Every finding on record at Winslow House Care Center

Based on observation, clinical record review, facility policy and staff and resident interviews the facility failed to appropriately transfer a resident from the bed to chair with the use of a mechanical lift in order to prevent a fall with injury for one of three residents reviewed (Resident #4). The full body lift tipped during Resident #4's transfer, and the resident sustained a bruise and skin tear. The facility reported a census of 47 residents.The facility corrected the deficient practice through past-noncompliance through the following actions: *Staff education completed 12/26/25 and 12/29/25 regarding full body lift safety *Removal of the full body mechanical lift pending inspection*Completion of weekly patient lift inspectionFindings include:1.The MDS (Minimum Data Set) dated 10/23/2025 revealed Resident #4 had no cognitive impairment, required substantial/maximum assistance to transfer from one surface to another and had diagnoses including heart failure, diabetes and pressure ulcer left heel.The Care Plan revised on 1/23/2026, identified the resident had a fall risk. It directed staff to use a full body lift and two staff to transfer the resident to the shower chair. The Morse Fall Scale dated 10/23/2025 revealed the resident had a moderate risk for falls. The facility incident report dated 12/26/2025 revealed Staff A, RN (Registered Nurse) found the resident still hooked to the full body lift with the machine on its side when she entered the room. She found the resident laying on the floor on her back with knees bent. Staff commented that they were turning machine when the machine tipped over sideways. Staff lowered the resident while the other staff tried to hold the machine to keep it from falling on the resident. The lift's crossbar hit the resident's right eyebrow and she sustained a bruise, 2.5 cm (centimeters) by 1 cm to the area. The lateral side of the right great toe had a skin tear that measured 1 cm by 0.5 cm., and a small plaque scab from the resident's psoriasis. The resident denied pain, headache or nausea. Staff A assessed the resident's vital signs and three staff assisted the resident back up into the shower chair using a different full body lift. The resident reported the machine tipped over when staff were transferring her.The 72 hour fall follow up progress note dated 12/29/2025 revealed the resident reported no pain or discomfort. Staff noted a light yellow discoloration of bruise above the right eyebrow.On 1/27/2026 at 2:00 pm, observation revealed the resident, alert and oriented, and in bed watching television. She indicated at the time of the incident everything went great and then suddenly things started collapsing. Two staff were present, Staff B, CNA tried to catch the resident from falling. Staff C., CNA ran the lift and it just tipped over. She bumped her forehead but was not really hurt, and she failed to recall the injury to her toe. On 1/27/2026 at 11:15 am, Staff F, Administrator reported Resident #4's fall happened on 12/26/2025. Staff G, DON (Director of Nursing) called her and informed her that Staff B and Staff C, CNA's did a transfer with the resident with a [Brand name full body mechanical lift] lift from her bed to a shower chair. When they went to turn her into the shower chair, the [full body mechanical lift name redacted] tipped over. Staff B was able to get her safely and lowered her without the lift tipping over on her. The bar that attaches the sling did hit her during that incident. Immediately they pulled the [lift] off of the floor until it could be inspected by Staff E, ADON who was on sight and Staff H, Maintenance when he returned from out of town. The facility rented a second [brand name] lift until that one could be cleared. Staff B and Staff C were interviewed and retrained by Staff E on proper lift use. Staff were re-educated and the entire following week they drilled it in at the 2 pm meetings with all staff training. The education was also written in the communication book. The inspection revealed the lift did work, however the last bit of opening takes longer. Staff failed to make sure the legs of the lift were open wider than the resident. They did not wait for the legs to open completely. They followed the policy except for waiting for the legs to open completely. They handled the situation to the best of their ability and the resident sustained minor injury.On 1/27/2026 at 11:50 am, Staff E, ADON reported he learned Resident #4 had a fall on the following Monday. He indicated staff used a [Brand name redacted] lift and failed to completely open the legs on the lift, causing the imbalance and the lift to tip. Two staff, Staff B and Staff C were present and were able to catch the resident to a point and lower her safely and keep them from hitting anything. Staff E provided one to one education and had Staff B and C demonstrate the safe use of the mechanical lifts prior to using the lifts again. The resident had no injury from the fall.On 1/27/2026 at 2:50 p.m., Staff A, RN revealed when Resident #4 had the fall with the lift, staff called for help. She entered the room and found the resident on the floor on her back. Staff B reported he supported her when she went down and the lift had tilted onto its side. Staff C, CNA managed the lift . They determined the legs on the lift did not open and it tipped. The resident had a bruise on her forehead and a small skin tear on her toe that healed within a few days. Staff A explained they had staff write statements, educated staff and completed the incident report and progress notes. On 1/28/2026 at 8:13 am, Staff G, RN, DON (Director of Nursing) went to Resident #4's room when she heard staff needed help. Staff B and Staff C were transferring her with the [Name redacted] lift bed to shower chair. The [lift] when it was being moved to the shower chair, it tipped. She went down assisted, but she did bump her head on the [lift] bar. She had a bump and bruise on the left side of her forehead and a skin tear on her toe. Staff G explained checked afterwards to see if the legs were spread. The legs did spread but not out all the way. Per the DON, brought the lift out afterwards and tested it, and the legs did spread out completely. The DON explained did education that when moving and turning the machine, the legs need to be completely spread out. Per the DON, the reason they think we said the lift was not working properly was because the legs did not spread as they should have. Per the DON, educated at the meeting at 2 p.m. the aides, all of them, and was is in the communication book.On 1/28/2026 at 8:30 am, Staff C, CNA reported when Resident #4 fell, she transferred her along with Staff B. Staff C called Staff B after she got the sling under the resident. They hooked the sling to the lift. Staff C operated the lift, got the lift up and pressed the button to separate both legs. The grinding noise had stopped and she assumed the legs had fully spread out. Staff C backed up from the bed, and when she went to turn the lift, it began to lean left. She reached out with her left hand in order to grab it and keep it from tipping, but it was too strong for her to stop it. The weight was stronger than her and they started going to the floor. The wheels capsized and lifted into the air. Staff C slid down as gently as she could and Staff B grabbed the resident in order to start steering her into the chair. Staff C's right foot slid and ended up underneath the [brand name lift] wheels. Staff B slid the resident to the ground. Once it started coming down, the whole thing came down. Thankfully, it was a padded lift. The crossbar hit the resident on the left side of the eyebrow and it bruised her. She also had a skin tear on her toe. Staff C believed the DON documented the lift malfunctioned. Staff C did training with Staff E, and she had to demonstrate using the lift. In the end, they determined the [brand name] lift did work correctly. They took that particular [brand name] lift off the floor, somebody checked it out and said it worked correctly. For some reason the legs did not spread out fully. Typically, when she heard a grinding noise it fully opened. The battery was fine so she assumed the legs were spread out. She received coaching and had to demonstrate the procedure. On 1/27/2026 at 4:05 pm, Staff B reported he had just finished across the hall and Staff C said she needed help with Resident #4. Staff C had the [brand name lift] controls and Staff B had the shower chair. Staff C raised the sling up from the bed. Staff B thought the [brand name lift] legs were not open as they should have, the [brand name lift] tipped and the resident hit her head on top of the lift. Staff B had a hold of the sling and tried to lower the resident. Staff B went to get the nurse, she assessed the resident and they got her up off the floor. After the incident he and Staff C were educated regarding safety issues, including the need to make sure the Hoyer legs are open all the way. The also had to demonstrate the procedure.The facility Full Body Lift policy included the following steps:a. Explain procedure to resident, provide privacy b. Appropriate sling size selected c. Two staff members present for transfer d. Sling placed correctly e. Sling correctly attached to the lift f. Resident instructed to cross arms g. One staff manages the lift while the second staff guides the resident, providing support as needed h. Resident positioned for comfort i. Sling removed. Sling may remain under resident in chair if addressed in resident care plan

Based on staff interview and Centers for Medicare and Medicaid Services (CMS) 2567 review, the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to identify previously identified deficiencies, resulting in a repeated deficiency cited on the current survey and cited in the previous survey. The facility reported a census of 47 residents. Findings include: The Centers for Medicare and Medicaid Services (CMS) 2567 form dated 9/25/2025, reflected a deficiency identified for staff failure to use Enhanced Barrier Precautions while doing resident cares for those identified as a risk. During the current complaint survey and facility reported incident survey dated 1/28/26, the team identified the same deficiency, Infection Control (F880).During an interview with the Administrator on 1/28/26 at 2:30 pm she reported she monitors and audits the effectiveness of the QAPI process and confirmed the concern related to the pattern of a deficiency at F880.

Based on observations, clinical review, staff and resident interviews, and facility policy review, the facility failed to complete wound treatment as ordered for 1 of 5 sampled residents (Resident #1). The facility reported a census of 47 residents. The facility corrected the deficient practice though past-noncompliance through the following actions: *All residents with active treatment orders were assessed and treatments confirmed as completed per physician order*Reeducation of all licensed nursing staff on 1/4/26 and 1/5/26*Post correction audits and weekly audits1.Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had diagnoses which included heart failure, diabetes, non-Alzheimer's dementia, vascular disease and a stage 3 pressure ulcer, and received pressure ulcer/injury care. The resident required substantial assistance from staff for toileting, bathing, and partial assistance for ambulation. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated the resident had severe cognitive impairment. Review of the Care Plan revised 1/24/26 revealed Resident #1 had an actual pressure ulcer related to impaired mobility, described as a Stage III (full-thickness skin loss) on the left lateral foot. The Care Plan intervention dated 1/24/26 directed the staff to provide adequate calories and protein for skin healing and integrity, and the interventions dated 9/17/25 revealed to assess the condition of the pressure ulcer and surrounding skin weekly and to complete treatments as ordered. Review of a Progress Note dated 12/16/25 revealed Resident #1 went out to a local [wound provider] appointment on December 16, 2025 and returned without new orders. Review of a progress note from a local [wound provider] dated 12/16/26 indicated the resident's wound appears worse as noted by an increase in dimensions. The diabetic left lateral wound described as clean, painful and fragile and has been present for more than a year. The Physician Order dated 11/17/25 directed the staff to cleanse the foot wound and surrounding skin. Paint callous and wound with betadine, cover with a foam dressing and secure with gauze wrap and tape. The wound care should be completed daily on the evening shift. Review of the Physical Therapy Treatment Encounter Note for date of service 12/18/25 signed by Staff L, Physical Therapy Assistant and Rehabilitation Director revealed, Pt (patient) states wound care was not completed last night. Wound cover is still dated 12/16 from wound Dr. (doctor) appointment. Per this note, the Administrator was notified. The Incident Report dated 12/18/25 for Resident #1 revealed, Administrator informed nurse that therapy aide informed her that the dressing to the residents left foot had a past date on it and had not been changed on the evening shift. The Resident Description section revealed, When day nurse went to change dressing, resident stated that no one has changed dressing for a couple days. The Immediate Action Taken section revealed, Nurse changed dressing ASAP (as soon as possible) after being informed it wasn't changed by 2-10 nurse.Review of Resident #1's December 2025 treatment record revealed Staff K, LPN (Licensed Practical Nurse) signed of the wound treatment which indicated he completed it on 12/15, 12/16 and 12/17/25. Staff K placed his initials with a check mark on the record indicating the treatment was completed. Interview with Staff K, LPN on 1/28/26 at 8:55 am revealed Staff K forgot to do the dressing change whatever day in December the resident went to the wound clinic. Staff K was uncertain of the day but stated it was around her appointment date. He admitted he just signed it off because the wound clinic did the dressing change that day. Staff K stated he really cannot remember the date, but stated he just signed it off and reported everyone else did it that way on the days a resident goes to the wound clinic. He stated he did not make any progress notes in regards to the wound in the resident's clinical record. He stated he got terminated for just signing off the dressing change without having completed it. During an interview with Staff G, Director of Nursing (DON) on 1/28/26 at 7:30 am, Staff G stated apparently he was not doing the skin treatments as ordered and was just signing it off as completed. She stated they became aware of the situation on 12/18/25 when Resident #1 had a wound dressing dated 12/16/25. Staff G stated Staff E, Assistant Director of Nursing (ADON) handled the investigation. During an interview with Staff E on 1/27/26 at 11:48, the incident was brought to his attention on 12/18/25 from the Administrator who she received a report from the [wound provider] in regards to Resident #1's dressings not being changed as ordered. Staff E stated the resident went to the [wound provider] on 12/16/25 and stated he really cannot remember if the reported date on the dressing was the day before the weekend or the weekend before. He stated he came into the investigation at the end and was told by the Administrator that on 12/18/25 Resident #1 had a dressing dated 12/16/25. During an interview on 1/28/26 at 1:00 pm with Staff I, Registered Nurse (RN), Staff I stated it was brought to her attention on 12/18/25 that Resident #1's pressure sore dressing currently had a date on 12/16/25 on it. She observed this to be true. She completed the scheduled dressing change on her shift as it was apparently not completed on 12/17 as ordered. According to the Medication Administration Policy last revised on 6/30/2023 directed staff to administer medications as prescribed. The procedure for dispensing medications is as follows:Wash hands with soap and water prior to beginning medication pass. Alcohol waterless sanitizer is acceptable between residents.Open medication cart with key held by licensed nurse/OMT/Director of nurses. Medication labels will be checked against current MAR for individual resident's medication pass.Remove medication with labels facing the nurse/certified medication technician. Check labels to medication administration record. Verify resident, drug, strength, dose, route and hours of administration with medication administration record.Follow manufacturer's directions for medication use.Dispense medication into medication cup.Return medications to cart. Close and lock medication cart. Identify the resident. Administer medication. Assure resident has taken the medication. Sign medication on the medication administration record.

