Every finding on record at Accura Healthcare of Ames, LLC

Based on clinical record review, policy review and staff interview, the facility failed to ensure the resident or representative received written bed hold information prior to a transfer to the hospital for 2 of 2 residents reviewed for hospitalization (Residents #3 and #69). The facility reported a census of 63 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a Brief Interview for Metal Status (BIMS) score of 4 indicating severe cognitive impairment. The MDS further revealed the resident had diagnoses including respiratory failure and end stage renal (kidney) disease and received dialysis. Review of Progress Notes for Resident #3 revealed the resident was transferred to the hospital from the dialysis center on 12/24/25 for treatment of low oxygen saturation (tissues not receiving sufficient oxygen). The clinical census for Resident #3 documented a hospitalization 12/24/25-12/29/25. Clinical record review for Resident #3 lacked documentation related to bed hold notification prior to the 12/24/25 hospitalization. 2. The MDS assessment dated [DATE] revealed Resident #69 had a BIMS of 13 indicating intact cognition. The MDS further revealed the resident had diagnoses including osteomyelitis and muscle weakness. Review of Progress Notes revealed Resident #69 was transferred and admitted to the hospital on [DATE] due to a hip fracture. The clinical census for Resident #69 documented the resident was hospitalized [DATE] and billing was stopped 1/20/26. Clinical record review for Resident #69 lacked documentation related to bed hold notification prior to the 1/18/26 hospitalization. Review of facility policy titled, Emergency Notice of Transfer/Discharge, updated 4/4/25 revealed the following: Even though our Facility expects that you will return to our Facility following your hospitalization, federal regulations under 42 C.F.R. SS483.15(c)(3) and (5) require that we provide you with a written notice regarding your transfer to the hospital and your appeal rights. During an interview 4/15/2026 at 2:26 PM the Administrator revealed he was not able to locate information regarding bed hold notification for Resident #3 or #69 with their most recent hospitalizations. During an interview 4/16/2026 at 12:00 PM, the Administrator revealed he would have expected bed hold notifications be presented for Resident #3's and Resident #69's hospitalizations.

Based on clinical record review, policy review, the Food and Drug Administration (FDA), staff, and resident interviews the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 3 of 20 residents reviewed (Residents #6, #8 and #62). The facility reported a census of 63 residents.Findings include:1. Resident #8's Minimum Data Set (MDS) dated [DATE] indicated they didn't have a serious mental illness and/or intellectual disability or related condition. The MDS included diagnoses of anxiety, depression, and bipolar disorder (a mental health condition that causes extreme mood swings). A notice of PASRR Level I screen outcome dated 11/17/25 reflected a positive screening and showed no status change. The PASRR Level I Identification Screen showed Resident #8 had evidence of a serious mental illness or an intellectual or developmental disability (IDD). The screen directed the facility to mark yes for question A1500 on the MDS. 2. Resident #6's MDS dated [DATE] lacked a diagnosis of diabetes mellitus. It indicated Resident #6 took insulin for 1 of 7 days during the lookback period. The Physician's Orders indicated Resident #6 took 10 milligrams (mg) of Zepbound (tirzepatide) under the skin once a week for weight management. On 4/14/26 at 2:40 PM, Resident #6 denied being diabetic and didn't take insulin. He stated he took a shot of something once a week for weight loss. 3. Resident #62's MDS dated [DATE] lacked a diagnosis of diabetes mellitus. The MDS reflected she took insulin 1 of 7 days during the lookback period. The Physician's Orders indicated Resident #62 took 12.5 mg of Zepbound under the skin once a week for weight management. On 4/14/26 at 2:35 PM, Resident #62 denied being diabetic and thought she took the insulin Wegovy once a week for weight loss. On 4/15/26 at 1:27 PM, Staff F, MDS Coordinator, stated she gathered information for the MDS by observing on the floor and talking to residents. When she answered question A1500 she looked at the last PASRR evaluation. If she knew it was marked wrong, she would submit a correction to the MDS which she will do. When she answered the question about insulin injections in the last 7 days on the MDS she looked at the Electronic Medication Administration Record (EMAR). She had several residents getting Wegovy and she marked them as 1 day of insulin, as they count as insulin. If she found out that was incorrect, she would submit an MDS correction.On 4/16/26 at 1:31 PM, the Director of Nursing (DON) stated she didn't know if Zepbound should be coded as an insulin on the MDS. She stated Resident #6 and Resident #62 both took it for weight loss. According to the Food and Drug Administration (FDA), Zepbound is a glucose-dependent insulinotropic polypeptide (GIP) receptor and glucagon-like peptide-1 (GLP-1) receptor agonist (a class of medications used to treat obesity) indicated for chronic weight management. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2025 defined insulin as a medication used to treat diabetes mellitus. The manual directed staff to code all high-risk drug class medications according to their pharmacological classification, not how they are being used. The Conducting an Accurate Resident Assessment policy updated April 2025 directed that all residents receive an accurate assessment by qualified staff. It instructed the Administrator to ensure all participants have the requisite knowledge to complete an accurate assessment addressing each resident's status and needs.

Based on record review and staff interview, the facility failed to develop and implement comprehensive care plans accurately reflecting the needs and safety interventions for 2 of 20 sampled residents (Resident #17 and Resident #72). Specifically, the facility didn't address smoking behaviors and supervision for one person and didn't ensure staff implemented established fall prevention interventions for another. The facility reported a census of 63 residents. Findings include: 1. Resident #17's admission Minimum Data Set (MDS) assessment dated [DATE], documented they didn't use tobacco. Resident #17's Smoking Evaluation dated 1/13/26, revealed they smoked 10 or more cigarettes a day in the morning, afternoon, evening, and night. Resident #17's Smoking Evaluation, dated 4/12/26, revealed they smoked 5 to 10 times a day in the morning, afternoon, evening, and night. The undated Smoking Information, form provided by the facility on 4/13/26, identified Resident #17 smoked and designated the 400 Hall Courtyard as the smoking area. On 4/15/26 at 9:16 AM observed Resident #17 smoking in the designated courtyard with staff present. On 4/16/26 at 9:25 AM observed Resident #17 smoking in the designated courtyard with staff present. Resident #17's Care Plan, initiated 1/16/26, lacked any documentation related to smoking or the necessary supervision for the activity. The facility's Resident Smoking Agreement policy, updated 4/14/25, required staff to document all smoking measures on the care plan and communicate them to the staff responsible for supervising people while smoking. During an interview on 4/15/26 at 3:08 PM, the Administrator revealed he expected Resident #17's Care Plan to include their smoking behaviors. 2. Resident #72's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The Fall Follow-Up note dated 7/1/25 indicated Resident #72 reported pain numbness to her left arm after she got it pinned between the bed and side rail. The review of Care Plan Interventions and effectiveness of the new intervention indicated Resident #72's Care Chart didn't have the Intervention of fall mat, but was listed on the Care Plan. Resident #72's Care Plan, revised on 4/15/25, directed staff to keep the bed in the low position and ensure a fall mat (a padded mat placed on the floor next to a bed to reduce the risk of injury from a fall) remained in place. Resident #72's Incident Report dated 7/1/25, documented staff found them on the floor with their left arm pinned between the mattress and side rail. The report noted staff failed to place the bed in the low position and failed to put the fall mat in place as required. During an interview on 4/16/26 at 12:25 PM, the Director of Nursing (DON) stated when the staff found Resident #72 on the floor, they didn't have the safety measures in place as they should've. She stated they educated the staff following the event. The facility's Comprehensive Care Plans policy, updated 12/3/25, required the facility to develop and implement person-centered care plans describing specific interventions to meet identified needs.

Based on observations, clinical record review, staff interviews, and policy review the facility failed to maintain infection control practices for 1 of 3 residents reviewed (Resident ##26). The facility failed to complete hand hygiene and change gloves when completing resident care. The facility reported a census of 63 residents. Findings include:Based on record review and staff interview, the facility failed to ensure staff practiced proper hand hygiene to prevent the spread of infection for 1 of 10 sampled residents (Resident #26). Specifically, staff failed to wash their hands or use sanitizer after removing contaminated gloves and before touching clean surfaces or moving between tasks.Resident #26's Minimum Data Set (MDS) assessment dated [DATE], indicated they had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS identified they depended on staff for toilet hygiene and transfers. The MDS included diagnoses of diabetes and depression. On 4/13/26 at 3:05 PM, observed Staff G, Certified Nurse Aide (CNA), and Staff H, CNA, enter Resident #26's room, apply gloves, and transfer them with a stand-up lift from the wheelchair to a commode. Staff H lowered their pants before they reached the commode. Staff G and Staff H removed their gloves when they exited the room but performed no hand hygiene. Staff G proceeded to the nurse's station while Staff H picked up a lift sling and walked down the hall.On 4/13/26 at 3:35 PM, observed Staff G and Staff H return to Resident #26's room. Staff H applied gloves and cleansed between Resident #26's buttocks, where stool was present. Staff H removed their gloves and applied new gloves without completing hand hygiene, then proceeded to pull up their pull-up and pants. Staff G and Staff H transferred Resident #26 back to the wheelchair. Staff G removed their gloves and proceeded to touch the sling, their clothing, and opened the window, without completing hand hygiene.The facility's Hand Hygiene policy, updated 11/13/24, instructed the staff to use proper handwashing techniques to protect against the spread of infection. The policy directed staff to always complete hand hygiene before donning (putting on) gloves, after removing gloves, and after handling contaminated (dirty) items.During an interview on 4/16/26 at 11:42 AM, the Director of Nursing (DON) stated she expected the staff to complete hand hygiene immediately after removing gloves and after completing cares. She added they should perform hand hygiene when going from a dirty task to a clean task.

Based on clinical record review and staff interview, the facility failed to submit a Level II Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 residents reviewed with a new mental health diagnoses (Resident #49). The facility reported a census of 69 residents. Findings include: Resident #49's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of anxiety disorder, depression and psychotic disorder. The MDS reflected Resident #49 took antipsychotic, antianxiety, and antidepressant medication in the lookback period. The Care Plan Focus revised 2/11/25 indicated Resident #49 had a potential for behaviors, he used his call light excessively without having a need and often wouldn't participate in self-care to his capabilities. The Goal identified Resident #49 would display appropriate interactions with peers, staff, and visitors over the next review period. The Interventions directed Resident #49 as sometimes impulsive or impatient. Resident #49's Medical Diagnoses reviewed 3/24/25 listed the following diagnoses dated: a. 2/18/25: Delusion disorders b. 11/7/24: Adjustment disorder with mixed anxiety and depressed mood c. 10/18/24: Anxiety disorder d. 8/30/24: Depression Resident #49's March 2025 Medication Administration Record included the following new orders: a. 2/22/25: Zoloft (antidepressant) 75 milligrams (mg) 1 time a day related to unspecified depression. b. 1/31/25: Seroquel (antipsychotic) 25 mg 2 times a day related to adjustment disorder with mixed anxiety and depressed mood. c. 3/21/25: Amitriptyline HCL 25 mg. Give 10 mg by mouth once a day due to adjustment disorder with mixed anxiety and depressed mood. Resident #49's Notice of PASRR Level 1 Screen Outcome dated 9/6/23 indicated he didn't have a mental health diagnosis at the time and if changes occurred a new screening must be submitted. On 3/24/25 at 12:51 PM, the Social Worker provided documentation of Resident #49's Level II PASRR evaluation processing began 3/23/25. During an interview 3/24/25 at 3:45 PM, the Administrator reported the facility didn't have a specific policy or protocol regarding the completion of PASRRs, as they generally tried to follow the regulations. The Administrator added he expected the staff to submit Level 2 PASRRs evaluations in a timely manner.

Based on record review, resident interview, staff interview and facility process review, the facility failed to ensure residents environment was free from accidents and hazards by not assessing a resident for safety that verbalized he used a vape pen in his room for 1 of 2 residents reviewed for smoking (Resident #67). The facility reported a census of 69 residents. Findings include: Resident #67's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS listed Resident #67 as dependent on staff for bathing, toileting, and transfers. They required set up assistance with personal hygiene. They used a wheelchair for mobility. The MDS included diagnoses to include muscular dystrophy (genetic condition that causes a breakdown of skeletal muscle over time and progressive weakness), post-traumatic stress disorder (PTSD), anxiety, tachycardia (elevated heart rate greater than 100 beats per minute) and second degree burns of right and left lower legs. The facility provided list of smokers lacked Resident #67. Resident #67's clinical record lacked documentation of completed smoking evaluations. The Admission Checklist, signed by Resident #67 on 2/17/25, reflected he signed that the facility provided him a copy of the Resident Smoking Process and he understood the process. In an interview on 3/23/25 at 1:57 PM, Resident #67 reported he used a vape pen and the staff allowed him to use it in his room. In an interview on 3/25/25 at 11:29 AM, Resident #67 said he kept his vape pen in his room and he currently had it on his person. He reported the vape pen needed to be charged and he could do that himself. He added he rarely got out of bed so he didn't get up to vape and vaped in his room throughout the day whenever he felt like it. Resident #67 reported he signed many things on admission and didn't remember if he signed the smoking policy. He thought some staff knew he vaped in his room but he didn't know for sure how many as he didn't know all the staff. He denied knowing that he couldn't vape in his room. He reported he couldn't remember if he told the facility on admission that he vaped or not. In an interview on 3/25/25 at 11:32 AM, Staff A, Certified Nursing Assistant (CNA), stated if a resident smoked or vaped, they had to do it outside with supervision and the residents couldn't keep the smoking or vaping supplies in their room. She didn't believe Resident #67 smoked or vaped but if he did, he most likely did it in his room when no one was around. In an interview on 3/25/25 at 11:48 AM, Staff B, Registered Nurse (RN), stated she believed Resident #67 vaped because she saw the vape pen in his room before. She said he never got up, so she assumed he vaped in his room. Staff B stated residents weren't to smoke or vape in their rooms. She didn't know if anyone knew Resident #67 vaped or not. She stated no staff mentioned it to her and she never witnessed him vaping. She reported she had told him, that he couldn't vape in his room but stated she never reported it on to administration. In an interview on 3/25/25 at 12:45 PM, the Administrator reported he didn't know Resident #67 smoked or vaped. He stated residents weren't to keep any smoking or vaping supplies in their rooms. He reported residents weren't to vape in their rooms and no one reported to him about Resident #67 vaping or having vape supplies in his room. He reported on admission they ask the residents if they smoked or vaped. They're supposed to review the policy to ensure they understood it prior to signing it. He stated he expected the staff to report it to him if they knew a resident had vaping supplies or vaped in their room. Review of the Resident Smoking Process, updated 4/21/22, provided by the facility indicated it applied to cigarettes, cigars, pipes, or any other materials that require fire. This also included electronic or vapor cigarettes and chewing tobacco. - All tobacco products including smoking tobacco, matches, lighters, chewing tobacco, or other smoking paraphernalia will be kept by family members, or stored by facility staff in a secure location. - Residents may not store smoking materials or supplies on their person, in their belongings, or in their rooms. - Smoking inside the facility is expressly prohibited. - A Smoking Evaluation with Care Plan interventions addressing safety issues must be completed upon admission, quarterly, annually and for change in condition assessments. - The resident and/or the resident representative must sign the resident smoking agreement upon admission, and as needed, which confirms understanding of the smoking policy and schedule. - Following the completion of the Smoking Evaluation and Acknowledgement of this policy, residents will be allowed to smoke in the designated smoking area with the supervision of a family member, resident representative, or employee. No resident is authorized to smoke independently, employees, family, or other resident representatives must supervise them. When staff are providing supervision, smoking will only occur at times designated by the facility.

Based on staff interview, resident interview, clinical records and observation the facility failed to provide appropriate interventions to minimize or prevent urinary tract infections for 3 of 4 residents reviewed with urinary catheters (Residents #11, #55, and #68). The facility reported a census of 69 residents. Findings include: 1. Resident #11's Minimum Data Set (MDS) assessment dated [DATE] identified she admitted on [DATE] to the facility. She had a skilled therapy stay from 1/27/25 to 2/18/25. The MDS identified Resident #11 had a Brief Interview of Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. Resident #11 required substantial/maximum assistance with toileting hygiene. The Care Plan Focus revised 3/11/25 indicated Resident #11 had an indwelling catheter. The Goal reflected Resident #11 wouldn't have signs or symptoms of a urinary infection. The Interventions instructed the following: a. Change the catheter as ordered b. Check tubing for kinks c. Monitor for signs and symptoms of discomfort and pain due to the catheter, report to the doctor symptoms listed. Resident #11's Medical Diagnoses listed she had the following urinary related diagnoses: a. Retention of urine b. Acute kidney failure c. Chronic kidney disease d. Urinary tract infection (UTI) e. Obstructive and reflux uropathy (blockage of urine that causes the urine to flow backward into the kidneys). An Emergency Department (ED) After Visit Summary dated 1/15/24 identified Resident #11 had an ED visit for urinary retention. The diagnoses list included acute urinary retention and UTI. On 3/23/25 at 2:11 PM, saw Resident #11 in bed with her catheter tubing touching the carpeted floor before going into a plastic pan that held the attached catheter bag for urine collection. 2. Resident #55's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS reflected Resident #55 had an indwelling catheter. The MDS included a diagnosis of neurogenic bladder (lack of bladder control). The Care Plan Focus dated 3/2/23 indicated Resident #55 had a urinary catheter due to neuromuscular dysfunction (impaired bladder control) of the bladder. The Goal listed Resident #55 wouldn't develop a UTI. The Interventions directed the following: a. Change the bag as ordered b. Monitor and report to the charge nurse decreased output, odorous urine, leakage around catheter, dark urine, and any complaints of discomforts of catheter. The Health Status Note dated 3/14/25 at 10:53 PM reflected Resident #55 received 1-liter (L) of intravenous (IV) fluids at 9:30 PM without any urinary catheter output. The staff repositioned the catheter and flushed it with good return. Resident #55 continued to have altered mental status, unable to answer questions appropriately. The facility received orders to send Resident #55 to the ED for an evaluation and treatment. A Physician Order for Resident #55 dated 3/17/25 directed to give an antibiotic, Bactrim 400-80 milligrams (mg) for UTI daily by mouth for ten days. On 3/23/25 at 11:08 AM, observed Resident #55 in bed with her catheter tubing touching the floor tiles before going into a plastic pan that held the attached catheter bag for urine collection. 3. Resident #68's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 13, indicating intact cognition. The MDS included diagnoses of Benign Prostatic Hyperplasia (BPH) (referring to enlarged prostate that can block the flow of urine) and unspecified urine retention. The Care Plan Focus dated 3/6/25 identified Resident #68 had an indwelling catheter related to BPH and urinary retention. The Goal reflected Resident #68 wouldn't have signs/symptoms of infection. The Interventions directed the following: a. Check tubing for kinks each shift b. Monitor for signs and symptoms of UTI c. Position the catheter bag and tubing below the level of the bladder. On 3/25/25 at 9:16 AM, witnessed Resident #68 sitting outside with another resident and a staff member who supervised the residents smoking. Resident #68 sat on a chair with his catheter bag hanging on the walker. The catheter tubing from his shorts touched the outside patio cement before extending up to the catheter bag. On 3/26/25 at 10:40 AM, observed Resident #68 sitting in the common area. His catheter bag hung from the last rung of his walker with his tubing touching the carpeted floor. Resident #68 reported sometimes he got a leg bag otherwise he used the bag that hung from his walker. On 3/26/25 at 10:47 AM, while observing Resident #68 with the Director of Nurses (DON), noted Resident #68's catheter tubing touch the floor while he sat in the common area. The DON explained she expected the catheter tubing to not be on the floor. The DON acknowledged the possibility of the introduction of bacteria that could lead to a UTI. On 3/26/25 at 11:06 AM, the Administrator reported he expected the staff to follow protocol for catheters. He added he knew repeat and ongoing education for staff is needed regarding catheters. The Administrator acknowledged the repercussions (unintended negative outcome) included infection and sepsis (severe infection that spreads to the blood). On 3/26/25 at 11:56 AM, the Assistant Director of Nurses (ADON) / Infection Preventionist (IP) acknowledged they knew about the UTI trends in the facility. They looked at nursing staff peri-care techniques, ensured hygiene audits, and even provided supplemental cranberry (increase the acid concentration of the urine). The ADON acknowledged the facility need to implement additional interventions and education related to catheters included catheter and tubing placement. The facility staff explained they didn't have a specific policy on urinary catheters.

Based on observation, policy review, and staff interview, the facility failed to label, date and store food/utensil in accordance with profession standards for food safety to reduce the risk of contamination and food borne illness. The facility reported a census of 69 residents. Findings include: On 3/23/25 at 10:08 AM, during the initial observation of the facility's kitchen, observed refrigerators and freezers with uncovered food items including two drinks in adaptive plastic cups, various salads in bowls and plated. The food packages lacked labeling to identify the product, the open date, and/or use by date, including unidentified meat in a plastic zip lock bag and several bagged items in the freezer (photos available). On 3/23/25 at 10:14 AM, the Dietary Manager (DM) reported he knew the foods should be covered and labeled. He added he reviewed this in training. The DM reported staff brought in several items in the refrigerator in a grocery bag not dated or labeled. On 3/23/25 at 10:18 AM, observed the ice machine with the ice scoop on top of the ice machine, without a container. On 3/23/25 at 10:19 AM, the DM acknowledged the ice scoop utensil should be stored in a container for sanitary purposes. On 3/25/25 at 9:12 AM, the Administrator reported he ordered a special container to adhere to the ice machine to hold the ice scoop. The Administrator confirmed the refrigerator shouldn't have uncovered, undated, and unlabeled food. The facility provided a policy titled, Food Storage dated 2021, it directed all leftover food should be stored covered wrapped carefully, clearly labeled, and dated before refrigerated. Then it must be used within seven days or discarded.

