Every finding on record at Woodland Health and Rehabilitation

Based on clinical record review, review of Long Term Care Ombudsman notifications of transfers and discharges, and staff interview, the facility failed to notify the Ombudsman of a transfer to the hospital for 2 of 3 residents sampled (Residents #58 and #7). The facility reported a census of 57 residents.Findings included:1. Review of the Minimum Data Set (MDS) assessment for Resident #58, dated 2/27/26, revealed the resident discharged to an acute care hospital on 2/27/26 and was not expected to return to the facility.Review of Notice of Transfer Form to the Long-Term Care (LTC) Ombudsman, dated February 2026, revealed Resident #58 not listed as a hospital transfer/discharge. During an interview on 4/22/2026 at 8:09 AM, the Administrator reported being responsible for sending a monthly notification of resident transfers and discharges to the LTC Ombudsman. The Administrator explained that she did not send notification to the LTC Ombudsman if a resident was sent to the hospital and the resident was expected to return to the facility. For Resident #58, the Administrator reported that she had missed sending the notification to the LTC Ombudsman. 2. Review of the MDIS assessment for Resident #7, dated 3/31/26, revealed the resident admitted to the facility on [DATE]. Review of the electronic health record (EHR) revealed a Nurses Note dated 3/15/26 at 5:58 AM, revealed at 4:15 AM resident stated she had 10/10 pain in ruq (right upper quadrant). Denied SOB (shortness of breath), but lips looks purplish and she was pursed lip breathing. Notified DON (Director of Nursing) and provider. Order to transfer to ED (Emergency Department) for further eval (evaluation). Notified [name redacted], per resident request. A Nurses Note dated 3/15/26 at 6:06 AM, revealed resident left facility via ambulance at 5:05 AM. Did not take any personal belongings. The Nurses Note dated 3/15/26 at 10:18 AM, revealed resident returned to facility via ambulance. Review of the Notice of Transfer Form to Long Term Care Ombudsman dated March 2026 lacked Resident #7 name for being an emergency transfer to the hospital. During an interview on 4/22/26 at 11:04 AM, the Administrator stated she didn't know she needed to notify the Ombudsman for emergency transfers if the resident wasn't admitted to the hospital.

Based on observation, clinical record review and staff interview, the facility failed to ensure staff administered medicated inhalers per physician order for 2 of 3 sampled residents (Residents #24 and #7). The facility reported a census of 57 residents. Findings included: 1. Review of the Minimum Data Set (MDS) Assessment for Resident #24, dated 4/15/26, revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated a severe cognitive impairment, and a diagnosis of dementia. Review of the Physician Order List for Resident #24 revealed an order, dated 11/5/25, for Asmanex Inhaler (an inhaled corticosteroid medication) 200 micrograms (mcg) per actuation, two puffs inhaled orally two times per day for chronic obstructive pulmonary disease (COPD) with acute exacerbation. Rinse mouth with water and spit (after use). Review of the Medication Administration Record (MAR) for Resident #24, dated February 2026, revealed an order for Asmanex Inhaler two puffs two times per day and to rinse mouth with water and spit. On 4/20/2026 at 4:20 PM, Staff A, Certified Medication Aide (CMA), administered the Asmanex inhaler for a total of two puffs to Resident #24. Staff A did not have the resident rinse and spit after use of the inhaler. In an interview during the same observation, Staff A reported the Medication Administration Record (MAR) did not include instructions to rinse and spit after use of the inhaler, so she did not have the resident rinse and spit. On 4/22/2026 at 8:22 AM, during an interview, Staff B, Registered Nurse (RN) reported residents needed to rinse and spit after use of a corticosteroid inhaler. Staff B explained the directions for use of the inhaler should be included in the physician order and flow over to the MAR. On 4/22/2026 at 8:23 AM, during an interview, the Director of Nursing (DON), reported residents should have been instructed to rinse and spit after the use of corticosteroids, and Resident #24's MAR did include an order for the resident to rinse and spit after use. On 4/22/26 at 9:46 AM, during an interview, Staff A, CMA, reported residents needed to rinse and spit after the use of a corticosteroid inhaler, because if the medication sat in the resident's mouth, it could lead to thrush (a type of yeast infection). Staff A explained that she was unfamiliar with the medication, and was unaware of the need to have the resident rinse and spit after inhalation. Review of the undated facility policy, titled Medication Administration Procedure, revealed, in part, for staff to review the resident's Medication Administration Record (MAR) prior to administration of medications. 2. The MDS assessment dated [DATE] revealed Resident #7 scored a 13 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed diagnoses for pulmonary embolism, and asthma/chronic obstructive pulmonary disease/ or chronic lung disease. Review of Physician Orders revealed an order for Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 mcg (micrograms)/act (actuation)- 1 puff inhale orally in the morning for COPD with acute exacerbation Rince Mouth After Use; Hold breath for 5-10 seconds after use During an observation on 4/21/26 at 8:19 AM, Staff C, Certified Medication Aide (CMA), administered a Trelegy inhaler to Resident #7. Resident #7 inhaled one puff and held her breath for 10 seconds and then Resident #7 took another drink of the water mixed with Miralax. Resident #7 did not swish and spit after taking a puff from the Trelegy inhaler and Staff C did not prompt Resident #7 to swish and spit. During an interview on 4/21/26 at 8:35 AM, Staff C, CMA queried if there were any special instructions with some inhalers and Staff C stated she administered a few residents that swished and spit after administering an inhaler. Staff C asked why a resident would need to swish and spit after inhalation of an inhaler and Staff C stated to get the extra particles out. During an interview on 4/21/26 at 8:57 AM, Staff C, CMA stated residents swish and spit with steroid inhalers to get out the residual particles and prevent fungal infections. During an interview on 4/22/26 at 8:13 AM, Staff C, CMA queried if residents needed to swish and spit after administration of the Trelegy inhaler and Staff C looked it up and stated yes, and Staff C would start doing that with all steroid inhalers.

Based on observations, clinical record review, and staff interviews, the facility failed to ensure 2 foot pedals used when a staff pushed a resident in their wheelchair for 1 of 7 (Resident #17) reviewed for accidents. The facility reported a census of 51 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 scored a 00 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The MDS indicated resident impaired on one lower extremity. The MDS indicated resident used a manual wheelchair and walker. The MDS revealed medical diagnoses for non-Alzheimer's dementia; hemiplegia or hemiparesis; arthritis; and hip fracture. The Care Plan revealed a focus area dated 10/10/24 for anytime ambulation program- increased risk for impaired physical mobility related to decreased strength, endurance, and chronic illness, as evidenced by generalized weakness ADL (Activities of Daily Living) self performance level and support level required to complete ADL task. During an observation on 4/06/25 at 2:39 PM, Resident #17 pushed in her wheelchair by staff. The resident had no foot pedal for the left foot while resident's wheelchair was pushed by staff. Observation on 4/06/25 at approximately 3:31PM, Staff C, Certified Nursing Assistant (CNA) pushed Resident #17 in her wheelchair, while the wheelchair had a foot pedal applied for one foot only. During an observation on 4/7/25 at 12:45 PM, Staff D, CNA assisted Resident #17 to out of a recliner and into a wheelchair. Staff D placed one foot pedal on the right side of the wheelchair and made a comment about the other foot pedal by the recliner. Staff D then asked Resident #17 to cross her legs on the one foot pedal. Resident #17's foot fell off the other foot and hung down as Staff D pushed the wheelchair out of the common area. During an interview on 4/8/25 at 2:03 PM, Staff A, CNA queried on how Staff A transported Resident #17 in her wheelchair, and stated Resident #17 self propelled. Staff A queried how they pushed Resident #17 in a wheelchair, and stated they put foot pedals on and pushed her. Staff A queried if they could push Resident #17 with one foot pedal, and stated no, not to her knowledge. During an interview on 4/8/25 at 2:44 PM, Staff B, CNA queried if she could push Resident #17 in her wheelchair with one pedal. Staff B stated she wouldn't push her from behind with one foot pedal because Resident #17 always dragged her feet. During an interview on 4/8/25 at 2:53 PM, Staff D, CNA queried if Resident #17 could be pushed in her wheelchair, stated yes, and acknowledged the resident needed two foot pedals. Staff D stated she got Resident #17 up and pushed her with one foot pedal to the bathroom. Staff D stated she tried to put the other foot pedal on the wheelchair but it didn't connect because a piece was broken. During an interview on 4/9/25 2:01 PM Staff C, CNA explained she worked Sunday from 6:00 AM to 6:00 PM. Staff C explained depended on the day whether Resident #17 used foot pedals, explained resident sometimes used, and sometimes didn't. Staff C further explained the second foot pedal peg that connected pedal to the chair was broken off. When queried if the connection piece broken when Staff C came in on Sunday, Staff C responded yes, and explained she was not sure if anyone else was aware. When queried if had been like that Saturday, Staff C could not recall. When queried how may pedals to have on if pushed in wheelchair, Staff C acknowledged two. During an interview on 4/9/25 at 2:41 PM, the DON (Director of Nursing) informed of the situations with one foot pedal used during wheelchair transport for Resident #17 and the DON stated Resident #17 needed 2 foot pedals when pushed if she was not able to keep her feet on one foot pedal. Per mail from the Administrator on 4/9/25 at 3:43 PM, no policy for wheelchair transports. 45338

Based on clinical record review, facility policy review, and staff interview, the facility failed to accurately obtain and implement advanced directives per resident and family directives upon admission for 1 of 1 residents (Resident #202) reviewed. The facility reported a census of 51 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed Resident #202 had been admitted to the facility on [DATE] from a short term general hospital. Review of Resident #202's Order Summary Report, dated [DATE], revealed a verbal order for CPR, effective [DATE]. Review of Resident #202's electronic health record (EHR) revealed a lack of a signed document, by Resident #202, Resident Representative, or physician, to confirm Resident #202's wishes for life sustaining measures. During an interview on [DATE] at 11:28 AM, the Director of Nursing (DON) retrieved a binder which included the resident's Iowa Physician Orders for Scope of Treatment (IPOST). An IPOST is a document that allows a person to communicate their preferences for key life-sustaining treatments such as CPR, full treatment verses comfort measures only, and artificial nutrition administration. The DON stated Resident #202's IPOST was not present in the binder. During an interview on [DATE] at 3:18 PM, the DON stated Resident #202's family was called on [DATE] and identified Resident #202's wished for DNR. DON stated an IPOST was completed indicating a DNR on [DATE] and faxed to the physician to be signed. During an interview on [DATE] at 3:25 PM, the Social Services Director (SSD) explained that a call was placed to Resident #202's family on [DATE], but she was unable to leave a voicemail. The SSD acknowledged she did not document the attempt to contact Resident #202's family on [DATE]. The facility policy, titled Advanced Directives, dated [DATE], revealed upon resident admission, the facility would provide a resident who is medically deemed competent, or resident representative, who does not have an existing Advance Directive with written information and instructions regarding the right to make Advanced Directives prior to the initiation of care or at any requested time. The Policy revealed all facility employees are responsible for implementation of Advanced Directive Policy. The Policy listed Social Services Director and Facility Administrator as responsible for monitoring this Policy.

Based on Centers for Medicare and Medicaid Services (CMS) Certification and Survey Provider Enhanced Reports Reporting (CASPER) system, review of the facility Quality Assurance Performance Improvement (QAPI) Policy, and staff interview the facility failed to ensure effective measures had been taken to correct deficiencies that continue. The facility reported a census of 50 residents. Findings include: A review of the facility CASPER report revealed the facility cited for F641 (Accuracy of Assessments) in February 2024 and will be cited during the current recertificaton survey. A review of Resident #49 and #18 Minimum Data Set (MDS) Comprehensive Assessments showed both coded as no, for use of tobacco in Section J Health Conditions. On 11/13/24 at 4:49 PM, the Director of Nursing acknowledged that Resident #49 and Resident #18 currently smoked at the facility. On 11/13/24 at 4:52 PM Staff A, MDS Coordinator acknowledged both Resident #49 and #18 were coded wrong and she would be submitting (MDS) corrections. Staff A stated they have a policy for MDS accuracy. During an interview on 11/13/24 at 5:18 PM the Administrator reported she had just audited the MDS for smoking not that long ago and everything should have been coded correctly. She couldn't believe there was an issue with the MDS coding. She voiced they do not have an MDS policy, the facility utilizes the CMS Resident Assessment Instrument (User's Manual) for MDS coding. Interview on 11/14/24 at 10:10 AM the Administrator, with the Regional Director of Operations and DON present stated regarding the F641 Citation, the new MDS Coordinator was aware of the plan of correction from the last survey for the F641 MDS accuracy tag. They had audited through the Quality Assurance (QA) program the medication section of the MDS for accuracy and they looked at the MDS as a whole for accuracy. She reported they had looked at the smoking issue as a whole more in regard to care plan verses the MDS, but had looked at MDS as part of the process. A review of the facility Quality Assurance & Process Improvement (QAPI) Policy, dated 8/20/20, directed the QAPI Plan will describe how the facility will ensure care & services are delivered, meet accepted standards of quality, identify problems and opportunities for improvement, and ensure progress towards improvement is achieved and sustained. The QA Committee will meet monthly to assess and monitor the quality of services provided to residents and identify potential problems or areas of opportunity for improvement. The QA Committee will implement and systematically evaluate programs and processes to identified problems in order to proactively improve health care delivery. The QAPI Policy Procedure included: a. Performance improvement is a proactive and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and implementing new approaches to resolve systemic problems. b. Utilize data obtained from a variety of sources to identify quality problems or opportunities for improvement and set priorities for resolution. c. Perform root cause analysis, identify trends/patterns, set targets, & implement action items to improve the process.

Based on observation, clinical record review, policy review, resident, guardian, and staff interviews, the facility failed to notify the legal guardian of laboratory refusals and resident change in condition for 1 of 5 resident reviewed for medication use (Resident #7). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 7/04/24, for Resident #7 listed diagnoses included schizophrenia, diabetes mellitus, stroke, aphasia (a disorder that affects a person's ability to understand and express language, including reading and writing), hemiplegia (paralysis or weakness on side of the body), and anxiety disorder. A Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicated a moderate cognitive impairment. The MDS listed medications taken seven days a week which included insulin, antipsychotic, and an antidepressant. The MDS identified Resident #7 as not exhibiting rejection of care during the review period. A clinical record review revealed an Iowa District Court Letter of Appointment, issued on 6/10/24, that ordered [agency name redacted] to serve as guardian for Resident #7. The order included full power and authority to exercise any and all of the duties, powers, and responsibilities granted to guardians under Iowa Law. An Order Summary Report, signed by the Provider on 8/15/24, listed the following orders: a. BMP (basic metabolic panel - a test that measures eight different substances in the blood) laboratory draw every 6 months related to hypertensive (high blood pressure) heart disease. b. Psychological services and Medication Management. c. Use a Freestyle Libre for blood sugar checks (continuous blood glucose monitoring system) d. Basaglar Kwik Pen Subcutaneous (SQ) Solutions (insulin) 100 units/milliliter (ML). Inject 10 units SQ in the evening related to type 2 diabetes mellitus with hyperglycemia. e. Fiasp Flex Touch SQ Solution (insulin) Pen-injector 100 units/ML. Inject 8 units SQ before meals related to type 2 diabetes mellitus with hyperglycemia. f. Fiasp Flex Touch SQ Solution (insulin) Pen-injector 100 units/ML (insulin). Inject as per sliding scale insulin. g. Furosemide Tablet 40 milligrams (MG) (diuretic medication or often called a water pill). Give 1 tablet by mouth one time for swelling related to essential high blood pressure. h. A1C (hemoglobin A1C - a test that measures average blood sugar levels over the past three months) laboratory draw every 3 months. The Care Plan, Date Initiated: 3/10/23, Revision on 10/10/24 included a Focus area to address [Name redacted] has a history of/potential for resistance to care: Repositioning, pericare/check and change and outside appointments. Interventions did not include refusals to have blood drawn for lab work, and notifying the legal guardian of such refusals. During an observation on 11/12/24 at 11:15 AM, Resident #7 in bed, with the head of the bed elevated. Resident #7 stated she is fine and wanted more cookies. Cookies present on the residents bedside table, and within her reach. A review of Resident #7 clinical record revealed: a. An ear-Medication Administration Note on 9/01/24 at 1:10 PM, Note Text: BMP (Basic Metabolic Profile) one time a day every 6 month(S) starting on the 1st for 1 day(S) related to HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE. Resident Refused to have blood draw. Educated resident about purpose of blood draw. Resident continues to refuse. The record did not include documentation that the residents legal guardian notified of the refusal. b. An INTERACT BAR (acronym for Situation, Background, Assessment, and Recommendation, communication tool) on 9/5/2024 at 5:26 PM, Note Text: The Change in Condition/S reported on this CIC (change in condition) Evaluation are/were: Other Change in condition at the tome of evaluation resident/patient vital signs, in part; Blood Glucose: BS: 501.0 9/5/24 R 5:08 PM .Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Give 18 U (units) short acting insulin, and recheck 30-45 minutes. The record did not include documentation that the residents legal guardian notified of the change in condition and provider recommendation. c. An ear-Medication Administration Note on 11/4/2024 at 9:54 AM, Note Text: A1C every shift every 3 month(s) starting on the 1st for 1 day(s) Resident refused Blood Draw. ARNP (Advanced Registered Nurse Practioner) Aware. The record did not include documentation that the residents legal guardian notified of the refusal. d. A Nurses Note on 11/8/2024 at 9:02 AM, Note Text: Left great toe bumped on the hoyer during transfer after her shower. Scratch noted on cuticle that is bleeding a small amount. Bandage applied. Shower chair caused a superficial open area on gluteal [NAME] that measures 2x1x0 cm (centimeter). Barrier cream applied per order. The record did not include documentation that the residents legal guardian notified of the injury. During an interview on 11/13/24 at 5:00 PM , the Assistant Director of Nursing reported Resident #7 had refused her last BMP draw and it was documented in the progress notes on 9/01/24. The ADON voiced Resident #7 refuses her blood draws all the time. She really hates them. During an interview on 11/14/24 at 7:33 AM, Staff F, Licensed Practical Nurse (LPN) verbalized Resident #7 is confused at times. She has whole conversations with other people in her head, so you never know what you're going to get when you walk in her room. She was in and out of psychiatric wards long before she was at the facility. She has been this way a long time. Staff F had to ask the Director of Nursing (DON) who they notify of Resident #7 new orders. Staff F could not answer if it was appropriate for Resident #7 to be making her own decisions and asked the DON. During an interview on 11/14/24 at 7:34 AM, the DON responded to Staff F Resident #7 guardian should be notified of new orders. The DON voiced she knew Resident #7 had refused her last laboratory draw on 9/01/24. She would have to look further into Resident #7 to see if the guardian or the physician had been notified of the refused laboratory draws. During an interview on 11/14/24 8:51 AM, the court appointed legal guardian representative for Resident #7 reported she did not know anything about the resident refusing a lab draws or that the resident had a history of refusing laboratory draws. She has not been notified of any changes in the residents health condition. The only time she finds things out is when she goes to the facility. She comes to the facility monthly. She checks in with whoever is at the desk and then she goes to see the resident and looks her over. She wants to be involved in Resident #7 care and would have wanted to be informed that Resident #7 refused her laboratory draw as something like that at Resident #7 age is not good. During an interview on 11/14/24 at 9:45 AM, Resident #7 Physician reported residents have rights and he is aware of Resident #7's condition and refused labs. He feels the facility does the best they can. He voiced his next visit at the facility is 11/22/24 and he had planned to talk with Resident #7 about the missed lab draws and encourage her to have her labs drawn. During an interview on 11/14/24 at 10:14 AM, the DON reported Resident #7 had also refused her A1C lab (measures the average level of glucose (sugar) in your blood over a period of about three months; a test used to monitor diabetes) on 11/04/24 and the Advanced Registered Nurse Practitioner (ARNP) was notified at that time, but the ARNP and guardian had not been notified of the laboratory draw refusal on 9/01/24. The facility also had not notified the guardian of the laboratory refusal on 11/04/24. The DON verbalized the nurses would normally contact the guardian on something like that. During an interview on 11/14/24 a 10:16 AM, the Administrator reported she thought the facility originally had been the one to start the guardianship process. She voiced there was a temporary guardianship in place in June 2024. There was a progress note on 10/07/24 that the facility received the final permanent guardianship. She voiced the facility should have notified the guardian of any changes to the resident from the time of the temporary guardianship. The facility policy, dated 4/26/23, titled Notification of a Change in Condition Policy statement declared the Attending Physician/Physician Extender (Nurse Practitonioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a Change in a Resident's Condition per Standards of Practice and Federal and/or State Regulations. The section titled Procedure 1. Guideline for Notification of Physician/Resident Representative (not all inclusive); in part, Significant Change or Unstable Vital Signs, Accident/Incident, Abnormal Laboratory Results, Repeated refusal to take prescribed medications, Glucometer reading below 70 or above 200 (unless specific parameters were given by the Physician for reporting.). 2. Document in the Interdisciplinary Team (IDT) Notes, included, in part; Notification of Resident Representative.

Based on clinical record review, resident and staff interviews, the facility failed to complete post dialysis assessments for 1 of 1 residents sampled (Resident #12). The facility identified a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment, dated 11/01/24, for Resident #12 documented a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating moderate cognitive loss. The MDS identified Resident #12 received dialysis for a diagnosis of end stage renal disease. The Care Plan, Date Initiated: 9/8/24 included a Focus area to address Dialysis at [provider name redacted] on M-W-F (Monday-Wednesday-Friday) at 10 AM and transportation via [provider name redacted] transport. A review of the October 2024 Electronic Registered Nurse/Licensed Practical Nurse Medication Administration Record (RN/LPN MAR) revealed an order, dated 9/6/24, Vital Signs prior to sending and returning from dialysis two times a day every Mon, Wed, and Fri. The vital signs documented at 0700 (7:00 AM) and 1500 (3:00 PM) included: BP (blood pressure), Temp (temperature), Pulse, Resp (respirations). Vitals signs were not documented at 1500 on 10/7/24, and 10/28/24. A review of the November 2024 RN/LPN MAR revealed a continued order, dated 9/6/24, Vital Signs prior to sending and returning from dialysis two times a day every Mon, Wed, and Fri. Vital signs were not documented at 1500 on 11/4/24, and 11/11/24. During an interview on 11/13/24 at 12:22 PM, Staff D, Registered Nurse (RN) reported the nurses do vital signs as part of the pre and post dialysis assessment. They have a dialysis communication form they fill out, place in a binder and the binder goes to and from dialysis with Resident #12. They also record the fistula assessment on the MAR. A 11/13/24 3:30 PM review of Resident #12 dialysis binder revealed the following: a. The Dialysis Communication Record, undated, with the 10/07/24 local dialysis center documentation lacked documentation of any post dialysis assessment for vital signs. b. The Dialysis Communication Record, undated, with the 10/28/24 local dialysis center documentation lacked documentation of any post dialysis assessment for vital signs. c. The Dialysis Communication Record, undated, with the 11/04/24 local dialysis center documentation of a post dialysis assessment for vital signs. c. The Dialysis Communication Record 11/11/24 lacked documentation of a post dialysis assessment of Resident #12 vital signs. A review of the electronic health record sections for vital signs, progress notes and assessments revealed no documentation for vital signs or assessments post dialysis (1500) for Resident #12 on October 7, 28 and November 4 and 11. During an interview on 11/13/24 at 4:33 PM, Staff D RN reported the post dialysis assessment if it was done should be documented on the dialysis communication sheet or in the electronic health care record. She is aware they are to do a post dialysis assessment to ensure a resident is stable. She verbalized the assessment may have gotten written on a piece of paper and never made it to the resident's chart. During an interview on 11/13/24 at 4:38 PM, the Director of Nursing reported if the post dialysis assessment was not on the (dialysis communication) paper or in the computer, most likely it got done, but did not get documented. If it wasn't documented, it wasn't done. The DON verbalized she would check to see if the facility had a procedure for completing post dialysis assessments. During an interview on 11/13/24 at 6:12 PM, the Administrator responded the facility follows dialysis professional standards of practice. The facility did not have a dialysis assessment policy.

Based on observation, clinical record review, and staff interviews the facility failed to ensure resubmission of the a Preadmission Screening and Resident Review (PASRR) after a change in mental health diagnoses for 1 of 1 residents reviewed (Resident #21). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) for Resident #21, dated 9/26/24, included the following diagnoses: anxiety disorder; major depressive disorder, moderate, recurrent; pervasive developmental disorder; adjustment disorder; and psychotic disorder. The Brief Interview for Mental Status (BIMS) score of 15 out of 15, included intact cognition. The clinical record revealed Resident #21's diagnoses list with date added to the record. The list reflected Major Depressive Disorder, single episode, unspecified 5/28/19; Anxiety Disorder unspecified 5/28/19; Pervasive Developmental Disorder 5/28/19; Generalized Anxiety Disorder 5/28/19; Adjustment Disorder unspecified 5/28/19; Major Depressive Disorder, recurrent, moderate 7/1/24; and Unspecified Psychosis not due to a substance or known physiological condition 7/1/24. A document titled PASRR Notice of Exemption From PASRR, dated 5/27/19, recorded the resident did not meet the criteria for serious mental illness or a developmental condition and was not subject to PASRR requirements at that time. Page 2 further noted the resident was diagnosed with Depressive Disorder, Generalized Anxiety Disorder, and Rule Out Agoraphobia with symptoms of tearfulness, anxiety, and worry. A Psychiatric Initial Assessment, dated 2/1/24, revealed the resident was experiencing symptoms of depression, anxiety, psychosis, and insomnia. The Assessment/Plan section documented diagnoses of generalized anxiety disorder, major depressive disorder, and unspecified psychosis not due to a substance or known physiological condition. A Psychiatric Subsequent Assessment, dated 11/11/24, diagnoses list included Generalized Anxiety Disorder, Major Depressive Disorder (recurrent, moderate), Insomnia, and Unspecified psychosis not due to a substance or known physiological condition. During an observation on 11/13/24 at 10:59 AM, Resident #21 returned to her room. The resident stated she has mental health services via telehealth. She stated she could not remember if staff discussed her mental health with her recently and thought she would report concerns to the nurse. During an interview on 11/13/24 at 04:47 PM, the Director of Nursing reported the Social Services Director (SSD) was responsible for completing PASRR when diagnoses changed. She stated nursing got the orders and social services did the therapies because they had a closer relationship with the providers. During an interview on 11/13/24 at 5:02 PM, the SSD stated an updated PASRR would be submitted if there was a new diagnosis or change in status. Diagnoses for Resident #21 and the exemption were reviewed with the SSD who said she would have to look into it. On 11/14/24 at 10:10 AM, the SSD confirmed a new PASRR needed to be submitted. She was not sure why it had not been done at the time of the new diagnosis in February and indicated she was not aware the diagnoses had been added to the resident's diagnosis list in July. During an interview on 11/14/24 07:32 AM, the Administrator stated after review she determined the actual change in diagnoses happened in January. The prior SSD left in December, and she herself had been responsible for helping with PASRRs during those staff transitions. They missed adding the new diagnoses to the list in January and therefore did not submit a new PASRR. A staff member only working at the facility for a month added the diagnoses in July, and did not communicate it to the team which was why there was not a new submission then either. The facility did not have steps in place to audit for missing PASRRs. On 11/14/24 at 11:17 AM, the Administrator stated the facility did not have a policy related to PASRR submission, and followed federal guidelines established for the contracted company completing the assessments.

Based on clinical record review, Center for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, resident and staff interviews, the facility failed to complete the Minimum Data Set to accurately reflect the tobacco status for 2 of 2 residents reviewed for smoking (Resident #49 and #18). The facility identified a census of 50 residents. Findings include: 1. A Minimum Data Set (MDS) assessment, dated 9/30/24, for Resident #49 included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. MDS Section J Health Conditions indicated Resident #49 did not utilize tobacco. MDS Section V Assessment Administration documented I certify that the accompanying information accurately reflects resident assessment information for this resident and that I collected or coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable Medicare and Medicaid requirements. I understand that this information is used as a basis for ensuring that residents receive appropriate and quality care, and as a basis for payment from federal funds. I further understand that payment of such federal funds and continued participation in the government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and that I may be personally subject to or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false information. I also certify that I am authorized to submit this information by this facility on its behalf. Staff A signed she completed Section J Health Conditions on 10/01/24. A 9/24/24 Smoke Safety Evaluation identified Resident #49 utilized tobacco and did not exhibit any safety concerns with smoking. A Progress Note dated 9/24/24 at 10:43 AM, completed by the Director of Nursing (DON) documented Resident #49 goes out to smoke and is safe to smoke. A Progress Note dated 9/25/2024 at 5:11 PM, completed by the Assistant Director of Nursing (ADON) documented Resident #49 adjusting well to the facility and went out to smoke on all three smoke breaks today. During an interview on 11/12/24 at 11:09 AM, Resident #49 reported he goes out three times a day to smoke and his smoking supplies are kept at the nurses station. A staff member always goes out to smoke with him During an interview on 11/13/24 at 1:45 PM, Staff B, Certified Nursing Assistant (CNA) reported Resident #49 has smoked since he admitted to the facility. During an interview on 11/13/24 02:05 PM Staff C, CNA reported Resident #49 has always gone out to smoke since he was admitted . 50874 2.The MDS, dated [DATE], for Resident #18 included a BIMS score of 12 out of 5 indicating moderate cognitive impairment. MDS Section J Health Conditions documented Resident #18 did not utilize tobacco. Staff A, MDS Coordinator signed she completed Section J Health Conditions for accuracy on 8/14/24. During an interview on 11/13/24 at 11:49 AM, Resident #18 stated she is a current smoker. Resident #18 stated she smokes in the designated smoking area at the allowed times with supervision. Resident #18 verbalized she smokes 2-3 times per day. During an interview on 11/13/2024 at 12:13 PM, with Staff C, CNA revealed Resident #18 has smoked since she was admitted to the facility. During an interview on 11/13/24 at 4:49 PM, the DON acknowledged that Resident #49 and Resident #18 currently smoked at the facility. The DON verbalized she did not understand why it was coded wrong on the MDS and she needed to check with the MDS Coordinator. During an interview on 11/13/24 at 4:52 PM, Staff A, MDS Coordinator acknowledged both Resident #49 and #18 were coded wrong and she would be submitting (MDS) corrections. Staff A stated they have a policy for MDS accuracy. During an interview on 11/13/24 at 5:18 PM, the Administrator reported she audited the MDS for smoking not that long ago and it should been coded correctly. She voiced they do not have an MDS policy, they utilize the RAI for MDS coding. The LTC RAI 3.0 User's Manual Version 1.19.1 October 2024 page 1-4 documents the RAI process has multiple regulatory requirements. Federal regulations at 42 CFR (Code of Federal Regulations) 483.20 (b)(1)(xviii), (g), and (h) require that the assessment accurately reflects the resident's status. Page J-26 for Section J Health Condition instructs to code yes if the resident or any other source indicates that the resident used tobacco in some form during the look-back period.