Based on observations, clinical review, staff interviews and facility policy review, the facility failed to utilize Enhanced Barrier Precaution (EBP) for 1 of 3 sampled residents reviewed (Resident #1). The facility reported a census of 47 residents.Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had diagnoses which included heart failure, diabetes, non-Alzheimer's dementia, vascular disease and a stage 3 pressure ulcer (full thickness skin loss), and received pressure ulcer/injury care. The resident required substantial assistance from staff for toileting, bathing, and partial assistance for ambulation. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated the resident had severe cognitive impairment. Review of the Care Plan dated 9/8/25 indicated the resident needed Enhanced Barrier precautions due to a wound. The Goal section informed staff the precautions would reduce the spread of infectious agents and minimize the transmission of infection. The Care Plan interventions dated 9/8/25 directed the staff to wear a gown and gloves for high contact activities and to have personal protective equipment (PPE) available for staff near the entrance of the resident's room. Additional interventions dated 9/8/25 directed staff to maintain signage on the outside of the resident's door regarding the precautions needed, required PPE, and high contact resident care activities, and to practice good hand hygiene.Observations on 1/27/26 at 1:50 pm revealed the resident's bedroom door did not have a PPE sign hanging on it and the room did not have PPE available for staff use. Staff J, Registered Nurse (RN) entered the resident's room to complete her daily dressing change. Staff J failed to put on a disposable gown as she assembled the needed supplies. Staff elevated the resident's foot and removed the soiled dressing which appeared to have a dark substance on it and then proceeded to perform wound measurements and completed the wound treatment. Staff J re-dressed the resident's wound and cleaned up the room. Staff J completed all of these tasks without having on a disposable gown as directed by the EBP requirements. During an interview with Staff J, RN on 1/27/26 at 4:00 pm, the RN stated she did not wear a disposable gown per policy while completing the wound treatment earlier today at 1:50 pm. She stated she forgot to put it on because the resident's room did not have a sign on the door indicating a need for PPE and the resident recently had a room change. During an interview with Staff E, Assistant Director of Nursing on 1/28/26 at 2:30 pm, Staff E was informed about Staff J not wearing a gown when completing the wound dressing change yesterday for Resident #1. Staff E stated he re-educated her after the last survey regarding this issue. Staff E stated the resident recently changed rooms and the staff must not have not brought the sign and PPE with her.Review of the policy for Transmission Based Precautions updated on 4/1/24 informed the staff Enhanced Barrier Precautions (EBP) referred to an infection control intervention designed to reduce the transmission of multi-drug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The policy directed the staff to use personal protective equipment such as gloves and gowns. The staff should don the protective equipment prior to high-contact care activities. The policy identified high-contact activities: wound care: any skin opening requiring a dressing.

Based on observations, clinical record review, staff interviews and facility policy review the facility failed to utilize Enhanced Barrier Precaution (EBP) for 4 out of 4 encounters with residents (Resident #3 and Resident #32) and their environment, and failed to personal protective equipment (PPE) while handling dirty laundry. The facility reported a census of 48 residents.Findings include: The Minimum Data Set (MDS) assessment for Resident #3 dated 8/1/25, listed diagnoses of pressure ulcer of the left heel, and diabetes mellitus (DM) The MDS listed the Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The Care Plan for Resident #3 dated 10/3/25 reflected she needed for EBP related to wound care.On 9/22/2025 at 10:25 AM Staff K, Certified Nurse Aide (CNA) reported the EBP sign on the door of Resident #3's room because of her wound.1. On 9/23/2025 at 2:03 PM Staff A, Certified Nurse Aide entered Resident#3's room washed her hands. The Care Coordinator stood back to observe. Staff A applied gloves. Staff B, CNA entered the room, washed her hands, and put gloves on. Staff A and Staff B applied the gait belt and with the slide board, and moved Resident #3 to the bed in a slow smooth motion. Staff A put the resident's feet up on the bed. On 9/23/2025 at 2:10 PM, Resident #3 stated she needed to get back for cake and ice cream activity. Staff A sat her back up on the side of the bed, and both CNA's moved Resident #3 back in the wheelchair (w/c). Both CNAs failed to use EBP. The EBP sign hung on the room door and the supplies hung on the back of the room door.2. On 9/24/2025 at 7:55 AM, Staff B, CNA staff entered Resident #3's room to make her bed, They talked about her leaving at 9:30 for the wound clinic. Staff B reported they needed to get her boot on, they forgot right away this morning. Staff B put the w/c pedals on Resident #3's w/c and put the arms on her w/c. Staff B failed to use any EBP when she made the bed, put the arms, w/c pedals and placed the boot on Resident #3.3. The MDS for Resident #32 dated 8/21/2025 included diagnoses of stroke, hypertension and anxiety. The MDS listed the BIMS score of 15 out of of 15, which indicated intact cognition. The Care Plan for Resident #32 dated 9/17/2025 identified stage II pressure ulcers to her right and left buttocks. The Care Plan directed the resident needed EBP. On 9/24/2025 at 8:07 AM Staff C took Resident #32 into the bathroom. Staff C failed to wear a gown or gloves in the bathroom or as she walked Resident #32 to her recliner. Staff C confirmed she just got Resident #32 up for breakfast. The sign that hung on the room door for Resident #3 and Resident #32 directed stop, Enhanced Barrier Precautions. Everyone Must: clean their hands, including before entering and when they leave the room. Providers and staff must also: Wear gloves and a gown for the following high contact resident care activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding, tube, tracheostomy. Wound Care: any skin opening requiring a dressing. 4. On 9/2/2025 at 10:02 AM, the black water pipe that hung above the hanging clean clothes in the laundry room held 1/2 an inch thick by 2 feet long debris. The 12-inch fan that hung on the wall over the folding table held 4 gray balls 1/2 inch thick of debris.On 9/2/2025 at 10:02 AM, Staff I, Laundry reported she failed to know who cleaned the pipe above the clean hung laundry, and she reported Environmental Supervisor cleaned the fan. Staff I failed to wear an apron while she removed dirty clothes form the basket and placed them in the washer. She reported she needed to wear a gown with isolation items but failed to need other PPE with moving dirty laundry. Staff I opened the cabinet and pointed out the PPE for the isolation. On 9/25/2025 at 10:17 AM the Environmental Supervisor reported the gowns, gloves, and goggles were in the cabinet the laundry. She reported the staff in the laundry room needed to use the PPE when isolation is used or if the laundry is really dirty, gloves and gown otherwise glove with dirty laundry out of the tube. She acknowledge the dirty fan on the wall.On 09/25/2025 at 9:43 AM Staff J, Registered Nurse (RN) reported the staff needed to use the EBP for residents with wounds, catheters, colostomy, any tubes from their bodies. She stated the staff are expected to use the EBP when they come in contact with the wounds or tubes. She said the EBP isn't needed to put foot rests in place on the wheelchair (w/c) or adjusting the resident in then w/c, and they didn't need EBP to remake the resident bed. On 9/25/2025 at 12:22 PM the Director if Nursing (DON) reported she expected the staff to use EPB as directed by the signs on their room doors with contact of the residents and their personal items. The DON reported she needed to check the policies for the personal protective equipment (PPE) the staff needed to use with dirty laundry. On 9/25/2025 at 12:51 PM the DON reported the appropriate PPE is an apron with moving dirty laundry from the bin to the washer.The facility provided a policy titled Infection Prevention and Control-Laundry dated 8/1/2017, that directed soiled linen shall be handled as little as possible and with minimum agitation to prevent gross microbial contamination of the air and of the person handling the linen. Staff will wear gloves and other appropriate PPE when handling soiled linen.

Based on observation, record review, interviews, and policy review the facility failed to maintain code status records for 1 of 3 residents reviewed (Resident #21). The facility was unable to locate code status documentation after a resident's return from the hospital. The facility reported a census of 48 residents. Findings include:The Minimum Data Set, dated [DATE] for Resident #21 revealed the resident scored 14 out of 15 on a Brief Interview for Mental Status exam (BIMS), which indicated intact cognition. The MDS further indicated diagnoses of coronary artery disease, mild persistent asthma with acute exacerbation, and obstructive sleep apnea.The resident's Care Plan did not include the resident's preference for Cardiopulmonary Resuscitation (CPR) or Do Not Resuscitate (DNR).The resident's Electronic Health Record (EHR) did not include the resident's preference for CPR or DNR.The resident's paper chart did not include the resident's preference for CPR or DNR.On [DATE] at 3:01 PM Staff H, Licensed Practical Nurse (LPN) confirmed he worked mostly overnight which meant he was the only nurse on duty. He stated code status documents should be in the front of the resident's paper chart. Staff H looked through chart sections more than two times and he was unable to find code status documents. When asked if there was any reason it would be removed, Staff H stated the resident had been to the hospital and indicated the nurse overseeing the resident's return to the facility was supposed to put the documents back in the chart. When asked where else the information might be found, Staff H did not know where else to look and was not able to communicate the resident's code status. When asked if he would do CPR on this resident without the form in the chart, Staff H looked through the chart again and did not answer.On [DATE] at 3:04 PM, the Director of Nursing (DON) confirmed Resident #21 came back from the hospital recently. She stated the care coordinator was in charge of the paperwork that came back and signatures. She contacted him and he did not think he had her code status documentation.During a follow up with the DON on [DATE] at 4:03 PM, she indicated the facility was unable to locate the document and would correct it.On [DATE] at 1:11 PM, the Administrator said that unfortunately the nurse sent the original code status form to the hospital without making a copy for the chart. She confirmed the resident went to the hospital [DATE] and came back [DATE]. A policy titled Cardiopulmonary Resuscitation (CPR) Policy Resuscitation Policy effective [DATE] documented each resident's resuscitation status will be maintained in the clinical record as follows: A signed CPR policy indicating the resident's choice of CPR or do not perform CPR will be placed directly under the front cover of the resident's chart.

Based on record review and staff interviews, the facility failed to accurately code all diagnoses and Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident reviewed for Minimum Data Set (MDS) assessments (Resident #7). The facility reported a census of 48 residents. Findings include: Record review of Resident #7's Notice of PASRR Level II Outcome dated 5/22/2024 revealed the resident had short term approval until 5/22/2025, and determined to be a Level II (a comprehensive, in-depth evaluation for individuals determined to have a Serious Mental Illness (SMI), Intellectual Disability (ID), or related condition that requires specialized services.) The PASRR documented the resident had the diagnosis of schizoaffective disorder, bipolar type (a mental health condition that combines symptoms of schizophrenia and bipolar disorder). The PASRR also included the following direction to the facility: The facility should document yes to the following question on the MDS Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?.The MDS dated [DATE] for Resident #7 documented the following question response was marked no: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The MDS also lacked documentation of her diagnosis of schizoaffective disorder, bipolar type.The MDS dated [DATE] for Resident #7 lacked documentation of schizoaffective disorder.During an interview on 9/25/2025 at 12:21 PM with the Director of Nursing (DON) informed Resident #7 MDS's dated 12/30/24 and 6/27/25 should reflect her current PASRR Level II status and her diagnosis of schizoaffective disorder, bipolar type. She also informed she followed the Resident Assessment Instrument (RAI) manual.

Based on interview and clinical record review, the facility failed to obtain a resident's Level II Preadmission Screen and Resident Review (PASRR), failed to implement Level II requirements, and failed to resubmit the Level I after expiration for one out of one resident reviewed (Resident #7). The facility reported a census of 48 residents. Findings include:The Minimum Data Set assessment for Resident #7 dated [DATE] included diagnoses of Bipolar disorder and cancer. The Brief Interview for Mental Status (BIMS) reflected a score of 11 out of 15, which indicated moderately impaired cognition. Review of Resident #7's Preadmission Screen and Resident Review (PASRR) dated [DATE] reflected following determination: Level 1 positive, No status change, and further documented did not require further PASRR evaluation due to lack of significant change since previous PASRR Level II evaluation. PASARR paperwork revealed the resident's previous summary of findings remained valid for the resident's stay at the nursing facility, should accompany resident if transferred to another nursing facility, and services in previous PASARR remained appropriate and should continue to be delivered. The PASRR directed since was determined resident had a PASRR condition, the facility needed to document the PASRR condition in important Medicaid nursing facility paperwork, and directed the following question should be marked yes on the MDS: Is the resident currently considered by the stated level II PASRR process to have a serious mental illness and/or instinctually disability or a related condition? PASRR paperwork directed that Resident#7's specific PASRR condition should be checked in question A1510, Level II PASRR conditions (on MDS).The PASRR outcome explanation revealed a PASRR Level II evaluation not required as no status change occurred and the current PASRR evaluation remained valid. The Level II PASRR for Resident #7 dated [DATE], obtained by the facility on [DATE], reflected approval for a short term stay that ended on [DATE]. The PASRR Level II reflected mental illness as schizoaffective disorder, bipolar type. The Level II PASRR for Resident #7 directed specialized services for her behavioral health and/or developmental condition were required. The nursing facility was required to Care Plan in a PASRR compliant fashion for all identified services including Specialized Services and Rehabilitative Services.The Care Plan for Resident #7 dated [DATE] failed to address PASRR recommendations. On [DATE] at 7:40 AM, Resident #7 reported she failed to sleep well last night related to bad dreams. On [DATE] at 8:44 AM the Activity Director reported Resident #7 reported yesterday morning she failed to sleep well the night before due to nightmares.On [DATE] at 2:37 PM, the Registered Nurse Consultant (RNC) MDS Coordinator, reported the facility obtained the PASRR Level I and placed in Resident #7's record. She reported the facility failed to obtain a copy of the PASRR Level II and they failed to complete a resubmission due to the short-term approval expired on [DATE]. The RNC reported she expected the facility to obtain the Level II PASRR put the recommendations in the Care Plan and she expected the a new PASRR completed before the expiration of the short-term approval. On [DATE] at 2:52 PM the Director of Nursing (DON) reported she failed to know Resident#7's Level II PASRR existed. She reported she expected the Level II PASRR addressed on the Care Plan. She stated she failed to know of a policy or procedure that addressed PASRR.