Based on the Center of Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staff Data Report (October 1, 2024 December 31, 2024) review, facility staffing assignments review, staff punch detail review, and staff interviews, the facility failed to submit accurate staffing data for the PBJ Staffing Data Report which indicated the facility had excessively low weekend staffing. The facility reported a census of 69 residents. Findings include: The facility's daily assignment sheets compared to the facility staff punch detail reports, reflected the following coding errors submitted to the CMS PBJ system for the reporting period of October 1, 2024 December 31, 2024: a. 10/12/24 - Certified Nursing Assistant (CNA) coded as a Certified Medication Aide (CMA) for 12 hours on day/evening shift b. 10/13/24 - CNA coded as a CMA for 12 hours on day/evening shift c. 10/19/24 - CNA coded as a CMA for 12 hours on day/evening shift d. 10/27/24 - CNA coded as a CMA for 5 hours on evening shift e. 11/2/24 - CNA coded as a CMA for 8 hours on day shift f. 11/3/24 i. Minimum Data Set (MDS) Coordinator worked as a Licensed Practical Nurse (LPN) for 16 hours on day/evening shift ii. Registered Nurse (RN) worked as a CMA for 4 hours on day shift iii. CNA coded as CMA for 4 hours on day shift iv. CNA coded as CMA for 8 hours on day shift g. 11/9/24 - CNA coded as CMA for 2 hours on day shift h. 11/10/24 i. 2 CNA's coded as CMA's for 12 hours each on day/evening shift ii. LPN worked as a CMA for 4 hours on evening shift. i. 11/16/24 i. CNA coded as CMA for 12 hours on day/evening shift ii. RN worked as a CMA for 4 hours on evening shift j. 11/17/24 i. CNA coded as a CMA for 8 hours on day shift ii. RN worked as a CMA for 4 hours on evening shift k. 11/23/24 i. 2 CNA's coded as CMA's for 12 hours each on the day/evening shift ii. RN worked as a CMA for 4 hours on evening shift l. 11/24/24 i. CNA coded as CMA for 10 hours on day/evening shift ii. CNA coded as CMA for 12 hours on day/evening shift iii. MDS Coordinator worked as CMA for 7 hours on evening shift iv. RN worked as CMA for 4 hours on evening shift m. 11/30/24 - RN worked as CMA for 4 hours on evening shift n. 12/1/24 - CNA coded as CMA for 8 hours on evening shift o. 12/7/24 i. CNA coded as CMA for 12 hours on day/evening shift ii. CNA coded as CMA for 4 hours on evening shift iii. LPN worked as CMA for 4 hours on evening shift iv. RN worked as CMA for 4 hours on evening shift p. 12/8/24 i. Assistant Director of Nursing (ADON) worked as CNA for 11 hours on day/evening shift ii. LPN worked as CMA for 4 hours on evening shift iii. RN worked as CMA for 4 hours on evening shift q. 12/14/24 i. MDS Coordinator worked as CNA for 8 hours on day/evening shift ii. CNA coded as CMA for 12 hours on day/evening shift iii. RN worked as CMA for 4 hours on evening shift r. 12/15/24 - MDS Coordinator worked as CNA for 8 hours on day shift i. ADON worked as CNA for 4 hours on day shift ii. RN worked as CMA for 4 hours on evening shift s. 12/21/24 i. CNA coded as CMA for 12 hours on day/evening shift ii. CNA coded as CMA for 16 hours on day/evening shift t. 12/22/24 i. CNA coded as CMA for 4 hours on day shift ii. CNA coded as CMA for 12 hours on day/evening shift iii. CNA coded as CMA for 4 hours on evening shift u. 12/28/24 i. ADON worked as CNA for 8 hours on evening shift ii. RN worked as CNA for 4 hours on evening shift v. 12/29/24 i. CNA coded as CMA for 4 hours on evening shift ii. RN worked as CNA for 4 hours on evening shift iii. ADON worked as CNA for 8 hours on night shift In an interview on 3/25/25 at 3:00 PM, the Administrator stated the Quality Assurance and Performance Improvement (QAPI) committee reviewed the Facility Assessment and updated it on an annual basis with the Medical Director. The planned to review it again in July 2025. In an interview on 3/25/25 at 3:02 PM, the Administrator stated he expected the staff working dual jobs ensure they clock in for the appropriate job duty they performed. The Office Manager and ADON had the responsibility to make sure the daily schedules match up with the employee's punches. He stated they have a corporate staff person that completed the PBJ submission after the facility reviewed the information first. A policy titled Nursing Services and Sufficient Staff last updated 2/23/25 stated the facility had the responsibility for submitting timely and accurate staffing data through the CMS Payroll Based Journal (PBJ) system.

Based on observation, clinical record review, staff interviews, facility self report and facility inservice record, the facility failed to ensure a resident was safe in the environment. Review revealed Resident #1 required assistance of one staff for personal hygiene and ambulation. On 7/4/24 at approximately 6:58 a.m., Staff A, Certified Nursing Assistant (CNA) assisted Resident #1 to the bathroom with a walker. Staff A proceeded to leave Resident #1 alone in the bathroom for which Resident #1 lost balance and fell to the bathroom floor and sustained a left hip fracture. Additionally on 8/27/24, Resident #2 was transported to an appointment with no staff assistance, fell while at the appointment, taken to the nearest emergency room and sustained a dental fracture to upper incisors. The facility reported a census of 65 residents. Findings include: 1. The Minimum Data Set (MDS) assessment with a reference date of 5/23/24 for Resident #1 documented a score of 8 on Brief Interview for Mental Status (BIMS) test which indicated moderately impaired cognitive impairment, was able to be understood and had the ability to understand others. The resident had diagnoses that included hypertension, diabetes mellitus, Non-Alzheimer's Dementia, anxiety and osteoarthrits and required substantial to maximal assistance with toileting, dressing and personal hygiene and supervision or touching assistance with oral hygiene and assistance with ambulation with walker. A Significant Change MDS assessment with a reference date of 7/18/24 for Resident #1 documented has the ability to be understood and ability to understand others. The resident had diagnosis that included hypertension, Non-Alzheimer Dementia and recent hip fracture, with recent fall with bone fracture and surgical wound. A Nursing Care Plan with a created date of 4/11/23, identified a problem of I have an Activity of Daily Living (ADL) self-care performance deficit related to weakness, deconditioning, impaired mobility and I am at risk for injury from falls due to impaired mobility and weakness, dementia and macular degeneration Interventions include: *(7/4/24), Non-skin strips placed on floor in bathroom. *Ambulate with me to the dining room and activities. *I use a front wheeled walker. *Please ensure my call light is in reach and remind me to use it for assistance. *Ambulation: Assist time 1 with front wheeled walker *Oral Cares: Assist times 1 *Toileting: Assist times 1 for toileting and peri cares. A Interdisciplinary Care Conference Worksheet dated 4/24/24, documented resident needs 1 assist with cares with front wheeled walker and has moderate cognitive impairment. A Fall Risk assessment dated [DATE], documented resident with no history of falls and is at moderate risk with shuffling steps and uses an assistive device, walker. The Progress Notes dated 5/23/24 at 9:23 a.m., documented Quarterly Nursing Assessment note: quarterly nursing assessment completed. Resident is disoriented to place and time. Wears glasses to aid in vision. Residents hearing is adequate. Has an upper extremity functional limitation in range of motion on one side of the body. No lower extremity limitations noted with range of motion. Resident transfers with supervision, one person physical assist. Is able to ambulate in corridor with supervision with setup help only. Resident uses a walker. Resident needs physical help with part of the bathing activity. Is able to dress self with limited staff assist. Completes personal hygiene with staff supervision. Resident is occasionally incontinent of urine. The Progress Notes dated 7/4/24 at 7:28 a.m., documented Health Status Note Text: Resident had a fall at 6:55 a.m. in resident's bathroom. Resident was found with head under the sink. Resident was using the walker at the time. Her slipper were off her feet. Resident was on her sides. Resident had loose stool in her brief. Resident states my left hip hurts very much. CNA, states I was in the room getting the husband. Then, I heard the noise from the bathroom and found her on the floor. No bleeding or bruises noted. No open injuries noted. Blood pressure inaudible with manual blood pressure cuff. 911 called at 7:00 a.m. and resident transferred to emergency room at 7:21 a.m. In an Unwitnessed Fall Report dated 7/4/24 at 6:58 a.m., documented CNA notified this nurse of fall of resident in bathroom at 6:56 a.m. At 6:58 a.m., Resident found on the floor of bathroom with head under the sink. Resident in right lateral posture lying on the floor and complaining pain to left hip. Resident then complained of pain to left leg. Resident husband waiting for her outside the room. Resident has small bowel movement in her brief, but due to nature of the fall and pain, no changes in position made to change the brief. Residents left leg was angled at knee and any movement to that limb aggravated pain. Pain level 10/10. No visible injuries or cut noted to head, limb or trunk at this time. Resident states I don't know what happened but my left leg hurts. Mobility status: Ambulatory with assistive device/with out assist at time of fall. An investigation self-report amendment submitted to the Department by the facility on 7/4/24, included the following: Resident is assist time 1 staff, was brought into bathroom with walker to brush her teeth, left unattended and fell . Injury of Fracture of the Left Femoral Neck on the left leg. On Thursday July 4th 2024, at approximately 6:55 a.m., Resident #1 was assisted by Staff A in getting set up with oral cares at the bathroom sink. Staff A then left the bathroom to assist the roommate. While assisting the roommate, Staff A heard a noise from the bathroom. Staff A re-entered the bathroom to find Resident #1 on the floor of the bathroom lying on her left side. Staff B, RN, performed a head-to-toe assessment on Resident #1. Resident #1 stated that my left hip hurts very much. Staff B, RN, made the decision to send Resident #1 to the emergency room per nursing judgement related to head-to-toe assessment and positioning of leg. Corrective Action: Staff A was provided 1-1 education on the need to stay with residents who are coded as needing assistance of 1 or more staff members at all times during personal care tasks. All facility staff members were educated on the need to stay with residents who are coded as needing assistance of 1 or more staff members at all times during personal cares tasks by the Director of Nursing on 7/5/24. The Hospital Consultative Note dated 7/4/24 at 10:53 a.m., documented, Resident #1 is an [AGE] year-old female, whom I was asked to see in consultation for a left displaced femoral neck fracture. She fell in the bathroom this morning. She walks with a walker. She complains of left hip pain. Diagnostic Data: X-rays of left hip reveal a displaced femoral neck fracture without preexisting arthritis. Assessment: Left displaced femoral neck fracture in an ambulator. Observation on 9/17/24 at 8:45 a.m., Staff C, Certified Nursing Assistant (CNA) and Staff D, CNA, transferred Resident #1 with the use of a gait belt and front wheeled walker from the wheelchair to a recliner. Resident had a slow steady gait and complained of left hip pain during the transfer. Interview on 9/16/24 at 2:30 p.m., Staff A, CNA stated that they went into Resident #1 room to assist the resident to the bathroom on 7/4/24 approximately 6:55 a.m. Staff A stated that as Resident #1 was in the bathroom the roommate attempted to open the door to the bathroom so Staff A, left Resident #1 alone in the bathroom as they assisted the roommate back to the recliner. Staff A then heard a noise come from the bathroom. Staff A stated that when they went back into the bathroom, Resident #1 was on the floor. Staff A stated that the expectation of the staff is to stay with a resident that needs assist of 1 for cares, including personal/oral hygiene and that Staff A got education on the need to stay with any resident that required staff assistance. Interview on 9/17/24 at 10:00 a.m., Staff B, Registered Nurse (RN) stated they worked on 7/4/24 when Resident #1 fell in the bathroom. Staff B, confirmed and verified that Resident #1 needed assistance of 1 staff for cares and that it is the expectation of the staff to stay with any resident that requires assistance and that the facility did education about the expectation of staying with a resident that requires assist. Interview on 9/17/24 at 1:50 p.m., The Director of Nursing confirmed and verified that the expectation of staff are to stay with any resident that requires cueing, supervision or assistance with cares. An Inservice Record dated 7/5/24, documented that Residents who are coded as needing assistance of one or more staff members for ADL's should not be left alone while they are completing a personal task (brushing teeth). They [NAME] be supervised throughout the completion of the task. 2. The MDS assessment with a reference date of 6/13/24 for Resident #2 documented a score of 6 on BIMS test which indicated severely impaired cognitive impairment, unclear speech, sometimes is understood and usually understands others. The resident had diagnoses that included hypertension, Alzheimer's Disease, Non-Alzheimer's Dementia, depression and Schizophrenia and is independent with ambulation with a walker and had a recent fall with 2 or more injuries. The Plan of Care with an initiated date of 9/10/20, had a focus area of I have impaired cognitive function or impaired thought processes related to cognitive communication disorder. Interventions include: *RESIDENT WILL HAVE STAFF PERSON OR FAMILY MEMBER GO TO APPOINTMENTS WITH HIM *Verbal communication can be difficult to understand at times. Sometimes I will write notes to staff to communicate or make my needs known. The Progress Notes dated 8/27/24 at 9:55 p.m., documented Health Status Note Text: Resident had gone to for a Dental appointment in the morning. In the afternoon after his consultation he had a fall there and was sent to Hospital ER. The Progress Notes dated 8/28/24 at 5:00 a.m., Comprehensive Encounter Date of Service: Chief Complaint: Post ER visit History of Present Illness: Patient is a [AGE] year old male with chronic health conditions. Schizoaffective disorder, insomnia, dyslipidemia, cognitive communication deficit, essential hypertension, regional lumbar radiculopathy, osteoarthritis, spinal stenosis, and Alzheimer's. Today he is seen in his room via telehealth, he is at baseline. He was at a dentist clinic visit yesterday and had a fall with injury to his mouth. He was sent to ER for evaluation. Noted open spot in top front gums from extraction and two small teeth have chips next to open spot, no bruising or bleeding. He is calm, pleasant, disorganized thought process. The Progress Notes dated 8/28/24 at 2:19 a.m., documented Health Status Note Text: Resident returned from ER at 11:15 p.m., accompanied/transported by the facility Administrator. Resident is alert, aware of surroundings. Told this Nurse he lost balance and fell at the dentist office earlier. Only injury is chipped tooth. Resident states only pain is to neck and back, but doesn't need anything for pain at present time. The Medical Center Emergency Department dated 8/27/24, documented, reason for visit is a fall, patient presents via Emergency Medical Services with complaint of being found on the bathroom floor of the dentist office. Patient was apparently dropped off at the dentist for a tooth extraction, but no one from the facility remained with the patient at the appointment. History of Alzheimer's dementia and schizophrenia. C-collar in place upon arrival. Description=fall , initial encounter with broken teeth. Patient presents with fall. History of dementia. Found on floor at dentist office with dental fractures. Dental fracture to upper incisors. Dental cement applied to fractured tooth. Patient brought to the Emergency Department by EMS after being found on the floor of the bathroom at the dentists office. Patient did not have any attendants at his visit. History taking is extremely limited from patient as is not oriented to person, place situation. Speaks in short sentences, difficult to understand. Appears to have multiple dental fractures, one tooth site oozing blood. Dried blood in mouth. Interview on 9/17/24 at 11:25 a.m., the facility administrator confirmed and verified that residents are to have staff accompany them to appointments if families are not able to.

Based on observation, clinical record review, resident interview, staff interview and policy review, the facility failed to provide adequate supervision to 3 of 5 residents observed (Residents #19, #31 and #46) during medication administration. The facility reported a census of 64 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #31, dated 2/15/24, documents a Brief Interview for Mental Status (BIMS) of 10, indicating mild impairment. The MDS included diagnoses of medically complex conditions, coronary artery disease, renal insufficiency, age related osteoporosis and depression. During an observation on 5/19/24 at 11:30 AM, Resident #31 had her tray table in front of her as she sat in a reclining chair in her room. On her tray table contained a small cup with 3 medications next to a glass of water. Resident #31 stated she didn't know what the pills were and said the nurse left them for her to take. Upon entry into Resident #31's room, observed no staff present in the room or outside of the room. Resident #31 didn't know how long the medication sat on the tray. Resident #31 shared a room with Resident #265, who was also present in the room. Resident #31's May 2024 Medication Administration Record (MAR) included the following orders: a. Gabapentin Capsule 100 MG, two capsules by mouth, - Noon dose administered by Staff E, Certified Medical Assistant (CMA), on 5/19/24. b. Tylenol 8-hour Arthritis pain tablet, extended release 650 MG, one tablet by mouth. - Noon dose administered by Staff E. The review of Resident #265's, Resident #31's roommate, clinical record identified a medical diagnosis of personal history of suicidal behavior. During an interview 5/20/24 at 11:29 AM, Staff E recalled going into Resident #31's room on 5/19/24 to give her, her noon medications. Staff E couldn't remember when she went in there, but believed it happened around 11:25 AM. Staff E stated when she went into Resident #31's room to give her the noon medications, which consisted of three pills, she was in the bathroom. Staff E stated said she called through the bathroom door to Resident #31, saying she had her noon medications and would leave them on her bedside tray. Staff E advised she left the medications on the bedside tray and left the room. Staff E recalled Resident #265 being in the room at the time. Staff E reported the facility policy and protocol is to watch residents take their medication, ensure they took their medication prior to leaving the room, and not to leave medication unattended in a resident's room. Staff E stated she should have taken the medication out of the room with her and gone back in the room when Resident #31 got out of the bathroom. During an interview 5/20/24 at 12:08 PM, the Director of Nursing (DON) reported that Staff E should have watched Resident #31 consume the medication, especially with her lower BIMs score. The DON stated Staff E shouldn't leave the medication in the room unattended. The undated Medication Administration Policy directed the facility to administer medications to residents in a safe manner. 44972 2. On 5/20/24 at 7:53 AM, observed Staff G, Registered Nurse (RN), enter Resident #46's room to complete a blood glucose test and administer sliding scale insulin if needed. After completing the glucose monitoring test Staff G went back to the computer on the medication cart to check the order for the amount of insulin to give Resident #46. When Staff G left, the container containing the blood glucose monitor, lancets, and 2 insulin pens on a tray table unattended in Resident #46 room, with her and her roommate present in the room. After administering the insulin, Staff G returned to the medication cart to document the administration of the insulin on the TAR. At this time, witnessed that she failed to close the screen, leaving Resident #46's information visible for others to see. 3. On 5/20/24 at 8:15 AM, witnessed Staff F, Certified Medication Aide (CMA), leave a glass of water containing Miralax (a laxative) at the dining table for Resident #19, failing to supervise her drinking the medication. Resident #19 and her husband sat at the table with numerous other residents in the area. In an interview on 5/21/24 at 3:40 PM, the Director of Nursing (DON) stated the facility didn't have a policy related specifically to leaving medications unattended with a resident. The DON stated they expected the staff to follow professional standards of care. The undated Medication Administration Policy directed the facility to administer medications to residents in a safe manner. In an interview on 5/21/24 at 3:40 PM, the DON stated they expected the staff to follow the 5 rights of medication administration unless a physician order directed otherwise. She added that she expected the staff to close the computer screen when away from or not in view of the computer.

Based on observation, staff interview, and policy review, the facility failed to serve food to maintain a safe and appetizing temperature. The facility reported a census of 64. Findings include: On 5/21/24 at 11:38 AM, Staff A, Cook, checked the temperature of 13 menu items on the steam table for lunch. All 13 items revealed a temperature above 135 Fahrenheit (F). At 12:17 AM, Staff A placed a resident's plate on a serving tray and the Dietary Manager (DM) placed a cup of milk on the tray then placed the tray on the top shelf of the delivery cart. At 12:25 PM, Staff A, placed a resident's plate of food on the last tray on the delivery cart. Staff B, Cook, confirmed the commitment to deliver the food. When asked to check the temperature of the items on the first tray placed on the delivery cart, the DM received a temperature for the broccoli of 99.0 F; the tater tots 127.9 F; and the milk's 44.7 F. At 12:50 PM, Staff A checked the temperature of the remaining food on the steam table. The chicken soup's temperature measured 117.2 and the tomato soup's measured 130.1 F. On 5/22/24 at 9:14 AM, the Administrator stated they should have discarded the food and prepared a new plate of food for the resident. The Food Temperatures policy dated 2021 instructed to cook all hot food items to appropriate internal temperatures, held, and served at a temperature of at least 135 F. It also indicated cold foods stay below 41 F during the holding, plating process, and until food leaves the service area.

Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing and serving food. In addition, the dietary staff failed to wear hairnets while in the food service area. The facility reported a census of 64 residents. Findings include: On 5/19/24 at 9:10 AM, a kitchen observation identified the following findings: A Traulsen refrigerator contained: 1) An undated Jarritas orange drink. 2) Two unlabeled blue pitchers that contained clear liquid. 3) An undated small tub of beef paste. A Whirlpool refrigerator contained: 1) An uncovered, unlabeled, and undated aluminum pan of red items resembling strawberries. 2) An opened, undated plastic container of strawberries. 3) An undated, previously opened carton of Lactaid. 4) An unlabeled bag of shredded, orange item resembling cheese. A Whirlpool freezer contained: 1) An unlabeled, undated bag of breaded items. 2) An unlabeled, undated plastic bag of flat, yellow items. A General Electric (GE) freezer contained: 1) An unlabeled, undated bag of flat, yellow items. An Amana and three (3) Frigidaire freezers contained undated, unlabeled, previously opened food items. The Scotsman ice machine scoop was lying on top of the ice machine without a barrier. On 5/19/24 at 4:10 PM, observed Staff C, Dietary Aide (DA), in the food preparation area wearing a white ball cap without a hairnet covering the exposed hair nor the beard. On 5/21/24 at 11:18 AM, Staff D, Maintenance Assistant, walked through the food service area without wearing a hairnet nor beard covering. On 5/21/24 at 11:50 AM, Staff A, Cook, removed a pan of bread off the resident menus on the top shelf of the steam table and place it on the rear stack of plates within the steam table serving area. Between 11:55 AM and 12:10 PM, noted the pan of bread on three (3) resident's plates used to serve lunch. On 5/21/24 at 1:05 PM, during a follow up kitchen observation reflected all concerns corrected from the initial tour on 5/19/24 except the Whirlpool freezer still contained an unlabeled, undated bag of breaded items. On 5/22/24 at 9:14 AM, the Administrator stated the maintenance staff shouldn't be in the kitchen area unless repairing equipment. All staff in the kitchen should cover all of their facial and head hair with a hairnet. He added the staff should label, date, and cover all food prior to putting in storage. The Food Storage policy dated 2021 directed to cover, label, and date all refrigerated and frozen foods. The General Food Preparation and Handling policy dated 2021 instructed to thoroughly clean and sanitize any utensil or serving dish prior to use. The Food Safety and Sanitation dated 2021 indicated the facility required hair restraints that should cover all hair on the head. In addition, the facility required beard nets with visible facial hair.

Based on observation, interview, and clinical record review, the facility failed to maintain confidentiality of 2 of 5 residents reviewed (Residents #19 and #46) during the process of medication administration. The facility reported a census of 64 residents. Findings include: 1. On 5/20/24 at 8:15 AM, witnessed Staff F, Certified Medication Aide (CMA), leave a glass of water containing Miralax (a laxative) at the dining table for Resident #19, failing to supervise her drinking the medication. Resident #19 and her husband sat at the table with numerous other residents in the area. 2. On 5/20/24 at 7:53 AM, observed Staff G, Registered Nurse (RN), enter Resident #46's room to complete a blood glucose test and administer sliding scale insulin if needed. After administering the insulin, Staff G returned to the medication cart to document the administration of the insulin on the TAR. At this time, witnessed that she failed to close the screen, leaving Resident #46's information visible for others to see. In an interview on 5/21/24 at 3:40 PM, the Director of Nursing (DON) stated the facility didn't have a policy related to ensuring the securing of the computer screen with resident information when away from the computer. The DON stated they expected the staff to follow professional standards of care. In an interview on 5/21/24 at 3:40 PM, the DON stated they expected the staff to follow the 5 rights of medication administration unless a physician order directed otherwise. She added that she expected the staff to close the computer screen when away from or not in view of the computer.

Based on clinical record review and staff interview, the facility failed to refer one resident (Resident #57) with a Level I Preadmission Screening and Resident Review (PASARR) with a diagnosed serious mental disorder for evaluation of a Level II PASARR at the time the diagnosis was known to the facility for 1 of 1 resident reviewed for PASARR. The facility reported a census of 64. Findings include: Resident #57's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 10, indicating moderate cognitive impairment. The MDS included diagnoses of Type II diabetes mellitus, specific personality disorders, anxiety disorder, generalized anxiety disorder, personality disorder unspecified, vascular dementia, and post traumatic stress disorder (PTSD). The MDS reflected Resident #57 took antipsychotic and antidepressant medications. The Care Plan Focus revised 7/10/23 indicated Resident #57 had a history of trauma/life event resulting in PTSD and used high risk medications to treat mood disorders. Resident used antipsychotic medication and antidepressant medication to assist with negative behaviors. Resident #57's Level I PASARR completed 11/21/23 documented no Level II PASARR required as she had no serious mental impairment, intellectual disability, or other related conditions. The Level I PASARR included a diagnosis of an anxiety disorder. In addition, documented Resident #57 received Depakote for anxiety with Namenda and Risperdal for dementia. The screening listed no further PASARR screening required unless she had a significant change. Resident #57's clinical record lacked a PASARR following 11/21/23. Resident #57's Medical Diagnoses reflected the following diagnoses: a. Specific personality disorders added 2/2/24 b. Personality disorder unspecified added 12/15/23. Resident #57's May 2024 Medication Administration Record included the following psychotropic medication orders: a. Mirtazapine oral tablet 3.75 milligrams (mg) one time a day for personality disorder with a start date of 2/5/24 b. Sertraline HCL oral tablet 75 mg one time a day for personality disorder with a start date of 1/11/24. In an interview on 5/21/24 at 3:50 PM, the Administrator stated the facility didn't have a facility policy relating to PASARR's but the facility followed the federal mandated regulations for the completion of them. In an interview on 5/21/24 at 3:50 PM, the Administrator stated they expected the facility to audit the PASARR process regularly and update the PASARR's as required. He provided a copy of a Level I PASARR submitted for Resident #57 on the date of interview with the new diagnosis and medications.

Based on observation and staff interviews, the facility failed to maintain a safe environment by leaving a medication cart unlocked and unsupervised. The facility reported a census of 64 residents Findings include: In an observation on 5/20/24 at 9:12 AM, Staff F, Certified Medication Aide (CMA), left the medication cart unlocked and unattended when she walked into Resident #1's room to administer their medications. The medication cart sat against the wall outside of Resident #1's room out of sight from the room. In an interview on 5/21/24 at 3:40 PM, the Director of Nursing (DON) stated they didn't have a facility policy related to ensuring staff locked the medication carts when not in sight. She expected the facility staff to follow the professional standards of care. In addition, she expected the staff to have the medication cart be locked at all times when away from the cart or when unable to see the cart.

Based on observation, menu review, staff interview, and policy review, the facility failed to serve the correct serving size of protein for 3 of 5 residents who received pureed diets. The facility reported a census of 64 residents. Findings include: On 5/21/24 at 11:12 AM, Staff A, [NAME] stated the facility had five (5) residents who required pureed diets. She placed five (5) portions of pork casserole, two (2) cups of pineapple sauce, and five (5) slices of bread into a blender and pureed the contents. She measured the pureed mixture and noted five (5) cups of pureed contents. She referred to the pureed portion conversion chart and verbalized the required serving as two #8 serving scoops. The #8 serving scoop equaled 4 ounces which indicated the serving should measure a total of 8 ounces. Between 12:05 PM and 12:25 PM, Staff A prepared 3 pureed diet plates with one #8 scoop of protein, half of the required portion size. An observation at the end of meal service revealed the pureed protein had more than half remaining. On 5/22/24 at 9:25 AM, the Administrator stated the staff member should follow the pureed conversion chart during meal service. The undated document labeled Puree Process directed staff to find the correct scoop size that corresponds to the portion size.

Based on observation, staff interview, and policy review, the facility failed to maintain proper infection control practices to protect against potential cross contamination for 2 of 16 residents observed (Resident #2 and #41). As a Certified Medication Aide (CMA) prepare Resident #2's medication, they failed to perform hand hygiene after coughing and blowing their nose. In addition, the facility failed to keep a resident's blanket clean after placing in a shared sink before putting it back on a resident (Resident #41). The facility reported a census of 64. Findings include: 1. On 5/20/24 at 7:45 AM witnessed Staff H, Certified Medication Aide (CMA), prepare Resident #1's medications. Staff H began to cough into her hands and blow her nose. She failed to perform hand hygiene after and continued to prepare Resident #2's medication, then administer it to them. In an interview on 5/21/24 at 3:40 PM, the Director of Nursing (DON) stated she expected staff to complete hand hygiene before and after each medication pass. If the staff coughed or blowed their nose, they needed to perform hand hygiene before continuing the medication pass. 47079 2. On 5/19/24 at 12:11 PM when Staff B, Cook, delivered Resident #41, their lunch tray, they removed the blanket from his legs and placed it in a shared sink with another resident. Resident #41's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #41 required set up assistance with eating and oral hygiene, the needed maximum assistance with personal hygiene. The MDS included diagnoses of severely impaired vision, retrolental fibroplasia (a disease that causes blindness) and cerebral vascular accident (stroke). The Care Plan Focus dated 4/9/24 indicated Resident #41 had impaired visual function. The Interventions directed the staff to arrange Resident #41's personal belongings on his right side to promote independence. On 5/19/24 at 4:10 PM, observed Resident #41's blanket back over his legs. On 5/20/24 at 9:24 AM, witnessed Resident #41's blanket lying on the floor to the left of his recliner as he slept. On 5/22/24 at 9:09 AM, the DON stated the staff member should have placed the blanket on his wheelchair and not in the sink. The General Guidelines policy dated 10/5/23 directed staff to maintain a sanitary environment for the staff, residents, visitors, and the general public.

Based on record review, facility policy review, staff, and resident interviews, the facility failed to follow professional standards for medication administration by failing to administer Dilaudid, a narcotic pain medication for 1 of 3 residents reviewed (Resident #6) as ordered by the provider as needed for post-surgical pain. Findings include: Review of Resident #6's electronic progress notes included the following entries on 2/14/23: The Admission Summary Note on 2/14/24 at 10:54 AM described Resident #6 as oriented to person, place, time, and situation. She had severe pain that made it hard to sleep and limited day to day activities. The N Adv Pain and Vitals Only Note dated 2/14/24 at 11:09 AM indicated Resident #6 reported moderate to severe pain in her back up to her neck. The Health Status Note dated 2/14/24 at 11:10 AM reflected Resident #6 just had fusion surgery on her C3-C7 (Cervical discs located in the upper spine including the neck) vertebrae. She had incisions present on the front and back of her neck. Resident #6's February 2024 Electronic Medication Administration Record (EMAR) included the following orders: a. 2/15/24: Dilaudid Oral tablet 2 milligrams (mg). Give 1-2 tablets by mouth every 4 hours as needed (PRN) for pain control. Give 1 pain pill if pain is rated 1-5, give 2 pain pills if pain is rated 6-10. Documentation indicated Resident #6 received Dilaudid at the following times on 2/16/24: i. 12:45 AM: 2 tablets for a pain rating of 8. Documented as effective. ii. 7:35 AM: 2 tablets for a pain rating of 6. Documented as effective. iii. 12:51 PM: 2 tablets for a pain rating of 5. Documented as effective. iv. 5:48 PM: 1 tablet for a pain rating of 9. Documented as ineffective. v. 10:42 PM 1 tablet for a pain rating of 7. Documented as unknown effectiveness. In an interview 2/19/24 at 1:45 PM Resident #6 stated she admitted to the facility after having a cervical spinal fusion with hardware installed. She described it as very painful and debilitating. Resident #6 added on 2/16/24 at approximately 9:15 PM she asked for Dilaudid for pain, because she had a lot of pain. The nurse told her, she couldn't have pain medication at that time. Resident #6 said she questioned that, and asked the nurse to go check because she was sure that she was entitled to have and needed for pain. The nurse returned later with one 2 mg Dilaudid. She stated she replied that she knew that she could have 2 pain pills or 4 mg depending on her pain rating. Resident #6 confirmed she only received one pain pill, that didn't control her pain. In an interview on 2/21/24 at 1:20 PM the Director of Nursing (DON) stated that the facility staff failed to administer Resident #6's PRN Dilaudid as ordered for relief due to her post-surgical pain. The DON reported she expected staff to administer pain medication as directed and to follow the parameters directed for determination of one or two pain pills. The DON clarified that the facility assesses pain by asking the resident to rate their pain on a scale from 1-10 and if a resident can't rate their pain, the nurse needed to use the scale for the cognitively impaired. The DON explained she expected the staff to use the pain rating as identified by the resident. Review of undated facility policy titled Medication Administration Policy included the following: Medication the physician orders at a specific time will have the time listed. The facility was unable to provide a policy specific to PRN medication administration.

Based on clinical record review, observations, and staff interview, the facility failed to ensure that residents did not develop avoidable pressure ulcers for 1 of 1 residents reviewed (Resident #8). The facility reported a census of 64. Findings include: The quarterly Minimum Data Set (MDS) dated [DATE] for Resident #8 identified a Brief Interview for Mental Status (BIMS) score of 11 indicating a moderate cognitive impairment. The MDS revealed the resident required extensive assistance of 1 staff member for bed mobility and personal hygiene, and extensive assistance of 2 staff members for transfers. The MDS further revealed the resident did not walk in her room or in the corridor. The MDS documented diagnoses that included diabetes, prior hip fracture, Parkinson's Disease, prior stroke, depression and traumatic brain injury. The comprehensive care plan revealed a focus area of Activity of Daily Living (ADL) deficit, revision date of 9/8/21. The care plan failed to direct staff to do any bed mobility or repositioning of the resident. The care plan additionally revealed a focused area of Impaired Skin Integrity related to decreased mobility, revision date of 12/6/22. This section of the care plan also failed to direct staff to do any bed mobility or repositioning of the resident. Record review of the current care plan revealed the facility failed to implement interventions related to the presence of a pressure ulcer that was identified on 12/15/22 until it was revised on 1/23/22. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The Braden Scale for Predicting Pressure Sore Risk revealed documentation the resident scored a 15 indicating a low risk for the development of pressure ulcers. A score of 9 or less indicates a severe risk. A score of 10-12 indicates a moderate risk. A score of 13-14 indicates a mild risk. A score of 15-18 indicates a low risk. A score of 19 or higher indicates a resident is not considered at risk for pressure ulcer development. The skin sheet, non-ulcer assessment dated [DATE] revealed the resident had blister to her right heel which had burst. The assessment documented the measurements were 7.0 cm x 3.0 cm x 0.1 cm. The skin sheet, non-ulcer assessment dated [DATE] documented the blister to be resolved. The skin sheet, ulcer assessment dated [DATE] documented the resident to have a Stage 2 pressure ulcer to her right heel. The assessment documented the pressure ulcer had measurements of 1.5 cm x 1.5 cm x 0.3 cm and further documented the pressure ulcer as facility acquired. Additional description included scant yellow drainage with no odor and the wound base having granulation tissue (pink or red tissue with a shiny, moist appearance). The skin sheet, ulcer assessment dated [DATE] documented the pressure ulcer measurements had increased to 2.5 cm x 2.5 cm x 0.6 cm. Further description included scant yellow drainage with the wound base having pink or red tissue with a shiny, moist appearance. Further description included scant yellow and brown odorous drainage with the wound base having slough (yellow or white tissue that adheres to the ulcer bed in strings or clumps or is mucinous). The skin sheet, ulcer assessment dated [DATE] documented the pressure ulcer had measurements of 2.2 cm x 2.2 cm x 0.2 cm. The ulcer was now noted to be a Stage 3 pressure ulcer. Further description included scant serosanguineous drainage (thin and watery fluid pink in color due to presence of small amount of red blood cells) with the wound base having pink or red tissue with a shiny, moist appearance. Further description included scant yellow and brown odorous drainage with the wound base having slough (yellow or white tissue that adheres to the ulcer bed in strings or clumps or is mucinous). Weekly weight and skin review notes dated 12/7/22, 12/15/22 and 12/29/22 lacked documentation of Resident #8 being discussed during the any of these weekly meetings. On 1/25/23 at 3:50 pm, the Director of Nursing (DON) stated there were only 3 meetings in December due to the holidays. Review of document titled Dietitian fax to Physician revealed the resident was seen by a Registered Dietitian on 10/28/22. Review of document titled Consultant Dietitian Report revealed the resident was seen by a Registered Dietitian on 1/16/23. The facility was unable to provide documentation of a Registered Dietitian performing any other visits in between those two dates. A progress note dated 1/4/23 at 4:34 pm by Staff A, Licensed Practical Nurse (LPN) documented a noted decline to the wound and physician notification was made. A progress note dated 1/9/23 at 10:48 am by the Assistant Director of Nursing stated a new order for an antibiotic was received for possible cellulitis to the right foot. A progress note dated 1/12/23 at 9:20 am by Staff D, facility Registered Dietitian stated a recommendation of LiquaCel (a liquid collagen liquid protein) to promote skin healing of the stage 2 pressure ulcer. A progress note dated 1/23/23 at 4:03 pm by the ADON stated a referral had been received to send the resident to a wound clinic. A visit note dated 12/19/22 by Staff H, Nurse Practitioner revealed documentation of a Stage II pressure ulcer to the right heel containing 60% slough. A visit note dated 1/23/23 by Staff H, Nurse Practitioner revealed documentation of a Stage III pressure ulcer of the right heel that was black and appeared necrotic (dead skin). Observation on 1/23/23 at 10:55 am revealed the resident to be in her wheelchair wearing heel protectors on both feet. Observation on 1/24/23 at 9:41 revealed the resident to be in her recliner wearing heel protectors on both feet. Observation on 1/25/23 at 10:42 am revealed the resident to be lying in bed with heel protectors on both feet. Observation on 1/26/23 at 9:13 am revealed the resident to be sitting in her wheelchair wearing a sock on her left foot and a slipper on her right foot. No heel protectors were in place. On 1/24/23 at 12:34 PM, Staff I, Licensed Practical Nurse (LPN), MDS Coordinator stated she is new to the role of MDS Coordinator in the facility. She voiced she is currently going through the care plans of all of the residents and updating them as she felt they were not accurate at the time she began the position. On 1/25/23 at 10:08 am, the ADON stated she is the primary person who manages wounds in the facility. She stated she has received no specialty wound training. She further stated the facility used to have a wound Nurse Practitioner for the facility but those visits stopped perhaps last summer. She stated in the beginning of December a blister was found and it slowly declined. She felt it was going back and forth in wound healing. She stated she talking to the Registered Dietitian a couple of weeks earlier about a dietary supplement and that the resident is diabetic. She stated the facility Nurse Practitioner assessed the wound on 12/19/22 and 1/23/23. She voiced the protocol for wounds are that she assesses them once a week unless she is informed of a decline in the wound. She stated her expectation is that a resident who needs assistance to be repositioned should be assisted every 2-3 hours. On 1/25/23 at 1:31 pm, the Director of Nursing (DON) stated that prior to the resident's wound being discovered, interventions for prevention of development of a pressure ulcer would include whatever was on her care plan. She stated she had a pressure reducing cushion on her recliner. She stated the resident does not have a specialty mattress on her bed but all of the mattresses in the facility are considered pressure reducing mattresses. She stated when the resident was in her wheelchair for meals she would be transferred to her bed or recliner after meals. She voiced her expectation is residents should be assisted to reposition every 2-3 hours if they are unable to reposition themselves. On 1/25/23 at 3:47 pm, the Regional Nurse Specialist for the facility stated the facility does not have a policy for Registered Dietitian reviewing residents. She stated it would be considered a standard of care to have the Registered Dietitian involved in residents with wounds. On 1/25/23 at 3:50 pm, the DON stated updating care plans is an interdisciplinary approach. She stated her expectation is that care plans should be updated quarterly and with significant changes. She stated they follow the Resident Assessment Instrument (RAI) process for care plan reviews. She further stated the ADON is the person who typically updates the care plans for any skin issues or any incidents filed in Risk Management (a portion of the Electronic Health Record for incident reports such as falls, skin injuries, etc.).

