Every finding on record at Windmill Manor

Based on observation, resident and staff interviews, and facility policy review, the facility failed to serve food at a safe, preferred temperature and palatable. The facility reported a census of 111 residents. Findings include: 1. During the observation of the noon meal on 04/07/2026 at 12:05 PM, Staff N, took the temperature of the pork entree with a result of 171 degrees Fahrenheit (F). The pureed pork had a temperature of 166 F. At 1:35 PM, Staff O, [NAME] took the temperatures of a test tray for the State Agency. The pureed pork had a temperature of 113 F, and the pork entrée had a temperature of 135 F. The pork entrée lukewarm upon the taste test. 2. The Minimum Data Set (MDS) assessment tool, dated 3/10/26, listed Resident #13's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. During an interview on 4/6/26 at 11:52 AM, Resident #13 stated she did not get her lunch serviced until after 1:00 PM and it was cold. 3. Review of the MDS assessment for Resident #86, dated 3/10/26, revealed a BIMS score of 12 out of 15, which indicated a moderate cognitive impairment. The assessment identified the resident had diagnoses of dysphagia (difficulty swallowing and vascular dementia, severe, with psychotic disturbances. On 4/6/26 at 11:30 AM, during an interview, Resident #86 reported the food was over-cooked with no flavor in the pureed form. The resident reported she usually ate in her room. During an observation on 4/7/26 at 1:08 PM, Resident #86 received her lunch. During an interview at 3:00 PM, Resident #86 reported her lunch was overcooked and cold. During an interview on 04/07/2026 at 12:03 PM, the Dietary Manager informed no food temperature entered in the log book for April 2026. The Dietary Manager stated this would be resolved immediately. The Dietary Manager stated hot foods should be served at a temperature between 145 F and 165 F. During an interview on 04/09/2026 at 9:04 AM, the Dietary Manager (DM) stated there is a lot of work to do in the kitchen. The DM stated the day of the meal observation the service was too slow and unorganized. The DM stated the process for logging food temperatures and dishwasher temperatures needs to change. The DM stated the other areas that need to improve are cleanliness, staff training and consistency. Review of the facility policy titled Meal Service in Dining Room or Other Area, dated 08/22 directed: It is the policy of this facility to serve meals to residents by following procedures that are in compliance with state and federal regulations. Dining Services staff will deliver food to all dining rooms in a hot cart. Hot food will be placed in the steamtable and covered until ready to serve. Staff will record the temperature of all hot food .

Based on observation, interview, and policy review the facility failed to ensure laundry was processed and transported in a safe and sanitary manner in a hallway with 31 residents and in the laundry room. The facility staff also failed to wear appropriate protective equipment when soiled laundry was sorted. The facility reported a census of 111 residents.Findings include: During a continuous observation that started at 1:30 PM on 04/07/2026, Staff A, Laundry, delivered clean laundry residents in hall 100. Staff A used a laundry cart covered with a bed sheet. During the transport, three pieces of clothes (blue pants, purple shirt and a red shirt) hung outside of the cart and touched the handrail along the hallway. Staff A removed the cover sheet, bundled it up and placed it on top of the cart. Staff A gathered clean clothes on hangers and while taking them into a resident's room they brushed up against her scrub top. At 1:37 PM and again at 1:39 PM, Staff A removed dirty clothing from a resident room and placed them in the cart with the clean clothing. At 1:42 PM, Staff A took dirty clothing out of a room under Enhanced Barrier Precautions and placed them on the top of clean clothing in the cart. The clean clothing card uncovered during the continues observation, which ended at 2:05 PM. During an interview on 04/09/2026 at 9:26 AM, Staff A, Laundry staff stated the clean laundry cart should be covered at all times in the hallways. Staff A explained a bath sheet is generally used to cover the cart. Staff A stated sometimes she did not cover the cart because she got busy and it took too much time. 2. During an observation on 4/8/2026 at 9:25AM, Staff E, Laundry staff sorted laundry wearing gloves but no gown. During an interview on 4/8/2026 at 9:30 AM, Staff C, Housekeeping and Laundry Supervisor, stated staff should wear gloves and gowns (Personal Protective Equipment or PPE) when they sorted laundry. During an interview on 4/9/2026 at 9:11 AM, Staff E, Laundry staff stated she should have been wearing a gown and gloves when sorting laundry. Review of the facility policy, titled Laundry and Linens Department Policy, dated 03/2024 directed the Laundry Supervisor ensured the department complied with established standards. A review of the facility policy Infection Control, dated 12/17/2019 directed the facility followed standard precautions which included hand hygiene, proper use of personal protective equipment, and care of laundry.

Based on observations, staff interviews and policy review the facility failed to ensure kitchen equipment and floors are maintained in a clean and sanitary manner, open food items dated, and expired food items discarded. The facility reported a census of 111 residents.Findings include:1. During a continuous observation on 4/6/26 starting at 10:40 AM, and ending at 11:09 AM the following noted: a. In the dry pantry – a wet, brown substance on the floor, and the floor felt sticky. The following opened items found in the dry pantry with no date labeled to indicate when opened - a low-calorie punch drink; a container of an unidentified white powerlike substance, and a bag of crispy fried onions. b. The main refrigerator temperature log blank from April 1 -4, 2026. A container of soy sauce opened with no open date indicated, and an outdated container of a pureed dessert dated 3/29/26 found in the refrigerator. c. The dishwasher logs for temperature and sanitizer yet to be completed for the April 2026. d. The kitchen floor noted to be sticky and have visible crumbs. e. The grill not cleaned of particles from breakfast, and a dirty grill scraper stored above the grill. f. The microwave found with food particles on the inside roof and a brown substance on bottom. g. The heat cart had a crusty substance on the outside and was sticky on the inside. h. Visible dry food and debris was observed on the bottom of shelving throughout the kitchen. No food temperature logs were completed for the month of April 2026. During an interview on 04/06/2026 at 10:40 AM Staff B, Dietary Manager, stated that it was her first day here and the kitchen hasn't had a manager in a month and a half. At 10:52 AM Staff B noticed and acknowledged an open container of bread crumbs that was expired and an open bag of pasta that had no date on it. Staff B removed both and disposed of them. At 11:06 AM Staff B showed and acknowledged the current cleaning schedule in which none of the cleaning tasks were signed off for the month. Review of the facility policy titled, Sanitation and Safety, dated 9/2010 revealed a Purpose statement which declared To prevent food contamination and food poisoning. To prepare food under safe and sanitary conditions. All daily and scheduled cleaning will be maintained.

Based on observation, clinical record review, resident interview, family and staff interviews, the facility failed to ensure the resident received food in a consistency based on physician orders for 1 of 2 residents (Resident #86) reviewed for therapeutic diet. The facility reported a census of 111 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #86, dated 3/10/26, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated a moderate cognitive impairment. The assessment identified the resident had diagnoses of dysphagia (difficulty swallowing) and vascular dementia, severe, with psychotic disturbances. Review of the Physician Order Report, dated 4/1/26 to 4/30/26, revealed an order, dated 3/30/26 for regular diet when supervised and pureed diet when unsupervised. Review of the Care Plan for Resident #86, dated 3/20/26, revealed the resident received a regular diet when eating supervised in the dining room, and received a pureed diet when eating unsupervised in her room. During an interview on 4/6/26 at 11:30 AM, Resident #86 reported the pureed food was over-cooked with no flavor. The resident reported she usually ate in her room. During an observation on 4/7/26 at 1:08 PM, the Speech Therapist brought Resident #86's lunch to the resident's room. The resident received pot roast in a soft mixed form (potatoes, gravy, meat all mixed together), sweet potatoes in a mashed form, pureed cauliflower and broccoli mix and a pureed fruit cobbler dessert. The Speech Therapist stayed in the room while the resident ate her lunch. On 4/7/26 at 3:00 PM, during an interview, Resident #86 stated it upset her to be served pureed food for lunch and she did not want pureed food.During an interview on 4/07/2026 at 4:55 PM, a family member of Resident #86' stated the resident hated the pureed diet. The family member stated when the Speech Therapist sat with the resident, the resident should then get regular textured food. The family member explained they understood if Resident #86 did not agree to have a staff member sit with her for every meal, or sit by the nurse's station, then the resident would get pureed food.On 4/8/26 at 2:19 PM, during an interview, the Speech Therapist/Rehabilitation Director reported she was the only staff the resident would let supervise her while the resident ate in her room. The Speech Therapist reported she tried to supervise the resident two to three times per week. When asked why the Speech Therapist brought the resident pureed food on 4/7/6 during the supervised lunch, the Speech Therapist responded she asked dietary for a regular diet, and they gave her the pureed food. During an interview on 4/8/26 at 2:57 PM, the Director of Nursing (DON), reported there was a care conference for Resident #86 on 4/3/26 to address the resident being upset about her pureed diet. The DON stated the resident coughed with regular consistency food, and it was not safe. The DON explained the resident refused to eat in the dining room, or near the nurse's station or have anyone but the Speech Therapist supervise her meals. The DON stated Resident #86 had an order for pureed food if she was not supervised during the meal.

Based on observations, staff interviews, and facility policy review the facility failed to properly store and secure resident safety and accessibility of a medication cart by leaving it unlocked and accessible to residents during medication pass near the main dining room. The facility identified a census of 111 residents. Findings include:During a continuous observation on 04/06/2026 started at 4:15 PM, Staff J, Certified Medication Aide (CMA), positioned the medication cart in the living room approximately 20 feet from the dining room. a. At 4:18 PM, Staff J, CMA walked away from the cart to administer medication and left all eight drawers unlocked, which included the first lock to the narcotics.b. At 4:40 PM and again at 4:50 PM, Staff J, CMA walked away from the cart to administer medication to a resident in the dining room. The cart remained unlocked. During an interview on 4/6/26 at 4:55 PM, Staff J, CMA stated she typically locked the medication cart when she walked away. She explained that since she went from the living room across to the dining room and the cart remained in her sight, she did not lock it. Staff J stated that when administering medications to residents in the dining room she would constantly have to lock and unlock the cart, but since the dining room was close, she did not lock it between residents.During an interview on 04/07/2026 at 8:24 AM, Staff K, Licensed Practical Nurse (LPN), stated the medication cart should be locked at all times. Staff K added that this is true even if a nurse administered medications without leaving the room. Staff K explained that many residents in the facility wander. Staff K stated that if she positioned the cart in the living room and administered medications to residents in the dining room the cart would be locked. During an interview on 04/08/2026 at 4:20 PM, the Director of Nursing and Administrator stated that medication carts must be locked at all times and a staff member should never walk away and leave a cart unlocked.Review of the facility policy titled, Pharmaceutical Procedure revised 01/05/2023, Section V Care and Storage of Medications subsection B directed:Resident's medications shall be properly labeled and stored at or near the nurses' station in: 3. one of more locked mobile medication carts.

Based on clinical record review, policy review, and staff interview, the facility failed to revise a care plan to ensure resident safety with a visitor after allegations of abuse had been identified for 1 of 1 residents (Resident #72) reviewed for care plans. The facility reported a census of 111 residents.Findings include:The Minimum Data Set (MDS), dated [DATE], listed diagnoses for Resident #72 which included diabetes, non-Alzheimer's dementia, and weakness. The MDS listed his Brief Interview for Mental Status (BIMS) score as 8 out of 15, indicating moderately impaired cognition. Review of Resident #72 Care Plan revealed no Problem area to address safety with visitors related to past allegations of abuse. Review of the electronic health record (EHR) revealed the following:a. A 5/17/25 Nursing Note entered at 3:34 PM, written by Staff H Registered Nurse (RN): During a visit, the resident began yelling at the visitor. In response, the visitor became upset, stepped on the resident's foot, and loudly told him to shut up. The nurse chose not to intervene at this time to avoid escalating the situation but would like to formally report the visitor inappropriate behavior toward the resident. b. A 2/14/26 Nursing Note entered at 6:07 PM: Nurse observed visitor getting aggressive with the resident due refusing care. Educated that if she is not able to keep her composure then she is able to leave the room during cares.During an interview on 4/8/26 at 8:05 AM, Staff G Social Worker stated the visitor identified in the 5/17/25 and 2/14/26 Nursing Notes was very involved in Resident #72's care. Staff G stated after one report to adult protective services, there had been a care conference with the visitor. When queried as to what interventions the facility implemented regarding the resident's safety and the visitor Staff G stated she wasn't sure.Review of the facility policy titled Care Plan Policy, revised 6/1/22, stated the comprehensive person-centered care plan would include the resident's mental and psychosocial needs and directed to incorporate any changes into the care plan.

Based on clinical record review, facility policy review, and staff interview, the facility failed to implement their policy to prohibit and report allegations of abuse of a resident for 1 of 1 resident (Resident #72) reviewed for abuse. The facility reported a census of 111 residents.Findings include:The Minimum Data Set (MDS), dated [DATE], listed diagnoses for Resident #72 which included diabetes, non-Alzheimer's dementia, and weakness. The MDS listed his Brief Interview for Mental Status (BIMS) score as 8 out of 15, indicating moderately impaired cognition. Review of the electronic health record (EHR) revealed the following:a. A 5/17/25 Nursing Note entered at 3:34 PM, written by Staff H Registered Nurse (RN): During a visit, the resident began yelling at the visitor. In response, the visitor became upset, stepped on the resident's foot, and loudly told him to shut up. The nurse chose not to intervene at this time to avoid escalating the situation but would like to formally report the visitor inappropriate behavior toward the resident. b. A 2/14/26 Nursing Note entered at 6:07 PM: Nurse observed [relationship to resident redacted] getting aggressive with the resident due refusing care. Educated that if she is not able to keep her composure then she is able to leave the room during cares. On 4/8/26, the Assistant Administrator provided an untitled, undated soft file regarding the 5/17/25 incident. A review of the file revealed a document which stated the visitor stated she did not purposely step on the resident's foot. Staff H stated he did not intervene in the situation because he was unsure if it was intentional. The document stated staff told the visitor that if she became anxious or frustrated, she should notify staff and ask them to assist with de-escalating behaviors. The facility educated the nurse to call the Administrator and intervene if the resident had any concerns .The facility unable to provide additional information regarding an investigation or report to adult protective services related to the incident on 5/17/25 or 2/14/26. During an interview on 4/8/26 at 8:31 AM, the Director of Nursing (DON) stated she remembered something about the visitor grabbing the resident or something to that extent. She stated she could not think of anything physical that occurred. She stated if there was a physical altercation with a visitor involved, they would report this to adult protective services She stated she was not aware that the visitor stepped on the resident's footOn 4/8/26 at 9:16 AM, via phone interview, Staff H, RN stated with regard to the 5/17/25 incident, the resident's visitor was frustrated with him when she stepped on his foot. He stated he could not be sure it was on purpose but she was angry at the time she carried out the action. During an interview on 4/8/26 at 11:35 AM, the Assistant Administrator stated if there was an allegation of physical abuse between a visitor and a resident, the facility would report this to adult protective services. During an interview on 4/8/26 at 12:40 PM, the Administrator stated if there was an allegation of abuse between a visitor and a resident, the facility would follow their abuse policy and investigate. Review of the facility policy titled Abuse Prohibition and Reporting, revised 11/28/19, revealed Policy statement which declared: The facility actively prohibits resident abuse including. The Purpose statement declared: To protect resident from any kind of abuse. The Procedure section directed: Initial steps and reports of alleged abuse or neglect -1. Facility employee or agent who becomes aware of alleged abuse or neglect of a resident should immediately report the matter to the facility Administrator.2. If the incident involves alleged abuse or neglect, the Administrator shall provide the Iowa Department of Inspection and Appeals with initiate notice of the alleged abuse or neglect.The policy did not specifically address visitor to resident allegations of abuse.

