Every finding on record at Willow Dale Wellness Village

Based on clinical record review, staff interview, guidance from the 2025 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual and facility policy review, the facility failed to update the Comprehensive Care Plan for 1 of 13 residents (Resident #32) reviewed for Care Planning. The facility reported a census of 29 residents. Findings include:The Annual Minimum Data Set (MDS) of Resident #32, dated 8/31/25, documented diagnoses that included atrial fibrillation, heart failure and hypertension. The Quarterly MDS dated [DATE] documented the same above diagnoses as still be active for Resident #32The History and Physical from the community hospital dated 8/18/25 documented Resident #32 arrived to the hospital emergency department on 8/17/25 and was admitted for acute congestive heart failure (a new diagnosis) with hypoxemia (when the heart suddenly gets very weak, failing to pump well, causing fluid to back up into the lungs, which then causes the oxygen levels in the blood to be lowered. This can lead to severe breathlessness). The notes from the community hospital, with a print date of 12/5/25 documented a registration date to the hospital of 12/1/25. The History of Present Illness documented the resident was transported to the emergency department for further evaluation with symptoms of back pain, abdominal pain and refusal to eat. The workup in the emergency department findings were acute on chronic congestive heart failure and hypoxemia, requiring intravenous (IV) diuretic medication (medication to remove excess body fluid). The Medical Administration Record (MAR) of Resident #32 for December of 2025 documented the resident had daily orders for Amlodipine for hypertension (high blood pressure), aspirin for atrial fibrillation (chronic irregular heartbeat), Furosemide (diuretic, water pill for heart failure), Lisinopril for hypertension, and Metoprolol for hypertension.The Comprehensive Care Plan of Resident #32, reviewed on 12/10/25 failed to identify the resident having any cardiac diagnoses or cardiac medications. The Care Plan documented use of diuretic medication related to edema. On 12/11/2025 at 9:45 am, the Director of Nursing (DON) stated the MDS Coordinator is the person who completes the care plans. She stated she was aware certain medications should be care planned and they audit the care plans for particular medications. On 12/11/2025 at 9:46 am, the MDS Coordinator stated the resident primary diagnosis was not required to be on the care plan. On 12/11/2025 at 9:47 am, the Regional Nurse Consultant stated the Corporate Reimbursement Specialist reviews the care plans. She stated they will speak to her regarding primary diagnoses being care planned. She added that any new diagnosis a resident receives should be reviewed and added to the Care Plan. The 2025 RAI manual states the Care Area Assessment (CAA) portion of the MDS for an Annual Assessment must be completed within 14 days of the ARD (the date of the assessment), and the Care Plan must be completed within 7 days of the CAA completion. Resident #32's most recent Annual Assessment was dated 8/31/25. The facility policy titled Care Plan Policy, revision date 7/2023 documented the following:Procedures:1. During admission, the facility will put in place baseline care plans within 48 hours to address resident's care.2. The baseline care plan at a minimum should include initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable.3. The facility will provide the resident/representative a written summary of the baseline care plan by the completion of the comprehensive care plan.4. After the comprehensive assessment (state/federal-required MDS) is completed, the facility will put in place person-centered care plans outlining care for the resident.5. These will be reviewed and revised by the interdisciplinary team after completion of MDS assessments when applicable and with changes that warrant a care plan revision.

Based on observation, staff interview, clinical record review, drug manufacturer guidance, and facility policy review, the facility failed to assure a medication error rate of less than 5%. Medication administration was observed for a total of five residents, with errors being observed for one of five residents (Resident #25). A total of 26 ordered medications were reviewed with two errors, an error rate of 7.7%. The facility reported a census of 29 residents. Findings include:On 12/10/25 at 7:48 am, the observation of the medication pass began. Staff A, Licensed Practical Nurse (LPN) stated Resident #25 was done eating his breakfast so she would start with him. Staff A prepared a total of 12 medications for Resident #25. Among the medications observed, Staff A prepared Breo Ellipta Inhalation (a maintenance inhalation medication used for the treatment of airflow obstruction for asthma or pulmonary disease). Staff A additionally administered Levothyroxine, a thyroid medication. Staff A administered the medications to the resident at 7:59 am. The Medication Administration Record (MAR) for December of 2025 for Resident #25 included the instructions for Breo Ellipta for the resident to rinse mouth after use. Staff A failed to instruct the resident to rinse his mouth after inhaling the medication. The MAR additionally included the instructions for Levothyroxine to administer on an empty stomach. Resident #25 had eaten his entire breakfast prior to medication administration.The Prescribing Information from the Breo Drug Manufacturer documented the following: BREO can cause serious side effects, including: fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using BREO to help reduce your chance of getting thrush.The Prescribing Information from the Levothyroxine Drug Manufacturer documented the following: Administer Levothyroxine Sodium Tablets as a single daily dose, on an empty stomach, one-half to one hour before breakfast.On 12/10/25 at 12:54 pm, the Director of Nursing stated after using Breo medication, the resident is to rinse his/her mouth. The DON stated all synthroid medications in the facility are scheduled with the morning medication pass per the Medical Director's approval. She stated she would clarify with the provider to remove the instructions of taking on an empty stomach. On 12/10/25 at 1:59 pm, the DON stated the facility Nurse Practitioner agreed to remove the verbiage from the levothyroxine order for Resident #25 to administer the medication on an empty stomach. The facility policy Medication Administration - Medication Pass, review date 5/2023, documented the following:Procedure Step 6: Read special medication administration instructions

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 for in 3 out of 12 sampled residents reviewed for comprehensive care plans (Resident #20, #21 and #22). The facility reported a census of 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 documented diagnoses of cancer, hypertension and diabetes mellitus. The MDS showed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately cognitive impairment. The MDS revealed the resident was taking diuretic medication in the review period. Review of the Order Summary Report signed by the physician dated 10/21/24 revealed an order for spironolactone tablet (diuretic medication) daily with a start date of 11/29/22 and furosemide tablet (diuretic medication) daily with a start date of 11/4/22. Review of the current Care Plan undated lacked information regarding the side effects of diuretic medication. 2. The MDS assessment dated [DATE] for Resident #21 documented hypertension, depression and low back pain. The MDS showed a BIMS score of 03 indicating severe cognitive impairment. The MDS lacked information of the resident taking opioid medication. Review of the Order Summary Report signed by the physician dated 9/12/24 revealed an order for morphine sulfate (opioid pain medication) with a start date of 7/12/24. Review of the current Care Plan undated lacked information regarding the usage and side effects of opioid pain medication. 3. The MDS assessment dated [DATE] for Resident #22 documented hypertension, orthostatic hypotension and edema. The MDS showed a BIMS score of 15 indicating no cognitive impairment. The MDS revealed the resident was taking anticoagulant medication in the review period. Review of the Order Summary Report signed by the physician dated 9/12/24 revealed an order for Eliquis daily (anticoagulant medication) with a start date of 2/25/24. Review of the current Care Plan undated lacked information regarding the side effects of anticoagulant medication usage. Interview on 11/14/24 at 8:58 a.m., with Staff A, Co-Director of Nursing revealed the facility only has a baseline care plan policy and after that the facility follows the RAI manual. Interview on 11/13/24 at 2:36 p.m., with Staff A, Co-Director of Nursing revealed the side effects to watch for should have been listed on the care plan for the staff.

Based on clinical record review and staff interview, the facility failed to refer two residents with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 2 out of 3 residents (Residents #6 and #7) reviewed for PASRR requirements. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnosis of dementia, depression, and anxiety disorder. The MDS included diagnoses of anxiety disorder and depression. Resident #7 used an antidepressant for seven out of seven days in the lookback period. Resident #6's Notice of Negative Level I Screen Outcome dated 11/2/16 revealed the PASRR level 1 screen remains valid for your stay at the nursing facility and should be transferred with you if you relocate. No further level I screening is required unless you are known to have or are suspected of having a major mental illness or an intellectual or developmental disability and exhibit a significant change in treatment needs. Further review revealed the following questions indicated the answer to be no: a. Does the individual have any of the following Major Mental Illnesses, which included major depression? b. Does the individual have any of the following mental disorders, which include anxiety disorder? c. Currently or in the past, has the individual received any of the following mental health services? d. Does the individual have a diagnosis of dementia or Alzheimer's disease? The Care Plan Focus revised 6/5/23 reflected that Resident #6 used antidepressant medication related to depression, agitation, and anxiety. The Intervention indicated that Resident #6 saw a psychiatric advanced registered nurse practitioner (PARNP) for symptoms and behaviors related to anxiety and depression. The Psychiatrist/Mental Health Provider Notes dated 8/25/22 at 12:55 PM listed that Resident #6 had significant agitation during his telehealth visit. The PARNP planned to increase his Zoloft to 50 milligrams (mg). The Progress notes listed that Resident #6 continued to see the PARNP on the following days 9/29/22, 11/9/22, 12/21/22, 1/6/23, 2/6/23, 4/6/23, and 6/8/23. The Telehealth Progress Notes dated 6/8/23 at 12:30 PM indicated that Resident #6 had a significant history of anxiety and dementia. Other diagnoses listed in the notes included major neurocognitive disorder and generalized anxiety disorder. The Medication list included the following orders: a. 12/9/22: Zoloft (sertraline) 50 milligrams (MG), take 75 MG by mouth for generalized anxiety disorder. b. 12/21/22: Trazodone 50 MG tablet, take 25 MG by mouth at night for major depressive disorder and trouble sleeping. The Order Summary Report dated 7/13/23 signed by the physician listed diagnoses of generalized anxiety disorder, depression, and dementia in other diseases classified elsewhere with behavioral disturbances. Review of Resident #6's chart on 8/23/23 showed the facility lacked a follow-up and resubmission of a PASRR with the additional diagnosis of major depressive disorder, major neurocognitive disorder, dementia, anxiety disorder and lacked information of the initiation of mental health services. 44474 2. The MDS assessment dated [DATE] for Resident # 7 identified a BIMS score of 0, indicating severe cognitive impairment. The MDS included diagnoses of anxiety disorder and depression. Resident #7 received an antidepressant for seven out of seven days in the lookback period. The Notice of Negative Level I Screen Outcome dated 6/2/22 revealed the PASRR level I screen remains valid for your stay at the nursing facility and should be transferred with you if you relocate. No further level I screening is required unless you are known to have or are suspected of having a major mental illness or an intellectual or developmental disability and exhibit a significant change in treatment needs. Further review revealed the following questions indicated the answer to be no: a. Does the individual have any of the following Major Mental Illnesses, which included major depression? b. Does the individual have any of the following mental disorders, which include anxiety disorder? c. Currently or in the past, has the individual received any of the following mental health services? d. Does the individual have a diagnosis of dementia or Alzheimer's disease? The undated Care Plan Focus reflected that Resident #7 used an antidepressant medication related to depression. The Physician's Order Summary dated 4/13/23 signed by the provider listed diagnoses of generalized anxiety disorder and major depressive disorder, recurrent. The Telehealth Progress Notes dated 2/6/23 described that Resident #7 reported having some hallucinations (hearing or seeing things not there) of seeing farm animals at times but stated it did not disturb him. He had a couple incidents of agitation and aggression since his last appointment. The note listed the following medications: a. 7/2/21: Lexapro (escitalopram) take 10 MG by mouth every day due to major depressive disorder. b. 8/25/22: Seroquel (quetiapine) take 50 MG by mouth daily due to behavioral disorders associated with dementia. c. Desyrel (trazodone) take 75 MG by mouth at night due to anxiety disorder and trouble sleeping. The Pharmacy Review - GDR Request Psychotropic Medications signed by the provider on 1/10/23 directed to please continue medications as ordered. Resident #7 continued to sundown (increased confusion that starts in the late afternoon into the night), paranoia (irrational suspicion or mistrust of others) and hallucinations at bedtime. Review of Resident #7's chart lacked a follow-up and resubmission of his PASRR due to his diagnosis of anxiety disorder, information regarding mental health services, or the increase in mental health symptoms. The facility reported that they did not have a policy for PASRRs, as they follow the PASRR recommendations. On 8/23/23 at 11:06 AM the Social Services explained that she expected the PASRR to have been resubmitted with the updated diagnosis and mental health symptoms.