Based on clinical record reviews, facility policy review, staff, Pharmacist, and Advance Registered Nurse Practitioner (ARNP) interviews, the facility failed to provide 3 of 5 residents (Resident #19, #34, and #50) with medications as ordered. On 4/13/22 Resident #19 received another resident's medications. Resident #19 required an overnight hospitalization due to chest pain experienced after receiving the medication. In addition, the facility gave a medication not as ordered to Resident #34 on 1/26/22 during an observation. This resulted in an excess of an anticonvulsant medication given. The facility also failed to administer Resident #50 hypertensive extended release (ER) medication as directed by crushing the medication, thus changing the release time of the medication. The facility reported a census of 64 residents. Findings include: 1. Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14, indicating no cognitive impairment. The MDS revealed she is independent with bed mobility, transfers, walking, and eating. The MDS documented a diagnosis of schizophrenia. The MDS indicated that Resident #19 use an antipsychotic medication for seven out of seven days in the lookback period. Resident #19's Clinical Census identified that on 4/13/22 she went to the hospital and returned on 4/14/22 to the facility. The facility document titled, Self-Report, dated 1/24/23 for Resident #19 documented on 4/13/22 that at approximately 7:58 AM, Resident #19 received medications not prescribed for her at approximately 7:15 AM. The form listed that while Staff H, Licensed Practical Nurse (LPN), did her morning medication pass, she mistakenly administered the following medications to Resident #19. a. Fetzima 120 milligrams (mg) (antidepressant medication) b. Jardiance 25 mg (diabetic medication) c. Metformin XR 1,000 mg (diabetic medication) d. Zyprexa 2.5 mg (antipsychotic medication) e. Perphenazine 24 mg (antipsychotic medication) The document instructed the facility notified Resident #19 family, psychiatric nurse, Nurse Practitioner, and Poison Control. Poison Control recommended that Resident #19 went to the emergency room , but she refused. At approximately 10:40 AM, while onsite at the facility, Staff F, Advanced Registered Nurse Practitioner (ARNP), gave an order to send Resident #19 to the Emergency Department (ED) for chest pain. Resident #19 got admitted to the local hospital from the ED for nursing observation. The History and Physical (H&P) from the local hospital dated 4/13/22 documented Resident #19 got evaluated at the local ED and is doing well, but she did have palpitations (feelings of having a fast-beating, fluttering, or pounding heart) and some left-sided chest discomfort with some nausea, but no vomiting. On 1/26/23 at 12:32 PM Staff G, Pharmacist, explained that the medications Resident #19 received in error on 4/13/22, Zyprexa and Perphenazine, may cause some drowsiness. He reported that he could speculate other side effects that could have happened, but he believed that medication error could cause those side effects. On 1/26/23 at 12:36 PM Staff F revealed that the error happened due to Resident #19 having the same first name as another resident. She added that Resident #19 also has a psychiatric doctor that she consulted and decided to keep her at the facility unless symptoms occur. She explained that when she arrived onsite on 4/13/22, Resident #19 was expressing symptoms of chest pain. At that time, they decided to send her to the local ED. Staff F revealed that Resident #19 likely had chest pain due to her anxiety. On 1/26/23 at 12:39 PM Staff H verified that she administered Resident #19 the wrong medications on 4/13/22. She reported Resident #19 as the first person she gave medications to that morning and the medications were right next to another resident in the cart with the same first name. She expressed that she immediately called the ARNP and checked Resident #19's vitals when she realized that she made the error. She expressed that she also called the nurse manager on call and informed Resident #19. After Resident #19 started having a complaint of chest pain, Staff F arrived to the facility and sent Resident #19 to the local hospital. She revealed she received education on the situation and that the facility fired her later that day. The facility's undated policy titled, Medication Administration Procedures, instructed staff to identify the resident before administering medications. 46873 2. On 1/26/23 beginning at 8:06 am observed Staff C, Certified Medication Aide (CMA), prepare the medications for Resident #34. Staff C poured liquid, levetiracetam 100 mg/ml, into a plastic medication cup as she held it up in the air. The medication cup appeared to hold 10 milliliters (ml) of medication, equaling 1000 mg. Resident #34's January 2023 Medication Administration Record (MAR) listed an order for levetiracetam 750 mg by mouth two times a day. 3. During this continuous observation on 1/26/23 watched Staff C prepare Resident #50 ' s medications, including metoprolol 25 mg, extended release (a blood pressure medication). After Staff C prepared all of Resident #50 ' s medications, she poured his medications into a pouch, including the metoprolol, and crushed the medications using a pill crusher. Then she mixed the crushed medications with pudding. Staff C reported that she crushed all of the medications. The Care Plan Problem dated 11/10/22 indicated that Resident #50 had a risk for adverse side effects (ASE) from high risk medications. The included Intervention dated 11/10/22 instructed the staff that Resident #50 takes anti-hypertensive medications. Please administer them to him as ordered. The document labeled which tablets should never be crushed updated 11/10/21 included a section regarding Controlled release medications. The section directed that these medications are designed to release medicine over an extended period to allow less frequent administration. Crushing may mean a fatal dose is released. Some slow-release tablets are scored and can be divided or halved, but not crushed. Examples include Toprol XL (metoprolol succinate) and Sinemet CR (carbidopa and levodopa). On 1/26/23 at 9:38 am, the Pharmacist Consultant stated the Metoprolol extended release should not be crushed. On 1/26/23 at 12:03 pm, Staff C explained that she knew that metoprolol should not be crushed and that she did it by mistake. She stated her procedure for liquid medications is to look at the lines on the medication cup and measure it. An undated document titled Medication Administration Procedures directed the staff regarding general procedures to follow for all medications: a. Note any allergies or contraindications the resident may have prior to drug administration b. Oral medication administration: - If the medication is liquid, pour the correct amount directly into a graduated medication cup or measuring device provided with the liquid.

Based on observation, record and policy review and staff interviews, the facility failed to ensure the 100 hall exit door was alarmed and failed to educate staff on how to properly ensure the exit alarm activated, and failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 3 residents identified by the facility at risk for elopement. A serious adverse outcome was likely when cognitively impaired Resident #1 exited the facility unsupervised and wearing inadequate clothing for the weather on 2/3/22. Weather temperatures reported at 5 degrees Fahrenheit and a feels like temperature of minus 8 degrees. Staff unaware the resident eloped until she returned to the facility after a nonstaff person saw the resident outside. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 58 residents. Findings include: 1. A Minimum Data Set (MDS) with a reference date of 1/27/2022 assessed Resident #1 with a Brief Interview for Mental Status (BIMS) of 5 (severe cognitive impairment). Resident #1 required supervision for transfers and ambulated independently in the room and on the unit with a walker. The MDS revealed the resident wandered less than daily during the observation period. The resident's diagnoses included: hypertension, unspecified dementia, and [CONDITION(S)]. An elopement risk assessment completed on 11/3/21 identified the resident with a score of 3. A score of 3 indicated a high risk of elopement. The assessment identified the resident with high elopement risk due to the following factors: independently mobile, diagnosis of Alzheimers, episodes of disorientation/confusion. The risk assessment identified the resident as care planned to wear a Wanderguard (system to protect residents at risk for wandering from elopement) and check the Wanderguard every shift. A care plan initiated on 3/8/21 identified Resident #1 at risk for elopement due to diagnosis of Alzheimer's disease, exit seeking behavior, and scored high on elopement assessment with a goal that resident wander safely and remain free from elopement. Interventions included: Wanderguard in place, check placement and functioning every shift and nurse to complete routine risk assessment for elopement. A progress note dated 2/3/22 at 7:00 p.m. and documented by Staff E, Licensed Practical Nurse (LPN) revealed staff last saw the resident at 5:50 p.m. walking down the 400 hall wearing a sweater, sweatpants, and thick socks using her walker. Staff F, Certified Nursing Assistant (CNA) informed Staff E, LPN that a technician for an independent testing provider visiting the facility found Resident #1 outside and returned the resident to the front door. Staff assessed the resident and obtained vital signs. The resident's skin felt cool to touch. Wanderguard alarm system function checked and determined working. In a late entry Staff E further documented 15 minute checks initiated after the resident returned and door alarms checked. The physician ordered laboratory tests for the resident and directed nursing staff to monitor toes, nose, earlobes and fingers for 72 hours. Review of a facility document titled, Missing Resident/Elopement Investigation signed and dated as completed by the Administrator on 2/4/22 included the following: On 2/3/22 Resident #1 was unaccounted for, for 2-5 minutes. She was found in the front parking lot of the facility by a technician for an independent testing provider at 5:52 p.m. Technician escorted the resident to the front entrance and called the facility phone. Facility staff met at the front entrance. The resident wore a long sleeve shirt, cotton pants, socks, and slippers. The outside temperature was 3 degrees Fahrenheit with a wind chill of minus 9 degrees. The resident exited the facility through the 100 hallway door, the door alarm wasn't armed, was not equipped with a Wanderguard monitor. Additionally, the report identified the resident exited through the 100 hallway door containing a Maglock (electromagnetic lock) device that needed to be armed to sound when opened. The door alarm device was not armed thus it did not activate when the resident eloped. Observation showed on 2/9/22 at 1:20 p.m. Resident #1 seated in a chair in the facility front dining room area. Resident stood independently from a seated position to a standing position, unaided. Resident ambulated with walker in hallway, stated she intended to return to her room. Staff directed towards her room. Resident's gait appeared steady and quick as she returned to her room. Resident observed wearing a wanderguard bracelet. During an environmental tour of the facility on 2/8/22 at 1:30 p.m. with the Administrator, Director of Nursing (DON), and the Maintenance Director the 100 hallway exit door was noted to have a white banner with a stop sign fastened across the door with a removable fastening device. A magnetic lock device observed at the top of the door with an easily visible red indicator light. The door was demonstrated to have a 15 second delay and an audible alarm at the door and at the front nurse's station when the alarm activated. To reset the alarm and reactivate, the Maintenance Director demonstrated that a key must be inserted, turned and then back to center. When the light changed from green to red, the key was removed. The red light indicated the alarm was activated. A green light indicated the alarm was deactivated, and the door was able to be opened without delay and without audible alarm. The door was observed to have an additional pull away alarm, reportedly added after the incident, which audibly alarmed after the door opened. On 2/8/22 at 1:30 p.m. during the environmental tour, the Administrator and DON stated they arrived at the facility 30 minutes after the elopement incident and noted the 100 hallway exit door white banner with the stop sign unfastened and hanging down rather than across the doorway. Additionally, they noted the indicator light on the magnetic lock was green which indicated the alarm was not activated which allowed the resident to exit without delay or audible alarm. The resident could just simply turn the door handle and exit. The Administrator confirmed they checked all doors and the Wanderguard bracelet Resident #1 wore worked properly, and alarmed when the resident re-entered the facility through the front entrance. The Administrator further stated the facility investigation determined Resident #1 exited the 100 hallway. The Administrator demonstrated the resident exited onto a sidewalk leading to the front parking lot where the facility bus was parked in front of the main entrance. The technicians van was parked in the first parking spot on the West side of the parking lot. The Administrator counted 80 toe to heel (measured 12.5 inches) paces to where Resident #1 was found in the front parking lot, approximately 1,000 feet. Highway 69, a busy 4 lane highway with a speed limit of 45 mph (miles per hour), runs in front of the facility. On 2/8/22 at 1:30 p.m. during the environmental tour the Maintenance Director reported there are only 3 keys to the 100 hallway magnetic lock alarm identified as held by the Maintenance Director, Administrator and the front desk nurse's key. The Maintenance Director stated he completes weekly checks of all doors and the 100 exit door was last checked on 1/27/22. On 2/9/22 at 2:20 p.m. a technician for an independent testing provider stated he approximated on 2/3/22 he exited the facility and loaded equipment in the back of his van. Stated it was twilight, cold and dark outside, and he couldn't see the resident but he heard the sound of metal scraping on cement, and investigated. He found Resident #1 on the far side of the facility bus. The parking lot pavement ended and there wasn't room to turn the resident around so he backed her out, and put his arm around her for warmth and to provide support. He identified the area as icy and the cement rough. He called the facility on the phone and informed them he found a resident in the parking lot. The facility reported they received his call at 5:53 p.m. and he confirmed this as accurate. On 2/9/22 at 1:30 p.m., Staff E, LPN confirmed she saw Resident #1 at approximately 5:50 p.m. near the front nurse's station in the 400 hall. Staff F, CNA alerted her the resident found outside at approximately 5:57 p.m. Staff E confirmed the wanderguard bracelet worn by the resident tested and worked properly. All exits were checked, Staff E noted the 100 hallway exit banner stop sign down. Staff E responded she did not notice the indicator light on the magnetic lock. Staff E further stated she did not know staff should be alert for an indicator light and did not even know there was an indicator light. Staff E completed an assessment on Resident #1 following the incident and reported no negative outcome or concerns assessed. On 2/8/22 at 3:30 p.m., Staff G, CNA stated she answered the phone call from the technician on 2/3/22 and assisted Resident #1 to return to the facility through the main entrance. Staff G confirmed the Wanderguard alarm sounded as the resident reentered the facility. Staff G stated she worked in the 100 hall prior to the incident, had not seen Resident # 1 in the 100 hall prior to the phone call, and did notice the banner on the 100 hall exit door fastened across the door and after the incident noticed it down. Staff G additionally reported she did not notice the indicator light on the magnetic lock because she did not receive education until after the incident. After the incident she received education to be alert for the light and what the green and red light indicated. On 2/10/22 at 9:00 a.m. the DON and the Assistant Director of Nursing (ADON) confirmed prior to the incident on 2/3/22 they had not had training nor had they provided training to staff regarding the indicator light on the magnetic lock on the 100 hallway exit but should have. The DON confirmed education and audits now completed, and staff are knowledgeable and expected to be alert that indicator light is red, and stop sign banner is up and to report immediately when not. On 2/10/22 at 10:05 a.m., the State of Iowa Climatologist reported the temperature in [NAME] in Story county on 2/3/22 at 5:50 p.m. was 5 degrees Fahrenheit with a feel like wind chill of minus 8 degrees Fahrenheit. The skies were clear, and sunset at 5:32 p.m. Review of facility policy titled Missing Resident/Elopement Process included: If an alarm is discovered de-activated, staff will perform an immediate head count to ensure all residents are accounted for. The nurse, DON, or Executive Director will question staff to determine who deactivated the door alarm and reason for doing. The State Agency informed the facility of the Immediate Jeopardy (IJ) past noncompliance on February 10, 2022. Facility staff removed the Immediate Jeopardy on February 3, through the following actions: a. Door alarm checks are conducted every shift by nursing staff or designee implemented 2/3/22. b. Coded breakaway alarm secured to the 100 Hallway exit door the evening of 2/3/22. c. Video education on how to identify the 100 Hallway exit door is armed and how to arm/disarm sent out to all staff via mass communication app immediately following the incident until all staff notified. d. Education on all facility exit doors, corresponding alarming devices on those doors, and how to properly clear an alarm provided to all staff members by facility Administrator on 2/3/22. e. Facility conducted an elopement drill on 2/4/22. Continued random elopement drills will continue to be conducted to ensure staff members know how to respond. f. A building assessment of all exit doors completed by a vendor on 2/7/22. The surveyor observed the corrections in place while onsite during the investigation. The immediate jeopardy began and ended 2/3/22 when Resident #1 eloped from the facility and immediate corrective actions were implemented. This resulted in past noncompliance for the facility. A serious adverse outcome was likely due to the resident's cognitive impairment and inadequate clothing worn outside in 5 degree weather. The ground was uneven and the facility located by a busy highway with speed limit 45.

Based on observation, policy and record review, manufactures recommendations, and staff interview, the facility failed to ensure Resident #41 received adequate supervision during an e-stim diatherapy treatment and failed to ensure the resident environment was free from hazards by failing to ensure the e-stim diathermy machine was safe for use when the facility failed to follow manufacturer recommendations for maintenance and calibration of the e-stim diathermy machine that resulted in Resident #41 receiving 2 second degree thermal [CONDITION(S)] to his right arm which had lack of sensation and impaired movement from a stroke for 1 of 1 residents reviewed. The facility reported a census of 63 residents. Findings Included: The quarterly Minimum Data Set (MDS) for Resident #41 dated 7/29/21 revealed a Brief Interview for Mental Status (BIMS) score of 9 (moderate cognitive impairment) and required extensive assistance of 2 staff for bed mobility and transfers. The MDS included diagnoses of cancer, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. The MDS identified the resident at risk for pressure ulcer/injuries. Resident #41's Care Plan revised on 8/24/21 included a focus area of impaired mobility and risk for skin breakdown related to history of [CONDITION(S)] ([CONDITION(S)]) with right sided [CONDITION(S)] and [CONDITION(S)]. The Care Plan directed staff to reposition frequently through the day and night and to observe skin with cares and alert nurse and provide treatments to right arm [CONDITION(S)]. According to the website https://www.webmd.com/pain-management/what-is-diathermy Diathermy is a treatment option that uses energy sources to deep heat areas of your body. Rather than a heat source, diathermy uses sources like sound and electricity, which are converted into heat by your body. Diathermy, also called deep heating, heats deep below the surface of your skin. It targets muscles and joints to provide therapeutic benefits. According to the website: https://www.webmd.com/pain-management/what-is-diathermy, there are risks with the use of diathermy: Risks of Diathermy The most common complication seen with diathermy is burning the patient. When the diathermy tool is left in the same place for too long without enough movement, the heat can build up and burn depending on the temperature of the treatment. However, [CONDITION(S)] typically occur from a combination of other factors, including compromised equipment, incorrect technique, and improper patient supervision. Resident #41's progress notes included the following; 8/23/2021 3:30 PM Skin/Wound Note Late Entry: Diathermy (e-stim) started on resident at 2:15 PM. Therapy went in at 2:50 PM to stop diatherapy machine, and noted [CONDITION(S)] and notified nurse immediately. Nurse assessed burn and then notified doctor's office at 2:57 PM with new orders received for [MEDICATION(S)] burn cream for 14 days. Wife notified of burn and new order for [MEDICATION(S)] cream at 3:10 PM. 8/23/2021 4:47 PM Skin/Wound Note: Resident obtained 2 [CONDITION(S)] on the right upper arm from diathermy. The burn in front measures 5.8 x 1.4 centimeters (cm.) and the second burn to posterior of arm measures 6.2 x 1.4 cm. Doctor's office notified with new orders for [MEDICATION(S)] cream to burn twice daily for 14 days, wife notified. Resident #41's Occupational Therapy Transitional Evaluation and Plan of Treatment for period 7/22- 9/15/21 included the following; a. 7/22/21 Occupational Therapy evaluation and plan of care developed. b. 8/2/21 no e-stim provided. c. 8/4/21 Resident tolerated electrical simulation to decrease pain in right upper extremity, 20 minutes at 36 CV . Skilled treatment included pre and post skin checks. d. 8/6/21 Resident tolerated electrical simulation to decrease pain in right upper extremity, 30 minutes at 25- 29 CV ((constant voltage) is equal to mA (milleamps)) to start but requested to turn it up to 40 volts of CV. Skilled treatment included pre and post skin checks. e. 8/11/21 E-stim applied to right shoulder for purposes of decreasing pain intensity settings at 35 CV. of 15 minutes. f. 8/12/21 Resident tolerated electrical simulation applied to his right shoulder to improve pain and mobility for self-care task. He tolerated 30 minutes at 39-42 CV. Skilled treatment included pre and post skin check. g. 8/16/21 Resident reported pain in right shoulder. he tolerated electrical simulation for 30 minutes at 37 CV no complaints of pain or adverse reactions. Skilled treatment included pre and post skin checks. h. 8/18/21 Resident tolerated electrical simulation to decrease pain in right upper extremity and improve mobility 30 minutes at 38 CV Skilled treatment included pre and post skin checks. i. 8/19/21 Resident tolerated electrical simulation to decrease pain in right upper extremity and increase mobility for self care tasks,320 minutes at 33. Skilled treatment included pre and post skin checks. j. 8/23/21 Resident agreeable to electrical simulation to right shoulder to decrease pain impeding ability to perform functional transfers, 30 minutes at 60 CV to start he requested to decrease to 58 with 18 minutes left of treatment during checking resident with verbal approval. Skilled treatment included pre and post skin assessments. pre treatment skin intact post treatment skin condition impaired removing patches resident presented with adverse skin reaction consisting of warm to touch, hard white skin, redness around area on right bicep and right medial deltoid (upper arm). An incident report (IR) dated 8/23/21 at 4:42 PM revealed Resident #41 obtained 2 [CONDITION(S)] to right upper arm from diathermy. Front burn measured 5.8 cm x 1.4 cm and the 2nd burn measured 6.2 cm x 1.4 cm. The skin integrity investigation dated 8/24/21 identified the resident with impingement syndrome of the right shoulder. The conclusion was: resident received burn from therapy machine. Skin sheets for Resident #41 included the following; a. 8/24/21 at 10:01 AM date 1st observed 8/23/21, right outer arm 5.8 cm x 1.4 cm b. 8/26/21 at 4:06 PM lesion like areas secondary to [MEDICATION(S)] patch right upper outer lesion 7.8 cm x 3.2 cm and inner lesion 6 cm x 2 cm. c, 9/2/21 at 10:56 AM burn upper right extremity deltoid outer area 7.5 cm x 1.6 cm inner area 6 cm x 2 cm. Metro Geriatric Services, identified the resident seen by a certified wound specialist (CWS) on 9/3/21. The CWS identified the burn as a second degree thermal burn, status unhealed. The wound measured 7.9 cm. by 11.4 cm. by 0.1 cm scattered areas. Tissue 20% biofilm, 80% epithelial. a. When seen on 8/27/21 CWS information included: resident underwent e-[NAME] to right upper extremity and obtained thermal burn secondary to device on 8/23/21. Started on [MEDICATION(S)] topically to the area BID (twice a day). Skin inspection location right upper arm etiology thermal burn 2nd degree wound status new measurement 7.4 cm x 10.6 cm x 0.1 cm scattered area tissue 15% slough, 5 % clear filled blister 80% epithelial Resident #41's Treatment Administration Record (TAR) for August and September 2021 included [MEDICATION(S)] cream 1 % apply to right upper arm topically two times a day for skin treatment with a start date of 8/24/21. Resident #41's Medication Administration Record (MAR) for August 2021 included [MEDICATION(S)] 500 mg (milligrams) (an antibiotic) give 500 milligrams (mg) by mouth three times a day for empirical burn until 9/5/21 with a start date of 8/28/21. On 8/31/21 at 8:57 AM Resident # 41, who had right side paralysis due to stroke, stated he had very little feeling in his right arm. On 8/31/21 at 3:00 PM the surveyor asked Resident #41 if the therapist asked him if it hurt during his treatment when he got burned he stated no. The surveyor asked if therapy looked at his skin during the treatment and he stated no only before and after treatment. On 9/1/21 at 11:32 asked Resident #41 what month it was and he answered August. When asked who the president was, he answered Biden. OMS rehab rent to own for vectra genisys 2 channel electrotherapy and ultrasound combination system signed 8/25/17 stated renter assumes ownership of equipment at the end of 24 month period, or sooner if the early buy-Out option is exercised by renter. Service and Maintenance during the rent to own Agreement included that OMS Rehab will provide annual calibration inspection and /or preventative maintenance on the equipment as listed above. The Vectral Genesis by Chattanooga user Manual for operation and installation instructions for Therapy systems 2 channel electrotherapy and ultrasound combination system provided by the company included the following: Safety Precautions listed Caution should be used in the presence of the following: a. over areas of the skin which lack normal sensation. Adverse Effects Skin irritation and [CONDITION(S)] beneath the electrodes have been reported with the use of powered muscle stimulators. Potential adverse effects with TENS are skin irrigation and [MEDICATION(S)] [CONDITION(S)]. Contraindications: This device should not be used on ischemic tissue in individuals with vascular disease where the blood supply would be unable to follow the increase in metabolic demand and tissue necrosis might result. Maintenance calibration requirements, calibrating ultrasound applicators. Annual factory calibration is required for all ultrasound applicators . Only the applicators should be sent to the factory or a field technician certified by DJO,LLC for this procedure. Policy and Procedure Manual [NAME] dated 7/18: Policy; industry standard and or manufacturer- recommended procedures will be followed during application of modalities to residents or patients. Objective; It is Blue Stone Therapy intent to provide for the maximum safety of our residents during all therapeutic interventions. Process; a. therapists and assistance will follow state licensure guidelines regarding utilization /applications of modalities. b. Industry standard Indications for applications of a specific modality will be adhered to. c. Industry standard Contraindications for applications of specific modality will be adhered to. d. Manufactures instructions for applications of the modality will be adhered to. e. Residents will be supervised, directly or indirectly based on need, during the application of the modality. * If resident is competent they may be left alone while receiving a modality treatment if they have immediate access to a nurse call light during treatment. * If resident presents with signs/symptoms of dementia, constant direct supervision of a staff member , qualified caregiver is required during a modality treatment. Resident safety will be monitored and assessed by the therapist/assistant as indicated during the duration of the modality treatment. Blue Stone Therapy Modality Preventive Maintenance Plan: a. Each community will secure a contract with a preventive maintenance company to provide annual calibration/preventive maintenance. b. Blue Stone Therapy Director of Clinical Services will perform preventive maintenance /calibration due date checks on each site visit. c. Blue Stone Therapy home office will keep a master list of preventive maintenance dated. Blue Stone Therapy home office staff will send an email to Rehab Director and Administrator one month prior to preventive maintenance due date. d. The community will be responsible for contacting preventive maintenance company to schedule annual preventive maintenance /calibration service. e. Rehab Director will track preventive maintenance due dates and take any equipment that is out of compliance out of service until preventive maintenance has been completed. f. Lead wires will be switched out at each preventive maintenance completion and more often if indicated. Policy provided by Staff C Rehab Director with hand written maintenance plan was implemented on 8/26/21 in response to the incident. Observation showed on 8/31/21 at 2:44 PM the Quality Assurance (QA) Nurse measure Resident #41's burn areas. The posterior burn measured 7.5 cm x 1.6 cm. The resident complained of pain during the procedure. The QA nurse stated the first day the burn area appeared white and hard, then blistered peripherally around the anterior area which measured 6 cm x 2 cm. The [CONDITION(S)] contained yellow slough and redness red around perimeters. On 8/30/21 at 3:11 PM Staff F Certified Nursing Aide (CNA) stated when she got to work on 8/23/21 she was informed during report that Resident #41 received [CONDITION(S)] from a machine that therapy used. Staff F did not remember who gave her report but confirmed on 8/23/21 she started work at 3 pm On 8/31/21 at 8:40 AM Staff C Therapy Director identified the e-stim machine as in the Assistant Director of Nursing (ADON's) office. Staff C stated she was still looking for the manual. On 8/31/21 at 9:33 AM Staff A License Practical Nurse (LPN) identified the resident as alone in the therapy room when she went to complete vital signs for Covid screening and heard the machine beeping with no one in the room. Staff A found and informed therapy the machine beeped so the treatment must be done. Later when Occupational Therapy (OT) worked with the resident, OT removed the electrodes and saw the burn marks right away. The areas had not yet blistered and appeared yellow colored. Staff A obtained orders for [MEDICATION(S)] cream twice a day for 14 days. The facility immediately took the e-[NAME] machine out of order for calibration. At a subsequent interview at 1 pm, Staff A identified the resident in his room in bed when the burn occurred. On 8/31/21 at 11:35 PM Staff E Occupational Assistant (OTA) identified Resident #41 in his room in bed when she got there and he requested to stay in bed. Staff E stated she completed therapy in his room while resident remained in bed. Staff E stated per protocol (code G-0283), the resident can not be unattended. Staff E acknowledged she left the resident's room to go to the therapy room to get a pen and then went back to the resident's room. Staff E explained she had training on the machine her first week of work. When asked when started employment, she stated the end of July. Blue Stone has a video and OT trained her. Staff E further explained she put the machine on for 30 minutes and identified all that information in therapy notes. She applied electrodes on then push start and then off after 30 minutes. On 8/31/2 at 10:02 the ADON stated the e-stim machine was in her bathroom. The ADON showed the surveyor the machine: Chattanooga Vectra Genisys and obtained the manual CD from the pocket on the machine. The calibration sticker located on the machine identified calibration completed by OMS technician on 2/27/20 and due again for calibration 2/21. On 8/31/21 at 10:14 Staff C revealed OMS conducted an in-service February 2000 and the rental agreement up and as of that time the facility owned the machine. On 8/31/21 at 10:30 AM the Administrator acknowledged she could not find any service/calibration record for the machine after the last serviced 2/27/20. On 8/31/21 at 10:23 AM the Maintenance Director stated he only worked on boilers and did nothing with medical except wheelchairs or walkers. On 8/31/21 at 10:38 AM the Administrator stated maintenance would not do anything maintenance-wise on medical equipment like the e-[NAME] machine. At 10:51 AM the Administrator stated she could not locate the OMS contract. The surveyor then asked for any contracts for medical equipment. She stated the facility did not have service agreements. With equipment such as hoyers and EZ stands, the facility would just get new ones if something went wrong. She stated she would call corporate to see if they have any agreements. OMS went out of business and she could not find a company for maintenance. On 8/31/21 at 1:03 PM Staff C stated per the director they did not have a maintenance plan before the incident with Resident #41. On 8/31/21 at 1:30 PM the surveyor asked Staff D Occupational Therapist (OT) how the OTA would know which setting to use on therapy's written plan. Staff D showed the goals area on the documentation. Staff D explained you start at 0 and turn up the intensity based on the residents comfort. The surveyor asked about the amount the OTA used the day Resident #41 received burn. Staff D showed where the voltage used prior to the burn was between 20-42 (lower than on the amount used during the burn incident. Staff D stated the day of the burn, Staff E came and got her and they went to the resident's room and then they went and got the therapy manager and then the nursing staff. On 8/31/21 at 3:30 PM the Administrator stated they had no more investigation into the incident available and stated they asked the nurse to put in a late nurses note to match the time line. On 8/31/21 at 3:45 PM the Clinical Director of Services was asked for investigation, training, in-services information and policy/procedure and protocol. She later provided the information in an e-mail. On 9/1/21 at 12:06 PM Resident #41's spouse stated the doctors told her the resident had scar tissue building up where he had brain surgery which caused limited sensation to his right arm. She stated he experienced pain in his shoulder but had limited feeling going down the arm. She stated he can feel some pain at times. On 9/1/21 at 12:31 Staff E acknowledged she used Dura Stick plus self-adhesive stimulation patches 2 inches x 3.5 inches lot 2. The surveyor asked her how long she left the resident unsupervised during the e-stim treatment, she stated 1 minute. The surveyor asked her why she tuned the machine down from 60 to 58 and she stated the resident asked her to turn it down. He said 58 from 60 was okay and gave a thumbs up. She turned it up from 0 to 60 per his tolerance. She stated the machine is set per resident tolerance. On 09/01/21 at 02:04 PM Staff C stated they reuse the patches for 10 times. On 9/08/21 at 10:38 AM the Administrator stated they are sending the machine to get it calibrated.

