Every finding on record at Accura Healthcare of Bancroft

Based on the Center of Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (October 1st- December 31), facility staffing assignments/schedules and staff interviews, the facility failed to submit accurate staff data for the PBJ Staffing Data Report. The facility reported a census of 18 residents. Findings include: The PBJ Staffing Data Report run date 5/28/2025 triggered for failure to have licensed nurse coverage 24 hours/day on the following infraction dates: 11/8, 11/17, 12/28, and 12/29. Review of the Facility Nursing Assignments/Schedules for the infraction dates reflected that the DON (Director of Nursing) covered the nursing shifts. A facility report titled 1702D Report from CMS revealed the DON's hours on 11/8, 11/17, 12/28 and 12/29 were not submitted to PBJ. On 6/3/25 at 10:30 AM, the Administrator verified the DON had covered nursing hours on 11/8, 11/17, 12/28, and 12/29. The Administrator reported the DON hours should have been reported to PBJ. She said the facility used an old system back then to report the PBJ hours and that the facility has a different system now. On 6/3/25 at 11:31 AM, the Administrator verified the DON's hours were not submitted to PBJ on 11/8, 11/17, 12/28 and 12/29. On 6/3/25 at 3:47 PM, the Administrator reported she recognized that with the old system the facility was having company wide errors so switching to the new system will allow to track PBJ hours monthly instead of quarterly. An undated facility procedure titled Getting Started with SimplePBJ documented the following steps for PBJ compliance: 1. Assemble data- gather data from payroll and/or timekeeping system, agencies, and contractors to load to SimplePBJ. 2. Validate data- Analyze for issues, review potential errors, and easily make changes to the PBJ data. 3. Predict five-star staff rating. 4. Submit data- create PBJ report and submit directly to CMS.

Based on observation, record review, and staff interview, the facility failed to hold hot foods at 135 degrees during 1 meal service. The facility reported a census of 18 residents. Findings include: The noon menu for 6/4/25 included a cheddarwurst on a bun with peppers and onions and a hashbrown patty. During a combined observation and interview on 6/4/25 at 11:43 a.m. Staff A Cook, temped all of the food, and all hot food greater than 165 degrees. During the meal service, Staff A served the peppers and onions from a pan on top of the stove. He removed a pan of the hashbrown patties from the oven and sat on top of stove. The oven doors remained open during the service. Right after the meal service Staff A temped the food. The cheddarwursts were above holding temperature (135 degrees), the hashbrown patties only reached 131 degrees, and the peppers and onions only reached 91 degrees. The Dietary Manager stated it was hard to keep things hot, which was why she served out of the oven rather than putting hot food on top. The undated facility policy, Food Temperatures, documented all hot foods must be cooked to appropriate internal temperatures and held at a temperature of at least 135 degrees.

Based on observation and staff interview, the facility failed to serve food in accordance with professional standards of quality for 1 meal. The facility reported a census of 18 residents. Findings include: During an observation and concurrent interview 6/4/25 at 11:59 a.m. Staff B, Dietary Aide (DA) was in and out of the kitchen several times taking fluids to residents, getting in and out of the refrigerator and opening and closing the door to the kitchen without washing her hands. Staff A, [NAME] washed his hands prior to the meal service. Staff A plated food placing his thumbs into the plate on both sides and then putting the food on the plate. Staff A placed several of the utensils with the handles on a cutting board, and then used the same cutting board to cut up hot dogs for residents. During the meal service Staff A also touched his face and his ear with his hand and did not wash his hands. He did not handle food, but he did handle the utensils including those on the cutting board. The Dietary Manager stated stated she should have been observing the dietary staff closer to ensure the were washing hands when needed, and not putting hands on the eating surface of the plates. It was Staff A's first survey, and he was nervous. On 6/5/25 at 8 a.m. the Administrator stated they did not have a hand washing policy specific to the kitchen. The facility policy Hand Hygiene updated 7/29/21 indicated hand washing should be performed by all staff as necessary to prevent cross contamination. The 2022 Food Code 2-301.14 directed when to wash hands included after touching bare human body parts other than clean hands and clean, exposed portions of arms.

Based on clinical record review, staff interview and facility policy review the facility failed to notify the ombudsman office of a discharge to the hospital for 2 of 2 residents (Residents #8, #17) reviewed for hospitalizations. The facility reported a census of 18 residents. Findings include: 1. Resident #8's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 04, indicating severely impaired cognition. Resident #8 ' s MDS included diagnoses of coronary artery disease, heart failure, transient cerebral ischemic attack (TIA/mini stroke) and non-Alzheimer ' s dementia. Review of Census and Progress Note dated 3/22/25 revealed Resident #8 was admitted to the hospital for pneumonia and respiratory syncytical virus (RSV). The facility form titled Notice of Transfer Form to Long Term Care Ombudsman used to track discharges and notify the Ombudsman of a discharge revealed Resident #8 was not listed on the forms for March or April 2025. 2. Resident #17's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 12, indicating moderately impaired cognition. Resident #17's MDS included diagnoses of diabetes mellitus, arthritis, non-Alzheimer's dementia, and presence of right artificial hip joint. Review of Census and Progress Note dated 2/24/25 revealed Resident #17 was admitted to the hospital due to a fracture of the right hip. The facility form titled Notice of Transfer Form to Long Term Care Ombudsman used to track discharges and notify the Ombudsman of a discharge revealed Resident #17 was not listed on the forms for February or March 2025. On 6/3/25 at 3:35 PM, the Administrator reported she was responsible for completing the notifications to the Ombudsman and was not aware that hospitalizations were required to be reported. She said she notified the Ombudsman of transfers that included discharges to home or to another facility. A facility policy titled Ombudsman Notification Process revised January 2023 documented the facility was responsible for notifying the Long Term Care Ombudsman of all transfers and discharges from the facility.

Based on observation, record review, and staff interview, the facility failed to serve food in a form to meet individual needs for 2 of 2 residents reviewed (Resident #17 and #13). The facility reported a census of 18 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #17 scored 12 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required partial/moderate assist assistance with eating. The resident had diagnoses including diabetes and non-Alzheimer's dementia. The Care Plan revised 4/16/25 identified the resident had dementia and diabetes. Speech Therapy (ST) recommended nectar thick liquids - which the resident refused. The resident had been on a mechanically altered texture diet in the past. The interventions included staff would cut up the resident's meat and cut sandwiches in half or fourths as the resident desired per therapy recommendations revised 5/10/25. A Diet Roster report printed 5/13/25 documented the resident had a Doctor's order for a regular diet with additional directions for cut up meat. A Rehab Communication dated 3/10/25 documented Speech Therapy recommended a diet upgrade to regular solids, and please cut all plated meats into bite size pieces, and cut sandwiches into half or fourth for resident to hold. 2) According to the MDS assessment dated [DATE], Resident #13 scored 14 on the BIMS indicating moderate cognitive impairment. The resident required set up/cleanup assist assistance with eating. The resident had diagnoses including non-Alzheimer's dementia. The Care Plan revised 7/10/24 identified the resident had a potential alteration in nutrition related to her dementia diagnosis, vision status as evidenced by the need of set-up assistance with meals, fair to poor meal intake, and slow weight loss. The interventions included the resident was on a regular diet, and cut-up foods to aid in self-feeding. A Diet Roster report printed 5/13/25 documented the resident had a Doctor's order for a regular diet with additional directions for cut up meats. During observation and concurrent interview on 6/4/25 during the noon meal service a white board in the kitchen had 3 residents listed that would get their meat cut up (including Resident #17 and #13). It didn't indicate how it would be cut up. Staff A [NAME] cut the cheddarwurst up in very large chunks for the 3 residents listed. During interview with the Dietary Manager (DM) she confirmed that they should be bite-size pieces, and they were not bite sized. In an email on 6/4/25 at 2:28 p.m. the Administrator wrote she could not find a policy on diet orders, but the DM said that they went by what the nurse told them and the care plan.

Based on clinical record review, document review, resident and staff interviews, the facility failed to revise the care plan to accurately reflect the risks of utilizing high-risk medications for 2 of 5 residents sampled for medication management, (Resident #11 and #16). The facility reported a census of 18 residents. Findings include: 1.The Minimum Data Set (MDS) Assessment for resident #11 dated 3/30/23 showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS documented Resident #11 received an anticoagulant medication (a medication that carries a risk of increased bleeding potential) during the 7 day MDS look back period. The Hospital discharged Instructions electronically signed by the physician on 3/24/23 documented a physician order for Apixaban 2.5 mg oral tablet give 4 tablets every 12 hours for 1 week then 5 mg twice a day. A review of the Resident's March and April 2023 Medication Administration Records (MARs) completed on 4/11/23 documented Resident #11 received an apixaban oral tablet 2.5 milligrams (mg) give 4 tablets by mouth two times a day from 3/24/23 - 4/11/23. The Resident also received aspirin (medication to minimize blood clotting) enteric coated tablet delayed release 81 mg, give 1 tablet by mouth one time a day for cardiac prevention related to non-st elevation (NSTEM) myocardial infarction from 3/9/21 - 3/21/23, 3/25/23 - 4/11/23. A review of the Care Plan with a revised date of 4/11/23 lacked documentation related to the use of anticoagulant medication (Apixaban) and risk factors for use. During an interview on 4/11/23 at 2:20 p.m. Resident #11 reported she is on a blood thinner due to having blood clots. An interview with the MDS Coordinator on 4/11/23 at 3:06 p.m., reported she updates the care plan according to the changes on the MDS. If a new order comes in and the MDS had recently been completed then she would add the changes to the care plan before the next review. During an interview on 4/11/23at 3:09 p.m. with Staff A, Registered Nurse, reported the care plan would have interventions and things to look for regarding medications. An interview with the DON on 4/11/23 at 3:12 p.m., verbalized the initial orders go into a folder that she keeps in her office. She gives the folder to the MDS Coordinator to insure the care plans are updated in the computer. During an interview on 4/11/23 at 3:18 p.m. the DON reported the facility does not have a care plan policy. 2. The MDS assessment dated [DATE] for Resident #16 showed a BIMS score of 15 indicating intact cognition. The MDS identified Resident #16 received an antidepressant medication (a medication that can carry side effects of dizziness, loss of appetite, insomnia and can alter mood status) during the 7 day MDS look back period. An Office Clinic Note dated 3/22/23 documented a diagnosis of anxiety and depression in which the Lexapro would be used to treat both conditions. A review of the Care Plan with a revised date of 4/3/23 lacked documentation related to the use of an antidepressant medication (Lexapro), the diagnoses of anxiety and depression, side effects to monitor for and psychosocial resident needs. A review of the Resident's March and April 2023 Medication Administration Record (MAR) completed on 4/11/23 revealed the Resident received the Lexapro 10 mg by mouth one time a day for generalized anxiety disorder from 3/1/23 - 4/1/23. The MAR further showed the Lexapro antidepressant medication had a start date of 11/24/22. During an interview on 4/11/23 at 2:30 p.m. Resident #16 reported that she recently started on a medication to help with her depression.