Based on observation, record review, interviews, and policy review the facility failed to provide a resident unable to carry out Activities of Daily Living (ADLs) independently the necessary services to maintain adequate personal hygiene and grooming (Resident #28). The resident was admitted to the facility 9/4/25 and was bathed/showered 1 time between 9/4/25 and 9/25/25. The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) for Resident #28 dated 9/10/25 documented diagnoses of stroke, non-Alzheimer's dementia, and depression. Section GG indicated the resident required supervision or touch assistance with tub/shower transfers and bathing. The resident's Brief Interview for Mental Status score was 2/15 which indicated severe cognitive impairment.The Care Plan for Resident #28 indicated she was at risk for skin breakdown due to incontinence and impaired mobility. It further documented her ability to complete Activities of Daily Living (ADLs) had deteriorated related to dementia and impaired mobility. An intervention dated 9/17/25 indicated the resident should get a whirlpool/shower two times per week. The care plan did not address bathing refusals or interventions.Observation on 9/22/2025 at 11:21 AM revealed the resident in the dining room with her hair up in partial pony tail. The hair in back that remained down appeared matted against the back of her head.On 9/23/2025 at 12:11 PM Resident #28's hair remained pressed against the back of her head and appeared stringy. The small pony tail was still in her hair with portions sticking out and twisted as though slept on.On 9/24/2025 at 8:12 AM the resident was at her table in the dining room. Her hair appeared stringy with strands clumped together around her ears and the back of her head.A final observation on 09/25/2025 at 7:55 AM revealed the resident's hair remained stringy around her ears.On 9/24/2025 at 2:52 PM, bathing sheets requested from the DON (Director of Nursing). She provided a document from the Electronic Health Record (EHR) titled Point of Care Audit Report which indicated the resident had scheduled bathing times on 9/8/25 at 1:59 PM, 9/10/25 at 1:41 PM, 9/16/25 at 1:46 PM, and 9/19/25 at 1:50 PM.An additional record titled Documentation Survey Report revealed that on 9/8/25 the resident received a bath/shower. On 9/10/25, 9/16/25, and 9/19/25 the resident refused.A review of the resident's progress notes revealed that on 9/10/25 at 5:18 PM the resident refused her shower 3 times that day. The progress notes did not include documentation that the resident refused any other days, whether or not she was offered alternate options such as a bed bath, or if any additional interventions were tried during the month. The progress notes did not include documentation that the Provider had been notified of the refusals, or that they had been communicated to the resident's responsible party.During an interview on 9/25/2025 at 8:20 AM Staff F, Certified Nurses Aide (CNA), stated residents who refused a bath or shower were offered a bed bath. Three approaches would be made and then they would usually not get a bath or shower until their next scheduled day.On 9/25/2025 at 12:21 PM Staff G, CNA stated that when a resident resident refused a bath or shower they notified the nurse and documented why the resident refused. She stated they would try the next day if there was time, otherwise the resident would wait until their next scheduled day. Staff G stated she had only gotten Resident #28 in for bathing once. She reported the resident had recently been changed to evening bathing but was not sure if that was working. When asked who completed bathing when she was out of the building, Staff G said it varied and there was not a set plan.On 9/25/2025 at 10:58 AM the Director of Nursing (DON) stated bathing schedules were determined at admission and residents were integrated into the list. Baths were offered Monday, Tuesday, Thursday, and Friday. If a resident refused they were reapproached and it was documented on the Point of Care list she had provided. The DON confirmed she was aware the resident was refusing bathing and thought they were eventually getting her to do it. Documentation lacked this occurred.The Administrator was asked for a bathing policy. On 9/25/2025 at 10:23 AM she provided documents titled Bathing Prompts that listed the steps staff should follow for showers and whirlpool baths. The documents were not specific to Resident #28 and did not include steps to take if a resident refused.

Based on observation, record review, and staff interviews the facility failed to update as needed and provide current daily staffing information for residents and visitors. The facility reported a census of 48 residents. Findings include: During an observation on 9/22/2025 at 9:17 AM, the facility's staffing posting on the wall at the main facility entrance was observed to be dated 9/19/25. Review of Daily Staff Posting records from September 1 to September 23, 2025 had no edits or changes in staffing for the month. During an interview on 9/24/25 at 2:40 PM Staff D, Registered Nurse (RN) and Staff E, RN informed they did not have anything to do with the Daily Staff Posting and the Director of Nursing (DON) completed them. During an interview on 9/24/25 at 2:45 PM with the DON, informed it was on the night nurses responsibilities to change them over. During a follow up interview on 9/25/25 at 12:20 PM with the DON, informed she was the only one that updated the Daily Staff Posting records. She also revealed she had had new night shift nurses who were supposed to change it over, and thought they had forgot.

Based on observation, staff and resident interviews, and facility policy and clinical record review, the facility failed to ensure an accurate inventory of medications by accounting for controlled medications that have been received, dispensed, and administered for four of four residents reviewed. (Residents #1, #5, #6, & #7). The facility reported a census of 44 residents. Findings include: 1. The MDS (Minimum Data Set) dated 2/5/2025 revealed Resident #1 had intact cognitive skills, transferred with assistance, had diagnoses including diabetes, chronic pain, and heart disease. The MDS indicated the resident had frequent pain rated at #8 on a scale of 1-10. The Care Plan identified the resident had pain and directed staff to administer medications as ordered and assess effectiveness. The physician's order's included an order for Hydrocodone-Acetaminophen Tablet 5-325 mg (milligrams). Give one tablet by mouth every 12 hours as needed for pain dated 12/11/2024. On 12/26/2024 the physician changed the order and instructed staff to administer one tablet every 8 hours. On 1/31/2025, the physician changed the order and directed staff to administer the medication every 4 hours as needed and 1 tablet scheduled at bedtime. A review of the resident's December, 2024 MAR (Medication Administration Record) and the Controlled Substance Shift Count and Usage Record revealed: 12/12/2024 and 12/23/2024, staff signed off Hydrocodone-Acetaminophen 5-325 mg tablets on the count sheet and failed to document the medication administration on the resident's MAR. 1/1/2025 - 1/31/2025, staff signed off the Hydrocodone-Acetaminophen 5-325 mg tablets on 1/6 (two times), 1/7, 1/9, 1/12, 1/14, 1/15, 1/18, 1/19, 1/20, 1/23. The count sheet indicated staff dropped the medication on 1/15/2025. On 3/31/2025 at 12:30 P.M. the resident voiced no concerns with his medications and currently found relief with Tramadol, a recent physician order. On 1/24/2025 the facility self reported to the Department of Inspections and Appeals a concern with Resident #1's Hydrocodone/Acetaminophen. On 1/23/2025 Staff E, Medication Aide identified the resident's medication cassette, the plastic tab that enclosed the medication in the cassette appeared loose and the Hydrocodone/Acetaminophen had been replaced with a Tylenol. The facility followed up with an investigation and reported it to police. The MDS dated [DATE] revealed Resident #5 had intact cognitive skills, had diagnoses including Parkinson's disease and breast cancer, and had constant pain rated as high as #10 on a scale of 1-10. The Care Plan identified the resident had back pain and directed staff to administer medications as ordered and assess the pain and effectiveness. The physician's orders included: Oxycodone 5 mg, every evening at bedtime started on 4/11/2024. Oxycontin ER 10 mg every 12 hours for pain started on 2/23/2025 and discontinued on 3/6/2025. Oxycodone 5 mg every 8 hours as needed for pain started on 3/20/2023. The Usage Record revealed: Oxycodone 5 mg, staff signed off on the count sheet on 1/17/2025 and failed to document the medication administration on the resident's MAR. The facility failed to provide the entire Controlled Substance Shift Count and Usage Records for Oxycodone 5 mg initiated on 1/21/2025 with 30 doses on hand through 1/31/2025 with 39 doses remaining. On 1/28/2025 29 the count sheet added 29 doses delivered from the pharmacy on 1/28/2025 The facility failed to provide the entire Controlled Substance Shift Count and Usage Records for Oxycontin ER 10 mg initiated on 11/17/2024 with 28 doses on hand through 11/22/24 with 13 doses remaining. The MDS dated [DATE] revealed Resident #6 had moderately impaired cognitive skills, diagnoses including dementia and scoliosis, and had frequent pain that affected sleep. The Care Plan identified the resident had pain related to scoliosis and directed staff to administer medications as ordered, assess the effectiveness and monitor signs of pain. The physician orders included an order for Hydrocodone-Acetaminophen 7.5 - 325 mg/15 ml (milliliters). Give 15 ml by mouth every 8 hours as needed. The facility failed to provide complete records of Hydrocodone/Acetaminophen 7.5/325 mg. administration and count sheets for pharmacy deliveries dated: 11/20/2024 - #45 doses 11/22/2024 - #473 doses 12/16/2024 - #90 doses 1/10/2025 - #100 doses 1/15/2025 - #73 doses 2/11/2025 - #473 doses A review of the resident's medication administration records, count sheets and pharmacy delivery sheets revealed incomplete documentation and verification. On 4/1/2025 at 1:15 P.M. the resident sat on the edge of her bed and indicated she often had pain in her legs, and took Lortab (Hydrocodone/Acetaminophen) one or two times a day. The MDS dated [DATE] revealed Resident #7 had severe cognitive impairment, diagnoses including spinal stenosis and diabetes, and received scheduled and as needed pain medication. The Care Plan indicated the resident had pain related to spinal stenosis and received opioid and non opioid medications. The Care Plan directed staff to administer medications as ordered, assess the effectiveness and monitor complaints of pain. They physician's orders included: Morphine 20 mg/ml, 5 mg every 4 hours as needed (0.25 ml). 1/16 - 1/17/2025. 1/17/2025 - new physician order - Give 0.5 ml every 4 hours as needed. 12/6/20204 - Fentanyl patch every 72 hours - 12 mcg (micrograms)/hour. Oxycodone 5 mg, one tablet every 4 hours as needed. 1/10- 1/17/2025 Oxycodone 10 mg - one tablet every 4 hours for pain. 1/10 - 1/17/2025. Hydromorphone 2 mg, one tablet every 6 hours as needed. 1/3- 1/10/2025. Fentanyl patch every 72 hours - 50 mcg/hour. 1/16 - 1/19/2025. Hydrocodone/Acetaminophen 10/325 mg., 1 tablet every 4 hours as needed. 11/8/2024. The Usage Record revealed staff signed off on the count sheet doses of the Hydrocodone/Acetaminophen 10/325 mg 2 doses on 12/11, 2 doses on 12/12, 1 dose on 12/17, and 1 dose on 12/18. Staff failed to sign off administration of the medication on the December MAR. The pharmacy delivery records included: #30 Hydrocodone/APAP 10 -325 mg delivered on 11/19/2024, 11/25/2024 and 12/3/2024. The facility failed to provide the Controlled Substances Shift Count and Usage Records to verify administration and accounting of the medication. 2. Observation on 4/1/2025 at 12:22 PM of a narcotic drug count for medication carts South and North/Northwest with Staff A-RN and Staff B-RN revealed the following: a. At 12:25 PM a bubble pack for Resident #8 labeled Hydro/APAP tab 5-325 milligrams to take 1 tablet by mouth 3 times a day laid on top of the cart empty. Review of the Controlled Drug Receipt record revealed there should have been 2 tablets remaining in the card. Interview with Staff A-RN at this time revealed Staff A gave the resident a dose of Hydro/APAP at 7 am and 1130 am but failed to sign the medication out this am after she administered the medication to the resident. Staff A-RN signed off the 2 narcotic tablets at this time that she gave earlier today. b. At 12:35 PM a bubble pack for Resident #1 revealed 36 Tramadol HCL tabs 50 milligrams to take 1 tablet by mouth 3 times daily. The Tramadol bubble pack revealed 36 Tramadol tablets but the Controlled Drug Receipt Record indicated there should be 37 Tramadol tablets. Staff A-RN stated she gave Resident #1 a Tramadol at 8:00 am today but failed to sign it out on the receipt record. Staff A signed off the narcotic at this time. During an interview on 4/1/25 at 1:00 PM with Staff C-Administrator, Staff C stated she would expect the nurses to sign out the narcotics at the time they dispense them. On 3/31/2024 at 12:35 P.M., Staff F, DON (Director of Nursing) reported working at the facility for one year. Staff E phoned Staff F on 1/23/2025 and reported the concern with Resident #1's Lortab (Hydrocodone/Acetaminophen). The Lortab had a Tylenol in the cassette in it's place. Staff F directed Staff E not to give it, and to give his Lortab. The investigation went from there. They reviewed the resident's pain, and he had no increase in pain, he felt he was getting the right medication and had no concerns. Staff reviewed all cassettes to ensure the medications were correct, and they found no further issues. A narcotic count on all residents failed to reveal any concerns. Nursing staff were re-educated regarding medication administration and narcotic counts. We also followed up with education regarding what a med aide's scope of practice is. Some of the nurses received written disciplines/education regarding signing out the narcotics on the count sheets and also documentation on the MAR in PCC (Point Click Care). Staff F reported she continued with weekly audits to ensure staff document medication administration correctly. The facility received corporate direction to keep medication cart keys with the assigned nurse at all times during the shift. On 4/1 at 3:45 PM - Staff F reported they had no further information related to the narcotics, MARS and count sheets to submit. On 3/31 at 1:08 P.M., Staff A, RN reported working at the facility for two years and had no concerns with narcotic counts. Staff always count with two staff and verify information. Prior to this incident Staff A would hand the keys to her medication cart to another staff RN or DON if she took a lunch break and left the facility, and would not count narcotics prior to leaving. Currently, she keeps the keys with her when she leaves the building during her lunch break. They were told to. Staff A had no concerns with any staff, and they were all re-educated, and the facility now uses medication blister packs instead of the plastic cassettes. Staff destroy narcotics with two staff, and place the discontinued medications in the drug buster. On 3/31/2025 at 10:50 A.M., Staff D, RN reported working at the facility for 6 years. Staff D verified her initials on the January, 2025 Controlled Substance Shift Count and Usage Record for Resident #1. NARCOTIC COUNT AND USAGE RECORD compared to the January 2025 MAR with Staff D: January 1 - two doses signed out at 0700 and 1110. MAR - No 0700 dose on MAR January 6 - two doses signed out at 0630 and 1200 - MAR - Neither dose on MAR January 9 - two doses signed out at 0700 and 1500 - MAR - Neither dose on MAR January 14 - dose signed out at 0800 - Not on MAR January 15 - 0800 dose dropped, one dose given at 0800 - Not on MAR January 19 - 0800 dose signed out at 0800 - Not on MAR January 20 - 0900 dose signed out at 0900 - Not on MAR Staff D indicated she must have forgotten to put in on the MAR. At 3:30 P.M. - Staff D reported on 1/15/2025 she dropped the Lortab as documented on the count sheet. She administered the medications while the resident sat in bed and she dropped the entire cup of his pills. She reported it to housekeeping and they swept and did not find it. Staff D received discipline for documentation errors, including education regarding signing out narcotics. Staff D revealed she used to give the medication cart keys to another nurse when she left the facility and went to lunch. About six weeks ago administration instructed staff to keep the keys on them at all times. Staff D still leaves, but she takes the keys with her. The keys in her possession include keys to the medication room, medication cart, and narcotic drawer. On 4/1/25 2:10 P.M. Staff E, Medication Aide, via phone interview reported working at the facility for four years. Staff E worked every weekend and 6-10 P.M. Monday through Friday. On 1/23/2025 Resident #1 asked for a PRN (as needed) pain medication . Staff E notified Staff H, RN the agency nurse on duty. He instructed Staff E to administer the PRN. When she attempted to open the cassette, the door appeared weak, and the pill did not look correct. It had the appearance of a Tylenol. Staff E reported the concern to Staff H, and notified the DON. The DON instructed her to fill out a form, lock up the medication and not to give it. The remaining pills in the cassette were correct. Currently, medication aides are allowed to count the narcotics along with a nurse at the change of shift. Pharmacy delivers medications during her shift, and both the nurse and medication aide can accept the medications, sign for them and place the delivery record in a folder in the medication room. Review of the undated Controlled Substance - Administration Steps procedure directed the staff to do the following: 1. Medications listed as Schedule II are stored separately from all other medications. 2. The medication aide/nurse on duty maintains possession of the key to controlled storage area. 3. When a controlled substance is administered, the med aide/licensed nurse administering the medication immediately completes the usage record. 4. At shift change, a physical inventory of all schedule II medications is conducted by (2) licensed nurses/med aide. Inventory must be completed with both staff present. 5. The 2 licensed nurse/med aide completing the inventory count, sign together verify the count is accurate. Discrepancies in count are immediately reported to the Director of Nursing. 6. A medication aide must consult with a licensed nurse prior to administration of an as needed medication. The facility Controlled Medication, Disposal Of Long Term Care policy effective 10/10/2029 included: Policy: Medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal and state laws and regulations. All medications will be disposed of in a safe, secure, non-retrievable system. The director of nursing and consultant pharmacist are responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nurses and pharmacy personnel have access to controlled medications.