Based on resident interviews, clnical record reviews, and staff interviews, the facility failed to provide Care Conferences or have each member of the Interdisciplinary Team (IDT) review the Care Plan with the resident for five (Residents #4, #12, #14, #19, and #28) of sixteen residents reviewed. The facility reported a census of 32 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. On 6/6/22 at 2:11 PM, Resident #4 stated she didn't know of any care conferences. She reported that she didn't attend a Care Conference or get invited to one. The review of Resident #4's Electronic Health Record (EHR) progress notes dated 11/2/21 - 6/9/22 lacked documentation of Care Conference meetings or a review of the care plan with her and each required member of the IDT. 2. Resident #12's MDS assessment dated [DATE], documented a BIMS score of 14, indicating intact cognition. On 6/6/22 at 1:10 PM, Resident #12 stated he didn't know what a Care Plan meetings was. Resident #12 denied being invited or attending a Care Plan meeting. The review of Resident #12's EHR progress notes dated 3/31/22 - 6/9/22 lacked documentation of a Care Conference meeting or a review of his Care Plan with him and each required member of the IDT. 3. Resident #14's MDS assessment dated [DATE] documented a BIMS score of 15, indicating no cognitive impairment for decision-making. On 6/7/22 at 10:05 AM, Resident #14 reported that she didn't get invited to Care Plan Conferences. The review of Resident #14's EHR progress notes dated 12/19/21 - 6/9/22 lacked documentation of care conference meetings or review of care plan with resident and each required member of the IDT. 4. Resident #19's MDS assessment dated [DATE] documented a BIMS score of 15, indicating no cognitive impairment for decision-making. On 6/6/22 at 1:24 PM, Resident #19 stated he didn't know of Care Plan meetings. Resident #19 explained that her did not attend or get invited to one. The review of Resident #19's EHR progress notes dated 11/2/21 - 6/9/22 lacked documentation of Care Conference meetings or a review of his Care Plan with him and each required member of the IDT. During an interview on 6/7/22 at 3:00 PM, the Director of Nursing (DON) explained that they were currently not holding care conferences due to novel Coronavirus 2019 (COVID), or group meetings. The DON added that each quarter each discipline meets with the residents individually and reviews their Care Plan with them. 5. Resident #28's MDS assessment dated [DATE] documented a BIMS score of 13, indicating intact cognition. On 6/7/22 at 9:39 AM, Resident #28 reported that Care Conferences did not occur. The review of Resident #28's EHR progress notes dated 11/8/21 - 6/8/22 lacked documentation of Care Conference meetings or a review of the Care Plan with her and each required member of the IDT. On 6/8/22 at 10:00 AM, the DON said that they used to do care conferences before COVID. The DON explained that she in progress to get them going again. Each department head reviewed the Care Plan with the residents. The DON listed the departments to be: dietary, social services, activities and MDS nurses. When asked if she expected Care Conference progress notes to be completed by each department the DON commented that they should be doing them. On 6/8/22 at 12:10 PM, the Nurse Consultant reported that she had already identified the Care Conference documentation issue. The Nurse Consultant reported they were currently working on a plan of correction. The Nurse Consultant reported the facility lacked a policy for Care Conferences.

Based on observations, clinical record reviews, and staff interviews, the facility failed to follow a comprehensive care plan for one (Resident #15) of sixteen residents reviewed. The facility reported a census of 32 residents. Findings include: Resident #15's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified Resident #15 as totally dependent on two persons for bed mobility and transfers. Resident #15 required total assistance of one person with dressing, toilet use, personal hygiene, and eating. A Brief Interview for Mental Status (BIMS) not completed, as resident rarely/never understood. The staff assessment for Resident #15's mental status indicated she had a short-term memory problem, a long-term memory problem, and had severely impaired daily decision making skills. The MDS identified Resident #15 had an impairment on both sides to her upper and lower extremities. On 6/6/22 at 1:52 PM, observed Resident #15 resting in bed and positioned on her left side, with a blue hand roll (splint device) in her left hand, and noted contractures to her right hand's fingers with no device in that hand. On 6/7/22 at 9:59 AM, witnessed Resident #15 resting in bed, positioned on her back, with both hands resting on her upper abdomen with no splint devices in either hands. Noted a sign on the wall with the following documentation: carrot (splint device) in right hand and blue roll to left hand during the day and remove at meals. Observed the blue roll on Resident #15's nightstand. On 6/8/22 at 8:47 AM, saw Resident #15 sitting in her wheelchair in her room, with a washcloth in each hand. Resident #15's Care Plan problem initiated 5/31/19 indicated to help her acheive and maintain physical, mental, and psychosocial functioning. The included goal initiated on 5/31/19 indicated to decrease further progression of hand contractures as evidenced by her ability to wear a hand splint. The included interventions directed the following a. (2/24/21) Staff to apply a therapy carrot in her right hand with her small finger placed at three centimeters (cm) marking. Perform gentle passive range of motion (PROM) to carefully open digits before application. Place from palm into her hand to avoid shearing. Ensure the tip of her small finger was fully over the top of the carrot. Resident #15 should wear daily and nightly. Remove during meals for skin checks. b. (3/3/22) Place left c-grip splint every night and remove each morning daily. c. (5/31/19) Left hand: Blue hand roll in place during the day and remove at meals. On 6/8/22 at 12:00 PM, Staff A, Occupational Therapist (OT), stated that each resident's restorative program got added to the Care Plan by OT. Staff A said that she expected the staff to follow the restorative programs as recommended. The OT Discharge Summary dated 3/18/22 the following comments: a. Resident #15 would tolerate appropriate splinting for one to two hours without any signs of skin irritation or skin breakdown. b. Staff would be consistent with OT recommendations related to Resident #15's range of motion (ROM), proper skin hygiene, wearing schedule, splint application, and splint removal. c. Resident #15 would tolerate ROM Functional Maintenance Program (FMP) and appropriate splinting to maintain ROM, prevent further contracture, decrease pain, and decrease skin breakdown. The Discharge Recommendations directed the staff on education in ROM, stretching, and splinting to maintain gains made during therapy. The Splint and Brace Program Established?Trained: indicated a therapy carrot on her right hand and a roll splint in her left hand. The prognosis to maintain current level of function documented as excellent with consistent staff support, excellent with participation in restorative nursing program, and excellent with participation in FMP. On 6/8/22 at 4:11 PM, the Nurse Consultant reported that she expected the staff to follow the resident's Care Plan.

Based on observation and staff interview, the facility staff failed to perform hand hygiene before and after using gloves for 1 out of 3 residents observed. The staff also failed to prevent cross contamination of a medication cup for 1 out of 3 residents observed. The facility reported a census of 32. Findings: On 6/9/22 at 7:46 AM observed Staff B, Registered Nurse (RN), fail to perform hand hygiene before she applied gloves for the administration of [MEDICATION(S)] Balance Solution 0.6% eye drops to Resident #21. After the administration Staff B exited the room and discarded the gloves. Staff B failed to perform hand hygiene before she touched the medication box, medication cart, and goggles. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #21. On 6/9/22 at 9:10 AM watched Staff B, RN, place Resident #24's calcium pills into a medication cup, then placed the mediation cup between her bicep and torso while she completed hand hygiene. After the nurse exposed the medication cup to her scrub top she gave Resident #24 the medication cup. Resident #24 placed her lips on the cup to take her medication. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy titled Handwashing revised 5/20 instructed staff to wash their hands with either soap and water or with an alcohol-based handrub before and after providing direct resident care, before and after using disposable gloves, and following contact with blood or any other infectious materials. Hands will also be washed after completion of a dirty task, prior to beginning a clean task. On 6/9/22 at 9:55 AM, the Director of Nursing, (DON), acknowledged that she witnessed Staff B fail to complete hand hygiene before and after using gloves for eye drop administration. The DON also acknowledged Staff B failed to prevent possible cross contamination when she placed the medication cup against her scrubs. The DON stated, absolutely the nurse should sanitize her hands before putting on gloves and afterwards. There was no denying that. On 6/9/22 at 2:55 PM, the Administrator stated, they absolutely expected the staff to perform hand hygiene before and after using gloves that is a standard. The Administrator acknowledged a risk of cross contamination occurred when Staff B placed the medication cup against her scrub top.

Based on observation, staff interview and record review, the facility failed to ensure that a resident who was unable to carry out the necessary services maintained good personal hygiene for one of 3 residents observed. The facility failed to provide complete incontinent cares for Resident #21. The facility reported a census of 29 residents. Findings include: Resident #21's Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive impairment). The resident required extensive assist of two staff for toileting. The resident was occasionally incontinent of urine. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation On 7/26/21 at 3:38 PM Staff B, Certified Nurses' Aide (CNA) entered resident's room to assist the resident with incontinent cares. The Director of Nursing (DON) also observed. Staff C, Licensed Practical Nurse (LPN) washed her hands then closed the curtains. Staff C and Staff B assisted the resident into standing position. Staff B pulled resident's pants down, then removed gloves then Staff B opened drawers. Staff B opened a drawer removing wipes and foaming peri wash. After placing supplies on the back of the toilet, Staff B checked the resident's pullup. Staff B identified the resident's brief as wet. Staff B then removed the wet brief as Staff C put on a new brief then Staff B put on the resident's pants. Staff C held the wipes as Staff B wiped the resident from the back side reaching forward to the resident's vagina to the buttock. No cleaning observed to the front anterior of the resident. Staff removed their gloves and redressed the resident then walked resident to her recliner. Care plan review The Care Plan problem dated 1/19/21 revealed the resident needed assistance with activities of daily living (ADLs) and she had limited physical mobility related to activity intolerance and weakness. The problem included the intervention dated 1/19/21 regarding toilet use stated that the resident needed assistance of one staff with a gait belt and walker for her toileting needs. If the resident was fatigued, staff could stand and pivot the resident to a wheelchair. The Care Plan problem dated 3/12/21 showed the resident at risk for potential infection related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Administration interview On 7/29/21 at 10:13 AM the Director of Nursing (DON) said she expected the staff to wash from front to back and to wash the front of the resident if they were incontinent. On 7/29/21 at 10:43 AM the DON stated the facility did not have an incontinent care policy. The DON said she expected staff to follow standards of care.