Based on observation, clinical record review, policy review and staff interview, the facility failed to minimize the risk of infection during the provision of catheter care for 1 of 1 resident reviewed, (Resident #12). The facility identified a census of 18 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. Resident #12 required extensive assistance with bed mobility, transfer, dressing, personal hygiene and toileting. The MDS listed a diagnoses of malignant neoplasm of the prostate and identified Resident #12 utilized an indwelling urinary catheter (a catheter that remains in place in the bladder that drains urine from the bladder into a bag outside of the body). A Physician Order Report signed by the Provider on 1/9/23 documented the following physician orders: a. Replace the Foley catheter every 30 days with a 16 French catheter with a 10 cubic centimeters (cc) bulb one time a day every 30 day(s) for infection control related to malignant neoplasm of the prostate and as needed. Active date 1/10/23. b. Change the catheter drainage bag every 15 days and as needed one time a day every 15 day(s) for infection control and as needed. Active date 1/10/23. A Care Plan Focus revised 11/11/22 by the DON documented Resident #12 had a catheter due to prostate cancer. The Care Plan directed the C.N.A.'s to provide catheter care twice a day and as needed with a care plan goal that Resident #12 would not develop a urinary tract infection due to the catheter use. During an observation on 4/11/23 at 7:32 a.m. the Director of Nursing (DON) assisted Staff B, Certified Nursing Assistant (C.N.A.) with catheter care. The DON stood by the head of the bed. She kicked the trash can toward the bed with her left foot, then bent down and used her right gloved hand to grasp the 1/2 full garbage can by the rim with her gloved thumb, index finger and middle finger to move the trash can by the bed. Observation revealed used Kleenex in the garbage can. The DON directed Staff B to do the catheter care because she had clean gloves on. The DON picked up a package of disposable wipes in her left gloved hand and used her right gloved thumb, index and middle finger to pull a disposable wipe from the package and handed the wipe to Staff B who used the wipe to cleansed around the urinary meatus (tip of penis) head at the catheter insertion site The DON pulled another disposable wipe with the gloved right hand, handing the wipe to Staff B. Staff B took the second disposable wipe and cleansed around the urinary meatus again. The DON pulled two more disposable wipes out of the package with her gloved right hand and handed to Staff B so she could cleanse the left and right groin folds with the disposable wipes. The DON then pulled another disposable wipe from the package with her right gloved hand handing the wipe to Staff B so she could cleanse from the catheter insertion site four inches down the catheter. The DON repeated the process a second time so Staff B could cleanse down the catheter one more time. Both Staff removed their gloves upon completion of the catheter care. During an interview on 4/11/23 at 2:51 p.m. Staff C, C.N.A. reported she had received training on catheter care. She reported she is to use clean gloves to provide catheter care. If she touched something dirty, she would have to change her gloves and do hand hygiene prior to performing catheter care. During an interview on 4/11/23 at 3:33 p.m. Staff D, Registered Nurse (RN) reported she would expect if gloves become contaminated prior or during catheter care, the gloves should be changed. During an interview on 4/12/23 at 11:40 a.m. the DON reported she expected staff to change gloves if gloves become contaminated and perform catheter care with clean gloves. The Hand Hygiene Policy updated 6/21/21 directed staff should always complete hand hygiene before and after putting on and taking off of gloves and after handling contaminated items and equipment such as dressings, secretions and excretions from residents. The Catheter Care Policy updated 6/21/21 documented a purpose to prevent infection and reduce irritation. The Policy directed to use peri wash, washcloths, towel, gloves and a surface barrier for equipment supplies. The Procedure documented the following steps: a. Wash hands, gather equipment and take to the bedside. b. Provide privacy and explain the procedure to the resident. c. Apply gloves. d. Clean the area at the catheter insertion. Do one side of the area and then using the clean area of the wash cloth do the other side. Be careful not to pull on the catheter or advance it further into the urethra. Make sure all debris is removed from the catheter insertion site. Always clean from the front to the back. For male residents retract the foreskin for thorough cleansing, making sure to pull the foreskin back down when finished. e. Gently pat dry. f. Discard equipment properly. g. Position the resident comfortably with the call light within reach. h. Wash hands. The Catheter Care Policy failed to direct the staff on when to change to clean gloves if gloves become contaminated by other environmental surfaces. The Standard Precautions Policy updated 6/21/21 directed gloves should be worn when touching blood, body fluids, secretions, excretions, and contaminated items. Gloves should be removed promptly after use and before touching non-contaminated items and environmental surfaces and before going to another resident. Hand washing should be completed after gloves are removed. The Policy indicated Standard Precautions are indicated for all residents. The Policy directed to handle Resident- Care equipment soiled with blood, body fluids, secretions, or excretions to prevent skin and mucous membrane exposure, contaminating of clothing and the transfer of microorganisms to other residents and environments. The Policy direct to clean reusable equipment and discard disposables.

Based on personnel file reviews, staff interviews, and facility policy review, the facility failed to obtain an evaluation by the Department of Human Services (DHS) prior to hire to determine if an employee with a criminal history could work in the facility for 1 of 5 current employees sampled (Staff C, Licensed Practical Nurse (LPN)) and ensure staff completed dependent adult abuse training within six months of hire (Staff D, Certified Nursing Assistant (CNA)). The facility reported a census of 19 residents. Findings include: 1. The personnel file for Staff C, LPN documented a hire date of 9/30/2021. The Single Contact License and Background Check(SING) dated 9/29/2021 indicated a possible criminal hit for Staff C, LPN which required the Department of Criminal Investigation (DCI) to clarify if the prospective employee did or did not have a criminal history. The personnel record revealed Staff C, LPN received clearance on 10/1/21. Review of the Nursing schedule for September 2021 revealed Staff C, LPN scheduled for September 30, 2021. Interview on 12/13/21 at 2:39 p.m., with the Director of Nursing (DON) revealed Staff C, LPN worked the evening shift on 9/30/21. Review of facility provided policy titled Abuse Prevention, Identification, Investigation and reporting policy with an effective and updated date of 4/14/17 revealed the following information: * The facility shall screen all potential employees for a history of abuse, neglect, exploitation, misappropriation of property or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] * This will be accomplished through the following (including maintaining documentation of such results): a. The facility will conduct an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to residents, prior to hire, in the manner prescribed under 481 Iowa Administrative Code 58.11(3). The facility will conduct a crimnal record check and dependent adult/child abuse registry check on all current employees and other individuals engaged to provide services to residents. Interview on 12/13/21 at 2:59 p.m., with the Administrator revealed the facility does not use a third party vendor for background checks and the facility did not have the clearance to have Staff C, LPN working. 2. On 12/13/21 at 1:56 PM a review of Staff D's employee file revealed no Dependent Adult Abuse Training certification on file. Staff D had a hire date of 5/12/21. On 12/13/21 at 2:40 PM in an interview with the DON, the DON stated it is the expectation staff have completed the dependent adult abuse training within six months of hire. On 12/13/21 at 2:40 PM in an interview with the Business Office Manager (BOM), she stated she was aware the certification was absent from Staff D's file. The BOM stated it is the expectation to have the certificate on file within the employee files within six months of hire. The facility policy labeled Abuse Prevention, Identification, Investigation, and Reporting Policy dated 04/14/17, stated each employee shall be required to complete two hours of training related to the identification and reporting of dependent adult abuse within six months of initial employment.

Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was stored and prepared under sanitary conditions. The facility identified a census of 57 residents. Findings include: An initial kitchen tour conduct on 12/8/21 at 10:27 a.m., revealed the following observations: 1. The following items stored in the refrigerator ready for service: 2 open ranch dressing lacked an open date. Open baking soda lacked an open date. Open enchilada sauce lacked an open date. Open salsa lacked an open date. Open bag of shredded swiss cheese with hard dried pieces lacked an open date. Open bottle of taco sauce lacked an open date. Open container of orange juice lacked an open date. Open container of pink lemonade lacked an open date. Open jug milk lacked an open date. Open container of tea lacked an open date. Water container lacked an open date. Open bottle of thickened kiwi strawberry lacked an open date. Open bag of cheddar cheese lacked an open date. Open bottle of nectar thick water lacked an open date. Open bottle of thickened apple juice lacked an open date. Open bottle of lemon juice lacked an open date. 2. The following items stored in the freezer ready for service: Pound cake with frost approx 1/8 inch around sides and top of package. Frozen [NAME] squash x2 with frost build up approx 1/8 inch around container. Hot dogs open with no open date frost build up in the bottom of bag. Open meat in a blue bag with frost buildup in the bag lacked a label of contents and lacked an open date no label. Open bag of chicken pieces with frost build up in the bag lacked an open date. Open bag of brats lacked an open date. Green yellow diced food with frost build up in bag labeled 10/18- lacked item label. Open bag of frozen bacon crumbles lacked an open date. Open bag of meatballs lacked an open date. Two bags of cubed meat lacked a label of contents. 3. The following items were stored and ready for service in the dry storage: Unopened potato casserole Au gratin potatoes with an expiration date of 11/24/21. 24 boxes of unopened boxes of baking soda with an expiration date of 7/30/21. 2 bags of Mini M&M's with an expiration date of 9/2021. Open bag of navy beans lacked an open date. Open bag of long grain rice lacked an open date. 4. The following items were stored and ready for service in the kitchen: Open bag of brown sugar lacked an open date. Open bag of instant breakfast with an open date of 2-19, was hard to the touch. Open box of baking powder lacked an open date. Open bottle of worcestershire sauce lacked an open date. Open bag of chicken gravy lacked an open date. Open bottle of soybean pan grill oil lacked an open date. Open bottle of syrup bottle lacked an open date. Open bottle of sugar free syrup lacked an open date . 2 containers of muffins- in cabinet no date on label. Open container of sugar lacked an open date. Open container of flour lacked an open date. Bag of three pieces of buttered banana bread in a bag with no label of item or date. (kitchen staff confirmed it was banana bread). 3 rolls in bag ready to be served noted 1 roll with a spot of black debri with fuzzy edges and 1 roll with 2 spots of black debri with fuzzy edges. Interview on 12/08/21 at 11:17 p.m., the Dietary Manager revealed she expects all items to be labeled and have open dates if they have been open. Interview on 12/13/21 at 12:40 p.m., the Administrator revealed the facility does not have a policy regarding food storage, the facility is to follow the food code regulations.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the PreAdmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 residents (Resident #1) reviewed for PASRR requirements. The facility reported a census of 19 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Review of the clinical record revealed a Notice of Negative Level I Screen Outcome dated 4/19/2018 revealed the PASRR level 1 screen remains valid for your stay at the nursing facility and should be transferred with you if you relocate. No further level 1 screening is required unless you are known to have or are suspected of having a major mental illness or an intellectual or developmental disability and exhibit a significant change in treatment needs. Further review revealed question #1- Does the individual have any of the following Major Mental Illnesses, which included [CONDITION(S)]. The box was marked no. Review of the MDS dated [DATE] revealed an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of hospital discharge notes dated 11/20/19 at 8:41 a.m., revealed active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Medication Review Report dated 8/24/2020 signed by the physician 8/26/20 revealed active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's chart lacked a follow-up and resubmission of a PASRR with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 12/09/21 at 9:34 a.m., with the Director of Nursing (DON) revealed Resident #1 does have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 12/13/21 at 12:52 p.m., with the DON revealed the facility does not have a policy on PASARR as they follow the regulations.

Based on record review, observation, staff interview and facility policy, the facility failed to provide complete and appropriate incontinence care in a manner to prevent urinary tract infections for 1 of 2 residents observed (Resident #15). The facility reported a census of 19 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #15 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed the Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Observation on 12/08/21 at 1:20 p.m., Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA explained to Resident #15 they were going to assist Staff #15 to the bathroom. Staff A and Staff B assisted Resident #15 into the bathroom. Staff A applied gloves and removed soiled incontinence pad. Staff A removed gloves without performing hand hygiene. Staff A applied a clean incontinence brief and applied another male pad inside the brief. Staff B assisted Resident #15 to a standing position. Staff A took out a disposable wipe and wiped the right side of the groin from the top of the pelvis down to perineum with one stroke and disposed of the wipe. Staff A took a disposable wipe and wiped down the left side of the groin area from the pelvis down to the perineum with one stroke and disposed of the wipe. Staff A took a disposable wipe and wiped the front of the pelvis down to the perineum with one stroke and disposed of the wipe. Staff A removed gloves and without performing hand hygiene pulled up Resident #15's incontinent brief and Resident #15's pants. Staff A and Staff B then assisted Resident #15 into bed and laid down. Review of Resident #15's Care Plan with a revision date 5/19/21 revealed Resident #15 was incontinent of urine and required an assistance of 2 with toileting. Review of facility provided document titled Competency for Peri Care updated 4/20/2021 revealed staff to cleanse penis by pushing back foreskin- gently wash around glans of penis, shaft, and scrotum. Wash anal area, front to back using facilty choice of solution and cloths or wipes, and wash buttocks and both hips. Interview on 12/13/21 at 1:46 p.m., the Director of Nursing (DON) stated expects the groin area and buttocks area to be fully cleansed, all areas the soiled brief could touch should be cleansed.

Based on observation, record review, facility policy and resident interview the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 resident who exited the facility unsupervised, (Resident #1). The facility reported a census of 21 residents. 1. Resident #1 had a Quarterly Minimum Data Set (MDS) assessment dated [DATE], that documented diagnoses of Diabetes Mellitus, Non-Alzheimer Dementia, [CONDITION(S)], Depression, Dementia with Lewy Bodies and restlessness and agitation and a score of 13 of 15 on a BIMS (brief interview for mental status) test which indicated no impaired cognition. The MDS documented delusions, no wandering and limited assistance with locomotion on the unit and off the unit. A Risk Assessment for Elopement form dated 7/20/21, documented: *Independently mobile with/without assistive device- no *Is the resident considered to be at risk for elopement- no Comments- Resident is assist time 1 with all transfers. Resident is not an elopement risk. A Care Plan dated as revised on 7/21/21, identified a focus area titled resident has visual hallucination at times that seem very real to me. Staff is unable to convince me that these hallucinations are not real, interventions include to: *I often accuse staff of not giving me my medications, please provide me reassurance as needed. *Staff will continue to provide medication for me as ordered. *Staff will not feed into my hallucinations or delusions but offer support and comfort. *Stall will sit with me and listen to my fears or concerns. When I am restless, anxious, or agitated, provide me 1-1. An entry in the Progress Notes dated 10/14/21 at 1:28 p.m., documented Resident #1 continues to have frequent periods of hallucinations and paranoid and accusatory behaviors towards staff and living arrangements. Staff attempts 1-1 with minimal success. An entry in the Progress Notes dated 10/14/21 at 6:05 p.m., documented Certified Nursing Assistant notified of missing resident. Staff split up into designated areas to search inside and around care center and roads. Notified the Director of Nursing that resident was missing and town police officer on call. Notified the son and continues search at this time. An entry in the Progress Notes dated 10/14 /21 at 6:25 p.m., documented notified that resident was found back behind nursing home with no injuries. Brought back into nursing home. Bed and chair alarm in place with 15 minute checks of location. Director of Nursing, Administrator, Son, and staff notified of safe return. Vitals obtained. Denies any pain or discomfort at this time. An Incident Report dated 10/14/21 at 6:05 p.m. documented Elopement: Nursing description- Certified Nursing Assistant went to get resident for supper and resident was not in their room. Staff reported to nurse on duty. Staff searched the nursing home and assisted living and resident was not found. Resident description- Resident stated There was a garage door open so I went in there. They are not giving me pills I need around here so I got out of here. I want my Tylenol every day and as long as we are on the same page now I will be ok. This nurse also asked the resident where they left the building at end resident stated I went out the activity room door. Description- Staff searched the entire nursing home and assisted living. Notified the Director of Nursing, who notified the Administrator, and then notified the Administrative Assistant to help search along with staff members outside. Head to toe assessment done. Vital signs taken and wit in normal limits. An updated Care Plan with date initiated 10/14/21, stated I am an elopement risk due to my Dementia, with interventions: *Encounter telehealth consult. *Staff will check all door alarms are on and working properly every shift. *Staff will check on me approximately 32 times per shift for 72 hours, then 8 times per shift times one week to make sure that I am safe. *Staff will redirect me, 1-1 reassurance or reorient me as needed if I am talking about or attempting to leave the building. * I am independent with my walker throughout the facility. Facilities investigation: Timeline of Incident: On 10/14/21 at approximately 6:08 p.m., Executive Director, was notified by the DON that the resident had an elopement from the facility. On 10/15/21 at 3:15 p.m., state was notified via phone by the DON and Executive Director. On 10/14/21 at approximately 6:00 p.m., a Licensed Practical Nurse notified the DON that Resident #1 was discovered missing from facility. At 5:00 p.m., resident was in the DONs office until 5:30 p.m., as resident was agitated and restless, stating staff was not giving the resident their medication. Resident was calmer at 5:30 p.m., so the DON was taking the resident back to their room when resident received a phone call. A CNA assisted resident back to their room after the phone call at approximately 5:40 p.m. At approximately 5:50 p.m., a CNA went to the resident room to get them for supper and resident was not in their room. Staff immediately notified the Nurse and staff began to search for the resident. CNA observed resident sitting at dining room table at approximately 5:40 p.m. before supper. Administrative Assistant arrived to the facility at approximately 6:15 p.m. to help search for the resident. Administrative Assistant located resident behind the facility by the garages at approximately 6:22 p.m., and assisted resident back to the facility. DON performed a head-to-toe assessment within normal limits and no injuries. Resident family member was notified on 10/14/21 at approximately 6:20 p.m Resident physician was notified on 10/14/21 at approximately 6:55 p.m., by the DON. Residents Care Plan at the time of the incident stated assist time ones with walker and gait belt and has the following interventions in place, staff will continue to offer medications as scheduled, staff will not feed into my hallucinations and will offer support and were being followed as stated in residents Care Plan at the time of the incident. 10/20/21 Interventions Implemented: -Lock box on alarm panel with a key for the staff only. -New double alarm boxes installed on the West and South entrance doors -Nurse check all door alarms every shift. -Educated staff on alarms and elopement. While continuing our investigation on 10/20/21, we witnessed Resident #8 reach for the alarm panel when a door alarm was going off. The Executive Director visited with the DON to interview the resident and ask about the alarm that went off last Thursday evening. From the interview it was founded that the resident shut off the alarm so there for the nursing staff might not have heard the alarm, when Resident #1 went out the door. Review of the Missing Residents/Elopement Process updated 2/22/2021. When the door alarm sounds: the facility staff shall: a. check the alarm panel to determine which door has been opened. DO NOT assume some one else has already done his. b. Check the exit door for any existing resident by means of a visual check. Visual check means observing the area around the exit and may require leaving the building. c. If the resident is discovered outside the facility inappropriately, staff will assist them back into the facility. d. Reset the door alarm after it is determined by visual check that no resident has exited the facility inappropriately or is returned to the facility. e. If an alarm is discoverer de-activated, staff will perform an immediate head count to ensure all resident are accounted for. During an interview on 10/20/21 at 2:00 p.m., Resident #8 confirmed and verified they were at the north end of the facility by the drinking fountain next to the nurses station and heard the alarm sound and proceeded to flip the switch off just as soon as the alarm was heard. Resident #8 stated they didn't tell any staff or anyone that they had flipped the alarm switch on and off the silence the alarm. During an environmental tour on 10/18/21 at 3:10 p.m., the facility Director of Nursing went around to all the alarms and the alarms were all activated.