Based on observation, record review, and staff interview, the facility failed to assure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and a resident did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 1 resident reviewed (Resident #3). The facility reported a census of 58 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #3 demonstrated long and short term memory problems and severely impaired skills for daily decision making. The resident depended on staff for all activities of daily living (ADL's) including bed mobility, transfer, toilet use, and personal hygiene. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS described the following pressure sores: a Stage I: intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. b. Stage II: partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. c. Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. d. Stage IV: full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. e. Unstageable: known but not stageable due to coverage of wound bed by slough and/or eschar. The Progress Notes dated 12/22/20 at 12:52 a.m. documented the resident admitted to the nursing facility from the hospital for skilled level of care. The resident depended on staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident's skin color normal, warm to the touch, dry, and had normal turgor. The resident had no pressure ulcers present. The Braden Scale for Predicting Pressure Sore Risk dated 12/22/20 and 1/11/21 documented the resident at high risk for developing pressure ulcers. The initial Care Plan dated 12/22/20 included the resident had risk for skin breakdown due to immobility. Interventions included: a. Observing skin with cares and alerting the nurse of any red/open areas so she could contact the Physician, initiated 12/22/20, b. Repositioning frequently, initiated 1/6/21, c. Pressure reduction mattress, initiated 1/1/21. The Progress Notes dated 1/23/21 at 10:48 p.m. documented the resident had a blackened area on the right heel approximately 2.5 by 2.5 cm. The provider faxed, and spoke to family with update on the condition change. A Skin Condition Record dated 1/23/21 documented the resident had a blackened right heel measuring 2.5 by 2.5 cm and left heel measuring 1.8 by 2 cm. On 1/27/21 the right measured 4.4 by 4 cm and the left 1.8 by 2 cm. They changed documentation to a pressure sheet on 2/3/21. The Progress Notes dated 1/24/21 at 10:16 a.m. documented receipt of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 1) Skin prep to the heels every shift. 2) Heel boots on at all times. An Order Summary dated 1/24/21 included skin prep to both heels 3 times a day. A Weekly Pressure Ulcer Record dated 2/3/21 documented the right heel measured 4.4 by 4 cm, dark purple/gray, and hard. The resident had an air mattress and blue float boots. On 2/10/21 the area measured 3.5 by 5 cm, dark gray, hard area with lifting edges. On 2/17/21 the area measured 4.4 by 3.5 cm, dark hard area with lifting dry, white edges. On 2/24/21 the area measured 3.5 by 1.2 cm, open area with scant bloody drainage, and wound bed with dark eschar 3.4 by 2.4 cm. On 3/3/21 the area measured 3 by 3.5 cm, hard, with wound bed 2.7 by 0.8 cm pink and peeling wound edges. On 3/12/21 increased pain noted. A Weekly Pressure Ulcer Record dated 2/3/21 documented the left heel measured 1.8 by 2 cm a dark hard gray with purple hue area The resident had a blue float boot. On 2/10/21 the area measured 2.7 by 1.3 cm, dark gray, tan. On 2/17/21 the area measured 2.3 by 1.3 cm brown, flat, with a dark hue around it. The current Care Plan identified the resident had impaired skin integrity related to impaired mobility, alteration in nutrition (gastrostomy status), history of [CONDITION(S)] (TIA) and [CONDITION(S)] (CVA), contractures to bilateral hands (admitted ), and history of pruritus. The Care Plan documented the resident had vascular ulcers to the following areas (changed from pressure to vascular by the Wound Care Advanced Registered Nurse Practitioner (ARNP) 4/8/21): left heel, right heel, right Achilles, right top foot, left ankle, right ankle, right 5th digit amputation 3/25/21. The interventions included: a. Observing skin with cares, alerting the nurse of any red/open areas, so she could contact the Physician initiated 12/22/20, revised 4/8/21, b. Consult the registered dietician for nutritional needs initiated 4/8/21, c. Hoyer (total mechanical lift) lift padded for resident's safety initiated 2/26/2021, d. Dependent for repositioning, ensure repositioned at least every 2-3 hours revised 4/8/21, e. Seen by wound management; follow up as recommended and follow recommendations initiated 4/8/21, f Alternating air mattress; staff to check for functioning every shift revised 4/8/21, g. Prevalon boots at all times to help reduce pressure to heels, staff would monitor feet for further skin breakdown every shift initiated 2/2/21, h. No compression to bilateral lower extremities at all, initiated 4/8/21. The Progress Notes documented: 1. On 1/24/21 at 8:59 p.m. the resident rested well, legs elevated, heel protectors in place, treated as ordered. 2. On 1/25/21 at 11:16 a.m. skin prep applied to the right heel wound, and foot elevated with pillows. 3. On 1/25/21 at 3:21 p.m. the resident rested in bed, heel protectors in place, and skin prep treatment to heels as ordered . 4. On 1/25/21 at 6:20 p.m. the resident rested with eyes closed, legs elevated in bed, treatment to right heel as ordered. 5. On 1/27/21 at 3:19 a.m. Health Status Note,Note Text: Resting in bed. Boots on feet, no [CONDITION(S)]. 6. On 1/27/21 at 11:24 a.m. skin prep applied to bilateral heels, areas continued. 7. On 1/27/21 at 1:23 p.m. the ARNP contacted the Registered Dietician (RD) with concerns regarding the resident's nutritional status and skin status. She had not yet received RD's recommendations that were made this morning, though RD reviewed them with her this afternoon. The ARNP agreed with all recommendations, aside from changing the resident's fluid flushes, concerned about resident's very dry/flaky skin and hesitant to make any fluid changes currently. Deep tissue injuries reported on bilateral heels and the back of one of her calves. Labs were ordered and once the results were received, the RD would review appropriateness of Tube Feeding (TF) formula and make changes as needed to help ensure resident received adequate kcals/protein to support weight maintenance and skin healing. 8. On 1/27/21 at 6:05 p.m. the resident rested in bed, heel protectors in place, and heels off loaded with a pillow. 9. On 1/28/21 at 1:39 a.m. boots on and heels floated while in bed. 10. On 1/28/21 at 5:16 p.m. the resident had large darkened areas to heels bilaterally, requesting orders for wheelchair positioning and assessment for custom wheelchair. 11. On 1/28/21 at 10:52 p.m. communication from the ARNP for orders for wheelchair positioning and assessment for custom wheelchair. 12. On 1/29/21 at 11:01 a.m. skin prep applied as ordered. Area continued to be hard and scabbed in appearance. 13. On 2/2/21 at 5:15 p.m. a plan of care note, the resident would wear Prevalon boots at all times to help reduce pressure to heels, and staff would monitor feet every shift. 14. On 2/9/21 at 11:31 a.m. face to face done for wheelchair assessment. The resident continued with unstageable pressure areas to bilateral heels, and contractures. No new orders given. 15. On 2/17/21 at 4:25 p.m. the resident had cream colored drainage from the right heel wound. The area continued with dark hard intact skin surrounding heel. Family updated and consented to see wound ARNP at the facility. 16. On 2/19/21 at 12:27 p.m. the ARNP came to the facility to assess the wounds to the resident's bilateral feet. The areas were intact without drainage. The right heel assessed and measured , with no thick drainage noted. Received new order for [MEDICATION(S)] soaked gauze to all wounds to bilateral feet, cover with ABD (dressing), gauze for extra protection, and follow up in one week. The Wound Treatment Plan notes dated 2/19/21 documented the wound ARNP saw the resident to assess several areas of concern to her bilateral lower extremities. The assessment included: a. Unstageable pressure ulcer of the right heel measuring 4.5 by 3.5 by 0.1 cm. b. Unstageable pressure ulcer of the lateral right ankle measuring 1.4 by 0.5 by 0.1 cm. c. Unstageable pressure ulcer of right anterior ankle secondary to medical device measuring 2.5 by 0.5 by 0.1 cm, (2 areas). d. Unstageable pressure ulcer of the right Achilles measuring 3.6 by 1.2 by 0.1 cm. e. Unstageable pressure ulcer of the left Achilles measuring 1 by 1 by 0.1 cm. f. Unstageable pressure ulcer of the left anterior ankle secondary to medical device 1.2 by 1.5 by 0.1 cm. g. Unstageable pressure area to left lateral heel measuring 1.5 by 1.8 by 0.1 cm. The plan included they would use bulky dressings to bilateral feet to add protection, continue with Prevalon boots, secured loosely, placing a Roho cushion to Broda chair and move foam cushion to the footrest area to provide additional padding until possible new chair obtained. They would obtain an ankle-brachial index (ABI) with arterial study to determine if adequate circulation present for wound healing, and use [MEDICATION(S)] with the goal of stabilizing the foot wounds. A Patient Report dated 2/24/21 documented the ABI results were abnormal bilaterally. The wound ARNP noted the report and directed no compression to the bilateral lower extremities, ever. A Patient Report dated 2/24/21 documented completion of a duplex scan, lower extremity arteries, arterial bypass grafts, and complete bilateral study for a history of bilateral heel ulcers. The report indicated abnormality. The wound ARNP directed referral to a vascular specialist if the family wished. The Wound Treatment Plan notes dated 2/26/21 documented wound assessment follow up. Staff reported new wound to 5th digit of right foot, etiology unknown by staff. ABI with arterial study showed critical stenosis on the left and small vessel disease to bilateral lower extremities. Orders given for no compression to bilateral lower extremities ever, and referral to vascular specialist if the family wished. The resident had a Broda chair with Roho cushion in the seat area and foam cushion covered the leg rest portion of the chair. The resident wore offloading boots to the bilateral lower extremities. The assessment included: a. Unstageable pressure ulcer of the right foot measuring 3 by 3.1 by 0.1 cm, improved. b. Unstageable pressure ulcer of the right lateral malleolus measuring 1.4 by 0.8 by 0.1 cm, improved. c. Unstageable pressure ulcer of the right anterior ankle measuring 2 by 0.8 by 0.1 cm, improved. d. Unstageable pressure ulcer of the right Achilles measuring 2 by 1.4 by 0.1 cm, improved. e. Unstageable pressure ulcer of the left Achilles measuring 1.2 by 1 by 0.1 cm, improved. f. Ustageable pressure ulcer of the left anterior ankle measuring 1.1 by 0.7 by 0.1 cm, improved. g. Unstageable pressure ulcer of the left lateral heel measuring 0.3 by 0.3 by 0.1 cm, not healed. The Wound Treatment Plan notes dated 3/5/21 documented a wound assessment follow up. The resident had a Broda chair with Roho cushion to seat and foam cushion covered leg rest portion of the chair. The assessment included: a. Unstageable pressure ulcer of the right heel measuring 3.2 by 2.8 by 0.1 cm, improved. b. Unstageable pressure ulcer of the right malleolus improved with 100% pink epithelial wound bed. c. Unstageable right ankle ulcer secondary to medical device measuring 4.8 by 0.9 by 0.1 cm (2 areas), improved. d. Unstageable pressure ulcer of the right Achilles measuring 3.6 by 0.6 by 0.1 cm, improved. e. Unstageable pressure ulcer of the left ankle 100% epithelial wound bed. f. Unstageable pressure ulcer of the left Achilles 100% epithelial wound bed. g. Unstageable pressure ulcer of the left lateral heel measuring 0.3 by 0.3 by 0.1 cm, not healed. A facsimile (fax) from the wound ARNP dated 3/5/21 directed to refer the resident to a vascular specialist to evaluate and treat as indicated related to poor ABI and arterial study results and poor wound healing. The Wound Treatment Plan notes dated 3/12/21 documented a wound assessment follow up. The assessment included: a. An unstageable pressure ulcer of the right heel measuring 3.3 by 2.8 by 0.1 cm, not healed. b. Unstageable pressure ulcer of the right malleolus 0.6 by 0.2 by 0.1 cm not healed. c. Unstageable right ankle ulcer secondary to medical device measuring 5 by 0.8 by 0.1 cm (2 areas), improved. d. Unstageable pressure ulcer of the right Achilles measuring 3.7 by 0.9 by 0.1 cm, not healed. e. Unstageable pressure ulcer of the left anterior ankle measuring 11.6 by 0.4 by 0.1 cm, not healed. f. Unstageable pressure ulcer left lateral heel measuring 0.3 by 0.3 by 0.1 cm, not healed. The Wound Treatment Plan notes dated 3/19/21 documented a wound assessment follow up. The assessment included: a. Unstageable pressure ulcer of the right heel measuring 3.4 by 2.5 by 0.1 cm, not healed. b. Unstageable pressure ulcer of the right lateral malleolus with resurfaced tissue. c. Unstageable pressure ulcer of the right anterior ankle measuring 4.2 by 0.7 by 0.1 cm (2 areas), improved. d. Unstageable pressure ulcer of the right Achilles measuring 1.7 by 0.3 by 0.1 cm (2 areas), not healed. e. Unstageable left anterior ankle pressure ulcer resurfaced. f. Stage 3 pressure ulcer of the left lateral heel measuring 0.2 by 0.3 by 0.1 cm, not healed. The Wound Treatment Plan notes dated 4/2/21 documented a wound assessment follow up. The assessment included: a. Unstageable pressure ulcer of the right heel measuring 3 by 2.5 by 0.1 cm, not healed. b. Unstageable pressure ulcer of the right anterior ankle measuring 7.3 by 3.5 by 0.1 cm (scattered areas), not healed. c. Unstageable pressure ulcer of the right Achilles measuring 3.8 by 0.3 by 0.5 cm, not healed. d. Right lateral foot, arterial measuring 1.5 by 1.2 by 0.1 cm, new. e. Stage 3 left lateral heel pressure ulcer measuring 0.3 by 0.3 by 0.1 cm, not healed. The Wound Treatment Plan notes dated 4/9/21 documented a wound assessment follow up. The assessment included: a. Unstageable pressure ulcer of the right heel measuring 3.1 by 2.5 by 0.1 cm, not healed. b. Unstageable pressure ulcer of the right anterior ankle measuring 9 by 3.8 by 0.1 cm not healed. c. Stage 4 pressure ulcer of the right Achilles with exposed tendon, measuring 4.2 by 1.2 by 0.1 cm, not healed. d. Right lateral foot, arterial measuring 1 by 0.8 by 0.1 cm, not healed. e. Stage 3 left lateral heel pressure ulcer measuring 0.3 by 0.3 by 0.1 cm, not healed. The plan included staff education on not letting the tendon dry out, and notifying podiatry of exposed tendon. During an observation on 4/13/21 at 11:02 a.m. the resident sat in the Broda chair. The resident wore bilateral heel boots and the footrest of the chair padded. Staff G Licensed Practical Nurse (LPN) stated the resident had received pain medication prior to the treatment. She said the resident had the Broda chair when she came in. Staff G cleansed and treated the wounds. The area on the left lateral heel small and difficult to visualize. The resident had an open area top of the right foot, tendon visible on the right Achilles, and an ulcer of the right heel. Staff G stated the area on top of the foot probably caused by the velcro on the 1st boot they used. At 12 p.m. Staff G brought the type of boot they initially put on the resident after she developed the pressure areas. It was a padded boot, and she said the velcro on the boot caused the injury to the top of the foot. She did not wear socks at times and it rubbed, On 4/12/21 at 1:30 p.m. the wound ARNP stated based on the history when she started seeing the resident on 2/19/21 the pressure ulcers were avoidable, but the facility did not implement measures to prevent them. She said when she investigated the ulcers she observed the resident sitting in a Broda chair, and her feet hit the bar. She said when the areas developed they applied boots, but they did nothing to pad the bar. The ARNP moved the seat cushion to the the foot rest, and they obtained a Roho cushion for the seat. She said the vascular issues may have caused the pressure ulcers to develop quicker, but if they had provided pressure relief measures, the pressure ulcers could have been avoided. On 4/14/21 at 1:55 p.m. the Director of Nursing stated they did not have a policy for pressure ulcers, they went by the standard of practice. According to the National Pressure Injury Advisory Panel (NPIAP), pressure injury prevention points included: Turning and repositioning all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. Choosing a frequency for turning based on the support surface in use, the tolerance of skin for pressure and the individual's preferences. Ensuring that the heels were free from the bed. Repositioning weak or immobile individuals in chairs hourly. Using heel offloading devices or [MEDICATION(S)] foam dressings on individuals at high-risk for heel ulcers.