Based on clinical record review, facility policy review and staff interviews, the facility failed to ensure medications available for administration as ordered for 1 of 3 residents (Resident #3). Resident #3 missed a total of four doses of medications due to two medications not be available in the facility. The facility reported a census of 105 residents. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 11/05/25, revealed Resident #3 admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The list of diagnoses included lung transplant status and adult failure to thrive. Review of the Care Plan, initiated on 10/30/25, revealed a Focus area for Resident #3 admission after hospitalization for adult failure to thrive, severe protein calorie malnutrition, and bilateral lung transplant requiring continued antirejection medications. The intervention instructed staff to administer antirejection medications per doctor orders. Review of the Medications Administration History, dated between 10/29/25 and 11/21/25, revealed the following medication orders: Azathioprine 50 milligram (mg) tablet to be administered daily at bedtime. Start date: 10/29/25 for diagnosis of lung transplant status. Tacrolimus 2mg capsule to be administered twice per day. Start date: 10/29/25 for a diagnosis of lung transplant status. Tacrolimus 0.5mg capsule to be given with the 2mg dose, to equal 2.5mg, every evening. Start date: 10/29/25 for a diagnosis of lung transplant status. Review of the Medications Administration History, dated between 10/29/25 and 11/21/25, revealed the following medication doses coded as, Not Administered: Drug/Item unavailable: On 11/12/25 at 7:13 PM, Azathioprine 50mg tablet coded as Not Administered: Drug/Item unavailable. On 11/13/25 at 7:54 PM, Azathioprine 50mg tablet coded as Not Administered: Drug/Item unavailable.On 11/13/25 at 7:54 PM, Tacrolimus 2mg capsule coded as Not Administered: Drug/Item unavailable. On 11/14/25 at 7:57 PM, Tacrolimus 2mg capsule coded as Not Administered: Drug/Item unavailable. Review of a nursing progress note, dated 11/12/25 at 1:23 PM, documented that the nurse called and spoke with [name redacted] at [facility redacted] lung transplant coordinator. The order for Tacrolimus is to be 2mg in the AM and 2.5mg in the PM. [Name redacted] stated to continue this order. Resident #3 will have labs done Monday. Review of a provider visit note, dated 11/13/25 at 10:40 AM, documented that Resident #3's Tacrolimus dosing was verified per [facility redacted] lung transplant coordinator. The provider documented that the plan for lung transplant status included continuing the immunosuppression regimen of Tacrolimus and Azathioprine. Review of Resident #3's Electronic Health Records (EHR), dated between 11/12/25 and 11/20/25, lacked documentation of attempts to obtain the unavailable medications and lacked documentation of physician notification to report that medications were not administered as ordered. Review of a Late Entry nursing note, recorded on 11/21/25 at 3:08 PM, dated for 11/14/25 at 3:06 PM, revealed that the nurse was alerted by medication aide that Resident #3's Tacrolimus 1mg is not available. This nurse called the pharmacy and spoke with the pharmacist who stated that he will have medication sent from a local pharmacy STAT (immediately) so that resident will not miss another dose. Review of a Late Entry nursing note, recorded on 12/04/25 at 3:47 PM, dated for 11/21/25 at 3:17 PM, revealed that the Assistant Director of Nursing (ADON) called the liver transplant team and talked with the doctor. The doctor was informed that the resident missed two doses of tacrolimus. The doctor reviewed the resident's labs from her previous visit and no new orders were received at this time. Review of pharmacy delivery requisitions revealed the following dates and amounts of Azathioprine and Tacrolimus delivered to the facility for Resident #3: 1. On 10/29/25:Azathioprine 50 mg tablets, 14 tablets delivered and received (14 day supply). Tacrolimus 0.5mg capsules, 14 capsules delivered and received (14 day supply). Tacrolimus 1mg capsules, 56 capsules delivered and received (14 day supply). 2. On 11/10/25: Tacrolimus 0.5mg capsules, 14 capsules delivered and received. 3. On 11/13/25: Azathioprine 50mg tablets, 14 tablets delivered and received.4. On 11/14/25: Tacrolimus 1mg capsules, 56 capsules delivered and received.5. On 11/20/25: Tacrolimus 0.5mg capsules, 14 capsules delivered and received. During an interview on 12/30/25 at 9:45 AM, Staff B, Registered Nurse (RN), confirmed having worked the morning (6:00 AM to 2:00 PM) shift on 11/14/25 and recalled that the Medication Aide reported being unable to locate Resident #3's Tacrolimus medication. Staff B stated that she looked at Resident #3's medication records and identified that the Tacrolimus had not been administered the previous evening (11/13/25), then called the pharmacy for a STAT delivery of the medication to be given for 11/14/25 evening dose. Staff B reported that the pharmacy told her the medication would be delivered from a local pharmacy and passed this information on to the evening shift nurse during the shift change report. Staff B stated that typically communication with the pharmacy for a STAT medication delivery would be documented in the nurses notes. During an interview on 12/30/25 at 9:15 AM, Staff A, RN confirmed having worked the evening (2:00 PM to 10:00 PM) shift on both 11/12/25 and 11/14/25. Staff A recalled that Resident #3's evening dose of Tacrolimus was not available to administer. Staff A stated that nursing staff called the pharmacy and were told that the pharmacy would send the pills, but then didn't show up. Staff A denied personally having tried to call the pharmacy when Resident #3 had unavailable medications, or called the pharmacy to follow up when medications were not delivered. Staff A unable to recall if physician was notified on these occasions related to omission of antirejection medications but did recall notification to Resident #3During an interview on 12/30/25 at 10:20 AM, Staff C, Certified Medication Assistant (CMA), confirmed having worked on 11/14/25 and recalled that Resident #3 did not have the evening dose of Tacrolimus. Staff C stated that she notified Staff A that the medication was missing from the medication cart, and was told that Resident #3 needed that medication, it was important and should have been filled. During an interview on 12/30/25 at 11:00 AM, Staff D, Licensed Practical Nurse (LPN) reported that the facility recently provided nursing staff with inservice education on what to do if a resident does not have medication available. Staff D informed that nursing staff are expected to call the pharmacy to see if they can bring it in and to document everything before charting unavailable.During an interview on 12/30/25 at 1:44 PM, Staff E, Pharmacist, stated that judging from when medication for Resident #3 was sent out on 10/29/25, the 14 day supply should have been up on 11/12/25, so the facility would need to re-order the medications to be refilled before they could be delivered. Staff E identified that the facility only reordered the Tacrolimus 0.5mg capsules on 11/10/25, but had not reordered the Tacrolimus 1mg capsules and stated that the pharmacy could only dispense what refills were requested by the facility. Staff E confirmed that the facility sent request for a STAT delivery of Resident #3's Tacrolimus 1mg capsules on 11/14/25, but was unable to provide documentation of medication delivery confirmation on 11/14/25. Staff E denied having additional communication from the facility on 11/14/25 to notify that medication was not delivered.During an interview on 12/30/25 at 2:50 PM, the Director of Nursing (DON), stated that she was notified on 11/21/25 that Resident #3 had missed 2 doses of her Tacrolimus and then the ADON called the lung transplant clinic to report this. The DON reported that she called the pharmacy to determine why Resident #3's medication was not delivered on 11/14/25 and was informed that there had been a mistake with the courier service. The DON revealed an expectation of facility nurses to keep calling the pharmacy or notify leadership nurses if a medication was not delivered. The DON stated that an inservice education was provided to all nurses and medication aides on medication ordering and delivery. The DON reported that omission of medication at scheduled times would be considered a medication error and the expectation for a medication error would be for nurses to notify the physician, the resident's responsible party, and document the incident. Review of the facility provided medication error report, completed by DON, dated 11/21/25, revealed that Resident #3 had an order for Tacrolimus 2mg every AM and 2.5mg every PM and described the error as medication not delivered by back up, missed 2 doses, and 11/14/25 PM dose was late. The report noted that the pharmacy did not order medication pick up in their system. The corrective action taken included education to nurses and measures taken to prevent in the future listed education and monitoring.Review of the facility in-service education for the nursing department related to medications, dated 11/21/25, instructed for nurses to follow: Unavailable Medications: When medication is unavailable, CMAs are to alert the nurse, never mark unavailable. The nurse is to go to the Stat Safe and try to pull the medication. If the medication is not in the Stat Safe the nurse is to call the pharmacy. The pharmacy can send it from a backup pharmacy. If the pharmacy sends it from back up and it does not come within 2 hours, call the pharmacy again. Notify the provider of missed doses and the POA/residents. CMAs, if you give the last dose of a medication, let the nurse know so that the nurse can call the pharmacy and get it sent before the next dose is due. Try to call after hours to see if they can still arrange for a back up pharmacy delivery. Review of the facility policy titled, Medication Administration, revised February 2004, revealed the Objective Statement is to provide the resident with those medications deemed necessary by the physician to improve and/or stabilize specified diagnosis of the resident. The Section: Procedures listed: #7. In the event that a medication cannot be given, the reason must be documented in the Nurses Medication Notes on the Medication Administration Record (MAR), and the time frame circled on the MAR.

Based on clinical record review, staff interviews, and policy review, the facility failed to provide appropriate supervision when a staff failed to use a gait belt to ensure each resident safety during a transfer for 1 of 3 residents reviewed (Resident #1) for safety. Resident #1 fell during the transfer which resulted in a left arm and wrist fracture. The facility reported a census of 109 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated moderate cognitive impairment. The MDS further indicated that the resident received partial/moderate assistance with transfers. The clinical census for Resident #1 revealed the following: a.7/21/25 admitted to the facility b.7/30/25 discharged from the facilityThe Care Plan initiated 7/22/25 indicated Resident #1 had a mobility deficit, utilized a front wheeled walker for transferring and required extensive assistance of 1 staff. A Progress Note dated 7/23/25 at 4:59 PM documented Resident #1 had been on the floor in the bathroom and according to the CNA the resident had been in front of the sink washing her hands and tripped backwards when she tried to turn with her walker. The CNA reported the resident dragged her down and she landed on the floor with the resident. An Incident Report (IR) dated 7/23/25 at 5:26 PM documented Resident #1 had a witnessed fall in the resident's bathroom after she had turned after washing her hands. The IR further documented a CNA had been with the resident but a gait belt had not been in place. An After Visit Summary dated 7/23/25 from a local emergency room (ER) revealed imaging tests were completed on Resident #1's left wrist and left elbow. The summary documented the reason for the visit was a fall, a diagnosis of a closed nondisplaced fracture of neck of left radius (forearm) had been determined and instructions to follow up with orthopedics for management of the fractures. The summary further documented the resident received an arm sling and left wrist splint. Review of the facility investigation of Resident #1's 7/23/25 fall revealed the resident had been sent to the ER immediately after the fall because she had been on a blood thinner. During an interview 9/16/25 at 12:25 PM, Staff A, Certified Nursing Assistant (CNA) revealed she had been in the bathroom with Resident #1 when the resident stepped back after washing her hands and then the resident tripped and fell back. Staff A stated she had been pulled down with the resident when she fell and landed next to the resident. Staff A stated she did not use a gait belt because she had looked around the room she did not see a gait belt. Staff A reported after the fall she went to get the nurse and the nurse was able to find a gait belt and she helped get the resident off the floor with a mechanical lift. Staff A acknowledged she was expected to use a gait belt when assisting residents with transfers. During an interview 9/16/25 at 12:35 PM, Staff B, Registered Nurse (RN) revealed the Staff A, CNA came and reported to her that Resident #1 was on the floor in the bathroom after she tripped after she had washed her hands. Staff B reported that Staff A had confessed to her that she had not been using a gait belt on Resident #1 prior to the fall. Review of the facility policy number 3.35 (IA) with the subject Gait Belts adopted 12/03, revealed all direct staff shall use a gait belt when transferring or ambulating residents for the protection of both staff and residents. All direct staff will have a gait belt available for use with transfers. No resident will be transferred or ambulated without the use of a gait belt, unless to do so is contraindicated and this would be identified on resident's plan of care. During an interview 9/17/25 at 9:40 AM, the Director of Nursing (DON) revealed it is an expectation staff utilize a gait belt per policy if a resident requires assistance with transfers.Review of the personnel file for Staff A, CNA revealed she completed the new employment checklist for a CNA on 9/13/24. The checklist included use of a gait belt. Review of in-service education revealed use of gait belt training had been completed on 9/30/24 and 7/16/25. Staff A, CNA signed that she had been present during both in-service training sessions.

Based on clinical record review, facility policy review and staff interviews, the facility failed to re-submit a Pre-Admission Screening and Resident Review (PASARR) for a stay longer than 60 days for 1 of 3 residents reviewed. The facility reported a census of 88 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #66 documented diagnosis of anxiety disorder, bipolar disorder and delusional disorders. Review of a PASARR, dated 10/22/2024 revealed results which included, in part: You may be admitted to a Medicaid certified nursing facility for up to 60 calendar days. You are expected to discharge within 60 days. If your stay goes beyond 60 calendar days, a NF (nursing facility) representative must submit a Status Change Level 1 to [company redacted]. During an interview on 4/16/25 at 2:19 PM, the Social Services Director (SSD) stated on of her is to process the PASRR. The SSD stated she had been in this position for over two years. She was not aware that time-limited PASARR 's had to be resubmitted if the resident was not discharged or circumstances changed. The SSD stated she did not know PASARR's needed to be updated when there is a time limit specified or a new mental health diagnosis. During an interview on 4/17/25 at 1:47 PM, the Administrator stated it is her expectation that all PASARR's are completed timely. Review of the facility policy, titled Preadmission Screening and Resident Review (PASARR) dated 02/17/2025, for Short Term Approvals directed: 1. Residents who are approved for admission on a short term basis will be assigned a PASARR designated, Approved - ST (short term). 2. If the resident is still in the facility upon completion of the Short Term approval time frame, the Social Service/Admissions Director or designee shall resubmit the PASARR.