Based on record review and staff interview, the facility failed to provide appropriate notifications on discharge from medicare services for 2 of 3 residents reviewed (Resident #8 and #12). The facility reported a census of 23 residents. Findings include: 1. A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review completed by the Minimum Data Set (MDS) Coordinator and received on 6/26/18 documented Resident #8 started Part A skilled services on 3/30/18 with the last covered day 4/20/18. The review indicated the resident and/or resident representative received a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN/ ), but lacked identification of the receipt of the Notice of Medicare Non-Coverage (NOMNC/ ) explaining the right to appeal the decision. The review lacked a reason for not providing the notice. The resident's record contained an SNFABN/ , but did not contain an NOMNC/ with the resident's rights to appeal. 2. An SNF Beneficiary Protection Notification Review documented Resident #12 started Part A skilled services on 4/20/18 with the last covered day 5/12/18. The review indicated the resident and/or resident representative received an SNFABN/ , but lacked identification of the receipt of the NOMNC/ . The review lacked a reason for not providing the notice. The resident's record contained an SNFABN/ , but did not contain an NOMNC/ with the resident's rights to appeal. During an interview on 6/26/18 at 10:20 a.m. the MDS Coordinator stated the Administrator told her she no longer had to give 2 notices.

Based on record review, and staff interview the facility failed to assess a resident's lung sounds, and respirations with a productive cough (Resident #14). The facility reported a census of 23 residents. Findings included: 1. According to the facility Progress Notes sheet Resident #14 had [DIAGNOSES REDACTED]. Record review revealed nursing Progress Notes documented the following: 2/3/18, at 7:42 PM Occasional productive noted. He states My throat feels scratchy sometimes. Temperature 97.6. 2/4/18, at 2:08 AM Slight cough noted throughout the night. No complaints voiced. Slept well per usual. Temperature 97.6. 2/4/18, at 1:41 PM Occasional productive cough remains. Temperature 98.3 2/4/18, at 8:19 PM Continued to have occasional productive cough. Temperature 97.9. He states, It's a nagging cough that makes my throat tickle. Will continue to monitor. The Progress Notes lacked any visualization of the resident's throat, auscultation of the resident's lung, respirations or description of the amount, color or character of the [MEDICATION NAME]. Record review revealed on 2/7/18 Resident #14's Physician's Assistant (PA) ordered the antibiotic [MEDICATION NAME] 100 milligrams (mg.) twice daily for 10 day noting a [DIAGNOSES REDACTED]. The resident's clinical record contained a *Final Report* dated 6/27/18 completed by the PA that documented the following: This is an addendum to the 2/7/18 visit. Resident seen for recertification at the nursing home. At the time the resident had complained of cough and tightness in his chest. I omitted these complaints from my dictation in error. He did not run a fever. Upon examination he did have scattered rhonchi throughout his lung fields that did not clear with coughing. I felt it appropriate to place the resident on an antibiotic. He was started on [MEDICATION NAME] on this date due to clinical examination findings which were omitted from my initial note in error. During interview on 06/27/18 at 08:34 AM the Director of Nursing (DON) stated, I agree with you about the assessment and confirmed the record lacked documentation indicating staff assessed the resident before or after [DIAGNOSES REDACTED]. Record review revealed the nursing Progress Notes documented the following: 3/12/18 at 4:57 PM Minimal cough throughout the night. Head Of Bed (HOB) elevated with some relief. He is observed sleeping well with no complaints. 3/14/18 at 7;50 PM Minimal coughing noted this shift. Ate well for supper per usual. Temperature 97.6. 3/18/18 at 5:17 PM Minimal cough noted throughout the night. HOB elevated for comfort. Slept well and voiced no complaints at all times. 3/18/16 at 8:48 PM Minimal cough noted at times this shift. No complaints voiced from resident. He is in bed with eyes closed at this time. HOB elevated for comfort. Will continue to monitor. 3/19/18 at 4:31 AM Minimal cough noted throughout the night. Slept well per usual. HOB elevated for comfort. No complaints voiced at this time. 3/19/18 at 7:32 PM Minimal cough noted throughout the shift. No complaints voiced at this time. 3/23/18 at 8:38 PM Minimal cough noted throughout the shift. No complaints voiced at this time. On 4/4/18 at 1:57 PM the resident's Physician Assistant (PA) examined the resident. No new orders. Resident denies complaints. The next entry dated 4/4/18 at 2:18 PM (21 minutes later) documented: Resident noted to be occasionally coughing during PA visit Rhonchi noted in left lower lung. New orders received. Record review revealed on 4/4/18 the resident's PA ordered the antibiotic [MEDICATION NAME] for treatment of [REDACTED].

Based on record review, staff interview and review of policy and procedures, the facility failed to report allegations of abuse for 1 of 4 records reviewed (Resident #1). The facility identified a census of 22 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 10/23/17. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMS (Brief Interview for Mental Status) score of 5. A score of 5 identified the resident had a severe cognitive impairment. According to the MDS the resident required extensive assistance with bed mobility, transfers, dressing and toilet use. The Care Plan dated 7/30/17 and revised on 11/20/17, directed staff to assist with cares for his needs and assist to dress, especially the lower extremities. Review of the Time Card sheet dated 10/15/17 through 10/28/17, identified Staff D, CNA (certified nursing assistant) worked the following dates and times: a. 10/23/17 1:29 PM to 10:40 PM b. 10/24/17 at 1:35 PM through 5:13 PM. Review of the sheet titled Immediate Employee Training dated October 24, 2017 at 8:12 PM, indicated the staff trained for Resident Rights and, Freedom of Abuse. On 2/6/18 at 9:50 AM, the Administrator was interviewed and stated the facility's policy is to immediately notify the charge nurse and the charge nurse to notify the Administrator and DON (Director of Nursing) of an incident of abuse. The Administrator stated she received notification on the evening of 10/24/17 and the DON and she immediately started education for all employees that evening. On 2/6/18 at 4:00 PM Staff G (CNA) was interviewed and stated she witnessed Staff D, CNA slap the resident with the palm of her hand 2 separate times on the evening of 10/23/18. Staff D slapped the resident on the upper arm in the whirlpool room after his bath and again when in the resident's room. Staff D stated she had been shocked and new (employee) so she did not tell anyone but spoke to her CNA instructor the following day. Staff G stated the instructor instructed her to report the incident. Staff G stated she received training about reporting abuse on the first day of employment. On 2/6/18 at 4:20 PM the Director of Nursing (DON) was interviewed and stated Staff G reported she witnessed Staff D slap a resident on the upper arm 2 times on 10/23/17 at approximately 9:30 PM. The DON stated she notified the Administrator and reported this to DIA (Department of Inspections and Appeals). The DON stated she asked the resident and assessed both arms. The resident was unable to confirm or deny the incident and the resident did not have bruising or red marks on either arm. Review of the policy and procedures titled Abuse Prevention, Investigation and Reporting Policy, dated 4/1/17, directed the staff to do the following: a. All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. b. All allegations of Resident abuse shall be reported to the Iowa Department of Inspections and Appeals not later than two (2) hours after the allegations is made. c. All allegations of Resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections and Appeals, not later than two (2) hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury.

