pulse oximeter back to the nurse's station. Staff B took the soiled washcloth to the soiled utility room, removed her glove, and sanitized her hands. Staff B then spoke with another staff member by the desk. At 10:35 AM, Staff B wheeled the cart with the medical equipment down the hall and into another resident's room and took the resident's vital signs. Staff B did not clean or disinfect the cart before or after use. During an interview 4/3/25 at 10:20 AM, Staff D, Co-DON reported she expected staff used germicidal wipes to disinfect equipment such as the mechanical lifts and carts. The equipment or surface needed to remain wet for 2 minutes to ensure the equipment or the surface had been properly disinfected. A General Infection Prevention and Control Nursing Policy reviewed 4/25/23 revealed all items for multi-resident use will be disinfected using germicidal wipes after use. 6. On 4/1/25 at 10:53 AM, Staff A, LPN, removed the blood sugar machine from a drawer in Resident #41's room, donned a pair of gloves, and cleaned the machine with an alcohol swab. Staff A took another alcohol swab and cleansed the resident's finger, then took a lancet and poked the resident's finger. Staff A placed a drop of blood on the strip in the blood sugar machine. After Staff A read the blood sugar result, she removed her gloves and disposed of items in the trash. Staff A did not change her gloves or sanitize her hands in-between cleaning the blood sugar machine and performing the blood sugar check. On 4/1/25 at 11:00 AM, Staff A prepared and administered insulin to Resident #41. Staff A recapped the needle, then disposed of the needle in the sharps container on the medication cart. During an interview 4/3/25 at 10:30 AM, Staff E, Co-DON, reported she expected gloves changed whenever going from a dirty task or area to a clean task or area. Staff E reported she expected staff performed hand hygiene and removed gloves and wash hands when visibly contaminated. She also expected staff washed hands after tasks completed such as after resident cares. A Standard Precautions policy reviewed 6/10/21 revealed hands washed after touching body fluids and contaminated items regardless of whether gloves are worn, after gloves removed. Hands washed or hand sanitized between tasks and procedures on the same resident to prevent cross contamination. Gloves changed after contact with material that may contain high concentrations of microorganisms. 7. During observation on 4/2/25 at 3:30 PM, Staff C, RN, donned gloves and administered Debrox Earwax ear drops into Resident #52's ears. Staff C then took latanopost eye drops and instilled a drop into each eye. Staff C did not change gloves or sanitize hands after she administered the ear drops and before she administered the eye drops. During an interview 4/3/25 at 10:30 AM, Staff E, Co-DON, reported she expected staff changed gloves in-between giving medications, including going from one route of medication to another. For example, staff should change gloves after an ear medication administered and before an eye medication administered. A Standard Precautions policy reviewed 6/10/21 revealed hands washed or hand sanitized between tasks and procedures on the same resident to prevent cross contamination. Gloves changed after contact with material that may contain high concentrations of microorganisms.

Based on observation, staff interviews, and policy review, the facility failed to safely and securely store resident and staff medications. The facility reported a census of 47. Findings include: During an observation on 3/31/25 at 10:00 AM, several over-the-counter medications were found in an unlocked cupboard in a prep area of the kitchen. The kitchen did not have a secured entrance. Medications included Pepto-Bismol, Ibuprofen, Tylenol, Tylenol Arthritis, Tums, and allergy relief. During an observation on 3/31/25 at 11:25 AM, the 100-hall treatment cart was unlocked. The cart had Biofreeze, Nystop powder, Diclofenac cream, and dressing supplies all with resident names. During an observation on 3/31/25 at 11:25 AM, Albuterol and Budesemide inhalers were seen on Resident #9's bedside table in their room. The inhalers were not labeled with any resident names. During an interview on 3/31/25 at 10:20 AM the Certified Dietary Manager, CDM, acknowledged the unsecured medications. The CDM reported these are for staff use. During an interview on 4/3/25 at 10:30 AM, Staff E, Co-Director of Nursing, reported medications are stored in on the medication cart or in the medication room. Resident inhalers are stored on the medication cart. Staff E believed Resident #9's family may have brought in the unlabeled inhalers. During an interview on 4/3/25 at 1:40 PM, Staff D and Staff E, both Co-Directors of Nursing, indicated the over-the-counter medications in the kitchen should have been, at the very least, locked-up. The undated policy Medication Labeling and Storage stated resident medications are properly labeled (name, room number, medication name, directions for use) and locked in a cart or cabinet. Medications for each resident are kept and stored in their originally received containers. Containers having no labels are to be destroyed in accordance with state and federal laws.

Based on clinical record review, observation, staff interview and manufacturer's instructions, the facility failed to administer insulin flexpen to ensure the proper amount of insulin administered for two of two residents observed for insulin administration (Resident #31 and #41). The facility reported a census of 47 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had diagnoses of diabetes and renal insufficiency. The MDS documented the resident took insulin 7 of 7 days during the look-back period. The Care Plan initiated 2/12/25 revealed the resident had diabetes. The Care Plan directed staff to administer insulin medication as ordered. The Medication Administration Record (MAR) dated 4/1/25 to 4/30/25 for Resident # 31 listed Novolog 8 units subcutaneous (SQ) administered on 4/2/25 for the mid-day dose by Staff B, Licensed Practical Nurse (LPN). During observation on 4/2/25 at 10:57 AM, Staff B, Licensed Practical Nurse (LPN), prepared to administer Novolog insulin for Resident #31. Staff B attached a needle on the end of a Novolog insulin flexpen, turned the dial to 2 (units) to prime the needle, then turned the dial to 8. At 11:01 AM, Staff B took the Novolog pen, counted 1, 2, 3, inserted the needle into the resident's left lower abdomen, pushed the button on the end of the insulin pen, and removed the needle after one second. During an interview 4/3/25 at 10:20 AM, Staff D, Co-Director of Nursing (DON) reported she was unsure if the facility had a policy for the insulin flexpens. Staff D reported she expected staff to follow the manufacturer instructions for insulin flexpens. On 4/3/25 at 12:50 PM, Staff D confirmed they facility did not have a policy or procedure for insulin flexpen. On 4/3/25 at 3:15 PM, Staff D reported she checked with the pharmacy about the insulin pens. The insulin pens were all different and the amount of time varied on how long the needle should be left in whenever insulin administered via the flexpen. Staff D stated she planned to tell staff the needle needed to be left in place for 10 seconds whenever they used an insulin flexpen to ensure the residents got the proper dose. According to the Novolog Manufacturer instructions revised 2/2023 revealed the following procedural steps for Novolog insulin injection 100 units/ ml flexpen: a. Turn the dose selector to the number of units needed for injection. b. Insert the needle into the skin. c. Press the push button all the way in until the 0 lines up with the pointer. d. Keep the needle in the skin for at least 6 seconds and keep the push button pressed all of the way in until the needle has been pulled out from the skin to ensure the full dose given. 2. The MDS assessment dated [DATE] revealed Resident #41 had diagnoses of diabetes and macular degeneration. The MDS documented the resident took insulin. The Care Plan initiated 2/12/25 revealed the resident had diabetes. Resident #41's MAR dated 4/1/25 to 4/30/25 listed Lispro insulin 100/ml SQ as directed per sliding scale. The MAR listed Lispro insulin 6 units for a blood sugar range of 251-300 was documented on 4/1/25 for the lunch dose. On 4/1/25 at 10:53 AM, Staff A, LPN, checked Resident #41's blood sugar with a blood sugar monitor. Staff A reported the blood sugar reading at 294. At 11:00 AM, Staff A, LPN, prepared an insulin flexpen. Staff A cleansed the end of the insulin pen with alcohol, attached a needle, turned the dial on the pen to 2, and pushed the button on the end of the pen as she held the pen horizontally. Staff A did not remove the needle cap to observe and ensure fluid seen on the end of the needle/pen. Staff A then turned the Lispro insulin dial to 6. Staff A inserted the insulin flexpen needle into the resident's right lower abdomen, pushed the button on the end of the pen, held the insulin pen in place for 3-4 seconds, then removed the needle from the administration site. Staff A did not check to ensure the dial showed zero, or hold the flexpen with the needle in the skin for a count of at least 6 seconds after the medication administered. The Lispro Kwikpen manufacturer instructions revised 7/2023 directed staff to prime the pen before each injection to remove air bubbles and check the patency of the needle, and to ensure the resident did not receive too much or too little insulin. The following procedural steps taken to ensure safe and effective usage of the Lispro Kwikpen Injector System: To prime the pen a. Push the capped needle onto the pen and twist the needle on tightly. b. Remove the outer needle cap. c. Turn the dose selector knob to 2 units. d. Hold the pen with the needle pointed up. e. Tap the top of the pen gently a few times to let any air bubbles rise to the top. f. Continue to hold the pen with the needle pointed up. g. Push the dose knob in until the dose counter shows 0. A drop of insulin should appear at the needle tip. Repeat steps until insulin seen at the tip of the needle, up to 6 times. If no insulin drop observed, change the needle and repeat the steps. h. Turn the dose knob to select the number of units needed for injection. i. Insert the needle into the skin. j. Push the dose knob all of the way in and continue to hold the dose know in and slowly count to 5 before removing the needle. A diagram on the same page suggested a 5 second hold to the skin. k. Pull the needle out of the skin. l. Check the number in the dose window. If a 0 seen, the full amount of insulin was received.

Based on clinical record review, observations, staff interview, manufacturer recommendations, and policy review the facility failed to ensure a medication error rate of less than 5%. During observations of medication administration, the facility had 2 errors out of 25 opportunities for error resulting in an error rate of 8.0 % (Residents #31 and #41). The facility identified a census of 47 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had diagnoses of diabetes and renal insufficiency. The MDS documented the resident took insulin 7 of 7 days during the look-back period. The Care Plan initiated 2/12/25 revealed the resident had diabetes. The Care Plan directed staff to administer insulin medication as ordered. The Medication Administration Record (MAR) dated 4/1/25 to 4/30/25 for Resident # 31 listed Novolog 8 units subcutaneous (SQ) administered by Staff B, Licensed Practical Nurse (LPN) on 4/2/25 for the mid-day dose. During observation on 4/2/25 at 10:57 AM, Staff B, Licensed Practical Nurse (LPN), prepared to administer Novolog insulin for Resident #31. After Staff B attached a needle on the end of a Novolog insulin flexpen, Staff B dialed the flexpen to 2 (units) to prime the needle, then turned the dial on the pen to 8. At 11:01 AM, Staff B took the Novolog pen, counted 1, 2, 3, inserted the needle into the resident's left lower abdomen, pushed the button on the end of the insulin pen, and removed the needle after one second. During an interview 4/3/25 at 10:20 AM, Staff D, Co-Director of Nursing (DON) reported she was unsure if the facility had a policy for the insulin flexpens. Staff D reported she expected staff to follow the manufacturer instructions for insulin flexpens. On 4/3/25 at 12:50 PM, Staff D confirmed the facility did not have a policy or procedure for insulin flexpen. On 4/3/25 at 3:15 PM, Staff D reported she checked with the pharmacy about the insulin pens. The insulin pens were all different and the amount of time varied on how long the needle should be left in whenever insulin administered via the flexpen. Staff D stated she planned to tell staff the needle needed to be left in place for 10 seconds whenever they used an insulin flexpen to ensure the residents got the proper dose. According to the Novolog Manufacturer instructions revised 2/2023 revealed the following procedural steps for Novolog insulin injection 100 units/ ml flexpen: a. Turn the dose selector to the number of units needed for injection. b. Insert the needle into the skin. c. Press the push button all the way in until the 0 lines up with the pointer. d. Keep the needle in the skin for at least 6 seconds and keep the push button pressed all of the way in until the needle has been pulled out from the skin to ensure the full dose given. 2. The MDS assessment dated [DATE] revealed Resident #41 had diagnoses of diabetes and macular degeneration. The MDS documented the resident took insulin. The Care Plan initiated 2/12/25 revealed the resident had diabetes. Resident #41's MAR dated 4/1/25 to 4/30/25 listed Lispro insulin 100/ml SQ as directed per sliding scale. The MAR listed Lispro insulin 6 units for a blood sugar range of 251-300 was documented on 4/1/25 for the lunch dose. On 4/1/25 at 10:53 AM, Staff A, LPN, checked Resident #41's blood sugar with a blood sugar monitor. Staff A reported the blood sugar reading at 294. At 11:00 AM, Staff A, LPN, prepared an insulin flexpen. Staff A cleansed the end of the insulin pen with alcohol, attached a needle, dialed the pen to 2, and pushed the button on the end of the pen while she held the pen horizontally. Staff A did not remove the needle cap to observe and ensure fluid seen on the end of the needle/pen. Staff A then turned the Lispro insulin dial to 6. Staff A inserted the insulin pen needle into the resident's right lower abdomen, pushed the button on the end of the pen, held the insulin pen in place for 3-4 seconds, then removed the pen. Staff A did not check to ensure the dial showed zero, or hold the flexpen with the needle in the skin for a count of at least 6 seconds after the medication administered. The Lispro Kwikpen manufacturer instructions revised 7/2023 directed staff to prime the pen before each injection to remove air bubbles and check the patency of the needle, and to ensure the resident did not receive too much or too little insulin. The following procedural steps taken to ensure safe and effective usage of the Lispro Kwikpen Injector System: To prime the pen a. Push the capped needle onto the pen and twist the needle on tightly. b. Remove the outer needle cap. c. Turn the dose selector knob to 2 units. d. Hold the pen with the needle pointed up. e. Tap the top of the pen gently a few times to let any air bubbles rise to the top. f. Continue to hold the pen with the needle pointed up. g. Push the dose knob in until the dose counter shows 0. A drop of insulin should appear at the needle tip. Repeat steps until insulin seen at the tip of the needle, up to 6 times. If no insulin drop observed, change the needle and repeat the steps. h. Turn the dose knob to select the number of units needed for injection. i. Insert the needle into the skin. j. Push the dose knob all of the way in and continue to hold the dose know in and slowly count to 5 before removing the needle. A diagram on the same page suggested a 5 second hold to the skin. k. Pull the needle out of the skin. l. Check the number in the dose window. If a 0 seen, the full amount of insulin was received.