Based on observation, record review, resident interviews, staff interviews, and policy review the facility failed to ensure comprehensive Care Plans were reviewed and revised in a timely manner for 2 of 12 residents reviewed. Resident #27's Care Plan lacked goals, triggers, and interventions related a diagnosis of schizophrenia. Resident #25's Care Plan lacked goals and interventions related to hearing impairment. The facility reported a census of 46 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #27 dated 7/25/24 documented a Brief Interview for Mental Status score (BIMS) of 15/15 indicating intact cognition. Diagnoses included depression, schizophrenia, and schizoid personality disorder. During an interview with the resident on 08/26/24 at 10:40 AM, the resident confirmed the diagnosis of schizophrenia and indicated he had it for 'a long time.' He said staff didn't do anything about it. On 08/26/24 at 12:27 AM observed resident in the dining room, raising his hand for assistance. Staff responded in less than a minute. At about 12:32 PM the resident put his hand up again. After about a minute he put it down with no response. A document from the resident's mental health provider with a visit date of 12/15/23 documented the resident denied active psychosis but had a history of paranoia and thought processes were questionable at times. A section titled DX (diagnosis)/Assessment Plan included diagnoses of undifferentiated schizophrenia, unspecified anxiety disorder, autism spectrum, and schizoid personality. Resident #27's Care Plan, with an admitted [DATE], included focus areas for Asperger's Syndrome, schizoid personality disorder, and depression as well as for psychotropic medications (antianxiety and antidepressant) and monitoring. The Care Plan lacked reference to the resident's diagnosis of schizophrenia such as focus areas, goals, interventions, or triggers. The resident's Progress Notes lack documentation of the new diagnosis, communication with the provider, or discussion with the resident for care planning. The electronic health record (EHR) diagnosis tab revealed the resident was diagnosed [DATE] and the entry created 6/14/24. On 8/28/24 at 9:26 AM Staff C, Social Services, revealed she had been in her social work role since May and was scheduled for one day per week. She received her list of people to visit from the Administrator or the Administrative Assistant. She was not responsible for updating the Care Plan. On 8/28/24 at 9:28 AM Staff B, MDS Nurse Coordinator stated she received information from the Director of Nursing when Care Plans needed to be updated. During an interview Staff A, Registered Nurse (RN) on 8/29/24 at 11:11 AM stated changes that need to be made in a resident's Care Plan were reported to the Director of Nursing. She was responsible for passing the information along to those who needed it. When asked for a policy or procedure for Care Planning, the facility provided a document dated 8/6/24 with a focus area titled comprehensive care plan. It documented the following plan: o MDS Nurse re-educated on the comprehensive care plan policy on 7/17/24. o Comprehensive Care Plan will be completed for each resident per regulation. o MDS Nurse will ensure timely update to the comprehensive care plan as needed. o MDS Nurse will ensure most up to date information is on the care plans through a variety of ways including but not limited to: -Morning meeting -Care Conferences -Therapy recommendations -Change of conditions -Resident preferences/requests -Dr. appointments 2. The Minimum Data Set (MDS) for Resident #25 dated 7/23/24 documented a Brief Interview for Mental Status score (BIMS) of 14/15 indicating intact cognition. Diagnoses included Meniere's disease, bilateral (causes hearing loss, ringing, and dizziness), unspecified hearing loss in the left ear, and anxiety. During an interview with the resident on 8/28/24 at 10:46 AM, when asked if staff accommodated for her hearing, she said 'hell no.' She clarified that the nurses were good about getting close to her, but the aides were in too much of a hurry. They didn't speak clearly or make sure she could hear while providing cares. The resident stated the facility did not ask about her hearing for Care Planning and staff didn't understand what it was like. She also reported concerns with her vision and glasses and indicated family was assisting with that. She revealed the nose pieces of her glasses had been damaged and someone had tried to fix them with pliers. She was currently unable to get them to sit right on her nose, and therefore could not see the small holes in her hearing aide to make sure they were clean. Resident #25's Care Plan included an intervention dated 7/30/24 to ensure the resident was wearing glasses which were clean, free from scratches, and in good repair. Damage should be reported to the nurse/family. The Care Plan lacked documentation related to the resident's hearing, hearing aide care, goals, or interventions. During an interview on 8/29/24 at 10:59 AM Staff E, Nurse Consultant for the facility acknowledged that the Care Plans needed to be reviewed and updated to reflect the resident's needs, and the MDS coordinator had already started working on them.

Based on observation, staff interviews, record review, and policy review the facility failed to follow professional standards of medication administration for 1 of 1 resident that required medications via gastric tube (Resident #20). Medications were given late without physician notification, an extended release tablet was crushed and Enhanced Barrier Precautions (EBP) were not followed appropriately. The facility reported a census of 46 residents. Findings include: The MDS dated [DATE] for Resident #20 was coded for a feeding tube. The Care Plan completed 6/6/24 for Resident #20 documented: Resident NPO status referred to nothing by mouth, directed to provide tube feeding and administer medications as ordered. The Medication Administration Record (MAR) dated August 2024 for Resident #20 documented the following medications to be given at 8:00 AM, enterally or per gastric tube: Potassium chloride solution, give 15 milliliter (ML) via gastric tube Omeprazole suspension, give 10 ML liquid via gastric tube Levetiracetam solution, give 15 ML via gastric tube Metformin 1000 milligram (MG) tablet, give via gastric tube Methenamine 1-gram tablet, give via gastric tube Gabapentin 300 milligram (mg) capsules, give two capsules via gastric tube Aspirin 81 Oral Tablet Chewable, give 1 tablet via gastric tube Vitamin C Oral Tablet 500 MG, give 500 mg via gastric tube Myrbetriq Oral Tablet Extended Release 24 Hour 50 MG, give 50 mg enterally During an observation on 8/28/24 began at 9:56 AM ended at 10:23 AM. Staff F, Registered Nurse, (RN) removed the medications prescribed for 8:00 AM from the medication cart. Staff F measured the liquid medications, added to a cup, opened the Gabapentin capsules and added the powder to the liquids in the cup, crushed the remaining pills and also added them into the cup. Staff F addressed the resident, ensured proper tube placement, flushed the tube with 100 ml of water, administered the medications from the cup into the gastric tube via syringe and flushed with another 100 cc of water. Staff F wore a mask and gloves, she did not wear a protective gown On 8/28/24 at 10:24 AM, Interview with RN, Staff F following medication administration regarding enhanced barrier precautions. Staff F relayed she had forgotten to put on a gown per the EBP education and per directions on the room door. Staff F acknowledged the EBP process with tube feeding included wearing a gown. RN Staff F acknowledged the medication time on the MAR directed medications to be administered at 8:00 AM or one hour before or one hour after 8:00 AM On 08/29/24 at 09:35 AM, interview with RN, Staff G, stated they had prepared 8:00 AM medications in the cup and was ready to administer the 8:00 AM medications via gastric tube. Relayed all pills were crushed, including the extended release, twenty-four-hour medication. Staff G acknowledged extended release medications should not be crushed and had not questioned the physician order. On 8/29/24 at 9:38 AM, Interview with Administrator designee, Staff D and designated Director of Nursing (DON) Staff H relayed medications are to be given within an hour before or an hour after they are scheduled otherwise they expected that staff notify the doctor and confirmed notification was not done on 8/28/24. Staff D and Staff H relayed the expectation is that staff follow EBP that included wearing a gown with tube feeding process, and also acknowledged it is standard of care that extended release medications should not be crushed and planned to reach out to the physician right away. Document titled Help keep our resident safe, Enhanced Barrier Precautions in Nursing homes outlined staff training dated 4/10/24, directed staff to wear a gown and gloves while caring for residents with gastric tubes. Policy titled Medication Administration revised 4/1/23 documented, medications may be administered one hour prior and one hour after the scheduled administration time. If occurred outside the time frame, physician notification is required.

Based on clinical record review, interview, and facility investigation review, the facility failed to maintain an environment as free as possible from hazards when wheelchair foot pedals had been omitted prior to transfer resulting in fracture injury for 1 of 3 residents reviewed for accidents (Resident #200). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed Resident #200 required a manual wheelchair for mobility, had lower extremity impairment, and dependent on staff for all transfers. Diagnoses included Heart Failure, Peripheral Vascular Disease (PVD), and polyneuropathy. Resident rated pain at 5 out of 10 that occasionally interfered with sleep and daily activities. The Care Plan, revised 01/19/24, revealed Resident #200 had a risk for falls related to a history of falls, limited mobility, and edema, an intervention informed staff that Resident #200 was non-ambulatory and utilized a wheelchair for locomotion. Care Plan included a focus area for pain related to tibia fracture and indicated Resident #200 required opioid and non-opioid pain medications. The Incident Report, completed 10/04/23 by Staff D, Registered Nurse (RN) revealed Resident #200 asked Staff E, Certified Nursing Assistant (CNA), to push her into the dining room with no foot pedals placed on the wheelchair, Resident #200 dropped her left foot and twisted her ankle during transfer. An immediate action taken to place foot pedals on the wheelchair and provide staff education to ensure foot pedals are used. Incident Report informed that Resident #200 sustained left outer ankle injury and swelling, with pain rated 4 out of 10. Review of Nursing Progress Notes revealed the following entries: a.) 10/04/23: Resident #200 asked to be pushed in wheelchair into dining room and did not have foot pedals on due to therapy wanting her to wheel herself. Resident #200 dropped left foot and twisted ankle. Orders obtained for portable x-ray related to left ankle pain and swelling. b.) 10/05/23: Provider ordered Resident #200 non-weightbearing until immobilizing boot arrived and instructed that resident is to wear boot for four weeks with a repeat x-ray at that time. c.) 10/05/23: Follow up to incident revealed left ankle remained painful to touch, slightly swollen, with no bruising noted. d.) 10/06/23: Resident continued to report pain associated with left leg (tibia) fracture and utilized Tramadol (pain medication) with some benefit. Resident #200 utilized a total lift for transfers until arrival of weight-bearing boot. e.) 10/07/23: Left ankle purple, warm to touch, Resident #200 complained of pain rated at 8 on a scale of 1-10 and continued using Tramadol as needed for pain. f.) 10/08/23: Left anterior tibia fracture swelling, surrounding areas purple and warm to touch. Resident #200 complained of pain rated at 10 out of 10 (severe pain). g.) Provider ordered Robaxin (muscle relaxant), 500 milligrams (mg) three times per day to try to break the tension. The Medication Administration Record (MAR), dated October 2023, revealed Resident #200 required an as needed dose of Extra Strength Tylenol 1000 mg on 10/04/23 and 10/05/23 for pain rated at 7 out of 10 following incident on 10/04/23. The pain medication Tramadol 50 mg, initiated 10/06/23, ordered to be given three times per day as needed, administered 13 times between 10/06/23 and 10/10/23 for pain rated between 5 and 10 out of 10, then increased to 100 mg three times per day as needed. The opioid pain medication, Hydrocodone/Tylenol (also known as Lortab), initiated 10/13/23, to be given every 6 hours as needed for pain, administered multiple times between 10/13/23 and 10/31/23. A Provider note, dated 11/28/23, indicated possible fracture, in addition to the tibia fracture, of the left fibula bone, associated with occurrence on 10/04/23. Provider continued order for weightbearing as tolerated and immobilizing boot to left leg and ordered for updated x-rays. A Provider note, dated 01/09/24, revealed Resident #200 continued to require non-weightbearing and immobilization of left leg. A review of Staff E employee file revealed a disciplinary action report issued on 10/05/23 for resident pushed in wheelchair without foot pedals in place and indicated that the infraction resulted in Resident #200 injury and fracture of ankle identified. Report notified Staff E to be suspended pending results of Department of Inspections and Appeals (DIA) investigation which may conclude with recommendation of termination due to seriousness of infraction that resulted in resident injury. The report signed by Staff E (CNA) on 10/05/23 described company policy that residents are to have proper foot pedals in place prior to being assisted by staff. On 03/06/24 at 11:28 AM, Staff D, Registered Nurse (RN) reported that she had been notified by Staff E (CNA) of incident. RN recalled that Staff E claimed Resident #200 had requested to be pushed in wheelchair, foot pedals had not been applied to wheelchair, and that Resident #200's foot got twisted during transfer. RN informed that she responded to incident with assessment of Resident #200's left ankle and noted no obvious injuries initially. RN stated she then notified the Provider and Facility Administrator of incident. RN instructed Staff E to write a statement of incident and RN completed an incident report. On 03/06/24 at 12:50 PM, Staff E (CNA), interviewed via telephone call, informed that she had pushed Resident #200 in wheelchair without foot pedals in place when incident occurred. Staff E informed that she heard Resident #200 say ow and complained that her ankle hurt, stopped transfer, went and got pedals, and reported to Staff D (RN). Staff E indicated there had been a few times prior to incident she had assisted Resident #200 without foot pedals on wheelchair. Staff E stated she returned to work the following day and Resident #200 continued to complain of left foot pain, she recalled that Resident #200 had an x-ray performed and Staff E was put on suspension with the results of x-ray. Staff E reported that facility provided her with education following incident when Corporate Nurse called and went over transfer education, Staff E decided to end employment with facility following incident. On 03/07/24 at 01:30 PM, the Director of Nursing (DON), revealed the expectation that foot pedals are placed on wheelchairs prior to resident transfer and that management continues to monitor for all staff compliance with this. The Facility Document, titled In-Service Education for all Staff, dated 10/05/23, informed staff of company policy that residents are not to be pushed in wheelchairs without foot pedals under any circumstances and informed that failure to follow policy would result in disciplinary action including suspension and, or possible termination.

