Every finding on record at Westwood Specialty Care

Based on clinical record review, resident interview, staff interviews, and facility record review, the facility failed to provide safe and adequate mechanical lift transfer to prevent an injury to the resident's forehead for 1 out of 3 residents reviewed (Resident #18). The facility reported a census of 77 residents. Past Noncompliance determined during the annual recertification survey of a facility incident that occurred on 4/15/26 regarding deficiency F689 with a scope and severity of a Level G. The facility provided evidence of education to the staff member directly involved in the facility incident that occurred on 4/15/26. The remainder of the nursing staff received education on 4/16/26. The facility was found to be in substantial compliance of F689 during the annual survey process that occurred on 4/19/26 through 4/29/26.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #18 documented diagnosis of fracture of left leg, muscle wasting and abnormalities of gait and mobility. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The MDS identified Resident #18 showed the resident dependent for chair to bed and toilet transfers. The Care Plan initiated on 2/26/26 for Resident #18 required two staff members to use a mechanical lift for transfers, due to activity as nonweight-bearing to the left leg. The update on 4/15/26 mandated to approach the wheelchair straight on and explicitly prohibited side approaches. Additionally, staff were instructed to have Resident #18 bend the right leg and turn away from the lift during the transfer. The Progress Note dated 4/15/26 at 11:08 AM for Resident #18 documented the following:During transfer the resident's head was hit on the lift. Assessment completed. The resident has a bruise to left forehead that measures 1.21 centimeters (cm) x 2.07 cm. Assessment completed pictures taken and applied ice to forehead. Neurological checks are negative. The resident and staff educated on proper placement of the lift. The Progress Note dated 4/15/26 at 11:47 AM for Resident #18 documented the following:Only use lift straight on with wheelchair transfers, do not come in sideways. Have the patient bend her right leg and turn the patient away from the lift pole prior to moving to bed. The Incident Report dated 4/15/26 at 8:00 AM for Resident #18 documented the following:During transfer the resident head was hit on the lift. Assessment completed. The resident has a bruise to the left forehead that measures 1.21 cm x 2.07 cm. The immediate action taken indicated staff was educated on proper placement of lift. The untitled skin sheet dated 4/15/26 for Resident #18 showed a protruding bump from forehead that measured 1.21 cm x 2.07 cm x 2.04 cm.In an interview on 4/21/26 at 1:42 PM, Resident #18 reported Staff H, Certified Nursing Assistant (CNA) and Staff I, CNA, transferred Resident #18 using the lift. The CNA's positioned the lift at the side of the wheelchair and began the lift. The lift tipped, hitting Resident #18's forehead with the part that held the sling. Resident #18 reported she sustained a large protruding bump on her forehead that was tender for multiple days. Both staff members prevented the lift from completely falling to the floor but required additional assistance to return it to an upright position. A physical therapy staff member informed Resident #18 that staff must place the mechanical lift directly in front of the wheelchair for transfers, not at the side. When asked if since then staff have used the lift correctly, the resident reported one of the aides positioned the lift at the side of the wheelchair but another CNA corrected the positioning. As a result, they performed the lift properly.In an interview on 4/22/26 at 1:46 PM, Staff H, CNA, report herself and Staff I, CNA, attempted a wheelchair transfer using the lift when the lift almost tipped, injuring Resident #18's forehead. Staff H and other staff prevented the lift from falling to the floor. Staff H reported she did not know the cause, but hypothesized the left wheels caught on a bar under the wheelchair because they used the lift from the side.In an interview on 4/22/26 at 1:59 PM, Staff I, CNA, reported assisting with the lift transfer when Resident #18 almost fell as the lift tipped. When asked why the lift tipped, Staff I stated, I don't know but we were thinking the lift might have got caught on the bars under the wheelchair. When asked how the CNA positioned the lift, the CNA stated, it was from the side. We were educated not to use the lift from the side. The resident has a brace that keeps her leg straight, she didn't want us hitting her leg on the lift so we the lift from the side like she asked. Now we know we can't and it's okay to tell her we can't do it that way because it's for safety. When asked what part of the lift hit the resident in the forehead, Staff I stated, the part that holds the sling. The In-Service Form dated 4/16/26 mandated the following for use of the mechanical lift: The lift must be operated straight forward only. The wheelchair must be positioned directly in front of the resident, ensuring straight-on alignment. Staff must avoid approaching or transferring the resident from the side.The undated Operator's Instructions for the mechanical lift instructed to position the bar spreader so the two sling hanger bars are parallel to the resident's body and to adjust the legs of the lift to go around the wheelchair- picture indicated the lift is in front of the wheelchair. In an interview on 4/23/26 at 2:03 PM, the Director of Nursing (DON) stated the proper procedure for a safe mechanical lift transfer. The DON explained that staff should position the mechanical lift directly in front of the wheelchair, rather than to the side. The DON also noted that physical therapy staff provided immediate education following the incident.

Based on clinical record review, observation, resident interview, staff interview, and policy review the facility failed to assist residents with activities of daily living for 5 of 8 residents reviewed (Residents #3, #1, #11, #27, and #85). The facility reported a census of 77 residents. Findings include:1. Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive functioning. The MDS further indicated Resident #3 was dependent on staff for personal hygiene. The MDS then revealed diagnoses of renal insufficiency, stroke, hemiplegia (a severe or total paralysis on one side of the body caused by brain or spinal cord damage), and seizure disorder. Observation 4/20/26 at 8:09 AM Resident #3 was observed to be unshaven at this time. Resident #3 revealed that he is getting his showers, but he doesn't get shaved every time. Interview 4/21/26 at 9:05 AM with Resident #3 revealed that he would like to be shaved more during his showers, but some staff just don't like to do it. Resident #3 was observed to be unshaven at this time. Resident #3 further revealed that he needs help to shave since he had a stroke. Review of a facility provided document titled, Weekly Shower Tracker dated 3/9/26 -3/15/26 indicated Resident #3 had a shower, but was not shaved. Review of another facility provided document titled, AM Bath List dated 4/13/26-4/17/26 indicated Resident #3 had a shower on 4/15/26 but did not indicate if Resident #3 was shaved or not. Interview 4/21/26 9:42 AM with Staff E Certified Nursing Assistant (CNA) revealed that she used to be a bath aid, and sometimes residents would refuse to be shaved during a shower. Staff E further revealed that the facility used to have bath sheets that stated when nails were clipped or male residents were shaved. Staff E then revealed that the facility no longer has that sheet, and she wishes they did as the bath aides would be more on top of residents getting shaved and nails clipped. Interview 4/21/26 9:48 AM with Staff F CNA revealed that she is the shower aide now. Staff F then stated that they used to mark on the bath sheets when shaving and fingernails were trimmed. Staff F then indicated that the new bath sheets don't have that, and the staff just initial when the baths/showers are completed. Staff F then confirmed that there were only two sheets for Resident #3 in the bath/shower book Interview 4/21/26 at 10:05 AM with the Director of Nursing (DON) revealed that when showers are completed staff should be offering, and assisting male residents with shaving. The DON further revealed that it should be documented when it is completed or if it is refused. Review of a facility provided policy titled, Shaving the Resident with a revision date of February 2018 indicated staff should record if the resident refuses, or if the task was performed. The policy further indicates staff should notify the supervisor if the resident refuses the procedure. 2. The MDS assessment dated [DATE] for Resident #1 documented muscle weakness, diabetes and hip fracture. The MDS showed the BIMS score of 4 indicating severe cognitive impairment. Review of the care plan with a revision date of 2/3/26 revealed resident is an extensive assist of 1 with bathing and would like only 1 bath a week. Review of Follow Up Question Report dated 2/10/26-4/21/26 for ADL Self Care- Shower/Bath Wednesday/Friday am revealed the following: Resident received a bath on February 24 and again on March 13. Resident went 17 days without a bath. Resident received a bath on March 13 and again on April 1. Resident went 19 days without a bath. 3. The MDS assessment dated [DATE] for Resident #11 documented depression, hypertension and anemia. The MDS showed the BIMS score of 3 indicating severe cognitive impairment. Review of Resident #11's task list revealed bathing as needed and scheduled for Wednesday morning and Friday afternoon. Review of the care plan with a revision date of 1/15/25 revealed need of assistance with bathing and lacked frequency of bathing. Review of Follow Up Question Report dated 2/10/26-4/21/26 for ADL Self Care- Shower/Bath Wednesday morning Friday afternoon revealed the following: Resident received a bath on January 31 and again on February 6. Resident went 6 days without a bath. Resident received a bath on February 10 and again on February 16. Resident went 6 days without a bath. Resident received a bath on March 13 and again on April 1. Resident went 18 days without a bath. 4. The MDS assessment dated [DATE] for Resident #27 documented depression, hypertension and anemia. The MDS showed the BIMS score of 3 indicating severe cognitive impairment. Review of Resident #27's task list revealed bathing as needed and scheduled for Monday and Thursday afternoon. Review of the care plan with a revision date of 2/3/26 revealed resident need 1 or 2 assist with bathing and would only like 1 bath a week. Review of Follow Up Question Report dated 2/24/26-4/21/26 for ADL Self Care- Shower/Bath Wednesday morning Friday afternoon revealed the following: Resident received a bath on February 24 and again on March 14. Resident refused her bath on 3/13. Resident went 19 days without a bath. Resident received a bath on March 14 and again on April 6. Resident refused her bath on 4/9. Resident went 20 days without a bath. 5. The MDS assessment dated [DATE] for Resident #85 documented hypertension, depression and need for assistance with personal care. The MDS showed the BIMS score of 15 indicating no cognitive impairment. Interview on 04/19/2026 at 1:27 p.m., with Resident #85 revealed she did not get 2 baths last week and would like to have them. Review of the care plan with a revision date of 12/31/25 revealed the resident is dependent for bathing and lacked frequency of bathing. Review of Resident #85's task list revealed bathing as needed and scheduled for Monday morning and Wednesday afternoon. Review of Follow Up Question Report dated 2/24/26-4/21/26 for ADL Self Care- Shower/Bath Monday morning and Wednesday afternoon revealed the following: Resident received a bath on February 24 and again on March 4. Resident went 12 days without a bath. Resident received a bath on March 4 and again on March 11. Resident went 7 days without a bath. Resident received a bath on March 14 and again on April 1. Resident went 18 days without a bath. Resident received a bath on April 13 and again on April 20. Resident went 7 days without a bath. Review of facility provided policy titled Bath, Shower/Tub with a revision date of February 2018 revealed the purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. The signature and title of the person recording the data. Interview on 04/21/2026 at 12:15 p.m., with the Regional Nurse Consultant revealed the bathing should be completed as scheduled.

Based on observation, staff interview, and policy review the facility failed to properly secure and store medications to minimize loss or access for 1 of 4 medication carts. The facility reported a census of 77 residents. Findings include:During continuous observation 4/19/26 at 2:12 PM a treatment cart was left unlocked with the computer screen left on with identifiable information left on the screen by Staff D Licensed Practical Nurse (LPN) for 4 minutes. Staff C Regional Consultant then was observed to come down the hall, and shut off the screen of the computer and lock the treatment cart. Staff C then revealed that she would like to see the treatment cart locked when it is not attended with the screen shut off so identifiable information is not showing. Interview 4/21/26 at 8:46 AM with the Director of Nursing (DON) revealed that she would have liked to have seen the med carts locked, and the computer screen locked when not in use or staff are not around. Review of a facility provided policy titled, Security of Medication Cart with a revision date of April 2007 indicated the nurse must secure the medication cart during medication pass to prevent unauthorized entry.

Based on previous CMS-2567 review, staff interview and facility policy review the facility failed to ensure a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 77 residents. Findings include: Review of the Department of Inspections, Appeals and Licensing (DIAL) website under the facility's visit history revealed repeated deficient practices identified during the facility's annual survey and complaint investigation on 3/27/25 and the facility's annual survey, complaint and facility reported incident investigation on 4/19/26. The repeat deficiencies cited included: F689- Free of Accident Hazards/Supervision/Devices. This deficiency was repeated in the previous three consecutive annual surveys. F880- Infection Prevention and Control. This deficiency was repeated in the previous four consecutive annual surveys. The QAPI Plan documented that the facility will review sources of information to determine if gaps or patterns exist in the systems of care that could result in quality problems or if there are opportunities to make improvements.In an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged F689 and F880 repeated in previous surveys. The Administrator reported the facility would review and discuss plans to improve.

Based on observation, resident interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 2 of 15 residents (Residents #3, and #94) reviewed. The facility reported a census of 77 residents.Findings include:1. Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive functioning. Interview on 4/19/26 at 1:49 PM with Resident #3 revealed that the food is not always warm. Resident #3 continued that he loves ice cream and when he ordered it, it was almost the consistency of chocolate milk. 2. Review of Resident #94's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognitive functioning. Interview on 4/19/26 at 1:50 PM with Resident #94 revealed that the hot food is never hot in the dining room, but it was today. Resident #94 further revealed there has only been one other time that the food has been hot. During continuous observation on 4/21/26 from 12:45 PM until 12:56 PM first Staff B (Dietary Services) prepared room trays for delivery. It was observed that the first room trays were sent to be delivered at 12:52 PM. A sample tray was obtained and the food had a temperature check completed at this time. The lemon chicken had a temperature of 130 degrees, and the broccoli had a temperature of 105 degrees. Interview on 4/21/26 at 1:13 PM with the Regional Dietician revealed that food temps should be warmer when served, and at a minimum of 135 degrees.IInterview on 4/21/26 at 1:16 PM with the Certified Dietary Manager (CDM) revealed that she would like to see the food temps served at 135 degrees or warmer.Review of a facility provided policy titled, Food Preparation and Service with a revised date of April 2019 indicated proper hot and cold temperatures are maintained during food service/distribution.

Based on observations, record review, staff interviews and policy reviews, the facility failed to provide proper hand hygiene during catheter care for 2 of 3 residents reviewed (Resident #12 and #15). The facility reported a census of 77 residents. Findings include:1. During observation on 4/21/2026 at 11:07 am Staff J, a Certified Nursing Assistant (CNA), completed catheter care for Resident #12. Staff J then emptied and rinsed the urine collection containers. The CNA removed the gown and soiled gloves and failed to perform hand hygiene. Staff J retrieved the trash bag from the receptacle, tied it, and placed the bag on the floor. Next, Staff J removed the roll of garbage bags from the bottom of the trash container and deposited the roll into the basket behind the sink. Staff J placed a new bag into the receptacle then shut off the bathroom light. Following this, the CNA opened the resident's door, obtained hand sanitizer with one hand, rubbed the sanitizer across her hand using that hand, and then entered the locked utility room.2. During observation on 4/22/2026 at 9:35 AM for Resident #15 showed Staff H, CNA completed cath care for Resident #15. Staff H then removed soiled gloves, failed to perform hand hygiene then donned new gloves. Staff H then emptied the urine collection containers, removed gown and soiled gloves, and failed to perform hand hygiene. Staff H then adjusted the resident's bedside table, opened the resident's door and exited the room. The Hand Hygiene Policy last updated in August 2019 identified hand hygiene is required immediately before donning and doffing gloves. During an interview on 4/22/26 at 2:16 PM, the Infection Preventionist indicated staff are expected to perform hand hygiene prior to putting on gloves, immediately after removing gloves, and when the staff leave the resident's room.During an interview on 4/23/26 at 1:49 PM, the Director of Nursing (DON), reported she expected staff to perform hand hygiene immediately before applying gloves and when staff removed gloves.

Based on observation, infection control policy and staff interview, the facility failed perform proper hand hygiene and adhere to infection control guidelines during medication pass for 4 of 4 residents observed (Resident #1, #4, #7 and #8) The facility reported a total census of 77 residents. Findings include: 1. Observation on 12/23/24 at 9:01 a.m., revealed Staff A, Licensed Practical Nurse (LPN) did not perform hand hygiene prior to applying gloves. Once the gloves were applied the nurse cleaned off the top of the insulin bottle with an alcohol swab and drew up the insulin into the syringe, with gloves still on, placed the bottle back into the box and placed into the medication drawer. Staff took the gloved hand and locked the computer screen, with the soiled gloves on, entered the residents room with the insulin syringe and with another alcohol swab cleaned the area and administered the insulin to the resident. When completed, removed gloves and performed hand hygiene. 2. Observation on 12/23/24 at 9:11 a.m., revealed Staff A, LPN preparing medications for Resident #4. The nurse pushed pantoprazole (medication to decrease stomach acid) out of the pill card and the medication dropped onto the top of the medication cart. Staff A without performing hand hygiene applied a glove, picked up the medication and placed it into the medication cup with the other medication. Staff A removed the glove and performed hand hygiene and administered the medications to Resident #4. 3. Observation on 12/23/25 at 9:27 a.m., of Staff B, Registered Nurse (RN) preparing Resident #1's medication. Staff B took out a pill cutter out of the medication cart to cut the Guaifenesin tablet (medication to relieve chest congestion) tablet. The pill cutter was observed to have a white power substance on the top and bottom of the pill cutter. Staff B did not clean the pill cutter and poured the tablet out of the bottle onto the pill cutter and without doing hand hygiene applied gloves. Staff B with a gloved hand placed the tablet in the correct spot to cut the tablet. Staff B cut the tablet and placed half into the medication cup and the other half into the sharps container, removed her glove and did not perform hand hygiene. Staff B placed the pill cutter back into the medication cart and finished preparing the medications. Staff B administered Resident #1's medications and returned to the medication cart and proceeded to the next resident. 4. Observation on 12/23/25 at 9:40 a.m., with Staff B, RN with Resident #7's medication pass. Staff B brought in residents Fluticasone-Salmeterol (an inhaler to reduce lung inflammation) inhaler into his room and laid it directly on the bedside table with no barrier. Staff administered medications and inhaler and when completed exited the room with the inhaler and without wiping down the inhaler placed the inhaler back into the box and placed into the medication cart. Review of facility provided policy titled Administering Medications with a revised date of April 2019 revealed staff follows established facility infection control procedures for the administration of medications as applicable. Review of the facility provided policy titled Handwashing and Hand Hygiene revised August 2019 revealed the use of an alcohol-based hand rub or soap and water for the following before and after handling medications and before applying gloves and after removing gloves. Interview on 12/23/25 at 10:10 a.m., with the Regional Nurse Consultant revealed staff should be following infection control measures at all times.

Based on observations, facility policy review and staff interview the facility failed to cover exposed catheter bags for 3 of 3 residents reviewed (Resident #1, #5 and #6). The facility reported a census of 77 residents Findings include: 1. Observation on 12/16/25 at 2:24 p.m., revealed Resident #1 laying in bed with a catheter bag hanging on the side of the bed with no privacy cover, urine visible in the bag from the hallway. 2. Observation on 12/16/25 at 9:59 a.m., revealed Resident #1 laying in bed with a catheter bag hanging on the side of the bed with no privacy cover, urine visible from the door in the hallway. 3. Observation on 12/16/25 at 2:25 p.m., revealed Resident #6 in bed with a catheter bag hanging on the side of the bed with no privacy cover and urine visible from the door in the hallway. 4. Observation on 12/16/25 at 10:04 p.m., revealed Resident #5 laying in bed with catheter bag hanging on the side of the bed with no privacy cover, urine visible from the door in the hallway Review of the facility provided policy titled Dignity with a revised date of February 2021 revealed Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, for example, helping the resident to keep urinary catheter bags covered. Interview on 12/22/25 at 3:43 p.m., with Regional Nurse Consultant, revealed all catheter bags should have a cover as that is a dignity concern.

Based on clinical record review, resident interview, staff interview and facility policy review the facility failed to provide bathing assistance as scheduled for 3 of 3 residents reviewed for bathing (Resident #2, #3 and #6). The facility reported a census of 77 residents. Findings include:1. The MDS assessment dated [DATE] for Resident #2 documented diagnoses of muscle wasting, repeated falls and disorientation. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. The care plan with an initiated date of 6/20/25 for Resident #2 showed the resident required assistance from one person for bathing.In an interview on 12/30/25 at 2:26 PM, Resident #2 stated he did not want to get anyone in trouble and reported that he is not routinely offered a bath twice per week. When asked about refusals, the resident stated that he sometimes refused bathing. He further stated that despite occasional refusals, he is not consistently offered bathing services twice weekly. The resident stated that at times he is bothered by missing a bath and at other times he is not.The Documentation Survey Report dated November 2025 indicated that Resident #2 scheduled to receive baths on Tuesdays and Fridays. Documentation showed the resident received only two baths during November, on 11/21/25 and 11/25/25.The Documentation Survey Report dated December 2025 indicated that Resident #2 scheduled to receive baths on Tuesdays and Friday. Documentation showed that the resident did not receive baths during the first 20 days of December.2. The MDS assessment dated [DATE] for Resident #3 documented diagnoses of dementia, Parkinson's Disease and failure to thrive. The MDS showed the Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS also revealed Resident #6 required partial to moderate assistance for bathing.The care plan with an initiated date of 2/20/25 for Resident #3 showed the resident dependent for bathing and required assistance from one person for bathing. In an interview on 12/30/25 at 2:47 PM, Resident #3 reported that baths are scheduled twice weekly. The resident stated the facility failed to offer baths twice per week in November and does not recall refusing a bath. Resident #3 reported that the bath schedule changed for some residents but reported that it did not appear to improve the situation.The Documentation Survey Report dated November 2025 indicated that Resident #3 scheduled to receive baths on Tuesdays and Fridays. Documentation showed that the resident failed to receive a bath on or around the following dates:a. 11/15/25b. 11/18/25c. 11/21/25The Documentation Survey Report dated December 2025 indicated that Resident #3 scheduled to receive baths on Tuesdays and Fridays. Documentation showed that the resident failed to receive a bath on or around the following dates:a. 12/2/25b. 12/5/25c. 12/12/25d. 12/23/25e. 12/26/253. The MDS assessment dated [DATE] for Resident #6 documented diagnoses of unsteadiness on feet, need for assistance with personal cares and repeated falls. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. The MDS also revealed Resident #6 required partial to moderate assistance for bathing.The care plan with an initiated date of 8/25/25 for Resident #6 showed the resident required substantial assistance from one person for bathing.In an interview on 12/30/25 at 3:02 PM, Resident #6 reported feeling very upset by the lack of bathing provided by the facility. Resident #6 stated, I haven't had a bath for a week then it was okay but before that I didn't get a bath for two weeks. When asked if she ever refused a bath, Resident #6 stated, it's not often.The Documentation Survey Report dated November 2025 indicated that Resident #6 scheduled to receive baths on Monday and Thursdays. Documentation showed the resident received only two baths during November, on 11/21/25 and 11/25/25.Documentation showed Resident #6 failed to receive a bath on the following dates:a. 11/3/25b. 11/6/25c. 11/10/25d. 11/13/25e. 11/17/25f. 11/20/25The Documentation Survey Report dated December 2025 indicated that Resident #6 scheduled to receive baths on Mondays and Thursdays. Documentation showed that the resident failed to receive a bath on or around the following dates:a. 12/8/25b. 12/11/25c. 12/15/25d. 12/22/25e. 12/25/25f. 12/29/25In an interview on 12/29/25 at 12:55 PM, Staff E, Certified Nursing Assistant (CNA) reported several CNAs have recently resigned after being held accountable for not completing assigned duties. Staff E revealed the facility previously used bath aides, and residents were not consistently receiving scheduled baths. As a result, a new plan was implemented in which some resident baths are assigned to day shift and others to night shift. Staff E reported that none of the residents in her hall who are scheduled for night-shift baths have received them. Staff E is now expected to complete those missed baths during the day in addition to her regularly scheduled assignments and baths often don't get done. The Bath, Shower/Tub policy last revised February 2018 identified for documentation the date and time the shower/tub bath was performed. The name and title of the individual(s) who assisted the resident with the shower/tub bath. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. How the resident tolerated the shower/tub bath. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. The signature and title of the person recording the data. For reporting, notify the supervisor if the resident refuses the shower/tub bath. Notify the physician of any skin areas that may need to be treated. Report other information in accordance with facility policy and professional standards of practice.In an interview on 12/31/25 at 8:12 AM, the Administrator reported that he expected shower schedules to be followed as planned. He explained that, in an effort to improve shower completion, the process had been changed to provide some residents with evening showers. The Administrator indicated no knowledge of issues with evening showers not completed.

Based on record review, resident and staff interviews and facility policy review the facility failed to provide physician ordered daily weights 1 of 1 residents reviewed (Resident #2). The facility reported a census of 77 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented heart failure, hypertension and coronary artery disease. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. Review of the physician order dated 7/17/25 at 3:21 p.m., revealed an order for daily weights if weight gain of greater than 3 pounds in one day or greater than 5 pounds in one week fax weights weekly. Review of daily weight records lacked daily weights on the following days:October 11, 17 and 31November 8, 9, 20, 21, 22, 28 and 30December 5 and 12 Review of the clinical record lacked any documentation the physician had been notified daily weights were not being completed and monitored as ordered. Review of the facility provided policy titled Physician Services with a revised date of February 2021 revealed supervising the medical care of residents includes monitoring changes in resident's medical status, providing consultation or treatment when called by the facility and overseeing a relevant plan of care for the resident. Interview on 12/30/25 at 2:01 p.m., with Regional Nurse Consultant revealed the facility should be doing daily weights if they are ordered and they should notify the physician if they are not being completed or per the order with weight gains.

Based on observations, staff interviews, and facility policy review, the facility failed to provide safe transfers of residents with transfers 2 of 3 residents reviewed (Resident #4 and #13). The facility reported a total census of 77 residents. Findings include: 1. Observation on 12/29/25 at 1:41 p.m., of Staff D, Certified Nursing Assistant (CNA) assisting Resident #4 into the bathroom. Staff D assisted Resident #4 to the grab bar. Resident proceeded to grab the bar and Staff D grabbed under resident's right armpit with her forearm and pulled her up to a standing position. When the resident was completed in the bathroom Staff D assisted the resident to a standing position by using her forearm pulling under her left armpit to a standing position. Review of the care plan with a revision date of 10/31/25 revealed Resident #4 required 1 assist with toileting and personal hygiene. Review of the MDS dated [DATE] revealed Resident #4 is dependent on staff assistance for toileting, requires partial to moderate assistance with personal hygiene and requires partial to moderate assistance with toilet transfers. Review of the facility provided policy titled Safe Lifting and Movement of Residents revealed in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Staff responsible for direct resident care will be trained in the use of manual ([NAME]/transfers belts) and mechanical lifts. Safe lifting and movement of residents is part of an overall facility employee health and safety program. Interview on 12/29/25 at 2:26 p.m., with Regional Nurse Consultant revealed when staff are assisting a resident with a 1 assist transfer she expects staff to use a gait belt and not to pull on their arms. 2. The MDS assessment dated [DATE] for Resident #13 documented diagnoses of seizure disorder, anxiety disorder and chronic obstructive pulmonary disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 04, which indicated severe cognitive impairment. The care plan with an initiation dated of 8/22/18 identified Resident #13 required assistance to the bathroom and required the mechanical stand lift with assistance of one for transfers. Observation on 12/16/25 at 12:35 PM revealed Staff E, a Certified Nursing Assistant (CNA), transferred Resident #13 from the bed to the toilet using a mechanical stand lift. While raising the resident from the toilet, Staff E failed to lock the lift brakes, paused when the resident was mostly standing, then locked the brakes and continued raising the resident to a fully standing position. Staff E then pushed the resident out of the bathroom and positioned the mechanical stand lift at the wheelchair. Staff E again failed to lock the brakes before lowering the resident into the wheelchair. The mechanical stand operators manual instructed staff to lock the stand brakes prior to lifting the resident or lowering the resident into a seated position. In an interview on 12/29/25 at 12:55 PM, the Administrator reported staff should follow the operators manual when using the mechanical stand lift.

Based on observations and staff interview, the facility failed to provide complete and appropriate incontinence care in a manner to prevent urinary tract infections for 2 of 3 residents observed (Resident #1 and #4). The facility reported a census of 77 residents. Findings include: 1. Observation on 12/23/25 at 12:14 p.m., of Staff C, Certified Nursing Assistant (CNA) empty Resident #1's catheter bag. Staff C cleaned the catheter end prior to emptying the urine from the bag. Staff C emptied the urine into the graduate, after the bag was empty she closed the end and without cleaning the end placed back into the bag and cleaned up her supplies for the resident. When completed, she removed gown and gloves and performed hand hygiene. 2. Observation on 12/29/25 at 1:41 p.m., of Staff D, CNA assisting Resident #4 to the bathroom. When resident #4 was completed in the bathroom, Staff D assisted her to a standing position and then took a disposable wipe and wiped from front to back with the first wipe, used the same side and wiped the rectum 3 times and disposed of it into the trash. Took another wipe and wiped from front to the back and with the same side of the wipe on the rectum 2 times and disposed of it into the trash. Took another clean wipe and wiped from the front to the back and with the soiled side wiped the residents rectum 3 times and disposed of it into the trash. Staff with soiled gloves on pulled up the residents brief, and with the soiled gloves on pulled up the residents pants and adjusted her sweater and pulled the wheelchair closer to the resident. After the resident was in the chair, removed gloves and performed hand hygiene. Interview on 12/29/25 at 2:26 p.m., with Regional Nurse Consultant revealed she expected staff to perform peri care properly and to use a clean part of the wipe when doing care. She further revealed staff should be using an alcohol swab after emptying the catheter tubing.

