Every finding on record at Accura Healthcare of Carlisle

Based on observation and staff interview, the facility failed to maintain a safe and clean environment throughout the facility's 3 of 3 carpeted hallways (100, 200, and 300 halls), and 1 of 1 residents reported issues of the dirty tiled floor in their rooms and broken sink (Resident #35). The facility reported a census of 78 residents. Findings include: 1.On 5/19/26 at 7:06 AM, a walkthrough of the facility revealed items stored on both sides of the 200 hallway. Two shower chairs sat on the left side when walking down from the dining room, and multiple wheelchairs, garbage cans, and resident transfer devices (lifts) lined the right side. On 5/20/26 at 12:01 PM, an observation of the 200 hallway revealed discoloration continued throughout the entire length of the carpeted flooring. On 5/21/26 at 12:39 PM, an interview and observation with the facility's Housekeeping and Laundry Supervisor (HLS) revealed she worked at the facility in her role since 2007, cleaned the 200 hallway carpet flooring every Tuesday, and confirmed staff last cleaned it on 5/19/26. While walking through the 200 hallway, the HLS confirmed black marks on the carpeted walls, a darker and different floor coloring on the perimeter of the hallway carpet, chipped paint on the metal door frames, and doors with scratches and rough wood exposed. On 5/20/26 at 2:00 PM, an interview with the facility Nurse Consultant, Director of Nursing, and Administrator revealed they redid so much, so they're working through it. They completed roof leak repairs, purchased a [NAME], laptops, a boiler, a washer and dryer, a mechanical transfer lift, and business office flooring. They haven't repaired the driveway or the call lights yet, but those projects are next on the list before they address the carpet. The carpet's on their radar, and they're just trying to finish up projects. 2. Observations on 5/17/26 at 11:35 a.m. revealed the 100 and 300 Hall carpets covered with multiple large dark and bleach-colored stains. 3. On 5/17/26 at 11:38 a.m., the sink in Resident #35's room had a large piece broken off in front. The edge of the broken piece was jagged. The floor around the resident's toilet was covered with black stains. The resident stated the floor was stained all around the toilet. On 5/20/26 at 11:06 a.m., the Administrator stated that resident furnishings should be in good working order. On 5/20/26 at 1:43 p.m. via email, the Administrator stated the facility did not have a policy related to a homelike environment.

Based on observation, clinical document review, resident interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 1 of 8 residents (Residents #41) reviewed. The facility reported a census of 78 residents.Findings include: Review of Resident #41's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive functioning. Interview 5/18/2026 at 10:25 AM with Resident #41 revealed that she eats in her room, and the food is often cold when brought to her. Observation 5/19/26 at 12:03 PM a sample tray was obtained with food temperatures for the creamy pork chop measuring 122.7 degrees, and the broccoli measuring 132.3 degrees. The facility policy Food Temperatures, dated 2021, stated hot food items should not fall below 135 degrees Fahrenheit after cooking. On 5/19/26 at 12:37 p.m., the Certified Dietary Manager(CDM) stated he expected hot foods held at 135 degrees Fahrenheit or above.

Based on observation, policy review, and staff interview, the facility failed to prepare food under sanitary conditions for 2 of 2 kitchen observations. The facility reported a census of 78 residents.Findings included: 1. Observations during the initial kitchen tour on 5/17/26 at 10:38 a.m. revealed the following concerns:A. A thick debris and dust layer on the floor under the shelves containing cans and dry goods in the pantry. B. A thick black dust layer covering the ceiling vent above and diagonal to the clean side of the dish machine room.C. A thick crusty-looking white buildup on the outside of the dishwasher.D. Dust particles hung down on 2 spigots of the fire suppression system located above the stove burners.E. Heavy dust buildup on the wall slats behind the stove burners.F. Orange splatters between the bottom of the stove and the stove door.G. Heavy dust buildup on a shelf with multiple steam table pans sitting face down. H. Multiple pudding-like splatters on the right side floor of the Arctic Air #2 refrigerator.I Clear plastic bowls sat face down in crumbs on a red tray.J. A white plastic piece on the interior ceiling of the ice machine covered with a black substance. Water dripped from the black areas into the ice in the bottom of the machine. The Certified Dietary Manager(CDM) was present and stated it appeared to be water mold. He stated he would empty the ice and would not want residents to consume(this ice). 2. A follow-up visit to the kitchen on 5/19/26 revealed that dust/debris remained on the shelves, ceiling vents, dishwasher, fire suppression spigots, and the wall slats behind the stove. On 5/19/26 at 12:37 p.m., the CDM stated he thought the sanitation in the kitchen was pretty good. He agreed that surfaces should be clean and without debris and that vents should be clean.The undated, untitled dietary cleaning schedule directed staff to clean items including: refrigerators, the pantry, the dishwasher, and dish racks.

Based on observation and staff interviews the facility failed to complete and/or maintain documentation of routine bed rail inspections for 10 of 10 residents with side rails. The facility reported a census of 78 residents. Findings include:A record review of Resident #32's current care plan revealed the resident used a side rail (bilateral half rails) to aid in repositioning and safety due to frequent falls out of bed. The goal, initiated on 6/27/25, directed that Resident #32 will remain free of falls out of bed and will assist with repositioning through the review date. A care plan intervention, initiated on 6/27/25, instructed staff to assist in resident independence with repositioning. On 5/20/26 at 9:48 AM, an observation and interview with the facility Administrator of bed rails revealed a resident had both upper quarter-length rails. The Administrator informed that the Housekeeping and Laundry Supervisor (HLS) currently oversees maintenance due to a recent staff changeover in that department.On 5/20/26 at 11:52 AM, an observation and interview with the Maintenance Director and Maintenance Assistant from a local sister facility revealed they're in Resident #32's room evaluating her bed rails, and one of the bed rails's removed and on the floor. They showed empty maintenance inspection sheets and stated facility staff didn't provide them with any prior documentation of bed rail assessments, and corporate management called them in today to check all bed rails in the facility. They revealed they didn't see anything wrong with Resident #32's bed rails, but they aren't used to this type and aren't verifying that the entrapment zone measurements were correct.On 5/20/26 at 12:19 PM, an electronic mail (email) from the Administrator informed that staff follow the regulations for side rails.On 5/20/26 at 12:39 PM, an interview with the HLS revealed she started her role in 2007, denied she's in charge of the maintenance department, and stated the facility will hire someone new who won't be from this location.On 5/20/26 at 1:55 PM, an interview with the Administrator revealed she provided a list of Bed Entrapment Inspections for all residents with bed rails, stating corporate or sister facility staff completed them today. A record review of the undated document the Administrator provided titled Bed Entrapment Inspection revealed 10 resident beds passed the inspection, but the form did not show who completed the assessments.

Based on employee personnel record review, staff interview and policy review, the facility failed to ensure a thorough background check had been completed before hire prior to working with dependent adults for 1 of 3 staff personnel files reviewed. The facility reported a census of 78 residents. Findings include: On 5/18/26 at 1:06 PM, the Administrator reported in an email that Staff A, Certified Nursing Assistant (CNA) had a start date of 9/9/25. Review of the Iowa Criminal History Record Check Request SING form dated 9/3/25 revealed Staff A had a history of criminal convictions. The SING form did not contain further research documentation to confirm whether or not Staff A could work at the facility. Review of facility policy updated 10/19/22 and titled, Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, 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 S58.11(3). The facility will conduct a criminal record check and dependent adult/child abuse registry check on all current employees and other individuals engaged to provide services to residents who have criminal convictions or founded abuse determinations after hire, or where the facility received credible information that an employee has had a criminal conviction or a founded abuse determination subsequent to hire. See Iowa Code S135C.33(7).On 5/20/26 at 2:15 PM the Administrator acknowledged the facility did not have a copy of Staff A's completed background check including the results that indicated whether or not further research was required. The Administrator had requested the results from the Iowa Department of Public Service on 4/10/26 however due to a system change, the results were not able to be obtained.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to report an allegation of abuse in a timely manner for 1 of 2 residents reviewed for abuse allegations(Resident #34). The facility reported a census of 78 residents.Findings included: 1. A 5/14/26 Brief Interview for Mental Status(BIMS) Evaluation listed Resident #83's score as 15 out of 15, indicating intact cognition. On 5/17/26 at 11:54 a.m., Resident #83 stated last night(5/16/26) staff yelled at her roommate(Resident #34). Resident #83 stated 3 staff assisted the resident on the toilet and they yelled at the resident. She stated she couldn't tell exactly what they said but stated they said if Resident #34 didn't do something, they would leave her on the toilet. Resident #83 stated she didn't know why they were so irritated but they were angry with Resident#34. She stated this was around 9:00 p.m. Resident #83 stated she informed Staff B Certified Nursing Assistant(CNA) about this this morning(5/17/26).2. The Minimum Data Set(MDS) assessment tool, dated 4/30/26, listed diagnoses for Resident #34 which included hemiplegia(one-sided paralysis), anxiety, and diabetes. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. The MDS documented that the resident required staff assistance with toilet transfers, chair/bed-to-chair transfer, and sit to stand.On 5/18/26 at 3:02 p.m., Resident #34 stated on Saturday night(5/16/26) staff were mean to her and screamed at her. A 5/17/26 Grievance Form, completed by Staff B, Certified Nurses Aide (CNA) stated Resident #83 reported to her that 3 staff members screamed at Resident #34 last night and were mean. Staff B wrote that Resident #34 also said they were being mean and did not want to take her to the bathroom. On 5/19/26 at 2:31 p.m., Staff B stated that she reported to the Assistant Director of Nursing(ADON) that Resident #34 reported to her that 3 girls that took care of her the night before were mean to her. Staff B stated she also filled out a grievance form. On 5/20/26 at 9:36 a.m., the Director of Nursing(DON) stated that she received a grievance related to Resident #34 on Monday(5/18/26). She stated the date on the grievance was 5/17/26. She stated she would want to know about something of this nature right away. On 5/20/26 at 9:42 a.m., the Assistant Director of Nursing(ADON) stated that she received a grievance on Sunday(5/17/26). She stated Staff B handed it to her but then took it back and stated she needed to add things to it. The ADON stated Staff B told her there was an issue with a resident but she didn't get any details. The ADON stated she probably should have determined whether it was a reportable situation. She stated Staff B placed the grievance in her mailbox and they talked about it on Monday(5/18/26). The facility lacked documentation they reported the allegation of abuse to the State Agency.On 5/20/26 at 11:06 a.m., the Administrator stated if a staff member heard that staff were mean, they should inform her or the DON right away. She stated if it was reportable, they should separate staff and complete an investigation. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 10/19/22 stated the facility would report all allegations of abuse to the Iowa Department of Inspections and Appeals not later than two (2) hours after the allegation was made. The policy stated the facility would investigate the incident including witness statements.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to investigate an allegation of abuse in a timely manner for 1 of 2 residents reviewed for abuse allegations(Resident #34). The facility reported a census of 78 residents.Findings included: 1. A 5/14/26 Brief Interview for Mental Status(BIMS) Evaluation listed Resident #83's score as 15 out of 15, indicating intact cognition. On 5/17/26 at 11:54 a.m., Resident #83 stated last night(5/16/26) staff yelled at her roommate(Resident #34). Resident #83 stated 3 staff assisted the resident on the toilet and they yelled at the resident. She stated she couldn't tell exactly what they said but stated they said if Resident #34 didn't do something, they would leave her on the toilet. Resident #83 stated she didn't know why they were so irritated but they were angry with her. She stated this was around 9:00 p.m. Resident #83 stated she informed Staff B Certified Nursing Assistant(CNA) about this this morning(5/17/26).2. The Minimum Data Set(MDS) assessment tool, dated 4/20/26, listed diagnoses for Resident #34 which included hemiplegia(one-sided paralysis), anxiety, and diabetes. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition.On 5/18/26 at 3:02 p.m., Resident #34 stated on Saturday night(5/16/26) staff were mean to her and screamed at her. A 5/17/26 Grievance Form, completed by Staff B, stated Resident #83 reported to her that 3 staff members screamed at Resident #34 last night and were mean. Staff B wrote that Resident #34 also said they were being mean and did not want to take her to the bathroom. On 5/19/26 at 2:31 p.m., Staff B, CNA stated that she reported to the Assistant Director of Nursing(ADON) that Resident #34 reported to her that 3 girls that took care of her the night before were mean to her. Staff B stated she also filled out a grievance form. On 5/20/26 at 9:36 a.m., the Director of Nursing(DON) stated that she received a grievance related to Resident #34 on Monday(5/18/26). She stated the date on the grievance was 5/17/26. She stated she would want to know about something of this nature right away. The DON stated she did not interview the resident's roommate because of the resident's high BIMS score. On 5/20/26 at 9:42 a.m., the Assistant Director of Nursing(ADON) stated that she received a grievance on Sunday(5/17/26). She stated Staff B handed it to her but then took it back and stated she needed to add things to it. The ADON stated Staff B told her there was an issue with a resident but she didn't get any details. The ADON stated she probably should have determined whether it was a reportable situation. She stated Staff B placed the grievance in her mailbox and they talked about it on Monday(5/18/26). The facility lacked documentation they completed an investigation into the alleged 5/16/26 incident prior to 5/18/26.On 5/20/26 at 11:06 a.m., the Administrator stated if a staff member heard that staff were mean, they should inform her or the DON right away. She stated if it was reportable, they should separate staff and complete an investigation. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 10/19/22 stated the facility would report all allegations of abuse to the Iowa Department of Inspections and Appeals not later than two (2) hours after the allegation was made. The policy stated the facility would investigate the incident including witness statements.

Based on Electronic Health Record (EHR) review, document review, policy review, and staff interview the facility failed to complete a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliation of all pre- and post-discharge medications for 1 of 3 residents reviewed (Resident #82). The facility reported a census of 78 residents.Findings include:Review of Resident #82's Minimum Data Set (MDS) dated [DATE] indicated Resident #82 was admitted to the facility on [DATE] and discharged on 2/20/26.Review of Resident #82's EHR page titled, Progress Notes indicated on 2/17/26 that Resident #82 was expressing a want to move to another facility. Further review of the Progress Notes revealed an entry 2/20/26 indicating transportation was at the facility to take Resident #82 to a new facility. Review of Resident #82's EHR page titled, Clinical Assessment revealed a discharge planning review assessment that had not been completed as of 5/19/26. Interview 5/19/2026 at 9:12 AM with the Director of Nursing (DON) revealed that a recapitulation of stay should have been completed. The DON further revealed that the discharge assessment had been completed, but had not been locked out, but this should have been done since the resident had been discharged [DATE]. Review of a facility provided policy titled, Discharge Planning Process with an updated date of 2/23/25 indicated the evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record.

Based on record review and staff interviews the facility failed to complete 1 of 4 residents discharge Minimum Data Set (MDS) assessments when they discharged home from the facility (Resident #50). The facility reported a census of 78 residents. 1.Review of Resident #50 Electronic Health Record (EHR) Census revealed she was admitted on [DATE] and discharged on 12/20/25. Review of Resident #50 Communication With family Note dated 12/17/25 at 11:30 AM documented she will discharge home on [DATE]. Review of Resident #50 Discharge Summary Note dated 12/20/25 at 10:41 AM documented she discharged from the facility on 12/20/25 at 8:30 AM. Review of Resident #50 EHR MDS log on 5/19/26 revealed the facility has completed an Entry MDS on 12/5/25 and admission MDS on 12/11/25, but has not completed a discharge MDS when she discharged on 12/20/25. On 5/20/26 at 11:59 AM, an interview with the facility Administrator and Nurse Consultant revealed staff follow the Resident Assessment Instrument (RAI) manual.

Based on a record review and staff interviews, the facility failed to ensure all mental health diagnoses were on 1 of 3 residents' Preadmission Screening and Resident Review (PASRR) documents for (Resident #8). The facility reported a census of 78 residents. Findings include: 1. Review of a Resident #8 Medical Diagnoses in her Electronic Health Record (EHR) documented she received the diagnosis of Post-Traumatic Stress Disorder (PTSD; a mental health condition triggered by a terrifying event) on 6/8/2021. A record review of Resident #8's current PASRR dated 6/10/2025 lacked her diagnosis of PTSD. On 3/27/26, a record review of a visit titled Modified Progress Note documented Resident #8 was changing from weekly to biweekly visits for the next 3 months, and mental health professionals continued to see her for her diagnoses of post-traumatic stress disorder PTSD and major depression (persistent and severe sadness). On 5/20/26 at 12:19 PM, an electronic mail (email) from the facility Administrator informed that staff follow the regulations for PASRR documents. On 5/20/26 at 12:45 PM, an interview with the facility Administrator revealed that a different person in the facility completed the Preadmission Screening and Resident Review (PASRR) documents up until about a week and a half ago, and now staff complete them centrally. The Administrator then revealed she'd expect post-traumatic stress disorder (PTSD) and any qualifying diagnosis to be on the PASRR and updated if need be. On 5/20/26 at 2:00 PM, an interview with the facility Nurse Consultant, Director of Nursing, and Administrator revealed they hadn't submitted the PASRR for Resident #8 regarding her PTSD, but they'd do that today.

Based on clinical record review, staff interview, and policy review the facility failed to develop a comprehensive care plan that included problems, goals, or interventions for 1 of 5 residents (Resident #2) reviewed for a resident with diuretic medication usage. The facility reported a census of 78. Findings include:Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed Resident #2 utilized diuretic medications during the 7 day look back period. The MDS documented that the resident was admitted to the facility on [DATE].Review of Resident #2's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order for Lasix (Diuretic medication) 40mg oral tablet to give 1 tablet twice a day with a start date of 8/26/25. Review of Resident #2's Care Plan with a revision date of 4/13/26 revealed no focus, goals, or interventions for diuretic use. Interview 5/20/26 at 12:42 PM with the Minimum Data Set (MDS) Coordinator revealed that Lasix should be in the care plan. The MDS Coordinator further confirmed Resident #2 had been on Lasix since August of 2025. Interview 5/20/26 at 12:44 PM with the Director of Nursing (DON) revealed that her expectation would be that the appropriate items are listed in the care plans.Review of a facility provided policy titled, Comprehensive Care Plans with an updated date of 12/3/25 indicated the comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.

Based on record review, resident and staff interviews, and policy review the facility failed to to provide the necessary care and services to ensure a resident received appropriate clinical monitoring, timely medical provider notification, and consistent administration of prescribed treatments for a Urinary Tract Infection (UTI) for 1 of 1 residents reviewed for UTI (Resident #31). Specifically, facility staff failed to conduct nursing assessments across two separate antibiotic regimens, delayed follow-up with an unresponsive medical provider regarding a recurrence of symptoms, omitted a scheduled antibiotic dose without clinical justification, and failed to update the resident's care plan to reflect a suspected multidrug-resistant infection and use of antibitoics. The facility reported a census of 78 residents. Findings include: A review of all Progress Notes and clinical records from 4/1/26 to 5/20/26 established a timeline of Resident #31's antibiotic therapies for a urinary tract infection (UTI), which included an initial order for Macrobid 100 milligrams twice a day for seven days on 4/25/26, a subsequent change to Cefdinir 300 milligrams twice a day for seven days on 4/27/26, and a new course of Ciprofloxacin Hydrochloride (Cipro) 500 milligrams twice a day for seven days ordered on 5/15/26.Resident #31's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating intact cognition. The MDS revealed Resident #31 had functional limitations to both lower extremities, depended on staff for all transfers and to go from a sitting to a standing position, and staff did not attempt to walk him due to his medical condition. The MDS further documented Resident #31 was occasionally incontinent of urine, frequently incontinent of bowel movements, and was not on a toileting program. The MDS recorded diagnoses of cancer, diabetes (a chronic condition affecting blood sugar regulation), Parkinson's disease (a progressive nervous system disorder affecting movement), and depression.On 5/18/26 at 11:37 AM, an interview with Resident #31 revealed he denied issues with all care and had no concerns related to his UTI (an infection in any part of the urinary system).A review of Medical Diagnoses in the Electronic Health Record (EHR) documented a current diagnosis starting on 4/24/26 of a UTI, site not specified.The Progress Notes from 4/1/26 to 5/20/26 recorded the following chronological entries:A Progress Note dated 4/23/26 at 3:23 PM recorded that staff called the local laboratory to follow up on a urine sample collected and sent the previous Thursday. The laboratory reported they never received the specimen. Staff re-collected the sample on 4/23/26 to send via courier the following day.A Progress Note dated 4/25/26 at 2:03 AM recorded that staff received urinalysis results from the laboratory. Staff placed a call to the on-call medical provider to request antibiotic orders, and received a new order for Macrobid 100 milligrams by mouth twice a day for seven days. the note recorded staff would call when final culture and sensitivity results became available.A Progress Note dated 4/25/26 at 2:08 AM recorded that staff pulled the first dose of Macrobid from the facility's on-hand medication supply and administered it.A Progress Note dated 4/27/26 at 11:32 AM recorded that staff received the final culture and sensitivity laboratory results. Following the provider's review, a change of antibiotic was ordered to discontinue Macrobid and initiate Cefdinir 300 milligrams by mouth twice a day for seven days.A Progress Note dated 4/27/26 at 8:17 PM recorded that vital signs were blood pressure 151/91, pulse 68, and temperature 98.0 F. Staff noted the resident continued on Cefdinir 300 milligrams for a UTI, with no adverse side effects observed at the time of the assessment.Progress Notes from 4/27/26 to 5/20/26 revealed that staff charted clinical updates on 4/28/26, 4/29/26, 4/30/26, and 5/2/26 indicating the resident denied burning or discomfort and fluids were encouraged. However, the progress notes lacked required daily nursing assessments regarding Resident #31's UTI signs, symptoms, and antibiotic usage on 5/1/26, 5/3/26, 5/4/26, 5/5/26, and from 5/7/26 through 5/12/26.A Progress Note dated 5/5/26 at 2:05 AM recorded that the resident was seen by the medical provider on 5/4/26, with no new orders documented at that time.A Progress Note dated 5/6/26 at 4:09 PM recorded a late entry noting that staff transmitted a fax to the provider to notify them that the resident continued to experience symptoms of burning with urination and minimal urinary urgency.A Progress Note dated 5/8/26 at 2:11 PM recorded a late entry noting that staff received no response from the provider. Staff re-faxed the communication to let the provider know that Resident #31 continued with symptoms after completing the antibiotic treatment.A Progress Note dated 5/13/26 at 11:02 AM recorded that staff obtained a urinalysis as ordered in a clean urinal, and they sent the specimen to the local laboratory.A Progress Note dated 5/15/26 at 4:15 PM recorded that staff received the urinalysis results back after the provider reviewed them, resulting in a new order for ciprofloxacin hydrochloride (Cipro) 500 milligrams twice a day for seven days, which staff faxed to the pharmacy and entered into the MAR.A review of the Medication Administration Record (MAR) for May 2026 showed Resident #31 received all doses as ordered for Cefdinir 300 milligram oral capsule, with directions to give one capsule by mouth two times a day for a UTI for seven days, starting on 4/27/26 at 8:00 PM. The May 2026 MAR further revealed a new order for Cipro 500 milligrams twice a day to be started on 5/16/26 for seven days. Staff did not give the medication on 5/16/26, and the record noted to see the progress notes. A review of the progress notes for 5/16/26 revealed no entry explaining why staff did not give the medication.A review of the Care Plan dated 4/21/26 identified Resident #31 had bladder incontinence related to impaired mobility. The goal directed that Resident #31 would remain free from skin breakdown due to incontinence and brief use through the review date. Interventions instructed staff to clean the perineal area with each incontinence episode and monitor and document for signs and symptoms of a UTI, including pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul-smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. Facility staff didn't revise the care plan to reflect Resident #31's recent antibiotic usage and recurrent UTI.A review of Assessments in the EHR from 4/1/26 to 5/20/26 revealed staff completed an Infection Screening Evaluation on 4/24/26, an Infection Screening Evaluation on 5/6/26, and an Antibiotic Time Out on 5/6/26. The EHR lacked daily nursing assessments to monitor Resident #31's UTI signs, symptoms, and antibiotic usage.On 5/19/26 at 12:40 PM, an interview with the Infection Preventionist (IP) revealed that the EHR system completes the clinical criteria and creates an infection control case. The IP stated staff follow a protocol when completing UTI antibiotics, and she confirmed staff should document assessments or progress notes regarding side effects for UTIs. The IP further confirmed staff should chart more clearly and concisely.On 5/19/26 at 12:51 PM, an interview with the Director of Nursing (DON) revealed that staff follow McGreer's criteria (surveillance definitions for infections in long-term care facilities) through the EHR system. The DON stated staff should complete close monitoring and documentation for antibiotics the entire time a resident takes the medication. The DON further confirmed Resident #31 was a different case because a laboratory result came back showing a possible multidrug-resistant organism (bacteria resistant to multiple antibiotics), so management decided to continue the antibiotics to ensure they treated the infection completely.On 5/21/26 at 9:08 AM, an interview with Staff C, Certified Nursing Assistant (CNA), revealed she knew Resident #31 had a UTI during the past month and was on his second round of antibiotics. Staff C stated Resident #31 seemed to be doing okay and had no complaints of pain, burning, or urgency to her. Staff C recalled hearing during a nursing report that staff possibly caught the infection because he acted a little off.On 5/21/26 at 9:21 AM, an interview with Staff B, CNA, revealed she knew Resident #31 had a UTI and was on his second round of antibiotics. Staff B stated she asked him about it, and he reported he felt better and that the medications helped. Staff B reported Resident #31 had no complaints of pain, burning, or urgency to her, and he was doing well.On 5/21/26 at 9:48 AM, an interview with Staff D, Registered Nurse (RN), revealed she knew Resident #31 was on an antibiotic for a UTI diagnosed at the end of April. Staff D stated Resident #31 acted normal per his baseline, had no complaints of pain or burning, and was doing great. Staff D reported that when a resident has a UTI, staff must assess and document vital signs, urinary frequency, urgency, pain, and burning once every shift.A review of the facility's policy titled Urinary Symptom Monitoring Protocol, dated 5/14/24, revealed that for residents exhibiting urinary symptoms, staff were required to notify the medical provider by phone, request orders for Vitamin C 1,000 milligrams (mg) daily, and initiate enhanced shift-by-shift tracking. The protocol strictly mandated that staff must document fluid intake in cubic centimeters (cc's) on the electronic Treatment Administration Record (eTAR) every shift, and utilize the facility's 24-hour sheet to document the resident's temperature, encouragement of fluids, and any observable symptoms every shift. The policy further directed that if at any time during the monitoring period the resident's condition appeared to be declining, staff were to notify the medical provider immediately.On 5/21/26 at 8:57 AM, an interview attempt was made to Resident #31's Doctor of Nursing Practice (DNP), but the provider didn't return the call.

Based on record review, resident and staff interviews, and policy review the facility failed to ensure that an effective pain management regimen was consistently implemented in accordance with professional standards of practice and the comprehensive plan of care for 1 of 1 resident reviewed for pain management (Resident #64). Specifically, the facility failed to administer prescribed pain medication as ordered, resulting in a failure to meet the resident's goals for care and preferences. The facility reported a census of 78 residents. Findings include: Resident #64's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status score of 13, indicating intact cognition. The MDS revealed staff admitted him to the facility on 4/21/26. The MDS revealed he uses a wheelchair, does not walk, and depends on staff for transfers. The MDS documented diagnoses of peripheral vascular disease (a circulatory condition where narrowed blood vessels reduce blood flow to the limbs), arthritis (joint inflammation causing pain and stiffness), malnutrition, asthma, and dislocation of the left hip. He occasionally experiences pain, and he rated his worst pain in the past five days as a seven out of 10.On 5/18/26 at 10:46 AM, an interview with Resident #64 revealed he had a lot of pain when getting in and out of bed.A review of the Medication Administration Record (MAR) for May 2026 revealed Resident #64 had an order starting on 5/7/26 at 8:00 PM for oxycodone hydrochloride (a strong opioid medication used to treat severe pain) five milligram capsule by mouth twice a day. Staff didn't manage the medication as ordered because:a. The staff missed both doses on 5/8/26 while Resident #64 rated his pain a two out of 10 each time.b. On 5/9/26, staff missed both doses while Resident #64 rated his pain a six out of 10 in the morning, and staff didn't assess his pain at bedtime.c. On 5/10/26, staff missed both doses while Resident #64 rated his pain a five out of 10 in the morning and a two out of 10 at bedtime.d. On 5/11/26, staff missed the morning dose, and Resident #64 rated his pain a six out of 10 when he finally received the medication on the night of 5/11/26.e. On 5/13/26, Resident #64 had worse pain with an eight out of 10 in the morning and a seven out of 10 in the evening.A review of the May 2026 MAR also showed that once the pharmacy filled the prescription, staff gave an as-needed dose on 5/11/26 at 2:47 PM for a pain rating of nine out of 10. The order directed staff to give oxycodone five milligram capsule every eight hours as needed for pain starting on 5/7/26. Resident #64 ran out of his scheduled twice-daily pain medications because the pharmacy didn't receive a written prescription after the doctor gave the order. The order remained on file, but the pharmacy couldn't fill it.A review of a Nurses Note dated May 2026 at 6:34 AM recorded that staff contacted the pharmacy because Resident #64 didn't receive his narcotic medication, and he continued to request a pain pill. A pharmacy technician stated Resident #64 didn't have a current prescription. The pharmacy technician reported they sent a refill prescription request on May 1st and still hadn't received a response. Staff couldn't pull the medication from the automated medication dispensing system because they didn't have a current prescription. Staff provided the on-call telephone number so the pharmacist could reach out to the on-call medical provider for a current prescription to deliver the medication.A review of a Nurses Note dated May 2026 at 1:26 PM recorded that staff awaited a three-day emergency prescription for Oxycodone before receiving a new prescription. Resident #64 showed continued pain to his left hip.A review of the Care Plan dated 4/21/26 identified Resident #64 had a potential for pain or actual pain related to chronic wounds and his disease process. The goal directed that Resident #64 would verbalize satisfaction with pain control over the next review period. Interventions instructed staff to assess for signs and symptoms of pain, give medications as ordered, and notify the physician of uncontrolled pain. Facility staff didn't follow the care plan interventions when they failed to provide the pain medications as ordered by the physician.On 5/20/26 at 9:20 AM, an interview with Resident #64 revealed his asthma (a respiratory condition causing breathing difficulties) is why he called emergency medical services (EMS) earlier in the month and wanted to see his local provider, it was not due to his pain.A review of an Administrator Email dated 5/20/26 at 12:30 PM recorded the facility did not have a policy for physician orders, and staff followed standards of practice.On 5/21/26 at 9:08 AM, an interview with Staff C, Certified Nursing Assistant (CNA), revealed Resident #64 complains about pain all the time. Staff C stated Resident #64 always complains about his hip and always complains about getting up. Staff C reported Resident #64 seems very uncomfortable a lot, and he always asks for pain pills.On 5/21/26 at 9:21 AM, an interview with Staff B, CNA, revealed Resident #64 complains about pain all the time, always wants pain medications, and always yells that he is in pain when staff change him. Staff B reported Resident #64 always complains about his hip.On 5/21/26 at 9:48 AM, an interview with Staff D, Registered Nurse (RN), revealed Resident #64 has complained about pain to her. Staff D reported Resident #64 has scheduled pain medications. Staff D stated if a resident had an order for pain medication but the pharmacy didn't receive a prescription, she would call the pharmacy and see if she could pull the medication from the emergency medication kit. Staff D reported she would try to call as soon as possible, would talk to the Director of Nursing, and then would call the doctor.On 5/21/26 at 8:57 AM, an interview attempt was made to Resident #64's Doctor of Nursing Practice (DNP), but the provider didn't return the call.The Pain Management Policy last revised on April 2025 directed staff to recognize when a resident is experiencing pain, manage or prevent pain consistent with the comprehensive assessment and plan of care, and develop, implement, monitor, and revise interventions to manage each individual resident's pain. The policy instructed staff to notify the practitioner if the resident's pain is not controlled by the current treatment regimen, and to revise the pain management regimen and plan of care if reassessment findings indicate pain is not adequately controlled.

Based on staff interview, observation, document review and facility policy review the facility failed to maintain an effective pest control program so that the facility was free from any infestation of any kind of vermin in the facility. The facility reported a census of 72 residents. Finding include:In an interview with Staff D, Licensed Practical Nurse (LPN) on 1/26/26 at 3:00 pm, she revealed there was a mice problem at the facility and in the staff break room. She further stated mice ate her snack that was in her personal locker inside the breakroom. This occurred about a week ago and the facility added mice traps and boxes at that time and the exterminator came out to the facility. The facility provided a document titled Work Orders for dates December 29, 2025 - January 29, 2026 and an entry log mouse in room [ROOM NUMBER] was documented as closed work order.During an observation of room [ROOM NUMBER] on 1/27/26 at 9:00 am, the 6-drawer clothing dresser revealed mice droppings in 4 out of 6 drawers. Drawers contained resident's clothing articles such as socks, jeans and personal items. During an observation of a vacant room [ROOM NUMBER] on 1/27/26 at 9:10 am mice droppings were noted in a corner of the room near the heat register. During an interview with Staff E, Maintenance Director on 1/27/26 at 10:45 am he reported the facility had an ongoing mice problem and the exterminator had made extra visits to the facility this month. He stated whenever there are sightings of mice they tackle the problem by calling for additional visits from the pest control company. He also added that staff told him they caught live mice a day prior in their work area but he was not in the building at that time. In an interview with Staff A, Housekeeping Aide on 1/27/26 at 11:45 am she revealed the mice problem was so bad that they had to throw away multiple items from the Activity Room storage closets. Staff were going through Christmas decorations items in the storage closet and while pulling out boxes, they discovered many items were torn and chewed up by mice and they seen a live mouse jumping out of one of the boxes. Staff A further revealed one of the resident's rooms, a recliner's cushion was pulled out revealed a bunch of mice poop in there and they threw away a few of her soft toys. In an interview with the Administrator on 1/27/26 at 12:05 pm she stated mice droppings were first noted at the beginning of January (2026) and pest control routinely serviced the building monthly but they made additional visits since then. She provided a facility wide education about proper food storage and to avoid bringing any candy or snack foods that could be attracting mice. The Administrator confirmed that the recliner that had mice droppings was replaced and they had an exterminator coming to the facility again this week. During an observation of the Activity Room on 1/28/26 at 9:55 am revealed 3 Residents were present in the room. Multiple mice droppings were noted around the room near the edges by the entrance door and near a nightstand located in the corner of the room on the right side of the entrance door. Some droppings were black and some were green. Behind the nightstand there was a white square box with debris all around it. In an interview with the Administrator on 1/28/26 at 11:00 am she stated the debris behind the nightstand in the Activity Room has been cleaned up and the mice droppings too. She further revealed a hole in the floorboard of the corner will be patched up. The facility provided policy titled Pest Control Program dated 12/3/25 documented the facility will maintain an effective pest control program for common household pests and rodents.

Based on document review, electronic health record review (EHR), staff interviews, and policy review the facility failed to report a resident's allegation of sexual abuse (Resident #4) to the State Agency within the required timeframe for 1 of 3 residents reviewed for abuse and dignity. The facility reported a census of 72. Findings include: The Quarterly Minimum Data Set (MDS) Assessment completed on 12/4/25 revealed Resident #4 with a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. The MDS documented that Resident #4 was dependent on staff for completion of personal cares and transfers and wheelchair use. The Incident Investigative Report showed the facility submitted on online report of sexual abuse involving Resident #4 on 1/22/26 at 8:13 AM to the Iowa Department of Inspections, Appeals, and Licensing. During an interview on 1/26/26 at 1:55 PM, Staff C, Certified Nursing Assistant (CNA), stated Resident #4 reported the morning of 1/22/26 that the guy from last night needs to be fired as he raped me. Staff F, CNA, who was also present when the comment was made, mentioned to Staff C that Resident #4 made the same type of statement the morning of 1/21/26. During an interview on 1/27/26 at 8:35 AM, Staff F, CNA confirmed Resident #4 reported the morning of 1/22/6 that they were raped. Staff F stated Resident #4 said the same thing the morning of 1/21/26 while they assisted completing personal cares on the resident. Staff F explained they were under the impression another staff member reported it to the nurse working on 1/21/26 but was not sure. During an interview on 1/27/26 at 935 AM, Staff G, CNA, explained Resident #4 reported the morning of 1/21/26 that the black guy raped me while completing personal cares. Staff G thought they had notified the Director of Nursing (DON) of the statement on 1/21/26. If they didn't the tell the DON, then they may have told the nurse working that day. Staff G unable to recall the name of the nurse working. During an interview on 1/28/26 at 10:00 AM, Staff H, CNA, explained Resident #4 reported to them on morning of 1/21/26 that a black man raped me and the black girl. Resident #4 said this man was the one who comes in and turns the light on. After completing personal cares, Staff H stated they went to inform Staff I, Registered Nurse, of the statements Resident #4 had made. Staff I acknowledged and told Staff H they would take care of it. Staff H's written statement dated 1/22/26, as noted in the facility's incident investigative file, documented on 1/21/26 they were getting Resident #4 ready for breakfast when the resident voiced the dark black man raped me. The statement further noted Staff H informed Staff I at approximately 8:00 AM of the allegation. During an interview on 1/28/26 at 2:00 PM, Staff I acknowledged Staff H approached them the morning of 1/21/26 to report Resident #4's rape allegation. Staff I explained they then called the DON at approximately 7:30-8:00 AM that morning to report. During an interview on 1/28/26 at 10:20 AM, the DON explained Staff I did not contact them on 1/21/26 regarding Resident #4's rape allegations. They were first made aware of Resident #4's rape allegation the morning of 1/22/26 by Staff D, Licensed Practical Nurse, via phone. With any allegations of abuse, the DON stated staff should immediately notify the charge nurse but also themselves and/or the facility administrator to ensure reporting and investigating timeframes are met. The policy Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, updated 10/19/22, noted the following: Allegations of resident abuse shall be reported to the Iowa Department of Inspections, Appeals, & Licensing no later than 2 hours after the allegations is made.

