**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, the facility failed to maintain the residents' dignity for two of three residents reviewed. (Residents #11 and #17) The facility reported a census of 62 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #11 as cognitively intact with a Brief Interview of Mental Status (BIMS) of 12 out of 15 possible points. The MDS documented diagnoses to include heart failure, paroxysmal atrial fibrillation and unspecified injury of muscles. It also identified the resident to be totally dependent on staff for locomotion on and off the unit and for bathing. During an observation and interview on 5/22/23 at 10:32 AM, as the resident sat up in her wheelchair in her room, she pointed to her bed (which did not have side rails) and reported she is not happy that side rails were removed from her bed as she used to use them to help her out of bed. She stated now she has to hold the window frame to help her get out of bed. She also stated she has to wait long as an hour to get her call light answered and she wets her pants every night. She stated she wakes up every morning soaking wet and is not happy about it. In an interview on 5/24/23 at 9:10 AM, Staff C, Licensed Practical Nurse (LPN) reported staff are made aware when a resident turns on their call light because call lights show up on screens that appear to be a monitors. She stated there is one in each hallway and staff would know when call lights are on if they stand in front of a monitor. The call lights are not audible. In an interview on 5/24/23 at 9:11 AM, Staff D, Registered Nurse (RN) reported Resident #11 did not have side rails on her bed as therapy had been evaluating her to develop a baseline as she is receiving therapy for positioning and strengthening. She also reported staff are made aware when a resident turns on their call light when the computer monitor in each hall makes a sound. She stated the staff should answer them within 10 minutes. In an interview on 5/25/23 at 6:00 AM, Staff F, Certified Nurse Aide (CNA) reported staff are made aware when a resident turns on their call light when the screen makes a noise. She stated there is one screen per hallway and if the light shows up on the screen and it is red this means it is a bathroom light. She stated staff should answer call lights within 15 minutes. In an interview on 5/25/23 at 10:18 AM, Staff C, LPN reported he did not know why Resident #11 did not have side rails on her bed and could not recall if she had complained to him about it. He also reported staff should answer call lights within 5 minutes. In an interview on 5/25/23 at 10:34 AM, Staff G , CNA reported Resident #11 used to have side rails on her bed. Staff G reported she had been told that state said it would be considered a restraint and they had just removed them the week before state walked in the building. The resident had complained to Staff G about it every day she worked with her. She really wants to use them to help her get in and out of bed. Staff G also reported staff should answer call lights within 5 minutes. In an interview on 5/25/23 at 10:48 AM, Staff A, CNA reported she did not know why Resident #11 did not have side rails on her bed and that the resident complained to her that she would like the side rails to help her sit up in bed. She also reported staff should answer call lights within 3 minutes. In an interview on 5/25/23 at 1:48 PM, the Director of Nursing (DON) reported she would expect staff to answer call lights as soon as possible. She stated the call lights are not audible. She would expect staff to make rounds hourly to check on the residents and check the monitors. 2. The MDS dated [DATE] identified Resident #17 as cognitively impaired with a BIMS of 7 out of 15 possible points. The MDS documented diagnoses to include renal insufficiency, neurogenic bladder and non-Alzheimer's dementia. It also identified the resident required extensive staff assistance with most activities of daily living and had an indwelling urinary catheter. The Care Plan identified Resident #17 with the for need assistance with activities of daily living due to impaired mobility and impaired cognition from encephalopathy, Parkinson's, dementia, and autonomic dysfunction. It did not direct staff to ensure the resident's privacy during provision of personal cares. During an observation of catheter care on 5/23/23 at 9:47 AM, Staff A, CNA and the Assistant Director of Nursing (ADON), entered the room. Staff A informed the resident of the need to change the catheter bag. The ADON pulled the privacy curtain, however, it did not provide 100% coverage as there was a gap from the end of the curtain to the wall which measured approximately 24 inches. At 9:43 AM, the housekeeping supervisor entered the room and started working on a soap dispenser in the bathroom. The ADON did not tell the housekeeping supervisor to leave the room and return later. Staff A had then pulled down the resident's pants while the housekeeper remained in the bathroom. At 9:57 AM the housekeeping supervisor left the room. In an interview on 5/25/23 at 6:00 AM, Staff F, CNA reported if a non-nursing staff entered the room while giving cares, she would cover up the resident, tell that person she was doing patient cares and if still doesn't leave the room, she would tell her to leave the room In an interview on 5/25/23 at 10:07 AM, Staff D, RN reported if a non-nursing staff entered the room while giving cares, she would cover up the resident, and she would have that person leave the room. In an interview on 5/25/23 at 10:18 AM, Staff C, LPN reported if a non-nursing staff entered the room while giving cares, he would tell that person he is doing cares and to come back later. In an interview on 5/25/23 at 10:34 AM, Staff G , CNA reported if a non-nursing staff entered the room while giving cares, she would pull the privacy curtain and tell them to leave the room until cares are done. In an interview on 5/25/23 at 10:48 AM, Staff A, CNA reported if a non-nursing staff entered the room while giving cares, she would tell that person to step out until she was finished with cares. In an interview on 5/25/23 at 1:48 PM, the Director of Nursing reported if a non-nursing staff entered the room while giving cares, she would expect the staff to ask that person to step out. In an interview on 5/25/23 at 7:32 AM, the Administrator reported the facility did not have a policy related to dignity. A review of the Resident's [NAME] of Rights dated as last revised November 2016 revealed in pertinent part: The resident has a right to be treated with respect and dignity, including: the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews, the facility failed to ensure the resident's call light had been placed within the resident's reach for one of one residents reviewed (Resident #11). The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #11 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 12 out of 15 possible points. The MDS documented diagnoses to include heart failure, paroxysmal atrial fibrillation and unspecified injury of muscles. The MDS documented the resident required minimal assist of one person for bed mobility, transfers, dressing, toileting and hygiene. Observations revealed the resident lying in bed without her call light in reach on the following dates and times: On 5/22/23 at 10:32 AM, as the resident sat up in her wheelchair in her room, the call light was on top of the other nightstand out of her reach. She stated she could scoot up to the call light, but it would not be so easy. On 5/22/23 at 2:10 PM, as the resident sat up in her wheelchair watching TV, the call light remained on top of nightstand out of her reach. On 5/22/23 at 4:44 PM, as the resident slept in her bed, the call light remained out of reach on top of nightstand behind her. On 5/24/23 at 8:52 AM, as the resident laid in bed, the call light was on top of nightstand out of her reach. On 11/28/21 the Care Plan identified the resident with the problem of being at risk for falls due to impaired cognition, impaired mobility, and right rotator cuff injury. The Care Plan directed staff on 9/10/22 to post a sign in her room to remind her to use the call light for needs. The care plan did not address the need to place the call light within her reach. In an interview on 5/25/23 at 6:00 AM, Staff F, Certified Nurse Aide (CNA) reported before leaving a resident's room, she should ensure the resident had her call light in reach. In an interview on 5/25/23 at 10:07 AM, Staff D, Registered Nurse (RN) reported before leaving a resident's room, she should ensure the the call light is in reach. In an interview on 5/25/23 at 10:18 AM, Staff C, Licensed Practical Nurse (LPN) reported before leaving a resident's room, he would ensure they are comfortable, if their needs are met and make sure the call light is reach. In an interview on 5/25/23 at 10:34 AM, Staff G , CNA reported before leaving a resident's room, she would make sure the resident is laying properly and the call light is near the resident. In an interview on 5/25/23 at 10:48 AM, Staff A, CNA reported before leaving a resident's room, she would make sure the call light is in reach. In an interview on 5/25/23 at 1:48 PM, the Director of Nursing stated she would expect staff before leaving a resident's room to make sure the call light is in reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and the MDS 3.0 Resident Assessment Instrument Manual (RAI), the facility failed to complete and transmit a discharge assessment for 1 of 1 resident (Resident #42) reviewed. The facility reported a census of 62 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #42 identified a Brief Interview for Mental Status (BIMS) score of 11 out of 15 possible points, indicating moderately impaired cognition. The Resident Census for Resident #42 documented the resident admitted to the facility on [DATE] and discharged from the facility on 12/29/22. Review of the clinical record for the resident revealed the discharge MDS assessment was not completed and not transmitted. On 5/24/23 at 9:40 AM the Director of Nursing (DON), verified and acknowledged the discharge assessment was not completed. The DON reported the facility follows the MDS 3.0 RAI guidelines for completing and submitting MDS.

Based on clinical record review, staff interviews and facility policy review the facility failed to ensure the accuracy of the Pre admission Screening and Resident Review (PASRR) for 1 out of 1 resident reviewed (Resident # 30). The facility reported a census of 62 resident. Findings include: The Minimum Data Set (MDS) Assessment for Resident # 30 dated 3/16/23, listed diagnoses of non-Alzheimer's dementia, and bipolar disorder. The MDS included a Brief Interview for Mental Status score of 13 out of 15 possible points indicating intact cognition. The MDS revealed Resident #30 rejected care 4-6 days in the 7 day look back period of the MDS. The Care Plan for Resident #30 dated 10/31/2022, listed he took psychotropic's (antidepressant, anti-psychotic) related to major depressive disorder and bipolar disorder. The Continuity of Care Document from the previous healthcare facility dated 10/20/22, included quetiapine 12.5 milligrams (mg) (anti-psychotic medication). The document revealed the Problem list included a diagnoses of bipolar disorder. The PASRR dated 03/16/21, included diagnoses major depressive disorder (MDD) and listed antidepressant medication. The PASRR failed to include Resident # 30's diagnoses of bipolar disorder and the anti-psychotic medication. On 05/25/23 at 11:10 AM, the Social Service Staff stated, she reviews the PASRR for accuracy before admission. If something is not correct on the PASRR, she will complete a new PASRR. On 05/25/23 at 11:19 AM, the Assistant Director of Nursing, (ADON) report it is the expectation the PASRR are accurate. She denied a policy or procedure directing to ensure PASRR accuracy. On 05/25/23 at 11:45 the Director of Nursing (DON) confirmed she expected the PASRR correct.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and facility record review the facility failed to follow proper infection prevention techniques with indwelling catheters for two of two residents reviewed (Residents #17 and #23). The facility reported a census of 62 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #17 as cognitively impaired with a Brief Interview for Mental Status (BIMS) of 7 out of 15 possible points. The MDS documented the resident had diagnoses to include renal insufficiency, neurogenic bladder and non-Alzheimer's dementia. It also identified the resident required extensive staff assistance with most activities of daily living and had an indwelling urinary catheter. On 8/16/22, the Care Plan identified Resident #17 with the problem of requiring a suprapubic urinary catheter related to neurogenic bladder. The Care Plan directed staff to not allow tubing or any part of the drainage system to touch the floor, store collection bag inside a protective, dignity pouch and use a catheter strap. Observations of Resident #17 included the following: On 5/22/23 at 11:41 AM, as resident sat in his wheelchair outside the main dining room, the Foley tubing was on the floor. On 5/23/23 at 9:38 AM, the resident asleep in bed and the urinary bag had not been placed in a dignity bag and the bottom of the bag touched the floor. On 5/23/23 at 9:47 AM, Staff A, CNA entered the resident room with the ADON (Assistant Director of Nursing). After Staff A pulled down the resident's pants, the resident did not have a thigh strap to prevent the tubing from being pulled. On 5/23/23 at 9:50 AM, after Staff A emptied the urinary bag, she clamped the spigot and placed the bag on the floor with the spigot side on the floor and proceeded to empty the graduate into the toilet. A review of a urine culture collected 2/9/22 revealed greater than 100,000 colony forming units of Proteus Mirabilis. The form included a new order to treat with Bactrim DS one tablet twice daily for seven days. 2. The MDS dated [DATE] identified Resident #23 as severely cognitively impaired with a BIMS of 5 out of 15 possible points. The MDS documented diagnoses to include traumatic subdural hemorrhage (stroke), osteoporosis and retention of urine. The MDS documented the resident required extensive staff assistance with dressing, toileting and totally dependent on staff for bathing. It also identified the resident with an indwelling catheter. On 10/14/22, the Care Plan identified Resident #23 with the problem she required an indwelling urinary catheter related to urinary retention and directed staff to position the bag below the level of the bladder, manipulate tubing as little as possible during care, use a catheter strap, and do not allow tubing or any part of the drainage system to touch the floor. Review of the residents clinical record revealed the following: On 3/8/23 at 1:15 PM the urinalysis revealed 3+ protein, 1+ ketones, 3+ blood and 4+ bacteria. Observations of Resident #23 revealed the following: On 5/23/23 at 6:30 AM asleep in bed with the foley (urinary drainage system) tubing on the floor. On 5/23/23 at 6:45 AM assessment unchanged. On 5/23/23 at 7:08 AM assessment unchanged with foley tubing on the floor. No staff observed in hall or near room. On 5/23/23 at 7:20 AM assessment unchanged with foley tubing on the floor. On 5/23/23 at 7:30 AM assessment unchanged with foley tubing on the floor. In an interview on 5/25/23 at 6:00 AM, Staff F, CNA reported before she leaves a resident with an indwelling catheter, she would make sure to never leave the bag or tubing on the floor. In an interview on 5/25/23 at 10:07 AM, Staff D, RN reported before she leaves a resident with an indwelling catheter, she would make sure make sure it's in place, should be in a dignity bag below bladder level. The tubing should be placed as much as you can in the dignity bag and should not be dragging on the floor. In an interview on 5/25/23 at 10:18 AM, Staff C, LPN reported before he leaves a resident with an indwelling catheter, make sure it's below bladder level, off the floor and in a privacy bag, make sure the tubing is not kinked. The tubing should not be on the floor. In an interview on 5/25/23 at 10:34 AM, Staff G , CNA reported before she leaves a resident with an indwelling catheter, she would make sure the bag is in the privacy bag. The catheter bag and tubing should not touch the floor. There should also be a thigh strap on the leg to keep it from pulling and verified Resident #17 did not have one. In an interview on 5/25/23 at 10:48 AM, Staff A, CNA reported before she leaves a resident with an indwelling catheter, she would make sure it's in the privacy bag and that there is a leg strap for the tube. The bag and tubing should not be touch the floor. In an interview on 5/25/23 at 1:48 PM, DON (Director of Nursing) reported before staff leave a resident with an indwelling catheter, she would expect staff to make sure the bag and tubing is not touching the floor and below bladder level. She would also expect drainage bag to be in a dignity bag. A review of the undated facility policy titled Catheter and Perineal Care for the Catheterized Resident documented it is the policy of the facility to conduct catheter and perineal care for catheterized resident in order to accomplish the following objectives: a. to prevent infections, b. to prevent inflammation and/or facilitate healing of reddened perineal area, c. to enhance the resident's comfort. The policy lacked interventions to direct the staff to prevent infections.