Based on record review and staff interviews the facility failed to provide and maintain accurate resident records to reflect an incident occurring in the facility for 1 of 3 residents (Residents #4). The facility reported a census of 77 residents.Findings include: The MDS assessment dated [DATE] for Resident #4 documented diagnoses of muscle wasting, dependence on a wheelchair and nerve damage. The MDS showed moderate cognitive impairment for daily decision making. The Clinical Physician Orders for Resident #4 dated 7/18/23 showed tramadol 50 milligram (MG) three times a day ordered for pain. The Controlled Drug Count Record dated 9/16/25 for Resident #4 showed Staff F, Certified Medication Assistant (CMA) failed to sign the count record at 6 AM. The Individual Narcotic Record for Resident #4 showed that on 9/16/25 PM shift the tramadol tablet count to be 30 tablets. The 9/17/25 AM tramadol showed the count to be 28 tablets. The September Medication Reconciliation for 2025 showed Staff F, CMA administered Tramadol 50 mg at bedtime to Resident #4. In an interview on 12/30/25 at 12:00 PM, Staff G, a Licensed Practical Nurse (LPN), reported that on 9/16/25, after bedtime medications were administered, Staff G assumed responsibility for Staff F's assigned medication cart and residents. Staff G reported that at the end of their shift, during the AM narcotic count with Staff F, they discovered two tramadol tablets missing. Staff G could not specifically recall the number of tablets. When asked what happened next, Staff G reported that Staff F refused to sign the Drug Count Record and immediately left the building. When asked whether they had previously encountered issues with incorrect narcotic counts involving Staff F, Staff G reported that she and Staff F were new and that Staff F no longer worked at the facility after the tramadol went missing. When asked if she reported the missing medication, Staff G stated that she immediately contacted the Regional Nurse Consultant. The Storage of Medications policy last revised April 2020 identified Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications. Controlled medications that are part of a single unit dose distribution system may be stored with non-controlled medications when the supply is minimal and shortages are readily detectable. The policy failed to address directions specific to narcotic counting, destruction of narcotics or action to be taken in the case of missing medication. In an interview on 12/29/25 at 12:55 PM, the Regional Nurse Consultant reported she received notification of missing tramadol the morning of 9/17/25 and arrived at the building shortly after. The Regional Nurse Consultant confirmed two tramadol 50 mg tablets went missing. She reported the facility is unable to determine the cause of the missing tramadol. The Regional Nurse Consultant reported the investigation concluded when Staff F did not come back to the facility or answer their calls.

Based on record review and staff interview, the facility failed to assure residents were free from significant medication errors for 1 of 3 resident reviewed (Resident #1). The facility reported a census of 77 residents.Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented a diagnosis of heart failure, renal insufficiency and stroke. The MDS showed a Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. The Medical Diagnosis report for Resident #2 showed no diagnosis of Diabetes [NAME]. The Clinical Physician Orders for Resident #2 showed no orders of jardiance or gabapentin. The Progress Note dated 11/3/25 at 7:30 AM for Resident #1 documented the following:Resident received wrong AM medications this AM. Spit out most of all medications. Received jardiance and gabapentin, but medications not ordered. Resident verbalizes understanding of receiving wrong medications. Denying pain and no signs of pain observed.Vitals within normal limits. No abnormal new assessment findings. Nurse from a supporting agency called. Nurse Practitioner explains to proceed with scheduled AM medications. Family updated. Administrator updated. The Progress Note dated 11/3/25 at 5:30 PM for Resident #1 indicated a nurse from a supporting agency present in the facility when the resident's family reported concerns regarding increased drowsiness. Upon assessment, the nurse observed new stroke-like symptoms not noted during prior evaluations. The nurse instructed facility staff to initiate emergency response. Emergency medical services contacted. In an Interview on 12/17/25 at 1:04 PM, Staff H, Licensed Practical Nurse (LPN) reported on the morning of 11/3/25 Resident #1 received another resident's medications. Staff H reported because of swallowing issues Resident #1 spat out most of the other resident's medications. Staff H indicated after identifying the individual medications spat out the resident ingested two or three medications. Staff H failed to recall the specific names of the medications swallowed, however identified one of the pills as diabetic medication. When asked whether she reported the specific names of the medications swallowed to the provider during notification, the Staff H reported that she did. When asked what orders were given, Staff H stated that the provider instructed her to monitor the resident and administer her scheduled medications. When asked whether she received specific monitoring parameters, Staff H stated that she did not. When asked if she received orders to check blood glucose levels, Staff H stated no. Staff H added, Looking back, I know I should have checked them, but I didn't. I checked on her several times. I thought the half life of jardiance was long acting. When asked whether she assessed vital signs, Staff H stated that she completed vital signs and cognitive checks. When asked if she documented the assessments, Staff H stated that she did not recall and acknowledged that she did not document all assessments. Staff H reported emergency medical services (EMS) transferred the resident to the emergency room. The Fire Rescue report dated 11/3/25 indicated upon arrival Resident #1 opened eyes in response to pain, not alert or orientated. EMS found Resident #1 very diaphoretic and hot. The report noted Resident #1 received the wrong medication of gabapentin and jardiance at 6:45 AM along with regularly scheduled tramadol. The report also noted a blood glucose level of 64 milligram per deciliter. Resident #1 transferred to the emergency room via ambulance. The Administering Medication policy last April 2019 identified:9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include:a. Checking identification band;b. Checking photograph attached to medical record; andc. If necessary, verifying resident identification with other facility personnel.10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. In an interview on 12/29/25 at 12:55 PM, the Regional Nurse Consultant reported staff should follow policy when administering medications. When asked if she would have expected staff to respond differently when Resident #1 received the jardiance and gabapentin, the Regional Nurse Consultant reported the staff notified the provider and followed physician orders.

Based on record review and staff interviews the facility failed to provide and maintain accurate resident records to reflect an incident occurring in the facility for 2 of 2 residents (Residents #2 and #4). The facility reported a census of 77 residents.Findings include: 1. The MDS assessment dated [DATE] for Resident #2 documented diagnoses of muscle wasting, repeated falls and disorientation. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Review of the untitled facility investigation dated 10/8/25 at 6:02 p.m. revealed an incident investigated by the Administrator involving the disappearance of $105 in cash from the pouch attached to Resident #2's walker. In an Interview on 12/30/25 at 2:01 PM, the Administrator stated that Resident #2 returned from the hospital and requested to speak with him. The Administrator went to the resident's room, where the resident reported that $105 was missing, consisting of one $100 bill and five $1 bills. The resident informed the Administrator that he kept the money in a pouch attached to his walker and that he had approximately $1,400.00 when he was admitted . The resident indicated that the money was present when he left for the hospital but was missing upon his return. Review of Resident #2's records on 12/30/25 at 2:30 p.m. revealed the facility failed to document information regarding the missing money. 2. The MDS assessment dated [DATE] for Resident #4 documented diagnoses of muscle wasting, dependence on a wheelchair and nerve damage. The MDS showed moderate cognitive impairment for daily decision making. Review of the facility investigation dated 9/16/25 revealed on 09/16/2025, during the narcotic count, staff discovered two tablets of tramadol 50 milligrams missing from Resident #4's medication bubble pack. Review of Resident #4's records on 12/30/25 at 1:07 PM revealed the facility failed to document information regarding the missing tramadol. The Charting and Documentation policy last revised July 2017 identified all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation 1. Documentation in the medical record may be electronic, manual or a combination. 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 4. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy. Certified Nursing Assistants may only make entries in the resident's medical chart as permitted by facility policy. 5. Information documented in the resident's clinical record is confidential and may only be released in accordance with state law, the Health Insurance Portability and Accountability Act (HIPAA) and facility policy. Refer all requests for information to the Director of Nursing Services, Nurse Supervisor/Charge Nurse or to the business office. 6. To ensure consistency in charting and documentation of the resident's clinical record, only facility approved abbreviations and symbols may be used when recording entries in the resident's clinical records. 7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting. In an interview on 12/29/25 at 12:55 PM, when asked whether the missing money and mediation should have been documented in the resident's records, the Regional Nurse Consultant stated something should have been documented.

Based on observation, staff interview and facility policy, the facility failed to provide complete and appropriate incontinence care in a manner to prevent urinary tract infections for 1 of 3 residents observed (Resident #6). The facility reported a census of 80 residents.Finding include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses of stroke, dementia and need for assistance with personal care. The MDS showed the Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment.Observation on 10/29/25 at 11:04 AM revealed Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA completed hand hygiene and donned gloves. Staff B removed the soiled brief, removed gloves, performed hand hygiene and donned gloves. Staff B then used cleansing wipes to wipe down the right and left side of the groin. Staff B obtained a new cleansing wipe, cleansed the entire groin, perineum area, shaft and around the urethral area of the penis. Staff B then removed gloves, performed hand hygiene and donned gloves. Staff B cleansed the resident's buttock using different areas of the same cleansing wipe. Staff A failed to cleanse the entire surface area of the resident's buttock. Staff A then discarded soiled gloves, failed to perform hand hygiene, donned new gloves and applied the resident's brief. The Perineal Care policy last revised February 2018 identified the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation,and to observe the resident's skin condition.Preparation1. Review the resident's care plan to assess for any special needs of the resident.2. Assemble the equipment and supplies as needed.Equipment and SuppliesThe following equipment and supplies will be necessary when performing this procedure:1. Wash basin;2. Towels;3. Washcloth;4. Soap (or other authorized cleansing agent); and5. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed).6. OR cleansing wipesSteps in the Procedure1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached.2. Wash and dry your hands thoroughly.3. Fill the wash basin one-half (1/2) full of warm water. Place the wash basin on the bedside stand within easy reach, orplace cleansing wipes within reach4. Fold the bedspread or blanket toward the foot of the bed.5. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet.6. Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident's body.7. Put on gloves.8. Ask the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary.For a female resident:a. Wet washcloth and apply soap or skin cleansing agent, or use cleansing wipesb. Wash perineal area, wiping from front to back.(1) Separate labia and wash area downward from front to back. (Note: If the resident has an indwellingcatheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gentlyrinse and dry the area.)(2) Continue to wash the perineum moving from inside outward to the thighs, Rinse perineum thoroughly insame direction, using fresh water and a clean washcloth.(3) If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the legto avoid traction or unnecessary movement of the catheter.(4) Gently dry perineum.(5) Remove gloves and sanitize/wash hands.(6) DON glovesc. Ask the resident to turn on her side with her top leg slightly bent, if able.d. Use new wash cloth and apply soap or skin cleansing agent, or use cleansing wipese. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks.f. Rinse and dry thoroughly.For a male resident:a. Wet washcloth and apply soap or skin cleansing agent, or use cleansing wipesb. Wash perineal area starting with urethra and working outward.c. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down thecatheter about 3 inches. Gently rinse and dry the area.d. Retract foreskin of the uncircumcised malee. Wash and rinse urethral area using a circular motion.f. Continue to wash the perineal area including the penis, scrotum and inner thighs.g. Thoroughly rinse perineal area in same order, using fresh water and clean washcloth.h. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg toavoid traction or unnecessary movement of the catheter.i. Gently dry perineum following same sequence.j. Reposition foreskin of uncircumcised male.k. Remove gloves and sanitize/wash handsl. Ask the resident to turn on his side with his upper leg slightly bent, if able.m. Use new washcloth and apply soap or skin cleansing agent, or use cleansing wipesn. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks.o. Dry area thoroughly.9. Discard disposable items into designated containers.10. Remove gloves and discard into designated container.11. Wash and dry your hands thoroughly.12. Reposition the bed covers. Make the resident comfortable.13. Place the call light within easy reach of the resident.14. Clean wash basin and return to designated storage area.15. Clean the bedside stand.16. Wash and dry your hands thoroughly.In an interview on 10/1/25 at 10:11 AM, the Regional Nurse Consultant revealed she expected staff to follow policy when performing personal care. When asked if staff should use a different wipe for the groin, front perineal, penis and urethral area, the Nurse Consultant stated, yes.

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (October 1 - December 31) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 81 residents. Findings include: The PBJ Staffing Data Report run date 3/13/25 for Quarter 1 2025 triggered for excessively low weekend staffing and one star staffing rating. Review of weekend staffing schedules for Quarter 1 months of October, November, and December revealed equal floor staffing during the week and the weekend. Decreased management staffing reported on the weekend. On 3/26/25 at 2:05 PM the Administrator stated Monday through Friday more management were present at the facility and the MDS Coordinator's hours went into floor staffing. The Administrator revealed the facility had 2 ADON's as well as a DON that works during the week. The Administrator said the DON was coming in to help with a few call in's on the weekend. The Administrator stated the hours she worked had been reported inaccurately. Review of a policy revised 10/17 titled, Reporting Direct-Care Staffing Information (Payroll-Based Journal) documented staffing and census information would be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act. Direct-care staffing information includes staff hired directly by the facility, those hired through an agency, and contract employees. Staffing information was collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. For auditing purposes, reported staffing information was based on payroll records, or other verifiable information.

Based on clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch, PASARR recommendations, oxygen usage and fluid restrictions for 4 out of 20 sampled residents reviewed for comprehensive care plans (Resident #20, #45, #72 and #231). The facility reported a census of 87 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 documented diagnoses of anxiety disorder, depression and vascular dementia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Resident #20's March Medication Administration Record revealed the following orders: a. Sertraline (antidepressant medication) 1 tablet daily for depression with a start date of 11/17/24. b. Morphine Sulfate (opioid medication) three times daily for pain with a start date of 3/13/25. c. Haloperidol (antipsychotic medication) as needed for agitation with a start date of 3/19/25. d. Lorazepam (anti-anxiety medication) twice daily for anxiety with a start date of 3/6/25. Review of the Care Plan dated 3/13/25 lacked information regarding antipsychotic medication usage, side effects and non-pharmalogical interventions for usage. The Care Plan lacked information on opioid medication, side effects and non-pharmalogical interventions for usage. The Care Plan lacked non-pharmacological interventions to use prior to anti-anxiety medications. The Care Plan lacked non-pharmacological interventions for antidepressant medication. 2. The MDS assessment dated [DATE] for Resident #72 identified a BIMS score of 15 which indicates no cognitive impairment. The MDS documented diagnosis included renal failure, need for assistance with personal care and anemia. Observation on 3/16/25 at 2:31 p.m., noted Resident #72 wearing oxygen via nasal cannula. Resident #72 reported he wears oxygen all the time. Review of Resident #72's Order Review History Report signed by the physician on 3/25/25 revealed the following orders: a. Oxygen as needed to keep saturation levels above 90% with a start date of 3/13/25. b. Change oxygen tubing weekly and as needed with a start date of 3/13/25. c. Visually inspect oxygen concentrator to ensure clean and free of debris every shift with a start date of 3/13/25. d. Check oxygen concentrator filter weekly and as needed with a start date of 3/13/25. e. Fluid restriction of 1500 ml's per day with a start date of 3/17/25. Review of Resident #72's March Medication Administration Record revealed the following orders: a. Oxygen as needed to keep saturation levels above 90%. b. Change oxygen tubing weekly and as needed. c. Visually inspect oxygen concentrator to ensure clean and free of debris every shift. d. Check oxygen concentrator filter weekly and as needed. e. Fluid restriction of 1500 ml's per day. Review of the Care Plan dated 2/24/25 lacked information regarding Resident #72 being on a fluid restriction and oxygen usage. 3. The MDS assessment dated [DATE] for Resident #231 identified a BIMS score of 15 which indicates no cognitive impairment. The MDS documented diagnosis included unsteadiness on feet, need for assistance with personal care and repeated falls. Review of facility provided document titled Incidents by Incident Type dated 3/26/25 revealed Resident #231 had witnessed fall incidents on 12/7/24, 12/13/24 and 12/16/24. Review of the Care Plan with a cancelled date of 3/10/25 lacked interventions to prevent further falls on 12/7/24 and 12/13/24. Interview on 3/26/25 at 1:30 p.m., with the Director of Nursing revealed the Care Plan should include side effects and non-pharmacological interventions for high risk medications, fluid restrictions, interventions for falls and oxygen usage. 47673 4. The MDS dated [DATE] for Resident #45 documented a BIMS of 3 indicating severe cognitive impairment. Review of document dated 4/4/24 titled Notice of PASRR Level II Outcome documented the nursing facility will be required to Care Plan in a PASRR compliant fashion for all identified services including Specialized Services and Rehabilitative Services. Community Placement Supports must be included in the Care Plan in a PASRR compliant fashion if the individual has received a Short Term PASRR approval, the individual at any time states they wish to return to a lower level of care, and/or the MDS Section Q-500 indicates that the individual wishes to discharge to a lower level of care. Review of Care Plan revealed no focus, goal or interventions / tasks suggested in the document titled, Notice of PASRR Level II Outcome. On 3/18/25 at 1:43 PM Staff A, Regional Nursing Consultant stated she would expect a Care Plan in place with the Level II Outcome approved and the recommendations included in Resident #45's Care Plan. On 3/24/25 at 12:51 PM the DON stated the care planning recommendation from PASARR should be addressed on Resident #45's Care Plans in the focus, goal or interventions / tasks. The DON acknowledged Resident #45's care plan lacked the recommendations from the document titled, Notice of PASRR Level II Outcome. Review of Policy revised 12/16 titled, Care Plans, Comprehensive Person-Centered documented A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and fictional needs are developed and implemented for each resident. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The IDT included other appropriate staff or professionals as determined by the resident's needs or as requested by the resident.

48004 Based on observation, document review, resident interview, staff interview, and policy review the facility failed to follow the menu and prepare food to meet the nutritional needs for 19 of 81 residents reviewed. The facility reported a census of 81 residents. Findings include: 1. Observation on 3/25/25 at 12:07 PM to 12:27 PM during continuous observation no wheat rolls were delivered with the first 18 plates served in the dining room. Review of a document titled Menu for the Week of 3/23/25 through 3/29/25 revealed that lunch on 3/25/25 consisted of BBQ pork, American fried potatoes, baked beans, wheat roll, and fresh orange slices. Interview on 3/25/25 at 1:01 PM with the Certified Dietary Manager (CDM) revealed her expectations would be for menus to be followed. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #66 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. On 3/17/25 at 11:37 AM Resident #66 stated she is shy and ate in her room and she was the last in the facility served. Resident #66 revealed the food was at best lukewarm and never hot ever. Resident #66 said food items are always missing. Resident #66 acknowledged she filled out the menu. Resident #66 stated the morning of 3/17/25 she had grape juice listed and did not get grape juice. Resident #66 revealed she did not get anything in its place.

Based on clinical record review, observation, resident interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 4 of 5 residents reviewed ( Residents #4, #28, #36, and #50). The facility reported a census of 81 residents. Findings include: 1. Review of Resident #28's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Interview on 3/16/25 at 3:09 PM with Resident #28 revealed the food is often cold when it should be hot. 2. Review of Resident #36's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Interview on 3/16/25 at 2:10 PM with Resident #36 revealed the food is cold. Resident #36 revealed the biscuits were cold that morning. 3. Review of Resident #50's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Interview on 3/17/25 at 10:50 AM with Resident #50 revealed the food has been cold several times instead of hot since Resident #50 had gotten here. Interview on 3/16/25 at 11:50 AM with Staff P cook revealed that the hot plate warmer has not worked in almost a year, and food was not served hot. During an observation on 3/25/25 at 12:56 PM a sample room tray was obtained. The American fried potatoes' temperature was taken and was 101.9 degrees, the BBQ pulled pork had a temperature of 124.7 degrees. Interview on 3/25/25 at 1:01 PM with the Certified Dietary Manager (CDM) revealed her expectation would be for food temps to be at the appropriate levels. Review of a facility provided policy titled, Food Preparation and Service with a revision date of April 2019 revealed: a. Proper hot and cold temperatures are maintained during food service. 47673 4. The MDS dated [DATE] for Resident #66 documented a BIMS of 15 indicating no cognitive impairment. On 3/17/25 at 11:37 AM Resident #66 stated she is shy and ate in her room and she was the last in the facility served. Resident #66 revealed the food was at best lukewarm and never hot ever. Resident #66 said food items are always missing. Resident #66 acknowledged she filled out the menu. Resident #66 stated the morning of 3/17/25 she had grape juice listed and did not get grape juice. Resident #66 revealed she did not get anything in its place. On 3/25/25 at 11:55 AM Staff C, Certified Nursing Assistant (CNA) stated Resident #66 complained about her food being cold frequently. On 3/25/25 at 4:13 PM Staff D, Certified Medication Assistant (CMA) stated she had heard residents complain about the temperature of food. Staff D explained she had heard residents complain about the temperature of the food more often than not. Staff D acknowledged the residents complained about the food being too cold. Staff D revealed room trays are complained about more than the dining room.

Based on clinical record review and facility policy review the facility failed to implement new interventions and adequate interventions, including adequate supervision, consistent with the resident's needs and cognitive status to mitigate the risk of falls and injuries for 1 out 3 residents reviewed (Resident #6). Findings included: The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6's cognitive skills for daily decision making as moderately impaired. The MDS included diagnoses of Parkinson's Disease, dysphagia (difficulty swallowing), altered mental status, and repeated falls. Resident #6's Incident Reports from a look back period starting 8/20/23 reflected she fell 38 times. The Incident Report dated 9/25/23 at 11:00 PM identified the nurse found Resident #6 sitting on her buttocks in front of her husband's closet. Observed with jerky movements, barefoot with the wheelchair in front of her. She had active range of motion to all of her extremities. Resident #6 could only state she fell and not what happened. She complained of pain of 8 out of 10 on the pain scale, indicating moderately severe pain. The report indicated Resident #6 didn't have injuries observed at the time of the incident. Predisposing Physiological Factors listed confusion and gait imbalance. The Progress Note dated 9/26/23 at 11:06 AM listed Resident #6 complained of pain to her left rib area, left hip area, and head. Staff Z, Medical Doctor (MD), gave an orders to send Resident #6 to the emergency room (ER) for x-rays. Resident #6 transported to the ER per facility van. The Incident Report dated 9/26/23 at 4:13 PM reflected Resident #6 noted to have bruises to the left knee, right knee, left hand and forehead. Resident #6 fell many times that past week. The emergency room documentation dated 9/26/23 indicated Resident #6 had a diagnosis of a fracture of the posterior 8th rib. The Progress Note dated 10/29/23 at 1:50 PM indicated the Certified Nursing Assistant (CNA) assisted Resident #6 to use her walker to ambulate to the bathroom. During the transfer Resident #6's went limp, and couldn't stand. Resident #6 grabbed the rail located by the toilet, and wouldn't let go. When the CNA could not reach the toilet with the resident, she sat the resident down on the ground. The Incident Report dated 10/29/23 at 1:35 PM documented Resident #6 as alert and oriented with periods of forgetfulness and confusion per her usual. Resident unable to state current location, date, or time. The report also indicated fall predisposing factors included confusion and impaired memory impaired. The emergency room documentation dated 10/30/23 showed Resident #6's physical exam significant for a small hematoma to the volar aspect of the right forearm with tenderness on palpation. No open wounds appreciated. Extremity vascular intact. Patient chronically aphasic (not able to talk). The differential diagnoses included a wrist fracture, forearm fracture, wrist sprain, and hematoma (a collection of blood under the skin). The Progress Note dated 11/25/23 at 10:15 PM for Resident #6 indicated Resident #6's roommate approached the desk to report her on the floor. Resident #6 found in the supine upward sitting position with the ability to move all extremities. Resident #6 pulled her brief off to attempt a bowel movement. The Intervention listed the nurse educated Resident #6 to use the call light. The Incident Report dated 11/25/23 at 2:45 PM indicated the staff witnessed Resident #6 while at the nurses' station move forward out of the wheelchair, to the floor, landing on her knees. The predisposing factors listed confusion and memory impaired. The Incident Report dated 11/25/23 at 10:15 PM reflected Resident #6's husband went to the nurses' station to tell the nurse Resident #6 was on the floor. The author described Resident #6 as in a supine upward sitting position and moved all extremities. She pulled off her brief to attempt to have a bowel movement (BM). Resident #6's neurological assessment determined within normal limits for her. Resident #6 started melatonin (vitamin that assists with sleep). The author described her as sleepy but easily arousable without injuries. The author encouraged the staff to anticipate her needs as she didn't use the call light. The report indicated Resident #6 didn't go to the hospital and had no pain. The injuries report post incident listed a facture to the right hip. The Communication - with Hospice dated 11/26/23 at 2:46 PM reflected Resident #6 complained of right sided hip pain. Resident #6 sent to the emergency room (ER) for further assessment. The History and Physical dated 11/26/23 at 5:44 PM indicated Resident #6 presented to the ER via an ambulance. Resident #6 fell 4 times that day and complained of right hip pain. Typically, Resident #6 is ambulatory but acutely required help with ambulation and getting out of wheelchair. The Problem List listed the principal problem as a closed right hip fracture. The provider discussed Resident #6's case with the hospice nurse who advised they would admit her because of her acute fracture. The History and Physical dated 11/26/23 at 10:52 AM reflected Resident #6 went to the ER a few times in the previous weeks with a right wrist fracture 3 weeks before. The provider described her as a poor historian due to dementia and they didn't know if she had head trauma loss of consciousness. The plan directed to keep her on bedrest, pain control, and a urinary catheter. The Palliative Care Consult Note dated 11/26/24 indicated Resident#6 had recurrent falls and went to theER on [DATE] with a right wrist fracture after a fall. Resident #6 still had a cast in place. She presented to theER on this occasion after experiencing another fall that resulted in a comminuted and displaced right intertrochanteric hip fracture. The family and medical staff had a discussion regarding surgical intervention versus comfort focused care with continued Hospice support and discharge back to the nursing home. The family unsure how to proceed and requested time to discuss the options. Resident #6's Incident Reports reflected the following predisposing factors for falls: a. 9/16/23 at 10:15 PM: gait imbalance, weakness, ambulating without assist b. 9/18/23 at 8:15 PM: confused, impaired memory c. 9/18/23 at 9:21 PM: confused, impaired memory d. 9/18/23 at 9:35 PM: confused, impaired memory e. 9/25/23 at 11:00 PM: confused f. 9/26/23 at 7:55 PM: impaired memory g. 10/8/23 at 2:00 PM: impaired memory h. 10/2/23 at 1:49 PM: confused i. 10/25/23 at 4:30 PM: confused j. 10/26/23 at 4:10 PM: confused k. 10/29/23 at 1:35 PM: confused, memory impaired l. 11/6/23 at 7:30 PM: confused m. 11/12/23 at 9:45 PM: confused, impaired memory n. 11/16/23 at 11:36 AM: confused, impaired memory o. 11/17/23 at 1:55 PM: confused p. 11/24/23 at 11:16 PM: confused, impaired memory q. 11/24/23 at 2:45 PM: confused, impaired memory Resident #6's Care Plan revised 12/13/23 included the following fall interventions of education: a. 10/8/23: Educate Resident #6 to tell the staff if she would like to sit on the floor. If she sits on the floor, provide a cushion, and check on her frequently. b. 10/23/23: Resident #6 educated on the risk of continuing to not asking for assistance and the risk for injury with her falls. c. 10/26/23: Resident #6 reeducated on the importance of using her call light and requesting assistance. d. 11/12/23: Educated on the importance of waiting for assistance. e. 11/20/23: Educate Resident #6 on the importance of not standing during vehicle transfer. f. 11/21/23: Resident #6 educated to ask for assistance in returning to her room. g. 11/22/23: Resident #6 reeducated on the importance of using her call light and waiting for assistance. h. 11/24/23: Resident #6 educated to tell staff when she is ready to go to bed. i. 11/25/23: Resident #6 reeducated to call for assistance and use her call light. j. 11/25/23: Resident #6 educated to ask staff for assistance with needs. The Falls and Fall Risk, Managing policy revised March 2018 instructed the staff to identify interventions, based on previous evaluations and current data, related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The policy defined a fall according to the MDS, as unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and they would have fell , if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Challenging a resident's balance and training him/her to recover from loss of balance is an intentional therapeutic intervention. The losses of balance that occur during supervised therapeutic interventions are not considered a fall. The policy included a list of fall risk factors as listed below: 1. Environmental factors that contribute to the risk of falls include: wet floors; poor lighting; incorrect bed height or width; obstacles in the footpath; improperly fitted or maintained wheelchairs; and footwear that is unsafe or absent. 2. Resident conditions that may contribute to the risk of falls include: fever; infection; delirium and other cognitive impairment; pain; lower extremity weakness; poor grip strength; medication side effects; orthostatic hypotension; functional impairments; visual deficits; and incontinence. 3. Medical factors that contribute to the risk of falls include: Arthritis; heart failure; anemia; neurological disorders; and balance and gait disorders; etc. The policy included the following Resident-Centered Approaches to Managing Falls and Fall Risk: a. The staff, with the input of the attending physician, if appropriate, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. b. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). c. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. d. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period. e. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. f. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. g. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. h. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. Included in the policy directed the following about Monitoring Subsequent Falls and Fall Risk a. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. b. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. c. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. d. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. On 2/27/23 at 1:57 PM, Staff CC, Certified Nursing Assistant (CNA), stated Resident #6 declined during her stay at the facility and became very confused towards the end of her stay. On 2/27/23 at 1:59 PM Staff DD, CNA, described Resident #6 as confused and unable to follow directions at times. In an interview on 2/28/23 at 8:36 AM, when asked if Resident #6 had Care Plan interventions related to confusion, the DON responded Resident #6 wasn't confused. When asked if education should be used for interventions for confused residents, the DON replied, Resident #6 wasn't confused. She knew she shouldn't get up but got up anyway.