Based on facility document review, staff interviews, and policy review the facility failed protect residents from further potential abuse once an allegation of sexual abuse was reported to staff, for 1 of 2 abuse allegations reviewed. An employee meeting the general description of the alleged perpetrator worked and had access to residents after the allegation was were made. The facility reported a census of 72. Findings include: During an interview on 1/28/26 at 10:00 AM, Staff H, Certified Nursing Assistant (CNA), explained Resident #4 reported to them on the morning of 1/21/26 that a black man raped me and the black girl when they asked the resident how they slept during the night. Resident #4 said this man was the one who comes in and turns the light on. After completing personal cares, Staff H stated they went to inform Staff I, Registered Nurse (RN), of the statements Resident #4 had made. During an interview on 1/28/26 at 2:00 PM, Staff I, RN acknowledged Staff H, CNA approached them the morning of 1/21/26 to report Resident #4's rape allegation. Staff I explained she then called the Director of Nursing (DON) at approximately 7:30 AM that morning to report. During an interview on 1/28/26 at 10:20 AM, the DON explained Staff I did not contact them on 1/21/26 regarding Resident #4's rape allegations. They were first made aware of the allegation the morning of 1/22/26. After reviewing schedules from the previous day, Staff J, CNA, was suspended, per protocol, as they matched the general description Resident #4 provided. The DON acknowledge Staff J had worked the night shift on 1/21/26. Staff J was informed of the work suspension on 1/22/26. The facility's staffing schedules reflected Staff J worked the night shift of 1/20/26 and 1/21/26. The policy Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, updated 10/19/22, noted the following: 1.Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. 2.If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: a. Suspending the employee b. Segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility; and in rare instances c. Separating the employee accused of abuse from the resident alleged to have been abused, but allowing the employee to care for and have contact with other residents, only if there is a second employee who remains with and accompanies the employee accused of abuse at all times to supervise all contacts and interactions with the residents.The Incident Investigative Report showed the facility submitted on online report of sexual abuse involving Resident #4 on 1/22/26 at 8:13 AM to the Iowa Department of Inspections, Appeals, and Licensing

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to perform proper transfer method as outlined in the Care Plan which contributed to a femur fracture which resulted in the need for surgical intervention for 1 of 4 residents reviewed for transfers (Resident #45). The facility reported a census of 70. Findings include: The Quarterly Minimum Data Set (MDS) Assessment completed on 6/12/25 revealed Resident #45 with a Brief Interview Mental Status score of 14, which indicated intact cognition. Diagnoses listed on the MDS include paraplegia, anxiety disorder, diabetes, and orthostatic hypotension (low blood pressure). The MDS noted the presence of a urinary catheter and a colostomy. Resident #45 is dependent on staff for chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers. The Care Plan with initiated date of 6/20/24 identified Resident #45 with an Activities of Daily Living self-care performance deficit related to paraplegia, limited mobility, limited range of motion (ROM), and pain. Interventions include the use of a mechanical lift with an assist of 2 staff members for transfers. The Restorative Nursing Program sheet for Resident #45, dated 1/23/25 and created by the attending Physical Therapist, outlined staff assistance of 1-2 for bed mobility and the use of a mechanical lift (Hoyer) for transfers with an assist of 2 staff members. The late entry Progress Note dated 7/8/25, created on 7/17/25, revealed Staff E, Licensed Practical Nurse, was notified by the Restorative Aide (RA) staff that Resident #45 had bumped their foot while RA staff had the resident in the shower chair. Staff E assessed and noted scabbing to both of Resident #45's feet. One toe on the right foot had a scab that had partially been removed and was no longer intact. One of the RAs had cleansed the toe and the scab came off. No open areas noted to toes or injuries to report The Progress Noted dated 7/15/25 at 2:54 PM documented a phone order from the Nurse Practitioner (ARNP) for right hip x-rays.The Progress Noted dated 7/15/25 at 5:34 PM documented x-ray results received and the Primary Care Provider was called. Orders received to send Resident #45 to the emergency room for a broken right femur (thigh bone). The Progress Note/Incident Note dated 7/17/25 at 1:14 PM documented Staff E was alerted by another nurse and RA staff that Resident #45's right leg was bending in a weird spot while performing ROM exercises. Staff E and the Director of Nursing (DON) both assess the resident. It was noted the right knee cap was turned inward when raised and there was a slight bend to the mid-thigh. Staff E called the doctor and a stat portable x-ray order was obtained. The facility document titled Self-Report revealed Staff K, RA, and Staff L, Certified Nurses Aide (CNA), had performed a stand-pivot transfer (way of moving from one surface to another by bearing weight on legs, standing up, turning, and then sitting down on a different surface) with Resident #45 in the shower room on 7/8/25. The DON and Facility Administrator interviewed Staff K who acknowledged the stand-pivot transfer from the wheelchair to the shower bench as Resident #45 had agreed. Staff K noted Resident #45 did not injure their right lower leg and appeared anxious due to left toe bleeding and not liking the shower bench. Staff K reported the stand-pivot transfer was utilized instead of the mechanical lift as they believed as RAs had leeway and could transfer residents during restorative tasks which were not in line with the Care Plan. The Self Report document also noted an interview with Staff L, CNA who acknowledged the completion of the stand-pivot transfer from a wheelchair to the shower bench and then again from the shower bench to a wheelchair. Staff L noted a scab on Resident #45's left toe had reopened further during the transfer. A facility fax received on 7/17/25, the Nurse Practitioner documented the following: Resident #45's x-ray indicated osteoporosis which increases the risk of fractureFractures did not appear spontaneous or pathologic purely due to osteoporosisA mild twisting of joints or other trauma could have resulted in these fracturesOriginal trauma unknown to this Nurse Practitioner The facility document titled Staff Interview Questions were completed by various staff and revealed the following: Staff O, Certified Medication Aide (CMA) reported they had not observed Resident #45 hitting their leg on a mechanical lift (Hoyer) or side table or rolling onto objectsStaff P, CNA, reported they had not observed Resident #45 hitting their leg on a mechanical lift (Hoyer) or side table or rolling onto objectsStaff Q, CNA, reported Resident #45 told them the RAs transferred and scratched her right footStaff R, CNA, reported Resident #45 told them they were hurt during a pivot transfer provided by the RA staffStaff S, CNA, reported they had not observed Resident #45 hitting their leg on a mechanical lift (Hoyer) or side table or rolling onto objectsDuring an interview on 7/28/25 at 11:30 AM, Resident #45 acknowledged the stand-pivot transfer performed on 7/8/25. Resident #45 reported they typically take bed baths but due to an outside appointment that day, agreed to a shower. Resident #45 explained the RA staff used a mechanical lift to transfer them from the bed to a wheelchair. Once in the shower room, Resident #45 placed their arms around the staff's neck while the staff member stood in front of them. Staff picked them up underneath the arms/shoulders and transferred them onto the shower bench. During the transfer, the resident explained one of their hands was on the right-facing arm rest of the shower bench and the other hand was on the back of the shower bench. Resident #45 stated staff had to turn their body (to the left) from the wheelchair to the shower bench. Once seated on the edge of the shower bench, Resident #45 heard one of the two staff members saying the resident's leg and foot was twisted underneath the shower bench. Staff then returned the resident back into the wheelchair. Resident #45 did not know which foot was twisted. Due to paralysis, Resident #45 did not report any pain. The only noticeable difference Resident #45 stated their knees were swollen. This was relayed to nursing staff and socks were ordered.During an interview on 7/28/25 at 1:00 PM, Staff M, CNA, explained they observed both RA staff members pushing Resident #45 into the hallway to the shower room on 7/8/25. Approximately 10 minutes later, Staff M observed the resident and both RA staff returning to the resident's room. Resident #45 was heard yelling and crying. Staff M saw a piece of skin hanging off of Resident #45's right foot and a cut to the left foot. Staff M heard Staff L tell the resident it was already like that, referring to the skin issues on the resident's feet. Staff M asked what had a happened and Resident #45 said They (RA staff) twisted my (f**cking) foot, They picked me up. Resident #45 was transferred to the bed, via a mechanical lift, and a bed bath was provided by Staff K and Staff M. Staff L had already left the room by this time to attend a resident group activity. Approximately 1hour later, Staff M checked on Resident #45 who appeared more calm. The resident voiced being pissed as her feet were twisted under the shower chair when staff was picking-up and transferring. Staff M noted the presence of a urinary catheter and colostomy. These appliances are emptied several times daily. Therefore no specific pericares are provided to Resident #45 on a daily basis. During an interview on 7/29/25 at 1:25 PM, Staff E, LPN acknowledged assessing Resident #45's feet on 7/8/25 after RA staff alerted them that the resident had bumped her foot. This was done after staff had returned the resident back to bed. Staff F noted a scab on the resident's right foot, 3rd or 4th toe, had broken loose. Staff E did not recall seeing any injuries on the resident's left foot. At the time of this assessment, Staff E was not aware of the stand-pivot transfer the RA staff completed earlier. A week later, on 7/15/25, Staff E stated another nurse and the RA for the day altered them to Resident #45's right left. Staff E and the DON both assess the resident and saw the right femur (thigh bone) bend and making weird noises. During an interview on 7/29/25 at 3:20 PM with the DON and the Regional Clinical Specialist, both acknowledged RA staff had completed an improper transfer with Resident #45 as the stand-pivot transfer did not align with the Care Plan. Both indicated completing this type of transfer is not within the RAs scope of practice. Both would expect the RAs to communicate with the therapists (Physical or Occupational) first for further guidance. The DON confirmed staff utilized the shower room on the 200 hallway and verified the shower bench used in the transfer. During an interview on 7/29/25 at 3:55 PM, Staff K, RA reported they had talked to Resident #45 on 7/7/25 about taking a shower the next day instead of a bed bath since the resident had an outside appointment. Staff K indicated they discussed the use of a shower bench and Resident #45 agreed. On 7/8/25, Staff K discussed the above again with the resident who still agreed. Staff K believed they had the authority to work outside a resident's care plan and believed the use of a stand-pivot transfer was safe. After a mechanical lift was used to transfer Resident #45 from the bed to a wheelchair, Staff K and Staff L, CNA wheeled the resident to the shower room.Once in the shower room the wheelchair was angled a short distance from the shower bench. Staff K, RA who was in front of the resident, lifted Resident #45 and placed on the shower bench. Staff K explained Staff L was standing behind the resident and guiding from behind. Staff L indicated Resident #45's left foot was twisted. Staff K did not hear or feel anything. Once on the bench Resident #45 was getting worked up and was transferred back to the wheelchair. The resident was returned to their room where a bed bath was provided. Staff K did not observe anything usual with Resident #45's right leg during this time. On 7 /11/25 while completing Resident #45's restorative exercises, Staff K, RA stated something was different with the resident's right leg. When asked the resident of any issues with the leg, Resident #45 denied and voiced a previous physician told them of a past hip dislocation. No further action was taken by Staff K. During an interview on 7/30/25 at 1:25 PM, Staff N, Physical Therapist Assistant (PTA), noted Resident #45 requiring a mechanical lift as long as they have been at the facility, which is approximately one year. Historically Resident #45 had been on active therapy case load with an attempt to sit at the edge of bed for core strengthening but resident declined the intervention. Staff N stated PTA/RAs unable to make judgement call or work outside a resident's care plan. Updated resident information or changes should go through the supervising therapist. During an interview on 7/30/25 at 3:30 PM Staff L, CNA acknowledged the stand-pivot transfer performed on 7/8/25 performed on Resident #45. Staff L explained this was initiated by Staff K and had no reason to believe this was inappropriate. On the day of the transfer, Staff L noted Staff K, RA had talked to the resident about the shower and use of the shower bench. Just prior to entering the resident's room, Staff L and Staff K discussed the transfer itself. Staff L asked Staff K are you sure and Staff K indicated this had been done before. Staff L and Staff K transferred Resident #45 from the bed to a wheelchair using a mechanical lift. The resident was taken to the shower room. The wheelchair was locked and facing south. The shower bench was facing north. Staff K was facing the resident w/their arms underneath and lifting. Staff L was behind the resident, guiding with use of a gait belt. Staff K picked-up the resident and placed them on the shower bench. Once on the bench, Resident #45 did not like and was transferred back to the wheelchair from the bench utilizing a fireman lift approximately 2 inches performed by Staff K. The resident was then returned to her room. No shower was provided in the shower room. Staff L indicated Resident #45 had one toe that touched the floor tile. The little toe hit the bench leg and a scabbed fell off. Staff L had told Staff K the resident's foot was twisted but it was not twisted at all. Staff L did not indicate which foot hit the bench leg. On 7/15/25, Staff L was completing restorative exercises with Resident #45 when they noticed something wrong with their right leg. Nursing was notified. During an interview on 7/31/25 at 9:15 AM, Staff B, Occupational Therapist (OT), confirmed the RA staff did not discuss the use of a stand-pivot transfer with Resident #45 prior to it occurring. Staff B believed this was an inappropriate transfer and one they would not recommend. Staff B not aware of any direction from previous Director of Rehab services that allowed leeway to RA staff to work outside a resident's Care Plan. Staff B noted the use of a mechanical lift would be a more controlled transfer compared to a stand-pivot transfer. Staff B explained the therapy department has undergone several supervisory changes since March 2025. More recently, an outside contracted agency oversees the department. The OTs and PTA report to this agency while the RAs do not. Staff B was under the impression the RA did not have an immediate supervisor from June 2025 (unclear of a specific June date) until 7/14/25. On this date, the RAs transitioned over to the facility nursing staff. When asked, the facility did not have a policy which outlined RA scope of practice. The policy Comprehensive Care Plans, updated April 2025, stated qualified staff responsible for carrying out interventions specified in the Care Plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on clinical record review, staff interview and the Resident Assessment Instrument (RAI) Manual the facility failed to accurately complete a Minimum Data Set (MDS) assessment for four of twenty-three residents reviewed (Residents #1, #3, #6 and #32). The facility reported a census of 70 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #3 had a diagnosis of coronary artery disease. The MDS documented the resident took an anticoagulant. The Electronic Health Record (EHR)revealed that Resident #3 had diagnoses of Aortocoronary bypass graft (heart arteries blocked or narrowed) and old myocardial infarction (heart attack). The Care Plan revised 4/12/24 revealed Resident #3 had a risk of abnormal bleeding related to routine use of hematological agents (drugs used to treat disorders of the blood). The Care Plan directed staff to administer medications as ordered and monitor for side effects. The EHR revealed Clopidogrel Bisulfate (Plavix) (an antiplatelet) 75 MG (milligrams) one time a day for an old myocardial infarction (heart attack) and presence of aortocoronary bypass graft (CABG) started on 1/13/21. The EHR lacked documentation that the resident had taken an anticoagulant medication. 2. The Quarterly MDS assessment dated [DATE] revealed that Resident #6 had a diagnosis of viral hepatitis. The MDS documented that this was an active diagnosis in the last 7 days. The Annual MDS dated [DATE] indicated that Resident #6 had diagnoses of anxiety, depression, bipolar disorder and schizophrenia in the last 7 days. It also indicated that there was not a Level II PASRR (Pre-admission Screening and Record Review) in place. The Electronic Medical Diagnosis List revealed that Resident #6 had a diagnosis of acute hepatitis without hepatic coma dated 1/19/23. It also indicated a Level I PASRR on 5/9/23 with a Level II PASRR approval for nursing level of care. Finally, it indicated a Level I positive indicating no status change and that the previous Level II PASRR findings remains valid. 3. The MDS assessment dated [DATE] revealed Resident #1 had diagnoses of a fracture. The MDS documented the resident took an anticoagulant (AC). The Care Plan revised 4/11/25 revealed Resident #1 had altered cardiovascular (heart and blood vessels) status and had a risk of abnormal bleeding related to routine use of hematological agents. The Care Plan directed staff to administer medications as ordered and monitor for side effects. The Electronic Physician’s Orders revealed Clopidogrel Bisulfate (Plavix) (an antiplatelet) 75 MG once a day for a blood thinner related to hypertension (high blood pressure). The Physician's Orders lacked documentation that the resident had taken an anticoagulant medication. 4. The MDS assessment dated [DATE] revealed Resident #32 had diagnoses of cerebrovascular accident (CVA) (stroke), quadriplegia, coronary artery disease, and viral hepatitis. The MDS documented the resident took an AC. The Care Plan revised 12/16/24 revealed Resident #32 had a risk of abnormal bleeding related to routine use of hematological agents. The Care Plan directed staff to administer medications as ordered and monitor for side effects. The Electronic Physician’s Orders revealed Clopidogrel Bisulfate 75 MG once a day for cerebral infarction (death of brain tissue) started on 11/12/24. the Physician's Orders lacked documentation that the resident took an anti-coagulant. The EHR Medical Diagnoses List revealed the resident had a diagnosis of chronic viral hepatitis C was added on 11/11/24. In an interview on 7/31/25 at 2:20 PM, Staff J, MDS Coordinator, reported she had worked in the MDS role since 12/1/24. She used the RAI Manual to reference how to fill out the resident’s MDS assessment. She did a look-back of 7 days and reviewed the resident's records, looked at the staff’s coding for section GG, and talked to the staff to gather information for completion of MDS assessments. Staff J reported she also used a “cheat sheet” for completion of the MDS. Staff J reported she looked at the order summary to see if a resident received medication such as an AC. Staff J stated that Plavix would be coded as an AC but aspirin would not be coded as an AC because aspirin was an antiplatelet. At the time, Staff J looked up a list of medications and the drug classification and reported Plavix was listed as an antiplatelet. Staff J acknowledged she did not know this. Staff J also responded she did not know the answer to when viral hepatitis would be marked under the diagnoses section. She presumed if the diagnoses was within 3 months, she would mark the viral hepatitis diagnosis under the diagnoses section. Staff J reported she looked at the current PASRR to determine if a resident had a Level II condition. She marked yes in the section about PASRR if the resident’s PASRR had listed a Level II condition. A medication drug classification list revealed Clopidogrel was a antiplatelet. The RAI Manual version 3.0 revealed there are two look-back periods for Section I, diagnosis list. Viral hepatitis would be coded as an active diagnoses if there was a physician-documenteddiagnoses in the last 60 days that had a direct relationship to the resident’s current functional status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Code antiplatelet medication such as clopidogrel if the resident took the medication at any time during the 7-day observation period.

Based on clinical record review, staff interview, and policy review the facility failed to develop a comprehensive care plan that included focus, goals, or interventions for 2 out 5 residents reviewed (Resident #5, #23). The facility reported a census of 70 residents. Findings include: 1. Review of Resident #5's Quarterly Minimum Data Set (MDS) dated [DATE] documented an admission date to the facility of 9/5/13. The MDS also documented a Brief Interview for Mental Status (BIMS) of 03 which indicated severe cognitive impairment. The MDS listed a diagnosis of Non-Alzheimer's dementia. Review of Resident #5's Electronic Health Record (EHR) document titled Care Plan last review completed date of 6/27/25 revealed no documentation of dementia diagnosis with a focus area, goals, or interventions. 2. Review of Resident #23's Quarterly MDS dated [DATE] documented an admission date to the facility of 6/8/23. The MDS listed active diagnoses of Urinary Tract Infection (UTI) (last 30 days). Review of Resident #23's Electronic Health Record (EHR) document titled Care Plan last reviewed date of 6/27/25 revealed no documentation of UTI diagnosis with a focus area, goals, or interventions. A review of the EHR revealed Resident #23's physician visited on 7/25/25 and documented a history of repeated UTIs as a present illness. The Progress Notes for Resident #23 documented Nurse's note on 6/20/25 physician ordered Cephalexin 500 milligrams by mouth twice a day for 7 days (antibiotic). The Progress Notes for Resident #23 documented a recent history of UTIs on 4/14/25 and 2/25/25 with a course of antibiotics each occurrence. In an interview on 07/31/2025 at 2:06 pm the Director of Nursing (DON) stated her expectations for the Care Plan to be accurate, reflect health conditions and to include diagnosis of dementia for Resident #5 and UTI for Resident #23 and interventions.The facility provided policy titled Comprehensive Care Plans updated April 2025 documented: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives andtimeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professionalstandards of quality.

Based on record review, observation, staff interview, and policy review, the facility failed to ensure staff appropriately completed a resident assessment and provide timely intervention for two residents. One resident with Lower Extremity (LE) wraps for 1 of 1 resident reviewed for edema (Resident #55) and one resident with Chronic Obstructive Pulmonary Disease (COPD) for 1 of 2 residents reviewed for oxygen (Resident #62). The facility reported a census of 70.Findings include:1. The Quarterly Minimum Data Set (MDS) for resident #55, dated 7/24/25, indicated diagnoses of hypertension, diabetes mellitus, and cerebral vascular accident.The Electronic Health Record (EHR) indicated that resident additional diagnoses of chronic peripheral venous insufficiency, localized edema and lymphedema.The EHR indicated and an active order from the primary physician for Lymphedema wraps to be worn 24 hours a day/seven days a week (24/7) and therapy to change starting 4/7/2025. The EHR also indicated that this order was discontinued 7/31/25 with a new order for compression stocking on in the morning and off at bedtime. May use ace wraps until ordered compression stocking arrive.The EHR lacked documentation of wraps being on or off from discharge from therapy 7/11/25 until 7/29/2025. The EHR also lacks notification of therapy about concerns with wraps being off with active order for wraps 24/7.The Care Plan for Resident #55, initiated on 3/25/25, indicated to follow Medical Doctor (MD) orders for compression wraps. It also indicated on 6/27/25 that Resident #55 is Non-Compliant with lymphedema wear as he removes the wraps on his own. The Care Plan lacks interventions and directions for noncompliance.In an observation 07/28/2025 at 2:36 PM, Resident #55 was noted to have bilateral swollen Lower Extremities (LE). There were 2 signs on the wall in the room, on said keep wraps on for 24 hours and to cover them when he gets his showers. The other sign said to please put ted hose on every morning. No wraps or ted hose noted to bilateral lower extremities. Right foot elevated on stool while left leg resting on the floor.In an observation 07/29/2025 at 10:49 AM, Resident #55 was resting in his chair with cover over his head. Had right foot elevated on stool but left remained on the floor. No wraps or [NAME] Hose were on lower extremities.In an observation 07/29/2025 at 3:34 PM, Resident #55 was sitting in his chair with both legs on the ground and no wraps noted to bilateral LE.In an observation 07/31/2025 at 8:08 AM, Resident #55 was sitting in his chair without wraps to bilateral LE.In an interview 07/29/2025 at 1:00 PM, Staff A, Registered Nurse (RN) stated wraps for Resident #55 done by Staff C, Occupational Therapist (OT) 2-3 times weekly. Sometimes she takes off and leaves off for a while but currently supposed to be on 24/7. Not sure of where documentation is kept about putting on wraps. States Resident #55 takes off sometimes. If he does, they put in the hot chart notes and notify therapy. Did not know where ted hose documentation was kept prior to the wraps. Staff A, RN then checked Resident #55 in the dining room noting lack of wraps. Stated he was going to notify therapy and the DON.In an interview 07/29/2025 at1:23 PM, Staff A, RN stated that OT here Tuesdays and Fridays but has not seen her today. Stated the Director of Nursing (DON) was texting Staff B, OT to see when Staff C, OT will be here next. Added that both can do the wraps.In an interview 07/29/2025 at 3:35 PM, Staff A, RN stated he did not here back from OT or the DON.In an interview 07/30/2025 at 1:00 PM, Staff C, OT stated she discharged Resident #55 on 7/11/25 with recommendation for compression socks 24/7 size 4XLg with 10-30 millimeters of mercury (mmHg). Stated she is no longer wrapping his legs. States she was not contacted on 7/29/25 about wraps not being put on but maybe they talked to the manager. Stated that about 2 weeks ago she saw that he was not wearing his socks and she could not find them. Maybe they were in the laundry. Stated when Resident #55 was getting wraps he would take them off until she educated him and then he kept then off until she discharged him. Stated it is her fault as she did not put in a note to the nursing staff. Stated she could order new compression socks but has concerns that the size would be different now. States would probably readmit and wrap for a while again before going back to compression socks. Stated is aware edema is back up.In an interview 07/30/2025 at 2:00 PM, Staff F, Certified Nurses Aid (CNA) stated she is not aware of the wraps and to speak with Staff C, OT. Stated pocket care plan still says lymphedema wraps and she reports to the nurse when they are not on.In an interview 07/30/2025 at 2:23 PM, Staff A, RN stated that after talking with the DON 7/29/25, he took down the sign about ted hose. When questioned about what the DON stated on 7/29/25 Staff A, RN stated the DON stated she is aware that he is noncompliant but would contact therapy. He stated he was not aware that Resident #55 was discharged from therapy with compression socks. Stated that maybe they didn't get a communication about it.In an interview 07/30/2025 at 2:37 PM, with the DON and Staff G, Regional Corporate Nurse, the DON stated that the process for therapy recommendations is that the nurse and the DON receive a communication from therapy and they get orders for the recommendations. Stated she just found out today from therapy that Resident #55 was discharged from therapy. Staff C, OT spoke with her interview. Plans to get recommendations yet today from Staff C, OT and obtain order. Staff G, Regional Corporate Nurse stated that they are working on hiring a Director of Therapy to help with communications between staff and therapy.In an interview 07/31/2025 at 8:45 AM with the DON and Staff G, Regional Corporate Nurse, the DON stated, concerning conversation 7/30/25, that the expectation of CNAs concerning the wraps being off would be for them to report to the charge nurse. The expectation of the nurse would be to report to therapy and to document in the nursing notes. Stated was not notified 7/29/25 about wraps being off by Staff A, RN. Only found out yesterday from Staff C, OT. Stated spoke with Staff A, RN this morning and aware that wraps remain off. Stated she was about to call the doctor to get an order for wraps or compression socks going forward.2. The 5-day scheduled MDS for resident #62, dated 6/3/25, indicated diagnoses of coronary artery disease, anemia, heart failure, pneumonia, and Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation. The MDS also indicated the resident is not on oxygen.The Care Plan for Resident #62, initiated on 6/9/21, indicated an altered respiratory status related to COPD, anxiety disorder and obesity. It lacked documentation of oxygen use.The EHR indicated and active order for oxygen at 2-4 Liters (L) per Nasal Cannula (NC) that may be titrated to keep oxygen saturations greater than 88 percent dated 5/30/25. It also indicated that this order was discontinued 7/30/25.The Progress Notes indicated that Resident #62 returned from the hospital on 5/30/25 receiving supplement oxygen and referred to the order. On 6/2/25, the Progress Notes also indicated that the oxygen saturation was stable on Room Air (RA). There is no further documentation noted of oxygen use until the order was discontinued on 7/30/25.In the vital signs section of the EHR, oxygen via nasal cannula was on with the oxygen saturation checks on 5/30/25, 5/31/25 and 6/3/25. No further documentation of oxygen use.The EHR lacked respiratory assessment in the progress notes to correspond with the oxygen use on 5/31/25 and 6/3/25.The Electronic Medication Administration Record (EMAR) lacked documentation for oxygen use for 5/30/25, 5/31/25 and 6/3/25.In an observation 07/29/2025 at 9:09 AM, Resident #62 had an oxygen concentrator and oxygen tubing in her room.In an interview 07/29/2025 at 11:03 AM, Resident #62 stated only used oxygen for a short while after getting out of hospital about a month ago. States she does not want it in her room as it takes up too much space. States told a couple nurses about getting rid of it and they told her they would keep it just in case she needs it again. States she thought of moving it into hallway herself but someone might take it and she would be in trouble.In an interview 07/30/2025 at 2:37 PM, with the DON and Staff G, Regional Corporate Nurse, The DON stated that the expectation for oxygen, including as needed oxygen, is for the nurse to document it's use on the EMAR and to do a respiratory assessment. Then she stated she didn't think they had a resident respiratory assessment so it should be in the nurse's notes. Stated it should also be documented on the EMAR. Staff G, Regional Corporate Nurse stated that oxygen was on the care plan and had been resolved but then added that she still does have an active order for as needed oxygen. States they will call the MD and get a discontinue order.An email from the Administrator dated 7/30/25, indicated that there is not an oxygen therapy policy, but physician's orders are followed as well as standards of care.

Based on observations, clinical record review, policy review, and staff interviews, the facility failed to prevent the development and worsening of a facility acquired pressure ulcer for 3 of 3 residents reviewed with pressure ulcers(Residents #1, #3, and #4). The facility reported a census of 75 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. The Annual Minimum Data Set (MDS) assessment tool, dated 8/12/24, listed diagnoses for Resident #1 which included Alzheimer's, non-Alzheimer's dementia, and anxiety. The MDS stated the resident required partial to moderate staff assistance for transfers and to roll left and right. The MDS stated the resident was at risk for developing pressure ulcers but had no unhealed pressure ulcers. The MDS listed her cognition as severely impaired. The facility policy Skin Management Protocol, dated 5/16/23, stated the facility would notify the wound nurse of a new skin alteration or skin ulcer and directed staff to follow wound care guidelines or physician orders. A 10/25/24 at 2:21 p.m. Health Status Note documented the resident had a new open area on her gluteal (pertaining to the buttocks) fold which measured 0.5 centimeters (cm) x 0.3 cm x 0.3 cm (length x width x depth) and stated staff sent an assessment to the physician to review and respond. A 10/25/24 Physician Encounter Note did not mention the resident's new skin area and stated the resident had no lesions or ulcers. An 11/1/24 Nurse Practitioner (NP) Encounter Note stated the resident had an open area to the buttocks, not able to visualize this day, and would request the wound NP to follow. An 11/4/24 Order Note stated the wound NP would see the resident for the area to the buttocks. An 11/5/24 Nurse Practitioner (NP) Wound Treatment Plan stated the resident had a new Stage 3 wound on her sacrum (pertaining to the back wall of the pelvis) which measured 3.0 cm x 1.4 cm x 0.2 cm. The plan directed staff to start wound cleanser to the sacrum, cover with foam border dressing, and change 3 times per week and as needed(prn). The plan directed staff to obtain and Equagel cushion (a cushion containing gel used to reduce pressure) or equivalent for her wheelchair. The facility lacked a treatment order prior to 11/5/24. An 11/10/24 Care Plan entry stated the resident had a Stage 3 sacral ulcer and directed staff to carry out treatments as ordered. An 11/19/24 Skin/Wound Note stated the resident continued with an open area to the top of the coccyx. The area had a strong odor with drainage noted. An 11/19/24 NP Wound Treatment Plan stated the resident's wound measured 3.3 cm x 2.0 cm x 0.5 cm and listed the wound status as deteriorated. The plan stated staff noted an odor yesterday. The plan directed staff to discontinue the current treatment and start to cleanse with quarter strength Dakins' (a diluted bleach solution used to treat and prevent infections in wounds) solution, Flagyl (used to treat infections) sprinkles (crushed Flagyl tablets sprinkled on wounds to treat infections and odors into the wound bed), apply calcium alginate (absorbent wound dressings made from alginate, a natural product extracted from seaweed) over the Flagyl, and cover with silicone super absorbent dressing, and change daily and prn. The plan directed staff to place an Equagel cushion or equivalent in her wheelchair. The October and November 2024 Treatment Administration Records (TARS) listed a 10/24/19 order for house barrier to the coccyx for prevention. The TARS lacked an additional treatment carried out from the discovery of the wound on 10/25/24 until 11/19/24. The TARS lacked documentation of implementation of the 11/5/24 order for the foam border dressing and lacked documentation the 11/19/24 order for Dakins', Flagyl, and calcium alginate was completed on 11/20/24 and 11/21/24. The TARS lacked documentation of an Equagel cushion implemented prior to 11/19/24. An 11/19/24 Order Note stated the Flagyl and calcium alginate were unavailable. An 11/20/24 Health Status Note stated the Flagyl and calcium alginate were not available for the treatment at this time and the wound had a mild odor. An 11/21/24 Skin/Wound Note stated the facility waited for the pharmacy to deliver wound supplies. A Care Plan entry, initiated 12/30/24, stated the resident had an Equagel cushion in her wheelchair. On 2/27/25 at 8:51 a.m., the Director of Nursing (DON) stated she was unable to find anything additional regarding treatments for Resident #1 (prior to 11/22/24). She stated the first time the resident saw the wound nurse was 11/5/24. 2. The Quarterly MDS assessment tool, dated 11/11/24, listed diagnoses for Resident #3 which included pressure ulcer to the sacral region, dementia, and depression. The MDS stated the resident was at risk for developing pressure ulcers but had no unhealed pressure ulcers. The MDS listed her BIMS score as 7 out of 15, which indicated severely impaired cognition. An 11/6/24 Care Plan entry stated the resident had a Stage 3 ulcer to the right buttock and directed staff to complete treatments as ordered. A 12/3/24 Wound Treatment Plan stated the resident had a foam cushion in her recliner with a chuck (disposable pad) over it. The plan stated the resident's Stage 3 pressure ulcer of the right buttock was healed and directed staff to obtain a roho (a cushion which is constructed of air filled cells) or Equagel (gel cushion) for her chair and to not utilize a foam cushion or a small pillow. Ulcer Skin Assessments stated the resident had a Stage 3 pressure ulcer to the right buttock, first observed 12/10/24. The assessments included the following measurements: 12/10/24 1.0 x 2.5 x 0.3 12/17/24 0.8 x 2.3 x 0.3 12/24/24 0.7 x 2.2 x 0.3 12/31/24 0.6 x 2.1 x 0.3 1/7/25 0.5 x 2.5 x 0.3 1/14/25 2.5 x 0.8 x 0.3 A 12/13/24 Skin/Wound Note stated the resident had an open area to the right gluteal fold. A 1/21/25 Wound Treatment Plan stated the resident had a completely flat foam cushion in her chair and directed staff to obtain an Equagel cushion for her chair. The plan stated the resident had a new Stage 3 pressure ulcer to the right buttock which measured 1.9 x 0.6 x 0.3. A 2/4/25 Wound Treatment Plan stated the resident had an Equagel in her recliner. On 2/27/25 at 11:00 a.m. Staff F Quality Assurance (QA) Nurse measured a red open wound on the resident's right buttock as 2.0 x 0.5 x 0.3. On 3/3/25 at 8:45 a.m., the DON stated Resident #3 had a gel cushion for a long period of time but thought staff moved it out of her recliner into the wheelchair. She stated the facility discussed getting two cushions. 3. The Quarterly MDS assessment tool, dated 2/3/25, listed diagnoses for Resident #4 which included Stage 3 pressure ulcer of the sacral region, Alzheimer's disease, and depression. The assessment stated the resident was at risk for developing pressure ulcers but had no unhealed pressure ulcers. The MDS listed her cognition as severely impaired. A 2/11/25 Wound Treatment Plan stated the resident had a new Stage 3 pressure ulcer to the left gluteal cleft(referring to a part of the buttocks) which measured 1.9 cm x 2.0 cm x 0.2 cm. The plan directed staff to start cleansing with wound cleanser and cover with a border dressing. The February 2025 TAR listed a 2/18/25 order for the left gluteal fold: cleanse with wound cleanser, cover with foam border dressing, change three times per week and prn. The TAR lacked documentation of a treatment started prior to 2/18/25. A 2/11/25 Care Plan entry stated the resident had a Stage 3 pressure ulcer to the left gluteal cleft. Observation on 2/27/25 at 1:45 p.m. revealed the resident lying on back in bed. On 3/3/25 at 3:43 p.m. via email, the DON stated she did not have any further documentation related to the completion of a dressing between 2/11/25 and 2/18/25. On 2/26/25 at 11:44 a.m., Staff A, wound NP stated usually they implemented some type of dressing to a new open area within 12-24 hours. She stated if the facility discovered a new open area, she assumed they addressed it with someone. On 2/26/25 at 2:29 a.m., the DON stated if they discovered a new open area she would want a treatment started by the next shift. She stated she was not sure about which treatments she was on but would check into it. On 3/3/25 at 8:45 a.m., the DON state she would want the wound NP's recommendations carried out.