Based on observation, interview, facility investigation review, and facility policy review the facility failed to ensure a severely cognitively impaired resident identified at risk for elopement, with wandering behaviors free from elopement on 4/30/24. The resident went through a set of double doors into a common area by the beauty salon, went through a door into the unoccupied assisted living portion of the facility when the keypad was disengaged, and exited through a third door present on the unoccupied assisted living portion of the facility which lead directly to the outside of the facility. The third door the resident exited from, present on the unoccupied assisted living section of the facility, did not alarm to the nursing home section of the facility for 1 of 1 resident reviewed for elopement (Resident #25). This deficient practice resulted in an Immediate Jeopardy (IJ) to the health and safety of residents who resided at the facility. The facility also failed to adhere to the plan of care when a resident dependent on a mechanical lift was raised up off of a wheelchair via the assistance of a non-mechanical lift, resulting in skin tears and bruising to the left lower arm for 1 of 4 residents reviewed for accidents (Resident #53). The State Agency informed the facility of IJ that began as of April 30, 2024 on July 2,2024 at 12:25 PM. The Facility Staff removed the Immediate Jeopardy on July 2, 2024 through the following actions: a. 100% Headcount of all Residents on 4/30/24 b. 100% Elopement Risk assessment completed on all residents on 4/30/24 c. 100% Care plan audit for all residents determined to be at risk for elopement on 4/30/24 d. Facility conducted 100% audit of all external doors to ensure they are in proper working order on 4/30/24 e. Door lock changed on 4/30/24 to assisted living interior door f. Facility conducted elopement drills x 3 shifts 4/30-5/1/24 g. Facility conducted Ad Hoc QAPI to address this alleged deficient practice on 4/30/24 h. Elopement binder updated on 4/30/24 i. Staff in-service on Elopement Policy on 4/30/24 The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 55 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, the resident had inattention and disorganized thinking which fluctuated, had delusions, and wandered daily. Review of Medical Diagnoses for Resident #25 revealed, in part, paranoid personality disorder, schizophrenia, and vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The Care Plan dated 1/30/24, revised and canceled on 5/3/24, revealed the following: History/potential for behavior problem. Resident is no longer allowed to smoke as he is at high risk for elopement. Interventions per the Care Plan included the following: a. (Initiated 1/30/24, revised/canceled 5/3/24): Administer medications as ordered. Monitor/document for side effects and effectiveness. b. (Initiated 1/30/24, revised/canceled 5/3/24): Anticipate and attempt to meet needs. c. (Initiated 1/30/24, revised/canceled 5/03/24): Explain all procedures before starting and allow time to adjust to d. (Initiated 1/30/24, revised/canceled 5/03/24): Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. e. (Initiated 1/30/24, revised/canceled 5/3/24):Observe behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. f. (Initiated 2/2/24, revised/canceled 5/03/24): Wander Guard in Place The Care Plan dated 1/30/24 revealed, the resident has depression and insomnia with diagnosis of schizophrenia. The Elopement Risk Evaluation V 2.0 dated 1/29/24 and 4/2/24 revealed the resident at risk for elopement, and the resident scored 4 on both assessments. It was noted a score of greater than one indicated at risk for elopement. Review of Progress Notes prior to Resident #25's exit from the building on 4/30/24 revealed the following: Review of Hospital Records from a visit dated 1/27/24 revealed, during time of his ED (emergency department) evaluation, patient had evaded our staff members when he was utilizing the bathroom, eloping from our facility as search was performed including contacting local law enforcement. Patient identified at gas station where [Hospital Name Redacted] EMS (Emergency Medical Services) identified him as well as patient voluntarily returned to our ED via EMS. Review of a Behavior Note dated 3/23/24 at 4:49 AM revealed, Resident has been pacing the halls constantly this shift, going in to other resident's rooms, and is short tempered with staff, especially when we attempt to redirect him from going into other resident's rooms. Message left with [Name Redacted, ARNP (Advanced Registered Nurse Practitioner)] awaiting response. The Risk Note dated 3/28/24 at 1:16 PM revealed, Risk IDT (interdisciplinary team) met to discuss residents more frequent wandering and agitation. Resident is not agitated with staff or residents almost seems as if he is agitated with himself or overwhelmed in this environment. Talked to SS (Social Services) about talking to [family member] to get him placed in a locked unit with less stimulus, will have her make prog [progress] note when she talks to [family member]. The Social Services Note dated 3/28/24 at 4:29 PM revealed, Contacted residents [family member, name Redacted] about potentially moving resident to a location that has less stimuli and calmer environment such as a locked dementia unit. The Behavior Note dated 3/31/24 at 3:46 AM revealed, Resident continues to have episodes of pacing, fidgeting with anything that is around him, and going in to other residents' rooms. Resident did settle down and has been sleeping in his bed since 9pm. The Nurses Note dated 4/1/24 at 11:26 AM revealed, Observed resident wandering up and down halls, noted to have layered clothing (a couple shirts) the top polo was on backwards. The Risk Note dated 4/5/24 at 1:52 PM revealed, Risk management held today to discuss residents behaviors. Resident continues to wander into other residents room and up and down hallways. Resident is easily redirected. Review of a Psychiatric Services Provider Clinical Note dated 4/9/24 revealed, Facilitator shared patient is wandering more and this is related to his dementia. She is working on a referral for him to move to a facility with a dementia unit that will be closer to family. The Nurses Note dated 4/12/24 at 3:46 PM revealed, Resident continues to wander throughout the facility on foot. No new behaviors observed or reported. The Behavior Note dated 4/14/24 at 12:49 AM revealed, Resident has been wandering all shift so far this shift. Going in to other resident's rooms, taking things off the med carts, trying to drink everyone's drink. Resident has yet to settle down and is still wandering and getting in to everything. The Behavior Note dated 4/15/24 at 2:49 AM revealed, Resident has been wandering all shift again this shift. Going into other resident's rooms, redirection has been mostly unsuccessful. At this time resident has finally went to his room and is laying in bed at this time. The Behavior Note dated 4/21/24 at 1:41 PM revealed, Resident continues to roam the halls. Called and spoke to [family member]. No other behaviors noted at this time. The Risk Note dated 4/25/24 at 1:39 PM revealed, Risk IDT met to discuss behaviors. Resident continues to wander daily. No new behaviors. The Nurses Note dated 4/25/24 at 6:46 PM revealed, Resident wondering facility. Not exit seeking. Redirected out of other residents room but resident continues to go into other residents rooms after aid redirected. Resident taken to his own room where he stood at door way opening and closing door. The Behavior Note dated 4/27/24 at 12:03 PM revealed, Resident continues to wander facility and into other residents rooms. Resident talked to [family member] this morning. He has been taking objects off of medication carts such as pens and markers. Very redirectable today. The Behavior Note dated 4/28/24 at 9:53 PM revealed, Resident noted to be sleeping in bed [Room number redacted, not resident's room]. Resident woke up and redirected back to his own bed where he laid down and has been asleep since. Review of a Psychiatric Subsequent assessment dated [DATE] revealed the resident was referred due to depression, anxiety, worrying, paranoia, hallucinations delusions, confusion, elopement, sleep disturbance, and paranoia. Review of Resident #25's clinical record and facility self report investigation regarding the resident's elopement on 4/30/24 revealed the following: The Facility Investigation for Resident #25 dated 4/30/24 revealed, On 4/30/24 at approximately 5:10am [Resident #25] was observed by staff standing on the east door sidewalk approximately 6-10 feet from the building, on facility property .Upon completion of the investigation, it was determined that [Resident #25] exited the facility through a door leading to the Assisted Living portion of the community which had a manual push button lock what was noted to disengage and exit through the door .[Resident #25] was last observed by CNA (Certified Nursing Assistant), during rounds at 4:40 am standing in his doorway to his room with no signs of distress noted and no signs or symptoms of exit seeking behavior demonstrated. Resident observed going back into room and shutting door at that time. Staff member [name redacted] reports that after seeing the resident at 4:40 am, she went to the area by the nursing station and returned to the hall to complete rounding at approximately 4:45 am in which she could not locate [Resident #25]. Nurse immediately notified and search initiated. During the resident interview, [Resident #25] reported he was sleepwalking and remembered last being in his room. Review of the Self Report for Resident #25 revealed approximate date/time event occurred as 4/30/24 at 5:05 AM. The Incident Summary per the Self Report documented, in part, Resident was standing in his doorway at approximately 4:45 AM, visually seen by CNA, as she exited room across hallway. CNA went towards nurses station to use restroom and after using restroom returned to hall. CNA went to [Resident #25's] room at approximately 5:05 as he was no longer in hall. [Resident #25] was not in his room, CNA made nurse aware and they began looking for him. No alarms were sounding. Nurse state she went outside and was hollering his name and seen him standing in grass approximately 15-20 feet from building. When he heard his name he turned around and when she got to him he willingly returned inside with her. Review of staff statements included as part of the facility investigation revealed the following: a. Verbal statement from [Staff N, CNA] 04/30/24: I did rounds on resident throughout the night and resident was asleep in his bed until I saw resident standing in his doorway at 0430. Went into [another room number, redacted] to check and change resident. I needed supplies and came out of the room and saw resident at 0440 in his doorway again, when resident went back into room and shut his door. After rounding I used the rest room and went back down to check on resident when I noticed he was not in his room. Let [Staff K]RN (Registered Nurse) know that he was not in his room and staff started checking the building for resident as there had been no alarm sounding. At approximately 0510, resident was found outside at the east end of the building by [Staff K] RN. b. Verbal statement from [Staff M, CNA] 04/30/24: At approximately 0435 (4:35 AM), I witnessed resident in hallway, attempting to go into other residents rooms and get into the linen closet. I took resident back to his room and I did not see him after that time. After being told that resident was not in his room, I checked north hallway for resident and he was not in any room, bathroom, or closet. c. Verbal statement from [Staff J,CNA] 04/30/24: I went down east hall to help [Staff N] check and change [another room number, redacted] at approximately 0430 (4:30 AM). I saw resident standing in his doorway at that time. We finished checking resident and I went down west hall to do rounds when I was told that resident was no longer in his room. Checked the rooms, bathrooms, and closets down west and resident was not in any of the rooms. d. Verbal statement from [Staff K, RN] 4/30/24: I was alerted at approximately 0445 (4:45 AM) that resident was not in his room. Did a search of the building, in all rooms, bathrooms, and closets and resident could not be located. Called DON (Director of Nursing), [name redacted] and let her know that resident could not be located. No alarms were sounding. Could not locate resident in the building. At approximately 0510 (5:10 AM), I went outside and saw resident at the east side of the building in the grass, with no shoes on. Resident came back into facility with no incidents. Skin and pain assessment completed. No signs or symptoms of trauma noted. VSS (vital signs stable). Review of the Nurses Note dated 4/30/24 at 5:15 AM revealed, Resident was last seen inside his doorway at approx 440 am when the CNAs (Certified Nursing Assistants) had come out of a room across the hallway. Resident was then seen outside on east side of building in the grass. Resident came back inside facility without incident and one on one care was <sic> initiated. The Social Services Note dated 4/30/24 at 11:39 AM revealed, I met with resident concerning this morning behavior. I asked resident if he was looking for something or wanting/needing something. Resident stated, I don't know what I was doing. My memory is bad. Maybe I was looking for some money I dropped (resident began to laugh). No, I am just joking. I don't know what I was doing. Observations and interviews conducted onsite during the time of the survey revealed the following: On 7/2/24 at 9:35 AM, a voicemail message was left for the State Climatologist. Information as to the weather in [Location where facility located redacted] requested for 4:40 AM to 5:10 AM. On 7/2/24 at 11:05 AM, the State Climatologist provided the following observations: Temperature: 46 degrees F (Fahrenheit), relative humidity: 93%, winds calm to [NAME] at 3 mph (miles per hour), wind chill: 45 degrees F, and fair conditions with no precipitation detected. On 7/1/24 at approximately 11:00 AM, the Administrator queried about camera locations at the facility, explained which areas had cameras, and the response provided did not include the area of the facility where the resident had exited the facility. A walk through was conducted of the doors the resident would have traveled through with the facility's Administrator. Observation revealed first was a set of double doors which went into a common area where the beauty salon was located, referred to by staff as the East day area. It was explained if the door was cracked [ajar], the door would not alarm. The second door was a door from the East day room into the unoccupied assisted living (AL) portion of the facility, and it was explained the lock on the door to the AL had not reengaged. Upon entry to the hallway of the unoccupied AL portion of the facility, a door (exterior door) observed to the right. It was explained the alarm to the door, noted to be third door in travel path, was not hooked to the main section of the facility. Observations of the double doors which lead from the end of 300 hallway into the East day area revealed no alarm sounded at the following times the door was opened by staff and/or surveyor: a.7/2/24 at 9:56 AM b. 7/2/24 at 9:59 AM c. 7/2/24 at 10:12 AM d. 7/2/24 at 2:56 PM. Observation revealed although the right side of the door had an alarm that sounded, the left side of the set of double doors could be opened without an alarm sounding. On 7/2/24 at 3:06 PM, observation conducted of the surrounding area of the facility revealed the facility was located on a two lane road with speed limit of 25 miles per hour. Observation of the area outside of the door where the resident exited the facility (from the assisted living section) revealed a concrete pad, then sidewalk which extended right towards the parking lot in front of the facility. The sidewalk did not have handrails present, and a gap of approximately three inches existed in places between the edge of the sidewalk and the grass. Outside of the door where Resident #25 exited the facility, there was a grass strip of approximately 10 to 15 feet wide between the facility and the parking lot of the neighboring business. On 7/2/24 at 5:56 PM, Resident #25 observed walking down the hall. The resident held a staff member's hand, and observed with tennis shoes to his feet. Observation on 7/2/24 at 6:25 PM revealed Resident #25 walked independently with tennis shoes to his feet. The resident stood upright and walked near a chair to the front common area/television area at the front of the facility. The resident held onto another chair while he attempted to sit in a stationary chair, and then sat down. On 7/3/24, observation of Resident #25 revealed the resident in his room with the wrong tennis shoe (left shoe) on his right foot, and wanderguard present to the resident's left ankle. Staff assisted the resident with his shoes. When queried if he (Resident #25) ever went out of the facility real early in the morning, the resident responded no. Observation revealed the resident again put the wrong shoe on his right foot. On 7/2/24 at 9:13 AM, Staff M, CNA, who worked the night the resident got out of the facility, explained the following about Resident #25: The previous night the resident was up and down, tried to feed him and he would eat a little bit and get back up. The resident said he wanted to go to bed, and a few minutes later was back up. Per Staff M, some nights the resident slept all night. When queried if she worked the night the resident got out, Staff M responded she was. Per Staff M, she was down North hall, and usually had an aide each hall. Per Staff M, the other girl said Resident #25 was missing. Staff M explained room to room checks and closet check done, Staff M said she could not find the resident. Per Staff M, the alarm must have been going off. When queried if alarms had been going off, Staff M responded she didn't hear any. Per Staff M, she thought the resident needed to be in a locked unit where he could roam free, explained sometimes at night may be in with a resident in another hall and may not see Resident #25 or notice him being gone. Staff M explained for the resident's safety, would be best if he could be in a locked unit. On 7/2/24 at 9:37 AM, interview conducted with Staff J, CNA, who worked when Resident #25 exited the building. Per Staff J, herself and another CNA went down East hall, and went down to answer a call light. Staff J explained the first time, she saw Resident #25 out of his room standing in his doorway. The second time, the door was cracked and she could tell Resident #25 wasn't in there, and Staff J had a feeling the resident was not in there. Staff J explained she went fully in the room and looked and the resident was not in there. Staff J further explained she and the CNA started looking all around all the hallways, looked everywhere, looked in the day area where the double doors were, and never thought to look at [AL name] as it was supposed to be locked. Per Staff J, she and the CNA told the nurse the resident was not in his room, and the resident was in there 20 minutes ago. Staff J explained they looked and looked and looked, and finally had to stop because pharmacy came. Per Staff J, the resident was outside the church's parking lot. Staff J further explained there had been three CNAs and one nurse, and all started looking, looked outside the back and the resident wasn't out there, pharmacy came, the nurse went out, and the resident was in the church parking lot. When queried if pharmacy found the resident, Staff J responded no, and said after pharmacy came looked again, and the resident was in the church parking lot in between the grass and the church. Staff J explained they did not hear alarms, the resident did not have a wanderguard on, and was supposed to as at risk for wandering. Per Staff J, the alarm to the double door was on , but they did not hear that go off at all, and thought it malfunctioned. Staff J further explained she found out later the resident went out that way to the [AL name redacted], call lights in the [AL] were going off, that is how figured out he was out there (figured out next day). Resident #25 went into the double door to the [AL], was messing with call lights and stuff, went out the side door, and was found in the church/facility grass area. When queried who first saw him outside, Staff J identified Staff K, Registered Nurse (RN), the nurse. Per Staff J, she knew trying to move the resident to a locked facility because the resident wandered too much and because of the incident in April. When queried about the resident's behaviors prior to April, Staff J responded the resident wandered a lot, still did, was very confused, and did not like to listen when told where his room was. Per Staff J, the resident's room had been moved so many times she did not think he (Resident #25) knew where room was at. Staff J further explained the resident got very agitated when told to do stuff, and Staff J explained did not have the staff or the right things to keep the resident in one spot. Per Staff J, the resident had previously escaped from the hospital, and one of the facility employees went on break to the gas station and Resident #25 was standing there. Staff J expressed they felt the resident needed to be moved to an actual locked facility as the resident wandered so much as to no one could keep an eye on him. Staff J also explained the resident was very fast, and the previous night they had to shut the double doors to each hallway, resident kept by the nursing station,and explained being so busy they could not keep eyes on Resident #25 24/7. Per Staff J, Resident #25 went into other peoples' rooms, and there were those that did not like that. On 7/02/24 at 10:32 AM during an interview with Staff L, Certified Medication Aide (CMA), Staff L explained Resident #25 was very restless and she felt like he was confused. Staff L explained the day before she had to sit with Resident #25 for lunch, and the resident wasn't understanding he could take a bite of bread. Per Staff L, the resident tried to take a fork and stab the bread. Staff L further explained the resident had certain areas that were familiar to him, where used to have his room, and the resident would stick by the nurses station. When queried if Staff L ever worked when the resident got out of the building, Staff L responded not when he got out, and one time out smoking and the resident kept going. Staff L explained need to have another face go hey, come back this way. Staff L explained the purpose of the alarm between the 300 hall and East day area was for Resident #25. The resident's previous room noted to have been in right next to the double doors to the East day area. Staff L explained the resident's room had been switched closer to the nurses station. Staff L explained a lot of times the resident would come back to the East day area and would need to be told to come to the front as it was vacant [in East day area]. On 7/2/24 at 10:51 AM during an interview with the Maintenance/Housekeeping Supervisor, the following was explained: The door to the AL had a manual code lock, and if someone put in the code it stayed until opened the door. Per the Maintenance/Housekeeping Supervisor, they though that it what happened, the resident found the door open, and went around the corner. The Maintenance/Housekeeping Supervisor also explained the following for the third door (door to exterior): the alarm was localized, and would not get an alarm at the nurses station. The old pad (to the AL) would only reset when the handle was turned and if put in the code and did not turn the handle, it stayed unlocked. On 7/02/24 at 2:40 PM, Staff A, CNA who worked nights, explained the following about Resident #25: When queried if the resident wandered, Resident #25 said yes. When queried how the facility instructed to address this, Staff A explained she would ask the resident if they wanted to go to the dining room, get something to eat, or watch television in the day area. When queried if it was successful, Staff A responded sometimes, and recently, if told the resident to do something, he forgot right away and started doing his own thing. When queried how long this had occurred, Staff A responded a few weeks ago. When queried if she worked when the resident got our of the facility in April, Staff A responded no. When queried how the resident presented prior, Staff A responded since he went down hill started wandering and went to the East day area (where beauty shop is). Per Staff A, they would catch the resident. Staff A explained there was always an alarm unless someone forgot to turn it back on. Per Staff A, everyone had a different opinion of what the resident was trying to do, and when Staff A looked at the resident, looked like the resident was trying to get us, he would watch, and knew what was going on. Staff A explained it seemed like the resident knew a way to get out back there. On 7/02/24 at 4:44 PM during an interview with the Social Services Director (SSD), the SSD queried about Resident #25's behaviors. Per the SSD, the resident's behaviors as of right now were very mild compared to what he was before when the resident first came. Per the SSD, the resident was doing much better, and what she meant by that of course was not trying to run off. The SSD further explained the reason the resident was running was the voices were telling him. Per the SSD, at that point the resident wasn't on psychotropic medications for schizophrenia, and the resident now saw [psychiatric services provider] for counseling and the psychiatric ARNP (Advanced Registered Nurse Practitioner). Per the SSD, the resident had a lot of wandering tendencies at times, and the resident was able to be redirected. The SSD explained that sometimes the resident would state someone was after him to kill him, and further explained that was the voices, and Resident #25 would be asked if the voices were being bad today. The SSD Director further explained they had been really trying to get the resident to another location closer to [family member], and had one place that was able to get a memory unit/locked unit so that the resident could get in a dementia unit to be more closely monitored so he wouldn't wander out. Per the SSD, the resident could be redirected easily, and was stubborn. When queried how long trying to seek out a locked unit for the resident, the SSD said she was not sure, and she knew it had been over a month. The SSD further explained the resident would be better in a setting that was quieter with more routine and structure. Per the SSD, the resident went from being able to dress himself to now, disorganized, and she thought there was an increase in vascular dementia quite a bit with trying to stabilize symptomatic concern with schizophrenia. The SSD explained the resident had even eloped from the hospital, the resident ended up at a gas station, and a facility staff member was off work getting gas. Per the SSD, that was prior when he resident did not have medications for schizophrenia. The SSD explained the resident did have a POA (Power of Attorney), and further explained the resident had previously tried to take off when in the smoking area because of the voices, and staff went after the resident. On 7/2/24 at 5:14 PM, Staff B, CNA, explained the resident was very distracted very easily. Staff B explained a lot of time spent redirecting the resident because he liked to go into other people's rooms, was very confused, and did not know where his room was because he was moved so much. Per Staff B, the resident tried to go into offices and down corridors. Staff B explained the door alarm (double doors between 300 hall and East day area) was supposed to be on 24/7 and there were numerous times where herself and numerous CNAs would go down the hall and make sure the alarm on, if busy doing something in other people's rooms want to hear alarms, and numerous times staff went out the door and did not turn the alarm on. Per Staff B, people would go back there and not turn on the alarm when came out. During an interview conducted 7/2/24 at 6:32 PM, Staff N, CNA explained the following about the incident: Resident #25 kept peeking his head out all night long. When Staff N attended to duties, and when we came back 5 to 10 minutes later, walked back down to make sure the resident went to bed, and the resident was not in his room. Staff N explained they started checking doors, checking every resident room, bathroom, and closet trying to find Resident #25. Staff N explained couldn't find the resident. Staff N explained she did not know who long it was from the time started looking and someone came back with Resident #25. When queried who came back with Resident #25, Staff N responded she did not know, and said she was outside a lot of the time running around. When queried how the resident did at night, Staff N explained sometimes the resident slept all night and other nights the resident would come hang out all night long, and in and out wanting snack/drink. Staff N explained hit or miss in terms of communication, explained the resident was very confused, and talked about how this (facility) was his house and everything. Interview conducted on 7/2/24 at 6:44 PM with Staff K, RN, revealed the following: Per Staff K, they were back in the back getting supplies when Staff K was called on the walkie [talkie] and told couldn't find Resident #25. Staff K explained she was told staff taking care of resident across the hall, Resident #25 peeked his head out, and had been in the room most of shift and was awake. Staff K explained Resident #25 stuck his head out standing in the doorway, staff took care of another resident, and when came back out, went to take care of someone else, went to Resident #25 and he was not in his room. Per Staff K, they went through a roster and checked resident in each room and kept looking for the resident. Staff K explained looking room to room, and explained all did so. Staff K explained they notified the Administrator and then called the police. Staff K explained looking outside in the parking lots once determined not in the building, and acknowledged looked for quite a while. Staff K further explained she remembered being out in the back walking around, came back in, still searching, explained she walked out the front, and Resident #25 was coming this way. It was explained the resident was right out in the grass by the front parking area, Staff K said the resident's name, and the resident came walking and said he was hungry. When queried what the resident was wearing, Staff K responded regular clothes she was sure because the resident never changed, and was fully dressed. When queried about footwear, Staff K responded she could not remember, and then said socks, and explained she assessed his feet and the resident didn't have shoes on. Per Staff K, she thought the resident had socks on, and explained the resident had no clue he did anything or went anywhere he was not supposed to go. Staff K explained the following about the incident: Before the incident, it went back and forth, and depended on whether the resident [TRUNCATED]

Based on clinical record review, staff interview and facility policy the facility failed to provide the resident or the residents representative the facility bed-hold upon transfer to the hospital for 1 of 2 residents reviewed for bed holds (Resident #11). The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #11 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 12 out of 15. The MDS included diagnoses: Coronary Artery Disease, Heart Failure and Renal Insufficiency (Kidney Failure). A review of a Progress Note dated 6/9/24 at 7:08 PM revealed Resident #11 transported to the hospital for evaluation, and admitted on [DATE] for intravenous antibiotic treatment for an urinary tract infection. Resident #11 transferred back to the facility on [DATE]. A review of the clinical record lacked documentation of a bed hold notice being given to the resident or residents representative upon transfer to the hospital. In an interview on 7/3/24 at 10:45 AM, Staff C, RN stated when a resident is sent to the hospital, the nurse sending the resident out is responsible for reviewing the Bed Hold Policy with the resident/family. The Bed Hold Policy should be reviewed with the resident/family within 24 hours of the transfer. Staff C stated there is a Bed Hold policy form but she has never filled it out and did not know if this should be documented in the electronic medical record. In an interview on 7/3/24 at 11:14 AM, the Administrator reported the Bed Hold Policy should be reviewed with resident/family by the nurse on duty within 24 hours. She could not recall where this should be documented. In an interview on 7/3/24 at 3:03 PM, the Director of Nursing (DON) stated when a resident is sent to the hospital, the nurse sending the resident out is responsible for reviewing the Bed Hold Policy with the resident/family. The Bed Hold Policy should be reviewed with the resident/family within 24 hours of the transfer. The DON stated there is a form that the resident/family signs or the nurse will get a verbal consent. This form gets scanned and entered into the electronic medical record. She could not explain why this had not been completed for Resident #11 as she was on medical leave at that time. A review of the facility policy, dated 11/15/22, titled Resident Bed Hold documented: The Facility will provide written information to the Resident and/or the Resident Representative regarding Bed Hold Policy prior to transferring a Resident to the hospital or Therapeutic Leave as required by State/Federal Guidelines.

Based on observation, clinical record review and staff interviews the facility failed to properly code diuretic, hypnotic and anticoagulant medications on the Minimum Data Sets for 2 of 4 residents (Resident #33 and Resident #38) reviewed. The facility reported a census of 55 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #33 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS included diagnoses: Atrial Fibrillation (an abnormal heart rhythm), Heart Failure and Diabetes Mellitus. The MDS failed to identify Resident #33 had taken a diuretic and had taken a hypnotic. A review of the Physician Orders revealed an order for toresemide (diuretic used to treat fluid retention) 40 mg (milligrams) 2 tablets twice daily on 1/11/24 related to ischemic cardiomyopathy (a condition that occurs when the heart's ability to pump blood is reduced due to damage to the heart muscle). And an order for temazepam (a hypnotic) 15 mg 1 tablet at bedtime for insomnia. An observation on 7/1/24 at 11:54 AM revealed Resident #33 lying in bed, properly positioned and appeared comfortable with his call light in reach and reported he had orders from hospice to receive a sleeping pill every night. In an interview on 7/3/24 at 10:45 AM, Staff C, RN reported Resident #33 had orders for torsemide, (a diuretic) and for temazepam (a hypnotic). In an interview on 7/3/24 at 12:30 PM, the Assistant Director of Nursing (ADON) stated she had been the MDS Coordinator from September 2023 to March 2024, prior to starting her current position. She stated if a resident has orders for a diuretic and hypnotic, they should be addressed on the MDS. The ADON stated she could not explain why the medications were not coded on Resident #33 MDS. In an interview on 7/3/24 at 3:03 PM, the Director of Nursing (DON) reported she would expect medications such as a diuretic and a hypnotic to be addressed on the MDS. 47336 2. The MDS assessment dated [DATE] revealed Resident #38 with scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS lacked documentation regarding anticoagulant medications. The Care Plan revealed a focus area revised on 6/25/24 for anticoagulant therapy. The interventions dated 5/6/22 revealed administration of anticoagulant as currently prescribed by the physician. The EHR (Electronic Health Record) revealed the following Physician Orders: a. Xarelto tablet 10 mg (milligrams)- give 10 mg by mouth in the evening with a start date 3/27/24. b. Anticoagulant medication- monitor for bruising, bleeding, increased bloody drainage from wounds, discolored urine, black tarry stools, sudden severe headache, nausea/vomiting; diarrhea, muscle joint pain, lethargy, sudden changes in mental status and/or vital signs, shortness of breath, and nose bleeds- every shift for anticoagulant monitoring During an interview on 7/3/24 at 12:49 PM, the ADON (Assistant Director of Nursing) stated Resident #38 took Xarelto and yes, it should be coded on the MDS. During an interview on 7/3/24 at 1:50 PM, the DON confirmed Resident #38 took Xarelto and it was an anticoagulant, so it probably should be coded on the MDS. During an interview on 7/3/24 at 3:01 PM, the DON stated they didn't have a policy for MDS, the facility followed the guidelines of the RAI (Resident Assessment Instrument) Manual.

Based on observation, clinical record review, resident and staff interview, the facility failed to update the care plan for 1 of 3 residents (Resident #48) to identify a focus area of smoking and needed interventions to ensure safety. The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #48 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 and had the following diagnoses: Seizure Disorder, Bipolar Disorder and Encephalopathy (a disease that affects the brain's function). The MDS identified Resident #48 as independent with most activities of daily living. The Admission assessment dated [DATE] Identified Resident #48 with a past history of smoking, however currently, not identified as a smoker. The Smoking Safety Evaluation Form dated 3/25/24 identified Resident#48 as a smoker with balance problems while sitting or standing. The Care Plan dated as last revised 6/27/24 did not identify Resident #48 as a smoker and include necessary interventions as per the facility policy. An observation on 7/2/24 at 3:10 PM Resident #48 sat in her wheelchair with both feet on foot pedals in the smoking area with Staff G, Certified Nursing Assistant (CNA) supervising her and the other residents. Staff G gave the resident one cigarette, and lit the cigarette. In an interview on 7/3/24 at 10:45 AM, Staff C, Registered Nurse (RN) stated the MDS Coordinator is responsible for updating Care Plans. She stated Resident #48 has been smoking for at least six months. Staff C stated if a resident smoked she would expect it to be included on the Care Plan, Smoking Assessments, evaluation for dexterity, smoking times, level of supervision needed, and the location of cigarettes and lighters at the nurses station. In an interview on 7/3/24 at 11:14 AM, the Administrator stated the MDS Coordinator, who started working a few weeks ago is responsible for updating the care plans. Resident #48 has been a smoker since March or April 2024 and a smoking assessment had been completed, and should have been added on the residents Care Plan. The Administrator stated common interventions would include: no cigarettes or lighters in the room, these are kept in a lock box, and smokers are to be supervised when out on 3 scheduled smoke breaks. In an interview on 7/3/24 at 12:30 PM, the ADON (Assistant Director of Nursing) stated she had been the MDS Coordinator from September 2023 to March 2024 then assumed the duties of the ADON. The MDS coordinator is responsible for updating the care plans, however, any nurse update the care plans. If a resident smoked, she would expect this to be addressed as a problem on the care plan. There should not be a reason for this not to be addressed on the care plan. Common interventions would include: supervised when out, cigarettes and lighter in lock box in nurse's station, and complete a Smoking Assessment A review of the undated Facility Policy titled: Smoking Policy/Safety had documentation of the following: a. Residents only may smoke in the designated smoking area in the front of the building. b. Residents may only smoke during scheduled smoke breaks at 10:00 AM, 2:00 PM and 7:00 PM. c. All smoking paraphernalia (cigarettes, lighters, e-cigarettes, etc) are to be locked up at the nurse's station in between smoke breaks. d. The smoking policy will be revisited at Care Plans for each smoking resident. e. All smoke breaks will be supervised.

Based on observation, interviews and facility policy review the facility failed to utilize standard hand hygiene precautions for infection control when handling soiled laundry. The facility reported a census of 55 residents. Findings include: During an observation on 07/02/24 at 03:20 PM Staff O, Housekeeping, brought a clear garbage bag of soiled laundry into the laundry room. Staff O attempted to use the bag as a barrier but ended up using her bare hand to get soiled laundry out of the bag and into the wash machine. Staff O stated the load of laundry was dirty clothing protectors from the residents. Staff O did not wash her hands after handling the soiled laundry. During an interview on 07/02/24 at 3:40 PM, the Administrator was queried about the process of handling dirty laundry. The Administer stated staff would be expected to use appropriate PPE when handling any soiled laundry including gloves. The Administrator stated she is comfortable knowing facility staff have good hygiene. When clarified the Administrator stated she would expect staff to wash their hands before or immediately after exiting the laundry room and many staff members carry small containers of hand sanitizer in their pockets. During an interview on 07/03/24 at 10:56 AM Staff F, Infection Control and Preventionist was queried regarding appropriate hand hygiene. Staff F stated all staff are trained for appropriate hand hygiene. Staff are required to go through both online and in person refreshers. The facility also does random audits where staff are required to perform hand hygiene to demonstrate competency. When handling soiled laundry all staff are required to wear gloves. When done handling dirty laundry should take off gloves and do appropriate hand hygiene before leaving laundry or touching anything else. Appropriate hand hygiene should be used every single time they take off gloves and definitely before leaving the laundry room. Staff F stated before handling any dirty laundry staff should put gloves on, open the bag, use their hand to put laundry in the wash machine and then throw away the dirty trash bag, take off gloves and perform hand hygiene. We have been doing continuous education with staff and making sure staff new and seasoned staff are aware of when they need to use PPE. On 07/03/24 at 02:49 PM Staff O was queried regarding hand hygiene. Staff O stated she is aware she did not utilize or practice appropriate hand hygiene in the laundry room the previous day. She stated she should have been wearing gloves and she should have stopped and washed her hands before leaving the laundry room. I forgot to put my gloves on and I should have washed my hands in the laundry room before leaving the area. A review of the policy policy, dated 4/28/22, titled Hand Hygiene documented the following: The facility will provide guidelines to employees on proper hand washing and hand hygiene techniques that will aid in the prevention of the transmission of Infections. Employees will be trained and receive ongoing education on the importance of Hand Hygiene in preventing the transmission of Health Care Associated Infections. Hand Hygiene should be performed following the Clinical Indications: 1. Before/after providing care. 2. Before/after performing aseptic task (e.g., placing an indwelling device). 3. Contact with blood, body fluids, or contaminated surfaces. 4. Before/after applying/removing gloves/PPE. 5. After handling soiled linens/items potentially contaminated with blood, body fluids, or secretions.

Based on observations, interview, and record review the facility failed to ensure proper hot water temperature for appropriate hand washing hygiene in the kitchen hand sink. The facility reported a census of 55 residents. Findings include: On 02/05/24 at 09:48 AM during the initial kitchen observation with the Dietary Manager, the Dietary Manager was observed as he washed his hands in the employee hand sink and when done he had left the water running for surveyor. The running water was cold to the touch. The cold water spicket was shut off. The hot water spicket was turned on and ran for approximately one minute longer and the water temperature maintained cold to the touch. When queried, the Kitchen Manager advised the water does get hot although he had washed his hands in cold water. On 02/06/24 at 11:09 AM the Regional Dietician (RD) was interviewed. The RD was informed the water in the hand sink is not getting hot enough. It ran for two minutes today and it barely got to lukewarm. The RD then consulted with the Maintenance Supervisor and advised he had been trying to adjust it because it was too hot. The RD advised she had been told the water was too hot for two days. RD advised the workers should be practicing good hand hygiene, and not washing their hands in cold water. On 02/08/24 at 8:55 AM An interview was conducted with the Maintenance Supervisor. He had been employed with the facility for six months. When queried about the cold water in the kitchen hand sink he advised on that side of the wall the boiler had just gotten fixed because it was old and the cold weather was preventing the water from getting hot. He advised he had been adjusting the water temperatures the last few days because of the new boiler. I have been adjusting it the last several days to get the temperature where I wanted it which is between 110-115 degrees. He advised the kitchen hand sink is checked daily. When requested, the Maintenance Supervisor showed me his water log temperatures. There is one entry for the Kitchen water checks daily for each day in January. When asked which kitchen water source is listed in his logs he advised he checks the temperatures on varies sinks in the kitchen daily. He does not always check the same water supply but checks something in the kitchen on a daily basis and logs it. On 02/08/24 at 09:08 AM An interview with the Administrator Maintenance Supervisor and the was conducted. The Administrator advised the facility had just gotten a new heat exchange at the end of the week last week. The Maintenance Supervisor had been doing water temps throughout the building as he does on a daily basis. When asked again the Maintenance Supervisor advised he doesn't check the temperature in the same sink in the kitchen everyday but that the kitchen is checked daily. He then advised the water temperatures were not an issue until last Friday. A copy of the Water temperature logs were requested. On 2/08/23 at approximately 10:30 AM documentation of the water logs was received. The water temperature checks in the kitchen were documented in the month of January and the first week of February. There was no documentation or verification that the hand sink was checked on a regular basis.

Based on interviews, record review, and the facility [NAME] of Rights, the facility failed to promote a dignified environment by allowing a resident to sit in a urine soaked pants and Hoyer sling in his recliner for over an hour before being changed for 1 of 2 residents reviewed for dignity (Resident #33). The facility reported a census of 55 residents. Findings include: The Admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #33 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed impairment on one side of lower extremity. The MDS revealed resident dependent with toileting and lower body dressing. The Care Plan revealed a focus area revised on 10/6/23 for Activities of Daily Living (ADL) self-performance deficit due to amputation (left below knee) and impaired balance. The interventions revised on 2/12/23 revealed the resident required staff assistance for toileting and the hygiene portion of toileting. During an interview on 2/6/24 at 9:15 AM, Resident #33 stated he had an accident on 2/3/24 in his recliner around 4:30 PM and overfilled his urinal and it spilled over his pants and on the sling under him. The Certified Nurse Aide (CNA) came in and wiped me with paper towels and told me they would come back and change me and they never came back. Resident #33 stated the Certified Medication Aide (CMA) came to his room around 6:00 PM and saw him visibly upset and asked what was wrong and I told her. Resident #33 stated she went and got help and they got him changed within the next 15 to 30 minutes. Resident #33 asked how that made him feel and he stated ashamed of myself and he still felt ashamed and cried. During an observation on 2/6/24 at 9:15 AM, Resident #33 sat in his wheelchair in a short sleeved shirt and shorts. Resident's left leg revealed a below the knee amputation. During an interview on 2/6/24 at 3:29 PM, Staff F, CMA queried about the incident with Resident #33 on 2/3/24 and she stated she went into his room to give him his medications and saw him crying and asked why. Staff F reported that Resident #33 stated he overfilled his urinal and got it on his pants on the sling. Staff F stated she paged for a nurse and a CNA to come in and check help and they changed him. Staff F stated the Resident told her which CNA didn't come back to change him and she told the CNA to go find her and bring her back to change him. Staff F stated Resident #33 should of never been left with urine all over him. During an interview on 2/6/24 at 4:07 PM, Staff G, CNA queried about the incident with Resident #33 on 2/3/24 and she stated she worked that evening and right after dinner Staff F came and got her and told her Resident #33 needed changed. Staff G reported the Resident told another aide to change him and she didn't come back and do it. Staff G stated Resident #33 assisted with changing him by lifting himself up off the recliner so they could remove the Hoyer sling and then they removed his pants. Staff G stated the Resident cried when she came in. She stated they got him changed around 6:10 PM and 6:15 PM. Staff G asked how she felt about the incident and she stated frustrated because a resident should never be left like that and if the CNA would of asked for help, someone would of helped her. During an interview on 2/7/24 at 12:14 PM, Staff I, CNA queried on the incident with Resident #33 on 2/3/24 and she stated she got there at 6 PM that night and she answered his light and he said he needed cleaned up and he was emotional. She stated she didn't recall how long he said he sat and waited to be changed. During an interview on 2/7/24 at 1:16 PM, Staff H, CNA queried on the incident with Resident #33 on 2/3/24 and she stated he overfilled his urinal. Staff H reported she told the resident the Hoyer slings still needed to dry and she would check to see if they had dried yet. Staff H stated the meal started and she couldn't leave the dining room until all the residents who needed assisted left the dining area. Staff H stated she was basically stuck in the dining room and she still tried to worked on getting Resident #33 helped. Staff H stated she knew that Resident #33 needed changed, about 4:45 PM another CNA switched with her in the dining room around 6:00 PM and she went to help change the resident. Staff H asked if Resident #33 should of been left with urine on him and she stated definitely not. During an interview on 2/8/24 at 10:16 AM, the Director of Nursing queried on the incident on 2/3/24 with Resident #33 and her expectations, and she stated the resident needed changed when the staff knew he was wet. The Facility's Resident's [NAME] of Rights dated 6/2023 revealed the following information: that directed staff. a. Be treated with respect: Resident had the right to be treated with respect and dignity.