Based on observation, record review, interview, and facility policy review the facility failed to treat 2 out of 3 residents reviewed with dignity during meals (Residents #42 and #21). The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #42 dated 2/22/24 included diagnoses of non-Alzheimer's dementia, gastroesophageal reflux disease without esophagitis (GERD), and Parkinsonism. The Brief Interview for Mental Status (BIMS) documented the resident was not able to complete the Brief Interview for Mental Status with staff documenting inattention and disorganized thinking. The MDS recorded the resident as dependent for eating with the helper completing the activity. The Care Plan for Resident #42, revised 10/11/23, documented a focus area of potential for variable intake and significant weight change due to Parkinson's with severe dementia, anxiety, depression, and GERD. Interventions included assistance at meals with setup, cuing, encouragement, and feeding as needed. On 03/07/24 at 8:40 AM observed Staff C, CNA assisted Resident #42 to eat the morning meal. She provided him a bite of his food and when some came back out of the left side of his mouth, she scraped it off with the spoon and put the spoon back in the resident's mouth. At 8:46 AM food dripped from the spoon onto the resident's right arm, clothing protector, and chin. Staff C scraped the spoon along his arm, up the clothing protector, and on the right side of his chin. She then put that food into his mouth and returned the spoon to the bowl. Staff C continued using the same spoon to feed the resident. At 8:48 AM Staff C scraped food from the resident's chin from left to right and put it in his mouth. At 8:56 AM she scraped the resident's spoon along the upper left half of his chin, causing food to drip on the lower left side of his chin, his clothing, and the clothing protector. Staff C did not use a napkin or wash cloth to clean the resident's arm, clothing, or face during the meal. 2. The Minimum Data Set (MDS), dated [DATE], revealed Resident #21 had severely impaired cognition and memory problems. Resident #21 required dependence on staff for eating. Diagnoses included: Neurocognitive disorder with Lewy bodies, Alzheimer's Disease, seizure disorder, and malnutrition. The Care Plan, revised 02/14/24, revealed Resident #21 at nutritional risk with potential for weight change related to dementia, aphasia (speech impairment), and dysphagia (difficulty swallowing). The Care Plan informed staff that Resident #21 required assistance with intake at all meals. On 03/04/24 at 01:07 PM, Staff C, Certified Nursing Assistant (CNA), gave Resident #21 bites of lunch, additional food on resident's chin and neck had been scooped up with spoon and fed to Resident #21 by Staff C. On 3/7/24 at 10:12 AM an interview with the Director of Nursing (DON) revealed CNAs received feeding assistance training as part of their CNA classes. The facility did not provide additional feeding assistance training that she was aware of. She stated a staff member would receive training if there was a specific concern. She confirmed scraping food from a resident's face, arm, and clothing protector and feeding it to the resident was a dignity concern. A policy titled Resident's [NAME] of Rights revised 12/23 documented the resident's right to a dignified existence. The facility must treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of quality of life.

Based on observation, interviews, record review, and facility policy the facility failed to administer medications within the facility scheduled time frame 15 times in 15 days for 1 of 3 residents reviewed (Resident #10). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) for Resident #10 dated 12/27/23 documented diagnoses of chronic obstructive pulmonary disease with acute exacerbation (COPD), encounter for palliative care, and heart failure. Section C, Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 11, indicative of moderate cognitive impairment. Section D, Mood, revealed a Resident Mood Interview (PHQ-2 to 9) score of 7 which indicated moderate depression. A Care Plan focus area revised 1/2/24 documented the resident had impaired cognition related end stage COPD. Interventions included medications administered as ordered and the resident's routine should be kept consistent to decrease confusion. A focus area revised 1/2/24 documented resident complained of pain related to COPD, scoliosis, spondylosis (abnormal wear on the cartilage and bones of the neck), radiculopathy (damage to nerve roots in the area where they leave the spine), and spinal enthesopathy (inflammation of connective tissue where tendons and ligaments meet bone). A document titled Medication Admin Audit Report dated 3/6/24 revealed between 2/21/24 and 3/6/24 medications were administered outside of facility scheduled time frames 15 of 15 days reviewed and included the following medications: Afrin 12 hour nasal solution .05% Albuterol sulfate inhalation nebulization solution (2.5mg/3ml) .083% decadron oral tablet 4 mg depakote oral tablet delayed release 125 mg fluticasone furoate-vilanterol inhalation aerosol 200-25 mcg/act furosemide oral tablet 40 mg hydroxyzine HCl oral tablet 25 mg ipratropium-albuterol solution .5-2.5 mg/3ml lorazepam concentrate 2 mg/ml methocarbamol oral tablet 500 mg montelukast sodium oral tablet 10 mg morphine sulfate oral solution 20 mg/ml nicotine patch 24 hour 7mg/24hr ocean nasal spray nasal solution .65% omeprazole oral capsule delayed release 40 mg pseudoephedrine HCl ER oral tablet extended release 12 hour 120 mg trazodone HCl oral tablet 100 mg A Progress Note titled Hospice Note dated 1/27/24 at 10:12 AM revealed the facility spoke with hospice regarding changes in medication times to meet residents needs. A Progress Note titled Behavior Note dated 1/31/24 at 9:39 PM documented the resident's complaint regarding medications he expected and the nurse's explanation of the interaction. The Progress Notes lacked documentation that the resident's provider or hospice were notified of the late medications. On 03/04/24 at 10:34 AM Resident #10 stated that his medications had been 3 hours late, and that a nurse argued with him about his medications. He said he knew his medication schedule and he knew they were late. The resident stated the nurses did not like making an extra trip down the hallway. On 3/5/24 at 2:37 PM an interview with Staff B, RN indicated that the resident did not usually sleep in, and that when she was here in the morning he was awake for 7:00 AM medications and usually seated in his wheelchair in the hallway. On 3/6/24 at 2:38 PM an interview with the Director of Nursing (DON) revealed medication administration times depended on the medication and resident's needs. She confirmed if a medication time was listed in the resident's Medication Administration Record (MAR), that was the time it should be given with an allowance of up to an hour before or after. If it could be given in a window, those were the numbers indicated in the MAR. The DON stated they were aware the number of late medications was a concern. On 3/7/24 at 10:02 AM an interview with Staff A, RN confirmed that Resident #10 received his medications late when staff were busy. She acknowledged some of the late medication times matched the resident's concern of 3 hours late. Review of facility policy titled Medication Administration, revised 4/1/23, documented medication may be administered one hour prior and one hour after the scheduled administration times and if administration occurs outside of these time frames, physician notification is required.

Based on clinical record review, observation, staff and resident interviews and policy review, the facility failed to ensure staff protected and prevented potential resident to resident abuse for 2 of 3 residents reviewed (Resident #1 and #2), when Resident #2 attempted to suffocate Resident #1 with a blanket and pillow while she lay in bed sleeping. Resident #2 had a known history of resident to resident altercations and the facility failed to evaluate the effectiveness of interventions implemented to prevent harm to other residents. A serious adverse outcome was likely to occur if the staff had not intervened and stopped Resident #2 from applying pressure with the pillow over another resident's face. The resident could have suffered asphyxia, when the body doesn't get enough oxygen. Without immediate intervention, it can lead to a loss of consciousness, brain injury, or death. This failure resulted in possible physical injury for the resident, therefore causing an Immediate Jeopardy (IJ) to the health, safety, and security of the resident. On April 19, 2023 at 3:30 p.m., the State Agency informed the facility of the Immediate Jeopardy (IJ) which began as of April 10, 2023. The facility removed the Immediate Jeopardy on April 19, 2023 by implementing the following actions: a. As of 04/11/2023 Resident #2 no longer has a roommate. b. Any staff providing 1 on 1 supervision will receive education on how to provide adequate supervision. Education will be provided by administrator, director of nursing, charge nurse or designee. c. Staff members have been scheduled for the next 24 hours for 1 to 1 supervision. The 1-to-1 scheduling will be on-going. d. Upon admission, residents will be evaluated for wandering and behaviors by admitting nurse. We will respond as needed to these behaviors and any issues will be addressed in the care plan. e. Resident #2's Care Plan has been updated to address 1 on 1 supervision as of 4/19/2023. f. All incidents of resident-to-resident violence will be reviewed at Quality Assurance. g. Incident Reports will be reviewed for intervention initiated and effectiveness during morning meeting. h. Resident #2 was sent out for evaluation at a local hospital at 5:30 PM on 4/19/2023. The scope lowered from J to D at the time of the survey after the State Survey Agency staff verified the facility implemented education and additional corrective actions. The facility identified a census of 45 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses that included: Non-Alzheimer's Dementia, arthritis and depression. The Brief Interview for Mental Status (BIMS) had a score of 3 out of 15, indicating severe cognitive impairment. The resident's behavior assessed over a 7-day period and the MDS documented the behaviors exhibited. The MDS documented the resident exhibited physical behaviors directed toward others such as hitting on 1 to 3 days and verbal behaviors directed toward others such as threatening others on 1 to 3 days of the 7-day look back period. The MDS documented the resident exhibited wandering behavior on 1 - 3 days during the 7-day look back period, and Resident #2 independent with transfers and toileting, she needed supervision with personal hygiene. Review of an Incident Report dated 10/9/22, revealed Resident #2 entered another resident's room and argued with the resident and then pushed the resident. No apparent injuries noted. Review of an Incident Report dated 10/14/22, revealed Resident #2 walked to the doorway of Resident #3's room and hit her on both sides of her face. Resident #3 walked away and no injuries noted. A Progress Note dated 10/14/22 at 2:27 PM, indicated Resident #2 involved in a physical altercation with another resident, residents separated, no injuries noted, MD notified, new order to increase Trazodone (antidepressant) to 50 milligrams (mg). The facility failed to develop a Care Plan to address behaviors until 10/27/22, when a Physical Behavior Symptoms Focus Toward Others initiated/implemented 10/27/22 revealed the following interventions: a. Assess whether the behavior endangers the resident and/or others. Intervene if necessary. b. Avoid over-stimulation (for example: noise, crowding, other physically aggressive residents). c. Avoid power struggles with resident. d. Convey an attitude of acceptance toward the resident. e. Maintain a calm environment and approach to the resident. f. Offer one step verbal directions for tasks. Allow for extra time to process the information. g. Praise resident when behavior is appropriate. h. Provide consistent staff and routines as much as possible. i. When a resident becomes physically abusive, keep distance between the resident and others (e.g. staff, other residents, visitors). j. When a resident becomes physically abusive, stop and try task later. Do not force resident to do task. Review of the Incident Report dated 1/23/23, Resident #3 reported Resident #2 had pushed her in the dining room. Review of the Electronic Health Record (EHR) failed to reveal any interventions implemented after this incident. Review of the Progress Note for Resident #2 dated 4/11/23 at 1:06 AM, revealed the resident was found standing over her roommate Resident #1 pushing the pillow down onto the resident's face around 11:55 AM on 4/10/23. When staff approached her she was aggressive, argumentative and kept yelling she hadn't done anything wrong. The residents were separated and 1:1 initiated for safety reasons. 2. Resident #1's MDS assessment dated [DATE] listed diagnoses that included: Non-Alzheimer's Dementia and a BIMS score of 2 out of 15 indicating severe cognitive impairment. The Progress Note for Resident #1 dated 4/11/23 at 1:18 AM, revealed the resident was attempting to call out in a muffled voice through a pillow and blanket due to staff found the resident's roommate (Resident #2) standing over her pushing a pillow and blanket down onto her face around 11:55 AM on 4/10/23. Resident #1's Progress Note dated 4/11/23 at 10:00 AM, revealed the resident developing a bruise to right medial upper arm, resident denies pain but states left foot hurts. Observation on 4/17/23 at 12:11 PM, Resident #2 in a chair in the front lounge across from the dining area. A food tray brought to the resident and she ate independently and stated the food is good. The resident's appearance neat and clean and staff talk to her and responded appropriately. No direct supervision provided to Resident #2. During an interview on 4/18/23 at 10:49 AM, Staff A, Registered Nurse (RN) stated on 4/10/23 at 11:55 AM she was in the lounge area across from the Dining Room and heard a muffled sound and Staff B, Certified Nursing Assistant (CNA) went down the North Hall and she went down the South Hall. Staff A reported she only made it to the top of South Hall when Staff B started yelling it is in here. Staff A went to Resident #2's room where Staff B assisted Resident #2 back to bed and noted she had a pillow and blanket in her hands. Staff A reported the resident became combative with her after the incident. During an interview on 4/18/23 at 11:00 AM, Staff B, CNA stated as she sat in the Dining Room on 4/10/23 at 11:55 AM and she heard a voice so she walked down the North Hall. Staff B walked into Resident #2's room and saw her pushing the pillow into Resident #1's face. Staff B reported she immediately called the nurse. Staff A separated the residents. Staff B stated she had not seen Resident #2 exhibit this behavior but she can be physically aggressive if staff try to stop her. During an interview on 4/19/23 at 7:50 AM, Resident #4 with a BIMS of 15 (intact cognitive status) said she is afraid of Resident #2, she wanders and will come into her room and Resident #4 tells Resident #2 she needs to leave, but Resident #2 will tell her no it is her room and raise her arm and threaten her, but never struck her. Staff can be slow to respond and sometimes takes 20 minutes or longer to get help from the staff. The staff tells the residents there is nothing they can do about Resident #2, stating she doesn't know what she is doing and we need to forgive her. During an interview on 4/19/23 at 9:52 AM with the Administrator states she is aware of the incidents of resident to resident altercations with Resident #2. The Administrator reported we did put interventions into place after each incident but she is not sure if they evaluated the effectiveness of the interventions and would have to ask the Director of Nursing (DON). During an interview on 4/19/23 at 10:10 AM, the DON stated I spoke to Resident #2's physician at the time of the second incident but he was hesitant with which direction to go with medications. We agreed to try some Trazodone (antidepressant). Not sure at what point we increased it. The DON reported she would evaluate the effectiveness of the medication on day one and if we were keeping a close eye on Resident #2. The DON explained, typically it would be in some Progress Notes if we evaluated the effectiveness of medications. Review of an email from the Administrator on 4/19/23 at 1:52 PM, revealed the facility failed to locate documentation they evaluated the effectiveness of interventions from the resident to resident altercations. Review of the undated policy titled, Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy documented - Resident-to-resident physical contact that occurs, which includes but is not limited to where residents are hit, slapped, pinched or kicked and results in physical harm, pain or mental anguish is considered resident-to-resident abuse. Resident-to-resident sexual harassment, sexual coercion, or sexual assault is also considered abuse. The facility will presume that instances of abuse cause physical harm, or pain or mental anguish in residents with cognitive and/or physical impairments which may result in a resident unable to communicate physical harm, pain or mental anguish, in the absence of evidence to the contrary. An example would be a resident slapping another resident who is physically or cognitively impaired, even though the resident who was slapped showed no reaction (e.g., yelp or grimace), it is presumed the resident experienced pain. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.