Based on clinical record review, policy review, and staff interviews, the facility failed to ensure staff were handling laundry carts in a safe manner and in accordance with facility policy. This failure resulted in a resident (Resident #56) being bumped with the cart, falling and breaking a hip and arm. The facility reported a census of 71 residents. Findings include: Resident #56's Minimum Data Set (MDS) dated [DATE] documented an admitted [DATE]. The MDS documented a Brief Interview for Mental Status (BIMS) of 4 indicating severe cognitive impairment. The MDS documented diagnosis included vascular dementia. Review of the Progress Note dated 5/6/23, the nurse was sitting at the nurse's station at 2:05 PM and heard a resident cry out for help. The note documented the nurse found the resident on the floor on her right side. The laundry cart and Staff F, Laundry Aide, next to the resident. The note explained Staff F did not see the resident and bumped her with the laundry cart. After an assessment, staff attempted to assist Resident #56 to stand. The resident buckled and said owe and was immediately laid back down. The resident was transferred to the Emergency Department (ED) at 2:20 PM. The untitled facility form completed on 5/6/23 at 2:42 PM documented the resident was ambulatory without assistance. The Progress Note written on 5/6/23 at 5:17 PM documented the nurse called the ED and was informed the resident had a broken hip and would be admitted to the hospital for repair. The Progress Note written on 5/9/23 at 12:18 PM documented the resident would be returning to the facility on this date via ambulance. The Progress Note written on 5/11/23 at 1:53 PM documented the resident was complaining of pain in her right shoulder with therapy. The Primary Care Provider (PCP) and daughter were made aware of concerns. The Progress Note written on 5/12/23 at 8:17 AM documented mobile x-ray services was in the facility and obtained right shoulder x-rays. The Progress Note written on 5/12/23 at 1:18 PM documented a minimally displaced longitudinal fracture along the lateral margin of the humorous (broken upper arm). The PCP and family were notified. The facility Medical Director completed and signed the Major Injury Determination Form on 5/8/23 at 10:00 AM. He determined the injury sustained was not a major injury. The PCP Progress Note written on 5/12/23 documented the resident as bed bound. The PCP Progress Note written on 6/13/23 documented the resident as wheelchair bound. The facility document Detailed Explanation of Non-Coverage dated 6/8/23 documented the resident had met her max potential and would be discharged from therapy. The undated facility policy titled Laundry Cart and Laundry Barrel Usage Policy directed staff to pull the laundry cart when in resident areas due to the size and shape of the carts. During an interview on 6/14/23 at 1:12 PM Staff F explained she was delivering clothes. She was pushing the laundry cart close to the wall so she could see around it to see any residents in the hall. She explained the hall was clear. Resident #56 came out of a room she was visiting. Staff F did not see her and bumped her with the cart. During an interview on 6/15/23 at 11:05 AM [NAME] President (VP) of Operations explained after the incident the cart was lowered 13 inches. She explained it was lowered as a safeguard to prevent further incidents. She further explained there is a policy that states carts are to be pulled, but the carts were lowered just in case they were being pushed. During an interview on 6/15/23 at 11:05 AM (the same time as the VP of Operations) the Director of Nursing stated after the incident Staff F was suspended for 3 day to allow time for a thorough investigation. She explained that through the investigation process Staff F was not found to be negligent or at fault. When questioned about the policy not being followed she stated There was no intent to cause harm.

Based on observation, clinical record and facility policy review, and staff and resident interviews, the facility failed to ensure employees followed the fire emergency policy on 12/03/22, when smoke and the smell of melting plastic was discovered in Resident #8's room. Staff determined the smoke and odor emitted from an electrical outlet near the bed in which a wall heater was plugged, but failed to move the resident out of danger. Staff removed the plug from the live outlet while the resident remained in the room. Although the outlet sparked, staff still did not remove Resident #8 from the room or activate the fire alarm system, which potentially exposed additional residents to the hazard. This situation constituted an Immediate Jeopardy to resident health and safety. The facility also failed to provide adequate nursing supervision and assistance devices to prevent accidents for 1 of 5 residents reviewed when staff transferred Resident #2 from the floor to a standing position without a gait belt after a witnessed fall on 8/29/22. The facility reported a census of 59 residents. Findings include: 1. The MDS dated [DATE] documented Resident #8 scored 15 of 15 possible points on the Brief Interview for Mental Status (BIMS) test which indicated the resident experienced intact cognitive abilities. The MDS revealed Resident #8 remained totally dependent on two staff for transfers and 1 staff for locomotion on the unit. The MDS listed diagnoses that included a stroke (cerebrovascular accident, or CVA) with hemiplegia. Observation on 12/5/22 at 2:00 p.m. revealed Resident #8 was in a low bed, with a fall mat located on the floor with the wall heater on and functioning. Resident #8 reported that on 12/3/22, Staff I, CNA had brought her back to her room after breakfast and noticed smoke and an awful smell like burning plastic. The staff person unplugged the heater and then she helped her leave the room because of the smell. Stated staff had used a fan to eliminate the smell. The resident informed that she chose to stay in her room, aware there would not be any heat. Maintenance had been waiting on a part and fixed this morning. Stated she was glad that staff were there with her, commenting that it would have been really bad if this had happened when she was alone because she can't get out of bed or walk on her own. In an interview on 12/5/22 at 3:15 p.m. Staff I, CNA stated on 12/3/22 at approximately 8:30-9:00 a.m. she assisted Resident #8 to return to her room (#321) via wheelchair. Staff I reported that when they entered the room, she smelled something burning and determined that the smell and a small amount of smoke came from the outlet near the resident's bed in which the wall heater was plugged. She said she then immediately unplugged the wall heater and recalled the outlet sparked when she removed the plug while Resident #8 remained in the room, so she assisted the resident to the TV room and alerted Staff J, Licensed Practical Nurse, (LPN). The nurse directed her to unplug all the other heaters in the hall. Staff I confirmed she had not removed the resident from the area, pulled the fire alarm, or dialed 911, but added there have been other problems with outlets in the 300 hall when the outlets weren't working properly. Staff I confirmed that she has participated in fire drills and identified the steps to take: rescue, pull alarm, close door, and confine. In an interview on 12/5/22 at 3:02 p.m. Staff J, LPN revealed on 12/3/22 shortly after breakfast Staff I, CNA informed him that there was smoke and an electrical melting smell in room [ROOM NUMBER]. Staff I further reported that she had unplugged the wall heater and found that the outlet was black and melted. Staff J went to the room and confirmed the black and melted outlet. He could not recall noting any smoke when he got there, only the smell of melting plastic and verified the smoke alarm had not sounded. He reported he then called the Administrator who told him to get in touch with the Maintenance Assistant and gave no further direction. Staff J said he had worked at the facility for a month, and was not aware of the exact protocols to take in the case of an electrical fire, and added he has had problems with some breakers and outlets not working at the end of the 300 hall. In an interview on 12/5/22 at 2:15 p.m. the Maintenance Assistant confirmed the Administrator had texted him on 12/3/22 at 9:30 a.m., and needed him to check the outlet. Staff informed him the outlet was smoking, and the breaker hadn't tripped. The Maintenance Assistant stated he would have expected the breaker to trip which would have cut off the power. He reported he turned off the breaker when he arrived and went to room [ROOM NUMBER], where he had smelled burning plastic. The Maintenance Assistant said he had replaced the outlet and removed the plug for the heater and then demonstrated where he had tripped the breaker at the panel. He also identified the outlet and cord plug he had replaced. Review of digital photos of the outlet and the heater plug revealed an outlet with black at the contact openings. The plastic appeared melted, bubbled, and burnt. In an interview on 12/13/22 at 2:40 p.m. the Administrator confirmed she would expect staff to follow facility policy in the event of a fire. Reviewed the policy and confirmed the first step would be to move the resident away from danger, and then pull the fire alarm or call 911. Monthly fire drills were provided and reviewed. Drills are completed by activating the fire alarm and staff are expected to respond, locate the fire, and carry out fire protocols. The Administrator confirmed that staff are not required during the drill to activate the fire alarm, because the alarm has already been activated to start the drill. The Administrator confirmed that the resident remained in the room when staff unplugged the heater which caused a small spark, and the fire alarm had not been pulled. Review of the Fire Emergency facility policy with no date included the following: Fire alarms are located in strategic places throughout the build. Each facility employee must know how to operate the alarm system. If a fire occurs, take the following steps as quickly as possible: 1. Rescue anyone in immediate danger. If possible, pull the nearest fire alarm. 2. Alert and Activate-pull the fire alarm and alert the charge nurse. The charge nurse will call the Fire Department-911. 3. Confine the fire 4. Extinguish the fire. The facility was notified of the Immediate Jeopardy (IJ) on 12/5/22. The facility provided information to show that the IJ was removed on 12/6/22 when the facility took the following actions: a. Completed fire rounds in the 300 hall every 15 minutes. b. Ensured a professional electrician inspected the electrical outlet and panel in the 300 hall and deemed it safe. c. Provided the following education to all staff: a. F689: Environment Free of Hazards - facility was found to have failed to provide an environment free of hazards related to a fire emergency. Electrical malfunctions such as melted plugs/cords have the potential to result in serious adverse outcomes, including injury and/or death. If you smell, see, or in any way observe areas that are potentially at risk of fire (smoke, melted wires/plugs, sparks, visible burn marks, buzzing or popping sounds, hot to the touch) this is an emergency and should be treated accordingly - follow directions in the Emergency Manual. If you notice ANY concerns regarding fire or electricity you must first intervene to protect any residents in the immediate area - remove the resident from a potentially harmful situation. Once the resident is moved to a safe area, and the Emergency Protocol is initiated, you must then notify the facility Administrator The scope and severity was lowered from a K to an E after the Immediate Jeopardy was removed. 2. The Minimum Data Set (MDS) assessment with a reference date of 8/1/22 for Resident #2 identified severely impaired cognitive skills for decision making. The MDS further revealed the resident required the limited assistance of one staff for transfers, and physical behaviors directed towards others and other behavioral symptoms such as pacing, screaming, and other disruptive behaviors. The MDS identified balance during moving from a seated to a standing position, and surface to surface transfer as not steady, and only able to stabilize with staff assistance. The resident had diagnosis that included Non-Alzheimer's dementia, anxiety, and depression. The MDS reported no previous falls. A witnessed fall report initiated on 8/29/22 at 6:05 p.m. by Staff A, Licensed Practical Nurse (LPN) documented that Resident #2 had sustained a witnessed fall. Staff A's description of the incident included: upon entering the unit Staff E, Certified Nursing Assistant (CNA) informed that the resident had fallen and sustained a skin tear to her elbow. Resident was up and walking in the hallway with a visible skin tear to her elbow. Staff A questioned how resident had gotten off of the floor, Staff E responded that they knew they should have gotten vital signs, but they had just gotten her up. Staff A instructed should never move a fallen resident without the nurse first assessing in case of possible injury. The incident report failed to provide any further information regarding assessment of injury or treatment. In an interview on 12/7/22 at 10:28 p.m. Staff E, Certified Nursing Assistant (CNA), stated that she had witnessed Resident #2 fall. Staff E recalled that she hollered for assistance and Staff H, CNA had responded. Staff E admitted that they had not waited for a nurse to arrive and assess the resident and had assisted her to stand. Staff E responded that they had failed to use a gait belt to assist to stand. Staff E stated that she was aware that she should have waited for the nurse to assess before assisting to stand and should have used a gait belt. In an interview on 11/30/22 at 1:16 p.m. Staff H, CNA confirmed that she had responded to Staff E yelling for help in the hallway. Resident #2 was on the floor when she arrived. Staff H questioned if the fall had been reported, Staff E responded she had not. Staff H stated that she advised needed to wait for the nurse to assess before getting the resident up. Staff H reported that Staff E lifted the resident up under her arms, confirmed a gait belt was not utilized for the transfer. Staff H confirmed that a gait belt was available for use on the unit. In an interview on 11/30/22 at 12:40 p.m., the Director of Nursing stated that she would expect staff to notify the nurse immediately of a fall and not move the resident until the nurse had completed an assessment for injuries and given direction to move resident. Would not have expected to lift resident from the floor without the use of a gait belt. A facility document titled Gait Belt directed the indication for use of a gait belt was any patient whose coordination and balance are unpredictable when transferring and walking.

Based on observation, clinical record review, and staff interviews, the facility failed to ensure staff provided adequate nursing supervision and assistive devices to prevent accidents for 2 of 4 residents reviewed (Residents #45 and #158). On 11/19/20 at 4:40 p.m., Staff A left Resident #45 in bed unattended and without a fall mat and body pillow as directed by the Care Plan. As a result, the resident fell from her bed to the floor and sustained a [CONDITION(S)] and a laceration to her head. The facility identified a census of 52 residents at the time of this investigation. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 10/13/20, Resident #45 had diagnoses that included Alzheimer's disease, atherosclerosis, depression, hypertension, and contractures. The MDS documented the resident displayed severe cognitive and memory impairment and could not understand or be understood by others. The MDS documented Resident #45 required assist of 2 staff with bed mobility, transfers, dressing, and personal hygiene, and did not walk during the assessment timeframe. The MDS documented no history of falls during the MDS look back period. A Morse Fall Risk Assessment Form dated 9/13/19 documented a score of 55 which placed her at a high risk for falls. The resident's undated Care Plan documented the resident experienced an activities of daily living (ADL's) self-care performance deficit related to (r/t) diagnosis of Alzheimer's disease, hypertension, depression, and [CONDITION(S)]. The Care Plan directed the following interventions or actions: a. Apply air loss mattress to bed b. Ensure the proper positioning of the resident's lower extremities when in w/c by applying hip abductor pillow, straightening the hips, and lowering leg rests with pillows folded under calves to float heels. c. Transfer the resident with assist of 2 staff and the Hoyer Lift. d. Staff to propel and utilize the resident's wheelchair for locomotion. e. Place knee support pillow between knees in bed and when up in w/c, and may use strap on pillow around the resident's leg if needed. Monitor the inside of the resident's thighs/knees for redness. f. The resident requires assist of 2 staff for bed mobility. On 11/20/20, the facility submitted a timely report to the Iowa Department of Inspections and Appeals as required that documented on 11/19/20, Resident #45 fell from the bed to the floor and sustained a head laceration and [CONDITION(S)] as a result. An Incident Report form dated 11/19/19 at 4:40 p.m. documented dietary staff told the nurse they found the resident on the floor. When the nurse entered the room they saw the resident lying on her right side on the floor with blood under their head and facing the bed. The nurse completed an assessment including vital signs, cleansed the laceration to the resident's right brow cleansed with normal saline and applied ice. The resident was unable to follow commands and indicate or describe pain. Staff ensured the resident remained on the floor until 911 arrived and placed a pillow under the residents head and covered the resident with a blanket with assistance from the Director of Nursing (DON) and an additional floor nurse. During an interview on 11/20/20 at 11:48 a.m. Staff A, CNA, (Certified Nursing Assistant) stated she entered the resident's room to assist Resident #45 out of bed for dinner. Staff A reported she raised the bed and, in the midst of providing cares, another CNA urgently required her assistance. She verified she did not lower the bed at that time and did not see a side rail to raise. Staff A said she thought the body pillow and fall mat were only used on night shift. She said believed interventions were on the pocket care plans, but she had not checked it prior to providing care for Resident #45. Staff A stated when she left the room, Resident #45 lay flat in bed and close to the wall with the bed in a raised position and no body pillow in place. She added she did not know Resident #45 would roll out of bed and was shocked when the administrator informed her of the resident's fall. During an interview on 11/20/20 at 2:52 pm, Staff B, the previous DON, stated the facility had placed care guides on the back of every resident's door. She said Resident #45 had rolled out of bed prior to the event on 11/19/19, and the facility added the directive to staff to lower the bed and replace the fall mat when Resident #45 was in bed to the care guide at that time. Staff B stated Staff A confirmed she had not read the care guide prior to providing cares for the resident. During an interview on 11/20/20 at 3:30 p.m., Staff C, the previous Administrator, stated she remembered the incident. Staff C said other staff had reported Staff A had been in the dining room when Resident #45 fell out of bed. Staff C added that signage was posted on the walls at the time of the fall that directed staff to place the pillow on the bed and put the bed in the low position, so Staff A should not have left Resident #45 unattended and in that position. 2. According to the Minimum Data Set (MDS) assessment tool dated 9/29/20, Resident #158 had diagnoses of Alzheimer's disease, [CONDITION(S)] (stroke) and coronary artery disease (CAD). The MDS revealed the resident scored 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) test, which meant the resident demonstrated severely impaired cognition. The MDS documented Resident #158 required extensive assistance of 1 staff for transfers, walking in his room, and toilet use. The Care Plan revised on 9/27/20 revealed Resident #158 was at risk for falls and instructed staff to follow the facility fall protocol. Review of transfers which included how Resident #158 moved between surfaces from 11/6/20-11/18/20 indicated Resident #158 required extensive assistance to complete dependence on staff for transfers during that time period. During an observation on 11/10/20 at 1:00 PM, after Resident #158 was given a shower in a shower chair, Staff D, Licensed Practical Nurse (LPN) and Staff E, Certified Nurse Aide (CNA) transferred Resident #158 without the use of a gait belt from a shower chair to a wheelchair. The facility policy titled Gait Belts (for use in ambulation and transfer), indicated gait belts should be used by all staff to allow for easier handling of resident which should help to avoid injuries both to residents and staff. The policy further indicated each staff will member will have a gait belt readily available for use when on duty. Procedures included apply the belt around the resident's waist, bringing the resident to a standing position by grasping the belt with both hands and if the resident begins to lose their balance, ease him/her down with your hold on the gait belt as this protects you and the resident from head or body injury. On 11/19/20 at 3:51 PM, the Administrator revealed if a resident requires assistance with transferring then the staff is required to use a gait belt during the transfer. On 11/23/20 at 12:44 PM, the Director of Nursing (DON) revealed there is not a facility fall policy in place.

Based on clinical record review, observation, staff interview, and facility record review, the facility failed to provide adequate nursing supervision to prevent hazards from self or others for 1 of 4 residents reviewed for adequate nursing supervision (Resident #1). The facility failed to ensure all staff were aware of a cognitively impaired resident's risk and history of putting non-food/foreign objects in his mouth, and failed to remove all potential choking hazards from the CCDI (Chronic Confusion and Dementing Illness) unit where the resident resided. On 2/6/20, a dentist found foreign material (cotton ball or toilet paper) wrapped around the resident's tooth; on 2/18/20 staff found a golf ball-sized wad of toilet paper in the resident's mouth; and on 3/20/20 staff found puzzle pieces in the resident's mouth, but were able to instruct him to spit them all out at that time. On 3/24/20 the resident ingested an entire puzzle and required transport to the hospital for evaluation and removal of additional puzzle pieces under anesthesia. These events resulted in an immediate jeopardy to the resident's health and safety. The facility reported a census of 63 residents. Findings include: The annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 identified a Brief Interview for Mental Status (BIMS) score of 3 (without signs/symptoms of [MEDICAL CONDITION]). A score of 3 indicated severe cognitive impairment. The MDS revealed the resident required supervision with assist of 1 staff for transfers, walking in the room, and locomotion on the unit. The resident remained independent with ambulation (walking) in the corridor and required supervision with set-up help only for eating. The MDS documented [DIAGNOSES REDACTED]. The Wandering Risk Scale assessment for Resident #1 completed 3/18/20 identified a score of 14.0, which categorized the resident as someone at high risk for wandering. The Oral Health Assessment for Resident #1 completed on 3/18/20 identified problems with swallowing. The care plan focus area revised 2/26/19 identified an ADL (Activities of Daily Living) self-care deficit. The interventions informed staff the resident transferred and ambulated independently throughout the CCDI unit with cuing needed if lost, and needed reminders to take a step. The interventions also informed staff the resident remained independent with staff set-up help for eating and directed to cue the resident to eat slowly. The care plan focus area revised 7/2/19 identified a potential nutritional problem. The interventions included a diet of pureed texture with thickened liquids and staff to monitor/document/report as needed any signs/symptoms of dysphagia (pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, or appearance of concern during meals). The care plan focus area revised 10/8/19 identified a communication deficit with unclear speech and revealed the resident sometimes understood. The care plan identified impaired cognitive function with impaired thought processes related to a [DIAGNOSES REDACTED]. The care plan focus area revised 12/20/19 identified a risk for activity deficit. The interventions lacked updates related to the resident's risk of putting puzzle pieces into his mouth or the need to keep puzzles in a locked area. The care plan focus area revised 1/6/20 identified an elopement risk as the resident wandered and paced the hallway going into other residents' rooms and turning on televisions. The care plan documented the resident had a history of [REDACTED]. The care plan focus area initiated 1/24/19 identified a behavior deficit related to compulsive, OCD-type behaviors. The care plan revisions included the following documentation: a. 1/24/19 - the resident had history of eating hand sanitizer, toothpaste, and hand soap. b. 2/18/20 - same information related to history of eating hand sanitizer, toothpaste, and hand soap. c. 3/23/20 - the revision included behavior of putting non-food items in his mouth. d. 3/26/20 - the revision identified the resident put non-food items/foreign objects in his mouth. The interventions were updated to include staff to monitor the resident throughout the day to check for foreign objects in his mouth and to redirect/encourage him not to put items into his mouth. The Dental Care visit notes dated 2/6/20 documented the patient pocketed some sort of cotton like material in his mouth and it was discussed with his nurse. The Physician Fax communication form dated 2/6/20 documented the dentist reported he found a pocketed foreign object approximately the size of a grape in the resident's mouth which looked like toilet paper or cotton. The form recorded an order: okay to check the resident's mouth every 2 hours and between meals as a nursing intervention to monitor for pocketing. The Medication Review Report dated 4/8/20 listed orders for: a. CCDI level of care active 8/28/18 b. General diet, pureed texture, nectar thick consistency for dysphagia (difficulty swallowing) active 10/3/19. c. Okay to send to ER (emergency room ) to evaluate and treat 3/24/20. The Progress Notes included the following entries: a. On 2/6/20 at 12:48 p.m. the dentist examined the resident and reported he found foreign objects pocketed in the resident's mouth of cotton, toilet paper, and/or another foreign material wedged in his cheek wrapped around a tooth. Staff initiated a nursing intervention to check the resident's mouth after every meal, every 2 hours, and when brushing teeth. The entry noted the resident at risk for choking and on thickened liquids with a pureed diet. b. On 2/18/20 at 9:18 a.m. staff found a golf ball sized piece of toilet paper in the resident's mouth that morning when getting the resident out of bed prior to breakfast. The entry noted the resident did not choke and the CNA (Certified Nurse Aide) removed the toilet paper from his mouth. The nurse removed all toilet paper and paper towels from the resident's room. The nurse placed the information on the 24 hour report sheet used by the nurses to communicate issues to monitor closely) and notified staff to no longer keep paper products in the resident's room. c. Entries from 2/19/20 thru 3/19/20 contained daily documentation of monitoring for items in the mouth except for 2/25/20 and 3/11/20 with nothing found. d. On 3/20/20 at 4:12 p.m. Staff C, Licensed Practical Nurse (LPN), wrote the resident noted with several pieces of puzzle in his mouth that morning after breakfast, but he spit them out when asked. The entry contained no other details of the incident. e. Entries from 3/21/20 thru 3/23/20 contained daily documentation of monitoring for items in the mouth with nothing found. The entries contained no follow up assessments related to the resident having puzzle pieces in his mouth on 3/20/20. f. On 3/24/20 at 1:34 p.m. Staff A, LPN from temporary staffing agency, wrote the resident was in the activity room when she went in to give medications and found puzzle pieces in his mouth. Staff A pulled out the puzzle pieces and discovered some stuck in the resident's throat. Other nurses and CNAs assisted and stayed with the resident until the ambulance arrived. g. On 3/24/20 at 1:42 p.m. the Assistant Director of Nursing (ADON) wrote she was called to the CCDI unit to help the charge nurse due to the resident eating puzzle pieces. The resident sat at a table in the TV room with mucus coming out of his nose and mouth. The charge nurse and ADON attempted to remove puzzle pieces from the resident's mouth with very large amount of pieces removed. Instruction given to the resident to cough but he did not and he gagged multiple times with audible wheezing heard. The nurse documented vital signs of temperature 97.6 degrees, 18 respirations per minute, 114 heart rate per minute (mayo clinic defines normal resting heart rate tat 60 to 100 beats per minute), and blood pressure of 149/86 (a top number above 120 indicated elevated blood pressure). The ADON directed the charge nurse to call 911 while she stayed with the resident until EMTs (Emergency Medical Technicians) arrived. h. On 3/24/20 at 3:58 p.m. the ER report described the resident as calm and waiting for GI (Gastrointestinal consult) to evaluate the resident. The resident was still gurgling at that time with a clear airway. i. On 3/24/20 at 6:29 p.m. the ER documented resident to be kept overnight for monitoring as they were unable to get all puzzle pieces out, the resident wheezed and gurgled, and they were waiting for the puzzle pieces to pass. j. On 3/24/20 at 6:46 p.m. the ER reported the resident went to surgery to retrieve the puzzle pieces lodged in the resident's esophagus. k. On 3/26/20 at 6:45 a.m. the hospital reported 4 puzzle pieces retrieved from the resident's esophagus during surgery, and the resident would have a repeat chest x-ray later that day as the x-ray the day before confirmed possible other pieces still in the resident's esophagus. The resident ran a low grade temperature of 100.3 degrees, and struggled to swallow; he needed a swallow study prior to being able to return to the facility. l. On 3/27/20 at 9:50 a.m. the hospital doctor reported the resident failed the swallow study. m. On 3/27/20 at 4:23 p.m. the resident arrived back at the facility from the hospital. n. Entries from 3/29/20 thru 4/9/20 contained daily documentation of monitoring for items in the mouth except for 4/5/20 with nothing found. o. On 4/10/20 at 8:31 a.m. an evaluation requested in regard to the resident's behaviors of consuming foreign objects and pocketing food in cheeks. The hospital ED Nursing Record dated 3/24/20 at 2:06 p.m. documented a triage note the resident took a handful of puzzle pieces, swallowed them, and was drooling with audible wheezes present. At 2:25 p.m. hospital staff assessed the presence of a productive, spontaneous cough with lung sounds of rhonchi (continuous low pitched, rattling sound that often resembles snoring; obstruction or secretions in larger airways frequent causes) and stridor (abnormal, high-pitched, musical breathing sound; caused by a blockage or narrowing in the upper airways). At 2:36 p.m. the ED physician documented the resident spit up another large puzzle piece on arrival and inspection revealed it to be cardboard-paper. At 6:11 p.m. the hospital record documented attempts made to give the resident water to drink in order to assess puzzle pieces. The resident had a gargle in his throat when talking and drooling of water at times after swallowing. The hospital Consult report dated 3/25/20 at 7:13 a.m. documented the resident vomited some of the puzzle pieces in the ED and overnight on the floor. The hospital Operative Report dated 3/25/20 at 6:20 p.m. documented an EGD (Esophagogastroduodenoscopy) (a procedure that [MEDICATION NAME] the esophagus, stomach and first portion of the small intestine using a long flexible tube with a camera) completed under general anesthesia due to foreign body ingestion with dysphagia, inability to tolerate secretions, and drooling. The endoscope removed 4 pieces of cardboard puzzle from the oral cavity. The hospital Progress Notes dated 3/27/20 at 8:19 a.m. documented the resident had some ongoing fevers and [MEDICAL CONDITION](increased heart rate) and would be monitored for aspiration pneumonia (lung infection which occurs after inhaling something into the lungs). The hospital Surgical Pathology Final Report dated 3/27/20 at 3:56 p.m. documented a [DIAGNOSES REDACTED]. The Gross Description documented the foreign body extraction consisted of multiple pieces of gray cardboard consistent with pieces of puzzle, measured at 8 by 8 by 0.5 cm (centimeters) in aggregate. Facility Investigation Staff A, LPN, witness statement signed 3/26/20 included the following: Staff A signed for the medications at 11:30 a.m. and went to give medications when Resident #1 refused to take them at that time. Staff A placed medication in the top of the locked nurse's cart to attempt again later. The last time Staff A saw Resident #1 was when she passed food trays and he ate his lunch in the activity room with Staff B, CNA, at 12:30 p.m. Staff A attempted to five the meds around 1:00 p.m. when she found Resident #1 with puzzle pieces inside his mouth. Staff A called for CNAs help and destroyed medications. After no success, Staff A instructed CNA to go find another nurse for help. The ADON witness statement signed without a date included the following: The ADON was at the east nurses station when Staff B approached her from the cottage (CCDI unit) and said the cottage nurse needed assistance because Resident #1 ate puzzle pieces. Upon entering the activity room in the cottage, the resident sat at the table. Staff A stood next to him attempting to remove puzzle pieces from his mouth. The ADON applied gloves and attempted to assist Staff A. Resident #1 noted had an excessive amount of saliva coming from his mouth she instructed him to spit out the puzzle pieces at that time. Resident #1's cognitive deficits made him unable to follow instructions at that time. The ADON asked the resident to open his mouth, but the resident clenched teeth and began to have audible wheezing. The ADON instructed Staff A to call 911 while the ADON stayed with the resident until EMTs arrived. Review of signed interview notes dated 3/26/20 at 12:15 p.m. revealed Staff B, CNA, last saw the resident at 12:30 p.m. when she returned from break and sat with him during lunch. Staff B could not recall how long the resident normally took to eat lunch. The signed, undated statement written by the Admissions and Marketing Coordinator (AMC), included the following: On 3/25/20 the ADON and AMC walked through the CCDI activity room and found several puzzles in unlocked cabinets and on the table. All puzzles removed from the cottage and given to the Activity Director. Several locked activity cupboards contained games and items smaller than fist sized such as checkers, dice, and additional puzzles. Those items also removed from the cottage and given to the Activity Director. An activity list posted in the CCDI activity room which listed activities that included items of inappropriate size. The list removed and a new policy for size requirements for activities posted. The facility policy titled CCDI Activities implemented 03/2020 included the following with 16 staff signatures: Purpose - To ensure the safety of our residents in the CCDI unit. Procedure - There will be no activities in the CCDI unit that are smaller than an adult fist. If there is an activity to be done that has pieces smaller than an adult fist, it will be locked up away from residents for their safety. Such activities can only be used while in the presence of a staff member. When an activity completed, the activity will be placed back behind a locked door. Staff Interviews On 4/9/20 at 6:38 p.m. Staff C, LPN, reported she started working at the facility a year prior. Staff C confirmed she worked as the charge nurse on the CCDI unit on 3/20/20. Staff C recalled her progress note for that day and documenting she found puzzle pieces in Resident #1's mouth. Staff C stated Resident #1 sat in the TV room after lunch when she found a few pieces of puzzle in his mouth. Staff C reported the resident able to follow command to spit them out but he couldn't get 1 piece past his teeth. Staff C responded prior to that incident, she was never made aware of or received education from the facility about the resident's behavior of ingesting non-food items. Staff C stated she knew they had to sit with Resident #1 when he ate as she heard he would shovel food in his mouth. Staff C responded she was not aware of the 2/6/20 incident of the dentist finding cotton in the resident's mouth or the 2/18/20 incident of the resident having toilet paper in his mouth. Staff C commented she felt if she had known then she would have put the resident on more frequent charting, 24 hour report, or incident report. Staff C voiced at the time she didn't think 2 or 3 pieces of the puzzle a big deal because it was an adult puzzle so the pieces were small: she had seen piece sticking out. Staff C responded she did not tell Staff E, LPN, of the incident during end of shift report 3/20/20. Staff C responded she didn't receive any education after 3/24/20 incident, and just found out through word of mouth that the resident went to the hospital for ingesting puzzle pieces that day. Staff C commented no education happening and the communication was not good. Staff C said communication consisted of whatever the nurse relieving her told her to follow-up on. Staff C reported no one was very good about looking at the care plans, but a snapshot for personal cares was mounted on the bathroom doors. Staff C stated Resident #1 stayed where staff put him and rarely got up on his own. On 4/10/20 at 2:30 p.m. Staff M, CNA/RA (Restorative Aide), reported she started at the facility on 2/14/20 in the Restorative Aide (RA) role. Staff M recalled she worked in the CCDI unit on 3/20/20 when pulled off the unit to give a shower. Staff M reported when she returned, Staff C, LPN, told her she needed to watch Resident #1 more closely and showed her puzzle pieces removed from his mouth; Staff M assumed Staff C put the puzzle away. Staff M commented the puzzle pieces on 3/20/20 were already out of the resident's mouth at the time Staff C told her to watch him more. Staff M stated the day Resident #1 went to the hospital, 3/24/20, she asked what happened. Staff M said other aides knew about the puzzle pieces Staff C removed on 3/20/20 because Staff M told them but Staff M had not told any other nurses or management as she thought Staff C took care of it. Staff M commented she had never seen that before and if she had she wouldn't have had the puzzle out on the table. Staff M responded she had not received education from the facility before or after the incident for any actions taken to mitigate the risk of choking hazards for Resident #1. Staff M stated her first education occurred the day of the interview, 4/10/20, and showed a paper she had just received. Staff M said she heard what happened on 3/24/20 through the grapevine. Staff M responded she was not aware of Resident #1's incidents on 2/6/20 or 2/18/20 of foreign objects being in his mouth, and commented the only other thing she was taught was to keep out of reach of children items put away. On 4/10/20 at 12:07 p.m. Staff K, CNA/Housekeeping Manager, recalled working on the CCDI unit on 3/20/20 starting at 4:00 p.m. Staff K responded she had not been told anything from Staff C or Staff E about Resident #1 having puzzle pieces in his mouth that day nor had she ever seen that behavior before. Staff K stated she was aware of the resident's history of going to the hospital on [DATE] due to eating puzzle pieces. Staff K responded after the 3/24/20 incident she did not receive any orientation with regard to actions taken to mitigate further risks of choking for Resident #1. On 4/9/20 at 12:23 p.m. Staff E, LPN, reported she was hired 2/27/20 and she was familiar with Resident #1. Staff E stated she received orientation then once or twice worked in the CCDI unit. Staff E responded she was not aware she needed to watch Resident #1 for pocketing of pills or food. Staff E verified she worked the night of 3/20/20 but did not recall being aware the resident ingested puzzle pieces that day. Staff E stated she did not know until after the resident went to the hospital that he would put things in his mouth. Staff E commented she had not worked on the CCDI unit since the resident was sent to the hospital on [DATE] and had not she received any education about the facility's action plan. Staff E responded no one told her about the toilet paper found in the resident's mouth in February and was Staff E stated she was not aware of any protocols about locking items up. Staff E explained the day room had a puzzle on a table, she did not know if they put it away at certain times, and it looked like a regular sized puzzle. On 4/9/20 at 10:49 a.m. Staff A, LPN, recalled the event on 3/24/20 at noon with Resident #1. Staff A responded she did not work often for the facility but lately had regular hours (12 hour shifts, 3 times a week). Staff A reported she had only worked on the CCDI unit a handful of times, and reported it was just she and Staff B assigned and working in the unit that day. Staff A reported the resident wouldn't take his noon pills at first, so she set them on top of the cart to retry. Staff A stated the resident ate lunch with Staff B in the room and then Staff A attempted to give him his medicine again. Staff A reported she discovered puzzle pieces in the resident's mouth and then removed a ridiculous amount. Staff A said the resident would not open his mouth further and then bit her, so she sent Staff B to get the ADON for help. Staff A reported other nurses came and called the ambulance and the family. The EMTs arrived and the ADON had been able to remove a few more pieces, but more could be seen in his throat and he would not allow anyone to retrieve them. When asked, Staff A responded she was not told the resident had a history of [REDACTED]. Staff A stated they kept a puzzle kept on the table to keep the residents busy and if she would have known Staff A didn't think she would have left the room. Staff A described the puzzle as regular size and she did not know how many pieces were in the box, but the resident put the entire box in his mouth. Staff A said she thought the puzzle was less than a 100 piece puzzle and not tiny pieces; possibly a 24 piece puzzle. Staff A recalled a mountain of puzzle pieces on the table comprised of what she removed from his mouth. Staff A commented the resident must have eaten the puzzle fast as Staff B cleaned up the dining room and took other residents back to their rooms after lunch. Staff A thought the incident occurred maybe around 12:30 p.m. and Resident #1 was not alone in the community room long before she found him. Staff A reported she had never seen the resident ingest foreign material before. Staff A stated Resident #1 was able to ambulate on his own, and responded she didn't think the incident could have been prevented if it had never happened before. Staff A commented she had never, ever heard of him eating anything other than food. Staff A responded she was not aware the resident ate puzzle pieces on 3/20/20 and never told of his history of pocketing toilet paper. On 4/10/20 at 12:15 p.m. Staff B, CNA, reported she started working at the facility in January 2020 and not told Resident #1 could eat foreign objects. Staff B stated she got word someone found cotton in Resident #1's teeth. Staff B recalled working in the CCDI unit on 3/24/20. Staff B said she and an agency nurse, Staff A, worked the unit and Resident #1 was okay in the TV room with supervision given at the table. Staff B said once Resident #1 finished eating, she asked him if he wanted to go sit in his room. Staff B reported the resident wanted to stay in the TV room and there were a couple of puzzles out on the table. Staff B said a tray table with a regular puzzle box of 300 or 500 pieces was present and they were big pieces. Staff B reported she went to talk to everyone else and going to rooms to get food trays. Staff B stated Staff A then found puzzle pieces in Resident #1's mouth and asked her for assistance. Staff B stated the resident refused to let them help, clenched his teeth, and they could see gray puzzle pieces in his mouth. Staff B went to get the ADON. Staff B recalled a couple other staff also arrived to help. Staff B stated one of the nurses told her to come back and make phone calls and she saw them trying to get the resident to spit out the pieces when the ambulance arrived. When asked, Staff B stated she was not aware of the 3/20/20 incident of Resident #1 putting puzzle pieces in his mouth or of the dentist incident on 2/6/20. Staff B commented the communication at the facility not very good as information did not get communicated especially when she worked other halls. Staff B stated 1 aide and 1 nurse not enough staff when residents had behaviors that got out of hand on the CCDI unit. Staff B did not remember formal education completed after the 3/24/20 incident but she told someone she put the puzzle pieces away in the cupboard. On 4/9/20 at 12:39 p.m. the ADON reported she started working at the facility on 2/10/20. The ADON stated she became familiar with Resident #1 and knew the nurses charted hourly checks in regards to not pocketing food. She recalled on 3/24/20 around lunch time Staff B told her Resident #1 ate puzzle pieces, so she walked into the unit to find Staff A encouraging Resident #1 to spit out puzzle pieces as he sat at the activity table. The ADON stated the resident did not appear to be choking; no noises, no gurgling, but presented with audible wheezes so she told Staff A to call 911 while she stayed with the resident until EMTs arrived. The ADON stated she tried to encourage the resident to cough and spit out the puzzle pieces but he leaned forward and did not try due to his cognition. The ADON reported there were quite a lot of normal sized puzzle pieces from probably a 100 piece puzzle and was not sure if the puzzle box got thrown away. The ADON responded she was not aware at that time resident had put puzzle pieces in his mouth on 3/20/20. She said it was known the resident pocketed food and meds, but the ADON would have expected Staff C, LPN, to put the 3/20/20 incident on hot charting (24 hour report sheet used by the nurses for communication). The ADON responded she knew about the dental appointment 2/6/20 beforehand and toilet paper and paper towels removed from Resident #1's room. The ADON reported she did not do a lot with care plans, and did not know of any staff education completed in relation to Resident #1 and his risk to ingest foreign objects Additional Staff Interviews On 4/9/20 at 2:50 p.m. the Administrator responded she was aware the dentist found a cotton ball in Resident #1's mouth on 2/6/20, but was not aware of the 2/18/20 incident with the golf ball sized wad of toilet paper in his mouth or that the care plan lacked information until 3/23/20. She responded she could not say for certain if the facility had anything on paper regarding education to staff about Resident #1's risk of ingesting foreign objects. The Administrator stated she remembered a conversation in a morning meeting where she told the previous DON (Director of Nursing) to follow up and make sure everyone knew. The Administrator said she did not know until 2 hours before the interview that Resident #1 put puzzle pieces in his mouth on 3/20/20. The Administrator stated she needed to speak to Staff C about why she didn't tell anyone and said she needed to educate all staff. The Administrator said she took a copy of the activity policy and had the staff that worked on the CCDI unit sign it, but acknowledged the 16 signatures would not represent all the staff would possibly work on the CCDI unit. The Administrator stated she knew the Admissions Marketing Coordinator and the Activity Director did a full sweep of the CCDI unit and removed everything that was smaller than a fist. On 4/9/20 at 1:54 p.m. Staff D, LPN, reported she worked at the facility for 2 years full time and she was familiar with Resident #1. Staff D responded she first became aware Resident #1 would ingest foreign objects after a dentist reported finding a cotton ball in the resident's mouth and from then on she checked his mouth 3 to 4 times a day. Staff D responded there was not a formal place to document those checks; it was on the 24 hour report to pass on to the next shift to check for items. Staff D responded she was aware of the 2/18/20 incident of Resident #1 having toilet paper in his mouth. Staff D responded a new nurse or agency nurse would know to monitor the resident from having it passed on in report. Staff D stated she was not aware of the 3/20/20 incident and the only education she knew management did was remove the puzzle from the unit and they went thru the unit to look for other items. Staff D commented she identified the previous evening an agency nurse hung up Easter eggs which Staff D could put in her mouth so the next day Staff D took them down. Staff D commented the resident monitored quite closely. On 4/9/20 at 2:120 p.m. the Activities Director reported the new activity policy anything smaller than fist sized has to be monitored and not allowing puzzles on the CCDI unit for now. The Activities Director explained facility education done thru a group me app and a copy posted on the activity cupboards in the cottage for staff. The Activities Director stated staff need the keys to get something out. The Activities Director reported she had always known the resident may put toilet paper or paper towels in his mouth as long as she had known him, but never anything weird. The Activities Director stated one time about a month or so prior the resident tried to put a poker chip for bingo in his mouth so they switched to giving him a slid card. The Activities Director said the puzzle pieces had been out for months so it took everyone by surprise. The Activities Director voiced they would finish a puzzle, come get another one, and typically 100 or less puzzle pieces size used with the Alzheimer's unit. On 4/9/20 at 3:07 p.m. the Social Service Designee (SSD) verified she revised Resident #1's care plan on 3/23/20 to include the non-food items, she did not know if that was enough, and so on 3/26/20 she added the non-food/foreign objects portion. The SSD stated she did recall anyone telling her about the dentist finding a cotton ball in the resident's mouth or reading the note about the golf-ball sized toilet paper. The SSD stated because she read the progress notes documenting the incident 3/20/20 with puzzle pieces, she updated the care plan to mention foreign objects. On 4/9/20 at 5:59 p.m. Staff F, Certified Medication Aide (CMA), reported she was familiar with Resident #1. Staff F stated she experienced once about a year prior the resident put a napkin in his mouth that he tried to eat. Staff F said since that time she had not seen the behavior but she knew it happened off and on. Staff F reported she got report about the dentist finding the cotton on 2/6/20 and on 2/18/20 all toilet paper taken out of the resident's room. Staff F commented Resident #1 didn't really wander in to others rooms. Staff F said the resident spent a lot of time in the TV room and the puzzle always out. Staff F responded she had no idea the resident put puzzle pieces in his mouth 3/202/20. Staff F responded after 3/24/20 she did not really get formal education of action plan but she was pretty much aware they all knew to watch him. Staff F responded new staff or agency staff would know to watch the resident thru word of mouth. On 4/9/20 at 6:26 p.m. Staff I, CMA, reported she worked for the facility just over 6 months and familiar with Resident #1. Staff I stated she heard about the incident 3/24/20 after it occurred. Staff I commented she thought there was 1 instance of the dentist finding something, but she was not sure as she did not work back on the CCDI unit often. Staff I stated she was educated after 3/24/20 that nothing less than the size of a fist could be left out and if so had to be locked up. Staff I responded new staff or agency staff would get education by staff telling would tell. Staff I stated a care plan in place on the back of the resident's door and the nurs (TRUNCATED)