Based on clinical record review, staff, paramedic, and physician interviews, the facility failed to complete a timely assessment and interventions for 5 of 18 residents reviewed (Residents #143, #42, #59, #38 and #62). This failure resulted in a death, several hospitalization s, and visits to an emergency room for treatment for the residents, therefore causing an Immediate Jeopardy to the health, safety, and security of the residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 3:57 PM. The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: - The facility will continue to assess and intervene with change of conditions of residents in accordance with professional standards of care. - Licensed staff received education on [DATE] on the process that is to occur to complete with a change of condition. - The Agency staff received education on a change of condition through their orientation checklist. - The Certified Nurse Aides (CNA) received education on how to alert the nurse when they notice a change has or is occurring with the resident needs and or cares. - The facility determined the residents affected and who had a potential of being affected by reviewing all residents with a diagnosis of respiratory disease. - Corrective action taken for resident(s) affected: Assess the resident(s) upon return from the hospital. - Stand up meeting of the clinical alerts, weights, and vitals and 24-hour report. - Stand up meeting reviewed to assure that the Primary Care Provider (PCP) will be contacted for a change of condition for further needs or orders. - The management staff addressed in the morning meeting how to assure the review of alerts and change of condition (COC). The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 80 residents. Findings include: Resident #143's Minimum Data Set (MDS) assessment dated [DATE] listed an admitted [DATE] from an acute (short-term) hospital and discharged on [DATE] to the hospital. The MDS lacked documentation of behaviors. The MDS identified a completed staff assessment for mental status that indicated that Resident #143 had an ok short-term memory. Resident #143 could make consistent and reasonable decisions independently. The MDS included diagnoses of severe sepsis (body's extreme response to an infection), sepsis due to other specified staphylococcus (infection), acute congestive heart failure (sudden inability to for heart to pump blood fast enough for the body's needs), chronic congestive heart failure, chronic kidney disease (kidneys are unable to filter blood like they should), chronic obstructive pulmonary disease (a group of diseases that cause difficulty breathing), diabetes, and sleep apnea (breathing intermittently stops while sleeping). Resident #143's functional status documented in the MDS indicated that he needed extensive assistance for bed mobility, transfers, dressing, and toilet use. On [DATE] at 3:30 PM Staff EE, (CNA), approached the surveyor and asked if they came about Resident #143. When queried the identity of Resident #143, Staff EE replied the guy that died . Staff EE reported that he thought the resident died the week before. Staff EE explained that the day CNA's told the nurse a couple of times that Resident #143 did act like himself, but the nurse said that Resident #143 was just having a behavior. Staff EE stated that they told him the nurse did not do anything and the resident ended up going to the hospital and died . Resident #143's Census report identified the following: - Admission on [DATE] - Hospital stay less than 24 hours on [DATE] - Medicare A active on [DATE], indicating Resident #143 returned to the facility. - Stop [NAME] status as of [DATE]. The SPN - Admit/Re-Admit Note [DATE] at 4:37 PM defined Resident #143 as alert and oriented to person, place, time, and situation. The Orders - Administration Note dated [DATE] at 9:28 PM listed Resident #143 as out of the facility. The Nurses Note dated [DATE] at 12:47 AM indicated that Resident #143 returned to the facility from the emergency room (ER) with a peripheral IV. The facility received directives for Resident #143 to return to the hospital on that Monday ([DATE]) to get a PICC line (a specialized IV that is inserted through a vein in your arm that goes up into the larger veins near the heart, they can be used approximately for six weeks). The Chart lacked the reason for the ER visit or a documented assessment prior to the visit. The SPN - Skilled Evaluation Note dated [DATE] at 1:14 PM listed Resident #143 could verbalize his needs, oriented to person, place, time, and situation. The IDT (Interdisciplinary Team) Note dated [DATE] at 12:05 PM indicated Resident #143 had sepsis due to a staph infection. Physical Therapy (PT) and Occupational Therapy (OT) work with Resident #143 on his left lower extremities due to non weight-bearing transfers, activities of daily living (ADLs), activity tolerance, strengthening, and balance. Resident #143's anticipated last covered day is [DATE] with a goal to discharge home with family on [DATE]. The SPN - Focused Evaluation Note Text: Reason for Evaluation: Hot Charting (Not related to incident/accident/unusual occurrence) dated [DATE] at 5:52 PM listed Resident #143 continued on hot charting for emesis (vomiting) on [DATE] and discontinuation of Paxil (antidepressant). Resident #143 felt much better that day and did not have an emesis yet in the shift. The staff would continue to monitor. The Communication - with Physician Note dated [DATE] at 2:47 PM indicated that Resident #143 had three emesis since admission on [DATE]. The nurse discussed with the provider who gave new orders for Zofran 8 milligrams (mg) by mouth every six hours as needed (PRN). The SPN - Focused Evaluation Note Text: Reason for Evaluation: Hot Charting (Not related to incident/accident/unusual occurrence) dated [DATE] at 3:34 PM indicated that Resident #143 had a large emesis of partially digested food and liquid. Resident #143 reported that he had nausea off and on. The nurse gave PRN Zofran, and planned to monitor for results. Assessment revealed clear lung sounds with bowel sounds active in all four quadrants. Resident #143 reported that he had loose stools. Resident #143 continued on an IV antibiotic for the infection in his foot. The dressing remained intact to his left foot. Resident #143 voiced no complaints of pain or discomfort. The SPN - Focused Evaluation Note Text: Reason for Evaluation: Hot Charting (Not related to incident/accident/unusual occurrence) dated [DATE] at 6:12 PM. Resident #143 continued on hot charting for emesis. He had more emesis during day shift and evening shift. Resident #143 did have a new order for Zofran that is effective in reducing nausea. The nurse planned to continue to monitor. The Orders - Administration Note dated [DATE] at 9:38 PM indicated that Resident #143 received Ondansetron HCl (Zofran) Tablet 8 MG one tablet for nausea and vomiting. The Orders - Administration Note dated [DATE] at 10:35 PM indicated that Zofran worked to relieve the vomiting. The SPN - Focused Evaluation Note Text: Reason for Evaluation: Hot Charting (Not related to incident/accident/unusual occurrence) dated [DATE] at 1:51 AM included a blood pressure of ,d+[DATE] and a description of Resident #143 appearing pale in color. The Incident, Accident, Unusual Occurrence Note dated [DATE] at 4:30 PM indicated a CNA walked past Resident #143's room and noticed him attempting to self transfer. Before the CNA could reach Resident #143 his feet slipped out from underneath him and he fell on his bottom. The CNA reported that he did not hit his head. Resident #143 had his back against the bed frame with his feet out in front of him. The assessment revealed no new injuries noted, with range of motion (ROM) within normal limits (WNL), no internal or external rotation (potential sign of a hip fracture) noted and Resident #143 denied pain. Resident #143 wore a non-skid sock on his right foot and had his left foot wrapped with ace wrap. Resident #143 did not have his call light on and had his wheelchair next to his bed. Resident #143 explained that he tried to get into his wheelchair, as he thought he could do it on his own. Resident #143 reported that he did not want to bother any of the staff as they are always so busy. With the assistance of four staff, Resident #143 got into his wheelchair. The nurse provided Resident #143 with education to use his call light, he verbalized understanding. The nurse notified the medical doctor and due to Resident #143 being his own representative she did not notify anyone else. The Incident, Accident, Unusual Occurrence Note dated [DATE] at 10:30 PM identified that the nurse got called to Resident #143's room due to him kneeling on the floor between his wheelchair and the bed with his wound to his foot bleeding. The nurse redressed the wound and assisted Resident #143 to the toilet and back to bed. Resident #143 had low oxygen (O2) saturation (sat) with his BIPAP (a machine used to push air into the lungs) switched to oxygen per nasal cannula. The nurse initiated neurological checks (Neuros) and notified his sister of the fall and left a notation for the Nurse Practitioner (NP). The SPN - Skilled Evaluation Note dated [DATE] at 1:20 PM listed a blood pressure of ,d+[DATE] and O2 sat at 95% with O2 via nasal cannula. The Nurses Note dated [DATE] at 4:58 PM identified that Resident #143 left the facility by ambulance. The Nurses Note dated [DATE] at 7:16 PM report received from the ER that Resident #143 coded in the ambulance. The ER staff brought him back once in the ER. Resident #143 reported to be in asystole (heart stopped beating) and family had made him a do not resuscitate (DNR, no external measures to make the heart start again). The notification received indicated they did not think Resident #143 would return. The Nurses Note dated [DATE] at 8:48 PM indicated that Resident #143 expired (passed away) in the ER and the hospital would contact the medical examiner. The Incident, Accident, Unusual, Occurrence Note dated [DATE] at 11:07 PM identified that two CNA's reported to the nurse that Resident #143 appeared unresponsive with white foam coming out of his mouth. Resident #143 laid on his back in bed with the head of the bed elevated to 45 degrees receiving O2 by nasal cannula. Resident #143 did not respond to verbal stimuli but would open his eyes with a sternum rub and squeeze the nurse's hand when asked to do so. The nurse pulled the code light at that time. Another nurse assesses Resident #143 while the other nurse called 911. Resident #143 did not respond to hand grips and will not open eyes with a sternum rub and is limp with diaphragmatic breathing (using stomach muscles to breathe). The nurse applied oxygen via a face mask at 5 Liters per nasal cannula. Resident #143 transported to the hospital. The Nurses Note dated [DATE] at 11:07 PM listed the facility closed the neuro evaluation due to Resident #143's discharge. The Incident, Accident, Unusual Occurrence Note dated [DATE] at 1:21 PM indicated the facility received a signed notification from the medical doctor of Resident #143's fall. The Task: Monitor - Behavior Symptoms reviewed on [DATE] for the previous 30 days lacked documentation of any behaviors. Resident #143's chart lacked notification to the physician that he continued to required Zofran and he continued to vomit. On [DATE] at 10:30 AM Staff V, CNA, said that on [DATE] he went to Resident #143's room to see about giving him a bath as he had missed one the day before. He reported that Resident #143 would not respond, had white foam coming from his mouth and his breathing was off. He stated Staff C, Licensed Practical Nurse (LPN), did a sternum rub and another nurse, Staff FF, (LPN), showed up. He stated he didn't know anything about residents having behaviors. He also stated that the day CNA's, Staff GG, Nursing Assistant (NA) and Staff HH, CNA, told him that they had told Staff II, RN, that something was wrong with the resident a couple of times, but she didn't do anything. He stated they also told him that the resident had passed out at the lunch table earlier that day During an interview on [DATE] at 10:35 AM with Staff II, Registered Nurse (RN), she explained that she worked the morning of [DATE] and Resident #143 woke up lethargic. She said that he had been acting tired all week and she attributed it to the fact that residents often refused to wear his CPAP (breathing machine used to treat sleep apnea, though the resident used a BIPap). She reported that a resident fell the night before and that the nurses did neuros on them. She described Resident #143 as alert and oriented. Staff II reported that he sat up in the wheelchair that day. She explained that Resident #143 became a little sluggish throughout the day but felt that he maintained his baseline. On [DATE] at 11:00 AM Staff GG, Nurse Aide (NA), reported that he worked as the float NA that morning and heard that Resident #143 might be having behaviors. He stated the resident had his eyes open and appeared alert for the first part of the day, but became less responsive as the day went on. On [DATE]at 11:10 AM Staff HH, CNA, described Resident #143 as kinda out of it, but he sat in a wheelchair and had lunch at the table that day. Staff HH stated Resident #143 spilled his food. Staff HH explained that she and Staff GG reported the information to Staff II. She stated that Staff II took Resident #143's vitals and they were normal. Staff HH stated Resident #143 never had behaviors. On [DATE] at 7:45 AM Staff FF, RN, explained that she first worked with the residents on [DATE]. She commented that she received report from the previous nurse, Staff II, that Resident #143 had been lethargic. Staff II told her she thought it had to do with Resident #143 refusing to wear his CPAP during the night. Staff FF explained that Staff HH asked if she knew about Resident #143 being lethargic and she replied that she did. Staff FF added that she did not check on Resident #143 right away because she had a couple of other issues she needed to deal with first. She reported being in hall 6 doing a breast exam when the code alarm went off. When she got to Resident #143's room, she observed Staff C, LPN there and Resident #143 had foam coming from his mouth. Staff FF explained that someone brought the crash cart in. She stated she gave him a hard sternal rub. At that time he opened his eyes slightly and they appeared to be rolling around. She explained that Resident #143 made an ugh sound when she did the rub. She reported that she thought he had low blood pressure at ,d+[DATE] (an average person's is ,d+[DATE]) and had an O2 sat in the 80's (usually expected to be greater than 90%). She described Resident #143 as hot and sweaty. Staff FF explained that she saw the bed elevated and she heard the death rattle. At this time she applied a rebreather mask on the resident at ,d+[DATE].5 Liters. Staff FF remarked that she peeked at Resident #143 at approximately 3:30 PM as she went down the hallway. At the time he appeared relaxed and sleeping. She explained the report she received described him as himself during their shift. On [DATE] at 8:35 AM, Staff C, MDS Coordinator, explained that Staff V, CNA, or Staff JJ, NA, came to her and told her about Resident #143 foaming at the mouth. When she arrived to his room, she heard him mumbling and noted he had an O2 sat of 83% on O2 with a nasal cannula at ,d+[DATE] Liters. During a follow-up interview on [DATE] at 8:50 AM, Staff C said that Resident #143 laid on his back, with the head of the bed pretty flat so she raised it up to approximately 45 degrees. She commented that Resident #143 did not have a pillow behind his head and had his head back. She remarked that he had a good airway. On [DATE] at 11:25 AM Staff KK, RN, reported that she worked overnight the night before Resident #143 got transferred to the ER. She stated that when she came to work that night, she learned in report that Resident #143 had a witnessed fall earlier in the evening. She explained that he kept taking off his bi-pap, so she put oxygen on him at 3 Liters per nasal cannula in hopes that he would leave that on. She said Resident #143 appeared groggy but responsive during her shift. She added that Resident #143 would grab her hand when she did her checks and that he knew his name. Staff KK stated she did not know of any policy of when residents should be sent out to the emergency department. She described Resident #143 as not real lethargic and she did not feel that he needed to go to the emergency room . She expressed that had she known what was going on, she would have sent him. On [DATE] at 11:50 AM the Emergency Medical Services Paramedic explained that they got a call at 4:26 PM about an unconscious male last seen at 2:30 PM by the staff. When they arrived at the scene, they noted the Fire department already at the facility. She reported that Resident #143 did not respond to the sternum rub. Resident #143 appeared pink, warm, and dry with a strong irregular heartbeat. An electrocardiogram (EKG) showed Resident #143 in atrial fibrillation (abnormal heart rate). She explained that the staff believed it to be a new rhythm. Resident #143's heart beat at 60 beats per minute (BPM), which is normal, pupils pinpoint and nonreactive. Resident #143's appearance caused her to question an opioid overdose. She explained that the facility staff reported that he did not have any opioids. Resident #143's lungs sounded clear, he had a blood sugar of 178 (elevated but not too high, average 70 - 150), respirations 12, blood pressure ,d+[DATE], and an O2 sat at 90% on a simple mask at 5 Liters of oxygen. She said that she attempted to start an IV in his arm, but could not get it started. The team inserted an interosseus (IO) (needle placed into bone to quickly administer medication), in his left lower leg, and they called the hospital with a stroke alert. When they flushed the IO with normal saline, Resident #143 grimaced. The team gave Lidocaine due to the appearance of pain from the IO. The ambulance crew applied a nonrebreather (NRB) oxygen mask with 10 Liters of oxygen on Resident #143, moved him to the ambulance, and put on a cardiac monitor. The monitor detected an abnormal heart rhythm and the ambulance crew sent the EKG to the hospital. Resident #143 began having snoring respirations so they inserted an airway through his nose and used an ambu bag (device to assist or make breathing more effective). During his transfer to the hospital, as the IO stopped working, the ambulance crew replaced the IO in the right lower leg. The ambulance crew gave Resident #143 Narcan (medication given to reverse effects of opioid overdose) with no change in Resident #143's responsiveness. She stated at one min from the hospital, he went into cardiac arrest and they started cardiopulmonary resuscitation (external pushing on the chest to attempt to restart the heart). On [DATE] at 10:05 AM the Fire Department's Paramedic explained that he arrived first at the facility. He stated they receive calls to the facility almost every day. He commented that when he walked into Resident #143's room, he observed three facility staff standing at the foot of the bed. He described the head of the bed elevated to ,d+[DATE] degrees, Resident #143 had a simple oxygen face mask on with oxygen running at ,d+[DATE] Liters and he only responded to painful stimuli. The facility staff told him that Resident #143 did not get out of the bed, and he was lethargic all day. He stated the staff told him the last check on him at 2 PM. He explained that he placed a non rebreather oxygen mask on Resident #143 and inserted an IO. He also reported that Resident #143 had pinpoint pupils and that they called a stroke alert. They gave Narcan with no response. On [DATE] at 11:05 AM Resident #143's Primary Care Physician (PCP) prior to his admission to the facility explained that he received a report from the hospital about Resident #143. The PCP reported that knew Resident #143 had an ST elevated myocardial infarction (STEMI, heart attack). He denied receiving a cause of death yet. He added that his office did not receive any calls since Resident #143 went to the facility. The PCP reviewed Resident #143's recent falls, low blood pressure, and oxygen saturations prior to his ER transfer on [DATE] with another physician. The PCP said that with a STEMI, it would not likely affect the blood pressure that much. However, he would have definitely wanted to be called with the pressures and saturations as low as stated. He added that he would have ordered Resident #143 to be transferred to the emergency room for further evaluation and treatment. In closing, the PCP stated that he did not believe the STEMI had a connection to the low blood pressures and oxygen saturations. He did feel that Resident #143 should have gone sooner to the emergency room than he did. On [DATE] at 10:10 AM the Administrator explained that she expected the nurses to recheck abnormal vital signs. If the recheck remained abnormal, then she would expect the nurse to contact the physician for further instructions. 44474 2. Resident #62's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of heart failure, anxiety, and hypertension. On [DATE] at 11:39 AM Resident #62 that she has been sick for a while and they could not figure out what is going on. Observed Resident #62 wearing supplemental oxygen with a nasal cannula. Resident #62 explained that she wears the oxygen all the time. Progress Notes Review [DATE] at 9:31 AM a resident was tested for COVID due to a new positive staff member, results are negative. [DATE] at 11:08 AM labeled Late Entry: negative COVID test. [DATE] at 10:55 AM call placed to primary care physician's office per Resident #62's request, complaints of some nasal congestion with clear drainage, will wait for a call back. [DATE] at 1:55 PM received a verbal order to swab for flu and nasal congestion per physician. [DATE] at 3:52 AM Resident #62 continued to be monitored for signs and symptoms of an upper respiratory infection (URI). Resident #62 tested negative for both influenza and strep. PCP was faxed with results. No complaints of pain or shortness of breath during the overnight shift. Will Continue to monitor. [DATE] at 4:23 PM Resident #62 tested again for strep and influenza A and B. At 3:23 PM strep swab results negative and at 4:32 PM flu swab results negative as well. [DATE] at 4:34 PM also performed a rapid antigen COVID test and results pending. The 2 PM - 10 PM nurse to read the COVID test results and notify the doctor of all three test results. [DATE] at 4:50 PM covid test negative [DATE] 10:49 PM a CNA alerted the nurse that Resident #62 did not act like herself. Upon assessment Resident #62 had an O2 sat of 75%, she felt warm but clammy. Resident #62 responded at the time and denied pain. The nurse informed Resident #62 to take deep breaths, but her O2 only came up to 80%. Resident #62 started to decline further, with diminished lung sounds throughout with evident sounds of fluid. The nursing staff stayed with Resident #62 until the ambulance arrived to take over. The on-call physician called and gave an order to send Resident #62 out. The nurse contacted the non-emergent ambulance but then canceled it as Resident #62 required emergency transport to the hospital. Resident #62 left the building at 10:03 PM by an emergency ambulance. [DATE] at 5:50 AM the facility called the hospital emergency room and received report by the nurse that Resident #62 got admitted to the Intensive Care Unit (ICU) for acute respiratory failure with hypoxia. Review of the vital sign records in the clinical record revealed the last time vital signs were taken was on [DATE]. The Hospital Records dated [DATE] at 2:00 AM revealed Resident #62 arrived at the ER via emergency medical staff (EMS) from the facility after she had issues with hypoxia (low blood oxygen levels). Resident #62 normally uses oxygen at 2 Liters per the nasal cannula at all times at the facility and has a history of Warnicke's Encephalopathy (a brain and memory disorder that requires immediate treatment). The EMS reported that upon arrival Resident #62 had an O2 sat at 70% on 4 Liters of oxygen. The EMS started a CPAP started en route, upon arrival to the ER, the staff applied a 15 liters non rebreather mask on Resident #62. With the non rebreather mask, Resident #62's O2 sat raised to 96%. Resident #62 had decreased levels of consciousness and got started on a BiPAP machine in the ER. Resident #62's lungs sounded coarse (indicating decreased air flow in the lungs due to some form of blockage). Resident #62 appeared pale in appearance with generalized edema throughout the body in all four extremities and her face. Resident #62 had an ill-appearance with dry mucous membranes, demonstrating respiratory distress, abdominal distension, general swelling, and edema (swelling) present in her lower extremities. Resident #62 seemed disoriented, with symptoms consistent with Warnicke's encephalopathy. The Hospital Note dated [DATE] at 10:19 PM listed that Resident #62 received treatment for right sided pneumonia. On [DATE] at 2:26 PM Staff O, Certified Medication Assistant (CMA), revealed that she went into Resident #62's room and found her confused on the time of day. Staff O explained that she took her pills and Staff O noticed her doing a little twitch type movement. Resident #62 wanted her breathing treatment and after her treatment, Staff O alerted Staff P, RN, about her concerns with Resident #62. Staff P went down right away and assessed Resident #62. Staff P called for a non-emergent transport and got told it would be a half hour. Staff P called back and had EMS come as an emergent transport and sent Resident #62 to the hospital. On [DATE] at 2:18 PM Staff P reported that a CNA alerted him that Resident #62 did not act like herself and had some twitching. Staff P revealed that he went down to Resident #62's room around 8:50 PM and assessed her. At the time Resident #62 had an O2 sat of 75% with diminished lung sounds in the bases. Staff P turned up Resident #62's O2 and called the doctor while another staff member stayed with her. Staff P reported that when he got back to the Resident #62's room, her lungs sounded worse and continued to get worse. Staff P explained that he called dispatch back and requested an emergent transport. Staff P added that during the shift report the off-going nurse reported that they tested Resident #62 for flu, strep, and COVID but they all came back negative. Resident #62 did complain about a sore throat. 3. Resident #38's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of heart failure, chronic obstructive pulmonary disease (COPD), pneumonia and septicemia (serious blood infection). Resident #38's Order Summary Report dated [DATE] revealed the following orders: - Call the physician if Resident #38 has shortness of breath or edema every shift with a start date of [DATE]. - Call the physician's office with weight gain or shortness of breath every shift with a start date of [DATE] - Daily weight every shift with a start date of [DATE] The Care Plan Focus dated [DATE] indicated that Resident #38 experienced sleep apnea. The Intervention instructed the staff to assist her with her BIPap/CPAP equipment each night. The Care Plan lacked additional information regarding the use of the CPAP. The Care Plan Focus dated [DATE] indicated that Resident #38 had congestive heart failure. The Care Plan included the following Interventions: - Dated [DATE]: Evaluate Resident #38 for excessive fluid retention. - Dated [DATE]: Monitor, document, and report as needed any signs or symptoms of Congestive Heart Failure: dependent edema of legs and feet, periorbital edema, shortness of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes on auscultation (listening) of the lungs, orthopnea, weakness and/or fatigue, increased heart rate (tachycardia) lethargy and disorientation. - Dated [DATE]: oxygen settings: O2 via nasal cannula at 2 Liters continuously. - Dated [DATE]: directed to do daily weights as ordered by the medical doctor. Progress Notes Reviewed [DATE] at 12:09 AM no weight done on this shift and no new complaints of (c/o) shortness of breath (SOB). [DATE] at 1:17 AM no increase in edema or c/o SOB. [DATE] at 3:01 AM lung sounds diminished throughout with no increase in SOB or cough noted at this time. [DATE] at 12:25 AM no weight done on this shift and no new c/o SOB. [DATE] at 12:31 AM no increase in edema or SOB noted. [DATE] at 2:15 AM lung sounds diminished throughout with some occasional expiratory wheezes heard. Has had no increase in SOB or cough noted. [DATE] at 11:54 PM no weight done on this shift and no new c/o SOB. [DATE] at 12:36 AM no increase in edema or SOB noted. [DATE] at 1:21 AM lung sounds diminished throughout with some occasional expiratory wheezes heard. Has had no increase in SOB or cough noted. [DATE] at 12:03 AM no weight done on this shift and no new c/o SOB [DATE] at 12:12 AM no increase in edema or SOB noted [DATE] at 2:11 AM lung sounds diminished throughout and has had no increase in SOB or cough notes. [DATE] at 12:37 AM no weight done on this shift and no new or increase in SOB noted [DATE] at 2:19 AM lung sounds diminished throughout and has had no increase in SOB or cough noted [DATE] at 4:37 AM no increase in edema or SOB noted. [DATE] at 4:22 AM Resident completed her antibiotics for pneumonia on [DATE]. [DATE] at 12:39 AM no weight done on this shift and no new or increase in SOB noted. [DATE] at 1:26 AM no increase in edema or SOB noted. [DATE] at 12:49 AM no weight done on this shift and no new or increase in SOB noted. [DATE] at 1:23 AM no increase in edema or SOB noted. [DATE] at 1:33 AM no weight done on this shift and no new or increase in SOB noted. [DATE] at 1:43 AM no increase in edema or SOB noted. [DATE] at 12:15 AM Resident #38's lungs sounded diminished and rubbed bilaterally. Encouraged her to consider going to the hospital, which she refused, and said that she has a doctor's appointment already scheduled and that she will have the doctor check her lungs out then. [DATE] at 1:07 AM no weight got done on this shift and no new or increase in SOB noted. [DATE] at 2:05 AM no increase in edema or SOB noted. [DATE] at 12:17 AM no weight done on this shift and no new or increase in SOB noted. [DATE] at 12:58 AM no increase in edema or SOB note. [DATE] at 12:17 AM no weight done on this shift and no new or increase in SOB noted [DATE] at 1:14 AM no increase in edema or SOB noted [DATE] at 6:37 PM Received a call from hospital ER stating Resident #38 went to the ER after her appointment and still remained there. [DATE] at 7:11 PM Resident #38 will be admitted due to fluid retention and abnormal labs. Review of facility recorded weights lacked documentation on the following days: [DATE]-5, 2023 [DATE] [DATE]-13, 2023 [DATE] On [DATE] at 11:53 AM, observed a CPAP in Resident #38's room sitting next to the bed. Resident #38 revealed she used a CPAP when she was sleeping. Resident #38's [DATE] Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked an order for a CPAP or settings for CPAP usage. The MAR co[TRUNCATED]