Based on clinical record review, observation, and staff interviews the facility failed to provide adequate supervision to prevent a potential resident to resident abuse to occur for a resident diagnosed with Dementia and identified to exhibit verbal and physical behaviors to others(Resident #2) for 2 out of 3 residents reviewed (Residents #1 and #2). Resident #2 attempted to suffocate Resident #1 with a blanket and pillow while she lay in bed sleeping. Resident #2 had a known history of resident to resident altercations and the facility failed to evaluate the effectiveness of interventions implemented to prevent harm to other residents. A serious adverse outcome was likely to occur if the staff had not intervened and stopped Resident #2 from applying pressure with the pillow over Resident #1's face. The resident could have suffered asphyxia, when the body doesn't get enough oxygen. Without immediate intervention, it can lead to a loss of consciousness, brain injury, or death. This failure resulted in possible physical injury for the resident, therefore causing an Immediate Jeopardy (IJ) to the health, safety, and security of the resident. On April 19, 2023 at 3:30 PM, the State Agency informed the facility of the Immediate Jeopardy (IJ) which began as of April 10, 2023. The facility staff removed the Immediate Jeopardy on April 19, 2023 by implementing the following actions: a. As of 04/11/2023 resident #2 no longer has a roommate. b. Any staff providing 1 on 1 supervision will receive education on how to provide adequate supervision. Education will be provided by administrator, director of nursing, charge nurse or designee. Staff members have been scheduled for the next 24 hours for 1 to 1 supervision. The 1-to-1 scheduling will be on-going. c. Upon admission, residents will be evaluated for wandering and behaviors by admitting nurse. We will respond as needed to these behaviors and any issues will be addressed in the care plan. d. Resident #2 care plan has been updated to address 1 on 1 supervision as of 04/19/2023. e. All incidents of resident-to-resident violence will be reviewed at Quality Assurance. f. Incident reports will be reviewed for intervention initiated and effectiveness during morning meeting. g. Resident #2 was sent out for evaluation at a local Hospital at 5:30 PM on 04/19/2023. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 45 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses that included: Non-Alzheimer's Dementia, arthritis and depression. The Brief Interview for Mental Status (BIMS) had a score of 3 out of 15, indicating severe cognitive impairment. The resident's behavior assessed over a 7-day period and the MDS documented behaviors exhibited, which consisted of the resident exhibiting physical behaviors directed toward others such as hitting on 1 to 3 days and verbal behaviors directed toward others such as threatening others on 1 to 3 days of the 7-day look back period. The MDS documented the resident exhibited wandering behaviors on 1 - 3 days during the 7-day look back period, and Resident #2 independent with transfers and toileting and needed supervision with personal hygiene. Review of an Incident Report dated 10/9/22, revealed Resident #2 entered another resident's room and argued with the resident and then pushed the resident. No apparent injuries noted. Review of an Incident Report dated 10/14/22, revealed Resident #2 walked to the doorway of Resident #3's room and hit her on both sides of her face. Resident #3 walked away and no injuries noted. A Progress Note dated 10/14/22 at 2:27 PM, revealed Resident #2 involved in a physical altercation with another resident, residents separated, no injuries noted, MD notified, and a new order received to increase Trazodone (antidepressant) to 50 milligrams (mg). The facility failed to develop a Care Plan to address behaviors until 10/27/22, when a Physical Behavior Symptoms Focus Toward Others initiated/implemented 10/27/22 and revealed the following interventions: a. Assess whether the behavior endangers the resident and/or others. Intervene if necessary. b. Avoid over-stimulation (for example: noise, crowding, other physically aggressive residents). c. Avoid power struggles with resident. d. Convey an attitude of acceptance toward the resident. e. Maintain a calm environment and approach to the resident. f. Offer one step verbal directions for tasks. Allow for extra time to process the information. g. Praise resident when behavior is appropriate. h. Provide consistent staff and routines as much as possible. i. When a resident becomes physically abusive, keep distance between the resident and others (e.g. staff, other residents, visitors). j. When a resident becomes physically abusive, stop and try task later. Do not force resident to do task. Review of the Incident Report dated 1/23/23, showed Resident #3 reported Resident #2 had pushed her in the dining room. Review of the Electronic Health Record (EHR) failed to reveal any interventions implemented after this incident. Review of a Progress Note for Resident #2 dated 4/11/23 at 1:06 AM, revealed the resident was found standing over her roommate, Resident #1, pushing a pillow down onto Resident #1's face around 11:55 AM on 4/10/23. When staff approached Resident #2, she was aggressive, argumentative and kept yelling she hadn't done anything wrong. The residents were separated and 1:1 initiated for safety reasons. 2. Resident #1's MDS assessment dated [DATE] listed diagnoses that included: Non-Alzheimer's Dementia and a BIMS score of 2 out of 15, indicating severe cognitive impairment. The Progress Note for Resident #1 dated 4/11/23 at 1:18 AM, revealed the resident was attempting to call out in a muffled voice through a pillow and blanket when staff found the resident's roommate (Resident #2) standing over her pushing a pillow and blanket down onto her face around 11:55 AM on 4/10/23. Resident #1's Progress Note dated 4/11/23 at 10:00 AM, revealed the resident developing a bruise to right medial upper arm, resident denies pain but states left foot hurts. The facility provided 15-Minute Check Documents for Resident #2, completed from 10:00 PM to 6:00 AM 4/13/23 through 4/16/23, after the incident occurred. Observation on 4/17/23 at 12:11 PM, Resident #2 in a chair in the front lounge across from the dining area. A food tray brought to the resident and ate independently and stated the food is good. The Resident's appearance is neat and clean and staff talk to her and responded appropriately. During an interview on 4/18/23 at 10:49 AM, Staff A, Registered Nurse (RN) stated on 4/10/23 at 11:55 AM, she was in the lounge area across from the Dining Room and heard a muffled sound. Staff B, Certified Nursing Assistant (CNA) went down the North Hall and I went down the South Hall. Staff A reported she only made it to the top of South Hall when Staff B started yelling it is in here. Staff A went to Resident #2's room where Staff B assisted Resident #2 back to bed and noted she had a pillow and blanket. Staff A reported the resident became combative with me after the incident. During an interview on 4/18/23 at 11:00 AM, Staff B, CNA stated as she sat in the Dining Room on 4/10/23 at 11:55 AM and she heard a voice so she walked down the North Hall. Staff B walked in Resident #2's room and saw her pushing the pillow into Resident #1's face. Staff B reported she immediately called the nurse. Staff A separated the residents. Staff B Stated she had not seen Resident #2 exhibit this behavior but she can be physically aggressive if staff try to stop her. During an interview on 4/18/23 at 3:00 PM, Staff D, CNA stated being aware of Resident #2's behaviors. Staff D stated, Resident #2 can get aggressive and had been aggressive to the staff. Staff D reported she saw Resident #2 be verbally aggressive to other residents on a whim and never knew what you were going to get with her. Staff D explained interventions for Resident #2 included supervision as needed and try to keep her separate from other residents. Resident #2 is a wanderer and roams the facility so we will attempt to redirect her as able. Staff D reported as a CNA there is nothing for interventions but keeping an eye on her. We attempt to not let her around residents if she has an incident. Resident #2 does wander into rooms and other residents will tell her to get out. During an interview on 4/18/23 at 4:03 PM, Staff C, RN said Resident #2 displayed behaviors and in the evenings it could be worse. Resident #2 doesn't know boundaries related to Dementia. Staff C stated she tried to distract Resident #2 and get her involved with activities or try to get her to sit in her room. The area Resident #2 is at is overstimulating, but when her mood is good she can sit at the table with her peers. Staff C explained sometimes Resident #2 will eat in her room or there is a seating area in the North Hall and staff get her involved in a conversation for distraction. Staff C explained she worked with Resident #2 when she became aggressive with other staff but not with other residents, Resident #2 will threaten other residents but I have not witnessed her become physical with them. During an interview on 4/19/23 at 7:50 AM, Resident #4 with a BIMS of 15 (intact cognitive status) said she is afraid of Resident #2, she wanders and will come into her room and Resident #4 tells Resident #2 she needs to leave, but Resident #2 will tell her no it is her room and raise her arm and threaten her, but never struck her. Resident #4 commented staff can be slow to respond and sometimes takes 20 minutes or longer to get help from the staff. The staff tell the residents there is nothing they can do about Resident #2, she doesn't know what she is doing and we need to forgive her. During an interview on 4/19/23 at 9:52 AM, the Administrator stated she is aware of the incidents of resident to resident altercations with Resident #2. The Administrator reported we did put interventions into place after each incident but she is not sure if they evaluated the effectiveness of the interventions and would have to ask the Director of Nursing (DON). The Administrator reported the facility did not attempt to determine the root cause of the behaviors. After the last incident we did increase supervision just for the next day and did not provide any additional supervision after that. During an interview on 4/19/23 at 10:10 AM, the DON she stated at no time before the last incident did the facility provide any increased supervision. We would try to keep residents separated and if they were around one another we would encourage them to separate. After the last incident we did provide 1:1 supervision for a little over 24 hours but Corporate instructed us we did not need to continue with it. After the previous altercations there was a medication review done. The DON stated I spoke to Resident #2's physician at the time of the second incident but he was hesitant with which direction to go with medications. We agreed to try some Trazodone (antidepressant). Not sure at what point we increased it. The DON reported she would evaluate the effectiveness of the medication on day one and if we were keeping a close eye on Resident #2. The DON explained, typically it would be in some Progress Notes if we evaluated the effectiveness of medications. Review of an email from the Administrator on 4/19/23 at 1:52 PM, revealed the facility failed to locate documentation they evaluated the effectiveness of the interventions attempted after the resident to resident altercations involving Resident #2.

Based on observations, staff interviews, and clinical record reviews, the facility failed to provide showers twice a week for 3 out of 3 residents reviewed (Residents #1, #5 and #7). A review of the Shower Records for a 30 day look back period revealed that Resident #1 had 6 out of 9 showers documented as given, Resident #5 had 8 out of 9 showers documented as given and Resident #7 had 0 showers given. The facility reported a census of 44 residents. Findings Include: 1. A Minimum Data Set (MDS) Assessment Tool dated 9/22/22, documented that Resident #1's diagnoses included Alzheimer's dementia and epilepsy. The Brief Interview for Mental Status (BIMS) revealed a score of 00 out of 15, which indicated severe cognitive impairment. This resident was totally dependent on 2 staff for bathing. A Plan of Care (POC) Response History printed on 12/6/22 at 2:45 PM, documented resident required total dependence for Bathing: SELF PERFORMANCE - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair). The look back period was 30 days from 11/6/22 to 12/6/22. The documentation revealed the resident only received a bath/shower on the following days: a. On 11/11/22. b. On 11/21/22. c. On 11/24/22. d. On 11/28/22. e. On 12/1/22. f. On 12/5/2022. This resident should have had 1 shower prior to 11/11/22 documented and 2 showers between 11/11/22 and 11/21/22 documented. All observations of Resident #1 during the survey revealed she was neat, clean and odor free. 2. A MDS dated [DATE], documented that Resident #5's diagnoses included Chronic Obstructive Pulmonary Disease (COPD) and chronic atrial fibrillation (irregular heart beat). A BIMS for Resident #5 revealed a score of 13 out of 15, which indicated intact cognition. This resident was totally dependent on 1 staff for bathing. A POC Response History printed on 12/6/22 at 2:47 PM, documented resident required either total dependence or physical help in part of bathing activity for Bathing: SELF PERFORMANCE - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair). The look back period was 30 days from 11/6/22 to 12/6/22. The documentation revealed the resident received bath/shower on the following days: a. On 11/7/2022. b. On 11/10/2022. c. On 11/17/2022. d. On 11/21/2022. e. On 11/24/2022. f. On 11/28/2022. g. On 12/1/2022. h. On 12/5/2022. Resident #5 should have had 1 shower between 11/10/22 and 11/17/22. All observations of Resident #5 during the survey revealed he was neat, clean and odor free. 3. A MDS dated [DATE], documented Resident #7's diagnoses included Parkinson's disease, Chronic Obstructive Pulmonary Disease (COPD) and a seizure disorder. A BIMS documented a score of 13 out of 15, which indicated intact cognition. This resident was totally dependent on 2 staff for bathing. A POC Response History printed on 12/6/22 at 10:39 AM, lacked any information for Bathing: SELF PERFORMANCE - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair). The look back period was 30 days from 11/6/22 to 12/6/22. The documentation revealed the resident did not receive bath/shower during the 30 day look back period. This Resident should have had 8-9 showers, depending on her shower days, during this period. On 12/5/22 at 2:10 p.m., Resident #7's hall door was open. She was sitting in her wheelchair next to her bed with her socks off. Her hair was disheveled. On 12/6/22 at 11:03 a.m., the resident noted in her bathroom with disheveled hair and she was in a zip up gown. On 12/6/22 at 10:35 a.m., the Administrator stated showers are documented in Point Click Care (PCC - the facility's electronic health system) and on paper. When asked if they are documented in the PCC under tasks, she said she thought so. When asked where to find the paper copies, she stated she will ask the Shower Aides, as they are both were there on this day, to gather them up. On 12/6/22 at 4:30 p.m., the Administrator stated they do not have Shower Sheets or documentation on paper. She stated the Shower Aides use a dry erase board and then document the showers in PCC. The Administrator stated that if the showers are not documented in PCC that would mean showers were not done. The Administrator further explained that the residents are to receive 2 showers a week unless Care Planned differently. When told that 3 residents reviewed did not have twice a week showers consistently documented in the past 30 days and there were no refusals documented, the Administrator acknowledged that it would mean a shower was not done and the resident did not refuse to have one done. An undated Resident Refusal of Bath policy, documented the objective of the policy was to assure residents received hygiene assistance necessary to maintain skin integrity and promote dignity. The policy directed the following: a. Residents will be scheduled for a minimum of 2 baths or showers per week. b. If the resident refuses his/her routine bath or shower, the bath aide will offer to adjust the time and/or method of bathing. c. If resident continues to refuse, bath aide will notify charge nurse of the refusal. d. The Charge Nurse will encourage resident to accept his/her bath and attempt to determine the reason for refusal. e. If unsuccessful in persuading resident to bath, the Director of Nursing (DON) will be notified. f. The facility will facilitate family involvement. Added Points included: **If refusal of bathing compromises skin integrity or puts the resident at risk for infections, the Physician will be notified. **Resident's rights will be respected unless the health and well being of the resident is compromised.