Based on clinical record review, observations, and staff interviews, the facility failed to provide oxygen according to the physician orders for 1 of 1 resident reviewed for respiratory services (Residents #4). The facility reported a census of 62 residents. Findings include: The Minimum Data Set (MDS) for Resident #4 dated 4/13/23 documented a Brief Interview for Mental Status (BIMS) score of 6 out of 15 possible points, indicating severely impaired cognition. The MDS identified Resident #4 required oxygen while a resident at the facility. The MDS documented diagnoses to include heart failure, hypertension, pulmonary fibrosis and dependence on supplemental oxygen (O2). The Care Plan revised on 4/19/23 documented Resident #4 to have oxygen as needed. The Care Plan directed staff to follow the doctor orders for liter flow and to provide assistance with the oxygen concentrator and portable oxygen tank. The Physician Order dated 3/2/2023 directed staff to administer oxygen at 2 liters per nasal cannula (NC) as needed for comfort. Review of resident vital sign records for oxygen saturation (oxygen level in the blood) revealed the following documentation: On 5/13/23 at 2:11 a.m.- O2 on at 3 liters. On 5/13/23 at 11:47 p.m.- O2 on at 3 liter. On 5/17/23 at 6:09 p.m- O2 on at 3 liters. On 5/20/23 at 3:35 p.m.- O2 on at 3 liters. On 5/21/23 at 7:06 p.m.- O2 on at 3 liters. On 5/23/23 at 10:20 a.m. observed the resident sitting in her room in a wheelchair with oxygen on at 4 liters per NC. On 5/24/23 at 7:29 a.m. observed the resident sitting in the dining room with oxygen on at 2.5 liters per NC. On 5/24/23 at 10:42 a.m., the Director of Nursing (DON) reported the facility does not have a oxygen policy. The DON reported oxygen was administered per physician orders. On 5/24/23 at 1:19 p.m., the DON stated she would expect staff to follow physician orders for oxygen administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS assessment for Resident #55 dated 5/11/23, documented diagnoses to include stroke and weakness. The MDS revealed Resident #55 scored a BIMS of 12 out of 15 possible points indicating moderate cognitive impairment. The MDS documented the resident required extensive assist of 2 staff for toileting and extensive assist of 1 staff for personal hygiene. The Care Plan for Resident #55 dated 8/2/22 documented she needs assistance with toileting due to impaired mobility from a stroke. The Care Plan listed a goal that she will be kept clean, dry and odor free. The Care Plan also identified the use of a diuretic medication related to fluid volume overload. On 5/22/23 at 1:05 PM, Resident # 55, stated she can wait sometimes for help. She pointed out she has a clock and knows how long it takes them. She revealed at times she can wait up 45 minutes for staff to help her. Review of the Device Activity Report for Resident # 55's room revealed the following: On 5/25/23 the call light on over 15 minutes and over 45 minutes. On 5/24/23 the call light on over 15 minutes 1 time. On 5/23/23 the call light on 2 times over 15 minutes. On 5/21/23 the call light on over 25 minutes. On 5/20/23 the call light on 2 times over 15 minutes. On 5/19/23 the call light on one time over 25 minutes. 3. The MDS assessment for Resident #25 dated 5/4/23, included diagnoses of edema. anemia, and cervical (neck) disc disorder. The MDS documented a BIMS of 15 out of 15 indicating intact cognition. The MDS revealed she needed extensive assist of 1 staff for bed mobility, transfers, dressing and toileting. The Care Plan for Resident #25 dated 8/24/22 documented the need for assistance with toileting due to impaired mobility from deconditioning and coordination deficit. The Care Plan listed a goal that she will be kept clean, dry and odor free. The Care Plan also identified the use of diuretic medication related to her edema (swelling). On 05/22/23 at 4:29 PM, Resident # 25 revealed she waited over an hour for the staff to come help her. She reported she ordered out food and they delivered the food before the staff answered her call light. Resident #25 stated she waits over 15 minutes almost daily. Review of the Device Activity Report for Resident # 25's room revealed the following: On 5/25/23 the call light on over 15 minutes three times. On 5/24/23 the call light on over 15 minutes one time. On 5/23/23 the call light on over 15 minutes six times. On 5/22/23 the call light on over 15 minutes three times In an interview on 5/25/23 at 1:30 PM, the Maintenance Supervisor reported when reading the device activity report which shows how long it took for staff to answer the call light, the rows that show the event locator showed alarm will show how long it took for the call light to be answered. In an interview on 5/25/23 at 7:32 AM, the Administrator reported the facility did not have a policy on call lights. Based on observations, clinical record review, resident and staff interviews, the facility failed to answer resident call lights in a timely manner for three of three residents reviewed (Residents #11, #25 and #55). The facility reported a census of 62 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #11 cognitively intact with a BIMS (brief interview for mental status) of 12 out of 15 possible points. The MDS documented diagnoses to inclue heart failure, paroxysmal atrial fibrillation and unspecified injury of muscles. The MDS documented the resident required limited assitance of one person for transfers, dressing, toileting and hygiene and did not walk. The MDS documented the resident was occasionally incontinent of urine. The Care Plan dated 11/28/21 identified the resident with the problem of being at risk for falls due to impaired cognition, impaired mobility, and right rotator cuff injury and directed staff on 9/10/22, to place a sign in the room to remind resident to use her call light for needs. On 5/22/23 at 10:32 AM, observed the resident up in her wheelchair in her room with a digital clock radio on her nightstand that is highly visible from her bed. She stated she's waited as long as an hour to get her call light answered and she wets her pants every night. She stated she wakes ep every morning soaking wet and is not happy about it. In an interview on 5/24/23 at 9:10 AM, Staff C, Licensed Practical Nurse reported staff are made aware when a resident turns on their call light because the call lights show up on screens. She stated there is one in each hallway and staff would know when call lights are on if they stand in front of a monitor. She stated the call lights are mot audible. In an interview on 5/24/23 at 9:11 AM, Staff D, Registered Nurse stated staff are made aware when a resident turns on their call light when the computer monitor on each hall will make a sound. She stated the staff should answer them within 10 minutes. In an interview on 5/25/23 at 6:00 AM, Staff F, Certified Nurse Aide (CNA), reported staff are made aware when a resident turns on their call light when the screen on a computer monitor makes a noise. She stated there is one screen per hallway and if the light shows up on the screen and it is red this means it is a bathroom light. She stated staff should answer call lights within 15 minutes. In an interview on 5/25/23 at 10:18 AM, Staff C, LPN reported staff should answer call lights within 5 minutes. In an interview on 5/25/23 at 10:34 AM, Staff G , CNA reported staff should answer call lights within 5 minutes. In an interview on 5/25/23 at 10:48 AM, Staff A, CNA reported staff should answer call lights within 3 minutes. In an interview on 5/25/23 at 1:48 PM, the Director of Nursing (DON) reported she would expect staff to answer call as soon as possible. She stated she would expect staff to make rounds hourly to check on the residents and check the monitors. A review of the Device Activity Report (which shows time frame it took for staff to answer call lights) revealed the following: On 5/21/23 at 2:47 PM call light answered after 17 minutes 44 seconds. On 5/21/23 at 6:28 AM call light answered after 47 minutes and 43 seconds. On 5/19/23 at 1:37 PM call light answered after 24 minutes and 43 seconds. On 5/18/23 at 6:17 PM call light answered after 25 minutes 23 seconds. On 5/17/23 at 12:00 AM call light answered after 43 minutes and 44 seconds. On 5/16/23 at 11:05 PM call light answered after 24 minutes and 14 seconds. On 5/15/23 at 9:05 PM call light answered after 21 minutes and 38 seconds. On 5/16/23 at 2:40 PM call light answered after 23 minutes and 29 seconds. On 5/16/23 at 9:11 AM call light answered after 24 minutes 46 seconds. On 5/16/23 at 2:09 AM call light answered after 47 minutes 44 seconds. On 5/15/23 at 2:55 PM call light answered after 45 minutes 38 seconds. On 5/14/23 at 8:52 AM call light answered after 22 minutes and 5 seconds. On 5/13/23 at 3:38 AM call light answered after 33 minutes and 34 seconds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and manufacturer's user recommendations, the facility failed to ensure wander guards (a monitoring bracelet with activated alarm when exiting) were monitored for placement and functioning for resident safety for 4 of 4 resident's reviewed (Resident #58, #28, #59, and #14) for wandering and risk for elopement. The facility also failed to assess 1 out of 4 residents (Resident #14) with the removal of a wander guard. The facility reported a census of 62. Findings include: 1. The Minimum Data Set Assessment (MDS) dated [DATE] for Resident #58 identified a Brief Interview for Mental Status (BIMS) score of 5 out of 15 indicating severely impaired cognition. The MDS identified Resident #58 had signs and symptoms of delirium with inattention and disorganized thinking with behavior present and fluctuates. The MDS identified the resident was independent with transfers and ambulation with no assistive devices. The MDS documented diagnoses that included Alzheimer's dementia, anxiety, and depression. The Care Plan revised 5/23/23 identified Resident #58 had a wander guard. The care plan lacked documentation on the location of the wander guard device. The care plan lacked direction on when and how often to check for placement and functioning. The Elopement Risk Assessments for the resident documented the following: On 12/9/22= 5. A score of 5 or greater indicated risk On 2/28/23= 5. On 5/23/23= 15. On 5/22/23 at 11:22 AM observed Resident #58 with a wander guard device to her left wrist. The resident stated she does not want to live at the facility and her daughter had dumped her at the facility. On 5/23/23 at 5:30 PM the Administrator reported a restorative aide checks the wander guards for placement and functioning daily. A review of the forms titled Daily Wandergard Check dated December 2022, January 2023, February 2023, March 2023, April 2023 and May 2023 lacked documentation the wandergard had been checked daily for Residents #58. On 5/24/23 at 9:30 AM the Director of Nursing (DON) reported the Restorative Aide checked the wander guards for placement and functioning. The DON stated when the Restorative Aide was off there was not another staff member assigned to check the wander guards. On 5/24/23 at 10:14 AM Staff E, the Restorative aide reported she checked the wander guards for placement and functioning when scheduled Monday through Friday. 2. The Minimum Data Set, dated [DATE] identified Resident #28 as cognitively impaired with a BIMS of 0 out of 15 possible points. The MDS documented diagnoses to include coronary artery disease, depression and repeated falls. The MDS documented he had a history of two falls without injury and two falls with minor injury. It identified the resident required limited staff assistance with dressing, toileting and personal hygiene and totally dependent on staff for baths. It also identified the resident with a wander/elopement alarm used daily. On 5/24/23 at 2:36 PM observed the resident standing by the exit door by the private dining room off South hall. He pushed on the safety bar of the door which triggered the alarm to sound as he had on a wandergard bracelet. Staff C, Licensed Practical Nurse (LPN), re-directed the resident away from the door and walked with him to sit on the sofa at the end of the hall. The resident then began to ambulate down the hall using his wheeled walker with steady gait with a Certified Nursing Assistant (CNA) walking beside him. On 11/15/22 the Care Plan identified the resident with the problem of being at risk for falls and on 11/16/22 the intervention of a wandergard placed on the resident had been added. It did not direct the staff to document checks on the wandergard daily. 