Based on observations, interviews and record review the facility failed to monitor and prevent the development of pressure ulcers for 3 of 4 residents reviewed (Residents #29, #60, and #129). Resident #29 developed an open pressure on his right gluteal. As his wound declined the staff failed to document or contact the physician. Resident #60 had infected toes that eventually required amputation. The chart lacked documentation of the initial discovery of the sore or monitoring. The facility reported a census of 80 residents. 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. Findings included: 1. Resident #60's MDS dated [DATE], identified a BIMS score of 15, indicating intact cognition. Resident #60 required extensive assistance from two persons for bed mobility, transfers, dressing and toilet use. Resident #60 had an impairment to one side of his lower extremities. The MDS listed Resident #60 as dependent with putting on and taking off his footwear. The MDS indicated a risk of developing pressure ulcers/injuries. Resident #60 did not have pressure ulcers. Resident #60 did have a surgical wound(s) that required surgical wound care. Resident #60 received IV (medications given through a vein) medications during the previous 14 days of the lookback period while being a resident and while not being a resident. The Care Plan Focus dated 3/9/23 indicated that Resident #60 had impairment to his skin due to amputated toes. The Interventions directed to - Monitor for and document location, size, and treatment of skin injury. The nurse should report abnormalities (different than his usual), failure to heal, signs and symptoms of infection to the physician. - Document weekly including measurement of each area of skin breakdown, type of tissue and exudate and any other notable changes or observations. The resident requires assistance from staff with grooming and personal hygiene related to limited mobility, and left hemiplegia. On 3/14/23 at 12:52 PM, observed Resident #60 sitting in his wheelchair and wearing a protective boot on his right foot. He explained that he had a hospital stay for about 2 weeks. He added that initially he went in because of a fall. While he stayed at the hospital, they decided that he needed to have some toes amputated. A physician's order was completed on 1/7/23 at 8:20 AM for the resident to be seen by a podiatrist for ingrown toenail to the right great toe. The Progress Note dated 2/6/23 signed by the provider indicated that Resident #60 got seen due to an improving ingrown toenail. The Assessment and Plan related to his ingrown toenails directed to continue salt soaks and to follow-up with podiatry (foot doctor) for hygiene care. An approval for the resident to be seen by podiatry from the Veterans Administration was dated 2/16/23 at 2:54 PM. According to a podiatry note dated 2/20/23. The resident had been seen in office on that date for an ingrown toenail. The resident opted to have the toe nail removed from his right great toe at that time. A review of the chart revealed that from 12/19/22 through 2/20/23 the weekly skin documentation indicated that the resident had no skin issues. The Incident Report dated 2/24/23 at 11:45 PM indicated that Resident #60 called out from his room requesting help. When staff arrived at his room, they discovered him on the floor in his bathroom. Upon an inquiry of his pain, he replied that his left side and right ankle hurt. The Immediate Action listed that Resident #60 went to the hospital. The History and Physical dated 2/25/23 listed that Resident #60 recently had his great toenail removed. Resident #60 started on Keflex (antibiotic) on 2/22/23. The provider ordered to hold the antibiotic while on IV antibiotics. The Hospital Consultation Report dated 3/1/23 listed the Chief Complaints as cellulitis and osteomyelitis (infection of the bone) of the right foot. Resident #60 complained about his toes, right third toe and right hallux (big toe), being extremely painful. Examination of the right foot revealed cellulitis, red and inflamed with purulent drainage from the right hallux, with a complete nail lysis (removal). Resident #60 had cellulitis and an abscess on his right hallux, and also very painful ulcers on the tip of the right third digit for over 2 weeks, complicated by rigid claw toe deformity (toe stuck in a bent position). Resident #60 reported that he has dealt with an infection in his right big toe for a while, he explained that the week before he had his right big toenail removed by one of his doctors. Resident #60 said it got so bad from the infection that he had discussed removing his toe. Resident #60 stated he chose to have the right big toenail removed hoping that the infection and pain would be resolved. Resident #60 stated that the right big toe had even more pain, very tender to the touch, with the pus all over the right big toe with purulent (infected fluid) drainage, swelling, and throbbing. Resident #60 had a full-thickness stage IV necrotic ulcer, 2 cm x 2.5 cm x 0.5 cm diameter with tissue necrosis that extends to the distal phalangeal (toes) bone. Ischemic (loss of blood) changes extend to the bone, with tissue necrosis of the nail bed, and tracking proximally (near) into the level of the interphalangeal joint (knuckle). The proximal margin of the right hallux, showed exposed bone. Direct palpation (assessment touch) is tender and painful to the patient. In addition, Resident #60 had a stage IV ulcer, of 0.5 cm x 1 cm x 1 cm diameter at the distal tip of the right third digit, exposed to the distal phalangeal bone, with erythematous (redness and swelling) and edema (swelling), painful purulent drainage. It is further complicated by rigid claw toe deformity with the patient practically walking the tip of his right third toe. The Plan section indicated the physician discussed all findings of his evaluation with Resident #60, and reviewed his x-rays and his foot as well as an MRI (special imaging of the internal body) with him, and explained to him the severity of his condition. The physician explained to Resident #60 that he will need surgeries on his right foot, at best he could have an amputation of his right first and third digit, at worst he could end up with trans metatarsal (removal of all the toes) amputation. The physician explained to him that he would need more than one surgery. He stated he understood and that he wanted him to go ahead with the surgery. On 3/15/23 at 6:14 AM Staff II, Registered Nurse (RN), said that she noticed the redness in Resident #60's foot and notified the Nurse Practitioner (NP) and she ordered an antibiotic. Staff II described his foot as very swollen and very red after the nail removal. She said that Staff AA, RN, was responsible for the wounds and skin assessments. Due to that, Staff II assumed that Staff AA documented and monitored the wound. On 3/14/23 at 4:40 PM Staff V, CNA, said that he saw Resident #60's foot red and swollen in the days leading up to his hospitalization . He described it as dark red and several sizes larger than normal. He explained that he did tell a nurse but he did not know if anyone followed up. On 3/15/23 at 8:09 AM Staff AA said that she saw Resident #60's foot after the removal of his nail. Staff AA described it as red and reported they soaked his foot. She denied noticing any redness on the third digit. Staff AA said if the evaluation tab did not have the skin assessment in the evaluation tab, then it should be documented in the nursing notes. On 3/15/23 at 9:08 AM the NP said that she saw Resident #60 on 2/6/23, 2/1/23, 2/15/23, and 2/17/23 while at the facility. On the 15th Resident #60 had COVID and she noted that he had mild redness and pain. She ordered an antibiotic at that time. She said that after the removal of the toe nail, she did not manage that care. At that time, the staff should have gone to the podiatrist with concerns. On 3/15/23 at 9:56 AM Staff FF, Licensed Practical Nurse (LPN), said that she saw Resident #60's toes leading up to his hospitalization . Staff FF described his toes as swollen and irritated. She said that Resident #60 took pain medications quite often. She said that she only worked with him one time so she didn't have a baseline for his foot or be able to recognize a decline for him. On 3/15/23 at 1:09 PM the Podiatrist said that Resident #60 came in for an appointment on 2/20/23, with inflamed toes from ingrown nails. The Podiatrist said that he would have been fine with just clipping the nails back but the resident insisted on him taking the nail off because he was tired of dealing with it. The doctor did not know that Resident #60 went to the hospital and had a partial amputation of his great toe and third toe. The Podiatrist explained that he had chronic ingrown nail problems. The Podiatrist said that he didn't think osteomyelitis could have developed in just 4 days so it may have been present before the podiatry appointment. The Podiatrist expressed that he would have liked to have seen Resident #60 sooner. 2. Resident #29's Minimum Data Set (MDS) dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive deficit. Resident #29 required extensive assistance with the help of two persons for bed mobility, transfers, and dressing. He required extensive assistance from one person for toilet use and hygiene. The MDS listed that Resident #29 had a pressure ulcer/injury, he had a risk for developing pressure ulcers/injuries, and he had one or more unhealed pressure ulcers/injuries. Resident #29 had one stage 2 pressure ulcer that developed after admission, entry, or reentry. Resident #29 had a pressure reducing device for his bed, pressure ulcer/injury care, applications of ointments/medications other than to feet, and application of dressing to his feet. The Care Plan Focus revised 10/5/22 indicated that Resident #29 had an impairment to his skin. The Interventions directed the following Interventions: - Dated 9/22/22: Monitor and document the location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection to the physician. - Dated 9/22/22: Weekly treatment documentation to include a measurement of each area of skin breakdown, type of tissue and exudate, and any other notable changes. - Dated 2/7/23: Float heels while in bed. - Dated 2/7/23: Prevalon boots (specialized boots to prevent pressure ulcers) to both feet. The Order Details dated 10/19/22 included an order for a treatment to Resident #29's left buttock - cleanse the wound then apply zinc cream then calmoseptine cream - do twice a day. The clinical record included an order dated 11/15/22 at 2:00 PM for Triad paste to coccyx and scrotum to be used twice daily. The clinical record lacked documentation of a skin issue on the gluteal. The NSG: Skin Observation Tool - V2 dated 2/15/23 indicated that Resident #29 did not have any new skin issues. The NSG: Skin Observation Tool - V2 dated 3/6/23 indicated that Resident #29 did not have any new skin issues. On 3/14/23 at 3:40 PM Resident #29 reported that he had a lot of pain on his bottom. He explained that he experienced a lot of pain on the rides to and from dialysis because he had to sit in a wheelchair. On 3/14/23 at 4:00 PM observed Staff X, Certified Nursing Aide (CNA), and Staff V, CNA, provide incontinence care for Resident #29. Upon removal of his brief, noted Resident #29 incontinent of bowel. As the staff moved Resident #29 from side to side he moaned as they cleaned him. The observation revealed an open sore on his left buttocks about the size of a silver dollar and two smaller open areas down his thigh. Staff X reported that Resident #29 usually had a cream in the room with a yellow lid that the CNA's would apply to his bottom but she couldn't find it. The staff put a brief back on him without calling the nurse for the triad cream. On 3/14/23 at 4:13 PM Staff Y, Assistant Director of Nursing (ADON), said that they had a wound nurse that monitored and documented any wound issues. She expected a completed wound assessment with the weekly skins and notification to the provider regarding any deterioration. On 3/14/23 at 5:45 PM Staff Z, CNA, said that the aides put a cream on Resident #29's gluteal (buttocks) from a yellow tube. She said that the gluteal area looked horrible for over a week and she told the wound nurse, Staff AA, Registered Nurse (RN). Staff Z said that Staff AA came in the room with her one day and applied the cream to Resident #29's bottom. Staff Z reported that at the time, Resident #29 had an open wound. Resident #29's clinical record lacked documentation of notification to the doctor regarding his wound on his bottom. On 3/14/23 at 6:13 PM Staff B, CNA, said that she helped Resident #29 get up a few times and she did get him changed one time with Staff AA with her. At that time, Staff AA applied ointment on his bottom. On 3/14/23 at 6:32 PM, Staff CC, CNA, said she had noticed the open areas on the resident's bottom. Licensed Practical Nurse (LPN) Staff Q had come in and helped. While their Staff Q put cream on Resident #29's wound on his bottom. Staff Q said that she would follow up and get a better treatment order. The Skin and Wound Evaluation dated 3/16/23 at 8:44 AM described Resident #29's sacrum (a portion of the lower spine that extends into the tailbone) wound as an in-house acquired Moisture Associated Skin Damage (MASD) due to incontinence associated dermatitis. The wound measured 1.1 total area x 1.9 length x 0.8 width, with no depth, no evidence of infection, and that the resident indicated no pain. The Wound Center progress note dated 3/16/23 at 9:15 AM identified that Resident #29 had six separate wounds to be evaluated. The History of Present Illness indicated that Resident #29 had the following pressure injuries - Wound #1, open, cause of wound listed as pressure ulcer with a date acquired documented as 2/7/23. The wound clinic classified the wound as unstageable/unclassified with etiology of a pressure ulcer, located on the left calcaneus (heel bone). The wound measured 5.4 centimeters (cm) length by (x) 7.8 cm width x 0.2 cm depth. The wound contained 67-100% of necrotic tissue within the wound bed including adherent slough (sticky soft, moist, dead tissue). - Wound #4, open, cause of wound listed as pressure ulcer with a date acquired documented as 3/8/23. The wound clinic classified the wound as a stage II pressure on his right gluteus (buttocks) measuring 2.3 cm length X 1.3 cm width X 0.2 cm depth. The wound had subcutaneous tissue exposed. The wound did not have tunneling or undermining noted. The wound contained a medium amount of serosanguineous (common type of drainage that appears clear to pale red or pink color) drainage noted and medium (34-66%) pink granulation (new tissue indicating healing) within the wound bed. The wound also contained a medium (34-66%) amount of necrotic (dying) tissue within the wound bed. - Wound #5, open, unknown cause with an acquired date of 3/8/23. The wound clinic listed the etiology (cause) as to be determined with a location on the right ischium (hip bone). The wound measured 1.3 cm length X 0.7 cm width x 0.2 depth. The section labeled Procedure indicated that the wounds received the following treatments - Wound #4, pre-procedure diagnosis listed as a pressure ulcer located on the right gluteus. The Nurse Practitioner removed 3.68 square (sq) cm of non-viable tissue/material (not able to develop, grow, or survive). The procedure removed slough (only present in stage III or higher wounds, it slows the healing process), biofilm (a bunch of bacteria in the wound that affects healing), fibrin (major component of a blood clot), and exudate (fluid in the wound). Post procedure measurements listed 2.3 cm length X 1.6 cm width X 0.2 cm. The wound diagnosis did not change following the treatment. - Wound #5, pre-procedure diagnosis listed as a pressure ulcer located on the right ischium. The Nurse Practitioner removed 0.91 sq cm of non-viable tissue/material. The procedure removed slough, biofilm, fibrin, and exudate. Post procedure measurements listed 1.3 cm length X 0.7 cm width X 0.2 cm. The wound diagnosis did not change following the treatment. The Order Details dated 3/16/23 included an order to cleanse his right gluteal wound with one-fourth (1/4) strength peroxide for cleaning. Apply calcium alginate with silver to the wound bed (silicone border). Cover the wound with a foam border three times a day. 3. Resident #129's MDS assessment dated [DATE] listed an admitted [DATE] from an acute hospital. The MDS identified a BIMS score of 13, indicating intact cognition. Resident #60 required extensive assistance from two persons for bed mobility, transfers, dressing, locomotion and toilet use. The MDS indicated that Resident #129 had a risk for developing pressure ulcers/injuries. The MDS indicated that Resident #129 did not have pressure ulcers, but he did have moisture associated skin damage (skin irritation caused by increased moisture). The NSG: Admission/Readmission Evaluation - V 9 form dated 10/13/22 at 12:17 PM listed that Resident #129 had non-pressure areas of bruises to his right hand, right toe, with abrasions to his right lower leg in the front, and right lower leg in the back. Resident #129's Census reviewed on 3/21/23 listed an admission to the hospital on 10/26/22 and an order to stop billing. The Care Plan Focus dated 10/17/22 indicated that Resident #129 had an impairment to his skin. The Interventions directed - The staff to monitor for and document location, size, and treatment of skin injury and to report abnormalities, failure to heal, signs and symptoms of infection to physicians. - Weekly treatment documentation to include, measurement of each area of skin breakdown, type of tissue and exudate, and any other notable changes or observations. The Skin and Wound Evaluation V5.0 dated 10/18/22 identified that Resident #129 had a new abrasion to his coccyx that measured 1.6 cm x 1.8 cm x 2 cm. The wound did not have the epithelial of the wound covered. Resident #129's wound appeared to bleed with a scab covering. Resident #129 had pain with touch. The Skin and Wound Evaluation V5.0 dated 10/24/22 at 1:53 PM identified that Resident #129 had a new abrasion to his coccyx that measured 0.8 cm x 1.4 cm x 1.0 cm. The Order Details note dated 10/18/22 at 10:26 AM listed an order for Resident #129 to see the provider related to a treatment of his right buttocks and scrotum. The order continued to direct to apply calmoseptine twice a day and get seen by the provider on 10/19/22. On 3/28/23 at 11:57 AM a Wound Clinic Receptionist reported that they did not have any record that they saw Resident #129 at the clinic during the month of October 2022. The Pressure Injury Risk Assessments policy dated March 2020 instructed the staff to document any change in the resident's skin condition if identified. The condition of the resident's skin, such as: size and location of redness or tender areas. A pressure or a non-pressure form should be initiated related to the type of alteration in skin, if noted. Then document the notification of the attending physician if new skin alteration is noted. On 3/29/23 at 10:12 AM the Director of Nursing said that when a change in skin condition is identified it should be documented and monitored to include description and measurements. The physician should be notified with any changes.

Based on clinical record, facility policy, and staff interview, the facility failed to assist residents with bathing for 2 of 3 residents reviewed (Resident #12 and #7). The facility reported a census of 77 residents. Findings include: 1. Resident #12's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 3, indicating severely impaired cognition. Resident #12 required total assistance of one person with bathing. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Plan of Care (POC) Response History for the Activity of Daily Living (ADL) task of bathing from 8/3/22 to 8/28/22 revealed the resident received 5 baths in the 25 day review period with no bath given for the week of 8/21/22. The Care Plan with a resolved date of 2/11/22 recorded that Resident #12 was to have two baths per week and as needed. The Clinical Record for the resident lacked information as to why the resident did not receive two baths per week during the review period. The Bath, Shower/Tub policy revised 2/2018 described the purpose of the procedure as to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. In an interview on 9/20/22 at 1:43 PM, the Director of Nursing (DON) reported that she expected residents to receive two baths per week at a minimum. 2. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 15, indicating no cognitive impairment. The MDS indicated that Resident #1 required total assistance of one person with bathing. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/6/22 at 4:30 p.m. Resident #1 explained that she went almost two weeks without having a bath at the facility. The Admission MDS dated [DATE] included the question of how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Resident #1 responded very important. Resident #1's Care Plan lacked information regarding the need for personal care assistance. Review of Resident #1's documentation of bathing assistance and schedule revealed bathing is to take place on Wednesdays and Saturdays. Documentation for bathing completed between 5/1/22-5/31/22 revealed the following information: a. 5/7/22 - not applicable b. 5/8/22- not applicable c. 5/11/22- not applicable d. 5/14/22- yes e. 5/18/22- yes f. 5/21/22- yes g. 5/25/22- yes On 9/19/22 at 12:11 p.m. the DON reported that bathing is done on a resident preference but should be done twice weekly. If a resident is scheduled to have a bath twice a week it should be done twice a week. 3. Resident #7's MDS assessment dated [DATE] identified a BIMS score of 12, indicating moderate cognitive impairment. The MDS indicated that Resident #7 required extensive assistance of two persons for bed mobility, transfers, dressing, and toilet use. Resident #7 required total assistance of two persons with bathing. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/6/22 at 11:59 PM, Resident #7 explained that she should get a bath twice a week. Sometimes she got them and sometimes she did not. Resident #7 reported that she took one when she could get one, she did not refuse. The MDS dated [DATE] for Resident #7 also identified Resident #7 to be dependent on bathing needs. The Care Plan revised on 7/27/22 for Resident #7 lacked direction related to personal care assistance. The Progress Note of a care conference dated 9/7/22 documented that Resident #7's family would like to see her get a bath twice a week. The bathing schedule for July 2022 through August 2022 included a bathing scheduled for every Wednesday and Saturday. The documentation for bathing revealed Resident #7 either did not receive a bath or staff documented bath not applicable. The facility failed to provide a bath on the following scheduled bath days: a. 7/2/22 b. 7/13/22 c. 8/20/22 d. 8/31/22 4. Resident #19's MDS assessment dated [DATE] identified a BIMS score of 15, indicating no cognitive impairment. The MDS indicated that Resident #19 required limited assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 9/20/22 at 10:12 AM, Resident #19 explained that he only had a shower five to six times in 10 weeks. Resident #19 reported that his last shower happened on Friday. He explained that he did not refuse a shower, as he needed help with the shower, as he can't move his one side very well because of a stroke. The bathing schedule for August 2022 through September 31, 2022 directed that Resident #19 should have a bath on Wednesdays and Saturdays. Resident #19's bathing documentation failed to show that Resident #19 received a bath. The facility failed to provide a bath on the following scheduled bath days: a. 8/3/22 b. 8/6/22 c. 8/10/22 d. 8/17/22 e. 8/24/22 Resident #19's documentation showed only three baths for the month of August 2022. f. 9/3/22 g. 9/7/22 h. 9/10/22 i. 9/14/22 j. 9/17/22 Resident #19's documentation showed only one bath in the month of September 2022 through 9/21/22. In an interview on 9/8/22 at 12:49 PM, Staff L, CNA, stated residents did not always get their baths, as the staff did not have enough time.