Based on observations, staff and resident interviews and clinical record review, the facility failed to ensure 6 of 6 sampled residents received the appropriate diet, ( Residents #1, #4, #5, #6, #7 and #8) coupled with adequate nursing supervision while consuming an altered textured diet, ( Resident #1). Resident #1 was to receive a mechanical soft diet and was to be supervised while eating due to the altered textured diet. Resident #1 received whole brussel sprouts and although a Certified Nurses Assistant (CNA) assisted Resident #1 to dine, the CNA failed to identify that the resident was on a mechanically soft diet which resulted in Resident #1 pocketing the brussel sprouts (keeping the food in her cheeks instead of swallowing the food). Resident #1 choked on the food given to her, resulting in an obstructed airway which resulted in multiple unsuccessful attempts of the [MEDICATION(S)] maneuver during the lunch meal on [DATE] and ultimately death. Resident #1 expired within the hour of her airway becoming obstructed. That situation constituted Immediate Jeopardy to resident health and safety. The facility identified a census of 62 residents. Findings include: 1. A Minimum Data Set (MDS) with an Assessment Reference Date of [DATE], documented Resident #1's diagnoses included non-Alzheimer's disease, [CONDITION(S)], and [CONDITION(S)] (CVA). The resident's Brief Interview for Mental Status (BIMS) score was 99, indicating the resident was unable to complete the interview. The Staff Assessment for Mental Status was recorded at a 2 indicating Resident #1 had moderate cognitive impairment, the resident's decisions were poor and the resident required cues and supervision. Resident #1 required extensive assistance of 1 for bed mobility, transfer, dressing and eating. This resident had a mechanically altered diet which required change in texture of food or liquids. A Care Plan with a focus area dated [DATE], documented that Resident #1 had a potential for altered nutrition. This focus area directed staff to monitor for any signs or symptoms of dysphagia, choking, aspiration, or intolerance to diet or liquid texture and report to physician/speech therapist. It directed staff to provide assistance, encouragement, cueing, and/or supervision at meals as needed. Staff were to provide a mechanical soft diet with thin liquids. Active Doctor's Orders dated [DATE], ordered a regular diet with mechanical soft texture. The facility was unable to produce any Speech Therapy notes for Resident #1. A hospital progress note dated [DATE], documented Active Hospital problems included [CONDITION(S)]. Under assessment and plan, it listed that this resident had a syncopal episode related to a choking spell. The following progress notes were documented on [DATE] by Staff A, Registered Nurse (RN): 1. At 12:46 p.m., Staff B, CNA informed Staff A that Resident #1 had pocketed a large amount of food in her mouth and would not swallow, and that resident had grabbed the chocolate milk and started drinking it while mouth was full. Resident #1 was sitting in the dining room at table alert and wheezing with inspiration. Staff noted resident was having a hard time breathing and could not verbally responding. Resident was encouraged to cough and spit out food but was unable to do so. [MEDICATION(S)] maneuver was ineffective. Resident went unresponsive and was cyanotic (blue). Resident was assisted to her room and into her bed. Oxygen was placed for comfort. Hospice and Assistant Director of Nursing (ADON) were notified. Blood pressure was ,d+[DATE], respiration rate was labored at 18 breaths per minute, and oxygen saturation reading was at 66 % with oxygen on at 2 liters. Her temperature was 99 degrees Fahrenheit. 2. At 1:13 p.m., Resident #1's daughter was notified of resident's condition. Resident's respiration rate was at 10 breaths per minute and remained labor. The oxygenation saturation was not registering a percentage. Hospice nurse was on her way. 3. At 1:22 p.m., Resident #1 was without vital signs. Hospice was notified and a message was left for the doctor. 4. At 2:00 p.m., an order was received to release the body to the funeral home. A meal ticket sheet provided by the facility and dated [DATE], showed the main meal for Resident #1 for lunch on [DATE] was ground roast pork, mashed potatoes and pork gravy, chopped brussel sprouts, a roll with margarine and pie. A Week 4 Sunday menu provided by the facility for the day of [DATE], showed the mechanical soft lunch to be 3 ounces of ground roast pork, #8 scoop of mashed potatoes, 2 ounces of pork gravy, 4 ounces of chopped brussel sprouts, 1 roll, 1 margarine, 1 slice pie, and 8 fluid ounces of milk. The menu was not approved and was not signed by a dietitian. A Progress Note dated [DATE] at 2:47 p.m. and written by the facility's dietitian, documented that Resident #1 was tolerating a mechanical soft diet. The resident had lost weight in the prior 6 months but was stable in the last month and that the resident's BMI (Body Mass Index) was within normal limits for this resident's age. There were no recommendations for changes at that time. In an interview on [DATE] at 2:45 p.m., the Nursing Home Administrator (NHA), showed the chair that the resident always sat in, in the dining room. He said her BIMS was 00. The table was located in back dining room, the facility has 2 dining rooms. The NHA stated that Staff B was assisting Resident #1 to dine. Staff B reported to him that Staff B would scoop up a bite on the fork, and Resident #1 would tap on Staff B's hand to alert Staff B that the resident was ready for another bite. On the day of the incident, Staff B told the NHA that the resident grabbed Staff B's hand instead of tapping it, and when Staff B looked at the resident, Staff B felt the resident was choking. Staff B immediately got the nurse. NHA stated he believed the resident was on a mechanical soft diet and that she had received the correct diet. NHA also stated the resident was on Hospice. On [DATE] at 5:00 p.m., the NHA stated he felt Staff B acted as she should have by immediately getting the nurse. The NHA further stated that Staff B had since been terminated for reasons not associated with this incident. In an interview on [DATE] at 4:00 p.m., the Food Service Director (FSD), stated she started at the facility on [DATE]. She was not at the facility during that week due to training in another town and was not in the facility on [DATE], the day of the incident. The FSD had just found out about the incident that morning, as the ADON had told her that a self-report had been turned in on Monday. Her staff had not talked about any resident, at least not to her knowledge and no one had said anything about a resident receiving the wrong diet. An observation of supper being served on [DATE], revealed residents with a mechanical soft diet were served shredded lettuce. In an interview on [DATE] at 12:07 p.m., Staff C, Licensed Practical Nurse (LPN), identified Resident #1 as the resident who had the choking incident. The resident's nurse that night was Staff A. Staff A had sent Staff B to get Staff C from the front hall where Staff C was working. This happened during her noon medication pass. Staff C arrived to the back hall dining room. Resident #1 was very pale and Staff A stated Resident #1 was choking. Staff A had given this resident the [MEDICATION(S)] maneuver and had also tried to clear the resident's mouth. The resident gasped. There was a lot of food in the resident's mouth and Staff A was trying to get it cleared. The resident took in a deep breath and inhaled it again. The resident was sweaty and her lips were cyanotic. There were big pieces of food, halves of brussel sprouts. In Staff C's opinion, they were not appropriate for a resident on a mechanical soft diet. Staff C believed that this resident was on a general diet. Most of this resident's food needed to be cut by staff. This resident was an assist to dine. Doesn't remember what was on her plate. Staff C did remember the brussel sprouts were not soft, they were the dry and they were baked. The resident had half chewed brussel sprouts in her mouth with a bunch of saliva. The resident's teeth were on the plate. Staff C assumed that Staff A had removed them when she was trying to clear the food out of the resident's mouth. Staff A had said to Staff C to look at all of this food. Staff A meant the resident had been fed too much, there was way to much food in the resident's mouth. Staff C stated there was a gob in the resident's mouth, not just a bite. Staff C tried to remove more than a bite of food and that was after Staff A had already taken a mouthful out. Staff C stated she could feel there was more food in the resident's mouth even after she had taken what she could out. Staff A and a CNA (unclear on which one) stood the resident up and Staff C tried the [MEDICATION(S)]. The resident passed out. Staff C said this is not working, grab her w/c we got to get her in her bed. Resident was laid onto the bed onto her side. She was gasping and Staff C could tell the resident was obstructed. Staff A said that this resident was a DNR and on Hospice. Staff A and Staff C talked about what they could do for her. Staff A went to call the doctor and Staff C got the crash cart and suctioned the resident and placed oxygen on the resident. The oxygen saturation was in the 80's but was starting to drop. Staff C cleared the resident's nose and placed the oxygen back on the resident. Staff C said the resident's eyes were fixed. The head of the bed was elevated. The resident was gasping and Staff C could hear that the resident was obstructed. Staff C asked the CNA to stay with the resident as she did not want Resident #1 to be alone as she felt the resident was dying. Staff C stated it was terrible. They couldn't do CPR as resident was a DNR. Staff C thought that Staff A was going to contact Hospice as well. Staff C asked her to get a hold of social services, as the resident and the social services staff person had a close relationship. The resident's family lived far away. Staff C said she returned to the front as she had to finish her med passing duties. Staff C stated the whole incident lasted ,d+[DATE] minutes. In an interview on [DATE] at 1:14 p.m., the NHA stated the dietitian for the facility is contracted and is not fulltime. He has not seen her in the facility since he started in August. The dietitian gets paid for looking over things for the facility. In an interview on [DATE] at 1:36 p.m., Staff B stated how she assisted Resident #1 to dine was by cutting her food for her. Staff B stated that technically this resident could eat on her own. The resident tapped on Staff B's hand when she was ready for a bite of food. Staff B stated the resident wasn't on a specific diet that she knew of. That day the resident's meal was pork loin, mashed potatoes, and lemon meringue pie. Staff B said this resident didn't make it to her pie. Staff B reported she cut up the pork loin and the resident ate that and the mashed potatoes fine. Staff B cut up the brussel sprouts for the resident because even Staff B would cut up brussel sprouts for herself to eat. Staff B stated this resident would take breaks while she was eating. Staff B reported that she had a tray as well and was eating the same food that Resident #1 had on her plate. The resident had ground meat one time before, but Staff B felt it was because the meat was tough, not because this resident was on a special diet. Staff B said the resident had polish sausage once and it came out regular, so Staff B cut it up. Staff B stated she had assisted resident to dine 4 to 5 times before the incident and had never had a problem with this resident. Staff B started working at the facility in December of 2020. The pork loin on Staff B's tray fell apart in her mouth. The middle of the brussel sprouts was soft but the outside was crunchy. Staff B thought if the resident would have had problems with anything it would have been the outside of the brussel sprouts. Staff B stated the resident doesn't really open her mouth wide enough for Staff B to see inside. Some days Resident # 1 would feed herself yogurt for a snack after Staff B would give her one bite, but some days she just wouldn't. Staff B stated she did not look inside of the resident's mouth the day of the incident. Staff B thought what happened was that Resident #1 was pocketing food at the back of her mouth. Resident #1 grabbed Staff B's hand aggressively and pulled Staff B forward. Staff B tried to give this resident her milk. The resident took a sip but that was it. Staff B stated she ran down the hall and told the RN she thought Resident #1 was choking. Staff A tried to get the resident to cough it up and asked Staff B to get a box of gloves. Staff A then put on gloves and tried to get the food out of the resident's mouth and then tried the [MEDICATION(S)]. Staff A got some of the food out but not all of it. Staff B repeated she thought the resident was pocketing food in the back of her throat. Staff were trying to get the resident to cough it up but she wouldn't. Staff B stated it was weird because right before the resident started choking, the resident had said yes when Staff B asked if she wanted to watch a movie. Staff B stated the resident talked a little but not much. Staff B stated Staff A tried the [MEDICATION(S)] and she thought Staff C tried it too after Staff B had went and got Staff C because Staff A had asked Staff B to get Staff C. Staff A and C continued to try and remove the food. Staff B said they got the resident into the resident's room and tried the [MEDICATION(S)] again. Then Staff B was asked to go help the agency CNA in the back with laying residents down and front staff CNAs said they would stay with the resident. When asked if she would have done anything differently, Staff B stated she would check the resident's mouth between bites but Staff B had never had a problem before. Staff B said she could have given the resident a few seconds more after she tapped her hand to be sure she had gotten the food down. Staff B reported that she looked at the resident when she gave the resident bites of food. Repeated that the resident did not open her mouth very much. Staff B reported she had no indication that the resident was pocketing food. Staff B stated if she would have had an indication she would not have given her another bite. Staff B said diets are on slips and kitchen staff prepare the residents' trays. Nursing staff look at the name and take the tray. Staff B stated she knew that certain residents get their food mashed up and which residents eat in the dining room. Staff B stated when she first started at the facility the only thing she was told was when to be there and where. Staff B stated she did not get trained on anything with food, diets, etc. Staff B said the only thing she knew about diets was what she could see. For example, one lady's food was always mashed up. Staff B was certified to become a CNA in November of 2020. Staff B learned different diets and types, what people can and cannot eat on certain diets. She learned how to feed someone and what to do when a resident starts choking. Staff B stated she did everything she was taught to do. Staff B stated she learned about mechanical soft diets but not super in depth. Staff B stated she did not know Resident #1 was on a mechanical soft diet. Staff B said she thought the brussel sprouts should not have had such tough skin on them. Staff B stated she did not know the slips had the diet on them. Staff B had never looked that close at the slips nor had anyone told her to look at the diet slips as the diets were on them. Staff B stated she only had 2 days of orientation. This was her first job after becoming a CNA and because of Covid-19 they had to use mannequins for their training. In an interview on [DATE] at 1:27 p.m., Staff A stated the incident happened on a Sunday, Valentine's Day. Staff A was passing noon pills between 12:00 and 12:15 p.m. Staff B came down and told her that Resident #1 was pocketing food. Staff B reported that Resident #1 had grabbed the chocolate milk and started drinking it and her mouth was completely full. Staff A reported this resident's diet was mechanical soft. Staff A remembered seeing round brussel sprouts on the resident's plate. Staff A stated they weren't cut up. Staff A stated the brussel sprouts looked kind of soft but that you can have a mixture of texture with brussel sprouts. Staff B had told Staff A that this resident was having a hard time chewing. Staff A felt that Staff B didn't make it seem like it was a big deal. Staff A was just down the hall outside of a resident's room. Conversation stopped at this time related to another scheduled call. Conversation continued at 2:57 p.m., on the same day. Staff A stated that when Staff B came and got her, Staff A locked her medication cart then went to the south dining room. Staff A sat down across from Resident #1. Staff A reported the resident's lips were pink and the resident was looking at her but this resident was wheezing. Staff A stated she was telling the resident to spit the food out, the resident clenched her teeth. The resident then did the universal sign of choking by putting her hand up to her throat. Staff A got behind her and did the [MEDICATION(S)]. The resident started breathing again but was wheezing badly. Staff A could hear the obstruction. The resident would not open her mouth, she had her teeth clenched shut. This resident has dentures. The resident took a pretty good sized breath in and then started turning blue. Staff A said after the [MEDICATION(S)] she started breathing a little again. The resident's dentures fell out. Staff A was able to get a lot of food out of the side of her mouth. The food was like pudding. There was no liquids in her mouth. Staff C showed up and started working with the resident as well. Staff A then went to the phone and called Hospice. Staff A got a hold of someone at Hospice and they were going to contact family with an update. Hospice said they would send a nurse but it would take 30 minutes. Staff C was suctioning the resident. The pulse oximeter went up to ,d+[DATE]%, but then started to drop. The resident was in bed at that time and there was nothing in her mouth. Staff A could still kind of hear the wheezing. The doctor was called. The resident was not doing well at all when Staff A returned to the room. Staff A talked with the daughter. Staff A stated the daughter understood the situation and wanted to know how long her mother had to live. Staff A stated she was unable to tell the daughter a time but did tell her it did not look good. The Doctor called back but Resident #1 had already passed away. He gave the order to release the body. Staff A stated Resident #1 had pocketed food. Staff A was unaware of a history of choking. Staff A said Resident #1 didn't pocket food all the time, she thought this resident pocketed the food if she didn't like it. Staff A said that sometimes this resident would tap staff's hand if she wanted a bite or she would occasionally feed herself. Staff A stated this resident had a lot of food in her mouth before the [MEDICATION(S)] was administered. Staff A said she must have taken 4 fingers full of food out of the sides of her mouth, nothing removed from the middle of her mouth. She did not remove any whole brussel sprouts, it was like a paste but took out a lot of chunks. Staff A stated the resident's dentures were kind of rattling in her mouth. When the resident sort of passed out, Staff A was able to remove them. Staff A said there were no liquids at all in the resident's mouth. The resident had chocolate milk in her hand when Staff A walked up to her. Staff A asked the resident for the milk and this resident handed it to her. Staff A stated she was trying not to scare the resident and was trying to help her to cough the food out. Staff A stated that sometimes diets come out and they are not right. Staff A stated they normally catch it, and did not know of another resident having a bad outcome from a wrong diet not being caught. In an interview on [DATE] at 2:05 p.m., Staff D, CNA, stated she worked the day shift on [DATE]. She did not assist anyone to dine that day as she was floating and doing showers. Staff D stated there were whole brussel sprouts on Resident #1's plate that day. Staff D stated everything else on the plate was chopped up like it was supposed to be. Staff D did not know if Staff B was cutting the brussel sprouts up before giving them to the resident. Staff D stated that CNA work is just common sense. Staff D felt the whole thing could have been avoided. This resident never pocketed food for Staff D, which told Staff D that Staff B was not giving Resident #1 enough time to chew. Staff D said it was pretty traumatic for her, and that she cannot look at a brussel sprout without thinking of Resident #1. Staff D said it was awful. Staff D assisted with getting Resident #1 into her room, getting the resident cleaned up, and putting the head of her bed up. Staff D reported the resident was suctioned and the resident pinked up but then went back to white again. The staff put on Elvis for the resident. The resident was gasping for air. The resident fought them when they changed her so Staff D felt that the resident was still there. Staff D said her and a peer just had to watch her die. The resident was a DNR and on Hospice so there was nothing anyone could do. Staff D felt that Staff B was very nonchalant about the incident, like Staff B did not think it was her fault. Staff D stated she was mad and avoided Staff B. Staff D added she has not seen Staff B since that day so Staff D is pretty sure Staff B was not working there anymore. Staff D did not think the diets were on the diet slips. When shown a diet slip, Staff D acknowledged that the diets were on the slips. Staff D stated she knew Resident #1 was on a mechanical soft diet and she did not understand why the kitchen would put whole brussel sprouts on the plate. In an interview on [DATE] at 2:50p.m., Staff E, Cook, stated for mechanical soft diets she would: 1. run lettuce through robocoup (food processer) on evenings to give it a good shred 2. if vegetables were soft she would leave them but if they were a little hard she would give them a good chopping up. 3. All meat is chopped up. Staff E stated all food served from the kitchen is per each resident's diet. Staff E would not expect a CNA or nursing staff to cut the food to the right consistency. Staff E stated she had not served brussel sprouts as they are not on the evening shift menus. In an interview on [DATE] at 3:12 p.m., the contracted Dietitian stated that she did not know a lot about the event that happened. The Nurse Practitioner (ARNP) had informed her Resident #1 had received brussel sprouts and choked and then eventually passed away. The ARNP had called and notified the Dietitian. The Dietitian stated her first reaction was to question why this resident would have received brussel sprouts when she was on a mechanical soft diet. The Dietitian stated she recently had done an evaluation on this resident as the resident's weight had trended down and the ARNP had requested a review. The resident was on Hospice for maybe over a year. The resident was started on a supplement. The Dietitian said she did not make any recommendations. Resident #1 had been on a mechanical soft diet for a while. The resident did not have any problems with liquids. When asked about whether or not shredded lettuce was appropriate for a resident on a mechanical soft diet, she responded that she didn't particularly care for that and that speech therapy would have to clear a resident to allow shredded lettuce. The Dietitian stated she did a lot of communication over phone with speech therapy and would individually care plan when they would let her know. She stated no residents at this facility were care planned for shredded lettuce. She stated that they should not be serving brussel sprouts at all to residents on mechanical soft diets and this should have been on the spread sheets. She stated that menus used to be sent to her to approve through the mail and she had not received any menus for approval since the new NHA started. Furthermore, she stated the facility would have needed to get new menus to her for approval in the fall. The fall menu was not approved by her and they have been using the menu without approval by her. The last menu she had signed was the spring and summer menu last year. When asked if a resident on a mechanical soft diet should receive garlic bread, she responded they should not have received garlic bread at all. The Dietitian stated that on the National Dysphagia Diet dysphagia-diet.com it stated to avoid brussel sprouts. When asked about nectar consistency liquids, she stated that regular juice should not be given, the juice would need to be thickened. She stated that if she care planned food to be cut up, her expectation would be for the kitchen to cut the food up. She had probably done the Spring/Summer review in April as that is when she normally does the review. She stated the facility she was at on day of interview fall menus started in September and will go through April. She stated that it is the facility's responsibility to get the menus to her for approval. The other building she had been working for had mailed her the menus. Resident #1 was doing okay with a mechanically soft diet. The Dietitian said if this resident received food outside the diet prescribed it is definitely a risk. In an interview on [DATE] at 4:15 p.m., the ARNP stated that she had a resident early on in her career who choked on broccoli. The ARNP stated she found out that this resident had choked and passed away on Monday (the following day). The ARNP stated her partner released the body. The ARNP received the death certificate. She called the Medical Examiner (ME) office and sent them the resident's Progress Notes. The ARNP stated she was pretty sure the ME's office had already signed the death certificate. This resident was stable on Hospice. The ARNP stated Resident #1 was declining but not at a super-fast rate. This resident was not on thickened liquids and was not on the ARNP's radar at all for a choking incident. The ARNP stated the last time she saw Resident #1, Resident #1 was sitting at the table and doing fine eating. The ARNP stated this resident got on Hospice because she had a hospitalization so they parred her medications all the way down like from 13 to 2. They put her on Hospice, she declined a little bit. The ARNP stated if this resident would not have gotten brussel sprouts she would not have choked. The ARNP stated that the other concern she had was when she had contacted the Dietitian, the Dietitian did not know anything about the incident. This resident had mild dysphagia. In an interview on [DATE] at 4:40 p.m., the ARNP stated she viewed the Death Certificate and it listed the cause of death as Accidental Asphyxiation related to choking. She stated this is public record and a copy can be requested through Iowa Department of Public Health. In an interview on [DATE] at 5:20 p.m., the NHA stated he was unable to come up with any signed approved menus. He had talked with the last Dietary Manager about who reviewed and signed/approved the menus and she said she had the food distribution company do it. He let her know it had to be a Dietitian. The NHA said he was unable to produce approved menus signed by a Dietitian and it had not been done. In an interview on [DATE] at 10:34 a.m., Staff F, agency CNA, stated she did not work the day of the incident. When asked where she would find what diet a resident is on, she stated she really didn't know where to find a resident's diet. She stated some residents are on pureed diets and some are on mechanical soft diets. When asked again where she would find the diet order, she stated maybe their pocket care plans? She reached into her pocket and pulled out a pocket care plan and confirmed that yes, the diet was on the pocket care plan. In an interview on [DATE] at 10:55 a.m, Staff G, agency CNA, stated she worked the day of the incident. She went to answer a call light and when she returned to the dining room, Staff B was running to get the nurse, who was close, ,d+[DATE] rooms away. Staff G stated the resident was on Hospice. Staff G stated she has twins and all she knew was that Resident #1 had way too much food in her mouth, the nurse pulled out way too much food out of this resident's mouth. The RN was like fish hooking and there was ,d+[DATE] tablespoons of food that she had pulled out and there was still more in there. Staff G stated the resident really didn't know what to do with the food. The resident tried to breathe and just sucked the food back in. The resident passed out and went limp. The nurse was trying to get food out and was saying try to cough the food out. Staff G state the resident mouthed I'm trying, but she just couldn't do it. The patient was close to coming out of Hospice, that's what one of the other CNA's had said. Staff G continued on saying it just didn't make any sense. This resident could converse and overall the resident just needed help taking bites. Staff G stated it should have been a couple of bites and then a drink. Staff G stated the food in her mouth was chewed. Staff G stated the brussel sprouts that were served that day were huge. She had to cut them in half and then half again. Staff G said she was assisting a resident to dine who was on a regular diet without thickened liquids but was unable to feed herself. Staff G stated Resident #1 was way more coherent then the resident Staff G was assisting. Staff G said the brussel sprouts were the size of golf balls and honestly they were kind of hard. Staff G said she would have had to cut them into fourths for herself to eat. Staff G was able to tell the resident had pocketed food. Staff G did not think that Staff B knew how to properly assist someone to dine, like give to bites and then a drink. Staff G stated that in CNA class you learn how to assist someone to dine and they fed residents and learned. Staff G stated that if Staff B was unable to do that in her training due to COVID then that would have definitely interfered with her ability to learn and know what cues to watch for. Staff G stated if she questioned what diet a resident was on, she would ask a nurse. She was not told where she could find diet orders for residents and did not recall the diets being on sheets. Staff G stated Staff B had told her she had only been a CNA for 2 months and became one in December (2020). Staff B had told Staff G that the resident kept grabbing at the fork, so Staff B would just give her another bite. Staff G thought Staff B did not know to check for pocketed food. Staff B had told Staff G that she had never seen that before. Staff B was a caring CNA and Staff G felt that Staff B knew about the residents' Activities of Daily Living (ADLs) and Staff G hoped Staff B would not get in to trouble. Staff G stated the facility should provide education/training on the residents that need assistance with eating. Staff G stated she could have been Staff B and probably would not have known, because all they do is put food on the tray, hand you the tray and tell you who it is for. They don't tell you to cut it up, or watch for pocketing, or anything like that. In an interview on [DATE] at 11:15 a.m., Staff H, CNA, stated she was working that day in the front. Staff B came to her and told her that she needed an oxygen tank. Staff H grabbed the tank and ran to Resident #1's room. The nurses, Staff A and Staff C, were in the room. They put oxygen on the resident, suctioned the resident and were in there for a little bit. Staff H sat with Resident #1 and played Elvis for her until she passed. Staff H stated when she was sitting with this resident, the resident was gasping for air and kind of gurgling. Staff H stated she had fed this resident before. Resident #1 had not pocketed any food and would not open her mouth if sh [TRUNCATED]