Based on resident and staff interview, and record review, the facility failed ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents. A facility staff failed to use a gait belt appropriately on Resident #3. Resident #3 fell and the fall resulted in two rib fractures and a two night observation stay at the hospital for pain management. The resident returned to the facility on 3 Liters (L) of oxygen (O2). Facility census was 29 residents. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive assistance of one staff with transfers and limited assistance of one staff for ambulation in her room. The resident had no falls since the previous assessment. The resident had occasional pain 8 out of 10 on the pain scale. The resident did not use oxygen therapy. The resident had diagnoses of [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. Resident interview On 7/26/21 at 4:54 PM the resident stated she had a fall. On 7/28/21 at 10:15 AM the resident said that she thought her room is the same as it has been. Care Plan: A care plan with initiation date of 10/23/17, and in place when the incident occurred, revealed the resident required assistance with ADLs (activities of daily living) related to weakness and poor balance as evidenced by requiring staff assist of 2 with gait belt and walker to safely transfer. The intervention dated 1/29/21 stated therapy alert the resident could be assist of one with gait belt and walker in room and assistance of two staff with ambulation using gait belt and walker to and from meals (follow with wheelchair). Record review: An untitled facility form dated 7/23/21 revealed the resident fell in her room at 10:45 AM and the assessment identified pain in the mid [MEDICATION(S)] back area. Staff G was on the resident's left side (strong side) while the resident sat in the recliner with the side table on the right of the recliner and the wheelchair perpendicular to the recliner on the right side. The resident wore a gait belt with the walker in front of her and the wheelchair brakes locked. The care plan directed staff to transfer the resident with the assistance of one staff and gait belt and walker for transfers. The resident had therapy treatment and training for her right sided weakness including transfers and performed well. The resident typically transferred from the recliner with the wheelchair positioned on her right side, using a walker, gait belt, and assist of one staff. The resident occasionally required cues to reach for the chair and required assistance with balance but did well. The resident had no recent history of illness or increased weakness or dizziness. The resident worked with therapy to transfer from her recliner to her wheelchair to the right (her weak side) using her walker, gait belt and assist of one staff. The CNA transferred with the same setup per the therapy routine, and assisted the resident to stand with the gait belt. The CNA assisted the resident during the pivot transfer to the locked wheelchair to the right and the resident started to lose her balance. The CNA could not catch the resident when the resident fell backwards. It was unclear if the resident lost her balance or if her right foot caught on the wheelchair wheel as the incident happened very fast. The Action Plan was to re-enact the incident twice. The investigation including the staff interviews and chart review completed on 7/23/21. Therapy was to re-evaluate and treat the resident to determine if the setup still remained appropriate for the resident for transfers and determine the most appropriate level of assistance required. The progress note labeled Incident Report dated 7/23/2021 at 12:31 PM identified a staff member present when the fall occurred. Staff G Certified Nurse Assistant (CNA) transferred the resident from recliner to wheelchair with a gait belt. The resident fell backwards hitting her back on the bedside table and her left hip on the arm of the recliner. The resident did have her head in chin-tuck position and did not hit her head per resident and CNA. The resident's head faced the bathroom with her knees bent upwards. She complained of severe back pain and right shoulder pain. The resident wore shoes which were in good repair. The floor contained carpet and free of clutter. The resident was continent of bowel and bladder. The resident denied dizziness following the fall. The resident stated she needed to get off the floor. Staff assessed the resident's range of motion (ROM) and found no abnormality. The resident stood with assistance of three staff and a gait belt, then transferred to the recliner. The resident experienced increased sharp pain when standing. The resident did not tolerate sitting upright in the recliner, so staff reclined the recliner and administered Tylenol (analgesic) for pain the resident rated as 10 (on a scale of 0 to 10 with 0 being no pain and 10 being the worst imaginable pain). When the nurse entered the room, she observed the over bed table against the bed, the garbage can next to the resident's head, and the wheel chair by the window to make room for the assessment. The resident wore the call pendant but not activated. The assessment of the resident including ROM (range of motion) and pain showed the resident with limited movement to her right shoulder. When she transferred, she rated her pain 10 out of 10. When the resident stood, she cried with pain. When the ambulance arrived, they attempted to transfer the resident to the cot and her legs would not move. The resident continued to cry in pain, even as she laid on the cot. The resident was alert and oriented to person, place, and time (A&O x 3). The resident did not receive any (PRN) medication before the incident. The resident did not experience any acute conditions at the time of the fall. The description of injuries identified the resident's legs with two red areas and one bruise, measuring 4 centimeters (cm) by (x) 2 cm. and a skin tear to the right forearm, measuring 4 cm x 0.2 cm. Staff steri-stripped the skin tear and covered with [MEDICATION(S)] tape. No discoloration noted to the resident's back at the time of transfer. The list of relevant interventions in place at the time of the incident included: ensure resident's call light in reach and encourage her to use it for assistance as needed. Ensure the resident wore appropriate footwear such as gripper socks or shoes when she ambulated and transferred. The resident wore a pendant to use when the resident needed assistance. The preliminary recommendations for consideration as further preventative measures was for staff to make the belt tighter and use two staff assistance with transfers, and ambulation. The facility notified the daughter and the physician received notification via facsimile (fax). The emergency room (ER) received a report at 12:35 PM. The Change in Condition Assessment V0114.1 dated 7/23/21 at 11:19 AM showed the resident's O2 saturation was 95% on room air (RA). The resident had new onset of [CONDITION(S)] in her lower extremities. The resident had a functional status change and needed more assistance with ADL's. The resident had new or worsening pain and new skin integrity issues noted. The additional notes section revealed the change of condition due to the resident fell backwards during a transfer from her recliner to her wheel chair. The resident hit the [MEDICATION(S)] area of her back and her left hip on the arm of her recliner. The resident had trouble lifting her right arm. The resident felt the majority of pain in right posterior rib region. The resident rated her pain 10 out of 10. The Transfer to Hospital Summary dated 7/23/21 at 11:59 AM revealed the resident fell hitting her back and left hip. The Health Status Note dated 7/23/21 at 12:22 PM revealed the resident left the facility via ambulance. The right shoulder showed no discoloration or [CONDITION(S)] at the time of the transfer. The resident did have additional bruising to her right knee with no bruising to her back at the time of transfer. The Health Status Note dated 7/23/21 at 2:30 PM revealed the resident returned from the hospital by ambulance. The resident sustained a fracture to her 8th and 9th ribs. The ER didn't order anything for pain management. The resident's daughter arrived at the facility and staff provided emotional support. The daughter expressed concerns that the resident did not receive anything for pain management in the ER. The nurse obtained orders from the resident's physician for pain. The Orders - Administration Note dated 7/24/21 at 2:34 AM said to give two tablets of [MEDICATION(S)]-acetaminophen (narcotic) tablet 5/325 milligrams (MG) as needed for pain rating of 8 to 10 and may give orally or rectally. The Major Injury Determination Form dated 7/23/21 at 3:00 PM described the injury as a fracture to the 8th and 9th rib. The circumstance of the incident causing the injury as a fall. The Advanced Registered Nurse Practitioner (ARNP) signed the form marking that after reviewing the circumstances of the incident causing the injury, the previous functional ability of the patient, and the patient's prognosis, he believed that the injury sustained was not a major injury pursuant to the 481 Iowa Administrative Code 59.7(i)(a)(3). The Shift Follow Up to Incident Note 7/24/21 at 2:50 AM described the incident follow up related to the fall on 7/23/21. The assessment of the resident and/or area of concern showed the resident continued to have severe right side rib pain, PRN medication given and effective for three hours or so. The resident rested quietly after PRN medication administered by mouth. The resident did not have nausea with the PRN medication. Staff applied ice to the resident's affected area. The upper extremity and lower extremity ROM appeared limited due to pain. A dressing on the right forearm remained intact with minimal dry drainage. Staff checked and changed the resident that shift, and did not have incontinence. The resident was alert and oriented. The resident did have discomfort with movement, and rated pain as 8 out of 10. The new intervention implemented following the incident directed staff to make the belt tighter and use two staff assist with transfers, and ambulation. The Transfer to Hospital Summary dated 7/24/21 at 10:45 AM identified the reason for transfer as uncontrollable pain due to fractured ribs. The Structured Progress Note related to a change in condition dated 7/24/21 at 10:52 AM documented a potential condition change noted for the resident. The resident's functional status change showed the resident required more assistance to complete ADL's. The resident was noted to have pain. The resident had a fall on 7/23/21 that resulted in two fractured ribs on the right side, the resident's pain was not alleviated with PRN pain medications [MEDICATION(S)] and [MEDICATION(S)]. The resident was uncomfortable laying or sitting. The resident and family would like the resident in the hospital for pain relief. The Health Status Note 7/24/21 at 1:26 PM described the resident admitted to the hospital for pain control. Nursing progress notes dated 7/26/21 at 11:15 a.m. identified the resident returned to the facility from the hospital. The resident arrived via staff transport using wheelchair on 3 liters of oxygen per nasal cannula and new orders for pain management. Staff transferred the resident into the recliner using a gait belt and 2 staff. The Orders - Administration Note dated 7/26/21 at 12:31 PM revealed [MEDICATION(S)]-acetaminophen tablet 5-325 MG to give two tablets by mouth every four hours as needed for pain rating of 8 to 10 may give by mouth or rectally PRN. The administration documented as ineffective as the follow-up pain scale was 5 on the 0 to 10 pain scale. The Order Note dated 7/28/21 at 8:54 AM said that PT and OT was ordered to evaluate and treat one time only for pain for thirty days with a start date of 7/28/21 and end date of 8/27/21. The order was faxed to therapy and called the daughter to update. The Order Note dated 7/28/21 at 12:31 PM showed that the physician ordered a 72 hour 25 mcg per hour [MEDICATION(S)] patch. They were to apply one patch transdermally every 72 hours for pain and remove per schedule to start on 7/28/21. Incident report review The Incident Report dated 7/23/21 at 10:45 AM identified the incident as a fall. The Incident Report lacked documentation, and only identified no injuries observed at the time of the incident and that the family, Director Of Nursing (DON) , Administrator, and physician notified. The notes section dated 7/23/21 revealed the facility received ER report of a computed tomography (CT) performed. The CT found the 8th and 9th rib fractured on the right side and the resident would return to the facility. Hospital record review The Radiology Report - Final dated 7/23/21 at 12:49 PM revealed the exam a CT to the chest without contrast performed. The indication was the resident fell while transferring from the wheelchair, hip right mid rib area. There was no comparison CT. The findings said there was no sign of pneumothorax or pulmonary contusion. There was an isolated acute fracture of the posterior lateral portion of the right eighth rib at the level of the inferior margin of the right scapula. The Radiologist questioned artifact versus subtle fracture adjacent right ninth rib. No other rib fractures of scapular fractures were noted. The impression included the following: A. Isolated fracture posterior lateral portion right eighth rib, with a questioned artifact versus subtle fracture of the right ninth rib with no spinal fracture. The ER report final - dated 7/23/21 at 3:35 PM identified the chief complaint as a fall at the nursing home. The resident presented with right rib pain. The History of the Present Illness showed the resident had a misstep, striking her right shoulder and chest against the table. The resident complained of pain in the right lower chest. Initially it was thought the resident injured her shoulder as well, but no complaints of pain in the shoulder at the time and moved shoulder without difficulty. The review of symptoms showed the resident had some splinting pain related to the right lower rib cage with some local tenderness. The resident did have good air exchange throughout. The assessment showed the 8th rib fractured. The plan said no further interventions required. The resident had Tylenol ordered at the nursing home for pain. The Doctor said he believed some ice packs and immobilization with breathing treatments should have been adequate. The instructions were reviewed with the family there. The resident was to transferred back to the nursing home by ambulance. The Outpatient Observation Progress Note - Transcription - Preliminary Report dated 7/24/21 at 6:38 PM said that the reason for admission was uncontrolled pain. The resident was seen in theER on [DATE] and diagnosed with rib fractures after a fall at her facility. The resident returned to the nursing home could not control pain with orders from the emergency department of Tylenol and ice packs. The facility contacted the on-call physician who gave orders for [MEDICATION(S)]-acetaminophen 5/325 milligrams (MG) one to two tablets every fours for pain. This was still unsuccessful managing the resident's pain so the facility brought the resident to the ER for further evaluation and management of pain. Upon arrival the resident rated pain as 8 to 10, indicating severe pain. The resident had a history of hypertension, renal impairment, type 2 diet diabetes, [CONDITION(S)], [CONDITION(S)], restless leg, [CONDITION(S)], refractory nausea, and sleep disorder. The Review of Symptoms showed that the resident's chest wall positive for pain on the right-side and was worse with coughing with nausea. The resident blood pressure was 160/90 and O2 saturation of 93% on 2 L. The assessment and plan said the following: A. Rib fractures to the right 8th and possibly the 9th. The resident admitted to observation with [MEDICATION(S)] 2 MG every two hours. The hospital would try to transition to a [MEDICATION(S)] patch at 25 micrograms (MG) per hour to replace the patch every three days. The staff were to monitor for sedation. If sedation occurred pull the patch and consider a 12.5 mg patch. Will hope that a patch could provide adequate pain control, that it would allow the resident to be transferred back to the nursing home within the next 48 hours. B. Refractory nausea was an issue possibly due to the pain and the [MEDICATION(S)]. The Care Plan problem dated 10/23/17 revealed the resident needed assistance with ADL's related to weakness and poor balance as evidenced by requiring staff assist of 2 with gait belt and walker to safely transfer was updated on 7/26/21 to: transfer the resident assist of two with gait belt and walker in room. The resident may prefer to pivot transfer due to rib fractures. The resident was to use a wheelchair for long distances. The problem included the following intervention: PT and/or Occupational Therapy (OT) to evaluate and treat as per Medical Doctor's orders. The Care Plan problem dated 7/26/21 identified the resident at risk for pneumonia due to decreased lung expansion related to a fall with rib fractures. Staff interviews On 7/27/21 at 6:32 PM , Staff G CNA (certified nurse aide) identified the fall occurred in the morning as they got residents ready for the activity. At that time, the resident requested to go to the activity so Staff G put the wheelchair right next to the resident's recliner. Staff G then had her pivot and turn into her wheelchair. The resident started to fall backwards and he couldn't hold her. Staff G said he stood on the resident's left side. Staff G said that sometimes the resident exhibited weakness on her right side so he went to her front. He moved his right hand off of the gait belt and placed his right hand on the resident's shoulder. Staff G planned to grab the gait belt with his left hand but the resident fell and he could not get to her. Staff G did not have either hand on the gait belt to steady the resident or break the fall. On 7/28/21 at 9:41 AM Staff G identified himself as on the resident's left side (strong side) when he stood her so he went around to the front of her. He could not reach the gait belt from the resident's back, so he put his hand on her shoulder while he walked from her left side to the front. He started to get around the resident and then she fell straight backwards. Staff G stated the resident walks pretty well but when she walked too much, she did get weak and her right side would start to drag. Staff G stated therapy worked with the resident and they trained her to transfer from her right side. Staff G said that he only started working at the facility in May. Since the resident's fall, one of the interventions he noted was that her room was rearranged to allow transfers from either side. Prior to the room rearrangement, the resident's bed was there so he didn't have room to get to the right side as he couldn't fit over there. Staff G said the resident didn't show any signs of difficulty, she just stepped to her right, and then she just fell . Staff G said that she denied being dizzy, stood up easily, and she didn't have any weakness. When asked if he thought he could have prevented the fall or lowered the resident if he would have maintained a hold of the gait belt, Staff G said that was a tough one to answer. The resident had a bedside table to the right of her recliner. The only way he could've slowed her fall and helped her back down was if he was standing directly behind her because she fell straight back. Staff G said he and the DON talked it through with Physical Therapy (PT) and some corporate ladies. They asked if there was better ways to do transfers with the resident. On 7/28/21 at 12:11 PM Staff H, Physical Therapy Assistant (PTA) identified the resident as a pivot transfer from her recliner but she did not know assistance the resident required when walking. When transferring the resident, the wheel chair would be on her right side. They didn't want to change the way the resident did things. Staff E stated the resident was used to transferring to her right side. As this was what she was most comfortable with, they worked with her to continue transferring this way. With the recliner facing the television before the fall, the wheelchair was to be positioned on the right side. On 7/29/21 at 8:38 AM Staff F, LPN stated when she entered the room following the fall, the resident laid on the floor holding her head up. The resident complained of pain in her right mid back. The recommendation to make the gait belt tighter was because the gait belt wasn't tight enough on the resident when she fell . Staff F said she had no idea if the resident used a walker at the time of the fall. On 7/29/21 at 8:53 AM Staff G stated after the incident the facility got a new gait belt for the resident that buckles now and has straps on the sides. Staff G said that he didn't have any grip on the resident when she fell as it was so sudden. If he was to do it over, he would've started on the resident's right weaker side instead of her left strong side. Observation On 7/28/21 at 10:18 AM the Administrator demonstrated the recliner faced the television but now changed to face the hallway. Employee record review The Warning Notification form dated 7/23/21 showed Staff G received a second verbal warning regarding gait belt usage and failing to follow the policy resulting in unsafe practices. The summary identified improper use of a gait belt while transferring a resident. The form was signed by Staff G and the DON on 7/23/21. Policy review The Gait Belt Policy dated 11/08 directed staff to use gait belts on residents who required assistance with transfers and/or ambulation when mechanical lifting devices not used. To apply the belt, staff should stand in front of the resident and the belt around the resident's waist, securing it with approximately one finger's space between the belt and the resident. Prepare for the transfer by placing all necessary equipment in the proper position. If the resident has a weak side, whenever possible, transfer the resident toward the stronger side by positioning them so it is nearest the final destination of the transfer. When doing a stand-pivot transfer, use a comfortable standing posture by maintaining the normal curve of the spine, slighting, bending knees and keeping feet 12 to 20 inches apart. Squat slightly and grasp the gait belt on both sides. If the resident is able, encourage him/her to participate by pushing up on the chair arms, bearing weight and pivoting to the strong side to complete the transfer. When assisting a resident with a transfer utilizing a walker, always keep one hand on the resident's gait belt and the other hand on the walker until the resident has reached the standing position. Administrative interviews On 7/29/21 at 10:13 AM the DON stated she expected staff to follow the gait belt policy. On 7/29/21 at 12:32 PM the Nurse Consultant said she was providing the incident report under protest due to the incident report was part of their internal documentation. The Nurse Consultant showed the incident report and pointed to the incident report saying the charge nurse usually completes it but since the DON was involved in the incident from the beginning, she completed the charge nurse synopsis.