Based on interview, record review, and the facility policy, the facility failed to ensure insulin held per physician ordered parameters. The facility also failed to recheck blood glucose when the readings were below 70 milliliters per deciliter (mg/dL), and gave insulin when blood glucose below 70 mg/dL for 2 of 3 residents reviewed for residents with insulin orders (Resident #12 and Resident #25). The facility reported a census of 55 residents. 1. The MDS Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed the medical diagnosis of diabetes mellitus. The MDS documented the resident received insulin 7 out of 7 days. The Care Plan revealed a focus area dated 11/27/23 for diabetes mellitus. The interventions dated 11/27/23 directed staff as follows; a. administration of diabetes medications as ordered by the doctor b. monitor/document side effects and effectiveness of medication c. monitor/document/report as needed signs/symptoms of hypoglycemia which included sweating, tremors, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, and staggered gait. The Electronic Medical Record (EMR) revealed the diagnosis of Type II diabetes mellitus with unspecified complications. The Physician Orders revealed the following information: a. ordered on 12/21/23- Humalog solution 100 unit/ml (milliliter)- discontinued on 1/16/24- Inject 15 unit subcutaneously before meals for Blood Glucose (BG) greater than 101 to 450 b. ordered 12/29/23- FreeStyle Libre Sensor System Miscellaneous (Continuous Blood Glucose System Sensor)- Inject 1 unspecified subcutaneously as needed for blood sugar reading every 10 days and as needed and inject 1 unspecified subcutaneously one time a day every 10 day(s). Change sensor every 10 days and As Needed (PRN) c. ordered 12/29/23: Ok to do fingerstick blood sugar checks if needed. d. ordered 1/16/24- Humalog solution 100 unit/ml - Inject 10 unit subcutaneously before meals related to for BG greater than 101 to 450. Hold if less than 100. Review of the Medication Administration Record dated January 2024 revealed Humalog administered on the following date when the blood sugar level outside of parameter: a. 1/1/24 at 8:00 AM- 91.0 mg/dL b. 1/1/24 at 12:00 PM- 94.0 mg/dL c. 1/2/24 at 8:00 AM- 78.0 mg/dL d. 1/3/24 at 8:00 AM- 69.0 mg/dL e. 1/4/24 at 8:00 AM- 97.0 mg/dL f. 1/8/24 at 8:00 AM- 63 mg/dl g. 1/8/24 at 12:00 PM- 75.0 mg/dL h. 1/17/24 at 8:00 AM- 80.0 mg/dL i. 1/18/24 at 5:00 PM- 94.0 mg/dL j. 1/19/24 at 8:00 AM- 97.0 mg/dL k. 1/23/24 at 5:00 PM- 79.0 mg/dL l. 1/25/24 at 8:00 AM- 99.0 mg/dL m. 1/30/24 at 8:00 AM- 68.0 mg/dL During an interview on 2/8/24 at 8:27 AM, Staff E, Licensed Practical Nurse (LPN) queried if Resident #25 Humalog insulin ordered had parameters and she stated yes she believed to hold if under 100 mg/dL. Staff E asked if the check on the MAR indicated the insulin given and she stated yes it did. She stated the HD meant hold and the NI meant no insulin required. She stated she knew not to give the insulin if below 100, and that she must of charted it incorrectly. During an interview on 2/8/24 at 10:11 AM, the Director of Nursing (DON) queried on the expectations of following insulin order parameters. The DON reported Resident #25 FreeStyle lets the nurse know what the blood glucose read, and when the resident is done eating, she requested her insulin when her blood glucose goes up. The DON stated the nurse would give the insulin when the resident felt okay, and the nurse should recheck the blood glucose reading and document. 2. The Quarterly MDS assessment dated [DATE] revealed Resident #12 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed the medical diagnosis of DM, and the resident received insulin 7 out of 7 days. The Care Plan revealed a focus area dated 11/2/21 of diabetes mellitus. The interventions dated 11/2/21 revealed the resident maintained a very rigid control of her blood sugars, and restricted her diet which caused her severe drops in her blood sugars characterized by confusion, unresponsiveness, and inability to function. The interventions dated 7/4/22 directed staff as follows; give diabetes medications as ordered by the physician with monitored/documented side effects, and effectiveness including monitored blood sugars as ordered and as needed. The EMR revealed the diagnosis of Type I diabetes mellitus with unspecified complications. The Physician Orders reviewed the following orders dated 10/09/23: a. Humalog injection solution (Insulin Lispro)- Inject as per sliding scale: if 150 - 199 = 1 units; 200 - 249 = 2 units; 250 - 299 = 3 units ; 300 - 349 = 4 units; 350 - 351 = 5 units 350 and greater give 5 units, subcutaneously with meals b. Humalog injection solution (Insulin Lispro)- Inject 7 unit subcutaneously with meals. Hold if NPO (nothing by mouth) or not eating c. Insulin glargine solution 100 unit/ml (milliliter)- Inject 23 unit subcutaneously at bedtime for diabetes d. Glucagon Emergency Kit 1 milligram inject imtramuscularly as needed for hypoglycemia (blood glucose below 60) The Blood Sugar Summary revealed the following dates the blood glucose level below 70 mg/dl. a. 12/12/23 at 5:55 PM 64.0 mg/dL b. 12/13/23 at 6:47 PM 69.0 mg/dL c. 12/15/23 at 12:21 PM 61.0 mg/dL d. 12/29/23 at 12:06 PM 63.0 mg/dL e. 1/18/24 at 5:53 PM 63.0 mg/dL f. 1/23/24 at 6:05 PM 66.0 mg/dL g. 1/27/24 at 12:11 PM 61.0 mg/dL h. 1/29/24 at 6:09 PM 66.0 mg/dL i. 2/1/24 at 5:18 PM 69.0 mg/dL j. 2/4/24 at 12:51 PM 61.0 mg/dL k. 2/5/24 at 5:17 PM 63.0 mg/dL The facility lacked documentation the blood glucose readings above rechecked after the nurse documented a reading below 70 mg/dL. During an interview on 2/8/24 at 8:43 AM, Staff E, LPN queried on if blood glucose were rechecked when a resident's reading read below 70 and she stated she rechecked the blood sugars, but admitted she didn't always chart them after she checked them. Staff E stated Resident #12 got upset when she didn't get her insulin, but also didn't understand how much she needed to eat when she received her insulin. She stated the resident preferred to be in the 70's for her blood glucose levels. Staff E stated she understood not charting the blood sugar recheck, it looked like she didn't complete it. During an interview on 2/8/24 at 10:13 AM, the DON queried on her expectations for rechecking blood glucose levels when they showed readings below 70 mg/dl and she stated she believed staff completed the rechecks but they didn't document the recheck. She stated the provider only wanted notified of blood glucose readings below 60 mg/dl and above 350 mg/dl. The DON stated the staff normally rechecked the blood glucose 30 to 45 minutes after the meal, and seen how the resident felt. The DON stated the nurses rechecked if the blood glucose below 60 mg/dl, and used nursing judgment on how the resident felt if they rechecked it when the blood glucose reading above 60 mg/dl. During an interview on 2/8/24 at 11:35 AM, the DON stated the facility didn't have a protocol for hypoglycemia. The DON asked how the staff knew what they needed to do when a residents blood glucose was low, and she stated they used the [NAME] guidelines. The [NAME] Nursing 2003 Volume 33, Number 2 for hypoglycemia revealed a blood glucose level below 70 mg/dl indicated hypoglycemia (low blood sugar). The Facility Specific Medication Administration Procedures and Administration Procedures for all Medications Policy dated 12/2017 revealed the following information: a. Review 5 Rights (3) times 1. Check MAR for order 2. check for vital signs, other tests done during/prior to medication administration b. Obtained and recorded any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration.

Based on observations, interviews, and record review the facility failed to utilize proper transfer techniques when using a Hoyer lift for one of two residents observed for transfers. (Resident #202).This deficient practice resulted in increased pressure to the back of the neck for one resident. In addition, the facility failed to intervene when one of two residents observed consumed too hot of food. This deficient practice resulted in a high risk of a burn to the resident. (Resident #23). The facility reported a census of 55 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #202 listed diagnoses of Traumatic Spinal Cord Dysfunction Cervical Disc Disorder at C5-C6 (called the stress vertebra because they sustain the majority of the weight from the neck and head) with Myelopahty (severe compression injury) . The MDS documented the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The Care Plan dated 11/21/2023 identified a focus area for Resident #202 as Risk for Falls Interventions include: a. Low bed, fall mat and a concave mattress. b. Continue interventions on the at-risk plan. c. Discussed with therapy resident is to use Hoyer for transfers. Date Initiated: 01/02/2024 d. For no apparent acute injury, determine and address causative factors of the fall. e. Neuro-checks per facility standard of practice f. Pharmacy consult to evaluate medications. g. Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound. h. PT consult for strength and mobility. i. Resident educated to use call light when wanting to transfer. j. Resident to be check on every 2 hours when in room. k. Resident to have proper footwear on during transfer. l. Staff educated that when resident states she is weak to call for extra assistance before transferring resident. A Nurses Note dated 1/24/24 documented the following; received report from Hospital that the resident had a spinal fusion on 1/22/24. The resident has a C-Collar (medical device used to support and immobilize a person's neck) on that can be taken off with meals. A Nurses Note dated 1/25/24 documented the C-Collar is to be on at all times except for meals. On 02/05/2024 at 12:00 PM an observation was made of a Hoyer lift with Resident #202 in the dayroom. Resident #202 was being transferred from a chair to a wheelchair. Two staff members assisted and while performing the procedure they did not raise her head during the lift. Resident was almost in a laying position and her neck was out over the back of the Hoyer sling. Resident wears a neck brace, and this transfer process did not provide neck support while in the Hoyer lift position. On 02/06/24 at 02:20 PM another observation was made of a Hoyer lift with Resident #202. After some conversation between the Physical Therapy Assistant and staff member there seemed to be some confusion on what color straps to use and where to connect each strap to the lift. Staff proceeded to lift the resident from the chair in the dayroom to her wheelchair. The method used positioned the resident in an almost lying flat position. This position appeared to be too horizontal and therefore uncomfortable for the resident in a neck brace. As the resident was in the sling the resident appeared to raise her neck while wearing the neck brace. While in the sling, staff pulled the sling up behind the resident to elevate the resident's head. The two members had hooked up all of yellow straps to the Hoyer and therefore putting the resident in a laying down position with her head over the top of the sling. The resident did not appear comfortable and the sling did not provide any neck support. 02/06/24 at 02:25 PM An interview with the Physical Therapy Assistant was conducted. The therapist reported she typically used the cross sling not the open sling they just used with the identified resident. She advised she never hooks all of the same color straps to the Hoyer. We used the yellow straps just now because that was what the person that assisted me told me to do, but I have never done that before. It placed the resident too flat. 02/08/24 at 11:36 AM an interview with the Director of Nursing (DON), was conducted. The DON was asked about the transfer procedure and stated, for our specific lifts we do not have to lock the wheels. We have two lifts. One is a bariatric lift and the other can be used for residents up to 600 pounds. When the sling is raised the resident should be sitting up. The color of all of our slings are blue and the trim on the outside of the sling determines which sling should be used as they go by weight. If the same color strap is used on the the resident they would be in a laying position, more flat. From chair to wheelchair staff would use red, yellow and green because they would want the resident sitting up and not laying down. If a resident has a neck brace we try to not have the sling too high up on the brace to prevent pushing on the brace and not tipping the head forward. The DON advised training for the Hoyer lift process is mainly on the job training for the CNA's. The CNA's usually follow an already trained CNA for awhile and once they are comfortable they start doing things on their own. Our CNA's train the new CNA's on the procedure. There is no competency testing or return demonstration done prior to a CNA working on their own. The facility last provided a Hoyer Lift Transfer training last fall and she was requested to provide that additional documentation. The DON advised the facility has both cross slings and full body slings. We have one resident that we only use the cross sling with and either type of sling can be used with the rest of the other residents. When asked specifically, how the resident should be positioned in the Hoyer sling the DON advised it wouldn't really matter if the resident was laying down or sitting up. If the resident was lying down it is not necessarily a problem but it would require staff to work harder to get that resident in a position to sit up in a wheelchair. It would require more muscle and staff would have to use the handles and pull back on the sling to assist the resident in sitting up. When queried about the procedure with a a resident wearing a neck brace the DON responded we definitely would want to make sure the sling is supporting the neck and brace. 02/08/24 01:08 PM Staff J, Certified Nurses Aid( CNA) advised she had employed her for a year and a half. The CNA works the various halls and is familiar with most of the residents. Staff J was asked about the Hoyer lift process and training and she advised it was on the job training. As a CNA you are with a trainer (another CNA) for about a week and then once you get the hang of it you start doing things on your own. The CNA also advised they complete health care academy online classes and refreshers. Yearly, they have an Inservice training where they are trained on incontinent care, Cath care and Hoyer's. In our mandatory meetings we go over adult abuse. The staff member advised the CNA's had Hoyer training at the facility sometimes around last Thanksgiving. CNA's group up and the nurses and DON go through trainings with us. Once you are a CNA you can use the Hoyer. You have to have two people assisting. She has never been concerned about any staff member using the Hoyer lift that wasn't properly trained. The CNA then explained how the Hoyer is used at the facility. You want to make sure the resident is sitting up to make it easier to place them in the chair. She advised she always makes sure they are using the red, yellow and green straps so the resident is sitting up. If you use all the same color they would be laying flat. Lock the wheelchair, and make sure the resident is pulled up in the sling. The sling is positioned on the back of the head in the middle to support the neck. 02/08/24 at 11:42 AM another observation of a Hoyer lift was observed. Staff used the red, yellow and green straps on each of the six hooks. The sling was placed at the base of the resident's neck. Also present was the DON and the Administer. 02/08/24 at approximately 12:45 PM a document titled Education In-Service Record, Hoyer Lift Transfers was received from the facility. The document was dated 08/27/23. Subject: Hoyer Lift training per manufacturer guidelines. Sling selection, checking for sling integrity. Return demonstration. 62 staff members were listed as attending this training with approximately 17 completing the training via the phone. The facility policy dated 11/28/2022 and titled Total Lift Transfer documented, the Facility will utilize a Total Lift Device on Residents who are unable to assist with transfers. 25855 A review of the facility policy titled: Total Lift Transfer dated as last reviewed 11/28/22 had documentation of the following: a. Position the Sling under the Resident with the base of the Sling at the base of the Resident's spine, top of the Sling at the top of the head; Cross Straps prior to hooking the Straps of the Lift. b. Match the corresponding colors on each slide of the Sling& observe that all Sling loops are securely connected. A review of the manufacturer's recommendations for the Protekt 600 Lift had documentation of the following instructions for a transfer from a wheelchair Grasp the sling at each corner of the U shape of the commode aperture. The sling should be fitted with the handle on the back section facing outward. Help the user lean forward slightly, then slide the sling down between the chair and the user's back. Position the commode aperture where the buttocks meets the seat. Position the sling equally around both sides of the body. Draw the leg sections to the front along the length of the user's thigh. Check the sling's central positioning by comparing the lengths of the leg sections when they are drawn forward. Reposition the sling if the leg sections are not equal in length. Feed the leg sections under the thighs. From between the legs, gently pull the leg section up the inner thigh. Feed as much material as possible under and between the thighs. Ensure the leg sections are positioned midway under the thighs to provide good support and greater comfort. Move the lift slowly towards the user and position the spreader bar over the user's chest. Attach Loop a of sling to Hook A on Spreader Bar; attach Loop b to Hook B; attach Loop c to Hook C; attach Loop d to Hook D. Lift patient above the wheelchair by using the hand control. Pull lift away from wheelchair. Position patient over bed and lower patient onto it. 2. The Annual Minimum Data Set (MDS) dated [DATE] identified Resident #23 with moderalty impaired cognitive skills. The MDS documented the resident had the following diagnoses: Parkinson's Disease with Dyskinesia (involuntary erratic movements of the face, arms, legs or trunk), Diabetes Mellitus and Anxiety Disorder. The MDS also identified Resident #23 as dependent on staff assistance with most activities of daily living, and required supervision or touching assistance with eating. On 1/18/22 the Care Plan identified Resident #23 with the problem of Activities of Daily Living (ADL) self-care performance deficit, and independent with eating. Observation on 2/7/24 at 12:10 PM, Resident #23 had a plate with pureed food and picked up a spoonful of pureed meat which showed steam from the spoon. She spit it out. Staff D, CNA instructed Resident #23 to let the food cool down, however did not move the plate away from the resident. Resident #23 took another bite and spit it out again. Staff D instructed the resident again to allow the food to cool down, and did not move the plate away from Resident #23. Staff D asked Resident #23 if she wanted milk while the food cooled down. Staff D left to get the milk, and before she returned, Resident #23 took a third bite of the food and spit it out again. On 2/7/24 at 12:47 PM , the Dietitian reported Resident #23 was able to feed herself with cues. The pureed food was too hot for Resident #23. We don't want the food to sit too long and get cold. The Dietitian reported her expectation of the staff would be to move the plate out of her reach while it cooled off. On 2/7/24 at 1:49 PM, Staff D, CNA reported Resident #23 will not allow the staff to assist her with meals and staff are to encourage her to slow down. When asked why she had spit out her food earlier, Resident #23 said it was too hot. On 2/7/24 at 2:37 PM, the administrator reported the facility did not have a policy that addressed feeding.

Based on Centers for Medicare and Medicaid Services (CMS) Certification and Survey Provider Enhanced Reports Reporting (CASPER) system, review of the facility Quality Assurance Performance Improvement (QAPI) Plan, and staff interview the facility failed to ensure effective measures had been taken to correct deficiencies that continue. The facility reported a census of 55 residents. Findings include: A review of the CMS CASPER reports revealed the following deficiencies had been cited for 658 professional standards in 2019, 2021, March 2023 and [DATE] . This will be cited again February 2024. In an interview on 2/8/24 at 8:29 AM, the Administrator reported the following: 1. When problematic trends are identified and the committee felt they could improve upon, would begin the Quality Assurance (QA) process. 2. Current QA projects the facility has been monitoring included: falls and pressure ulcers 3. The facility had a mock survey conducted by an outside service on January 16, 2024. 4. 658 has been problematic- the facility completed education on medication administration to ensure correct orders were followed, audits on med administration on the Medication Administration Records (MARS) She was unsure if there was an audit conducted on the medication administration process. A review of the facility QAPI Plan Policy dated as last reviewed 8/20/20 revealed the following: POLICY The QAPI Plan will describe how the facility will ensure Care & Services delivered meet Accepted Standards of Quality, Identify Problems and Opportunities for Improvement, and ensure Progress towards Improvement is achieved and sustained. The QAA Committee will meet monthly to assess and monitor the Quality of Services provided to Residents and Identify potential problems or areas of opportunity for Improvement. The QAA Committee will Implement and Systematically Evaluate Programs and Processes to Identified Problems in order to Proactively Improve Health Care Delivery. PURPOSE a. Identify how Quality Assurance & Process Improvement activities will be incorporated into the operations of the organization so that all team members recognize the value of participating in activities that improve Resident Care & Quality of Life. b. Create Systems to provide Care & achieve compliance with Nursing Home Regulations. c. Strive to Achieve Improvement in specific Benchmarks, i.e. Falls, Wounds, Urinary Tract Infections (UTI's) d. Utilize data obtained from a variety of sources to identify Quality problems or opportunities for improvement and set priorities for resolution. e. Performance Improvement is a proactive and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and implementing new approaches to resolve systemic problems. f. Performance Improvement projects may be assigned to focus on a problem in one area of the facility or facility wide. g. Perform Root Cause Analysis, Identify Trends/Patterns, set Targets, & Implement Action Items to Improve the process.

Based on observation, record review and staff interview, the facility failed to utilize proper infection prevention techniques when emptying an indwelling urinary catheter bag for one of one residents reviewed (Resident #46). The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #46 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 and had the following diagnoses: Renal Insufficiency, Neurogenic bladder, Diabetes Mellitus and Pressure Ulcer of sacral region. It also identified Resident #46 required substantial staff assistance with toileting, showers, dressing and putting on footwear. It also identified Resident #46 had an indwelling urinary catheter. A review of the physician orders dated 1/29/24 to change 16 French Foley Catheter with 10 cc balloon monthly. On 1/26/24 the care plan identified Resident #46 with the problem of requiring catheterization with an indwelling 16 French catheter with a 10 cc(cubic centimeters) balloon. It did not direct staff on how to properly empty the drainage bag. An observation of cares on 2/26/24 at 11:45 AM revealed the following: Staff A, CNA entered the room and informed Resident #46 of the need to empty out the catheter drainage bag. She used the correct technique to empty the bag into a urinal and emptied the urinal into the toilet. Staff A then proceeded to rinse out the urinal with soapy water and emptied it out into the sink a total of four times. Staff A then emptied out the rest of the contents of the drainage bag into the urinal and emptied it into the toilet. Then she rinsed out the urinal with soapy water and emptied it out into the sink a total of four times. Resident #46 shared the room with another resident. In an interview on 2/7/24 at 7:39 AM,Staff B, CNA reported when she would empty out an indwelling catheter drainage bag, she would empty the urinal or graduate into the toilet, wash it and dump that water out into the toilet. In an interview on 2/7/24 at 7:42 AM, Staff C, CNA reported when she would empty out an indwelling catheter drainage bag, she would empty the urinal or graduate into the toilet, wash it and dump that water out into the toilet, dry it and return it to the storage rack in the bathroom. In an interview on 2/7/24 9:57 AM, the infection preventionist reported she would expect staff to rinse out urinals/graduates after emptying Foley and after they rinse should empty it out into the toilet. A review of the facility policy titled: Catheter Care and last reviewed 7/13/22 had documentation of the following: In an interview on 2/7/24 at 3:28 PM, the administrator reported the facility did not have a policy that addressed how to properly empty a catheter bag.

Based on clinical record review, staff interview, facility investigation review, and facility policy review, the facility failed to ensure safe transfer of a resident via Hoyer (mechanical) lift and failed to ensure a resident remained free from a preventable accident for two of four residents reviewed for accidents (Resident #37, Resident #39). On 3/12/23 the strap to the Hoyer sling ripped and Resident #39 fell approximately 3 feet during a Hoyer lift transfer. Resident #39's fall on 3/12/23 required transfer to the hospital. On 6/22/23 Resident #39 was lowered to the floor due to the Hoyer lift hydraulic breaking and the lift tipped. On 7/18/23, Resident #39 fell from the Hoyer when the sling broke. On 7/30/23, Resident #39 slid from the Hoyer, Resident #39 landed in a chair, and per documentation the Hoyer tipped during the process. This deficient practice resulted in an Immediate Jeopardy to the health and safety of residents who resided at the facility. The facility reported a census of 54 residents. : On 8/27/23, the Iowa Department of Inspections, Appeals, and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. The facility staff removed the immediacy on 8/28/23 after the facility staff completed the following: 1. Identified Resident was assessed to ensure proper transfer mode is being used. 2. Staff were educated on the use of slings for mechanical lifts as well as use of the mechanical lifts on 8/27/23 to follow manufacturer guidelines of the mechanical lift. 3. Staff will provide return demonstration of proper mechanical lift techniques on 8/27/23. Staff not available will not be allowed to work until this has been completed. 4. Staff were educated on sling inspection for any potential problems with tears/mars/torn stitching which may lead to a sling potentially malfunctioning. Education included bringing slings to the Director of Nursing (DON) for further inspection. The facility audited mechanical lifts slings on 8/27/23 and disposed of slings that were questionable 5. Lifts were inspected on 8/27/23 and are in proper working order. Facility will continue to follow protocols on lift inspection to assist in ensuring lifts are properly working The scope lowered from J to D at the time of the survey. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, the resident required the extensive assistance of two plus persons for transfer. Review of the Care Plan dated 2/28/22 documented, ADL (activities of daily living) self-care performance deficit: lymphedema, HX (history) of Left foot fx (fracture), decreased mobility. The intervention dated 2/28/22 revised 7/19/23 documented, ADL-Transferring-Hoyer-2 assist Sling Size XX-Large (Orange). Review of Task History per Resident #39's Care Plan documented the following per transferring: a. 3/14/23: Transferring-Hoyer-2 assist b. 5/30/23: Transferring - Hoyer- 2 assist Sling Size XX-Large c. 7/19/23: Transferring - Hoyer- 2 assist Sling Size XX-Large(Orange) The Care Plan dated 2/2/22 revised 7/19/23 documented, The resident is at risk for falls Deconditioning, Gait/balance problems, history(HX) of falls 7.18.23 witnessed fall, non-injury. Review of interventions included, in part, the following: a. 7/19/23: Hook installed in resident room to hold only residents' personal sling. Laundry educated to wash slings and place back in room on hook to ensure correct sized sling is being used with resident during all transfers. Staff educated to location of residents' slings. b. 7/20/23: Resident only to use orange sling in hooks found in room for Hoyer transfers. c. Date Intiated 7/20/23, revised 8/27/23: Resident only to use orange sling(criss cross) OR Full Body sling, that is labeled with her name. These will be found on the hook behind her door (clean) Or left in her wheelchair (during the day for multiple use) Review of Resident #39's Care Plans lacked direction for which weight capacity lift(s) would be used for the resident's Hoyer transfer. The Physician Order dated 2/2/23 documented, Apixaban (a blood thinning medication) Tablet 5 MG (milligram) Give 5 mg by mouth two times a day. The Physician Order dated 5/30/23 documented, Transfers: Assist of 2 with Hoyer Sling Size XX-Large . Review of the Monthly Weight Report for Resident #39 documented the following documentation of weight for the resident: a. March 2023: 404.6 pounds b. April 2023: 393.5 pounds c. May 2023: 406.6 pounds d. June 400.8 pounds e. July 2023: 416.6 pounds f. August 2023: 422.8 pounds The Incident Report dated 3/12/23 at 2:30 PM documented, in part, the following incident description: Res. (resident) lying flat on floor at an angle with approx. (approximately) 6 inches under the bed on bed post. 2 CNA's (Certified Nursing Assistants) in room with Hoyer lift with a weight of 450 pounds. Strap to Hoyer sling ripped during transfer causing res. to fall from approximate height of 3 feet. The Resident Description section documented, I fell out of the lift. I have had nightmares regarding this. Review of the Witnesses section of the report documented the following statements dated 3/12/23: a. Staff K, former CNA: See witness statement. This CNA unable at this time to provide statement. Will add statement when available. Myself and [name redacted] were transferring [Resident #39] with a Hoyer and when pulling away from bed to wheelchair, Hoyer sling broke causing res. to fall to floor. Immediately called for help. b. Staff D, former Hospitality Aide. Myself and [Name Redacted] were transferring [Resident #39] by Hoyer lift when pulled away from bed the lift sling broke. Resident fell to floor. Immediately called for help. The Incident Note dated 3/12/23 at 2:36 PM documented, Res. (resident) ALOx3. Res. does report hitting head with fall. Sheet placed under res. to be able to slide res. out from under the bed. Equal grip strength. No visible injuries noted. Pupils equal and reactive at a +3. No shortening of any extremities. Neg. homan'ssign. 4 staff members in room with nurse at this time. This nurse did send a staff member out to get RN (Registered Nurse) who informed nurse to not move res. and call 911. Pillows placed under res. head to stabilize. DR.(Doctor) [Name Redacted] notified of incident after calling 911. Res. daughter [Name Redacted] notified of incident and that ambulance on the way to transfer res. to ER (emergency room ). DR. and daughter both requested res. go to ER immediately for eval. (evaluation) and tx (treatment). This nurse also called report to ER and spoke with [Name Redacted]. Report given to [Name Redacted] included notification of res. starting on Cipro yesterday due to blood in urine , positive UTI (urinary tract infection), and that res. is on Eliquis. Await for EMTs (Emergency Medical Technician) to arrive. EMTs arrived and when this nurse entered the room one EMT was asking res. if she really wanted to [NAME] hospital. EMT was stating that res. was unable to fit on the stretcher. It was also reported to this nurse that the EMT had multiple times referred to resident as too big and too heavy to be taken in the ambulance and that she would not fit on the stretcher. This nurse informed EMTs and res. that the physician wanted res. to be assessed and that daughter was aware also. Informed res. it was ultimately her choice and if she wanted to call and speak with PCP (Primary Care Physician) and daughter to notify of her wishes that washer choice. Reminded res. of blood in urine and new start of ATB (antibiotic). Also of her overall condition yesterday. Res. did report that it would be best to be looked at. EMTs then went to call for a different lift transfer res. with. Paperwork sent with res. Current BP (blood pressure) 108/72, p (pulse)-72, resp. (respirations) 20, spo2 (oxygen saturation) 94%RA (room air), Temp 97.9. EMT did leave with resident after a second ambulance arrived. The Physician Order dated 3/12/23 at 2:45 PM documented, Send to ER (emergency room ) to eval. and tx.(treat). The Hospital Notes for Resident #39, arrival time dated 3/12/23 at 3:19 PM, documented the following: The History of Present Illness section documented, Chief Complaint: FALL. Location of injuries-head. The injury occurred just prior to arrival. Occurred at a nursing home. (Patient was being transferred in a Hoyer lift at her nursing home. The straps tore and patient was dropped approximately 3 feet to the floor, landing on her buttocks and striking her head. She denies any pain, and has remained oriented for NH staff and EMS (emergency medical services). She is on Eliquis for Afib (atrial fibrillation). The Clinical Impression section documented, Minor closed head injury. No loss of consciousness. Fall. The Nurses Note dated 3/12/23 at 3:51 PM documented, Inservice provided immediately after and all slings checked for any freys or tears. The Nurses Note dated 3/12/23 at 5:52 PM documented, in part, the following: Per hospital dx closed head wound. Review of documentation for 3/12/23 from an undated summary provided by the facility documented the following: 3/12/23 Resident fell from lift, sling broke. Education provided to staff regarding appropriate use of lift. Laundry educated on proper wash/dry of slings. All slings re-evaluated and made sure that current slings were in good working order. The Incident Report dated 6/22/23 at 9:40 AM documented the following Incident Description: CNAs called for nurse to residents room. Resident on the floor, CNA behind resident and CNA with Hoyer lift. Hoyer lift hydraulic broken and lift was tipped. The Resident Description section documented, Resident stated, I was lowered to the floor. The Notes section of the Incident Report documented, IDT (Interdisciplinary Team) met to discuss incident. Broken lift taken out of service. New lift being acquired, awaiting delivery. Review of documentation for 6/22/23 from an undated summary revealed the following: Resident was lowered to the floor, after hydraulic lift broke. Leg of lift buckled, bolt broke Lift was taken out of service. Rental lift acquired to use while awaiting new lift to arrive New lift, maximum weight 600lbs (pounds). The Nurses Note documented by the Nurse Practitioner dated 6/23/23 at 4:08 AM documented, in part, Resident was in Hoyer for transfer and lift failed Resident would like to be able to be able to stand pivot transfer and not use the lift. The Risk Note dated 6/29/23 at 1:12 PM documented, IDT (interdisciplinary team) met to discuss incident from last week, when the lift broke during a transfer. New bariatric lift is in the building, and in use. Resident has started PT/OT (physical therapy/occupational therapy) for strengthening and transfers also. No new interventions needed at this time. The Incident Report dated 7/18/23 at 1:27 PM documented the following Incident Description: Nurse called to resident room, when nurse arrived, resident on the ground with Hoyer lift in front of her, broken sling under resident. Resident sitting on her bottom with feet in front of her. 3 CNAs in room, attempting to transfer resident into shower chair. The Resident Description section of the form documented, Resident crying, stated she is not hurt, just embarrassed. Review of the Witnesses section of the form documented the following, dated 7/18/23: Got resident hooked up to Hoyer with sling. Lifted her up with 3 CNAs in room to transfer to shower chair when sling broke. Resident landed on her bottom on the ground. Did not hit her head. Review of the Notes section of the Incident Report documented, IDT team met to discuss fall. Resident will have her own slings, size orange. These slings will be hung on the back of her door. Education was provided to staff regarding the appropriate sling size. Also updated this on the care plan. Review of the Nurses Note dated by the Nurse Practitioner dated 7/18/23 at 2:51 PM documented, in part, staff reports that resident had a fall today during transfer to shower chair. Per report Hoyer sling broke and resident landed on her bottom on the floor. She did not hit her head. She denies injury. Resident is embarrassed, this is not the first time she has fallen while using the Hoyer. She does not understand why it keeps happening. Review of an undated summary provided by the facility revealed the following documentation for 7/18/23: Resident was in lift, when sling ripped, and resident was assisted to the ground. 3 CNAs (Certified Nursing Assistants) present. No injury. Education provided immediately to all staff present that day. Follow up education Provided to all staff on 7/19/23. Resident is to only use the orange bariatric slings. Slings will be kept on a hook, on the back of Her door, to ensure that they are the only ones used. Directions for use Hoyer, hung on Hoyer lift as an easy access reminder. Extra slings were ordered at this time as well. To ensure there are enough. The Incident Report dated 7/30/23 at 4:45 PM documented, in part, the following Incident Description: Staff reported at around 16a:24 (4:24 PM) that while assisting [Resident #39] with transfer in the morning when getting her up that she started to slide and they caught he and finished transfer with [Resident #39] landing in the chair at some point the lift started to tip and hit the CNA [Resident #39] landed in the wheelchair and was not hit by anything. The Resident Description section of the form documented, I'm fine the Hoyer tipped when I was getting in my chair. The Immediate Action Taken section of the Incident Report dated 7/30/23 documented, The Staff had the correct size sling and they were using the correct Hoyer. Intervention was to get her back in bed and wait until sling criss cross vs (versus) full body could be sorted through to get her up again and then they should use 3 [NAME] <sic>. On 9/6/23 at 12:10 PM, review of Resident #39's current task documentation revealed, ADL (activities of daily living) - Transferring - Hoyer- 2 assist Sling Size XX-Large(Orange) Review of documentation for 7/31/23 from an undated summary revealed the following: New facility lift, arrived at facility. Rental and new lift remain in facility to ensure that there is always a weight appropriate lift in the building. The Risk Note dated 8/3/23 at 1:27 PM documented, IDT team met to discuss resident recent accident with Hoyer lift tipping during transfer. It was brought up that resident family continues to bring snacks in for resident despite multiple attempts to educate on resident weight gain and health status. Staff was educated on proper use of Hoyer lift and correct sling choice. No further incidents of this nature have occurred. Nursing management will continue to monitor proper use of Hoyer lift and slings. The Nurses Note dated 8/5/23 at 12:57 PM documented, There were issues w/ (with) the bariatric Hoyer that is to be used solely for this resident. Res was asst (assist) x 3 using the other 600# lift. Res tolerated well. Maintenance was called to address issue. will cont to monitor. Review of Educational In-Service Records revealed the following: a. On 5/30/23, an inservice was provided for Hoyer transfer floor to bed and included videos as part of the education. The inservice sheet documented the Hoyer transfers policy was reviewed. b. On 5/31/23 an inservice was given for Hoyer Demo. c. On 6/10/23, an inservice was given titled Hoyer Scale Operation. d. An undated inservice, title [Resident #39's name], documented the following subject: She has her own slings. We have more on order they are bariatric slings w/ (with) mx weight of 600 lb (pound) they are to be kept on the hook on her door when not in use. Ensure the slings are her slings (and sign) in good condition prior to using if issues let us know ASAP (as soon as possible). The slings will be labeled w/ (with) initials. e. An undated inservice titled Hoyer Lift Transfers The undated inservices were provided back to the facility. The Hoyer Lift Transfers inservice and previously undated inservice for Resident #39 noted above (items d and e) were dated 7/19/23. There was also an education dated 7/18/23 for Reducation on proper sling choice for lifts. Observation on 8/28/23 at 12:57 PM revealed Resident #39 transferred from wheelchair to bed in their room utilizing a Hoyer lift. The weight capacity on the Hoyer lift utilized was 660 pounds. Three staff members assisted with Resident #39's Hoyer lift transfer. The resident used a blue sling with orange border, and staff hooked up the red loops of the Hoyer sling to the Hoyer lift. Observation revealed a particular brand of sling was used for the transfer. Review of a document posted inside a door across from the nursing station labeled [Brand Name Observed Used During Resident #39's Transfer Observation] Hoyer Sling Size documented the following for Resident #39: Orange has her own [Brand Redacted Different Brand Than Observed During Transfer Observation] slings. The Key section on the paper documented the following for Orange: XX-Large=400-600lbs Orange. Another sheet also present documented an orange binding color was suitable for 400 to 600 pounds. The facility provided a picture of the label on a sling by the same manufacturer utilized during Resident #39's transfer observation. Per the picture of the sling by the same manufacturer that was sent via email by the facility's Administrator, the following guidelines were included on the label per the warning section: IMPROPER sling size, type or attachment, or improper sling and lift inspection can cause death or serious injury. LOCK the wheels on the bed or chair before lifting patient. Follow manufacturers guidelines for locking casters on lifting equipment. ENSURE that leg straps are criss crossed, unless care plan dictates otherwise. Lift patient 1-2 inches over bed or chair to ensure sling is holding patient securely before further lifting. Also present on the label next to a picture of a yellow triangle with an explanation point inside was the following: ALWAYS INSPECT SLING BEFORE EACH USE FOR DAMAGE, SIZE, AND STYLE. Per the label in the picture, the orange binding color matched the approximate weight guideline of 400 to 599 pounds. On 8/28/23 at 8:12 AM during an interview with the current Director of Nursing (DON) and the Administrator together, the following was explained: It was noted the DON and Administrator did not work in the job positions at the time of the resident's Hoyer incident in March 2023. When queried if there was an incident when a bolt came out of the lift, it was explained on 6/22/23 the bolt snapped. The Administrator explained for the root cause analysis while the mechanical lift was rated appropriately, maybe it was not. The DON explained it was taken out of service, and the Administrator explained the lift was not bulky enough. Per the Administrator, they thought they should get a different type of lift for the resident, took the lift out of service, and rented another one. It was explained the facility wanted to get something over rated for the resident which is what was done. Per the DON, the lift was appropriately weighted for the resident. The Administrator explained the facility did not have any lifts that were underrated per weight, and even if to 450 it would have been appropriate for the resident due to weight under 450. In regard to the incident on 7/18/23, the DON explained the resident had the wrong sling put underneath of her. When queried as to the color of the sling, the DON explained she could not tell for sure, and that is how it had been reported to her. When queried as to the weight capacity for the sling, the Administrator explained they did not know if they could get ahold of that person and they did not know if they would be able to drill that down. During the joint interview, the event explanation provided clarified not a lift issue as much as the sling tore. During the joint interview for the resident's incident on 7/30/23, explanation given was not a fall, the wheel came up slightly, and the lift was finished. The Administrator explained the event occurred while the resident was over the wheelchair and being positioned, which caused one of the wheels to come up slightly. Per the DON, the transfer was completed with no issue. On 8/28/23 at approximately 8:40 AM, observations of Hoyer lifts at the facility were conducted with the Maintenance Supervisor. Interview with the Maintenance Supervisor also conducted at this time. Observation revealed three Hoyer lifts, two of which accommodated 600 pounds and the third accommodated 660 pounds. On 8/28/23 at 9:35 AM during an interview with Resident #39, when queried if the lift had tipped or broken, the resident acnowledged the lift had tipped more than once and explained they only hit the floor one time. The Maintenance Supervisor explained once a month he was going to pull all the lifts in, explained he periodically worked on on them, and was going to make it once a week. Per the Maintenance Supervisor, he was never trained on how to properly inspect them, and further explained he did a functions test on the lifts. The Maintenance Supervisor explained there was a system used for work orders. When queried if work orders had been put in on the lifts since he started, the Maintenance Supervisor explained yes, under the name of the previous person in the role. Per the Maintenance Supervisor, there had not been work orders with the functions of the lifts since he started. The Maintenance Supervisor explained he did not have access to information done by the previous person in the role. When queried as to the process if there were a concern, the Maintenance Supervisor explained he would be notified, explained this had happened recently, he had come in, and the concern was not something that took the lift out of operation. The Maintenance Supervisor explained in this instance he took the lift back to the shop, worked on it, and tightened up bolts. The Maintenance Supervisor explained he had upcoming training on the work order system and was trying to figure out actual proper functioning per the work order system standards. The Maintenance Supervisor explained he thoroughly checked the lifts over. When queried as to training he received, he explained the previous person in the role trained him, explained making sure the lift went up and down as should, taking out the wheels, cleaning those off, greasing the wheels, making sure the breaks worked, and the scale functioned. When queried as to whether the facility's work order system had a check sheet for needed items, the Maintenance Supervisor explained it was just a check sheet went though, and he needed training to understand it a little better. When queried if it would be written down when he took a lift in for service, the Maintenance Supervisor responded no, it was basically a mental note. The Maintenance Supervisor acknowledged this week coming up with a new plan to have weekly documentation. Review of an undated document titled Tasks due this week provided from Maintenance revealed a check mark located next to the category of resident lifts, with the title of Inspect mobile lifts. No additional detail was provided on the form about what the inspection entailed. On 8/28/23 at 3:30 PM when queried about the resident's incident with the Hoyer which occurred in March, Staff D, former Hospitality Aide, explained she really honestly thought the sling used was used too much, could not bear the resident's weight, and ended up snapping. When queried what the sling looked like, Staff D explained the sling was blue. When queried about the color/border around the edge of the sling, Staff explained they were pretty sure it was dark blue. Per Staff D, if they remembered correctly the resident was up in the air and getting ready for transfer from bed to wheelchair. Staff D explained they had yelled out for help and another person, she could not recall who, had been present in with Staff D at the time. In terms of the response, Staff D explained she believed others thought they were joking, and finally got the nurses in. Per Staff D, the resident did not have visible injuries, and the resident ended up hitting the back of her had where you lock the bed. When queried as to the resident's response, Staff D explained the resident said ow and started crying. When queried as to her duties as a hospitality aide, Staff D explained, in part, that she could stand there and be a second eyeball for a CNA. When queried as to how she would know what kind of sling a resident needed, Staff D explained it was posted on the door where the slings were located, and if the information was not on there updated she could go to the head nurse and ask someone real quick. On 8/29/23 at 4:43 PM during an interview with Staff H, Registered Nurse (RN), Staff H explained the following about the incidents which occurred on 6/22/23 and 7/18/23. It was noted Staff H documented progress notes about both incidents: a. 6/22/23: Staff H explained if she remembered correctly, for the incident they had two or three CNAs in the room. Staff H explained when she went in, the arm part of the Hoyer was tipped over to the side, there was a CNA behind her (resident), and then another staff was holding up the arm so it was not hitting the resident. Per Staff H, at first what it looked like was the lift tipped when actually the legs were on the floor and the arm was tipped and broken. Staff H explained the resident was on the floor with her legs out in front of her, and the sling was still underneath. When queried as to which sling it was, Staff H could not recall, and acknowledged the sling was intact. When queried as to the resident's response, Staff H explained the resident said it tipped over on her, giggled, and the resident not in pain. Staff H acknowledged the resident was already on the floor when she responded. b.7/18/23: Staff H explained the incident was the one where the sling broke. When queried which sling utilized, Staff H was unable to recall. When queried if she was there when it broke, Staff H acknowledged she responded after. When queried as to the resident's reaction, Staff H explained the resident cried, but said she wasn't in pain and was just embarrassed. When queried why she thought the sling broke, Staff H responded it could be numerous things. When queried if there was any kind of inspection or check done on slings at the facility, Staff H explained staff should check them before use and check all the loops. When queried if she saw staff doing that, Staff H responded yes, she had seen some. When queried about sling availability, Staff H explained she had heard of one time when it was in the dryer and waiting for a sling to be available. When queried who said it was in the dryer, Staff H responded housekeeping. When queried about how long ago this occurred, Staff H responded she did not know, and further explained a couple weeks. When queried how CNAs would know which lift to grab for residents, Staff H explained the lift that was used for Resident #39 looked a lot different than the other lifts, had a wider base and area where the sling hooked to. On 8/30/23 at 10:14 AM, an interview was conducted with Staff J, former Social Services/Certified Nursing Assistant (CNA), about the resident's Hoyer incident, noted per the incident report, dated 7/18/23. It was noted Staff J had been the listed witness to the event. Staff J explained the following: Per Staff J, she assumed the event queried about was the one where the resident fell . When queried who else assisted other than herself. Staff J explained she did not know, and named one person she explained may have been there possibly and another one. Per Staff J, the transfer was from wheelchair to bed, when queried as to whether a Hoyer transfer Staff J said yeah, and it was the only way she (resident) was transferred. Per Staff J, she went in and the resident was already hooked up and everything. Staff J explained she was present to be the third person to guide the resident, and was attempting to make sure everything was ok. Staff J explained she could not remember who had come to her office and asked her (Staff J) to come into the room to assist with transfer. Staff J explained sending an email at the time, and said to get the resident hooked up and Staff J would be in in a second. Staff J explained she finished her email then went to help, and the others were waiting for her. The resident started to be lifted up, and Staff J stood by and talked to the resident. Staff J explained they joked about a previous situation which had occurred prior. Staff J then explained boom. When queried as to the resident's positioning, Staff J explained the resident was high enough to clear the handles of the wheelchair, and acknowledged the resident was raised to that point prior to the fall. When queried as to the sling and specifically what had broken/ripped, Staff J explained she was more concerned with the resident than anything, it was a scary thing and she herself would not want to be the person going down like that. Staff J explained her focus was on making sure the resident was ok. On 8/30/23 at 12:09 PM an interview was conducted with Staff L, CNA explained she worked every other weekend. When queried about Hoyer lift transfers, Staff L identified Resident #39. When queried about slings for the resident, she explained she knew the resident had one that did not leave her room. When queried about the Hoyer the resident used, Staff L explained there was one that was only used for Resident #39. When queried about the number of staff utilized, Staff L explained they started with two (persons), and realized they needed three to be on the safe side. When queried about the Hoyer tipping, Staff L explained she would not necessarily say it tipped, and further explained the wheels did leave the ground a little bit. Staff L explained the resident was brought over the wheelchair and the other CNA have maneuvered the buttons. Per Staff L, the resident hovered over the wheelchair, Staff L pulled back on the resident when the resident came down so the resident was not sliding out of the wheelchair. Staff L explained she thought she pulled a little too hard and it raised up a little bit. Per Staff L, that was when she realized she wanted to use three. Staff L explained she believed it had been before lunch, she believed the resident had been laid down to use the toilet and they had been getting the resident back up. Per Staff L, it had either been before lunch or breakfast. When queried as to when this occurred, Staff L responded the 12 or 13 of August, and explained that was the last time she had worked. Staff L explained the following reaction to the event: our heart stopped when it happened. On 8/30/23 at 2:14 PM, an interview was conducted with the Traveling DON about Resident #39's Hoyer incidents. For the incident in March, the Traveling DON explained she believed the issue was with the sling. Per the DON, the right sling was used, it looked good, was appropriate, and was not damaged in any way. Per the DON, the resident was lowered and then sent out for more precautionary manner. The Traveling DON explained the resident came back without any new orders. The Traveling DON explained she was not at the facility, had the slings inspected immediately, and the manager on duty inspected all the slings. When queried if staff would document what sling and lift were used, the Traveling DON explained they would be using the 600 pound rated lift, explained the resident had bariatric slings, and further explained the resident had double x slings orange. Per the Traveling DON, she did not know if this would necessarily be documented because it was care planned. Per the Traveling DON, the 600 pound higher rated Hoyer would be used. Per the pre[TRUNCATED]