3. The MDS dated [DATE] identified Resident #59 as cognitively impaired with a BIMS score of 3 out of 15 possible points. The MDS documented the following diagnoses to include atrial fibrillation (an abnormal heart rhythm), coronary artery disease and heart failure. The MDS identified the resident required staff supervision only with dressing and personal hygiene and required extensive staff assist with bathing. It also identified the resident with a wander/elopement alarm used daily. On 5/23/23 at 6:59 AM observed the resident ambulated independently from her table to the next table without using her walker. Staff D, Registered Nurse (RN) reminded the resident to use her walker when she walked. The resident wore a wandergard bracelet to her right wrist. Observed the resident to return to sit in a dining room chair. On 3/30/23 the Care Plan identified the resident with the problem of history of wandering in the hallways and will exit seek. The Care Plan did not direct the staff to document checks on the wandergard daily. A review of the forms titled Daily Wandergard Check dated December 2022, January 2023, February 2023, March 2023, April 2023 and May 2023 lacked documentation the wandergard had been checked daily for Residents #28 and #59. In an interview on 5/25/23 at 10:07 AM, Staff D, RN reported the Restorative Aide checks the wandergards daily. She brings a wrist bracelet to check the exit doors and will check each of the residents who have a wandergard. In an interview on 5/25/23 at 10:18 AM, Staff C, LPN reported once a day, the Restorative Nurse checks every morning the wandergard alarms daily. She will check all the exit doors with a wrist bracelet wandergard and open the door and checks batteries in the resident's bracelets. In an interview on 5/25/23 at 10:34 AM, Staff G , CNA reported the Restorative Aide checks wandergards every day. She will test the door to make sure the alarm works. She also check the resident's bracelet to make sure the batteries are working. 4. The MDS Assessment for Resident #14 dated 2/23/23, documented diagnoses that included Alzheimer's dementia and heart failure. The MDS included a BIMS score of 8 out of 15 possible points indicating moderately impaired cognition. The MDS documented the resident as independent for transfers and set up with ambulation. The Care Plan dated 3/3/23, revealed Resident #14 verbally expressed her intent to leave the facility unsupervised. The goal documented the resident will not exit seek. The Care Plan directed staff to equip the resident with a device that alarms when wanders and to provide reassurance and redirection when the resident experiences paranoia or other symptom/reason that may be causing exit seeking behavior. The Elopement Risk assessment dated [DATE], revealed Resident #14 may be at risk of elopement. The Elopement Risk assessment dated [DATE], revealed the resident may be at risk of elopement. The Elopement Risk assessment dated [DATE] for the resident is incomplete. A review of the forms titled Daily Wandergard Check dated February 2023, March 2023, and April 2023 lacked documentation the wandergard had been checked daily for Resident #14. On 5/24/23 at 9:10 AM, Staff H, CNA reported Resident #14 wandered all over the place and does go outside to sit in the locked area. Staff H, reported Resident #14 wore a wander guard and the Restorative Nurse checked it first thing in the mornings. Staff H, revealed she is unaware who checks the wander guards on the weekends. On 5/25/23 at 11:40 AM, the DON confirmed at the time the facility discontinued Resident #14's wander guard she didn't expect the facility to complete an assessment. The DON revealed now she expected an assessment done before the removal of a wander guard. The undated wander guard manufacturer's user manual directed the facility to test the wander guard bracelets daily and to record the test results in the resident's records. The user guide further documented that it was important to test the wander guard bracelet before putting it into use and daily thereafter. The user guide documented failure to do so could result in injury or death. The undated facility policy titled Missing Resident Policy lacked documentation regarding the Wanderguard system. On 5/24/23 at 10:25 AM, the Administrator and DON acknowledged the manufacturer's user manual recommendations and verified the wander guards were not checked daily and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interviews, the facility failed to follow facility processes and state rules related to an Involuntary Discharge for one of three residents reviewed (Resident #6). The facility reported a census of 57 residents. Findings Include: The Minimum Data Set assessment dated [DATE] identified Resident #6 as severely cognitively impaired and unable to complete a Brief Interview for Mental Status (BIMS) test. It also identified her with the following diagnoses: Alzheimer's Disease, mood disorder and repeated falls and totally dependent on staff for toileting, personal hygiene and bathing. A review of the Care Plan identified the resident on 3/5/21 with the problem of needing long term nursing care with the following interventions: Per resident representative request, only ask the resident about his/her desire to return to the community, as well as making referrals to local contact agencies during comprehensive assessments, encourage verbalizations of fears and concerns with care. Provide reassurance when necessary and arrange for quarterly care conference with resident and family. Allow resident to make independent choices as able. A review of the Nurse's Notes revealed the following: a. On 5/29/22 at 9:41 PM, this aggressive resident had been observed in person by Unit Certified Nurse Aide's (CNA) and on cameras present in unit wrapping hands around anterior neck of another resident. This incident was unprovoked by other resident. Aggressive resident was removed from situation and redirected. This writer did not observe this incident in person. b. On 5/31/22 at 11:36 AM, called placed to resident's family member with the Director of Nursing (DON) , Assistant Director of Nursing (ADON), Social Worker and Administrator to inform of facilities' inability to provide placement for the resident based on notes from the hospital on restraints and requirements for one on one care. c. On 5/31/22 at 2:52 PM, Involuntary Discharge Notice issued to the resident and her representative via certified mail. A review of the proposed decision by the Iowa Department of Inspections and Appeals Division of Administrative Hearings regarding the Basis for Involuntary discharge: Continuing Threat to Welfare of Other Residents and Staff, the title implies the Administrative Law Judge (ALJ) did not find Resident #6's physical aggression towards residents and staff justified an Involuntary Discharge. However, reading the paragraph it appears the ALJ is ruling that she found the facility failed to follow the Involuntary Discharge requirements and that Resident #6's continuing threat to the welfare of others is time and fact sensitive and based on the type of discharge issued by the facility. Other than the headline, the ALJ did not rule on whether or not Resident #6's behaviors were a continuing threat to the welfare of other residents and staff. Because finding number one's title is misleading and findings two through four better explain the issues with the discharge, the first finding is not adopted. 11/14/22 8:20 AM interview, the resident's family member reported the state ALJ had already made a decision regarding the Involuntary Discharge and provided documentation as such. In an interview on 11/29/22 at 11:22 AM, the Social Worker reported a. The process when issuing an Involuntary Discharge would be notify the family usually, not sure what the time frame is to issue it. b. Resident #6 had been discharged from the facility because she had an altercation with a male resident in the Memory Care Unit. Her daughter did not agree with our choice to do so. We felt the other residents were at a significant risk for injury. c. We issued the notice about her discharge the day she left here before she went to the hospital. d. The reason she had not been allowed to return to the facility from the hospital had been due to her aggressive behaviors with other residents. She had strangled another male resident. In an interview on 11/29/22 at 12:13 PM, the DON reported she had been unsure of the process when issuing an Involuntary Discharge. When asked about the discharge for Resident #6, she reported the resident had aggressive behaviors and sent out to the hospital. The DON had been off on medical leave when the resident had been discharged .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Minimum Data Set (MDS) Assessment identified Resident #9 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 upon admission on [DATE] and Then re-scored at 12 on 10/18/22. Diagnoses included: A left hip surgical repair (patient had fallen and fractured left hip July 22), Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), chronic Atrial Fibrillation and Premature Ventricular Contractions (both irregular heartbeats), Benign Prostrate Hypertrophy with urinary obstruction and had required a suprapubic catheter placement due to urinary retention, a history of colon/rectal cancer had led to surgery and the placement of a colostomy (for bowel) 2015. The admission MDS identified Resident #9's skin conditions as a surgical wound (left hip) and moisture associated skin damage (MASD) of the coccyx area. The Care Plan dated as last revised 8/11/22 stated Resident #9 had needed staff assistance with management of the bowel colostomy to include assistance with emptying the colostomy bag, monitor the stoma and surrounding area and to notify the physician with concerns. The resident Care Plan lacked being updated to include colostomy stoma skin issues, resident pain incurred during colostomy bag changes, and lacked updating the changed process of colostomy stoma wafer, bag changes and Provider ordered colostomy products to be used. A review of the facility Progress Notes documented the following: a. On 9/15/22 at 6:31 PM, Staff X, Registered Nurse (RN) documented Resident #9's stoma site with excoriation and bleeding and a fax had been sent to the residents' Provider. b. The next colostomy/stoma documentation on 9/20/22 at 2:16 PM, stated the Physician had ordered for Resident #9 to have an evaluation of colostomy for fit. c. The MDS Coordinator documented on 9/23/22 at 11:43 AM, a clarification for colostomy bag change to have been every 3 days. d. On 9/24/22 at 3:07 PM, documentation indicated 50% of the stoma site had been excoriated and bleeding. e. On 9/26/22 at 8:15 PM, documentation showed the colostomy bag was leaking, and the skin surrounding the stoma had been open and excoriated. f. Staff N, RN documented on 9/26/22 at 9:59 PM, that a fax received from Resident #9's Provider directed to use Stoma Powder and a Wound Clinic or Ostomy Nurse needed to be contacted for colostomy treatment and recommendations; information had been left for the facility DON. The facility Progress Notes showed further documentation of the colostomy stoma/skin excoriation, bleeding, and leaking colostomy bag issues had been documented as follows: a. On 9/28/22 by the consulting Pharmacist, 9/29/22 by Nursing Staff. b. On 10/7/22 a provider fax received for referral to the Wound Clinic for colostomy skin issues. c. On 10/10/22 a Wound Nurse called by a facility staff nurse and a voice message left. d. On 10/11/22 colostomy stoma excoriated and painful when leaking colostomy bag changed. e. On 10/12/22 Resident #9 admitted to Hospice service. f. On 10/18/22 documentation reported the colostomy bag change had been painful; stoma and surrounding skin excoriated, with no new treatment orders. g. On 10/19 the colostomy bag had leaked. h. On 10/22/22 the colostomy bag had leaked. i. On 10/26 the consulting Pharmacist documented there had been problems with excoriated skin around the stoma and the leaking of the colostomy bag. j. On 10/30/22 the facility obtained non-alcohol-based products from Hospice to use during colostomy bag change. k. Documentation on 11/4/22 shown Resident #9 experienced pain with colostomy bag change and the change of bag needed due to leaking. l. On 11/5/22 the facility documented the Hospice Nurse obtained a new order for Resident #9 to have oral