Based on observation, clinical record review, facility policy review, resident and staff interviews, the facility failed to provide services that met professional standards regarding accurately transcribing physician's orders for 1 (Resident #28) of 16 residents reviewed. The facility reported a census of 47 residents. Findings include: Review of Resident #28's Minimum Data Set (MDS) dated [DATE], revealed Resident #28's admission to the facility on [DATE] with a Brief Interview of Mental Status ( BIMS) score of 13, indicating Resident #28 as cognitively intact. Resident #28's diagnoses include congestive heart failure (CHF), atrial fibrillation, coronary artery disease, renal insufficiency, and peripheral vascular disease. The MDS also indicated Resident #28 on hospice level of care with oxygen therapy. Resident #28 is independent with mobility with the assistance of a walker. Review of Resident #28's admission orders dated 1/17/25 indicated an order for supplemental oxygen 2-4 liters via nasal cannula for comfort. The Care Plan dated 2/5/25 revealed, Resident #28 and his family have chosen to receive hospice services with interventions to administer medications, oxygen and treatments as ordered for comfort. Review of Hospice Interdisciplinary Meeting (IDT) on 2/10/25 indicated an order, with start date 11/8/24, oxygen via nasal cannula, 2 liters per minute as needed for shortness of breath and breathing comfort. Review of the Medication Administration Record (MAR) for January 2025 indicated a hand written oxygen order, with documentation of Resident #28's use of 2-4 liters supplemented oxygen regularly during the evening and overnight shift and intermittently during the day shift. Review of the MAR for February 2025 indicated a hand written oxygen order, with documentation of Resident #28's use of 2-4 liters supplemented oxygen intermittently during the evening and night shift and rarely during day shift. Review of the MAR's for March and April 2025 failed to indicate an oxygen order and documentation of usage. Review of the Physician's Orders Summary for orders dated 1/17/25-3/31/25, signed by the Physician on 3/14/25, failed to indicate Resident #28's as needed oxygen order. Observation on 3/31/25 at 1:19 PM, revealed a portable oxygen concentrator outside of Resident #28's doorway and an oxygen concentrator in Resident #28's room between the bed and recliner with nasal cannula tubing attached. During an interview on 4/2/25 at 2:30 PM, Resident #28 stated he uses his oxygen as needed and will often wear it at 2 liters for a few hours in the evening, after supper and before bed. During an interview on 4/2/25 at 6:15 PM, Staff D, Co- Director of Nursing (DON) and Staff E, Co-DON stated to their knowledge, Resident #28 doesn't use oxygen and doesn't have an oxygen concentrator in his room. On interview on 4/3/25 at 11:58 AM, Staff D, Co-DON acknowledged the oxygen order for Resident #28 was not included on the MAR's for March and April 2025 or the signed Physician's Order Summary as it should have been. Staff D, Co-DON stated the monthly MAR's are made by transcribing the orders from the Physician's Order Summary to the paper format MAR's and Resident #28's oxygen order had not been discontinued, the facility failed to transcribe the orders accurately. Review of facility provided Checklist for new order medication/treatment procedure indicated the following: 1. New order is written on the MAR/TAR, with date, medication/treatment, route, frequency, time, specific instructions, Also added to the next month ' s MAR/TAR if available. 2. Phone order written if needed. 3. Old order discontinued on MAR/TAR 4. Medications pulled from med cart drawer. 5. New orders for follow up on the calendar. 6. Follow up appointments made. 7. Transportation arrangements made and put in calendar. 8. Family and Pharmacy notified. 9. Entry in nurses notes. 10. Order noted with signature, date and time by nurse.

Based on clincal record review, staff interview, and admission agreement review, the facility failed to obtain bed hold confirmation for 1 of 2 residents reviewed for hospitalization (Resident #19). The facility reported a census of 47. Findings include: Review of Resident #19's Minimum Data Set (MDS) revealed a Discharge Return Anticipated/End of PPS Part A Stay assessments were completed on 2/8/25 and 2/26/25. Resident #19's Census showed Resident #19 was hospitalized from [DATE]-[DATE] and 2/26/25-3/10/25. Review of Progress Notes revealed the following: a. On 2/8/25, Resident #19 was transferred to a local hospital due to a decline in medical status. A copy of the bed hold policy was provided to Resident #19's husband. No further documentation identified which indicated the bed hold was signed or if a verbal consent for a bed hold was obtained from either the resident or their husband. b. On 2/26/25, Resident #19 was directly admitted to a local hospital due to an acute medical condition. No documentation identified that a bed hold consent form was signed or if a verbal consent was obtained from either the resident or their husband. During an interview on 4/3/25 at 11:00 AM, Staff K, Business Office, indicated a blank copy of the facility's bed hold policy is provided to the resident when they are sent to the hospital. Staff K will then attempt to follow-up with the resident or their representative (within 24-hours or the first business day of the week) to obtain bed hold consent, either by a signed bed hold form, verbal, or email. These verifications are kept in the business office files. Staff K acknowledged they do not always get a response regarding bed hold consent from residents or their family. Staff K did not have any further documentation indicating Resident #19 or their family consented to a bed hold for both of the hospitalizations in February. During an interview on 4/3/25 at 1:45 PM, Staff D, Co-Director of Nursing and Staff E, Co-Director of Nursing, acknowledged the challenges of obtaining bed hold consent. Staff D explained a blank copy of the bed hold policy is always sent out with the resident when hospitalized . Staff D voiced nursing staff do not fill out any of the bed hold forms as they do not have the required information to accurately complete them. Review of the Resident admission Agreement, revised 3/31/25, revealed the facility will ask the resident or representative if they wish for a bed hold. Upon request by the resident or representative, the bed will be held and the resident will be billed for the full daily per diem rate for the first ten days.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to provide oxygen therapy as prescribed by the physician for 1 of 2 residents reviewed for respiratory care (Resident #3). The facility reported a census of 47. Findings include: Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3's Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Diagnoses include atrial fibrillation, chronic obstructive pulmonary disease, coronary artery disease, and heart failure. The MDS further indicated Resident #3 receiving oxygen therapy. During an observation on 4/2/25 at 10:30 AM, the oxygen setting for Resident #3 was at 3 liters. April 2025 Physician Order sheet for Resident #3 revealed the following order: Oxygen at 2 liters to keep oxygen saturation equal to or greater then 89%. Review of the Medication Administration Review (MAR) sheets revealed the following: a. March 2025 MAR showed staff initials indicating oxygen setting was at 2 liters for the month. No further adjustment or updates to the MAR was identified. b. February 2025 MAR revealed an unknown staff member changed the order for oxygen setting to 3 liters from 2 liters. Staff initialed and wrote in an oxygen setting at 3 liters on 2/1/25 and 2/2/25. No date noted on the MAR to indicate when the order on the MAR was changed. Staff initials for the rest of the month indicated the oxygen setting was at 3 liters. c. January 2025 MAR showed staff initials indicating oxygen setting was at 2 liters. No further adjustments or updates to the MAR was identified. d. December 2024 MAR showed staff initials indicating oxygen setting was at 2 liters. No further adjustments or updates to the MAR was identified. Review of the Oxygen Saturation Summary report in the facility's electronic health record revealed the following: a. During the month of March, oxygen setting documented at 3 liters on 3/16/26 and 3/17/25. b. During the month of February, oxygen setting documented at 3 liters on 2/17/25. c. During the month of December, oxygen setting documented at 3 liters on 12/1/24. Review of the electronic medical record as well as the paper medical record, which include all physician orders, lacked documentation to support the change in the oxygen setting from 2 liters to 3 liters as identified from December 2024 to April 2025. During an interview on 4/2/25 at 12:45 PM, Staff B, Licensed Practical Nurse, could not initially recall Resident #3 current oxygen order and referred to the MAR. When informed of the observation of the oxygen set at 3 liters instead of 2 liters, as ordered, Staff B reported they have typically seen the oxygen set at 3 liters. Staff B could not estimate a time frame on how long the oxygen has been set at 3 liters. Based on their assessment, Resident #3 feels the best at 3 liters. Staff B reported no standing physician orders in place to titrate oxygen settings based on nursing assessments. During an interview 4/2/25 at 2:15 PM, Staff D, Co-Director of Nursing and Staff E, Co-Director of Nursing, both confirmed the facility did not have a protocol or standing orders in place for titrating oxygen settings. Nursing staff would need to contact the physician for any changes. The policy Administration of Oxygen Therapy, revised 10-22, states the oxygen flow rate is set to the prescribed dosage.

Based on record review and staff interview, the facility failed to notify the Long-Term Care Ombudsman of resident discharge/transfers as required for 2 of 2 residents reviewed for hospitalizations (Residents #19 and #47). The facility reported a census of 47. Findings include: 1. The Minimum Data Set (MDS) summary tab of the facility's Electronic Health Record (EHR) for Resident #19 revealed a Discharge Return Anticipated/End of PPS Part A Stay assessments were completed on 2/8/25 and 2/26/25. Entry assessments were completed on 2/14/25 and 3/10/25. Review of Resident#19's Census indicated Resident #19 was hospitalized from [DATE]-[DATE] and 2/26/25-3/10/25. Review of Resident #19's Progress Notes revealed the following: a. On 2/8/25, Resident #19 was transferred to a local hospital due to a decline in medical status. b. On 2/26/25, Resident #19 was directly admitted to a local hospital due to an acute medical condition. Review of facility provided, Admission/Discharge To/From Report, which was emailed to the Long-Term Care Ombudsman on 3/3/25, lacked documentation for Resident #19's discharges to the hospital on 2/8/25 and 2/26/25 as required by federal regulation. 2. Review of Resident #47's MDS revealed a Discharge Return Anticipated assessment was completed on 12/18/24. An Entry assessment was completed on 12/23/24. Review of Resident #47's Census indicated Resident #47 was hospitalized [DATE]-[DATE]. Review of Progress Notes revealed Resident #47 was transferred to a local hospital on [DATE] due to a decline in medical status. Review of the facility provided email to the Long-Term Care Ombudsman on 1/7/25, lacked documentation for Resident #47's discharge to the hospital on [DATE] as required by federal regulation. In an interview on 4/3/24 at 11:00 AM, Staff J, Resident Relations Coordinator, reported the only information provided on the Long-Term Care Ombudsman's monthly reports are facility admissions and discharges. Staff J stated they do not send information when residents are transferred to the hospital. The facility did not provide a policy regarding monthly resident census information to the Long-Term Care Ombudsman.

Based on interviews, review of record and facility policy, the facility failed to re-evaluate and update one resident's (Resident (R)1) out of two sampled residents for advance directives, code status wishes. The facility's deficient practice increased R1's risk of inconsistent (wishes/desires) code status treatment. On [DATE] at 5:06 PM, the Administrator and the Director of Nursing (DON) were notified of immediate jeopardy (IJ) at F578- Advance Directives. The Immediate Jeopardy began on [DATE] when the team identified the facility failed to re-evaluate one resident's (R1) wishes for her code status. The facility provided an acceptable removal plan for the Immediate Jeopardy at F578 on [DATE] at 7:36 PM. The removal plan included that on [DATE] the Social Services Director (SSD) reviewed code status with R1 and that R1 confirmed that she wanted to remain a Do Not Resuscitate (DNR). On [DATE], the Administrator and DON reviewed code status with R1 and once again R1 confirmed that she wanted to remain a DNR. The facility kept the DNR status in effect for R1, and notified R1 Power of Attorney (POA). The facility planned to review her code status quarterly with R1. The facility will ensure R1 has the opportunity to attend all future care conferences. The facility will review the care conference summary with R1 if they refuse to attend. On [DATE], the facility reviewed code status with all residents and/or representatives. No changes to code status were requested by residents and/or representatives. The facility planned to review code status quarterly with all residents and/or representatives. The facility will ensure all residents and/or representatives have the opportunity to attend all future care conferences. The facility will review and/or distribute care conference summaries to residents and/or representatives who refuse to attend care conferences. On [DATE], the IPOST policy and procedures were updated. On [DATE], the SSD, MDS Coordinator, and Nurse Managers educated the Administrator on Iowa Physician Orders for Scope of Treatment (IPOST) policy and procedures. The survey team verified all elements of the facility's IJ Removal Plan and determined the facility removed the IJ on [DATE] at 9:45 PM and decreased the citation to a D level deficiency. Findings include: Review of the facility policy titled. IPOLST revealed .To ensure that the president's request for life sustaining choice is followed .Capable adults have a right to make their own health care decisions .The IPOST should be reviewed periodically and a new Physician Orders for Life Sustaining Treatment (POLST) form completed when the patient/resident's treatment preference changes . Review of R1's undated Admission Record under the front cover of the paper chart revealed an admitted [DATE] with multiple diagnoses including chronic kidney disease, diabetes, and renal aneurysm. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Review of R1's IPOST indicated that if she had no pulse and is not breathing she requested to be a DNR. The Medical Director signed the IPOST on [DATE] and R1 signed it on [DATE]. Review of R1's [DATE] ' s Physician's Orders listed her code status as DNR. Review of R1's [DATE] Medication Administration Record (MAR) included a code status of DNR. Review of R1's comprehensive Care Plan revised [DATE] indicated that she did not want to be resuscitated. During an interview on [DATE] at 2:47 PM, R1 stated that she wanted Cardiopulmonary Resuscitation (CPR, chest compressions with air provided to the person) performed by the facility in the event of cardiac (heart stopped) or respiratory event/arrest (inability to breathe). R1 stated if there was hope she could be saved she would like to be. During a second interview on [DATE] at 1:39 PM, R1 stated she wanted the facility to provide CPR in the event of an emergent incident/cardiac or respiratory event. R1 stated the facility did not discuss her code status with her since her admission to the facility in 2020. R1 stated she did not want her code status to be a DNR. R1 stated she did not attend any care plan meetings at the facility and did not know when or what they were. R1 stated the facility did not invite her to attend her care conferences. During an interview on [DATE] at 5:44 PM, the DON 1 confirmed the facility should review the resident's code status or IPOST, four times a year during the care conference with the resident and or family representative. Then update the code status as needed and with any change of condition. During a third interview on [DATE] at 10:26 AM, R1 stated she did not report to anyone she wanted CPR provided for her. R1 stated she probably forgot her code status was DNR on admission to the facility, so she didn't realize she needed to tell anyone her code status needed to be changed. During an interview on [DATE] at 11:33 AM, R1's Family Member (FM)1 stated he knew of R1's DNR code status at the facility. R1's FM stated he had not discussed R1's desires for her advance directive or code status in years. R1's FM1 described R1's mind as sharp, and that she made her own medical decisions. R1's FM1 stated he did not attend her care conferences but thought his sister did at times and did not know if they discussed R1's code status at her care conferences. During an interview on [DATE] at 10:38 AM, SSD verified that R1's Physician signed her IPOLST prior to her admission to the facility and prior to R1 signing the IPOLST herself. The SSD stated that the Medical Director should have signed after R1 signed the document. The SSD verified R1's care conference documentation indicated R1's DNR code status or advance directives were not discussed on [DATE] or [DATE] because R1 did not attend either care conference. The SSD stated he could not recall the last time R1's advance directives or code status was discussed with her. The SSD confirmed he did not discuss R1's code status with R1's family. The SSD confirmed R1's care conference lacked documentation of a discussion. The SSD described R1's code status and advance directives as her decision. The SSD confirmed after review of R1's medical records the facility would not provide CPR in the event she suffered cardiac or respiratory arrest and the facility needed to ensure her code status wishes and desires were up to date and addressed with her. During an interview on [DATE] at 11:27, the MDS Coordinator (MDSC) stated she created the facility's resident's Care Plans, attended the resident's care conferences, and edited the resident's Care Plans. The MDSC stated the facility scheduled resident's care conferences with/for the resident's every 13 weeks or sooner if necessary. The MDSC stated the IDT [interdisciplinary team] addressed all the areas of the resident's care plan at their care conferences. The MDSC stated if the resident or the representative did not attend their care conferences the facility resident's care plans, edits or alternations in the resident's care plan were not discussed with the residents/or family representative. The MDSC verified R1's care conference documents dated ,d+[DATE] and ,d+[DATE] lacked documentation of a discussion with R1's of her advance directives or code status, indicating her code status did not get discussed with her. The MDSC stated R1 had a BIMS of 15 and was very much with it mentally/cognitively. The MDSC stated R1 made her own medical decisions. The MDSC stated she did not specifically go over R1's choice for her code status yearly. The MDSC confirmed if R1 suffered a cardiac or respiratory arrest the facility would not provide her with CPR because of her documented code status of DNR. The MDSC explained that the resident ' s charts had a red dot on the spine of the resident's paper chart at the desk, indicating a code status as DNR. Observed R1's paper chart with a red dot. The MDSC stated that staff use the red dot on the paper chart as a reference in the event a resident suffered cardiac or respiratory arrest. During an interview on [DATE] at 11:52 AM, Licensed Practical Nurse (LPN)1 reported that the nursing staff had a list with their MARs on the medication cart to reference the resident's code status. LPN1 stated the residents with a code status of DNR had a red dot on the spine of their chart next to their name. LPN1 stated she would not provide CPR for a resident with a DNR code status. LPN1 confirmed R1's code status was a DNR according to her care conference document for [DATE]. LPN1 verified that her MAR code status list indicated R1's code status as DNR. During an interview on [DATE] at 3:45 PM, the Medical Director confirmed he was R1's primary care physician prior to her admission to her facility. The Medical Director stated he did not know how he signed R1's IPOLST prior to her admission to the facility and prior to her signing her IPOST. The Medical Director stated R1 on admission to the facility indicated DNR. The Medical Director stated he did not expect the facility staff to re-evaluate the resident's code status after admission to the facility with the resident. The Medical Director stated he was unsure if the facility had standing orders or policies regarding revaluation of a resident's code status.