Based on observation and staff interview the facility failed to ensure all medications were kept locked in the medication cart. The facility identified 14 resident as cognitively impaired. The facility census was 25 residents. 1. During observation on 4/18/17 at 11:42 a.m., a medication cart in the south hall way was unlocked and unattended. The medication drawers contained resident medications, a pair of scissors, insulin pens, and lancets. Observation revealed no staff in the area. Observation revealed Resident #11, with a Brief Interview for Mental Status a score of 4, which indicates severe cognitive impairment, propelled him/her self past the medication cart. When interviewed on 4/18/17 at 11:44 a.m., Staff A (Registered Nurse) stated she got pulled away into a residents room and that is the reason the medication cart failed to be locked. Staff A confirmed that it needed to be locked. 2. Observation on 4/19/17 at 7:57 a.m., Staff A proceed to go into a residents room and failed to lock the medication cart and left unattended in the east hallway. Staff A stated I forgot to lock the cart again. 3. Observation on 4/19/17 at 1:55 p.m., medication cart left unlocked and unattended behind the north nurses station with no staff in the area. Staff A came out of the therapy room and stated the medication cart is left unlocked and unattended again and confirmed that it needed to be kept locked at all times.

Based on clinical record review and staff interview the facility failed to care plan an antidepressant medications and monitoring for adverse side effects for 1 of 6 resident reviewed with depression medications (Residents #4). The facility reported a census of 25 residents. Findings include: 1. According to the Minimum Data Set (MDS) with the assessment reference date of 4/30/17 Resident #4 had a [DIAGNOSES REDACTED].#4 had received an antidepressant medication daily during the assessment period. The April 2017 Medication Administration Record [REDACTED]. Resident #4's current care plan with an initiated dated 3/6/17 did not address the residents [DIAGNOSES REDACTED]. Interview on 4/19/17 at 2:55 p.m., the facility director of nursing confirmed the antidepressant medications and monitoring of side effects needed to be on the plan of care and that the care plan lacked the medications and side effects.

Based on personnel file review, staff interview, and policy review the facility failed to ensure 1 of 5 new employees reviewed had licensure verification check completed before hire and 2 of 5 new employees did not have criminal background checks and dependant adult abuse registry checked prior to hire The facility reported a census of 27 residents. Findings included: 1. The facility's Employee Hired Since Last Survey sheet documented Staff B's ( Licensed Practical Nurse) hire date had been 11/3/15. Review of Staff B's employee file on 3/15/16 lacked documentation that a criminal background check, a dependant adult abuse registry check and professional license verification had been completed. During interview on 3/15/16 at 10:50 a.m. Staff C stated the facility does not have documentation to show a criminal background check, a dependant adult abuse registry check and professional license verification had been completed for Staff B. Staff C stated she must have overlooked it. On 3/16/15 at 1:30 p.m. the Director of Nursing provided a Single Contact License and Background Check that had been completed on 3/14/16. The form Showed Staff B had an active nursing license and was not found on the abuse registries and not found in the data base for criminal history background check. 2. The facility's Employee Hired Since Last Survey sheet documented Staff A had been hired on 5/4/15. An Employee Payroll Worksheet showed Staff A had effective date 5/4/15. Review of Staff A's employee file on 3/15/16 revealed a Single Contact License and Background Check completed on 5/7/15, three days after Staff A had been hired. During interview on 3/15/16 at 10:50 a.m. Staff C stated she did not know why Staff A had been hired prior to background checks completed. The facility Abuse Prevention Policy and Procedure included the facility shall screen all potential employees for a history of abuse, neglect or mistreating residents. This will be accomplished through the following; the facility will conduct a criminal record check and dependant adult/child abuse registry check on all prospective employees prior to hire. For those employees with licenses the facility will conduct a check with the appropriate licensing board to assure that there is no history of abuse, neglect or mistreating residents.

Based on clinical record review and staff interview, the facility failed to conduct ongoing assessments of resident activity programs and needs for 4 of 9 current residents reviewed (Residents #9, #6, #3, and #7). The facility identified a census of 27 residents. Findings include: 1. The Care plan for Resident #9, documented [DIAGNOSES REDACTED]. The care plan with a goal target dated 5/13/16 documented; I wish to know about all activities that are taking place. I enjoy being social and especially like fitness, religious activities, musical performances and special programs. I am willing to try any activity. Approaches include to staff will provide me with assistance in getting to and from activity of choice, staff will remind me of activities taking place. Review of the clinical record revealed the last quarterly activity assessment completed on 6/15/15 and 1/14/16 with no documentation of an assessment completed between the two dates. 2. The Care plan for Resident #6, documented [DIAGNOSES REDACTED]. The care plan with a goal target dated 4/11/16 documented I enjoy being social and would like to participate in activities of my choice. Approaches include staff to remind me of the daily activities taking place. Review of the clinical record revealed the last quarterly activity assessment completed on 11/3/15, with no documentation after the assessment. 3. The Minimum Data Set (MDS) assessment tool, dated 2/2/16, documented Resident #3 with short and long term memory problems and severely impaired cognitive skills for daily decision making. Resident #3 had a [DIAGNOSES REDACTED]. Review of Resident #3's clinical record lacked documentation of a quarterly activity assessment done with the Minimum (MDS) data set [DATE]. 4. The Minimum Data Set (MDS) assessment tool, dated 12/29/15, documented Resident #7 with cognitively intact skills for daily decision making. Resident #7 had a [DIAGNOSES REDACTED]. Review of Resident #7's clinical record lacked documentation of a quarterly activity assessment done with the Minimum (MDS) data set [DATE]. During interview on 3/16/16 at 11:55 a.m. the Director of Nursing confirmed there is no activity assessment for the 12/29/15 quarterly MDS. During interview on 3/16/16 at 12:20 p.m. the Director of Nursing stated they were aware they had missing activity assessments.