Based on clinical record reviews, observations, resident, and staff interviews, the facility failed to provide adequate nursing supervision to prevent accidents and injuries for 3 of 4 residents reviewed (Residents #4, #6, and #16) for accidents and hazards. 1. Resident #6 got changed from an extensive assist of one person with transfers to independent without determining her to be safe by some type of an assessment. Two weeks after Resident #6 changed from extensive assist of two persons to independent, she fell resulting in multiple upper and lower body fractures. Resident #6 did not get evaluated by a physician or Advanced Registered Nurse Practitioner (ARN) until four days later who ordered diagnostics. That day, Resident #6 went to the hospital where she admitted for multiple rib fractures, clavicle (collar bone), pelvis, and wrist fracture. 2. Resident #4's documentation indicated that she had multiple falls. Following her falls, the facility failed to reevaluate her risk for falls after one fall, the facility failed to complete a thorough neurological assessment, they failed to implement an intervention following one fall, and failed to follow physician's orders after she fell . Three hours after Resident #4's fall on 4/29/22, the nurse contacted the on-call physician regarding her increased pain to her right knee. The on-call physician gave orders one including to follow-up with her physician in the morning. The facility did not contact the physician until the afternoon. After contacting the physician they ordered x-rays. After Resident #4 had her x-ray to her right knee, they discovered a fracture to right femur. Resident #4 received an immobilizer and an order to follow up with the doctor as soon as possible. Resident #4 could not complete range of motion (ROM) to her right knee until 7/11/22. 3. Following Resident #16's bath, a nurse and a Certified Nurse Aide (CNA) transferred him from the shower chair to his bed with a full-body mechanical lift. In the process of the transfer, staff failed to notice the full-body mechanical lift's sling pull on Resident #16's catheter. As they continued to transfer him, the sling pulled farther resulting in a large amount of blood filling the catheter bag. Resident #16 went to the hospital where he required continuous bladder irrigation that produced numerous clots and significant drainage. After this incident, Resident #16 decided to take a break from baths. The facility reported a census of 77. Findings include: 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included diagnoses of a fracture of left ilium (pelvis) and [CONDITION(S)] (weak and brittle bones). The MDS indicated that Resident #6 required extensive assistance of two persons with bed mobility and toileting. Resident #6 required extensive assistance of one person with transfers. The Toileting and Transfers task revised 8/11/22 listed Resident #6 as independent with mobility with her two wheeled walker. The Clinical Record lacked documentation of assessments or other updated clinical documents related to the change in her mobility. The Incident, Accident, Unusual Occurrence Note dated 8/25/22 at 10:45 PM documented that the staff responded to Resident #6's call light and found her sitting on the floor. The nurse went to the room and found Resident #6 sitting on her buttocks against the front side of the bed leaning back against the side of it with her bilateral (both) lower extremities extended outward and bilateral arms at her sides. Neuro checks within normal limits (WNL) for Resident #6. She had adequate ROM to upper and lower extremities. Resident #6 had on gripper socks at the time with her walker inside the bathroom. The nurse observed Resident #6 with a 1 centimeter (cm) by (x) 0.9 cm v-shaped skin tear to the top of her left wrist that had a small amount of bloody drainage noted. In addition Resident #6 had a 1.2 cm superficial abrasion to her upper right back. Resident #6 reported that she walked out of the bathroom, slipped and fell on her butt. She explained that she scraped her right side of her back on the doorway and hit her left hand on the doorway as she fell . Resident #6 explained that she guessed she did not use her walker, but she did not know why. Resident #6 told the nurse that she scooted herself on her butt over to her bed so she could call for help. The nurse assessed Resident #6 and started neuro checks on her. The staff assisted Resident #6 off the floor with the assistance of three people and a gait belt. The nurse took Resident #6's vital signs (VS taken). Then assessed, measured, and applied a dressing to her injuries. The nurse left the injuries to Resident #6's wrist and abrasion on her back open to air. The nurse implemented the intervention to check on Resident #6 every two hours while in bed and reminded her to use the call light when she needed help and to always use her walker. The Orders - Administration Note dated 8/25/22 at 10:45 PM recorded an ineffective administration of two acetaminophen tablets 325 milligrams (MG) as needed PRN Administration with a follow-up pain scale of 5 out of 10, indicating moderate pain. The Orders - Administration Note dated 8/26/22 at 1:45 AM recorded that Resident #6 received two tablets of 325 MG of acetaminophen due to complaints of left sided pain and right shoulder pain. The Orders - Administration Note dated 8/26/22 at 4:00 AM documented an effective administration of acetaminophen with a follow-up pain scale of 2, indicating mild pain. Resident #6 reported that the medication helped but she continued to be a little sore. The SPN - Focused Evaluation Note: Reason for Evaluation: Hot Charting (Not related to an incident, accident, unusual occurrence) dated 8/26/22 at 5:52 AM documented that Resident #6 complained of left side pain and right shoulder pain at 1:45 AM as she fell earlier in the shift. Resident #6 received PRN Tylenol given per her request with relief noted. Resident #6 continued to report that the area remained a little sore but did not request anything else for pain. The nurse planned to continue to monitor her. The Orders - Administration Note dated 8/26/22 at 7:47 AM indicated that Resident #6 received one tablet of 50 MG of [MEDICATION(S)] due to moderate pain related to complaints of right side, hip, and back pain. The two Orders - Administration Notes dated 8/26/22 at 10:08 AM documented effective administrations of acetaminophen and [MEDICATION(S)] with a follow-up pain scale of 0, indicating no pain. The SPN - Focused Evaluation Note: Reason for Evaluation: Hot Charting (Not related to an incident, accident, unusual occurrence) dated 8/27/22 at 1:40 PM recorded that Resident #6 had a dark purple bruise to her left shoulder and right rear back. She got PRN pain medication with relief. Resident #6 verbalized understanding to use her call light to get assistance with transfers and ambulation. The SPN - Nursing/Therapy Communication dated 8/28/22 at 10:10 AM recorded communication from Nursing to Therapy indicating that Resident #6 had an unwitnessed fall on 8/25/22 while in the bathroom that could warrant therapy. The Nursing/Therapy Communication Note dated 8/28/22 at 2:59 PM documented therapy not indicated at the time. The SPN - Focused Evaluation Note: Reason for Evaluation: Hot Charting (Not related to an incident, accident, unusual occurrence) dated 8/28/22 at 9:47 PM documented that Resident #6 complained of pain in her left hand. At 4:15 PM she received PRN Tylenol. The Nurses Note dated 8/29/22 at 1:42 PM recorded that Advanced Registered Nurse Practitioner (ARNP) came to the facility and saw Resident #6. The ARNP gave new orders for an x-ray of her left wrist, hand, right shoulder with clavicle (collar bone) view, a head computerized tomography (CT) scan without contrast. The nurse contacted non-emergency transport for imaging, scheduled for 5:00 PM that evening. The Nurses Note dated 8/29/22 at 1:50 PM documented that the nurse called 911 to arrange transportation as the non-emergency transport couldn't take Resident #6 until 5 PM. The Nurses Note dated 8/29/22 at 3:01 PM indicated that the Emergency Medical Technicians (EMTs) arrived at 2:50 PM and left at 3 PM. The Nurses Note dated 8/30/22 at 2:21 AM indicated that the nurse called the hospital who reported Resident #6 remained in the emergency room (ER) waiting for a bed for admission. The Nurses Note dated 8/30/22 at 12:14 PM documented that the nurse called the ER for an update. The ER staff reported that Resident #6 remained in the ER waiting for available room for admission. The ER nurse reported that Resident #6 had multiple rib fractures in addition to a fractured pelvis and clavicle. The Progress Note dated 9/7/22 documented that Resident #6 did not plan to return to the facility. On 9/14/22 at 9:43 AM, Staff J, Registered Nurse (RN), reported that she changed Resident #6 to be independent with mobility after the CNAs reported to her that she walked without needing as much assistance. Staff J denied knowing that any additional assessment or documentation needed to be done. On 9/20/22 at 1:46 PM, the Director of Nursing (DON) reported that the nurse would contact therapy to determine if therapy services could be started to determine the resident's safest mobility. 2. Resident #4's MDS assessment dated [DATE] identified a BIMS score of 1, indicating severe cognitive impairment. Resident #4 required total assistance of two persons for transfers. The section labeled balance during transitions and walking indicated that Resident #4 could only stabilize with staff assistance due to not being steady for surface-to-surface transfers. The activities of moving from seated to standing position, walking, and turning around did not occur. The questions regarding functional limitation of ROM lacked documentation. Resident #4 documented that she did not have any falls since her Admission/Entry or Reentry or Prior Assessment. Resident #4's MDS dated [DATE] assessment identified a BIMS score of 7, indicating moderate cognitive impairment. The MDS identified Resident #4 had fluctuating signs and symptoms of [CONDITION(S)] with inattention. The MDS indicated that Resident #4 required extensive assistance of two persons with bed mobility. Resident #4 required total assistance of two persons with transfers and toilet use. The MDS listed Resident #4 as non-ambulatory and required a wheelchair for locomotion. The section labeled balance during transitions and walking identified Resident #4 as not steady and only able to stabilize with staff assistance with the following situations: moving from seated to standing position, moving on the toilet, off the toilet, and surface-to-surface transfers. The MDS indicated that Resident #4's did not walk or turn around. The MDS documented Resident #4 had occasional incontinence of bowel and bladder. Resident #4's MDS included diagnoses of Alzheimer's disease, anxiety disorder, depression, pain in right hip, polyarthritis, [NAME] syndrome, [CONDITION(S)] and repeated falls. Resident #4's MDS assessment dated [DATE] indicated that she had one fall without injury since her admission/entry or reentry or prior assessment. Resident #4 required total assistance of two persons for transfers. Resident #4 had a functional limitation in ROM due to impairment on both sides. Resident #4 used a wheelchair for mobility. The section labeled balance during transitions and walking indicated that Resident #4 could only stabilize with staff assistance due to not being steady for moving from a seated to standing position, moving on the toilet, moving off the toilet, and surface-to-surface transfer. The activities of walking and turning around did not occur. The MDS documented Resident #4 had occasional incontinence of bowel and bladder. Resident #4's MDS included diagnoses of Alzheimer's disease, anxiety disorder, depression, pain in right hip, polyarthritis, [NAME] syndrome, [CONDITION(S)] and repeated falls. The January 2022 to May 2022 Facility Incident Reports (IR) indicated that Resident #4 fell on the following dates: 1/7/22, 4/21/22, and 4/29/22. Resident #4's Fall Risk Evaluations documented the following scores and fall risk 12/3/21=11 - High Risk (Total Score of 10 or Above represents a High Risk) 2/25/22=13 - High Risk 4/21/22=9 4/29/22=13 - High Risk 5/17/22= 9 Resident #4's clinical record lacked a fall risk evaluation after she fell on [DATE]. On 9/22 at 10:15 a.m. the Regional Nurse Consultant, Staff E reported that fall risk evaluations are to be completed on admission, quarterly, and with a fall. She said the charge nurses are responsible for completing the fall risk evaluation when a fall occurs. An IR dated 1/7/22 at 12:28 a.m. identified Resident #4 had an unwitnessed fall in her room. The staff observed Resident #4 sitting on the floor next to her bed. Resident #4 stated that she tried to get up to play bingo and forgot to press her call light. The IR lacked information regarding Resident #4's level of pain, level consciousness, mobility, and mental status. The IR lacked an immediate intervention put in place following the fall. The IR had no documentation related to an investigation on when the staff last saw Resident #4 or when the staff last assisted her. The IR failed to determine if Resident #4 had a call light at the time of her fall. Resident's #4's progress notes lacked documentation of the 1/7/22 incident. The Progress Note dated 1/7/22 at 9:37 a.m. recorded that the interdisciplinary team instructed maintenance to place a fall mat on the floor and replace Resident #4's call light with touch pad call light. The Care Plan revealed the resident is to transfer with a two person assistance with a full-body mechanical lift effective 12/16/19. The Care Plan identified staff to encourage the resident to use the call light for assistance effective 3/19. The Care Plan identified the resident to have a low bed effective 3/11/21. The Care Plan revealed the resident had a fall mat as an intervention previously and was resolved on 9/24/21. A neurological (neuro) flowsheet dated 1/7/22 lacked documentation of assessments initiated immediately after Resident #4's unwitnessed fall. The clinical record lacked additional neuro assessments and vital signs on 1/7/22 and 1/8/22 for the following time frames: 1/7/22 - First 15 minute check - flow sheet blank 1/7/22 - Second 15 minute check - flow sheet blank 1/7/22 - Third 15 minute check - flow sheet blank 1/7/22 - Fourth 15 minute check - flow sheet blank 1/7/22 - First 30 minute check - flow sheet blank 1/7/22 - Second 30 minute check - flow sheet blank 1/7/22 - 1st One hour check - flow sheet blank 1/7/22 - 2nd One hour check - flow sheet blank 1/8/22 - Sixth 8 hour check - flow sheet blank The clinical record lacked updated vital signs with the neuro assessments on 1/7/22, 1/8/22 and 1/9/22: 1/7/22 - Second 8 hour check - Vital signs dated 1/5/22 and 1/6/22 1/8/22 - Fifth 8 hour check - Vital signs dates 1/5/22 and 1/6/22 1/9/22 - Eight 8 hour check - Vital signs sated 1/5/22 and 1/6/22 1/9/22 - Ninth 8 hour check - Vital signs dated 1/5/22 and 1/6/22 On 8/30/22 at 2:30 p.m. the Regional Nurse Consultant, Staff E verified that Resident #4 did not have additional neuro documentation or assessments. On 8/30/22 at 9:40 a.m. with Staff C, Licensed Practical Nurse (LPN), reported that neurological assessments are to be completed when a resident has an unwitnessed fall. Staff C revealed that the facility used a neuro cheat sheet as a guideline. Staff C reported the cheat sheet instructs the staff on when to complete the neuro assessments. The undated Neurological Time Checks (cheat sheet) form instructed the staff to complete neuro documentation in the electronic medical record (EMR) and to complete neurological assessments at the following frequency: Initial assessment First 15 min check Second 15 min check Third 15 min check Fourth 15 min check First 30 min check Second 30 min check First 1 hour check Second 1 hour check First 8 hour check Second 8 hour check Third 8 hour check Fourth 8 hour check Fifth 8 hour check Sixth 8 hour check Seventh 8 hour check Eighth 8 hour check Ninth 8 hour check The Neurological Assessment Policy Med Pass, Inc. revised October 2010 indicated the purpose of the procedure is to provide guidelines for a neurological assessment. Neuro assessments should be completed upon a physician's order, after an unwitnessed fall, subsequent a fall with a suspected head injury, or when indicated by the resident's condition. The policy directed that when assessing a neurological status, always include frequent vital signs. The policy instructed that documentation in the medical record should include the date/time of the procedure, name, and title of the individual who performed the procedure, all assessment data obtained during the procedure, how the resident tolerated the procedure, if the resident refused the procedure, the reason(s) why, and the intervention taken. The signature and title of the person recording the data. An IR dated on 4/21/22 at 3:50 p.m. recorded Resident #4 had an unwitnessed fall in her room. The staff observed Resident # 4 sitting on the floor with her back against the bed and both legs extended out in front of her. Resident #4 reported that after waking up from a nap, she attempted to get out of bed and do things on her own. Resident #4 explained that while she sat on the edge of her bed, she slid down the side of the bed and fell on to the floor. The IR lacked an immediate intervention put into place after her fall. On 8/30/22 at 9:40 a.m. Staff C verified that Resident #4 did not have a new intervention implemented immediately after she fell on [DATE]. Staff C reported that she reinforced the low bed. The Care Plan revised on 4/22/22 instructed to place a wedge for boundary identification. On 4/22/22 the facility resolved the intervention of Resident #4's fall mat. An IR dated on 4/29/22 at 1:12 a.m. documented Resident #4 had an unwitnessed fall in her room. The staff heard Resident #4 yelling for help. The staff noted Resident #4 sitting on her bottom with her legs facing the recliner. Resident #4 appeared confused and stated that she tried to get up because she heard someone yelling for her. The nurse did not observe injuries at the time of the incident. The IR recorded that four staff members assisted Resident #4 into bed. The IR included a new intervention of a winged or scooped mattress to Resident #4's bed when available. The IR lacked an investigation on when staff last saw Resident #4 or when they last assisted her. The IR lacked interventions already in place at the time of her fall. The clinical record indicated that on 4/29/22 at 4:30 a.m. Resident #4 complained of right knee pain. She reported that her right knee hurt worse when she rolled over. The nurse contacted the on call doctor (DR) and received orders to give Resident #4 Tylenol, apply ice to her right knee, and re-evaluate in the morning. The clinical record lacked follow up documentation in the progress notes on the morning of 4/29/22. The clinical record revealed that on 4/29/22 at 1:58 p.m. Resident #4 continued to complain of pain to her right knee with movement. The nurse notified the DR and received an order for x-ray. Resident #4 went to the emergency room and had not returned at that time. The Nurses Note dated 4/29/22 at 8:30 PM indicated that Resident #4 returned from the ER. Resident had a fracture to her right femur. Resident #4 had an immobilizer placed to right lower leg. Orders received to schedule a follow-up appointment as soon as possible with her primary provider. The emergency room Summary dated 4/29/22 revealed Resident #4 had a closed bicondylar fracture of the right distal femur (right knee fracture). Resident #4 got discharged with a right knee immobilizer and received a referral to orthopedics. The Social Services Note dated 5/2/22 at 11:56 AM documented that Resident #6 last saw the provider on 3/28/22. She had an appointment scheduled due to a hip fracture over the weekend. The Nurses Note dated 5/3/22 at 8:43 AM indicated that the specialist called about the appointment scheduled that day. Resident #4 did not yet have a CT scan done. The nurse reported that she would check with the doctor and call them back. The Progress Notes lacked additional documentation related to the CT scan or an appointment until 5/19/22. The Appointment/Visit Note dated 5/19/22 at 2:22 PM documented that Resident #4 returned from the specialist regarding right knee. The specialist gave orders to continue NWB to her right lower extremity, keep knee immobilizer on at all times except during hygiene, inspect skin under immobilizer per shift, and adequately pad skin beneath brace. Resident #6's next follow-up appointment scheduled for 6/2/22 at 1:50 PM with the specialist. The Care Plan revised on 4/29/22 documented an intervention to place a scooped or winged mattress when available and to check Resident #4 every hour. The Care Plan revised 5/9/22 directed to use a winged mattress. On 8/29/22 at 10:35 a.m. observed Resident #4 lying in bed without a wedge for boundary identification and no touch pad call light as directed by the Care Plan. Resident #4 had a call light with a push button instead. On 8/29/22 at 1:45 p.m. witnessed Resident #4 sitting in her wheelchair in her room. The push button call light laid across the night stand located behind Resident #4 and out of her sight. On 8/29/22 at 3:50 p.m. noticed Resident #4 sitting in her wheelchair in her room with her push button call light lying in her partially closed nightstand drawer. The call light continued to remain out of site and behind Resident #4. On 8/30/22 at 10:07 a.m. observed Resident #4 lying in her bed without a wedge. The observation showed Resident #4's wedge on the floor against the wall across the room between the wingback chair and TV stand. On 9/1/22 at 2:00 p.m. noticed Resident #4 lying in bed without a wedge. The wedge remained in the same location as observed on 8/30/22 at 10:07 a.m. (on the floor against the wall). On 8/29/22 at 11:00 a.m. Staff F, Certified Nursing Assistant (CNA), stated that Resident #4's current fall interventions included a winged mattress and low bed. She stated that after Resident #4's fall a couple months ago, the staff would check on her every half an hour or so but they do not do that anymore. On 8/28/22 at 2:47 p.m. Staff E, the Regional Nurse Consultant, reported that she could not locate the documentation for the one hour checks per the Care Plan. On 8/30/22 at 12:15 p.m. the Administrator and Staff G, Maintenance Team Member, reported that when Resident #4's touch pad call light broke a couple of weeks ago, Staff G replaced the touch pad call light with a push button call light. Staff G reported that the facility did not have a touch pad available and they are on backorder. On 8/31/22 at 5:15 p.m. Staff H, CNA, reported that Resident #4 had a wedge in her room but it is not used every day. On 9/22/22 Staff E reported the company stopped using fall mats for fall interventions. She reported the company made that decision a few months before. She said that the facilities were to discontinue the fall mats and put a different intervention in place. She reported that fall mats did not prevent a fall and are a trip hazard for some residents. She denied that Resident #4's fall mat caused a risk of a trip hazard and that she required a full-body mechanical lift for transfers. 3. Resident #16's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS identified Resident #16 required extensive assistance of two persons with bed mobility, transfers and toilet use. The MDS indicated that Resident #16 did not ambulate and required a wheelchair for locomotion. The balance during transitions and walking section identified Resident #16 as not steady and only able to stabilize with staff assistance with the following situations: moving from seated to standing position, moving on and off the toilet, and surface to surface transfers. Resident #16 did not walk or turn around. The MDS indicated that Resident #16 frequently had incontinence of bowel and bladder. Resident #16 had an indwelling catheter. The MDS included diagnoses of [CONDITION(S)], [CONDITION(S)] bladder, anxiety disorder, depression, [CONDITION(S)], and psychotic disorder. The MDS documented an admitted as 1/24/22. On 9/6/22 at 11:26 a.m. Resident #16 declared that he is taking a break from showers. Resident #16 reported an accident on the previous Wednesday with his shower. Resident #16 explained that his catheter tube got pulled during a transfer with the lift. Resident #16 stated that the catheter had blood from the tube being pulled. Resident #16 reported that he went to the emergency room (ER) and stayed there between 2 p.m. to 10 p.m. Resident #16 explained that he had basic checks completed in ER. Resident #16 reported that he had to have his bladder flushed. When the ER staff flushed his catheter a lot of clots and other stuff came out. An IR dated 8/31/22 at 1:12 p.m. documented that at 11:30 a.m. during a full-body mechanical lift transfer after a shower, Resident #16's catheter tubing got caught between the full-body mechanical lift straps causing it to get pulled but not dislodged. As a result Resident #16's catheter drained blood. The nurse attempted to flush the catheter two times with no urine return. The nurse contacted the doctor and received orders to send Resident #16 to the emergency room (ER) for an evaluation. The Emergency Department Note dated on 8/31/22 documented Resident #16's primary diagnosis as gross hematuria (presence of blood). The emergency room staff removed Resident #16's previous indwelling catheter and placed a new indwelling catheter. Following the insertion of the new indwelling catheter Resident #16 required bladder irrigation (continuous fluid flowed into the bladder through a catheter) that produced numerous clots and significant drainage. The hospital discharged Resident #16 back to the facility on [DATE] with a follow up DR. appointment on 9/22/22. Resident #16's Progress Note dated 8/31/22 at 11:39 p.m. documented that he returned from the emergency room with 200 cubic centimeters (cc) of urine in his urinary catheter with a slight amount of frank blood around his penis and catheter. On 9/7/22 at 12:50 p.m. Staff I, CNA, reported that she used the mesh shower sling that crisscrosses between the resident's legs to transfer Resident #16 with the full-body mechanical lift. Staff I reported that as Resident got lifted up the sling shifted and caused the catheter tubing to get pinched between the full-body mechanical lift pad and his groin. Staff I stated she did not get instructed on what type of sling to use on a male resident with a catheter. Staff I questioned if a full body sling would be appropriate for Resident #16. On 9/7/22 at 2:30 p.m. Staff J, Registered Nurse (RN), reported that she got summoned into the shower room by Staff I to assist with Resident #16's full-body mechanical lift transfer. Staff J reported that she primarily ran the buttons on the full-body mechanical lift during the transfer. Staff J stated that when the full-body mechanical lift started to go up, she noticed the catheter tubing get tight and immediately saw blood in his tubing. Staff J reported that she never saw anyone bleed like that. Staff J reported it as an oversight on her and the CNA's part. Staff J explained that Resident #16 had a diagnosis of [CONDITION(S)] so they guided his lower legs and they didn't see his catheter get caught. Staff J reported that she did not do full-body mechanical lift transfers a whole lot and did not feel 100% comfortable using the full-body mechanical lift. On 9/7/22 at 3:00 p.m. the Regional Nurse Consultant, Staff K reported that the CNAs would not know what type of full-body mechanical lift sling to use unless the resident Kardex or task list had the information in the electronic medical record. Staff K confirmed that Resident #16's Kardex and task list did not include what type of full-body mechanical lift sling to use for transfers.

Based on record and policy review and staff interviews, the facility failed to ensure one (1) of three (3) residents received adequate supervision to protect against hazards in the environment. The care plan failed to identify how staff should transfer the resident. Staff interviews revealed Resident #2 required assistance of two staff with a EZ stand for transfer. On 1/26/22, Staff Q certified nurse aide assisted Resident #2 to transfer with a walker and without a gait belt. Staff Q stated she did not know how the resident should transfer and stated she failed to use a gait belt for the transfer. The resident's legs gave out and Staff Q lowered the resident to the floor. The resident sustained a left femur fracture that required surgical repair. The facility reported a census of 77 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE] identified Resident #2 with diagnoses that included: cancer, hypertension, pneumonia, [CONDITION(S)], and diabetes mellitus. The MDS assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15 (no cognitive impairment). The resident depended on two (2) staff for bed mobility, toilet use, transfer, ambulation, dressing and personal hygiene. The resident had no falls. A Nursing Care Plan initiated on 12/23/21 identified a focus area of risk for falls with goal not to experience any injuries related to falls, and directed the following interventions: *safe environment without clutter *Make sure appropriate footwear worn. * Order for Physical and Occupational Therapy services *(1/28/22) 2 staff assist upon return from the hospital *(1/31/22) mechanical lift for all transfer (Hoyer) *(1/31/22) 2 person assistance with all transfers Another focus area of the care plan dated 12/23/21 revealed resident unable to transfer independently but did not contain any directives for staff on how to transfer the resident. A Physical Therapy (PT) Treatment Encounter form dated 1/11/22 revealed sit to stand transfers performed using non-mechanical lift from edge of bed, elevated with minimum assist of 2 staff. Patient demonstrates good progression with transfers using non-mechanical lift today. An Occupational Therapy (OT) Treatment Encounter form dated 1/10/22 identified EZ stand transfer performed from edge of bed to toilet with one staff assist. EZ stand transfer from toilet to recliner with one staff assist. An OT Treatment Encounter form dated 1/11/22, identified the resident completed sit to stand from edge of bed with edge of bed raised, with non-mechanical sit to stand machine, minimum assist of 2 staff for safety. The resident required moderate lift assist of 2 staff from toilet with non-mechanical sit to stand machine. A Fall Risk assessment dated [DATE] documented a score of 8 (a score of 10 or above represents high risk). Progress notes dated 1/26/22 at 10:36 a.m., documented fall with possible injury to left leg and sent to emergency room (ER). An Incident Report (IR) dated 1/26/22 at 6:56 a.m., and prepared by Staff K RN (registered nurse) revealed Staff Q CNA (certified nurse aide) transferred the resident from bed to wheelchair and staff lowered the resident to the floor. The resident stated she felt her leg pop loudly 2 to 3 times and then it gave out. The IR revealed that upon entry to room, the resident sat in front of the bed with right leg extended to front and the left leg bent back at the knee. The resident complained of extreme pain on movement. Staff Q CNA stated she entered the resident room and asked the resident what she needed help with. The resident stated she wanted to get up from bed with the stand aide. Staff Q asked if that meant her walker and the resident said yes. Staff Q asked the resident if she could stand, and she said yes. Staff Q braced the walker with both of her feet and the resident stood up hanging on to walker. Staff Q reached behind to pull up her pants and the resident started to fall. Staff Q braced the fall as best she could and when the resident fell , the left leg bent side ways. Staff Q got a nurse immediately. A hospital consult note dated 1/26/22 at 11:08 a.m., revealed the resident reported she resided at the facility for the past 6 weeks after COVID. Since COVID, the resident can not ambulate. Staff usually uses a Sara Steady or stand aide to transfer her from place to place. She reported this morning she attempted to get out of bed using a walker with staff assistance. The resident felt her left leg gave out causing a fall. She had an immediate onset of severe leg pain and knee pain with inability to ambulate and obvious deformity. Prior to COVID she reports that she was able to ambulate independently and was living at home. The physical exam revealed the left lower extremity had obvious deformity and swelling present at the left distal femur and knee. The resident had early ecchymosis beginning at the anterior lateral aspect of the knee. Anterior and posterior and lateral radiographs of the left femur reveal a severely displaced, comminuted left distal femur periprosthetic fracture. CT scan of the left femur verified the radiography findings and showed enough distal femur attached to the total knee prosthesis for an ORIF (open reduction and internal surgical fixation procedure to be performed. A surgical report dated 1/26/22 revealed the resident underwent the following procedure: open reduction internal fixation of left periprosthetic distal femur fracture under spinal anesthesia. The resident had blood loss of 200 ml (milliliters) and had a stainless steel left sided distal femur locking plate with 6 5.0 locking screws and four 4.0 locking screws placed to repair the fracture. The resident returned to the facility 1/31/22. On 1/19/22 at 5:20 p.m., Staff M CMA (certified medication aide) confirmed staff are expected to utilize a gait belt with 1-2 person transfers. On 2/2/22 at 1:10 p.m., Staff F RN (Registered Nurse) confirmed she was in Resident #2 room when the resident was on the floor and no gait belt was around the resident. Staff F also acknowledged that Resident #2 was a EZ stand transfer due to safety concerns and gait belts are expected to be used with all transfers. On 2/2/22 at 3:00 p.m., Staff C CNA confirmed staff are expected to utilize a gait belt at all times during a resident transfer. On 2/3/22 at 10:44 a.m., Staff O (OT assistant) and Staff P (PT assistant) confirmed Resident #2 used an EZ stand for transfers due to safety reasons and that therapies worked with the resident to utilize the walker, but staff were expected to utilize the EZ stand until therapies discharged the resident and recommended walker use. Staff O and Staff P stated the facility failed to have a system in place for new admits regarding transfer needs and since this incident the facility implemented a form that directs therapy to see the patient first and then document how staff should transfer the resident. Staff O and Staff P stated staff is expected to utilize gait belts with all 1-2 person transfers. On 2/8/22 at 3:22 p.m., Staff N CNA confirmed staff are expected to utilize gait belts at all times with 1-2 person transfers. On 2/9/22 at 1:36 p.m., Staff K RN confirmed the resident used an EZ stand for transfers prior to the fall due to safety concerns, and when Staff K went into the resident room after the fall, there was no gait belt around the resident and staff are expected to utilize a gait belt with all transfers. On 2/9/22 at 2:22 p.m., Staff G CMA confirmed there was no gait belt around Resident #2 when the fall occurred and the resident used an EZ stand for transfers due to safety concerns and all staff are expected to use gait belts with transfers. On 2/10/22 at 10:30 a.m., Staff Q CNA confirmed she did not utilize a gait belt for the transfer from bed to wheelchair with Resident #2. Staff Q stated she never worked with Resident #2 before and didn't know how to transfer the resident. Staff Q stated she asked Resident #2 how staff usually transferred the resident and Resident #2 told her the stand aide. Staff Q stated she observed a walker next to the dresser in the room and just thought that is how the resident transferred. Staff Q maneuvered the walker in front of the resident and assisted the resident to the edge of the bed, placed the walker in front of the resident and started to assist the resident to stand. Staff Q stated she heard a pop in the resident's left leg and the resident stated her leg just popped so Staff Q lowered the resident to the floor and got the charge nurse. Staff Q stated staff are expected to always utilize a gait belt at all times during a transfer, however, Staff Q left the gait belt at home and failed to get one from the facility when came into work. On 2/15/22 at 2:00 p.m., Staff A RN confirmed staff are expected to utilize gait belts with all transfers and since this incident the facility implemented a procedure that all new admissions will be screened by therapy prior to staff transferring them and a form will be filled out to assist the staff on how to transfer a new resident. Review of a facility policy titled, Gait Belt ( for use in ambulation and transfer) directed gait belts all staff should use gait belts, to allow for easier handling of residents which should help to avoid injuries to both residents and staff. 1. Each staff member will have a gait belt readily available for use, when on duty 3. Apply the belt around the residents waist snug enough to eliminate the possibility of sliding up on the ribs. 4. Assist the resident to the edge of the chair/bed/surface, with both feet on the floor. 9. If a resident begins to lose their balance, draw resident close to you, ease him/her down with your hold of the gait belt. This protects you and the resident from head or bodily injury. Call for assistance and do not move resident until he/she has been assessed by the nurse.