morphine sulfate (narcotic pain medication) prior to colostomy bag changes. m. On 11/10/22 the facility Assistant Director of Nursing (ADON) documented Resident #9 had excoriation around the stoma and had discussed with the Hospice nurse. n. On 11/15/22 facility Staff N had documented Resident #9 had experienced pain during the colostomy bag change, had been pre-medicated prior to bag change, had excoriated skin, colostomy bag had been changed due to leaking. Review of Hospice Care documentation showed Resident #9: a. admitted to Hospice services 10/12/22. admission orders had included Hospice would supply colostomy supplies. b. Hospice staff had documented on 10/24/22 Resident #9 had pain with colostomy bag change, edge of colostomy stoma excoriated and open, new barrier creams and spray adhesive applied with colostomy bag change. c. On 10/27/22 Hospice staff had documented the facility staff had verbalized that overnight; the colostomy bag had leaked, therefore changed, and resident had pain with colostomy bag change. d. On 10/31/22 the Hospice staffs had documented Resident #9 had pain with colostomy bag change and had also documented on 10/31/22 the facility DON had been contacted by text; due to Hospice staffs not having access to the facility Electronic Health Records. e. Hospice staff documented on 11/4/22 that facility staff had reported Resident #9 had pain with colostomy bag change and had requested the Hospice staff contact Provider for pain medication pre-colostomy bag change. f. On 11/5/22 the Hospice staff had documented an order for liquid pain medication had been obtained from Resident #9 provider. g. On 11/10/22 the Hospice staff documented resident's colostomy bag leaked overnight, had been changed and the resident had pain. h. The Hospice staff documented on 11/14/22 that Resident #9's colostomy bag had been changed four times overnight due to leaking, Hospice staff changed the colostomy bag again on 11/14/22 (Fifth time) due to bag having leaked, and the stoma/skin documented as red, excoriated, and bleeding. i. On 11/17/22 Hospice staff documented the colostomy stoma/skin continued to be red, excoriated, and bleeding. j. On 11/19/22 the Hospice staff documented being contacted by facility staff that resident needed the colostomy bag change overnight due to the bag leaking, resident had been pre-medicated, and Resident #9 verbalized pain with procedure and medication had not helped to relieve pain. Review of the Provider Orders Charted the following: a. On 8/2/2022 the Provider ordered Tylenol 500 mg, and Resident #9 could take two up to three times a day as needed. b. On 9/27/22 the Provider ordered Stomahesive Powder, apply as ordered and then discontinued it on 10/28/22. c. On 10/07/22 the resident's Provider ordered for Resident #9 to have a referral for colostomy evaluation by a Wound Nurse or Ostomy Nurse. The facility documented a voice message left for an Ostomy Nurse on 10/10/22. d. On 10/28/22 to 11/2/22, the Provider ordered for Stomahesive Powder to be applied to gauze and then patted onto the stoma site as directed. e. On 11/2/2022 the Provider ordered for Stomahesive Powder and then Stomahesive Spray to be used. Directions had been provided for the colostomy change process. f. The Provider had ordered on 11/5/22 and then discontinued on 11/9/22 a medication order for Morphine Concentrate Solution administer 0.25 milliliters orally as needed for pain every four hours. g. Resident #9's Provider ordered on 11/9/22 and discontinued 11/21/22 for pain control medication, Morphine Concentrate Solution dose had remained the same; 0.25 milliliters, but now every 2 hours as needed for pain (Colostomy pouch changes, suprapubic catheter changes, or shortness of breath). h. On 11/21/22, Resident #9's Provider increased the Morphine Sulfate Concentration Solution to 0.5 milliliters as needed every two hours for pain. Review of Resident #9 Electronic Medication Administration Records (EMAR) had shown the following: a. The October 2022 EMAR had shown Resident #9 had been administered Tylenol 1000 milligrams a total of three times for leg pain. Review of the residents November 2022 EMAR shown the resident had been administered the pain medication Morphine Concentrate Solution a total of zero times between 11/5/22 and 11/9/22. Further review of the pain medication administration EMAR shown for November 2022 from 11/9/22 forward there had been a total of six times the resident had been administered the as needed every two hours medication. Review of the November 2022 EMAR showed the dates of administration as: 11/11, 11/15, 11/18, 11/19, 11/22 and 11/23/22. Further review shown Resident #9 had not been administered Tylenol during the month of November 2022. Review of the Narcotic Administration Record shown pain medication administration had been a total of seven times on the dates: 11/11, 11/14, 11/16, 11/18, 11/19, 11/22 and 11/23/22. In an interview on 11/28/22 at 8:50 AM, the Hospice Nurse revealed the documented facility colostomy bag changes and the number of bags provided by the Hospice Nurse had not been equal. The Hospice Nurse stated keeping the facility supplied with ostomy supplies had been challenging due to the facility Treatment Assessment Record not being completed with every colostomy bag change, therefore to reconcile the number of colostomy bag changes completed had not been achievable. The Hospice Nurse further stated the resident had not been medicated pre-colostomy change procedure as ordered. The Hospice Nurse requested a phone call be made to a daughter-in-law (by Hospice) to obtain information for a stoma spray that had been used in the past successfully by the resident. The Hospice Nurse stated the adhesive spray product had then been supplied by Hospice. In an interview on 11/28/22 at 1:18 PM, the facility Pharmacist, reported no communication between the Pharmacist and the facility DON, facility staff, or Hospice staff regarding the Stomahesive Spray. The Pharmacist stated a product called Stomahesive spray did not exist to purchase, and no product sent to the care facility. The Pharmacist further stated the facility DON entered the order on the EMAR. The Pharmacist stated a voice activated message from the Provider received and the facility had not asked the Pharmacy to clarify with the Provider. During an interview with the DON on 11/29/22 at 1:41 PM, the subject of Care Plans and updating resident need changes discussed. The DON stated the resident admitted to Hospice 10/12/22 and then Hospice should have completed the updates on the Care Plans. When asked about Skin Sheets, the DON stated the nurse who assessed a skin discrepancy was expected to initiate a Skin Sheet. When asked about the resident order for an Ostomy or Wound Nurse to evaluate the stoma skin and colostomy bag attachment issues, the DON stated the Hospice Nurse was to evaluate. The DON when asked about assessment of resident pain, stated the facility had not completed pain sheets daily or by shifts. The DON further stated the resident pain is documented on the EMAR if pain medication had been administered. On 11/29/22 at 3:56 PM an interview was completed with Staff N, RN who stated she had asked the DON to set up a resident colostomy evaluation early October 2022. Staff N further stated during the facility third shift (Staff N worked) that calling for a consult had not been possible. Staff N stated the facility Administration and the DON had not initiated a colostomy evaluation for the resident. Staff N unaware if Resident #9 had a Skin Sheet for the colostomy stoma. Staff N explained the facility Treatment Administration Record (TAR) had not included an area to document as needed colostomy bag changes. Staff N knew Hospice supplied the stoma adhesive spray. When asked about pain documentation, Staff N stated the documentation would have been written within the Progress Notes or if pain medication had been administered then the EMAR would have had a pain number documented pre and post pain medication administration. Based on observation, record review and staff interview, the facility failed to update Care Plans for two of three residents reviewed (Resident #2 and #9). The facility reported a census of 57 residents. Findings Include: A review of the Minimum Data Set, dated [DATE] identified Resident #2 as severely cognitively impaired and unable to complete the Brief Interview for Mental Status (BIMS). It also identified her with the following diagnoses: Alzheimer's Disease and seizure disorder and required extensive staff assistance with toileting, dressing and hygiene and completely dependent on staff for bathing. It also identified she had problems with inattention and disorganized thinking on a continual basis without fluctuation. A review of the Incident Report dated 8/27/22 revealed a description of an incident where a male resident (Resident #1) fondled the chest of a female resident (Resident #2) in her room, the resident was fully dressed and incident lasted approximately one to two minutes. A review of the statement provided by the Director of Nursing (DON) revealed the following: a. On 8/27/22 she had been notified by Staff J, Licensed Practical Nurse (LPN) about an incident where resident Resident #1 found fondling the breast of Resident #2. This had been initially reported by Staff T, Housekeeper who had been in Resident #2's bathroom changing out the paper towels and witnessed Resident #1 caressing Resident #2's breast. A Certified Nurse Aide (CNA) had been called in immediately and removed Resident #1 from the room. A self report was initiated with Department of Inspections & Appeals (DIA) at the time of notification by the DON. Care Plans updated and staff notified of treatment plan for Resident #1. A review of the Care Plan dated as last reviewed 11/15/22 did not include new interventions to address the above incident on Resident #2's Care Plan. A review of the Nurse's Notes revealed the following entries: a. On 8/27/22 at 2:30 PM, resident resting in her recliner. No signs/symptoms of distress related to the groping incident. b. On 8/29/22 at 1:30 AM, no concerns with resident related to the inappropriate touching event. Observations of the resident revealed the following: a. On 11/2/22 at 1:06 PM, sitting up in dining room chair, wearing clean clothing and non-skid shoes. Resident #1 sat at another table and did not have any interactions with her. b. On 11/2/22 at 1:31 PM Staff C, CNA held resident's hand and assisted her to walk to her room, Resident #1 not in the hallway. c. On 11/2/22 at 2:01 PM, resident currently sitting in her recliner in her room, Resident #1 not in the hallway or in her room. d. On 11/3/22 at 8:30 AM, sitting up in dining room chair with both feet resting on the floor, Resident #1 not in the hallway or in her room. c. On 11/3/22 at 10:34 AM, ambulating in hallway with steady gait with her son holding her left hand and her daughter-in-law holding her right hand. Resident #1 not in the hallway. d. On 11/3/22 at 1:39 PM, sitting up in her recliner Resident #1 not in the hallway or in her room. e. On 11/9/22 at 7:30 AM, Sitting in main dining room (MDR) chair Resident #1 sat at another table without interacting with her. f. On 11/9/22 at 8:43 AM, Staff E, CNA held back of the gait belt around the resident's waist as resident ambulated without devices from the MDR in the hallway to her room. Resident #1 not in the hallway or in her room. g. On 11/9/22 at 9:40 AM sitting up in recliner in her room, Resident #1 not in the hallway or in her room. In an interview on 11/9/22 at 8:20 AM, Staff T, Housekeeper reported she had witnessed Resident #1 fondle Resident #2's breast in August 2022 and that he had a history of being inappropriate behavior with females. In an interview on 11/14/22 at 1:04 PM, Staff J, LPN reported an incident that involved Resident #1 fondled Resident #2's breast, that Resident #1 had a history of inappropriate behavior to females, after the incident they had been immediately separated. Staff J reported he would expect that to be addressed on Resident #2's Care Plan and that the Care Plans in the rooms did not address inappropriate behaviors and interventions. In an interview on 11/14/22 at 10:29 AM interview with Staff V, CNA reported in August 2022, she witnessed Resident #1 touching Resident #2's breast and that she had no idea what had been care planned for Resident #2 if the incident occurred again. She also reported there are care plans in the room, but they don't address behaviors. In