Based on observation, record and policy review, and staff interview the facility failed to ensure staff washed their hands after touching items that were considered dirty before touching items that were used for multiple use purposes for 3 out of 11 residents observed for infection control. The facility reported a census of 29 residents. 1. Observation on 07/28/21 at 11:21 AM revealed that Staff A, Licensed Practical Nurse (LPN) used her bare hands to pick items up from the floor of Resident #79's room. Staff A then touched a sign on the resident's room door frame. Staff A used hand sanitizer after touching the sign. Observation on 07/28/21 at 11:38 revealed that Staff A took a lancet out of Resident #15's room. Staff A then removed her gloves, did not perform hand hygiene and put the lancet back into the general supply box of lancets without sanitizing the lancet. The Handwashing Policy dated 05/20 revealed that hands will be washed after completion of a dirty task prior to beginning a clean task. 2. Resident #21's Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive impairment). The resident required extensive assist of two staff for toileting. The resident was occasionally incontinent of urine. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations On 7/26/21 at 3:38 PM Staff B, Certified Nurses' Aide (CNA) entered resident's room, applied gait belt, then removed the resident's pressure reduction boots. Staff B then washed hands and applied gloves. The Director of Nursing (DON) also observed. Staff C, Licensed Practical Nurse (LPN) washed her hands then closed the curtains. Staff C and Staff B assisted the resident into standing position. Staff B pulled resident's pants down, then removed gloves then Staff B opened drawers before washing hands. Staff C washed her hands then Staff B washed her hands. Staff B put on new gloves and then opened a drawer removing wipes and foaming peri wash. After placing supplies on the back of the toilet, Staff B checked the resident's pullup. Staff B identified the resident's brief as wet, then with her gloves still on, Staff B opened the closet and got new brief then moved the resident's walker. Staff B then removed the wet brief as Staff C put on a new brief. Staff B with the same gloves on she put on the resident's pants. Staff B washed her hands and put on new gloves. On 7/28/21 at 12:34 PM Staff C completed the dressing change to the left heel and then gathered the garbage. Staff C placed the garbage bag on the floor near the sink, then without cleaning her hands, Staff C opened the treatment cart. Staff C got out sanitizing wipes to clean the barrier tray then threw away the wipe, opened the treatment cart and got another new sanitizing wipe. Staff C opened the sanitizing wipe and placed on the tray. Staff C then picked up the garbage bag and then without cleaning her hands, Staff C opened the treatment cart to put away the saline spray. Care plan review The Care Plan problem dated 1/19/21 explained the resident needed assistance with her activities of daily living (ADLs) and she had limited physical mobility related to activity intolerance and weakness. The problem included the intervention dated 1/19/21 regarding toilet use stated that the resident needed assistance of one staff with a gait belt and walker for her toileting needs. If the resident was fatigued, staff could stand and pivot the resident to a wheelchair. The Care Plan problem dated 3/12/21 showed the resident was at risk for potential infection related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Administration interview On 7/29/21 at 10:13 AM the Director of Nursing (DON) stated she expected staff to clean their hands after touching garbage and she expected them to follow the hand hygiene policy. Policy The facility handwashing policy revised 05/20 directed staff to wash hands after completion of a dirty task, prior to beginning a clean task.

Based on record review, resident and staff interview, the facility failed to complete an incident report for a resident that fell resulting in fractures for one of one residents reviewed (Resident #3). Per the Iowa Inspections and Appeals state rule 58.15(4)a indicated that each nursing facility shall maintain an incident record report and shall have available incident report forms. Additionally the Iowa Inspections and Appeals state rule 58.15(4)b said the Report of Incidents shall be in detail on a printed incident report form. The facility reported a census of 29 residents. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive assistance of one staff with transfers and limited assistance of one staff for ambulation in her room. The resident had no falls since the previous assessment. The resident had occasional pain 8 out of 10 on the pain scale. The resident did not use oxygen therapy. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident interview On 7/26/21 at 4:54 PM the resident said that yes she had a fall. On 7/27/21 at 12:34 PM the surveyor requested an incident report regarding the resident's fall. On 7/27/21 at 12:34 PM the Administrator said that they have everything written on chicken scratch and may not be completed yet, but to let them know what we needed related to the resident's fall and she could get it for the surveyors. The Administrator said the incident report was sent to the progress notes and it could be found there. The progress note labeled Incident Report dated 7/23/2021 at 12:31 PM identified a staff member present when the fall occurred. Staff G Certified Nurse Assistant (CNA) transferred the resident from recliner to wheelchair with a gait belt. The resident fell backwards hitting her back on the bedside table and her left hip on the arm of the recliner. The resident did have her head in chin-tuck position and did not hit her head per resident and CNA. The resident's head faced the bathroom with her knees bent upwards. She complained of severe back pain and right shoulder pain. The resident wore shoes which were in good repair. The floor contained carpet and free of clutter. The resident was continent of bowel and bladder. The resident denied dizziness following the fall. The resident stated she needed to get off the floor. Staff assessed the resident's range of motion (ROM) and found no abnormality. The resident stood with assistance of three staff and a gait belt, then transferred to the recliner. The resident experienced increased sharp pain when standing. The resident did not tolerate sitting upright in the recliner, so staff reclined the recliner and administered Tylenol (analgesic) for pain the resident rated as 10 (on a scale of 0 to 10 with 0 being no pain and 10 being the worst imaginable pain). When the nurse entered the room, she observed the over bed table against the bed, the garbage can next to the resident's head, and the wheel chair by the window to make room for the assessment. The resident wore the call pendant but not activated. The assessment of the resident including ROM (range of motion) and pain showed the resident with limited movement to her right shoulder. When she transferred, she rated her pain 10 out of 10. When the resident stood, she cried with pain. When the ambulance arrived, they attempted to transfer the resident to the cot and her legs would not move. The resident continued to cry in pain, even as she laid on the cot. The resident was alert and oriented to person, place, and time (A&O x 3). The resident did not receive any (PRN) medication before the incident. The resident did not experience any acute conditions at the time of the fall. The description of injuries identified the resident's legs with two red areas and one bruise, measuring 4 centimeters (cm) by (x) 2 cm. and a skin tear to the right forearm, measuring 4 cm x 0.2 cm. Staff steri-stripped the skin tear and covered with [MEDICATION(S)] tape. No discoloration noted to the resident's back at the time of transfer. The list of relevant interventions in place at the time of the incident included: ensure resident's call light in reach and encourage her to use it for assistance as needed. Ensure the resident wore appropriate footwear such as gripper socks or shoes when she ambulated and transferred. The resident wore a pendant to use when the resident needed assistance. The preliminary recommendations for consideration as further preventative measures was for staff to make the belt tighter and use two staff assistance with transfers, and ambulation. The facility notified the daughter and the physician received notification via facsimile (fax). The emergency room (ER) received a report at 12:35 PM. On 7/29/21 at 10:43 AM the Director of Nursing (DON) and the Nurse Consultant brought the requested documents. On 7/29/21 at 10:46 AM review of the documents provided lacked an incident report. On 7/29/21 at 12:03 PM the Surveyor requested the incident report as it wasn't given in the packet of information. On 7/29/21 at 12:07 PM the Nurse Consultant and the DON came to the room that was set up for the surveyors to use. They questioned what the surveyors were requesting regarding the incident report. The Surveyor explained that it was a form that explained additional information that progress notes didn't always show. In the Electronic Health Record it was usually under the Risk Management section. The Nurse Consultant said that she could print off the report from Risk Management but it wouldn't say anything different than the progress notes. On 7/29/21 at 12:32 PM the Nurse Consultant said she was providing the incident report under protest due to the incident report was part of their internal documentation. The Nurse Consultant showed the incident report and pointed to the incident report saying the charge nurse usually completes it but since the DON was involved in the incident from the beginning, she completed the charge nurse synopsis. Incident report review The Incident Report dated 7/23/21 at 10:45 AM identified the incident as a fall in the resident's room on 7/23/21 at 10:45 a.m. The Incident Report was blank, except stated there was no injuries observed at the time of the incident. (inaccurate skin injuries observed) The last page of the report showed that the family, DON, Administrator, and Physician notified. The report also stated no witnesses found (inaccurate) The Notes section dated 7/23/21 said that the facility received report from the ER, that the ER did a computed tomography (CT). The CT found the 8th and 9th rib was fractured on the right side and they would be sending her back to the facility. An ambulance was paged to return the resident to the facility. The following areas of the incident report were incomplete: Incident description, immediate action taken, level of pain, mental status, predisposing environmental factors, predisposing physiological factors and predisposing situation factors.

Based on observation, interviews, and record reviews, the facility failed to follow care plan interventions for one of one resident reviewed (Resident #1). Resident #1 did not have a urinal in their room. The care plan directed a urinal at the bedside. The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) completed with an Assessment Reference Date (ARD) of 6/24/20 showed the resident had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The resident required extensive assistance of one staff member with toileting and transfers during the seven day lookback period. The MDS identified the resident as not steady and only able to stabilize with staff assistance for walking, the surface to surface transfer, toileting, and going from a seated to a standing position. The resident received opioids for seven days in the lookback period. The resident was frequently incontinent with urine. The resident did not have falls since the previous assessment. On 8/10/20 at 12:33 PM, observed revealed the resident in bed with curtains pulled around the bed to provide privacy in the isolation area. The floor next to the bed was clear, with no floor pad. On 8/3/20 at 6:20, the Incident Report labeled as a Late Entry completed by Staff A RN (registered nurse) said the housekeeper heard an alarm sounding while cleaning the railings. When the housekeeper opened the door, she observed the resident on the ground. The nurse arrived at the resident's room and upon entering, noted resident's door only open a little bit. The resident laid on the ground in front of the roommate's recliner with legs extended. The resident was leaning on the left elbow with his right hand, gripping the walker. The walker hovered over the resident's body. The nurse noted blood on the floor and, upon inspection, noted blood running down the back of the resident's head. The nurse applied a washrag to the resident's head. The resident was last checked on at 6:05 AM by a Certified Nurses' Aide (CNA). The CNA stated that the resident had their eyes closed and appeared to be sleeping. The resident's pendant call light was not activated, and the pendant was on the left wrist. The alarm was sounding and noted the door was only open a smidge (small amount). The resident attempted to go to the bathroom due to the urinal not on the walker. The resident was incontinent of urine due to not making it to the toilet on time. The resident was continent of bowel at the time of the fall. The resident was barefoot at the time of fall. The resident ambulated to the bathroom without any assistance. The resident usually required assistance from one staff with a gait belt and a front wheeled walker (FWW). The floor was dry and free of clutter before fall. After the resident fell , the floor was wet with the resident's blood from two skin tears on the right arm and a head injury. Two staff and a gait belt with the FWW assisted the resident in a standing position. The staff then sat the resident into the wheelchair, taking the resident to the bathroom. Upon standing the resident, the nurse noted one skin tear on the right elbow and another skin tear to the back of the right upper arm. The resident's gait was steady per usual. The resident did not have any additional as needed medication before the fall. The resident's assessment showed a range of motion (ROM) within normal limits (WNL). The resident did hit their head. The resident's roommate's chair was upright tilted forward. It appeared that the resident hit the head, right elbow, and the back of the upper right arm on the metal frame of the back of the roommate's chair-the description of the injuries 1. The top middle of the resident's head noted to have an open area measuring 1 centimeter (cm) x 0.1 cm x 0.1 cm with a moderate amount of sanguineous drainage. 2. The resident's right elbow measured an open area of 3 cm x 3 cm x 0.1 cm with a moderate amount of sanguineous drainage. 3. The resident's upper right arm on the posterior side showed a skin tear with a scant amount of sanguineous drainage measuring 1 cm x 3 cm x 0.1 cm. Treatment provided to the areas was areas 1. The resident's head was cleaned with normal saline and left open to the air. 2. The skin tears to the right elbow, and the back of the upper right arm cleaned with normal saline, padded dry with a four by four (4x4) gauze. 3. Steri strips applied to the resident's elbow with the skin tear. An oil [MEDICATION NAME] dressing applied covered with a 4x4 gauze and then wrapped with conforming wrap. The dressings were to be changed on bath days and as needed (PRN) until healed. The list of relevant interventions that were in place at the time of the incident included: Toileting: The resident likes to use a urinal at night for toileting, and kept at the bedside. Please offer to help the resident to go to the toilet when assisting the roommate in the bathroom. Floor pad next to the bed when in bed. The preliminary recommendations for consideration for further preventative measures were to ensure the urinal is in the resident's room and on the walker. After the incident, the nurse identified placing a urinal on the walker in the resident's room. Care plan review The care plan problem dated 1/28/20 identified the resident at risk for falls related to psychoactive drug use and pain at times, as evidenced by requiring the assistance of one staff with a gait belt and a walker to safely ambulate as the resident had a history of [REDACTED]. The toileting intervention said the resident liked to use a urinal at night for toileting and keeps it at the bedside. Please off to help the resident with the toilet as the roommate assisted with toileting. (Created 9/24/19) Interview: On 8/11/20 at 9:50 AM, Staff A, Registered Nurse (RN), stated staff that went to check on the resident the morning of the fall reported the resident's eyes were closed and staff did not want to wake them. Staff reported that the resident did not have a urinal in their room when the fall occurred. Follow-up interview On 8/11/20 at 12:25 PM, the Director of Nursing said the expectation was that if the care plan said the resident was to have a urinal at the bedside, the resident should have a urinal. After the surveyor exited the facility, they faxed a note from the ARNP (advanced registered nurse practitioner) that stated the resident most likely sustained a pathological fracture causing the 8/3/20 fall.