Based on observation, interviews, clinical record review, and hospital record review the facility failed to ensure residents are provided assessments and care in accordance with professional standards of practice when they failed to consistently, properly assess, and document changes in condition for a resident who had required immediate transfer to a hospital for septic shock. Also, the facility failed to consistently follow the following physician's order for another resident with a known history of Congestive Heart Failure; weigh resident daily and notify the physician for a three-pound weight gain. The facility staff did not consistently assess this resident or document for this resident with the weight gains. The resident had frequent hospitalization s as a result of fluid overload. The facility reported a census of 54 residents. On 9/5/23 at 10:30 AM, the Iowa Department of Inspections, Appeals, and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. The facility staff removed the immediacy on 9/6/23 after the facility staff completed the following: 1. eINTERACT Change in Condition Evaluation; Point Click Care/Assessments or UDA or User Defined Assessment a. Definition/What is a Change in Condition: b. eLearning Platform is Healthcare Academy eCourse Identifying Changes in Condition: Nurses. 2. Notification/Change in Condition Policy: Guideline for Notification of Physician/Resident Representative (not all inclusive): a. Significant Change or Unstable Vital Signs b. Emesis/Diarrhea c. Onset of Pressure Injuries d. Accident/Incident e. Signs/Symptoms of Infection f. Abnormal Laboratory Results g. 5% Weight Gain/Loss in 30 Days h. Repeated Refusal to take Prescribed Medications i. Change in Level of Consciousness j. Abnormal Complaints of Pain, Ineffective Relief of Pain from current Regimen k. Unusual Behavior l. Missing Resident m. Glucometer reading Below 70 or Above 200 (Unless specific parameters were given by Physician for Reporting). 3. Nursing Completes an eInteract Change in Condition Evaluation/Assessment. a. Communicated via Shift-to-Shift Report. b. Changes in Condition are Reviewed in Stand-Up Meeting; Nursing/Interdisciplinary Team. 1. All Residents have an Assessment Completed upon Admission/Readmission. a. Nursing Admission Screening, Located in Electronic Medical Record; Point Click Care/Assessments. 4. Monthly/Weekly Weights are Obtained by Shower Aide. a. Monthly/Weekly Weights are Documented in Electronic Medical Record/Point Click Care, Vital Sign Tab. b. Daily Weights are Documented eMAR (Electronic Medication Administration Record) & Obtained by CNA Assigned to Resident. 4. Scales: a. Standing Scale; Residents who can Stand. b. Wheelchair Scale; Residents who are in Wheelchairs. c. All Wheelchairs are Labeled with Chair Weight. d. Hoyer Scale; Resident who are in bed. The scope lowered from a J to a D at the time of the Survey. The facility reported a census of 54 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #37 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 and had the following diagnoses: Amputation, Coronary Artery Disease and Heart Failure. The MDS also identified Resident #37 required extensive staff assistance with bed mobility, locomotion on and off the unit, dressing and toileting. The MDS also identified Resident #37 was totally dependent on staff for transfers and bathing. On 1/18/22, the Care Plan identified Resident #37 with the problem of Congestive Heart Failure and directed the staff to: a. Monitor/document/report as needed (PRN) any signs/symptoms of Congestive Heart Failure: dependent edema of legs and feet, periorbital edema, SOB (shortness of breath) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of lungs, Orthopnea, weakness and/or fatigue, increased heart rate (Tachycardia) lethargy and disorientation. b. Weight monitoring Daily Weight Date Initiated: 02/12/2023 Revision on: 06/14/2023 The care plan did not direct staff to notify the physician with a weight gain of more than 3 pounds. The After Visit Summary from a hospital dated 6/12/23 directed the resident to be weighed daily in the morning after emptying the bladder and before eating breakfast, document the weight daily, and if there was a gain or loss of three pounds from the baseline weight, the resident had been instructed to call the local cardiologist or primary care provider. A review of the Physician Order dated 6/12/23 revealed an order for daily weight and notify cardiology or primary care provider if gain or loss 3 pounds from the baseline weight every day shift related to heart failure. A review of the electronic medical record did not have weights documented on June 14, 21, 29, July 5, 6, 22, 23, 29, August 22, 2023. A review of the Progress Notes lacked documentation that the physician had been notified of significant weight gains on 7/31/23 and 8/17/23. A review of the weights documented in the EMR revealed the following: 7/30/23 weight 355 pounds 7/31/23 weight 361 pounds (6 pound weight gain) 8/16/23 weight 361.8 pounds 8/17/23 weight 366 pounds (5 pound weight gain) A Progress Note documented on 7/18/23 at 4:09 PM, the cardiologist's nurse called with update with an order for Resident #37 to go to the hospital or to talk to facility doctor about palliative care. Resident #37 chose to go to hospital and transported to the hospital by Emergency Medical Technicians (EMT's) A Progress Note dated 7/18/2023 at 4:49 PM documented the following Assessment; Blood Pressure 108/71, Temperature 97.7 F, Pulse 93, Respirations 22, Oxygen saturation 96.0%. On 6/17/23, Resident #37 weighed 335 pounds. On 7/17/23, Resident #37 weighed 364.3 pounds. A weight gain of 29 pounds in one month's time. Resident #37 is on a 1.5 liter per 24-hour fluid restriction which he is not compliant with. Resident's diuretic was not available, and he went without, medication then changed. Transferred to hospital on 7/18/23 due to fluctuation in weight. A Progress Note on 7/31/2023 12:41 documented that the Resident is on 1.5 liter fluid restriction. Nurse to write a progress note on compliance with fluid restriction and nurse is to educate and document this education in the Progress Note every shift every shift for fluid resident. Resident non-compliant with fluid restriction. 6 pound weight gain. Resident educated on the importance of complying with fluid restriction for his health and his heart. The Progress Notes Lacked documentation to show the physician had been notified of the weight gain. A Progress Note on 8/17/23 at 9:14 AM revealed the Resident non-compliant with fluid restriction. Weight gain of 2 pounds (EMR weight documentation of weight gain of 5 pounds) Resident educated on the importance of following fluid restriction and what the increased fluid does to his heart and body. On 9/5/23 at 11:50 AM, when queried about Resident#37's lack of documentation on daily weights, the Director of Nursing (DON) reported corrective actions were implemented to ensure the resident would get his weights documented and that assessments would also get documented when he had a significant weight gain. The DON stated that if weights are documented in the weights in Electronic Medical Record (EMR) and not in the Treatment Administration Record (TAR), it did not float over to the TAR. The DON reported that the CNA's who would weight the resident will enter the weight into the EMR. The DON stated there are weights documented for Resident#37 everyday, under the hot charting in the Progress Notes with the medication under display EMAR. On 8/30/23 at 12:37 PM, Staff I, LPN reported that when a resident has an order for daily weights, the CNA's weight the resident, then tell the nurse the weight and the nurse will enter into the EMR either under the weight section and the Medication Administration Record (MAR). Staff I stated if a weight is not documented, in the EMR, that means the weight was not done. Staff I reported that when a resident has Congestive Heart Failure (CHF), 3 to 5 pounds would be considered a significant weight gain in 24 hours. Staff I affirmed that the physician should be notified if the resident had a weight gain of 3 to 5 pounds in 24 hours. Staff I communicated that if the resident gained 30 pounds in one day, the staff should re-weigh the resident a couple of different times, sometimes on the lift and sometimes on the scale, call the doctor and send to the hospital and this should be documented in the progress notes. Staff I divulged that the DON and ADON are responsible checking new orders with residents who come back from the hospital. When they are not here, the charge nurse would be responsible for checking the orders. Staff I reported that the order may have been missed as he had lost so much weight in the hospital. On 8/30/23 at 1:00 PM, Staff E, LPN reported that when a resident has orders for daily weights, the CNAs are responsible for obtaining those weights which should be reported to the nurse who should enter the weight on to the MAR, then once it is entered onto the MAR, it will automatically populate in to the weights section in the EMR. Staff E stated that if a weight is not documented, it would mean the resident refused and this should be documented. Staff E indicated that when a resident has CHF, a 3 to 5 pound weight gain in 24 hours would be considered a significant weight gain and the physician should be notified. Staff E expressed that if a resident gained 30 pounds in one day, the staff should assess lung sounds, monitor output, re-weigh the resident and notify the doctor and this should be documented in the progress notes. Staff E affirmed that the DON or ADON are responsible for checking new orders when residents return from the hospital. On 8/30/23 at 1:15 PM, Staff H, RN reported that when a resident has orders for daily weights, the CNAs are responsible for obtaining those weights and report it to the nurse, then the nurse should enter the weight into the EMR and to the MAR. Staff H affirmed that if the weight is not documented, that would mean the CNAs did not get the weight and this should be documented in the progress notes. Staff H stated that if a resident has CHF, any weight gain over 3 pounds in 24 hours is considered a significant weight gain and the physician should be notified. Staff H stated that if the resident gained 30 pounds in one day, the staff should re-weigh the resident, if the resident is in the wheelchair, reweigh the wheelchair, assess for lung sounds and contact the doctor. This should be documented in the progress notes. Staff H affirmed that the DON and ADON are responsible for checking new orders with residents who come back from the hospital. When they are not in the facility, the nurses are responsible for checking new orders. On 8/30/23 at 1:36 PM, the DON reported that when a resident has orders for daily weights, the CNAs are responsible for obtaining those weights and report it to the nurse then the nurse will chart the weight in the MAR and weight section in the EMR. The DON stated that if the weight is not documented, that would mean the resident had refused to be weighed and if the resident refused, this should be documented in the progress notes. The DON voiced that if a resident has CHF, the facility policy states a significant weight gain would be over 5 pounds in 24 hours. the DON indicated that some physicians will order to be notified of a weight gain of 3 pounds in 24 hours, then this should be documented in the progress notes. The DON indicated if the resident gained 30 pounds in one day, the staff should assess the resident, re-weigh and notify the physician. The DON affirmed that she also reported the weight for 6/23/23, she believed was not accurate as they did not use the Hoyer scale correctly. The DON reported that any weight gain more than 3 pounds in 24 hours should be reported to the physician and documented in the progress notes. On 9/5/23 at 11:50 AM, the DON reported that if weights are documented in the weights area in the EMR and not in the Treatment Administration Record (TAR) for Resident #37 it will not float over to the TAR. The DON stated to correct this the CNA's that weight the resident will enter the weight into the EMR. The DON reported that Resident#37 had documented weights every day under the hot charting Progress Notes with the medication under display EMR. On 9/5/23 at 11:50 AM, the DON reported for Resident #18, the output was added to the Care Plan so the CNA's and nurses can see it needs to be done and we can see his output documented. The DON state that all residents on antibiotics will have temperatures taken once a day, and a field was attached to the antibiotic order so that the staff would have to take the temperature as they give the medication other wise they can not chart it as given in the computer. The DON confirmed that she provided education with the nurses and spoke to them about the importance of assessing that a resident who has a catheter will have documentation for an output,t and implemented an admissions checklist that has it on there so if there is a catheter, we chart an output On 9/6/23 at 9:15 AM, the Administrator reported he could not find documentation that weights had been obtained on June 14, 21, 29, July 5, 6, 22, 23, 29, August 22, 2023 that should have been done per physicians orders. The Administrator state that no documentation could be found about notification to the physician of the significant weight gains on 7/31/23 and 8/17/23. A review of the facility policy titled: Notification of a Change in Condition dated as last revised 4/26/23 directed staff as follows: The Attending Physician/Physician Extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a Change in a Resident's Condition, per Standards of Practice and Federal and/or State Regulations. 1. Guideline for Notification of Physician/Resident Representative (not all inclusive): a. Significant Change or Unstable Vital Signs b. Emesis/Diarrhea c. Onset of Pressure Injuries d. Accident/Incident e. Signs/Symptoms of Infection f. Abnormal Laboratory Results g. 5% Weight Gain/Loss in 30 Days h. Repeated Refusal to take Prescribed Medications i. Change in Level of Consciousness j. Abnormal Complaints of Pain, Ineffective Relief of Pain from current Regimen k. Unusual Behavior l. Missing Resident m. Glucometer reading Below 70 or Above 200 (Unless specific parameters were given by Physician for reporting). 2. Document in the Interdisciplinary Team (IDT) Notes: a. Resident Change in Condition b. Physician/Physician Extender Notification c. Notification of Resident Representative A review of the facility policy titled: Weight Variances dated as last reviewed 3/31/21 directed staff as follows; All residents who experience significant, insidious and/or unintentional/unplanned weight loss or gains shall be assessed for nutritional status by Registered Dietitian. Recommendations from Registered Dietitian to include but not limit to adding calorie rich/preferred snacks between meals, fortification, supplements, liberalizing diet, and plan or expected weight changes. Residents receiving supplements shall be monitored for acceptance by the Dietary Manager/Nursing Staff. Residents at risk for unintentional/unplanned weight variance may be monitored with weekly weights. Weights shall be reviewed by the Registered Dietitian for review and assessment. 47336 2. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS documented resident used indwelling catheter and received an antibiotic for 6 out of 7 days. The MDS revealed diagnoses of amputation; complete traumatic amputation at the level between knee and ankle, right lower leg, sequela; completed traumatic amputation at level between knee and ankle, left lower leg, sequela; neurogenic bladder; Paraplegia; Depression (other than bipolar); pressure ulcer of other site, Stage 4. The Baseline Care Plan dated 8/1/23 documented resident took antibiotics and did not check the box for nurse monitoring. The Care Plan with revision date 8/16/23 revealed a focus area of required catheterization of a suprapubic catheter due to a diagnosis of neurogenic bladder. The interventions with initiated date 8/3/23 directed staff as follows; monitor and document intake and output per facility policy; and monitor, record, report signs and symptoms of Urinary Tract Infection (UTI) to the provider such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp,urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. The Care Plan dated 8/16/23 revealed a focus problem of antibiotic therapy. The interventions dated 8/8/23 directed staff as follows: Administer antibiotic medications as ordered by physician; monitor and document side effects and effectiveness every shift; monitor/document/report as needed (PRN) adverse reactions to antibiotic therapy: diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions (rashes, welts, hives, swelling face/throat); and monitor/document/report PRN signs and symptoms of secondary infection related to antibiotic therapy such as oral thrush (white coating in mouth, tongue), persistent diarrhea, and vaginitis/itchy perineum/whitish discharge/coating of the vulva/anus. The Physician Orders revealed the following orders: a. ordered 8/1/23- Macrobid capsule 100 mg (microgram) - give 100 mg by mouth two times a day for UTI for 10 Days- prescription ended on 8/12/23 b. ordered 8/1/23 and started 8/2/23- Amoxicillin oral capsule 500 mg - give 500 mg by mouth every 12 hours for UTI for 7 Days- prescription ended 8/9/23 c. ordered 8/13/23 at 3:48 AM- Send to [Name Redacted] Emergency Department The Weights and Vitals Summary revealed the following vitals: a. 8/1/2023 at 3:01 PM: 97.6 F Temperature; 8/1/2023; 95 bpm (beats per minute) Pulse; 142/86 BP (blood pressure) b. 8/13/2023 at 3:43 AM: 67 bpm- Pulse c. 8/13/2023 at 3:42 AM: 68/42 BP The Electronic Medical Record (EMR) lacked documentation of vitals for the all the other dates not shown between 8/1/23 and 8/12/23. The EMR failed to include documentation of catheter care and urinary catheter output completed. The Progress Note dated 8/7/23 at 3:35 AM revealed resident continued antibiotic therapy related to UTI. No side effects noted. Suprapubic catheter intact, patent, and drained well. Fluids encouraged & provided. Call light within reach. Will continue to monitor. The EMR failed to include documentation of Progress Notes of for catheter care/output or resident's presentation for effectiveness of antibiotic therapy or signs and symptoms of UTI. The August MAR revealed the resident refused his HS (bedtime) medications of mirtazapine, pregabalin, sennosides, baclofen, L-arginine, oxybutynin, and phenazopyridine on 8/12/23 for the 8:00 PM doses. The Progress Note dated 8/12/23 at 12:17 PM revealed a late entry of the resident had 3 loose stools this shift. Resident received suppository for morning bowel program. The resident stated that that suppository definitely did its job. The Progress Note dated 8/13/23 at 4:39 AM revealed at 3:30 AM this nurse called to resident room for resident unresponsive during CNA (certified nurse assistant) check and change. It was communicated to this nurse that resident had no output from suprapubic catheter since 10:00 PM. This nurse assessed the resident who not aroused by sternal rub. This nurse attempted to wake resident and unsuccessful. Resident diaphoretic and cool to the touch. Pulse oximetry could not be obtained. Blood pressure 68/42 manually on left arm in lying position. Heart rate 67. Temperature 97 F. This nurse then called Advanced Registered Nurse Practitioner (ARNP) at 3:37 AM for further instruction. Phone orders received to send resident to Emergency Department (ED). Emergency services called and resident sent via ambulance to local hospital. Report called to ED Nurse at 4:14 AM. Director of Nursing (DON) notified of transfer to hospital. Change of Condition evaluation dated 8/13/23 at 4:48 AM revealed the following: a. signs and symptoms identified: abnormal vital signs and unresponsiveness; started in the morning b. general background information: the resident in the facility for post acute care c. mental status evaluation: unresponsive d. functional status evaluation: general weakness and had abrupt changes in status to unresponsive and weak. e. genitourinary status evaluation: yes, the genitourinary/Urine assessment relevant to the change in condition been reported, decreased urine output; abrupt decrease in urinary output, with lower abdominal distention, discomfort over bladder, or bladder volume > 400 cc f. neurological status evaluation: yes, a neurological assessment relevant to the change in condition been reported; Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse); sudden change in level of consciousness or responsiveness; and resident unresponsive to painful stimuli g. review findings and provider notifications: Things that make the condition or symptoms unchanged (or unable to determine)- Resident sent to ED (Emergency Department due to abrupt change. Resident found to be unresponsive to painful stimuli. Resident BP 68/42. Urine output decreased. The Emergency Medical Servie Run Report dated 8/13/23 revealed the dispatcher dispatched the local emergency service to the facility at 4:00 AM for a male resident who had an unresponsive episode and altered level of consciousness. Upon arrival at the scene, the resident found in his room lying supine in bed. The resident appeared to be dazed. Limited bedside report given by the facility Licensed Practical Nurse (LPN) and CNA . The resident transferred to our stretcher via a four person slide. The Chief complaint revealed altered level of consciousness. The history of present illness revealed facility staff reported that the resident had a diminishing level of consciousness for the past day or so. They reported that the resident normally alert and oriented, but hadn't been for some time now. The resident with a history of dementia, per facility staff. The Assessment revealed the resident semi conscious, unable to answer any and all questions. Glasgow Coma Score (GSC) at worse (2/2/4) 8, at best (3/2/3), The resident unable to speak or communicate effectively. The resident responded to most stimuli by screaming. The Cardiopulmonary assessment revealed the airway patent, as evidenced by ease of screaming, with some concern for compromise. The resident appeared to have intermittent apnea episodes, the resident would quickly begin to breath again in a large gasp followed by a sparse episodes. The four-lead cardiac monitor revealed NSR (normal sinus rhythm) with any abnormalities. The resident connected to the four lead cardiac monitor because the 12-lead ECG (electrocardiogram) unable to be obtained due to the patient's poor cooperation. IV (intravenous)access unable to be obtained as the patient would not allow his arm to be repositioned. The Physicians Clinical Report from the local hospital dated 8/13/23 at 4:24 AM revealed the resident's chief complaint decreased mental status. The resident described as having decreased responsiveness. This started today and still present. Resident found by nursing home staff, agitated, screaming, with decreased mental status, hypotensive. Resident had decreased urine output. Resident oriented x 3 at baseline. No know recent falls or injuries. Usually alert and oriented x 3 . (Resident with multiple chronic conditions of history of bilateral below knee amputation (BKA), paraplegia, pressure ulcer of sacral region, depression, chronic pain, hypertension (HTN), gastroesophageal reflux disease (GERD), chronic osteomyelitis, neurogenic bladder. UTIs, indwelling suprapubic Foley catheter. Resident been hospitalized several times at another hospital for sepsis. Resident took Macrobid for UTI. The progress and procedures section of documentation documented the Course of Care of resident very lethargic, hypotensive. Resident on 3 L of normal saline, blood pressure initially improved to 95/60 then dropped to 70/50. Ordered vasopressors, levophed drip. BP improved to 129/72. Blood cultures order, with IV antibiotics Zosyn/vancomycin. The resident needed transferred to hospital if indicated, may include critical care. The Physician Clinical Report from the local hospital dated 8/13/23 at 4:24 AM revealed the resident needed a higher level of care and the resident approved to transfer to another hospital with a ICU (Intensive Care Unit). The resident transferred by ground ambulance. The Physicians Clinical Report from the local hospital dated 8/13/23 at 4:24 AM documented the following information: The Clinical Impression revealed the following conditions: a. Severe sepsis with shock and acute cardiovascular failure central nervous system failure and renal failure. b. renal failure c. urinary tract infection. The CT (computerized tomography) Head without contrast completed on 8/13/23 at 4:35 AM for the clinical indication of altered mental status and dementia revealed the impression of no acute intracranial process; mild cerebral volume loss. mild chronic small vessel ischemia disease. The Nurses Clinical Report dated 8/13/23 at 4:52 AM- documented the following; a. vitals: BP 54/44, Heart rate 89; RR 12. O2 (oxygen) saturation 95%. Temp. 97.1 b. The Physical Assessment revealed an General/Neuro/Psych assessment with the following documented information: The resident pale and dehydrated, confused and combative and bedridden. He appeared older than stated age and unkempt. Decreased awareness (didn't open eyes to pain and combative). No apparent seizure activity. The resident didn't appear post-ictal. Resident's speech incoherent and loud. Resident appeared unkempt. Marked body odor. Clothes dirty. Hair uncombed. c. The Respiratory Assessment revealed decreased breath sounds in the bases bilaterally. d. GI (gastrointestinal)/GU(genitourinary): Urinary catheter in place on arrival (suprapubic) The Chest X-ray completed on 8/13/23 at 6:42 AM for hypotension and sepsis. No acute cardiopulmonary process found. The higher level of care hospital ICU [Hospital Name] dated 8/13/23 at 1:20 PM documented the following findings: a. Chief complaint: septic shock b. HPI (History of Present Illness HPI): [AGE] year old male with significant past medical history of spinal cord and resulting paraplegia, bilateral BKA (bilateral knee amputation), Hepatitis C. Self care neglect and deficits. Information primarily obtained from medical documentation from the outside facility. All 40 pages of documentation reviewed. No physician documentation. Recent evaluation at another hospital for stage 4 decubitus ulcer, which found positive for Extended Spectrum Beta-Lactamase (ESBL), Escherichia coli (E. Coli)on 7/30/23. Reported resident admitted to nursing facility at the beginning of August due to multiple episodes of self care deficits and readmission. Documentation reported patient complained of Altered Mental Status (AMS) and hypotension, worked up for sepsis at outside hospital. Received vancomycin and piperacillin-tazobactaum. Required norepinephrine, 2L IVF (Intravenous fluids) bolus given. Critical labs of procalcitonin 6.840, creatine 2.4. Resident noted confused and combative. GCS documented between 6-13. CT head/brain displayed no acute findings. The Discharge Summary from Hospital dated 8/21/23 revealed the following: a. The urine culture collected on 8/13/23 at 2:38 PM revealed gram negative rods >100,000 col/ml (colonies/milliliter) yeast b. The stool culture collected on 8/14/23 at 3:33 PM revealed a positive result for Clostridium Difficile on 8/14/23 at 5:28 AM. The Facility discharge form from the hospital dated 8/14/23 revealed hospital notes which documented chief complaint of septic shock and resident worked up for sepsis at outside hospital and received vancomycin and piperacillin -tazobactum. required norepinephrine and required a 2 litter of Intravenous fluid (IVF) bolus given. critical labs revealed procalcitonin 6.840 and creatine 2.4 with resident noted combative and confused. The physical exam revealed T: 99 degrees Farenheit, heart rate: 84; blood pressure: 109/54 respiration: 23 pulse oximetry: 95% on 3 liters nasal cannula. Psych assessment: Confused and encephalopathic. Resident responded with 1-2 words. GCS 14. The assessment documented resident with septic shock secondary to unknown source, possibly UTI vs osteomyelitis and cellulitis of sacrum, present on admission and complicated by stage 4 decubitus ulcer, hypotension, and hypoxia. The plan documented resident worked up for septic shock after the patient required norepinephrine. Initially started on vancomycin and Zosyn. This has been continued following arrival to the ICU (Intensive Care Unit). Patient arrived on norepinephrine. Norepinephrine stopped for a brief moment following arrival to the ICU but needed restarted at low doses. This was apparently will be stopped for a brief moment following arrival to the ICU. Ordered 100 milliliters/hour of IV fluids to continue for continued gentle hydration. Resident urinary output from 8/12/23 at 11:01 PM to 8/13/23 11:00 PM totaled 179 milliliters. The resident received the following medications in the last 24 hours: a. ertapenem IVPB (intravenous piggy back) 1 gram(s) IVPB daily b. fluconazole IVPB 200 milligram(s) IVPB daily c. Heparin injection SQ (subcutaneouly) 5000 Unit(s) Subcutaneous every (12) twelve hours d. lactated ringers 1000 milliliter(s) Intravenous <Continuous> e. norepinephrine Infusion 4 mcg/min Intravenous <Continuous> f. pantoprazole INJ 40 milligram(s) Intravenous Push daily g. sodium chloride 0.9% flush bag 500 milliliter(s) Intravenous <Continuous> h. vancomycin 125 milligram(s) By Mouth every 6 hours i. vancomycin ADULT IVPB 1000 milligram(s) IVPB every (24) twenty-four hours The Discharge Summary from Hospital dated 8/21/23 revealed the following: a. The urine culture dated 8/14/23 at 11:20 AM revealed gram negative rods >100,000 COL/ML yeast. b. The urine culture dated 8/16/23 at 9:29 AM revealed gram negative rods >100,000 COL/ML yeast c. The urine culture dated 8/19/23 at 7:41 AM revealed pseudomonas aeruginosa with organism stenotrophomonas maltophilia 1500 col/ml The Progress Note dated 8/21/23 at 4:51 PM revealed resident arrived to facility via hospital transport with hospital transport. Resident in stable condition, A&O x 3. VSS (vitals signs stable). Resident transferred to electric wheelchair. Suprapubic catheter in place and draining. Admission nursing assessment completed. The Weights and Vitals Summary revealed the following vitals: a. 8/21/2023 at 3:48 PM: 97.8 F Temperature; 73 bpm Pulse; 116 / 78 BP b. 8/23/2023 at 3:51 PM: 98.3 F Temperature; 84 bpm Pulse; 126 / 72 BP c. 8/27/2023 at 2:21 PM: 97.6 F Temperature; 90 bmp Pulse; 110 / 60 BP d. 8/31/2023 at 2:30 AM: 97.4 F Temperature; 82 bmp Pulse; 114 / 58 BP The Physician Orders revealed the following orders: a. ordered 8/21/23- vancomycin HCl (hydrochloride) oral capsule 125 mg (milligram)- give 125 mg by mouth every 6 hours related to UTI, site not specified, discontinued on 8/24/23 b. ordered 8/24/23-