an interview on 11/29/22 at 10:46 AM, Staff D, LPN reported she could not verify the exact date when the above incident occurred, but it had been more than a few months ago. She also reported the MDS Coordinator had been responsible for updating Care Plans which should occur with any changes and that after the above incident, typical interventions that should have been added to the care plan include: Separate them immediately if it happened, report it to the nurse, the nurse would assess the resident In an interview on 11/29/22 at 11:02 AM, Staff Y, Registered Nurse (RN) reported Care Plans should be updated when there are any changes at all in their mentation, medical condition, etc. She thought the MDS Coordinator with help from the DON and the Assistant Director of Nursing (ADON). She also reported the MDS Coordinator had been working the floor a lot. In an interview on 11/29/22 at 12:13 PM, the DON reported the following: a. When asked when she would expect Care Plans to be updated, it would depend on the situation, but with changes on the resident's condition. When the changes are made, these are can be found in the computer. The CNAs have access to the computers to look at the plans. Every room has a Care Sign posted for all staff, how they transfer, assistive devices, etc. b. The MDS coordinator is responsible for updating the care plans. The DON and ADON can also update. c. The incident between Resident #1 and #2 occurred in August 2022. d. Interventions she would expect to be added to Resident #2's care plan after that incident would include: separate the two residents, provide emotional support, continue to monitor, report it to the Charge Nurse who would then complete an incident report e. When asked to explain why Resident #2's Care Plan had not been updated, she reported she updated Resident #1's Care Plan, but did not think to update Resident #2's care plan. Upon request for a policy on Care Plans, the Administrator reported the facility did not have one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Minimum Data Set (MDS) Assessment identified Resident #9 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 upon admission 8/2/22 and then rescored a 12 on 10/18/22. Diagnoses included: A left hip surgical repair (patient had fallen and fractured left hip July 22), Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), chronic Atrial Fibrillation and Premature Ventricular Contractions (both irregular heartbeats), Benign Prostrate Hypertrophy with urinary obstruction and had required a suprapubic catheter placement due to urinary retention, a history of colon/rectal cancer had led to surgery and the placement of a colostomy (for bowel) 2015. The admission MDS identified Resident #9's skin conditions as a surgical wound (left hip) and moisture associated skin damage (MASD) of the coccyx area. The Care Plan dated as last revised 8/11/22 stated Resident #9 had needed staff assistance with management of the bowel colostomy to include assistance with emptying the colostomy bag, monitor the stoma and surrounding area and to notify the physician with concerns. The resident's Care Plan lacked being updated to include colostomy stoma skin issues, resident pain incurred during colostomy bag changes, and lacked updating the changed process of colostomy stoma wafer, bag changes and Provider ordered colostomy products to be used. A review of the facility Progress Notes documented the following: a. On 9/15/22 at 6:31 PM, Staff X, Registered Nurse (RN) documented Resident #9's stoma site with excoriation and bleeding and a fax had been sent to the residents' Provider. b. The next colostomy/stoma documentation on 9/20/22 at 2:16 PM, stated the Physician had ordered for Resident #9 to have an evaluation of colostomy for fit. c. The MDS Coordinator documented on 9/23/22 at 11:43 AM, a clarification for colostomy bag change to have been every 3 days. d. On 9/24/22 at 3:07 PM, documentation indicated 50% of the stoma site had been excoriated and bleeding. e. On 9/26/22 at 8:15 PM, documentation showed the colostomy bag was leaking, and the skin surrounding the stoma had been open and excoriated. f. Staff N, RN documented on 9/26/22 at 9:59 PM, that a fax received from Resident #9's Provider directed to use Stoma Powder and a Wound Clinic or Ostomy Nurse needed to be contacted for colostomy treatment and recommendations; information had been left for the facility DON. The facility Progress Notes showed further documentation of the colostomy stoma/skin excoriation, bleeding, and leaking colostomy bag issues had been documented as follows: a. On 9/28/22 by the consulting Pharmacist, 9/29/22 by Nursing Staff. b. On 10/7/22 a provider fax received for referral to the Wound Clinic for colostomy skin issues. c. On 10/10/22 a Wound Nurse called by a facility staff nurse and a voice message left. d. On 10/11/22 colostomy stoma excoriated and painful when leaking colostomy bag changed. e. On 10/12/22 Resident #9 admitted to Hospice service. f. On 10/18/22 documentation reported the colostomy bag change had been painful; stoma and surrounding skin excoriated, with no new treatment orders. g. On 10/19 the colostomy bag had leaked. h. On 10/22/22 the colostomy bag had leaked. i. On 10/26 the consulting Pharmacist documented there had been problems with excoriated skin around the stoma and the leaking of the colostomy bag. j. On 10/30/22 the facility obtained non-alcohol-based products from Hospice to use during colostomy bag change. k. Documentation on 11/4/22 shown Resident #9 experienced pain with colostomy bag change and the change of bag needed due to leaking. l. On 11/5/22 the facility documented the Hospice Nurse obtained a new order for Resident #9 to have oral morphine sulfate (narcotic pain medication) prior to colostomy bag changes. m. On 11/10/22 the facility Assistant Director of Nursing (ADON) documented Resident #9 had excoriation around the stoma and had discussed with the Hospice nurse. n. On 11/15/22 facility Staff N had documented Resident #9 had experienced pain during the colostomy bag change, had been pre-medicated prior to bag change, had excoriated skin, colostomy bag had been changed due to leaking. Review of Hospice Care documentation showed Resident #9: a. admitted to Hospice services 10/12/22. admission orders had included Hospice would supply colostomy supplies. b. Hospice staff had documented on 10/24/22 Resident #9 had pain with colostomy bag change, edge of colostomy stoma excoriated and open, new barrier creams and spray adhesive applied with colostomy bag change. c. On 10/27/22 Hospice staff had documented the facility staff had verbalized that overnight; the colostomy bag had leaked, therefore changed, and resident had pain with colostomy bag change. d. On 10/31/22 the Hospice staffs had documented Resident #9 had pain with colostomy bag change and had also documented on 10/31/22 the facility DON had been contacted by text; due to Hospice staffs not having access to the facility Electronic Health Records. e. Hospice staff documented on 11/4/22 that facility staff had reported Resident #9 had pain with colostomy bag change and had requested the Hospice staff contact Provider for pain medication pre-colostomy bag change. f. On 11/5/22 the Hospice staff had documented an order for liquid pain medication had been obtained from Resident #9 provider. g. On 11/10/22 the Hospice staff documented resident's colostomy bag leaked overnight, had been changed and the resident had pain. h. The Hospice staff documented on 11/14/22 that Resident #9's colostomy bag had been changed four times overnight due to leaking, Hospice staff changed the colostomy bag again on 11/14/22 (Fifth time) due to bag having leaked, and the stoma/skin documented as red, excoriated, and bleeding. i. On 11/17/22 Hospice staff documented the colostomy stoma/skin continued to be red, excoriated, and bleeding. j. On 11/19/22 the Hospice staff documented being contacted by facility staff that resident needed the colostomy bag change overnight due to the bag leaking, resident had been pre-medicated, and Resident #9 verbalized pain with procedure and medication had not helped to relieve pain. Review of the Provider Orders Charted the following: a. On 8/2/2022 the Provider ordered Tylenol 500 mg, and Resident #9 could take two up to three times a day as needed. b. On 9/27/22 the Provider ordered Stomahesive Powder, apply as ordered and then discontinued it on 10/28/22. c. On 10/07/22 the resident's Provider ordered for Resident #9 to have a referral for colostomy evaluation by a Wound Nurse or Ostomy Nurse. The facility documented a voice message left for an Ostomy Nurse on 10/10/22. d. On 10/28/22 to 11/2/22, the Provider ordered for Stomahesive Powder to be applied to gauze and then patted onto the stoma site as directed. e. On 11/2/2022 the Provider ordered for Stomahesive Powder and then Stomahesive Spray to be used. Directions had been provided for the colostomy change process. f. The Provider had ordered on 11/5/22 and then discontinued on 11/9/22 a medication order for Morphine Concentrate Solution administer 0.25 milliliters orally as needed for pain every four hours. g. Resident #9's Provider ordered on 11/9/22 and discontinued 11/21/22 for pain control medication, Morphine Concentrate Solution dose had remained the same; 0.25 milliliters, but now every 2 hours as needed for pain (Colostomy pouch changes, suprapubic catheter changes, or shortness of breath). h. On 11/21/22, Resident #9's Provider increased the Morphine Sulfate Concentration Solution to 0.5 milliliters as needed every two hours for pain. Review of Resident #9 Electronic Medication Administration Records (EMAR) had shown the following: a. The October 2022 EMAR shown Resident #9 administered Tylenol 1000 milligrams a total of three times for leg pain. Review of the resident's November 2022 EMAR shown the resident administered the pain medication Morphine Concentrate Solution a total of zero times between 11/5/22 and 11/9/22. Further review of the pain medication administration EMAR shown for November 2022 from 11/9/22 forward a total of six times the resident administered the as needed every two hours medication. Review of the November 2022 EMAR showed the dates of administration as: 11/11, 11/15, 11/18, 11/19, 11/22 and 11/23/22. Further review shown Resident #9 had not been administered Tylenol during the month of November 2022. Review of the Narcotic Administration Record shown pain medication administration had been a total of seven times on the dates: 11/11, 11/14, 11/16, 11/18, 11/19, 11/22 and 11/23/22. In an interview on 11/28/22 at 8:50 AM, the Hospice Nurse revealed the documented facility colostomy bag changes and the number of bags provided by the Hospice Nurse had not been equal. The Hospice Nurse stated keeping the facility supplied with ostomy supplies had been challenging due to the facility Treatment Assessment Record not being completed with every colostomy bag change, therefore to reconcile the number of colostomy bag changes completed had not been achievable. The Hospice Nurse further stated the resident had not been medicated pre-colostomy change procedure as ordered. The Hospice Nurse requested a phone call be made to a daughter-in-law (by Hospice) to obtain information for a stoma spray that had been used in the past successfully by the resident. The Hospice Nurse stated the adhesive spray product had then been supplied by Hospice. In an interview on 11/28/22 at 1:18 PM, the facility Pharmacist, reported no communication between the Pharmacist and the facility DON, facility staff, or Hospice staff regarding the Stomahesive Spray. The Pharmacist stated a product called Stomahesive spray did not exist to purchase, and no product sent to the care facility. The Pharmacist further stated the facility DON entered the order on the EMAR. The Pharmacist stated a voice activated message from the Provider received and the facility had not asked the Pharmacy to clarify with the Provider. During an interview with the DON on 11/29/22 at 1:41 PM, the subject of Care Plans and updating resident need changes discussed. The DON stated the resident admitted to Hospice 10/12/22 and then Hospice should have completed the updates on the Care Plans. When asked about Skin Sheets, the DON stated the nurse who assessed a skin discrepancy was expected to initiate a Skin Sheet. When asked about the resident order for an Ostomy or Wound Nurse to evaluate the stoma skin and colostomy bag attachment issues, the