Based on clinical record review and staff interview, the facility failed to complete a comprehensive and accurate assessment using the Resident Assessment Instrument (RAI) specified by the Centers for Medicare and Medicaid for one of 12 residents reviewed (Resident #14). The facility reported a census of 34 residents at the time of the survey. Findings include: The Annual Minimum Data Set (MDS) assessment tool dated 3/27/18 recorded Resident #14 had Brief Interview for Mental Status (BIMS) score of 12, which indicates moderate cognitive impairment. The MDS listed the following [DIAGNOSES REDACTED]. The MDS indicated Resident #14 received an anticoagulant (blood thinner) for 7 days during the review period. Review of Resident #14's care plan revealed no documentation of her receiving an anticoagulant medication. Review of Resident #14's order listing report dated and signed by her primary care physician on 4/9/18 did not list an anticoagulant or aspirin as a current medication. Review of the Medication Administration Record [REDACTED]. Review of discontinued medications revealed Resident #14 did not have an order for [REDACTED]. During interview on 6/12/18 at 2:14 PM, the Director of Nursing (DON) stated it was a mistake to have the MDS reflect the use of an anticoagulant. The DON stated she talked with the MDS Coordinator and she doesn't know why she put that on the MDS. During interview on 6/13/18 at 11:15 AM, the MDS coordinator stated she was new to the position when she completed Resident #14's MDS. She stated she had worked in this position for about 2 to 3 weeks and goofed. She believed it happened because the resident was on aspirin, which triggered her to mark the use of an anticoagulant.

Based on clinical record review and staff interview, the facility failed to ensure appropriate nursing supervision maintained for residents that transferred in wheelchairs by the facility van for 1 of 4 current residents reviewed (Resident #1). The facility identified a census of 32 current residents. Findings include: 1. According to the MDS (minimum data set) assessment dated [DATE], Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs (brief interview for mental status) score of 6 which indicated severe cognitive impairment. According to the MDS the resident required extensive assistance with bed mobility, transfers, dressing and toilet use and total dependence with locomotion. The care plan dated 3/16/17 directed staff to use the assistance of one staff and a gaitbelt and walker for ambulation. The care plan also directed the resident used a wheelchair for their primary mode of locomotion and can propel him/herself. The Fall Risk assessment dated [DATE] revealed the resident had a total score of 14 which indicated a moderate risk for falls. Review of the Progress Notes titled Incident Report dated 4/12/17 at 10:10 AM revealed the nurse called to the parking lot stat. The back door to the van open, the lift in the down position and resting on cement. The wheelchair was tipped back with the back of the wheelchair laying on the lift gate. The resident lay in the wheelchair with his/her back touching the back of the wheelchair and his/her head on the concrete. The resident's body turned slightly to the right side and both knees were bent in a flexed position. Five staff assisted the resident to the wheelchair with the use of a gait belt. The resident wore non-slip shoes in good repair, continent of bowel and had an indwelling catheter for urine. The resident had been assisted by the facility's driver in exiting the van. The resident complained of significant pain across his/her lower back, rating 6 out of 10 and the resident could not rate the pain to back of their head. Staff documented notation of the following areas: a. A 7 cm (centimeter) by 7 cm raised bump to back of head with 2 horizontal lacerations and each measured 4 cm by 0.5 cm in length in the center of bump. b. A 7 cm by 7 cm raised hard lump to the left outer lower extremity with skin intact. Review of the emergency room report dated 4/12/17 revealed the following impressions: a. Contusions and abrasions to the lower occipital scalp. b. Cervical strain. c. Left lower leg contusion. The resident received Toradol (an analgesic) 30 mg (milligrams) which gave him/her relief of his/her symptoms within about 40 minutes. Review of the written statement by Staff A, Van Driver dated 4/12/17 revealed Staff A lowered the lift to the ground. Staff A pushed the resident in the wheelchair backward in the van and felt it lower down. The resident tipped backwards and fell on to the lift. During an interview with the Maintenance Supervisor on 5/3/17 at 10:00 AM he stated Staff A had been educated and competent on use of the lift and had not previous concerns or disciplinary actions. The facility completed annual training and In-service training for all van driver staff. The in-service training included a return demonstration for use of the lift. During an interview with the Administrator on 5/3/17 at 11:00 AM she stated the transport van had been immediately taken out of commission and inspected by the Maintenance Supervisor and herself on 4/13/17 with no concerns noted. All van driver staff were re-educated and performed return demonstration for all aspects for safety the lift and securing the wheelchair and resident which had been completed on 4/13/17. Review of the Course Completion History dated 5/31/16 revealed Staff A completed Proper use and Demonstration of Braun Van Lift. Review of the Van In-service Sheet dated 9/8/16 revealed Staff A completed In-service training for the van which included manually work the lift.

Based on record review and staff interviews, the facility failed to provide adequate supervision and assistance to prevent accidents (Resident #1). The sample consisted of 5 residents and the facility reported a census of 37 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 7/26/15. The MDS reflected Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident with a brief interview for mental status score of 10 (moderately impaired cognitively). The MDS indicated the resident required extensive assistance with bed mobility, dressing, toilet use and limited assistance with transfers and ambulation. The resident experienced occasional episodes of bladder incontinence. The Care Plan dated 11/5/14, reflected the resident at risk for falls related to poor endurance. The interventions directed the staff of the following: a. Call light within reach (of resident) and encourage to use it for assistance as needed. b. Ensure th4 resident wears appropriate footwear such as shoes or gripper socks when ambulating or transferring. c. Use 14 foot oxygen tubing instead of the 21 foot tubing since at risk for tripping on tubing. d. Have sign on walker to remind the resident to use the walker at all times. e. Place personal items close when in the room; call light, Kleenex, TV remote & water pitcher. On 6/11/15 the following updates were made: The resident is to ambulate and transfer with walker and the assistance of 1 (staff) with a gait belt. On 7/7/15 the following update was made: a. Currently receiving Cipro (antibiotic) for UTI (urinary tract infection). Monitor for 10 days. On 7/8/15 the following update: a. Hourly visual checks while awake and offer toilet while being treated for [REDACTED]. Review of the Physician Appointment Report dated 7/7/15 identified the resident with a UTI and confusion and the new order for Cipro 500 mg (milligrams) 2 times a day for 10 days. Review of the physician facsimile dated 7/18/15 revealed the order to increase Lasix (diuretic) to 40 mg 2 times a day for 1 week then change to Lasix 40 mg every day. Review of the Progress Notes titled Incident Reports revealed the following: On 7/7/15 at 3:55 PM - Resident had an un witnessed fall and found lying on the floor on the right side on the right elbow facing the roommates recliner with the legs extended towards the doorway. Three staff, a gait belt and a front wheeled walker was used to assist the resident up and to the bathroom. The resident had been last toileted at 2:30 P.M. The resident wore tennis shoes in good repair. The staff found the front wheeled walker between the dressers and recliners and the resident had used the walker. The resident stated she/she was going to the neighbors to use the phone to call about possibly getting a phone and the cost. The resident received a skin tear to the right forearm which measured 6.5 centimeters by 3 centimeters. The note dated 7/8/15 at 4:22 A.M. identified the resident began treatment for [REDACTED]. On 7/20/15 at 1:45 PM the staff was called to the resident's room by the roommate. Staff found the resident sitting on the floor beside the small dresser by the sink. The resident had bilateral legs extended. The resident had a dark red area present on the front right knee. The note reflected an intervention for staff to assist the resident to the bathroom every 2 hours while awake. The note dated 7/24/15 at 9:10 a.m. reflected the staff rearranged the resident ' s room to make the restroom more easily accessible. On 8/6/15 at 3:56 P.M. the resident self- transferred to the bathroom and did not use the call light for assistance. On 8/7/15 at 12:12 P.M. the resident has needed one staff person to assist with transfers this morning and gait continues to be unsteady. The call light is within reach but the resident will not always use the call light. On 8/8/15 at 4:45 PM - the resident ' s roommate activated the call light. The resident sat on the floor, in front of the bathroom door and sink. The resident ' s legs extended out and bent at the knees. The resident sitting upright and his/her arms around the knees. The resident assisted to a standing position with 2 staff assisting and the resident ' s unable to bare weight on the left leg. The staff placed a wheelchair under the resident. The resident transported to the emergency room via ambulance for left hip/leg pain. Review of the Radiology Report dated 8/8/15 identified the resident had a left femur intertrochanter fracture (hip). Review of the Progress Notes Health Status Note revealed the following: On 6/12/15 at 1:54 PM, the resident will frequently ambulate per self and needs reminding to call for assist. On 6/14/15 at 11:28 A.M. the resident is skilled care for physical and occupational therapy. The resident needs assistance of 1 staff person and the use of a walker and gait belt. On 6/17/15 at 9:50 A.M. therapy alert noted the resident needing assistance of 1 staff person in the room/facility. The resident required contact guard assistance and stand by assistance with transfers and contact guard assistance with ambulation. On 6/19/15 at 2:20 AM - Resident had been up to the bathroom per self (reported by roommate) 3 times. On 6/25/15 at 2:15 PM - Resident ambulates in room per self with oxygen continuously. On 6/27/15 at 2:46 PM - Resident had been independent in room. On 7/24/15 at 9:10 AM - Resident room rearranged to make the restroom more easily accessible. On 8/6/15 at 3:56 PM - Resident self- transferred to the bathroom. The call light close and not used. On 8/7/15 at 12:12 PM - Resident had been 1 assist with transfers and gait continued to be unsteady. The call light within reach but will not always use. Review of the Nursing Department Internal Audit System Plan of Correction dated 7/20/15 revealed the resident fell taking self to the bathroom. The plan included to offer 2 hour reminders and assist to the bathroom while awake. During an interview on 9/22/15 at 11:45 A.M. with Staff I, LPN (licensed practical nurse), she stated the resident had been toileted at 12:30 AM on 8/8/15. The girls always checked on the resident. If the roommate's call light goes off (activated) staff answer it right away. Staff I stated the resident to be cognitively intact and knew he/she needed assistance. The resident said Don't chew me out, I just came out and lost my balance. She also stated the resident didn't want to bother staff during the night. On 9/22/15 at 10:00 PM, Staff A (certified nursing assistant) was interviewed and stated she found the resident outside the bathroom on the floor and the walker had been in the bathroom. Earlier in the shift the resident turned the call light on (activated) and staff took him/her to the bathroom. The resident had a habit to get up on his/her own and didn't want any help. On 9/22/15 at 10:10 p.m., Staff B, CNA was interviewed and stated the resident did not ask for help. The resident usually up on own and the roommate put on the call light. Also, when we went by the room we would see him/her up in the bathroom and go assist. The resident had been stubborn and did not want help. On 9/23/15 at 8:45 AM, Staff D, CNA was interviewed and stated the resident was toileted 2 to 3 times a shift and staff checked the resident before and after meals. The resident did get up on his/her own and had been independent. On 9/23/15 at 2:40 P.M. Staff J, CMA (certified medication assistant) was interviewed and stated the resident had been independent and then changed to 1 staff person to assist. The resident had been very independent and at that point, the staff would catch him/her in the bathroom. Staff checked on the resident every 2 hours. Staff find updates in the communication book. The staff also gives each other report at the change of shift (2 on 2) and on the care plan. During an interview with the Director of Nursing on 9/23/15 at 2:48 PM she stated that staff are responsible to look at the communication book every shift. Staff do not initial or place signatures on the forms.