Based on observation, record review, resident and staff interviews, the facility failed to prevent a facility acquired Stage 4 pressure ulcer for one of two residents reviewed with pressure ulcers (Resident #6). The facility reported a census of 54 residents. Findings included: The Quarterly Minimum Data Set, dated dated dated [DATE] identified Resident #6 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 14 and had the following diagnoses: Neurogenic Bladder, Septicemia and Wound Infection. The MDS also identified Resident #6 with one stage 3 pressure ulcer (identified as facility acquired) and one stage 4 pressure ulcer (identified as present on admission). It also identified Resident #6 required extensive staff assistance with bed mobility, dressing, toileting and personal hygiene and totally dependent on staff for bathing. A review of the Admission Skin Observation Tool dated 12/20/20 had documentation that Resident #6 only had one Stage 4 pressure ulcer to the coccyx area. A review of the Weekly Wound Observation tool dated 10/26/22 documented Resident #6 with a new Stage 4 pressure ulcer to the left ischium with 5% necrosis noted to the wound bed. The pressure ulcer measured 1.0 cm (centimeters) long, 2.0 cm wide and no depth documented. Electronic Medication Administration Note dated 8/9/23 at 3:07 p.m. documented that the Resident expressed pain at a level 5 (on a scale of 1 to 10) to her ischium wound while debridement occurred. Electronic Medication Administration Note dated 8/9/23 at 5:42 p.m. documented that the final pathologic diagnosis is gone with acute osteomyelitis from the left ischium wound. The Weekly Wound Observation tool dated 8/24/23 the pressure ulcer to the left ischium remained with 5% necrosis and slough in the wound bed. The pressure ulcer measured 1.0 cm long, 0.5 cm wide, 0.1 cm deep and now with tunneling: 1.0 cm. at 11 o'clock. Now infection is suspected. On 10/26/22 the Care Plan identified Resident #6 with a Stage 4 pressure ulcer on the coccyx and on 7/24/23 a stage 4 pressure ulcer to the Left Ischium. Interventions in place prior to the pressure ulcer that developed to the left ischium included the following; a. Administer medications as ordered. Monitor/Document for side effects and effectiveness. Date Initiated: 12/28/20 b. Encourage Resident #6 to not be up in the wheelchair more than 3 hours at a time for wound healing. Date Initiated: 09/21/22 c. Low Air Loss (LAL) pressure reduction mattress to bed Date Initiated: 02/02/22 Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 12/28/20 d. Registered Dietitian to evaluate and make diet change recommendations PRN (as needed). Date Initiated: 12/28/20 e. ROHO cushion (used to decrease the amount of pressure on the sitting area) to wheelchair Date Initiated: 02/02/22 f. Wound physicians to consult/ review wounds as indicated Date Initiated: 02/02/22 Weigh per facility protocol Date Initiated: 12/28/22 On 11/15/22, the resident was treated by the wound care physician who had recommendations (which are also considered new orders) to float heels in bed, offload wound, reposition per facility protocol, turn side to side and front to back every 1-2 hours if able, sponge boot and may take off sponge boot for ambulation, otherwise should be on 100% of the time. This was not added on to the Care Plan or on the Treatment Administration Record (TAR). A review of the facility's timeline of the pressure ulcer to the left ischium provided by the DON had documentation of the following preventive measures dated 2/22/22: Wound care physician to consult/review wounds as indicated Resident #6 to be the first one up for meals and the last down Low air loss mattress on the bed Roho cushion in the wheelchair An observation of wound care on 8/28/23 at 12:21 PM revealed Staff E, Licensed Practical Nurse (LPN) used the correct technique to cleanse the wound to the coccyx area with gauze dipped in 1/2 strength Dakins solution. She did not measure the wound which appeared to be healing . The surrounding skin did not show signs of infection. Staff E used the correct technique to apply skin prep to the surrounding skin and bordered gauze to the wound. Staff E also verified the wound to coccyx was present on admission and the wound to the ischial tuberosity was facility acquired. Staff E then removed the soiled dressing to ischial tuberosity wound and placed in plastic bag, used the correct technique to cleanse the wound to the left ischial area with 1/2 strength Dakins solution. She then applied calcium alginate dressing to ischial tuberosity wound and covered with border dressing which had today's date. The wound appeared to be healing and the surrounding skin without signs of infection. In an interview on 8/29/23 at 8:27 AM, Staff A, Certified Medication Aide (CMA) reported the following interventions that were in place to prevent pressure sores from developing on Resident #6 included repositioning Resident #6 every 2 hours. Staff A stated that the resident is supposed to be up in her power chair, however, it has been broken since last week, and did not think there was another chair for Resident #6 to get up to. Staff A state she could not recall how what caused the pressure ulcer, but Resident #6 had a history of refusing to be repositioned. Staff A indicated that when the resident refuses the aides are supposed to report it to the nurse, and then the nurse will re-educate or try to get another staff member to reposition the resident. In an interview on 8/29/23 at 8:49 AM, Staff B, Certified Nurses Aide (CNA) reported interventions that were in place to prevent pressure sores from developing on Resident #6 included: foam boots, pillows underneath her, reposition her every 1-2 hours. Staff B stated the staff should try to get her out of bed when she wants to, but her power chair has been broken for a couple weeks now, this is the only chair the staff can use for her. Staff B confirmed that the resident complains of pain only when the staff clean her up, she could not recall what caused the pressure ulcer. Staff B reported that Resident #6 has refused to be repositioned and when she does, the aides should report it to the nurse On 8/29/23 at 9:37 AM, Staff E, LPN reported the following interventions that were in place to prevent pressure sores from developing on Resident #6 included: air loss mattress, position with pillows, remind her to keep up less than 30 degrees, up in her wheelchair, special cushion in her wheelchair. Staff E revealed that the resident is only up one hour a day, and that right now her power chair has been broken for a week or two weeks. Staff E stated that therapy is working on getting her another chair, this is the only type of chair she will get in. Staff E reported that the resident has heel protectors on all the time, and the staff try to get her to lay on her belly, but she will refuse. Staff E voiced that the staff reposition her every few hours and use pillows. Staff E also verified the pressure ulcer to the left ischium was facility acquired and may have been caused by the resident's refusal to go to physician appointments on a stretcher. Staff E reported that when Resident #6 refuses repositioning, staff are supposed to educate her and remind her of the need to reposition or get another staff member. On 8/29/23 at 10:05 AM, the Resident reported her power chair had been broken for 4 or 5 months and she had not been out of bed since then. Since she received the 2nd pressure ulcer, she has had more pain which she rated as 7 on the pain scale (scale of 1 to 10 with 10 being the worst pain). The staff are supposed to turn her every few hours, but she reported they do not. She reported they turn her once a shift. First shift does pretty good, second and third shift not as much. She is not able to turn herself as her left hand does not really work. On 8/29/23 at 10:15 AM, the Director of Nursing (DON) reported the interventions that were in place to prevent pressure sores from developing on Resident #6 included: reposition her every 2 hours, boots for her feet, wound doctor will write orders on how long she would be up in the chair. The DON revealed the Resident's power chair has been broken since last week and the therapy manager, Occupational Therapist (OT) has been working on getting her current chair in working condition until the new one arrives. The DON stated she could not recall what caused the pressure ulcer to the left ischium, and Resident #6 could be very non-compliant with repositioning, turning her on her stomach. The DON reported that if the Resident is non-compliant, she would expect the aides to ask another person to come in and try to get the resident to comply and report the resident refusal to the nurse. The DON confirmed the left ischial area as facility acquired Stage 4 pressure ulcer. On 8/29/23 at 12:36 PM, the Wound Physician (WP) reported that Resident #6 was at risk for developing additional pressure ulcers as she did have some on her legs earlier, and the wounds are chronic and would open and close. The WP stated that the resident did not have any vascular problems. The WP indicated that typical interventions she would expect to be implemented to prevent from further ulcers from developing would include: offloading bony prominence's, low air loss mattress, repositioning frequently, making sure she's getting her protein. The WP verified the pressure ulcer to her left ischial tuberosity opened up in [DATE], and the cause of the wound was due to her non-compliance with repositioning. The WP could not confirm if the wound could have been prevented. The WP stated that Resident #6 has appointments out of the facility every 6 to 8 weeks where she can be gone for almost a whole day, and they have encouraged her to go by gurney, however, the resident has refused and prefers to be in her chair. A review of the facility policy titled: Turning and Repositioning dated 7/21/22 directed staff as follows; The Facility will aid with Turning & Repositioning Residents to prevent Skin Breakdown. Nursing Employees will Turn & Reposition Residents as reflected in their Plan of Care. Nursing Assistants will Assist with Turning & Repositioning Residents, Utilizing the Kardex & Informing Charge Nurse on Resident Refusals. Charge Nurse may Assist with Turning & Repositioning Residents and are Responsible for Turning/Repositioning of Residents as indicated in the Plan of Care. Turning & Repositioning Schedules will not be posted in Resident Rooms in order to Maintain Privacy. Director of Nursing, Administrator and Quality Assurance Team Members will Monitor for Compliance.

Based on observation, record review, and staff interviews, the facility failed to follow physician orders and interventions to prevent further weight loss for a resident with identified significant weight loss (Resident #5). The facility reported a census of 54 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 3/17/23 revealed Resident #5 had diagnoses that included non-Alzheimer's dementia, depression, muscle weakness and other lack of coordination, scored 9 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated moderate cognitive impairment, required physical assistance of 1 staff for eating, weight of 168 pounds without significant increase or decrease, defined as a change of 5 percent or more in 1 month or 10 percent or more in 6 months. The following weights recorded in pounds were recorded for Resident #5: 12/7/22 173.5 1/10/23 170.8 2/8/23 163.2 3/7/23 168.2 4/5/23 167.2 4/11/23 150.0 4/17/23 159.0 4/20/23 148.8 4/24/23 143.4 4/26/23 144.6 4/28/23 143.0 5/2/23 146.0 5/8/23 140.6 The Weight Summary dated 5/11/23 included documentation of the Residents weight at 148. 8 pounds (lbs) on 4/20/23 with the comparison weight of 173 lbs. from the date 10/19/22 (180days) for a 13.9 percent loss. Also, a 5 percent weight loss with the comparison weight documented on 4/5/23 of 167.2 lbs (a 5 percent weight loss from 4/5/23 to 4/20/23). Physician orders directed staff: 3/15/23 Serve Regular diet with regular texture, thin liquids at meals. 3/17/23 Serve Mighty Shakes (4 ounce liquid supplement/220 calories) nutritional supplement with meals. 4/15/23 Serve 2 ounces (60 milliliters/120 calories) of 2.0 nutritional supplement (liquid supplement) 4 times daily. 4/30/23 Provide extra butter and gravy with meals. 4/30/23 Serve Super Potatoes (high calorie/fortified potatoes) 2 times a day at lunch and supper. 4/30/23 Serve Super Cereal (high calorie/fortified hot cereal) 1 time daily at breakfast for weight loss. The following problems and interventions were listed on the resident's Nursing Care Plan: 1. Needs supervision while eating meals, initiated 9/3/22, directed staff: Prefer resident to come to dining room as much as possible. Resident needs to have supervision when eating in her room. 2. Activity of Daily Living (ADL) performance deficit, initiated 5/6/22, directed staff: Staff supervision/cueing required for eating. 3. Nutritional problem related to recent COVID-19 infection , dementia and depression diagnoses, initiated 7/8/22, directed staff: Monitor/document/report any signs or symptoms of dysphagia that include pocketing food in mouth, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Monitor/record/report to physician signs or symptoms of malnutrition that include emaciation (cachexia), muscle wasting, significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Provide/serve regular diet, regular texture, monitor intake and record amount at every meal. The Regular diet planned menu for the supper meal on 5/10/23 included: 4 breaded chicken tenders 4 ounces cooked spinach 4 ounces macaroni & tomatoes alternate menu item #6 scoop (5.33 ounces) pork with rice casserole Observations in the facility kitchen on 5/10/23 at 4:55 p.m. revealed the described menu items on the steam table and dietary staff prepared to serve the supper meal. Super Potatoes were not on the steam table. Continuous observations on 5/10/23 between 4:55 p.m. and 6:06 p.m. revealed Staff G, Cook, plated the resident's meal at 5:32 p.m. that included the alternate pork with rice casserole, noodles with tomatoes and spinach, Staff G placed 3 packages of butter (approximate 1 Tablespoon size per package) on the tray with the resident's plated food, nursing staff delivered the food to the resident seated at a table in the dining room, placed the 3 butter packages on the table next to the plate and did not apply to the resident's food, or offer further set-up assistance to the resident. The resident was seated at a table with 1 other resident positioned at her left side, and 1 CNA (Certified Nursing Assistant) positioned on the left side of the 2nd resident (away from Resident #5 and not positioned to assist her). Observation at 5:41 p.m. revealed the resident did not have Super Potatoes, the 3 butter packages remained unopened, the resident had ate approximately 1 or 2 bites of the macaroni and tomatoes, without staff assistance or support. Observation at 5:56 p.m. revealed the resident ate 2 or 3 bites of the macaroni and tomatoes, her head leaned forward and downward, she did not have Super Potatoes, had not ate anything else, and had no staff assistance or offers to obtain food items the resident might have preferred. At 5:57 p.m., Staff H, Certified Medication Aide (CMA) delivered a liquid supplement served in a box-like- package with a straw to the resident, did not sit next to the resident or offer other assistance to the resident. The facility's Physician Order's policy last reviewed 928/22 directed staff to ensure physician orders were transcribed and implemented in accordance with professional standards, state and federal guidelines. The facility's Plan of Correction, dated 4/5/23 for date of acceptable compliance, related to the same deficiency cited during the facility's annual recertification survey completed 2/20/23 to 3/2/23, stated: 1. Director of Nursing (DON) completed audit on resident weights on 3/30/23. 2. Nurse Consultant completed In-Service with RDLD/Dietary Manager on appropriate dietary intervention with weight loss on 3/8/23. 3. RDLD completed In-Service with Dietary Manager on completing weights timely on 3/8/23. 4. DON/Designee will monitor through Facility Audit Tool 5 times a week for 4 weeks then monthly to ensure ongoing compliance. Monitored findings will be reviewed at the monthly QAPI (Quality Assurance) meeting. 5. Date of compliance 4/5/23. During an interview on 5/10/23 at 6:04 p.m., Staff G and the facility's Registered and Licensed Dietician (RDLD), present in the kitchen throughout the meal service on 5/10/23, acknowledged Super Potatoes were not prepared or served to Resident #5, that was a physician order and should have been followed. During an interview on 5/11/23 at 8:41 a.m., when asked about interventions in place for the resident's weight loss, the facility's DON stated the resident's family had considered initiating Hospice services for the resident.

Based on clinical record review, hospital record review, staff interviews, and facility policy review the facility failed to provide a safe environment, and follow interventions which resulted in Resident#4 sustaining injuries from a preventable fall for 1 of 3 residents reviewed for supervision. The facility reported a resident census of 53. Findings include: The 5/4/23 Minimum Data Set (MDS) Assessment tool revealed Resident #4 had diagnoses that included history of pulmonary embolism (blood clot in the lung), weakness, unsteadiness on feet with repeated falls, scored 11 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated moderate cognitive impairment, and required extensive physical assistance of at least 1 staff for transfers to and from bed and chair, ambulation and toileting, walker required for ambulation, and had 1 fall without injury and 1 fall with minor injury since the previous assessment completed 2/10/23. The risk for activity of daily living (ADL) self-care performance and mobility deficit problem initiated 2/13/23 on the Nursing Care Plan directed staff: 1. Requires staff assistance to turn and reposition in bed. 2. Staff assist with transferring. 3. Encourage use of call bell for assistance. 4. Assist with toileting tasks 5. Continue to remind resident/offer and give resident her walker when ambulating in room/hall The risk for falls related to history of falls prior to admission problem initiated 2/13/23 on the Nursing Care Plan directed staff: Interventions initiated 2/13/23 1. Anticipate and meet resident's needs. 2. Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. 3. Ensure the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. Intervention initiated 5/8/23 4. Apply hipsters when getting resident ready for the day. Intervention initiated 5/10/23 5. Fall mat by bed (right side). An Incident Report dated 5/6/23, without time of incident specified, stated the resident stood unassisted in the doorway to her room, a Housekeeper (Staff F) in resident room and had mopped the floor, Staff B, Licensed Practical Nurse (LPN) was across the hall, the resident turned to go in her room and fell on the wet floor before the staff could intervene. The resident fell forward, hit her head on the floor, bled from lacerations on her forehead and right temple area of head, pressure applied to wounds, neurological status (neuro) checks initiated, Nurse Practitioner notified, and staff called 911 for ambulance transport to the ER. A document dated May 10, 2023 related to Resident#4 contained the following; a. On 5/06/23 at approximately 7:00 a.m. Staff F, Housekeeper entered Resident#4's room, and alerted nursing that the resident ambulated independently in her room. b. During an interview Staff F, reported the floor was mopped and still damp when the resident turned around in the doorway and started to walk across the floor and lost her balance falling forward. Staff F reported that she had called out to redirect the resident. c. Upon completion of the investigation, it was determined that Resident#4's injury was a result of independent ambulation and loss of balance on a wet surface. The 5/6/23 hospital ER Clinical Report described the resident treated for a minor closed head injury that included 2 lacerations on her head, 1 to the scalp that measured 3.5 centimeters (cm) in length, closed with tissue adhesive, and a laceration 1.5 cm long on the forehead, also closed with tissue adhesive. Due to the fall and head injury, computed tomography (CT) scans of the head and cervical spine were required, and both negative for acute findings or changes. The resident was discharged back to the facility by ambulance at 11:51 a.m. with instructions to protect wounds and keep wound areas clean, allow skin adhesive to dissolve over the next 2 weeks, and the resident received a Tetanus-Diphtheria-Pertussis vaccination (Tetanus shot) administered to the right upper arm. Staff interviews revealed: 5/9/23 at 2:21 p.m. Staff C, Certified Nursing Assistant (CNA) stated on 5/6/23, she wasn't certain of the time, she had been in the resident's room for cares, the resident was in bed and had been more confused lately, she took a gown and linen from the resident's room and hadn't got to the Soiled Utility Room with it (less than a minute) when she heard a page over the Walkie- Talkie they needed a nurse in the resident's room. She ran back to the resident's room, the resident was on the floor by the doorway of her room. 5/9/23 at 12:51 p.m. Staff E, CNA, stated she had cared for the resident before, she required 1 to 1 staff assistance for transfers and ambulation, she was in the dining room feeding residents breakfast on 5/6/23 when she heard the resident had fallen, she got up on her own and fell in the doorway of her room. 5/11/23 at 7:28 a.m. Staff B, LPN, stated she was doing blood sugars across the hall from the resident's room on the morning of 5/6/23, not sure of the time, the Housekeeper was in her room and had mopped the floor, the resident stood in the doorway of her room barefoot, turned to go into her room, she tried telling the resident not to go in there because of the wet floor) and before she could get to the resident she fell forward and hit her head on the floor. Staff B yelled for help, went to the resident and noticed right away that she bled from her head. 5/11/23 at 8:04 a.m. Staff F, Housekeeper, stated the resident stood in the doorway of her room on 5/6/23 when she mopped the floor and cleaned her room, and fell by the doorway. The Fall Management Policy with last review date of 2/28/23 included the following guidance: a. To provide an environment that remains as free of accident hazards as possible. The facility will complete a Morse Fall Scale Evaluation on residents to determine who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent to minimize further falls and/or reduce injuries. b. Risk factors to review included examples such as inappropriate footwear, wet floors, Resident confusion, balance, walking ability.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure a resident maintained acceptable parameters of nutritional status for 1 of 2 residents reviewed for weight loss (Resident #13). The facility reported a census of 54 residents. Findings: 1. The MDS(Minimum Data Set) assessment tool, dated 1/20/23, listed diagnoses for Resident #13 which included anemia, kidney disease, and muscle weakness. The MDS listed the resident's weight as 114 lbs and stated the resident had a loss of 5% in 1 month or 10% in the last 6 months and was not on a physician-prescribed weight-loss regimen. The MDS listed a BIMS(Brief Interview for Mental Status) score of 7 out of 15, indicating severely impaired cognition. The resident's Weights and Vitals report listed the following weights: 10/20/2022 129.0 Lbs 11/16/2022 128.0 Lbs 1/10/2023 108.4 Lbs 1/19/2023 114.4 Lbs 1/31/2023 97.2 Lbs 2/7/2023 93.4 Lbs The facility lacked documentation of a weight obtained for the resident between 11/16/22 and 1/10/23. The resident's weight loss percentage between 11/16/22 and 1/19/23 calculated as a 10.63% loss. The resident's weight loss percentage between 11/16/22 and 2/7/23 calculated as a 27.03% loss. An 10/27/22 Nutrition History directed staff to offer super cereal. An 11/28/22 Nutrition History documented the resident had a recent weight loss and to add super cereal, which is the same intervention from the previous report. A 12/10/22 Nutritional Assessment revealed the resident's most recent weight was 128.0 lbs. The assessment stated the resident's weight was stable. A 1/19/23 Nutritional Assessment stated the resident's most recent weight was 114.4 lbs and stated the resident had a 14# or 11% decrease in 3 months. The assessment stated the resident moved to an assist table which had stabilized her weight. The assessment contained no further dietary recommendations and stated the resident would maintain current weight. A Risk Meeting Follow-Up form displayed a 1/19/23 entry to move the resident to an assist table. A RD(Registered Dietician) Recommendations document had a 1/19/23 entry to begin supercereal at breakfast, ice cream at lunch and supper, and Mighty Shakes at all meals. The February 2023 Medication Administration Record(MAR) listed a Supplement 2.0 with meals for weight loss with a start date of 2/13/23. The MAR lacked documentation of a supplement initiated prior to 2/13/23. A 2/20/23 untitled telemed physician's note did not address the resident's weight loss. A 2/21/23 Nutrition History stated the resident's most recent weight was 93.4 lbs and stated the resident had poor appetite, a recent change in intake/appetite, and had a recent weight loss. The document stated the resident needed some assistance depending on the day. The document lacked further documentation related to dietary interventions to treat the resident's significant weight loss. Care Plan entries, dated 1/5/23, stated the resident had a nutritional problem related to Chronic Obstructive Pulmonary Disease(COPD), hypertension, chronic kidney disease, anemia, hyperlipidemia(high fat percentage in the blood), gastroesophageal reflux disease(GERD), and constipation. The entries stated the resident would maintain adequate nutritional status as evidenced by maintaining current weight, having no signs and symptoms of malnutrition, and consuming 50-75% at meals daily through the review date. The entries stated the resident required set up assistance at meals and directed staff to invite the resident to activities that promoted additional intake and to monitor refusals to eat. The entries also directed staff to: -monitor/record/report to the physician signs and symptoms of malnutrition: muscle wasting, significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. -obtain and monitor lab/diagnostic work as ordered and report the results to the physician and follow up as indicated. -provide and serve a regular diet with regular texture and monitor intake and record every meal. -evaluate(per dietician) and make diet change recommendations as needed. -weigh and record weight per facility protocol. A 2/12/23 Care Plan entry directed staff to provide the resident with a supplement with meals. A 2/23/23 Care Plan entry directed staff to encourage the resident to come to the dining room or eat up in chair in her room to help with better intake to improve hydration and nutrition. The Care Plan lacked further interventions related to the resident's significant weight loss. The facility lacked documentation of communication with the resident's physician regarding the resident's significant weight loss. Via email correspondence on 3/1/23 at 10:15 a.m., the Administrator stated she searched for additional documents related to Resident #13 and could not locate any. The facility policy Weight and Hydration Management Practice Guidelines, dated February 2016, stated the facility would maintain acceptable parameters of nutritional status unless the resident's clinical condition demonstrated it was not possible. The policy stated the facility would establish a weight management program with a systemic approach to assist with optimization of a resident's nutritional status. The policy stated the facility would complete monthly weights and defined a significant weigh loss as 5% in 30 days, 7.5% in 90 days, and 10% in 180 days. The policy stated that residents with a significant weight loss would have a SBAR(Situation Background Assessment Recommendation) completed and the physician and family would be notified. The policy stated the facility would develop an individualized care plan including resident specific interventions. During a phone interview on 3/2/23 at 8:22 a.m., the Registered Dietician stated weights were completed monthly by the 10th of the month. She stated she formulated a weekly list of weight concerns and stated there were times occasionally when there were no weights to review but stated there were residents who refused. She stated Resident #13 had a significant weight loss and was sick in December. She stated the resident should be on weekly weights the way she had been decreasing and stated facility should notify the physician of weight loss. She stated with regard to Resident #13, she dropped the ball on that. During an interview on 3/2/23 at 12:14 p.m., the DON(Director of Nursing) stated Resident #13's weight loss was sudden and drastic and was not gradual. She stated she was now receiving Hospice services and stated the dietician was in contact with the Administrator. She stated weights should be completed monthly and if the resident had a significant weight loss, they reviewed them at the risk meeting and made recommendations. She stated the resident was on Mighty Shakes. She stated it was strange that there was nothing documented with regard to the resident's weight loss and stated the documentation was not reflective of what was done.

Based on clinical record review, physician interview, staff interview and hospital record review, the facility failed to respond to a warning for possible interaction between an antibiotic and anticoagulant medication and failed to intervene appropriately once new bruising was observed in multiple locations, which was an indicator of an adverse side effect of an anticoagulation medication for 1 of 2 (Resident #1) residents reviewed on anticoagulant therapy. The facility reported a census of 56 residents. This 2567 had been amended on February 3, 2023. Findings include: Resident #1's Admission Minimum Data Set (MDS) dated [DATE] documented an admitted [DATE]. The MDS documented a Brief Interview for Mental Status (BIMS) of 15, which indicated no cognitive impairment. The MDS documented the resident received an anticoagulation medication each of the last 7 days. Progress Note written on 11/30/22 at 2:56 PM documented a request sent out to the Primary Care Provider (PCP) for the next INR (lab test to measure anticoagulant) due date. Progress Note written on 11/30/22 at 6:41 PM documented the PCP ordered the INR to be drawn in 2 weeks, on December 14, 2022. Progress Note written on 12/5/22 at 6:30 PM documented the PCP was notified of the resident having an elevated temperature throughout the PM shift, nausea and dizziness. Progress Note generated by the Electronic Health Record (EHR) on 12/5/22 warned of a possible drug interaction between Jantoven (warfarin, Coumadin) 5 milligrams (mg) given daily for blood thinning and the antibiotic Keflex. The EHR identified the interaction as a moderate severity. The use of the medications together had the potential to increase the risk of bleeding complications. The Progress Notes lack notification to the PCP of the warning. The Progress Notes lack documentation of the PCPs decision and rationale for using the medications together despite the risk of interaction. Progress Note written on 12/11/22 at 8:11 PM documented turned resident to side, wound on sacrum draining large amount of foul smelling red and black substance. Appears to be blood. Dressing changed, and resident repositioned. New bruising on the resident's left shin, left upper back, and on her ribs on the left side. The bruises were purple on color. The Advanced Registered Nurse Practioner (ARNP) was made aware of bruising and other assessment findings. The Progress Note documented her response as if giving blood thinners twice a day, decrease to once a day. It was noted the resident would be having an INR drawn in 3 days. The resident's Care Plan alerted staff the resident was on an anticoagulant and it required lab monitoring. The resident was identified as not needing terminal care. The Medication Administration Record (MAR) for Resident #1 included warfarin 5 milligrams (mg) daily. It was given daily from 12/1/22 thru 12/10/22. It was not given on 12/11/22 or 12/12/22. Review of the hospital records for Resident #1 (Clinical Report dated 12/12/22 under History of Present Illness) documented that her INR was therapeutic on 11/29/22 at 2.9 (normal for this resident's use of the medication is 2.0 to 3.0). Review of the hospital records, Clinical Report dated 12/12/22 documented that when the resident arrived in the emergency room her INR was greater than 17.3 (the lab analyzer could not actually determine a level as it did not read that high). The lab results document an INR of over 10 is considered critical for a resident on warfarin therapy. During an interview on 12/14/22 at 3:29 PM the Emergency Department (ED) physician stated when the resident was admitted to the ED on 12/12/22 she had bruising on her arms, legs and trunk. Her hemoglobin (hgb- protein that carries oxygen to the tissues and organs) was low. The physician reported that the resident was found to have a gastrointestinal bleed (GI Bleed) and had lost about 4 units of blood presumably through her stools. The hospital was setting up a unit of blood to give to the resident but she passed before it was ready. During an interview on 12/15/22 at 11:52 AM the PCP stated he was notified on 12/5/22 that the resident was not feeling well. She had an elevated temperature and nausea. He stated he ordered Keflex for the elevated temperature and because she had a pressure ulcer on her sacrum. Stated he was concerned she may be developing an infection in that and so the antibiotic was for skin bacteria. He stated he requested and received a status update on 12/7/22. He ordered some blood tests. The bloodwork came back with her hgb at 11.6, she was a little anemic. He stated he did not receive notification about the possible interaction between the warfarin and the Keflex. He stated she had previously used warfarin and Keflex together successfully many times. He stated if her intakes decreased that could cause her warfarin to be more potent but did not feel the Keflex was the cause. He stated he was not notified of the resident's decreased intakes and he was not notified prior to sending her to the ED on 12/12/22. During an interview on 12/15/22 at 10:28 AM Staff A stated if she had a question about a medication dosage or interaction there was a drug book available for reference. She was unable to locate the book. She entered the Director of Nursing's (DON) office to ask about the book. After a few minutes, the surveyor entered the DON's office to see if they had found the book. The DON was on her computer and stated she was looking for it. A minute later Staff A and the DON entered the medication room to look for the book. Staff A came out of the medication room and stated there was not a book in there. The Clinical Nurse Consultant entered the nurses station and stated the medication information was in the EHR. He was unable to locate it or show staff where to find it. The DON stated there is a single desktop computer at the nurses station that has full Internet access. She stated they could either use that or their personal cell phones to Google medications if they had a question about dosages or interactions. She stated they do not issue facility phones to use for references. An Immediate Jeopardy (IJ) was identified on 12/15/22 (with the start date being noted as 12/5/22), and the facility was notified of the IJ on 12/15/22. The IJ was removed on 12/15/22 when the facility developed and implemented the following corrective action plan: -Facility Nurses were educated by the DON/Admin on 12/15/22 policies PCU56-Medication Monitoring, PCU-58Medication Discrepancies and Adverse Medication Reactions -Facility Nursing staff were educated on policy NursA.9 Notification of Change in Resident Condition by DON/Admin. -Staff educated on 12/15/22 on monitoring PCC for alerts for potential drug/drug interactions by DON -Staff educated on the importance of monitoring bruising on residents with Anticoagulant therapy on 12/15/22 for Dr. Notification by DON -Facility did a 100% audit on all residents on Coumadin to ensure appropriate routine lab in place for PT/INR. Don completed this audit The scope and severity level of the IJ deficiency was lowered from a J to an G at the time of the survey after the facility completed the above removal plan.