Based on observation, clinical record review, facility policy review, provider, resident and staff interviews, staff interview the facility failed to follow physician orders for three (3) of three (3) residents reviewed (Resident #1, #2 and #3). The facility identified a census of 101 residents. Findings include: 1. Review of Minimum Data Set Assessment (MDS), dated [DATE] indicated Resident #3 diagnoses list included anxiety, depression, bipolar disorder, delusional disorders and alcohol dependence. A Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated intact cognition. Review of the Care Plan indicated Resident #3 had the following Problem area with included the following Approach as dated: a. The resident had depression and anxiety. Start Date 11/2/24. 1. Staff to have administered Clonazepam one (1) milligram (mg) by mouth (po) three (3) times a day (TID). Start Date 11/2/24. According to a Medication Error Report form dated 12.9.24 the facility staff failed to follow Physician orders for Clonazepam 1 mg TID on 12.8.24 and 12.9.24 which caused increased anxiety for the resident which resulted in an emergency room (ER) transfer. During an interview 3.18.25 at 10:21 a.m. Resident #3 confirmed staff failed to have administered her Clonazepam in December. 2. According to a Medication Error Report form for Resident #2, dated 9/27/24 at 9:00 p.m. the facility staff administered Lyrica 150 milligrams (mgs) versus the 100 mgs ordered which caused no side effects. A Care Plan indicated the resident had the following Problem area with included the following Approach as dated: a. The resident suffered from acute and chronic pain related to chronic back pain with a recent traumatic fracture of his T10 (thoracic - middle of spine) vertebrae after a fall that required surgical repair and resulted in an infection to his spinal fixation device. Start Date 3/21/24. 1. Staff to have administered pain medication as ordered. Start Date 3/21/24. 3. According to a Medication Error Report form for Resident #1 dated 11/20/24 the facility staff administered Atorvastatin (for high cholesterol) 80 mgs, Senna (constipation) 8.6 mgs and Tamsulosin (for an enlarged prostrate) 0.4 mgs to the resident at 7:38 p.m. which had been prescribed for another resident with no side effects documented. During an interview on 3/18/25 at 3:52 p.m. the Interim Administrator confirmed she expected the facility staff to have followed Physician orders as written. During an interview on 3/18/25 at 3:57 p.m. the resident's provider confirmed he expected staff to have followed his orders as written as a matter of safety for the residents. A Pharmaceutical Procedures policy revised 1/5/23 included the following: All such orders should of had the signature of the Physician and administered as prescribed.

Based on clinical record review, resident interview and facility policy review the facility failed to implement care plans for two (2) of three (3) residents reviewed (Resident #2 and #3). The facility reported a census of 101 residents. Findings include: 1. Review of Resident #3 Care Plan indicated the following Problem area which included the following Approach as dated: a. The Resident had Depression and Anxiety. Start Date 11/2/2024. 1. Staff to have administered Clonazepam (for a panic disorder) one (1) milligram (mg) by mouth (po) three (3) times a day (TID). Start Date 11/2/2024. According to a Medication Error Report form dated 12/9/24 the facility staff failed to follow Physician orders for Clonazepam 1 mg TID on 12/8/24 and 12/9/24 which caused increased anxiety for the resident and transferred to the emergency room (ER). During an interview 3/18/25 at 10:21 a.m. Resident #3 confirmed staff failed to have administered her Clonazepam in December. 2. According to a Medication Error Report form for Resident #2 dated 9/27/24 at 9:00 p.m. the facility staff administered Lyrica (for nerve pain) 150 milligrams (mgs) versus the 100 mgs ordered. effects. Review of Resident #2 Care Plan indicated the Resident had the following Problem area with included the following Approach as dated: a. The Resident suffered from acute and chronic pain related to chronic back pain with a recent traumatic fracture of his T10 (thoracic, which is in the middle of the spine) vertebrae after a fall that required surgical repair and resulted in an infection to his spinal fixation device. Start Date 3/21/24. 1. Staff to have administered pain medication as ordered. Start Date 3/21/24. The facilities Care Plan Policy revised 6/1/2022 included the following: The policy of the facility included the development and implementation of a Base Line Care Plan, a Comprehensive Person-Centered Care Plan and conduct Care Plan Meetings as appropriate for each resident, consistent with resident rights, that included measurable objectives and time frames to have met a resident's medical, nursing, and mental and psychosocial needs identified in the resident's comprehensive assessment.

Based on observations, clinical record review, family and staff interviews, the facility failed to provide timely assessment and intervention for 1 of 2 residents (Resident #7) taking an anti-coagulant medication and voicing concern due to multiple episodes of diarrhea and blood in an incontinent brief. The facility reported a census of 81 residents. Findings include: The Minimum Data Set (MDS) for Resident #7, dated [DATE], list of diagnoses included pulmonary embolism, hypertension and dysphagia. The assessment revealed Resident #7 requires moderate assistant for transfers. The resident speech clear, with distinct intelligible words. The MDS included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The Care Plan for Resident #7 dated [DATE] that directed staff to provide the assistance of two staff for transfers, toileting and required the need for disposable briefs due to incontinence. The Progress Notes for Resident #7, documentation by Staff A, Licensed Practical Nurse (LPN) that revealed: a. [DATE] at 7:53 pm Resident refused a shower, did not feel good and denied pain. b. [DATE] 12:23 am Vital Signs: 96.5 (temperature) ,d+[DATE] (blood pressure) 76 (heart rate) 97% (blood oxygen saturation). c. [DATE] 4:53 am Resident #7 was not feeling well 97.6 (temperature) ,d+[DATE] (blood pressure) 119 (heart rate) 18 (respirations) 98% (blood oxygen saturation), 2 large loose Bowel Movements (BM), Tylenol 650 milligrams (mg) given, resident requested for pain all over. d. [DATE] at 5:35 am Resident was very weakness after 2 large loose BM, included rectal bleeding. The resident requested to go to emergency room (ER) for evaluation & treatment and was sent with records. e. [DATE] at 5:38 am Call to the Power of Attorney (POA) and updated. During an interview on [DATE] at 1:45 pm, Staff B, Certified Nursing Assistant (CNA) stated she worked on [DATE] at 10 pm to 6 am and provided care for Resident #7. Staff B stated at 10:30 pm she assisted Staff C, CNA with changing Resident #7's brief due to incontinence. Staff B stated there was blood in with the BM and was reported to Staff A, LPN. Staff B stated at 12:30 am, Resident #7 initiated the call light, was incontinent of liquid BM and had a medium amount of bright red blood. Staff B stated Resident #7 was shaky, difficulty to stand with the stand lift, assisted to the bathroom, and had blood in the toilet. Staff B stated Staff C had Staff A come to the room to see the brief and results in the toilet, whom responded She is fine. Staff B stated this was not normal for Resident #7, who was asking to go to the hospital and to have family notified. Staff B stated Staff A took Resident #7's vitals and returned to the nurse's station. Staff B stated Staff A asked her to go check on Resident #7 as she didn't want to go to the hospital. Staff B stated Resident #7 was still in pain and wanted to go to the hospital but the nurse would not send her. Staff B stated this went on all night until the ambulance came at 5 am. Staff B stated that Resident #7 didn't sleep all night due to the pain. During an interview on [DATE] at 2:28 PM, Staff C, CNA stated she worked on [DATE] at 10 pm with Resident #7. Staff C stated she did not receive a report that Resident #7 was not well, she was just completing her normal rounds at start of shift, assisted Resident #7 and found bloody BM in her brief, and stated she was not well, was in pain. Staff C stated she was flushed, pale, in pain, and she had notified Staff A, LPN. Staff C stated that at midnight, Staff B asked for assistance to take Resident to the bathroom with the stand lift. Staff C stated Resident #7 was not herself, weak, large liquid BM with blood and was in pain. Staff C stated, She wanted to go to the hospital. Staff C stated she saved the brief for Staff A to view as it had bright red blood from the front to the back of the brief. Staff C stated Staff A took the vitals and gave a Tylenol but did not send Resident #7 to the hospital and stated she did not want to go to the hospital. Staff C stated She said she wanted to go to the hospital clearly. Staff C stated she had looked for the other nurse in the facility but was unable to locate her. Staff C stated she was scared for Resident #7 and insisted Staff A call for an ambulance which she did at 5 am. During an interview on [DATE] at 3:09 pm, Resident #7's niece was at bedside with her aunt who stated she told the nurse multiple times that she wanted to go to the hospital due to the blood in her stool and the nurse replied that it was not important, not to worry about it, she was not going to go. The niece stated She Po-Pooed her. The niece stated Resident #7 reported no one would call her POA, that she was up all night and miserable. The niece stated she believed that if the aids would not have intervened, her aunt would have died . During an interview on [DATE] at 11:10 am, Staff E, CNA stated she had worked on [DATE] at 2:30 pm to 10 pm and had offered Resident #7 a shower but she refused due to not feeling well. Staff E stated she had reported that to the nurse, Staff A, LPN. During an interview on [DATE] at 9:37 am Staff D, LPN stated she was the charge nurse on [DATE] at 6 am and Staff A, LPN stated Resident #7 had gone to the hospital due to pain and blood in her BM. Staff D stated if a resident requested to go to the hospital, the nurse would make an assessment of their symptoms and call the family. Staff D stated, If they request to go, they have a right to go. Staff D stated Mediprocity is the system the facility utilized to communicate with the physician and the administrator. It also had the ability to track if they had read the message. The facility provided the Metiprosity (Printed Discussion for Resident #7) that revealed: a. On [DATE] at 6:46 am, Staff A, LPN sent a notification to the Administration staff and Staff F, MD regarding Resident #7's condition during the night, transferred to the hospital and called the Power of Attorney (POA). b. The Read Receipt revealed Staff F read the report on [DATE] at 7:25 am. c. The Read Receipt revealed The Administrator read the report on [DATE] at 6:57 am. The County Ambulance report dated [DATE] for Resident #7 revealed: a. Emergency Medical Services (EMS) received the call at 5:27 am. b. EMS arrived to the facility at 5:36 am. c. Dispatched for resident #7 for hemorrhage and laceration. d. CNA's reported changed Resident #7's Depends 3 times with large amounts of bright red blood. e. Resident #7 reported having diarrhea, bleeding, feeling weak, nauseous and had reported the symptoms to the nurse who stated she was fine and didn't need to go to the hospital. f. The CNA's reported they repeatedly requested the nurse to call an ambulance. g. The nurse responded to the room, handed over paperwork and left the room without giving a report on the patient. The paper work was for a different resident and EMT had to find the nurse to obtain the correct paperwork for Resident #7. h. Resident #7 was conscious, alert, and oriented to person, place, time and event. i. Resident #7's skin was pale and cool to touch. j. Resident #7's abdomen was soft and tender to palpitations (touch). k. Resident #7 reported she takes Aspirin and Xarelto blood thinners for a diagnosis of bilateral Pulmonary Emboli's (blood clot in both lungs). l. Blood pressure ,d+[DATE] hypertensive (high blood pressure) and pulse 104 tachycardic (fast heart rate). m. Resident #7 transported to the hospital at 5:54 am. The Hospital Emergency Department notes for Resident #7 revealed: a. Arrived on [DATE] via ambulance with a complaint of rectal bleeding. b. Lab values: Hemoglobin 11.0 (normal range for women ,d+[DATE] g/dl (grams per deciliter) and [NAME] Blood Count 10.9 (normal range 4,500 to 11,000 per microliter). The Hospital Admitting notes for Resident #7 revealed: a. CT (computed tomography) scan revealed a defect in the urinary bladder concern for bladder malignancy. No evidence of acute (short term) gastrointestinal bleeding. Above average stool in rectal vault and sigmoid colon suggesting constipation. b. Hemoglobin on [DATE] was 8.8 g/dl. c. A Urologist was consulted. d. Recommended Operating Room for cystoscopy (a scope used to visualize the inside of the urinary bladder) for possible left ureteral stent placement. e. The cystoscopy revealed there was no tumor, the large mass was a blood clot. f. Hemoglobin on [DATE] was 7.7 g/dl. During an interview on [DATE] at 1:10 pm The Administrator stated that Resident #7 should have been transported to the hospital when she had requested to be transported. The policy titled Emergencies dated [DATE] revealed: a. The nurse in charge will evaluate the resident's condition. b. Notify the resident's physician and follow orders. c. Call for an ambulance. d. Notify the family.

Based on observations, clinical record review, family and staff interviews, the facility failed to respect a resident's right to request a transfer to the emergency room for an evaluation related to blood in stool for 1 of 1 residents (Resident #7) reviewed. The facility reported a census of 81 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], for Resident #7 listed the diagnoses as pulmonary embolism, hypertension and dysphagia,. The MDS assessed the resident required moderate assistance for mobility. The assessment listed speech as clear with distinct intelligible words. The MDS listed the Brief Interview for Mental Status (BIMS) score as 15 of 15, indicating intact cognition. The Care Plan for Resident #7, dated [DATE], included a Problem related to the use of anti-coagulants medication related to a history of PE (pulmonary embolism). The plan directed staff to monitor for side effects of anticoagulant therapy such as: fever, headache, diarrhea, bruising, bleeding, nausea, vomiting, mouth ulcerations, melena (black, tarry stool associated with bleeding in the gastrointestinal tract), theatrical (blood in urine), jaundice, urticaria (hives), and rash. During an interview on [DATE] at 3:09 pm, a family member stated Resident #7 reported to her she [Resident #7] told a nurse multiple times that she wanted to go to the hospital due to the blood in her stool and the nurse replied that it was not important, not to worry about it, she was not going to go. The family member stated She Po-Pooed her. The family member stated Resident #7 reported to her no one called the family, she was up all night and miserable. The family member stated she believed that if the aides (Certified Nursing Assistants, or CNA) would not have intervened, her aunt would have died . During an interview on [DATE] at 1:45 pm, Staff B, CNA stated she worked on [DATE] from 10 pm to 6 am and provided care for Resident #7. Staff B stated Resident #7 had multiple bowel movements (BM) with blood, she felt sick and was in pain. Staff B stated Resident #7 was asking Staff A, Licensed Practical Nurse (LPN) to call her family as she wanted to go to the hospital and Staff A stated she didn't need to go to the hospital. During an interview on [DATE] at 2:28 pm, Staff C, CNA stated that she provided care for Resident #7 on [DATE] starting at 10 pm. She stated the resident had multiple BM's with blood, weakness, abdomen pain and was requesting to go to the hospital. Staff C stated she knew Staff A, LPN was aware of Resident #7's request to be transported to the hospital as she went back and forth all night between the resident and the nurse with the request. During an interview on [DATE] at 8:32 am, Staff A, LPN stated she was the charge nurse on [DATE] from 6 pm to 6 am. Staff A stated that it was reported to her, that Resident #7 refused her shower, was not feeling well and had loose BM with little blood. Staff A stated at 10 pm Resident #7 wanted to go to the hospital. Staff A stated she continued to monitor Resident #7 after administering Tylenol at midnight. Staff A stated the CNA's recommended the hospital but did not remember if Resident #7 asked, She had her own phone. During an interview on [DATE] at 9:37 am Staff D, LPN stated she was the charge nurse on [DATE] at 6 am and Staff A, LPN stated Resident #7 had gone to the hospital due to pain and blood in her BM. Staff D stated if a resident requested to go to the hospital, the nurse would make an assessment of their symptoms and call the family. Staff D stated, If they request to go, they have a right to go. A review of local emergency medical services record revealed Resident transported to the hospital on [DATE] at 5:54 am. A review of hospital emergency records, dated [DATE], included an Assessment and Plan indicating bright red blood per rectum possibly due to lower GI (gastrointestinal) bleeding, cannot rule out upper GI bleeding.