Based on record review and staff interviews, the facility failed to revise and supervise the implementation of the written health care plan in order to prevent falls (Resident #1). The sample consisted of 5 residents and the facility identified a census of 37 residents. Resident #1 experienced multiple falls and the facility knew the resident would self-transfer, however, did not identify this and implement interventions to keep the resident safe. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 7/26/15. The MDS reflected Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident with a brief interview for mental status score of 10 (moderately impaired cognitively). The MDS indicated the resident required extensive assistance with bed mobility, dressing, toilet use and limited assistance with transfers and ambulation. The resident experienced occasional episodes of bladder incontinence. The Care Plan dated 11/5/14, reflected the resident at risk for falls related to poor endurance. The interventions directed the staff of the following: a. Call light within reach (of resident) and encourage to use it for assistance as needed. b. Ensure th4 resident wears appropriate footwear such as shoes or gripper socks when ambulating or transferring. c. Use 14 foot oxygen tubing instead of the 21 foot tubing since at risk for tripping on tubing. d. Have sign on walker to remind the resident to use the walker at all times. e. Place personal items close when in the room; call light, Kleenex, TV remote & water pitcher. On 6/11/15 the following updates were made: The resident is to ambulate and transfer with walker and the assistance of 1 (staff) with a gait belt. On 7/7/15 the following update was made: a. Currently [MEDICATION NAME](antibiotic) for UTI (urinary tract infection). Monitor for 10 days. On 7/8/15 the following update: a. Hourly visual checks while awake and offer toilet while being treated for [REDACTED]. Review of the Progress Notes titled Incident Reports revealed the following: On 7/7/15 at 3:55 PM - Resident had an un witnessed fall and found lying on the floor on the right side on the right elbow facing the roommates recliner with the legs extended towards the doorway. Three staff, a gait belt and a front wheeled walker was used to assist the resident up and to the bathroom. The resident had been last toileted at 2:30 P.M. The resident wore tennis shoes in good repair. The staff found the front wheeled walker between the dressers and recliners and the resident had used the walker. The resident stated she/she was going to the neighbors to use the phone to call about possibly getting a phone and the cost. The resident received a skin tear to the right forearm which measured 6.5 centimeters by 3 centimeters. The note dated 7/8/15 at 4:22 A.M. identified the resident began treatment for [REDACTED]. On 7/20/15 at 1:45 PM the staff was called to the resident's room by the roommate. Staff found the resident sitting on the floor beside the small dresser by the sink. The resident had bilateral legs extended. The resident had a dark red area present on the front right knee. The note reflected an intervention for staff to assist the resident to the bathroom every 2 hours while awake. The note dated 7/24/15 at 9:10 a.m. reflected the staff rearranged the resident ' s room to make the restroom more easily accessible. On 8/6/15 at 3:56 P.M. the resident self- transferred to the bathroom and did not use the call light for assistance. On 8/7/15 at 12:12 P.M. the resident has needed one staff person to assist with transfers this morning and gait continues to be unsteady. The call light is within reach but the resident will not always use the call light. On 8/8/15 at 4:45 PM - the resident's roommate activated the call light. The resident sat on the floor, in front of the bathroom door and sink. The resident's legs extended out and bent at the knees. The resident sitting upright and his/her arms around the knees. The resident assisted to a standing position with 2 staff assisting and unable to bare weight on the left leg. The staff placed a wheelchair under the resident. The resident transported to the emergency room via ambulance for left hip/leg pain. Review of the Radiology Report dated 8/8/15 identified the resident had a left femur intertrochanter fracture (hip). Review of the Progress Notes Health Status Note revealed the following: On 6/12/15 at 1:54 PM, the resident will frequently ambulate per self and needs reminding to call for assist. On 6/14/15 at 11:28 A.M. the resident is skilled care for physical and occupational therapy. The resident needs assistance of 1 staff person and the use of a walker and gait belt. On 6/17/15 at 9:50 A.M. therapy alert noted the resident needing assistance of 1 staff person in the room/facility. The resident required contact guard assistance and stand by assistance with transfers and contact guard assistance with ambulation. On 6/19/15 at 2:20 AM - Resident had been up to the bathroom per self (reported by roommate) 3 times. On 6/25/15 at 2:15 PM - Resident ambulates in room per self with oxygen continuously. On 6/27/15 at 2:46 PM - Resident had been independent in room. On 7/24/15 at 9:10 AM - Resident room rearranged to make the restroom more easily accessible. On 8/6/15 at 3:56 PM - Resident self- transferred to the bathroom. The call light close and not used. On 8/7/15 at 12:12 PM - Resident had been 1 assist with transfers and gait continued to be unsteady. The call light within reach but will not always use. Review of the Nursing Department Internal Audit System Plan of Correction dated 7/20/15 revealed the resident fell taking self to the bathroom. The plan included to offer 2 hour reminders and assist to the bathroom while awake. During an interview on 9/22/15 at 11:45 A.M. with Staff I, LPN (licensed practical nurse), she stated the resident had been toileted at 12:30 AM on 8/8/15. The girls always checked on the resident. If the roommate's call light goes off (activated) staff answer it right away. Staff I stated the resident to be cognitively intact and knew he/she needed assistance. The resident said Don't chew me out, I just came out and lost my balance. She also stated the resident didn't want to bother staff during the night. On 9/22/15 at 10:00 PM, Staff A (certified nursing assistant) was interviewed and stated she found the resident outside the bathroom on the floor and the walker had been in the bathroom. Earlier in the shift the resident turned the call light on (activated) and staff took him/her to the bathroom. The resident had a habit to get up on his/her own and didn't want any help. On 9/22/15 at 10:10 p.m., Staff B, CNA was interviewed and stated the resident did not ask for help. The resident usually up on own and the roommate put on the call light. Also, when we went by the room we would see him/her up in the bathroom and go assist. The resident had been stubborn and did not want help. On 9/23/15 at 8:45 AM, Staff D, CNA was interviewed and stated the resident was toileted 2 to 3 times a shift and staff checked the resident before and after meals. The resident did get up on his/her own and had been independent. On 9/23/15 at 2:40 P.M. Staff J, CMA (certified medication assistant) was interviewed and stated the resident had been independent and then changed to 1 staff person to assist. The resident had been very independent and at that point, the staff would catch him/her in the bathroom. Staff checked on the resident every 2 hours. Staff find updates in the communication book. The staff also gives each other report at the change of shift (2 on 2) and on the care plan. During an interview with the Director of Nursing on 9/23/15 at 2:48 PM, she stated that staff are responsible to look at the communication book every shift. Staff do not initial or place signatures on the forms.

Based on observation, clinical record review and staff interview, the facility failed to provide accurate assessment and provisions of appropriate care and treatment for 1 of 2 residents identified by the facility with a pressure ulcer (Resident #3). Record review continued to document the resident ' s left heel ulcer as Stage I from 2/19/19 to 3/30/15, however onsite observations on 3/30/15 determined the left heel ulcer with black/dark color eschar. Resident #3 ' s left heel pressure ulcer failed to show some evidence of progress toward healing and the record lacked re-evaluation of the treatment plan including determining whether to continue or modify the current interventions. The facility failed to implement preventive interventions in accord with their own standards of practice. The facility reported a census of 38 residents. Findings included: According to a Minimum Data Set (MDS) with an assessment reference date of 1/27/15, Resident #3's [DIAGNOSES REDACTED]. The same MDS identified the resident's mental status as severely impaired and required extensive assistance from staff with bed mobility, transfer and ambulation. The MDS identified the resident had a prior pressure ulcer on the prior MDS assessment that healed. According to a history and physical examination [REDACTED]. According to a Discharge Summary report dated 1/20/15, a Medical Provided documented the resident as discharged from the above hospitalization on [DATE] (13 day hospitalization ). According to an Admission/Readmission Nursing Assessment Progress Note form dated 1/20/15, staff documented the resident had a pressure ulcer on his/her coccyx prior to hospitalization on [DATE] and upon return to the facility on [DATE], staff documented no open areas noted on his/her coccyx. Review of Resident #3's care plan in regards to pressure ulcers, included the following interventions with revision dates as follows: * assess the resident's skin with cares and report any suspicious areas to a charge nurse (date initiated - 7/1/14) * turn and reposition the resident in bed approximately every 2 hours in bed (date initiated - 5/6/14) * encourage the resident to reposition every 2 hours (dated initiated -3/22/15) * air mattress for bed (date initated - 2/10/15) * uploading boots to promote skin healing on heals ( date initiated - 3/22/15, after the development of the resident's stage I pressure ulcers) * nurse will measure and assess weekly and report to a Physician every week (date initiated - 2/10/15) According to Interdisciplinary Progress Notes dated 2/19/15 at 2:00 P.M., staff noted dark purple areas on both heels. Staff measured the left heel dark purple area as 1.5. centimeters (cm) by 2 cm in size and the right heel 0.3 cm by 0.3 cm in size. Staff documented the skin as intact and non- blanchable. A). Review of a Weekly Pressure Ulcer Progress Report form with an initial date of 2/19/15, included an assessment of a scattered dark purple intact area on the resident's left heel and measured 1.5 cm by 2 cm in size. Staff B/skin nurse documented the area as a Stage I pressure ulcer. (The form defined a Stage I as intact skin with non-blanchable redness.) Staff B assessed the left heel weekly and documented the following: On 2/23/15 - 1.8 cm by 0.3 cm in size, purple in color, Stage I. On 3/2/15 - 1.5 cm by 0.3 cm in size, purple in color, Stage I. On 3/9/15 - 3.5 cm by 3 cm in size, no color identified, Stage I. On 3/16/15 - 3.8 cm by 3 cm in size, no color identified, Stage I. On 3/23/13 - 2.0 cm by 2.5 cm in size, no color identified, Stage I. On 3/30/15 - 1.8 cm by 2 cm in size, no color identified, Stage I. (See surveyor observation on 3/30/15 & and photographs of the area taken by the surveyor on 3/31/15). Staff B documented the area on the left heel as a Stage I pressure ulcer (redness of intact skin) from 2/19/15 to 3/30/15. B). Review of Resident #3's Nursing progress notes documented on 3/2/15 at 8:34 a.m., the heel skin sheet sent to the doctor, left heel had several small areas hard to measure. Review of Resident #3's Nursing progress notes revealed the following: on 3/9/15 at 12:04 P.M. - skin condition sheets faxed to the doctor, dark purple area to heel remains. Review of a facsimile to Resident #3's medical provider on 3/9/15, revealed an order for [REDACTED]. Review of Resident #3's Nursing progress documented on 3/16/15 at 9:41 a.m., skin condition sheets faxed to the doctor, left heel is "...much worse," than right. The documentation did not describe how the heel appeared. A Care Area Assessment (CAA) form dated 3/18/15, staffs assessment of the resident included a Stage I pressure area on the resident's left heel. Staff documented the resident as at risk for friction, had poor nutrition, immobility and dementia. A Braden Scale For Predicting Pressure Sore Risk form dated 3/19/15, identified the resident at very high risk for the development of a pressure sore (ulcer). Review of Resident #3's Nursing progress notes documented on 3/23/15 at 10:07 a.m., skin condition sheets faxed to the doctor, heel remains purple. Review of Resident #3's Nursing progress notes documented on 3/30/15 at 9:20 a.m., skin condition sheets sent to the doctor. C). According to a Hospice Initial/Comprehensive Nursing Assessment form, Resident #3 began Hospice Services on 3/12/15 due to [DIAGNOSES REDACTED]. The resident had a hospice goal to maintain his/her skin integrity dated 3/19/15. Review Resident #3's Hospice nursing progress notes revealed the following: 3/16/15 11:30 a.m., - continues to have dry dark areas on both heels. Review Resident #3's Hospice nursing progress notes revealed the following: 3/19/15 at 2:30 p.m., - left heel has dark skin. Review Resident #3's Hospice nursing progress notes revealed the following: 3/26/15 at 9:45 a.m. - left heel skin intact, but there is a dark spot. Review Resident #3's Hospice nursing progress notes revealed the following: 3/30/15 at 12:00 p.m., - left heel has a small dark spot, but not spongy. Note: Even though the facility nursing staff documented the resident's left heel skin impairment area as having no color 3/16/15, 3/23/15 and 3/30/15, Hospice nursing staff assessed the resident with a dark spot on the residents left heel. Observation on 3/30/15 at 9:30 a.m., revealed Resident #3 ' s heel protectors and gripper socks were on his/her heels. The nurse used Skin-Prep to the resident ' s left heel. The left heel showed an area two quarter size with eschar. The right heel showed no eschar and some dry skin. Eschar is define as follows: Eschar is described as thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties & biological activity. Eschar may be loose or firmly adhered to the wound. Observation on 3/30/15 at 1:10 p.m., of Resident #3's left heel revealed a thick scaly area with a dark brown and black center of the scaly area. The scaly area appeared to be approximately 3 cm by 4 cm in size (approximately the size of 2 quarters) and the dark center appeared to be approximately 2 cm by 2 cm in size (approximately the size of 1 nickel). On 3/31/15 at 4:05 p.m., the surveyor obtained photographs of Resident #3 ' s left heel area at this time. During interview on 3/31/15 at 1:40 p.m., the facility Director of Nursing (DON) stated she had not seen Resident #3's left heel until yesterday (3/30/15). The DON confirmed the resident's left heel pressure ulcer as not staged correctly and confirmed the resident's physician needed to be notified at the time of eschar (slough or dead tissue that is cast off of the surface of the skin) development. During telephone interview on 3/31/15 at 3:20 p.m., the resident's physician's nurse stated the resident's physician expected to be notified at the time of a change in an ulcer in order for a change in treatment. During interview on 3/31/15 at 1:50 p.m., the facility WCC (Wound Care Certified) Registered Nurse/RN reported the facility contacted her to look at the resident ' s pressure area on the resident ' s buttocks on 2/27/15 as the area was open. The WCC RN reported Resident #3 heels were not boggy and had a couple of brown spots that were intact. She advised the staff to treat the area with Skin-Prep and offloading the resident's heels. She reported that was the last time she saw Resident #3 as he/she had been discharged to hospice. The WCC RN reported she looked at the resident's left heel today (3/31/15) and attributed the condition of the left heel to a buildup of Skin-Prep (Skin-Prep is a liquid film -forming dressing that forms a protective film to reduce friction). A web search on A Skin-Prep protective barrier wipe or pump spray indicates the following: Skin-Prep is a liquid film-forming dressing that, upon application to intact skin forms a protective film to help reduce friction during removal of tapes and films. Skin-Prep moves naturally with patients' skin and won't crack or peel. Skin-Prep should only be use on intact skin. During telephone interview on 3/31/15 at 3:45 p.m., Staff B, RN (identified as the facility skin nurse), stated she noted the change in the residents left heel on 3/30/15. Staff B stated she could not remember if she documented the change. Staff B stated she had not considered the area in question eschar, but considered that area to be caused from a buildup of Skin-Prep. Staff B confirmed she noted a slight change in the resident's left heel the week prior. (Record review revealed no documentation by Staff B in regards to the presence of a scaly discolored area of the left heel between the weeks of 3/23/15 and 3/30/15.) During telephone interview on 4/1/15 at 8:15 a.m., the facility Hospice nurse reported the first time she examined Resident #3's left heel, the heel felt spongy. The Hospice nurse reported she only actually assessed the resident's left heel herself on a couple of times. The Hospice nurse reported the resident gets upset so she had asked the facility staff how it's healing. The Hospice nurse reported Hospice doesn ' t do his/her treatments and stated we (Hospice) are not totally responsible for his/her assessments. The Hospice nurse stated if a resident's heel changed from a red appearance to an eschar appearance, the resident's physician needed to be notified of this change. During telephone interview on 4/1/15 at 8:22 a.m., the facility DON reported Staff B as had no special training in skin assessment (as the skin nurse). The surveyor asked the DON if she thought the dark center of the (left) heel was from a build-up of Skin-Prep and the DON did not answer. Review of a facility policy for Pressure Ulcer Risk and Documentation, included a procedure for nursing staff to notify a physician in the condition of a wound deteriorates and re-evaluate the treatment plan accordingly. The resident's record lacked documentation from the physician with the rationale for continuing the present treatment (for example, why some, or all, of the plan's interventions remain relevant despite little or no apparent healing). The definitions for the stages of pressure ulcers identified below are from the Long-Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0. Stage I - An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: - Skin temperature (warmth or coolness); - Tissue consistency (firm or boggy); - Sensation (pain, itching); and/or Stage II - Partial thickness 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. 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 or tunneling. Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.