Based on interviews, record review, document review and facility policy review, the facility failed to ensure one resident ((R)1) out of five sampled for unnecessary medications, was not administered an antibiotic (Erythromycin) eye ointment for an excessive duration of time (over seven days). The facility deficient practice increased R1's risk of complications of antibiotic resistant infections. Findings include: Review of the facility's policy titled Antibiotic Stewardship Accountability dated 06/10/21 revealed .will support the safe use of antibiotics .Consulting Pharmacists will review ATB [antibiotic] usage and make recommendations as needed . Review of manufacturer's instruction document titled erythromycin .ointment . Bausch & Lomb Incorporated located on National Library Of Medicine revealed .Erythromycin ophthalmic ointment is an antibiotic .for the treatment of superficial ocular infections .the use of antimicrobial agents may be associated with the overgrowth of non-susceptible organisms . Review of R1's Admission Record undated under the front cover of the paper chart revealed admitted [DATE] with multiple diagnoses including presence of intraocular lens, hypermetropia unspecified eye, astigmatism unspecified eye, and dry eye syndrome without eye infection. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/9/23, revealed a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 indicating she was cognitively intact, had no diagnoses of infection and received antibiotic seven out of seven days. Review of R1's Physician's Orders dated March 2023 under the Physician Orders tab located on the paper medical record revealed, .Erythromycin 5 mg [milligram]/opt [ophthalmic] ointment place one-half inch strip into the lower eye did of both eyes at bedtime . dated 5/21/22. Review of R1's Medication Administration Record (MAR) dated March 2023 provided by the facility revealed, .Erythromycin 5 mg/opt ointment place one-half inch strip into the lower eye did of both eyes at bedtime with staff initials entered 3/1/23-3/22/23, 3/24/23-3/27/23 indicating the medication was administered on those dates. The medication was discontinued on 3/29/23. Review of R1's comprehensive Care Plan provided by the facility revealed no problem, goal or intervention related to eye infection or use of antibiotic ointment for the eyes. During an interview on 3/30/23 at 9:34 AM, R1 stated the facility administered her antibiotic eye ointment for over a year. During an interview on 3/30/23 at 2:53 PM, the Pharmacy Consultant (PC) stated R1 had an order and received her antibiotic eye ointment since 5/21/22 (over the manufacturer's recommended duration of seven days). The PC stated R1 received their antibiotic eye lubricant for an excessive duration, and he did not know why. The PC stated he reviewed R1's medication physician's orders monthly. The PC stated R1 administration of antibiotic eye ointment for the excessive duration of time increased her risk of exposure to germs resistant to the antibiotic. PC stated he did not make a recommendation to R1's provider regarding excessive duration of antibiotic eye ointment and he should have. During an interview on 3/30/23 at 4:39 PM, the Physician Assistant Certified (PAC) stated the recommended duration for prescribing antibiotic eye ointment was seven days. PAC stated she considered any duration over seven days as excessive for R1's antibiotic eye medication. PAC stated ordering and administering R1's antibiotic eye ointment for 10 months was an excessive duration. PAC stated the R1's antibiotic administration for the excessive duration of time increased her risk of antibiotic resistant infection. During an interview on 3/29/23 at 11:18 AM, the Director of Nursing (DON)2 stated they monitor antibiotic use monthly and the physician reviews monthly antibiotic usage. DON2 stated the facility also monitors if they need to make the physician aware of unnecessary antibiotics.

Based on record review, interview, document review, and policy review, the facility failed to provide adequate assistance and supervision to prevent an accident for one of three sampled residents (Resident (R)34) reviewed for falls. In addition, the facility failed to conduct a thorough investigation and determined the root cause from the investigation after a resident sustained a fall to prevent further falls for one of three sampled residents (R52). Findings include: 1. Review of the facility's policy titled, Unusual Occurrence dated November 2019 instructed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents as much as possible . Upon admission, assess each resident for falls utilizing the Minimum Data Set (MDS) 3.0 . a fall assessment will be completed .If the resident is at risk for falls, identify causative factors, and put interventions into place to minimize the risk factors .An investigation of cause needs to be completed with each occurrence. Interventions to prevent further incidents, need to be outlined in the plan of care. Review of R52's Admission Record listed an admitted [DATE] and included diagnoses of a history of displaced fracture of the right humerus bone, anxiety disorder, osteoarthritis, and muscle weakness. Review of R52's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/8/22 identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS indicated the resident required limited assistance of two plus persons for transfers. The resident only walked in the room once or twice during the assessment period. The resident's locomotion required extensive assistance of one person, toilet use required extensive assistance of two persons. The MDS indicated that Resident #52 could only stabilize with assistance due to an unsteady balance during transfer from seating to standing and from surface-to-surface transfers. The MDS indicated the resident did not display any behaviors during the assessment period. The MDS indicated the primary medical condition category indicated debility (weakness caused by an illness), cardiorespiratory (heart and lung) condition. The MDS indicated no falls or fractures in the six months prior to admission. The MDS indicated the resident received antianxiety medication in the last seven days. Review of R52's admission Morse Fall Scale dated 11/2/22 in the paper chart revealed R52 scored 85. A Morse fall score of 45 or above is considered high risk for falls. The document indicated R52 had previous falls. R52's paper Care Plan dated 11/2/22 included the following interventions: - 11/22/22 Anticipate needs - Clutter free environment - call light in reach - check frequently - Report falls; - Handwritten interventions: * Fall 11-30-22 abrasion right back treatment ordered, report changes as needed, medicate for pain as needed, staff to assist her into recliner and not leave in wheelchair in room; * 12/1/22 advise Physician Assistant Certified (PA-C) if needed; * 12/2/22 Chair alarm recliner and wheelchair; * 1/16/23 fell that morning, laceration left side of head-keep lift chair remote out of reach. Review of R52's Incident Report dated 11/30/22 provided by the facility indicated that the staff found R52 on the room floor near the bathroom door. Review of the investigative file provided by the facility lacked evidence that the facility assessed the circumstances and possible contributing factors related to the resident's fall. There was no evidence that the facility investigated various environmental factors such as the availability of the call light per the Care Plan as well as other factors such as a resident's footwear and when the resident went to the toilet last. The investigation file did not include a root cause or conclusion as to the cause of R52's fall. R52's Care Plan was updated on 12/1/22 to read assist the resident in the recliner and do not leave her alone in her room in a wheelchair. However, the facility did not provide any evidence to indicate the cause of the fall and that the intervention could prevent future falls in a similar nature. Review of R52's Incident Report revealed that on 1/16/23 the staff responding to an alarm found R52 laying on her left side in front of her lift chair, both of her legs were extended out with her arm under her. The nurse rolled R52 to her back and placed pillows under her head. R52's nose appeared to be bleeding with a small laceration observed to the head. R52 responded slowly to the nurse and raised her left arm by herself. R52 could not follow directions to move any other extremities. R52 ' s blood pressure measured 202/190 (average 120/80). A Certified Nurse Aide reported she took R52 to the bathroom at 5:30 AM. R52 ' s History of Present Illness dated 1/16/23 indicated that she went to the hospital after a fall on the floor. R52 had a head laceration on the left as well as a hematoma close to her left eye. The facility staff reported that the resident could speak, however at the time of the exam, she could not. The documentation listed her general appearance as unresponsive with a coma scale total of 11. The Provider had a discussion with the family and they chose not to do surgery but did wish to have a CT scan (radiological imaging). The CT scan revealed a massive bleed in the subarachnoid subdural (bleeding around the brain) and intraparenchymal bleeds (sudden bleeding in the brain tissue) of the brain. The document listed a diagnosis of subarachnoid hemorrhage after traumatic injury without an open intracranial (within the skull) wound, with prolonged (long time) loss of consciousness (awake and aware), and return to pre-existing level of consciousness. The Major Injury Determination Form signed by the Provider identified that R52 had a major injury following a fall from a chair. The form indicated R52's previous functional ability as an assist of one with a front-wheeled walker and a wheelchair for distance. The Investigation Report signed 1/20/23 indicated that a CNA heard an alarm sound and found R52 on the floor. The CNA alerted the nurse who completed an assessment on R52. The nurse transferred R52 to the hospital where they discovered a bitemporal (both temples) intraparenchymal hemorrhage (life-threatening condition where blood leaks into the brain ' s fluid filled spaces that cushion the brain) with extensive (large) subarachnoid and subdural blood. In addition, R52 had a small amount of intraventricular hemorrhage. The hospital admitted R52. On 1/17/23, R52 passed away at the hospital. During an interview with the MDS Coordinator on 3/30/23 at 6:03 PM, she stated the facility could not provide evidence that the facility completed a full investigation and determine the root cause of the 11/30/22 fall. The MDS Coordinator stated that she updated R52's Care Plan to include putting her in the recliner and not to leave her alone in a wheelchair when in room, because someone left R52 alone in the wheelchair prior to the fall. The MDS Coordinator added that she updated the Care Plan for R52 to have an alarm to her recliner and wheelchair on 12/2/22 after she observed R52 walking unattended in her room. During an interview on 3/30/23 at 7:30 PM, the Director of Nursing (DON) confirmed that the facility provided all of the investigation documentation and had no other information to provide. The DON confirmed that the facility did not have documentation of a thorough investigation into the root cause for R52's falls. During an interview on 3/30/23 at 9:00 AM, the Administrator stated that a root cause analysis should be completed when there is a major occurrence or injury. 2. During an interview on 3/27/23 at 2:40 PM, R34 stated that an agency Certified Nursing Assistant (CNA3) assisted her with a toilet transfer but they would not listen to her instructions which resulted in an injury to her ankle. R34 ' s Face Sheet listed an admitted [DATE] with the diagnoses of hemiplegia (paralysis, or inability to move on one side of the body) and hemiparesis (weakness on half the body) affecting the right non-dominant side. R34's MDS'' with an ARD of 2/14/23 identified a BIMS score of 15, indicating intact cognition. R34 required extensive assistance from two persons for transfers and toilet use. R34's paper Care Plan Problem initiated on 8/24/22 and revised on 2/22/23 with handwriting that indicated that she needed help with her care. The Goal listed that she would like to do what she could. The typed interventions instructed the following: - She had limited mobility on her right side from a prior stroke - Toilet assist: 2 persons assist. - Transfer: 1 person assist with transfers - Assist of 2 to toilet transfer only. Use an assist of 1 staff with the above transfer method and a second aide for dressing/hygiene assistance. Review of R34's Morse Fall Scale dated 2/14/23 and 11/17/22 listed a score of 50, indicating a high risk of falling. The untitled Document dated 1/3/23 indicated that R34 required an assist of one for all mobility transfers except in the bathroom. R34 required the assistance of two staff in the bathroom. The Toileting Plan Pull up/brief listed that R34 needed the assistance of two staff. The Comments identified that R34 had right sided weakness, transfer from the front. R34 needed the assistance of two staff with toilet use. The second staff completes the hygiene and dressing. The Incident Report dated 1/3/23 at 8:00 PM indicated that on 1/3/23 the nurse received a report that R34 complained of discomfort to her left foot following a transfer in the bathroom earlier in the shift. Upon exam at 8 PM, the nurse did not see discoloration or edema. R34 reported it felt better and thought it was ok. The Resident Description listed that CNA3 didn't transfer her the way she preferred, and she bumped her left foot during the transfer. The Immediate Action Taken directed CNA3 to transfer her only with the assistance of two in the bathroom. Additional information identified that CNA3 did not feel comfortable transferring R34 as she requested as she could not do clothing management from the front. Due to this, CNA3 transferred R34 from the side. The Incident Note dated 1/8/23 at 1:20 PM documented the summary of the incident as R34 advised the nurse that morning that she twisted/sprained her left ankle during a transfer earlier in the week. The nurse assessed the ankle and noted some bruising to the bottom of her foot. R34 went to the urgent care clinic for an evaluation with her daughter. Per R34 ' s daughter, the foot had a sprain (stretching or tearing of ligaments) but no fracture (break). R34's Radiology Report dated 1/8/23 identified that she had a three view X-ray of her left ankle due to ankle pain. The findings indicated that R34 Diffuse Osteopenia [low bone density]. No acute fracture of dislocation. Impression: Osteopenia without displaced fracture. CNA3's undated and unsigned statement described the incident with R34 as on January 6, 2023, she assisted a resident to the bathroom. CNA3 wrote that she placed a gait belt around R34 and helped her from her recliner chair to her wheelchair. Once they got to the bathroom, CNA3 had R34 help her with her transfer to the toilet. Once R34 finished using the bathroom, CNA3 helped her from the toilet by asking her to hold on to the bar in the bathroom so that she could wipe her and pull up her underwear. After R34 got cleaned and transferred back to her wheelchair she said she hurt her leg. CNA3 documented that she reported it to the nurse and the nurse went to.check on her. Certified Medical Assistant (CMA)2's Employee ' s Statement Form, dated 1/9/23, described the incident, as while she got people out for supper CNA3 came up to her and explained that R34 did not transfer well on the toilet. CNA3 reported that she had R34 grab onto the bar and transfer on the toilet. That Wednesday, R34 complained of left foot pain. CMA2 told CNA3 that R34 required two persons when using the toilet .After supper R34 told CMA2 what happened and wanted to talk to the nurse. CMA2 let the nurse know about the situation .When she put R34 to bed on 1/3/23 her left foot did not appear red or bruised. During an interview on 3/30/23 at 3:55 PM, CMA4 reported that R34 used the assistance of two persons to use the toilet. During an interview on 3/30/23 at 4:05 PM, CMA2 stated that following the incident, she received education regarding the incident and instructions to utilize a gait belt and two persons assist for toileting R34. During an interview on 3/30/23 at 6:30 PM with DON1 and DON2, both confirmed that the agency staff received education regarding transfers prior to their first shift. The DONs provided a copy of the education packet that they completed with all agency CNAs. DON1 and DON2 confirmed the involvement of CNA3 with the incident with R34. CNA3, has not worked at the facility following the incident. Review of the facility's education packet indicated information regarding two person transfers. The facility's form titled, Overview of questions/procedures that are expected to be known and followed by nursing staff revised November 2011 instructed the following - If I don't have time to read the resident's Care Plan, how do I know how to take care of them? CNA's are to utilize the ADL group sheets which are cheat sheets' to help you take care of the residents. Use of these are Mandatory every day and are passed from shift to shift. The 6a-2p shift shall initiate the ADL group shifts daily - If a resident is listed as being a two-person transfer but I feel like I can transfer them alone is that okay? NO! Care Plan/Activities of Daily Living (ADL) group sheets are to be followed at all times. They must be transferred with the assistance of two . CNA3's Personnel File included that she signed the form titled, Overview of questions/procedures that are expected to be known and followed by nursing staff on 12/30/22. Review of the undated facility's policy titled, Transfer (Standing Pivot Maximum Assist) One or Two Person revealed, Purpose: 1. To allow the resident, who is unable to initiate or sustain movement, to transfer with assistance. 2. To transfer the resident safely from bed to chair, toilet, or tub .Procedure: 1. Review the resident's plan of care and/or nurse aide care instructions .Two Person Transfer 1. Secure transfer belt around resident's waist. 2. CNAs stand facing the resident one on each side .7. Move the resident by having resident pivot feet, and CNAs moving their feet . 27071