Based on clinical record review, observation, staff interviews, and facility record review, the facility failed to protect residents from abuse that resulted in injury and psychological harm for 5 of 6 residents reviewed for abuse (Residents #2, #47, #55, #36 and #33). The facility reported a census of 67 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented an admitted [DATE]. The MDS identified a BIMS score of 3 with sign/symptom of [MEDICAL CONDITION] with fluctuating presence of inattention; a score of 3 indicated severe memory and cognitive impairment. The MDS documented the resident exhibited physical and verbal behavioral symptoms directed toward others and wandering on 1 to 3 days of the 7-day look back period. The MDS recorded the resident's behaviors impacted others putting others at significant risk for physical injury and significantly disrupted care or the living environment. The MDS recorded he was independent with transfers, walking in the room and corridor, and locomotion on the unit. The MDS documented [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] for Resident #2 documented a Discharge Return Not Anticipated. The MDS dated [DATE] for Resident #2 documented the resident re-entered the facility. The care plan focus area dated 11/1/18 identified Resident #2 as independent with ADLs (activities of daily living) and transferred independently. The care plan focus area dated 11/5/18 identified an elopement risk/wanderer with behaviors of exit seeking, kicking exit doors, pacing, and going into other residents' rooms related to increased agitation when he did not have cigarettes and could not go out to smoke when he wanted. The care plan informed staff the resident resided on the CCDI (or dementia) unit. The care plan focus area dated 11/5/18 identified a behavior deficit related to physical and verbal behaviors towards others, hitting other residents, shoving another resident; increased agitation when out of cigarettes or couldn't go out to smoke when he wanted or get into the fridge when he wanted and throwing items off nurses cart and throwing nurses tablet breaking it. The care plan informed staff the resident with a history of: yelling/cursing at others; getting upset because the fridge locked; threw juice at staff; took items off med cart, shook drawers on med cart and tried to open them; threatened staff; lifted up a chair and threatened to break window; rammed his shoulder into nurses station door causing damage to facility property; kicked exit door and damaged facility property; and broke locks on cupboard doors in dining area. The care plan identified the resident diagnosed with [REDACTED]. An intervention dated 11/5/18 directed staff to intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention; and remove from situation and take to alternate location as needed. An intervention dated 11/7/18 directed staff to monitor behavior episodes and attempt to determine underlying cause; consider location, time of day, persons involved, and situations; and document behavior and potential causes. The care plan intervention dated 12/28/18 directed staff to educate the resident expectations of keeping his hands to himself and on successful coping, interaction strategies. The care plan instructed when Resident #2 became agitated, staff should attempt to intervene and redirect him before agitation escalated, guide him away from the source of distress, engage calmly in conversation and if he had an aggressive response, staff should walk calmly away and approach later. The care plan focus area dated 11/9/18 identified a mood deficit related to [DIAGNOSES REDACTED]. The care plan directed staff to monitor, record, report to physician as needed risk for harming others (increased anger, labile mood or agitation), if he feels threatened by others or thoughts of harming someone and possession of weapons or objects that could be used as weapons. The Progress Notes dated 10/26/18 at 7:23 a.m. documented the nurse asked to go to the CCDI unit at 2:45 a.m. to help watch Resident #2 along with another nurse because of behaviors. Resident #2 complained/cussed because of a cold room, a locked refrigerator and he wanted something to drink. When staff gave the resident mile and juice, he threw the juice at the nurse saying it was not the kind he wanted. The Progress Notes dated 10/27/18 at 1:22 a.m. documented Resident #2 was upset at 3:00 a.m. and the nurse called back to the unit. At 9:52 a.m., at 6:15 a.m. Resident #2 acted agitated due to wanting to smoke and the refrigerator being locked. The entry recorded Resident # 2 threatened staff with foul language, took items off the med cart, shook the drawers to try to open them, tried to go in others' rooms and the office, then got more agitated when told he couldn't go out to smoke because no staff were available to go with him. The Progress Notes dated 10/28/18 at 3:46 a.m. documented Resident #2 became agitated due to the lack of a lighter, cursed, stated someone stole his lighter and threatened assault. The nurse attempted to redirect the resident 3 times and he continued to make comments regarding the lighter. Staff assisted the resident to smoke and he demanded staff return his lighters or he would leave after breaking a window. He then picked up a chair and headed towards the window. Staff removed residents and Resident #2 put the chair down then rammed his shoulder against the outside door. Staff then called the police and Resident #2 transferred to the ER (emergency room ). Resident #2 said he would rather be on the streets. ER called the facility, stated Resident #2 was alert and oriented in the ER, without signs/symptoms of violence, and they needed to send Resident #2 back as he was a frequent flyer with too many visits too count and this was the best they had ever seen him. The Progress Notes dated 11/2/18 at 2:28 p.m. documented Resident #2 acted agitated after being assisted with smoke breaks at 6:10 a.m., 7:30 a.m., 10:00 a.m., 11:45 a.m., and 12:30 p.m. Resident # 2 displayed agitation after the nurse did not go out right that minute for a cigarette and demanded the supervisor be called. While waiting Resident # 2 kicked the doors so staff paged for help and took the resident out to smoke. The Progress Notes dated 11/2/18 at 4:46 p.m. documented a Plan of Care Note and documented staff reported Resident # 2 had verbal behaviors and would curse/yell at staff when agitated/upset. Staff reported physical behaviors. Resident #2 would threaten staff, threw juice at the nurse, threatened to break a window with a chair, rammed his shoulder into a door of the nurses' station, kicked a door, took items off nurses cart, and shook drawers on the nurses cart to try to open them. Resident # 2 got easily agitated and upset related to the refrigerator in the CCDI unit being locked with increased behaviors when he didn't have cigarettes or couldn't go out to smoke whenever he wanted. The entry recorded Resident # 2 wandered on occasion, paced, and would go into other residents' rooms. The Progress Notes dated 11/15/18 at 2:28 p.m. documented the resident kicked the CCDI unit door open while waiting for staff to get him cereal and broke all the cupboard locks in the dining area by pulling the doors apart until they broke. The Progress Notes dated 11/15/18 at 10:36 p.m. documented Resident #2 was found in a female resident's room with his head towards her groin area. Staff removed the resident from the area, and called to the DON (Director of Nursing) to ask if they needed to report the event. At 10:57 p.m. staff placed the resident on 15 minute observation checks and then found the resident back in the female resident's room, sitting on the end of her bed. The Progress Notes dated 11/16/18 at 10:51 a.m. documented Resident #2 wanted a razor and then kicked open the locked supply door when staff did not respond to his request fast enough. At 11:30 a.m. staff informed his physician of Resident # 2's behaviors which involved staff members, other residents, as well as damage of property. Staff received an order received to send the resident to the ER due to a high risk of injury to himself and others. At 12:30 p.m. Resident transferred to ER and at 4:50 p.m. he returned to the facility. The Progress Notes dated 12/3/18 at 3:24 p.m. documented Resident #2 approached another male resident to request salt and pepper and when that resident did not understand, Resident #2 became verbally aggressive and grabbed the salt/pepper from that resident. Resident #2 said told that resident to not act stupid. At 5:57 p.m. Resident #2 refused medication, stating he felt like a prisoner and after being served a plain hamburger. Resident #2 threatened to go to his room to get his boots in order to kick in the door and he told staff he could smoke anytime he wanted, he did not care what the nurse said. Staff responded they needed Resident #2 to wait a bit because they did not have a second person in the unit at the time to take him out. The Progress Notes dated 12/5/18 at 6:32 a.m. documented Resident #2 as awake and pacing since 4:00 a.m. waiting for a cigarette with no staff available to take him out to smoke. The Progress Notes dated 12/7/18 at 3:01 p.m. documented the CCDI unit nurse paged to the unit and the ADON (Assistant DON) found another resident lying on the floor with spilled coffee around him and a skin tear. Resident # 2 made contact with the other resident, resulting in a fall. Resident # 2 said he wanted in to the other room to make a phone call and the other resident stood in the doorway so he asked him to move but he didn't move. Resident # 2 said he didn't push him, he moved him, and would never push another man. The entry documented Resident # 2 placed on 15 minute checks. At 3:06 p.m., another nurse documented Resident # 2 had approached the nurses station, shoved another resident at the doorway at the same time he told that resident to get out of his way as he wanted to call his sister. The Progress Notes dated 12/7/18 at 11:06 p.m. documented Resident # 2 with 1 episode of questionable behavior when he yelled at another resident about the TV remote. The Progress Notes dated 12/11/18 at 5:47 p.m. documented Resident # 2 left the dining room stating he wanted the boss called to get some decent food. When staff informed him the boss had gone for the day, Resident # 2 said he would kick the door in and pack his stuff up to go back to the streets. Staff called the Administrator at home and instructed kitchen staff to cook what Resident # 2 agreed to. Resident # 2 responded that he didn't want that, yelled, appeared threatening in his approach in the dining room and upsetting other residents, so staff asked Resident # 2 to leave the room with the writer, which he did. The late entry Progress Notes dated 12/14/18 at 8:10 a.m., created by the MDS Coordinator, documented upon the MDS Coordinator's arrival to the facility at 5:00 p.m. Resident # 2 was found standing in front of the TV in the West dining area of the facility yelling about the food being the same for 4 days. The MDS Coordinator approached the aide standing next to Resident # 2 to ask why he was out of the unit to which the CNA responded to ask his nurse. The charge nurse in the CCDI unit attempted to call the on-call staff. The MDS Coordinator walked the resident back to the CCDI unit and Resident # 2 stated he would pack his bags to get out of the place. The MDS Coordinator went back to the Assisted Living (AL) side of the facility and 20 minutes later, staff called to inform her Resident # 2 refused his medications and wanted to smoke; she instructed them to take the resident to smoke. Twenty minutes after that, staff reported Resident # 2 kicked open the CCDI door again and headed out the front door with a CNA following behind. Staff called the police to assist in redirecting Resident # 2 back to the facility and into the CCDI unit. The Progress Notes dated 12/14/18 at 1:27 p.m. recorded Resident # 2 with increased agitation when another resident wore his socks and with increased anxiety when another resident wandered into his bathroom. At 5:31 p.m. Resident # 2 went to the dining area and wanted some 'real food'. Resident # 2 cursed and walked straight to the CCDI unit door, kicked it open and stated staff couldn't keep him there, he was leaving. Resident #2 went and told the kitchen staff they had served that food for 4 days but he refused any substitutes. Management staff walked him back to the unit where he packed his belongings. At 9:53 p.m. the notes documented that at 6:05 p.m. Resident # 2 knocked open the CCDI unit door again and a CNA escorted him to the main entrance of the building and called police. The Progress Notes dated 12/16/18 at 5:30 a.m. documented Resident # 2 yelled at another resident who watched TV in the activity room. Resident #2 complained that resident didn't know what he was doing and needed to stop messing with the TV. Resident # 2's behaviors came out of nowhere; he scolded a wandering resident and had unpredictable behavior, hard to redirect. At 9:17 p.m. Resident # 2 told the night nurse he would kick the door in that night so she would have paperwork. The entry recorded Resident #2 then calmed to take his medications but escalated within a few seconds to yell at a resident watching TV. The felt anxious and afraid of Resident # 2's unpredictability and potential for violence, so she called the DON to report and the DON reshuffled staff to ensure the nurse was not alone with Resident # 2 after 8:30 p.m. The Progress Notes dated 12/19/18 at 7:19 a.m. documented Resident # 2 wanted to smoke at 6:30 but staff informed him they had no lighter as the resident had it in his room from another staff member. The resident laughed at staff and denied having the lighter but when he realized he couldn't go to smoke he obtained the lighter from his room. The Progress Notes dated 12/21/18 at 8:53 p.m. documented Resident # 2 ran out of his room into the commons area and yelled at 2 residents in the TV room; the nurse noted Resident # 2's behavior as very unpredictable. At 9:23 p.m. Resident # 2 again yelled at 2 residents watching TV telling them they should be in bed and stop messing with the TV. The Progress Notes dated 12/22/18 at 9:26 p.m. documented Resident # 2 screamed at another resident who accidentally entered his room then he wanted to go smoke. When staff couldn't go right away, Resident # 2 became upset and screamed at the ladies sitting in the hallway and upon returning from a smoke break went to a room looking for 'that idiot'. The Progress Notes dated 12/23/18 at 3:40 p.m. documented Resident # 2 walked in the hallway when another resident with an episode of increased agitation yelled inappropriate language to him at which time Resident # 2 called the resident a crazy b**** and staff redirected him away. At 7:47 p.m. Resident # 2 appeared cocky and strutted arrogantly in the hallway scaring female residents (#47 and #33), by saying 'Boo' in their faces and then yelled at another resident (#24) for messing with the TV. The Progress Notes dated 12/26/18 at 9:59 p.m. documented Resident # 2 exhibited increased agitation toward another resident yelling and getting in the other resident's face to tell him to stay out of his room and to stop messing with the TV. The Progress Notes dated 12/28/18 at 2:42 p.m. documented a late entry for 12/22/18. The entry recorded a CNA reported after breakfast Resident # 2 walked past another resident and smacked them on the bottom. The other resident swung at Resident # 2 and hit him in the left shoulder. Staff separated both residents immediately and noted no injuries. The Progress Notes dated 12/29/18 at 2:50 a.m. documented Resident # 2 had 2 unpleasant interactions with Resident #24 about the TV. The entry recorded Resident # 2 as difficult to redirect. The Progress Notes dated 12/30/18 at 4:14 a.m. documented Resident # 2 had 3 episodes of using abusive language towards Resident #24 early in the shift when Resident # 2 called Resident #24 names and told him to stop messing with the TV. The nurse intervened with limited success. The Progress Notes dated 1/2/19 at 2:03 a.m. documented Resident # 2 called Resident #24 an idiot at snack time and said the resident would have a bowel movement (BM) all over the place. The late entry Progress Notes dated 1/2/19 at 8:14 a.m. documented Resident # 2 refused his meds and wanted to smoke. Resident # 2 pushed past the nurse cursing and stating, he could do whatever he wanted at the facility, could smoke whenever he wanted and staff couldn't stop him or tell him what to do. Resident # 2 went into the nurses office, threw a side table down the hall and grabbed his cigarettes and lighter. Staff I, CNA, took him out to smoke. Resident # 2 refused to return the lighter and stated he didn't mind going back to jail because the food better and he hadn't eaten in 3 days, and that he could do what he wanted because the state paid for him to stay at the facility. The nurse contacted the Administrator who informed staff the resident was no longer allowed to light his own cigarettes and staff must maintain possession of the lighter and keep the nursing office door closed at all times. The Progress Notes dated 1/4/19 at 10:45 p.m., created by the MDS Coordinator, documented at approximately 8:15 p.m. she spoke with another staff member on the phone while Resident # 2 stood 2.5 feet behind her asking to go smoke in a loud voice. The MDS Coordinator informed Resident # 2 she was the only staff member in the unit and no one could take him outside. Resident # 2 yelled he wanted to go f***ing smoke and they better get staff back here to take me. The MDS Coordinator locked the medication cart, went into the nurses station, and shut the door. The MDS Coordinator documented she was not going to cater to Resident # 2's temper tantrum. The MDS Coordinator documented Resident # 2 ripped the computer from the wall plug, threw it down the hallway, and cleared the medication cart of every single item on it. The MDS Coordinator called 911 then a code red for help and a nurse from the west side of the facility arrived within a few minutes to find Resident # 2 standing up against the railing and within 2 more minutes, the police arrived. The MDS Coordinator informed the Administrator and then police and EMS (Emergency Medical Services) who escorted the resident from the premises. The Progress Notes dated 2/19/19 at 2:05 p.m. documented Resident # 2 returned to the facility via a taxi service, he recognized staff and greeted them accordingly. At 3:25 p.m. the resident recognized all management staff and made jokes about the gang being back together and he already broke the rules. The Progress Notes dated 2/24/19 at 1:00 a.m. documented staff educated Resident # 2 after he jumped around in hallway in front of others yelling, Hi-Ya, and kicking his leg and waving his arms. Resident # 2 said he was just showing them his karate moves and repeated his actions in front of the nurse. They educated Resident # 2 on inappropriate behavior. At 12:57 p.m. Resident # 2 continued 15 with minute checks and he had been very demanding that day. Resident # 2 waved a paper in a female resident's face and antagonizing her. When staff attempted to redirect him, Resident # 2 was slow to respond and stared at that person in a defiant manner. The Progress Notes dated 2/25/19 at 6:49 p.m., created by Staff G, LPN (Licensed Practical Nurse) documented she received report Resident # 2 sought out staff to take him to smoke and was agitated he couldn't go; he had a smoking schedule to follow. Staff G documented Resident # 2 was in the TV lounge, smacked a resident in the left temple of face, then went down CCDI hallway, smacked another resident on the buttocks and then ducked aside in another residents room. The nurse immediately notified the management team of the behavior/incidents, police arrived at 1:15 p.m. and Resident #2 transferred to the hospital. Observation on 2/25/19 at 11:57 a.m. revealed Resident # 2 requested Staff K, Certified Nurse Aide (CNA) to take him out to smoke then shower. Staff K informed Resident # 2 the next smoke break would be at 1:00 p.m., asked him to shower and have lunch and then it would be almost time for his smoke break. Resident # 2 demanded Staff K call the director to report he couldn't go out to smoke. Staff K informed the resident she would call but had something to do right that moment. Resident # 2 became angry and stated he was going out to smoke and Staff K better call the director right then. Staff K responded she would call but the director in a meeting at that time and would just tell him the same thing. Observation on 2/25/19 at 12:04 p.m. revealed Staff C, Certified Medication Aide (CMA) took 3 other residents out the CCDI unit doors to the East hallway. Resident # 2 stood at the medication cart by the door and got in line behind the others to leave. Staff K blocked the entrance when Resident # 2 attempted to walk through with the others. Staff K held onto both doors as Resident # 2 pushed against her. Staff K continued to hold the doors and Resident # 2 increased his agitation. The Admissions Coordinator intervened at the door and told Staff K to let Resident #2 through and then walked with Resident # 2 hand in hand to the front offices. The DON and the Admissions Coordinator walked with the resident back to the CCDI unit. The DON was able to keep the resident calm and approached him gently; joking lightly with the resident. Resident # 2 allowed the DON to tie his shoes once on the unit and discussed smoking times. Resident # 2 interacted well with the DON. Resident #2 agreed to the 1:00 p.m. smoke time and shower and the DON encouraged him to take off his coat. As Resident # 2 took off his coat, he repeated shower-smoke, shower-smoke, then Resident # 2 said he wanted to smoke now. The DON had to continue to interact with the resident to redirect him away from the topic of smoking. The Admissions Coordinator accompanied the DON and Resident # 2 back to his room with encouragement to lay down for a while. Observation on 2/25/19 at 12:45 p.m. revealed Resident #2 walked up the hallway from the TV room by the nurse's station passing Resident #47. A loud slap could be heard and Resident #47 yelled Ouch; I'm tired of you hitting me. Resident #2 made eye contact with surveyor and quickly walked into room [ROOM NUMBER]. Resident #47 turned and walked back down to the TV room. Another resident (#36) walked up the hall to the nurses station from the TV room at the same time and informed Staff K that Resident #2 just slapped him. The surveyor reported the slap on Resident #47's buttocks immediately to Staff J, CNA, and Staff K. Staff J called for management help in the unit immediately. Staff Interviews revealed the following information: On 2/25/19 at 11:53 a.m., the Activities Assistant stated Resident #2's current condition was about the same as before he left the unit to the hospital. The Activities Assistant confirmed the resident lived in the facility since approximately (MONTH) of (YEAR). The Activities Assistant commented that residents seemed intimidated by Resident # 2. On 2/25/19 at 11:59 a.m., Staff K stated she did not know the resident's previous level of functioning as she was new to the facility and only worked her third orientation day. Staff K was not working on her own yet. On 2/25/19 at 2:11 p.m., the Administrator and the owner reported a police officer was in the building and would be escorting Resident # 2 to the hospital as they were actively initiating an involuntary discharge related to resident safety. The Administrator and owner reported they were forced by the Administrative Law Judge (ALJ) to take the resident back from the hospital 2/19/19. They stated the ALJ informed them they provided the wrong language in the Emergency Involuntary Discharge notice they gave upon discharge in (MONTH) (1/4/19). They didn't want to take the resident back but they had to follow the judge's order. In an interview on 2/25/19 at 2:55 p.m., Staff G, LPN, stated she assessed Resident #47 and she did not have any marks (on 2/25/19). Staff G responded Resident # 47 recalled what happened and stated she felt scared of Resident #2. Staff G didn't think Resident #2 had been gone long enough for the residents to get him out of their heads (when he left 1/4/19). Staff G said Resident #47 stated she always walked on the far side of the hall because she had to look out for Resident #2. At 3:25 p.m., Staff G stated she thought Resident # 2's behaviors for that day were set off by his desire to go out and smoke. Staff G stated she was a rule follower and told Resident # 2 he had to wait until the scheduled smoke time of 1:00 p.m. to go out. When the resident first came to the facility he was more aware of the exits and of the other residents' disabilities which frustrated him. Staff G felt Resident # 2 did not understand mentally why the other residents were confused due to their cognitive declines. Staff G gave the example when a resident would be exit seeking, Resident # 2 informed the exit seeker there was a back door and he would take them to the door to try to help them out. On 2/26/19 at 7:46 a.m., Staff G reported the residents were much calmer than the day before. Their anxiety level were way down since Resident #2 left the night before versus when Resident #2 resided on the unit. Staff G thought the residents were aware Resident #2 had gone and thought they had been hesitant to even sit next to Resident #2 for fear he would bully them. On 2/26/19 at 8:00 a.m., Staff L, CNA, stated she had worked for the facility for 3 years. The residents acted more calm that day and she felt they knew when Resident # 2 was on and off the unit. Staff L stated Resident #33 acted scared of Resident # 2; she felt Resident # 2 knew it and focused in on Resident #33's fear. Resident #2 always had behaviors since his admission in (MONTH) (YEAR). Staff tried to redirect Resident # 2 to the TV room or to play checkers but activities did not divert Resident # 2. Resident # 2 would get into the residents' personal spaces, especially Resident #33. Resident # 2 would get into Resident #33's face, wave his arms around, and when Resident #33 tried to walk away with staff, Resident # 2 followed them and continued to antagonize the residents. Staff L thought Resident # 2 knew what he was doing when he intimidated the other residents and it was possible the resident did things to other residents that staff were unaware of when they weren't looking due to being a full watch hall. Staff L explained a full watch hall meant they were constantly going up and down the halls to observe everything going on, so if they went down the hall one way and Resident # 2 went the other way, it would be possible for Resident # 2 to have interactions with other residents without her being aware of it. On 2/26/19 at 2:25 p.m., the DON discussed her summary of what the facility did to increase supervision of Resident #2 after signs of aggression and resident-to-resident altercations occurred. The DON said for the incident of resident-to-resident contact between Resident # 2 and Resident # 55 that occurred on 12/7/18, they increased to 15 minute checks, the doctor evaluated Resident # 2 on 12/13/19 and changed medications. The DON stated for the incident of resident-to-resident contact between Resident # 2 and Resident # 47 that occurred on 12/22/18, they did not become aware of the incident until 12/28/18. The DON said at that time they notified the DIA (Department of Inspections and Appeals), disciplined a charge nurse for not reporting immediately and placed Resident #2 on 15 minute checks; when 15 minute observation checks were initiated, they conducted them for 72 hours, but if the behaviors continued they would put a resident back on the checks. The DON had Resident #2 sign a contract agreement to acknowledge the expectation that all residents keep their hands to themselves, residents cannot pinch, slap, grab, or make contact with another resident in any other manner, it was not a joke, it was not funny, and it was not allowed. The DON confirmed the resident a BIMS score of 3 but they still presented the contract as they felt he was aware of his actions. When the facility accepted Resident # 2 back the second time 2/19/19, they did not get any information about him needing to be held down in the hospital for injections or that he had been moved units due to some sexual interactions. The DON stated they did not receive that information until approximately 2 days after the resident returned to the facility. The DON stated when Administrative Law Judge (ALJ) ruled they must take Resident # 2 back on 2/19/19, they decided to place him on 15 minute checks indefinitely. The DON reported the facility called the police who witnessed the resident's sister receiving notification of an Emergency Involuntary Discharge notice and then the police officer escorted the ambulance to the hospital to deliver the paperwork to the hospital 2/25/19. In an interview on 2/27/19 at 11:00 a.m., Staff N, CNA/Scheduler stated she knew of 2 residents on the unit who showed they were bothered by Resident # 2: Resident #47 and Resident #33. Staff N stated she had not received a directive to staff 2 staff members on the CCDI unit until Resident # 2 returned to the facility on [DATE]. In an interview on 2/27/19 at 11:30 a.m., Staff E, LPN, stated she worked for the facility for 5 years but did not work back on the unit often. At the time of the interview, Staff E worked as the charge nurse on the CCDI unit. Staff E had only worked with Resident # 2 one time but she had heard staff report every day that Resident # 2 tried to intimidate staff and residents with weird noises, kicking doors, and hitting people. Staff E responded they usually just staffed 2 people on the CCDI unit even when a resident exhibited behaviors. In an interview on 2/27/19 at 11:40 a.m., Staff J, CNA, responded she did not work back on the CCDI unit often. Staff J acknowledged she was familiar with Resident # 2 and the resident always had behaviors. 2. The MDS assessment dated [DATE] for Resident #47 identified BIMS score of 3 without signs/symptoms of [MEDICAL CONDITION]. The MDS documented the resident exhibited no behavioral symptoms during the 7-day look back period. The Resident #47 transferred and walked in her room independently and required supervision while walking in the corridor and with locomotion on her living unit. The MDS documented [DIAGNOSES REDACTED]. Incident # 1: The Progress Notes dated 11/15/18 at 10:30 p.m., written by Staff H, Licensed Practical Nurse (LPN), documented an incident at 10:20 p.m. another resident was not seated in the TV room and not found in their own room. Staff searched for the resident (#2) and found him in Resident #47's room, sitting at the end of her bed and leaning over towards her groin area. Staff reported Resident #47 did not have any blankets on her, but was clothed as when put to bed. Staff removed the other resident from Resident #47's room and Staff H contacted the DON to report the incident. Staff H put both residents on 15 minutes checks and the DON planned to call the Administrator and call Staff H back. At 10:50 p.m. Staff H received a call from the DON who inst