Based on observation and staff interviews, the facility failed to maintain sanitization of cold air return vents in the kitchen. The facility reported a census of 31 residents. Findings included: Observation during initial tour of the kitchen 1/21/14 at 9:50 a.m., revealed 2 cold air return vents on the ceiling, each measured approximately 2 feet square, and both with water drops around the entire parameter. Observation revealed 1 ceiling vent located in the kitchen area near the dish washer with approximately 4 inches by 2 feet of the vent above a metal shelf unit. The top shelf had several upside down bowls with drops of water on top. The second shelf from the top had a tray with several scoops placed on the tray, some with the food surface up and others with the food surface down. The second ceiling vent was located just inside the main double door entrance to the kitchen and directly in front of a counter top where the 4-slice toaster used. The floor below the vent had several wet areas. The Dietary Supervisor also noted the water drops on both ceiling cold air return vents and stated the condensation happened when the kitchen got warm from the oven and dishwasher heat. During observation 1/22/14 at 7:15 a.m., the ceiling cold air return vent by the dishwasher felt moist to touch and the Corporate Dietitian verified the moisture. The ceiling cold air return vent near the entrance to the kitchen had less moisture and neither vent had drops hanging. During interview 1/22/14 at 3:20 p.m., the Corporate Dietitian stated facility staff placed 2 metal sheet pans on the top shelf of the dish drying rack to catch moisture from the cold air return and prevent drying dishes from moisture. The Dietitian stated the cold air return vents felt dry when she arrived at the facility 1/21/14. The Dietary Supervisor added that she wiped the drops off the vents soon after the initial observation on 1/21/14 and the drops froze. During interview 1/23/14 at 9:30 a.m., the Maintenance Supervisor stated he placed foam covered with plastic wrap above the 2 cold air return vents in the kitchen to minimize condensation below the vents.

Based on record review, observation, State Fire Marshal information and staff interview, the facility failed to ensure resident's free of hazards with falls for 1 of 6 residents reviewed for supervision (Resident #7), ensure a lack of hazards in the environment and ensure only approved items plugged into surge protectors. The facility reported a census of 31 residents. Findings include: 1. According to the MDS (minimum data set) assessment dated [DATE], Resident #7 had [DIAGNOSES REDACTED]. The MDS identified the resident displayed total dependence on staff for bed mobility and transfers. The assessment documented that staff could not test the resident for impaired balance. The assessment did not document falls since the prior assessment. The care plan dated (not dated) directed staff the resident required the total dependence on 2 staff for repositioning and turning in bed. It also directed staff to check on the resident for safety and to anticipate any needs, because the resident could not verbally express his/her needs. Review of the Interdisciplinary Progress Notes dated 1/27/14 at 3:20 PM revealed staff in the hallway outside of the resident's room and heard a thump. Staff looked into the room and noted the resident on the floor on the left side of the bed between the bed and wall. They observed the bed in a raised position, the sidereal in the up position, a staff member on the right side of the bed and another staff member by the sink getting gloves. The resident had their knees bent between the bed and the wall. Staff documented Resident #7 had a bruised area to the right knee measured 6 x 2.5 cm (centimeters) with a crescent shape mark measured 2 cm and an abrasion at 1.5 x 1 cm. The resident also had an 11 x 5 cm abrasion to the back of the head on the left side and reddened area to the left shin that measured 1.5 x 1.4 cm. During an interview with Staff A, LPN (Licensed Practical Nurse) on 1/22/14 at 4:00 PM she stated that she had been right outside the resident's room to administer medications to another resident. She heard a thunk and went inside the resident's room, finding the resident on the floor. She saw Staff C, CNA (certified nursing assistant) standing next to the resident's bed and Staff D, CNA by the sink in the resident's room. She also saw the bed in a waist high position. During an interview with Staff C, CNA on 1/22/14 at 4:30 PM she stated that she and Staff D, CNA were going to get the resident up out of bed and had the bed in a normal working position (identified as hip height) and pulled away from the wall. Staff D left the resident's room to get supplies. She stated she had positioned the resident to his/her side. Staff D returned and she stated that she turned and took 1 to 2 steps away from the resident's bed towards Staff D to get gloves. She turned around and saw the resident falling from the bed. She reached and grabbed the resident's shirt but could not stop the resident from falling. During interview on 1/23/14 at 1 p.m., Staff D stated she remembered that she left to go get supplies, handed the supplies to Staff C and the resident fell out of bed. She did not recall much else about the day. During an interview with the Director of Nursing on 1/23/14 at 8:15 AM she expected staff to keep the resident safe according to the care plan and to put the resident in a safe position that would be individualized per that resident's needs. Staff received education from the Physical Therapist for resident safety. An undated facility investigation regarding the incident documented that Staff C had worked at the facility for many years and that Staff D worked there for 1 year. Both staff members had fairly good job performance histories. After the incident and over the weekend, the resident showed no signs or symptoms of pain. All skin abrasions were superficial and showed no signs of swelling or infection. 2. Observation during the Environmental tour with the Maintenance Supervisor on at 8:24 AM revealed the following: a. An unlocked west hall linen closet with 2 boxes of 90 count denture cleanser tablets. b. An unlocked north hall linen closet with 2 boxes of 90 count denture cleanser tablets. The boxes directed to keep this product out of reach of children. Review of the MSDS (material safety data sheet) dated 11/4/03 directed the following: a. Skin contact: No general concern, can cause moderate skin irritation. Broken skin can be cleansed with soap and water. Immediately remove contaminated clothing and wash affected area with soap and water. If irritation or other symptoms develop, call physician. b. Eye contact: Can cause eye irritation. Wash with copious amounts of water; hold eyelids open to ensure adequate flushing. If irritation persists, call physician. c. Inhalation: Dust may irritate nasal passages or cause irritation to respiratory tract. If, encountered, remove to fresh air. d. Ingestion: Expected to be slightly toxic by ingestion. If swallowed, do not induce vomiting; give large amounts of water or milk to dilute ingested material. Call Poison Control Center. During an interview with the Director of Nursing on 1/24/14 at 1:05 PM she identified 2 residents with cognitive impairment as independent and mobile via wheelchair or ambulation. 3. Information provided to facilities in 2/04 revealed direction from the Iowa State Fire Marshal Division that facilities should not utilize surge protectors allowed on items that included motor driven appliances and battery chargers. Observation 1/21/14 at 11:35 a.m. and 3:50 p.m., revealed resident room #306 with an electric fan on the floor plugged into a metal surge protector on the floor. Observation 1/21/14 at 11:44 a.m. and 3:50 p.m., revealed resident room #301 with a resident's nebulizer machine plugged into a metal surge protector on the floor. Observation 1/21/14 at 4:00 p.m., revealed resident room #102 with an electric lift chair and telephone charger plugged into a surge protector. During interview 1/21/14 at 4:02 p.m., the Administrator verified resident room #102 had a surge protector and items plugged into it. The Administrator stated she planned to inform maintenance. During interview 1/21/14 at 4:05 p.m., the facility Maintenance Supervisor voiced awareness that facilities should not use surge protectors with motorized and other items, but did not reply when asked who plugged the items in. During interview 1/21/14 at 4:20 p.m., the Corporate Nurse Consultant stated maintenance staff removed the items from the surge protectors.

Based on record review and staff interview the facility failed to issue a Notice of Medicare Provider Non-coverage (CMS form ) for 1 of 4 residents reviewed for termination of Medicare part A services (Resident #12). The facility reported a census of 31 residents. Findings included: Information provided by the facility revealed Resident #12 received skilled services from 9/14/13 - 11/6/13. Review of Resident #12's revealed no Notice of Medicare Provider Non-coverage (CMS ) form, signed by the resident or resident's representative, prior to termination of Medicare Part A skilled services. During interview 1/23/14 at 9:40 a.m., the Administrator stated the resident received Medicare part A skilled services from 9/14/13 to 11/6/13 and the facility forgot to provide the CMS form to the resident or resident's representative.