Based on observation, interviews, record review and facility policy review, the facility failed to ensure the staff provided personal hygiene assistance to remove her facial hair for one of one resident (Resident (R16) sampled for activities of daily living (ADL). The facility's deficient practice increased R16 risk of negative impact on her self-esteem. Findings include: During an observation on 3/27/23 at 2:00 PM, R16 had multiple white/gray hairs on her chin (less than 10). When questioned about her facial hair, R16 cupped her hand over her chin and stated I must take care of those. During an observation on 3/28/23 at 1:36 PM, R16 had multiple white/gray hairs on her chin and next to the left side of her lip. During an observation on 3/28/23 at 5:07 PM with Certified Nursing Assistant (CNA) 6 while in R16's room CNA6 confirmed R16 had facial hair on her chin and lip. R16 told CNA6 she did not like or want facial hair. CNA6 stated the nursing assistants were responsible for assisting resident's personal hygiene including removal of facial hair. During an interview on 3/28/23 at 5:12 PM, Certified Medical Assistant (CMA)2 stated she was assigned to provide R16 ADL care that day. CMA2 stated R16 had facial hair and the hair should have been removed. CMA 2 stated the nursing assistant staff were responsible for ensuring residents were groomed when they got up from the bed in the mornings including the removal of facial hair. CMA2 verified on R16's Electronic Medical Record (EMR) the previous shift CMA5 documented she provided R16 with personal hygiene (the list included shaving) care that day, but she did not. During an interview on 3/30/23 11:29 AM, Registered Nurse (RN)1 stated she was assigned to R16's care. RN1 stated she was responsible for supervising the CNA staff. RN1 stated that the facility's policy directed the staff to shave women who had facial hair. RN1 stated the CNA and nursing staff were responsible for shaving the residents. RN1 stated she observed that R16 had facial hair at times. RN1 stated R16 should be shaved in the morning as part of her care. RN1 stated shaving residents should occur a couple times a week, daily, or whenever someone noticed they had hair. RN1 stated facial hair on female residents had potential to cause depression because of feeling embarrassed or feeling down on themselves because they cannot take care of themselves. Review of R16's undated ADMISSION RECORD under the front cover of the paper chart revealed R16 had an admitted [DATE] with multiple diagnoses including dementia and disorientation. Review of R16's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/7/23 revealed a Brief Interview for Mental Status (BIMS) with a score of seven out of 15, indicating severely cognitively impaired. The MDS included a diagnosis of dementia. R16 required one-person physical assistance with her ADLs. Review of R16's comprehensive Care Plan located in a binder provided by the Director of Nursing (DON)1 revealed I need help with my care initiated 11/16/22 and revised on 2/15/23 .personal hygiene .1 person assist ., without specific information regarding shaving. Review of the undated facility's policy titled Shaving The Resident revealed, .To improve the resident's appearance and self-esteem .To remove facial hair .

Based on observations, interviews and clinical record review, the facility failed to prevent pressure ulcers for 1 of 1 residents reviewed (Resident #33). The facility assessed the resident at high risk for pressure sore development per Braden assessment tool and care plan. The resident required extensive assistance of 2 staff with bed mobility and total assistance of 2 staff with transfers. The care plan failed to identify a repositioning plan for the resident prior to development of the deep tissue injury (DTI) heel pressure sore even though the resident required 2 staff to reposition and staff documented they observed the resident's heels pressing into bed and chair. According to occupational therapy (OT) notes, the resident used a standard wheelchair with foot buddy instead of her usual recliner chair due to repairs. Dietary did not address the DTI sore until one month after it developed and then ordered a supplement for healing. The facility reported a census of 85 residents. Findings include: A quarterly Minimum Data Set (MDS) with a completion date of 8/21/2019, showed [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS), documented a 9 out of 15 indicating moderately impaired cognition. The resident did not reject care. The resident was always incontinent of urine and frequently incontinent of bowel. The MDS documented the resident required 2 staff for transfers and bed mobility. The MDS coded the resident with limited range of motion upper and lower extremities, both sides. The MDS did not identify the resident with unhealed pressure sores. The MDS identified the resident used a pressure reducing device for bed and chair. It did not identify a turning/repositioning program. A care plan with initiation date of 11/30/18 and renewed 2/27/19, 5/29/19 and 8/21/19 identified the resident at risk for skin problems. The care plan failed to identify a repositioning plan for the resident prior to development of the heel sore even though the resident required 2 staff to reposition and was at high risk for pressure sore development. A plan sheet of paper contained with the care plan and dated 8/19/19 contained the first positioning directive which instructed staff to off load heels at all times and use a heelz up cushion/pillow as needed. Observation during initial tour at 10:28 AM on 10/28/19, revealed a dressing to left heel dated 10/28/19 and heel boots on bilaterally. The resident stated the dressing covered an intact sore area. According to the Matrix, the resident had a facility acquired, unstageable pressure ulcer. The MDS identified the following descriptions of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. An observation of the wound at 12:34 PM on 10/29/19 revealed an area on residents left heel approximately the size of a half dollar and black in color. Multiple observations during the survey period, found the resident to wear heel protectors in place to bilateral feet and heels floating with use of pillow. A Care Plan with original initiation date 11/30/18, revealed the resident required 2 person assist for bed mobility and transfers, with use of mechanical lift. The care plan identified a problem that revealed the resident at risk for skin problems. The care plan approaches were use of pressure relieving mattress and cushion in chair, and to offer heel bonnets at bedtime. On 8/20/19 documentation on the care plan identified a purple area to left heel; elastogel dressing left heel, assess daily and change as needed; and occupational therapy (OT) to evaluate and treat to off load heels. On 8/20/19 offload heels at all times using heelz up cushion or pillow as needed. On 9/18/19 [MEDICATION NAME] dietary supplement 2 times a day for wound healing. On 9/25/19 initial dressing intervention was discontinued and new treatment added; cleanse wound with wound cleanser, apply [MEDICATION NAME], cover with elastogel dressing as needed, and heelz up cushion in bed and recliner. A Braden Scale for predicting pressure sore risk dated 8/12/2019 indicated resident was at high risk for developing a pressure ulcer with a score of 15. A nursing progress note dated 8/19/19 at 3:30 PM revealed staff had noted a purple area to left heel, measuring 3.2 centimeters (cm) by 2 cm. The progress note identified the resident as very rigid and pressed her heels into the bed and recliner. The resident's son and Advanced Registered Nurse Practitioner (ARNP) were notified of the area at that time. The communication to the ARNP identified the area as a deep tissue injury (DTI). The ARNP responded with an order for [REDACTED]. A skin impairment form dated 8/19/19 at 2:21 p.m. did not identify any changes in status that contributed to sore development. A dietary progress note dated 8/21/19 at 9:26 PM did not identify pressure ulcers even though staff identified the pressure ulcer on 8/19/19. A dietary progress note dated 9/16/19, was the first assessment by dietary since the pressure ulcer developed on 8/19/19. Following the 9/16/19 dietician evaluation of the resident's status and the DTI of the heel, the dietician ordered [MEDICATION NAME] twice a day for wound healing Orders dated 8/19/19 by ARNP Occupational therapy to evaluate and treat for positioning Ensure plus 4 ounces twice per day with medication pass Elastogel dressing to left heel, assess daily and change as needed, and offload heels Order dated 9/17/19 by ARNP from nutritional recommendations [MEDICATION NAME] twice a day for wound healing Order dated 9/24/19 by ARNP following notification of increased size of DTI of left heel 3.8 cm. by 2.4 cm. Unstageable pressure ulcer to left heel Cleanse left heel wound with wound cleanser twice a day Apply [MEDICATION NAME] twice a day Cover with Elastogel dressing and change as needed Make sure to use heels up cushion in recliner and bed A non-pressure skin condition report sheet initiated on 8/19/19 identified the area as due to deep tissue injury. Dark purple area to left heel measured 3.2 cm x 2 cm. No exudate and surrounding skin pink in color. On 8/22/19, the area was documented as dark purple and measured 3.2 cm x 2 cm. No exudate and surrounding skin pink in color. No change. On 8/22/19, the area was documented as dark purple/brown and measured 3.2 cm x 2 cm. No exudate and surrounding skin pink in color. No change. On 8/26/19, the area was documented as dark purple intact skin and measured 3.2 cm x 2.1 cm. Surrounding skin pink in color and no change. On 8/29/19, the area was documented as dark purple intact and measured 3.2 cm x 2.1 cm. No exudate and surrounding skin normal in color. No change. On 9/5/19, the area documented as dark purple, not open and measured 3.2 cm x 1.8 cm. No exudate and surrounding skin normal in color. No change. On 9/9/19, the area documented as dark, not open and measured 3.4 cm x 2 cm. No exudate and surrounding skin normal in color. No change. On 9/12/19, the area documented as dark intact skin and measured 3.4 cm x 2.1 cm. No exudate and surrounding skin normal in color. No change. On 9/16/19, the area documented as dark purple intact skin and measured 3.5 cm x 2.2 cm. No exudate and surrounding skin normal in color. No change. On 9/19/19, the area documented as dark purple intact skin and measured 3.6 cm x 2.2 cm. No exudate and surrounding skin normal in color. No change. On 9/23/19, the area documented as dark, skin intact and measured 3.8 cm x 2.4 cm. No exudate and surrounding skin normal in color. No change. On 9/26/19, the area documented as dry & intact dark purple, tender to palpate and measured 5 cm x 3.7 cm. No exudate and no change. On 9/30/19, the area documented as dry & intact dark purple/black and measured 5.4 x 3.7 cm. No exudate and no change. On 10/3/19, the area documented as dry & intact dark purple and measured 4 cm x 3.6 cm. No exudate and no change. On 10/7/19, the area documented as dry & intact, dark purple/black and measured 4.3 cm x 4 cm. No exudate and skin color surrounding purple in color. No change. A wound/skin healing record report sheet was initiated on 10/11/19 for the left heel. Documentation revealed an unstageable area that measured 4 cm x 4.1 cm. with wound bed black eschar. No depth, no exudate, no odor, and skin surrounding normal in color. On 10/14/19, the area documented as unstageable and measured 4 cm x 4 cm. Wound bed black. No depth, no exudate, no odor, and normal skin color surrounding. Undated measurement 4 cm x 4 cm. Wound bed black/brown eschar. No depth, no exudate, no odor, and normal skin color surrounding. On 10/21/19, the area documented as unstageable and measured 4 cm x 4 cm. Wound bed black/brown eschar. No depth, no odor, no exudate, and normal skin color surrounding. On 10/28/19, the area documented as unstageable and measured 4 cm x 4 cm. Wound bed black/brown eschar. No exudate, no odor, and normal skin color surrounding. An OT note dated 8/30/19 identified in the area clinical impressions the resident with pressure reported on feet. The resident had a foot buddy on the wheelchair and had increased sitting time in the wheelchair as her lift chair was being fixed. An OT note dated 8/20/19 revealed the resident presented in standard wheelchair with foot buddy in place due to recliner being fixed at this time. The resident reported pain all over especially in feet. On 10/30/19 at 12:50 PM Staff C, the Co-Director of Nursing (Co-DON), reported the area to the resident's left heel was considered a deep tissue injury from the onset on 8/19/19 and nursing staff documented on the incorrect skin sheets. The Co-DON reported there were not positioning interventions in place for resident prior to the development of the pressure area to the left heel. The Co-DON reports she would expect the dietician to have reviewed and addressed resident's skin issues on 8/21/19.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure one of four residents were free from abuse (Resident #1). The facility identified a census of 90 residents. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] documented the pertinent [DIAGNOSES REDACTED].#1. The assessment documented the resident unable to complete a Brief Interview of Mental Status (BIMS) cognitive test, had short and long term memory losses, had unclear speech, sometimes understood verbal communication. The assessment identified Resident #1 exhibited physical and verbal behaviors 1-3 days of the 7 day assessment period. Resident #1 required limited assistance with one staff for completion of transfers, bed mobility, and ambulation; and two staff assistance for completion of hygiene and toileting. The assessment revealed Resident #1 always incontinent of bladder and frequently incontinent of bowel. Resident #1 received antipsychotic, antianxiety, and antidepressant medications for 7 of 7 days of the assessment period. The care plan problem initiated 4/20/14 and revised on 4/20/16 identified Resident #1 had alteration in thought processes/impaired mood and behaviors related to his/her [DIAGNOSES REDACTED]. The care plan documented Resident #1 utilize a wheelchair with a seat belt alarm, and for staff to not leave the resident unattended. The care plan problem dated 4/20/15 and revised 4/20/16 identified the resident incontinent of bladder and directed staff to complete perineal care as thoroughly as resident will allow. A Progress Notes entry completed by Staff A, registered Nurse (RN) on 6/19/16 at 12:41 AM documented the resident had been awake and smacking his/her fist into the other hand and taken to the common area at this time for distraction, given a snack as well as emotional support and music without success. Staff administered Latvian ( an antianxiety medication) at 11:45 PM for emotional comfort. The entry also documented the resident incontinent of bowel and bladder 2 times thus far on this shift. The Progress Notes entry completed by Staff A on 6/19/16 at 1:58 AM documented the resident had been out in the common area due to inability to calm and go to sleep, returned to bed at this time and had struck Staff A twice in the arm when readying the resident to return to bed. During interview on 7/22/16 at 1:39 PM, Staff A, RN stated she and Staff B, certified nursing assistant (CNA) were assigned to Resident #1 on 6/18/16 (Saturday) from 10:00 PM to 6:00 AM 6/19/16 (Sunday). Staff A stated Resident #1 exhibited physically aggressive behaviors towards staff during care through the shift. Staff A the resident had been in the common area and had been heavily incontinent of bowel. Staff A reported Staff A and Staff B stated took Resident #1 to his/her room. Staff A assisted Staff B with provision of perineal care. Staff A stated the resident hit her 2 times on the arm and had been kicking and swinging his/her arms at both she and Staff B. Staff A stated she witness Staff B backhand the resident on the right hand and said no, don't after the resident struck Staff B on her side. Staff A described what she meant by backhand and stated Staff B had stuck Resident #1 with the back of Staff B ' s open hand. Staff A told Staff B her action had been inappropriate and she should not have done that, and Staff B replied, she was sick of this sh(expletive). Staff A stated she considered Staff B's action towards Resident #1 as abusive and felt that she did report it immediately as she left a note for her supervisor; however, she also acknowledged she did have the ability to call management staff to report the incident at the time of occurrence. The facility's Abuse Prevention and Identification policy dated 11/15 included the following: All residents have the right to be free from mistreatment, verbal and mental abuse. The policy defined physical abuse and included hitting and slapping. During interview on 7/22 16 at 9:40 AM Staff C provided copies of staff education on the facility's abuse reporting policy conducted on 6/20-6/21/16. Staff C stated both Staff A and B were suspended on 6/20/16 after she received the note from Staff A when she came to work on the morning of 6/20/16. Staff C stated both Staff A and B were terminated from employment after facility investigation completed.