Based on observation, record review and staff interviews, the facility failed to ensure residents environment remained as free of accidental hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 4 residents (Resident #1 and Resident #4). Resident #1 left the facility without staff knowledge and a visitor brought him/her back inside. Resident #1's wanderguard alarm did not function; and staff turned off the door alarm system without checking to ensure who caused the alarm to sound. The findings constituted an immediate jeopardy to residents' health and safety. Resident #4 fell in the dining room and all 3 nursing staff were in a resident's room with the door shut and 2 of the staff stated they did not hear Resident #4's pressure alarm. A nearby dietary staff heard Resident #4's alarm but did not immediately respond thinking someone else would get it. Resident #4 had been found about 6 feet from his/her wheelchair and sustained a hip fracture. The facility identified a census of fifty (50) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 5/5/16, assessed Resident #1 with a brief interview for mental status (BIMS) score of 3 (severe cognitive impairment). The MDS identified the resident with an acute change in mental status. The resident had a behavior problem of rejection of care. The MDS did not identify a concern with wandering. The resident transferred and ambulated independently. A balance during transitions and walking test revealed the resident as not steady but able to stabilize with staff assistance. The resident used a walker with ambulation. The resident had [DIAGNOSES REDACTED]. The resident had one fall without injury since the prior assessment. An elopement risk assessment dated [DATE] identified the resident with a score of 11. Five (5) or more points revealed the resident at risk for elopement. The risk assessment revealed the resident could not recognize safety risks and had impaired decision making skills. The resident had a history of [REDACTED]. A care plan dated 5/4/16 revealed the resident had alteration in thought processes/cognitive with BIMS score of 3 and senile dementia. The care plan revealed the resident used a wanderguard (a device to alert staff if the resident left the building without staffs knowledge) for elopement risk. An addendum dated 5/27/16 revealed the resident exited the building unattended. Staff replaced the wanderguard on the left wrist and placed a wanderguard on the walker. On 6/9/16 staff removed the wanderguard on the walker due to potential interference issues. The care plan also identified the resident at risk for falls. Nurses notes, dated 5/27/16 at 8:50 p.m. and written by Staff A LPN (licensed practical nurse) revealed at around 1:30 p.m. the resident walked into the building from the parking lot by a family member of another resident. When asked what he/she did outside, the resident stated he/she couldn't find their way home. Assessment showed no injury. Observation revealed the resident's wanderguard in place but the wanderguard did not activate when the resident left the facility. Staff placed the resident on hourly checks until maintenance repaired the wanderguard concern. An elopement investigative report dated 5/27/16 revealed the Director of Nursing viewed the resident approximately between 1:15 p.m. and 1:30 p.m. sitting by the front door. The resident exited from the front door. A family member of another resident brought the resident back in the facility at 1:30 p.m. The weather was sunny, temperature in the 70's with a breeze blowing. The resident had been dressed in shoes, socks, slacks and a shirt. Staff checked the door alarms after the incident and the door and the alarms all functioned. An elopement investigative procedure dated 5/31/16 revealed that when the incident occurred, the door alarm functioned and a CNA (certified nurse aide) turned the alarm off without checking to see if a resident went outside. Visitor that discovered resident outside: On 6/13/16 at 2:19 p.m. the visitor stated she was coming to the facility to assist with a birthday party at 1:30 p.m. She observed the resident outside with a walker. The resident was across the parking lot and just about to the grass in front of Grand Avenue. The resident stated he/she tried to find their way home. Prior to returning back into the facility, the resident requested to sit on the bench in front of the facility. They sat there for a minute and came back in. Staff B, CNA was at the desk when they came back into the facility and looked shocked that Resident #1 had been outside. Staff B was the only one that saw her bring the resident inside. The visitor stated no alarm sounded when they came back in. She pushed the door alarm button so that would not sound but she did not hear any other alarm (wanderguard). She stated she found out a CNA left at noon and maybe no one filled on for the staff that left and they were short staffed. Staff working when the incident occurred: On 6/13/16 at 11:50 a.m. Staff B CNA stated there was a lot of visitors coming and going the day of the incident. The other CNA left at 12:30 p.m. so she and Staff E LPN (licensed practical nurse) had to lay everyone down. They were in a room with a resident that was screaming and wanting up for the birthday party. They had the room door shut while providing care to the screaming resident. As soon as Staff B opened the room door she heard the door alarm sounding. Staff B did not hear the alarm in the room. Family and visitors were going in and out all day long and the wanderguard did not sound so Staff B just assumed it was staff/family and shut it off. She stated normally the nurse stays at the nurses station, but that day the nurse had to help with cares because they were short staffed. After that, they laid more residents down. Staff B did not think any resident left because the wanderguard did not sound. Staff B sat down to do books and saw Resident #1 come in with a visitor who said she saw the resident outside. Staff B stated the wanderguard did not sound when the resident came back in the facility. She stated 2 weekends ago (after Resident #1's incident) the wanderguard did not sound when Resident #2 followed Staff C CNA out. Staff B stated she had training on responding to the door alarm after the incident but not before the incident. Staff B received an employee disciplinary report and signed it 6/2/16. The report revealed Staff B shut off the door alarm without checking to see if any residents went outside and that was a huge safety violation. The disciplinary report stated anytime any alarm sounds staff is to immediately check it to assure the safety of residents. Staff B documented on the report in the employee comment section. Staff B wrote they were short staffed and she was with another resident doing cares. That resident was screaming because Staff B left so she returned to the resident. The wanderguard did not go off and family came in and out all day so Staff B assumed it was family because no other alarm went off. All the residents up front were either in bed or in the living room so she kept providing cares because she was the only CNA up front. On 6/14/16 at 2:07 p.m. Staff B stated the panel on the alarm panel box indicated the door alarm sounding was from the front door. After she saw the visitor bring the resident back into the facility she said she did not tell anyone and then someone came and asked her about it. On 6/14/16 at 10 a.m. Staff H CMA/medical records stated there was no CNA orientation checklist for Staff B to show he/she was educated on door alarm response. Review of facility in-service records showed the facility reviewed the alarm/elopement policy 3/10/16 and Staff B attended. On 6/14/16 at 12:36 p.m. Staff A LPN stated she came to work at 2 p.m. on the day of the incident. The resident was already back inside. She stated she was informed that the wanderguard did not sound. She stated Staff D LPN was also told the wanderguard did not sound. Staff A stated if staff is in a room with a door shut halfway to the end of the hall, staff can ' t hear the alarm. On 6/13/16 at 12:35 p.m. Staff E LPN stated she worked with Staff B on the day of the incident. She stated she did not know the resident left until she heard someone talking about it. The resident was already back inside then. Staff E stated the resident lives on the back of the facility but comes to the front wing every day to watch the television. She stated she didn't even know who the resident was or that the resident wore a wanderguard. She stated it would have been nice to know the resident was a flight risk. She was in a resident room with Staff B when she heard an alarm. Staff E held the resident as Staff B cleaned the resident. When the alarm sounded, Staff B went and checked and then came back. Staff B said it was the door but didn't say who it was. It was a busy day and no one was pushing the button. Staff E guessed that Staff B thought it was a visitor. On 6/14/16 at 10:05 a.m. Staff D LPN stated she was the resident's nurse the day of the incident. The resident spends most of the day in the front sitting in the television lounge area. She checked the resident's wanderguard that morning and it worked. She stated she didn't hear the alarm that day or turn it off. She stated the resident was his/her usual self that day. She stated maintenance stated the wanderguard range was low so they increased the range. On 6/13/16 at 3:04 p.m. Staff F CNA stated she was in the shower room when the incident occurred. She heard about it later. She stated she didn't hear the alarm or turn it off. On 6/14/16 at 12:42 p.m. Staff F stated when in rooms toward the end of the hall with door shut then she can ' t hear the alarms. On 6/13/16 at 12:50 p.m. Staff G CNA stated she didn't remember hearing any alarms that day. On 6/13/16 at 11:38 a.m. Staff H CMA (certified medication aide) stated she heard the resident got out. They didn't know what happened with the wanderguard so they cut the wanderguard bracelet off the resident after the incident and took it to the door and the alarm sounded. She applied a new bracelet to the resident's wrist. Staff previously applied a new bracelet 2 days before the elopement incident. Staff H stated she did not hear the alarm. The resident was already back inside when she heard about the incident around 2:15 p.m. to 2:30 p.m. She did not know when the resident left. She stated staff did not know why the wanderguard did not sound. Staff H stated she did not know if staff could hear alarms when in rooms. On 6/13/16 at 3:10 p.m. the Director of Nursing (DON) stated she did not hear the alarms. She stated there was a lot of commotion that day. She was in her office in the C-hall. The first she knew if the resident leaving was when the resident and family walked down the hall a little after 2 p.m. Awhile later a lady (visitor) told the activity director she saw the resident in the parking lot. The resident was heading out and she went up to the resident. The DON stated the visitor waited 30 minutes before telling a staff about the incident. The DON stated they checked the wanderguard and it worked on the door. She saw the resident around 1:15 p.m. to 1:30 p.m. sitting by the front door. The resident stated he/she was looking for his/her way home when outside. The DON stated they asked staff if anyone turned the wanderguard off and could not find anyone saying they shut it off. The DON denied any issues with the wanderguard before the incident. On 6/13/16 at 1:25 p.m. the MDS/care plan nurse stated she heard about the incident after it occurred. She worked in her office in C-hall and didn't recall if she heard any alarms. With the birthday party that day, she may not have heard it. If she hears an alarm she will go check. She stated she didn't turn off any alarms that day. She was not aware of the resident trying to leave before 5/27/16. She denied any concerns with the wanderguard not working. On 6/13/16 at 1:38 p.m. the nurse manager stated she was informed by Staff I (registered nurse) 2 p.m. to 10 p.m. nurse that the resident exited the building. She stated she didn't hear any alarms and didn't turn any off. She stated if staff is working in the back that they can ' t hear the alarms in the front. The resident never tried to leave before. He/she would stand in the doorway but never tried to leave. She stated if maintenance was not at the facility to check the door alarms that staff needed to check them. She stated after the incident they placed a wanderguard on the resident's walker as well as his/her left wrist. The wanderguard/alarm repair person said not to use one on the walker since it may interfere with the wanderguard on the wrist so they removed it from the walker. Other staff: On 6/14/16 at 9:27 a.m. Staff J (registered nurse) stated there had been problems with the wanderguard alarm not always activating. Anytime this occurred staff notified maintenance and maintenance would check the wanderguard. On 6/14/16 at 12:12 p.m. Staff C CNA stated Resident #2 followed him/her out and the wanderguard did not activate. She identified Staff I (registered nurse) as a witness to the incident and after that maintenance checked it. On 6/14/16 at 2:30 p.m. Staff I (registered nurse) confirmed that Staff C went out the front door followed by Resident #2 (who wore a wanderguard). The wanderguard did not sound so she called the maintenance person who came out and worked on the wanderguard. On 6/14/16 at 12:25 p.m. Staff K CNA stated the wanderguard did not work right for a couple weeks. It either didn't sound or it sounded when no one was around. On 6/13/16 at 12:12 p.m. the maintenance person denied there had been any problems with the wanderguard prior to the incident. He stated he didn't know why the wanderguard didn't sound on 5/27/16. He stated the wanderguard/alarm person moved the wanderguard box to the door frame. It was further away before it was moved. The sensitivity was increased and now should activate when a resident gets within 3.5 feet of it. He stated he was not here the day the incident occurred. He was on vacation that day until 6/1/16. Wanderguard/alarm repair person: On 6/13/16 at 2:02 p.m. the wanderguard/door alarm repair person stated the wanderguard activated when a resident wearing the wanderguard got right to the door so he increased the sensitivity. When asked why the wanderguard didn't sound when the resident exited on 5/27/16, he stated the system was old so interference was an issue. When the system was developed years ago we didn't have all the electronic things we have now. Someone may have had something electronic on them as the resident went through the door causing the wanderguard not to sound. It is unknown what may have interfered with it. The system was prone to interference. Prior to the 5/27/16 incident, no one told him there were issues with the wanderguard. On 6/14/16 at 12:03 p.m., the DON stated she checked the doors during the maintenance person's vacation except for 5/29/16. She stated she did not check the doors 6/4/16, 6/5/16, 6/11/16 or 6/12/16. The facility identified 3 residents wore wanderguards. Observations: Observation showed, on 6/13/16 at 10:45 a.m. the wanderguard alarm activated when Staff H CMA walked with Resident #1 to the front door. The resident walked with a walker and wore a wanderguard on the left wrist. On the same date at 1:40 p.m. the resident sat in the front television lounge area and denied walking out of the facility into the parking lot. On 6/13/16 at 11:15 a.m. all doors contained 2 alarms. All wanderguards and door alarms activated appropriately when checked by the surveyor and Staff H. On 6/14/16 at 12:25 p.m. the surveyor went in the room that staff were in when the incident occurred on 5/27/16 with the door shut (to test the alarms.) The surveyor could not hear the wanderguard or door alarm. Staff K CNA was in the room with the surveyor and stated she did not hear them either. On 6/15/16 Staff H and the surveyor measured the distance from the front entrance of the facility to the grassy area between the parking lot and Grand Avenue. The distance measured 84 feet. A missing resident drill conducted on 6/8/16 at 4:15 p.m. revealed the front door alarm sounded and the DON responded. The DON documented that the nurse was in A hall with a resident and the room door shut and the CNAs were in B hall with the door shut. On 6/14/16 at 1:07 p.m. the surveyor asked the DON about documenting staff were in rooms with doors shut. Did she document doors shut because they didn ' t hear the alarm sound in the rooms or did she mean they were too busy to answer the door alarm? The DON stated she thought they were busy in rooms. She didn ' t recall if she asked staff why they didn ' t respond. The DON stated she wasn ' t sure if staff could hear alarms in rooms with air conditioning running and the doors shut. She stated she could hear the door alarm in her office with the air conditioning running but she keeps her office door open. Wanderguard/alarm person: On 6/15/16 at 9:15 a.m. the wanderguard/alarm person stated he was putting in a louder speaker for door alarm. He stated the prior speaker was not part of the original door panel box system. Someone had glued a personal alarm speaker in the alarm panel box and when he opened up the alarm box he discovered the speaker at the bottom of the alarm panel box so it was not a functional alarm speaker. Following installation of the new speaker in the alarm box on 6/15/16, the surveyor went to the same room where staff worked when the 5/27/16 incident occurred to test the audibility of the alarms. The new alarm speaker was clearly audible. Administrator timeline: The Administrator gave the surveyor a timeline on the morning of 6/14/16. She documented the facility checked the wanderguard door alarms weekly until 6/1/16 and then they started checking them daily. The facility went back to weekly checks 6/7/16 due to wanderguard and new keypad updates. Resident #1 was on hourly checks until 5/31/16 when the facility got a keypad on the front door. On 6/7/16 the wanderguard/alarm person moved the wanderguard at the front entrance and applied a new door alarm keypad and increased sensitivity of wanderguard sensors. The nurses checked bracelets for placement and function every shift. That was in place before the incident and after. Policy: The facility walk away/missing resident policy revealed the following: If a door alarm sounds, identify the door that caused the alarm to activate. Proceed to that door and attempt to verify the cause of the alarm activation. Should staff be unable to determine the cause of the alarm activation, all known potential elopement risk residents should be accounted for. If all are accounted for, a further accountability of all residents is warranted. If an elopement risk resident cannot be accounted for, a systematic search of the facility premises and grounds should be initiated under the instruction of the charge nurse. On 6/14/16 at 11:55 a.m. the Administrator gave the surveyor a list of staff that identified which staff had or had not been in-serviced regarding alarm response. The surveyor asked about weekend staff and other staff that had not been in-serviced. The Administrator stated that is why she planned weekly in-services for a month. By the end of the month, everyone should have received the in-service training. On 6/14/16 at 12:25 p.m. the Administrator stated 14 of 51 staff listed had not been in-serviced yet. The elopement occurred on 5/27/16 and staff placed the resident on hourly checks until maintenance repaired the wanderguard concern and the resident received a new wanderguard bracelet. On 5/31/16, the facility in-serviced some staff with instructions to not turn off the door alarm until they are sure residents did not leave. The Administrator reported the following timeline: Resident #1 was on hourly checks until 5/31/16 when the facility got a keypad on the front door. The facility checked the wanderguard door alarms weekly until 6/1/16 and then they started checking them daily. The facility went back to weekly checks 6/7/16 due to wanderguard and new keypad updates. On 6/7/16 the wanderguard/alarm person moved the wanderguard at the front entrance and applied a new door alarm keypad and increased sensitivity of wanderguard sensors. The nurses checked bracelets for placement and function every shift. That was in place before the incident and after. On 6/8/16, the facility completed missing resident drill/s for some staff. The facility abated the IJ on 6/14/16 when they completed education to all staff on wanderguard and door alarm procedure/elopement to go outside and determine if a resident triggered the alarm before turning the alarm off. Also staff were educated to tell the nurse to complete a head count of residents. These actions lowered the IJ from J severity to D severity with the need of ongoing monitoring to ensure residents received adequate supervision. 2. A MDS with assessment reference date of 4/21/16 assessed Resident #4 with a BIMS score of 3 (severe cognitive impairment). The resident required extensive staff assistance with bed mobility, transfers and toileting. The resident required limited staff assistance with ambulation. a balance during transitions and walking test revealed a score of 2 in all areas of testing. A score of 2 revealed the resident was not steady and only able to stabilize with staff assistance. The resident used a walker for ambulation. The resident had [DIAGNOSES REDACTED]. The MDS did not identify previous falls. A care plan dated 4/20/16 revealed the resident at risk for falls related to impaired mobility and history of cerebrovascular accident (stroke). The care plan identified on 4/4/16 the resident self-transferred and laid self in the floor in the dining room. Staff initiated a pressure alarm at all times after that incident. An addendum dated 5/30/16 identified another incident. The resident self-transferred and fell in the dining room. The resident went to the emergency room (ER). Nurses notes dated 5/30/16 at 2:15 p.m. and documented by Staff E LPN revealed at approximately 7:55 a.m. Staff E heard residents in the dining room yell at someone and then they began to yell nurse she fell ! Staff E went to the dining room and observed the resident lying on his/her left side on the floor of the dining room yelling loudly that his/her right leg hurt. Staff E phoned the DON, ARNP (advanced registered nurse practitioner) and the resident's family. In addition to a leg injury, observation revealed a contusion to the right eyebrow and the resident's eyeglasses appeared bent. The resident transported to the emergency room at 8:30 a.m. Nurses notes dated 5/31/16 at 4 p.m. revealed the resident returned to the facility with a [DIAGNOSES REDACTED]. The hospital history and physical (H & P) dated 5/30/16 revealed the resident was in the dining room in a wheelchair and attempted to get out of the wheelchair and suffered a fall. The fall was not witnessed. Staff found the resident on the floor and the right leg appeared shortened. The resident transported to the hospital and x-rays revealed a closed intertrochanteric comminuted hip fracture. The H & P also identified a CT (computerized tomography) of the head and neck showed no acute abnormalities. The H & P revealed the resident would transport back to the nursing home at family request. The family elected to treat without surgery due to the resident's advanced dementia and chronic non-ambulatory state. An ED (emergency department) note identified the resident had an unwitnessed mechanical fall at the nursing home with a right hip fracture. The note identified the resident with [DIAGNOSES REDACTED]. On 6/15/16 at 9:18 a.m. Staff E LPN stated all 3 front nursing staff were in the same room with the door shut when the resident fell and no one in the room heard the alarm. When they opened the room door Staff E heard everyone saying the resident was on the floor. She stated she ran to the resident who was screaming saying he/she had a broken leg. Staff E stated no staff was with the resident when she arrived. On 6/19/16 at 3:31 p.m. Staff B CNA stated all 3 front nursing staff were in a resident room with the door shut and didn't hear the resident's alarm. Staff B stated they didn't know anyone fell or an alarm was sounding until someone from dietary knocked on the door and said someone fell . When they came out of the room, they could hear the alarm. Staff B stated it was Memorial Day and they were short staffed. She identified Staff F CNA as in the room. She said Staff F is a shower aide but that day had to work as a regular CNA because they were short staffed. On 6/15/16 at 10:07 a.m. Staff L (dietary) stated she heard the alarm in the kitchen for 1 to 2 minutes before she went to investigate. She stated she waited because she thought other staff would respond to the alarm. She stated she was the first one to arrive and the resident was on the floor. She waited for a nurse aide to show up. After about 30 seconds the dietary manager arrived and right after that Staff B showed up. Staff L stated she was told to let nursing handle alarms unless it rings for an extended time. On 6/15/16 at 9:52 a.m. the dietary manager stated she heard the alarm for a little while when she was in the back unit. She heard it and waited about 45 seconds to a minute and it still sounded so she went to check. She stated she thought the front unit staff would get it. When she arrived to the front, she observed the resident on the floor and Staff L kneeling by the resident. Staff B and Staff E then came out of a room. The dietary manager stated the resident's wheelchair still had the foot pedals down and the resident was about 6 feet away from the wheelchair. On 6/29/16 at 9:55 a.m. Staff F CNA stated she was supposed to give showers that day but there was no one there to work with Staff B so she could not give the scheduled showers. She stated she heard the alarm sound in the room and went to it right away. When questioned that the other 2 staff stated no one heard the alarm and no one reported seeing Staff F by the resident after the fall, she stated she either heard Resident #4's alarm or Resident #3 because Resident #3 also activated his/her alarm. Observations: On 6/15/16 at 1:10 p.m. observation showed 2 staff transfer the resident to bed. The resident complained of the right leg hurting badly. On the same date at 1:18 p.m. the surveyor went in room A10 (where staff was when Resident #4's incident occurred) and shut the door. The surveyor did faintly hear the personal alarm sound from the dining area by the piano (where Staff E stated the resident fell ). When the surveyor exited room A10, Staff E was outside the door and said the test the surveyor just conducted was not totally accurate because there were 3 staff in room A10 all talking and working with the 2 residents in the room when the incident occurred. On 6/15/16 at 12:42 p.m. the Administrator stated all staff received training and instruction to respond to personal alarms right away. She stated she knew the dietary manager said she heard the alarm 45 seconds to 1 minute and they responded quickly. She stated the dietary manager spoke with Staff L (dietary) about responding to alarms. On 5/31/16 the facility trained all staff to respond to alarms.