Based on clinical record review, staff interviews, and policy review the facility failed to implement and modify interventions, and provide safety to 1 of 3 residents reviewed for falls (Resident #67) who fell repeatedly at the facility and sustained two (2) fractures. The facility reported a census of 94 residents. Findings included: The Minimum Data Set (MDS) dated [DATE] for Resident #67 documented a Brief Interview of Mental Status (BIMS) score of 4 indicating he has severely impaired cognition. The MDS documented he does not walk, stand, or use the toilet and he is dependent on staff for toilet hygiene, and changing positions from lying to sitting and for transfers. The MDS also documented his primary diagnosis of fractures and other multiple traumas, Alzheimer's, and hip fracture. 1. Record review of a Progress Note dated 11/08/2023 at 4:14 PM for Resident #67 documented the kitchen chef walked down the hall and saw Resident #67 sitting on the floor in bathroom in front of his stool and notified staff. Resident #67 observed sitting with his back against the stool and facial grimacing with tears running down his cheeks. His right knee was bent out toward the wall. Resident #67 unable to straighten it due to pain, and he had an abrasion to the front of his knee. Resident #67 complaining of excruciating pain. Brief wet, changed. Vitals Signs taken and he was lifted to his bed using a mechanical lift. As needed, pain medication given and the resident sent to the local emergency room (ER). Record review of a Progress Note dated 11/08/2023 at 5:10 PM documented Resident #67 left by ambulance, he became briefly unresponsive when transferred, then again complained of severe pain to his knee. Record review of a Progress Note dated 11/09/2023 at 10:42 AM revealed the facility notified by Resident #67 daughter that he broke his right tibia (also known as the shin bone, is one of the two bones that make up the lower leg). Record review of a Progress Note dated 11/15/2023 at 1:30 PM Resident #67 returned to the facility and is non-weight bearing to his right side and a cast in place. Record review of a Progress Note dated 11/17/2023 at 3:26 PM by the Medical Practitioner revealed Resident #67 has a right tibia fracture and no surgical intervention at this time. 2. Record review of a Progress Note dated 1/08/2024 at 4:58 PM documented Resident #67 found sitting on the floor leaning on his wheelchair in the library with both legs out in front of him. Activity staff present and informed he slid to the floor with his left leg bent underneath him. Activity staff member tried to help him by slowing the fall and then sliding his left leg out from underneath him and to the front. During assessment when left leg was bent to assess Range of Motion (ROM) resident began to groan from pain and saying ow that hurts. Resident assisted back to his wheelchair using a mechanical lift with the nurse holding his left leg straight ahead per residents request. When placed in the wheelchair, the left leg appears to be rotated slightly outwards. Resident taken to his room and transferred into bed and transferred to the local ER. Record review of a Progress Note dated 1/16/2024 at 1:35 PM documented Resident #67 returned to the facility with a left femur fracture that had been surgically repaired. Record review of a Progress Note dated 1/17/2024 [Recorded as Late Entry on 01/24/2024 at 9:39) by Resident #67 Nurse Practitioner documented he was examined today and is on skilled services after hospitalization following another fall at the facility, this time with a left femur fracture. He has a new onset of decrease in strength, decrease in functional mobility, and reduced balance. The plan is to continue his comprehensive rehab program, strengthening and improving functional mobility. 3. Record review of a Progress Note dated 5/03/2024 at 11:00 AM revealed he went to the local urgent care and has a closed displaced fracture of the shaft of the fifth metacarpal bone (pinky finger) of his right hand. During an interview on 05/15/24 at 03:45 PM with the Assistant Administrator revealed the facility would have completed medical incident reports when the resident would have a fall but the facility is not able to provide that documentation at this time. She informed the provider was notified and determined the falls are not a major injury but does not have documentation to show this for all three of Resident #67 falls. During an interview on 5/15/24 at 5:11 PM with the facilities MDS Coordinator, she stated after continuous falls with Resident #67 it has been hard, because sometimes he knows what he is doing and sometimes he does not. One minute he is clear and the next he isn't. Record review of Resident #67 Care Plan with a start date of 10/25/2023 identified a Focus Area of Falls related to weakness, limited mobility and use of antidepressant medication. The Care Plan included the following interventions with start dates: a. Weight bearing as tolerated. 3/1/24 b. Activity staff either alert nursing when resident is done with an activity or take resident back to the common area near nursing. 1/30/24 c. Remind Resident #67 to call for assistance with cleaning up afternoon snacks.1/19/24 d. Total assist of 2 staff with transfers using manual stand lift. 11/15/23 e. Remind Resident #67 to call and wait for assistance with transfers, ambulation and to.11/10/23 f. Encourage Resident #67 to use side rails and handrails as needed.10/25/23 The Care Plan failed to identify appropriate interventions for resident cognitive status after each fall. Review of a Policy titled, Emergency Care Procedure last revised 4/3/2018 instructed the following: 1. Nurse in charge of the resident will evaluate the resident's condition. If help is needed and there is more than one nurse available, the nurse assigned to the resident will stay with the resident and will send a nurse's aide to go call the other nurse. The nurse's aide will also bring emergency equipment if needed. 2. Immediate Care of the Resident: A. Falls 1. Check the resident immediately for ability to move extremities. 2. Check residents ability to explain what happened; evaluate condition before fall 3. Check if, or with anyone who witnessed the accident. Determine, if possible, where, how and when. 4. Check for any apparent dislocation or possible fracture. If any signs of this are noted, stabilize the resident until the ambulance arrives.

Based on observations, policy review, and staff interviews the facility failed to keep the kitchen free of flies, keep garbage cans covered, keep bare hands off the drinking surface of the glass, keep the kitchen surfaces clean, store food items at the correct temperatures, keep stored foods dated and closed, keep bare hands off of food, and use gloves correctly during food preparation. The facility reported a census of 94 residents. Findings include: During the initial tour of the kitchen on 5/13/24 at 10:29 AM the following items were found soiled: a. Food and paper particles on the floor; sticky substance on the floor. b. Orange appearing leak pooled and dripping onto the surface under the juice machine. c. Milk splatters inside the front refrigerator. d. Splatters and food matter on the range and grill, oven door handle and front. e. Food debris and cabbage leaves on food prep counter and shelf below which housed clean dishes. f. Cracked raw egg splatter on and around the freezer fan . g. Dust on and around refrigerator fans. h. Food spatters on the back-refrigerator door. i. Steam table wells with food matter caked onto the sides, brown sludge-like liquid in the fourth well. The following items were found open and undated: a. Lunch meat in an unlabeled bag. b. Cheddar broccoli soup, unlabeled. c. Tomato juice. d. Dry spaghetti, fettuccini, elbow, rigatoni noodle bags, untied. e. Cheerios. f. [NAME] cracker crumbs, not covered. g. 6 hash brown boxes, not covered. h. Cake mix, bag untied. i. [NAME] sugar, bag untied. j. Flour and sugar containers with scoops placed inside, unlabeled. k. Sliced meat, unlabeled. l. Sauce bag, unlabeled. m. Ground frozen meat, bag untied. Two flies were observed in the kitchen landing on food preparation surfaces. Staff observed and did not clean surfaces after the flies landed or try to remove them. The garbage can left open and full near the stove. The front refrigerator measured 46 degrees Fahrenheit (F). During an observation of the noon meal on 5/13/24 from 11:47 AM to 12:08 PM Staff A, Dietary Assistant served three glasses to three residents with bare fingers touching the drinking rim surface of the glass. Staff B, Dietary Assistant served three glasses to two residents with bare fingers touching the drinking rim surface of the glass. Staff C, Dietary Assistant served five glasses to four residents with bare fingers touching the drinking rim surface of the glass and the inside surface of the glass. During a continuous observation on 5/14/24 of the noon meal preparation and serving from 11:27 AM to 12:35 PM observed the following: a. Three flies landed on food preparation surfaces, staff, and the uncovered garbage next to the food preparation table. b. Staff D, Head [NAME] wore gloves, took bread out of the bag, plated the bread and placed it in microwave. Staff D failed to change gloves and touched the bread to rearrange it on a plate. c. Staff D wore gloves and opened the sandwich bun bag, opened the bun, scooped out ground beef from the pan, and failed to change gloves before he closed the bun by hand and grabbed two new plates. He then failed to change gloves and plated two sets of buns, touched the scoop for the meat, failed to change gloves again and placed the bun on top of it, touched the scoop for potato salad and its container, grabbed another plate, and failed to change gloves and grabbed another bun, opened it by hand and plated it. This process was observed an additional 41 times. Staff E, [NAME] did this 3 times as well. d. Staff E wore gloves and grabbed cheese, then touched the stove dial, touched a pan, and failed to change gloves before he touched the cheese sandwich and placed it in a pan. He grabbed another pan, turned the stove dial, and failed to change gloves before he grabbed bread and cheese, assembled the sandwich and placed it in the pan, rewrapped cheese and placed it in a container, touched the refrigerator handle and put the container in the refrigerator. He then threw away the bread bag, touched the stove dial and a spatula, and failed to change gloves before he used his hand to help flip the sandwich in the pan. This occurred for an additional sandwich with no glove change. e. Staff A used bare hands to cut the grilled cheese. No hand hygiene was observed. f. Staff F, [NAME] did not perform hand hygiene and used his bare hands to grab bread out of a bag, spread jelly on the bread with the food directly on the counter, and cut and plate the sandwich. g. Staff F did not perform hand hygiene and used bare hands to grab cheese and bread, assemble the sandwich, and placed it in a pan. During an observation on 5/14/24 at 2:56 PM the refrigerator in the kitchenette of Memory Lane left open with milk and drinks exposed. The temperature gauge on inside of the refrigerator read 70 F. During an interview on 5/14/24 at 12:00 PM Staff G, [NAME] noted he asked maintenance to fix the open window a week ago and it is still open so they have flies. During an interview on 5/14/24 at 12:33 PM Staff D reported staff use fly swatters to kill the flies but they just keep coming back in. He explained he's broken two fly swatters already trying to kill them. He reported there is no cleaning protocol or special chemicals used to clean where they have landed. He noted he's been here for two years and the window has been broken about a year and a half. During an interview on 5/15/24 at 10:49 AM the Food Service Supervisor (FSS) explained he expected staff to follow the rules and regulations for handling cups and glasses. Hands are to be underneath the plate and on the lower part of the cup, not near the top. He reported the kitchen has monthly, weekly, and daily cleaning duties. He gave the example: staff are to clean out the microwave and under shelves where pans are daily; weekly they must clean the food prep area; monthly they must wash the walls in dish room. Floor cleaning is to be done at shift change. He expected staff to clean anything they see dirty when they see it, including in the refrigerators and freezers. He expected staff not to wear gloves when preparing food other than getting bread out of bags. They should only be using them when cleaning. Staff have utensils and should be using them for preparation, assembly, cooking, and serving of all foods. He noted the garbage must be emptied after every meal, and the can must be cleaned before another bag is placed in it. He reported the kitchen has a window that won't go all the way up and he talked to maintenance about it. He expected staff to keep food covered due to the flies. There is no extra cleaning at this time. He noted he expected the freezer to be kept at around -3 F and all refrigerators in the building should be 34-35 F. He expected staff to date all items taken out of the shipment box. If a package is opened he expected staff to close it, date it, and then put it on the shelf. If staff are cooking they must put the food in a bag with a label and date. The facility policy titled Sanitation and Safety, revised 9/10 instructed staff to prepare all foods with the least possible manual contact, with suitable utensils, and on surfaces that have been cleaned and sanitized prior to use. Garbage cans and their lids are to be scrubbed thoroughly inside and outside. All shelves are to be wiped with detergent solution and air-dried. Stove tops must be cleaned daily and monthly. The sides, back plate, and splatter shall be cleaned with detergent solution, rinsed, and wiped dry. Refrigerators and freezers are to be cleaned on the assigned schedule. Food shall be covered and labeled with the name, date, and time of refrigeration. Steam tables are to be cleaned with detergent and degreaser if needed. All counter tops are to be wiped with detergent solution and sanitized. Floors are to be swept and mopped daily. The cleaning schedule must be developed and posted by the FSS and employees assigned tasks. The facility policy titled Food Storage and Labeling Procedure, revised 9/22 instructed staff to keep open bags of food such as pasta, cake mix, gelatin mix closed with tape or a rubber band or in a large re-sealable bag. It instructed staff not to store any utensil in a container of food. Refrigerated food must be labeled with the product name, date placed in the refrigerator, discard date, and staff initials. Food items left in the original container must be marked with the date it was opened. Non-perishable food removed from the original container must be marked with the name of the product and the date opened. It instructed staff to keep the refrigerator at 41 F or below. The facility policy titled Fly Prevention Policy, adopted 8/19 instructed staff to check for holes or cuts in window screens and repair if needed. Staff must make sure the kitchen is clean and free of food debris on counters, racks, equipment and floors. A cleaning schedule must be developed and staff cleaning must be monitored on a daily basis. Staff must clean under reach-in refrigerators/freezers, large equipment, counters and shelves. They must also make sure all food in storeroom is sealed. Staff are to use containers with tight fitting lids or resealable bags to store food out of original containers. To eliminate fly breeding grounds staff must prevent sources of moisture such as leaking pipes or dirty, clogged drains. They must work with Maintenance to make repairs as soon as possible.