Based on clinical record review, observation, resident interview, staff interviews, and facility record review, the facility failed to increase nursing supervision on the CCDI (Chronic Confusion Dementing Illness) unit after several incidents involving resident to resident interactions to prevent potential for abuse for 5 of 6 residents reviewed for abuse (Residents #2, #47, #55, #36 and #33). The facility failed to identify the need for increased supervision housing multiple residents, with the potential for physical and verbal behaviors directed towards others, on the same unit. The facility failure resulted in an Immediate Jeopardy situation identified on 12/8/18 and abated on 2/27/19. Fourteen residents resided on the CCDI unit. In addition, based on clinical record review and staff interviews, the facility failed to provide adequate transfer assistance during a resident transfer that resulted in a fall with fracture for one of 23 residents reviewed (#25). The facility reported a total census of 67 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented an admitted [DATE]. The MDS identified a BIMS score of 3 with sign/symptom of [MEDICAL CONDITION] with fluctuating presence of inattention; a score of 3 indicated severe memory and cognitive impairment. The MDS documented the resident exhibited physical and verbal behavioral symptoms directed toward others and wandering on 1 to 3 days of the 7-day look back period. The MDS recorded the resident's behaviors impacted others putting others at significant risk for physical injury and significantly disrupted care or the living environment. The MDS recorded he was independent with transfers, walking in the room and corridor, and locomotion on the unit. The MDS documented [DIAGNOSES REDACTED]. The MDS dated [DATE] for Resident #2 documented a Discharge Return Not Anticipated. The MDS dated [DATE] for Resident #2 documented the resident re-entered the facility. The care plan focus area dated 11/1/18 identified Resident #2 as independent with ADLs (activities of daily living) and transferred independently. The care plan focus area dated 11/5/18 identified an elopement risk/wanderer with behaviors of exit seeking, kicking exit doors, pacing, and going into other residents' rooms related to increased agitation when he did not have cigarettes and could not go out to smoke when he wanted. The care plan informed staff the resident resided on the CCDI (or dementia) unit. The care plan focus area dated 11/5/18 identified a behavior deficit related to physical and verbal behaviors towards others, hitting other residents, shoving another resident; increased agitation when out of cigarettes or couldn't go out to smoke when he wanted or get into the fridge when he wanted and throwing items off nurses cart and throwing nurses tablet breaking it. The care plan informed staff the resident with a history of: yelling/cursing at others; getting upset because the fridge locked; threw juice at staff; took items off med cart, shook drawers on med cart and tried to open them; threatened staff; lifted up a chair and threatened to break window; rammed his shoulder into nurses station door causing damage to facility property; kicked exit door and damaged facility property; and broke locks on cupboard doors in dining area. The care plan identified the resident diagnosed with [REDACTED]. An intervention dated 11/5/18 directed staff to intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention; and remove from situation and take to alternate location as needed. An intervention dated 11/7/18 directed staff to monitor behavior episodes and attempt to determine underlying cause; consider location, time of day, persons involved, and situations; and document behavior and potential causes. The care plan intervention dated 12/28/18 directed staff to educate the resident expectations of keeping his hands to himself and on successful coping, interaction strategies. The care plan instructed when Resident #2 became agitated, staff should attempt to intervene and redirect him before agitation escalated, guide him away from the source of distress, engage calmly in conversation and if he had an aggressive response, staff should walk calmly away and approach later. The care plan focus area dated 11/9/18 identified a mood deficit related to [DIAGNOSES REDACTED]. The care plan directed staff to monitor, record, report to physician as needed risk for harming others (increased anger, labile mood or agitation), if he feels threatened by others or thoughts of harming someone and possession of weapons or objects that could be used as weapons. The Progress Notes dated 10/26/18 at 7:23 a.m. documented the nurse asked to go to the CCDI unit at 2:45 a.m. to help watch Resident #2 along with another nurse because of behaviors. The entry recorded Resident #2 complained/cussed because of a cold room, upset the refrigerator locked, and he wanted something to drink and when staff gave drinks the resident threw the juice at the nurse as not the kind he wanted. The Progress Notes dated 10/27/18 at 1:22 a.m. documented Resident #2 was upset at 3:00 a.m. and the nurse called back to the unit. At 9:52 a.m., at 6:15 a.m. Resident #2 acted agitated due to wanting to smoke and the refrigerator being locked. The entry recorded Resident # 2 threatened staff with foul language, took items off the med cart, shook the drawers to try to open them, tried to go in others' rooms and the office, then got more agitated when told he couldn't go out to smoke because no staff were available to go with him. The Progress Notes dated 10/28/18 at 3:46 a.m. documented Resident #2 became agitated due to the lack of a lighter, cursed, stated someone stole his lighter and threatened assault. The nurse attempted to redirect the resident 3 times and he continued to make comments regarding the lighter. Staff assisted the resident to smoke and he demanded staff return his lighters or he would leave after breaking a window. He then picked up a chair and headed towards the window. Staff removed residents and Resident #2 put the chair down then rammed his shoulder against the outside door. Staff then called the police and Resident #2 transferred to the ER (emergency room ). Resident #2 said he would rather be on the streets. ER called the facility, stated Resident #2 was alert and oriented in the ER, without signs/symptoms of violence, and they needed to send Resident #2 back as he was a frequent flyer with too many visits too count and this was the best they had ever seen him. The Progress Notes dated 11/2/18 at 2:28 p.m. documented the resident upset and demanding after assisted with smoke breaks at 6:10 a.m., 7:30 a.m., 10:00 a.m., 11:45 a.m., and 12:30 p.m. The entry recorded Resident # 2 agitated the nurse did not go out right that minute for a cigarette and demanded the supervisor be called; while waiting Resident # 2 kicked the doors so staff paged for help and the resident taken out to smoke. The Progress Notes dated 11/2/18 at 4:46 p.m. documented a Plan of Care Note and documented staff reported Resident # 2 had verbal behaviors and would curse/yell at staff when agitated/upset. Staff reported physical behaviors. Resident #2 would threaten staff, threw juice at the nurse, threatened to break a window with a chair, rammed his shoulder into a door of the nurses' station, kicked a door, took items off nurses cart, and shook drawers on the nurses cart to try to open them. Resident # 2 got easily agitated and upset related to the refrigerator in the CCDI unit being locked with increased behaviors when he didn't have cigarettes or couldn't go out to smoke whenever he wanted. The entry recorded Resident # 2 wandered on occasion, paced, and would go into other residents' rooms. The Progress Notes dated 11/15/18 at 2:28 p.m. documented the resident kicked the CCDI unit door open and broke all the cupboard locks in the dining area by pulling the doors apart until they broke. The Progress Notes dated 11/15/18 at 10:36 p.m. documented Resident #2 was found in a female resident's room with his head towards her groin area. Staff removed the resident from the area, and called to the DON (Director of Nursing) to ask if they needed to report the event. At 10:57 p.m. staff placed the resident on 15 minute observation checks and then found the resident back in the female resident's room, sitting on the end of her bed. The Progress Notes dated 11/16/18 at 10:51 a.m. documented Resident #2 wanted a razor and therefore he kicked open the locked supply door when staff did not respond to his request fast enough. At 11:30 a.m. the notes recorded staff informed the physician Resident # 2's behaviors involved staff members, other residents, as well as damage of property; an order received to send the resident to the ER due to high risk of injury to self and others. At 12:30 p.m. the notes documented the resident sent to the ER and at 4:50 p.m. noted the resident returned to the facility. The Progress Notes dated 12/3/18 at 3:24 p.m. documented Resident #2 approached another male resident to request salt and pepper and when that resident did not understand, Resident #2 became verbally aggressive and grabbed the salt/pepper from that resident. Resident #2 said told that resident to not act stupid. At 5:57 p.m. Resident #2 refused medication, stating he felt like a prisoner and after being served a plain hamburger. Resident #2 threatened to go to his room to get his boots in order to kick in the door and he told staff he could smoke anytime he wanted, he did not care what the nurse said. Staff responded they needed Resident #2 to wait a bit because they did not have a second person in the unit at the time to take him out. The Progress Notes dated 12/5/18 at 6:32 a.m. documented Resident # 2 had paced since 4:00 a.m. waiting for a cigarette as no staff available to take the resident out to smoke. The Progress Notes dated 12/7/18 at 3:01 p.m. documented the CCDI unit nurse paged to the unit and the ADON (Assistant DON) found another resident lying on the floor with spilled coffee around him and a skin tear. Resident # 2 made contact with the other resident, resulting in a fall. Resident # 2 said he wanted in to the other room to make a phone call and the other resident stood in the doorway so he asked him to move but he didn't move. Resident # 2 said he didn't push him, he moved him, and would never push another man. The entry documented Resident # 2 placed on 15 minute checks. At 3:06 p.m., another nurse documented Resident # 2 had approached the nurses station, shoved another resident at the doorway at the same time he told that resident to get out of his way as he wanted to call his sister. The Progress Notes dated 12/7/18 at 11:06 p.m. documented Resident # 2 yelled at another resident about the TV remote. The Progress Notes dated 12/11/18 at 5:47 p.m. documented Resident # 2 left the dining room stating he wanted the boss called to get some decent food. When staff informed him the boss had gone for the day, Resident # 2 said he would kick the door in and pack his stuff up to go back to the streets. Staff called the Administrator at home and instructed kitchen staff to cook what Resident # 2 agreed to. Resident # 2 responded that he didn't want that, yelled, appeared threatening in his approach in the dining room and upsetting other residents, so staff asked Resident # 2 to leave the room with the writer, which he did. The late entry Progress Notes dated 12/14/18 at 8:10 a.m., created by the MDS Coordinator, documented upon the MDS Coordinator's arrival to the facility at 5:00 p.m. Resident # 2 was found standing in front of the TV in the West dining area of the facility yelling about the food being the same for 4 days. The MDS Coordinator approached the aide standing next to Resident # 2 to ask why he was out of the unit to which the CNA responded to ask his nurse. The charge nurse in the CCDI unit attempted to call the on-call staff. The MDS Coordinator walked the resident back to the CCDI unit and Resident # 2 stated he would pack his bags to get out of the place. The MDS Coordinator went back to the Assisted Living (AL) side of the facility and 20 minutes later, staff called to inform her Resident # 2 refused his medications and wanted to smoke; she instructed them to take the resident to smoke. Twenty minutes after that, staff reported Resident # 2 kicked open the CCDI door again and headed out the front door with a CNA following behind. Staff called the police to assist in redirecting Resident # 2 back to the facility and into the CCDI unit. The Progress Notes dated 12/14/18 at 1:27 p.m. recorded Resident # 2 with increased agitation when another resident wore his socks and with increased anxiety when another resident wandered into his bathroom. At 5:31 p.m. Resident # 2 went to the dining area and wanted some 'real food'. Resident # 2 cursed and walked straight to the CCDI unit door, kicked it open and stated staff couldn't keep him there, he was leaving. Resident #2 went and told the kitchen staff they had served that food for 4 days but he refused any substitutes. Management staff walked him back to the unit where he packed his belongings. At 9:53 p.m. the notes documented that at 6:05 p.m. Resident # 2 knocked open the CCDI unit door again and a CNA escorted him to the main entrance of the building and called police. The Progress Notes dated 12/16/18 at 5:30 a.m. documented Resident # 2 yelled at another resident who watched TV in the activity room. Resident #2 complained that resident didn't know what he was doing and needed to stop messing with the TV. Resident # 2's behaviors came out of nowhere; he scolded a wandering resident and had unpredictable behavior, hard to redirect. At 9:17 p.m. Resident # 2 told the night nurse he would kick the door in that night so she would have paperwork. The entry recorded Resident #2 then calmed to take his medications but escalated within a few seconds to yell at a resident watching TV. The felt anxious and afraid of Resident # 2's unpredictability and potential for violence, so she called the DON to report and the DON reshuffled staff to ensure the nurse was not alone with Resident # 2 after 8:30 pm. The Progress Notes dated 12/19/18 at 7:19 a.m. documented Resident # 2 wanted to smoke at 6:30 but staff informed him they had no lighter as the resident had it in his room from another staff member. The note recorded the resident laughed at staff and denied having the lighter but when he realized he couldn't go to smoke he obtained the lighter from his room. The Progress Notes dated 12/21/18 at 8:53 p.m. documented Resident # 2 ran out of his room into the commons area and yelled at 2 residents in the TV room; the nurse noted Resident # 2's behavior as very unpredictable. At 9:23 p.m. Resident # 2 again yelled at 2 residents watching TV telling them they should be in bed and stop messing with the TV. The Progress Notes dated 12/22/18 at 9:26 p.m. documented Resident # 2 screamed at another resident who accidentally entered his room then he wanted to go smoke. When staff couldn't go right away, Resident # 2 became upset and screamed at the ladies sitting in the hallway and upon returning from a smoke break went to a room looking for 'that idiot'. The Progress Notes dated 12/23/18 at 3:40 p.m. documented Resident # 2 walked in the hallway when another resident with an episode of increased agitation yelled inappropriate language to him at which time Resident # 2 called the resident a crazy b**** and staff redirected him away. At 7:47 p.m. Resident # 2 appeared cocky and strutted arrogantly in the hallway scaring female residents (#47 and #33), by saying 'Boo' in their faces and then yelled at another resident (#24) for messing with the TV. The Progress Notes dated 12/26/18 at 9:59 p.m. documented Resident # 2 exhibited increased agitation toward another resident yelling and getting in the other resident's face to tell him to stay out of his room and to stop messing with the TV. The Progress Notes dated 12/28/18 at 2:42 p.m. documented a late entry for 12/22/18. The entry recorded a CNA reported after breakfast Resident # 2 walked past another resident and smacked them on the bottom. The other resident swung at Resident # 2 and hit him in the left shoulder. Staff separated both residents immediately and noted no injuries. The Progress Notes dated 12/29/18 at 2:50 a.m. documented Resident # 2 had 2 unpleasant interactions with Resident #24 about the TV. The entry recorded Resident # 2 as difficult to redirect. The Progress Notes dated 12/30/18 at 4:14 a.m. documented Resident # 2 had 3 episodes of using abusive language towards Resident #24 early in the shift when Resident # 2 called Resident #24 names and told him to stop messing with the TV. The nurse intervened with limited success. The Progress Notes dated 1/2/19 at 2:03 a.m. documented Resident # 2 called Resident #24 an idiot at snack time and said the resident would have a bowel movement (BM) all over the place. The late entry Progress Notes dated 1/2/19 at 8:14 a.m. documented Resident # 2 refused his meds and wanted to smoke. Resident # 2 pushed past the nurse cursing and stating, he could do whatever he wanted at the facility, could smoke whenever he wanted and staff couldn't stop him or tell him what to do. Resident # 2 went into the nurses office, threw a side table down the hall and grabbed his cigarettes and lighter. Staff I, CNA, took him out to smoke. Resident # 2 refused to return the lighter and stated he didn't mind going back to jail because the food better and he hadn't eaten in 3 days, and that he could do what he wanted because the state paid for him to stay at the facility. The nurse contacted the Administrator who informed staff the resident was no longer allowed to light his own cigarettes and staff must maintain possession of the lighter and keep the nursing office door closed at all times. The Progress Notes dated 1/4/19 at 10:45 p.m., created by the MDS Coordinator, documented at approximately 8:15 p.m. she spoke with another staff member on the phone while Resident # 2 stood 2.5 feet behind her asking to go smoke in a loud voice. The MDS Coordinator informed Resident # 2 she was the only staff member in the unit and no one could take him outside. Resident # 2 yelled he wanted to go f***ing smoke and they better get staff back here to take me. The MDS Coordinator locked the medication cart, went into the nurses station, and shut the door. The MDS Coordinator documented she was not going to cater to Resident # 2's temper tantrum. The MDS Coordinator documented Resident # 2 ripped the computer from the wall plug, threw it down the hallway, and cleared the medication cart of every single item on it. The MDS Coordinator called 911 then a code red for help and a nurse from the west side of the facility arrived within a few minutes to find Resident # 2 standing up against the railing and within 2 more minutes, the police arrived. The MDS Coordinator informed the Administrator and then police and EMS (Emergency Medical Services) who escorted the resident from the premises. The Progress Notes dated 2/19/19 at 2:05 p.m. documented Resident # 2 returned to the facility via a taxi service, he recognized staff and greeted them accordingly. At 3:25 p.m. the resident recognized all management staff and made jokes about the gang being back together and he already broke the rules. The Progress Notes dated 2/21/19 at 5:03 a.m. documented Resident # 2 wanted a smoke and repeated 4 times he needed a smoke to go back to sleep. The nurse re-educated Resident # 2 of the signed rules to which Resident # 2 started to pace the halls stating, take me back to the hospital, you better call somebody. The nurse attempted to give as needed anxiety medication but Resident # 2 refused and pulled on the main door. The note documented after an inability to open the door, Resident # 2 sat down and finally relented. The Progress Notes dated 2/24/19 at 1:00 a.m. documented staff educated Resident # 2 after he jumped around in hallway in front of others yelling, Hi-Ya, and kicking his leg and waving his arms. Resident # 2 said he was just showing them his karate moves and repeated his actions in front of the nurse. They educated Resident # 2 on inappropriate behavior. At 12:57 p.m. Resident # 2 continued 15 with minute checks and he had been very demanding that day. Resident # 2 waved a paper in a female resident's face and antagonizing her. When staff attempted to redirect him, Resident # 2 was slow to respond and stared at that person in a defiant manner. The Progress Notes dated 2/25/19 at 6:49 p.m., created by Staff G, LPN (Licensed Practical Nurse) documented she received report Resident # 2 sought out staff to take him to smoke and was agitated he couldn't go; he had a smoking schedule to follow. Staff G documented Resident # 2 was in the TV lounge, smacked a resident in the left temple of face, then went down CCDI hallway, smacked another resident on the buttocks and then ducked aside in another residents room. The nurse immediately notified the management team of the behavior/incidents, police arrived at 1:15 p.m. and Resident #2 transferred to the hospital. Review of the clinical record revealed Resident #2 on continual 15 minute observation checks from 10/29/18 through 2/25/19. Observations: Observation on 2/25/19 at 11:57 a.m. revealed Resident # 2 requested Staff K, Certified Nurse Aide (CNA) to take him out to smoke then shower. Staff K informed Resident # 2 the next smoke break would be at 1:00 p.m., asked him to shower and have lunch and then it would be almost time for his smoke break. Resident # 2 demanded Staff K call the director to report he couldn't go out to smoke. Staff K informed the resident she would call but had something to do right that moment. Resident # 2 became angry and stated he was going out to smoke and Staff K better call the director right then. Staff K responded she would call but the director in a meeting at that time and would just tell him the same thing. Observation on 2/25/19 at 12:04 p.m. revealed Staff C, Certified Medication Aide (CMA) took 3 other residents out the CCDI unit doors to the East hallway. Resident # 2 stood at the medication cart by the door and got in line behind the others to leave. Staff K blocked the entrance when Resident # 2 attempted to walk through with the others. Staff K held onto both doors as Resident # 2 pushed against her. Staff K continued to hold the doors and Resident # 2 increased his agitation. The Admissions Coordinator intervened at the door and told Staff K to let Resident #2 through and then walked with Resident # 2 hand in hand to the front offices. The DON and the Admissions Coordinator walked with the resident back to the CCDI unit. The DON was able to keep the resident calm and approached him gently; joking lightly with the resident. Resident # 2 allowed the DON to tie his shoes once on the unit and discussed smoking times. Resident # 2 interacted well with the DON. Resident #2 agreed to the 1:00 p.m. smoke time and shower and the DON encouraged him to take off his coat. As Resident # 2 took off his coat, he repeated shower-smoke, shower-smoke, then Resident # 2 said he wanted to smoke now. The DON had to continue to interact with the resident to redirect him away from the topic of smoking. The Admissions Coordinator accompanied the DON and Resident # 2 back to his room with encouragement to lay down for a while. Observation on 2/25/19 at 12:45 p.m. revealed Resident #2 walked up the hallway from the TV room by the nurse's station passing Resident #47. A loud slap could be heard and Resident #47 yelled Ouch; I'm tired of you hitting me. Resident #2 made eye contact with surveyor and quickly walked into room [ROOM NUMBER]. Resident #47 turned and walked back down to the TV room. Another resident (#36) walked up the hall to the nurses station from the TV room at the same time and informed Staff K that Resident #2 just slapped him. The surveyor reported the slap on Resident #47's buttocks immediately to Staff J, CNA, and Staff K. Staff J called for management help in the unit immediately. Staff Interviews revealed the following information: On 2/25/19 at 11:53 a.m., the Activities Assistant stated Resident #2's current condition was about the same as before he left the unit to the hospital. The Activities Assistant confirmed the resident lived in the facility since approximately (MONTH) of (YEAR). The Activities Assistant commented that residents seemed intimidated by Resident # 2. On 2/25/19 at 11:59 a.m., Staff K stated she did not know the resident's previous level of functioning as she was new to the facility and only worked her third orientation day. Staff K was not working on her own yet. On 2/25/19 at 2:11 p.m., the Administrator and the owner reported a police officer was in the building and would be escorting Resident # 2 to the hospital as they were actively initiating an involuntary discharge related to resident safety. The Administrator and owner reported they were forced by the Administrative Law Judge (ALJ) to take the resident back from the hospital 2/19/19. They stated the ALJ informed them they provided the wrong language in the Emergency Involuntary Discharge notice they gave upon discharge in (MONTH) (1/4/19). They didn't want to take the resident back but they had to follow the judge's order. In an interview on 2/25/19 at 2:55 p.m., Staff G, LPN, responded she assessed Resident #47 and she did not have any marks (2/25/19). Staff G responded Resident # 47 recalled what happened and stated feeling scared of Resident #2. Staff G didn't think Resident #2 had been gone long enough for the residents to get him out of their heads (when he left 1/4/19). Staff G said Resident #47 stated she always walked on the far side of the hall because she had to look out for Resident #2. At 3:25 p.m., Staff G stated she thought Resident # 2's behaviors for that day were set off by his desire to go out and smoke. Staff G stated she was a rule follower and told Resident # 2 he had to wait until the scheduled smoke time of 1:00 p.m. to go out. When the resident first came to the facility he was more aware of the exits and of the other residents' disabilities which frustrated him. Staff G felt Resident # 2 did not understand mentally why the other residents were confused due to their cognitive declines. Staff G gave the example when a resident would be exit seeking, Resident # 2 informed the exit seeker there was a back door and he would take them to the door to try to help them out. On 2/26/19 at 7:46 a.m., Staff G reported the residents were much calmer than the day before. Their anxiety level were way down since Resident #2 left the night before versus when Resident #2 resided on the unit. Staff G thought the residents were aware Resident #2 had gone and thought they had been hesitant to even sit next to Resident #2 for fear he would bully them. On 2/26/19 at 8:00 a.m., Staff L, CNA, stated she had worked for the facility for 3 years. The residents acted more calm that day and she felt they knew when Resident # 2 was on and off the unit. Staff L stated Resident #33 acted scared of Resident # 2; she felt Resident # 2 knew it and focused in on Resident #33's fear. Resident #2 always had behaviors since his admission in (MONTH) (YEAR). Staff tried to redirect Resident # 2 to the TV room or to play checkers but activities did not divert Resident # 2. Resident # 2 would get into the residents' personal spaces, especially Resident #33. Resident # 2 would get into Resident #33's face, wave his arms around, and when Resident #33 tried to walk away with staff, Resident # 2 followed them and continued to antagonize the residents. Staff L thought Resident # 2 knew what he was doing when he intimidated the other residents and it was possible the resident did things to other residents that staff were unaware of when they weren't looking due to being a full watch hall. Staff L explained a full watch hall meant they were constantly going up and down the halls to observe everything going on, so if they went down the hall one way and Resident # 2 went the other way, it would be possible for Resident # 2 to have interactions with other residents without her being aware of it. In an interview on 2/26/19 at 8:45 a.m., the Activities Assistant responded she was in charge of activities in the CCDI unit and out in the main facility. The Activities Assistant stated she did some activities on the unit but tried to gather residents from the CCDI unit and take them out to the main facility to join activities. The Activities Assistant stated she provided some supervision when present on the unit but she had no set times scheduled there. On 2/26/19 at 2:25 p.m., the DON discussed her summary of what the facility did to increase supervision of Resident #2 after signs of aggression and resident-to-resident altercations occurred. The DON said for the incident of resident-to-resident contact between Resident # 2 and Resident # 55 that occurred on 12/7/18, they increased to 15 minute checks, the doctor evaluated Resident # 2 on 12/13/19 and changed medications. The DON stated for the incident of resident-to-resident contact between Resident # 2 and Resident # 47 that occurred on 12/22/18, they did not become aware of the incident until 12/28/18. The DON said at that time they notified the DIA (Department of Inspections and Appeals), disciplined a charge nurse for not reporting immediately and placed Resident #2 on 15 minute checks; when 15 minute observation checks were initiated, they conducted them for 72 hours, but if the behaviors continued they would put a resident back on the checks. The DON had Resident #2 sign a contract agreement to acknowledge the expectation that all residents keep their hands to themselves, residents cannot pinch, slap, grab, or make contact with another resident in any other manner, it was not a joke, it was not funny, and it was not allowed. The DON confirmed the resident a BIMS score of 3 but they still presented the contract as they felt he was aware of his actions. When the facility accepted Resident # 2 back the second time 2/19/19, they did not get any information about him needing to be held down in the hospital for injections or that he had been moved units due to some sexual interactions. The DON stated they did not receive that information until approximately 2 days after the resident returned to the facility. The DON stated when Administrative Law Judge (ALJ) ruled they must take Resident # 2 back on 2/19/19, they decided to place him on 15 minute checks indefinitely. The DON reported the facility called the police who witnessed the resident's sister receiving notification of an Emergency Involuntary Discharge notice and then the police officer escorted the ambulance to the hospital to deliver the paperwork to the hospital 2/25/19. In an interview on 2/26/19 at 4:00 p.m., the DON responded the staff on the unit responsible for completing the 15 minute observation checks and confirmed no additional staff had been put back in the unit to assist with 15 minute checks. In an interview on 2/27/19 at 11:00 a.m., Staff N, CNA/Scheduler stated she knew of 2 residents on the unit who showed they were bothered by Resident # 2: Resident #47 and Resident #33. Staff N stated she had not received a directive to staff 2 staff members on the CCDI unit until Resident # 2 returned to the facilit

Based on record review, and resident, family and staff member interviews, the facility failed to ensure that residents remained free of significant medication errors for 1 of 7 resident records reviewed (Resident #1). The facility reported a census of 85 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 2/19/17 revealed Resident #1 had [DIAGNOSES REDACTED]. least 1 staff member for transfers to and from bed and chair, dressing, bathing, toileting and personal hygiene, unable to ambulate, able to make self understood and understood others. The nursing care plan included problems identified as potential for fluid deficit related to medication use, diabetes, potential for depressive symptoms related to depression diagnosis, potential for pain symptoms and nutritional deficits, and directed staff to administer medications as ordered, monitor and document side effects and effectiveness of medications. Physician orders [REDACTED]. Aspirin 81 milligrams (mg) administered oral daily at bedtime. Buproprion [MEDICATION NAME] (an antidepressant) 300 mg extended release administered oral daily. Carbodopa/[MEDICATION NAME] [MEDICATION]) 25-100 mg administered oral daily. [MEDICATION NAME] AER 20-100, 2 puffs inhaled by mouth 5 times daily. Duloxetine (an antidepressant) 20 mg administered oral daily. [MEDICATION NAME] (treats prostatic enlargement) 5 mg administered oral daily. [MEDICATION NAME] (a diuretic) 20 mg administered oral 3 times weekly on Monday, Wednesday and Friday. [MEDICATION NAME]/[MEDICATION NAME] 500-400 tablet (supplement for arthritis treatment) oral daily. Oyster Shell/Vitamin D 500/200 mg tablet oral daily. [MEDICATION NAME] (laxative) 17 Grams in 4 - 8 ounces of water or juice daily. [MEDICATION NAME] (anti-cholesterol) 40 mg administered oral daily Tamsulosin (eases urination) 0.4 mg administered oral daily. Thera Beta multivitamin with minerals tablet oral daily. [MEDICATION NAME] (anti-diabetes) 5 mg administered oral daily Humalog insulin 20 units injected subcutaneously (under the skin) 3 times daily at meals. [MEDICATION NAME] 60 units injected subcutaneously daily at bedtime Humalog insulin administered subcutaneously 4 times daily on sliding scale related to blood glucose results, for blood glucose of 151 or above. The facility's Medication Administration Policy dated as last reviewed on 12/18/12 directed staff: 1. Identify resident by pictures and check the medication administration record (MAR). Check to see if the resident has any allergies [REDACTED]. 2. Read the label 3 times before dispensing medication into the medication cup: When taking from the drawer. Before pouring it (removal from dispensing container). When putting container back in drawer. 3. Remove the medication from the dispensing container. 4. Record the medication given on the MAR by initialing the proper square (on the MAR). Never chart a medication as given until it has been administered. The facility's self-reported incident described Resident #1 received another resident's medication (Resident #2) by mistake on the morning of 4/9/17. Record review revealed Staff A, licensed practical nurse (LPN), administered the following oral medications to Resident #1 on the morning of 4/9/17, the medications were labeled and ordered for Resident #2: 1. Aspirin 81 mg. 2. [MEDICATION NAME] (muscle relaxer) 30 mg. 3. [MEDICATION NAME] (muscle relaxer) 10 mg. 4. Dantrolene (muscle relaxer) 100 mg. 5. Dexilant (treats [MEDICAL CONDITION] reflux) 60 mg. 6. [MEDICATION NAME] Sodium (stool softener) 100 mg. 7. [MEDICATION NAME] (diuretic) 40 mg. 8. [MEDICATION NAME] ([MEDICATION NAME] and anti-[MEDICAL CONDITION]) 200 mg. 9. [MEDICATION NAME] sprinkles (potassium supplement) 10 milliequivalents. 10. L-[MEDICATION NAME] (amino acid) 500 mg. 11. [MEDICATION NAME] ([MEDICATION NAME]) 10 mg. 12. Milk of Magnesia (laxative) 1 ounce. 13. [MEDICATION NAME] ([MEDICATION NAME] that relaxes bladder muscles) 5 mg. 14. [MEDICATION NAME] (a strong narcotic [MEDICATION NAME]) 30 mg CR (continuous release). 15. [MEDICATION NAME] (laxative) 17 Grams in 8 ounces of water or juice. 16. [MEDICATION NAME] (antipsychotic) 50 mg 17. Sennalax-S (stool softener and laxative) 8.6-50 mg, 2 tablets. 18. Thera Beta multiple vitamin. An undated written statement signed by Staff A stated on 4/9/17 at 9:00 a.m., she administered Resident #2's medications to Resident #1 by error, realized she made a mistake when she returned to the medication cart to prepare Resident #2's medications, placed a phone call to Resident #1's physician, a return call at 9:15 a.m. by the provider on-call for the physician directed her to administer the routine medications to Resident #1 with exception of [MEDICATION NAME] and Duloxetene which were to be administered at bedtime, the resident to remain observed with hourly vital signs for 8 hours, if the resident became more somnolent they could transfer to the emergency room at the hospital. A Nurse's Note transcribed by Staff A on 4/9/17 at 10:02 a.m. stated the resident received another resident's medications at 9:00 a.m., the physician notified and the orders received. The next Nurse's Note entry on 4/9/17 at 1:53 p.m., also transcribed by Staff A, stated the resident remained very lethargic, unable to open eyes or elicit verbal response, family concerned that resident was unresponsive, requested transfer to the emergency room and call placed for ambulance transport to the emergency room . The emergency room physician progress notes [REDACTED]. liters per minute per nasal cannula applied. The resident remained somnolent in the emergency room , aroused to painful stimulus and voice, required hospital admission with cardiac monitor for altered mental status secondary to medication overdose. The resident remained hospitalized for [REDACTED]. Observation of the medication dispensing system used by the facility revealed each medication in a dispensing card with 31 compartments that corresponded with the date of the month, and each card labeled with the resident's name, medication name, dosage, frequency, route and prescription number. Staff A's personnel file revealed she was hired as an LPN on 8/10/16, and made a medication error on 1/20/17 when she administered 10.5 milligrams of [MEDICATION NAME] (a high dose of a blood thinning medication) to the wrong resident when the medication dispensing card was mixed up with the wrong resident's other medication dispensing cards. The resident required [MEDICATION NAME] (a medication used to clot or thicken blood) 2.5 milligrams administered oral 1 time. The Medication Error Report form that described the incident directed the employee to pay more attention to the names on the medication dispensing cards. During an interview on 6/12/17 at 3:30 p.m., the director of nursing (DON) denied the staff member received disciplinary action or the medication error because it was her 1st medication error. During an interview on 6/7/17 at 10:37 a.m., Staff A stated she thought the medication error with Resident #1 happened because she was distracted, she had the MAR opened to Resident #1's record, realized when she pulled Resident #2's medication dispensing cards and noticed that the medications for the 9th had already been dispensed she had made the error, and she had made medication errors before but not like the one of 4/9/17. During an interview on 6/12/17 at 12:10 p.m., the DON stated Staff A told her she hadn't looked at the MAR or read the medication dispensing cards when she interviewed her about the error. The DON also stated Resident #1's and Resident #2's medications were contained in the same drawer on the medication cart and the employee did not read the name on the cards before she dispensed the medications. During an interview on 6/7/17 at 6:25 a.m., Staff B, certified nursing assistant (CNA) and certified medication aide (CMA) stated when she dispensed medications she located the resident's medication dispensing cards labeled with the resident's name in the medication cart, compared the dispensing instruction on the dispensing card to the MAR and verified they were the same before she dispensed the medication. During an interview on 6/7/17 at 9:30 a.m., Staff C, CNA, stated she worked on the day shift on 4/9/17, the nurse (Staff A) directed the CNA's they had to keep an eye on the resident, they moved the resident to a recliner by the dining room after breakfast, normally the resident transferred with a stand lift but they had to perform a manual 2 man transfer because the resident was lethargic and couldn't stand, the lethargy started around 10:30 a.m., when the paramedics came she could tell they were nervous and they asked why they hadn't been called sooner. During an interview on 6/7/17 at 9:04 a.m., Staff D, CNA, stated she worked on the day shift on 4/9/17, they transferred the resident from a recliner chair to his/her power wheel chair with the stand lift before lunch, the resident didn't eat lunch, and manually transferred by 3 staff after lunch because the resident couldn't stand and they couldn't get the resident to respond, thought it happened between 12:30 p.m. and 1:00 p.m. During an interview on 6/7/17, the resident's responsible party stated he/she was notified of the medication error a few hours after it had occurred, when they arrived at the nursing home the resident was very lethargic, didn't respond to questions and wouldn't wake up, and he/she had to demand the resident's transfer to the emergency room , that Staff A kept telling him/her they could monitor the resident at the facility, but he/she volunteered as an Emergency Medical Technician and knew the resident needed to go to the hospital based on his/her worsening condition. During on interview on 6/8/17 at 3:02 p.m., the nurse practitioner at the resident's physician's office stated the medication error on 4/9/17 was a significant medication error and caused Resident #1's symptoms that required hospitalization and treatment.

Based on record review, staff interviews and review of policy/procedures, the facility failed to perform a nursing assessment prior to moving a resident after the resident fell which caused the resident pain and placed the resident at risk for further injury (Resident #6). The sample consisted of 4 residents and the facility reported a census of 86 residents. Findings include: 1. Resident #6 had a MDS (Minimum Data Set) assessment with a reference date of 5/22/16. The assessment identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMS (Brief Interview for Mental Status) score of 14 out of 15. A score of 14 identified the resident had no cognitive problems. The MDS indicated the resident required assistance of one staff person for ambulation, toileting, and transfers. The Care Plan dated 10/29/14, and revised on 12/2015, included the resident had a risk for falls due to a history of stroke, right [MEDICAL CONDITION], and poor balance. The Care Plan directed staff to place the call light within reach, respond promptly to all requests, and encourage the resident to use a reacher (device to grab items) or ask for assistance. A fall assessment form dated 7/14/16 at 9:20 p.m., identified the resident leaned forward to reach the bed control and fell , landing on his/her right side. The resident complained of left hip pain. Review of the Nursing Notes dated 7/14/16 at 10:00 p.m., revealed the staff found the resident on the floor beside the bed. The resident fell when he/she reached for the bed control and slid out of the wheelchair. Staff H, Registered Nurse, documented the resident was found lying on the floor on his/her right side, but able to stand and sit on the side of the bed. Staff H documented the resident complained of left hip pain and vital signs stable. Staff H charted the resident had no wounds or injury, the resident moved both legs and feet, and had normal range of motion. The nurse obtained an order and requested a stat portable x-ray. Review of a History and Physical progress note and the transfer form dated 7/16/16 revealed the resident had an impacted left femoral head fracture. The hospital physician visit note dated 8/1/16 identified the resident had surgical repair of the left femur fracture and postoperative debility. The resident had a left hip incision with 26 staples and without signs and symptoms of infection. and pain controlled. A facility policy and procedures titled Fall Assessments, dated 2/16/10 directed the staff that fall assessments will be performed on all residents experiencing a fall. The procedure directed staff to evaluate the resident for injuries, provide first aid treatment and obtain vital signs after a fall. On 10/26/16 at 2:45 p.m., Staff G, Certified Nursing Assistant (CNA) was interviewed and stated Resident #6 fell on ,[DATE] and 7/14/16. On 7/14/16, she found the resident on the floor and the resident complained of a lot of pain. Staff G reported Staff H, Registered Nurse (RN), came into the resident's room and told the CNAs to get the resident up. Staff G told Staff H the resident had reported he/she heard a crack in his/her hip when the resident fell . Staff H told Staff G and Staff C, CNA, to stand the resident up. Staff G then asked Staff H if she was sure. Staff G reported that Staff H had not assessed the resident, did not perform a neurological assessment, or checked any vital signs before Staff G and Staff C assisted the resident up. Staff H left the room and called the physician. Staff G heard Staff H tell the physician she didn't think the resident broke (fractured) anything. Staff G and Staff C assisted the resident into bed. Staff G reported when the resident sat on the bed, the resident started screaming. Staff G stated the facility procedures after a resident fell included the nurse should perform an evaluation on the resident, ask the resident to move arms and legs, determine if the resident had pain anywhere, and check vital signs before staff got the resident up. On 10/26/16 at 3:08 p.m., Staff H, RN, reported she hadn't worked at the facility since September 2016. Staff H recalled Resident #6 had two falls in a row within a couple of days. A CNA informed her when the resident fell on [DATE]. Staff H stated she went to the resident's room and found the resident lying on his/her side. The resident was alert, and complained of hip pain. Staff H reported she could not recall if she obtained vital signs before or after the staff CNAs put the resident back in bed or a chair. Staff H kept repeating she didn't remember. Staff H was read the statement in the Nurse ' s Notes of 7/14/16. Staff H reported she vaguely remembered the incident. On 10/27/16 at 1:30 p.m., Staff C, CNA, reported another resident told her Resident #6 was found lying on the floor. Staff C stated she went to the resident's room and asked Resident #6 if he/she had any pain. The resident said no. Staff H told the CNAs to stand the resident up. Staff H did not check any vital signs or assessed the resident while the resident lay on the floor. Staff C asked Staff H is she was sure about getting the resident up, and Staff H said to get the resident up. Staff C stated she had questioned Staff H three times on checking the resident over before they got the resident up, and Staff H told Staff C to just stand the resident up. When Staff C placed a gait belt around the resident and stood the resident up, the resident complained of pain. Staff C reported she didn't know what to do when Staff H insisted on getting the resident up after the resident had fallen, and Staff H hadn't evaluated the resident per facility procedures. Staff C reported she didn't want to get the resident up until after a nurse had evaluated the resident, but Staff H was the charge nurse and insisted the CNAs needed to get the resident up. During an additional interview on 10/27/16 at 4:02 p.m., Staff H stated again that she could not remember if the time documented in the nurse's notes was the actual time when the resident fell or the time she documented in the nurse's notes. When asked Staff H if an assessment and vital signs had been completed before staff assisted the resident off the floor or after the resident was assisted off the floor, Staff H continually responded that she couldn't remember. Staff H stated she couldn't remember if an x-ray had been completed during her worked shift. During an interview on 10/27/16, at 2:10 p.m., the Director of Nursing (DON) reported Staff C had reported to her Staff H had not performed an assessment after Resident #6 fell on [DATE]. The DON reported she had just found out what had occurred on 7/14/16, when Staff C had confided to her that Staff H did not complete an assessment before directing 2 CNAs to stand the resident up. The DON stated that Staff H had falsified documentation and failed to perform assessments when Staff H worked at the facility. The DON reported Staff H failed to change a dressing on a resident for 3 days, but had documented the treatment and dressing changes were completed. The DON also reported Staff H had not completed assessments on a couple of the residents, but later documented the assessments as done. The DON stated the facility terminated Staff H ' s employment on 9/8/16. During an additional interview on 10/31/16, at 2:35 p.m., the DON stated she expected the staff follow the fall assessment procedure when a resident fell . The DON reported the fall assessment included: checking the resident for obvious signs of injury or bleeding, neurological assessment performed, and vital signs checked, before the residents are moved. The DON stated the staff received education on 10/27/16 when she learned staff had not followed protocol or completed an assessment before a resident, who had fallen, had been moved.