DON stated the Hospice Nurse was to evaluate. The DON when asked about assessment of resident pain, stated the facility had not completed pain sheets daily or by shifts. The DON further stated the resident pain is documented on the EMAR if pain medication had been administered. On 11/29/22 at 3:56 PM an interview was completed with Staff N, RN who stated she had asked the DON to set up a resident colostomy evaluation early October 2022. Staff N further stated during the facility third shift (Staff N worked) that calling for a consult had not been possible. Staff N stated the facility Administration and the DON had not initiated a colostomy evaluation for the resident. Staff N unaware if Resident #9 had a Skin Sheet for the colostomy stoma. Staff N explained the facility Treatment Administration Record (TAR) had not included an area to document as needed colostomy bag changes. Staff N knew Hospice supplied the stoma adhesive spray. When asked about pain documentation, Staff N stated the documentation would have been written within the Progress Notes or if pain medication had been administered then the EMAR would have had a pain number documented pre and post pain medication administration. Based on observation, record review and staff interviews, the facility failed to follow physician orders for two of three residents reviewed (Residents #8 and #9). The facility reported a census of 57 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #8 as moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 11 out of 15 and with the following diagnoses: heart failure, peripheral vascular disease and diabetes mellitus. The MDS also identified the resident as independent with most activities of daily living except bathing which she required extensive staff assist with. The Care Plan identified the resident with the problem of potential for skin breakdown on 6/20/22 due to peripheral vascular disease. Interventions included: 10/5/22 tubigrips to both legs, high-low bed with pressure reduction mattress and half rail to inner side of bed and grab bar to outside of bed. to help with repositioning, check her skin with cares & bathing. She needs assist with repositioning. On 11/15/22 at 8:47 AM, attempted to complete an observation of the resident in the dining room, Staff Y, Registered Nurse (RN) reported the resident is currently in the hospital and had problems with her toe and being diabetic. In an observation on 11/21/22 at 8:00 AM, the resident asleep in bed lying on right side with two one half side rails up. Dressing dry and intact to right foot. Call light in reach. Bed alarm in place and activated. Properly positioned and appears comfortable. A review of the Progress Notes revealed the following: a. On 10/25/22 at 2:25 PM, resident has an area on the right great toe with scabbed areas on the right 2nd and 5th toes. Recently took antibiotic to treat cellulitis to the right foot b. On 11/04/22 at 12:18 PM, area to right second toe resolved. New order to discontinue treatment. c. On 11/11/22 at 1:39 PM, right foot swollen, red and warm to touch. Odor coming from area to right fifth toe. Call placed to doctor to notify of changes to foot. Order to send to emergency room (ER) for evaluation. d. On 11/11/22 at 6:09 PM, this nurse received call from resident's family to notify the facility of resident being admitted to hospital for infection in fifth toe of right foot. e. On 11/14/22 at 10:06 AM, spoke with resident's family who informed that the resident's Orthopedic Doctor recommended amputation of the right small toe. Tentative plan for surgery is tomorrow. f. On 11/18/22 at 7:51 PM, resident admitted right 5th toe amputee, refused to have dressing changed as she said they just changed it at the hospital earlier that day. A review of the Physician Orders and November Treatment Administration Record (TAR) revealed an order dated 6/20/22 - Menarin cream apply to legs and feet daily (scheduled for 2nd shift) No doses signed out to show the treatments had been completed. A review of the Hospital Wound Nurse Assessment note dated 11/18/22 documented the resident had a right 5th toe amputation on 11/15/22. In an interview on 11/15/22 at 7:35 AM, Staff A, Licensed Practical Nurse (LPN) reported Friday, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) called and asked me about Resident #8's little toe and told me they saw a Mepilex foam bandage which she dated and put her initials on it. They informed they could not find orders for it. Staff A reported there had been an order and that it had not been discontinued and it had not been scanned into the electronic record. The DON and ADON are responsible for scanning orders into Electronic Medical Record (EMR). In an interview on 11/29/22 at 10:46 AM, Staff D, LPN reported the following: a. The Pharmacy had the responsibility of adding new orders to the Medication Administration Records/Treatment Administration Record's (MARs/TARs). They would have to call the Pharmacy if orders came in after hours or on the weekend. b. The double check system in place to ensure the orders were transcribed correctly is new orders are reviewed by the next shift and noted on the 24 hour report and it gets noted on the 24 hour report sheet. Any new orders should be addressed on the nurse's progress note with follow-up after new medications are started. c. The process she follows when administering medications is to find out who the patient is, what the medication is, make sure the order is correct, make sure the order is matching the medications in the unit dose envelopes d. She could not explain why the treatments for Resident #8 had not been signed out for the month of November. In an interview on 11/29/22 at 11:02 AM, Staff Y, RN reported the following: a. The DON and ADON will process new orders, fax the order to the pharmacy and call the nurse if something needs to be started right away. She could not remember who entered the new orders, thought the Pharmacy entered the new orders on to the MARs/TARs. b. There had not been a double check system to ensure the orders had been transcribed directly. Most of the nurses will check the original order to make sure it's been transcribed directly. c. The process she takes before she gives medications is: check the medication against the MAR to make sure they match, mark off each medication that she had checked, make sure it's the right dose, time and day, give medication then sign off the medications on the MARs and TARs. d. She admitted sometimes medications are not signed out because nurses will forget to do this. She gives medications to at least 20 residents, some take an extreme amount of time to take their medications and sometimes this causes the nurses to forget to sign out the medications. In an interview on 11/29/22 at 12:13 PM, the DON reported the following: a. When asked who is responsible for adding new orders to the MARs/TARs, she reported the nurse receiving the order, however, any nurse can verify the order. After a new order is received, it is sent to the Pharmacy by fax. All orders are entered on the Pharmacy end and they populate into the chart at the facility. The facility began using Electronic Medication Administration Records (EMAR) on 10/26/22. Problems arose when orders came over had to be corrected as the scheduled times had not been included. She had to add all the correct times to all the MARs. b. When a new order comes in, Pharmacy checks it and it is double checked by the DON and verified by a nurse. c. The process she expected the nurses to follow when administering medications is to use the 5 rights, right resident, right medication, right dose, right time and compare what they have to what is documented on the MAR. d. When asked why the order dated 6/20/22 for Menarin cream apply to legs and feet daily (scheduled for 2nd shift) for Resident #8 had not been signed out for the month of November, she reported the order had not been entered into the EMAR. e. When there are parentheses around initials on the MARS, she thought it meant the medications had not been administered or not charted. Every PRN medication given should have an assessment documented in the Nurse's Notes. Upon request for the facility policy regarding following Physician Orders, the Administrator reported they did not have one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS identified Resident #9 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 upon admission 8/2/22 and then rescored a 12 on 10/18/22. Diagnoses included: A left hip surgical repair (patient had fallen and fractured left hip July 22), Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), chronic Atrial Fibrillation and Premature Ventricular Contractions (both irregular heartbeats), Benign Prostrate Hypertrophy with urinary obstruction and required a suprapubic catheter placement due to urinary retention, a history of colon/rectal cancer had led to surgery and the placement of a colostomy (for bowel) 2015. The admission MDS identified Resident #9 skin conditions as a surgical wound (left hip) and Moisture Associated Skin Damage (MASD) of the coccyx area. A review of the facility Progress Notes documented the following: a. On 9/15/22 at 6:31 PM, Staff X, Registered Nurse (RN) documented Resident #9's stoma site with excoriation and bleeding and a fax had been sent to the residents' Provider. b. The next colostomy/stoma documentation on 9/20/22 at 2:16 PM, stated the Physician had ordered for Resident #9 to have an evaluation of colostomy for fit. c. The MDS Coordinator documented on 9/23/22 at 11:43 AM, a clarification for colostomy bag change to have been every 3 days. d. On 9/24/22 at 3:07 PM, documentation indicated 50% of the stoma site had been excoriated and bleeding. e. On 9/26/22 at 8:15 PM, documentation showed the colostomy bag was leaking, and the skin surrounding the stoma had been open and excoriated. f. Staff N, RN documented on 9/26/22 at 9:59 PM, that a fax received from Resident #9's Provider directed to use Stoma Powder and a Wound Clinic or Ostomy Nurse needed to be contacted for colostomy treatment and recommendations; information had been left for the facility DON. The facility Progress Notes showed further documentation of the colostomy stoma/skin excoriation, bleeding, and leaking colostomy bag issues had been documented as follows: a. On 9/28/22 by the consulting Pharmacist, 9/29/22 by Nursing Staff. b. On 10/7/22 a provider fax received for referral to the Wound Clinic for colostomy skin issues. c. On 10/10/22 a Wound Nurse called by a facility staff nurse and a voice message left. d. On 10/11/22 colostomy stoma excoriated and painful when leaking colostomy bag changed. e. On 10/12/22 Resident #9 admitted to Hospice service. f. On 10/18/22 documentation reported the colostomy bag change had been painful; stoma and surrounding skin excoriated, with no new treatment orders. g. On 10/19 the colostomy bag had leaked. h. On 10/22/22 the colostomy bag had leaked. i. On 10/26 the consulting Pharmacist documented there had been problems with excoriated skin around the stoma and the leaking of the colostomy bag. j. On 10/30/22 the facility obtained non-alcohol-based products from Hospice to use during colostomy bag change. k. Documentation on 11/4/22 shown Resident #9 experienced pain with colostomy bag change and the change of bag needed due to leaking. l. On 11/5/22 the facility documented the Hospice Nurse obtained a new order for Resident #9 to have oral morphine sulfate (narcotic pain medication) prior to colostomy bag changes. m. On 11/10/22 the facility Assistant Director of Nursing (ADON) documented Resident #9 had excoriation around the stoma and had discussed with the Hospice nurse. n. On 11/15/22 facility Staff N had documented Resident #9 had experienced pain during the colostomy bag change, had been pre-medicated prior to bag change, had excoriated skin, colostomy bag had been changed due to leaking. Review of Hospice Care documentation showed Resident #9: a. admitted to Hospice services 10/12/22. admission orders had included Hospice would supply colostomy supplies. b. Hospice staff had documented on 10/24/22 Resident #9 had pain with colostomy bag change, edge of colostomy stoma excoriated and open, new barrier creams and spray adhesive applied with colostomy bag change. c. On 10/27/22 Hospice staff had documented the facility staff had verbalized that overnight; the colostomy bag had leaked, therefore changed, and resident had pain with colostomy bag change. d. On 10/31/22 the Hospice