Based on observations, policy review, and staff interview the facility failed to bring foods to the correct temperature prior to serving residents and keep it at the correct temperature throughout meal service to serve food and drink that is palatable, attractive, and at a safe and appetizing temperature. The facility reported a census of 94 residents. Findings include: During a continuous observation of the noon meal preparation and serving on 5/14/24 from 11:38 AM to 12:35 PM, the following items did not meet the correct cold temperature of 41 degrees Fahrenheit (F) or less prior to serving: a. [NAME] milk: 52.5 F b. Chocolate milk: 50.0 F c. Fortified milk: 50.1 F d. Half-and-Half creamer: 73.2 F e. Potato salad (main dining): 48.2 F f. Potato salad (Memory Lane): 45.3 F Observation revealed drinks not served on ice during the meal. During an observation of the post-meal temperatures at 12:27 PM, the following items did not meet the correct holding temperature of 41 F or below: a. Chocolate milk: 56.5 F b. Fortified milk: 55.7 F c. Half-and-Half creamer: 56.5 F d. Potato salad (main dining): 45.1 F e. Potato salad (Memory Lane): 42.8 F During an interview on 5/15/24 at 10:49 AM the Food Service Supervisor explained he expected all cooked foods to be 178-180 F and cold foods to be 34-35 F. He expected foods should not be lower than 165 F by the end of food service. Cold items, including beverages, should be on ice and remain at 34-35 F throughout service. The facility policy titled Meal Service Procedure adopted 11/14/22 instructed staff to return food items to the kitchen if cold food is above 41 F. Cold food should remain in the refrigerator or on ice during meal service.

Based on observations, clinical record review, staff interviews and policy review the facility failed to provide adequate incontinent cares for 3 out of 3 residents reviewed (Resident #49, #71 and #74). The facility identified a census of 92 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 3 which indicates severe cognitive impairment. The MDS indicated frequently incontinent of bowel and bladder. Resident #74 requires moderate assistance with toileting hygiene. She has a diagnosis of Non-Alzheimer's Dementia. The Care Plan initiated 8/17/23 documented in the resident care information section that Resident #74 is incontinent of bladder and requires briefs. The Care Plan failed to have an intervention to direct staff to provide incontinent cares. Observation on 05/15/24 at 7:25 AM Staff J, Certified Nursing Assistant (CNA) provided incontinent cares to Resident #74. Observed the residents brief wet as she removed it. Staff J utilized disposable wipes and wiped center of the perineal area 3 times. Staff J rolled her to right side and used 2 wipes to center of buttocks. Staff J wiped in a front to back motion and changed the surface of cloth with each wipe. She failed to cleanse the groin, abdominal folds, buttocks or hips to bilateral sides of resident. Strong urine odor present in the room. During an interview on 05/16/24 at 9:44 AM with the Director of Nursing (DON) she stated she would expect them to wash the front of the perineal area including the abdominal folds and then wash their bottom they should also wash the buttocks and hips. 2. The MDS dated [DATE] revealed Resident #49 had a BIMS score of 12 which indicates mild cognitive impairment. The MDS indicated the resident always incontinent of bowel and bladder and totally dependent with toileting hygiene. She has a diagnosis of Non-Alzheimer's Dementia. The Care Plan dated 4/13/21 directed staff to provide extensive assist of one with toileting/incontinent cares. On 05/15/24 at 10:44 AM observed Staff K, CNA and Staff L, CNA provide incontinent cares to Resident #49. They provided correct incontinent cares to the perineal area and then rolled Resident #49 on her side after removing a wet brief. Staff L cleansed the buttock area. Staff L failed to provide any incontinent cares to the left or the right hip. 34821 3. The MDS for Resident #71 dated 4/30/24, included diagnoses of dementia and high blood pressure. The BIMS reflected a score of 13, intact cognition. The MDS revealed the resident always incontinent of bladder. The Care Plan for Resident #71 dated 4/22/23, lacked direction to provide incontinent care after each incontinent episode. On 5/15/24 at 10:44 AM, Staff H CNA, and Staff I CNA, transferred Resident #71 to the toilet. Staff I reported the resident pants felt wet from urine. Staff H and Staff I stood the resident up from the toilet, Staff H washed the resident's buttocks. Both of the CNA's pulled up the resident's pants and placed him in his wheelchair. Staff H failed to wash Resident #71's front peri area. On 5/15/24 at 10:53 AM, the Assistant Director of Nursing (ADON) reported she expected the staff to wash the front peri area after incontinence episodes. On 5/15/24 at 10:55 AM, Staff H confirmed she needed to wash his front peri area. On 5/16/24 at 9:18 AM, the Assistant Administrator reported she expected resident cares after incontinent episodes. On 5/16/24 at 9:46 AM, the Director of Nursing, (DON) reported she expected the staff to wash areas that were soiled. The facility provided a policy titled Incontinence Care dated 2/4, directed at point # 7 wash all soiled skin areas and dry very well, especially between skin folds

Based on observations, policy review, and staff interviews the facility failed to keep the resident in clean clothes and with a clean face after every meal in order to maintain dignity for 1 of 3 resident reviewed (Res #51). The facility reported a census of 94 residents. Findings include: The Minimum Data Set (MDS) report dated 2/15/24 for Resident #51 documented deficits with short and long-term memory with severely impaired cognitive skills for daily decision making. It documented diagnoses including: progressive neurological conditions (mental deterioration), Alzheimer's disease, and type 2 diabetes mellitus. The MDS indicated staff must provide supervision or touching assistance for upper and lower body dressing, and partial/moderate assistance for personal hygiene. The Care Plan updated 2/09/24 instructed staff to provide limited assist of 1 for dressing and assist with setup and cueing for grooming. It documented the resident can reject cares and be physical when redirected. It instructed staff to stop and re-approach with a different staff if he is rejecting cares. In an observation on 5/13/24 at 12:17 PM observed the resident seated at the dining table in Memory Lane with wet-appearing stains down the front of his shirt. He was not wearing a clothing protector. At 3:52 PM observed the resident with the same shirt on in the common area. There was drool dripping out of his mouth and no staff offered to assist him. In an observation on 5/14/24 at 7:55 AM observed the resident seated in a chair in his room drinking water; crumbs present on his shirt. At 10:48 AM the resident remained in his room sleeping in the chair with the shirt unchanged and crumbs present. At 2:32 PM the resident sitting in the activity area with the same shirt on, new streaks of brown and wetness down the center of the chest and up the right shoulder present. In an observation on 5/15/24 at 9:37 AM observed the resident seated in a chair in his room; food spatters present on his pants and on the center abdominal area of his shirt. At 12:52 PM the resident was seated in the chair in his room after lunch. The resident had food matter on his chin and the food spatters remained on his shirt and pants. During an interview on 5/16/24 at 9:50 AM the Memory Lane Coordinator noted the resident is on behavior plan for being resistive to cares. They do cares in the morning and night as he gets physically combative with attempts. She reported all of his shirts are stained. At 10:59 AM she explained sometimes they have a good crew (staff) who will try and change him after meals and clean him up, and other times the staff won't even try because they know he will fight it. During an interview on 5/15/24 at 1:18 PM the Director of Nursing explained she expected staff to take the resident back to their room to wash their face and change clothes if they were found to have food matter on them. The facility document titled Resident Rights, revised 11/28/17 reported the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on staff interviews, facility record review and facility policy review the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in repeated deficiencies cited on the current survey and cited in previous surveys. The facility reported a census of 94 residents. Findings include: The Centers for Medicare and Medicaid Services (CMS) 2567 form dated 2/7/2023, reflected deficiencies identified for Reporting Alleged Violations, Accidents and Hazards, and Food Procurement, and Store/Prep/Serve-Sanitary. During the current recertification, complaint and survey dated 5/16/23, the team identified same deficiency for Reporting Alleged Violations, Accidents and Hazards, and Food Procurement, and Store/Prep/Serve-Sanitary. On 5/16/24 at 2:00 PM, the Administrator reported the facility monitors and audits the deficiency from the prior surveys with QAPI. The facility provided the QAPI Pan dated 6/28/23, that included feedback, data systems, and monitoring that stated the facility will put into place systems to monitor care and utilize data from various sources. It directed it will include tracking, investigating, and monitoring adverse events every time they occur, and actions implemented through the Plan, Do, Study, Act (PDSA) cycle of improvement to prevent recurrence. The QAPI Plan dated 6/28/2023, directed Overall Performance Improvement Projects (PIP) Plan; Performance Improvement Projects will be a concentrated effort on a particular problem in one area of the nursing center or on a facility-wide basis. They will involve gathering information systematically to clarify issues or problems and intervening for improvements. the nursing center will conduct PIPs to examine and improve care or services in areas that the nursing center identifies as needing in PIPs. Recognizing Problems and Improvement Opportunities: The facility will use a through an highly organized structured root cause analysis approach (e.g. Failure Mode and Effects Analysis, Flow Charting, Five Whys, Fishbone Diagram etc.) to determine and how identified problems may be caused or exacerbated by the way care and services are organized or delivered. This systematic approach will help determine when in-depth analysis is needed to fully understand the problem it's causes, and implications of a change. Theses systematic actions will comprehensively across all involved systems to prevent future events and promote sustained improvement, The focus will be on continues learning and improvement.