Based on record review and staff and resident interviews, the facility failed to protect Resident #8 against environmental hazards. The sample consisted of 8 residents reviewed with falls. The facility identified a census of 90 residents. Resident #8 left the walker and walked into the dining room. The laundry person pulled a laundry cart and the cart swung around and bumped into the resident which caused the resident to fall. As a result of the fall, the resident received facial, knee and eye bruising and a fractured humerous (upper arm). Findings include: 1. Resident #8 had a Minimum Data Set (MDS) assessment, with a reference date of 1/11/16.The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had no cognitive problems and independent with all activities of daily living (ADL's) skills. The resident ambulated with a four wheeled walker. The Nurse's Note dated 3/19/16 at 11:55 a.m. indicated the resident sustained [REDACTED]. The resident parked the walker in the hallway and ambulated to the dining room table. The laundry aide pulled the laundry cart and she believed the cart swung out and hit the resident. The resident stated something bumped me. The Nurse's Note continued assessment identified a 7.8 by 7.8 centimeter (cm) light purple bruise to the left cheek and eye area, a 3 by 1.2 cm abrasion on right knee and the Resident reported pain in the right arm but did not want to be evaluated in the emergency room . At 8:00 p.m. on the same day, Resident #8 continued to report pain to the right elbow. At 1:05 a.m. on 3/20/16 the resident complained of discomfort in the right arm and due to this pain refused to allow the nurse to touch the area; however the nurse did note a bruise to the right inner arm. The note on 3/20/16 at 11:30 p.m. documented the resident requested medication for pain to the right arm and knee and received two Tramadol tablets (a medication for pain relief). An x-ray report from the clinic dated 3/21/16, documented a possible nondisplaced right proximal humerus (upper arm) fracture with a follow up recommended (with physician). The physician's orders [REDACTED]. The Care Plan dated 3/22/16 indicated the resident needed increased assistance with ADLs as condition warranted during the acute episode. An undated statement from Staff G, a laundry aide, documented she pulled the personal clothing cart eastward along the south side of the south hallway on 3/19/16 when she bumped into Resident #8 with her back causing the resident to lose her balance and fall. The MDS assessment dated [DATE] documented Resident #8 now required one person physical assist with bed mobility, transferring, walking, dressing, toilet use and personal hygiene. During an interview on 5/11/16 at 3:10 p.m., the Laundry Supervisor reported it was his understanding that the aide was pulling the laundry cart backwards and did not see the resident and backed into him/her. The covered laundry cart is 5 foot long and 2 feet long and at least 6 foot tall with wheels that rotate in all directions. On 3/20/16 he implemented stable wheels on the laundry carts but staff did not like that so the facility implemented using 2 staff to move the cart through the halls, one to push and one to pull to maintain visibility. On 5/10/16 at 10:15 a.m. Resident #8 was interviewed and stated when standing in the hall with a walker, the tall laundry cart came up from behind and bumped the resident causing the fall. The resident reported continued pain in the right arm and knee.

Based on observation, medical record review, and resident and staff interviews, the facility failed to provide a safe environment to prevent accidents and failed to implement care plan interventions to prevent further burn injuries for one of eleven (11) residents reviewed (Resident #5). The facility reported a census of 92 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #5 dated 4/20/2015 included [DIAGNOSES REDACTED]. The MDS documented the resident's Brief Interview for Mental Status (BIMS) scores 15 out of 15, which indicated resident's cognitive level intact. The MDS documented the resident required one staff assistance with transfers, toilet use, dressing and hygiene. The MDS documented resident independent for eating and locomotion on the unit. The Care Plan dated 8/27/2014, and revised on 4/29/2015, indicated the resident had a risk of skin problems, and at risk for injury. The care plan documented a blister on the resident's right (R) thigh 1/6/2015, and on 5/6/2015, a note indicated resident spilled hot water on him/her(self). The care plan included the following interventions: a. Stop giving resident microwaved water or microwaving it so long or hot (1/6/2015). b. Do not microwave resident cup of hot water (1/7/2015). c. Staff re-educated not to give resident water heated in the microwave (5/6/2015). d. Advanced registered nurse practitioner (ARNP) to follow up for wound care. e. Monitor red areas, and observe for signs and symptoms of infection or deterioration of wounds and notify ARNP of any changes, and as needed. f. Monitor for pain and medicate as needed. Notify ARNP if unable to control discomfort. g. Treatment as ordered. h. High protein nutritional supplement. i. Waterproof clothing protector to be worn when drinking hot liquids. j. Anticipate resident's needs due to resident's right side affected. The physician's orders [REDACTED]. The resident told a Certified Nurse Aide (CNA) he/she dropped a cup of hot water. A dietary order sent to not microwave water so long or hot. In a progress note dated 1/5/2015 at 8:30 p.m., revealed reddened area on right (R) thigh measured 13 cm x 8 cm and small clear fluid filled blister. The resident reported he/she dropped and spilled cup of hot water at supper table. The intervention included dietary educated not to microwave water so long or hot. On 1/14/2015, the nurse documented on progress note, area to right thigh resolved. The progress note and an incident report dated 5/5/2015 at 4:15 p.m., revealed a CNA requested nurse to the resident's room to check burns the resident received from a cup of hot water. The nurse documented both inner thighs bright red and the left (L) thigh had a large blister. The nurse documented the (R) thigh had redness and 4 small blistered areas. The nurse left the resident's room and obtained dressing supplies. When the nurse returned to the resident's room, found the resident pulled blisters on left (L) thigh off and discarded the skin in the toilet. The nurse documented the wound sizes as follows: a. (L) thigh - 17.5 cm x 21 cm and drained large amount of clear serous drainage b. (R) inner thigh - reddened area measured 15 cm x 16 cm c. (R) proximal thigh blistered areas measured 3.9 cm x 4 cm d. (R) distal outer thigh blistered area measured 1 cm x 2 cm e. (R) distal medial thigh blistered area measured 2 cm x 2 cm f. (R) distal inner thigh blistered area measured 1.5 cm x 1.5 cm The nurse indicated elastogel and kling applied to both thighs per policy. The nurse documented the resident stated he/she sat at the dining room table and had hot water in a blue mug with a lid on. The resident reported when the cup tipped into lap, the lid came off, and hot water spilled on thighs. The physician's orders [REDACTED]. The physician requested to have the ARNP follow up and assess the resident on 5/7/2015. The intervention included no staff or dietary to heat liquids in microwave until further notice, and dietary notified. On 5/6/2015, the physician's orders [REDACTED]. The order included wound cleanser to cleanse wound, and application of silvadene, ABD dressing, and kling. On 5/8/2015, the physician's orders [REDACTED]. The order included an aquacel dressing applied to 2nd degree burn areas for 14 days. The treatment included daily and PRN (as needed) application of silvadene and dressing changes to 3rd degree burn area. The physician's orders [REDACTED]. a. Tramadol 50 mg four times a day as needed b. Silver sulfa cream 1% applied to 3rd degree burn daily. c. Aquacel AG 4x5 dressing applied to 2nd degree burn and leave on for 14 days. On 5/8/2015, the nurse documented treatment continued to bilateral thighs. The nurse indicated the blisters on (R) thigh intact and surrounding area reddened and tender. On the (L) thigh, area reddened and had 80% tan slough and tender to touch. The wounds had a large amount of serosanguinous drainage. The skin condition report included wound measurements on the resident's right (R) inner thigh on the following dates: 5/5/2015 - Reddened area 15 cm x 16 cm and 4 blistered areas: a) proximal blister 3.9 cm x 4 cm, b) distal outer blister 1 cm x 2 cm, c) distal mid-thigh blister 2 cm x 2 cm, and d) distal inner thigh blister 1.5 cm x 1.5 cm 5/6/2015 - reddened area 13 cm x 17 cm 5/11/2015 - 13 cm x 16 cm 5/18/2015 - 13 cm x 17 cm 5/28/2015 - 14 cm x 15 cm 6/4/2015 - 13.3 cm x 15 cm 6/15/2015 - one wound 1 cm x 1 cm, and one wound 1.5 cm x 1 cm 6/22/2015 - 0.5 cm x 0.2 cm 6/29/2015 - pink scar tissue present The skin condition report included wound measurements on the resident's left (L) inner thigh on the following dates: 5/5/2015 - 17.5 cm x 21 cm; the wound had a moderate amount serous drainage. 5/6/2015 - 18 cm x 23.5 cm 5/11/2015 - 18.8 cm x 20 cm 5/18/2015 - 18 cm x 20 cm; The wound had 95 % tan slough, and 5% red granulation tissue and a moderate amount serosanguinous drainage. 5/28/2015 - 16 cm x 20 cm; No drainage from wound. 6/4/2015 - 16 cm x 18 cm; the wound had a small amount of serosanguinous drainage. 6/15/2015 - unable to measure due to aquacel AG dressing not to be removed until seen by ARNP. 6/16/2015 - 11.5 cm x 7.5 cm; wound measured by ARNP on this date. 7/2/2015 - 11 cm x 4 cm; the wound had a scant amount of serous drainage The individual resident controlled substance record revealed 11/1/2014 as the last date the resident received Tramadol. The pain scale dated 4/20/2015 revealed the resident rated pain at 0, which indicated no pain. No documentation found regarding the resident's pain level since 4/20/2015. The medication administration record (MAR) revealed no PRN (as needed) Tramadol administered during the months of February 1, 2015 through May 13, 2015. According to the PRN administration record, on 5/14/15 Resident #5 received Tramadol three times in 24 hour period due to resident's legs ached. The resident continued to receive PRN Tramadol at least once a day consecutively from 5/15/2015 until 6/5/2015 for complaint of leg pain and burns. The resident received Tramadol PRN 27 times from 6/9/15 to 6/29/2015. During the seven day look back of survey dates, the resident continued to receive Tramadol 7/1/15, 7/2/15, 7/3/15 and 7/5/15. During initial tour on 7/6/2015 starting at 8:55 am, Staff J, Co-Director of Nursing reported the resident had a burn to leg from hot water spilled. During observation on 7/7/2015 at 9:27 a.m., Staff E, Licensed Practical Nurse (LPN) removed the dressing on the resident's (L) thigh. Observed (L) thigh burn area reddened and had large open area on (L) inner thigh. The entire area had an irregular oval shape, 6.5 inches x 4 inches, and tissue protruded through open areas on (L) upper medial thigh. The (R) thigh burn area appeared pinkish white with reddened areas. The (R) thigh burn healing and left open to air. During interview 7/8/2015 at 4:05 p.m., Resident #5 reported hot water spilled on lap 2 months ago. The resident reported staff normally brings him/her a cup of hot water and place the water on a stand next to the chair in his/her room. On the afternoon on 5/5/15, the resident went to the dining room and requested a cup of hot water. An aide placed the water in the microwave. The aide brought cup of hot water and set it on the table. When the resident turned in chair, the cup of hot water tipped over and the lid on cup came off, and spilled hot water on the resident's legs. The resident stated he/she called for help but nobody in area. The resident went back to his/her room to the bathroom and moved his/her pants down, and called for assistance. The resident stated, his/her legs were scalded. The resident stated he/she had a stroke, and his/her right side is paralyzed. The resident reported burned area painful for a while and recently the burned area hurt when staff removed dressing and performed wound care. The resident reported took pain medication for discomfort related to leg pain and burns. Resident #5 voiced a concern a scar would be left from burns. The resident reported liquids or hot water cup placed on table in dining room anywhere on the table, not placed on (L) side where cup would be more accessible. During interview on 7/8/2015 at 4:25 p.m., Staff F certified nursing assistant (CNA), stated they are not supposed to warm anything in microwave, and had not warmed anything in microwave since told not to. During interview on 7/8/2015 at 4:28 p.m., Staff G, CNA, reported not no longer able to warm things up in microwave. Staff G reported they are not allowed to warm things in microwave since a resident got burned. During interview on 7/8/2015 at 4:32 p.m., Staff H, dietary aide, revealed the safeway, divided plates don't warm up very well in microwave, so food placed in another container and placed in microwave and heated up. When microwaved, the container placed in microwave about a minute, checked to see if item hot enough, and then place container or cup back in microwave if needed. During interview on 7/8/2015 at 4:35 p.m., Staff I, dietary aide, advised he/she doesn't heat water in microwave. Staff I stated carafe filled with hot water or coffee, and gave residents water or coffee obtained from carafe. On 7/9/2015 at 9:25 a.m., Staff K, Co-Director of Nursing advised no policy for skin or burns and gave copy of unusual occurrence policy. In a revised policy dated 10/09, titled Unusual Occurrences , revealed purpose to ensure resident's environment remained as free of accident hazards as possible, and to ensure resident received adequate supervision and assistive device to prevent accidents. On 7/9/15 at 10:25 a.m., (during report of findings), the dietary manager stated they ordered a special waterproof clothing protector so the resident didn't burn him/her(self). The dietary manager reported challenge of resident would not wear the clothing protector because the protector looked different than what the other residents wore. Staff K, also present reported things are not warmed in microwave by staff. When a resident requested something to be warmed up, they don't do it. Coffee and hot water obtained from Carafe, and liquid in carafes already hot or what temperature should be.