staffs had documented Resident #9 had pain with colostomy bag change and had also documented on 10/31/22 the facility DON had been contacted by text; due to Hospice staffs not having access to the facility Electronic Health Records. e. Hospice staff documented on 11/4/22 that facility staff had reported Resident #9 had pain with colostomy bag change and had requested the Hospice staff contact Provider for pain medication pre-colostomy bag change. f. On 11/5/22 the Hospice staff had documented an order for liquid pain medication had been obtained from Resident #9 provider. g. On 11/10/22 the Hospice staff documented resident's colostomy bag leaked overnight, had been changed and the resident had pain. h. The Hospice staff documented on 11/14/22 that Resident #9's colostomy bag had been changed four times overnight due to leaking, Hospice staff changed the colostomy bag again on 11/14/22 (Fifth time) due to bag having leaked, and the stoma/skin documented as red, excoriated, and bleeding. i. On 11/17/22 Hospice staff documented the colostomy stoma/skin continued to be red, excoriated, and bleeding. j. On 11/19/22 the Hospice staff documented being contacted by facility staff that resident needed the colostomy bag change overnight due to the bag leaking, resident had been pre-medicated, and Resident #9 verbalized pain with procedure and medication had not helped to relieve pain. Review of the Provider Orders Charted the following: a. On 8/2/2022 the Provider ordered Tylenol 500 mg, and Resident #9 could take two up to three times a day as needed. b. On 9/27/22 the Provider ordered Stomahesive Powder, apply as ordered and then discontinued it on 10/28/22. c. On 10/07/22 the resident's Provider ordered for Resident #9 to have a referral for colostomy evaluation by a Wound Nurse or Ostomy Nurse. The facility documented a voice message left for an Ostomy Nurse on 10/10/22. d. On 10/28/22 to 11/2/22, the Provider ordered for Stomahesive Powder to be applied to gauze and then patted onto the stoma site as directed. e. On 11/2/2022 the Provider ordered for Stomahesive Powder and then Stomahesive Spray to be used. Directions had been provided for the colostomy change process. f. The Provider had ordered on 11/5/22 and then discontinued on 11/9/22 a medication order for Morphine Concentrate Solution administer 0.25 milliliters orally as needed for pain every four hours. g. Resident #9's Provider ordered on 11/9/22 and discontinued 11/21/22 for pain control medication, Morphine Concentrate Solution dose had remained the same; 0.25 milliliters, but now every 2 hours as needed for pain (Colostomy pouch changes, suprapubic catheter changes, or shortness of breath). h. On 11/21/22, Resident #9's Provider increased the Morphine Sulfate Concentration Solution to 0.5 milliliters as needed every two hours for pain. Review of Resident #9 Electronic Medication Administration Records (EMAR) had shown the following: a. The October 2022 EMAR had shown Resident #9 had been administered Tylenol 1000 milligrams a total of three times for leg pain. Review of the residents November 2022 EMAR shown the resident had been administered the pain medication Morphine Concentrate Solution a total of zero times between 11/5/22 and 11/9/22. Further review of the pain medication administration EMAR shown for November 2022 from 11/9/22 forward there had been a total of six times the resident had been administered the as needed every two hours medication. Review of the November 2022 EMAR showed the dates of administration as: 11/11, 11/15, 11/18, 11/19, 11/22 and 11/23/22. Further review shown Resident #9 had not been administered Tylenol during the month of November 2022. Review of the Narcotic Administration Record shown pain medication administration had been a total of seven times on the dates: 11/11, 11/14, 11/16, 11/18, 11/19, 11/22 and 11/23/22. In an interview on 11/28/22 at 8:50 AM, the Hospice Nurse revealed the documented facility colostomy bag changes and the number of bags provided by the Hospice Nurse had not been equal. The Hospice Nurse stated keeping the facility supplied with ostomy supplies had been challenging due to the facility Treatment Assessment Record not being completed with every colostomy bag change, therefore to reconcile the number of colostomy bag changes completed had not been achievable. The Hospice Nurse further stated the resident had not been medicated pre-colostomy change procedure as ordered. The Hospice Nurse requested a phone call be made to a daughter-in-law (by Hospice) to obtain information for a stoma spray that had been used in the past successfully by the resident. The Hospice Nurse stated the adhesive spray product had then been supplied by Hospice. In an interview on 11/28/22 at 1:18 PM, the facility Pharmacist, reported no communication between the Pharmacist and the facility DON, facility staff, or Hospice staff regarding the Stomahesive Spray. The Pharmacist stated a product called Stomahesive spray did not exist to purchase, and no product sent to the care facility. The Pharmacist further stated the facility DON entered the order on the EMAR. The Pharmacist stated a voice activated message from the Provider received and the facility had not asked the Pharmacy to clarify with the Provider. During an interview with the DON on 11/29/22 at 1:41 PM, the subject of Care Plans and updating resident need changes discussed. The DON stated the resident admitted to Hospice 10/12/22 and then Hospice should have completed the updates on the Care Plans. When asked about Skin Sheets, the DON stated the nurse who assessed a skin discrepancy was expected to initiate a Skin Sheet. When asked about the resident order for an Ostomy or Wound Nurse to evaluate the stoma skin and colostomy bag attachment issues, the DON stated the Hospice Nurse was to evaluate. The DON when asked about assessment of resident pain, stated the facility had not completed pain sheets daily or by shifts. The DON further stated the resident pain is documented on the EMAR if pain medication had been administered. On 11/29/22 at 3:56 PM an interview was completed with Staff N, RN who stated she had asked the DON to set up a resident colostomy evaluation early October 2022. Staff N further stated during the facility third shift (Staff N worked) that calling for a consult had not been possible. Staff N stated the facility Administration and the DON had not initiated a colostomy evaluation for the resident. Staff N unaware if Resident #9 had a Skin Sheet for the colostomy stoma. Staff N explained the facility Treatment Administration Record (TAR) had not included an area to document as needed colostomy bag changes. Staff N knew Hospice supplied the stoma adhesive spray. When asked about pain documentation, Staff N stated the documentation would have been written within the Progress Notes or if pain medication had been administered then the EMAR would have had a pain number documented pre and post pain medication administration. Based on observation, record review and staff interviews, the facility failed to document assessments per the facility fall protocol for one of two residents reviewed (Resident #5) and failed to document assessments of a resident's skin surrounding the stoma after the colostomy bag had been changed four times in a day (Resident #9). The facility reported a census of 57 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 4 out of 15. The MDS also identified her with the following diagnoses: cerebrovascular accident (a stroke), Non-Alzheimer's Dementia and spinal stenosis, and she required extensive staff assistance with locomotion off the unit and with bathing. A review of the Incident Report dated 10/9/22 at 10:00 AM, documented the resident with a hematoma to the right side of her head which measured 5 centimeters (cm) by 5 cm. Fall not witnessed and occurred in her room. On 8/7/22 the Care Plan identified the resident with the problem of being at risk for falls due to impaired mobility and impaired cognition from spinal stenosis, chronic pain, and dementia. The Care Plan directed the staff to follow these interventions: a. Regarding the fall on 10/1/22: sign in room to remind resident to use her call light for help and high-low bed with bilateral grab bars to assist me with repositioning myself. b. Needs the assist times one staff with gait belt and walker for transfers and ambulation. c. Use a wheelchair that staff propel her in when her back pain is limiting her ambulation or for off unit i.e.: scale as needed, appointments, etc. d. Regarding fall on 3/18: Lyrica discontinued. e. Staff are to not put a chux on resident's recliner. f. Staff to remind resident to walk closer to her walker when ambulating as needed to help her maintain better balance. A review of the Nurse's Progress Notes revealed the following: a. On 10/9/22 at 2:01 PM, this nurse called to this resident's room, upon entry noted resident lying on her right side facing the bathroom. Grips equal. This nurse rolled resident onto her back no shortening of either leg and no rotation noted to either foot. Resident sat in sitting position and she says her leg hurts. This nurse palpated both hips and noted no difference at this time. Gait belt placed on resident and this nurse and a Certified Nurse Assistant (CNA) stood resident up and the resident expressed that her leg hurts and this nurse noted outward rotation to right foot. Resident placed in bed and pillow placed between legs. Physician called and received orders to transport to the emergency room (ER). b. Ambulance left with resident around 11:30 AM. c. At 1:31 PM the hospital called and reported fracture to right hip. A review of the Neuro Flow Sheet revealed only one assessment with vital signs and a neuro check completed at 10:00 AM. No documentation noted for 10:15, 10:30, 10:45 and 11:00 AM as per fall protocol of every 15 minutes 4 times after fall occurred. In an interview on 11/14/22 at 1:20 PM, Staff J, Licensed Practical Nurse (LPN) reported after a resident experiences an unwitnessed fall, the nurse should check vital signs, do neuro checks, check for any rotation to any of the extremities, check for injury and should be done every 15 minutes four times, every 30 minutes four times and hourly four times then every 4 hours twice and once a shift for 72 hours. In an interview on 11/14/22 at 1:34 PM, the MDS Coordinator/LPN reported the following: a. After a resident has an unwitnessed fall and there is a hematoma noted to the head, the nurse should check neuros and vital signs every 15 minutes four times, every 30 minutes four times, hourly four times, every 4 hours twice then once a shift for the next 72 hours. These should be documented on the Neuro Flow Sheet. b. When Resident #5 fell on [DATE] in the morning, before lunch in the morning. The aide notified her of the fall and when she assessed the resident, the resident laid on the floor and complained of pain. She did have a hematoma above her right eyebrow. c. When asked why the Neuro Flow Sheet did not have any documentation of vitals, neuro checks, etc after 10:00 AM, she reported she had been preparing for the resident to be taken to the hospital. That it happened on a weekend where only one other nurse and an aide worked the Care Center (where the long term residents reside). In an interview on 11/16/22 at 10:37 AM, Staff R, LPN reported when a resident has an unwitnessed fall, the nurse should assess, get vital signs, find out if it was unwitnessed, any injuries, check the area to see if there is a safety concern, do the neuro checks every 15 minutes for an hour, hourly after the first hour for 4 hours and after that she could not recall how often. These should be documented on a Neuro Assessment/Post Fall Form, this is recorded on a paper form, then gets scanned into the Electronic Medication Record (EMR), but don't know who is responsible. She also reported the MDS Coordinator did not call her for help to complete some of those assessments. And the only reason she could think of as to why it was not done was they were short staffed. On the weekends, it would be common for one nurse to be responsible for 30 residents. Staff often call in sick on the weekends. She could not recall any other details regarding Resident #5's fall as she had cared for residents in the opposite hall. Staff R did recall the hospital called later to report the resident had a fracture of the hip. Upon request for a policy on assessment/intervention, the Administrator reported the facility did not have one.