Based on facility record review, hospital record review, and staff, family and Physician Assistant (PA-C) interviews, the facility failed to assess, update providers, and obtain interventions when a resident had a significant decline in activities of daily living (ADLs) and a decreased blood pressure reading (Resident #4) and when a resident had a pending abdominal x-ray with abdominal distension (Resident #10) for 2 of 3 residents reviewed for assessment. Resident #4 admitted to the hospital with pneumonia and acute metabolic [CONDITION(S)] secondary to medication. Resident #10 admitted to the hospital with sigmoid volvulus with signs of ischemia. The facility reported a census of 56 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 4/6/22, revealed Resident #4 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status (BIMS) documented a score of 7, indicating severe cognitive impairment. He required limited assistance of one staff for bed mobility, transfers, walking, dressing, and hygiene. He ate independently, was continent of bowel and had occasional bladder incontinence. He weighed 206.2 pounds. The Care Plan, dated 5/6/22, documented Resident #4 used [CONDITION(S)] medications related to anxiety and agitation and used anti-anxiety medications related to anxiety. It directed staff to administer the medications as ordered and monitor for side effects and effectiveness every shift. The Care Plan, dated 5/6/22, documented Resident #4 required the assistance of 1 staff for hygiene, toilet use, transfers, dressing, and bed mobility, and could eat independently. Occupational Therapy (OT) and Physical Therapy (PT) Discharge Summaries, dated 4/20/22 documented the resident continued to require assistance of one staff for mobility and could ambulate up to 200 feet with minimal assistance of 1 staff. On 4/23/22, a Progress Note documented the resident fell while attempting to get up on his own and when staff attempted to help him to the bathroom, the resident pushed, hit, and swatted staff. The physician ordered [MEDICATION(S)] 1mg every 4 hours prn for increased agitation with behaviors. The resident received a dose at 11:50 a.m. and then received a dose of prn [MEDICATION(S)] at 12:40 p.m. when the behaviors continued. The physician then ordered [MEDICATION(S)] 1mg three times a day. A Progress Note on 4/24/22 at 9:17 p.m. stated the resident slept most of the day but would grab staff's hands and say no during cares. It documented resident had scheduled [MEDICATION(S)] three times a day as well as the scheduled [MEDICATION(S)]. The April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nutritional Assessment, dated 4/12/22 and locked on 4/28/22, described the resident as more drowsy with recent adjustment in medications. The resident's record contained no evaluation or assessment of the effectiveness or any side effects of the scheduled [MEDICATION(S)] or scheduled [MEDICATION(S)] from 4/24/22 to 4/29/22. A Progress Note on 4/29/22 8:56 p.m. stated the resident's emergency contact #2 visited the facility and expressed concern about the medication dosage. The resident appeared drowsy in the morning during the visit. The nurse could not reach the physician. The resident appeared more alert and talkative later in the day. The April MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress notes on 5/1/22 documented the resident with a cough and audible congestion. An x-ray showed no abnormalities. The resident's record contained no evaluation or assessment of the effectiveness or any side effects of the scheduled [MEDICATION(S)] or scheduled [MEDICATION(S)], outside of the cough/x-ray documentation on 5/1/22, from 4/29/22 until 5/3/22. A Progress Note on 5/3/22 at 7:50 p.m. by the facility's Advanced Registered Nurse Practitioner (ARNP), reported the family, at the facility, expressed concerns about the resident's extreme drowsiness. The documentation stated the resident started [MEDICATION(S)] 1mg three times a day and [MEDICATION(S)] 1mg three times a day due to abusive behavior to staff and other residents and a fear of him also hurting himself due to impulsive behavior. The ARNP discontinued the scheduled [MEDICATION(S)]. On 5/4/22, a Care Conference note documented intakes over the last 3 weeks: 26.8%, 83.4%, and 90.9%. On 5/6/22 at 7:30 p.m., a Progress Note documented an unwitnessed fall. Staff notified the physician of blood pressures 80s/50s with neurological assessments completed after the fall. The physician planned to see the resident over the weekend. After no further assessments following completion of neurological assessments on 5/7/22 at 1:41 p.m., on 5/8/22 Progress Notes stated the resident's Power of Attorney (POA) came to the facility and reported concern about the resident sleeping all the time and having a cough. The POA asked when the physician would be visiting, and the nurse contacted the physician who stated the family should make an appointment with the resident's primary Physician Assistant (PA-C) or could go to the emergency room (ER) if concerned. On 5/9/22 at 1:01 p.m., Staff recorded a blood pressure of 60/22 in the resident's record under vital signs but recorded no follow-up, progress note, or notification to the physician. On 5/10/22, a clinic visit note documented the PA-C visited the resident at the facility. The PA-C described the resident as very lethargic, acutely ill, sleeping in a chair, unable to arouse. The resident presented in a wheelchair, unable to sit up independently, with garbled speech. The resident had diminished lung bases and upper respiratory congestion, which cleared with cough. The PA-C documented the resident as lethargic, likely from [MEDICATION(S)] use, since [MEDICATION(S)] had not been used recently. The PA-C decreased the [MEDICATION(S)] dose to 0.5mg three times a day. The May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . It showed no documentation of monitoring behaviors or medication side effects. Review of the Documentation Survey Reports for April and May 2022 showed the resident with increasing incontinence of bowel and bladder. The Nutrition Report for the week ending 5/10/22 showed average meal intakes decreasing: a. 81% for week ending 4/19/22 b. 52% for week ending 4/26/22 c. 41% for week ending 5/3/22 d. 27% for week ending 5/10/22 The Documentation Survey Report recorded staff's assistance with Activities of Daily Living (ADLs) and meal intakes. The April report showed the resident ate greater than 50% for at least two meals daily through 4/23/22 when the scheduled [MEDICATION(S)] started. Following 4/23/22, the April and May reports only documented >50% intake for two meals on of 4/26/22 and 4/27/22. From 5/1/22 to 5/10/22, the resident ate 25% or less for 18 of 30 meals and required extensive or full assistance by staff to eat for 19 of 28 meals recorded. The Documentation Survey Report documented the resident required extensive to full assistance by two or more staff for transfers from 4/20/22 until 5/10/22. Prior to that time, the resident required limited assistance of 1 staff. On 5/11/22 at 8:59 a.m. a Progress Note recorded the resident as unresponsive, even with sternal rub. The nurse noted a blood pressure of 70/50s and oxygen saturation 82% and sent the resident to the hospital. The hospital Discharge Summary for the resident's stay starting 5/11/22 recorded principal diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It described the resident as very sedated due to medications at the facility. Although the family stated the resident had a low blood pressure normally, the blood pressure was likely lower than normal due to [CONDITION(S)] and dehydration. The resident weighed 182 pounds. The Discharge MDS dated [DATE] documented the resident required extensive assistance of staff for bed mobility, transfers, walking, dressing, hygiene, and eating. He was always incontinent of bowel and bladder. On 9/26/22 at 2:30 p.m., the resident's power of attorney (POA) reported either she, the Emergency Contact #2, or both, visited the resident at the facility daily over the last 2 weeks of his stay. She reported the resident sat in a recliner in the community room and would barely open his eyes. He would mutter if needing to use the bathroom. When staff assisted him, he would be soaked. It took two to four staff to get him out of the chair at the end. When he admitted to the facility, he ate on his own. The last two weeks, staff had to feed him. When the POA tried to feed the resident, he did not do well. When he arrived to the hospital, he could not swallow or talk. The hospital held the [CONDITION(S)] medications, and he began to talk but could never swallow safely. When the POA asked the facility not to give the [CONDITION(S)] medications, they said they had to give them because the physician had ordered them. Staff said the physician would come see the resident, but he never did. The POA had to call in the resident's prior primary care provider. The ARNP who came into the facility eventually stopped the [MEDICATION(S)] but stated the physician needed to cut medications back further. On 9/26/22 at 2:00 p.m., the Emergency Contact #2 reported visiting the resident often at the facility, especially in the last two weeks when he was more unresponsive. The family tried to get the medications stopped, but the facility would not budge. At home, the resident had [MEDICATION(S)] and took a half a tablet at night only. He took a whole tablet three times a day at the facility. He did not open his eyes. He would squeeze hands in response to talking. The ARNP finally took him off one medication. The physician never saw him. Staff had to assist him to eat the last couple of weeks. The resident would have his eyes shut and staff would poke food down him. The resident had trouble swallowing pills. In the end it took 3-4 staff to move him out of his wheelchair or recliner. On 10/3/22 at 11:35 a.m., Staff A, Certified Nurse Aide (CNA), stated Resident #4 punched her in the face and gave her a concussion. He would have sudden, angry outbursts and seemed confused and unaware of his surroundings. The medications helped, and he calmed down. He took naps but still interacted with staff. The last two weeks of his stay, he would not do much of anything for himself. Staff had to assist with everything, including feeding him. He did not eat well. On 10/3/22 at 12:00 p.m., Staff B, CNA, reported Resident #4 initially walked with a walker but had more difficulty due to his [CONDITION(S)] and shuffling gait and so then used the wheelchair. He may have used a mechanical lift for transfers at the end of his stay. His dementia worsened, and he started to need more assistance and started hitting. He seemed more settled at the end of his stay. On 10/3/22 at 12:15 p.m., Staff C, Registered Nurse (RN), recalled the resident could be physical. She described his behaviors as bad. He hit his roommate and a CNA, who went to the hospital with a concussion. He was a big guy, and female staff had a hard time handling him. The behaviors often came out of nowhere with no known triggers. He could have been overstimulated at times since he spent the majority of his time in the day room for monitoring and safety due to behaviors and falls. The day room could be loud. The [MEDICATION(S)] and [MEDICATION(S)] calmed him. His Emergency Contact #2 expressed concern with doses of [MEDICATION(S)] and [MEDICATION(S)] on a weekend, and Staff C attempted to contact the physician. The resident declined at the end of the stay, but Staff C could not say if from medications or just overall decline. Without the medications, the resident would be all over the place. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/3/22 at 1:40 p.m., Staff D, Certified Medication Aide (CMA), described Resident #4's behaviors as wild and stated they happened so fast. He could be standing still and then running down the hall. He slammed his hand on a medication cart and wiped blood all over and tried to knock over a CNA with a bedside table. Staff D recalled no triggers or indications prior to behaviors. The medications calmed the behaviors down so not as bad or as frequent. The resident was more tired and seemed to fall asleep right before family came in. He would be up prior to their visits. The facility decreased the medication towards the end of the resident's stay since family felt he took too much. The resident's transfers and walking declined. He would not walk, and it took two people to get him into a chair. Eating depended on the day. He would eat if he wanted to. Staff assisted him at the end of his stay. His incontinence increased. At the end, he needed his pills crushed or he would spit them out. He drank water OK with a straw. On 10/3/22 at 2:35 p.m., Staff E, Licensed Practical Nurse (LPN), reported the resident could become violent. She obtained a one dose order for [MEDICATION(S)] when he became agitated and pounded his hand on a medication cart while she tried to wrap a bleeding cut on his hand. The resident had confusion with his [CONDITION(S)] and dementia diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications made him relax so he could sleep, but he would easily wake if asked about snacks, drinks, or using the bathroom. His family thought he slept too much, but they always visited after meals or medications when he would nap. The facility changed the medications because the family did not want him overly drowsy. The resident had to be fed by staff towards the end of his stay, and his intakes may have decreased. He went from taking pills whole, to taking them whole in pudding, and then to crushed in pudding. His transfers declined, and staff may have used a mechanical lift. It appeared to be a gradual decline. He never wanted to be in the facility and seemed to give up. On 10/3/22 at 4:00 p.m., the PA-C who saw the resident in the facility on 5/10/22 reported she felt the resident received too much medication. She described the resident as awake but unable to speak on 5/10/22. He would try but nothing came out or he mumbled. She had seen him prior to his admission to the facility, and he could walk and talk. She felt medications may have initially been warranted for his behaviors. She could not say if the least restrictive alternative had been used for the least amount of time since she had not seen him prior in the nursing facility, but when she saw him, he appeared overmedicated. He could not speak, and he drooled. His pills sat in his mouth, showing he had no control. On 10/3/22 at 4:15 p.m., the Director of Nursing (DON) reported she had been concerned with all the scheduled [CONDITION(S)] medications and had portalled (messaged) the physician. The physician had responded to continue the scheduled [MEDICATION(S)] and [MEDICATION(S)]. The resident could be sleepy when the family visited but had been up a lot at night. The family voiced concern for safety when the DON discussed a plan to get the resident off the [CONDITION(S)] medications. The DON felt the resident was declining from day one of his admission with his [CONDITION(S)] and dementia. He accepted more help from staff later in his stay than he would allow earlier. 2. The Quarterly MDS assessment, dated 7/19/22, revealed Resident #10 had an ostomy for her bowels. She had both long- and short-term memory problems. Review of Progress notes revealed that on 6/17/22, the resident had an emesis (vomited) at breakfast. Resident #10 reported feeling fine. Staff documented active bowel sounds in all quadrants and vital signs checked and within normal limits. Later on 6/17/22, at 6:02 p.m., a note documented the resident had nausea, vomiting, and diarrhea that day. The resident had hypoactive bowel sounds on the right side and a distended, firm abdomen. Staff obtained an abdominal x-ray order. On 6/18/22 at 2:56 a.m., a Progress Note recorded the completion of an abdominal x-ray around 10:40 p.m. on 6/17/22. The resident had been closely monitored with vital signs within normal limits. Bowel sounds continued to be hypoactive. The abdomen remained firm, tender, and distended. The X-ray Report, with date of service 6/17/22 and fax stamp 6/18/22 at 10:55 a.m., documented moderate colonic distension without evidence of pathologic calcification or obvious soft tissue mass. It listed an impression: moderate colonic dilatation, may be subacute obstruction or ileus, recommend follow up in 2 days. The Progress Notes lacked any follow-up on the x-ray report or any assessment of the resident, after the 6/18/22 2:56 a.m. note, until 6/19/22 at 11:58 a.m. when staff charted giving a [MEDICATION(S)] suppository. At 3:27 p.m., staff documented the physician ordered the suppository when updated on the x-ray report. The resident had become sweaty with slurred speech, and the facility sent her to the hospital. Review of the hospital History and Physical Report, dated 6/19/22, revealed the resident presented with a sigmoid volvulus with significant signs of ischemia. The note described the abdomen as quite distended. Surgical Documentation, dated 6/20/22, recorded a post-operative diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/3/22 at 12:15 p.m., Staff C, RN, stated the nurses and certified medication aides (CMAs) primary check vital signs. Staff wrote concerns for follow-up assessment or charting on a hot charting paper at the desk. On 10/3/22 at 2:35 p.m., Staff E, LPN, said nurses gave verbal and/or written report to the next shift. The DON reviewed the hot charting paper at the desk and updated it as needed. Nurses completed skilled residents' assessments daily, otherwise any assessments would be documented in the progress notes. Staff E recalled she called the physician multiple times for Resident #10 during the day shift on 6/19/22 due to the resident not acting right and having stomach distension and pain. Staff E stated when she finally checked Resident #10's vital signs, the resident had a low blood pressure and a high pulse and needed to be sent out. On 10/3/22 at 4:15 p.m., the DON stated staff add to the hot charting sheet, and she also updated it based on the staff's documentation in the residents' charts.

Based on facility record review, hospital record review, and staff, family and Physician Assistant (PA-C) interviews, the facility failed to provide ongoing re-evaluation of [CONDITION(S)] medications (drugs capable of affecting the mind, emotions, and behavior) to ensure the least restrictive regimen possible for 1 of 3 residents reviewed with [CONDITION(S)] medication orders (Resident #4). The resident declined, became unresponsive and had been admitted to the hospital with pneumonia and acute metabolic [CONDITION(S)] secondary to medication. The facility reported a census of 56 residents. Findings include: The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had been admitted on [DATE]. The MDS documented that the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. The MDS revealed that the resident received both anti-psychotic and anti-depressant medication, and had no behaviors in the 7-day look-back period. The MDS documented that the resident required limited assistance of one staff for bed mobility, transfers, walking, dressing, and hygiene. According to the MDS the resident ate independently, had been continent of bowel and had occasional bladder incontinence. The MDS revealed that the resident weighed 206.2 pounds. The Order Recap Report dated 3/30/22 to 5/11/22 showed the resident admitted on [CONDITION(S)] medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan, dated 5/6/22, documented Resident #4 used [CONDITION(S)] medications related to anxiety and agitation and used anti-anxiety medications related to anxiety. It directed staff to: a. administer the medications as ordered and monitor for side effects and effectiveness every shift b. Consult with pharmacy, doctor to consider dosage reduction when clinically appropriate at least quarterly c. Monitor/document/report as needed any adverse reactions of the [CONDITION(S)] medications such as unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, [CONDITION(S)], social isolation, blurred vision, diarrhea, fatigue, [CONDITION(S)], loss of appetite, weight loss, muscle cramps, nausea, vomiting, and behavior symptoms not usual to the person d. Monitor/document/report as needed any adverse reactions to anti-anxiety medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan, dated 5/6/22, documented Resident #4 required the assistance of 1 staff for hygiene, toilet use, transfers, dressing, and bed mobility, and could eat independently. The Care Plan failed to address behaviors. A Progress Note dated 4/18/22 at 9:59PM documented as follows; Certified Nurses Aid (CNA) reported to this nurse that Resident#4 pushed his roommate and hurt his roommate's right elbow. By the time this nurse and Director of Nursing (DON) responded to the scene, the resident had refused to have his brief changed and pushed the CNA away and grabbed her arms really tight. On assessment Resident #4 had a small superficial cut noted on his own right hand, which had been cleaned and a band-aid applied. Staff updated the physician and received an order to increase [MEDICATION(S)] to 1mg every 4 hours prn for increased agitation and aggressive behaviors. Occupational Therapy (OT) and Physical Therapy (PT) Discharge Summaries, dated 4/20/22 documented the resident continued to require assistance of one staff for mobility and could ambulate up to 200 feet with minimal assistance of 1 staff. The OT/PT discharge recommendations revealed that the resident would remain an assist of one person with waking, and could benefit from a walk to dine and restorative program. A Progress Note dated 4/22/22 at 10:22 p.m. documented as follows; Resident #4 ran down one hall to another hall, swung at the nurse, and hit the medication cart, which opened up a wound on his hand. The resident ripped his hand away from the nurse who attempted to stop the bleeding and wiped blood on the nurse's forearms. It took three staff to get the resident into a wheelchair. The on-call physician ordered a one-time dose of [MEDICATION(S)] (an anti-psychotic), which the resident took orally. A Progress Note dated 4/23/22 at 1:34 p.m. documented that the resident fell when he attempted to get up on his own and when staff attempted to help him to the bathroom, the resident pushed, hit, and swatted staff. The physician ordered [MEDICATION(S)] 1mg every 4 hours prn for increased agitation with behaviors. The resident received a dose at 11:50 a.m. and then received a dose of prn [MEDICATION(S)] at 12:40 p.m. when the behaviors continued. The physician then ordered [MEDICATION(S)] 1mg three times a day. Another Progress Note on 4/23/22 recorded the resident slid out of his recliner around 6:30 p.m. while trying to get up on his own. The resident had increased agitation, hit and kicked staff, swatted, and punched staff's noses as they tried to assist him. The resident had already received scheduled [MEDICATION(S)] and so received prn [MEDICATION(S)]. The April Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had received no prn [MEDICATION(S)] prior to 4/23/22. A Progress Note on 4/24/22 stated the resident slept most of the day but would grab staff's hands and say no during cares. It documented resident had scheduled [MEDICATION(S)] three times a day as well as the scheduled [MEDICATION(S)]. The Order Recap Report for the resident's stay showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A Correspondence with the physician dated 4/25/22 questioned the resident's orders for [MEDICATION(S)] 1mg three times a day, [MEDICATION(S)] 1mg three times a day and prn, and [MEDICATION(S)] 25mg every day, and the physician responded on 4/26/22 to discontinue the [MEDICATION(S)]. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nutritional Assessment, dated 4/12/22 and locked on 4/28/22, described the resident as more drowsy with recent adjustment in medications. The resident's record contained no evaluation or assessment of the effectiveness or any side effects of the scheduled [MEDICATION(S)] or scheduled [MEDICATION(S)] from 4/24/22 to 4/29/22. A Progress Note on 4/29/22 at 8:56 p.m. stated the resident's emergency contact #2 visited the facility and expressed concern about the medication dosage. The resident appeared drowsy in the morning during the visit. The nurse could not reach the physician. The resident appeared more alert and talkative later in the day. The April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress notes on 5/1/22 documented the resident with a cough and audible congestion. An x-ray showed no abnormalities. The resident's record contained no evaluation or assessment of the effectiveness or any side effects of the scheduled [MEDICATION(S)] or scheduled [MEDICATION(S)], outside of the cough/x-ray documentation on 5/1/22, from 4/29/22 until 5/3/22. A Progress Note on 5/3/22 at 4:09 p.m. by the facility's Advanced Registered Nurse Practitioner (ARNP), reported the family, at the facility, expressed concerns about the resident's extreme drowsiness. The documentation stated the resident started [MEDICATION(S)] 1mg three times a day and [MEDICATION(S)] 1mg three times a day due to abusive behavior to staff and other residents and a fear of him also hurting himself due to impulsive behavior. The ARNP discontinued the scheduled [MEDICATION(S)]. A Care Conference Note dated 5/4/22 at 3:58 p.m. documented intakes over the last 3 weeks: 26.8%, 83.4%, and 90.9%. It stated [MEDICATION(S)] ([MEDICATION(S)]) had changed to prn with continued scheduled [MEDICATION(S)]. The resident continued to have delusions but did not verbalize what he saw. A Progress Note dated 5/6/22 at 11:17 a.m. by Staff A, ARNP, documented staff reported no falls or behaviors following the discontinuation of the scheduled [MEDICATION(S)], family present and expressed concerns over the increased drowsiness of the resident. A Progress Note on 5/6/22 at 7:30 p.m. documented an unwitnessed fall. Staff notified the physician of blood pressures 80s/50s with neurological assessments completed after the fall. The physician planned to see the resident over the weekend. After no further assessments following completion of neurological assessments on 5/7/22 at 1:41 p.m., on 5/8/22 Progress Notes stated the resident's Power of Attorney (POA) came to the facility and reported concern about the resident sleeping all the time and having a cough. The POA asked when the physician would be visiting, and the nurse contacted the physician who stated the family should make an appointment with the resident's primary Physician Assistant (PA-C) or could go to the emergency room (ER) if concerned. On 5/9/22 at 1:01 p.m., Staff recorded a blood pressure of 60/22 in the resident's record under vital signs but recorded no follow-up, progress note, or notification to the physician. On 5/10/22, a clinic visit note documented the PA-C visited the resident at the facility. The PA-C described the resident as very lethargic, acutely ill, sleeping in a chair, unable to arouse. The resident presented in a wheelchair, unable to sit up independently, with garbled speech. The resident had diminished lung bases and upper respiratory congestion, which cleared with cough. The PA-C documented the resident as lethargic, likely from [MEDICATION(S)] use, since [MEDICATION(S)] had not been used recently. The PA-C decreased the [MEDICATION(S)] dose to 0.5mg three times a day. A Progress Note by the PA-C on 5/10/22 documented cough with decreased air movement in the lung bases. Medication decreased due to overmedication. The May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . It showed no documentation of monitoring behaviors or medication side effects. Review of the Documentation Survey Reports for April and May 2022 showed the resident with increasing incontinence of bowel and bladder. The Nutrition Report for the week ending 5/10/22 showed average meal intakes decreasing: a. 81% for week ending 4/19/22 b. 52% for week ending 4/26/22 c. 41% for week ending 5/3/22 d. 27% for week ending 5/10/22 The Documentation Survey Report recorded staff's assistance with Activities of Daily Living (ADLs) and meal intakes. The April report showed the resident ate greater than 50% for at least two meals daily through 4/23/22 when the scheduled [MEDICATION(S)] started. Following 4/23/22, the April and May reports only documented >50% intake for two meals on of 4/26/22 and 4/27/22. From 5/1/22 to 5/10/22, the resident ate 25% or less for 18 of 30 meals and required extensive or full assistance by staff to eat for 19 of 28 meals recorded. The Documentation Survey Report documented the resident required extensive to full assistance by two or more staff for transfers from 4/20/22 until 5/10/22. Prior to that time, the resident required limited assistance of 1 staff. On 5/11/22 at 8:59 a.m. a Progress Note recorded the resident as unresponsive, even with sternal rub. The nurse noted a blood pressure of 70/50s and oxygen saturation 82% and sent the resident to the hospital. The hospital Discharge Summary for the resident's stay starting 5/11/22 recorded principal diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It described the resident as very sedated due to medications at the facility. Although the family stated the resident had a low blood pressure normally, the blood pressure was likely lower than normal due to [CONDITION(S)] and dehydration. The resident weighed 182 pounds. The Discharge MDS dated [DATE] documented no behaviors in the 7-day look-back period and stated the resident received anti-psychotic medication 1 day and both anti-anxiety and anti-depressant medications on all 7 days. He required extensive assistance of staff for bed mobility, transfers, walking, dressing, hygiene, and eating. He was always incontinent of bowel and bladder. The facility's [CONDITION(S)] Management Guidelines, revised September 2017, listed practice guidelines: 1. Upon admission, the Licensed Nurse will implement the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The Licensed Nurse will communicate via the 24-hour report to the interdisciplinary team regarding the medication order or medication change. 3. The Interdisciplinary Team (IDT) will complete the psychoactive medication evaluation and consent on admission, quarterly, annually, and significant change. 4. The Licensed Nurse will complete the Abnormal Involuntary Movement Scale (AIMS) test upon initiation and/or change of medication and every 6 months thereafter for residents receiving antipsychotic medications. 5. The Licensed Nurse will institute the appropriate behavior monitoring form associated with the drug category to identify specific behaviors, to document the number of episodes of behaviors, and to document interventions and outcomes. 6. The IDT will individualize the resident Care Plan and address: a. the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] b. appropriate interventions to include nonpharmacological interventions c. goal for reducing/eliminating the drug if not contraindicated d. outcomes On 9/26/22 at 2:30 p.m., the POA reported either she, the Emergency Contact #2, or both, visited the resident at the facility daily over the last 2 weeks of his stay. She reported the resident sat in a recliner in the community room and would barely open his eyes. He would mutter if needing to use the bathroom. When staff assisted him, he would be soaked. It took two to four staff to get him out of the chair at the end. When he admitted to the facility, he ate on his own. The last two weeks, staff had to feed him. When the POA tried to feed the resident, he did not do well. When he arrived to the hospital, he could not swallow or talk. The hospital held the [CONDITION(S)] medications, and he began to talk but could never swallow safely. When the POA asked the facility not to give the [CONDITION(S)] medications, they said they had to give them because the physician had ordered them. Staff said the physician would come see the resident, but he never did. The POA had to call in the resident's prior primary care provider. The ARNP who came into the facility eventually stopped the [MEDICATION(S)] but stated the physician needed to cut medications back further. On 9/26/22 at 2:00 p.m., the Emergency Contact #2 reported visiting the resident often at the facility, especially in the last two weeks when he was more unresponsive. The family tried to get the medications stopped, but the facility would not budge. At home, the resident had [MEDICATION(S)] and took a half a tablet at night only. He took a whole tablet three times a day at the facility. He did not open his eyes. He would squeeze hands in response to talking. The ARNP finally took him off one medication. The physician never saw him. Staff had to assist him to eat the last couple of weeks. The resident would have his eyes shut and staff would poke food down him. The resident had trouble swallowing pills. In the end it took 3-4 staff to move him out of his wheelchair or recliner. On 10/3/22 at 11:35 a.m., Staff A, CNA, stated Resident #4 punched her in the face and gave her a concussion. He would have sudden, angry outbursts and seemed confused and unaware of his surroundings. The medications helped, and he calmed down. He took naps but still interacted with staff. The last two weeks of his stay, he would not do much of anything for himself. Staff had to assist with everything, including feeding him. He did not eat well. On 10/3/22 at 12:00 p.m., Staff B, CNA, reported Resident #4 initially walked with a walker but had more difficulty due to his [CONDITION(S)] and shuffling gait and so then used the wheelchair. He may have used a mechanical lift for transfers at the end of his stay. His dementia worsened, and he started to need more assistance and started hitting. He seemed more settled at the end of his stay. On 10/3/22 at 12:15 p.m., Staff C, Registered Nurse (RN), recalled the resident could be physical. She described his behaviors as bad. He hit his roommate and a CNA, who went to the hospital with a concussion. He was a big guy, and female staff had a hard time handling him. The behaviors often came out of nowhere with no known triggers. He could have been overstimulated at times since he spent the majority of his time in the day room for monitoring and safety due to behaviors and falls. The day room could be loud. The [MEDICATION(S)] and [MEDICATION(S)] calmed him. His Emergency Contact #2 expressed concern with doses of [MEDICATION(S)] and [MEDICATION(S)] on a weekend, and Staff C attempted to contact the physician. The resident declined at the end of the stay, but Staff C could not say if from medications or just overall decline. Without the medications, the resident would be all over the place. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/3/22 at 1:40 p.m., Staff D, Certified Medication Aide (CMA), described Resident #4's behaviors as wild and stated they happened so fast. He could be standing still and then running down the hall. He slammed his hand on a medication cart and wiped blood all over and tried to knock over a CNA with a bedside table. Staff D recalled no triggers or indications prior to behaviors. The medications calmed the behaviors down so not as bad or as frequent. The resident was more tired and seemed to fall asleep right before family came in. He would be up prior to their visits. The facility decreased the medication towards the end of the resident's stay since family felt he took too much. The resident's transfers and walking declined. He would not walk, and it took two people to get him into a chair. Eating depended on the day. He would eat if he wanted to. Staff assisted him at the end of his stay. His incontinence increased. At the end, he needed his pills crushed or he would spit them out. He drank water OK with a straw. On 10/3/22 at 2:35 p.m., Staff E, Licensed Practical Nurse (LPN), reported the resident could become violent. She obtained a one dose order for [MEDICATION(S)] when he became agitated and pounded his hand on a medication cart while she tried to wrap a bleeding cut on his hand. The resident had confusion with his [CONDITION(S)] and dementia diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications made him relax so he could sleep, but he would easily wake if asked about snacks, drinks, or using the bathroom. His family thought he slept too much, but they always visited after meals or medications when he would nap. The facility changed the medications because the family did not want him overly drowsy. The resident had to be fed by staff towards the end of his stay, and his intakes may have decreased. He went from taking pills whole, to taking them whole in pudding, and then to crushed in pudding. His transfers declined, and staff may have used a mechanical lift. It appeared to be a gradual decline. He never wanted to be in the facility and seemed to give up. On 10/3/22 at 4:00 p.m., the PA-C who saw the resident in the facility on 5/10/22 reported she felt the resident received too much medication. She described the resident as awake but unable to speak on 5/10/22. He would try but nothing came out or he mumbled. She had seen him prior to his admission to the facility, and he could walk and talk. She felt medications may have initially been warranted for his behaviors. She could not say if the least restrictive alternative had been used for the least amount of time since she had not seen him prior in the nursing facility, but when she saw him, he appeared overmedicated. He could not speak, and he drooled. His pills sat in his mouth, showing he had no control. On 10/3/22 at 4:15 p.m., the Director of Nursing (DON) reported she had been concerned with all the scheduled [CONDITION(S)] medications and had portalled (messaged) the physician. The physician had responded to continue the scheduled [MEDICATION(S)] and [MEDICATION(S)]. The resident could be sleepy when the family visited but had been up a lot at night. The family voiced concern for safety when the DON discussed a plan to get the resident off the [CONDITION(S)] medications. The DON felt the resident was declining from day one of his admission with his [CONDITION(S)] and dementia. He accepted more help from staff later in his stay than he would allow earlier.

Based on clinical record review and staff interviews, the facility failed to identify a pressure sore, failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/3/21, Resident #4 admitted to the facility with a pressure sore on the coccyx. The facility failed to identify the pressure sore upon admit, failed to complete routine assessments of the area, failed to initiate treatment orders timely, and failed to complete treatments as ordered. The area deteriorated to the point Resident #4 had bone visible within the wound. Resident #4 readmitted to the hospital on 12/28/21 for an infected sacral pressure ulcer. The failures resulted in Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a census of 47 current residents. Findings include: The Minimum Data Set (MDS) assessment defines pressure ulcers as follows: Stage I - Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II - A partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. The wound may also present as an intact or open/ruptured blister. Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. The wound may include undermining and tunneling. Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed and it often includes undermining and tunneling. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. According to the MDS assessment dated [DATE], Resident #4 had short and long term memory deficits and a minimal cognitive impairment. Resident #4 required extensive assistance with his bed mobility, transfer, dressing, toilet use and personal hygiene needs. Resident #4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to hospital skin assessments, Resident #4 was first identified with a pressure sore over his coccyx area on 11/27/21, which remained present upon his discharge 12/3/21. The resident's facility Admission Skin Assessment completed by Staff A and dated 12/3/21 at 10:14 a.m., recorded a skin tear on Resident #4's right buttock, but no wound area identified over his coccyx. In an interview on 2/1/21 at 8:16 a.m. Staff A, Assistant Director of Nursing, stated she vaguely recalled Resident #4. Staff A stated she admitted Resident #4 and completed the admission skin assessment on 12/3/21. Staff A did not recall that Resident #4 had a wound on his coccyx, noting maybe her reference of a skin tear on his right buttocks is instead the coccyx wound. Staff A stated there were no treatment orders for his coccyx wound sent from the hospital. According to a Skin Observation Tool dated 12/8/21 at 12:15 p.m. written by Staff B, Licensed Practical Nurse, Resident #4 had a deep tissue injury (DTI) identified on his coccyx which measured 7.0 centimeters by 6.5 centimeters. According to the Initial Wound Evaluation and Management Summary dated 12/8/21, Resident #4 had an unstageable DTI (pressure wound) within and around the wound measuring 7.0 centimeters by 6.5 centimeters. The wound had been surgically debrided. The physician ordered Alginate calcium applied once daily for 30 days, place a gauze island with border dressing once daily for 30 days and recommended off-loading the wound and repositioning him per facility protocols. Review of Resident #4's Care Plan revealed no care plan interventions addressing his wound risk or the care and/or treatment interventions including off loading, repositioning frequency and using a low loss air mattress. According to the 12/21 Treatment Administration Record (TAR), staff failed to transcribe the resident's 12/8/21 order for the wound dressing until 12/11/21. The TAR indicated staff did not complete the wound treatments on 12/8, 12/9, 12/10, 12/11, 12/12, 12/13, 12/15, 12/16, 12/18, 12/19, 12/22 and 12/28/21. According to the Wound Evaluation and Management Summary dated 12/15/21, Resident #4's DTI now measured 11.0 centimeters by 9.0 centimeters by 1.0 centimeters. The wound area was debrided with new orders to discontinue the Alginate calcium and instead crush metronidiazole (an antibiotic) 500 milligrams and sprinkle the medication lightly onto the wound bed, followed by Alginate calcium with silver once daily and as needed for 30 days with a gauze island with border for 30 days. Recommendations included to off-load the wound, reposition Resident #4 per facility protocol and place a group 2 mattress/low air loss mattress. According to the 12/21 TAR, staff did not transcribe the order of 12/15/21 to discontinue the Alginate calcium and instead crush metronidiazole 500 milligrams and sprinkle it lightly onto wound bed, followed by Alginate calcium with silver once daily and as needed for 30 days with a gauze island with border for 30 days. A Progress Note dated 12/20/21 at 4:47 p.m. written by Staff C, Licensed Practical Nurse documented the nurse spoke with the resident's wound physician who had no recommendations. During the conversation, it was discovered the crushed antibiotic treatment ordered on 12/15/21 was missed. Staff added the antibiotic order to the TAR on 12/21/21. In an interview on 2/1/21 at 3:03 p.m., Staff B stated the facility hired her as an Assistant Director of Nursing (ADON) and wound nurse and she worked a couple of weeks before quitting on 12/12/21 due to not getting adequate orientation and training. Staff B stated she was unaware that Resident #4 had a pressure sore on his coccyx prior to 12/8/21 when the facility's wound physician saw him. Staff B could not explain why the wound treatment orders on 12/8/21 were not transcribed on the TAR until 12/11/21. Staff B stated she had a lack of training on the computer. Staff B stated the previous wound nurse did resident weekly skin assessments and she was not sure when that nurse left. Staff B stated Staff A also worked as an ADON and was responsible for resident MDS assessments and care plans. Staff B stated she is unaware of anything that happened after 12/12/21. According to the Hospital Discharge Summary, Resident #4 admitted to the hospital on 12/28/21 for [CONDITION(S)] and an infected sacral pressure ulcer and discharged from the hospital on 1/10/22. The State Agency notified the facility of the Immediate Jeopardy on 2/2/2022 at 1:30 p.m. The Facility removed the Immediate Jeopardy on 2/3/22, 2022 by implementing the following actions: a. Initiated 100% wound care order audit on 2/2/22. b. Initiated 100% Care Plan/Kardex audit on 2/2/22 to ensure interventions in place to prevent further skin breakdown. c. Initiated 100% audit on wound care documentation. d. All nursing staff educated on skin assessments, documentation, initiating treatment, and following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] e. Education provided to staff on updating the Care Plan/Kardex with interventions to prevent further skin breakdown. f. Director of Nurses to conduct weekly visits to ensure nursing assessments completed. g. Education provided to Agency staff and education incorporated in orientation for newly hired staff on 2/3/22. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and updated their policy and procedure.

Based on clinical record review, resident interview, facility staff interview, and wound clinic staff interview, the facility failed to assess and measure pressure ulcers weekly and provide treatment as ordered by a physician for 3 of 3 residents reviewed with pressure ulcers (Residents #2, #5, and #7). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident had 4 unstageable pressure ulcers when admitted on [DATE] and received pressure ulcer care. The Care Plan, dated [DATE], stated Resident #2 had pressure ulcers to both heels and listed interventions: a. Administer treatments as ordered and monitor for effectiveness b. Monitor dressing to ensure it is intact and adhering. Report loose dressing to nurse. Review of a physician Order Entry revealed a treatment order obtained [DATE] to cleanse the coccyx and cover with a silicone dressing, changing 3 days per week. Review of the [DATE] Treatment Administration Record (TAR) from [DATE] to [DATE], when the resident died , revealed no documentation schedule for the treatment. 2. The MDS assessment dated [DATE] revealed Resident #5 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS failed to document any pressure ulcer. The Care Plan contained a focus area for potential of skin integrity impairment on [DATE]. It stated to follow facility protocol for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A Weekly Wound Observation assessment dated [DATE] documented a new coccyx pressure ulcer. The TAR for [DATE] and [DATE] indicated a treatment order starting [DATE] and ending [DATE] for hydrogel impregnated gauze 3 days a week to the coccyx. During this timeframe, nursing initialed the treatment as completed only once. Review of a Wound Evaluation & Management Summary physician note dated [DATE] revealed new treatment orders: alginate calcium daily and [MEDICATION(S)] ointment twice daily and as needed. Review of a Wound Evaluation & Management Summary physician note dated [DATE] revealed a change in the alginate calcium to 3 days a week and [MEDICATION(S)] ointment to continue twice daily and as needed. Review of the TAR for [DATE] revealed the [DATE] order on the TAR to start [DATE] and end [DATE] and the [DATE] order documented to start [DATE]. Nursing staff failed to initial the treatment as completed on [DATE] and [DATE]. In addition, the [MEDICATION(S)] oxide twice daily only appeared on the TAR on Mondays, Wednesdays, and Fridays to complete. 3. The Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #7's Brief Interview for Mental Status (BIMS) as 14, indicating intact cognition. The MDS documented the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It further documented 2 stage 3 pressure ulcers in addition to the stage 4 pressure ulcer. The Care Plan contained a Focus area, revised [DATE] of pressure ulcers of the sacrum, right upper thigh, and left anterior upper thigh with interventions: a. Administer treatments as ordered and monitor for effectiveness, revised [DATE] b. Assess/record/monitor wound healing weekly and as needed. Measure length, width, and depth where possible. Assess and document the status of wound perimeter, wound bed, and healing process. Report improvements and declines to the MD, dated [DATE] c. Monitor dressing to ensure it is intact and adhering. Report loose dressing to nurse. Revised [DATE] Review of the clinical record for Resident #7 revealed no pressure ulcer assessments with measurements from [DATE] to [DATE]. Review of a Wound Evaluation & Management Summary physician note dated [DATE] revealed new treatment orders: alginate calcium with silver daily to all pressure ulcers. Review of the TAR for [DATE] revealed no order for daily alginate calcium with silver until [DATE]. From [DATE] to [DATE], staff failed to initial the treatment as completed on the 8th, 9th, 10th, 15th, and 16th. On [DATE] at 12:13 p.m., Resident #7 stated staff had not done her pressure ulcer treatments at times, maybe missing one or two in the last week or so. On [DATE] at 2:05 p.m., Staff D, Registered Nurse (RN) stated the floor nurses are responsible for wound treatments if no wound nurse is scheduled. The wound nurse has typically been responsible for entering treatment orders into the electronic health record, but the facility has been without a wound nurse. On [DATE] at 11:30 a.m., Staff O, RN, reported taking over doing the wound treatments a week ago since it could be difficult for nurses to provide all the ordered treatments with all their other duties. She stated a wound clinic physician has recently been seeing residents weekly at the facility except for last week when on vacation. On [DATE] at 1:15 p.m., Staff H, Licensed Practical Nurse (LPN), reported a nurse went with the Wound Clinic Physician each week on rounds and was responsible for entering new treatment orders into the electronic health record. Based on clinical record review, observation, resident interview, facility staff interview, and wound clinic staff interview, the facility failed to assess and measure foot wounds weekly and provide treatment as ordered by a physician for 2 of 2 residents reviewed with foot wounds (Residents #4 and #6). The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident scored 13 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. A Care Plan focus area, revised [DATE], recorded Resident #4 as having a nonstageable pressure injury to his left plantar foot related to diabetes with interventions dated [DATE]: a. Administer treatments as ordered and monitor for effectiveness b. Assess and record wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress c. Check dressing to ensure it is intact and adhering; report loose dressing to nurse Review of a Wound Evaluation & Management Summary physician note dated [DATE] revealed documentation of the left foot wound as a diabetic wound. The physician ordered a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A Confidential Fax signed by the resident's primary care provider on [DATE] and noted by nursing staff on [DATE] documented agreement of the [DATE] order. Review of Wound Evaluation & Management Summary physician notes dated [DATE], [DATE], and [DATE] revealed all stated to continue the alginate calcium treatment daily. The Treatment Administration Record (TAR) for [DATE] contained no order for alginate calcium. It documented a treatment to the left foot of a [MEDICATION(S)] dressing every other day from [DATE] to [DATE]. The TAR for [DATE] documented the daily alginate calcium treatment started [DATE] and ended [DATE] then started again on [DATE]. From [DATE] through [DATE], staff only initialed the treatment as completed 3 times. Review of the resident's clinical record revealed no assessment and measurement of the foot wound from [DATE] to [DATE]. During an observation on [DATE] at 11:30 a.m., Staff O, Registered Nurse (RN), provided wound treatment to a wound on the bottom of Resident #4's left foot near the base of the 5th toe. 2. MDS assessment dated [DATE] revealed Resident #6 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan focus area, revised [DATE], recorded Resident #6 as having venous wounds to both lower extremities. Interventions documented [DATE] included: a. Provide a weekly wound assessment and documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. b. Administer treatments as ordered and monitor for effectiveness Review of a Wound Evaluation & Management Summary physician note dated [DATE] revealed a new lymphodemic wound on the resident's right foot with treatment orders of [MEDICATION(S)] (an antibiotic) 500mg crushed on the wound 3 days a week. The TAR for [DATE] contained no order for the [MEDICATION(S)] until [DATE]. Review of the resident's clinical record revealed no assessment and measurement of the foot wound from [DATE] to [DATE]. On [DATE] at 7:45 a.m., Resident #6 reported having wound treatment on Mondays, Wednesdays, and Fridays. Open areas tend to come and go to his legs and feet. Until recently, staff did not always complete the treatments 3 times per week. On [DATE] at 2:05 p.m., Staff D, RN stated the floor nurses are responsible for wound treatments if no wound nurse is scheduled. The wound nurse has typically been responsible for entering treatment orders into the electronic health record, but the facility has been without a wound nurse. On [DATE] at 11:30 a.m., Staff O, RN, reported taking over doing the wound treatments a week ago since it could be difficult for nurses to provide all the ordered treatments with all their other duties. She stated a wound clinic physician had recently been seeing residents weekly at the facility except for last week when on vacation. On [DATE] at 1:15 p.m., Staff H, Licensed Practical Nurse (LPN), reported a nurse went with the Wound Clinic Physician each week on rounds and was responsible for entering new treatment orders into the electronic health record. She had gone with the physician on [DATE] but had not entered orders in until the following week. If the Wound Clinic Physician is not through to assess the wounds, the facility nurses should complete the assessments. On [DATE] at 3:00 p.m., the Wound Clinic Physician reported knowing the facility had not been getting the ordered treatments onto the TAR timely. She had rounded with a different nurse each time she had come to the facility and had seen that the newest ordered treatments were not always on the wounds. She stated she is not responsible for the weekly assessment of the wounds. Nursing should be ensuring assessments with measurements are completed. The facility's Skin Management Guidelines Overview revised ,d+[DATE] stated residents with wounds and/or pressure injury are identified, assessed, and provided appropriate treatment to encourage healing. On [DATE] at 3:20 p.m., Staff N, Interim Director of Nursing, stated staff assessed the wounds last week with the Wound Clinic Physician out; they just did not measure them. She is training all staff on entering physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She has been reviewing all wound orders to ensure they are properly in the electronic health record. On [DATE] at 3:00 p.m., the Wound Clinic Physician reported knowing the facility has not been getting the ordered treatments onto the TAR timely. She has rounded with a different nurse each time she has come to the facility and saw that the newest ordered treatments were not on the wounds. She stated she is not responsible for the weekly assessment of the wounds. Nursing should be ensuring assessments with measurements are completed. The facility's Skin Management Guidelines Overview revised ,d+[DATE] stated residents with wounds and/or pressure injury are identified, assessed, and provided appropriate treatment to encourage healing. On [DATE] at 3:20 p.m., Staff N, Interim Director of Nursing, stated staff assessed the wounds last week with the Wound Clinic Physician out; they just did not measure them. She is training all staff on entering physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She has been reviewing all wound orders to ensure they are properly in the electronic health record.