Based on observations, clinical record and policy review, resident and staff interview, the facility failed to adequately supervise residents at risk for elopement for 1 of 3 residents reviewed (Resident #1). On 6/27/21, the resident left the facility without staff knowledge and propelled himself in in his wheelchair to the south side of the facility and down a hill. On 7/10/21, the resident again left the facility in his wheelchair without staff knowledge (a second elopement) through the kitchen service door. The facility also failed to provide adequate supervision for residents during active construction in the resident hallways for 1 of 3 residents reviewed (Resident #4) who fell due to torn up flooring from construction. The residents fall resulted in a displaced fracture to the left ankle, and involved the tibia and fibula. Facility census was 77 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #1 with a completion date of 6/22/21, identified a Brief Interview for Mental Status (BIMS) score of 1 (severe cognitive impairment and decision making skills). The MDS documented the resident exhibited wandering on 1-3 days of the 7 day look back period. The resident required limited assistance of 1 staff for transfers, and supervision with 1 person physical assistance for locomotion on and off the unit. The MDS documented diagnosis of Non Alzheimer's Dementia and anxiety. The resident admitted to the facility 6/8/21. The Care Plan with initiation date of 6/14/21, identified the resident at risk for elopement &/or wandering related to history of attempts to leave the facility unattended and wandering aimlessly. The care plan interventions included: alert staff to wandering behavior (6/14/21); if wander away from the unit, staff stay with the resident (6/14/21), converse and gently persuade the resident to walk back to the designated area (6/14/21); note which exits are favored for elopement from the facility and alert staff working in those areas (6/14/21); monitoring device placed that sounds alarm when leaving the building; provide diversional activities (6/14/21); and assign staff to account for my whereabouts throughout the day, one to one (7/12/21). The care plan with initiation date of 6/10/21, identified the resident enjoyed reading, food activities, listening to country music, being around animals, watching the television, and being outside. The Admission Wandering Evaluation dated 6/8/21, identified the resident high risk for wandering with a score of 10, due to: independently ambulates, independent with wheelchair, diagnosis of dementia & orientation, and history of wandering. A total score of 10 or higher indicated wander guard bracelet (monitoring device designed to activate an alarm if the resident attempts to leave the building) needed to be applied. The Significant Change Wandering Evaluation dated 6/12/21, identified the resident as high risk for wandering with a score of 12, due to: statements of wanting to leave the facility, anxious behavior, independent with wheelchair, diagnosis of dementia & orientation, and attempts to leave facility since admission. The progress notes revealed: a. 6/8/21 at 8:18 AM, Admit - the resident arrived at the facility accompanied by brother and sister in law. The resident orientated to person and place with impaired decision making ability. The resident confused and forgetful. b. 6/10/21 at 4:38 PM, activity - one to one with the resident outside in the gazebo. c. 6/12/21 at 11:58 PM, incident - the resident wheeled himself to the emergency exits and front entrance throughout the facility. d. 6/13/21 at 2:38 AM, focused evaluation - staff continued to monitor the resident for exit seeking behaviors. The resident rested quietly in bed this shift, came out of his room one time in wheelchair and asked where's everyone at? Staff re-orientated the resident and assisted him back to bed. The wander guard on wheelchair and functioning. The resident displayed no exit seeking behaviors. e. 6/15/21 at 3:37 AM, focused evaluation - the resident got up at 3:00 AM, reported not sleeping. The resident wandered around the facility in wheelchair, no behaviors and pleasant mood. The resident offered the bathroom and snack, refused. f. 6/15/21 at 6:58 PM, focused evaluation - the resident attempted to exit the door, returned to his room to watch television. g. 6/19/21 at 12:04 AM, focused evaluation - the resident roamed throughout the common areas in the facility, observed looking out the windows but does not appear interested in opening the doors. Constant supervision provided to the resident. Wander guard in place and successfully tested . h. 6/20/21 at 8:20 PM, focused evaluation - the resident wandered this shift in wheelchair independently. The resident looked at picture books in the dining room. i. 6/21/21 at 2:28 AM, focused evaluation - the resident wandered throughout the shift despite redirection attempts, encouragement and reminders by staff. The resident read items posted on bulletin board and the newspaper. The resident did not appear to exit seek, roaming. j. 6/23/21 at 2:57 PM, focused evaluation - the resident asked the nurse to take him home after lunch, easily re-directed. k. 6/27/21 at 2:18 AM, focused evaluation - the resident had no exit seeking behaviors. l. 6/28/21 at 1:52 AM, focused evaluation - the resident exit seeking 2 times, out the 600 & 700 hall doors with the wander guard alarm sounding. The resident sat at the nurse's station and offered snack. The resident toileted and assisted to bed at 1:45 AM. m. 6/28/21 at 2:17 PM, focused evaluation - the resident continued to exit seeking. The resident goes to several halls at different times, opened doors and exits facility. The resident not easily re-directed and upset with staff. The progress notes revealed no documentation that Resident #1 left the facility without staff knowledge (eloped) or of an assessment of the resident upon the return to the facility following an elopement on 6/27/21. The facility document titled Elopement Prevention dated January 2015, directed: a. Evaluate all residents for potential of elopement from the facility b. For new admissions, review any history of elopement and behavior patterns in prior living arrangement c. Evaluate and identify factors for potential elopement from the facility: Alzheimer/dementia, mobility, medication, aimless wandering, verbally expresses desire to leave, effect of new environment on behavior, perimeter wandering, and/or sudden change in behavior. d. Provide wander guard bracelet to all residents determined to have a potential for elopement e. Take identification picture on admission and update with care plans f. Document all attempts for elopement and evaluate precipitating factors. Document effect measures taken to return the resident to the facility g. Assess the resident's ability to remain in the facility safely h. The resident care plan will contain interventions and actions to monitor and prevent elopement. i. All staff respond promptly to all door alarm activations. If immediate reason for the door alarm is not determined, all residents will be accounted for at that time. j. All door alarms checked daily by a Quality Assurance (QA) team member to make sure they are working properly. QA will document conditions of the alarms. k. Quarterly elopement drills are highly recommended: all staff are involved in elopement drills, send a person out to hide where a resident might elope to, initiate the search, note time and place the resident found, keeps records for QA, and have staff work on problem solving. The facility procedure titled Missing Resident undated, indicated upon notification that a resident is missing, the following procedure will be implemented: a. If after normal business hours, notify the Administrator b. Assemble all department heads c. Organize and institute a thorough search of the facility and the surrounding grounds and buildings d. If a search of the facility and grounds is not successful, notify the next of kin e. Notify the local law enforcement f. Recall off-duty personnel as needed g. Notify local civil defense agency and request search assistance if needed h. Contact volunteer assistance groups for additional search personal i. Organize and institute an expanding search of neighborhood surrounding the facility j. Notify know relatives, friends, and favorite stopping places that the resident is missing k. When the resident is located, notify all agencies and individuals involved in the search that the resident had been found The facility document titled Missing Resident revised 12/7/09, stated the facility would maintain a list of residents identified at risk for exit seeking. The list will be kept at the Nurses station and include the resident's picture and pertinent information on each resident listed. Upon notification that a resident missing: a. If off duty hours, notify the Administrator and Director of Nursing (DON) b. Assemble all available department heads c. Organize and institute a thorough search of the facility d. If a search of the facility and grounds failed to locate the missing resident, notify the next of kin e. Notify local law enforcement f. Recall off duty personnel as needed g. Notify the Divisional Director and the Nurse Consultant h. Notify the Director of Safety Observations of Resident #1 on: a. 6/29/21 at 3:49 PM, in his wheelchair, at the dining room table with fell ow residents. Wander guard transmitter located on the resident's wheelchair. b. 6/29/21 at 5:05 PM, sat in wheelchair by the front door of the facility. The resident with eyes closed and head down. Wander guard transmitter located on left side of wheelchair. c. 6/29/21 at 5:41 PM, propelled self in wheelchair to the dining room and transferred self to dining room chair. d. 6/30/21 at 8:54 AM, propelled self out to the dining room table in wheelchair, and visited with fell ow residents. e. 6/30/21 at 10:33 AM, in recliner in his room with eyes closed f. 6/30/21 at 1:30 PM, at dining room table in wheelchair, wander guard transmitter on wheelchair g. 6/30/21 at 6:00 PM, at the dining room table in wheelchair, consumed 100% of meal. h. 7/1/21 at 7:50 AM, at dining room table in wheelchair with wander guard transmitter in place on wheelchair i. 7/1/21 at 8:25 AM, the transportation driver propelled the resident to the front door, told the resident leaving for an appointment at the Veterans Clinic. Wander guard alarm sounded as the resident was assisted through the front door by the transportation driver. j. 7/1/21 at 10:42 AM, returned to the facility with the transportation driver. The door alarm and wander guard alarm sounded as the resident is assisted through the front door. k. 7/1/21 at 2:10 PM, sat at the end of the 100 hall by the nurse's station in wheelchair. The resident well groomed, non-skid footwear and wander guard on wheelchair. The resident propelled self to the 200 hall and turned around, returned to the nurse's station. l. 7/6/21 at 11:29 AM, in recliner in room, eyes closed. The wheelchair placed beside the recliner. m. 7/6/21 at 2:29 PM, lying in bed facing the wall at this time. The wheelchair placed beside the bed. n. 7/7/21 at 10:15 AM, sat in wheelchair at dining room table, wander guard on wheelchair. The resident visits with fell ow residents. o. 7/7/21 various times throughout the afternoon Resident #1 at the front door of the facility, stated he wanted to leave. The resident asked about getting key to collect the garbage. Resident #1 asked Resident #2 to punch in code so they could go outside. Resident #1 did not open the front door at any time and easily re-directed by facility staff. The resident in wheelchair at all times. p. 7/8/21 at 9:56 AM, sat at the dining room table with fell ow residents, wander guard on wheelchair. Observation on 6/30/21 at 1:20 PM, by the surveyor of the area where the resident was found in his wheelchair on 6/27/21 related to the location of the facility. The observation showed the resident crossed the street, went downhill, and ended up located at an incline in the driveway with 3 cars present. The distance the resident traveled from the facility could vary from 159 - 175 steps depending on the door he exited the facility from. It took the surveyor approximately 3 minutes to continuously walk the distance without any stops. On 6/30/21 at 4:20 PM, door alarm check completed with the Administrator and Staff X Licensed Practical Nurse (LPN) revealed Staff X opened the door at the end of 200 hall, only door alarm sounded. The local red box alarm did not sound. Observation at that time showed the red box alarm located at the top of the door (local alarm) turned to the OFF position. Staff X turned red box alarm on and proceeded to open door, both alarms sounding. The Administrator stated she did not know why the alarm turned to OFF. The front door, south dining room door, north dining room door and 500 hall contained wander guard alarms and door alarms. The 100, 200, 300, 600, and 700 hall door contained door alarms and local red box alarms in place. On 6/29/21 at 4:26 PM, Staff E Certified Nurse's Aide (CNA) stated she headed into the facility on [DATE], for her scheduled shift at 2:00 PM and observed Resident #1 in his wheelchair, 3-4 houses down the hill from the facility. Staff E stated Resident #1 went across the street, down the hill, and sat in a driveway. Staff E stated she went to the resident as he sat next to the sloped section of the driveway. She observed the resident wore slacks, short sleeve shirt, hat, and glasses. Staff E stated Resident #1 told her he could not get up the hill. Staff E identified the weather as hot on 6/27/21. Staff E stated she did not observe any injuries, bruising or bleeding to Resident #1. Staff E stated Resident #1 had a history of exit seeking and setting off the alarms. Staff E confirmed Resident #1 had a wander guard transmitter in place on the wheelchair. Staff E stated when Resident #1 returned to the facility, staff did not know he was missing. Staff E stated when Staff F CNA arrived at the facility for her scheduled shift on 6/27/21, Staff F observed the resident being assisted up the hill back to the facility, and inquired what occurred. Staff E stated an agency nurse also arrived for her scheduled shift at that time and observed the resident being returned to the facility. Staff E stated she took Resident #1 into the facility through the front doors and entered the door alarm code when she entered. The wander guard alarm did sound upon entrance. Staff E stated she took Resident #1 to the nurse's station and notified Staff G LPN (licensed practical nurse) that she found the resident outside and down the hill from the facility without staff with him. Staff E stated she did not know if Staff G LPN completed an assessment of Resident #1. Staff E stated it was the weekend and no administrative staff worked so she placed a note under the Administrator's door of the incident. She did not receive call from the facility regarding the incident. Staff E stated Resident #1 had a history of exit seeking behaviors, and got to the door previously but staff intervened. Staff E stated the facility did not provide any education after the 6/27/21 incident with Resident #1. Staff E stated she did not know what door Resident #1 exited from and the resident would not be able to confirm what door he exited. Staff E identified concerns for Resident #1's safety due to the potential of rolling into the street &/or tipping out of his wheelchair. Staff E stated she informed Staff G LPN that she left a note for the Administrator regarding the incident. On 6/30/21 at 1:04 PM, Staff F CNA stated when she arrived to her scheduled 2:00 PM shift on 6/27/21, she observed Staff E CNA propelling Resident #1 up the hill back to the facility. Staff F stated she asked Staff E what occurred and Staff E informed her Resident #1 had been down the hill in a driveway across the street. Staff F stated the 2 CNA's assisted the resident inside the facility and took him to the nurse's station and staff had no knowledge the resident had gone outside. Staff F stated she informed Staff G LPN Resident #1 went outside and Staff G responded okay. Staff F stated to silence the alarms, staff on duty at the time would have to go to the door to shut off the alarm, and staff waited too long to shut off and then did not observe Resident #1 outside. Staff F stated the CNA's on duty at the time did not know the resident was missing. Staff F stated Resident #1 appeared he was outside for a while and was sweating. Staff F stated the resident wore pants and long sleeve shirt. On 6/30/21 at 9:26 AM, Staff G LPN confirmed she worked the day shift on Sunday 6/27/21. Staff G stated Resident #1 frequently tried to leave the facility and stated the resident set the alarms off and staff would respond. Staff G stated Resident #1 attempted to leave the facility earlier in the day, before noon, on 6/27/21. Staff G stated the door alarm and the wander guard alarm sounded, she responded and Resident #1 did not get outside. Staff G denied staff reported to her that they found Resident #1 outside unattended on 6/27/21. Staff G denied Resident #1 ever outside the facility unattended or off the facility grounds. Staff G stated she was not aware of Resident #1 off the facility grounds on 6/27/21 and denied any CNA reported this to her. On 6/30/21 at 8:08 AM, Staff H CNA confirmed she had worked the day of 6/27/21. Staff H stated no residents attempted to leave the facility on 6/2721, and no door alarms sounded. Staff H stated door alarms only sound when the manager on duty checks the doors. Staff H stated Resident #1 set the door alarms off when he attempted to leave the facility a few days after admission to the facility, and Staff H did not know of any other time. On 6/30/21 at 11:03 AM, Staff H CNA identified the last time she observed Resident #1 as at noon meal on 6/27/21. Staff H revealed the noon meal finished around 1:00 PM, and she passed lunch trays. Staff H identified Resident #1 in the dining room at the table, at that time. Staff H stated she did not recall making observation of Resident #1 after that time. Staff H stated when she left the facility for the day at approximately 2:00 PM, she did not observe the resident. Staff H stated she did not know of any alarms not functioning and unaware of any other residents out of the facility undetected. Staff H stated she may have turned an alarm off on 6/27/21 after breakfast. On 6/30/21 at 8:15 AM, Staff I CNA confirmed she worked the day shift on 6/27/21. Staff I stated no residents attempted to leave the facility undetected and she did not recall any door or wander guard alarms sounding. Staff I stated if a resident had a wander guard transmitter on, 2 alarms activated if the resident attempted to leave the facility. Staff I stated Resident #1 never attempted to leave the facility while she was on duty. Staff I stated Resident #1 asked frequently about going out to pick up furniture, go up and down the halls, and look out the windows, however, he never left. Staff I stated she would remember if Resident #1 tried to leave on Sunday 6/27/21. Staff I stated she left the facility at 2:00 PM on 6/27/21, and stated someone told her to go look at Resident #1 before she left, as he was asleep in another resident's bed. On 6/30/21 at 12:05 PM, Staff I CNA stated she did not recall how long Resident #1 stayed in the dining room after the noon meal on 6/27/21. However, stated she believed she saw Resident #1 in Resident #2's bed between 1:00 - 1:30 PM. Staff I took garbage out when she observed the two residents in Resident #2's room. Staff I identified Resident #1 as in a pleasant mood. Staff I never observed him agitated. On 6/30/21 at 1:55 PM, Staff W Housekeeping stated on 6/27/21 she worked down hall 200 at 9:00 AM and cleaning in room 201 and observed Resident's #1 & #2 ambulating down the hall and within short time, heard alarm sounding. Staff W stated Staff G LPN and herself responded to the alarm at the front door and found Resident #1 in the breezeway. Staff W stated Resident #1 easily re-directed and returned into the facility. On 6/30/21 at 9:06 AM, Staff J CNA confirmed she worked 6:00 AM - 10:00 PM on Sunday 6/27/21. Staff J stated she did not know of Resident #1 attempting to leave the facility unattended on 6/27/21, and did not recall door alarms or wander guard alarms sounding. Staff J stated Resident #1 would try to leave the facility, however, the alarm would sound and staff would immediately respond. Staff J stated she never saw Resident #1 get out of the facility. On 6/30/21 at 9:16 AM, Staff K LPN confirmed she worked on Sunday 6/27/21. Staff K stated she did not remember any resident attempting to leave the facility on 6/27/21. Staff K stated Resident #1 frequently attempted to leave the facility. Staff K denied knowledge of Resident #1 attempting to leave the facility on 6/27/21, as she was not his nurse. Staff K stated alarms always go off, and when she responded, someone already took care of the alarm. Staff K stated no one reported to her that Resident #1 eloped from the facility. Staff K stated residents' wander guard transmitters are checked every shift for placement and functioning. Staff K stated the weekend manager came in to check the door and wander guard alarms, and checked them on Saturday 6/26/21. On 6/30/21 at 11:11 AM, Staff T CNA confirmed she worked the day shift on 6/27/21. Staff T stated she did not recall Resident #1 agitated or upset. Staff T stated she heard about the resident found outside the facility after the incident occurred. Staff T stated she informed the evening shift to keep an eye on Resident #1 due to the incident that occurred on the day shift. Staff T then identified Resident #1 as irritated on 6/27/21 but did not know why. Staff T stated she did not see Resident #1 at the exit doors and she did not turn off any alarms on 6/27/21. Staff T stated staff cannot turn alarms off unless after physically looking outside first. Staff T stated she questioned if the alarm sounded when Resident #1 exited the facility on 6/27/21 but no one responded to her question. Staff T stated she did not know of alarms not functioning and unaware of any other residents outside without staff aware. On 6/30/21 at 11:21 AM Staff U CNA confirmed she worked on the day shift 6/27/21. Staff U identified her last observation of Resident #1 on 6/27/21 as in the dining room before breakfast. Staff U stated the resident wanders throughout the building frequently. Staff U could not recall the resident making comments about leaving the facility on 6/27/21. On 6/30/21 at 11:32 AM, Staff O RN stated she arrived at work on 6/27/21 at 6 PM. When she arrived, she observed Resident #1 at the front door with the wander guard alarm sounding. Staff O stated the staff followed the resident into the breezeway and returned him into the facility. Staff O stated Resident #1 had history of exit seeking behaviors. On 6/30/21 at 11:53 AM, Staff V RN stated when she arrived at the facility on 6/27/21 for her scheduled shift at 2:00 PM, observed a CNA bringing Resident #1 back into the facility. Staff V stated the incident did not look unusual and she did not know the resident eloped out of the facility unattended. Staff V stated the facility staff informed her to keep all alarms on due to Resident #1 attempting to leave the facility. On 6/29/21 at 5:52 PM, Staff A LPN stated the wander guard alarms are located only on the normally exited doors; the front door, the 500 hall, and the north & south dining room doors. Staff A stated all other exit doors have a door alarm that sounds at the nurses station. Staff A stated the doors without a wander guard alarm contain a handle alarm and a red box local alarm located at the top of the doors, that sounds separately from the door alarm. Staff A stated the exit doors contain a red alarm or a wander guard alarm, in addition to the door alarm. Staff A stated the wander guard transmitter, located on the resident, is checked every shift and documented on the respective resident's treatment administration record (TAR). Staff A stated the transmitters are replaced every 90 days, and as needed. Staff A proceeded to demonstrate how to check the wander guard transmitter. Staff A identified 2 current residents that attempt to leave the facility, however, staff have intervened prior to them exiting the facility. Staff A identified one of those residents as Resident #1. Staff A stated all staff respond to alarms that sound. Staff A denied knowledge of any residents leaving the facility undetected. On 6/29/21 at 6:05 PM, Staff B CNA identified Resident #1 with active exit seeking behaviors, confusion, and wandering. Staff B stated staff re-directs Resident #1 frequently while exit seeking. Staff B denied knowledge of Resident #1 leaving the facility undetected. On 6/29/21 at 6:07 PM, Staff C Registered Nurse (RN) stated she worked the night shift. Staff C stated Resident #1 displayed exit seeking behaviors during the night shift. Staff C stated Resident #1 exited the facility, in direct sight of staff, and returned to the facility. Staff C stated staff provided food and fluids to the resident, however, the resident continued to go up and down the halls. Staff C stated staff checks wander guard transmitters every shift for functioning. On 6/29/21 at 6:09 PM, Staff D LPN stated she worked the 2-10 PM shift. Staff D denied knowledge of Resident #1 leaving the facility undetected. Staff D stated there one time the resident exited and the alarm activated. Staff brought the resident back inside and another time the resident stood at the doorway of the facility with the door open. Staff D stated she did not know the date Resident #1 was outside, however, it occurred at the North dining room door. On 6/30/21 at 10:24 AM, the Regional Director of Clinical Services stated the facility did not have cameras inside the facility or outside on the facility grounds. The Regional Director of Clinical Services stated the facility needed to complete a self-report regarding the 6/27/21 elopement. The Regional Director of Clinical Services stated Staff E CNA left a note for the Administrator on Sunday 6/27/21, regarding an elopement. The Regional Director of Clinical Services stated the Administrator observed 3 notes when she arrived at work on Monday 6/28/21, however, had not read the notes until today 6/30/21. The Regional Director of Clinical Services stated they were conducting interviews, working on staff education, and the charge nurse in question suspended until investigated. The Regional Director of Clinical Services stated Staff G LPN informed her she did not recall anyone informing her of Resident #1 found outside. The Regional Director of Clinical Services identified the facility in process of notifying Resident #1's primary care provider, family, and on line report to DIA. On 6/30/21 at 6:05 PM, the Regional Director of Clinical Services stated she could not locate an elopement drill for the last year, as directed in the facility policy. On 6/30/20 at 10:04 AM, the State climatologist reported the temperature on 6/27/21 at 1:00 PM, 81 degrees with north/northwest wind 6 miles per hour (mph) and heat index of 82 degrees. The state climatologist reported the temperature at 2:00 PM, 81 degrees with a calm wind, heat index of 82 degrees, and scattered showers in the area. On 6/30/21 at 2:32 PM, the Administrator stated she had been employed at the facility for short time and when she arrives at work will have notes under her door. The Administrator stated notes are requests to visit with certain residents. The Administrator stated this week she tried to get staffing filled and pushed the notes to the side on Monday 6/28/21 and did not read them. The Administrator stated she read the notes today (6/30/21) and read the note regarding Resident #1 found outside the facility on 6/27/21 by staff who arrived to work for their scheduled shift at 2:00 PM. On 6/30/21 at 4:57 PM, the Administrator identified the alarm log as weekly alarm checks. Maintenance previously completed the checks daily. The Administrator stated the alarm log matched the weekend manager's duty assignment sheet for weekly check. The Administrator stated the facility did not currently have a full time maintenance employee so maintenance currently not completing daily checks. The Administrator and surveyor checked the red box alarm on the 200 hall door exit and found the alarm in the off position during alarm checks. The Administrator confirmed the observation and stated the facility would have to start to complete daily alarm checks instead of weekly. On 7/8/21 at 10:13 AM, the Administrator stated she expected facility staff to call herself &/or the Director of Nursing (DON) when staff found Resident #1 outside the facility unattended on 6/27/21. The Administrator stated she expected the nurse to complete an assessment after the nurse determined the resident safe. The Administrator stated she expected staff to notify the resident's family and primary care provider of the elopement. The Administrator stated she would have filed a report with DIA within 24 hours of the elopement and within 2 hours, if the resident received an injury. The Administrator stated once the resident safe; determine what happened, obtain staff statements, and put interventions in place to prevent. Second Elopement for Resident #1 that occurred on 7/10/21: The progress notes revealed: a. 7/10/21 at 2:51 PM, focused evaluation - the resident exited the facility through the kitchen and went out back. The resident brought back inside the facility and head to toe assessment completed with vital signs. b. 7/10/21 at 3:16 PM, focused evaluation - the resident continued to exit seek and roamed this shift. Redirection and distractions effective this shift. c. 7/10/21 at 6:24 PM, nurse's note - the resident found outside, another resident witnessed him go through the kitchen through the back door. The resident was brought back into the facility. d. 7/10/21 at 6:30 PM, nurse's note - this nurse notified by another resident, observed the resident go to the kitchen and minutes later observed the resident outside. The CNA's immediately went out and the resident returned to the facility. This nurse took vitals and head to toe assessment completed. The resident denied pain. The resident alert confused to place, time and day. No injuries noted. Full range of motion to all extremities. The resident noted to be incontinent and the CNA's assisted the resident with cares. The MDS nurse and Administrator notified. e. 7/10/21 at 7:52 PM, nurse's note - the resident's power of attorney notified and voiced no concerns. f. 7/11/21 at 3:55 AM, focused evaluation - the resident up in wheelchair at 3:15 AM, one to one care. The resident brought to the nurses station for observation. The facility incident report titled Elopement dated 7/10/21 at 6:20 PM, indicated the incident occurred outside; the resident seen going into the kitchen and staff went to the kitchen and the resident out the door. Immediate action taken: placed one to one immediately. No injuries observed at the time of the incident. No witnesses found. Observations of Resident #1 on 7/12/21 at: a. 3:45 PM, lying in bed, facing the wall, and blankets in place. The resident's wheelchair beside the bed. Staff E CNA in the resident room providing one to one. b. 4:37 PM, the resident continued to be lying in bed with Staff E CNA providing one to one. c. 5:25 PM, sat in wheelchair at the dining room table, Staff E CNA providing one to one. The wander guard transmitter on the wheelchair. d. 5:50 PM, propelled self in wheelchair, Staff E CNA providing one to one. e. 6:18 PM, sat in wheelchair in room with Staff E CNA providing one to one. Observations of Resident #1 on 7/13/21 at: a. 7:55 AM, sat in wheelchair at the dining room table, conversed pleasantly with tablemates. Staff N C

Based on record review, staff, POA (power of attorney), physician and physician nurse interviews, the facility failed to provide care, consistent with professional standards of practice to prevent pressure ulcers and once pressure ulcers developed the facility failed to ensure the resident received the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 1 of 6 residents reviewed. (Resident #1). The facility reported a census of 71 residents. Findings Include: A Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/25/20 for Resident #1 assessed the resident with a score 5 on the Brief Interview of Mental Status test indicating severe cognitive impairment. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident with 1 Stage II pressure ulcer. Definition of Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated [MEDICAL CONDITION], intertriginous [MEDICAL CONDITION] (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). A Weekly Pressure QA Meeting dated 12/3/20 revealed the resident had a lower left extremity unstageable pressure sore measuring 5.8 centimeters x 3.4 (cm.) with black eschar and foul smell. The resident went to physician and from the appointment was a direct admit for intravenous (IV) antibiotics. The previous physician visit date was 9/16/20. A Pressure Injury Evaluation dated 10/26/20 completed by Staff A Licensed Practical Nurse ( LPN) showed a pressure ulcer located on the left heel measuring 4.8 cm. X 2.7 cm. X 0.1 cm. Stage II, with no drainage, no tunneling, with pink/red granulation bed, normal surrounding skin, and no odor and marked as a new area. The facility notified the physician, the POA (power of attorney) and dietary. The facility made no care plan changes and the resident did not have pain related to the pressure sore. A fax communication dated 10/26/20 revealed the facility informed the physician of a blister on the left heel measuring 4.8 cm. X 2.7 cm. X 0.1 cm., no longer fluid filled and wound bed red. The facility asked for an order to cleanse area with wound cleaner, pat dry, paint the area with [MEDICATION NAME], cover with 4x4 gauze and wrap with kling, change twice a day and as needed until healed. The physician indicated yes to the order. A Pressure Injury Evaluation dated 11/2/20 completed by Staff B Registered Nurse (RN) showed a pressure ulcer present on the left heel measuring 4.2 cm. x 2.8 cm. x 0.1 cm. Stage II with small amount of serosanguineous drainage, no tunneling, hard black eschar of the wound bed and inflamed surrounding skin, no odor, progress marked as improved, continue treatment, no notification to physician or family. A Pressure Injury Evaluation dated 11/9/20 completed by Staff B RN showed a pressure ulcer present on the left heel measuring 4.2 cm. x 2.7 cm. x 0 cm. unstageable, small amount of serosanguineous drainage, hard black eschar to wound bed, normal surrounding skin, no odor, no change in condition, continue treatment, no notification to physician or family of previous changes in wound. A phone order dated 11/10/20 revealed Staff B RN asked the physician for a different treatment. New treatment ordered of clean left heel with wound cleanser, pat dry, apply absorbent dressing every day shift on Mondays. The [MEDICATION NAME] was discontinued. On 12/8/20 at 12:45 am Staff B RN stated she had a conversation with the DON (Director of Nursing) about the changes in the pressure ulcer, but thought the wound was improving. The DON and Staff B agreed that a new dressing was appropriate and the request was made to the physician office on 11/10/20, but Staff B did not notify the physician of the red/ inflamed surrounding skin or hard black eschar. A Pressure Injury Evaluation dated 11/16/20 completed by Staff B RN showed a pressure ulcer on the left heel measuring 6 cm x 2 cm x 0 unstageable with moderate serosanguineous drainage, loose yellow /tan slough of wound bed, red/inflamed surrounding skin, no odor, marked as improved, to continue treatment with no notification to the physician or family about the changes in the wound. A Pressure Injury Evaluation dated 11/23/20 completed by Staff C LPN showed a pressure ulcer on the left heel measuring 5.5 cm. x 3.2 cm. x 0 unstageable with small amount of purulent yellow/tan drainage, loose yellow/tan slough of wound bed, red/inflamed surrounding skin, slight odor, odor after irrigation, continue treatment, and no notification to the physician or family about the changes in the wound. On 12/8/20 at 1:10 pm Staff C LPN stated she had a conversation with Staff B RN on 11/23/20 about the changes in the wound and Staff B RN directed Staff C to continue the current treatment. The facility did not inform the physician or the family about the changes in the wound. A Pressure Injury Evaluation dated 11/30/20 completed by Staff B RN showed a pressure ulcer to the left heel measuring 5.8 cm. x 3.4 cm. x unknown unstageable, small amount of serosanguineous drainage, soft black eschar to wound bed, normal surrounding tissue, slight odor, and odor after irrigation, condition deteriorated and physician contacted on 11/30/20. On 12/8/20 at 12:45 pm Staff B RN stated she did not contact the physician or family about the pressure ulcer until 11/30/20 when she had the charge nurse on duty call the physician's office and request an antibiotic for the left heel. Nurse Notes dated 11/30/20 at 2:00 pm showed Staff D LPN called the physician's office to request the antibiotic for the left heel. On 12/7/20 at 10:12 am the Resident Power of Attorney (POA) stated she received notification in October of a small blister located on the left heel. Approximately 2 weeks later the POA received notification of the blister getting worse and measuring approximately 2 cm x 3 cm The POA stated she was notified the physician requested to see the resident at an appointment prior to starting antibiotics for the pressure ulcer on the left heel. The resident's POA met the resident at the physician appointment on 12/1/20. The POA stated she was stunned at the sight of the wound and could not believe this was just a blister. On 12/8/20 at 1:20 pm the interview with the physician's nurse at MercyOne Specialty Clinic that cared for the resident during the appointment on 12/1/20 revealed the resident came to the office as requested by the physician due to the facility requesting an antibiotic for the wound on the residents left heel. The nurse stated when she went to the lobby to get the Resident, she could smell a foul odor coming from the resident. The nurse stated when the foot was uncovered and the dressing removed the area appeared large and black, and had a foul smell. The nurse stated the foot looked like it had gangrene. The nurse stated she reviewed all communications and faxes received from the facility and the only time their office was notified about the wound was on 10/26/20 when a new blister was reported and [MEDICATION NAME] treatment was requested. The next communication was on 11/10/20 when the facility requested an absorbent dressing to replace the [MEDICATION NAME]. The Facility gave no update on the wound condition. The nurse stated the resident had a telehealth appointment on 11/17/20 and there was no mention of any skin issues. The nurse identified another telehealth appointment on 11/24/20 and she was the nurse who took the nurse to nurse report from the facility as to what issues needed to be addressed during the visit and it was stated that the facility was doing weekly dressing changes to the heel and discussed the moisture area on the buttock requiring zinc. The facility reported that they were continuing with the dressing changes to the heel ( that was all that was said about the heel) There was no mention to the physician about the pressure sore change in condition during this telehealth visit, and the pressure sore was not shown to the physician at this time. The nurse stated on 11/30/20 the facility contacted the office asking for an antibiotic for the heel wound and the physician requested a visit due to not understanding why the facility wanted an antibiotic for a blister. The physician was still under the understanding the heel are was a blistered area due to no communication regarding the appearance of the area since 10/26/20 Review of the Physician notes for the Telehealth visit on 11/17/20 lacked any documentation of skin issues. Notes from the visit identified the integumentary system review as negative for rash or [MEDICAL CONDITION]. Review of the Physician office visit notes for 12/1/20 revealed the reason for the office visit as wound. Documentation identified the wound was aggravated by local pressure. The wound measured 4 cm. by 8 cm. with black base to ulcer. Additional information: gangrenous pressure ulcer to left heel. The assessment/plan was: heel ulceration, left, with unspecified severity. Refer to wound center for further care today. Review of the wound center consultation report dated 12/1/20 at 5:23 pm revealed the resident had hip surgery in September and following that, the pressure ulcer of the left heel developed. The resident presented with a left heel ulcer consisting of eschar measuring 4.2 cm. by 6.2 cm. by 0.2 cm. surrounded by 5 to 10 cm. of redness without obvious purulent drainage. There was however a foul odor from the heel. The resident began experiencing pain from the pressure ulcer about 3 weeks ago. The wound center obtained a culture of the wound. The wound center identified the resident with an acutely infected left heel ulcer. It is malodorous with surrounding [MEDICAL CONDITION]. The ulcer did not require debridement at that time. The recommendation of hospital admission for treatment of [REDACTED]. The resident will be admitted to the hospital and the expectation is the resident would receive IV antibiotics. Local wound care will consist of pressure relief and the use of Dakins soaked gauze dressings to suppress superficial bacteria and generally keep the heel dry. The resident will also be evaluated for [MEDICAL CONDITIONS]. Review of progress notes dated 12/2/20 at 11:35 revealed the Resident admitted to the hospital and started on intravenous antibiotics (IV). The preliminary culture report showed streptococcus and gram negative bacillus cultured from the heel. The gram stain showed gram positive cocci. The resident received antibiotics [MEDICATION NAME] and meropenem. The physician thought the resident likely had [MEDICAL CONDITION]. While hospitalized the resident used a PRAFO boot to keep the heel off the bed. Progress notes also revealed if the resident had adequate blood supply, the ulcer should heal although would likely take months. On 12/9/20 at 2:55 pm the Physician at MercyOne Specialty Clinic stated that it is hard to know if a wound treatment is effective without seeing the wound. The Physician stated that if he would have been notified of changes so he could evaluate or even if the facility sent pictures or showed the heel during a telehealth appointment, then treatment would have been started sooner and a hospital stay and IV antibiotics could have been prevented. On 12/8/20 at 2:05 the DON stated she expected the physician and the family to be notified of all changes. Review of the Pressure Ulcer Skin Assessment protocol dated January 2015 revealed Nursing is expected to notify the physician, notify the family member or responsible party and include that information in the nurse's notes. On 12/8/20 at 2:05 pm the DON stated the expectation is for nursing staff to notify the physician and the resident's family of all changes in health status. A hospital history and physical dated 12/1/20 identified the resident with left heel ulcer with eschar, [MEDICAL CONDITION] mild to left leg, red warm to midshin, minimal. She complained of her left heel hurting. Hospital progress notes dated 12/6/20 revealed the resident was found to have severe PAD (peripheral artery disease) pending further peripheral angiogram with vascular on Monday. Hospital Progress notes stated 12/7/20 revealed the heel looked better with respect to the [MEDICAL CONDITION] resolving. The resident's white count was now normal. The resident will undergo a vascular procedure today that will hopefully improve blood supply to the heel. Hospital progress notes dated 12/8/20 revealed the resident underwent [REDACTED]. The physician documented the resident's heel achieved most of what was wanted at this time. The [MEDICAL CONDITION] and infection of the foot and lower leg resolved. The black ulcer of the heel remains but with improved blood supply it will give it a chance to heal if the heel can keep pressure off of it. The most important part of the resident's care is to keep pressure off of the heel. The resident remained hospitalized during the investigation. Care Plan: The resident's care plan initiated 9/23/20 and revised 10/28/20 revealed the resident had pressure ulcers. The care plan directive dated 9/23/20 directed staff to monitor for changes in skin status that may indicate worsening of pressure ulcers and notify the physician. The care plan directive dated 10/28/20 directed staff to use proper fitting shoes, elevate bilateral lower extremities (BLE) due to [MEDICAL CONDITION] and apply heel boots to BLE when in bed and recliner. The care plan did not direct staff to free float heels to keep them pressure free. The care plan did not address pressure reduction for the bed or repositioning for the resident when in bed