Based on record review and staff and physician interviews, the facility failed to assess and provide timely interventions for a resident with a change in condition (Resident #3, #5). The sample consisted of 4 residents and the facility identified a census of 35 residents. Findings include: 1. A MDS (Minimum Data Set) with a reference date of 8/12/13 identified Resident #5 with impaired memory and decision making skills. The resident required extensive staff assistance with bed mobility, transfers, dressing, eating, personal hygiene and bathing. The resident was frequently incontinent of bowel and bladder. The resident had [DIAGNOSES REDACTED]. The resident measured 61 inches tall and weighed 153 pounds. A quarterly assessment dated [DATE] at 12:30 p.m. by the dietician, identified the resident fed his/herself and did not have a swallowing problem. The resident's intake averaged as 91% for breakfast, 66% for lunch and 79% for supper. The resident did not have care plan problems noted or needed for nutrition. A nutritional data/assessment, dated 7/25/13, identified the resident's fluid needs as 1800 to 1900 cc per day. The assessment documented that the resident's BUN (blood urea nitrogen) was 14 and creatinine 0.9 (both normal) on 6/10/13. The resident's sodium was 139 (normal) on 6/10/13. The resident's normal average fluid intake was 171 cc at breakfast, 105 cc at lunch and 138 cc at supper. The resident's record contained a therapy referral request dated 8/8/13 for a speech therapy screen due to the resident pocketing food. A care plan, dated 5/16/13 identified the resident as at risk for dehydration due to history of urinary tract infections and history of [MEDICAL CONDITION]. The resident had poor intake at meals. The care plan directed staff to assess for dehydration symptoms such as poor skin turgor, dry lips or mouth, dry skin and/or concentrated urine. The care plan also directed staff to encourage fluids and encourage resident to eat 75% at meals. The intervention reflected the resident received a general diet and thin liquids. A food fluid intake log dated August 2013 documented the following intake decline beginning 8/5/13. 8/5/13 Breakfast- bites and sips, lunch-zero solids and liquids, supper- bites and sips. 8/6/13 Breakfast- bites and sips, lunch- 25% solids and 90 cc liquids, supper- 25% solids and 60 cc liquids, 8/7/13 Breakfast -25% solids, 90 cc liquid, lunch-no solids or liquids, supper- 25% solids and 60 cc liquid. 8/8/13 Breakfast- bites and sips, lunch-zero solids and liquids, supper- 25% solid and 60 cc liquids. 8/9/13 Breakfast -nothing lunch-nothing, supper- bites and sips. 8/10/13 Breakfast- 50% solid and 180 cc liquid, lunch-25% solid and 180 cc liquid, supper bites and sips. 8/11/13 Breakfast-refused, lunch-nothing, supper-nothing. 8/10/13 intake log, on 9/16/13 at 2:13 p.m., the surveyor questioned On 9/16/2013 at 2:13 p.m., Staff H (nurse aide) was questioned about the 8/10/2013 intake log. Staff H stated dietary documents what is gone (eaten) from the tray when documenting intakes. When staff fed the resident, the resident did not take the amount identified on the intake log. The resident let food and liquids run out of his/her mouth. Interdisciplinary progress notes (ID notes) reflected the following: a. On 8/5/13- No documentation in the ID notes regarding intake. b. On 8/6/13- No documentation in the ID notes regarding intake, however at 9:45 a.m. the resident was given a drink of water. c. On 8/7/13 at 4:30 a.m. it identified the resident took a few sips of water. d. On 8/8/13 at 5 a.m. identified the resident took a few sips of water. At 6:30 p.m. staff documented the resident went to the main dining room and took bites of food and pocketed it in his/her cheeks. Staff cleaned the resident's mouth. The resident maintained the ability to swallow some liquids and refused staff assistance with feeding. The resident exhibited increased drooling. e. On 8/9/13- no documentation in ID notes regarding intake. f. On 8/10/13 at 8:30 a.m. revealed the resident's vital signs: Temperature 98 degrees, pulse 135, respiration 24 and blood pressure 168/101. The resident refused to eat and let food and fluids run out of his/her mouth. The resident was awake and alert, responding to physical and verbal stimuli. Staff could not understand the resident's verbal communication. The resident moaned and made anxious type sounds. The resident refused his/her oral medications. At 10:30 a.m. staff rechecked the resident's blood pressure and it read 180/107 with no distress noted. The resident continued to refuse oral intake. The resident's left side of the mouth appeared droopy and drooling. Hand grasps equal. Blood oozed from the resident's oral cavity. Staff provided care as allowed by the resident. At 12:30 p.m. the resident refused oral medications. Took bites of food but then let it run out of mouth. The resident remained awake. The resident moaned and appeared slightly anxious. Staff attempted to redirect the resident. At 2:45 p.m. staff left a message at the hospital for the doctor on call to call the facility regarding the resident's condition. g. The record lacked any further documentation until 8/11/13 at 6:45 a.m. when Staff E (Registered Nurse) documented the resident was incontinent of urine. The resident moaned to physical stimuli and did not open eyes. The resident's extremities were limp. Vitals signs were pulse 131, respirations 32 and blood pressure 146/94. Staff did not note any further bleeding from the mouth. Staff repositioned the resident. At 8:30 a.m. the resident continued to let fluids run out of his/her mouth. The resident did respond to verbal and physical stimuli. At 10 a.m. Staff E updated the resident's daughter on the resident's condition and the fact the physician did not return yesterday's call. The daughter stated to keep the resident comfortable and just wait and see. Staff E placed a note in the facility appointment book to update the physician in the morning regarding resident condition. At 12 p.m. staff held oral medications and fluid. Staff repositioned the resident. At 10 p.m. Staff D (Registered Nurse) documented the resident remained in bed and took sips of fluid. h. On 8/12/13 at 5:30 a.m. staff could not obtain vital signs as resident pulled arm away from the nurse. At 8 a.m. staff documented the resident was not awake enough to swallow. The resident's daughter arrived and decided the resident should go to the emergency room (ER). At 11 a.m., a speech therapist arrived to conduct a swallowing evaluation but the resident was gone to ER. At 2 p.m. the facility was informed by the hospital that the resident was admitted into the hospital. A hospital history and physical, dated 8/13/13 identified the resident was admitted to the ER yesterday with a history of altered mental status. The resident had a decreased level of consciousness for 3 days. Evaluation identified the resident as severely dehydrated with [MEDICAL CONDITION] and acute [MEDICAL CONDITION]. The report reflected an admission to the hospital for acute care, intravenous (IV) rehydration and monitoring of labs and clinical status. The resident's weight on hospital admission was 136 pounds (a loss of 17 pounds from the MDS weight of 8/12/2013). The hospital assessment revealed the mucous membranes were dry. Impressions included: a. Decreased mental status b. Dehydration c. [MEDICAL CONDITION] d. Dementia e. Acute [MEDICAL CONDITION] A patient results dated 8/12/13 (day of hospital admission) report identified the following: BUN (blood urea nitrogen) 52- high (normal range 8-21), Creatinine- 1.4 high (normal range 0.5-1.3), BUN/creatinine ratio- 37.1, Calcium-11.3 high (normal 8.4-10.2), Sodium-157 high (normal 138-145), Chloride- 121 high (98-107). After 4 days of hospital rehydration, the blood laboratory results were as follows: BUN- 17 normal, creatinine-0.8 normal, calcium-9.5 normal, sodium- 146 (high with normal 138-145), Chloride-115 (high with normal 98-107) A hospital transfer form, dated 8/21/13 identified the resident transferred to a nursing facility with [DIAGNOSES REDACTED]. Physician Interview: On 9/16/13 at 11:10 a.m. the resident's physician stated he would expect the facility to notify him if the resident had little to no intake for 48 to 72 hours. He would then evaluate the resident. He also stated he would expect the facility to have assessed the resident in the time frame between 8/10/13 at 2:45 p.m. to 8/11/13 at 6:45 a.m. He stated he also would expect staff to assess for dehydration. He stated if staff did not document it then it is a concern. Interviews with staff that worked 8/10/13 and 811/13: On 9/16/13 at 10:35 a.m., Staff H (nurse aide) stated the resident did not eat that weekend. The resident was unresponsive and moaning. The resident did not drink either. On 9/16/13 at 5:13 p.m., Staff I (nurse aide) stated the resident was quiet that weekend. The resident did not fight or resist cares like usual. She stated she tried to give the resident food and liquid and it ran out of the resident's mouth. She stated the resident did not urinate much and it appeared pretty concentrated. On 9/16/13 at 2:17 p.m. Staff A (nurse aide) stated the resident wasn't his/herself that weekend and wasn't eating like usual. The resident would not swallow it (fluids/food). She stated the resident was like this maybe a week and the problems started before that weekend. On 9/16/13 at 12:40 p.m. Staff C (nurse aide) stated she did not recall entering the resident's room that weekend. Nothing triggers her memory about the resident that weekend or the time before that. On 9/16/13 at 12:20 p.m. Staff D (Registered Nurse) stated the resident slept more that weekend but was not unresponsive. At times the resident does not have a good intake so nothing seemed abnormal. Staff D stated if she assessed the resident it would be found in the ID notes. On 9/16/13 at 12:50 p.m. Staff E (Registered Nurse) stated she worked every other weekend. The resident experience a decline and she spoke with the resident's family about the resident ' s condition. The resident had been declining for several days. She stated she attempted to notify the physician and got no response. The next day she spoke with the resident's daughter about no response from the physician and the daughter stated "Let's just wait". On 9/16/13 at 3:15 p.m. Staff J (nurse aide) stated the resident was in bed and not well. She couldn't get the resident to eat or drink and the resident wasn't acting like his/her usual self. The resident did not respond. Other staff: On 9/16/13 at 1:15 p.m. Staff G (Co-Director of Nursing) stated she did not recall the resident with issues of pocketing. She stated on 8/8/13 a swallow/speech evaluation screen was requested. She stated if staff says they need the evaluation right away, they will come right away. She stated the facility policy for physician notification did not identify what to do if the physician did not call back. There may have been a meeting where that was discussed. On 9/16/13 at 4:15 p.m. she stated there had been no formal discussion on what to do if the physician does not return the facility's call. It is standard nursing practice to call again if the facility does not receive a call back. On 9/16/13 at 4:18 p.m. Staff B (Corporate Nurse) stated the care plan directed staff to note symptoms of dehydration and she would not expect a specific assessment. The facility charts by exception. She stated the resident had previously been on Hospice from 9/11 to 11/12 and the resident rallied and was removed from Hospice. The actual [DIAGNOSES REDACTED]. The facility pureed the resident's food during this time. They thought she was going back to that condition and that's why it was reasonable that the daughter said to wait and see. On 9/16/13 at 1:45 p.m. Staff B stated the swallowing/speech screen did not take place before the resident went to the hospital because they have 2 working days to get to the facility. She stated the facility does not need a physician order [REDACTED]. Update: After the surveyor left the facility, the facility submitted additional information on 9/18/13 at 4:36 p.m. The facility obtained a physician clinic note that reflected the facility notified the physician, on 8/8/13 of the resident pocketing food. The clinic note did not indicate the facility informed the physician of the resident's decreased intake or letting fluids and food run out of mouth. In response to the call, the physician ordered a swallowing evaluation by the speech therapist and to adjust diet as needed. The facility did not document this information. 2. A Minimum Data Set (MDS) with assessment reference date of 9/9/13 assessed Resident #3 with a brief interview for mental status score of "13" (no cognitive impairment). The resident required limited staff assistance with toileting and personal hygiene. The resident had [DIAGNOSES REDACTED]. On 9/5/13 at 11:20 a.m. the resident informed the surveyor that he/she had a sore area in his/her right groin/scrotal area. The resident stated staff pulled a hair out and "now it's festered" When asked how long this had been going on, the resident stated 2 to 3 days. When asked what staff was doing for it, the resident replied, "They haven't done much". The resident showed the surveyor the area. The area appeared as a large raised red area in the right peri area with a black scab in the center. The resident stated it felt sore since last evening at least. Following the observation, the surveyor reviewed the resident's interdisciplinary progress (ID) notes. ID notes dated 9/4/13 at 10 a.m., and documented by Staff D (registered nurse) identified the resident with two ingrown hairs on the scrotum. The entry did not contain a description of the area. Subsequent documentation, dated 9/4/13 at 7 p.m. and 9/5/13 at 5 a.m. stated the resident did not complain about the ingrown hair scrotal area. The entries did not contain documentation regarding assessment of the area. On 9/5/13 at 4:05 p.m. the surveyor asked Staff D to examine the area and see if it changed in appearance. The surveyor accompanied Staff D to the room. At that time, Staff D stated the area was normal color and did not have a scab. The area was now red and it changed. ID notes dated 9/5/13 at 4:05 p.m. and documented by Staff D identified she assessed the area and noted it progressed from two whiteheads into an open area, 2 centimeters (cm.) by 1 cm. with serosanguineous drainage. Staff D cleansed the area and sent a facsimile to the physician. On 9/6/13 at 4 p.m. staff obtained an order to culture the wound with culture and sensitivity if indicated. The physician directed staff to begin the antibiotic [MEDICATION NAME] 300 milligrams four times a day for 10 days. On 9/8/13 at 3 p.m. the wound culture returned as positive [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staphylococcus). On 9/11/13 the Wound Nurse assessed the area. The Wound Nurse directed staff to apply skin barrier to the right scrotum and right inner thigh three times a day; encourage resident to stand at urinal and notify the physician if wound worsens. On 9/16/13 at 3:15 p.m. observation revealed the resident seated in a wheelchair in his/her room. The resident stated he/she was still taking an antibiotic and the area was drying up (healing). The resident stated, "I think I ' m on the road to recovery " . On 9/16/13 at 1:50 p.m. Staff H (nurse aide), who put the resident to bed the evening of 9/4/13 stated she did not remember putting the resident to bed that night for sure but the resident had the red scrotum for a while. It was red on and off for 1 to 2 weeks. Staff was directed to wash it good and then apply lotion and powder. ID notes did not contain documentation of any red area in the one to two weeks prior to 9/5/13.

Based on record review, staff interview and review of facility policy/procedures, the facility failed to ambulate Resident #4 with a gait belt to ensure safety of the resident. The sample consisted of 3 residents and the facility reported a census of 26 residents. Findings included: 1. Resident #4 had a Minimum Data Set (MDS) assessment with a reference date of 9/10/12. The MDS reflected Resident #4 required assistance from staff with transfers and walking. The same MDS indicated the resident could stabilize only with staff assistance when moved from a seated to a standing position, walking, turning around to face the opposite position and transfer between a bed, chair and/or wheelchair. The assessment documented the resident had no falls since admission or the previous assessment. The Physician order [REDACTED]. The fall risk assessments completed 9/20/11 and 9/10/12 identified the resident as a fall risk. The Care Plan with a start date of 9/11/06 identified Resident #4 with the risk for falling related to a history of falls and needing assistance from staff with ambulation. The same care plan included an approach for staff to assist the resident with ambulation of one staff member and the use of a gait belt. The Interdisciplinary Progress Notes (IPN) dated 8/29/12 at 3:15 P.M., revealed a Certified Nurse Aid (CNA) assisted the resident with ambulation from the bed to the bathroom. Staff documented the resident lost his/her balance, leaned back and hit head on the corner of a closet wall. Staff documented the resident sustained [REDACTED]. The IPN note indicated the staff had not used a gait belt when ambulating with the resident. After the fall, the resident received Tramadol (analgesic) 50 milligrams for comfort. A Registered Nurse educated the staff member to use a gait belt when transferring the resident. The facility investigation form (not dated) indicated the resident had a fall on 8/29/12 at 3:15 p.m. in the resident ' s room. The form indicated a recommendation for CNA to receive education to use a gait belt and to have the resident sit on the edge of the bed a couple minutes if just waking up if possible. The facility policy/procedures titled Transfer/Gait Belt Ambulation, revised 11/08, identified staff are to use a gait belt on a resident who required assistance with transfers and/or ambulation when mechanical lifting devices are not used. During an interview on 11/19/12 at 4:00 P.M., the facility Administrator confirmed a CNA failed to use a gait belt when she transferred Resident #4 on 8/29/12. The Administrator relayed she expected staff to use a gait belt with residents who required assistance with ambulation.