Based on observations, interviews, and clinical record reviews, the facility failed to provide accurate and timely assessment and interventions for 1 of 5 residents reviewed (Resident #7 ). Through observations it was noted that this resident had 2 open areas and through record review it was noted that these open areas were not documented on accurately, nor was a wound record created documenting when the areas opened or were first noted. The facility reported a census of 44. Findings Include: A Minimum Data Set (MDS) Assessment Tool dated 9/29/22, documented Resident #7's diagnoses included Parkinson's disease, Chronic Obstructive Pulmonary Disease (COPD) and a seizure disorder. A Brief Interview for Mental Status (BIMS) documented a score of 13 out of 15, which indicated intact cognition. Resident #7 required limited assist of 1 for transfer, ambulation and toileting. This MDS documented that Resident #7 was at risk for developing pressure ulcers and was receiving applications of a non-surgical dressing. A Care Plan had a focus area revised on 6/10/21, which documented Resident #7 was at risk for skin breakdown related to incontinence, impaired mobility, and diabetes. The goal revised on 8/16/22 was Resident #7's skin will remain intact. The following interventions initiated on 2/17/21 directed staff to: a. Assess resident for presence of risk factors. Treat, reduce, and eliminate risk factors to extent possible. b. Assist with repositioning. c. Keep clean and dry as possible. Minimize skin exposure to moisture d. Monitor skin during cares. Report redness, breakdown. e. Report any signs of skin breakdown (sore, tender, red or broken areas). f. Skin treatments as ordered for any areas of impaired skin integrity. g. Use incontinence products to maintain personal hygiene and dignity. h. Use moisture barrier product to perineal area PRN (as needed). A Treatment Administration Record (TAR) for the month of December 2022, directed that Resident #7 was to receive the following wound treatment: a. Mepilex AG (antimicrobial foam dressing) to open area on left gluteal fold every 72 hours for open area. Change every 3 days This TAR documented a treatment was due on 12/6/22 at 8:00 p.m., and the last dressing change was done on 12/3/22. This treatment was initially ordered on 6/7/22. On 12/6/22 at 3:53 p.m., Staff D, Registered Nurse (RN), stated this resident's wound treatment was done last night. When Staff D was asked if it was due this night, she looked and said it was due at 8:00 p.m. Staff D stated she would do the treatment now. This RN had put the gait belt on this resident and helped Resident #7 to stand. She then changed the dressing and assisted this resident to sit back down. Staff D then removed the gait belt. When doing the treatment Resident #7 told Staff D that the area was small but she was told it's now gotten bigger. The resident stated the area hurt. The Director of Nursing (DON) observed the dressing change. During the dressing change the resident stated staff had told her there were 2 blisters there. During this observation it was noted there were 2 open areas approximately the size of a penny each. The area surrounding the open areas was discolored. This RN removed the old dressing from the left gluteal fold and without cleaning the areas, measuring the areas, or doing hand hygiene or glove change, this RN put the new dressing on covering the open areas. This resident stated the new dressing felt better. Staff D disposed of the dressing into the trash when she removed the dressing. On 12/6/22 at 4:02 p.m., a Wound Sheet was provided by Staff D and documented there was one wound and it measured 10 centimeters (cm) x 3 cm. When Staff D was asked when she measured the area, Staff D stated the dressing was coming off a little in the shower earlier on this day, so she looked at it then. When asked when this resident had a shower, Staff D stated on this day around 2 p.m Staff D stated that is when she looked at the wound and measured it. The Wound Sheet also documented that the Physician, Dietitian, and Family were notified about the wound. When asked if Staff D had done the notifications, Staff D stated she hadn't but she planned to notify them later. When asked how she came up with 10 cm x 3 cm, as clearly there were 2 open areas when she changed the dressing, Staff D stated she was planning on changing the sheet as she hadn't noticed that where were 2 separate wounds when she looked at the area in the shower. She stated the dressing that was on in the shower was dated 12/5/22 and she was able to reapply it. She stated she was told that the area was healed and that she just needed to put powder under this resident's breasts. When asked if she could see that the measurements being incorrect and the notifications not done were an issue, she acknowledged that it was. When asked about changing gloves, she stated she should have changed gloves after removing the dressing. When asked about sanitizing hands, she stated she should have sanitized hands between removing the gloves and putting on new ones. When asked about cleansing the wound, she stated she could have done that but then pointed out on the Medication Administration Record (MAR) and TAR screen that the Doctor's Order doesn't say to cleanse the wound. Following the above discussion, the dressing was checked as it remained in this resident's trash can in this resident's room. The dressing was dated 12/5/22. 12/6/22 at 4:15 p.m., discussed the above with the DON and the Administrator. Both acknowledged the issue with infection control, wrong wound measurements, and documenting notification of Doctor, Dietitian and family at 2 p.m. when she had not done this yet. 12/6/22 at 4:30 p.m., previous Wound Records were looked through with the DON. The left gluteal fold wound was documented as a Stage 2 pressure ulcer and documented as healed in October of 2022. The last wound record was on 10/10/22. The Mepilex treatment was not discontinued and no new Wound Record was initiated until this day 12/6/22. The DON stated there was an issue with the wound treatment not being discontinued. She acknowledged there was a week of measurements that were missed in the old documentation. She stated she could not see the open areas during the dressing change, but acknowledged there was no way the area could have been 10 cm x 3 cm. A Protocol for Skin Care: MANAGEMENT OF SKIN BREAKS AND PRESSURE ULCERS dated 10/2022, included documentation of the plan to manage pressure ulcers must include both prevention and treatment protocols. The Management Program must be put into effect when an at-risk or actual pressure ulcer problem is identified. Prevention protocol includes: (Refer to Prevention of Skin Breaks and Pressure Ulcers) Risk Assessment, Pressure Reduction, Skin Care, Nutritional care, and Movement of resident. Management Protocol included: a. Assessment-purpose is to evaluate wound to determine appropriate treatment and response to the treatment. b. Visual assessment with every dressing change: documented assessment at least weekly. Documented assessment includes: a. Date of Onset/Date Updated, Location. b. Size in centimeters. c. Depth. d. Stage. e. Condition of surrounding skin: normal, induration (abnormal hardening of tissue), peripheral tissue edema, maceration, rolled edges. f. Presence of drainage, odor, amount. g. Condition of wound bed: normal, pink, granulation tissue, slough, black eschar tissue. h. Current treatment and response. i. Pain. j. Family notification (date). k. Physician notification (date). l. Dietary notification (per review of Skin Book). m. Dressing When assessing an ulcer, it is important to do the following: a. Differentiate the type of ulcer. b. Determine the stage. c. Describe the ulcer's characteristics. d. Monitor progress toward healing. e. Determine of infection is present. f. Assess. g. Treat. h. Monitor pain. i. Monitor dressings and treatments.

Based on clinical record review, staff and resident interviews the facility failed to provide appropriate transfer assistance for one of three residents reviewed for transfer technique. (Resident # 2). The facility reported a census of 49 residents. Findings include: 1. The MDS (Minimum Data Set) dated 1/23/2019 revealed Resident #2 had no memory impairment, required extensive assistance of two staff to transfer from one surface to another, dress and bathe. The resident failed to ambulate and had [DIAGNOSES REDACTED]. The Care Plan revealed Resident #2 had a fall on 3/27/2019 and sustained a right knee fracture. It directed staff to transfer the resident with assist of two staff and a full body lift, physical therapy to evaluate and treat, wheel chair for locomotion and apply a right lower extremity immobilizer on at all times except for bathing and skin checks. Prior to 3/27/2019, the Care Plan directed staff to transfer/ambulate the resident with assistance of two staff, a gait belt and walker. Wheel chair to follow with ambulation. Resident #2's Care Cards with no dates included: A. Transfer with assist with two and a gait belt and walker, wheel chair to follow for ambulation. B. Resident non-ambulatory, transfer with a full body lift and assistance of two. On 3/27/2019, Staff A, RN ( Registered Nurse) documented in Resident #2's Progress Notes at approximately 8 o'clock p.m. Staff B, CNA (Certified Nurse's Aide) reported the resident informed Staff B he/she fell during a transfer from the wheel chair to toilet. Staff A questioned the resident. The resident stated Staff C, CNA assisted him/her to the restroom, when the resident stood from the wheel chair his/her knees became weak and he/she started to go down and landed on his/her knees. Staff C had a gait belt on the resident and got him/her up on the toilet. The resident indicated he/she did not hit his/her head. Staff A did an assessment and the resident could only lift the right lower leg about 1/4 of the way without having pain. The right knee had bruising and swelling. Three staff assisted the resident off the toilet using a stand up lift. The physician ordered a portable x-ray, which revealed a right patella fracture. Staff administered ice and Tylenol and transferred the resident to the emergency room . The Emergency Department Notes dated 3/28/2019 revealed Resident #2 fell at the long-term care facility, landed on both knees and complained of bilateral knee pain. Patient sent to the Emergency Department for further evaluation. The resident's final [DIAGNOSES REDACTED]. The Discharge Summary revealed the resident discharged to the facility on [DATE] with an immobilizer. The Incident Report dated 3/27/2019 at 8:30 p.m. revealed staff transferred the resident from wheel chair to toilet and CNA on duty was unaware the resident required assistance of two staff. The resident became weak and started to fall. CNA had hold of the gait belt and resident landed on knees. The resident could not lift his/her right knee and had pain. During an interview on 4/17/2019 at 1:15 p.m., Resident #2 could not recall who assisted him/her when he/she fell , thought there may have been two, and one may have been a student. The resident stood up, held the bar and said, Don't let me fall. The staff person said don't worry, I won't and then the resident's knees buckled and down he/she went. The resident thought the knees hit the floor but was not sure, it happened fast. The resident could not straighten the knee and had pain. The resident thought there had always been two people and could not recall what happened next. During an interview on 4/23/2019 at 9 o'clock a.m., Staff C, CNA reported working for an agency and on 3/27/2019, he/she worked at Winslow House for the first time during the evening shift. Staff D, CNA orientated Staff C to the facility and explained the resident Care Cards. Staff D informed Staff C the Care Cards were not always up to date, she he/she needed to check them. Before supper time, Staff C observed Staff D transfer Resident #2 using a gait belt and without assistance from the wheel chair to toilet. Staff D never informed Staff C that the resident required assistance of two staff to transfer. Prior to bedtime, the resident had the call light on and Staff C responded to it. The resident requested to get ready for bed and transfer from the wheel chair to the toilet. Staff C could not locate the resident's Care Card in the room, put the gait belt on the resident and had the resident stand up from the wheel chair and hold on to the grab bar. As the resident turned towards the wheel chair, his/her knees became weak and the resident dropped onto Staff C's thigh. Staff C had no knowledge of the resident hitting the floor, but thought the resident's knees could have hit the wall or wheel chair. Staff C assisted the resident onto the toilet and asked him/her to use the call light when finished. Later, Staff C heard that the resident reported a fall and he/she fell and sustained a knee injury. Staff C learned that the resident transferred with the assistance of two staff. Staff C did not know the resident required two assist, he/she would have asked for help. During an interview on 4/17/2019 at 4 o'clock p.m., Staff D indicated he/she orientated Staff C on 3/27/2019. Staff D educated Staff C regarding resident Care Cards and the residents on the assigned hall. Resident #2's call light came on and Staff D asked Staff C to assist because the resident required the assistance of two staff to transfer. The resident's wheel chair had been placed near the toilet, Staff D stood in front of the resident, and Staff C stood behind the resident. Staff D used the gait belt to stand the resident and did most of the work. Staff C had his/her hand on the gait belt and possibly the resident's shoulder. Later that evening, Staff D asked the resident what happened. The resident said he/she held onto the grab bar and ended up on his/her knees and fell . The resident did not identify the staff person but did say it was one person. Staff D had informed Staff C before supper that the resident was a two-person assist. During an interview on 4/18/2019 at 9:41 a.m., Staff E, CNA reported answering Resident #2's bathroom call light on 3/27/2019. The resident sat on the toilet and appeared short of breath. The resident said he/she fell and hit his/her knees, and the agency aide put the resident on the toilet. Staff E asked the resident who got him/her up from the floor and the resident reported that same agency aide did without help. Staff E asked Staff C about the incident. Staff C indicated he/she caught the resident and did not fall and said, Oops, my bad, I'm sorry when Staff E informed Staff C the resident was a two-person assist.