Based on observation, interview, record review, and facility policy review, the facility failed to provide a safe transfer while using a mechanical lift which resulted in an arm fracture, hematomas, and pain for 1 of 2 residents reviewed for mechanical lift transfers. (Resident#24) The facility reported a census of 81. Findings include: The Annual Minimum Data Set (MDS) assessment set dated 11/1/22 revealed the resident scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognitively intact. The MDS documented that the Resident required two staff for total dependence for transfers. The MDS revealed that the Resident required total dependence of staff for the following transfers; chair/bed-to-chair, toilet transfer, and car transfer. The MDS documented that the resident required extensive assistance with bed mobility with a two plus person physical assist. The MDS identified that the resident had the diagnoses which included generalized muscle weakness, unsteadiness on feet, morbid (severe) obesity due to excess calories, and a body mass index between 45-49.9. The Care Plan dated 10/26/21 with a problem of Falls revealed Resident #24 was at risk for falls related to pain, weakness, Atrial Fibrillation, and use of anti-depressants. Interventions dated 7/5/22 indicated the resident needed a total assist of 2 staff with transfers using a full mechanical lift. A Search Vitals Results dated 6/28/22 to 2/02/23 documented the following weights for Resident#24; 12/5/22 309.2 pounds and on 1/4/23 294 pounds The Fall Risk assessment dated [DATE] identified a score of 13 which indicated a Moderate Fall Risk for Resident #24. The Event Report dated 12/26/22, stated Resident #24 fell from the mechanical lift sling when transferred with the Hoyer lift. The resident slipped out of the Hoyer sling resulting in left forearm pain. The resident sent to the Emergency Department and evaluated. The Emergency Department (ED) Provider Aware Notes on 12/26/22 at 12:47 PM stated resident was transferred via Hoyer lift on 12/26/22 and there was some sort of issue and the resident fell from the lift. The Provider Note revealed the resident stated she landed on her left side and buttocks and complained of moderate pain in her left wrist along the ulnar process that was constant and non-radiating. The Progress Notes dated 12/26/22 at 1:22 PM, revealed CNA (Certified Nurse Aide) reported to the nurse Resident #24 slipped from the Hoyer sling during the mechanical lift transfer. The resident found laying on her back and the left side parallel to the bed with the Hoyer sling hooked up to the Hoyer lift. Resident #24 confirmed she had slipped out of the sling while transferring to her wheelchair and landed on her buttocks and the left side. Resident #24 complained of a 6 out of 10 pain to her left forearm and redness and swelling observed by the nurse. Resident refused initially to be transported to the hospital but eventually changed her mind and sent to the hospital. The Radiology report dated, 12/26/22 at 1:23 PM, showed findings of severe degenerative changes of the first and second carpal-metacarpal joints. The findings also included an old distal left ulnar fracture. The lateral view showed a fracture of the radius, ulna, or both. The report recommended dedicated left forearm radiographs. The Emergency Department (ED) Discharge Instructions dated, 12/26/22 stated the ED clinical impression was scapholunate (wrist ligament) instability with acute wrist pain. Additional information included that due to the arthritis and osteopenia it was difficult to determine if there was a fracture present. There was an old injury to the wrist also visible, recommend a removable splint at this time. The Progress Notes, 12/26/22 at 3:20 PM showed Resident #24 returned from the Emergency Department (ED) and an X-Ray had been performed on her left arm and the ED was unable to determine if Resident #24 left arm was fractured due to arthritis. The Physical Therapy Encounter Notes dated 12/27/22 at 4:38 PM revealed the resident presented to therapy at baseline functional mobility and level of assistance. The resident reported increased left hip pain since she had fallen out of the Hoyer sling and landed on her hip. Therapy services for pain management and re-evaluate and reestablish HEP (Home Exercise Program). The Nurse Practitioner Progress Notes dated, 12/29/22 at 10:25 AM revealed Resident #24 had continued pain in her lower back and hip since the fall. The imaging was negative for any fractures/dislocations. Hydrocodone prescribed for pain as needed for 5 days for pain management. The Progress Notes dated, 12/29/22 at 12:00 PM showed resident's daughter was notified her mother was being sent to the hospital due to increased pain. The Progress Notes dated 12/29/22 at 12:20 PM revealed the resident was sent to the hospital and took a blue sling with her to the hospital. The ED Provider Aware Notes dated 12/29/22 at 1:32 PM revealed the resident was sent to the emergency room due to continued worsened hip pain and wanted further imaging. The Computerized Tomography Scan (CT) without contrast of the pelvis dated 12/29/22 at 2:30 PM revealed a 11.7 x 0.9 x 11.9 centimeters (cm) right rectus sheath hematoma. The scan also identified an additional high density collection measured approximately 9.3 x 5.1 x 6.7 cm superior to the bladder. A CT with contrast was performed on 12/29/22 at 5:14 PM, to rule out intra-abdominal bleeding. The results found the right rectus sheath hematoma in better effect as well as the adjacent area of hemorrhage. These encompass a single large hematoma which extended from the right rectus muscle into the central to the right lateral aspect of the space of Retzius, retropubic extraperitioneal space. The acute hematoma measured approximately 20 cm in craniocaudal extent, 14 cm in maximum width, and 7 cm in anteroposterior (AP) dimension. The Progress Notes dated 12/31/22 at 8:19 AM showed the resident had pain that radiated from her arm to her chest and was sent by ambulance to the hospital. Resident told the staff it hurt to breathe, move or doing anything period. Resident cried when head of bed (HOB) was raised. The ED Provider Aware Note dated 12/31/22 at 8:37 AM, revealed resident had a X-ray of the left wrist with concern of a scapholunate ligament injury and was in a thumb spica splint. It also appeared that there was a possible diaphysis fracture of the radius and dedicated forearm X-rays were recommended but didn't appear to be completed. The resident's pain was constant, aching, and mild in severity and worsened with palpation. The resident was then placed in a long ulnar gutter splint and discussed ongoing supportive care, pain control, and that the fracture was non-operative. Resident was on Oxycodone for pain. The Radiology Report dated 12/31/22 at 9:27 AM, showed a nondisplaced fracture of the diaphysis of the distal left ulna. It was noted the fracture was present on the prior exam described in the report. The Progress Notes dated 12/31/22 at 10:48 AM, revealed the nurse received report from the hospital that showed a non-displaced ulnar fracture was found. The Progress Notes dated 1/1/23 at 12:37 AM, indicated the resident had an immobilizer applied to the left wrist and the fracture should heal in 4 to 6 weeks. The CT scan of the abdomen and pelvis dated 1/2/23 10:44 AM showed the rectus sheath hematoma may had slightly decreased in size and the mass effect upon urinary bladder was also stable. The Discharge Summary dated 1/4/23 at 9:33 AM, stated the resident was seen on 12/26/22 after a fall and had a nondisplaced left distal ulnar fracture. The Discharge summary stated the resident seen on 12/29/22 with hip pain after a fall, found to have a rectus sheath hematoma and a hematoma to the posterior bladder area. The Progress Notes dated 1/4/23 at 6:39 PM, revealed the resident returned to the facility and a splint and ace wrap were applied to the left wrist. Resident complained of aching of the wrist and burning of the hematoma behind the bladder. The Nurse Practitioner Progress Notes dated 1/5/23 at 10:27 AM, showed resident had a cast to the left wrist and stated further imaging showed a fracture. The Physician Progress Notes on 1/16/23, revealed a non-displaced mildly comminuted left distal fracture ulnar metaphyseal fracture. A short arm cast with fiberglass rolls applied in the physician's office. During observation on 1/30/23 at 11:18 AM, revealed Resident's #24 left wrist in a cast elevated on a pillow. During an interview on 1/30/23 at 11:18 AM, Resident #24 stated she fell out of the Hoyer lift during a transfer on 12/26/22. She stated she had a bruise on her bladder that they gave her pain medication for it. Resident #24 stated she had slid out of the Hoyer and hit her head, arm, and landed on her bottom. During an interview on 1/31/23 at 8:23 AM, queried Staff G, CNA (Certified Nurse Aide) about how do they know what size of Hoyer sling size to use and Staff G stated it goes by the weight of the resident. Staff G stated it goes by the binding (color of outer edge) of the sling, not the color of the sling. Staff G stated red is the smallest, then yellow, green, and blue. The Medical Sling recommended Sizing Chart provided and also observed in the utility room of the facility documented the following: a. Small 75 to 124 pounds (Red) Maximum 600 pounds. b. Medium 125-174 pounds (Yellow) Maximum 600 pounds. c. Large 175-249 pounds (Green) Maximum 600 pounds. d. Extra Large 250-399 pounds (Blue) Maximum 600 pounds. e. Extra, extra Large 400-750 pounds (Orange) Maximum 1000 pounds. Documentation on 12/26/22 had revealed the resident weighed 303.3 pounds which showed the recommended sling would be blue. During an interview on 2/1/23 at 11:20 AM, queried Staff D, LPN (Licensed Practical Nurse) about the Hoyer lift incident with Resident #24. Staff D stated she was at the nurse's station when a CNA came and got her. Staff D stated Resident #24 did not have pain except for her back and she had chronic back pain. Staff D stated Resident #24 didn't want to go to the hospital at first so they put her back in the bed. Asked Staff D what size the Hoyer pad was and Staff D responded she did not do a lot of Hoyer transfers so she would have to look it up. Staff D stated the facility ordered two special slings for Resident #24 that night or the next day. Queried Staff D how Resident #24 fell and Staff D stated she came straight down out of it and Resident #24 had scrapes on her legs where the leg straps had rubbed against her. Queried how did the CNAs know what sling to use and Staff D stated if the CNA question the size, they would ask a nurse to look it up. During an interview on 2/1/23 at 12:42 PM, queried Staff G about the Hoyer lift incident with Resident #24. Staff G stated they used the Hoyer sling the same way they had always done it. Staff G stated the slings legs were criss-crossed like they were supposed to be. The straps were blue on the bottom, green in the middle, and yellow on the top (noted to be the colors of the loops on the sling to connect loops to Hoyer lift). Staff G stated they were moving Resident #24 towards the wheelchair and her feet started to go up and the Resident #24 hit her arm and then her bottom fell out of the sling. Staff G stated her body was in the sling like it was supposed to be and the resident had marks on her legs where the leg straps were criss-crossed. Staff G stated nothing was broke on the Hoyer and the straps were still intact and secured on the lift. Queried Staff G what size of sling Resident #24 used and Staff G stated blue. Asked Staff G what color of sling they used on the day of the incident and Staff G stated they used a green sling because they could not find a blue sling to use and there was already a green sling in the resident's room. Staff G stated the resident was not much off from the green because she fluctuated in weight. Staff G stated she had never used a green sling with the resident but other staff had before. Queried Staff G what sling they used to put the resident back in bed on 12/26/22 and she stated they found a blue sling hanging up in laundry that had dried. Staff G stated the Administrator didn't want the other sling used until it was inspected. Staff G stated new slings were ordered and they are bariatric slings and they are used for Resident #24. Staff G stated she was not aware when the new slings were ordered. Staff G stated the facility purchased new Hoyer lifts last year and she thought they received 4 new slings with them. During an interview on 2/2/23 at 10:18 AM, Resident #24 stated they had left her in her chair too long yesterday evening and she was too sore to get out of bed today. When asked how long she had been in the chair Resident #24 responded she was not sure, she didn't have a watch. During an observation on 2/2/23 at 10:20 AM, revealed Resident #24 lying in bed with her left arm casted elevated on a pillow. A gray sling with a blue binding was laid on the chair next to her bed. Staff H came into the room and asked Resident #24 if she was going to get up and Resident #24 stated no, she hurt to much. Staff H asked her if she wanted her to speak to the nurse to see if it was time for her pain pill and Resident #24 said no, the nurse knew when it would be time. During an interview on 2/2/23 at 11:01 AM, queried Staff H, CNA about the Hoyer incident with Resident #24. Staff H stated they did not have the right size sling because they could not find the blue sling. Staff H stated they got the resident dressed and in the sling and lifted her off the bed and everything was fine. Staff H stated when they moved her, the resident's bottom fell out of the sling. Staff H stated they double checked the straps and they were correct and the legs were criss-crossed and you could tell because the resident had marks on her legs from the leg straps. Asked Staff H what sling size they were to use on Resident #24 and she stated we are supposed to use a blue sling but we used a green sling. Staff H stated she believed the green one was smaller. Asked Staff H how did she know which sling to use and Staff H responded they had a chart in the utility room room that showed what sling to use with the resident's weight. Staff H stated Resident #24 was on the border between the slings. Staff H stated if they question a resident's weight they went and asked the nurse what the resident's weight was and went to the chart for clarification. Queried Staff H if she used the slings in the resident's room and Staff H responded no we usually have what we need on the floor, and that day they used green because they did not have blue available. Staff H stated Resident #24 needed a bariatric sling not because of her weight but because of her width. Staff H stated they had asked prior to the incident for bariatric slings for Resident #24 but it took this incident for them to order them. Staff H stated the bariatric slings are gray ones and they are only used for Resident #24. During an interview on 2/2/23 at 12:04 PM, queried Staff H, CNA if the facility gave an education on the incident. Staff H stated they told them they had been doing this long enough they should know what to do. She stated she had been telling them Resident #24 needed a bariatric sling since November and she was told the resident was in the weight range of the slings they had. Staff H stated the facility printed off something and put it at the nurse's station and they were told to read and sign it. Staff H stated the Administrator and the shift coordinator talked to them that day about the incident but they did not do an inservice for the incident. During an interview on 2/2/23 at 1:14 PM, queried the Administrator about the Hoyer incident with Resident #24, and she stated she came in at approximately 1:30 PM and the resident did not initially want to go to the hospital but the nurse convinced her to go. The Administrator stated she had Staff H and Staff G do a return demonstration with her in the sling and they did everything correctly. She stated the CNAs stated they didn't know what happened and it might have been from her shape she fell down. The Administrator stated she inspected the sling herself and there were no tears, rips, or anything wrong with the sling they used. She stated the CNAs did it exactly to policy and when the incident was investigated nothing was found to be in error. Queried the Administrator on the expectations of staff when performing Hoyer lifts and she stated to follow policy and procedure of which they did. Asked the Administrator what should staff do if the right size sling is not available and she responded she was not aware of that ever happening and the right size was always available because they had ample supply. Queried the Administrator about how staff know what size sling to utilize and she responded they have a manual they go over and a chart is in the utility room for the color to match the weight. Queried the Administrator if any interventions were put in place for the resident after the incident and she stated the resident was sent to ER (emergency room ) and she had spoken to her support service staff and after discussion ordered a different sling (a long seat sling) for the resident. She stated they ordered a different sling from a different manufacturer with the correct size. She stated the new sling was compatible with the Hoyer lift they used. She stated the manufacturer of the Hoyer lifts they currently used stated the facility's previous slings they used were compatible with the new Hoyer lift. Asked what sling was used with the Hoyer incident and the Administrator responded they used the previous style sling with the new lift but it was approved. Queried the Administrator if any education was done with the staff after the incident and she stated yes they did an in service on that day. During an interview on 2/2/23 at 2:58 PM, queried the Administrator on what color sling was used during Resident #24 incident, and she responded it was blue. Asked the Administrator the color of the sling used for the return demonstration and she responded blue. Asked if she used a different sling than Resident #24 and said no, they were both blue and they were the appropriate size. When notified the staff had said the sling they used was green, the Administrator responded that maybe they were green, she would have to check because she might be thinking of the color of the pad and not the cord (binding). She stated there was an overlap in sizes and stated she would provide a chart. When asked if the chart was the same for all, the slings and the Administrator stated yes. During an interview on 2/2/23 at 3:18 PM, the Administrator stated she had initially forgot but Resident #24 was in the green sling. She stated she had spoken to the CNAs and pointed to the sling sizing chart and stated these are the recommended weights for the slings but the maximum weight was 600 pounds. She stated they didn't know how she slid out of the sling because you could go down a size but not go up in size. When asked if the older slings were used, the Administrator stated yes. When asked the Administrator what sling she used for the return demonstration, she stated it must have been the blue but still the maximum was 600 pounds. She stated the resident should have not fell out because the hole would have been smaller. The Administrator then stated the resident could have used the blue or green with both types of slings. Per the Hoyer full back sling manual for the type of Hoyer lift, it was documented, warning .Hoyer slings and lifters are not designed to be interchangeable with other manufacturer's products. Using other manufacturers on Hoyer products is potentially unsafe and can result in serious injury to patient or caregiver. The Hoyer Instructions Manual also documented the warning . For the safety of the patient and carer, before use of a sling a full assessment must be conducted that ensured the correct sling choice, method of position in sling, and the procedure for transfers had been determined for the patient. The Sling manual documented the following warnings: a. Select a sling that was sized appropriately for the resident. Slings that are too small may force a resident to fall out or exert unsafe pressure on the pelvic area. b. Sling failure or improper sling sizing or improper attachment may cause serious injury. Comply with instructions, inspections, and warnings. The Facility Policy Lifting Devices dated 2/12 stated all staff would be instructed on the proper use of the lifts, and each staff person would do a return demonstration in the proper techniques of use of the lifts.