Based on observation, record review, interviews with certified wound and ostomy care nurse (CWOCN), and staff interview, the facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable for one (1) of four (4) residents (Resident #1). An unidentified staff placed Resident #1 on the bedpan and left the resident on the bedpan for an undetermined amount of time. When staff later found the bedpan under the resident, the resident suffered Deep tissue Injury to the buttocks due to prolonged bedpan placement. Facility census was ninety-two (92) residents. Findings include: 1. A Significant Change Minimum Data Set (MDS) with assessment reference date of 2/12/14 assessed Resident #1 with a brief interview for mental status (BIMS) score of "9" (moderate cognitive impairment). The resident required extensive assistance of 2 staff with bed mobility and total assistance of staff with dressing, eating, toileting, personal hygiene and bathing. The resident did not ambulate. The resident had functional range of motion limitations of one side of the upper and lower extremities. The resident was incontinent of bowel and not on a toileting plan. The resident had [DIAGNOSES REDACTED]. The resident had a condition that may result in a life expectancy of less than 6 months. The resident was 72 inches tall and weighed 344 pounds. The MDS identified the resident with a Stage 2 pressure sore present since 2/6/14. On 3/12/14 at 9:15 a.m., Staff E (Director of Nursing) stated the Stage 2 area identified on the MDS was a blister found on the resident's chest. A urinary incontinence and indwelling catheter care area assessment (CAA) worksheet dated 2/13/14 identified the resident as incontinent of bowel since a recent [MEDICAL CONDITION]. The resident also used an indwelling Foley catheter. The resident's skin was dry, intact and without redness or open areas. The resident was on Hospice. A pressure ulcer CAA dated 2/13/14 identified the resident at risk for pressure areas related to altered mobility. The resident recently had [MEDICAL CONDITION] resulting [MEDICAL CONDITION]. According to the CAA, staff turned the resident routinely in bed and performed all cares for the resident. A Braden scale for predicting pressure sore risk dated 2/13/14, identified the resident with a score of "11". A score of 12 or less identified the resident at high risk for pressure sore development. Resident progress notes dated 1/30/14 at 3 p.m., identified the resident readmitted to the facility from the hospital with [DIAGNOSES REDACTED]. The resident's had slurred speech. The resident appeared lethargic and the skin appeared intact. The entry also identified that the resident admitted to Hospice when he/she readmitted to the facility. A care plan dated 2/13/14, revealed the resident required assistance with cares and used a catheter. The resident may ask to use the bedpan for a bowel movement (BM) or the resident may have incontinence. The care plan advised staff to check the resident routinely. The resident required two staff for dressing, personal hygiene, bed mobility and transfers with a mechanical lift using the green sling. The care plan also identified that the resident had skin issues and used an air flow mattress on the bed. The care plan did not address repositioning. Review of the nurse aide care sheets dated 2/16/14 and 2/17/14 did not address repositioning. An Incident/Accident Report dated 2/17/14 documented at 4:15 p.m. Resident #1 ' s physician had been informed the resident had been sitting on a bedpan. The steps to prevent recurrence identified the resident would not be left alone while on bedpan. Staff may stand outside the door to provide privacy. The care plan for skin problems dated 2/17/14 identified the resident did not want to lay on his/her side and wanted to stay on his/her back. The care plan revealed staff should encourage the resident to change position. On 2/17/17 the care plan directed the CNA who places the resident on the bedpan must stay with him/her until he/she was finished; and if the resident had been given the bedpan around shift change, the CNA must stay with the resident until he/she finishes. On 2/18/14, the facility padded the bedpan every time the resident needed to use it and sent it to laundry for cleaning. Wound Assessment: On 2/3/14 a physician telephone order directed staff to reposition the resident every two to four hours. On 2/17/14 resident progress notes identified the initial wound measurement as 28 centimeters (cm.) by 23 cm. red ring to the bilateral buttocks Width at the top of the ring was 0.4 cm. and pale pink, on the right of the ring it measured 1.3 cm. and was dark red, at the bottom end of the ring the measurement was 1.3 cm. and pale pink and the left side of the ring measured 1.1 cm. and was dark red. The tissue was intact and surrounding tissue normal for skin. The resident did not voice any discomfort. Resident progress notes, dated 2/17/14 at 12:45 p.m. also identified a 1 centimeter (cm.) by 2 cm. superficial abrasion to the left midbuttock that appeared at the same time as the bedpan ring skin injury. On 2/21/14 the CWOCN (certified wound and ostomy care nurse) examined the areas and identified the resident with traumatic pressure after resident found on fracture pan. The resident presented with abrased tissue in the outline of a fracture pan. The area measured 28 centimeters (cm.) by 23 cm. with an area of the abrased pressure area of the left opened to partial thickness skin loss measuring 3.5 cm. long by 0.5 cm. wide. The abrased area were healing well with the widest measurement at 0.5 cm. No other open areas other than the left buttock with a small amount of serosanguineous drainage. The resident voiced that he/she did not want to turn every two hours. The CWOCN diagnosed the resident with: Deep Tissue Injury related to pressure/trauma of fracture pan. The CWOCN identified an area on the left buttock that healed. The CWOCN directed staff to apply 3M foam with [MEDICATION NAME] to the left buttock shear area daily and Valsolex to the "ring" twice a day. Resident progress notes dated 2/24/14 at 2 p.m., revealed the resident continued to have dark red areas on lateral aspects of the red ring, measuring 20 centimeters (cm.) long by 1 cm. wide. The proximal and distal areas appeared essentially resolved. The area on the left buttock measured 3.5 cm. by 1 cm. partial thickness skin loss with scant amount of serosanguineous drainage. A new area of shearing on the right buttock measured 8 cm. by 1 cm. partial thickness skin loss with scant amount of serosanguineous drainage. At that time, staff updated the CWOCN and received orders for the right buttock Resident progress notes dated 2/28/14 at 11:30 a.m., revealed the reddened areas on the lateral aspects of the red ring appeared lighter in color. The partial thickness areas on both sides had granulation tissue present. The remainder of the skin on the buttocks was intact. Resident progress notes dated 3/4/14 revealed the lateral red lines on the bilateral buttocks continued to improve. The reddened area left buttock measured 18 centimeters (cm.) in length with superficial open area measuring 5.5 cm. by 0.7 cm.. The reddened line on the right side measured 12 cm. by 0.5 cm. with skin intact. Resident progress notes dated 3/10/14 at 10:45 a.m. revealed the red line on the left buttock measured 18 centimeters in length with 3 superficial areas noted on the medial aspects proximal to the distal measuring 0.6 cm. by 0.3 cm., 2.6 cm. by 0.4 cm. and 0.5 cm. by 0.4 cm. with scant amount of serosanguineous drainage noted on old dressing. The reddened area on the right buttock measured 9.5 cm. in length with a 4.5 cm. by 0.3 abraded intact area on the medical aspect. The resident denied discomfort from areas except when areas 'rubbed". Observation showed on 3/10/14 at 10:18 a.m. two staff turn the resident, while Staff F measured and provided treatment to the resident's buttock areas. Prior to beginning treatment, Staff F identified that the resident's air mattress was broken. A piece on the pump connection broke. Observation showed two large foam/[MEDICATION NAME]es on the resident's buttocks one on the right and one on the left buttock. Dates on the patches were 3/9/14. Long linear red welt type areas were present on each buttock Staff F measured the left linear area as 18 cm. and the right linear area as 9.5 cm. The left linear area contained three linear open areas (see above for measurements) and the right contained a abraded indented area measuring 4.5 cm. by 0.3 cm. Staff F provided treatment to the areas as ordered. At 10:40 a.m. of the same date the surveyor spoke with the resident. The resident identified self as on the bedpan too long and stated he/she did not remember who placed him/her on the bedpan. When asked how long he/she thought he/she laid on the bedpan, the resident stated 3 to 4 minutes. The resident was able to identify the year, town and name of the facility correctly. The resident did not know the month or the President's name. On 3/11/14 at 1:03 p.m. the CWOCN stated when she observed the areas one side was open alittle and later Staff F called and said the other side opened. She stated normally deep tissue injury eventually does open. It makes the area more fragile so just moving the resident alittle can shear the area and open it. She stated the deep tissue injury opened into a shear since it was fragile due to the fracture pan in place for a prolonged period. She stated she had no idea how long the fracture pan would have been in place to create the area. She was told 6 hours. She stated the resident's alternating mattress is not a reason not to turn the resident. The mattress doesn't really get the resident off his/her bottom. It is still against the mattress and the resident is heavy. The mattress is better than no repositioning however. The skin injury was not from lack of repositioning. The skin injury was from the prolonged bedpan placement. On 3/11/14 at 12:05 p.m. Staff F (licensed practical nurse) stated an abraded area showed up on the inner left buttock at the same time as the bedpan ring. She measured the initial areas and performed the subsequent measurements. The following gives information concerning Resident #1's placement on a fracture (low flat) bedpan [MEDICATION NAME] for an undetermined amount of time: Staff Working 2/16/14 6 a.m. to 2 p.m. shift On 3/10/14 at 12:18 p.m. Staff I (nurse aide) stated she gave the resident the bedpan at 1:45 p.m. and informed the oncoming shift (at 2 p.m.) staff of the resident using the bedpan. Staff I stated she told Staff A, Staff C, Staff R and Staff T the resident had been on the bedpan. Staff Working 2 p.m. to 10 p.m. shift On 3/6/14 at 1:40 p.m. Staff A (nurse aide) confirmed she heard the resident used the bedpan at the change of shift report. She stated right after 2 p.m. report, she asked the resident if he/she finished and the resident said no so she left to give the resident more time and she forgot to go back. Staff A reported Resident #1 used the Hoyer lift and she did not hear anyone radio for help. Staff A reported then Staff C (nurse aide) said he gave the resident a shower and she heard Staff T had helped. Staff A was unsure of the time the resident received the shower or see the resident out of bed coming or going from the shower. Staff A went in to give bedtime care around 9 p.m. to 9:30 p.m. and then it dawned on her the resident had last been on the bedpan. Staff A thought the resident was cognitively intact so she asked the resident if he/she was still on the bedpan. The resident denied being on the bedpan. During bedtime care, Staff A did not do anything with the resident's posterior side because the resident said he/she did not want to be moved because he/she felt comfortable. That was the last time Staff A saw the