Based on resident, family and staff interviews, clinical record review and facility policy, the facility failed to ensure that each resident remained free from abuse for one of four reviewed (Resident #1). The facility reported a census of 46 residents. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had moderately impaired decision making skills, required extensive assistance of one staff to transfer and use the toilet, no behavioral symptoms and [DIAGNOSES REDACTED]. Staff A, RN reported the BIMS test completed on 1/9/2017, revealed the resident scored 10, also indicating moderately impaired cognitive skills. The Care Plan identified Resident #1 had dementia without behavioral disturbance. The Care plan identified the resident had a risk for skin breakdown, required ADL (Activities of Daily Living) assistance due to weakness, impaired mobility and impaired cognition due to dementia, pain due to arthritis and compression fracture. The resident received anticoagulant therapy due to [MEDICAL CONDITION] Fibrillation and [MEDICAL CONDITION]. The Care Plan directed staff to transfer the resident with the assistance of one staff and a gait belt, administer medications as ordered, observe for signs of active bleeding, and protect from injury/trauma - provide for added skin protection. On 11/21/2016 the Care Plan identified the resident had a behavior problem related to at times yells out at staff with dementia diagnosis. The Care plan directed staff to anticipate his/her needs, encourage to express feelings appropriately, redirect and reassure, explain procedure prior to initiating assist, intervene as necessary to protect the rights and safety of others, speak in a calm manner, divert attention, remove from situation and take to alternate location and provide activities of interest. The physician's orders [REDACTED]. The Nurse's Notes dated 1/8/2017 at 7:00 p.m., documented the resident's family member reported Resident #1 had a bruise on the right hand/wrist and indicated a CNA caused it. The resident reported to staff that a CNA on the day shift grabbed his/her arm and it began to hurt. Staff took measurements, soaked right wrist and hand in warm soapy water, dried and applied antibiotic ointment with [MEDICATION NAME] and wrapped gauze around the same. Staff notified the physician and the DON and completed an assessment. Staff found the resident alert and oriented to month and person but confused to date/time, lungs clear and diminished, no [MEDICAL CONDITION], and left heal pain. Skin Condition Records dated 1/8/2017: 1. Right lateral wrist bruise - 3.5 cm by 1 cm (centimeter), pink/red 2. Right lateral wrist laceration - 1.5 cm by 2 cm, L shaped. 3. Right hand bruise - 2 cm by 0.6 cm, pink/red 4. Right hand laceration 0.9 cm by 0.3 cm. The physician ordered antibiotic ointment to the right wrist and hand for lacerations, and a urinalysis. On 1/15/2017 the physician reviewed the urinalysis and had no new orders. During an interview with Staff C, RN on 1/31/17 at 3:30 p.m., she reported working on 1/8/17 when Resident #1's family member reported a bruise on his/her wrist. Staff C stated the resident told his/her family member that Staff B had done it (allegedly caused the bruise). Staff C stated Resident #1 also described the physical appearance of the alleged staff. Staff C reported Resident #1 was upset, and she reported the alleged abuse to the DON and Administrator. Staff C completed the skin assessment and reported the marks were consistent with the way Resident #1 demonstrated and described how Staff B allegedly grabbed his/her wrist and allegedly twisted his/her hand. Staff C reported occasionally comments from Resident #1 whereas he/she says, That woman isn't here, is she? During an interview on 1/31/2017 at approximately 1:40 p.m., Resident #1 reported getting into a fight with a staff member, when staff clawed and twisted his/her hand and called the resident every name in the book. The resident described and demonstrated the twisting motion. The resident failed to recall the staff member's name, but described him/her as pretty and having blonde hair. Resident #1's family member was interviewed by phone on 1/31/2017 at 1:20 p.m. On 1/8/2017 family visited the resident at the facility. The resident sat on the toilet and asked for the family member to come into the bathroom to see what an aide on the day shift did to his/her hand. Family observed bruises and three areas that looked like the shape of fingernails. The resident reported he/she attempted to help another resident with a drink of water when the aide came up and grabbed the resident's hand. The Resident identified the staff member as Staff B, Certified Nurse's Aide (CNA). During an interview with Staff E, CNA on 2/9/17 at 3:30 p.m., she reported another resident had been calling out for water and Resident #1 said he/she would get it to him/her. Staff E observed Resident #1 stand up from his/her wheelchair in the hall and he/she had to go to the bathroom. Staff E did not see any mark on Resident #1, but he/she had been wearing long sleeves. During an interview with Staff D, RN on 1/31/17 at 2:40 p.m., she reported on 1/8/17 she overheard Staff B ask Resident #1, why he/she had kicked her. Staff D reported she got up from where she was charting and heard Staff B yell at Resident #1, and state Why did you kick me. Staff D told Staff B to step away and asked another CNA to take the resident to the bathroom. Staff D reported Staff B can sound rough at times and she's been talked to about that. Staff D reported Resident #1 had never reported anything since. During an interviewed on 2/9/2017 at 1:55 p.m. , and 2/10/2017, Staff, B, CNA reported on 1/8/2017 at approximately 10:15 a.m. he/she observed Resident #1 inside the door of another resident's room, and attempted to redirect the resident to the appropriate room. According to Staff B, the resident held up an electric razor in the right hand and acted like he/she might hit Staff B with it. Staff B attempted to grab the razor and the resident grabbed Staff B's left hand with his/her left hand. Staff B indicated he/she never touched the resident and the resident finally let go of his/ her hand. Staff B attempted to remove the razor from the resident's hand, grabbed the razor and released his/her fingers by peeling back the resident's fingers. The resident left marks on Staff B's arms. Staff B reported he/she never caused a skin tear to the resident. Staff B went to room another resident's room to answer a light, and when Staff B returned, Resident #1 tripped him/ her. Staff B fell into the wall and sustained a leg bruise. That morning, Staff B assisted the resident with morning cares and failed to observe any bruises or skin tears. After the incident, other staff assisted the resident with cares for the remainder of the shift. Observation on 1/31/2017 at 12:10 p.m. revealed Resident #1 at the dining room table, clean and neat, wearing slippers and able to feed self, alert and verbal with staff and table mates. At 1:10 p.m. the resident remained seated at the dining room table with staff clearing the tables. Observation at 1:35 p.m. revealed two very small dark scabs on the right hand and wrist area. The facility investigation included: On 1/8/2017 at approximately 7:00 p.m., Resident #1's family reported to Staff C, RN, the resident revealed Staff B, CNA who worked on the day shift, grabbed his/her right wrist and twisted it after the resident swore at the CNA. The resident had bruises and lacerations to the right wrist and hand (see skin records). The CNA received suspension pending investigation. Staff notified the physician and DIA (Department of Inspections and Appeals). The investigation concluded an incident occurred between the resident and Staff B the morning of 1/8/2017. Due to conflicting statements and the resident's cognitive status, the facility failed to determine for certain if the injury occurred due to this incident. On 1/9/2017 the Care Plan update added the resident had a potential to be physically aggressive, attempted to hit/kick staff. The care plan directed staff to give the resident choices about care and activities, monitor/document/report and signs of resident posing danger to self or others, and if agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation. Walk away and approach later if resident had an aggressive response. The facility Abuse policy identified Abuse is defined differently under Federal and State law and regulations and included the following: Statement: All residents have the right to be free of abuse including any physical or chemical restraint not required to treat the resident's medical symptoms. Dependent Adult Abuse is defined under law, pursuant to Iowa Code 235E as: 1. Any of the following as a result of the willful misconduct or gross negligence or reckless acts or omissions of a caretaker, taking into account the totality of the circumstances: a. A physical injury to, or injury which is a variance with the history given of the injury, or assault of a dependent adult which involves a breach of skill, care, and learning ordinarily exercised by a caretaker in similar circumstances. Assault of a dependent adult means the commission of any act which is generally intended to cause pain or injury to a dependent adult or which is generally intended to result in physical contact which would be considered by a reasonable person to be insulting or offensive or any act which is intended to place another in fear of immediate physical contact which will be painful, injurious coupled with the apparent ability to execute the act.

Based on observation, staff interview and physician interviews and clinical record review, the facility failed to perform a complete skin assessment upon admission and then a daily assessment in order to identify pressure ulcers for a resident wearing an immobilizer leg brace and timely provide interventions for 1 of 1 resident (Resident #2). The facility reported a census of 44 residents. Findings include: 1. Observation on 3/11/14 at 7:15 a.m. revealed Staff C, Registered Nurse (RN) remove the walking cast, Ted hose, and old dressings to Resident #2's right lower extremity. The Resident ' s anterior (front) ankle contained an open area measuring approximately 2.6 centimeter (cm) wide and 3 cm long with a brownish tan scab wound bed surrounded by dark red skin. The anterior ankle area did not have a dressing covering the wound. The open area produced a scant amount of serosanguineous (thin watery bloody) drainage. The Resident's posterior (back) ankle had three open areas. The wound bed of the first area, closest to the knee, appeared dark red and measured 2.5 cm long by 1.5 cm wide, and 0.1 cm deep. The wound bed of the second area, just below the first area appeared dark red and measured 1 cm long by 1 cm wide and 0.1 cm deep. The wound bed of the third area, just below the second, had a 3.5 cm area of eschar (scab). During an interview on 3/11/14 at 7:15 a.m., Staff C, RN reported the resident had a wound clinic appointment scheduled for 3/13/14. During an interview on 3/11/14 at 7:15 a.m., Staff D, Nurse Consultant reported the pressure sore to the top of the foot and posterior ankle may be a result of the previous leg immobilizer. During an interview on 3/11/14 at 3:10 p.m., the Director of Nursing reported the posterior pressure sore with the eschar was missed on the admission assessment and the anterior pressure sore is more recent. During an interview on 3/13/14 at 7:55 a.m., Staff E, RN reported the resident had a full right leg immobilizer upon admission that extended from the right groin to the right ankle. Staff E explained that staff should complete a full skin assessment on every new admission. Furthermore, staff had a physician ' s order to remove the immobilizer at night. According to Staff E, Staff F (the nurse on duty when the resident admitted to the facility) should have removed the immobilizer to complete a full skin assessment. During an interview on 3/13/14 at 8:20 a.m., the resident's attending Physician reported the resident had underlining problems including Diabetes Mellitus, [MEDICAL CONDITION] (decreased circulation in the vessels), and poor sensation to the lower extremities. The Physician stated, diabetic patients need to check their skin daily and he would expect staff to conduct a complete skin inspection upon admission. During an interview on 3/13/14 at 10:15 am, the Wound Clinic Physician reported the resident had pressure sores to the posterior and anterior right lower extremity due to friction from the previous immobilizer device. The Wound Clinic Physician reported the wounds showed various layers of healing related to failure to use the immobilizer, and the wounds could be 7 to 14 days old. During an interview on 3/13/14 at 10:25 am, the Wound Clinic Nurse reported the resident ' s treatment orders included weekly visits to the wound clinic, as well as, daily dressing changes to the anterior and posterior pressure sores. The orders also directed staff to apply a [MEDICATION NAME] broader dressing (soft foam dressing that absorbs wound fluid) to the right knee to be changed every five days or if it became dislodged. The Wound Clinic Nurse reported all foot pulses had been palpable. Observation on 3/13/14 at 10:15 am, revealed the Wound Clinic Physician completed mechanical debridement (removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) to the resident ' s anterior pressure sore, and the Wound Clinic Nurses completed measurements and photographs to the resident ' s right lower extremity. The Wound Clinic Nurses palpated the resident ' s foot pulses, and confirmed the pulses with a Doppler, which, sounded a double tone on all four locations. Resident #2's clinical record lacked identification of an anterior right ankle pressure sore, or a posterior right lower leg pressure sore upon the resident's date of admission February 24, 2014. The admission assessment dated [DATE], lacked identification of skin concerns on the resident's right anterior ankle or posterior lower leg. The Braden Skin assessment dated [DATE], documented a total score of 20. A score of 15 to 18 identified the resident at risk for pressure ulcers. The Braden Skin assessment dated [DATE], documented a total score of 16 (at risk). A Wound/Skin Healing Record dated 3/11/14 identified a new, unstageable, pressure ulcer to the anterior right lower extremity which measured 2.6 cm long by 3 cm wide, without depth documented. A Skin Condition Record for Non-Pressure Ulcer Skin Conditions documented an abrasion to the resident's right lower, ankle below a larger wound, on 3/6/14, which measured 2.5 cm long by 0.5 cm wide, and less than 0.1 cm deep. The report documented the wound bed was a tan scab. A Wound/Skin Healing Record dated 3/6/14 documented an unstageable pressure ulcer to the right posterior ankle which measured 7 cm long by 3 cm wide, without depth documented. A Skin Condition Records for Non-Pressure Ulcer Skin Conditions sheets dated 2/24/14 documented an anterior right lower leg bruises of various stages with non-[MEDICAL CONDITION] (leg swelling) from just below the knee to the ankle. Documentation also included descriptions of three right leg incisions, tape blister to the right knee, left lower shin, left inner arm, right inner arm, top of right foot, left upper buttock, right thigh, and right posterior thigh. A Hospital Report dated 2/24/14 documented the resident had [DIAGNOSES REDACTED]. An Order Summary Report contained orders documented on 2/25/14 which directed staff they may remove Ted hose (supportive stockings) twice a day, and may have the right leg immobilizer off while in bed. A Treatment Record dated 2/01/14 to 2/28/14, and documented by staff signatures, revealed the resident had the Ted hose removed twice a day, and the right leg immobilizer removed while the resident laid in bed. The resident ' s Care Plan identified a focus area with an initial date of 3/4/14 . The focus area identified the resident at risk for skin breakdown related to limited mobility and assistance need for transfers. The Care Plan directed staff to keep the resident ' s skin clean and dry as much as possible, to minimize skin exposure to moisture, monitor skin during cares, and report redness, and breakdown areas. Clinical record review revealed the Nurse ' s Notes dated 2/24/14 to 3/10/14 lacked documentation of pressure sores to the right lower extremity. A Post-Operation check- up dated 3/5/14 documented the resident had a transition to an eboot (walking cast) to the right extremity, and directed staff to maintain skin checks, with a follow up appointment in 4 weeks. A Fax sheet dated 3/6/14 notified the Physician of an unstageable pressure ulcer to the resident ' s right posterior ankle. A Fax sheet dated 3/11/14 notified the Physician of a new unstageable pressure ulcer to the resident ' s anterior right lower extremity where the leg meets the foot. Resident #2's Minimum Data Set (MDS) assessment with a reference date of 3/3/24 identified [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of 2 staff with transfers, and toilet use, and extensive assistance of 1 staff with dressing. The MDS revealed the resident scored a 15 out of 15 for the brief interview for mental status (BIMS), meaning the resident was cognitively intact.