Based on record review, staff interviews, review of personnel files and review of the wheelchair lift operator's manual, the facility failed to provide adequate supervision to ensure against hazards from self and elements in the environment during a transport in a facility van (Resident #5). The sample consisted of 6 residents and the facility reported a census of 96 residents. Resident #5 required transport in a van from a dialysis facility three times a week. An untrained facility van driver and a malfunctioned wheelchair lift caused the resident in a wheelchair to roll back off of a raised lift and onto the ground. The resident experienced loss of consciousness for approximately 10 seconds and had back and head pain (small laceration). The facility used the van for this resident 2 trips, three times a week and placed this and other residents needing the van lift to be in an immediate jeopardy situation due to an unsafe working lift and untrained driver. The facility trained and retrained all 7 drivers and took the van out of operation on 6/12/17 for repair of the lift. Findings include: 1. Resident #5 had an admission MDS (Minimum Data Set) assessment with a reference date of 6/12/17. The MDS identified the resident had a BIMS (Brief Interview for Mental Status) score of 14. A score of 14 indicated the resident had no cognitive impairments. The MDS noted the resident required extensive assistance of one staff member for transfers, ambulating off the unit, and required the assistance of 2 staff with toilet use and personal hygiene. The MDS indicated the resident had functional impairment of one side of the lower extremities. The resident's [DIAGNOSES REDACTED]. The resident's Care Plan identified a problem area with an initiated date of 6/06/17. The problem area identified RCIS (Resident Care Information Sheet and not an appropriate problem), identified approaches that the resident used a wheelchair for the primary mode of locomotion and required a stand pivot transfer of one staff person. Review of a form titled Event Report dated 6/09/17 at 4:20 PM identified Resident #5 had a fall outside and not on facility grounds. The resident complained of pain to the back of head. Review of the facility's typed report, indicated on 6/9/17 at approximately 4:20 PM, the facility received a call via employee, Staff A, Certified Nurse Aide (CNA) who was at the dialysis center to pick up Resident #5. Staff A reported the resident had fallen from the raised lift and had hit his/her head. Staff A indicated that 911 notified. The Director of Nursing (DON) and another employee arrived at the scene about 10 minute's thereafter. Staff A and 2 dialysis nurses were present and assisting the resident. There was no blood noted, resident responding appropriately to verbal stimuli. Resident's neurological status assessed and within normal limits. Resident complained of blurry vision and pain to the back and back of head and dialysis staff stabilized the resident's neck. The first responders arrived shortly thereafter and transported the resident to the emergency room . All the equipment of the van remained in its position. The lift was fully raised to be level for entry into bus. The resident was directly adjacent to the wheel chair. Everything was in a straight line from the lift, perpendicular to the side of the bus. The bus was parked in the routine pick up, drop off spot, which is marginally slanted towards the lift side of the bus. Initial interview with Staff A indicated he had raised the resident in the lift without incident with the resident facing the van. The resident's legs were raised on the elevated foot pedals. Staff A reported he unlocked the wheel chair brakes and asked the resident if was ok and the resident responded with thumbs up. At that point Staff A went to enter the bus. Staff A reported as he was stepping into the bus the resident yelled out and Staff A turned, and saw resident rolling backwards in the wheel chair and off of the lift. Staff A stated he jumped out of the van to help the resident, but was unable to reach him/her in time. Staff A reported the resident rolled backwards off the lift. Staff A reported the lock gate was flattened at that point. Staff A reported the resident and wheel chair hit the ground and the resident thrown out if it from the impact. Staff A assessed the resident who is not immediately responding. After 10 seconds, the resident came too and responsive. Staff A reported he notified 911 and staff from dialysis center came out of building to assist. Staff A reported he did not think he could reach the breaks from inside the van and thought the lock gate would prevent any movement of the wheel chair. Staff A stated he did not realize that the gate had not locked. The resident returned to the facility later at 10:30 PM with no major injuries. The resident sustained [REDACTED]. The van and wheel chair was removed from use until investigation complete. The facility report identify that on 6/12/17 the investigation determined contributing factors beyond the unlocking of the wheel chair brakes, the gate not fully locked and the resident facing the non-preferred direction. The shocks on the gate required tightening, so the gate would have more tension and could have locked after its initial momentum stopped by the back wheels of the wheel chair. Review of the hospital Emergency Department Encounter Notes dated 6/18/17 at 4:54 PM indicated Resident #5 presented (to the emergency room ) after a 3 feet fall from a ramp of a van wheelchair lift. Resident in wheelchair when he/she rolled backwards off the ramp and struck the back of his/head on the ground. Resident was unresponsive for approximately 15 seconds. Resident suffered a scalp injury and complaint of neck and back pain. The x-rays were performed and negative for acute findings. The physician treated the resident with Lortab (analgesic) which demonstrated some relief. The resident was released with a prescription for Lortab for pain. Review of Progress Notes dated 6/9/17 at 10:16 PM indicated Resident #5 returned to the facility. At 11:19 PM resident complained of pain to left foot and back of head rating pain 8 out of 10. The nurse administered pain medication. The Progress Notes date 6/10/17 at 5:14 A.M. indicated the resident voiced complaints of pain all over and at back of head, at a scale of 8 out of 10. On 6/27/17 at 3:05 PM Resident #5 was interviewed and stated he/she remembered being picked up from the dialysis center by the facility van. Resident #5 stated the van driver is new; he put me into the van lift, feet first, and raised it up. The resident stated the van driver went to get into van when he rolled backwards out of lift landing on his back in the wheelchair on ground. Resident #5 stated he/she didn't think the wheelchair was locked and the back guard malfunctioned. Resident #5 reported he/she not instructed to hang onto the hand bars in the lift, but does now because of feeling scared of falling again. Resident #5 stated he/she was knocked out for about a minute after the fall and remembered getting into the ambulance and going to the emergency room . Resident #5 stated he/she had pain to the back of head, neck, and back and a slurred speech after the fall. On 6/27/17 at 10:30 A.M. Staff A, Certified Nurse Aide (CNA) was interviewed and stated he worked at the facility for 4 years and drove year for resident transport 2-3 times a month. Staff A stated he never received any training on transporting residents' in the van until after this incident. Staff A reported on 6/9/17, he went by himself to the dialysis center to transport Resident #5 back to the facility. Staff A stated he put the van lift down and assisted the resident into the lift feet first. At that time, the outer barrier was in a down position. Staff A stated he then locked resident's wheelchair and raised the lift up to van entry level, the outer barrier in an up position. Staff A stated he then unlocked the resident's wheelchair brakes at that time because he did not think he would be able to reach the brakes once inside the van to bring the resident in off the lift. Staff A stated he asked the resident if ok and the resident gave him thumbs up. Staff A stated he then went to step up inside the van, approximately 7 feet away, when he heard the resident yell out and turned and saw the resident roll off the ramp in his/her wheelchair, hitting the ground and landing on back with wheelchair. Staff A stated he immediately went to the resident who lay on the ground, still in wheelchair on back, and unresponsive. Staff A stated he called 911 and then the facility as he stayed with the resident. Staff A stated the staff from the dialysis unit came out to help and then the DON came to the scene. Staff A reported the ambulance arrived and the resident transported to the hospital. Staff A stated if the wheelchair would have been locked, it would have made a difference, and it would have stopped the resident from rolling off the lift. On 6/27/17 at 2:05 PM the Maintenance Supervisor was interviewed and stated he is in charge of the training of the van drivers who transport residents and also the person that does the weekly inspections of the van. The Mt. Supervisor stated the van drivers are trained before they transport residents in the van. The Mt. Supervisor stated residents' wheelchairs are to be locked at all times while in the lift of the van, unlock when bring into van or taking off lift. Mt. Supervisor stated the manual and training videos does not indicate if residents should be loaded onto the lift feet first or back wheels first and either is acceptable. Mt. Supervisor stated he did not recall if he gave training to Staff A but if he did it would be in the employee file. Review of Staff A's employee file revealed lack of indication of van transportation training being given or done. On 6/27/17 at 1:43 P.M. the Transportation Director was interviewed and stated he had transported the resident to dialysis three times a week (Monday, Wednesday and Friday). Review of the van operator's manual, dated March 2010, and included Lift Operation Safety: -Whenever a wheelchair passenger is on the platform, the passenger must be positioned fully inside yellow boundaries, wheelchair brakes must be locked, inner roll stop and outer barrier must be up (vertical), outer barrier latches must be fully engaged, passenger should grip both handrails (if able), discontinue lift use immediately if any lift or vehicle interlock does not operate properly, position and secure the wheelchair-equipped occupant seat belt before loading onto the wheelchair lift platform, do not use platform inner roll stop or outer barrier as a brake, stop and brake wheelchair when loading onto platform, maintenance and lubrication procedures, must be performed as specified in this manual by authorized (certified) service personnel. The Van Inspection Report document indicated the van was taken out of service on 6/12/17. The Work Order Invoice indicated the lift was put out of service on 6/12/17 and repaired after replacing a roll stop gas springs, harness and plate, replaced occupied switch and seat belt kit, After repair of the van; the van was placed into service on 6/15/17. The facility identified 7 staff members drove the facility van. The facility presented documentation of the retraining of 6 drivers and training of Staff A on 6/12/17.

Based on record review, hospital records, and staff interviews, the facility failed to monitor anticoagulant medication for one (1) of (4) residents reviewed. Resident #17 received [MEDICATION NAME] (blood thinner) medication from 2/22/16 to 2/28/16 with an ordered to monitor his/her INR (International Normalized Ratio) on 2/23/16. Resident #17 continued to take his/her [MEDICATION NAME] medication until found unresponsive and sent to the emergency room . While in the emergency room his/her INR was elevated to high critical level of greater than 10 (with a therapeutic INR range under 4.0). The resident required an immediate medical procedure to control bleeding due to supra-therapeutic INR. The physician noted the presence of dark tarry fecal matter and evidence of [MEDICAL CONDITION]. Interview with the Director of Nursing revealed the laboratory test did not get ordered to monitor the resident's medication levels and he took full responsibility for the missed laboratory order on 2/23/16. The findings constitute an immediate jeopardy to the resident's health and safety. The facility reported a census of 92 residents. Finding include: The Minimum Data Set (MDS) Assessment tool dated 2/26/16 revealed Resident #17 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident scored 13 out of 15 possible points on the Brief Interview of Mental Status (BIMS) cognitive assessment; and the MDS documented the resident did not have symptoms of [MEDICAL CONDITION]. The resident required extensive assistance for transfers to and from bed and chair, bathing, dressing, toileting and personal hygiene. The Hospital discharge record dated 2/22/16, revealed Resident #17's laboratory values recorded on 2/22/16 identified an INR of 3.1 (normal and expected values under 4.0), hemoglobin stable at 8.4 (a measurement of the red blood cells ability to carry oxygen with normal value range from 13.2 to 17.7), and white blood cell count of 10.6 (white blood cells fight infection with normal value range of 4500 - 1100). The discharge planning directed the resident ' s INR rechecked in 1 day (on 2/23/16). (International Normalized Ratio)/test for blood clotting that measures how long it takes for blood to clot when taking oral anticoagulant medication.) The physician orders [REDACTED]. 1. Aspirin 81 milligrams (mg) oral daily. 2. [MEDICATION NAME] (an anticoagulant medication) 5 mg on Saturday, Sunday, Tuesday and Thursday. 3. [MEDICATION NAME]/([MEDICATION NAME]) 2.5 mg on Monday Wednesday and Friday. 4. [MEDICATION NAME] (an antibiotic) 500 mg oral 4 times daily. The Medication Administration Record [REDACTED]. Record review revealed the facility did not perform the INR as ordered on [DATE]. A nursing note entry on 2/29/16 at 6:31 a.m. revealed Staff I, licensed practical nurse (LPN), entered the resident's room at 5:45 a.m. to administer medication and found the resident non-responsive to verbal and painful stimulus, obtained a blood pressure of 76 over 43, pulse of 65, oxygen saturation between 80 and 90 percent (normal value 97 to 100 percent), notified the family and sent the resident to the hospital. Hospital records revealed the resident arrived in the Emergency department on 2/29/16 at 6:55 a.m. as emergency response personnel actively supported the resident's respirations with an ambu bag (used to give breaths). Laboratory blood work collected at 6:59 a.m. revealed an INR of greater than 10, hemoglobin of 5.0 (both critical values) and white blood count of 28.0. The resident had been given KCENTRA and Vitamin K for anticoagulation reversal. (KCENTRA is given for urgent reversal of acquired coagulation therapy ([MEDICATION NAME]) for adults with acute major bleeding.) The resident received 2 L (liters) of NS (normal saline) and 1 unit of blood/PRBCS (packed red blood cells) and Vitamin K 10 mg (a clotting medication used as an anecdote for anticoagulation). An additional 2 units of blood were ordered. The hospital history and physical H & P documented the resident had been diagnosed with [REDACTED]. The resident required an immediate medical procedure to control bleeding due to supra-therapeutic INR. The physician noted the presence of melena (the presence of dark tarry fecal matter and evidence of [MEDICAL CONDITION]); and had received KCENTRA to corrected INR to 1.2. The black stool had been identified when nurses were changing bedding. The resident remained in the hospital until 3/7/16. Interviews with Staff I on 4/13/16 at 10:17 a.m., revealed she worked on 2/29/16 and found the resident unresponsive and sent him/her to the hospital. Staff I stated she had not seen any black or tarry stools or abnormal bleeding for the resident when she worked with him/her. Interview with Staff J, registered nurse (RN) on 4/13/16 at 1:14 p.m. she reported not seeing any tarry stools or black stools or abnormal bleeding. During an interview on 4/13/16 at 11:10 a.m., the Director of Nursing (DON) stated he took full responsibility for the missed laboratory order on 2/23/16. He entered the orders on the computer, an error in the way the order was entered did not alert staff to perform the lab test, and all staff had been educated on the correct order entry procedure on 3/1/16. The DON stated he had spoken with the resident's family member since the 2/29/16 and was aware that the resident had a high INR and admitted to the hospital [MEDICAL CONDITION]. The resident's hospital records for the 2/29/16 admission, and the DON stated he would not be able to request them without the family's authorization to do so. On 3/1/16, the facility held an educational in-service meeting with all nursing staff and directed staff from here forward all residents requiring INRs will be added to INR tracking upon admission or receipt of first order of [MEDICATION NAME]. The new INR Flowsheet required staff to document the following: date dawn, INR results, current [MEDICATION NAME] or [MEDICATION NAME] Dose and or changes to new dose, Order ' s received, and next lab due date. Staff were also retrained on the INR tracking form adopted 8/2010. The procedure required staff to perform the INR as ordered, report labs to the physician; the order for the next/[MEDICATION NAME]/[MEDICATION NAME] dosage would be recorded and kept in the electronic MAR indicated [REDACTED] All of these actions were implemented on 3/1/16. The facility corrected the noncompliance and is in substantial compliance at the time of the current investigation from 4/11/16 to 4/19/16.