Based on record review, staff interviews and review of the facility policy/procedures, the facility failed to provide appropriate care and services to prevent the development of avoidable pressure ulcers (Resident #5). Resident #5 required 2 or more staff to reposition in bed. The facility did not have a turning or repositioning program and did not implement pressure relieving measures to prevent the development of pressure sores on the heel and the coccyx area. The sample consisted of 4 residents and the facility identified a census of 92 residents. Findings include: 1. Resident #5 had an admission Minimum Data Set (MDS) assessment, with a reference date of 3/22/16. The MDS identified the resident had severely impaired cognition, required extensive assistance from staff for activities of daily living including ambulation, hygiene cares, and toileting. The resident required 2 or more staff for bed mobility needs. The MDS identified the resident ' s [DIAGNOSES REDACTED]. The resident was admitted on [DATE] for skilled cares related to the hip surgery. The MDS identified the resident at risk for the development of pressure ulcers. The MDS reflected the resident did not have any pressure ulcers, venous or arterial ulcers on admission. The preventive items listed in the MDS Skin and Treatment Section noted a pressure reducing device for the chair and bed was provided for the resident. The MDS reflected the resident was not on a turning or repositioning program or nutritional supplements aimed at prevention of skin issues. The admission Braden Scale (pressure sore risk assessment) documented Resident #5 had a score of 19 on 3/15/16 and 14 on 3/22/16. The Braden Scale identified the resident as initially assessed as not at risk but became a moderate risk as staff became more familiar with the resident. The scale for the Braden scores is as follows: <9 =very high risk 10-12= high risk 13-14= moderate risk 15-18= at risk The undated Interim Plan of Care instructed staff to provide routine skin care for Resident #5. The dietary component of the Care Plan instructed staff to assess the skin integrity every day PRN (as needed). The Admission Resident Data Collection form noted Resident #5 had a surgical incision on the outer aspect of his/her right hip with a dressing and skin was warm and dry. Review of individual Non-Pressure Skin Condition reports dated 3/15/16 revealed the resident ' s following skin issues were identified at the time of admission- right knee bruise, right hand bruise, left leg (foot) bruise, right wrist bruise, right bicep- no description of issue, left shin bruise, left wrist bruise, and right hip/thigh surgical wound. Review of individual Non-Pressure Skin Condition report dated 3/27/16 revealed an unknown staff member documented a new skin issue located on the mid-buttocks with excoriation and measuring 0.5 centimeters (cm) by 1 cm and a thin layer of skin- no drainage. Staff A, Assistant Director of Nursing (ADON) and wound nurse, initiated an individual Non-Pressure Skin Condition Report on 3/27/16 and documented the resident had an excoriated perineal-rectal area with yeasty foul odor. A Wound/Skin Healing Record, dated 3/30/16 indicated Staff A documented a pressure ulcer was located on the resident ' s coccyx. Staff A assessed and measured the wound as 4 cm by 4 cm stage two with a 10 cm pink area surrounding the open area. The wound bed was described as pink, beefy red, slough, and granulation tissue. Staff A documented on the form that on 3/31/16 she ordered an alternating air mattress for the resident and requested the physician order for [REDACTED].>An individual Non-Pressure Skin Condition report dated 3/30/16 documented the identification of a 9 cm by 3.5 cm area on the resident ' s mid- back with purple excoriation. A nurse sent a facsimile (fax) report to the physician on 3/27/16 with notification of the yeasty excoriated perineal-rectal area and the open area located on the coccyx. The physician ordered Lotrisome Cream for the perineal-rectal area twice a day for 14 days and to clean the coccyx wound, pat dry, and apply [MEDICATION NAME] ointment twice a day until healed. A second fax report was sent to the physician on 3/27/16 with notification that Resident #5 had a 3 cm red/purple blister on the right heel. The Nurse, Staff B, Licensed Practical Nurse (LPN), requested a treatment of [REDACTED]. Staff B also told the physician that she placed Prafo boots (padded boots used to relieve pressure off of the heels when a resident is in bed) on the resident at this time. A fax report was sent to the physician on 3/30/16 by Staff A and described the coccyx area as 9-10 cm in diameter, open with yellow-white slough. She requested an order to apply a [MEDICATION NAME] dressing for protection of the area. Staff A also requested an order for [REDACTED]. Review of the East Shower Schedule indicated Resident #5 was to receive a shower on Tuesdays and Fridays. The resident received three showers during the two weeks he/she was at the facility (3/18, 3/25, and 3/29). The shower aide was responsible for a total skin assessment each time a resident had a shower and documented findings on an individual form for each resident. The individual skin sheets for Resident #5 did not identify any skin issues on 3/18/16 or 3/29/16. The shower aides documented on 3/25/16 the resident ' s abdominal folds were reddened. The Nurse ' s Notes dated 4/1/16 identified the resident as vomiting and having issues with fluctuating blood pressure readings. The physician ordered the resident be sent to the emergency room for evaluation and treatment. Review of hospital emergency room document titled Integumentary Assessment- Skin Abnormality grid dated 4/1/16, noted the resident had the following skin issues: 1. Buttock- bilateral, posterior, ecchyomotic (bruising) areas/ulcer. 2. Sacral- Bilateral, upper, posterior, ecchyomotic areas/ulcer, excoriation (abrading or wearing off of skin). 3. Vagina- Bilateral, ecchyomotic areas, excessive dryness, bumps. Comment: when cleaning up patient noticed a sacral ulcer Stage 2-3 and buttock ulcer stage 1-2 on bilateral buttock. The MDS identified a Stage II pressure sore as 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. The MDS identified a Stage III pressure sore as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. On 4/27/16 at 4:00 PM the Director of Nursing (DON) was interviewed and stated the admission procedure is to assess the resident ' s skin and provide interventions for protection of skin integrity as determined by the assessment. She stated all residents are given a pressure relieving mattress for their bed. Most residents also receive a Mosaic pressure relieving cushion for their wheelchairs. The DON acknowledged that Resident #5 recently had hip surgery and was restricted in mobility initially on admit. She agreed the interventions should be in place to prevent the development of skin issues upon admission for all residents who are not independently able to ambulate. She stated the bath aides are responsible for noting any new skin issues and reporting to the nurse. The DON stated the CNAs providing perineal hygiene cares for residents are also responsible for notifying nurses of new skin issues. She stated she had identified an issue with failure of staff to consistently re-position residents and recently had been re-educating staff about this to prevent pressure ulcers. She stated she prefers to educate and coach staff when issues indicating staff non-compliance arise. However, the next step would be disciplinary actions. She stated the ADON and Staff C are currently auditing staff on multiple cares. On 4/28/16 at 9:30 AM Staff A, Assistant Director of Nursing (ADON) and Wound Nurse was interviewed and stated she is responsible for assessing resident skin issues weekly and documentation of the findings. She stated if a skin issue is identified during the day, the nurse will come get her to assist with the initial assessment. If the issue is identified when Staff A is not at the facility, then the nurse will do an assessment, notify the physician for treatment, and leave a note for her or leave a message for her during shift report. Staff A stated she was not informed of Resident #5 ' s skin issues until 3/27/16. She initiated skin sheets and interventions at that time for the resident ' s buttock and perineal area issues. She stated she ordered an air-alternating mattress and requested orders from the physician to insert an indwelling catheter. Staff A does not recall she received notification of the blister on the resident ' s heel and this is why a skin sheet was not started. She agreed that if interventions had been in place for Resident #5 prior to the development of skin issues then the resident may not have developed the issues or the severity might have been lessened. Staff A stated the resident did not receive a weekly skin check during the week of 3/18/16 through 3/25/16 because the resident did not receive a shower as scheduled and this also could have contributed to the late notification of the resident ' s skin issues. On 4/28/16 at 10:30 AM, Staff B, LPN (Licensed Practical Nurse) was interviewed and stated she identified the blister on the resident ' s heel on 3/27/16. Staff B stated the Wound Nurse was not working that day so Staff B notified the physician, placed preventative boots on the resident ' s feet, started a wound sheet, and called Staff A at home to notify her of a new skin issue for the resident. Staff B stated the skin sheet she started must have been misplaced. Review of a policy titled Skin Care Management Program, dated 10/10, identified a plan to prevent skin breakdown should be initiated to meet the resident ' s needs based on the admission assessment and according to this policy. Each resident was to receive a weekly skin assessment completed by an assigned nurse utilizing the Weekly Skin Assessment Sheet forms. A skin record/report should be initiated at the time that a new pressure ulcer or break in the integrity is found.

Based on record review and staff interviews, the facility failed to provide adequate supervision to avoid accidents for one resident known to be a fall risk (Resident #1) and the facility failed to provide adequate supervision for residents on a chronically confused and demented individual unit (CCDI) that wander into other resident rooms. (Resident #2 and #11) The facility census was 89. Findings include: RESIDENT #2 FALL 6/12/15 1. According to Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 exhibited short term memory deficits and moderately impaired cognitive skills for daily decision making. Resident #2 required limited assistance of one staff member for transfers, ambulation, dressing, toilet use and personal hygiene. Resident #2 was incontinent of bladder. Resident #2 had an unsteady gait while walking, but was able to stabilize without staff assistance. Resident #2's [DIAGNOSES REDACTED]. According to Resident #15's MDS assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 4 indicating severely impaired cognitive status. Resident #15 required limited assistance with dressing, toilet use and personal hygiene. Resident #15's [DIAGNOSES REDACTED]. Resident #2's care plan dated 1/8/2015 indicated a problem with history of falls. Interventions included: *Safe, clutter free environment. *Call light within reach. *Appropriate footwear. *Encourage resident to lie down in the afternoon. *Non-skid strips at bedside. Resident #2's care plan dated 1/8/2015 identified he/she exhibited aggressive behaviors at times. Interventions included: *Approach calmly. *Explain procedures before completion. *Maintain eye contact. *Listen to concerns identified. *Attempt to redirect when agitated. *Separate from individual in which he/she is showing aggression towards (updated 4/20/15). *Offer diversion activities (updated 4/20/15). *Moved to CCDI unit where it quieter and calmer (updated 6/3/15). Nursing Documentation and Fall Assessment Form dated 6/12/15 at 3:25 p.m. indicated Resident #2 was in the room of Resident #15 and Resident #15 attempted to get Resident #2 to leave. Resident #2 lost balance and fell face forward. Resident #2 sustained a skin tear to his/her hand, abrasion on the nose and shoulder and a laceration to upper lip. Nurse's notes dated 6/12/15 at 3:25 p.m. indicated the unit nurse was not on the unit at the time of the fall and was summoned by a certified nurse aide (CNA) back to the unit. In an interview on 8/5/15 at 4:00 p.m. the Director of Nursing (DON) indicated Resident #15 was generally quiet and had no history of altercations or aggression towards other residents. In an interview on 8/5/15 at 4:45 p.m. Staff L CNA, indicated she was in the room of another resident next door to Resident #15's room on 6/12/15. Staff L heard a commotion coming from Resident #15's room and as she exited the room she saw Resident #2 falling face first from Resident #15's room into the hallway. Staff L stated Resident #2's head was in the hallway and his/her feet appeared to be located in Resident #15's doorway. In an interview on 8/5/15 at 5:23 p.m. Staff O, licensed practical nurse (LPN) indicated she was working on the CCDI unit on 6/12/15 when Resident #2 fell from Resident #15's room. Staff O confirmed she was off the unit sending a facsimile (fax) when Staff L opened the doors and stated a resident fell . Staff O told additional staff of the fall and responded back to the CCDI unit and found Resident #2 lying on the floor with his/her head into the hallway and legs in Resident #15's doorway. Staff O stated she feared that Resident #15 may have pushed Resident #2, but someone had stated they heard Resident #15's comments to Resident #2 and he/she sounded calm and sounded as if he/she was trying to assist Resident #2 from his/her room. Staff O stated Resident #2 sustained a skin tear on his/her hand and abrasions on his/her shoulder and nose. In an interview on 8/6/15 at 10:35 a.m. Staff N CNA, indicated she was working the evening shift on 6/12/15 and was in the dining room for 3:00 p.m. snacks when Resident #2 fell while in Resident #15's room. Staff N stated she witnessed Resident #2 in the hallway minutes before. Staff N stated she heard the commotion and entered the hallway. Resident #2 was lying in the hallway, outside Resident #15's room. Staff N stated she could not remember for sure, but believes Resident #2's head and upper body was in the hallway and Resident #2's feet towards the doorway of Resident #15 ' s room. RESIDENT #2 FALL 7/13/15 According to Resident #7's MDS assessment dated [DATE], revealed Resident #7 s BIMS score of 15 that indicated an intact cognitive status. Resident #7 was independent with mobility and toilet use. The MDS identified Resident #7, required supervision with dressing and personal hygiene. Resident #7's [DIAGNOSES REDACTED]. Nursing Documentation and Fall Assessment Form dated 7/13/15 at 10:05 a.m. indicated Resident #2 was observed falling out of the doorway of Resident #7's room face first with the door closing directly behind Resident #2. Nurse's notes dated 7/13/15 at 12:50 p.m. indicated Staff G was walking up the hallway from the dining room when she observed Resident #2 ' s fall forward from the doorway of another resident and the door close behind. Resident #2 ' s fall was observed as face first onto the floor. Resident #2's pants were down at his/her knees. Resident #2 was assessed and emergency medical services notified and transported Resident #2 to the hospital. History and Physical dated 7/13/15 indicated CT scan of head found Resident #2 sustained a massive acute left cerebral hemorrhage. Decedent Information noted Resident #2's time of death was 7/17/15 at 3:45 a.m. and immediate cause of death was cerebral hemorrhage. In an interview on 7/27/15 at 4:20 p.m. Staff G LPN, indicated on 7/13/15 she and Staff H were walking from the dining room towards the nurse's station when they observed Resident #2 fall forward onto his/her face from the doorway of Resident #7's room and the door closed immediately behind him/her. Staff G stated failed to witness of any physical contact between Resident #2 and Resident #7. Staff G indicated she last observed Resident #2 in the TV room between 9:30 a.m. and 10:00 a.m. Staff G stated she went in the dining room to fix a snack for another resident and was in there 5-10 minutes. In an interview on 7/28/15 at 8:30 a.m. Staff H CNA, indicated on the morning of 7/13/15 she went to the dining room to inform Staff G she was going to lunch. As they walked together up the hallway, Resident #2 fell forward from the doorway of Resident #7's room and the door closed immediately behind Resident #2. Staff H denies seeing any physical contact between Resident #2 and Resident #7. Staff H stated she just observed Resident #2 minutes earlier in the TV room. Staff H indicated Resident #2 is a wanderer and has been known to enter other resident rooms. In an interview on 7/28/15 at 9:00 a.m. Staff I CNA, indicated she was assigned to the CCDI unit during the day shift on 7/13/15. At the time of the fall she was in the restroom. Staff I stated she, Staff G and Staff J questioned Resident #7 regarding Resident #2 ' s fall. Staff I stated that Resident #7 confirmed placing hands on the back of Resident #2. Staff I failed to recall, whether Resident #7 was asked if he/she pushed Resident #2 during the incident. In an interview on 7/29/15 at 8:32 a.m. Staff J the Assistant Director of Nursing (ADON), indicated following the fall of Resident #2 on 7/13/15, she spoke with Resident #7. Staff J the ADON confirmed Resident #7 stated, Resident #2 entered his/her room and was messing with stuff on the dresser. Resident #7 asked Resident #2 to leave several times. Resident #7 then stood from his/her recliner and escorted Resident #2 from his/her room. According to the interview with Staff J ADON, Resident #7 admitted to placing his/her hands on Resident #2 and that Resident #2 stumbled and fell . Resident #7 shut the door to his/her room after the fall. In an interview on 7/27/15 at 5:50 p.m. the Director of Nursing (DON) stated Resident #2 was known to wander into other resident rooms and staff members are expected to redirect him/her from other resident rooms when observed. The DON identified the facility failed to implement formal interventions addressing Resident #2 ' s entering other resident rooms. In an interview on 7/27/15 at 4:45 p.m. Resident #7 indicated Resident #2 had come into his/her room and was messing with his/her stuff. Resident #7 stated he/she asked Resident #2 to leave and was following Resident #2 out when he/she stumbled and fell . Resident #7 then shut the door behind him/her. Resident #7 stated Resident #2 would come into his/her room 2-3 times per week and often needed much encouragement to leave. In an interview on 8/5/15 at 11:55 a.m. Assistant Administrator indicated Resident #7 went through a phase 2-3 years ago in which he/she made sexually inappropriate comments about other residents in the presence of staff. The Assistant Administrator stated she knew of no instances that Resident #7 had any inappropriate sexual contact with any residents. The Assistant Administrator stated medication changes for Resident #7 caused the comments to subside. The Assistant Administrator stated she has never known Resident #7 to be aggressive although admits he/she does get frustrated if residents enter his/her room. RESIDENT TO RESIDENT ALTERCATION 7/21/15 2. According to Resident #10's MDS assessment dated [DATE], identified a BIMS score of 6 indicating severely impaired cognitive status. Resident #10 was independently ambulatory and resided on the chronically confused and demented individual (CCDI) unit. Resident #10's [DIAGNOSES REDACTED]. According to Resident #11's MDS assessment dated [DATE], identified a BIMS score of 3 indicating severely impaired cognitive status. Resident #11 was independently ambulatory and resided on the CCDI unit. Resident #11 required limited assistance of one staff member for dressing and personal hygiene. Resident #11's [DIAGNOSES REDACTED]. and Non-Alzheimer's Dementia. Resident #11's plan of care dated 8/5/14 indicated a problem with walking in the halls at all times with interventions which include: *Redirect when wandering. *Observe resident's location to ensure safety. In an interview on 7/29/15 at 10:50 a.m. Staff K CNA, indicated at shift change on 7/21/15, she, Staff L and Staff M performed rounds when a resident requested a sandwich. Staff K, L and M stepped into the dining room to prepare the sandwich. Within less than 5 minutes, staff members heard a commotion across the hall and responded. Upon entering the room of Resident #10, staff members identified both Resident #10 and Resident #11 on the floor holding onto each other and swinging at each other. Staff members separated Resident #10 and Resident #11s and reported the incident to the nurse. In an interview on 7/28/15 at 3:35 p.m. Staff L CNA, indicated at shift change on 7/21/15, she was in the dining room getting food for a resident when she heard a scream and Resident #10 calling someone a [***] . She entered Resident #10's room and found Resident #10 and Resident #11 on the floor facing each other. Resident #10 had a hold of Resident #11's wrists. Staff members separated Resident #10 and Resident #11 and Staff L escorted Resident #11 to the dining room. Resident #11 was confused, claiming he/she was in his/her room when Resident #10 began hitting him/her. Staff L stated she was later told by Resident #10 that Resident #11 came into his/her room and used the bathroom, leaving the toilet unflushed and feces on the toilet. Resident #10 got upset and the altercation occurred. In an interview on 7/29/15 at 3:35 p.m. Staff G, Licensed practical nurse, indicated she was working the day shift on the CCDI unit on 7/21/15 and left the unit to handle some lab work prior to Resident #10 and Resident #11 ' s altercation. RESIDENT #1 FALL 7/5/15 3. According to Resident #1's MDS assessment dated [DATE], identified a BIMS score of 9 indicating moderately impaired cognitive status. Resident #1 required extensive assistance of one to two staff members for transfers, ambulation and personal hygiene. Resident #1 required limited assistance of one staff member for bed mobility and dressing and total dependence on two staff members for toilet use. The MDS listed Resident #1 incontinent of bladder and bowel. Resident #1 required a walker and wheelchair for mobility. Resident #1's [DIAGNOSES REDACTED]. Fall Risk Evaluation dated 6/22/15 scored Resident #1 at a 17, indicating high risk for falls. Admission care plan for Resident #1 failed to identify fall risk interventions until 7/7/15 upon Resident #1's return from the hospital to the facility following the fall on 7/5/15. Care Plan dated 7/14/15 indicated a problem At risk for falls related to past history of falls with interventions which included: *Assistance of two staff with transfers. *Call light within reach with prompt response to all requests. *Bed to be in low position with mat at bedside. *Assistance of one with ambulation with walker. (7/24/15) *Utilize a wheel chair for long distances. (7/24/15) Nurse's notes dated 6/22/15 at 10:30 a.m. written by Staff A, indicated Resident #1 to be discharged from a rehabilitation unit to the facility. Resident #1 is an assist of one with walker, confused with dementia, will attempt to self-transfer, has difficulty remembering to utilize the call light, but at times will call out verbally. In an interview on 7/29/15 at 2:00 p.m. Staff A, LPN, indicated she received a call from Resident #1's previous residence and was informed of the pending admission to the facility. Staff A was informed that Resident #1 was confused with dementia, attempts to self-transfer and doesn't always remember to use his/her call light. Resident #1 recently fell resulting in a pelvic fracture. Staff A stated she shared this information with the admissions coordinator, who placed Resident #1 at the end of the hallway. Staff A questioned Resident #1 being placed so far away from the nurse's station given his/her history. Staff A stated Resident #1 seemed anxious and would yell out, but no one ever reported to her that he/she attempted independent transfers. Nurse's notes dated 6/22/15 at 12:20 p.m. written by the Director of Nursing, indicated Resident #1 admitted for skilled nursing level of care with physical and occupational therapies status [REDACTED]. Resident #1 confused to place and time. In an interview on 7/29/15 at 3:06 p.m. the Director of Nursing (DON) indicated she spoke with the hospital prior to Resident #1's admission and was told Resident #1 had not been attempting self-transfers. The plan was for Resident #1 to receive physical and occupational therapies. Staff utilized partial side rails. The DON stated she believed the interventions upon admission were adequate to address Resident #1's fall risk and condition. The DON stated she was unaware of Resident #1 attempting to crawl out of bed unassisted and had she known, she may have tried additional interventions. In an interview on 7/29/15 at 1:43 p.m. Staff B CNA, indicated Resident #1 was non-compliant using a call light and on occasion attempted to crawl out of bed. Staff B failed to recall anytime Resident #1made it completely out of bed. Staff B stated Resident #1's room was at the far end of the hall. Staff B stated the only fall interventions identified was to remind Resident #1 to use the call light. In an interview on 7/29/15 at 2:25 p.m. Staff C CNA, indicated Resident #1 as confused and anxious at times. Resident #1 screams when he/she wanted something and did not use the call light. Resident successful at getting anywhere. On the afternoon of 7/5/15 Resident #1 was known to try to get up unassisted, but was never #1 was in bed. Staff C was assigned hall 3 and had just came out of the shower room when she noticed a call light blinking off and on.(activated by Resident #1's roommate) Staff C ran down the hall and found Resident #1 lying awkwardly on the floor. Staff C hollered for help and remained with Resident #1 until emergency medical services arrived. Staff C indicated residents are usually checked on every 30-45 minutes, but was not certain who last checked on Resident #1. In an interview on 7/29/15 at 2:16 p.m. Staff D CNA, indicated Resident #1 was ornery and would take off his/her oxygen and try to climb out of bed. Resident #1 rarely used the call light. Resident #1 required assistance of one staff and a walker with transfers and ambulation and was slow, but steady. In an interview on 7/29/15 at 2:45 p.m. Staff E CNA, indicated Resident #1 was admitted in a lot of pain, was confused and not doing well. Resident #1 used the call light on occasion and generally remained in bed. Resident #1 did not come to the dining room for meals. Staff E stated he had never known Resident #1 to attempt to get up unassisted. On 7/5/15 Resident #1 was completely different. Resident #1 was sitting up at his/her bedside, alert and happy. Just a little later into his shift, Resident #1's roommate had activated the call light to alert staff Resident #1 had fallen. Nurse's notes dated 7/5/15 at 4:25 p.m. indicated Staff F was summoned to Resident #1's room and discovered Resident #1 on the floor. Resident #1 unable to say what happened, but roommate stated Resident #1 started to get up and fell right away, landing on his/her left side and hitting his/her head. Resident #1 was assessed and emergency services contacted and Resident #1 sent to the hospital. Radiology report dated 7/6/15 indicated Resident #1 sustained a left insufficient sacral fracture. Note: At the time of the onsite investigation the deficiency was coded at a K level for immediate and serious jeopardy. By August 5, 2015 the facility had implemented measures that adequately addressed the jeopardy issue and the grid placement was lowered to an E level. The facility provided a staff training plan regarding supervision of residents. Additional training of 6 hours included training on Dementia and residents located in the Dementia units. Evaluations done on wandering residents and completed risk evaluations. A monitor was initially placed in the Dementia unit to help with supervision of residents.

Based on record review, staff interviews and review of facility policy/procedures, the facility failed to administer the correct medications as ordered by the physician to Resident #6 which resulted in a significant medication error. As a result of the significant medication error, the resident developed [MEDICAL CONDITION] and required hospitalization in an acute intensive care unit and required a respirator to assist with breathing. The facility reported a census of 77 residents. Findings include: 1. Resident #6 had an MDS (Minimum Data Set) assessment with a reference date of [DATE]. The MDS reflected the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which reflected no cognitive impairment. The resident had no signs and symptoms of [MEDICAL CONDITION] and had [DIAGNOSES REDACTED]. The resident ' s [DATE] Medication Administration Record revealed Resident #6 had orders to receive the following on the evening of [DATE]: [MEDICATION NAME] (insulin) 35 units subcutaneous (sub-Q), [MEDICATION NAME] (insulin) 6 units sub-Q before meals for blood sugar readings greater than 100, [MEDICATION NAME] (cortisone for inflammation 10 milligrams (mg), [MEDICATION NAME] ([MEDICATION NAME]) 650 mg, [MEDICATION NAME] (builds cartilage) 1000 mg twice daily, Senekot S (laxative) tablet, [MEDICATION NAME] (for Alzheimer ' s disease) 4.6 mg/24 hour patch, and [MEDICATION NAME] (lowers cholesterol level) 20 mg. The resident did not have physician orders [REDACTED]. The Nurse's Notes dated [DATE] at 10:00 a.m. reflected at 8:20 a.m., the staff certified nursing assistants reported the resident as unresponsive when getting the resident up for breakfast. The nursing assistants brought the resident to the dining room and notified the nurse. The nurse assessed the resident and determined the resident as unresponsive to pain and verbal stimuli, had labored breathing with episodes of apnea (not breathing). The resident ' s lung sounds were diminished with no cough noted. The blood sugar reading was 118 (normal ,[DATE]). The resident ' s pulse oximetry as 94 percent (normal ,[DATE]) and on 3 liters of oxygen. The blood pressure reading documented was ,[DATE]. The nurse notified the physician and was directed to transfer the resident to the hospital emergency room for an evaluation and treatment. The resident's medication administration record (MAR) was copied and sent with the resident. The Nurse ' s Notes dated [DATE] at 2:00 p.m. reflected the hospital nurse telephoned the facility and reported the resident had opiates (narcotic) in system and asked for the clarification of medications. (The resident did not have a physician order [REDACTED]. The ADON contacted the hospital and the physician of the possible medication error on [DATE] around 9:00 p.m. with a list of medications which may have been administered. The hospital nurse described the resident as now drowsy and vomiting. The Nurse's Notes dated [DATE] at 3:00 p.m. reflected an incident report was completed and the medication cart was audited and determined there were no medication discrepancies with Resident #6's medications noted. The Nurse's Notes dated [DATE] at 4:00 p.m. reflected the ADON contacted the hospital and the hospital nurse informed the facility the physician admitted the resident into the intensive care unit. The resident had a [DIAGNOSES REDACTED]. Staff interviews: On [DATE] at 3:55 p.m. Staff M, certified nursing assistant (CNA) was interviewed and stated on [DATE] she entered Resident #6's room at the beginning of her shift and informed the resident she would be back later to get him/her up and the resident opened his/her left eye a little and nodded ok (alright). Staff M returned approximately ,[DATE] minutes later and noted the resident continued to be asleep and snoring which was not completely unusual for the resident. At approximately 8:00 a.m. Staff M stated she and another aide went in and dressed the resident for the day, and completed the mechanical lift transfer. Staff M stated the resident was sleepy but was sometimes difficult to awaken in the morning and did open his/her left eye at times. Staff M stated as she dressed the resident and noticed that she (Staff M) was practically yelling in the resident's ear. Resident #6 seemed pretty lethargic and the resident ' s arms just hung down. She reported concerns to the nurse, and later observed the paramedics with the resident. On [DATE] at 2:44 p.m. Staff K, licensed practical nurse (LPN), was interviewed and stated on [DATE] Staff M, CNA, reported Resident #6 wasn't his/her normal self. Staff K stated the resident just looked at her and when Staff K touched her nose, the resident just looked at her. The resident did not respond to painful stimuli. The nurse stated she then noticed the resident had labored breathing with periods of apnea. Staff K stated she notified the physician and family and transferred the resident to the hospital. On [DATE] at 6:01 p.m. Staff E, CNA, stated he was not aware of any medication error on his shift and did not administer any medications because he was a CNA, and unable to administer medications. On [DATE] at 5:24 p.m. Staff CC, LPN, confirmed she worked the night prior to Resident #6's hospitalization . Staff CC stated she started passing bedtime medications at approximately 7:00 p.m. rather than 8:,[DATE]:00 p.m. Staff CC stated she recalled administering Resident #6's medications at the dining room table. Staff CC learned that Resident #7 did not want medications until around 9:00 p.m. so she wrote Resident #7's name on the medication cup, then placed the labeled medication cup with medications in the top drawer of the medication cart. Staff CC stated the evening progressed and she went into Resident #6's room to administer a breathing treatment which took approximately 10 minutes to complete. Staff CC indicated while the breathing treatment was completed she prepared to complete catheter care and administer medications to Resident #7. Staff CC stated, "that's where it gets foggy." Staff CC stated she entered Resident #7's room with Staff E, then left the room for needed catheter supplies. Staff CC stated she thought she left the medication cup unattended in Resident #7's room with Staff E and stated that was "my bad." Staff CC stated when she returned to Resident #7's room she was unable to locate the medications. Staff CC indicated she spent time looking for the medications and was unable to locate them. Staff CC admitted she signed the Medication Administration Record (MAR) that the medications were administered even though she did not administer these medications. Staff CC admitted she did not document the occurrence, did not notify any other staff that the medications were not administered and voiced concerns that she worried another staff member would have taken the narcotic medications. Staff CC stated she could have administered Resident #7's medications to Resident #6. Review of Resident #7's MAR and Controlled Medication Utilization Record (a narcotic sign out sheet used to count narcotic medications) reflected that on [DATE] Staff CC administered the following medications: [REDACTED]. On [DATE] at 11:25 a.m. Resident #7 stated he/she didn't know if his/her medications were missed and was sometimes "groggy" because sometimes the medications are administered too closely together and he/she gets "groggy." On [DATE] at 8:43 a.m. Resident #6's family member stated that on Saturday, [DATE] at approximately 9:00 a.m. the facility called and said (Resident #6) was rushed to the hospital with a blood sugar of 14. The family member stated the resident's blood sugar was never that low and not certain where that came from. The family member then stated the hospital physician stated they found opiates in his/her blood stream and called the facility for records. The family member stated Resident #6 was unresponsive and "just looked dead." The family member stated the doctor ordered [MEDICATION NAME] (a medication used to reverse opiate overdose) twice to offset the opiates before the doctor started a [MEDICATION NAME] drip and put the resident on a respirator (mechanical device/machine to help the resident breathe). The family member stated the physician advised the respirator would either be effective or the resident would die. The family member stated the resident was hospitalized for [REDACTED]. The resident was transferred to a different long term care facility and still has to question nursing staff about his/her medications and tells the staff about the incident. On [DATE] at 2:10 p.m. the resident's physician/ medical director was interviewed. The physician stated he had a concern regarding the medication error and commented the resident could have died . The physician stated he did not think there ' s any defense except someone messed up, very concerned and hoped the facility had a system in place. The physician stated if a narcotic naive person received a long acting opiate and a muscle relaxant it could be very sedating. A long acting opiate should never be started on a person who is narcotic naive. The hospital History and Physical report dated [DATE], reflected the concern identified the patient had received [MEDICATION NAME] and [MEDICATION NAME] which are not the resident's medications. The physician documented this could play a role in the resident's unresponsiveness and hypercarbic [MEDICAL CONDITION]. The facility Medication administration policy/procedure dated [DATE], directed staff to identify the resident by pictures and check the MAR. Each medication is to be verified for right dose, right medication, and right time as well as right route by comparing the label on the medication container to the MAR. Also look at the proper date and the time column on the MAR to be sure that the medications are not already given or charted.