Based on clinic record reviews, the facility failed to provide routine medically related social services (SS) through assessment and care planning for 4 of 9 current residents reviewed (Residents #9, #8, #1, and #6). The facility reported a census of 27 residents. Findings included: 1. The Care Plan for Resident #9, documented [DIAGNOSES REDACTED]. The Care Plan with a target dated 5/13/16, documented, I tend to get bored while in my room. I am unable to ambulate alone so I am unable to go out and about to give me something to do. I don't like to pull my call light because I don't want to be a bother the staff when they have other things to do. Review of the clinical record revealed a quarterly social service assessment completed on 3/11/15 and 9/1/15 with no social service assessment completed between the two dates. 2. According to the Care Plan with a target date of 4/6/16, Resident #8 had [DIAGNOSES REDACTED]. The Care Plan stated, I have a photo albums in my room of my family and friends that I enjoy looking through with others. Approaches are for staff to provide one on one time with me to look through my photo albums. Review of the clinical record revealed a quarterly social service assessment completed on 5/18/15 and 10/13/15 with no other assessment completed between the two dates. 3. According to the Care Plan with a target date of 4/27/16, Resident #1 had [DIAGNOSES REDACTED]. The Care Plan stated, I am very sad since I had to leave my home. Approaches included to encourage me to participate in activities of my choice, and if I feel sad please spend time talking with me. Review of the clinical record revealed a quarterly social service assessment completed on 9/15/15 and 2/1/16 with no social service assessments completed in between the two dates. 4. According to the Care Plan Resident #6, had [DIAGNOSES REDACTED]. Review of the clinical record revealed a quarterly social service assessment completed on 8/4/15 with no prior social assessment completed. Interview on 3/16/16 at 2:30 p.m., the facility Director Of Nursing confirmed and verified that the clinical record lacked any documentation of Social Service assessments and that the Social Service assessments needed to be completed on a quarterly and annual basis.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and the environment and there was no evidence that the Director of Nursing had attempted to supervise the implementation of the care plan and toilet the resident as directed by the plan and ensure the planned alarm device operated for 2 of 4 residents reviewed (Resident #1, and #3). The facility reported a census of 30 residents. Resident #1 had a history of [REDACTED]. On 08/25/12 Resident #1 got up from his/her recliner while in the reclined position, walked to the dining room and fell on his/her face resulting in bilateral nasal and septum fractures. The alarm did not sound and was not turned on at the time of the fall. Prior to the fall Resident #1 put his/her call light on 2 times, after being assisted from the dining room to his/her recliner. Staff did not offer to take him/her to the bathroom or check the alarm while in the room. After Resident #1 fell he/she stated he/she was going to the bathroom. Resident #3 had a history of [REDACTED]. Observation revealed the resident sitting in a recliner chair and the mat alarm not always placed in front of the recliner chair to alert staff when the resident attempted to stand up and attempt to transfer self. Findings include: 1. According to the Minimum Data Set (MDS) assessment, with a reference date of 07/23/12, Resident #1 scored 9 on the Brief Interview for Mental Status (BIMS) which indicated cognitive impairment. Resident #1 required extensive assistance with activities of daily living (ADL's) including transfers, dressing, toilet use and personal hygiene. Resident #1 was unsteady and only able to stabilize with staff assistance when moving from a seated to a standing position, walking, turning around, moving on and off the toilet, and surface to surface transfer. Resident #1's [DIAGNOSES REDACTED]. The MDS documented Resident #1 had a fall with an injury. A Physical Therapy Rehabilitation Screen dated 12/20/11 indicated Resident #1 wanted to be more independent. They talked to Resident #1 regarding safety and demonstrated to push up and reach back with his/her hands, and to ambulate closer to his/her walker. Resident #1 could not remember the safety tasks after instructed and the resident not as interested in increased activity, but wanted more independence. Secondary to Resident #1's decreased safety awareness after a stroke, not possible. A Care Area Assessment regarding cognitive loss dated 02/08/12 and indicated Resident #1 was admitted to the facility following a hemorrhagic stroke with [DIAGNOSES REDACTED] following. This required a ventricular shunt placement. Resident #1 had not shown progressive signs of dementia. Resident #1 tended to ignore staff requests to ask for assistance to get up and toilet or walk, stating he/she wanted to be independent. A Care Area Assessment regarding falls dated 02/08/12 documented Resident #1 had balance issues status [REDACTED]. Resident #1's goal was to prove to staff he/she was capable of self-sufficiency. Resident #1 was cognitively aware he/she should ask for assistance when getting up. Many times he/she used the call light, but at other times he/she chose to try things on his/her own. During these times Resident #1 had falls. Resident #1 needed stand by assist for transfers and ambulation. Resident #1 had no falls the past quarter. Physical performance limitations included balance, gait, strength, and muscle endurance. Internal risk factors included balance issues status [REDACTED]. A Quarterly Nursing assessment dated [DATE] documented staff took Resident #1 to the bathroom every 2 to 3 hours and upon request. The Falling Potential directed staff to check all that applied, and then add the # of checks. Resident #1 had checked (1) use of assistive device, (2) use of safety device (alarm), (3) use of antidepressants, (4) use of diuretics, (5) cognitive impairment, (6) CVA. This brought Resident #1's score to 6. A score of 6+ indicated high risk. A Quarterly Nursing assessment dated [DATE] documented Resident #1 generally continent of bowel and bladder. The resident had a toileting program approximately every 2 hours and he/she remained dry. The falling Potential Assessment directed to check all that applied and then add the # of checks. Resident #1 checked for (1) cognitive impairment, (2) antidepressants, and (3) diuretics. The assessment did not check (4) the use of assistive devices (walker), (5) use of safety devices (alarm), (6) [DIAGNOSES REDACTED]. This brought Resident #1's score to 8, with 6+ indicating high risk. The Care Plan identified Resident #1 with a history of falls due to a desire to be independent, initiated on 02/09/12. The interventions directed staff to: a. Staff would place a chair alarm in Resident #1's chair and a bed alarm in his/her bed. Staff would make sure the alarm boxes were out of Resident #1's reach so he/she could not turn them off. b. Staff would continue to encourage Resident #1 to use his/her call light when needing to go to the toilet, walk, etc. Staff would make sure the call light was within reach. c. Staff would leave Resident #1's walker by his/her chair/bed so when he/she got up him/herself he/she would be safer until staff could answer his/her alarm. d. Staff would take Resident #1 to the bathroom every 2 to 3 hours during the day. The care plan identified due to Resident #1's stroke he/she had some problems with balance and had difficulty with arm movements at times. The interventions directed staff to: a. Staff would offer stand by assist when Resident #1 transferred or ambulated. Resident #1 enjoyed walking and staff would assist with ambulating to and from meals and activities. Resident #1 needed to use a walker and a gait belt. The care plan identified Resident #1 with the awareness of the need to toilet, but may dribble a small amount of urine if could not get to the toilet in time. The interventions directed staff to: a. Staff would offer Resident #1 toileting approximately every 2 hours and when he/she requested it during the day. The care plan identified due to Resident #1's stroke he/she could not always think of the words he/she wanted to say. The interventions directed staff to: a. Staff would allow Resident #1 time to think of the words he/she wanted to say if having difficulty. Staff would help cue Resident #1 for the words if Resident #1 could not come up with the words. An Incident/Accident Report dated 05/24/12 at 4:30 p.m. documented a CNA walked with Resident #1 to his/her recliner from the dining room. Resident #1's Velcro shoe strap became undone. The CNA bent over to strap the shoe and Resident #1 fell backward, striking his/her head on the corner of the bathroom doorway. Resident #1 had a cut to the left side of the head. Resident #1 went to the emergency room . A Follow-Up Instructions sheet dated 05/24/12 documented Resident #1's wound was cleaned and closed with skin staples. A Nursing Home Note dated 05/30/12 documented the Physician's Assistant came to the facility for staple removal. Resident #1 fell the previous week and lacerated his/her scalp. The staples were removed without difficulty or bleeding. A Fall report dated 08/25/12 at 5:37 p.m. documented the CNA's summoned the nurse to the dining room, and noted Resident #1 on the floor with a large amount of blood on the floor. Resident #1 had a large abrasion to the forehead and his/her nose bled large amounts of dark red thin blood. The nose appeared black and blue, and Resident #1 expelled a large blood clot from his/her mouth. Resident #1 demonstrated raspy respirations. Resident #1 stated he/she was going to the bathroom. Resident #1 went to the hospital. He/she stated hurting a whole lot. The predisposing physiological factors included a gait imbalance and impaired memory. The predisposing situational factors included ambulating without assist. The Progress Notes dated 08/25/12 at 5:53 p.m. documented at 5:40 p.m. the CNA's summoned the nurse to the dining room. Resident #1 was noted on the floor with a large amount of blood on the floor from the nose. The nose appeared black and blue with severe pain when touched. Resident #1 alert and talking. He/she denied any dizziness or blurry vision. The chair alarm in Resident #1's room did not sound. Resident #1 stated he/she was going to the bathroom. They noted a large abrasion to the forehead, bleeding a small amount. At 5:56 p.m. the ambulance arrived to transport Resident #1 to the emergency room . At 10:57 p.m. staff received a report from the nurses from the hospital and they were keeping Resident #1 for observation, with facial bone fractures each side of his/her nose. Radiology Report dated 08/25/12 documented Resident #1 had bilateral nasal bone fractures and fracture of the nasal septum. A Hospital History and Physical dated 08/25/12 indicated Resident #1 fell in the dining room tonight, landing on his/her face. The resident had a bloody nose and came for an evaluation. The resident denied loss of consciousness. The resident had a mild headache where he/she had an abrasion. The physical exam noted Resident #1 had extensive ecchymosis around his/her eyes, and swelling of the nose. There were multiple areas that seemed like tears of the nasal mucosa, and believed to be where the bleeding came from. Resident #1 had a superficial abrasion/skin tear on his/her forehead measuring about 2.5 cm in diameter. The plan documented they had a difficult time getting the bleeding to stop in the emergency room . They placed a Rhino rocket in his/her left nostril then the right nostril began to bleed more. Initially it did not seem to bleed at all. They then placed a second Rhino rocket in the right nostril but it seemed to bleed around it. The rocket was removed and packing placed with Neosynephrine. It seemed to have things controlled, but he/she certainly warranted observation. They would send Resident #1 upstairs, check a CBC, control nausea, and start him/her on Keflex while the packing was in. The Progress Notes dated 08/26/12 at 3:09 documented at 2:35 p.m. Resident #1 returned from the hospital per ambulance. Large bruises were around the bilateral eyes and nasal area. A chair alarm and floor alarm were in place and working properly. At 10:15 p.m. Resident #1 ate 1/2 dish of ice cream for supper with assist and much encouragement. Sips of water given with cares could not open mouth completely, only opened it a little bit. The call light placed in reach, but does not use due to forgetfulness per usual behavior. The chair and floor alarm were in place, on, and working properly for safety. At 11:35 p.m. staff documented at 10:00 p.m. they changed the bandage to Resident #1's forehead due to a large amount of bloody drainage. The Progress Notes dated 08/27/12 at 4:32 a.m. documented multiple areas of discoloration to Resident #1's face, with the eye area discolored and swollen. He/she had a dressing to the skin tear on the forehead, with nasal packing in place. Resident #1 accepted sips of water from a spoon, and demonstrated difficulty in swallowing. No emesis or fresh bleeding noted. At 12:45 p.m. Resident #1 sat in the recliner. He/she tried to open his/her eyes when spoken to, but his/her eyes were swollen and black and blue. Resident #1 shook his/her head to respond. At 2:37 p.m. Resident #1's bilateral eyes remained