The following relates to # -I Based on clinical record review and interviews, the facility failed to plan for and develop care plan intervention(s) to ensure one (1) of seven (7) residents received adequate supervision and positioning from hazards in the environment (Resident #1). Record review and staff interviews determined Resident #1 had an unwitnessed fall from his/her specialized wheelchair on 12/5/13. At the time of the fall, staff interviews revealed the resident's specialized wheelchair had not been positioned to meet his/her safety needs. The resident's care plan lacked directives to recline/tilt the specialized wheelchair to meet his/her safety needs. The resident sustained [REDACTED]. The facility reported a census of 87 residents. Finding include: According the MDS (Minimum data set) assessment tool with a reference date of 9/17/13, Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident with a BIMS (Brief Interview for Mental Status) score of 7 out of 15. The MDS identified Resident #1 required one staff to physically assist with bed mobility, and the resident had been totally dependent on staff for transfers, ambulating, dressing, eating, and for toilet use. The MDS documented the resident had one fall since prior assessment being completed. The MDS documented the balance assessment during transition and walking indicated the resident not steady and only to stabilize with staff assistance or the activity did not occur. The MDS indicated the resident had functional limitations in both upper and lower extremities and in range of motion, which placed the resident at risk for injury. Record review identified Resident #1 had falls (according to the Event Reports) on: 6/29/13, 7/19/13, 7/22/13, 8/12/13, 10/6/13, 10/26/13 and 11/18/13. The fall Event Report form dated 11/18/13, written by the Director of Nursing (DON) identified a referral for occupational therapy (OT) to evaluated Resident #1 for positioning in his/her chair (wheelchair). The Occupational Therapy (OT) Evaluation and Plan of Treatment form dated 11/20/13 revealed the resident had been referred to OT due to an exacerbation of decreased postural alignment and reduced static (motionless) and dynamic (in motion) balance. The OT report identified a background of falls, including a history of falls out of chair, falling forward, falling sideways and falls by sliding out of chair. The evaluation documented the following short term goals: Resident #1 will improve midline position while sitting in wheelchair with use of bilateral support for 1 hour with contact guard assistance static sitting balance in order to reduce the risk of falls and improve proper joint alignment (target (goal date) 12/3/130). The plan also identified the resident would sit upright in chair with use of adaptive equipment to facilitate correct anatomical alignment for 1 hour without sliding or complaints of pain/discomfort. The evaluation identified the resident had demonstrated good rehabitation potential as supported by evidence from staff to consistently follow-through. The plan identified the resident had responded with improved stability during the BRODA chair, decrease forward flexed posture and not leaning to the left due to lateral supports. Review of the Therapy Recommendation-Communication form dated 11/22/13 indicated recommendations of a BRODA chair for positioning. The OT therapist identified the resident's current status as problems with the following: poor wheelchair positioning in resident's standard wheelchair, problems with the resident leaning to left, problems with severe forward neck and back flexion (looking at floor), and an increased risk for falls from wheelchair. The OT therapist recommended the resident be positioned in a BRODA wheelchair with midline posture as tolerated. The OT therapist suggested the BRODA wheelchair to improve the resident's posture and to decrease the risk of falls. The OT's recommendations were sent to the DON and MDS/Care Plan (coordinator/staff). The OT Discharge Summary dated 11/22/13 documented the OT therapist had trained the primary caregivers in proper positioning of Resident #1 in the BRODA chair. The Care Plan with a start date of 12/12/12 listed a problem that included falls. The falls related to [DIAGNOSES REDACTED]. The goal of the care plan is that the resident will adapt to the facility and remain free from injury. The approaches directed staff that included: a) Start date of 11/27/13 a BRODA chair obtained for trail with occupational therapy recommendations. b) Position resident in the BRODA wheelchair with midline posture as tolerated. c) Start Date of 11/18/13 occupational therapy to evaluate and treat for wheel chair positioning. d) Resident enjoys sensory activities. Place at the table and give the resident a magazine, blocks, wash clothes to fold, etc. to keep the resident busy. e) Do not leave resident in wheelchair while in his/her room unattended. Resident will transfer with walker, gait belt, and assist of one staff member. f) Resident needs several cues and reminders not to transfer self. The care plan lacked any approach to recline, or tilt the BRODA wheelchair to safely address the resident ' s safety needs. Review of the resident's Progress Notes dated 12/5/13 at 8:50 a.m. revealed documentation of Staff D, LPN (Licensed Practical Nurse), that Staff D summoned to day room near the Nurses station. Staff documented the resident observed on the floor lying on right side, noted laceration to right temporal lobe and direct pressure applied. Staff D indicated the resident to have several skin tears to bilateral upper extremity and dressings applied to areas. Staff D reported assessing the resident's extremities and noted no problems. Staff D indicated the resident responds to name and pain with crying. Staff D documented the family and physician were notified and the resident to be sent to the emergency room for further evaluation and treatment. Review of the facility's Event Report dated 12/5/13 at 8:50 a.m. revealed the resident's location of fall is in the Day Room, not witnessed, and resident to have moderate pain with abrasion, bruising, bump, redness, skin tear, and laceration noted. The Event Report indicated the resident had returned back from breakfast prior to fall. The report determined the resident would be reevaluated by OT for positioning. Review of the History and Physical dated 12/5/13, from the hospital, revealed the resident was in his/her normal health until today when the resident fell from the wheel chair and fractured right hip and received a laceration to the scalp. The resident's injury to the scalp wound was repaired and due to the head injury the resident is at risk for concussion. The resident is not an operative candidate due to the type of fracture and the fact the resident is non weight bearing at baseline. The resident admitted to the hospital under hospice care after discussion with a family member. The BRODA seating operating manual for Models 785 Tilt Recliner or 85 V Tilt Chair identified potential hazards for position of chair, danger of falling. The manual documented immediately after a resident is transferred into a chair, the chair's seat should be tilted sufficiently to prevent the resident from sliding or falling forward off the chair. The manual recommended the chair be used in a supervised area to prevent untrained residents, caregivers or third parties from unauthorized operation, movements or unsafe actions, etc.. Interviews: Interview on 1/8/14 at 10:08 a.m., Staff F, CNA (Certified Nurse Aide), indicated she/he had just started working for the facility the day before the resident fell . Staff F stated he/she had been instructed by other staff members in the dining room to take the resident from the dining room. Staff F indicated she/he pushed the resident from the dining room table in the resident's wheelchair/BRODA chair to the Nurses station/common area. Staff F reported he/she had not been given instructions or education on the resident's wheelchair/BRODA chair prior to pushing the resident from the table. Staff F stated the resident sitting in an upright position in the wheelchair/BRODA chair prior to him/her removing the resident from the table, after the resident ate breakfast, and pushed the resident to the common area by the nurses station. Staff F stated he/she left the resident in an upright position in the wheelchair/BRODA chair and left the area. Staff F indicated no other staff present at the time she left the resident in the common area. Interview on 1/7/14 at 12:42 p.m., Staff E, Activity Aide, stated around 9:15 a.m. he/she found the resident lying on right side on the floor of the common area in front of the wheel chair/BRODA chair. Staff E indicated he/she went to the resident and called out to staff for help. Staff E stated the resident's wheel chair/BRODA chair had been in an upright position. State E reported that the wheelchair/BRODA chair should never be left in an upright position; for the resident's safety to prevent fall from chair. Staff E stated the resident the resident's wheelchair/BRODA chair in a reclining position as the resident always attempts to pull him/her forward in the wheelchair/BRODA chair. Interview on 1/3/14 at 10:20 a.m., Staff A, CNA, stated he/she had just come out of the bathroom by the nurses station and heard Staff E yell out for help. Staff A stated the resident on the floor on right side by the wheelchair/BRODA chair in the common area. Staff A stated he/she the resident prior in the BRODA chair in the dining room eating. Staff A indicated the resident was not in the common area prior to her/him going into the bathroom and no other staff members present. Staff A stated the resident's wheelchair/BRODA chair had been in an upright position. Staff A indicated that if the wheelchair/BRODA chair had been positioned in a recline position that would have prevented the resident's fall. Staff A stated that a resident in a wheelchair/BRODA chair should never be left unattended in an upright position. Interview on 1/3/14 at 11:03 a.m., Staff D, LPN, stated he/she was in the dining room when staff summoned her/him of the resident's fall. Staff D stated she/he observed the resident lying on right side on the floor by the nurses station in the common area. Staff D assessed the resident and applied direct pressure to the resident's laceration on the right side scalp. Staff D reported the resident's family and physician notified and the resident sent to the emergency room via ambulance. Staff D stated he/she does not recall the position the wheelchair/BRODA chair had been in. Staff D stated he/she has taken care of the resident before and recalls the wheelchair/BRODA chair would be in a recline position. Staff D further stated he/she does not sure what midline position is (means). Interview on 1/3/14 at 10:46 a.m., Staff B, CNA, stated residents in wheelchair/BRODA chairs, when not eating, the chair is placed in a recline position for the residents safety. Staff B indicated after a resident is done eating the wheelchair/BRODA chair should be placed in a recline position before transporting resident. Interview on 1/3/14 at 11:50 a.m., Staff C, COTA (certified Occupational Aide) stated residents should not be left in an upright position in a wheelchair/BRODA chair unless he/she was eating. Staff C stated that a midline posture/position is a recline position in the BRODA chair. Interview on 1/8/13, the Administrator stated the resident never returned back from the hospital and the resident passed away at the hospital on [DATE].

Based on clinical record review, staff, resident and physician interviews, the facility failed to follow physician's orders and provide nursing provisions with timely assessment and interventions for one of three residents with an adverse change in physical condition. Resident #2 required surgical irrigation, debridement of his/her elbow and 6 weeks of intravenous antibiotics to clear up an infection as result of the facility staff not changing the dressing or assessing the resident's skin. The facility identified a census of 52 residents. Findings include: The face sheet revealed Resident #2 had [DIAGNOSES REDACTED]. According to the Discharge Summary dated 7/1/11 Resident #2 admitted to the facility with a humerus fracture. The Discharge Summary revealed orders to remove ortho splint twice a day for twenty minutes for skin checks, keep incision clean and dry and change dressing daily using dry gauze. The Care Plan dated 7/1/11 directed staff to monitor the incision for and signs or symptoms of infection and report to the physician as appropriate and directed the nursing staff to remove the staples and apply steri strips per physician orders. The Admission Body assessment dated [DATE] revealed a bruise to the right antecubital space. The assessment did not show the incision to the right elbow. The Progress Note dated 7/1/11 at 5:50 p.m. revealed the resident wears an orthoplast splint with instructions of no range of motion at this time, splint can be removed for 20 minutes for skin checks. The Progress Note dated 7/4/11 at 4:59 p.m. revealed the skin under the splint shows no signs of infection or redness. The Progress Note dated 7/6/11 at 4:21 p.m. revealed the skin under the brace without breakdown although the resident complaining of pinching in the arm pit area. The Progress Note dated 7/9/10 at 11:05 a.m. and 7/10/11 at 1:29 p.m. revealed the resident continues to wear the brace on the right arm and states that he/she has pain constantly. On 7/10/11 the resident had a low grade temperature and staff gave Tylenol and two hours later was afebrile. The vital sign flow sheet revealed on 7/10/11 at 1:28 p.m. the resident had a temperature of 100.4 degrees Fahrenheit. On 7/11/11 at 2:05 p.m. the resident had a temperature of 99.1 degrees Fahrenheit. The PRN Medication Notes revealed the resident received [MEDICATION NAME]-[MEDICATION NAME] 5-325 milligrams two to four times a day from 7/1/11 to 7/11/11. An interview on 7/13/11 at 2:38 p.m., Staff C reported the staff informed him/her on 7/11/11 that the physician found Resident #2's incision red and alerted the charge nurse. Staff C reported that Staff D completed the orders on admission and did not put the orders for the skin checks and dressing change in the computer and generate treatment sheets. Staff C indicated that the skin checks and dressing changes were not completed as ordered. Staff C indicated the facility protocol directs the night shift nurse to double check the orders. Staff C had a nurses meeting on 7/1/11 and addressed the orders for new admissions including the following shift needed to continue, recheck and finish the admission. The Progress Note dated 7/11/11 at 3:00 p.m. revealed the physician at the facility and asked the charge nurse to look at the resident's incision. The nurse noted the elbow was swollen and red, staples intact, blister to area that popped and yellow and green drainage noted on the old dressing. The physician gave a verbal order to send the resident to the emergency room for evaluation and treatment. According to the emergency room notes dated 7/11/11 at 6:40 p.m. revealed the resident reported the staff at the nursing home never asked or looked at his/her elbow and never changed the bandage. The resident was unsure if there was an order to change the bandage. The resident told the nursing home staff that he/she had a lot of pain and was always asking for pain medications. The resident reported he/she had a low grade temperature for the last two days and told the staff that it had an odor and drainage. The hospital staff called the nursing home and spoke to a Registered Nurse. The Registered Nurse indicated that there was a miscommunication on the orders and they did not get into place. The emergency room staff asked the Registered Nurse if he/she assessed the site. The Registered Nurse reported caring for the resident the day prior and did not look at the area. The emergency room staff asked if the Registered Nurse noticed redness and swelling outside the bandage. The Registered Nurse reported he/she did not assess or look at the area but the resident received pain medication around the clock. The hospital records revealed the resident admitted to the hospital with [REDACTED]. A wound culture was taken on 7/11 and was positive (X2) for Staph Aureus. The resident was started on intravenous antibiotics. The resident had irrigation and debridement of the wound again on 7/15/11. An interview on 7/14/11 at 8:55 a.m. the physician reported he/she was not contacted by the facility at all regarding his/her arm. The physician reported seeing the resident at the facility on 7/11/11. The resident had the splint/immobilizer on. The physician could see the top of the bicep was red and swollen. There was gauze around the antecubital area. There was not drainage on the gauze. However, there was a lot of drainage weeping from the [MEDICAL CONDITION] on the upper arm. The splint went from the thumb up to the mid bicep. The incision on the back of the elbow went from the mid tricep down below the elbow. The physician indicated that the incision could not be visualized with the splint on. The entire back side of the arm was swollen and red. The soft tissue around the incision had [MEDICAL CONDITION]. There was more than one but less than ten blisters on the back of the arm. The physician showed the nurse the arm and ordered to send him/her to the emergency room . The physician talked to the Administrator and Director of Nurses and asked them to review what happened and take appropriate action. The physician thinks the admitting nurse checked the area from 7/1 to 7/4 but it was not passed on to the other nurses to check. An interview on 7/14/11 at 12:00 p.m. Resident #2 reported he/she did not know what the orders were for the arm when he/she admitted to the nursing home. Resident #2 received two showers while at the facility and the staff covered the splint with plastic bags. Resident #2 indicated that the splint was never removed by anyone at the nursing home. Resident #2 received therapy and the therapist never removed the splint. Resident #2 reported having pain the entire stay and it got worse over the stay. An interview on 7/15/11 at 10:00 a.m. Staff A reported the resident wore a sling. Staff A did not know if the resident had an incision and never checked. An interview on 7/15/11 at 10:51 a.m. Staff B reported the resident wore a sling and he/she never removed it. Staff B did not know the resident had an incision. An interview on 7/15/11 at 11:30 a.m. Staff E reported the resident wore a sling/immobilizer brace and he/she never removed it. Staff E did not know the resident had an incision. Staff E never visualized the skin under the device. Staff E reported checking the skin around the brace. Staff E entered the medication orders in the computer the day the resident admitted to the facility to help out Staff D because Staff D had two admissions that night and had to train a new nurse. Staff E told Staff D to verify the medication administration records so they could be printed. Staff D could not be reached for interview as he/she had left the country with an unexpected date of return. An interview on 7/15/11 at 1:05 p.m. Staff F reported the resident wore a device on the right upper extremity. Staff F never removed the device. Staff F was not aware the resident had an incision until the resident went to the hospital. An interview on 7/19/11 at 10:16 a.m. Staff G reported he she did not remove the splint. Staff G was not aware the resident had an incision. An interview on 7/19/11 at 10:56 a.m. Staff H reported he/she was the only therapist that worked with the resident. Staff H never removed the splint. Staff H figured occupational therapy would check it. On 7/6, Staff H discovered that occupational therapy was not going to work with the resident. That is when Staff H started range of motion exercises on the right shoulder and hand. An interview on 7/19/11 at 11:10 a.m. Staff I reported the resident had a brace on the right arm that was to be left on at all times. Staff I did not know the resident had an incision. Staff I never removed the brace. The physician called Staff I to the room to show him/her the arm. The physician had already removed the brace. The elbow was swollen, red and warm to the touch. The Kerlix around the forearm had yellow/green drainage on it. The physician asked Staff I if he/she was aware of the incision. Staff I told the physician he/she was not aware the resident had an incision. The physician later went to the nurse's station with the missed orders circled. An interview on 7/19/11 at 11:45 a.m. Staff J reported he/she was not aware the resident had an incision. Staff J never removed the splint. An interview on 7/20/11 at 2:56 p.m. the emergency room physician reported the arm was infected, swollen and had yellow and brown drainage. It was evident that there was lack of care. The dressing was old and looked like it had not been changed in 2 - 3 days if not longer. This could have been prevented and the infection could have been caught earlier. The physician indicated this is the worst wound infection he/she has seen in the [AGE] years of working the emergency room . It was urgent that the resident go to the operating room. An interview on 7/20/11 at 4:14 p.m. the orthopedic physician indicated that it is hard to what the resident's prognosis is at this point. The resident needs to complete 6 weeks of intravenous antibiotics to clear up the infection. It's possible the infection will not clear up and surgery may be required. The orthopedic physician stated the worst case scenario the limb would need amputated.