resident that night and that was around 10 p.m. Staff A stated the resident normally used his/her call light to let staff know they finished using the bedpan. Since the resident came back from the hospital on [DATE], the resident has not used the call light at all but Staff A was not aware of that on 2/16/14. Staff A stated all the staff working that night knew the resident was on the bedpan and they probably all waited for the resident to put his/her call light on and when the resident didn't, they just thought someone else removed the bedpan. She stated she asked the resident to reposition but the resident will say no because he/she is comfortable. On 3/6/14 at 4:04 p.m. Staff C (nurse aide) stated he asked the resident at the beginning of the shift about taking a shower. The resident agreed to the shower. Around 5:30 p.m. he gave the shower. He stated Staff T (nurse aide) assisted with the transfers in and out of bed. Staff C stated when they got the resident up, the resident was not on the bedpan and when they laid the resident down, he did not place the resident on the bedpan. On 3/11/14 at 2:25 p.m. he stated the skin on the resident's bottom was intact and without redness when he provided care on 2/16/14. Staff T (nurse aide) did not return phone calls. In an employee statement form, dated 2/18/14 Staff T stated she assisted Staff C in transferring the resident for a shower between 5 p.m. and 6 p.m. She fed the resident supper shortly after 6 p.m. Between 6:20 p.m. and 6:30 p.m. the resident finished eating and she refilled the resident's water pitcher and left the room. That was the last time Staff T saw the resident that shift. Staff T documented she was never asked to assist in the resident ' s room and never notified he/she was on the bedpan or needed off the bedpan. On 3/6/14 at 2:10 p.m., Staff D (registered nurse) stated the resident received a suppository on the day shift on 2/16/14 and between 5 p.m. and 6 p.m. Staff C and Staff T gave the resident a bed bath and he/she was not on the bedpan then. Staff D stated she did not know of staff placing the resident on the bedpan on her shift (2 p.m. to 10 p.m.) Staff D stated staff normally provides the bedpan and then leaves the resident for privacy and the resident rings the call light when finished. Staff D stated since the resident's hospital return, he/she is not as reliable about using the call light. She stated the staff tries to reposition the resident but the resident will refuse. The resident also uses a special mattress that alternates pressure. On 3/10/14 at 2:20 p.m. Staff P (nurse aide) stated she did not work with the resident that day. On 3/10/14 at 4:33 p.m. Staff R (nurse aide) stated she did not go in the resident's room that shift. All other staff working on other units were questioned and wrote statements that they did not provide care to the resident. Staff Working 11 p.m. to 7 a.m. 2/16/14 into 2/17/14 On 3/16/14 at 2:48 p.m., Staff B (nurse aide) stated on 2/16/14 staff did not do rounds on the resident. They only went in if the resident called staff in with the call light. She stated staff tries to reposition the resident but the resident and family stated not to if the resident didn't want it. She stated she checked on the resident that night. She stated checking did not include repositioning or checking the resident's bottom. She stated she didn't ask the resident if he/she used the bedpan that evening. On 3/6/14 at 3:47 p.m. Staff G (licensed practical nurse) stated they had a very busy night on 2/16/14. She saw the resident 3 to 4 times that night. She stated it takes two to three people to turn the resident at night. She stated the resident was repositioned that night. She did not assist but at 11 p.m. rounds she observed the resident on the right side, at 1 a.m. the pillow was out from the resident and at 3:30 p.m., she observed the resident on his/her back. She stated normally staff takes the resident off the bedpan when he/she puts the call light on. She stated the resident's family requested that staff not reposition the resident as often. For awhile they repositioned the resident once a shift but she stated that night it was every two hours. On 3/13/14 at 9:24 a.m. Staff U stated she did not go in the resident's room that night. She looked at the resident when she passed by in the hall and the resident appeared asleep. All other staff that worked on other units were questioned and wrote statements that they had no contact with the resident. Staff Working 2/17/14 6 a.m. to 2 p.m. shift: On 3/10/14 at 12:18 p.m. Staff I (nurse aide) stated she worked 2/17/14 and when she and Staff J (nurse aide) prepared to get the resident up at 11:45 a.m., they found a bedpan sealed to the resident's bottom. They observed loose stools in the bedpan. The resident said "ouch" when they removed the bedpan and also at that time, they observed a red mark outline of the bedpan on the resident's bottom. The resident said he/she had been on the bedpan for awhile. She stated no one from night shift reported the resident was on the bedpan at shift report. Staff I stated she cleaned the front of resident up that morning and the resident denied pain. She stated she did not turn the resident that morning and did not check the resident's posterior side. She stated the resident stated he/she would get up for lunch so she planned on finishing care to the posterior side of the resident then. She stated the resident used a mattress that turned him/her. On 3/11/14 at 1:35 p.m. Staff I stated she did ask the resident to reposition twice that morning and the resident refused. Staff I prepared an activity log as to what she did for the resident on 2/17/14 at 6 a.m. She wrote the resident was asleep. At 7:15 a.m., Staff I cleaned the resident and refilled his/her water and gave the resident a drink. At 8:15 a.m. Staff J (nurse aide) checked to see if the resident wanted anything for breakfast. Staff I wrote in her written statement that she did not see the bedpan under the resident when she cleaned him/her. At 11 a.m. Staff I and Staff J went in to see if the resident was ready to get up and the resident stated he/she needed a few more minutes. At 11:45 a.m. they went back in and he complained of pain and they found the bedpan. On 3/10/14 at 12:47 p.m. Staff J (nurse aide) stated she got a text at 5:30 a.m. on 2/17/14 from Staff C. Staff C asked her to mark the resident's shower in the book because he forgot the night before. About 8 a.m. of the same date, she asked the resident if he/she wanted a drink and she gave the resident water. Around 11 a.m. she asked the resident if he/she was ready to get up. At 11:45 a.m. she went back to the resident and started getting the resident ready for lunch. She pulled up the resident's bottom sheet and began to apply the resident's socks and pants and when she got to the resident's knees with the pants, she moved the sheet over and saw the bedpan. She asked Staff I if she put the resident on the bedpan and Staff I said no. They turned the resident to remove the bedpan. After removing the bedpan they saw the ring on the resident's bottom. Staff J stated the bedpan was "sealed" to the resident's bottom. Staff J reported Resident #1 requires two person to assist with his/her needs. They called Staff Q (licensed practical nurse). The resident stated he/she used the bedpan for quite awhile. Staff J stated the resident normally called when he/she finished using the bedpan. Regarding repositioning, Staff J stated staff was told they could ask the resident to reposition and if the resident said no then leave the resident alone. This was a family request. She stated she asked the resident to reposition at 8 a.m. but the resident said no because he/she was comfortable. Staff J then asked the other staff on the unit if they placed the resident on the bedpan and they all said no. When night shift gave her report, they never said the resident was on the bedpan. On 3/10/14 at 4:10 p.m., Staff Q (licensed practical nurse) stated she worked on 2/17/14. Staff I came to her and told her she would give the resident a bedbath between 8 a.m. and 9 a.m. and Staff Q said fine. At 11 a.m. the nurse aides called Staff Q into the room regarding the bedpan they removed. Staff Q stated she called Staff F (licensed practical nurse). Staff Q asked who put the resident on the bedpan and all staff denied they placed the bedpan. At the end of the shift, Staff Q wrote Staff I up because she failed to do a complete bath. Later Staff I stated she told Staff Q she hadn' t performed the posterior side of the resident's bath but Staff Q stated Staff I did not report this information at the time. Staff Q stated the night shift did not report that the resident had loose stools or was on the bedpan. Staff Q stated when the resident returned from the hospital on [DATE], the resident's family told staff if the resident didn't want to reposition then don't reposition him/her, but still offer it. Staff Q stated before the resident went to the hospital, he/she would let staff know when they wanted off of the bedpan. Staff Q stated she observed the resident's bottom after the bedpan removal. There was an indented area that allowed staff to see perfectly where the bedpan was. She stated one of the buttocks contained an abrasion but it was not in the indented areas. On 3/6/14 at 3:20 p.m. Staff F (licensed practical nurse) stated the nurse aides informed her they found the resident on the bedpan and that they did not put the resident on the bedpan. Staff F stated the resident has not been as good about using the call light since return from the hospital. The resident does ask for the bedpan and it takes 2 to 3 people to place the bedpan under the resident. Staff F stated the resident is on a repositioning mattress and would refuse repositioning. On 3/10/14 at 1:45 p.m. Staff L (nurse aide) stated she did not go in the resident's room on the day staff found the bedpan under the resident. She stated no one reported the resident was on the bedpan that morning. On 3/10/14 at 1:27 p.m. Staff K (nurse aide) stated she was not in the resident's room that morning. She stated since the resident returned from the hospital, she places the bedpan and then goes back in 20 to 30 minutes. She stated staff goes and checks on the resident if they haven't heard from him/her when the bedpan is in place. Staff K stated someone placed the resident on the bedpan and it takes two people to do it. No one is coming forward and no one turned the resident during that time. All staff working on other units, other than two staff that did not return phone calls, were interviewed and they all denied placing the bedpan. Facility Policy: The facility bedpan/urinal/fracture pan policy directed staff to "never leave a resident sitting on a bedpan/fracture or with a urinal for a prolonged period, as contact with them can create pressure and irritation". The policy indicated if a resident is unable to call, check them frequently while the bedpan is in place. On 3/6/14 at 11:45 a.m., Staff E (Co Director of Nursing) identified herself as in charge of the unit that Resident #1 lived on. She stated she investigated the incident and could not conclude who placed the bedpan. She stated statements from staff identified staff that placed the resident on the bedpan are not being truthful and coming forward. It takes two staff to place and remove the bedpan. She stated prior to the resident's stroke on 1/24/14 the resident was "interviewable". Prior to the stroke the resident called for the bedpan and then called when he/she finished using the bedpan. The resident used a fracture pan for elimination. Since the stroke the resident declined cognitively and physically and is on Hospice. Staff is now directed to stay with the resident until the resident is finished using the bedpan.