swollen and bruised, and deep purple in color. The nose and the area below the nose swollen. Noted a bruise on the bridge of the nose. Dressing intact to the right outer side of the forehead. At 3:43 p.m. Resident turned head away and said no when administering artificial tears eye drops. Resident #1 refused Metoprolol, could not open mouth. At 7:48 p.m. refused Ocuvite, Senna, and Zantac, would not open mouth. At 8:56 p.m. refused Keflex and Trazadone, would not open mouth. At 10:06 p.m. Resident #1 refused meds and wouldn't open mouth to eat supper, took 2 sips of water from a cup. No verbal response. At 11:06 p.m. administered a Tylenol suppository for Resident #1 moaning while repositioning. The Progress Notes dated 08/28/12 at 3:24 a.m. documented Resident #1 received a Tylenol suppository for discomfort while repositioning. At 7:15 a.m. the packing remained in the nose. Resident #1 responded to verbal stimuli with yes or no. He/she did not open eyes due to swelling and bruising around the eyes. He/she opened his/her mouth slightly, and took 10 cc of water. At 10:44 a.m. Amlodipine, Metoprolol, Milk of Magnesia, Ocuvite, Quinipril, and Senna, not given due to condition. At 10:48 a.m. for 10:30 staff documented Resident #1 took 25 cc's of great shake. He/she opened his/her mouth slightly. At 10:45 Resident #1 took Keflex and Lasix when dissolved in water. He/she took 30 cc's with great shake. He/she could take small amounts from a straw, and able to open eyes slightly. At 12:16 p.m. the Physician's Assistant came to see Resident #1 and removed the nasal packing. Dried blood noted, but no frank bleeding. Resident #1 responded to verbal stimuli with shaking of head and yes and no. He/she took sips of water with a straw. A Nursing Home Note dated 08/28/12 documented the Physician's Assistant (PA) came to the facility to evaluate Resident #1. He/she had a fall over the weekend and unfortunately fractured his/her nose. The Physician saw Resident #1 in the emergency room and placed a Rhino rocket in his/her left nares. The Physician asked the PA to remove the rocket that day. Resident #1 did not eat very well the previous day, and states having no appetite. Resident #1 as obviously very bruised from the fall and nasal fracture. He/she had raccoon eyes. He/she had copious amounts of dried bloody drainage in the nares... The facility investigation revealed the following: a. Staff H, Certified Nursing Assistant (CNA), worked with Staff E CNA on south. Staff H assisted Resident #1 to the bathroom at 1:30 p.m. He/she was continent, voiding in the stool. When Staff H left at 2:30 p.m. Resident #1 sat in his/her chair with the pressure alarm on and in working order. The call light in the chair on the left side of Resident #1. The recliner sat back with his/her feet up. The 1:30 bathroom and voiding did not get documented. Staff H said Resident #1 did not ring his/her call light and not need anything when she worked in the a.m. Resident #1 always told Staff H what he/she wanted. Resident #1 mostly called for the bathroom by standing up. He/she didn't use the call light very much. b. Staff A, Registered Nurse, passed pills at 4:50 p.m. At 5:15 p.m. she sat for supper with Staff D CNA. At 5:20 p.m. staff called over the intercom to go to the dining room stat by Staff E CNA. She treated Resident #1, called the Administrator, Director of Nursing (DON) Physician, and transferred Resident #1. She talked with Resident #1's family member. Resident #1 was at snacks in the dining room at 3:00 p.m. then she didn't see him/her after that (until after the incident). c. Staff D worked on west. At approximately 4:15 p.m. she took Resident #1 back to his/her room from the dining room. Staff D offered Resident #1 the bathroom and he/she declined. Staff D stated she always turned the alarm on, and always checked them. Staff D went on break with Staff A around 5:00 p.m. Staff D put the recliner back, covered Resident #1 with a blanket, and gave him/her the call light. d. Staff B, CNA indicated Resident #1 put his/her light on 2 times. The first time approximately 3:30 p.m. Resident #1 said he/she just pulled that. Resident #1 denied needing anything. Staff B did not offer the bathroom. The second time approximately 3:45 to 3:50 p.m. Resident #1 said he/she did it for kicks. It was the first time Staff B worked with Resident #1. Staff B and Staff C CNA were in the room across the hall before supper. When they went in that room, Resident #1 sat in his/her chair. They had the door shut working with another resident. They heard a loud thud. Upon investigation they found Resident #1 on the floor in the dining room under a table straight ahead. Resident #1 didn't say anything to Staff B. Staff B summoned the nurse, who arrived quickly. Resident #1 normally asked to go to the bathroom or stood up. Resident #1 was in the dining room prior to 3:30 p.m. Staff D walked Resident #1 back to his/her room. e. Staff C heard a loud kaboom at approximately 5:00 to 5:10 p.m. She went to the dining room and saw Resident #1 on the floor. Resident #1 stated he/she fell . Staff C asked where he/she was going. Resident #1 said to the bathroom. Staff C did not take Resident #1 to the bathroom between 2:30 and 5:30 p.m. Resident #1 did not have incontinence at or after the incident. Resident #1 had a history of [REDACTED]. Resident #1 summoned to bathroom need by getting up out of the chair. The alarm did not go off, but it was working. f. On 08/25/12 at approximately 6:15 p.m., Staff A educated the CNA's on the importance of double checking alarms were on and working properly after returning residents to their rooms. On 09/19/12 at 9:45 a.m. Staff A, was interviewed and stated prior to being summoned to the dining room for Resident #1's fall, Resident #1 had been in his/her room. Staff A stated after the fall she checked Resident #1's alarm and it was not turned on. Staff A stated it was a pressure alarm and the alarm box would not be in reach of the resident while sitting in the chair. She said you could tell the alarm was on when the green light flashed. Staff A stated Staff D told her she remembered double checking the alarm and it was on. Staff D stated this had not happened before to her knowledge. Staff A stated normally staff took residents to the bathroom after activities when they take them back to their rooms. Staff A stated Resident #1 would tell them when he/she needed to go to the bathroom. On 09/19/12 at 3:18 p.m., Staff D stated she worked on west hall. Staff D saw Resident #1 sitting in the dining room after snack time. Staff D decided she would help them out and take Resident #1 back to his/her room. Staff D asked Resident #1 if he/she needed to use the restroom and he/she said no. Staff D asked Resident #1 if sure and he/she said he/she was. Staff D had shut off the alarm when she assisted Resident #1 from the dining room. Staff D put the alarm in the chair and the box on the foot of the bed. She assisted Resident #1 to sit in the chair and put his/her feet up. Staff D stated looking back she could not remember if she turned the alarm on. Staff D stated normally she checked the alarm twice before leaving the room. Staff D stated she was on break when the fall occurred. During an interview on 09/19/12 at 9:54 a.m. Staff B stated she was new to the facility. She oriented on 08/17 and 08/20, then worked 08/25/12. Staff B stated Resident #1 sat in the dining room when she came to work. Staff B did not take Resident #1 back to his/her room. Staff B went to Resident #1's room 2 times to answer the call light. Staff B did not check the alarm when in the room those 2 times. Staff B did not ask Resident #1 if he/she needed to go to the bathroom. Staff B stated during orientation they told her Resident #1 could tell her if he/she needed to go to the bathroom. Staff B stated Resident #1 sat in his/her recliner in the reclined position when in his/her room. After the fall, the recliner remained in the reclined position. The alarm box was out of Resident #1's reach, but not turned on. Staff B stated now they are to check alarms when in the room, and ask Resident #1 if he/she needs to use the bathroom. On 09/19/12 at 2:21 p.m. Staff C was interviewed and stated she worked across the hall from Resident #1's room at the time of the fall. Staff C did not have any knowledge about when Resident #1 went back to his/her room. Staff C stated they normally took the alarm to whatever chair Resident #1 sat in. When they worked in the other room they heard a thud, and Resident #1 was on the dining room floor. Staff C stated sometimes Resident #1 put the call light on, otherwise they asked him/her every 2 hours. Staff C stated sometimes Resident #1 put the call light on for fun, and then pulled again 15 minutes later. When Resident #1 did that Staff C would say let's go to the bathroom. Staff C stated Resident #1 would stand up unattended and the alarm would sound. On 09/19/12 at 4:00 p.m., Staff E CNA was interviewed and stated she worked the day Resident #1 fell and after 2:30 p.m. she worked east. She didn't know what happened or anything about the alarm. Staff E stated they routinely toileted Resident #1. Resident #1 did ask sometimes. They encouraged him/her to go if he/she said no. Before Resident #1 fell he/she would set the alarm off trying to get up on his/her own. On 09/19/12 at 10:23 a.m. observation revealed Resident #1 sitting in the recliner. The alarm box rested on the side of the recliner (not out of reach). A mat sat on the floor in front of the recliner with the alarm box on the dresser, and the call light within reach. Resident #1 was noted with an abraded area to the right forehead and bruising under both eyes. Resident #1's feet were elevated. On 09/20/12 at 10:28 a.m. observation revealed Resident #1 sitting in the recliner in his/her room. The chair alarm was in place with the box on the outside arm of the chair (not out of reach). The floor mat alarm sat in front of the chair. 2. According to the MDS assessment with a reference date of 07/02/12, Resident #3 scored 4 on the Brief Interview for Mental Status (BIMS). The score of 4 identified a severe cognitive impairment. Resident #3 depended on staff for activities of daily living such as bed mobility and transfers, and required extensive assistance with ambulation in the room, dressing, toilet use and personal hygiene. The MDS indicated Resident #3 had [DIAGNOSES REDACTED]. The MDS identified a fall without injury. The Care Plan for Resident #3 indicated the resident had a history of [REDACTED]. The interventions included: a. Staff would assist with all transfers and ambulation. b. Staff would have a bed alarm in place when in bed and a chair and floor alarm in front of Resident #3's chair when in the chair. A Fall report dated 06/15/12 at 11:41 a.m. documented staff heard Resident #3 calling out, entered room and found him/her on the floor in front of the chair. Resident #1 apparently fell when attempting to stand by himself/herself. The alarm sounded, but they could not hear the alarm sounding due to the vacuum running. Resident #3 could not give a reason for the fall. A Fall report dated 07/01/12 at 10:34 a.m. documented a CNA found Resident #3 on the floor in front of the recliner in his/her room and summoned the nurse. Resident #3 stated he/she slid out of the chair. The report did not indicate whether the alarm sounded. A Fall report dated 09/07/12 at 4:36 p.m. documented staff heard Resident #3's personal alarm go off and responded. Staff found Resident #3 on the floor in front of the wheelchair on his/her buttocks. Resident #3 stated he/she slid out of his/her chair. The facility progress notes indicated the following: On 9/27/2012 at 12:21 the staff notified the Physician Assistant (PA) and the Physician of the resident ' s left knee swollen and the resident inability to bear weight on leg. The physician ordered the facility to send the resident to the hospital for an evaluation on 9/28/2012. The hospital x-ray report dated 9/28/2012 at 10:51 a.m. revealed a comminuted left hip fracture. The Progress Note dated 10/2/2012 at 2:06 p.m. indicated the resident returned to the facility from the hospital. On 09/19/12 at 4:00 p.m. Staff E (Certified Nursing Assistant) was interviewed and stated the day Resident #3 slid out of the chair, the pressure alarm remained partially under Resident #3, so it still had pressure on it and it didn't sound. Staff E stated that's why they added the floor mat. On 09/19/12 at 4:10 p.m. Staff A (Registered Nurse) was interviewed and stated the alarm remained under Resident #3 and it didn't go off, which was why they added the floor mat. A Certified Nursing Assistant report for September 2012 directed the floor and chair alarm on when in chair. Check function and placement every shift. The report documented the check on 09/20/12 at 9:53 a.m. On 09/20/12 at 10:13 a.m., observation revealed Resident #3 sitting in the chair in his/her room. Resident #1 did not have a floor mat in front of the chair. Staff F CNA stated she didn't know if Resident #3 still used it, and could not say if it was on the care plan. Staff F pulled the mat from under the bed. Staff G CNA came into the room with Resident #3. On 09/20/12 at 10:25 a.m. Staff G (Certified Nursing Assistant) was interviewed and stated Resident #3 was to have the floor mat alarm in front of the chair. Staff G stated it was there then. Staff G stated she put Resident #3 in the chair around 9:30 a.m. Staff G stated sometimes housekeeping kicked the alarm under the bed.