Based on observation, record review and family and staff interviews, the facility failed to ensure that (1) The resident environment remained as free from accident hazards as is possible; and (2) each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 6 residents. Resident #1 required staff assistance with food and drink. The resident received a burn from hot coffee. No staff saw the resident receive the coffee or spill the coffee. The facility reported a census of 68 residents. Findings include: 1. A Minimum Data Set (MDS) assessment, with a reference date of 3/18/17, identified Resident #1 with short and long term memory impairments and severely impaired decision making ability. The resident had the following indicator of delirium: disorganized thinking that came and went and fluctuated in severity. The resident had the following behavioral symptoms identified: physical and verbal behaviors directed towards others 1 to 3 days out of 7. The resident required extensive staff assistance with bed mobility, transfers, locomotion on unit, dressing, eating, personal hygiene and toileting. The resident was non-ambulatory. The resident used a wheelchair for mobility. The resident had [DIAGNOSES REDACTED]. The MDS did not identify the resident with burns. The resident was admitted to the facility 11/10/15. A CAT (care area triggers) worksheet for ADL (activities of daily living) functional/ rehabilitation potential dated 3/21/17 identified the resident required assistance with cares. The resident admitted to the facility with a sacral fracture that limited the resident's mobility and ability to complete cares and the resident continued to require extensive assistance with cares. The resident had a [DIAGNOSES REDACTED]. The resident received Hospice care. A Care Plan containing a problem with an onset date of 12/4/15 revealed the resident was particular about meal selections and had a poor appetite. The Care Plan directed staff to assist the resident with meals as necessary. An addendum to the Care Plan dated 3/24/17, directed staff to put ice in hot drinks to cool down prior to thickening (coffee spill). The approach indicated the nursing/kitchen staff were educated to place lids on beverages. The Nurse's Notes dated 3/25/17 at 12:55 p.m. and documented by Staff A RN (registered nurse) identified a CNA (certified nurse aide) alerted Staff A that she removed a coffee filled blanket from the resident's lap after lunch and observed a burn to the resident's leg. Staff A assessed a 22 centimeter (cm.) by 23 cm. red area with scattered intact blisters to the right thigh. The resident denied pain. Staff A notified the physician and obtained a treatment order for the burn. Staff A instructed dietary to put ice in the resident's hot drinks before serving the hot drinks to the resident. Staff A also placed a note in the staff communication book that contained the same information. A form titled Incident/Accident/Unusual Occurrences, identified an event occurred on 3/25/17 at 12:55 p.m. A CNA noted the resident's right thigh appeared blistered after taking a blanket off the resident's lap. The right thigh contained a 22 cm by 23 cm red area with scattered intact blisters. An injury investigation dated 3/25/17 revealed staff last saw the resident at lunch eating. The resident could not tell staff what happened. The form titled Injury Investigation, asked what do you think contributed to the injury? Staff A documented the resident declined in function which led to the resident's inability to hold a cup. An internal quality assurance investigation form identified the resident dumped coffee. Preventive measures implemented and dated 3/27/17 revealed the resident should have ice added to hot drinks prior to serving to cool prior to thickening. The resident should not have beverages/food without staff present. The facility educated the staff to ensure the resident had lids on all hot/warm drinks. A telephone order dated 3/25/17 indicated the following physician order [REDACTED]. Apply Silvadene 1% cream to the area. Cover with Telfa dressing and paper tape BID (twice a day) and PRN (as needed). Discontinue the treatment when healed. The Nurses Notes dated 3/27/17 at 1 p.m. indicated the right thigh area measured 22 cm. by 22 cm. with scattered superficial areas, red areas and blisters. Staff Interviews: Staff working when the incident occurred: On 4/3/17 at 1:22 p.m. Staff A RN (registered nurse) stated Staff B CNA got her after lunch and asked if anyone told Staff A the resident received a burn. Staff B only noticed it when she took the blanket off the resident's lap after lunch. Staff A stated Staff C CNA sat at the resident's table at lunch. She stated she did not know who delivered the coffee to the resident's table but Staff D (dietary) and Staff E (dietary) delivered drinks that day. Staff A stated the resident sat at an assisted table so someone was supposed to sit at the table with the resident if the resident had food or drink. Staff A did not know when the resident received the coffee. She stated she did not recall seeing the resident with food/drink items and no one present. Staff A stated the resident had spills in the past. The resident sometimes drops the glass or throws the liquid. Staff A stated it was probably not safe to leave the resident alone with hot coffee. She stated she assessed the burn. It was red and slightly raised with a couple fluid filled blisters only on the upper thigh. Staff A stated that prior to the incident, dietary was not supposed to deliver drinks or food and leave it at the table without staff present with the resident. Staff A didn't give the resident coffee and didn't know who did. On 4/3/17 at 1:35 p.m. Staff B CNA stated she was the resident's CNA that day. She got the resident up from bed and the resident's leg looked fine. She took the resident to the table around 11:40 a.m. to 11:45 a.m. She did not apply a clothing protector. When Staff B placed the resident at the table she did not see drinks present. After the meal, she took the resident from the table and she and Staff F CNA laid the resident down. The resident wore a clothing protector and had a blanket over his/her lap with a wadded up clothing protector in the resident's lap. She stated the spill area on the blanket felt cool and smelled like coffee. It was brown in color. Staff B removed the clothing protectors and blanket and she and Staff F laid the resident down. As she positioned the resident's legs, she observed one had a large red area with blisters on the upper thigh. Staff B stated it looked like a hot liquid poured on the leg. Staff B stated the resident was not acting normally that day. The resident appeared sleepy. Staff B tried to wake the resident to ask if the burn hurt and the resident did not respond. Staff B reported all of her findings to Staff A who came right away and took care of the resident. Staff B stated she didn't see who passed coffee that day. The resident is not supposed to get coffee unless someone is with the resident. She stated staff were instructed of this directive through meetings and the communication book. Staff B stated the wadded up clothing protector showed that someone tried to clean up the coffee spill. The resident was not his/herself that day and not able to speak and let anyone know he/she was burning. Staff B stated the person sitting with the resident at the meal must have known the resident spilled. They would have seen the wadded clothing protector and wondered about it. Staff B stated the resident needed supervision at the table and needed to be fed. The resident spills a lot. It's not safe the leave the resident with hot coffee without someone there. Staff knew this before the incident. On 4/4/17 at 1:59 p.m. Staff C CNA stated when she arrived at the resident's table; the resident already had his/her drinks. Staff C stated she observed a spill streak about 4 inches long on the resident's shirt on the chest area. The spill spot was cold. She looked under the shirt and didn't see any red areas so she applied a clothing protector. She did not look elsewhere. The blanket could have had a spill on it but she may not have noticed it due to the way the resident sat at the table. She stated the resident ate and grabbed drinks per self that meal. The resident had a blanket covering his/her lap. Staff C stated she did not notice a wadded clothing protector. Staff C stated the resident did not spill or throw drinks at the meal and there were no spills on the table. After the resident finished, Staff B took the resident away from the table. She stated she saw the resident 6 times in the past few months with drinks and no one with the resident. Staff C stated all assisted residents should have someone there if they have food or drink present. She stated she informed the dietary manager when she saw it. The Dietary manager didn't say anything. Staff C didn't know who served the liquids that she observed. She also denied knowing who gave the resident coffee on the day of the incident. She thought someone from the kitchen served it. Staff C didn't know the resident had a burn until the end of her shift. On 4/3/17 at 1:33 p.m. Staff D dietary aide stated she didn't know the resident got burned that day. She didn't know until Wednesday when someone asked her about it. On the day of the incident, she stated she first observed the resident with coffee when she observed Staff C sitting with the resident. The coffee did not have a lid. Staff D stated the resident's blanket was up to the resident's neck and the resident sat with his/her eyes closed. Staff D stated she served the resident a coffee with a lid when Staff C sat at the table. The one without the lid was there when she gave the resident the cup of coffee with the lid. Staff D stated she did not know who gave the resident the coffee before she did. The other dietary aide (Staff E) only served juice and water. When she served the coffee, she asked Staff C if Staff C would stay with the resident and Staff C said yes. Staff D stated she takes break from 10:30 a.m. to 11 a.m. and about 7 times in the past 2 or 3 weeks she has seen the resident sitting by self with a cup of coffee without a lid. When Staff D has asked who gave it to the resident, no one knows. She stated she informed the dietary manager who said there was nothing they could do because they didn't know who was giving the coffee. Staff D thought a resident's spouse could be serving the coffee. Staff D saw her give it to the resident in the past. On 4/4/17 at 9:05 a.m. Staff D stated she observed a resident's spouse give an assisted resident coffee about 2 weeks ago. She couldn't recall who it was for. She informed the dietary manager. She stated a couple months ago the same spouse fixed the resident coffee with thickener and she informed the dietary manager. On 4/3/17 at 4:05 p.m. Staff E (dietary aide) stated she worked when the incident occurred. She stated she passed juice and water. She did not pass any coffee. Staff E stated on the day of the incident, the resident was out of it and was covered with a blanket up to the neck. When she passed juice and water to the resident, he/she already had coffee. She stated she entered the dining room area around 11:35 a.m. and she supplied drinks to the first half of the dining room. She got to the second half of the dining room (where the resident sat) around 11:45 a.m. When she was doing the first half, the CNAs brought the resident to the dining room. She stated she didn't see who gave the resident coffee. She stated a resident's spouse was in the dining room and that person could have given the resident coffee. That person has given drinks to residents before. Staff talks to her and she quits for a while and then starts doing it all over again. She observed the resident with coffee without a lid on the resident's table. She stated the resident was asleep and the coffee was at the center of the table so she didn't tell anyone or take it away. On 4/3/17 at 2 p.m. Staff F CNA stated after lunch she helped Staff B transfer the resident to bed. She left the room immediately after the transfer because she had to assist another CNA. She stated she did not see the resident in the dining room and she did not give her any coffee and didn't know who did. She stated she assisted Staff B with the transfer into the wheelchair before lunch and didn't see anything. Staff F stated it was not safe to leave the resident unattended with hot coffee. That is why the resident sat at an assisted table. The resident has spilled and dropped drinks and food before. Staff F stated the resident used lids on a blue cup before the incident. Staff E stated the rule (even before the incident) was assisted residents could not have food or liquids without staff sitting there. The kitchen knows they are not to serve the food until someone is there. On 4/4/17 at 1:41 p.m. the Activity Director stated she saw the resident's spouse (that has been known to give residents coffee) around 1 to 1:30 p.m. that day. The spouse could have been at the facility earlier but that was the first the Activity Director saw her/him. The Activity Director stated she saw the resident in the dining room unattended with coffee once or twice in the past few months. She stated she didn't report it to anyone. The coffee did have a lid on the cup when she saw it but she did not see who gave it to the resident on those occasions. On 4/4/17 at 12:08 p.m. Staff G CNA stated she heard about the burn when she was asked to write a statement. She stated the resident would throw glasses of liquid but she never actually saw the resident spill. She also observed a resident's spouse give assisted residents' liquids before and also use thickener in liquids. It has been awhile since Staff G saw the spouse do that. Staff G stated even before the incident, assisted residents were not to have coffee or food when they were unattended. She didn't see anyone in the dining room before lunch because she works on hall 3 and doesn't get to the dining room until everyone is already out there. On 4/4/17 at 2:26 p.m. Staff H RN stated she knew the resident received a burn but did not know how it happened. She stated Staff C was at the resident's table at lunch. She didn't see anything or anyone give coffee to the resident. Staff H stated dietary usually waits before they give assisted resident's their meal until staff is present. She thought it was Ok for dietary to give the drinks before staff was present. She stated she thought it was OK because she saw drinks served without staff present before. She observed Resident #1 unattended with coffee before. On 4/4/17 at 10:58 a.m. Staff I LPN (licensed practical nurse) stated she was charting and heard Staff A call the doctor about the burn. She stated she did not see anything on the day of the incident. She stated she observed the resident at meals and the resident usually needs assistance. She stated she heard a resident's spouse gave drinks to residents needing assistance. If she observed that, she would talk to the spouse. On 4/4/17 at 11:12 a.m. Staff J CNA stated she didn't know anything occurred on the day of the incident. She stated she didn't know how the resident got the coffee. She stated the resident used lids on cups before the incident. Staff J observed the resident throw cups and spill usually just on the table or ground. On 4/4/17 at 11:33 a.m. Staff K CNA stated she didn't know anything occurred. She didn't see anything or know how the resident got the coffee. On 4/4/17 at 1:35 p.m. Staff L housekeeper stated she was in the resident's room around 8 a.m. the morning of the incident and saw a coffee cup with half cup of thickened coffee sitting on the resident's night stand. The coffee wasn't hot and was not spilled and was far enough away that the resident could not reach it. On 4/3/17 at 2:12 p.m. Staff M stated she didn't know anything about the incident until the next day. She stated it would not be a good idea to give the resident coffee without someone present. She denied giving the resident coffee. On 4/3/17 at 2:18 p.m. with Staff N (dietary cook) stated she didn't know much about the incident. She stated dietary knows if resident are at an assisted table that a staff needs to be present. She did not know of staff not to following that rule. Staff N stated she did not give the resident coffee that day. She stated the resident used lids on cups for a long time (years). She stated Staff D told her there was a cup of coffee already at the table when Staff D passed coffee that day. She stated she informed the dietary manager a couple months ago that a resident's spouse gave residents coffee. Other interviews: On 4/4/17 at 8:36 a.m. the dietary manager stated she wasn't present on the day of the incident. Staff told her the resident got coffee and it spilled and the resident's legs got burned. The coffee was thickened and no one knew who gave it to the resident. She stated a resident's spouse pours coffee and tea for residents a lot and she was sure that person still did that. She stated she remembered a couple months ago that Staff D told her that person fixed coffee and thickened it for assisted residents. She stated she told the Administrator. The spouse stops for a week or so and then starts doing it again. She stated the coffee comes out of the wall at 190 degrees. When it sits in the warmer in the coffee pot it is 165 degrees. She put some in a cup (like the resident used) and then checked the temperature. It was 161 degrees. She did the testing after the incident. On 4/4/17 at 12:30 p.m. the dietary manager stated she did not recall Staff D telling her about the 7 times in the past 2 weeks that she observed Resident #1 alone with hot coffee. On 4/5/17 at 1:11 p.m. Staff O CNA stated the policy before the incident was there had to be someone with residents if they had food or drink. This policy was in place ever since Staff O worked at the facility which was [AGE] years. Staff O stated the resident needed help at meals. On 4/5/17 at 10:05 a.m. Staff P CNA stated she needed to feed the resident most of the time. On 4/5/17 at 11:30 a.m. the Administrator stated he remembered discussing thickener with a spouse of a resident but couldn't 100% say he talked to the spouse about serving assisted residents coffee. He stated he spoke with the spouse awhile back-he did not have a date. On 4/4/17 at 12:49 p.m. the Director of Nursing (DON) stated on 3/25/17, she got a text from the on call nurse. When she returned the call, they said the resident spilled coffee and had a red blistered thigh. The DON called Staff A at home and discovered the incident occurred at lunch and staff discovered the burn when staff removed a blanket that covered the resident and was wet with coffee prior to laying the resident down. She did not apply a clothing protector and there was no food or drink present at that time. The resident had a shirt on and a brief. The resident did not have pants on and was covered with a blanket over the legs. That was the same blanket that was wet with coffee. Staff C assisted the resident at lunchtime and said she did not see a spill. She did see a spill on the chest so she looked to see if there was a red area under the shirt. Staff C didn't see a red area. When Staff C arrived at the table, the resident had coffee. On 3/27/17 the MDS/care plan nurse informed her that Staff A told her the day after the burn, the resident had a cup of coffee that Staff A took away. There was no ice in the coffee and no staff present and Staff D gave it to the resident. The DON stated she first observed the burn on 3/27/17 and saw some red areas going towards the groin and blistering on the top of the thigh. The look of the burn made the DON think the coffee was thickened because if the coffee was thin it would have run more. Throughout her investigation, no one confessed to giving the resident the coffee. She stated that the policy prior to the incident was that no assisted resident should have coffee without a staff present. Assisted residents are not to have food or drink until a staff is there. There have been many meetings containing this information and it has also been in the communication book. The new intervention was to place ice in the resident's coffee prior to thickening and serving to the resident. The facility is also placing lids on assisted resident's drinks. The DON stated it is not safe to leave coffee with the resident unattended. Follow Up Interview with Staff A and Staff D: On 4/4/17 at 1:30 p.m. Staff A stated the day after Resident #1 got burned, she observed the resident in the dining room around 11 a.m. with coffee and no staff present. The resident had a small coffee spill on the blanket (about 50 cent size) she dumped some thickened water on it and pushed the coffee away. The coffee was hot with a lid on the cup. She observed Staff D and Staff E passing liquids in the dining room. They had served liquids to Resident #1 because the thickened water they passed is what Staff A used to pour on the hot coffee. She said out loud that they should not pass liquids until staff was present with the resident. When told Staff D denied hearing Staff A say anything, Staff A stated Staff D may not know English well. The resident did not sustain injury because the blanket was folded in 4's so the liquid did not get through the blanket thickness. On 4/4/17 at 1:41 p.m. Staff D denied knowing anything about the resident getting hot coffee on 3/26/17 or Staff A saying anything to her about it. Observation of the coffee area with dietary manager at 9:22 a.m. showed the coffee area in a small room off the dining room. It contained coffee and a variety of other beverages. The coffee area was open and available to whoever may want to use it. A can of thickener was available on the counter. On 4/4/17 at 2:44 p.m. a resident's spouse denied giving the resident hot coffee. Coffee Temperature Checks: On 4/3/17 at 12:02 p.m. Resident #1's coffee temperature was 101.4 degrees. Other assisted resident coffee registered at 124.9 degrees. At that time, Staff D stated only Resident #1's coffee got ice. Staff D stated they pour the other resident's coffee and let it sit awhile before serving. They just started that after 3/25/17. On 4/4/17 at 12:05 p.m. Resident #1's coffee registered at 110.9 degrees and other resident's coffee registered at 121.3 degrees. Observation: Observation on 4/3/17 at 12:12 p.m. identified Staff P feeding the resident. The resident could hold finger foods and drinks. On 4/3/17 at 6 p.m. the resident fed with a spoon by staff. The resident had lids on cups. Observation identified on 4/5/17 at 12:10 p.m. the resident fed by staff. The resident had lids on cups. On 4/4/17 at 9:40 a.m. observation identified the resident in bed. Staff Q LPN performed a treatment to the burn area. Observation showed a large irregular area with redness around the outer edges on the inner right thigh. The area was covered with a thick yellow brown scab. There were also smaller scattered burn areas on the top of the right thigh. When Staff Q cleansed the areas, the resident stated, That pushes on it and I don't like it. When Staff Q applied Silvadene cream to the areas, the resident said Ow Ow. A non-pressure skin condition report dated 4/3/17 identified the area measured 20 cm. by 20 cm. yellow with red areas. On 4/4/17 at 11:50 a.m. the resident's daughter stated about a week ago she asked to have someone with the resident because the resident needed assistance and to ensure the resident received proper nutrition. On 4/5/17 at 12:10 p.m. the Administrator stated they decided last night to lock the door to the coffee room and use a wireless doorbell for people to use so there would be a staff to assist when someone accessed the coffee room. The coffee room would no longer have open access. He confirmed the resident's daughter spoke with him about the resident needing assistance but that was after the incident. The policy titled Dining Room Service, dated February 2016, directed the staff that no meal would be served to residents eating in the dining room until at least one member of nursing staff or qualified designee was in the dining room to assist with meal service and to be available to handle any emergency that may arise.

Based on observation, record review, and staff interviews, the facility failed to prevent the development of avoidable pressure ulcers and failed to provide care to promote healing of the pressure ulcers (Resident #1, #3, #9). The sample consisted of 5 residents and the facility identified a census of 67 residents. Findings included: 1. According to the MDS (Minimum Data Set) assessment, with a reference date of 11/3/16, Resident #9 scored 6 on the BIMS (brief interview for mental status) test. A score of 6 identified the resident with a severe cognitive impairment. Resident #9 required extensive assistance with ADL's (activities of daily living) including bed mobility, transfers, personal hygiene, and toilet use. Resident #1's [DIAGNOSES REDACTED]. The MDS documented Resident #9 was not at risk for developing pressure ulcers and did not have arterial or venous ulcers. The resident had a pressure reducing device for the bed. A Pressure Ulcer Healing Record dated 8/17/16 documented Resident #9 had a Stage II pressure ulcer of the right heel measuring 0.8 by 1 cm. The nurse identified the wound healed on 9/26/16. The MDS identified a Stage II pressure ulcer as a partial loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. According to the MDS assessment, with a reference date of 1/26/17, Resident #9 Resident #9 required extensive assistance with ADL's including bed mobility, transfers, personal hygiene, and toilet use. The MDS documented Resident #9 was not at risk for developing pressure ulcers and did not have venous or arterial ulcers. The MDS documented Resident #9 had an unstageable pressure ulcer due to presence of slough and/or eschar, measuring 2.7 by 3.5 cm. Resident #9 had no pressure ulcers on the prior assessment. The MDS identified slough as necrotic tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist and stringy (at times). The MDS described Eschar as a thick leathery, frequently black or brown in color comprised of necrotic dead or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound. A facsimile dated 10/21/16, indicated the staff notified the physician that Resident #9 had orders for heel lift boots to bilateral feet when in bed, off when out of bed. The fax questioned if they could have orders to apply heel boots to bilateral feet in bed, and may be worn during the day if tolerated. The physician responded and approved. The physician signed the order. The Treatment Record for December 2016 showed Resident #9 wore the heel boots to each foot in bed. The record lacked any documentation of Resident #9 wearing the heel boots during the day as tolerated. The record documented the staff assisted Resident #9 to the recliner after meals, 3 times a day. The Treatment Record for January 2017 showed Resident #9 wore the heel boots in bed until 1/9/17 and then had a new order. The record lacked any documentation of Resident #9 wearing the heel boots during the day as tolerated. The record documented Resident #9 assisted to the recliner after meals 3 times a day. The Treatment Record showed Resident #9 had the heel boots to the bilateral lower extremities at all times, may remove for hygiene and transfers only, starting 1/9/17. The Care Plan, with an initial goal target date of 8/26/16, identified the resident needed assistance with bed mobility. The interventions included a pressure reducing mattress to the bed and wheelchair cushion, 5/12/15 air mattress to bed, 4/15/16 heel boots to bilateral lower extremities while in bed, 9/5/16 recliner after meals, 1/9/17 heel boots at all times, remove for hygiene and transfers. A fax dated 1/9/17 notified the physician Resident #9 had an area to the inner left heel, white hard area with fluid surrounding measuring 3 by 3.5 cm, and asked for a treatment order. A Pressure Ulcer Healing Record dated 1/9/17 documented Resident #9 had an unstageable pressure ulcer of the inner left heel measuring 3 by 3.5 cm. The record defined an unstageable ulcer as a known ulcer but not stageable due to coverage of the wound by slough and/or eschar (dead/necrotic tissue). The area measured 2.8 by 4.5 cm on 1/30/17 and described as a black, dark purple wound bed. During an observation on 1/31/17 at 1:35 p.m. Resident #9 sat in the recliner. Staff E Licensed Practical Nurse (LPN) performed the treatment to Resident #9's left heel. With the heel boot off, Resident #9's heel rested on the footrest of the recliner. The ulcer appeared purple, circular, with raised crusted edges. During an interview on 2/1/17 at 9:48 a.m. Staff B Certified Nursing Assistant (CNA) stated prior to the left heel ulcer Resident #9 often sat in the recliner after meals with his/her feet elevated. She did not recall anything under his/her legs (to float his/her heels), and thought he/she wore gripper socks. Resident #9 wore the boots in bed. During an interview on 2/1/17 at 9:50 a.m. Staff C CNA stated prior to the left heel ulcer, Resident #9 wore gripper socks. She did not recall using anything under Resident #9's legs (to float his/her heels). Resident #9 wore the heel boots only in bed. During an interview on 2/1/17 at 9:53 a.m. Staff D CNA, stated they had tried a device under Resident #9's legs when in bed at first, but it didn't work, so they used the boots in bed. Staff D stated Resident #9 often sat in the recliner with the footrest elevated, and they did not put anything under his/her legs to float his/her heels that she could remember. Resident #9 currently wore the boots all the time. During an interview on 2/2/17 at 7:30 a.m. the Director of Nursing stated they could find no documentation they tried the boots during the day when out of bed or that Resident #9 could not tolerate them. She could find no documentation they implemented other measures to protect the heels, or to float the heels. 2. Resident #1 had a MDS assessment with a reference date of 1/26/17. The MDS identified Resident #1 demonstrated long and short term memory problems and severely impaired skills for daily decision making. Resident #1 required extensive assistance with activities of daily living (ADL's) including bed mobility, transfers, dressing, and toilet use. Resident #1's [DIAGNOSES REDACTED].#1 was at risk of developing pressure ulcers and had a pressure ulcer. A Hospice Face to Face Encounter Attestation Form dated 10/26/16 documented Resident #1 had a non-healing stage III coccyx ulcer despite treatment. Resident #1 reliant (dependent on someone) for all ADL's. A Braden Scale-For Predicting Pressure Sore Risk dated 1/19/17 scored Resident #1 at 14 indicating a moderate risk for developing pressure ulcers. A Pressure Ulcer Healing Record documented Resident #1 had a pressure ulcer of the coccyx with an onset date of 1/3/16. On 1/30/17 the area measured 4 by 2 cm. The Care Plan dated 2/25/16, identified Resident #1 required assistance with bed mobility, with a goal. Resident #1 would have no skin breakdown related to pressure with a goal target date of 2/9/17 (resident already had breakdown related to pressure). The interventions included a pressure reducing cushion to the wheelchair and bed, and Prafo boots to bilateral lower extremities at all times. The care plan lacked any kind of repositioning program (the resident required extensive assistance with bed mobility. During an observation on 1/31/17 at 6:25 a.m. Resident #1 sat in the wheelchair. At 8:45 a.m. Resident #1 sat in the wheelchair in his/her room. Staff stated he/she had just had a whirlpool. Resident #1 asked several times if he/she could go to bed. Staff A Certified Nursing Assistant (CNA) and Staff B CNA transferred Resident #1 to bed. Resident #1 laid with his/her legs leaning toward the right, but staff provided no support to keep off his/her back/buttocks/coccyx area. At 10:22 a.m. Staff E, Licensed Practical Nurse (LPN) changed the dressing to Resident #1's coccyx ulcer. The open area had a red base with pink surrounding skin. The ulcer had depth. At 1:30 p.m. Resident #1 laid in bed toward the right. At 4:35 p.m. Resident #1 remained in the same position. During an observation on 2/1/17 at 6:20 a.m. Resident #1 sat in the wheelchair with his/her eyes closed. At 8:20 a.m. Resident #1 remained in the wheelchair. At 8:33 a.m. Resident #1 in bed toward the right. At 10:25 a.m. Resident #1 remained toward the right. At 11:10 a.m. staff went in Resident #1's room. At 11:20 a.m. Resident #1 sat in the wheelchair. During an interview on 2/2/17 at 7:30 a.m. the Director of Nursing stated hospice noted Resident #1's wounds were unavoidable due to terminal condition, but agreed all interventions should be implemented including at least every 2 hour repositioning. The facility policy/procedures titled Prevention of Pressure Ulcers, January 2015 Edition, identified the purpose of the policy was to relieve pressure, restore circulation and promote skin protection in the affected area. The guidelines included utilizing pressure reduction devices on bed and chair as necessary, repositioning resident routinely and positioning with pads and pillows to protect bony prominence's and maintain proper alignment, using elbow and/or heel foot protectors if needed. The care plan would identify the problem, establish goals, and develop approaches. The facility policy and procedures titled General Wound and Skin Care Guidelines, January 2015 edition, documented the following general wound and skin care guidelines should be followed for all residents with potential and/or actual impairment in skin integrity. Turn/reposition every 2 hours while in bed and at least hourly when in a chair. 3. Resident #3 had a MDS with a reference date of 11/19/15. The MDS documented the resident had no impairment of cognitive function and required extensive assistance of staff for bed mobility and transfers. The resident's Braden Scale Pressure Sore Risk assessment documented the resident at mild risk for the development of pressure sores from 2/15/16 through 1/6/17. During an observation on 2/1/17, Staff E, Licensed Practical Nurse (LPN) provided a treatment to an open area on the resident's coccyx/sacrum. Observation identified the resident's mattress as a standard mattress and not pressure reducing. Staff F, LPN stated and confirmed the mattress to be a regular mattress and not pressure reducing. During an interview on 2/1/17 at 11:15 a.m. the Director of Nursing (DON) stated the area was not due to pressure, but due to the resident picking at the area. A 1/19/16 Wound Clinic Progress Note documented the resident had an open wound in the gluteal crease that measured 0.8 by 0.4 by 0.2 cm. which underwent excisional debridement of surrounding necrotic tissue and scar to a size of 1.4 by 0.7 by 0.2 cm. The Progress Note diagnosed the wound as a Stage III decubitus ulcer of the coccyx. The MDS defines a Stage III Decubitus (Pressure) Ulcer as 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 the tissue loss. May include undermining and tunneling. On 1/28/16 Wound Clinic notes documented the coccyx wound 1.0 by 0.8 by 0.4 cm. The facility staff documented the area healed on 2/8/16. On 2/18/16 Wound Clinic notes documented the coccyx ulcer 1.0 by 1.3 by 0.2 cm. and described the area as Stage III decubitus ulcer with the fat layer exposed. Facility records lacked any further assessment of the coccyx ulcer until 5/30/16. Wound Clinic notes documented the following: On 3/15/16 the Stage III decubitus coccyx ulcer with fat layer exposed measured 1 by 0.3 by 0.1 cm. On 3/29/16 the Stage III decubitus coccyx ulcer with fat layer exposed measured 1 by 0.4 by 0.4 cm. On 4/12/16 the Stage III decubitus coccyx ulcer with fat layer exposed measured 0.4 by 0.3 by 0.2 cm. On 4/26/16 the Stage III decubitus ulcer with fat layer exposed measured 0.1 by 0.1 by 0.1 cm. On 5/10/16 the Stage III decubitus ulcer with fat layer exposed measured 0.6 by 0.3 by 0.1 cm. slightly larger. They also identified an open wound to the right upper posterior back 1.4 by 1.5 by 0.4 cm. which may have been a remnant from an abscess. On 4/11/16 at 3:20 p.m. staff documented in the Nurse's Notes the resident had a red area to the right back/shoulder which measured 1.2 by 1.2 cm. Wound Clinic Notes subsequently documented on 5/26/16 the Stage III decubitus of the sacrum/coccyx measured 1.2 by 0.3 by 0.2 cm. initially and 3.5 by 1.5 by 1.0 cm. after excision and debridement. The ulcer was then primarily closed. They documented the back lesion 0.8 by 0.8 by 0.2 cm. and described it now as a decubitus ulcer with breakdown of skin. Facility staff continued to document condition of the right back/shoulder lesion on a Non-Pressure Skin Condition Report. The record lacked any documentation indicating staff recognized either area as a pressure sore (decubitus ulcer) or implemented any interventions appropriate to treatment of [REDACTED]. On 5/30/16 facility staff documented on a Non-Pressure Skin Condition Report a surgical wound on the Gluteal Crease. They documented the area tender with assessment. Staff measured the area 4 by 1 cm. On 6/6/16 facility staff documented the area measured 4 by 2 cm. and noted the sutures spreading. On 6/9/16 Wound Clinic Notes documented the coccyx ulcer measured 4 by 2 by 1 cm. after the removal of the sutures. Wound Clinic staff documented another small ulcer on the left buttock measuring 0.3 by 0.3 by 0.1 cm. The sutures were removed and new sutures placed to re-approximate the edges. On 6/13/16 facility staff documented the area on the gluteal crease 4 by 2 cm. and noted 5 sutures. On 6/16/16 Wound Clinic Notes stated the resident still had a lot of pain at the site of the coccyx ulcer. The sutures tended to pull through the skin causing a lot of pain with movement. They removed the stitches. The note lacked any measurements of the coccyx ulcer or any mention of the left buttock ulcer. On 6/27/16 facility staff documented the wound on the gluteal crease measured 3 by 4 by 0.1 cm. On 6/28/16 Wound Clinic Staff documented the Stage III decubitus ulcer measured 3.7 by 1.4 by 0.8 cm. with the fat layer exposed. They did no debridement at that visit. On 7/4/16 facility staff documented the area measured 4.2 by 3.2 by 0.4 cm. On 7/5/16 Wound Clinic staff documented the resident had less pain with the sutures removed but was still bothered especially when they removed the dry dressings. They measured the Stage III decubitus ulcer of the coccyx 4 by 3 by 0.3 cm. They did not debride the ulcer. On 7/11/16 facility staff documented the area measured 4 by 3 by 0.2 cm. On 9/5/16 facility staff measured the area 3.5 by 1.1 by .1 cm. From 7/12/16 to 9/6/16 Wound Clinic staff documented the Stage III ulcer progressively decreased in size from 4 cm. by 3 cm. by 0.3 cm. to 3 by 1 by 0.6 cm. On 9/6/16 they also documented an open area on the right buttock 0.8 by 0.8 cm. On 9/12/16 facility staff documented the area on the gluteal crease as 3.5 by 1 by 0.1 cm. On 9/13/16, Wound Clinic staff documented the coccyx ulcer 3 by 0.5 by 0.5 cm. They noted an ulcer on the left buttocks, possibly related to tape trauma which measured 0.6 by 0.8 by 0.1 cm. The note made no mention of the open area on the right buttocks. They debrided both areas. On 9/20/16 Wound Clinic staff documented the left buttocks ulcer measured 0.8 by 0.8 by 0.1 cm. The sacral ulcer measured 3 by 1 by 0.1 cm. and noted it had developed an area of dead tissue. They measured it post debridement 3.7 by 1.7 by 0.1 cm. On 9/27/16 Wound Clinic staff documented the ulcer 4 by 2 by 0.4 cm. and noted it continued to enlarge in size. Again they debrided the ulcer which then measured 4 by 2.5 by 0.5 cm. From 10/11/16 to 1/31/17 Wound Clinic Notes documented weekly debridement of the coccyx/sacral ulcer. The size of the ulcer varied slightly from week to week. On 1/31/17 they measured the ulcer 3.2 by 2 by 0.3 cm. During an interview on 2/1/17 the DON stated they had not treated the coccyx wound as a pressure ulcer. She confirmed the resident did not have a pressure relieving device on the bed. She stated the facility had not obtained any of the Wound Clinic Progress notes until that day. They had not considered the open area a pressure ulcer. The resident's Care Plan stated he/she needed assistance with repositioning related to left [MEDICAL CONDITION] and identified a goal the resident would have no skin breakdown related to pressure. The Care Plan indicated the resident should have a pressure reducing mattress on the bed, but staff identified the mattress as standard. The Care Plan made no mention of the open area on the resident's coccyx.