Based on clinical record review, hospital record review, observation, mechanical lift User's Manual review, and staff interviews, the facility failed to provide a safe transfer during a full body mechanical lift transfer for 1 of 3 residents reviewed for transfers (Resident #11). The unsafe transfer resulted in the resident falling out of the sling onto the floor. The resident hit her head causing a subdural hematoma and subsequent death. The facility also failed to add and implement interventions for falls for 1 of 3 residents reviewed for falls (Resident #5). The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 with diagnoses that included dementia and muscle weakness. The MDS identified the resident transferred and walked with assistance of one staff. The resident had long- and short-term memory impairment. A Care Plan focus dated [DATE] identified the resident as at risk for falls. The Care Plan contained no interventions for falls after [DATE] except for two placed on [DATE]: a. Toilet after each meal due to resident wandering when needing to go to the bathroom b. Resident is to be settled in a recliner in the day area between meals so there are more people around to watch her to prevent her getting up on her own. Review of Facility Fall Reports revealed Resident #5 fell 13 times from [DATE] to [DATE], falling on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Review of the resident's Progress Notes revealed an intervention following the [DATE] fall to not have the footrest elevate on the recliner in the resident's room. On [DATE], the resident again fell out of her recliner with the footrest elevated. On [DATE] at 2:05 p.m., Staff D, Registered Nurse (RN), stated in the past the MDS Coordinator updated Care Plans. With changes in staff, all nurses will be responsible for some Care Plan updates in the future. The facility's Falls Management Guideline Practice Guidelines document dated [DATE] stated: a. The interdisciplinary team (IDT) will review all resident falls within ,d+[DATE] hours at the morning IDT meeting to evaluate circumstances and probable cause for the fall. b. The IDT modifies and implements a Care Plan and treatment approach to minimize repeat falls and the risk of injury related to the fall. The Care Plan will be reviewed and revised as indicated. c. The At-Risk Review committee members will review weekly all residents with falls for documentation, compliance, and interventions to determine that interventions are appropriate. On [DATE] at 3:20 p.m., Staff N, Interim Director of Nursing (DON), stated the nurse should set an initial intervention at the time of the fall. Then the IDT meets within ,d+[DATE] hours, reviews the fall, and comes up with an intervention, which is placed on the Care Plan. 2. The admission MDS assessment dated [DATE] revealed Resident #11 with diagnoses that included stroke and reduced mobility. The MDS identified the resident transferred with total assistance of two staff and did not walk. The resident had long- and short-term memory impairment. A Care Plan focus dated [DATE] identified the resident with a problem of limited physical mobility related to stroke. The care plan revealed the resident did not bear weight or walk and transferred with the Hoyer (full body) lift and assistance of two people. The Invacare Reliant 450 User manual dated 2018 directed the operators to: a. Check to ensure the sling is properly connected to the hooks of the hanger bar when the patient is elevated a few inches off the surface of the stationary object (wheelchair, commode, or bed). b. Make adjustments for safety and comfort before moving the patient. c. Not use non-Invacare slings. Invacare slings are made specifically for use with Invacare Patient Lifts. For the safety of the patient, DO NOT intermix slings and patient lifts of different manufacturers. The undated facility document titled How to use a Hoyer Lift directed the operators to: a. Position the sling under the patient b. Connect the sling to the lift c. When the patient is clear of the bed surface, swing their feet off the bed d. Move the lift away from the bed while turning the resident so that he/she faces the assistant operating the lift. A Progress Note dated [DATE] by Staff D, Registered Nurse (RN) revealed that at around 8:00 a.m. the resident slid out of a Hoyer sling during a transfer from the bed to the chair. Staff alerted Staff D, who arrived to the room and observed Resident #11 lying on her back on the floor with a pillow under her head. Resident #11 had no visible head injuries and reported her head hurt a little. The Certified Nurse Aide (CNA) onsite reported the resident might have hit her head on the floor. The sling was unhooked from the lift. Staff D checked the sling and documented it and the mechanical lift to be in good condition. An observation on [DATE] at 11:45 a.m., revealed Resident #11 lying in bed in her private room. A Geri (padded, reclining, wheeled) chair sat next to the bed. On [DATE] at 10:00 a.m., Staff J, Certified Medication Aide (CMA) reported completing cares on Resident #11 around 8:00 a.m. on [DATE]. Staff I, CMA, then came in to assist with the transfer out of bed into the Geri chair. Together, they placed a full-body sling under the resident and attached sling loops to the lift, same colored loops for upper body and same colored loops for lower body. The distance from the top of the bed to the floor was approximately ,d+[DATE] feet. As Staff J pulled the lift with the resident away from the bed, Staff I moved the Geri chair into position for Resident #11 to sit in. Resident #11's bottom had just cleared the bed, and her feet were maybe just grazing the bed, when she suddenly came out of the lift and landed on the floor. The resident had not moved herself in the sling. Due to a stroke, the resident had a flaccid side. Staff J reported the fall occurred so quickly she could not say how the resident came out of the lift sling. She felt the resident landed hard on her bottom on the floor in more of a seated position and then may have hit her head on the floor. The four loops of the lift sling remained attached to the Hoyer lift. During a follow-up interview on [DATE] at 3:39 p.m., Staff J, CMA, stated she had not paused at any time during the transfer. She described the transfer as normal and stated once the resident had been raised in the bed so that she could move freely away without any friction against the bed, she pulled the lift away from the bed. On [DATE] at 10:20 a.m., Staff I, CMA, reported trying to move the Geri chair behind the resident when the resident suddenly fell out of the lift, landing hard on her bottom on the floor. The sling remained hooked to the lift, unsure if by all four loops. Staff I could not recall if she moved the resident's feet off the bed during the transfer. On [DATE] at 3:05 p.m., Staff D, RN, reported staff alerted her to Resident #11 falling from the Hoyer lift around 8:00 a.m. on [DATE]. When she arrived, she observed the resident lying on the floor with a Hoyer sling under her, not hooked to the lift. She checked the sling as rolling Resident #11 to assess her and reported no concerns with the sling or Hoyer lift. Staff used the same sling and Hoyer lift to transfer the resident off the floor and into bed. On [DATE] at 3:45 p.m. Staff G, Advanced Registered Nurse Practitioner, ARNP, reported going into Resident #11's room just prior to the Hoyer transfer around 8:00 a.m. on [DATE] to perform a COVID-19 test. Staff G observed the sling in place, hooked to the Hoyer lift without noted concerns. She reported being just outside the resident's door when the staff called for help moments later. When she walked into the room, she observed the resident lying on her back on the floor between the Hoyer lift legs with an aide holding the resident's head. Staff G recalled pushing the Hoyer lift out of the way, with the sling hanging from it, to assess the resident. She could not recall seeing if all four loops of the sling were attached the lift hooks. She met Staff D, RN, in the hall coming to the resident's room as she was leaving. A Progress Note dated [DATE] documented Resident #11 began vomiting around 10:30 a.m. and was taken via ambulance to the local emergency department. The hospital Discharge Summary dated [DATE] documented Resident #11 admitted on [DATE] for comfort cares following a diagnosis of acute subdural hematoma with herniation related to the fall from the Hoyer lift. The resident died on [DATE]. An observation on [DATE] at 12:40 p.m. revealed Staff I, CMA, and Staff J, CMA, transferring Resident #12 with a Hoyer lift from a Geri chair to bed. The lift was noted to be labelled Invacare Reliant 450. The label on the blue, solid, full body sling under the resident listed the manufacturer as Proactive. Staff I and Staff J reported the Hoyer lift and the full body sling used with Resident #11's transfer on [DATE] looked the same. On [DATE] at 2:40 p.m., Staff D, RN, described the lift sling used for Resident #11 as a blue, solid, full-lift sling, with unknown manufacturer. Staff did not remove the sling from circulation. The supply closet contained the slings not currently in resident rooms or laundry. The facility has three Hoyer lifts. An observation on [DATE] at 2:40 p.m. of the slings in the supply closet by the nurses station revealed 11 full body slings matching the description of the sling used for Resident #11's Hoyer transfer on [DATE]. One had manufacturer label of [NAME], nine contained Proactive manufacturer labels, and one label was worn and unreadable. The labels stated the useful life of the slings to be 6 months from the date of purchase. The slings had no dates. Observation of the three Hoyer lifts revealed all three labelled as Invacare Reliant 450 with sling instructions for Proactive slings attached. On [DATE] at 9:10 a.m., the Administrator stated having matching Hoyer lift and sling manufacturers is not a regulation. Laundry watches and removes any worn slings from circulation. The facility ordered new slings from Invacare last week after the fall from the Hoyer lift. On [DATE] at 12:45 p.m., the Administrator and Staff L, CMA reviewed lift slings in the facility. The facility reported around 15 to 20 blue, solid, full body slings, none manufactured by Invacare. The facility had Invacare U-Slings with straps that cross between the resident's legs. On [DATE] at 12:50 p.m., Staff L, CMA, reported staff used the full body slings on all residents and not the U-Slings because in the past some residents had not tolerated the straps between their legs. On [DATE] at 12:52 p.m., the Administrator directed staff to remove non-Invacare slings from circulation and use the Invacare U-Slings as tolerated until the new slings arrive. She directed Invacare sling instructions to be attached to the Hoyer lifts.

Based on clinical record review, staff and resident interviews, interview with Wound Clinicians, and review of facility policy, the facility failed to provide the necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for three of five residents reviewed with pressure injuries (Residents #2, #4, and #7). The facility failed to ensure transportation secured for all residents requiring wound clinic services. For Resident #4, review of the resident's Weekly Skin Sheets showed the resident's wound on 10/4/21 measured 4.3 centimeters (cm) x 2.4 cm, and no depth, with inflammation, redness, and possible infection. On 10/11/21, the wound measured 8.0 cm x 4.0 cm and a depth of 0.5 cm. The Wound Care Clinic reported not being informed of the change in status for the wound. The Wound Clinic observed the shin pressure sore and the bone visible within the wound. The resident transferred and admitted to the hospital on 10/15/21 and an above the knee amputation occurred on 10/22/21 due to [CONDITION(S)] from the wound. This resulted in an Immediate Jeopardy, which the facility removed as of 10/28/21. The facility reported a census of 44 residents. Findings include: 1. Review of the Minimum Data (MDS) Assessment Tool Resident #2 dated 8/27/21 documented the resident's cognition intact based on a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The MDS identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reported the resident at risk for pressure injuries, and showed the resident had two Stage 3 pressure injuries and one Stage 4 pressure injury at the time of the MDS. The MDS stated the resident received treatments to help with pressure injuries, which included pressure-reducing device for bed and chair, repositioning program, nutrition and hydration intervention in place, pressure injury care, application of non-surgical dressings and application of ointments or other medications. The resident's Care Plan identified the resident with a self-care deficiency due to [CONDITION(S)] and required assistance with transfers, bed mobility and toileting. The Care Plan reported the resident is bedfast and had pressure injuries to the sacrum, left anterior upper thigh, and right trochanter. Staff directed to monitor dressings to ensure it the dressings are intact and adhering, report any changes in skin status and document treatments weekly to include measurement of each area including width, length, depth, type of tissue and exudate. Staff also to follow facility policy and protocols for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Pressure Injury Risk Assessment reported the resident's Braden Skin Score of 12 which is a high risk for a pressure injury. The assessment identified the resident of having very limited sensory perception, skin is often moist, the resident is often chairfast, and having very limited mobility. Review of the resident's Wound Assessments revealed on 10/11/21 the wound on the left thigh measured 1.5 centimeters (cm) by 1.2 cm by 0.5 cm., and then on 10/18/21 the wound measured 2.0 cm x 2.3. cm x 0.5 cm. On the 10/11/21, the right thigh wound measured 0.5 cm by 1.5 cm by 0.2 cm, then on 10/18/21, the right thigh measured 2.0 cm by 3.0 cm by 2.5 cm. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Treatment Administration Record (TAR) showed dates for treatment order of Vashe wound therapy solution not documented for left anterior upper leg on 10/5, 10/10, 10/19, 10/20, and 10/22. Further review of the TAR showed staff failed to document the Vashe treatment being applied for the right upper leg wound on 10/10, 10/11, 10/12, 10/19, 10/20 and 10/22. A policy for Notifying a Physician of a Change in a Resident's Condition dated 11/1/2018, directed staff to notify the resident's physician when there is a change in condition of the resident. A policy for Skin Management Guidelines dated 2/2016 directed the facility should consult with a Certified Wound Nurse or Surgeon and the Nursing Staff are to monitor the area closely during treatment to evaluate appropriateness of treatment regime. During an interview on 10/27/21 at 11:25 a.m., Resident #2's Primary Nurse Practitioner (NP) reported the resident a patient of the Wound and Vein Clinic and missed a couple appointments. The Primary NP reported unsure when the dates were but she remembered she had to write a script for the resident to have an ambulance used as a transport vehicle for her to make it to her appointments so she didn't miss anymore. During an interview on 10/28/29 at 12:25 p.m., the Clinical Wound and Vein Nurse Manager reported she remembered the resident did miss some of her appointments this past year but not documented in their charts for which dates Resident #2 missed. 2. The MDS dated [DATE] revealed Resident #4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reported the resident required extensive assistance of two staff for transfers and dressing, with the resident at risk for developing pressure injuries, and also identified the resident with a current pressure ulcer Resident #4's Care Plan dated 10/18/2021 identified the resident at risk for potential pressure injury development related to history of injuries, limited sensory perception and limited mobility. The resident had a potential for impairment to skin integrity related to incontinence and leakage of urine around supra pubic catheter. The Care Plan revealed the resident had a Stage 4 pressure ulcer on her sacrum. Interventions expected of staff are to follow facility policies and protocols for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] a. Staff are to inform the resident's guardian, caregivers of any new area breakdown. b. Staff are to report any changes in skin status including appearance, color, temperature, and firmness. c. Staff should also report wound healing and signs or symptoms of infection. d. Staff should obtain and monitor any lab or diagnostic work as ordered and report any results to the physician as indicated. Further review of the resident's Care Plan reported the resident required assistance with two staff members for bed mobility and toileting, and required assistance of a Hoyer lift and two staff for transfers. Review of the resident's Pressure Injury Risk Assessment documented the resident had a Braden skin score of 14 which identified the resident as a moderate risk for pressure injuries. The assessment showed the resident as having very limited mobility, inadequate nutrition and skin occasionally moist. Review of the Weekly Wound Assessments revealed the resident had three pressure ulcers: 1. Sacrum, 2. Right lower extremity, and 3. Left lower extremity. A Wound Assessment on 9/27/21 reported the wound on the right lower extremity measured 2.2 centimeters (cm) by 1.4 cm with black eschar, necrotic tissue present and peri-wound tissue within normal limits. On 10/4/21, the measurement of the right lower extremity measured 4.3 cm by 2.4 cm. The documentation showed the resident peri-wound tissue red and inflammation present. The document showed the wound suspected of infection due to redness and a foul odor, and also documented the wound had slough tissue and necrotic tissue present. The progress of the wound documented as worsened. A Wound Assessment documented on 10/11/21 reported the resident's wound measured at 8.0 cm by 4.0 cm and by 0.5 cm. Review of the Nurse Practitioner (NP) Progress Note dated 10/11/21 at 11:02 a.m., showed an assessment of the resident's skin and wounds including the wound on the right lateral aspect of the leg, which measured 8.0 cm x 4.0 cm x 0.5 cm. The NP documented large amount of foul black drainage on the old dressing and minimal [CONDITION(S)] surrounding the wound bed. Review of the Progress Notes revealed on 10/1/21 at 2:39 p.m., the facility Social Worker (SW) attempted to call an insurance group to schedule transport for the resident's upcoming appointment but unable to do so because the insurance had the wrong address on file. The SW called the resident's Guardian to update the address so the trip with the transport service could be scheduled. On 10/1/21 at 3:21 p.m., the address updated for the insurance company and the transport service to call with transport information. A Progress Note dated 10/8/21 at 1:41 p.m., revealed the transport service to call next week and give a trip number. The writer stated in the note if the transport service does not call by Tuesday (10/12/21) the transport company would be called. Review of documentation from the Wound and Vein Center revealed the resident missed two appointments on 9/23/21 and 10/7/21. The resident's last appointment was on 9/9/21. The documentation showed when the resident came to the clinic on 10/14/21, she had multiple ulcers which are not reflected in the facility's Weekly Skin Assessments in the Electronic Medical Record (EMR). The documentation showed Resident #4 had several ulcers on her left upper back, left lower back, left medial knee, right medial knee, open sacral ulcer, right 2nd toe and left flank. The documentation identified the resident's right medial ulcer progressed to a Stage 4 ulcer down to the tibial bone and reported orders for the facility to send the resident to the emergency room (ER) to have her wounds further evaluated. Further documentation review showed a brief interview between Resident #4 and the Wound Clinician, which showed the resident taking an antibiotic, is a smoker and spends more of her days in bed staring at the wall. Review of the local hospital's documentation noted the resident admitted to local area hospital on 10/15/21 at 11:30 a.m The documentation showed the resident admitted with multiple chronic ulcers and a Stage 4 ulcer with visible bone on the right shin with purulent discharge. The documentation showed the resident required two different intravenous (IV) antibiotics and had an elevated white blood count (WBC) which indicated the resident had an infection. The clinical impression indicated suspicion of right lower leg [CONDITION(S)], possible [CONDITION(S)] with a Stage 4 pressure ulcer with exposed bone. A wound culture obtained showed the wound bed infected with enterococcus. An x-ray obtained on 10/15/21 for right lower leg injury showed suspicious for chronic [CONDITION(S)]. A Progress Note documented the resident on a waiting list to be transferred to a higher-level care hospital due to the likely need of surgical consultation and long-term IV antibiotics. Review of the Surgical Consult Notes for Resident #4 reported the surgeon wanted to perform an above-the-knee amputation, on an urgent basis, to give the resident the best chance for survival. The documentation showed a Progress Note with plans for the resident to go into surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 10/20/21 at 11:10 a.m., the facility Wound Nurse reported she was out ill on 10/11/21. The Wound Nurse reported she rounds on Mondays with a rounding Wound Nurse Practitioner (NP) to assess wounds and change wound care orders as necessary. On the day the Wound Nurse out sick, the NP assessed wounds and documented them in the electronic medical record. During an interview on 10/20/21 at 8:41 a.m., the Clinical Wound and Vein Nurse Manager reported the facility never notified them of the changes in the resident's wound and the resident missed two of her appointments on 9/23/21 and 10/7/21. She reported the Wound Clinic makes sure to call the facility the day before and notify staff at the facility of the upcoming appointment. The Manager reported the resident didn't have an appointment on 10/14/21 but showed up and so they worked the resident in since she had missed two previous appointments. An additional interview on 10/28/29 at 12:25 p.m., the Clinical Wound and Vein Nurse Manager reported she felt the facility responsible because the resident missed her scheduled appointments to the Wound Clinic, and felt it contributed to the resident's wounds worsening. An interview on 10/20/21 at 3:30 p.m., the Social Worker stated she had issues with insurance when she called to schedule an appointment for transport. She reported the insurance group would not schedule transport until the issue with the address fixed. She reported the insurance still had the old address on file and worked with the insurance group for about two weeks trying to get the address changed. She reported any of the wound care clinic appointments, which were missed, were rescheduled. An interview on 10/21/21 at 9:40 a.m., the Wound Rounding NP reported she rounded with the facility Wound Nurse on 10/4/21, and suspected infection for Resident #4's right lower leg wound, and prescribed an antibiotic for 10 days. The NP reported she rounded on 10/11/21, and the wound did not look infected and no bone showing. When asked about the wound size going from 4.3 cm by 2.4 cm on 10/4/21 to 8.0 cm by 4.0 cm by .5 cm on 10/11/21, the NP reported not aware of change in size of the wound. She reported she could not answer whether or not the facility should have called the Wound Care and Vein Center Clinic. Review of Skin Management Guidelines dated 2/2016 instructed on staging classification for ulcers. The Guideline reveals characteristics of a Stage 4 ulcer show full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough, and/or eschar may be visible. 3. Resident #7's MDS dated [DATE] showed the resident's cognition intact with a BIMS score of 15 out of 15. The resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS identified the resident required extensive assistance of two staff members for toileting and utilized a walker and a wheelchair for mobility devices. Further review revealed the resident always incontinent of urine and stool. The MDS documented the resident at risk for developing pressure injuries and the resident with two venous and arterial ulcers present and had skin injury treatments including pressure-reducing device for chair, nutrition and hydration intervention, application of nonsurgical dressing, ointments or medications and applications of dressings to his feet. Review of the resident's Care Plan identified the resident at risk fro potential pressure injury, impaired skin integrity and venous wound development related to [CONDITION(S)], incontinence, limited mobility, and history of pressure injury. Staff directed to follow facility policies and protocols for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Pressure Injury Risk Assessment revealed the resident's Braden Skin Score as a 14 which means the resident is a moderate risk for skin injury. The assessment identified the resident as having skin often moist, the resident as chairfast, and her mobility as very limited. Review of the TAR for resident #7 documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the TAR revealed the treatment not documented for 10/5, 10/9, 10/10, 10/11, 10/16 and 10/17. During an observation on 10/28/21 at 9:00 a.m., noted the facility Wound Care Nurse administering treatments to the wounds, the resident lifted via a sit-to-stand lift, his pants pulled down and the wound cleaned. At the time of the observation, currently no dressing to the resident's right bottom noted and the area open to air. The staff member cleaned the resident's bottom, applied the topical ointments, and then placed the dressing to the resident's bottom. The resident began to have loose stools. An interview on 10/27/21 at 11:25 a.m., Resident #7's primary NP reported she came in to assess her resident's and found Resident #7's bottom macerated and no wound dressing on. She reported she knows there is an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/28/21 at 10:15 a.m., Staff A, Certified Nurse's Aide (CNA) reported when a wound dressing comes off during cares with Resident #7, staff are to inform the facility Wound Care Nurse so she may replace it. During an interview on 10/28/21 at 10:22 a.m., Resident #7 reported staff are good about getting him cleaned up. He reported he has bowel issues because he does not have a portion of his colon. The resident reported when he has loose stools, the dressing will come off but then it is not always replaced. The State Agency informed the facility of the Immediate Jeopardy on October 28, 2021 at 3:30 p.m. The Facility removed the Immediate Jeopardy on October 28, 2021 by implementing the following actions: a. The Director of Nursing (DON) and Wound Care Certified Licensed Practical Nurse (LPN) completed a 100% Skin Assessment of all residents at the facility. All treating physicians updated on current assessments of wounds including measurements. b. The DON and Wound Care Certified Nurse received education on changes in wounds and expectations via a Zoom meeting by a Regional Nurse consultant. c. All professional staff will receive education on wound decline identification, Skin Management Guidelines, Practice Guidelines and Derma Rite Wound Care Quick Reference Formulary and requirements for immediate notification of the Primary Care Physician and the Wound Care Center, if the resident is being followed by a Center, and no professional staff will work additional shifts prior to education. d. [NAME] Wound Physician will begin weekly observations either via Telehealth or In Person Visits beginning the week of November 1, 2021 for pressure injuries e. Weekly skin assessments will be reviewed the next business day by the Quality Assurance Performance Improvement (QAPI) Team to ensure that notifications and changes were documented appropriately. f. Audits to review physician notifications/updates will occur 5 times weekly. The scope lowered from K to E at the time of the survey after ensuring the facility implemented education and updated their policy and procedure.

Based on observation, record review, and staff interview the facility failed to provide adequate supervision for 1 of 4 sampled (Resident #1) for elopement. On 8/7/21 at 2:00 p.m., Resident #1 who had cognitive impairment eloped from the facility without staff knowledge. The staff reported the alarms failed to sound. The facility failed to fully repair a door alarm known to not function prior to the elopement. The facility failed to thoroughly investigate the root cause of the elopement. The failures resulted in Immediate Jeopardy to the health, safety, and security of the residents. The facility reported 5 resident had cognitive impairments and independently mobile. The facility reported a census of 50 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had diagnoses of anxiety and dementia and had Brief Interview for Mental Status score of 4, indicating severe cognitive impairments. Resident #1 required supervision of one with staff with transfers. The Care Plan dated 4/14/21 revealed Resident #1 had a memory problem, impaired decision making, problems understanding others, and disorganized speech. The Care Plan documented Resident #1 had a history of a fall with a right arm fracture and visual impairments due to [CONDITION(S)]. The Elopement-Wander Risk Scale dated 6/9/21 revealed Resident #1 had a low risk for elopement. The Weekly Door Alarm Inspections Error Log sheet dated 2021 documented on 8/6/21 locks not working. The Progress Notes dated 8/7/21 at 2:06 p.m., documented Resident #1 exited the front door and found to in the middle of the road at the end of the city block. The staff assisted Resident #2 back inside with her walker and placed a wanderguard bracelet on her. The staff notified the Director of Nurses by phone. During an interview on 8/31/21 at 10:00 a.m., Staff C (Licensed Practical Nurse) stated she was outside on break when an Assisted Living employee assisted Resident #1 to the back entrance of the facility with her walker. The Assisted Living Staff informed Staff C she found Resident #1 at the end of block in the middle of the street. Staff C figured Resident #1 exited the West door. Resident #1 stated she was trying to find her family. Staff C thought she observed Resident #1 inside the facility before exiting the facility for her break 10 minutes earlier. Staff C assessed Resident #1 and found no injuries, notified the Director of Nurses, and applied a wanderguard bracelet. Staff C reported the West door alarms were malfunctioning at the time. When the door opened it only set off the whistle not the buzzer. When opening the door from the outside to return inside there was no whistle or buzzer. At the time Resident #1 went outside there was nothing going off for alarms. There was no alarm sounding when Staff C entered the facility. They are in the process of fixing everything now. During an interview on 8/31/21 at 2:00 p.m., Staff E (Certified Nurse Aide) stated she was not sure when she last saw Resident #1 prior to the elopement. Staff E assumed Resident #1 exited the front door and reported the front door alarm was not working. The front door alarm sounded for no reason. During an interview on 8/31/21 at 2:20 p.m., Staff D (Certified Nurse Aide) stated she didn't recall hearing an alarm when Resident #1 eloped. Staff D answered another resident's call light and someone informed her Resident #1 eloped. Staff D reported something was going on with the front door alarm. Staff D did not know how long the alarms had malfunctioned. Staff D reported Resident #1 wandered the facility and required redirection to get back to her room. During an interview on 8/31/21 at 2:55 p.m., the Director of Nursing (DON) stated she worked the day Resident #1 eloped. The DON reported electrical problems and the alarm. The alarms sounded and the staff reset them and then they would sound again for not reason. The DON directed the staff to notify maintenance of the issue. The DON received a call on her way home informing her Resident #1 had eloped. The DON directed the staff to place a wanderguard bracelet on Resident #1. The DON worked again the following Monday, Tuesday, and half day on Wednesday and did not remember to do anything about it. The DON reported the nursing staff check the resident's bracelets for function but do not check the door alarms for function. However, due to the trouble with the alarms they are now checking the wandergaurd alarms on the doors. The DON did not know when the checks started as she was on vacation. During an observation on 8/31/21 at 8:43 a.m., revealed front door alarm going off and no resident at the door. Staff F (Laundry Aide) responded and shut alarm off and moved away from door. The alarm sounded again and Staff F walked away from the alarming door. An unidentified staff reset the alarm. During an interview on 8/31/21 at 11:25 a.m., the Maintenance Director explained the magnets for the fire doors were not working but the alarms were working. The staff just ignored it or didn't hear it. Someone must have silenced it. During an interview on 8/31/21 at 3:30 p.m., the Maintenance Director reported the staff called him in after dinner the evening of the elopement to ensure the door alarms functioned. The Maintenance Director found no issues with the door alarms. The Maintenance Director thought it was possible the switch got turned off but it was on when he arrived. He added a small battery operated alarm to the front door, north, east and west fire exit doors on 8/16/21 due to issues. The front door didn't lock but it did alarm and not sure why staff say it was not functioning. On 8/16/21 the Administrator had the Maintenance Director implement a log for checking all the door alarms due to the staff reports of it not functioning. The Maintenance Directed stopped the logs on 8/23/21. During an interview on 9/2/21 at 9:40 a.m., Staff A (Licensed Practical Nurse) stated recalled observing Resident #1 in the day area and then on the west wing 10 to 15 minutes prior to the elopement. The Assisted Living staff assisted Resident #1 back inside and reported they found Resident #1 in the road. Staff A reported she did not recall hearing any door alarms sounding. The Maintenance Director reported the door alarms were not functioning properly and to keep an eye on the residents. During an observation 9/8/21 at 12:45 p.m. revealed a posted speed limit of 25 miles per hour on the street where the staff found Resident #1 unattended. The facility had a large apartment complex across the street. During the observation 2 to 3 cars traveled east and west every minute. Uneven surfaces noted on the cement at end of driveway and the curb. During an interview with the State Climatologist on 9/8/21 at 12:28 p.m., revealed a temperature of 86 degrees Fahrenheit (F), relative humidity 66%, heat index 93 to 97 degrees F, winds out of the south at 13 miles per hour, skies clear and visibility of 10 miles on August 7, 2021 at 2:06 p.m. During an interview on 9/13/21 at 1:00 p.m., the Administrator reported an expectation of staff to notify the Director of Nurses or Administrator immediately following an elopement, and notify the police, the physician, notify the family, and conduct an assessment. Then the administrative staff conduct a root cause analysis to determine the cause of the elopement. The Administrator reported the staff should have implemented a plan to ensure the alarms were functioning at the time of the elopement. An email from an Alarm System dated 9/1/21 revealed a Technician made a visit on 8/17/21 and determined a fire panel without DC voltage and ordered a new power supply. On 8/23/21, a Technician back onsite with new power supply and installed. The contractor troubleshooted in the attic and agreed with the Maintenance Director that it might be cheaper and better to have an electrician troubleshoot circuiting. The wandergaurd doors operated when the Technician departed. The Maintenance Director verbalized a plan to have an electrician look into the corridor doors and let him know. The Contractor never heard back from either. The State Agency informed the facility of the Immediate Jeopardy on September 1, 2021 at 8:55 a.m. The Facility removed the Immediate Jeopardy on September 1, 2021 by implementing the following actions: a. Conducting Elopement Risk assessments on all residents and ensured interventions in place. b. Staff education for monitoring residents at risk for elopement, elopement policy including notification to Administrator, Director of Nurses, and Police, and ensuring door alarms are functioning. c. Ensuring newly hired staff receive education on hire. The scope lowered from K to E at the time of the survey after ensuring the facility implemented education and their policy and procedure.