Based on observation, record review, interviews with physician and staff, the facility failed to ensure Resident #1's physician order [REDACTED]. If the facility nurse would have followed the physician order [REDACTED]. Facility census was twenty three (23) residents. Findings include: A Minimum Data Set (MDS) with assessment reference date of 8/11/10 assessed Resident #1 with no memory impairments. The resident required limited assistance of staff with bed mobility and extensive assistance with personal hygiene. The MDS identified the resident as: height 64 inches and weight at 143 pounds. The MDS identified the resident with mild pain less than daily. Nurses notes dated 9/5/10 at 5:30 p.m. and written by Staff I, RN (registered nurse) identified Staff I summoned to the resident's room because the resident complained of back pain higher than "10" on the pain scale. (A pain scale ranges from 1 to 10, with 10 being the worst pain.) Staff I administered [MEDICATION NAME] (narcotic) 5/500 milligrams (mg.) and [MEDICATION NAME] (antianxiety). Staff also applied Ben Gay. The resident ' s temperature reading at 96.1 degrees, blood pressure at 112/42, and pulse at 82, and oxygen level 94% with oxygen running at 2 liters. At 6:15 p.m., the resident activated the call light and complained of excruciating pain. Staff I notified the physician with new orders received. A telephone order dated 9/5/10 and written by Staff I identified an order for [REDACTED]. At 8:30 p.m., staff administered the resident's new medication. The resident did not complain of pain and appeared very tired. His/her blood pressure at 102/52, pulse at 76, respirations at 18 and temperature at 97 degrees. The resident rested in bed with eyes closed. Review of medication administration records and the PRN (as needed) medication record identified Staff I administered the following narcotic and [MEDICAL CONDITION] medications on 9/5/10: On 9/5/10, at 5:30 p.m. [MEDICATION NAME] 5/500 one tablet for back and rib pain and [MEDICATION NAME] 0.5 mg. one tablet for anxiety. Neither tablet delivered relief. At 8:30 p.m., the PRN medication record identified [MEDICATION NAME] 10 milligrams per 0.10 milliliters (ml.) given for excruciating pain with relief obtained. The MAR indicated [REDACTED]. Observation of the [MEDICATION NAME] bottle and syringe during the investigation, identified the label saying the bottle contained 30 ml. when sealed. The dosage on the bottle read: 20 milligrams per ml. A 1.0 milliliter syringe accompanied the bottle. On 12/1/10 at 3 p.m., Staff I identified she administered one milliliter of [MEDICATION NAME] which would equal 20 mg. of [MEDICATION NAME]. She also stated when she opened the bottle, only 20 ml was present in the factory sealed bottle. On 11/17/10 at 8:23 a.m., and 11/23/10 at 10 a.m., the consulting pharmacist stated the [MEDICATION NAME] bottle was sealed by the manufacturer and goes through many quality control checks before going to the wholesaler who also checks the drug for the correct amount for reporting to DEA before selling the bottle to the pharmacy. She stated the probability of a [MEDICATION NAME] bottle short 10 ml. of [MEDICATION NAME] is very rare. It may be short .0001 but not 10 ml. It would be very close to 30 ml. The pharmacist, in [AGE] years of practice, has never seen a bottle short of the drug upon opening of a sealed bottle. She stated she also checked for recalls of liquid [MEDICATION NAME] which would occur if discrepancies in amounts were reported. There were no recalls. Nurse ' s notes, dated 9/6/10 and written by Staff B identified Staff B as entering the resident's room at 5:30 a.m. Staff B assessed the resident with labored respirations at 10 to 12 per minute. Oxygen saturation reading obtained at 92% with mouth breathing. Blood pressure at 117/62, temperature at 98.5 degrees and pulse at 76. The resident opened eyes to tactile stimuli but gave no direct eye contact. Extremities were flaccid and skin was cool, grey and clammy. Pupils assessed as pinpoint. At 5:45 a.m., Staff B notified the physician and the resident transported to the emergency room via ambulance. On 9/6/10 at 7:30 a.m., the hospital called and identified the resident as admitted for observation. A history and physical, dated 9/6/10, identified that the physician contacted Staff I who told him she had given 2 ml. of [MEDICATION NAME], which equals 40 mg. of the drug. The conclusion of the physician assessment was: Obtundation from combination of [MEDICATION NAME] and [MEDICATION NAME]. A 9/7/10 hospital progress note documented the resident with a pretty rough course all day long. The hospital physician documented he had given the resident three doses of [MEDICATION NAME] at 0.2 mg. subcutaneously. Each time the resident responded. A couple times the resident did have a fair amount of emesis and since those emesis the resident has had copious amounts of sputum. A 9/8/10 hospital progress note identified the resident with aspiration pneumonia. On 11/17/10 at 12:30 p.m., the surveyor asked the physician the following question," If the resident would have gotten the dose you prescribed would the resident have become obtunded? "The physician stated no. The surveyor then asked if it was the physician's opinion that the resident received too much [MEDICATION NAME] and he stated yes. The surveyor asked if the resident's aspiration pneumonia resulted from the resident being obtunded. The physician stated the aspiration resulted from the [MEDICATION NAME] the resident received. The resident received [MEDICATION NAME] 3 times and that is a significant amount of [MEDICATION NAME], so the physician can surmise the resident received a significant amount of [MEDICATION NAME] beyond what was ordered. If the resident did not need the [MEDICATION NAME] then she would not have gotten aspiration pneumonia. According to nurse's notes, the resident returned to the facility on [DATE] at 3:30 p.m. Staff Interviews: On 11/16/10 at 6:40 p.m., Staff B stated she came to work at 10:30 p.m. on 9/5/10 and she received report from Staff I (RN). They counted narcotics as usual. Staff I reported that she called the physician and received a [MEDICATION NAME] order for Resident #1. The resident slept ever since Staff I administered the [MEDICATION NAME]. Staff I then left the facility. Staff B and E did a routine round at midnight. Observation showed the resident resting quietly with eyes closed. At 2 a.m. Staff B stated she observed the resident and the resident continued to rest quietly with eyes closed and no apparent signs of pain. At 4:30 a.m. Staff B got her cell phone from her purse and saw a text message from Staff I. The phone identified Staff I sent the text at 11:15 p.m. The text identified Resident #1's [MEDICATION NAME] as in the top drawer of the medication cart. Staff I forgot to count it, make out a narcotic sheet for it or place it in the narcotic lock up. After receiving the text, Staff B got the [MEDICATION NAME] from the medication cart at 4:30 a.m. Staff B checked the [MEDICATION NAME] bottle and saw only 22 ml. left in the bottle. Staff B stated based on knowledge and previous experience, she is aware there is always 30 ml. in the bottle when it is opened. The bottle was upright without evidence of spilling. Staff B then checked the PRN medication record and saw that Staff I documented she gave 10 mg./10 ml. at 8:30 p.m. Staff B immediately notified the Director of Nursing of the situation. She also assessed Resident #1. She assessed the resident ' s respirations as 10 to 12 per minute, slightly labored loud and moist. There was a small amount of vomit on the resident ' s right shoulder and mouth. The resident ' s skin was grey, cool and clammy. The resident opened his/her eyes but did not focus them . Vitals signs obtained were within normal limits. Staff B notified the physician and the resident transported to the hospital. On 11/17/10 at 9 a.m., Staff E identified that she worked with Staff B the night of 9/5-6/10. She stated the resident always used the call light so at 12 a.m. and 2 p.m. rounds she observed the resident from the doorway and the resident appeared to be sleeping and breathing fine. At 4 a.m. bed check she stated Resident #1 was cold clammy and unresponsive with eyes rolled back in head. On 12/1/10 at 3 p.m., Staff I denied giving the resident too much [MEDICATION NAME]. She identified giving the resident one syringe full (1 ml.) She stated, when the physician called her to ask what amount of [MEDICATION NAME] she gave the resident, she just woke up and got confused by what the physician was asking and saying. She stated that is why she told the physician she gave 2 syringes of the [MEDICATION NAME] (2 ml.). She stated Staff H witnessed her give only one syringe full. Staff I also stated when she opened the sealed bottle of [MEDICATION NAME] that only 20 ml. was present in the bottle and that Staff H also witnessed this at the time. On 11/23/10 at 9:55 a.m. and 11/30/10 at 2:57 p.m., Staff H stated she observed Staff I enter Resident #1 ' s room with a syringe in her hand and nothing else in hand. She identified the syringe as the syringe that comes with the [MEDICATION NAME]. She stated Staff I informed Staff H there was only 20 cc in the [MEDICATION NAME] bottle. Staff H identified that Staff I informed her of this after she administered the medication to the resident. She did not know how long after administration that Staff I informed her of this. She stated she did not view the bottle or the amount of [MEDICATION NAME] it contained. After the incident, the facility issued employee warnings to both Staff B and Staff I for failure to count the [MEDICATION NAME] at shift change the night of 9/5/10.