Based on record review and staff interviews, the facility failed to provide adequate assessment and timely intervention for 1 of 8 residents reviewed (Resident #6). The facility failed to identify and assess a change in Resident #6's bowel pattern/function (including incontinence), low fluid intakes and new onset of back pain. Resident #6 was admitted to the hospital with [REDACTED]. The facility reported a census of 73 residents. Findings include: According to the Minimum Data Set (MDS) assessment with a reference date of 8/26/12, Resident #6 scored 13 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. Resident #6 required extensive assistance with toilet use and always had continence of bowel, with constipation present. The assessment documented [DIAGNOSES REDACTED]. The Care Plan dated 8/20/12 identified Resident #6 with episodes of constipation. The approaches included: a. Monitor bowels each shift and record-intervene as necessary; Resident #6 would request a PRN (as needed) as necessary. b. Administer medications per doctor order. c. Provide diet per doctor order. d. Offer the juice cart. e. Monitor bowel sounds/abdomen as necessary f. Monitor for a change in bowel pattern/function; notify the doctor and family. A History and Physical Report dated 10/4/12 at 10:59 a.m. documented a review of systems including the gastrointestinal system. The report indicated constipation present and abdominal pain, a change in bowel habits, diarrhea, nausea or vomiting as not present. A BM (bowel movement) Report dated 10/1/12 to 10/31/12 documented Resident #6's bowel record included: a. 10/6/12, a large continent stool. b. 10/9/12, a large continent stool. c. 10/11/12, a medium continent stool. d. 10/12/12, a large continent stool. e. 10/15/12, a medium continent stool. f. 10/18/12, a medium continent stool. g. 10/20/12, a large continent stool. h. 10/22/12, a small and a large continent stool. i. 10/25/12, a medium continent stool. j. 10/28/12, a smear at 12:18 a.m. and a medium incontinent stool at 6:49 a.m. k. 10/29/12, a small incontinent at 1:30 a.m. and a large continent stool at 9:30 a.m. l. 10/31/12, a medium incontinent stool at 9:56 p.m. A total of 13 stools for the month and continent of stool until 10/28/12. The Nurse's Noted dated 10/26/12 at 2:30 p.m. documented Resident #6 complained of hemorrhoid pain. Upon assessment dark red clots noted mixed with the resident's stool. Staff notified the physician. Bowel sounds were present times 4 and Resident #6 denied abdominal pain. His/her blood pressure measured 118/64. At 5:00 p.m. staff received a telephone order for hemoccults (a test for blood in stool) times 3. If Resident #6 continued with blood in the stool, to make an appointment with the physician on Monday. Staff received an order for [REDACTED]. Resident #6's blood pressure measured 150/68. The Nurse's Notes dated 10/27/12 at 4:30 a.m. documented they continued to monitor Resident #6 for blood in the stool. There were no bowel movements at the time and no signs of blood from the rectum. Bowel sounds were present times 4 and Resident #6 denied any abdominal pain. At 3:00 p.m. Resident #6 had no noted bowel movement, bowel sounds active times 4 and abdomen soft and non-tender. Staff noted no complaints of pain/discomfort The Nurse's Notes dated 10/28/12 at 3:00 p.m. documented Resident #6 had no BM noted (the resident's BM Report documented a medium incontinent stool at 6:49 a.m.). The Nurse's Notes dated 10/29/12 at 4:55 a.m. documented Resident #6 had a small BM. The note documented no blood visible and hemoccult test positive for blood in the resident's stool. The clinical record lacked documentation of the character of the stool. The Nurse's Notes dated 10/29/12 at 1:00 p.m. documented they continued to monitor for blood in Resident #6's stools and no stools noted during the shift (the resident's BM Report documented a large stool at 9:30 a.m.). A BM Report dated 11/1/12 to 11/15/12 documented Resident #6's bowel record included: a. 11/1/12 at 7:21 a.m. a small incontinent stool and at 11:50 p.m. a small incontinent stool. b. 11/2/12 at 9:00 a.m. a medium continent stool and 4:10 p.m. a small incontinent stool. c. 11/3/12 at 9:13 a.m. a small incontinent stool, at 3:32 p.m. a small incontinent stool. d. 11/4/12 at 1:43 a.m. a small incontinent stool, at 8:02 a.m. a medium incontinent stool, at 8:02 p.m. a small incontinent stool. e. 11/5/12 at 1:33 a.m. a small incontinent stool, at 6:00 a.m. a large continent stool, at 9:22 p.m. a small continent stool. f. 11/6/12 at 3:44 p.m. a small incontinent stool, at 11:37 p.m. a medium incontinent stool. g. 11/7/12 at 3:58 a.m. a medium incontinent stool, at 6:00 a.m. a medium continent stool, at 8:58 p.m. a large continent stool. h. 11/8/12 at 6:30 p.m. a large incontinent stool. A total of 18 stools in 8 days (five more than the entire month of October), with 13 recorded as incontinent. The Nurse's Notes dated 11/1/12 at 1:30 p.m. documented they continued to monitor for blood in the stool, with no noted BM during the shift (the BM Report documented Resident #6 had a small incontinent stool at 7:21 a.m.). The Nurse's Notes dated 11/2/12 at 2:00 p.m. documented Resident #6 had no noted BM during the shift (the BM Record documented a medium stool at 9:00 a.m.). The Nurse's Notes dated 11/2/12 at 10:00 p.m. documented Resident #6 had no blood from his/her rectum. He/she denied abdominal pain, bowel sounds active times 4. Resident #2 had a colonoscopy scheduled 11/09/12. The clinical record lacked any further documentation of assessment of Resident #6's bowel sounds or abdomen until 11/8/12 and lacked any assessment of the character of stools with a change in bowel pattern. A Nutritional Evaluation dated 8/24/12 identified Resident #6's fluid needs at 1,900 cc's (cubic centimeters) per day. The Fluid intake record documented Resident #6 took the following fluids in November 2012: a. 11/1 - 520 cc. b. 11/2 - 360 cc. c. 11/3 - 180 cc. d. 11/4 - 288 cc. e. 11/5 - 330 cc. f. 11/6 - 350 cc. g. 11/7 - 180 cc. h. 11/8 - 1494 cc. The clinical record lacked any assessment regarding the low intake of fluids. A PRN Record dated November 2012 documented Resident #6 received the following medication: a. 11/6/12 at 4:00 a.m. [MEDICATION NAME] for general discomfort. b. 11/7/12 at 2:00 a.m. [MEDICATION NAME] for complaints of back pain. c. 11/7/12 at 4:30 p.m. [MEDICATION NAME] for complaints of back pain, and [MEDICATION NAME] for complaints of back and left hip pain. d. 11/8/12 at 12:00 a.m. [MEDICATION NAME] for complaints of back pain. e. 11/8/12 at 5:30 p.m. [MEDICATION NAME] and [MEDICATION NAME] for complaints of left hip. The clinical record lacked any assessment of the new onset of back and left hip pain. The Nurse's Notes dated 11/8/12 at 11:15 p.m. documented Resident #6's vital signs registered a Temperature of 98 degrees, pulse 70, respirations 18 and blood pressure 210/90. Resident #6 had an emesis at 11:00 p.m. dark in color. Resident #6's abdomen was extended and hard and s/he had bowel sounds present times 4. Resident #6 appeared slightly confused and complained of a headache. The resident had colonoscopy prep and only had 1 BM on an earlier shift. Staff paged the on-call physician and received orders to send to the hospital for evaluation. On 11/9/12 at 4:00 a.m. Resident #6 admitted to the hospital. A hospital History and Physical dated 11/9/12 documented the physician was called to evaluate Resident #6 for nausea, vomiting and abdominal distention. X-rays revealed massive dilation of the colon, which was filled with stool. Resident #6 would be admitted for further evaluation and treatment. The physical examination revealed the abdomen grossly distended and bowel sounds reduced. The flat upright abdomen showed grossly dilated large bowels, which were filled with fecal material. The assessment included a large bowel obstruction secondary to fecal impaction, accelerated hypertension, and dehydration. They would keep Resident #6 NPO (nothing by mouth), start D5 half normal saline at 100 cc per hour, pass a [MEDICAL CONDITION] tube to decompress the abdominal distention, suspend the Aspirin and [MEDICATION NAME]. A [MEDICATION NAME] letter dated 11/13/12 documented Resident #6 had a flexible endoscope of his/her colon on 11/12/12 which appeared normal. The physician suggestions included the physician thought the admission to the hospital had been caused by severe fecal impaction. He suggested regularly scheduled medication to prevent fecal impaction. During an interview on 2/8/13 at 9:09 a.m. Staff K MDS/Care Plan Coordinator stated she did the care plan and recognized the intervention to monitor for a change in bowel pattern/function and notify the doctor and family. Staff K agreed that Resident #6's bowel pattern changed, going from continent days apart to multiple stools and incontinence. She agreed an assessment should have been done. She said it would be nice to know if they were loose stools. During an interview on 2/12/13 at 8:40 a.m. Staff H Certified Nursing Assistant (CNA) stated it seemed like there was a time when Resident #6 was incontinent with loose stools. She stated Resident #6 tended to strain with his/her bowels and they had noted him/her to try and digitally remove stool him/herself. She stated they would discourage it and encourage the resident to take a stool softener or something. Because Resident #6 was normally continent, Staff H felt she would have told the nurse about the change and kept the nurse informed. Staff H could not remember if she told a nurse or the time frame of any of it. During an interview on 2/12/13 at 9:09 a.m. Staff L CNA stated she didn't recall Resident #6 being incontinent or his/her bowel function. Staff L stated because Resident #6 had normal continence, she would report incontinence, but she didn't recall it. During an interview on 2/12/13 at 12:42 p.m. Staff A CNA stated she didn't recall anything about Resident #6's bowel function, but thought if he/she was incontinent of bowel it could be a behavior thing (problem). During an interview on 2/12/13 at 1:26 p.m. Staff M CNA stated she didn't specifically remember Resident #6 being incontinent of stool. Staff M stated she would not notify the nurse of incontinence; she would just document it through the headset into Accu-nurse. During an interview on 2/26/13 at 1:48 p.m. the Director of Nursing (DON) stated the nurses could check the BM record on Accu-nurse and do so to make sure residents went every couple of days. The DON stated Resident #6 did go through a time when he/she would not get out of bed and had stools in the bed. She thought it was documented when it occurred, but didn't know if it corresponded to what went on the first week of November. She agreed a new onset of back pain or a change in bowel function should be reported and assessed. The facility reference regarding Diarrhea (more than 2 episodes in a 24 hour period) directed to document the following: a. Vital signs. b. Character of stool. c. Abdominal pain, cramps, distention. d. Review of medications. e. Bowel sounds. f. If the resident had been checked for impaction. g. Frequency and duration of symptoms/approximate number of stools in a 24 hour period and time of BM's in relation to eating and medication. h. Physician/family notification.

Based on record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards to prevent accidents, failed to use proper transfer techniques with a mechanical lift and failed to implement the interventions of the care plan for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 73 residents. Findings include: Resident #1 had a Minimum Data Set (MDS) assessment, with a reference date of 11/29/12, which reflected a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 identifies no cognitive impairment. Resident #1 required extensive assistance with transfers, and did not ambulate. Resident #1's [DIAGNOSES REDACTED]. The Nurse's Notes dated 1/12/13 and documented at 3:20 p.m., reflected Resident #1 fell from the EZ stand (sit to stand mechanical lift) at 9:25 a.m. The resident fell down the side of the bed onto the floor. When the nurse asked what happened, the Certified Nursing Assistant (CNA) stated Resident #1 let go of the handles on the EZ stand and slid out of the lift down the side of the bed. Staff performed a head to toe assessment with no injuries noted at that time. Resident #1 did not hit his/her head and range of motion (ROM) was normal for Resident #1. Staff assisted Resident #1 back to bed from the floor. Vital signs were obtained. Two Staff used the Hoyer lift and assisted Resident #1 to the recliner. When in the recliner, Resident #1 stated he/she thought right knee broken. When asked about going to the emergency room to get it checked out, Resident #1 stated no. At 10:45 a.m. Resident #1 received medication for pain of the right knee. The resident described the pain at a 10 (scale of 1 to 10 with 10 at most intensity). Resident #1 refused to let the nurse assess the right leg/knee again, and he/she refused to go to the ER. At 11:35 a.m. staff notified Resident #1's family of the fall, pain to the right knee and Resident #1's refusal to go to the ER. The physician was notified. The Nurse's Notes dated 1/12/13 at 10:30 p.m. documented a follow up to the fall with no signs of injury. Resident #1 transferred with 2 assist to bed per resident's norm. He/she complained of pain to the right knee and as needed (PRN) medication given. They noted no swelling, redness or discoloration. The Nurse's Notes dated 1/13/13 at 5:45 a.m. documented no swelling or discoloration of the right knee, and Resident #1 offered no complaints during the shift. The Nurse's Notes dated 1/13/13 at 2:50 p.m. documented Resident #1 transferred from bed to recliner with 2 assist and the Hoyer lift due to him/her not standing with the EZ stand. Resident #1 tolerated it well with no injuries noted during the shift. Resident #1 denied pain/discomfort during the shift. The Nurse's Notes dated 1/13/13 at 10:30 p.m. documented Resident #1 complained of right knee pain. The resident stated she/he would have the knee examined. At 11:30 p.m. the resident ' s family member notified the facility that the resident had been admitted to the hospital and had a fractured femur and a urinary tract infection. A History and Physical dated 1/13/13 documented Resident #1 was a little groggy after receiving some Morphine in the emergency room for pain control. The resident stated that he/she did fall and injured his/her right leg, went to the ER for evaluation, found to have a femur fracture and admitted . An x-ray dated 1/13/13 revealed Resident #1 had a spiral type fracture of the distal right femur with approximately 1 cm of lateral displacement of the distal femoral fragment relative to the proximal fragment. A Consultation report dated 1/14/13 documented options were discussed with Resident #1 and a family member and they agreed to proceed with a right distal femur ORIF (open reduction and internal fixation). An Occupational Therapy Plan of Care dated 1/18/13 documented Resident #1 was referred due to a decline in functional mobility due to a recent fracture. Therapy necessary for bed mobility, caregiver education, and strengthening. Without therapy Resident #1 at risk for injury, caregiver dependence and falls. A Physical Therapy Plan of Care dated 1/19/13 documented Resident #1 fell and fractured his/her right femur above the right lower extremity ORIF. Therapy necessary for strengthening, balance and mobilization. Without therapy Resident #1 at risk for further functional decline. Resident #1 non weight bearing right and not ambulatory. Prior level of function non ambulatory but did weight bear for transfers. Cognition and safety awareness severely impaired. Resident #1 unable to communicate pain; level obtained by facial expressions and gesture. Range of motion right lower extremity limited into hip and knee extension due to pain complaints. The Care Plan indicated the resident required assist with transfers. The approaches included: a. Resident education to make sure his/her wheelchair was directly behind him/her and the brakes were locked before sitting down, dated 12/23/11. b. Transfer with 2 assist and the wheeled walker dated 2/11/12. c. EZ Stand, dated 1/12/13 (date of the fall). d. Staff education on proper transfer technique, 2 assist with EZ Stand lift, dated 1/12/13. e. 2 assist and Hoyer lift for transfers, dated 1/18/13 The Care Card for Resident #1 directed transfers and ambulation with 2 assist dated 2/11/12. Positioning and devices included wheelchair and walker. The Accunurse ADL Plan of Care-Transfers dated 2/6/13 showed on 2/15/12 Resident #1 had Dycem added in his/her recliner and on 1/18/13 Resident #1 up per 2 assist and the Hoyer lift. The Accunurse failed to show the sit to stand lift added to the plan of care. An Itemized ADL Coding Report documented Resident #1 transferred with one person assist on 1/5/13 at 6:21 p.m., 1/6/13 at 2:55 p.m., 1/7/13 at 9:16 a.m., 1/8/13 at 8:27 p.m., 1/9/13 at 9:29 a.m., 1/10/13 at 9:31 a.m., 1/11/13 at 3:25 p.m. During an observation on 2/6/13 at 9:14 a.m. 2 staff transferred Resident #1 from the bed to the wheelchair with the Hoyer lift. During an observation on 2/6/13 at 10:20 a.m. the care card on the bulletin board read: Transfer and Ambulation 2 assist dated 2/11/12. The care card did not identify the use of mechanical lift). During an interview on 2/6/13 at 4:11 a.m. Staff E Certified Nursing Assistant (CNA) stated she knew there should be 2 with the stand lift but other CNAs also transferred residents on their own. Staff E said she worked in another facility where they could transfer with 1. Staff E stated she had been on the hall where Resident #1 resided 2 times before. She thought they used the EZ stand then. Staff E stated others did it with 1 and it saved time. She stated there was no strap to use on the legs, or she would have used one. Staff E stated she had the safety strap around Resident #1's waist, but his/her legs would not hold up and the resident slipped through. During an interview on 2/6/13 at 10:17 a.m. Staff I Licensed Practical Nurse (LPN) stated she got paged when Resident #1 fell . She didn't know if the safety strap was fastened but Staff E said it was. The leg strap was gone at that point, but she (Staff I) didn't know it. Staff I stated 2 person assist were needed with any EZ stand transfer. Staff I said the care plan in the room directed staff to use 2 assist (did not indicate EZ stand), so she wrote Staff E up (disciplined) and educated her. During an interview on 2/6/13 at 9:33 a.m. Staff H, CNA stated Resident #1 transferred with the EZ stand prior to the fall/fracture, but she didn't know how long she transferred that way. Staff H stated they always had to have 2 people with the EZ stand. Staff H stated Resident #1 needed the assistance of 2 assist since s/he came back from the hospital. Staff H stated they talked to the Director of Nursing so it was care planned to use the lift. Staff H thought everyone in the building had used the EZ stand by themselves at one point or another. She stated the leg strap was broken and not useable at the time of Resident #1's fall. During an interview on 2/6/13 at 1:20 p.m. Staff G CNA/Restorative Aide (RA) stated the CNAs made her aware Resident #1 used the EZ stand. Staff G stated she never used the stand lift alone and always use the lift with 2. During an interview on 2/6/13 at 1:41 p.m. Staff J CNA stated when on hall 6, Resident #1 transferred with 1 assist. Staff J had used the stand lift with 2 people. She said she always use 2 with the lift. She said you could find out transfer technique on Accunurse (stand lift not added), or the transfer log at the nurse's station, which should now say Hoyer lift. Staff J stated the policy said 1 to 2 assist with the stand lift, but they used 2 with the stand lift. Staff J stated she trained Staff E on the Hoyer lift, but not on the stand lift. Staff J stated when she used the stand lift the leg strap was there and she always used it. She did not use the stand lift while the leg strap was broken or gone. Staff J stated she would have said something (reported). During an interview on 2/7/13 at 9:47 a.m. Staff A CNA stated you (CNA) always use 2 (staff) with the EZ stand, or any kind of mechanical lift. Staff A stated she didn't know how she knew that, but she had always known it. Staff A stated she never transferred with an EZ stand herself. Staff A stated she always used the leg strap when she transferred with the EZ stand. She didn't know the strap had been broken or removed prior to Resident #1's fall. She didn't know what Resident #1's care plan said (directed staff) regarding transfers, but she thought Resident #1 used the EZ stand for some time. During an interview on 2/7/13 at 1:30 p.m. Staff B LPN (Licensed Practical Nurse) stated you would know a resident's transfer status by looking at the care plan in their room. Staff B stated if it had 2 assist it meant 2 assist and the gait belt. She stated if it were a Hoyer or stand lift it should say 2 and Hoyer or stand lift (on 2/6/13 at 10:20 a.m. the care card on the bulletin board read: Transfer and Ambulation 2 assist dated 2/11/12). Staff B stated they were supposed to use 2 with the machines. When asked how staff are supposed to know that, Staff B replied they should be oriented that way. During an interview on 2/7/13 at 1:55 p.m. Staff C Registered Nurse (RN) stated she knew they used the EZ stand with Resident #1 because she saw staff transfer the resident. Staff C stated it should be on the care plan how Resident #1 transferred During an interview on 2/7/13 at 2:56 p.m. Staff D RN stated she floats (no specific assigned residents) and she worked with Resident #1 about every 2 weeks. Staff D stated Resident #1 transferred with 2 assist or the EZ stand. Staff D stated the facility policy directed 2 staff to use the EZ stand. Staff D saw Resident #1 transferred with the EZ stand. During an interview on 2/8/13 at 9:17 a.m. the MDS/Care Plan Coordinator stated she did not know staff were transferring Resident #1 with the stand lift prior to his/her fall. During an interview on 2/6/13 at 8:30 a.m. the Director Of Nursing (DON) stated the facility had 1 (sit to stand) lift at the time of Resident #1's transfer, now the facility had 2. The lift did not have the leg strap on it when Resident #1 fell . The DON stated Maintenance took it off but didn't tell the DON or take it out of service. The DON stated it apparently broke. The DON stated although the care plan changed to a stand lift on 1/12/13 for Resident #1, he/she used it prior to that time. The DON stated staff did not inform her or the care plan coordinator that they (staff) were using the mechanical lift so it did not get changed on the care plan. The DON stated the care plan did call for 2 assist and the walker and she expected staff to use 2 assist with the stand lift, even though the policy said (directed) 1 to 2 staff. The DON confirmed how that could be confusing. The Lift Mechanical; Sit to Stand facility policy/procedure, revised on March 2007, identified the purpose is to provide safe transfer for non-ambulatory residents. The policy indicated 1 to 2 staff members to use the equipment. The procedure indicated the resident care plan would include the number of staff members for transfer using the sit to stand. During an additional interview on 2/8/13 at 10:40 a.m. the DON stated there were no trainings or audits in 2012 regarding the stand lift. An Internal Quality Assurance Investigation Form dated 1/12/13 documented Resident #1's MDS/Care Plan type of assist not followed. Interventions according to the plan of care were in place. Staff E was responsible for not following the care plan, and Resident #1 let go of the EZ stand handles. The preventive measures implemented were to follow the care plan, and use 2 assist with the EZ stand. Staff were educated on the proper transfer technique; 2 assist with the EZ stand lift. A Summary Report of a Meeting dated 1/18/13 at 2:00 p.m. documented a review of concerns, including a review of proper Hoyer and stand lift transfers. The subjects covered were stand lift transfers, Hoyer transfers, sit to stand policy, need to follow resident's plan of care, and need to utilize leg straps on stand lifts.