The following deficiency relates to incident -C: Based on record review and staff interview the facility failed to ensure each resident receives adequate supervision to prevent accidents for 2 of 4 residents reviewed (Residents #2 and #7). Record review for Resident #2 identified following a fall on 5/3/14 the facility determined anti roll back brakes should be utilized to reduce the risk of Resident #2 falling when attempting to stand in his/her wheelchair. The anti-roll back brakes were installed on 5/5/14. On 6/16/14 a new high back wheelchair was provided to and utilized by Resident #2. The facility failed to remove the anti roll back brake system from the old chair and install it on the new chair until 7/3/14. Two falls on 7/1/14 and one with injury on 7/2/14 occurred which may have been prevented had the facility promptly exchanged the care planned anti roll back brake system to the new wheelchair. Record review for Resident #2 identified following a fall on 5/12/14 the facility determined a seat belt alarm should be utilized to reduce the risk of Resident #2 falling from his/her wheelchair. The alarms were ordered on [DATE] and arrived 5/17/14, but were incomplete and the facility staff did not reorder the alarms until 7/15/14. The alarms arrived on 7/17/14 and were installed on 7/18/14. Five falls occurred (on 5/24/14 with injury, on 5/26/14, on 7/1/14, on 7/2/14 with injury and 7/11/14 with injury) in which the facility staff had not implement the seat belt alarm intervention to reduce the risk of hazards. Resident #7 had similar concerns for adequate supervision also identified. The facility reported a census of 81 residents. Findings include: 1. The Minimum Data Set (MDS) with an assessment reference date of 6/1/14 indicated Resident #2 with a Brief Interview for Mental Status score of 3 indicating impaired cognitive skills for daily decision making. Resident #2 required physical assistance with of one staff with bed mobility, transfers, ambulation, dressing, toilet use, personal hygiene and bathing. Resident #2's [DIAGNOSES REDACTED]. Resident #2's plan of care dated 9/19/13 indicated Resident #2 with risk of injury related to history of falls with interventions which included: a. Pressure alarms on bed, recliner and wheelchair. b. Low bed with floor alarm at bedside. c. Personal safety alarm (PSA) while in bed. d. Baby monitor. e. Dycem below wheelchair cushion. f. Anti roll back brakes added to care plan on 5/4/14. g. Remove foot pedals when resident in wheelchair added to care plan 5/26/14. h. Seat belt alarm to wheelchair added to care plan 7/11/14. Nursing Documentation and Fall Assessment Form dated 5/3/14 at 3:00 p.m. indicated Resident #2 was sitting in his/her wheelchair in activity when nurse heard his/her alarm sound, saw Resident #2 stand and push down on wheelchair handles, then fall onto his/her buttocks. No injury noted. Conclusions and Findings: Request placed for anti roll back brakes. Maintenance records dated 5/5/14 indicated anti roll back brakes applied to Resident #2's wheelchair. Nursing Documentation and Fall Assessment Form dated 5/12/14 at 2:35 p.m. indicated Resident #2 was propelling self in his/her wheelchair down hallway. Alarm sounded and aide coming out of another resident's room saw Resident #2 standing, then falling. No injury noted. Conclusions and Findings: Will look into possible releasing alarm seat belt. Self-releasing seat belt alarm ordered 5/15/14. Nursing Documentation and Fall Assessment Form dated 5/24/14 at 8:00 p.m. indicated Resident #2 was propelling self in his/her wheelchair out of dining room when Resident #2 observed falling forward out of wheelchair. Sustained a carpet burn on his/her nose and left knee. No dycem noted in the wheelchair (care planned for dycem). Conclusions and Findings: Dycem replaced in wheelchair, foot pedals to be removed from wheelchair when resident is self-propelling, staff education on dycem in wheelchair. Nursing Documentation and Fall Assessment Form dated 5/26/14 at 1:20 p.m. indicated Resident #2 was sitting in his/her wheelchair, stood up, tripped and fell forward. No injury noted. Conclusions and Findings: Bag for wheelchair pedals ordered to allow access for pedals when resident self-propels. Nursing Documentation and Fall Assessment Form dated 6/11/14 at 4:30 a.m. through baby monitor, staff heard faint alarm, then loud noise. Resident #2 found lying on floor. Alarms had been placed under several pillows. Resident #2 sustained 2 inch laceration on head. Conclusions and Findings: Alarms zip tied to bed rail to prevent resident from hiding or burying alarms. Occupational Therapy Daily Note dated 6/16/14 Resident #2 placed in high back wheelchair on this date. In an interview on 8/13/14 at 11 a.m., the MDS Coordinator reported incidents of falls are discussed every morning Monday-Friday. The falls are reviewed and the interventions are discussed. When new interventions are initiated, she adds the interventions on the resident ' s care plan. Nursing Documentation and Fall Assessment Form dated 7/1/14 at 1:50 a.m. indicated Resident #2 was sitting in his/her wheelchair at nurse's station, resident stood to reach for a juice, wheelchair slipped back and Resident #2 fell on to his/her buttocks. No injury noted. Conclusions and Findings: Currently receiving occupational therapy services for wheelchair positioning. Anti-roll back brakes will be applied to his/her new high back wheelchair. Nursing Documentation and Fall Assessment Form dated 7/2/14 at 4:50 p.m. indicated Resident #2 was sitting in his/her wheelchair in dining room. Nurse heard a thump and saw Resident #2 lying on his/her right side. No alarms sounding. Conclusions and Findings: Resident #2 had been restless and given activity at dining room table. Resident #2 backed away from table and fell . Anti-roll back brakes not on wheelchair at this time. Nurse's notes dated 7/2/14 at 3:10 p.m. indicated Resident #2 sustained a hematoma from left cheek bone to eye brow and laceration to right palm. Sent to hospital for evaluation and treatment. Maintenance record indicated anti-lock brakes installed to new high back wheelchair on 7/3/14. Nurse's notes dated 7/11/14 at 5:30 a.m. written by Staff D, Registered Nurse, indicated Resident #2 had been restless and was brought up to the nurse's station in his/her high back wheelchair. Staff D noticed Resident #2 was attempting to scoot out of his/her wheelchair and she reminded Resident #2 to sit back into the wheelchair. Resident #2 complied. The day nurse (Staff E) arrived and together they started report and then heard a thud. Staff D indicated Resident #2 reportedly stood and got his/her shoe caught under his/her chair, fell forward striking the treatment cart and then landing face first onto the floor. Resident #2's right side of face instantly swelled up and Resident #2 complained of pain in his/her left knee. Resident #2 sent to the hospital for evaluation and treatment. (Staff D, registered nurse did not document an alarm sounded.) The DON confirmed there was no incident report for the 7/11/14 fall (Nursing Documentation and Fall Assessment Form). The Nurse ' s notes dated 7/11/14 documented Resident #2 returned from the hospital with bruising and swelling at right eye orbit. The report noted the resident was alert and able to express pain. Resident #2 reported right facility pain and had been given hydrocodone as needed for right eye pain. Staff documented Resident #2 ' s right eye was nearly swollen shut making it difficult to complete neurological (examination). Staff documented the bruising was extensive with all colors, red, blue, yellow, green and purple measuring 12 by 11 centimeter. The notes identified on 7/11/14, at 11:20 p.m., the resident was given as needed pain medication for discomfort. Interviews: Regarding the 7/1/14 fall, Staff J, (RN) stated on 8/14/14 at 2:29 p.m. that Resident #2 fell while trying to reach for a cranberry juice from the medication cart. Staff J explained Resident #2 stood to reach the item and the wheelchair rolled back. At the same time, Staff J told Resident #2 to wait a minute, she would get the item but the resident had (already) fallen back on his/her buttocks. At the time of the fall, Staff J stated there was no anti-roll back brakes on the wheelchair. In an interview on 8/14/14 at 3:20 p.m., Staff I (Licensed Practical Nurse (LPN) indicated she worked the day shift from 6 a.m. to 6 p.m. on 7/2/14 when Resident #2 fell in the dining room. Staff I reported the resident had been in his/her wheelchair at a dining room table. Staff I reported Resident #2 apparently stood up and his/her wheelchair rolled back and the resident fell . Staff I reported no alarm sounded initially and the wheelchair did not have the anti-lock brakes applied. In an interview on 8/14/14 at 3:53 p.m., Staff H (Registered Nurse (RN) reported occupational therapy (OT) had been evaluated Resident #2 for a high back wheelchair and failed to have the anti-lock brakes applied to the high back wheelchair when they switched. Staff F reported following the falls on 7/1/14 and 7/2/14, the brakes were applied. In an interview on 8/13/14 at 2:31 p.m. Staff D, indicated on the morning of 7/11/14 at Resident #2 attempted to get out of bed and was brought to the nurse's station to be monitored. At shift change the day nurse (Staff E) had arrived and they were at the nurse's station preparing to give report when Resident #2 stood and immediately fell forward into the treatment cart. Staff D reported the resident ' s alarm sounded. Staff D stated they could not reach Resident #2 to prevent the fall. Staff D and Staff E assessed Resident #2 and called 911 to have Resident #2 sent to the hospital for evaluation and treatment. Staff D indicated she remained with the resident until she left for the day. Staff D stated she did not think she was there when the emergency responders arrived. (Staff D's time sheet indicated she clocked out at 8:43 a.m. on 7/11/14). In an interview on 8/14/14 at 4:32 p.m. Staff E, Licensed Practical Nurse stated she worked the day shift on 7/11/14 (Staff E time sheet indicated she clocked in at 5:40 a.m.). As Staff E walked towards the nurse's station, she saw Resident #2 stand and fall face first into the treatment cart. Staff E assisted Staff D to assess Resident #2 and staff called 911. Staff E stated someone remained with Resident #2 on the floor at all times. Staff E could not identify who remained on the floor with the resident. (Staff E did not report hearing an alarm sound.) In an interview on 8/14/14 at 11:10 a.m. the Chief of Police provided response times to the facility on [DATE]. The Chief stated the 911 call was received at 5:57 a.m., an officer dispatched at 5:59 a.m., an officer on the scene at 6:03 a.m. and cleared the facility at 6.38 a.m. In an interview on 8/13/14 at 2:05 p.m. Staff A, Certified Nurse Aide, stated she worked the morning of 7/11/14. Staff A stated she was in another room when she heard a loud thud. As she entered the hallway she saw Resident #2 lying on the floor. Both Staff D and Staff E were attending to Resident #2. They got a pillow and placed it under Resident #2's head. Staff A stated she then returned to the floor to help other residents. Staff A indicated it was shift change and other staff were arriving to work. (Staff A did not report hearing an alarm sound.) In an interview on 8/13/14 at 2:05 p.m. Staff G, Certified Nurse Aide, indicated she had just arrived to work the morning of 7/11/14 when while walking down the hall saw Resident #2 stand and immediately fall face forward. Staff G did not recall an alarm sounding. Staff G stated the 2 nurses responded and attended to Resident #2. Staff G indicated she went about assisting other residents that morning. Maintenance record dated 7/11/14 indicated a special alarm was installed to Resident #2's wheelchair. On 7/18/14 a special alarm was removed from the old wheelchair and placed on the new wheelchair. In an interview on 8/13/14 at 11:35 a.m. Staff F, Assistant Administrator, indicated two seat belt alarms were ordered on [DATE] and arrived on 5/22/14. The seat belt alarms were incomplete, half of the belt(s) were missing. Staff F indicated she worked through the supplier and the belts were re-ordered on [DATE], arrived on 7/17/14 and applied to the wheelchair of Resident #2 on 7/18/14. 2. The Minimum Data Set (MDS) with an assessment reference date of 6/29/14 indicated Resident #7 with impaired long and short term memory and severely impaired cognitive skills for daily decision making. Resident #7 required physical assistance from one to two staff with bed mobility, transfers, ambulation, dressing, toilet use, personal hygiene and bathing. Resident #7's [DIAGNOSES REDACTED]. Resident #7's plan of care dated 1/31/14 indicated Resident #7 with risk for falls related to history of falls with interventions which included: a. Dycem under wheelchair cushion. b. Pressure alarm on at all times. c. Pummel cushion to wheelchair. d. Seat belt to wheelchair (7/28/14). e. Assure resident is positioned properly in wheelchair (7/30/14). Nursing Documentation and Fall Assessment Form dated 6/5/14 at 7:30 p.m. indicated alarm sounded and Resident #7 found sitting on his/her wheelchair pedals. Resident #7 had slid out of his/her wheelchair. No injury noted. Conclusions and Findings: Self releasing seat belt alarm ordered and will be placed as soon as possible. Nursing Documentation and Fall Assessment Form dated 7/14/14 at 11:00 a.m. indicated Resident #7 was sitting in his/her wheelchair in the dining room and slid down the front of the chair onto the foot pedals. No injury noted. Conclusions and Findings: Trial of self-releasing seat belt alarm. Maintenance records dated 7/18/14 indicated a special alarm (seat belt) was installed on Resident #7's wheelchair. In an interview on 8/13/14 at 11:35 a.m. Staff F, Assistant Administrator, indicated two seat belt alarms were ordered on [DATE] and arrived on 5/22/14. The seat belt alarms were incomplete. Staff F indicated she worked through the supplier and the belts were re-ordered on [DATE], arrived on 7/17/14 and applied to the wheelchair of Resident #7 on 7/18/14. The record indicated following a fall on 6/5/14 the facility determined a seat belt alarm should be utilized to reduce the risk of Resident #7 sliding from his/her wheelchair. Two alarms were ordered 5/15/14 and arrived 5/17/14, but were incomplete. The facility did not reorder the alarms until 7/15/14. The alarms arrived on 7/17/14 and were installed on 7/18/14. One fall occurred (7/14/14) in which a seat belt alarm may have prevented the resident from sliding out of his/her wheelchair had the facility promptly attained and utilized a seat belt alarm.

Based on record review, observation and staff interview the facility failed to ensure each resident received adequate supervision and implement interventions to reduce the risk of hazards 1 of 6 residents reviewed (Resident #9). The facility identified a census of 76 current residents. Findings include: 1. The MDS (Minimum Data Set) assessment dated [DATE] documented Resident #9 had [DIAGNOSES REDACTED]. The resident had impaired memory and cognition and required extensive staff assistance with transfers. The resident did not walk and had impaired balance when moving from a seated to a standing position, with toilet use and during surface-to-surface transfers. The Physician order [REDACTED]. Review of the nurse's notes dated 9/22/14 at 7:55 P.M. revealed Resident #9 put him/herself on the floor in the hallway and the resident wanted to go to bed. The resident did not receive any injury. The Plan of Care dated 7/16/14 documented Resident #9 as at risk for falls related to right [DIAGNOSES REDACTED] and past CVA. Resident #9 could be noncompliant at times and attempted to transfer themselves or not ask for help when needing assistance. On 9/23/14, staff added the intervention of a PSA with a shorter string and stronger clip applied at all times. Observation on 10/1/14 at 7:55 A.M. revealed Resident #9 lying in bed with the alarm box secured to the side rail on the left side of the bed. The clip lay on the floor, not attached to the resident. During interview on 10/1/14 at 8:00 A.M. Staff H, CNA (certified nursing assistant) verified that the clip alarm as unattached and on the floor. Staff H stated the alarm should be on at all times. Staff H spoke to Staff I, CNA who arrived to assist with a transfer and stated that Resident #9 could remove the clip alarm and did so frequently when clipped within reach. Staff H stated the alarm had been clipped on during walking rounds at 6 A.M. Observation on 10/1/14 at 9:45 A.M. revealed Resident #9 back in bed after breakfast with the clip again unattached and lying on the floor. Interview with Staff A, LPN (Licensed Practical Nurse) at that time revealed that Resident #9 could remove the alarm. Staff A stated that staff checked on the resident frequently and the CNAs were on break at that time. Interview with the Director of Nursing and Quality Assurance Nurse on 10/1/14 at 10:40 A.M. revealed that no awareness that Resident #9 took the alarms off. The resident had pressure alarms in the past and they did not know why this changed or how the resident got the alarm off. On 9/22/14, staff placed a heavy duty clip as the last clip slipped off but did not completely come out; the alarm still sounded. The Director of Nursing and Quality Assurance Nurse planned to follow-up with the resident and staff.

Based on record review, observation, staff and resident interviews, the facility failed to complete assessment and implement timely interventions for 2 of 17 residents (Residents #9 and Residents #14). The facility reported a census of 87 residents. 1. Record review for Resident #9 revealed [DIAGNOSES REDACTED]. Nurse's Notes for Resident #9 Included the following: The first nurse's note since [DATE] at 3:00 p.m. dated [DATE] at 5:25 a.m. oxygen saturation 83%. [MEDICATION NAME], and cough syrup given, and supplemental oxygen given at 2 L by nasal cannula. Non-productive cough, profuse sweating, and anxiety noted with expiratory wheezing/raspy cough at 5:20 a.m. The next entry dated [DATE] at 10:00 a.m. noted poor appetite, repositioned often, oxygen on, no cough, course lung sounds. [DATE] at 8:00 a.m. resident lethargic, low grade fever, states hurting all over, lung sounds left lobe decreased and adventitious. Right lobe clear. Resident SOB (short of breath) at rest. Oxygen level: 84%, oxygen applied at 2 L. [MEDICATION NAME] given. Moist cough. Call placed to physician office, new order received for chest x-ray. Call placed to resident's family member regarding change in condition and interventions. [DATE] at 10:00 a.m. chest x-ray results in and faxed to physician with current assessment. Resident responsive to physical and tactile. [DATE] at 12:00 noon, no improvement in status, in fact oxygen level 87%. Resident lethargic. Lung sound continues with decreased air movement. Moist cough. Short of breath at rest. Resident declines emergency room evaluation and treatment. Call placed to nurse practitioner with nurse's concern and current assessment. New order received for [MEDICATION NAME] and if condition continued to deteriorate, contact office. Call placed to resident's family regarding resident's condition and intervention taken. [DATE] at 5:50 p.m. resident currently in bed with eyes closed. Will report to oncoming nurse if condition worsens send to emergency room per family (POA/power of attorney) request. The original copy/review of this resident's clinical record revealed no entry dated [DATE] at 5:55 p.m. Review and copy of the clinical record revealed an additional entry made for [DATE] at 5:55 p.m. made sometime after [DATE]. [DATE] at 5:55 p.m. again nurse spoke with resident regarding emergency room evaluation and treatment and again the resident refused. Nurse placed call to family regarding nurse's concerns and DNR wishes. The next entry dated [DATE] at 10:30 p.m. noted the nurse went to help C.N.A. (certified nursing assistant) check and change the resident. Before entering the resident's bedroom, the C.N.A. stated the resident was not breathing. The nurse then went and called the physician on call of the change in condition. New order received to send the resident to the emergency room for evaluation. [DATE] at 10:35 p.m. nurse called ambulance for transfer to emergency room . [DATE] at 10:30 p.m. responsible party contacted and notified of intent to transfer. [DATE] at 10:50 p.m. ambulance arrived, no breath sounds upon entering room. Nurse instructed by ambulance attendants to call POA back and make sure no life saving efforts were wanted. At this time, nurse called responsible party. Responsible party requested attempt to stabilize resident. Compressions and breaths started (CPR) until parametric called it according to code status DNR. [DATE] at 10:30 p.m. another nurse, Staff BB documented an entry at a later date, periods of apnea, start/stop breathing with wet breath sounds, pulse 108, respirations 52, oxygen level 86%, pupils fixed and non-responsive. Non productive cough earlier in the evening. Gasping for breaths and periods of non-breathing. Resident DNR. Family requested compression per telephone. EMT (emergency medical technician) intubated patient. Both nurses provided compression to resident. Resident vomited and did not respond. Continued to intubate and compressions. Resident with no vital signs. EMT called time of death at 10:50 p.m. Family notified and arrived to visit with resident and have time to say goodbye. Family came by morning of [DATE] and get resident belongings. A late entry dated [DATE] at 1:30 p.m., Staff BB documented resident sitting up in bed on [DATE] at 10:35 p.m., pale in color, skin dusky, resident had difficulty breathing with chest congestion throughout both lung fields, heart sounds distant, oxygen 85%, nurse offered [MEDICATION NAME] and cough syrup, resident temperature 100.3, nurse informed resident that he/she may have to go to hospital, resident started to have more difficulty breathing at 10:30 p.m., this nurse summoned to resident room by another nurse, resident cyanotic and taking gasping breaths. Oxygen 84% and temperature 97.6. Heart rate 108. Resident had periods of stop/start breathing. Resident sitting at 45 degrees. Staff changed the resident's shirt and applied cool wash cloths to forehead. Resident not responding to staff. Mouth slightly open with raspy wet breathing. Resident's pupils non-responsive to light. This nurse stayed with resident in room and patted resident's chest, telling resident to continue to breathe. Resident continued periods of gasping breaths, lips cyanotic. Resident was sweating profusely with air conditioner on high. At 10:38 p.m. resident sighed one last breath and closed his/her eyes and stopped breathing altogether. Resident's family requested life-saving measures be started. This nurse and another nurse started chest compressions, followed by 2 breaths, 30 compressions to 2 breaths. This nurse and other nurse and EMT's continued to give chest compressions. EMT's checked for pulse and instructed nurses to stop chest compressions. EMT called time of death at approximately 10:50 p.m. A late entry written on [DATE] for [DATE] at 12:35 p.m. resident up to dining room table. Resident requested to lay back down in bed. Nurse instructed resident he/she could not lay flat in bed and instructed the resident it was not good for him/her. The nurse instructed the resident he/she needed to eat and he/she needed the head of his/her bed up. At 4:00 p.m. the nurse educated the resident on the importance of getting up for meals and asked the resident again if he/she would like to go to the hospital to be checked over. At 6:30 p.m. the nurse instructed the C.N.A. the resident needed to get up for the evening meal. Review of the Ambulation Program for May of 2014 revealed the resident walked 240 feet on [DATE], walked 250 feet on [DATE], walked 216 feet on [DATE], walked 178 feet on [DATE], walked 152 feet on [DATE] and again on [DATE]. This form indicated the resident then refused to walk on [DATE] and again on [DATE]. Review of the Range of Motion Passive or Active form for [DATE] revealed the resident refused therapy on [DATE] and again on [DATE]. Review of the Restorative Nursing Services Progress Notes revealed on [DATE] the resident refused therapy three times. The resident complained of not feeling well, too weak to do exercises. The restorative staff member, Staff B documented she informed the nurse, Staff S of the resident's refusal and complaints of not feeling well. Interviews: When interviewed on [DATE] at 3:40 p.m. the restorative staff member, Staff B stated the resident was a nice resident. On [DATE]th the resident stated he/she did not want to do the exercises in the morning and stated he/she was always going to be sick. The resident complained of a cough in the afternoon and stated he/she did not feel well. Staff B reported she informed the resident's nurse, Staff S of the resident's statements and refusal. The resident stated he/she had his/her cold for a long time and he/she complained of his/her chest and difficulty breathing. The nurse informed Staff B she would go and assess the resident. When interviewed on [DATE] at 4:55 p.m. a licensed practical nurse (LPN), Staff S stated she called the day Staff B came to her and reported the resident refused therapy and did not feel well. She went to the resident's bedroom and found the resident wearing oxygen. The night shift had started the oxygen. Staff S stated she normally documented in the nurse's notes when she assessed a resident. Staff S stated she did not document her assessment of the resident that day. On Thursday ([DATE]) the resident refused to get out of bed. The nurse told the resident he/she needed to get up for the evening meal. The resident then threw a really big fit. The nurse told the resident he/she had to get out of bed. The nurse told the resident he/she could not stay in bed all day long due to his/her lungs. Staff S stated the resident did not get out of bed on Tuesday ([DATE]). Staff S stated she did not document on the resident that day. On Tuesday she went to the resident's bedroom and told the resident he/she had to get up out of bed for the evening meal. On Wednesday ([DATE]) she told the resident he/she had to get up out of bed for the noon meal. On Wednesday the resident refused to get up out of bed for the evening meal. They put oxygen on the resident on Wednesday. She then went down to the resident's room to tell the resident he/she had to get up out of bed for the evening meal. When asked why she failed to document her assessment of the resident, the nurse stated the resident had times when he/she did not want to do anything. The nurse stated the resident was very stubborn. During report on Thursday ([DATE]) the off going nurse reported the resident was sweaty and the pulse ox, oxygen saturation level had dropped before breakfast. She told the C.N.A.'s they had to get the resident up out of bed for breakfast. The resident's lung sounds were course. The resident was sweaty. The resident's color was a little different, he/she was a little more pale. By the end of breakfast the resident was leaning over in the chair. The resident had a loose, moist cough. She then had the staff get the resident up, out of bed for the noon meal. The staff then asked her if the resident could eat lunch in bed. The nurse then went and asked the resident if he/she wanted to her to send him/her to the hospital. The nurse stated the resident had a history of [REDACTED]. She stated the resident was sweaty on and off that day, which was unusual for the resident. Staff S denied documenting in the clinical record for [DATE] or on [DATE]. Staff S stated after the resident died , she documented on his/her condition. Staff S denied calling the physician with this resident's change in condition and she failed to call the resident's family regarding the resident's decline in condition. Staff S stated she worked with this resident on [DATE], [DATE], [DATE] and again on [DATE]. Staff S stated the resident was not sweaty on [DATE] or on [DATE]. She stated the resident got up for meals on [DATE] and on [DATE]. She also stated the resident's color was normal for this resident on [DATE] and again on [DATE]. Staff S stated the changes she noticed in this resident's physical condition on [DATE] and [DATE] were the sweatiness, the refusal to get out of bed, the poor color, poor appetite and the need for staff to reposition the resident frequently when up due to the resident would lean to the side. Staff S denied giving the resident any pain medication or cough syrup. When interviewed on [DATE] at 5:30 p.m. a C.N.A. Staff L stated the resident would get up for meals. Staff L stated he first noticed a decline in this resident's condition on Monday ,[DATE]//14. The resident had oxygen on and the resident sounded horrible. The resident sounded congested like he/she had a chest cold. The resident was "out of it", not his/her normal self. The resident continued to get worse. In the past when the resident would get sick it would only be for one day. Monday the resident appeared worse than he had ever seen the resident before. The resident was leaning way over, and that was unusual. The nurse, Staff S asked the resident if he/she wanted to go to the hospital and the resident said no. On ([DATE] )Tuesday the resident sat up a little bit better. Staff L was off on [DATE], Wednesday. Staff L worked on Thursday [DATE] and immediately talked to the nurse Staff AA due to it looked like the resident was not breathing. The nurse increased the resident's oxygen to 2 ,[DATE] L. When they got the resident up for the noon meal, the resident was really leaning over to the side so they assisted the resident back to bed. Staff L thought the resident should go to the hospital. The resident's color was gray, and the resident was sweaty. The resident felt like he/she was burning up. The resident was not eating or drinking. When interviewed on [DATE] at 9:52 a.m. a licensed practical nurse, Staff AA stated she was routinely this resident's nurse. She had a couple days off and when she returned to work, four different staff members told her the resident had been ill since Monday ([DATE]). The resident was very lethargic and leaning over. The resident was almost leaning over on his/her own lap. She had the staff lay the resident back down in bed. She informed the resident he/she needed to go to the hospital. She called the nurse practitioner. The resident's lung sounds were course throughout with very little movement, she started the resident on oxygen. The nurse practitioner ordered Levoquin at which time Staff AA informed the nurse practitioner the resident was beyond Levoquin and he/she needed an IM (intramuscular) antibiotic. She then called the resident's family member, power of attorney. She contacted the POA throughout her shift. The last time she called the POA was 5:55 p.m. She called the POA multiple times throughout her shift. The POA instructed her if the resident got any worse to send the resident to the hospital. From the beginning of her shift to the end of her shift, she felt the resident was going to die. She informed the resident that was all she could do for him/her. The resident could not breathe. The resident was struggling to breathe. His/her lungs were full. She reviewed his/her record and determined the resident was a DNR. She discussed the resident's DNR status with the POA. The POA wanted the DNR order to be honored. The POA asked the nurse why she was the first one to call and inform him/her of the resident's condition. The nurse stated at 8:00 a.m. that morning the resident had a low grade fever. She believed if the fever was below 100, she did not need to call the physician. She would just give Tylenol. Staff AA stated she called the POA prior to 8:00 a.m. at which time she informed the POA exactly what she had documented in the nurse's notes. She informed the POA she believed the resident needed an antibiotic. The POA asked her to keep in contact with him/her. Staff AA reported from 8:00 a.m. to noon, the resident's condition deteriorated. She called the POA and informed the POA she believed the resident's condition was grave. Staff AA stated she called the POA again at 5:55 p.m. Staff AA stated she was on the phone with the POA when the next nurse came on duty at 6:00 p.m. The POA informed her the resident wanted to be with his/her spouse. The POA stated if the resident got to where he/she was not comfortable, the POA wanted the resident sent to the hospital. When interviewed on [DATE] at 2:02 p.m. the resident's family member/POA stated the facility staff had not informed him/her that the resident had been ill. Staff AA called him/her and stated the resident began on an antibiotic. This was the first time he/she was informed of any change in the resident. The resident had a history of [REDACTED]. The staff did not tell him/her of any fever or distress. The next thing he/she knew the facility called about 10:30 p.m. the nurse stated they had the resident as a DNR and asked if that was still his/her desire. The POA asked the staff to stabilize the resident until he/she arrived. The staff did not say the resident had ceased breathing and had no heartbeat. The POA stated the resident had a DNR and the POA did not wish to change the order. The POA voiced dissatisfaction due to the staff failed to call him/her earlier and failed to inform him/her of the resident's decline in condition and the resident had died . The POA stated had the staff called him/her earlier and reported the resident's actual change in condition, the POA could have come to the facility and seen the resident prior to the resident's death and the POA could have asked for the resident to be transfer to the hospital earlier and received a greater level of care during the resident's physical decline. The POA stated the facility normally called him/her with changes in the residents condition. The POA last saw the resident on [DATE]. The POA was totally unaware of any change in the resident's condition from [DATE] through [DATE]. The POA would have expected a call and update on the resident at the first sign of a change in condition. The POA stated had the facility informed him/her earlier of the resident's decline in condition the POA and family members could have come to the facility, visited the resident and participated in the decisions regarding seeking hospitalization to ensure care and comfort. The resident desired DNR status and no one ever asked him/her if they wanted to change the resident's DNR status, no one informed him/her the resident had died , and no one asked him/her if they wanted CPR or life saving measures. The POA was under the impression the resident was alive and preparing to go to the hospital by ambulance, and the POA only asked the staff to stabilize the resident until he/she arrived. Had the POA known the resident was dead, he/she would have asked the staff to honor the resident's DNR status. Review of the phone records for the resident's POA revealed the POA first received a phone call from the facility on [DATE] at 2:09 p.m. and the call lasted less than 2 minutes. The next phone call from the facility was on [DATE] at 10:36 p.m. and lasted less than 1 minute. The POA then received a phone call from the facility on [DATE] at 10:46 p.m. The telephone records were also reviewed and revealed no calls from the cell phone number of Staff AA. This report revealed Staff AA did not call the POA as documented on [DATE] at 8:00 a.m., at noon, or at 5:55 p.m. When interviewed on [DATE] at 9:52 a.m. Staff AA had been shown the POA's telephone records after she stated multiple times that she had called the resident's POA/family on [DATE] at 8:00 a.m., noon and 5:55 p.m. Staff AA then stated she knew for sure she called the POA with the new [MEDICATION NAME] order. Staff AA then stated she did not call the POA in the morning. After reviewing the telephone records with Staff AA, Staff AA stated she could have sworn she called the POA, but obviously she did not. Staff AA reported maybe she was thinking about another resident, and another resident's family member that she had called that day. When interviewed on [DATE] at 4:45 p.m. a licensed practical nurse, Staff BB stated a couple of nights before the resident died , she noted the resident was restless. She placed the resident on oxygen a couple of nights before he/she died due to the resident's blood oxygen levels dropped below 91%. She gave the resident Tylenol due to an elevate fever of 101. The resident had a cough and congestion. She knew the resident's lungs were not good. She told the next shift nurse to watch him/her. The next night she worked, the resident still wasn't on anything for his/her fever and cough. The resident still wasn't doing well. Other resident came up to her and asked her what was wrong with the resident. The resident was not him/herself and was not feeling well. Staff BB stated she did not call the resident's family/POA to report the resident's decline in condition. On the third day she noticed he/she was still not doing well. The resident had periods of apnea, where he/she would stop breathing. The resident had a fever and was clammy. She did not call the resident's family/POA. About 10:30 p.m. the other nurse called for help. When she entered the resident's bedroom, she saw the resident went periods about 10 seconds without breathing. She told the resident to keep breathing. The resident's eyes were glassed over. The resident stopped breathing two minutes before the EMT's arrived. Nurse C came to the room and stated the resident's family requested they try to resuscitate the resident and try any means possible to get the resident back. Staff C began chest compressions, and Staff BB and Staff C took turns performing chest compressions for approximately 10 minutes. The EMT's then instructed them to stop. Staff BB stated she wished she had called the resident's family when the resident first got sick. When interviewed on [DATE] at 6:20 p.m. Staff C stated she worked on Wednesday ([DATE]), Thursday ([DATE]) and Friday ([DATE]), however she was not assigned to this resident. On Wednesday the resident was having increased respiratory issues and was mouth breathing. The resident was on oxygen and was not getting up as usual. The resident was not doing his/her range of motion exercises and was not walking as usual. On Wednesday, other staff reported their concerns regarding this resident to her. The resident progressively went down hill. She heard on Thursday the resident had a pulse oxygen level of 77 %. On Friday she was not working with this resident, however a C.N.A. asked her for assistance. When they entered the resident's bedroom, the C.N.A. stated the resident stopped breathing. She observed the resident take one big gasp. The resident's pupils were fixed. The resident's color was gray. She ran and checked the resident's chart and saw the resident was a DNR. She called the other nurse. She then called for an ambulance to transfer the resident to the hospital. She then called the physician on call. She informed the physician the resident had respiratory issues, had one episode of apnea and asked the physician if they could send the resident out. She called the resident's family/POA and informed the POA they were sending the resident to the hospital. She verified which hospital the POA desired. She did not tell the POA of the resident's condition. When she called the ambulance she informed them the resident had been declining since Wednesday ([DATE]). She then went with the EMT's to the resident's bedroom. The resident was gone. The EMT's assessed the resident. The EMT's asked for the resident's code status. The EMT's then asked her to call the family and make sure they did not want any life saving measures. She called the POA. She did not tell the POA the resident was not breathing and did not have a heartbeat. She asked the POA if he/she wanted stabilization. The POA stated to do what they could to stabilize the resident. She then hung up the phone and grabbed the back board, went to the resident's room. They then began to perform CPR. The nurses did the compressions and the EMT's attempted to intubate the resident. The EMT's then stopped the CPR. The EMT's then asked her to get the POA on the phone at which time they informed the POA of the resident's death. Staff C stated she wrote out her nurse's notes after the fact. The Physician Discharge Summary dated [DATE] documented the resident's final [DIAGNOSES REDACTED]. The Pertinent Physical findings noted the resident's condition continued to decline, had numerous falls secondary to poor judgment skills. The resident expired. 2. A MDS (Minimum Data Set) assessment with a reference date of [DATE] identified Resident #14 scored 14 out of 15 in cognitive testing. The mood testing section revealed the resident had little interest or pleasure in doing things, the resident felt down, depressed or hopeless and the resident felt tired or had little energy. The resident had delusions. required limited assistance with transfers, walking, dressing, and toilet use. The active [DIAGNOSES REDACTED]. The pain assessment interview indicated the resident experienced frequent pain. The resident rated the pain at a 10 on a scale of 1 to 10 with 10 being the most severe. The resident received antipsychotic and antidepressant medications on a daily basis. The Plan of Care dated [DATE] noted one problem first identified on [DATE] of [MEDICAL CONDITION] drug use related to depression, as evidenced by use of antidepressant medications. The plan of care listed three goals for this problem: resident would not require an increase in medication, the resident would not require an increase in medication and resident would not exhibit adverse side effects from medication. The interventions listed on the plan of care included dose reduction as ordered by the physician, administer medication daily as ordered by the physician, monitor for adverse side effects and report to physician as needed, monitor mood and behavior, report changes to physician as needed, consult social services as needed and consult psych services as needed. The physician's orders [REDACTED]. A progress note by a nurse practitioner dated [DATE] noted this resident's active problems included depression. The psychiatric exam revealed the resident exhibited a decreased attention span, a decrease in ability to concentrate and inadequate visual attention. The resident's mood and affect were calm, depressed, flat, indifferent and quiet. The resident appeared poorly developed, poorly nourished, lethargic, chronically ill, frail, debilitated, minimally responsive and unkempt grooming. A Social Service Progress Note dated [DATE] noted the resident appeared disheveled and wore a dirty coat. The resident admitted to feelings of depression and hopelessness, feeling like having little energy, and when asked if he/she had any thoughts related to death, the resident stated he/she frequently thought he/she would like their life to end now. The resident spoke about not wanting to live since he/she never had visitors, especially family. The social worker informed the charge nurse and 15 minute checks were instituted and all items that could be used to harm him/herself were removed. Later in the day another nurse sent the resident to the emergency room due to significant mental status change. When interviewed on [DATE] at 3:00 p.m. the social worker stated the resident became tearful and expressed boredom. The resident told the social worker he/she did not want to live anymore. The resident appeared depressed. The resident sat with head down and flat eyes, no sparkle to the eyes. The resident stated he/she wanted to die. The social worker alerted the nurse who stated she would place the resident on 15 minute checks. The social worker then reported the resident's statements to the director of nursing. The director of nursing then instructed the staff to get rid of the resident's call light, give the resident a bell to ring for assistance, take the plastic bags out of the resident's room, and take the metal hangers out of the resident's closet. The social worker informed the nurse of the director of nursing instructions. When interviewed on [DATE] at 9:45 a.m. a licensed practical nurse, Staff DD stated the resident normally stayed to him/herself. The resident did not like to be bothered. The resident was normally very quiet. The resident's normal daily activities included going to the dining room for coffee, go outside to smoke and go to his/her room. The social worker came to her around 4:00 p.m. or 4:30 p.m. and informed her of the resident's desire to die. Staff DD told the social worker she would place the resident on 15 minute checks. The nurse did not check on the resident, she did not ask the resident how he/she was feeling and she did not notify the resident's physician of the comments on his/her desire to die. The director of nursing instructions included to remove the resident's pillow cases, remove the call light and give the resident a bell and take the trash bags out of his/her bedroom. The nurse stated she removed the trash bags from the resident's bedroom. She did not remove the call light cord due to she did not know where to find a bell. She did not inform housekeeping about the suicide precautions to not use plastic bags in this resident's bedroom, due to the housekeepers had left for the day. She stated the facility had a communication book for nurses to write in, to inform all certified nursing assistants of any changes. She stated she failed to document these suicidal precautions in the communication book to alert all staff and every shift of these new precautions. She stated she did not implement any new interventions to ensure this resident's safety while alone in his/her bedroom until a bell could be located and the call light cord could be removed. Staff DD reported they never found a bell before she left work that day at 6:00 p.m. A Nurse's Notes dated [DATE] at 4:15 p.m. written by Staff DD noted resident reported to social worker his/her desire to end it all. 15 minute checks started. The next Nurse's Note dated [DATE] at 5:50 a.m. noted resident compliant with bedtime medications. Resident's family called to send resident to hospital. Unable to contact resident's family. Received order to send to hospital at 7:17 p.m. Resident returned at 10:50 p.m. Resident's call light removed from room. Resident call bell provided. Resident stated he/she did not eat all day, except breakfast. Resident offered a snack. Resident upset that his/her shirt was damaged on leaving the facility. Resident did not make any comments to this staff or exhibit behaviors. Resident continued on 15 minute checks. A hospital Summary Of Care dated [DATE] documented encounter [DIAGNOSES REDACTED]. The form indicated the primary symptoms included dysphoric mood and negative symptoms. The current episode started more than one month ago. The mood worsened since onset. The resident characterized the problem as moderate. the mood included feelings of sadness, irritability and despair. The resident kept telling the staff at the nursing home that he/she wished he/she were dead. The resident stated he/she felt like no one cared about him/her. The negative symptoms began this week. The negative symptoms appear to have worsened since their onset. The degree of incapacity that he/she was experiencing as a consequence of his/her illness was moderate. Additional symptoms of the illness included agitation and feelings of worthlessness. The resident denied having a plan to harm him/herself. The resident admitted to suicidal ideas. Review of symptoms included: psychiatric/behavioral: positive for suicidal ideas, dysphoric mood and agitation. the resident stated that all his/her family members were deceased and that he/she felt like no one at the nursing home cared about him/her. He/she stated when he/she needed something, the nursing home staff did not respond to him/her so he/she would say things like he/she wished he/she were dead and might as well be dead. When interviewed on [DATE] at 4:07 p.m. Staff BB stated on [DATE] she sent the resident to the emergency room due to the resident was a threat to him/herself. When the resident returned she noted the resident was lonely and depressed. The resident was a bit confused that day. The resident informed her his/her life was not worth living anymore. She asked the resident why, at which time the resident told her to forget it. She thought the resident was embarrassed. A Nurse's Note dated [DATE] at 10:45 a.m. noted call light cord placed above resident's bed, out of reach three times this shift, noted bell on floor under sink twice, removed plastic trash bags from room three times. Observation on [DATE] at 10:45 a.m. resident in his/her bedroom. Call light hanging on the wall by the head of th

Based on record review and interviews with staff, physician, and family, the facility failed to complete assessment and implement timely interventions for 2 of 10 residents with changing medical conditions (Residents #10 and #9). The facility identified a census of 76 current residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #10 had [DIAGNOSES REDACTED]. The assessment documented Resident #10 had severely impaired memory and cognition. The resident required the assistance of one staff to complete dressing, personal hygiene and toileting activities. The nurse's notes dated 8/11/14 at 3:20 p.m. documented the resident vomited. The resident complained of an upset stomach. The notes contained no physical assessment of the resident or vital sign measurement. Nurse's notes dated 8/11 to 8/17/14 contained no documentation of any abdominal, bowel or stool assessment. The nurse's notes dated 8/17/14 (Sunday) documented the resident had very pasty and pale white skin. Staff attempted to walk the resident but the resident tired and staff returned the resident to the bed. The resident's intake of food and fluids had greatly diminished since 12 days ago. The resident refused to go to the hospital. The nurse's notes documented staff sent a facsimile to the physician. A facsimile dated 8/17/14 documented the resident's vital signs, an increase in weakness, a decrease in walking and a decrease in intake. During an interview on 10/1/14 at 3:45 p.m. the resident's physician stated he did not see a facsimile on 8/17/14. He did not know about the resident's condition until the facility called on 8/19/14 and he gave an order to send the resident to the hospital. The physician stated if he knew about the resident's condition on 8/17/14, he would have encouraged the resident to go to the hospital and would at least order blood tests. The nurse's notes dated 8/19/14 at 4:50 p.m. documented the resident as alert, but confused and anxious. Staff documented the resident as weak, complaining of thirst, with warm and dry skin and a decreasing blood pressure (from 107/57 at 11:40 p.m. to 98/42 at 12:35 p.m.). Staff contacted the resident's physician and family and the resident admitted to hospital at 4:15 p.m. with a [DIAGNOSES REDACTED]. A History and Physical Consultation dated 8/19/14 documented the resident came to the hospital after 1 to 2 weeks of having black stools according to the resident's family members. The consultation documented facility staff attributed the black stools to iron use and did not pursue it further. The day after hospital admission, the resident had black stools 6 times. A Discharge Summary dated 8/25/14 documented the resident had [DIAGNOSES REDACTED] ulcers and a Hemoglobin of 4.1 indicating [MEDICAL CONDITION] (normal hemoglobin levels measure between 12 to 16). The resident received 6 units of packed red blood cells and 2 units of frozen plasma. During an interview on 10/1/14 at 8:14 a.m. the Director of Nursing (DON) stated she would expect the nursing documentation to include the color and consistency of the resident's stools and complaints of nausea, vomiting, urine color, sputum color and the resident's intake. During interview on 10/1/14 at 1:08 p.m., Staff M, CNA (Certified Nursing Assistant) stated the resident had black stools before hospitalization . Staff M reported the stools to the nurses, who stated that was normal for the resident. During an interview on 10/2/14 at 11:12 a.m. Staff G, CNA stated the Resident #10 had loose dark stools prior to admitting to the hospital. During an interview on 10/2/14 at 10:45 a. Staff O, licensed practical nurse, stated she did not work two weeks before the resident went to the hospital. Staff O stated she saw a decline in the resident's condition; the resident needed more assistance with walking and had a poor intake. Staff O stated she sent a facsimile to the physician on a Sunday. She knew the physician would not get the fax until the next day but felt the condition change was non-emergent. Staff O did not recall any reports of black stools form the resident's family members or certified nursing assistants (CNAs). During an interview on 10/1/14 at 1:40 p.m. the resident's power of attorney (POA) stated that a couple of weeks before admission, Resident #10 had black and tarry stools. The POA would assist the resident to the bathroom and had observed the resident's stool. The POA stated s/he reported it to the nurse and the nurse attributed the black stools to an iron supplement. The resident had gotten weaker, needed help walking and looked pale. When Resident #10 went to the hospital, the doctor stated the black stools could be a sign of an intestinal bleed and had a low hemoglobin. 2. The MDS assessment dated [DATE] documented Resident #9 had [DIAGNOSES REDACTED]. The resident had impaired memory and cognition and required supervision with eating and a mechanically altered diet texture. The physician's orders [REDACTED].#9 with a mechanical soft diet. Nurse's notes dated 8/28/14 at 11:00 P.M. recorded that at 6:30 P.M., Resident #9 sat at the dining room table with the supper meal and started to choke. Staff performed the [MEDICATION NAME] maneuver and dislodged half of a hot dog. Resident #9 returned to the table and received education on taking smaller bites of food. Staff documented monitoring Resident #9 in the dining room and noting no further problems. The notes contained no documentation of assessment of the resident's lungs or measurement of his/her vital signs for symptoms of aspiration. Staff made the next entry in the nurse's notes on 9/14/14. The notes lacked any notification to the physician after the choking incident. Review of the physician progress notes [REDACTED]. Interview with Staff A, LPN (Licensed Practical Nurse) on 10/1/14 at 9:00 A.M. revealed she did not know of the choking incident. Staff A verified a lack of documentation of notification to the physician in the nurse's notes. Staff A stated an assessment of vital signs and lung sounds should be documented in the nurse's notes for a period of time after a choking incident. On 10/1/14 at 10:40 A.M., the Director of Nursing (DON) and Quality Assurance Nurse verified the record lacked documentation of notification of the physician after the incident and stated this information should be documented in the nurse's notes and incident reports. The DON and Quality Assurance Nurse indicated nursing staff did not complete an Incident Report for the choking incident. The DON stated Resident #9 did not get assessed for aspiration and/or stomach or throat problems after the incident. The DON stated staff should have followed up after the incident, but she could see the thought process. The resident appeared OK so they did not need to do anything. Interview with Staff B, LPN on 10/1/14 at 1:00 P.M. revealed awareness of the 8/28/14 choking incident for Resident # 9. Staff B stated assessments should have been documented for 72 hours or longer depending on the incident and the assessment results. According to the Physician's Progress Note dated 10/01/14 at 3:47 P.M., the physician examined Resident #9 on 10/1/14 for an acute episode of choking and respiratory distress. The physician documented the episode of choking on the hot dog occurred on 8/28/14. The Physical Examination documented a blood pressure of 126/80, pulse at 70 beats per minute, respirations of 14 breaths per minute and a temperature of 97.6. The resident displayed no distress with respiratory effort and breathed normally. The physician documented the resident's lung sounds showed rhonchi (a coarse sound) present. The resident's physician stated on 10/1/14 at 3:40 P.M. that he recalled being notified of the incident at some time after the fact. The physician could not state when notification occurred and indicated the episode was resolved.