Based on observation, record review, interviews with certified wound and ostomy care nurse (CWOCN), and staff interview, the facility failed to ensure Resident #1 received adequate supervision from hazards in the environment. An unidentified staff placed Resident #1 on the bedpan and left the resident on the bedpan for an undetermined amount of time. When staff later found the bedpan under the resident, the resident suffered Deep tissue Injury to their buttocks due to prolonged bedpan placement. Facility census was ninety-two (92) residents with four residents reviewed. Findings include: 1. A Significant Change Minimum Data Set (MDS) with assessment reference date of 2/12/14 assessed Resident #1 with a brief interview for mental status (BIMS) score of "9" (moderate cognitive impairment). The resident required extensive assistance of 2 staff with bed mobility and total assistance of staff with dressing, eating, toileting, personal hygiene and bathing. The resident did not ambulate. The resident had functional range of motion limitations of one side of the upper and lower extremities. The resident was incontinent of bowel and not on a toileting plan. The resident had [DIAGNOSES REDACTED]. The resident had a condition that may result in a life expectancy of less than 6 months. The resident was 72 inches tall and weighed 344 pounds. The MDS identified the resident with a Stage 2 pressure sore present since 2/6/14. On 3/12/14 at 9:15 a.m., Staff E (Director of Nursing) stated the Stage 2 area identified on the MDS was a blister found on the resident's chest. Resident progress notes dated 1/30/14 at 3 p.m., identified the resident readmitted to the facility from the hospital with [DIAGNOSES REDACTED]. The resident's had slurred speech. The resident appeared lethargic and the skin appeared intact. The entry also identified that the resident admitted to Hospice when he/she readmitted to the facility. A care plan dated 2/13/14, revealed the resident required assistance with cares and used a catheter. The resident may ask to use the bedpan for a bowel movement (BM) or the resident may have incontinence. The care plan advised staff to check the resident routinely. The resident required two staff for dressing, personal hygiene, bed mobility and transfers with a mechanical lift using the green sling. The care plan also identified that the resident had skin issues and used an air flow mattress on the bed. The care plan for skin problems dated 2/17/14 identified the resident did not want to lay on his/her side and wanted to stay on his/her back. The care plan revealed staff should encourage the resident to change position. On 2/17/17 the care plan directed the CNA who places the resident on the bedpan must stay with him/her until he/she was finished; and if the resident had been given the bedpan around shift change, the CNA must stay with the resident until he/she finishes. On 2/18/14, the facility padded the bedpan every time the resident needed to use it and sent it to laundry for cleaning. An Incident/Accident Report dated 2/17/14 documented at 4:15 p.m. Resident #1 ' s physician had been informed the resident had been sitting on a bedpan. The steps to prevent recurrence identified the resident would not be left alone while on bedpan. Staff may stand outside the door to provide privacy. A typed document with Resident #1 ' s name revealed effective immediately, anytime Resident #1 was on the bedpan, one staff will remain with him/her until he/she was finished. On 2/17/14 resident progress notes identified the initial wound measurement as 28 centimeters (cm.) by 23 cm. red ring to the bilateral buttocks Width at the top of the ring was 0.4 cm. and pale pink, on the right of the ring it measured 1.3 cm. and was dark red, at the bottom end of the ring the measurement was 1.3 cm. and pale pink and the left side of the ring measured 1.1 cm. and was dark red. The tissue was intact and surrounding tissue normal for skin. The resident did not voice any discomfort. Resident progress notes, dated 2/17/14 at 12:45 p.m. also identified a 1 centimeter (cm.) by 2 cm. superficial abrasion to the left midbuttock that appeared at the same time as the bedpan ring skin injury. On 2/21/14 the CWOCN (certified wound and ostomy care nurse) examined the areas and identified the resident with traumatic pressure after resident found on fracture pan. The resident presented with abrased tissue in the outline of a fracture pan. The area measured 28 centimeters (cm.) by 23 cm. with an area of the abrased pressure area of the left opened to partial thickness skin loss measuring 3.5 cm. long by 0.5 cm. wide. The abrased area were healing well with the widest measurement at 0.5 cm. No other open areas other than the left buttock with a small amount of serosanguineous drainage. The resident voiced that he/she did not want to turn every two hours. The CWOCN diagnosed the resident with: Deep Tissue Injury related to pressure/trauma of fracture pan. The CWOCN identified an area on the left buttock that healed. The CWOCN directed staff to apply 3M foam with tegaderm to the left buttock shear area daily and Valsolex to the "ring" twice a day. Resident progress notes dated 2/24/14 at 2 p.m., revealed the resident continued to have dark red areas on lateral aspects of the red ring, measuring 20 centimeters (cm.) long by 1 cm. wide. The proximal and distal areas appeared essentially resolved. The area on the left buttock measured 3.5 cm. by 1 cm. partial thickness skin loss with scant amount of serosanguineous drainage. A new area of shearing on the right buttock measured 8 cm. by 1 cm. partial thickness skin loss with scant amount of serosanguineous drainage. At that time, staff updated the CWOCN and received orders for the right buttock Resident progress notes dated 2/28/14 at 11:30 a.m., revealed the reddened areas on the lateral aspects of the red ring appeared lighter in color. The partial thickness areas on both sides had granulation tissue present. The remainder of the skin on the buttocks was intact. Resident progress notes dated 3/4/14 revealed the lateral red lines on the bilateral buttocks continued to improve. The reddened area left buttock measured 18 centimeters (cm.) in length with superficial open area measuring 5.5 cm. by 0.7 cm.. The reddened line on the right side measured 12 cm. by 0.5 cm. with skin intact. Resident progress notes dated 3/10/14 at 10:45 a.m. revealed the red line on the left buttock measured 18 centimeters in length with 3 superficial areas noted on the medial aspects proximal to the distal measuring 0.6 cm. by 0.3 cm., 2.6 cm. by 0.4 cm. and 0.5 cm. by 0.4 cm. with scant amount of serosanguineous drainage noted on old dressing. The reddened area on the right buttock measured 9.5 cm. in length with a 4.5 cm. by 0.3 abraded intact area on the medical aspect. The resident denied discomfort from areas except when areas 'rubbed". Observation showed on 3/10/14 at 10:18 a.m. two staff turn the resident, while Staff F measured and provided treatment to the resident's buttock areas. Prior to beginning treatment, Staff F identified that the resident's air mattress was broken. A piece on the pump connection broke. Observation showed two large foam/tegaderm patches on the resident's buttocks one on the right and one on the left buttock. Dates on the patches were 3/9/14. Long linear red welt type areas were present on each buttock Staff F measured the left linear area as 18 cm. and the right linear area as 9.5 cm. The left linear area contained three linear open areas (see above for measurements) and the right contained a abraded indented area measuring 4.5 cm. by 0.3 cm. Staff F provided treatment to the areas as ordered. At 10:40 a.m. of the same date the surveyor spoke with the resident. The resident identified self as on the bedpan too long and stated he/she did not remember who placed him/her on the bedpan. When asked how long he/she thought he/she laid on the bedpan, the resident stated 3 to 4 minutes. The resident was able to identify the year, town and name of the facility correctly. The resident did not know the month or the President's name. On 3/11/14 at 1:03 p.m. the CWOCN stated when she observed the areas one side was open alittle and later Staff F called and said the other side opened. She stated normally deep tissue injury eventually does open. It makes the area more fragile so just moving the resident alittle can shear the area and open it. She stated the deep tissue injury opened into a shear since it was fragile due to the fracture pan in place for a prolonged period. She stated she had no idea how long the fracture pan would have been in place to create the area. She was told 6 hours. She stated the resident's alternating mattress is not a reason not to turn the resident. The mattress doesn't really get the resident off his/her bottom. It is still against the mattress and the resident is heavy. The skin injury was from the prolonged bedpan placement. On 3/11/14 at 12:05 p.m. Staff F (licensed practical nurse) stated an abraded area showed up on the inner left buttock at the same time as the bedpan ring. She measured the initial areas and performed the subsequent measurements. The following gives information concerning Resident #1's placement on a fracture (low flat) bedpan lasting for an undetermined amount of time: Staff Working 2/16/14 6 a.m. to 2 p.m. shift On 3/10/14 at 12:18 p.m. Staff I (nurse aide) stated she gave the resident the bedpan at 1:45 p.m. and informed the oncoming shift (at 2 p.m.) staff of the resident using the bedpan. Staff I stated she told Staff A, Staff C, Staff R and Staff T the resident had been on the bedpan. Staff Working 2 p.m. to 10 p.m. shift On 3/6/14 at 1:40 p.m. Staff A (nurse aide) confirmed she heard the resident used the bedpan at the change of shift report. She stated right after 2 p.m. report, she asked the resident if he/she finished and the resident said no so she left to give the resident more time and she forgot to go back. Staff A reported Resident #1 used the Hoyer lift and she did not hear anyone radio for help. Staff A reported then Staff C (nurse aide) said he gave the resident a shower and she heard Staff T had helped. Staff A was unsure of the time the resident received the shower or see the resident out of bed coming or going from the shower. Staff A went in to give bedtime care around 9 p.m. to 9:30 p.m. and then it dawned on her the resident had last been on the bedpan. Staff A thought the resident was cognitively intact so she asked the resident if he/she was still on the bedpan. The resident denied being on the bedpan. During bedtime care, Staff A did not do anything with the resident's posterior side because the resident said he/she did not want to be moved because he/she felt comfortable. That was the last time Staff A saw the resident that night and that was around 10 p.m. Staff A stated the resident normally used his/her call light to let staff know they finished using the bedpan. Since the resident came back from the hospital on [DATE], the resident has not used the call light at all but Staff A was not aware of that on 2/16/14. Staff A stated all the staff working that night knew the resident was on the bedpan and they probably all waited for the resident to put his/her call light on and when the resident didn't, they just thought someone else removed the bedpan. She stated she asked the resident to reposition but the resident will say no because he/she is comfortable. On 3/6/14 at 4:04 p.m. Staff C (nurse aide) stated he asked the resident at the beginning of the shift about taking a shower. The resident agreed to the shower. Around 5:30 p.m. he gave the shower. He stated Staff T (nurse aide) assisted with the transfers in and out of bed. Staff C stated when they got the resident up, the resident was not on the bedpan and when they laid the resident down, he did not place the resident on the bedpan. On 3/11/14 at 2:25 p.m. he stated the skin on the resident's bottom was intact and without redness when he provided care on 2/16/14. Staff T (nurse aide) did not return phone calls. In an employee statement form, dated 2/18/14 Staff T stated she assisted Staff C in transferring the resident for a shower between 5 p.m. and 6 p.m. She fed the resident supper shortly after 6 p.m. Between 6:20 p.m. and 6:30 p.m. the resident finished eating and she refilled the resident's water pitcher and left the room. That was the last time Staff T saw the resident that shift. Staff T documented she was never asked to assist in the resident ' s room and never notified he/she was on the bedpan or needed off the bedpan. On 3/6/14 at 2:10 p.m., Staff D (registered nurse) stated the resident received a suppository on the day shift on 2/16/14 and between 5 p.m. and 6 p.m. Staff C and Staff T gave the resident a bed bath and he/she was not on the bedpan then. Staff D stated she did not know of staff placing the resident on the bedpan on her shift (2 p.m. to 10 p.m.) Staff D stated staff normally provides the bedpan and then leaves the resident for privacy and the resident rings the call light when finished. Staff D stated since the resident's hospital return, he/she is not as reliable about using the call light. She stated the staff tries to reposition the resident but the resident will refuse. The resident also uses a special mattress that alternates pressure. On 3/10/14 at 2:20 p.m. Staff P (nurse aide) stated she did not work with the resident that day. On 3/10/14 at 4:33 p.m. Staff R (nurse aide) stated she did not go in the resident's room that shift. All other staff working on other units were questioned and wrote statements that they did not provide care to the resident. Staff Working 11 p.m. to 7 a.m. 2/16/14 into 2/17/14 On 3/16/14 at 2:48 p.m., Staff B (nurse aide) stated on 2/16/14 staff did not do rounds on the resident. They only went in if the resident called staff in with the call light. She stated staff tries to reposition the resident but the resident and family stated not to if the resident didn't want it. She stated she checked on the resident that night. She stated checking did not include repositioning or checking the resident's bottom. She stated she didn't ask the resident if he/she used the bedpan that evening. On 3/6/14 at 3:47 p.m. Staff G (licensed practical nurse) stated they had a very busy night on 2/16/14. She saw the resident 3 to 4 times that night. She stated it takes two to three people to turn the resident at night. She stated the resident was repositioned that night. She did not assist but at 11 p.m. rounds she observed the resident on the right side, at 1 a.m. the pillow was out from the resident and at 3:30 p.m., she observed the resident on his/her back. She stated normally staff takes the resident off the bedpan when he/she puts the call light on. She stated the resident's family requested that staff not reposition the resident as often. For awhile they repositioned the resident once a shift but she stated that night it was every two hours. On 3/13/14 at 9:24 a.m. Staff U stated she did not go in the resident's room that night. She looked at the resident when she passed by in the hall and the resident appeared asleep. All other staff that worked on other units were questioned and wrote statements that they had no contact with the resident. Staff Working 2/17/14 6 a.m. to 2 p.m. shift: On 3/10/14 at 12:18 p.m. Staff I (nurse aide) stated she worked 2/17/14 and when she and Staff J (nurse aide) prepared to get the resident up at 11:45 a.m., they found a bedpan sealed to the resident's bottom. They observed loose stools in the bedpan. The resident said "ouch" when they removed the bedpan and also at that time, they observed a red mark outline of the bedpan on the resident's bottom. The resident said he/she had been on the bedpan for awhile. She stated no one from night shift reported the resident was on the bedpan at shift report. Staff I stated she cleaned the front of resident up that morning and the resident denied pain. She stated she did not turn the resident that morning and did not check the resident's posterior side. She stated the resident stated he/she would get up for lunch so she planned on finishing care to the posterior side of the resident then. She stated the resident used a mattress that turned him/her. On 3/11/14 at 1:35 p.m. Staff I stated she did ask the resident to reposition twice that morning and the resident refused. Staff I prepared an activity log as to what she did for the resident on 2/17/14 at 6 a.m. She wrote the resident was asleep. At 7:15 a.m., Staff I cleaned the resident and refilled his/her water and gave the resident a drink. At 8:15 a.m. Staff J (nurse aide) checked to see if the resident wanted anything for breakfast. Staff I wrote in her written statement that she did not see the bedpan under the resident when she cleaned him/her. At 11 a.m. Staff I and Staff J went in to see if the resident was ready to get up and the resident stated he/she needed a few more minutes. At 11:45 a.m. they went back in and he complained of pain and they found the bedpan. On 3/10/14 at 12:47 p.m. Staff J (nurse aide) stated she got a text at 5:30 a.m. on 2/17/14 from Staff C. Staff C asked her to mark the resident's shower in the book because he forgot the night before. About 8 a.m. of the same date, she asked the resident if he/she wanted a drink and she gave the resident water. Around 11 a.m. she asked the resident if he/she was ready to get up. At 11:45 a.m. she went back to the resident and started getting the resident ready for lunch. She pulled up the resident's bottom sheet and began to apply the resident's socks and pants and when she got to the resident's knees with the pants, she moved the sheet over and saw the bedpan. She asked Staff I if she put the resident on the bedpan and Staff I said no. They turned the resident to remove the bedpan. After removing the bedpan they saw the ring on the resident's bottom. Staff J stated the bedpan was "sealed" to the resident's bottom. Staff J reported Resident #1 requires two person to assist with his/her needs. They called Staff Q (licensed practical nurse). The resident stated he/she used the bedpan for quite awhile. Staff J stated the resident normally called when he/she finished using the bedpan. Staff J then asked the other staff on the unit if they placed the resident on the bedpan and they all said no. When night shift gave her report, they never said the resident was on the bedpan. On 3/10/14 at 4:10 p.m., Staff Q (licensed practical nurse) stated she worked on 2/17/14. Staff I came to her and told her she would give the resident a bedbath between 8 a.m. and 9 a.m. and Staff Q said fine. At 11 a.m. the nurse aides called Staff Q into the room regarding the bedpan they removed. Staff Q stated she called Staff F (licensed practical nurse). Staff Q asked who put the resident on the bedpan and all staff denied they placed the bedpan. At the end of the shift, Staff Q wrote Staff I up because she failed to do a complete bath. Later Staff I stated she told Staff Q she hadn' t performed the posterior side of the resident's bath but Staff Q stated Staff I did not report this information at the time. Staff Q stated the night shift did not report that the resident had loose stools or was on the bedpan. Staff Q stated when the resident returned from the hospital on [DATE], the resident's family told staff if the resident didn't want to reposition then don't reposition him/her, but still offer it. Staff Q stated before the resident went to the hospital, he/she would let staff know when they wanted off of the bedpan. Staff Q stated she observed the resident's bottom after the bedpan removal. There was an indented area that allowed staff to see perfectly where the bedpan was. She stated one of the buttocks contained an abrasion but it was not in the indented areas. On 3/6/14 at 3:20 p.m. Staff F (licensed practical nurse) stated the nurse aides informed her they found the resident on the bedpan and that they did not put the resident on the bedpan. Staff F stated the resident has not been as good about using the call light since return from the hospital. The resident does ask for the bedpan and it takes 2 to 3 people to place the bedpan under the resident. On 3/10/14 at 1:45 p.m. Staff L (nurse aide) stated she did not go in the resident's room on the day staff found the bedpan under the resident. She stated no one reported the resident was on the bedpan that morning. On 3/10/14 at 1:27 p.m. Staff K (nurse aide) stated she was not in the resident's room that morning. She stated since the resident returned from the hospital, she places the bedpan and then goes back in 20 to 30 minutes. She stated staff goes and checks on the resident if they haven't heard from him/her when the bedpan is in place. Staff K stated someone placed the resident on the bedpan and it takes two people to do it. No one is coming forward and no one turned the resident during that time. All staff working on other units, other than two staff that did not return phone calls, were interviewed and they all denied placing the bedpan. Facility Policy: The facility bedpan/urinal/fracture pan policy directed staff to "never leave a resident sitting on a bedpan/fracture or with a urinal for a prolonged period, as contact with them can create pressure and irritation". The policy indicated if a resident is unable to call, check them frequently while the bedpan is in place. On 3/6/14 at 11:45 a.m., Staff E (Co Director of Nursing) identified herself as in charge of the unit that Resident #1 lived on. She stated she investigated the incident and could not conclude who placed the bedpan. She stated statements from staff identified staff that placed the resident on the bedpan are not being truthful and coming forward. It takes two staff to place and remove the bedpan. She stated prior to the resident's stroke on 1/24/14 the resident was "interviewable". Prior to the stroke the resident called for the bedpan and then called when he/she finished using the bedpan. The resident used a fracture pan for elimination. Since the stroke the resident declined cognitively and physically and is on Hospice. Staff is now directed to stay with the resident until the resident is finished using the bedpan.