Based on observation, record review and staff and family interviews, the facility failed to plan for and direct the nursing care and services in order that each resident ' s needs are met and provide adequate supervision to ensure against hazards from self, others, or elements in the environment for 1 of 8 residents reviewed (Resident #1). The facility reported a census of 64 residents. Findings include: 1. Resident #1 had a quarterly Minimum Data Set (MDS) assessment with a reference date of 9/17/10, which identified a [DIAGNOSES REDACTED]. Resident #1 had periods of restlessness, difficulty paying attention, disorganized speech and wandered. The resident ambulated independently. According to the Care Plan-Potential for Wandering dated 6/21/10, the Care Plan directed the staff to provide an alert bracelet at all times, to provide diversion activities, monitor resident activity and involve in activities, to provide 1:1 as needed, assess the need for medication and administrator as ordered and to place a motion detector on the door at night. The motion detector intervention had an initiation date of 10/31/10. The Care Plan for altered thought processes dated 6/21/2010 had an intervention which directed staff to provide the resident with a safe environment each day and observe the resident for wandering/elopement. Review of the Elopement Risk assessment dated [DATE] indicated Resident #1 had a score of 6 points which identified the resident at risk for elopement. According to the Nurses Notes dated 11/1/10 on the 2-10 pm shift (no specific time) Resident #1 had supper at 5:30 p.m. Staff D attempted to locate the resident to administer the scheduled 6:00 p.m. medications at 6:55 p.m. and could not locate the resident on the back unit. Staff searched the building but failed to locate Resident #1. Staff D called the Director of Nursing, Administrator and placed a call to 911. The local police arrived at the facility and took over the search and rescue of the resident. During an interview with Staff E on 11/3/10 at 4:00 p.m. Staff E stated she/he was assigned to the unit where Resident #1 resided and had last seen the resident as the resident sat and ate the evening meal on 11/1/10. After the evening meal Staff E cleared the dishes, when she/he heard the patio door alarm sound. Staff E assisted that resident who had exited the dining room via the patio exit door, followed the wandering resident outside and returned with the resident noting 2 other door alarms sounding. At that time no other staffs were present in the immediate area. Staff E shut off the alarm for the patio exit door after the resident reentered. Staff E then located the source of the other sounding alarms. Staff E first looked out the double door windows and did not see a "back unit" resident and shut off that door alarm. Staff E located the second sounding alarm which was the ambulance exit door. Staff E looked out the window of the ambulance exit door and did not see anyone then shut off the door alarm. Staff E indicated earlier in the day the maintenance man deactivated the red box alarm (ambulance door exit). Staff E stated the ambulance exit door alarm did not sound, only the Wandergard alarm. During an interview with Staff D on 11/3 at 5:00 p.m. revealed Staff D attempted to give medication to Resident #1 on 11/1/10 at 6:55 p.m. and could not locate the resident. Staff D indicated she/he saw the resident at 4:00 p.m. and 4:30 p.m. in her/his room. At 6:55 p.m. Staff D could not locate the resident and a search ensued for the missing resident. Staff D indicated she/he did not know the red box alarm on the ambulance exit door had been deactivated. Staff D stated they have no idea how the resident got out of the facility. According to a facility generated list of residents who wander about the unit dated 11/3/10, the facility failed to identify Resident #1 as a resident who wandered. A revised list provided to the surveyor on 11/4/10 now identified Resident #1 as a resident who wandered. During an interview with Staff A on 11/4 at 7:50 a.m. Staff A stated the Resident #1 ' s name was accidently omitted from the list. During review of the Alarm Audit sheets dated 10/30/10, 10/31/10 and 11/1/10, the facility failed to have Resident #1 on the list of residents who utilized a Wandergard. The Alarm Audit form indicated which type of alarm each resident utilized and if the staff checked the alarm for proper functioning. Review of the local Police Department's occurrence report dated 11/1/10 indicated a white male missing from the facility in a striped shirt and black pants, no coat. The staff noticed the resident not in their room about 6:55 p.m. The report indicated the State Patrol made a request through Emergency Management for the National Guard to assist. The report provided details of the search and the rescue team found Resident #1 at 2:05 a.m., (7 hours after the resident went missing from the facility). The resident walked .9 miles from the facility in the dark of night. The emergency personnel found the resident laying in a ditch by a drainage grate. The ambulance transported the resident to a local hospital. During a review of the Prehosptial Patient Care Report (Ambulance report) dated 11/2/10. The report indicated emergency personal found Resident #1 lying on the ground in the woods, shivering and suffered from superficial frostbite. During an interview with the State Climatologist on 11/8/10, the Climatologist stated the outside temperature at 6:00 p.m. on 11/1/2010 was identified as 51 degrees with clear skies. The temperature on 11/2/10 at 1:00 a.m. was identified as 32 degrees with calm winds. Review of the emergency room report indicated the resident came to the hospital by ambulance on 11/2/10 with an initial body temperature of 96 degrees. Resident #1 suffered from cold exposure in inappropriate clothing after being found in the woods. The resident had final emergency room [DIAGNOSES REDACTED]. The emergency room physician admitted Resident #1 to the hospital for inpatient care. The physician documented the resident ' s condition as guarded with cold exposure and frail condition. Review of an undated Walk Away/Missing Resident policy directed the staff to do the following in the event a perimeter or wander door alarm should sound or if the facility staff are unable to locate a particular resident: a. If a door alarm sounds, identify the door that caused the alarm to activate. Proceed to that door and attempt to verify the cause of the alarm activation. b. Should staff be unable to determine the cause of the alarm activation, all known potential elopement risk residents should be immediately accounted for. c. If an elopement risk resident cannot be accounted for, a systematic search of the facility premises and grounds should be initiated under the instruction of the Charge Nurse. d. If the resident cannot be found, the Director of Nursing should be contacted. The remaining portion of the policy gave details of the search policy. At the time of the complaint investigation, the violation was coded at " J " , Immediate and Serious Jeopardy Level. By 11/5/2010 the facility had implemented measures that adequately addressed the jeopardy by training staff the alarm system so the scope and severity was lowered to " D " . As of 11/5/2010 the facility failed to: ? Continue to provide all and current and new employees the alarm system in-services, ? Continue to monitor the alarm system and proper response from staff when alarm is activated, ? Review and train staff the elopement policy/procedure, ? Continue to evaluate for adequate staffing so supervision of residents is provided.

Based on observations, record review and staff, resident and family interviews, the facility failed to protect a resident from the assaultive behaviors of another. The residents identified were Resident #6 and Resident #4. The sample consisted of 8 residents and the facility identified a census of 64 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment with a reference date of 9/17/10, indicated Resident #6 had [DIAGNOSES REDACTED]. The MDS indicated the resident required cues and supervision and had short and long term memory problems. The resident exhibited behaviors which included easily distracted, altered perception, disorganized speech with mental function that varied over the course of the day. Resident #6 required extensive assistance of 2 staff persons with ambulation, bed mobility and transfers. Review of the Behavior Care Plan dated 6/18/10 indicated Resident #6 had a resident to resident altercation on 11/5/10, had aggression, combative, wandering behaviors. The resident had a history of [REDACTED]. The Care Plan directed the staff to assess for the change in conditions, assess for contributing behaviors, review medications and do not rush the resident, allow he/she to proceed at own pace. Review of the Nurses Notes dated 11/5/10 at 6:30 p.m. revealed Resident #6 yelled at another resident and delivered a punch to the resident. The peer scratched Resident #6 on the left side of the neck and face. Continued review of the resident's Nurses Notes dated 11/9/10 at 7:30 a.m. revealed additional red scratches to Resident #6's neck and chest area. When staff questioned the resident, the resident did not know how she/he obtained the scratches. Review of the Non-Pressure Skin Condition Report dated 11/5/10 indicated Resident #6 had 5 red scratches on the left side of the neck and shoulder area. Review of the Non-Pressure Skin Condition Report dated 11//9/10 revealed Resident #6 had various red scratch marks to the chest area with some scabs forming. The nurse failed to measure the scratches and specifically noted the number of scratches. Review of the Quality Assurance Monitoring Tool dated 11/5/10 indicated Resident #6 obtained scratches to the face, neck and shoulder area while in the dining room, the tool failed to reveal how the resident sustained [REDACTED]. Review of the Quality Assurance Monitoring Tool dated 11/9/10 indicated Resident #6 had 4 linear abrasions to the front of the chest under the neck and down to the breast area. Observation of Resident #6 on 11/9/10 at 9:04 a.m. identified the resident to have 5 dark red scratches to the chest area. The scratches measured approximately 1/4 inches wide and 8 inches long. One scratch was noted to have an area of dried blood at the bottom of the scratch. During an interview with the resident at this time, Resident #6 could not remember how the scratches occurred. On 11/9/10 at 1:35 p.m. Staff F stated when she/he got the resident up in the morning; red marks on the chest area of Resident #6 were noted. Staff F stated she/he worked on 11/8/10 and did not notice red marks to the resident's chest. On 11/9/10 at 1:00 p.m., Staff G was interviewed and stated she/he had worked the evening shift on 11/8/10 and did not get a report of the scratches on Resident #6's chest area. Staff G stated she/he knew about the conflict the resident had last week when the resident sustained [REDACTED]. During an interview with Staff H on 11/9/10 at 1:45 p.m. Staff H stated the resident did not have red marks on the chest yesterday, but noted them this morning. 2. Resident #4 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 10/22/2010. The assessment identified cognition problems and [MEDICAL CONDITION] problems. The resident displayed hallucinations and [MEDICAL CONDITION] and displayed physical behavioral symptoms (e.g.: hitting, kicking, pushing, scratching, grabbing, and abusing others sexually). The resident also had verbal behavioral symptoms directed toward others (e.g.: threatening others, screaming at others, cursing at others). The resident displayed other behavioral symptoms not directed toward others each day. The physician's order [REDACTED]. The care plan dated 7/26/2010 identified the resident at risk for violence. The care plan dated 8/19/2010 indicated the resident had verbally and physically attacked another resident. The nurse ' s notes dated 11/5/2010 at 6:30 p.m. indicated Resident #4 was arguing with another Resident and became agitated with the other resident. Resident #4 told the other resident to " shut up " . Resident #4 then scratched the other resident in the face and shoulder after the resident hit Resident #4 in the stomach. Resident #4 had no apparent injury present and staff re-directed the residents. The nurse ' s notes dated 11/6/2010 at 3:60 a.m. indicated the resident continued with aggressive behaviors and attempted to hit and bite. Resident #4 scratched the staff who tried to help the resident. The resident was redirected easily. Observation on 11/16/2010 at 7:35 a.m. revealed the resident propelling self out of the unit doors with 3 staff members following. The resident yelled and said she/he was leaving. The staff coaxed the resident to return for ' hot tea ' . The staff nurse was asked if the resident required 1:1 supervision and he/she stated did not think the facility had enough staff and so the staff all worked together. The nurse stated the resident would soon become violent if he/she did not get the resident calmed. The facility knew and identified the resident had violent behaviors. The facility did not protect Resident #6 from this resident.

Based on record review, staff and family interviews and observations the facility failed to provide an assessment and timely intervention for a resident when emotional support would be needed due to a dying spouse (Resident #1). The sample consisted of 8 residents. The facility reported a census of 64 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment with a reference date of [DATE], Resident #1 had [DIAGNOSES REDACTED]. The resident made poor decisions and required cues and supervision with short and long term memory problems. Resident #1 had periods of restlessness, difficulty paying attention, disorganized speech, wandered and ambulated independently. The MDS indicated Resident #1 could make themselves understood at times and can sometimes understand others some of the time. Review of Resident #1's care plan dated [DATE]; the care plan failed to reveal Resident #1's spouse lived at the facility and had a [DIAGNOSES REDACTED]. Review of the 60 Day Nursing Home Physician's progress notes dated [DATE] revealed Resident #1 eloped from the building, broke off piece of a fence as he/she attempted to leave and required the assistance of 4 staff persons to return the resident back into the facility. The notes revealed at the time of the elopement the spouse of Resident #1 was currently at a local hospital. Review of the Nurses Notes dated [DATE] at 4:30 a.m. revealed Resident #1 paced the halls all night; he/she did wander into a peer ' s room, falling asleep in their chair. The staff attempted to direct the resident back to their room but the resident stated, "I think he/she is dead". The resident remained in the lobby. Review of the Social Service Progress Notes dated [DATE] revealed the Social Service Designee attempted to speak with Resident #1 about the spouse ' s decline but the resident could not verbalize his/her feelings. The notes continued to indicate Resident #1's spouse could not assist with the re-orienting of Resident #1 as had in the past. Resident #1 and his/her spouse shared a room within the facility. On [DATE] at 10:30 a.m. Resident #1's daughter was interviewed. The daughter stated if the facility staff had notified her of her parent's decline she would have been at the facility on [DATE] to be with her parents and offer support to the surviving parent. The daughter continued to state maybe her parent would not have eloped from the facility the evening of [DATE] if the family had been made aware and present in the facility. During an interview with Staff B on [DATE] at 2:30 p.m. revealed Resident #1 upset because his/her spouse was actively dying. The spouse of Resident #1 passed away while the resident eloped from the facility. During an interview with Staff J on [DATE] at 1:20 p.m. the staff member stated Resident #1 seemed down (depressed) because of the spouse ' s condition. Staff J stated the previous night he/she knew the spouse was dying and didn't want to be in the room. The facility staff did not assess and offer emotional support to Resident #1. The resident's spouse lived in the facility and shared a room with Resident #1. The resident refused to go into the room the day before he/she eloped, stating his/her spouse had died . The clinical record did not reflect the staff provided support to the resident on [DATE], the day his/her spouse passed away