Based on record review, and staff, pharmacist, physician and responsible party interviews, the facility failed to ensure residents were free from unnecessary drugs when they administered [MEDICATION NAME] 2 mg daily without adequate monitoring (Resident #8). This constituted an Immediate Jeopardy (IJ) to resident health and safety. The facility identified a census of 40 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated [DATE] revealed Resident #8 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documented the resident scored 7 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated the resident experienced cognitive impairment. The MDS revealed Resident #8 required extensive assistance of at least 2 staff for transfers to and from bed and chair, ambulation (walking), bathing, dressing, toilet use and personal hygiene, and remained continent of bowel and bladder. Physician orders [REDACTED]. 1. [MEDICATION NAME] ([MEDICATION NAME], a blood-thinning, anticoagulant medication) 2 milligrams (mg) administered oral daily (hospital staff did not administer prior to discharge on [DATE]) 2. Aspirin 81 mg delayed release tablet orally 1 time daily (last dose administered at the hospital on [DATE]. The orders also directed the facility to perform an INR blood test (International Normalized Ratio, a test that quantifies the anticoagulation effects of [MEDICATION NAME]), on [DATE], the physician to dose the [MEDICATION NAME] from the INR result. The resident's hospital records, included with the discharge orders, revealed INR results of 4.2 on [DATE], 4.0 on [DATE] and 4.1 on [DATE] (normal INR results are 1.1 or less, and 2.0 to 3.0 is the desired therapeutic range for people that take [MEDICATION NAME] for disorders that include [MEDICAL CONDITION]) and a hemoglobin of 12.2 on [DATE], and 11.7 on [DATE] (hemoglobin is the part of the red blood cell that contains iron and transports oxygen, normal range is 12.0 to 16.0, a decreased hemoglobin could be a sign of blood loss). The physician orders, transcribed at the facility by the director of nursing (DON) and dated [DATE], directed staff to administer [MEDICATION NAME] 2 mg oral daily and Aspirin 81 mg oral daily (the orders transcribed at the facility did not specify delayed release Aspirin), and the [DATE] INR test was not transcribed on the facility physician orders. The orders also included physical therapy and occupational therapy services. Medication Administration Records (MAR's) revealed staff administered 2 mg [MEDICATION NAME] and 81 mg of chewable Aspirin to the resident daily from [DATE] through [DATE]. The nursing care plan, dated as implemented on [DATE], included a bleeding risk problem due to anticoagulant medication, and directed staff to perform lab work as ordered by the physician, assess for signs or symptoms of bleeding, and notify the physician. An INR performed [DATE] at 5:25 a.m., with critical lab value results telephoned to Staff A, registered nurse (RN), on [DATE] at 8:00 a.m., reported a 14.4 INR result. Physician orders [REDACTED]. 1. Administer oxygen at 2 liters (per minute) per nasal cannula to keep oxygen (saturation) above 90 percent (normal value 95 to 100 percent without oxygen), transcribed on [DATE] at 4:00 p.m. 2. A facsimile (fax) to the physician on [DATE] at 9:49 a.m. described the resident ambulated to the bathroom without assistance, and the staff requested an order for [REDACTED].>3. Vitamin K (medication administered as an antidote for blood clotting problems) 5 mg administered now by intramuscularly (IM) injection, for critical INR value, repeat INR on [DATE], hold [MEDICATION NAME] and aspirin indefinitely, with order transcribed on [DATE] at 10:21 a.m. Nurse's Notes revealed the following entries: [DATE] at 4:00 p.m. - oxygen saturation 65 percent during assessment, physician notified with order for oxygen at 2 liters per nasal cannula as needed to keep saturation above 90 percent. Oxygen started at 2 liters. [DATE] at 1:10 p.m. - in recliner all day, sleeping most of the time. Oxygen on at 2 liters, saturation 89 percent, no signs of dyspnea or any respiratory distress, appetite poor. [DATE] at 10:35 a.m. - very tired this morning. An oxygen saturation of 96 percent recorded on [DATE] evening shift with vital signs. [DATE] at 11:00 p.m. - small amount reddish brown stool reported by certified nursing assistants (CNA's). Physician on call notified of bloody appearance of bowels, vital signs, [MEDICATION NAME] 2 mg daily with INR test scheduled on [DATE], physician directed staff to monitor for any adverse change in blood pressure or pulse, and call if any change. An oxygen saturation of 91 percent recorded on the evening shift with vital signs. [DATE] at 12:16 p.m. - lab phoned facility to notify of a high 14.4 INR. Faxed and called physician notified of INR results. Physician's office called back with order for Vitamin K 5 mg IM for critical INR value, repeat INR on [DATE], hold aspirin and [MEDICATION NAME] indefinitely, Vitamin K administered. [DATE] at 9:30 a.m. - staff summoned nurse to the resident's room at 6:10 a.m., resident on toilet and too weak to stand, skin pale, respirations slow and deep, and no response to verbal stimuli. Staff transported the resident to bed. The resident's oxygen saturation measured 80% percent, and the nurse left to obtain a stethoscope and blood pressure cuff. Upon her return to the room, nurse unable to obtain blood pressure or oxygen saturation, no pulse or respirations for 2 minutes at 6:20 a.m. Physical and Occupational Therapy notes revealed the following entries: By Staff B, physical therapy assistant (PTA): [DATE] at 4:34 p.m. - unable to stand longer than 62 seconds (with walker) on 1st attempt, 51 seconds on 2nd attempt and 22 seconds on 3rd attempt, with substantial rest breaks required between attempts. [DATE] at 1:40 p.m. - resident reports she felt extremely tired, doesn't have much pep. Unable to stand with assist from recliner, recliner elevated to approximately 45 degrees and able to stand with 50 percent assist by therapist, stood 65 seconds on 1st attempt, 42 seconds on 2nd attempt, and 15 seconds on 3rd attempt, immediate loss of trunk control upon 2 steps with wheeled walker. [DATE] at 1:51 p.m. - resident found in the restroom unattended last night, now alarmed with a pressure mat. Resident constantly complained of being too cold throughout the entire treatment, oxygen saturation 85 percent on 2 liters nasal cannula. Resident unable to sit unsupported for more than 40 seconds before fatigued, 20 seconds on 2nd attempt and 15 seconds on 3rd attempt. Frequent rest breaks required. By Staff C, occupational therapy assistant (COTA): [DATE] at 2:16 p.m. - maximal assistance required to stand from lift chair, transfer to wheel chair, and to don and doff clothes. [DATE] (documented on [DATE] at 8:41 a.m.) - maximal assist for sit to stand and pivot to recliner, therapist allowed the resident to rest. Upon return, increased time required to wake resident and get her to open her eyes. Staff assistance required and extra time for resident to sit to stand from recliner, stood 90 seconds with walker before sitting rest break required due to fatigue. [DATE] at 2:35 p.m. - increased time required to wake resident and to sit forward in recliner, did not tolerate sitting forward longer than 30 seconds, 3 attempts, with increased rest breaks required after each attempt. Staff, physician, pharmacist and resident responsible party (RP) interviews revealed: [DATE] at 2:56 p.m., Staff E, CNA, stated the resident wasn't short of breath or use oxygen and required only 1 staff assist for ambulation when she was first admitted , but after a few days became short of breath, used oxygen, and required 2 staff to assist with ambulation. Staff E reported Resident #8 bled from bowels or bladder (could not tell which one) that started a couple days after admission. She said she informed the nurse, Staff F, licensed practical nurse (LPN). [DATE] at 6:23 a.m., Staff D, CNA, stated the resident was supposed to have 1 staff assist for the toilet but the resident self-transferred and didn't alert staff; she was short of breath, although she didn't have oxygen at first. Staff D reported the resident had bleeding from her bowels or bladder; she couldn't really tell but saved it in the toilet and reported it to the nurse each time she observed it. Staff D stated the day the resident passed she had walked very slowly to the bathroom and was too weak to stand from the toilet, so the CNA called for help. It took 3 staff to carry the resident to bed, there was blood in the toilet, and the resident was non-responsive. [DATE] at 3:48 p.m., Staff F, LPN, stated staff reported the resident had blood in her stool, observed reddish brown stool in the toilet, called the physician on call and was directed to monitor her blood pressure. An INR was already scheduled for the next lab day. During another interview on [DATE] at 10:41 a.m., Staff F stated she had contacted the physician on call at approximately 9:00 p.m., the doctor asked what the INR was, and she looked through the chart and couldn't find an INR result. She then looked in the lab book and it was scheduled on the next lab day ([DATE]). When asked, she confirmed she was not aware the INR ordered for [DATE] had not been done. [DATE] at 6:06 a.m., Staff G, LPN, stated he worked on the night shift, the resident self-transferred to the bathroom and wasn't supposed to, had dark stools on [DATE], there was a fax from the doctor to get an INR if indicated. He said there wasn't one set up and scheduled it for the next lab day on [DATE]. Staff were supposed to watch her blood pressure. The night before she died her blood pressure had dropped 10 points. During another interview on [DATE] at 11:52 a.m., Staff G stated he knew to schedule the INR because of the fax from the physician on [DATE] that ordered the INR if warranted. Staff G felt a nurse couldn't make that determination so he scheduled the INR for the next lab day. He was not aware the INR ordered for [DATE] was not completed. [DATE] at 5:19 p.m., Staff H, registered nurse (RN), stated she had not observed bleeding, but the resident had to be carried out of the bathroom the day she died . [DATE] at 10:20 a.m., Staff B, PTA, and Staff C, COTA, were interviewed together and in agreement of their responses. Staff B stated the resident's endurance decreased during the time she was at the facility, instead of the number of repetitions per exercise, the normal protocol of therapists, they modified the resident's exercise program to the number of seconds that she could tolerate an activity. The resident was oxygen dependent and short of breath with any exertion, and this was reported to nursing staff. Staff C stated on [DATE], the resident was in a recliner chair with several blankets on and said she was cold; they were informed by the nurse that day of the resident's high INR. [DATE] at 8:09 a.m., Staff A, RN, stated she worked the day shift on [DATE] and lab notified of the high 14.4 INR from lab by phone. She reported it to the physician with order obtained to administer Vitamin K injection; she had looked through the Nurse's Notes and found something about bleeding but the information had not been passed on in report prior to the call from the lab. The resident was very weak, had not improved since admission to the facility and therapy had not advanced her activity level. On the day she died ([DATE]), there was blood in the toilet and she was 1 of the 3 staff that transferred the resident from the bathroom to bed, an described it as an emergency. Staff A reported she did not observe blood in the toilet or on the floor. [DATE] at 3:41 p.m., Staff J, registered pharmacist (RPh) from the facility's pharmacy, stated delayed-release aspirin is not the same as chewable aspirin. Staff J reported the pharmacy would have provided delayed-release aspirin if specified by the facility but it was not transcribed on the orders. Staff J stated chewable aspirin would affect actions of the [MEDICATION NAME]. [DATE] at 2:35 p.m., the director of nursing (DON), confirmed she transcribed the resident's physician orders [REDACTED]. Since then, the facility initiated a process where a 2nd nurse manager proof read all transcribed physician orders [REDACTED]. During another interview on [DATE] at 1:15 p.m., the DON stated she became aware the [DATE] INR order was missed when she returned to work on [DATE], the facility aware on [DATE] when INR results performed that day were called to the facility with critical value. [DATE] at 7:16 a.m., the assistant director of nursing (ADON), stated she admitted the resident on [DATE], saw the order for the INR on [DATE] but it was missed on the orders, the aspirin order was for delayed-release and chewable aspirin was not delayed-release. She reported orders were now double checked, sometimes triple checked by either the DON, QA (quality assurance) nurse or herself. [DATE] at 11:50 a.m., Staff L, physician assigned to the resident with admission to the facility, stated staff should have followed physician orders [REDACTED]. administered the [MEDICATION NAME] without the resident's INR results. Staff L reported he never saw the resident because she died the day she had an appointment to see him. [DATE] at 3:18 p.m., the nurse at Staff L's office, stated there was no documentation in the resident's record of notification of resident condition from the facility between [DATE] and [DATE]. She reported the office did not record communication with on-call physicians and it is not recorded in the record unless the on-call physician wrote it. [DATE] at 12:35 p.m., Staff K, physician, the facility's medical director, stated the facility informed him that a resident's INR order was missed and a critical high INR result obtained. He stated it was an oversight and was not aware of the action taken by the facility because the quality assurance committee had not met since the event. [DATE] at 12:06 p.m., Staff M, the resident's primary physician prior to admission to the facility, stated she was unaware the resident was admitted to a nursing home, she was notified the resident would discharge from the hospital to home and was to follow-up with an appointment with her in 1 week, in correspondence she received from the hospital. Staff M stated she didn't have information related to the resident's condition at the time of her death or when she completed the death certificate, other than information from her emergency room visit on [DATE]. Staff M stated it is required for the death certificate to be completed within 72 hours. During another interview on [DATE] at 4:07 p.m., Staff M stated she was not aware of the resident's 14.4 INR or symptoms of gastrointestinal/rectal bleeding when she completed the death certificate on [DATE], because didn't have other laboratory data or medical tests at the time of the resident's death and an autopsy was not performed. During an interview on [DATE], the resident's RP stated he/she arrived at the facility after staff notified him of the resident's death. The RP reported the resident was in bed, there were drops of blood on the floor between the bed and the bathroom, and red blood in the toilet. On [DATE] at 3:15 p.m., the administrator and DON stated the facility didn't have a policy or procedure for following physician orders; it was a professional standard staff were expected to follow. The facility abated the Immediate Jeopardy situation on [DATE] by implementing the following: 1. Changed the policy to require two of these three individuals to verify admission orders [REDACTED]. 2. Educated all nurses regarding physician's orders [REDACTED].

Based on observation, record review and resident and staff interviews, the facility failed to ensure one of four residents reviewed received kind and considerate care at all times and free from mental abuse (Resident #1). The facility reported a census of 55 residents. Findings included: 1. Resident #1 had an annual MDS (Minimum Data Set Assessment) assessment with a reference date of 01/26/16. The MDS identified the resident had modified independent cognition for daily decision making. The resident had no signs and symptoms of [MEDICAL CONDITION], mood or behavior problems. The MDS indicated the resident required extensive to total staff assistance with bed mobility, transfers, toileting, personal hygiene and bathing. The MDS identified the resident [DIAGNOSES REDACTED]. The MDS indicated the resident utilized a wheelchair for mobility and experienced occasional urinary incontinence but always continent of bowel. The resident's Care Plan with a review date of 04/25/16 documented the resident required staff assistance for activities of daily living (ADLs) related to cervical spinal cord injury and [MEDICAL CONDITION]. The Care Plan instructed staff the resident dependent for all cares, staff to anticipate needs, use communication cards due to language barrier and/or call family member, give praise and encouragement, provide visual cues, allow sufficient time to communicate, utilize short statements and simple questions. The Care Plan instructed staff to encourage the use of the commode/toilet, assist with perineal care and provide urinal for urinary continence. In a concern received by the Department of Inspection and Appeals on 04/07/16, the resident reported to the facility Administrator that around 1:30 a.m. he/she pulled the call light for staff assistance to use the bathroom. Staff A, Certified Nursing Assistant (CNA) came into the room and turned off the call light and exited the room. The resident again activated the call light. The CNA came back into the room and again turned off the call light without providing care. The resident claimed this happened a few times, and then the staff removed the call light from the resident's reach. The resident reported he/she began yelling out for assistance when Staff A came in and pulled the blankets up over the resident's head. The resident claimed after a while, the staff returned, gave the call light back, went out of the room and returned with the charge nurse who then helped him/her. Documentation in the Nurse's Notes dated 04/07/16 at 2:10 p.m. indicated the resident had been upset, the interpreter was notified and the wife and resident had a meeting with the facility Administrator and Director of Nursing. The facility abuse policy/procedures, revised on 2/2013 identified the resident has the right to be free from verbal, sexual, physical and psychological abuse, corporal punishment and involuntary seclusion. The policy indicated the facility will not permit residents to be subjected to abuse by any person, including staff members, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, sponsors, friends or other individuals. The policy indicated the facility will supervise staff to identify signs of burnout and inappropriate behaviors, such as using derogatory language, rough handling, or ignoring residents while giving cares. If such behaviors are noted, appropriate actions including education, counseling, disciplinary actions, and/or investigations of suspected abuse, will be taken. The facilities Chain of Command for Mandatory Reporting of Suspected Abuse instructed staff to: 1. Separate the victim and caretaker immediately 2. Notify Administrator, Director of Nursing (DON) or charge nurse immediately 3. Administrator contacts the Department of Inspection and Appeals (DIA) immediately (within 24 hours if suspected dependent adult abuse) 4. Charge nurse notifies DON/Administrator 5. DON/Administrator begin investigations and phone DIA immediately if suspected abuse possible after investigation 6. Investigation completed within 48 hours-submit paperwork to DIA 7. Confidentiality vital On 04/22/16 at 9:30 a.m. the resident, interpreter and family member was interviewed and observation identified the resident to be visibly upset when talking about the incident. The resident's voice had a shaky and indignant quality, and he/she became teary eyed while describing Staff A's actions. The interpreter explained the resident had voiced feeling fearful and unsafe with Staff A. During an interview with Resident #1 (through a language interpreter) conducted on 04/22/16 at 9:30 a.m. the resident revealed approximately one month ago, he/she had called for assistance when a nurse came into his/her room, shut the call light off and left. The resident stated he started to yell for assistance when the same staff came in, put her hand over his/her mouth, then jammed a urinal between his/her legs. The resident indicated he did not tell anyone except his /she spouse because did not want to get anyone in trouble. When asked if he/she knew the name of that person, but stated it was the night helper. The resident had been able to identify Staff A, CNA from a photograph. When asked to clarify when the incident had occurred, the interpreter noted the incident described had been the first incident with the staff. When asked what had happened on April 7, 2016, the resident stated he/she had pulled his/her call light for assistance. The resident stated Staff A, CNA came into the room and turned off the call light. The resident stated he/she needed to use the bathroom for a bowel movement and Staff A did not help him/her. The resident stated they had pulled the call light again and Staff A came in and took the call light away. The resident stated he/she started to yell for assistance, when Staff A returned and pulled the blanket over his/her face. The resident stated he/she had been able to pull the blanket off with his/her two fingers. The resident stated the staff returned a little later with Staff B, RN charge nurse who then helped to clean him/her up. The resident stated the other one (Staff A) came in later and jammed the urinal between his/her legs again and hurt him/her. The Resident insisted that Staff A had been the staff that had hurt him/her with the two different times. The resident's spouse and the interpreter stated they had noted scratches on the residents' legs after he/she had complained of the first incident. The spouse stated they had informed the day charge nurse they had seen blood on the incontinency pad when assisting the resident to get cleaned up later in the morning after the first incident. The language interpreter voiced these incidents had made the resident afraid of the CNA, felt that she would hurt him/her again so does not want her in his/her room. The interpreter stated that the resident did not feel safe and he/she should feel safe in the facility. He stated the resident had not had any problems with the facility staff before these incidents. on 04/21/16 at 1:35 p.m. Staff B, registered nurse, was interviewed and stated around 1:30 a.m. on 04/07/16, Staff A came to her and stated Resident #1 had been yelling at her and she did not know what he wanted. Staff B stated she went down to the resident's room with the CNA. She stated the resident had been agitated at the time. She stated the resident had been yelling and she asked the resident to calm down so she could understand what he/she needed. Staff B stated the resident took a deep breath and said pull me up. She stated she put the head of the bed down to reposition the resident, and with pulling the sheet down noticed the resident had been soiled with a bowel movement. She stated this is what she thought the resident had been upset about. Staff B stated that Staff A, CNA had been with her so she Staff B positioned and held the resident as Staff A cleaned the resident up. Staff B stated after finishing with the care, Staff A placed the urinal between the resident's legs. Staff A stated the resident grabbed the blankets and kept shaking them. Staff B stated the resident showed agitation and she had been afraid the resident would harm his/her eyes with the blanket (had just had cataract surgery). Staff B stated she sent Staff A from the room and the resident calmed down. Staff B stated she got the resident positioned in bed covered the resident up and the resident thanked her for the help. On 04/22/16 at 10:15 a.m. Staff C, CNA, was interviewed and stated around 5:30 a.m. she went into the resident ' s room to get his/her roommate, Resident #4 up for a shower. Staff A had been in the room to get Resident #4 ready, but the resident had soiled self, so she assisted Staff A to clean Resident #4 prior to transporting the resident to the shower room. Staff C stated Resident #1 began to yell out continuously. Staff C stated she does not remember Resident #1 yelling like that before. Staff C stated Staff A asked Resident #1 what do you need, we are in the middle of helping Resident #4. Staff C stated she continued to assist Resident #4 while Staff A went over to Resident #1's bed and took the urinal, she assumed because she saw Staff A coming out of the bathroom with the empty urinal and place it between Resident #1's legs. Staff C stated she told Staff A to take Resident #4 on out and she would try to figure out what Resident #1 needed. Staff C stated she went over and touched Resident #1 on the arm and asked what he wanted. Staff C stated she could not understand what the resident had been trying to say. She stated he had stopped yelling but continued to talk and making motions, trying to tell her something. She stated she just could not understand what he was saying but did recognize him saying the DON's and Administrator's names. Staff C stated that Staff A might have been frustrated because of Resident #1 yelling had been unusual or she might have been frustrated because they were so busy. Staff C stated she had only seen Staff A a few times in the morning in passing or when she had gone into help with a resident. Staff C stated she had not worked much with Staff A. Staff C stated she left the room and informed the charge nurse, Staff B about the resident being upset. Staff B stated she would go in the room in a minute and had been in the room earlier with the resident. On 04/25/16 at 8:45 a.m. Staff D, LPN (licensed practical nurse) was interviewed and stated he had worked with Staff A. Staff D stated he had not been aware of any incidents when Staff A had turned off a resident's call light and not assisted them. Staff D stated Staff A could be domineering and could be verbally aggressive but does not feel she would physically harm any resident. Staff D stated Staff A had used inappropriate language toward a resident prior to the incident with Resident #1. On 04/25/16 at 9:25 a.m. Staff E, (registered nurse) was interviewed and stated she worked with Staff A frequently. Staff E stated Resident #1 usually slept most of the night and seldom activated the call light for assistance. Staff E stated normally when Resident #1 pulled the call light, it was to get the urinal emptied. Staff E stated if the resident did turn on the call light then he/she really would have needed assistance for something. She stated the resident is very clear when making his/her needs known despite the language barrier. Staff E stated that if Staff A did not understand what Resident #1 wanted, she normally would come to her for assistance. Staff E stated Staff A could get frustrated with residents, and had told residents not to put the call light on if it is not an emergency. On 04/25/16 at 9:55 a.m. Staff F, CNA was interviewed and stated she had worked with Staff A 3-4 nights a week for the past couple of months. Staff F stated Resident #1 normally slept most of the night and will usually just used the call light when needed the urinal emptied. Staff F stated she had seen Staff A upset with residents all the time and could be rough with residents, rammy with cares. Staff F stated she did not think Staff A had been physically abusive but could be verbal. She stated she had seen Staff A not provide pericare when changing a resident and when she asked her don't you do pericare on the residents? Staff A told her she only did pericare when she got them up in the morning. Staff F stated she did tell the DON (Director of Nursing) and the DON had a group meeting with the shift nursing assistants. On 04/25/16 at 11:12 a.m. Staff G, CNA, was interviewed and stated she works on the 10:30 p to 7:00 a shift and had worked with Staff A, CNA a few times. She stated she had taken care of Resident #1 as part of her assignments. She stated resident #1 normally slept most of the night and will call for assistance about one time a night to get the urinal emptied or to get repositioned in the bed. She stated if the resident called to use the bathroom he would have needed to have a bowel movement and would need transferred to the wheelchair and taken to the shower room. Staff G stated she had not observed Resident #1 make accusations against staff or become disgruntled with staff. She stated if Resident #1 said someone had hurt him/her, she would believe them. She stated Resident #1 does not seem like a resident who would make things up. Staff G stated she did not see Staff A mistreat any resident but she was kind of abrupt with residents and did not have a very nice manner toward them. Staff G stated Staff A could be short tempered, easily annoyed and stern with her demeanor with any resident who pulled the call light all the time. On 04/25/16 at 2:30 p.m. Staff H, CNA, was interviewed and stated she works on the night shift and had worked with Staff A, CNA. Staff H stated Staff A had not been someone who she would want to take care of her family member. Staff H stated Staff A is rude to residents. She stated one resident does not like the oxygen concentrator close to the bed because it made it to warm for them. She stated Staff A moved the concentrator over close to the bed and when the resident asked her not to, she told the resident well you don't want the light turned on either, so I am going to just flip it on every time so I don't trip over your oxygen then. Staff H stated if a resident asked for something, Staff A acted like it put her out. She stated she did not see any physical aggression just more of a verbal problem. Staff H stated she had heard Staff A tell another resident if he/she put the call light on one more time she would hide it.

The following deficiency relates to complaint # -C: Based on record review and resident, physician and staff interviews, the facility failed to assess a resident at high risk for the development of pressure sores and provide timely interventions to prevent the development of pressure sores (Resident #3). The sample consisted of 3 residents with pressure ulcers. The facility reported a census of 59 residents. Resident #3 depended upon staff for all activities of daily living and was at high risk for pressure ulcers. Upon admission the resident had pressure ulcers on the buttocks. On 2/3/2011, the staff observed firm hard masses on the right and left lower buttocks (over the ischeal tuberosity bones) and the staff did not notify the physician. On 2/10/2011, the skin assessment nurse identified nonstageable pressure ulcers on each left and right lower buttocks region. The facility did not provide adequate pressure relieving devices or provide care in a manner to prevent the development of avoidable lower buttock pressure ulcers. The resident sat on a bed pan during the night hours of 1/28/11 - 1/29/2011 without repositioning which could cause pressure to the lower buttock areas. The resident had refused to lie down and sat in a wheelchair for long periods of time without proper repositioning/off loading of pressure and did not have an adequate pressure relieving device in the seat of the chair or the bed until after the development of the sores. The lower buttock pressure ulcers required debridement at a wound clinic. The wound clinic identified the wounds as Stage IV. Stage IV pressure ulcers are represented as a full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (tendons, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers. The resident developed heel ulcers on both feet. The facility identified the unstageable ulcers on 3/1/2011. The care plan directed staff to position resident in bed with protector boots. The care plan did not instruct staff what kind of boots to use or how to protect the resident ' s feet when out of bed. Findings include: 1. Resident #3 had a Minimum Data Set (MDS) assessment with a reference date of 3/11/11 which identified a [DIAGNOSES REDACTED]. Resident #3 required total dependence upon others for transfers, eating, dressing, toilet use, personal hygiene and bathing. Resident #3 had limited gross motor upper extremity movement. The resident scored a 10 on a scale of 0-15 with 10 as moderately impaired for cognition. Resident #3's care plan identified the resident as a skin pressure risk with current skin issues. The approaches directed staff to: a. Hoyer transfers. b. Use of commode. c. Position in bed with bilateral heal protectors. d. Reposition every 2 hours while in bed and every 25-30 minutes when in the electric chair. e. Low air loss mattress. f. Pressure cushion in the electric chair. g. Bowel management every day after suppository. The weekly pressure ulcer healing assessment records indicated pressure sores were noted on admission on 1/27/11. The right medial buttock had a stage II which measured 5 cm (centimeter) by 2.25 cm at a superficial depth. The left buttock had a stage II which measured 2 cm by 1 cm at superficial depth. The description of a Stage II pressure ulcer would be partial thickness skin loss involving the epidermis, dermis or both. The ulcer appearance would be superficial and presented clinically as an abrasion, blister, or shallow crater. In an interview on 3/23/11 at 2:00 p.m. Resident #3 stated was satisfied with the care received at the facility, but frustrated with the inability of getting his/her wounds healed. Resident #3 stated one evening was left on a bed pan all night. Resident #3 indicated he/she reported the incident and the problem was taken care of. The daily skilled nurse ' s notes reflected the following: On 1/28/11 at 1:51 a.m. (written by Staff C) Resident #3's skin to be checked daily for breakdown, repositioned every two hours when in bed and every 25-30 minutes when in wheel chair. On 1/28/11 at 2:00 p.m. (written by Staff G) Resident #3 refused to allow the skin nurse to assess skin or provide treatment. Resident #3 indicated she/he did not lie down during the day. Staff G indicated Resident #3 had an A/P overlay and own electric wheelchair with a pressure redistribution cushion. The staff notified the physician and received orders the resident was to reposition self in wheel chair every 25-30 minutes. On 1/29/11 at 12:44 a.m. (written by Staff C) Resident #3 with a wide spread rash over chest and neck and barely visible rash to groin, axilla, penis, scrotum and thighs. Pressure wounds noted upon admission and treated with [MEDICATION NAME] three times daily. On 1/29/11 at 10:35 a.m., Staff F indicated Resident #3 up in his/her electric wheel chair. Resident #3 refused to lie down for treatment. On 1/29/11 at 1:30 p.m. (written by Staff H-Director of Nursing) late entry-indicated Resident #3 had a Braden score (determines the risk for pressure sores) of 13 placed the resident at risk for pressure sores. An A/P overlay, heel protector and reposition every two hours while in bed. Resident #3 was encouraged to get out of wheel chair during the day. On 1/30/11 at 9:20 a.m. (written by Staff F) indicated Resident #3 was up in the wheel chair for breakfast. Resident #3 refused to lie down to have treatments completed on buttocks. At 12:45 p.m. Resident #3 continued to refuse to lie down so treatment could not be provided. On 1/30/11 at 9:00 p.m. indicated Resident #3 informed by nursing staff that his/her bottom was becoming seriously red and opened and he/she would need to lay down more often. Resident #3 indicated he/she would comply. On 1/31/11 at 12:55 p.m. (written by Staff F) indicated treatment to buttocks completed. Areas appeared worse. At 1:50 p.m. the note indicated the resident had been found on a bed pan on 1/29/2011 morning with red areas noted where bedpan contact made. The area indented and red. The note indicated the area had open blisters present where the bed pan had been. The physician was notified and the nurse applied [MEDICATION NAME] on 1/29/11 and 1/31/2011. On 1/31/11 at 3:00 p.m. the wound assessment (written by Staff G) indicated Resident #3 original wounds from admission are improved with two new house acquired stage II wounds located on the left buttocks (18.5cm by 0.9cm) and right buttocks (24cm by 1.8cm). Staff G indicated Resident #3 to continue using A/P overlay, to be repositioned every 25-30 minutes, resident using a timer and to utilize a pressure redistribution cushion. On 2/1/11 at 9:30 a.m. (written by Staff F) indicated Resident #3 continued to be up in wheel chair per his/her routine. On 2/2/11 at 12:30 p.m. indicated Resident #3 continued to be up in wheel chair per his/her routine. On 2/3/2011 at 2:00 p.m. indicated Resident #3 was up in the wheel chair. Treatment to buttocks area completed. At 4:10 p.m. Staff G indicated wounds improving, but noted two hardened firm fixed masses on bilateral buttocks at ischial tuberosities (very lower buttock region). On 2/4/11 at 12:55 p.m. the treatment to the resident ' s buttock completed and the resident up in the wheelchair. On 2/5/11 at 3:26 p.m. indicated Resident #3 treatments not completed after lunch as Resident #3 refused to get out of the wheel chair all day. At 4:00 p.m. Resident #3 agreed to lie down and treatments completed. On 2/6/11 at 3:06 p.m. (written by Staff C) indicated Resident #3 up to dining room for meals. At 6:49 p.m. Resident #3 was encouraged to lie down in bed to alleviate pressure. Resident #3 refused to lie down. On 2/7/11 at 10:00 a.m. (written by Staff F) indicated Resident #3 was up in his/her wheel chair for meal. Resident #3 finally agreed to lie down at 1:50 p.m. The note indicated the wheel chair beginning to not function properly at 9:00 p.m. On 2/8/11 at 3:58 p.m. indicated Resident #3's wheel chair did not function properly. Resident #3 remained in bed and repositioned every two hours. On 2/9/11 at 9:30 a.m. indicated Resident #3 up in chair in room. Wheel chair repaired and Resident #3 up and to the dining room for the supper meal. A weekly pressure ulcer healing assessment identified a stage III pressure ulcer present which measured .3 cm by .3 cm. A stage III pressure ulcer represents a full thickness of skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. On 2/10/11 at 10:10 a.m. (written by Staff F) indicated Resident #3 up in wheel chair for breakfast. Wound assessment completed at 3:30 p.m. by Staff G indicated left and right buttock stage II improved. Left and right ischial tuberosities, non stageable, 4cm by 4cm. Wound bed red with black discoloration. Physician notified with orders to continue A/P overlay, pressure redistribution cushion, positioning at times used for wheel chair repositioning. On 2/11/11 at 9:20 a.m. (written by Staff G) indicated Resident #3 received a new pressure reduction cushion in his/her wheel chair. Staff G indicated Resident #3's family member had replaced the facility provided cushion with the resident's old cushion. The facility ordered Resident #3 a low air loss mattress for the bed and a ROHO cushion in the wheel chair. At 7:25 p.m., staff assisted Resident #3 to the commode and the resident remained up for supper. On 2/12/11 at 10:20 a.m. (written by Staff F) indicated Resident #3 continued to be up in wheel chair for meals. Treatment provided to buttocks. At 3:00 p.m. Resident #3 was refusing to allow staff to administer a suppository. Resident #3 remained in the wheel chair. At 9:00 p.m. staff indicated the resident ' s wheel chair did not work properly again. On 2/13/11 at 12:30 p.m. (written by Staff F) indicated Resident #3 continued to be up in the wheel chair per his/her routine. Resident #3 noncompliant with allowing staff an opportunity to administer a suppository. At 3:00 p.m. Resident #3 sat in his/her recliner. The resident refused a suppository. The resident had a temperature of 100.5 F. On 2/14/11 at 1:00 p.m. Resident #3 was out of the facility to a doctor appointment. On 2/15/11 at 3:36 p.m. Resident #3 had penile drainage. Staff notified the doctor. Resident #3 continued to be placed on commode for bowel movements. On 2/16/11 at 10:30 a.m. (written by Staff G) indicated Resident #3 with left ischial tuberosity, nonstageable pressure ulcer with wound bed black eschar, surrounding skin purple, wound 6 cm by 6 cm with scant amount of sanguineous drainage without odor and the right ischial tuberosity, nonstageable with wound bed black eschar, wound 5cm by 4.5cm with scant amount of sanguineous drainage without odor. The staff notified the physician ' s office and received treatment orders for the ischial tuberosities. On 2/17/11 at 10:30 a.m. Resident #3 was up in his/her wheel chair that morning. Resident #3 reported not feeling well. On 2/18/11 at 8:20 a.m. the physician was notified of the rapid progression of wounds located on the ischial tuberosities. The physician ordered a wound clinic consult. At 3:00 p.m. Resident #3 requested to lie down. On 2/19/11 at 10:05 p.m. Resident #3 was up most of the afternoon and early evening. Placed on commode and had a medium bowel movement. On 2/20/11 at 6:30 p.m. (written by Staff G) indicated Resident #3 was up in wheel chair and refused to reposition. On 2/21/11 at 1:35 p.m. Resident #3 to lie down. At 8:00 p.m. Resident #3 laid down. On 2/22/11 at 9:55 a.m. Resident #3 was up early for breakfast and left facility at 7:00 a.m. for a wound clinic appointment. Resident #3 returned to the facility at 2:00 p.m. with strict bedrest, side to side positioning and not to lay on back or with head of bed greater than 30 degrees. The January 2011 Treatment Administration Record (TAR) for Resident #3 indicated to increase reposition and encourage weight shift in wheel chair every 25 to 30 minutes. The record reflected initialed once per shift as completed on day and evening shifts. The February 2011 Treatment Administration Record (TAR) for Resident #3 indicated to increase reposition and encourage weight shift in wheel chair every 25 to 30 minutes (has timer). The record revealed initialed once per shift as completed on day and evening shifts. The weekly pressure ulcer healing assessment indicated on 3/1/2011 multiple areas were identified as nonstageable pressure ulcer on the left heel. The measurements indicated the size to be 2 cm by 3 cm. on the left heel. The pad of the heel measured 5 cm by 5 cm. The left Achilles area measured 1 cm by 1 cm. The weekly pressure ulcer healing assessment indicated on 3/1/2011 the right heel had nonstageable pressure areas. The right heel measured 6 cm by 3 cm. The right pad of the heel measured 8 cm by 6 centimeters. The right Achilles area measured 1 cm by 2 cm. The care plan dated 2/14/2011 identified the resident had self care deficit problems with skin issues. The approach directed staff to position the resident in bed with bilateral heel protector boots on feet, position in a side lying position and place pillow between knees. The care plan did not provide an approach how staff were to protect the resident ' s heels when out of bed and did not identify which type of boots the staff should place on the resident while in bed. In an interview on 4/4/11 at 4:30 p.m. Staff G (skin nurse) indicated Resident #3 was admitted on [DATE] with two stage II ulcers on his/her right and left buttocks. Staff G indicated Resident #3 remained up in his/her wheel chair from morning to night and refused to off load. Resident #3 was placed on a repositioning schedule of every 25-30 minutes while in the wheel chair and staff used a timer. The repositioning consisted of tilting the wheel chair from front to back. On 1/31/11 the facility replaced the resident ' s chair cushion with an isch dish cushion. Staff G indicated the cushion was a gel and foam combination cushion. During a skin assessment on 2/3/11, Staff G discovered two hard masses at the ischial tuberosity sites. Staff G indicated she/he notified the physician. Then on 2/7/11 Staff G indicated Resident #3's wheel chair did not work properly and the resident spent more time in bed. On 2/10/11, Staff G assessed the resident ' s buttocks and discovered two necrotic, eschar wounds developing at the ischial tuberosity site. Staff G notified the physician. On 2/11/11 Staff G discovered the old cushion brought by the family had been placed back into the wheel chair. Staff G replaced the cushion with the isch dish cushion and discovered the cushion had been in the wheel chair since the weekend of 2/5/11. Staff G indicated the wounds became progressively worse and Resident #3 was referred to the wound clinic on 2/21/11 and seen on 2/22/11. Following the appointment, Resident #3 was placed on strict bed rest with frequent side to side repositioning. On 3/23/2011 at 4:00 p.m., the Administrator was interviewed and stated the resident ' s sister had switched the facility cushion in wheelchair with a cushion the resident had when entered the facility. A photograph was obtained of the cushion which identified excessive wrinkling of the seat cushion. In an e-mail to Resident #3's wound clinic physician on 4/5/11, the physician indicated the pressure device the resident was using was not anything he was familiar with and that Resident #3 would need a ROHO or J-cushion given his medical history. The physician also indicated it was obvious that Resident #3 should have been rotated regularly to off load any and all pressure points in the course of each and every day. The physician indicated when hard masses were discovered on 2/3/11, he would have expected to be notified.