Based on clinical record review, Hospice Nurse, Pharmacist and facility staff interviews, the facility failed to failed to assess and intervene for residents with pain for one of three residents reviewed. The facility reported a census of 57 residents. Findings Include: The MDS had identified Resident #9 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 upon admission 8/2/22 and then rescored a 12 on 10/18/22. Diagnoses included: A left hip surgical repair (patient had fallen and fractured left hip July 22), Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), chronic Atrial Fibrillation and Premature Ventricular Contractions (both irregular heartbeats), Benign Prostrate Hypertrophy with urinary obstruction requiring a suprapubic catheter placement due to urinary retention, a history of colon/rectal cancer had led to surgery and the placement of a colostomy (for bowel) 2015. The admission MDS identified Resident #9's skin conditions as a surgical wound (left hip) and Moisture Associated Skin Damage (MASD) of the coccyx area. The Care Plan dated as last revised 8/11/22 stated Resident #9 had needed staff assistance with management of the bowel colostomy to include assistance with emptying the colostomy bag, monitor the stoma and surrounding area and to notify the physician with concerns. The resident Care Plan lacked being updated to include colostomy stoma skin issues, resident pain incurred during colostomy bag changes, and lacked updating the changed process of colostomy stoma wafer, bag changes and Provider ordered colostomy products to be used. A review of the facility Progress Notes documented the following: a. On 9/15/22 at 6:31 PM, Staff X, Registered Nurse (RN) documented Resident #9's stoma site with excoriation and bleeding and a fax had been sent to the residents' Provider. b. The next colostomy/stoma documentation on 9/20/22 at 2:16 PM, stated the Physician had ordered for Resident #9 to have an evaluation of colostomy for fit. c. The MDS Coordinator documented on 9/23/22 at 11:43 AM, a clarification for colostomy bag change to have been every 3 days. d. On 9/24/22 at 3:07 PM, documentation indicated 50% of the stoma site had been excoriated and bleeding. e. On 9/26/22 at 8:15 PM, documentation showed the colostomy bag was leaking, and the skin surrounding the stoma had been open and excoriated. f. Staff N, RN documented on 9/26/22 at 9:59 PM, that a fax received from Resident #9's Provider directed to use Stoma Powder and a Wound Clinic or Ostomy Nurse needed to be contacted for colostomy treatment and recommendations; information had been left for the facility DON. The facility Progress Notes showed further documentation of the colostomy stoma/skin excoriation, bleeding, and leaking colostomy bag issues had been documented as follows: a. On 9/28/22 by the consulting Pharmacist, 9/29/22 by Nursing Staff. b. On 10/7/22 a provider fax received for referral to the Wound Clinic for colostomy skin issues. c. On 10/10/22 a Wound Nurse called by a facility staff nurse and a voice message left. d. On 10/11/22 colostomy stoma excoriated and painful when leaking colostomy bag changed. e. On 10/12/22 Resident #9 admitted to Hospice service. f. On 10/18/22 documentation reported the colostomy bag change had been painful; stoma and surrounding skin excoriated, with no new treatment orders. g. On 10/19 the colostomy bag had leaked. h. On 10/22/22 the colostomy bag had leaked. i. On 10/26 the consulting Pharmacist documented there had been problems with excoriated skin around the stoma and the leaking of the colostomy bag. j. On 10/30/22 the facility obtained non-alcohol-based products from Hospice to use during colostomy bag change. k. Documentation on 11/4/22 shown Resident #9 experienced pain with colostomy bag change and the change of bag needed due to leaking. l. On 11/5/22 the facility documented the Hospice Nurse obtained a new order for Resident #9 to have oral morphine sulfate (narcotic pain medication) prior to colostomy bag changes. m. On 11/10/22 the facility Assistant Director of Nursing (ADON) documented Resident #9 had excoriation around the stoma and had discussed with the Hospice nurse. n. On 11/15/22 facility Staff N had documented Resident #9 had experienced pain during the colostomy bag change, had been pre-medicated prior to bag change, had excoriated skin, colostomy bag had been changed due to leaking. Review of Hospice Care documentation showed Resident #9: a. admitted to Hospice services 10/12/22. admission orders had included Hospice would supply colostomy supplies. b. Hospice staff had documented on 10/24/22 Resident #9 had pain with colostomy bag change, edge of colostomy stoma excoriated and open, new barrier creams and spray adhesive applied with colostomy bag change. c. On 10/27/22 Hospice staff had documented the facility staff had verbalized that overnight; the colostomy bag had leaked, therefore changed, and resident had pain with colostomy bag change. d. On 10/31/22 the Hospice staffs had documented Resident #9 had pain with colostomy bag change and had also documented on 10/31/22 the facility DON had been contacted by text; due to Hospice staffs not having access to the facility Electronic Health Records. e. Hospice staff documented on 11/4/22 that facility staff had reported Resident #9 had pain with colostomy bag change and had requested the Hospice staff contact Provider for pain medication pre-colostomy bag change. f. On 11/5/22 the Hospice staff had documented an order for liquid pain medication had been obtained from Resident #9 provider. g. On 11/10/22 the Hospice staff documented resident's colostomy bag leaked overnight, had been changed and the resident had pain. h. The Hospice staff documented on 11/14/22 that Resident #9's colostomy bag had been changed four times overnight due to leaking, Hospice staff changed the colostomy bag again on 11/14/22 (Fifth time) due to bag having leaked, and the stoma/skin documented as red, excoriated, and bleeding. i. On 11/17/22 Hospice staff documented the colostomy stoma/skin continued to be red, excoriated, and bleeding. j. On 11/19/22 the Hospice staff documented being contacted by facility staff that resident needed the colostomy bag change overnight due to the bag leaking, resident had been pre-medicated, and Resident #9 verbalized pain with procedure and medication had not helped to relieve pain. Review of the Provider Orders Charted the following: a. On 8/2/2022 the Provider ordered Tylenol 500 mg, and Resident #9 could take two up to three times a day as needed. b. On 9/27/22 the Provider ordered Stomahesive Powder, apply as ordered and then discontinued it on 10/28/22. c. On 10/07/22 the resident's Provider ordered for Resident #9 to have a referral for colostomy evaluation by a Wound Nurse or Ostomy Nurse. The facility documented a voice message left for an Ostomy Nurse on 10/10/22. d. On 10/28/22 to 11/2/22, the Provider ordered for Stomahesive Powder to be applied to gauze and then patted onto the stoma site as directed. e. On 11/2/2022 the Provider ordered for Stomahesive Powder and then Stomahesive Spray to be used. Directions had been provided for the colostomy change process. f. The Provider had ordered on 11/5/22 and then discontinued on 11/9/22 a medication order for Morphine Concentrate Solution administer 0.25 milliliters orally as needed for pain every four hours. g. Resident #9's Provider ordered on 11/9/22 and discontinued 11/21/22 for pain control medication, Morphine Concentrate Solution dose had remained the same; 0.25 milliliters, but now very 2 hours as needed for pain (Colostomy pouch changes, suprapubic catheter changes, or shortness of breath). h. On 11/21/22, Resident #9's Provider increased the Morphine Sulfate Concentration Solution to 0.5 milliliters as needed every two hours for pain. Review of Resident #9 Electronic Medication Administration Records (EMAR) had shown the following: a. The October 2022 EMAR had shown Resident #9 had been administered Tylenol 1000 milligrams a total of three times for leg pain. Review of the residents November 2022 EMAR shown the resident had been administered the pain medication Morphine Concentrate Solution a total of zero times between 11/5/22 and 11/9/22. Further review of the pain medication administration EMAR shown for November 2022 from 11/9/22 forward there had been a total of six times the resident had been administered the as needed every two hours medication. Review of the November 2022 EMAR showed the dates of administration as: 11/11, 11/15, 11/18, 11/19, 11/22 and 11/23/22. Further review shown Resident #9 had not been administered Tylenol during the month of November 2022. Review of the Narcotic Administration Record shown pain medication administration had been a total of seven times on the dates: 11/11, 11/14, 11/16, 11/18, 11/19, 11/22 and 11/23/22. In an interview on 11/28/22 at 8:50 AM, the Hospice Nurse revealed the documented facility colostomy bag changes and the number of bags provided by the Hospice Nurse had not been equal. The Hospice Nurse stated keeping the facility supplied with ostomy supplies had been challenging due to the facility Treatment Assessment Record not being completed with every colostomy bag change, therefore to reconcile the number of colostomy bag changes completed had not been achievable. The Hospice Nurse further stated the resident had not been medicated pre-colostomy change procedure as ordered. The Hospice Nurse requested a phone call be made to a daughter-in-law (by Hospice) to obtain information for a stoma spray that had been used in the past successfully by the resident. The Hospice Nurse stated the adhesive spray product had then been supplied by Hospice. In an interview on 11/28/22 at 1:18 PM, the facility Pharmacist, reported no communication between the Pharmacist and the facility DON, facility staff, or Hospice staff regarding the Stomahesive Spray. The Pharmacist stated a product called Stomahesive spray did not exist to purchase, and no product sent to the care facility. The Pharmacist further stated the facility DON entered the order on the EMAR. The Pharmacist stated a voice activated message from the Provider received and the facility had not asked the Pharmacy to clarify with the Provider. During an interview with the DON on 11/29/22 at 1:41 PM, the subject of Care Plans and updating resident need changes discussed. The DON stated the resident admitted to Hospice 10/12/22 and then Hospice should have completed the updates on the Care Plans. When asked about Skin Sheets, the DON stated the nurse who assessed a skin discrepancy was expected to initiate a Skin Sheet. When asked about the resident order for an Ostomy or Wound Nurse to evaluate the stoma skin and colostomy bag attachment issues, the DON stated the Hospice Nurse was to evaluate. The DON when asked about assessment of resident pain, stated the facility had not completed pain sheets daily or by shifts. The DON further stated the resident pain is documented on the EMAR if pain medication had been administered. On 11/29/22 at 3:56 PM an interview was completed with Staff N, RN who stated she had asked the DON to set up a resident colostomy evaluation early October 2022. Staff N further stated during the facility third shift (Staff N worked) that calling for a consult had not been possible. Staff N stated the facility Administration and the DON had not initiated a colostomy evaluation for the resident. Staff N unaware if Resident #9 had a Skin Sheet for the colostomy stoma. Staff N explained the facility Treatment Administration Record (TAR) had not included an area to document as needed colostomy bag changes. Staff N knew Hospice supplied the stoma adhesive spray. When asked about pain documentation, Staff N stated the documentation would have been written within the Progress Notes or if pain medication had been administered then the EMAR would have had a pain number documented pre and post pain medication administration.

Based on observations, record review, family and staff interviews, the facility failed to properly maintain heat registers in the residents rooms to prevent any possible injuries to occur for two of three residents (Resident #3 and #4). The facility reported 57 residents. Findings Include: Observations of Resident #3's room revealed the following: a. On 11/2/22 at 2:35 PM, the heat register with metal pieces that appear bent. b. On 11/29/22 at 10:00 AM, heat register remains unchanged with bent pieces of metal and unrepaired. Observations on 11/8/22 at 11:29 AM with the Maintenance Director of Resident #4's room, revealed the heat register had one end still bent up. A review of Resident #4's Nurse's Notes revealed the following: a. On 10/2/22 at 12:34 PM, the resident observed with both feet hanging over edge of the bed with small abrasions noted to tips of great, 2nd and 3rd toes. Areas cleaned with NS and wrapped with gauze. In an interview on 11/2/22 at 7:15 PM, the Resident #4's family member reported there had been an incident where his foot fell over the side of the bed and hit the heat register which caused lacerations to his toes. In an interview on 11/3/22 at 12:28 PM, Staff A, Licensed Practical Nurse (LPN) reported the resident's spouse reported the resident's left leg fell off the bed and hit his foot on the foot register and got caught in between the metal parts. Staff A could not recall if the heat register had been repaired. In an interview on 11/8/22 at 11:29 AM, the Maintenance/Housekeeping/Laundry Supervisor reported when there are problems identified in resident's rooms, Nursing Staff are responsible for sending him requests for repairs. He reported he never received a request to repair the heat register in Resident #4's room. One of his Housekeepers reported that one of the heat register's covers popped off and they straightened it back up and put it back on. In an interview on 11/8/22 at 12:02 PM, the Director of Nursing (DON) reported she had not been informed of the heat register in the resident's room being in need of repair. She thought the family had reported it to the Social Worker. In an interview with the 11/10/22 at 1:54 PM, the resident's spouse reported underneath the windows are heat registers and there is one sheet of metal that goes across there. She had straightened up the sheets on his bed and noticed one of the panels from the heat register on the floor and a puddle of blood on the floor. She reported the problem to one of the nurse's and informed her that they required maintenance. No one ever came to fix it. Several days went by and that piece of the heat register still laid on the floor. The resident had been able to push the bed away from the wall enough that one of his legs dropped down in to the coil of the heater. He ended up getting some cuts to his toes to the left leg which the nurse cleaned up and put band aides on. In an interview on 11/29/22 at 11:22 AM, the Social Worker reported Resident #4's family informed her that his foot had fallen off the bed onto the register and the heat register caused him to have a scrape on his foot. She reported her follow-up for that had been that she contacted the Maintenance Director who informed her that it had already been fixed by that point. She did not have any documentation of this request. When asked if the facility had a policy regarding maintenance repairs, the Administrator reported they did not have one.