Based on clinical record reviews, observation, interviews the facility failed to plan for and direct nursing care and services to ensure residents received adequate supervision. Concerns noted for 6 of 8 current residents sampled for review (Residents #10, #6, #3, #4, #7, and Resident #5). The facility reported a census of 87 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] reported Resident #10 had impaired cognitive skills for daily decision making skills. The resident transferred with assistance of one staff, had no falls since admission. The resident had [DIAGNOSES REDACTED]. The Plan of Care dated 5/29/2014 identified Resident #10 had a risk for falls and directed staff to apply a Personal Safety Alarm (PSA) at all times, assist of one staff for transfers, place bed in low position with two side rails for bed boundaries and positioning. The CNA Care Plan directed the aides to apply a PSA at times, bed in low position, and ambulate with assist of one and walker. The Nursing Documentation and Fall Assessment Form dated 6/2/14 at 5:15 p.m., reported staff found Resident #10 lying on the floor on the left side. The resident attempted to get up from the chair and walk to the bathroom. The resident had dementia and unsteady gait, had a PSA alarm, not hooked to the resident. On 6/3/2014 the physician signed the Major Injury Determination Form, and determined Resident #10 sustained a major injury. The Radiology report dated 6/2/14 revealed Resident #10 had a displaced prosthetic fracture of the left hip. During an interview on 6/4/14 at 3:00 p.m., Resident #10's family member reported the resident got up without calling for help. The resident had dementia and had alarms in the bed and chairs. The family member had observed the alarms not in place when he/she visited on occasion. The resident now resided at the hospice house. During an interview on 6/4/2014 at 12:51 p.m., the D.O.N. (Director of Nursing) reported on 6/2/2014 he/she got a call to go to Resident #10's room. Staff T, RN (Registered Nurse) reported the resident complained of left hip pain and arm pain. Staff called for emergency services and remained with the resident on the floor. The clip alarm sat in the resident's recliner with the tab in the box. The residents in the room across the hall put their call light on when they observed the resident fall. The resident had a fall score of 18, indicating he/she had a high risk for falls. The resident had a history of [REDACTED]. They continued to provide personal alarms when admitted to the facility. During an interview on 6/4/2014 at 3:45 p.m., the A.D.O.N., (Assistant Director of Nursing) reported Resident #10 had no falls since admission, but had falls at home. The facility changed the alarm to clip alarm only and staff made sure he/she had the call light within reach. The resident's goal was to admit to hospice, but needed to get stronger to go home with hospice services. The resident had no history of removing alarms or attempts at self- transfers. The physician signed admission orders [REDACTED]. However, the resident only had a clip alarm at the time of the fall. During an interview on 6/4/14 at 1:00 p.m., Staff T reported on 6/4/2014 he/she worked on Resident #10's wing. The resident had intermittent confusion since admission, shut off his/her alarms, and unclipped the alarm on two occasions that day that Staff T had observed. Staff T witnessed the resident early that morning walking to the bathroom. The resident failed to put his/her call light on and had removed the clip alarm. The second time, the resident just started to stand up from the bed. Staff T intervened. Staff T indicated the resident had a clip alarm that staff moved from the bed to chairs. During an interview on 6/4/2014 at 3:09 p.m., Staff Y, LPN (Licensed Practical Nurse) reported Resident #10 removed the alarm, removed the batteries, very much noncompliant with the alarms. The resident attempted to self- transfer and ambulate. Staff re-educated the resident. The resident resided near the end of the hall, away from the nurse's station. The aides reported the resident's noncompliance, and Staff Y witnessed it as well. During an interview on 6/4/2014 at 3:09 p.m., Staff Z, RN (Registered Nurse) reported Resident #10 ignored the alarms, and stood before staff could get to him. The bed had a pressure pad alarm. The aides reported the resident ' s noncompliance as well. During an interview on 6/4/2014 at 1:20 p.m., Staff L, CNA reported working on Hall #2 on 6/2/2014. The call light across the hall from Resident #10 went off and Resident #11 and #12 reported witnessing Resident #10 fall. Staff L observed Resident #10 on the floor lying on the left side to the left of the recliner. No alarm sounded, the clip alarm remained intact, in the recliner. The resident reported he/she needed to go to the bathroom. The CNA care plan directed staff to apply a personal safety alarm at times (PSA). The resident had a pressure alarm on the bed, not on the care plan. During an interview on 6/4/2014 at 1:30 p.m., Staff U, CNA reported working on 6/2/2014. Staff U responded to the call light across the hall from Resident #10. When Staff U entered Resident #10 ' s room, he she witnessed no call light, no alarm sounding, and the resident lay on the floor, on his/her left side with drops of blood on the floor by his/her head. The resident reported feeling like his/her arm had broken. The TAB alarm sat in the resident ' s recliner, with the tab intact. Staff U had observed the resident attempt to self- transfer, but never observed the resident attempt to remove the alarm. For a while the resident had a pressure alarm on the bed, but it had been removed. During an interview on 6/4/2014 at 2:00 p.m., Staff V, CNA reported working the day shift on 6/2/2014 and left at 2:15 p.m. prior to Resident #10 ' s fall. Staff V observed the resident attempt to self- transfer and unclip the alarm from his/her shirt. The resident had a TAB (clip) alarm that staff moved from the bed to chair. The CNA care plan instructed them to apply the personal alarm at times, but Staff V applied it at all times since the resident had unsteady gait. During an interview on 6/4/2014 at 2:30 p.m., Staff W, CNA reported working second shift at the facility. Staff W revealed Resident #10 had a clip alarm at all times. The resident often refused help, wanting to do things independently. The pressure alarm sounded, but the resident unclipped the personal clip alarm. Staff knew the resident unclipped it, because they would connect it, and respond to the pressure alarm, with the personal clip alarm disconnected. During an interview on 6/4/2014 at 3:10 p.m., Staff X, CNA reported working on 6/2/2014. At approximately 3 o ' clock p.m., Resident #10 Staff X observed the resident seated at the edge of the recliner, preparing to stand. Staff X disconnected the personal alarm and assisted the resident to the bathroom. Staff X connected the alarm after the resident returned to the chair, and placed the call light within reach. At approximately 5 o ' clock p.m. Staff X and Staff U responded to the call light across the hall from Resident #10. They observed Resident #10 on the floor on the left side, near the recliner. Resident #10 ' s call light and alarm failed to sound. The resident never used the call light, either staff would respond to the alarm, or they would just catch the resident up. Everyone knew the resident had a risk for falls and was noncompliant with the alarm. 2. The Minimum Data Set (MDS) for Resident #6 completed 4/6/14, included active [DIAGNOSES REDACTED]. The MDS reported the resident required extensive assistance for bed mobility and transfers, the resident required total assist for dressing, toilet use and personal hygiene. The form indicated the resident had long and short-term memory impairment and severe cognitive impairment, hallucinations and delusions. The balance test for transitions and walking determined the resident was not steady and only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around, and moving on and off the toilet. A Geriatric Services note dated 5/5/14 documented resident did not respond and did not follow commands. The form indicated the resident had advanced dementia and chronic pain. The resident appeared lethargic and chronically ill. The form indicated the resident had weakness in both upper and lower extremities. The resident utilized a wheelchair for locomotion. The Plan of Care first documented the resident at risk for falls due to disturbed gait related to dementia, osteoarthritis and debility on 10/4/13. The form instructed the staff to provide assistance as needed with transfers to reduce the risk for falls. The resident could transfer independently at times and staff provided assistance with dressing, hygiene and toileting. The form noted the resident usually incontinent of bowel and bladder and wore adult incontinent products. A Nursing Documentation and Fall Assessment Form dated 5/9/14 at 1:15 p.m. indicated Resident #6 fell from the toilet when a C.N.A. turned to grab a washcloth. The resident sustained [REDACTED]. The Conclusions and Findings noted C.N.A.'s would provide standby assistance with toileting. The Fall Investigation Tool dated 5/9/14 indicated Resident #6 had been seated on the toilet when the staff member went to the sink to get a wet wash cloth and heard a loud thud. The staff then went to the bathroom and found the resident lying face first on the floor. The C.N.A. stated he/she last saw the resident one minute prior to the fall. A Non-Pressure Skin Condition Report dated 5/9/14 documented resident sustained [REDACTED]. The C.N.A. pocket plan of care, printed on 5/20/14 instructed the staff to not leave the resident alone in the bathroom. Observation on 5/20/14 at 4:55 p.m. revealed the resident had an injury on their left forehead measuring approximately 1 centimeter (cm) with an approximate 3 cm by 2 cm surrounding pink area. Observation on 5/21/14 at 9:10 a.m. revealed Staff D prepared to assist the resident from the dining room to his/her bathroom. Staff D set up supplies on an over bed table in the resident's semiprivate bedroom. Staff D then placed a gait belt around the resident, assisted the resident to a standing position and then walked backwards while holding the resident's hands. Staff D walked the resident into his/her bedroom, past the roommate and into the bathroom. Staff D lowered the resident's pants, removed the urine soiled brief and sat the resident down on the toilet. Staff D then left the bathroom. Staff D changed his/her gloves and closed the privacy curtain in the bedroom. Staff D was not visible from the bathroom. When Staff D left the bathroom, the resident voided in the toilet and then began to stand up, unassisted. The Assistant Director of Nursing, present in the bathroom to observe the care, intervened and instructed the resident to sit down. When interviewed on 5/21/14 at 9:28 a.m. Staff D verified she left the resident on the toilet while she left the bathroom to close the privacy curtain, change her gloves, and obtain supplies. Staff D stated this was typical for her. Staff D verified she could not see the resident while she was in the bedroom. Staff D verified she was not aware the resident stood up from the toilet. 3. The MDS for Resident #3 completed 2/2/14, included active [DIAGNOSES REDACTED]. The MDS reported the resident required assistance for bed mobility and transfers, and required total assist for dressing, eating, personal hygiene and bathing. The form indicated the resident had lower extremity impairments on both sides. According to the Brief Interview for Mental Status (BIMS) cognitive test, Resident #3 scored 0 of 15 which revealed the resident had severe cognitive impairments. A Portable X-Ray report dated 4/18/14 revealed three x-rays taken of the resident's right shoulder due to pain and bruising after a fall. The images of the right shoulder demonstrated obliquely oriented nondisplaced fracture of the distal clavicle. This was thought to be an acute fracture. A physician's orders [REDACTED]. A Physician report dated 5/6/14 noted the resident's fractured clavicle, advanced dementia and hospice status for comfort. The physician noted the resident's deformity of the right clavicle and tenderness and instructed the staff to continue current hospice care and comfort measures. Observation on 5/20/14 at 3:00 p.m. revealed Resident #3 lying on his/her bed. Observation revealed a arm/sling on the resident's right arm. Two C.N.A.'s, Staff A and Staff E came to the resident's room and prepared to provide personal care for this resident. Staff A unfastened the resident's brief. Observation revealed the resident incontinent of bowel and bladder. While turning the resident onto his/her side, Staff A placed her hand on the resident's right shoulder and pulled the resident towards her. The resident instructed the staff not to pull on his/her shoulder. The staff completed the care, dressed the resident and then sat the resident on the side of the bed. The staff then reached under the resident's right arm, grabbed the resident's right upper arm with her hand. The surveyor then asked the Assistant Director of Nursing (ADON) to intervene and prevent the staff from lift the resident by the arm/shoulder. The C.N.A. pocket care plan printed on 5/20/14 instructed the staff to utilize a clip alarm when resident in bed and to place a mat on the floor next to the bed. Observation on 5/21/14 at 3:20 p.m. revealed the resident laying in bed. The resident's wheelchair parked next to the resident's bed. Observation revealed the floor mat folded up and stored upright. Observation also revealed no PSA (personal safety alarm) on the resident at this time. When interviewed on 5/21/14 at 3:25 p.m. a C.N.A. Staff N stated she had not been in this resident's room since she came on duty. When interviewed on 5/21/14 at 3:25 p.m. a C.N.A. Staff O stated she had come into the resident's bedroom to bring the resident fresh ice water. Staff O stated she did not notice the fall mat not in place and the PSA alarm not on the resident as planned. When interviewed on 5/21/14 at 3:25 p.m. a nurse, Staff P stated she had come into the resident room to do a treatment on the resident's roommate. Staff P stated she did not notice the fall mat not in place and the PSA alarm not on the resident as planned. The Plan of Care dated 5/8/14 addressed this resident's risk for falls related to Alzheimer's Disease and debility, the form instructed the staff to utilize a pressure alarm at all times, utilize bed and wheelchair alarm at all time, provide a safe, clutter free environment. The care plan directed two staff to assist with transfers to reduce the resident ' s risk for falls. The plan of care also addressed the resident's altered comfort related to complaints of back pain. 4. The MDS for Resident #4 completed 3/16/14, included active [DIAGNOSES REDACTED].V.A. (stroke), Non-Alzheimer's Dementia, anxiety and depression. The MDS reported the resident required limited assistance for transfers, walking, dressing, toilet use, and bathing. According to the Brief Interview for Mental Status (BIMS) cognitive test, Resident #4 scored 3 of 15 which revealed the resident had severe cognitive impairments. According to the balance test for transition and walking, the resident was unsteady, and only able to stabilize with staff assistance when walking, moving on and off toilet and during surface to surface transfers. The resident sustained [REDACTED]. According to a Doctor's Progress Notes dated 1/22/14 the physician instructed the staff to utilize fall and skin precautions. According to the Fall Risk Evaluation dated 3/20/14 indicated Resident #4 was at high risk for falls due to his/her intermittent confusion, a history of falls in the last three months, resident chair bound, medication usage and predisposing diseases. The Plan of Care held on 3/27/14 addressed the resident's risk for falls related to dementia, and the need for assistance with ADL's (activities of daily living). The interventions included the resident would receive limited assistance of one staff with gait belt with transfers to reduce the risk for falls, provide a safe and clutter free environment. A new intervention for risk for falls dated 5/18/14 noted resident moved to room closer to nurse's station. The current interventions, first dated 10/2/13 included pressure alarm to bed and wheelchair. A Nursing Documentation and Fall Assessment Form dated 4/28/14 noted at 1:05 p.m. noted staff found resident on the floor, next to bed, wheelchair at resident's feet. Resident reported attempting to transfer self from wheelchair to bed and fell to the floor. A communication sheet sent to the physician on 4/29/14 noted resident returned from the emergency room with stitches to left leg laceration. Nurse's Notes dated 5/18/14 at 9:10 a.m. heard pressure alarm sound. C.N.A. went into resident's room and found resident lying down on stomach in front of wheelchair. Nurse's Notes dated 5/20/14 at 5:00 a.m. resident denied any pain or discomfort. Resident did have altercation with roommate earlier this evening. Roommate was moved to another room for night. Nurse's Notes dated 5/20/14 at 6:00 p.m. indicated staff moved this resident to another bedroom down another hallway. No injury noted from his/her shirt on 5/19/14. No injury noted past hip dislocation from fall. Nurse's Notes dated 5/21/14 at 2:20 p.m. staff re-directed resident from old bedroom. Nurse's Notes dated 5/24/14 at 2:00 p.m. resident required re-direction on two occasions to get to his/her room. Observation on 6/3/14 at 10:15 a.m. revealed resident lying on the bed in the bedroom he/she used to occupy. Observation revealed no alarm on the bed. When interviewed on 6/3/14 at 10:20 a.m. a C.N.A., Staff Q denied knowing the resident laid in his/her former bed. Staff Q verified the resident laid in the bed without any alarms. When interviewed on 6/3/14 at 10:25 a.m. a nurse, Staff R denied knowing the resident laid in his/her former bed. When interviewed on 6/3/14 at 10:33 a.m. C.N.A. Staff G denied knowing resident laid on his/her former bed. When interviewed on 6/3/14 at 10:35 a.m. C.N.A. Staff M denied assisting resident to his/her former bed. When interviewed on 6/3/14 at 10:40 a.m. C.N.A. Staff FF denied assisting this resident on this day. When interviewed on 6/3/14 at 10:42 a.m. C.N.A. Staff GG denied assisting this resident on this day. When interviewed on 6/3/14 at 10:45 a.m. R.N. Staff HH denied assisting this resident on this day. When interviewed on 6/3/14 at 10:47 a.m. C.N.A. Staff II stated she last observed this resident earlier that day when she gave this resident a shower. Staff II stated the resident had been going into his/her old bedroom and transferring him/herself into his/her old bed a lot lately. When interviewed on 6/3/14 at 1:20 p.m. the Director of Nursing stated she knew the resident continued to go to his/her old room and transfer him/herself into his/her old bed since they moved the resident to another bedroom. The Director of Nursing stated their only intervention for this potential problem was for the staff to intervene when they saw the resident go into his/her old bedroom. The director of nursing denied implementing any interventions to alert staff when the resident entered the old room and denied the use of any alarms to the resident's old bedroom and/or bed. The Pocket Plan of Care dated 5/19/14 noted pressure alarm at all times and transfer with assistance of one. The Social Service Progress Note dated 12/23/13 noted this resident's [DIAGNOSES REDACTED]. The resident scored 6 out of 15 on the BIMS which indicated severe cognitive deficits. 5. The MDS for Resident #7 completed 2/2/14, included active [DIAGNOSES REDACTED]. The MDS reported the resident required extensive assistance for transfers, and required limited assist for dressing and personal hygiene. The form indicated the resident had a lower leg impairment impairments on one side. According to the Brief Interview for Mental Status (BIMS) cognitive test, Resident #7 scored 3 of 15 which revealed the resident had severe cognitive impairments. The form indicated the resident had sustained a fall since admission to the facility. The Plan of Care dated 5/30/14 identified the resident's risk for falls related to dementia and poor safety awareness. Resident #7 had a history of [REDACTED]. Observation on 5/20/14 at 9:21 a.m. revealed Resident #7 seated in a wheelchair by the nurse's station. Observation revealed a large hematoma above the resident's right eye. A Non-Pressure Skin Condition Report dated 5/16/14 noted resident sustained [REDACTED]. The C.N.A. pocket plan of care, printed off on 5/20/14 indicated the resident a fall risk and required assistance of two persons for transfers. Observation on 5/20/14 at 9:45 a.m. revealed Staff G and Staff F transferred the resident by placing their arms under the resident's underarms and pulling up on the resident's arms/shoulders. The staff failed to use a gait belt for the assisted transfer. When interviewed on 5/20/14 at 9:55 a.m. the Director of Nursing (DON) described the transfer as good. When asked the facility's policy for assisted transfers, the Director of Nursing stated staff were to use a gait belt for all assisted transfers. The DON verified the staff lifted the resident under the resident's arms and failed to use a gait belt. When interviewed on 5/20/14 at 9:58 a.m. Staff F stated she totally failed to remember to use a gait belt. Review of the facility's undated policy and procedure, "Pacifica Health Services, LLC Modified Lifting Policy and Procedure" noted all employees were to exercise proper safety techniques when lifting and transferring residents and utilize safety materials, equipment and training designed to prevent personal and patient injury. The purpose of this policy was to set a consistent standard from which all employees exercised proper lifting and transfer techniques for each individual resident in order to achieve an accident-free environment. The guidelines in determining proper transfer methods included gait belts must be used 100% (percent) of the time. The facility's Therapy Orientation instructed staff gait belts were mandatory with all transfers. The facility's Transfer Training instructed staff to always use a gait/transfer belt and never pull up on resident arms. This document also noted if a resident required assistance to transfer, a transfer belt was required. The belt was used to hold onto the resident during the transfer. When interviewed on 5/20/14 at 12:32 p.m. the resident stated he/she hit his/her head when he/she stood up and tripped. The resident stated his/her head still hurt. Observation revealed an approximate 5 cm by 4 cm purple hematoma raised approximately 2.5 cm. Observation revealed purple bruising of the resident's right neck and cheek. 6. Review of the clinical record for Resident #5 revealed the admission date of [DATE] to the facility. An undated Pre-Admission Assessment Form listed the resident's admitting [DIAGNOSES REDACTED]. Pertinent Information included the resident exhibited increased agitation in evenings as evidenced by anxiousness, would get up and down repeatedly. The resident did not like male caregivers and wandered. Listed behaviors included the resident tried to leave his/her home and would get mad with redirection attempts. A Minimum Data Set (MDS) assessment tool dated 2/16/14 indicated the resident had short and long-term memory loss and severe cognitive impairment. Behaviors included delusions, physical aggression and wandering on a daily basis. The resident required two staff to assist with bed mobility, transfers, dressing, toilet use and bathing. The resident required two staff assistance with walking in the bedroom and in hallways and personal hygiene. The resident required staff assistance to stabilize his/her balance while changing positions, walking and turning. Active [DIAGNOSES REDACTED]. The resident was always incontinent of bowel and bladder. The resident weighed 198 pounds. The Plan of Care dated 10/10/13, (updated 2/19/14) noted resident at risk for elopement due to dementia as evidenced by the resident approached exit doors frequently and made statements of wanting to get out. The interventions instructed the staff to monitor the resident while up in merry walker and redirect as needed if resident seen near exit doors. The wandering care plan first dated 9/25/13 identified the resident's elopement risk as evidenced by a history of attempts to leave the facility unattended, wandered aimlessly, impaired safety awareness and disoriented to place. The plan of care also identified the resident's risk for falls due to dementia and poor safety awareness and instructed the staff to check frequently. The Psychosocial Care Plan dated 10/10/14 noted the resident's ineffective coping skills and failure to adjust to lifestyle change. A Social Service Progress Note dated 2/19/14 assessed the resident as a [AGE] year-old resident with significant long and short-term memory deficits and severely impaired decision making skills. The resident continued to utilize his/her merry-walker throughout the facility. The resident had exit seeking behaviors and would attempt to get out the doors several times a day. Staff continued to keep a close eye on the resident regularly. An Incident/Accident Report dated 4/24/14 at 7:50 p.m. noted the nurse was completing his/her report when notified by a C.N.A. (certified nursing assistant) that the resident was in front of the facility. The nurse noted the incident was unwitnessed. Nurse's notes dated 4/24/14 at 8:00 p.m. noted at 7:50 p.m. the nurse was alerted by a C.N.A. that the resident had exited the facility through the west door down the 200 hallway. At 7:53 p.m. three staff members rushed outside. They found the resident on the grassy area out front of the care center. The nurse re-educated the resident that he/she needed staff to accompany him/her & the nurse initiated 15 minutes check) on the resident. An undated, unsigned typed facility report indicated on 4/24/14 the resident exited the building through the 200 hall exit door. A C.N.A., Staff J was in another resident's bedroom when he noted this resident outside the building and immediately went to the dining room and alerted the nurse of the resident being outside. The facility installed a new alarm on the 200 hall door awaiting a wander guard alarm system for the 200 hall door. The facility held a mini in-service to educate staff members on correct use of alarm system. A communication form sent to this resident's physician dated 4/25/14 informed the physician the staff found the resident outside, on the front lawn. The staff began 15 minute checks on this resident. Observation on an environment tour beginning at 8:21 a.m. on 5/20/14 revealed an alarmed door at the end of the 200 resident hallway led to an enclosed area. This area contained a doorway to the physical therapy room, an incline to an alarmed doorway to the assisted living center and two alarmed doors to the outside. One of the alarmed exit doors led to the front yard and parking lot. A written statement by an assisted living employee, Staff K dated 4/25/14 indicated about 8:00 p.m. to 8:20 p.m. he/she and another assisted living employee, Staff I were busy passing medications in the assisted living when their pagers alerted and the computer was going crazy. The computer kept saying "West Door". Staff K and Staff I went to the beauty shop to reset the door alarm. He/she was unable to reset the alarm. Staff K then went to the facility's nurse's station and asked the staff why they were getting the alerts in the assisted living. The facility staff then informed the assisted living staff the resident was outside. A written statement by an assisted living employee, Staff I indicated on 4/24/14 the alarm sounded for the west door. The alarm kept popping up on their system for about 20 minutes. They tried to cancel the alarm. They attempted to get the facility staff to assist them. A second written statement by Staff I indicated on 4/24/14 around 7:55 p.m. the alarm for the west door went off, the pagers were going off as well as the alarm on the computer. The alarm went off for a few minutes so Staff I and Staff K decided to go and check it out. They went and tried to cancel the alarm. They were unable to cancel the alarm so they went to get assistance from the facility staff to cancel the alarm. When interviewed on 5/20/14 at 12:03 p.m. the assisted living employee, Staff I stated he/she had worded at the assisted living for one year. Staff I stated when the alarm and pagers alerted on 4/24/14 it felt like 20 minutes, however it could have been shorter. Staff I stated he/she was wondering why the alarm continued to sound. Staff I stated after what seemed like 20 minutes, he/she and Staff K went to see why the alarm continued to sound. A written statement by a C.N.A., Staff J indicated Staff J last observed the resident by the dining area. Staff J was in a resident's bedroom down the 300 hallway, closing the window blinds when he/she observed the resident outside of the care center. Staff J then alerted the nurse and went outside to assist the resident. When interviewed on 5/20/14 at 2:00 p.m. Staff J stated about 7:30 p.m. to 8:00 p.m. he/she was in a bedroom down the 300 hallway. Staff J looked outside the window and observed the resident outside the building. Staff J denied hearing any alarms sound. Staff J then went down the hall, to the front dining room area and alerted the nurse the resident was outside the building. They found the resident outside, behind the handicapped parking sign, on the grass, down a slope, approximately 12 feet from the sidewalk. It took three staff members to get the resident in the Merry Walker back up to the sidewalk. Staff J denied hearing any alarms sounding when outside. Staff J stated no staff knew the resident was outside the building until he/she saw the resident out the window. Staff J stated the 200 door had a quiet alarm that turned off when the door was closed. Staff J stated a resident who lived down the 200 hall, Resident #1 reported hearing the alarm sound. Staff J stated he/she felt this was an elopement due to no one knew the resident had exited the 200 door. When interviewed on 5/20/14 at 1:25 p.m. a licensed registered nurse, Staff C stated on 4/24/14 staff assisted the resident into a Merry Walker after the evening meal. Staff C stated the 200 door had an alarm that quit after the door was closed. At 7:50 p.m. Staff C was checking medications when Staff J came from the 300 hall, running towards the front door. Staff J informed the nurse, the resident was outside the building. Staff C followed Staff J out the door. They found the resident outside, behind the handicapped parking sign in a wet, soft grassy area. The resident normally would go to every exit door and attempt to exit the building. After this incident, they moved the resident to another room and put a new alarm on the 200 hall door. Staff C denied getting a pager alert until after he/she observed Staff J running down the 300 hallway. Staff C denied hearing any alarm. When interviewed on 5/21/14 at

Based on record review, observation and staff interview the facility failed to ensure each resident received adequate supervision and implement interventions to reduce the risk of hazards 1 of 6 residents reviewed (Resident #9). The facility identified a census of 76 current residents. Findings include: 1.The MDS (Minimum Data Set) assessment dated [DATE] documented Resident #9 had [DIAGNOSES REDACTED]. The resident had impaired memory and cognition and required extensive staff assistance with transfers. The resident did not walk and had impaired balance when moving from a seated to a standing position, with toilet use and during surface-to-surface transfers. They Physician order [REDACTED]. Review of the nurse's notes dated 9/22/14 at 7:55 P.M. revealed Resident #9 put him/herself on the floor in the hallway and the resident wanted to go to bed. The resident did not receive any injury. The Plan of Care dated 7/16/14 documented Resident #9 as at risk for falls related to right [DIAGNOSES REDACTED] and past CVA. Resident #9 could be noncompliant at times and attempted to transfer themselves or not ask for help when needing assistance. On 9/23/14, staff added the intervention of a PSA with a shorter string and stronger clip applied at all times. Observation on 10/1/14 at 7:55 A.M. revealed Resident #9 lying in bed with the alarm box secured to the side rail on the left side of the bed. The clip lay on the floor, not attached to the resident. During interview on 10/1/14 at 8:00 A.M. Staff H, CNA (certified nursing assistant) verified that the clip alarm as unattached and on the floor. Staff H stated the alarm should be on at all times. Staff H spoke to Staff I, CNA who arrived to assist with a transfer and stated that Resident #9 could remove the clip alarm and did so frequently when clipped within reach. Staff H stated the alarm had been clipped on during walking rounds at 6 A.M. Observation on 10/1/14 at 9:45 A.M. revealed Resident #9 back in bed after breakfast with the clip again unattached and lying on the floor. Interview with Staff A, LPN (Licensed Practical Nurse) at that time revealed that Resident #9 could remove the alarm. Staff A stated that staff checked on the resident frequently and the CNAs were on break at that time. Interview with the Director of Nursing and Quality Assurance Nurse on 10/1/14 at 10:40 A.M. revealed that no awareness that Resident #9 took the alarms off. The resident had pressure alarms in the past and they did not know why this changed or how the resident got the alarm off. On 9/22/14, staff placed a heavy duty clip as the last clip slipped off but did not completely come out; the alarm still sounded. The Director of Nursing and Quality Assurance Nurse planned to follow-up with the resident and staff.

Based on clinical record reviews, staff and resident interviews and observations the facility failed to provide adequate care to prevent further pressure sores from occurring for 1 of 4 sampled residents (Resident #4). The facility reported a census of 96 residents. Findings included: 1. According to the Minimum Data Set ((MDS) dated [DATE], Resident #4 had [DIAGNOSES REDACTED]. The resident had moderately impaired decision making. Resident #4 required assistance of 2 staff for bed mobility, dressing, toilet use with an indwelling urinary catheter and had total dependence of 2 staff for transfers but could independently feed themselves. The MDS indicated Resident #4 had 1 pressure sore greater than a Stage 1 and not present on the previous MDS. Review of Resident #4's Care Plan dated 10/13/13 indicated Resident #4 had a risk for developing skin breakdown related to their immobility. The care plan directed staff to keep the resident ' s skin clean, dry and keep his/her linens free of wrinkles. The care plan directed the staff to monitor skin integrity while providing cares and as needed, to turn and reposition and to remind the resident of the importance of being repositioned. The Resident required a pressure reducing mattress, pressure relieving devices in their chair. The care plan directed the Bath Aide to monitor the resident's skin twice weekly with their baths and report changes to the nurse and directed the nurse to complete daily skin assessments, document and report findings. The care plan directed staff to assist with hygiene, and provide peri-care after each incontinent episode as needed. The plan noted the resident wears adult incontinent products as needed. According to the Pocket Care Plan (Certified Nurses Aide Plan of Care) dated 1/14/14 directed the Aides to utilize a Hoyer Lift for transfers, to apply heel and elbow protectors, to turn and reposition when in bed, to utilize a wheel chair cushion and utilize 2 side rails while in bed. The physician's orders [REDACTED]. According to Resident #4's Skin Sheet dated 1/7/14, the resident had 1 open area which measured 2.1 x 2.1 x 0.2 centimeters, with a pink and clean wound bed. The staff were directed to utilize Calcium Alginate and secure with a Duoderm dressing which needed to be changed every three (3) days. The Skin Sheet indicated the pressure sore is chronic but acquired within the facility. The 1/7/14 Skin Sheet indicated the pressure had no odor and improving. According to the January 2014 Treatment record (TAR) Resident #4 had [DIAGNOSES REDACTED]. The treatment sheet documented daily skin checks were completed during the 6PM-6AM shift from 1/3/14 to 1/13/14. The same sheet identified weekly skin assessment had been done on 1/3/14 and on 1/10/14. Observation on 1/14/14 at 10:16 a.m. with Staff E Assistance Director of Nurse (A.D.O.N.)/Skin Nurse, the A.D.O.N. entered Resident #4's room with their treatment cart. The C.N.A.'s assisted the resident to roll over and Staff E proceeded with wound care. When Resident #4 rolled to their right side the resident found to have bowel movement on their brief and a foul odor noted. Staff E removed the Duoderm dressing and commented the wound now black in color and had been pink. Staff E admitted the Duoderm dressing had bowel movement on it with a foul odor. Staff E cleansed the areas and measured 4 open areas on the residents buttocks, the measurements are as follows: a. The original area to the center of the right buttocks now measures 3.5 x 2.1 and black in color. b. The open area to the upper left buttock measured 2.0 x. 06 and bright red in color. c. The lower left open area on buttock measured 1.4 x 0.5 centimeters and bright red in color. d. The open area to the right side of the buttock measured .8 x 1.2, the area appeared to have a layer of peeling skin sloughing off the wound. During the cleansing, measuring and re-dressing of the wounds, the resident complained of pain with the most intense pain during the cleaning of the wounds. During an interview with Staff F RN on 1/14/14 at 11:28 a.m. revealed Staff F removed Resident #4's Duoderm dressing on 1/11/14 and noted they had some drainage on their dressing but the area had a pink wound bed with a dark red center. Staff E stated the wound did not have a black appearance and stated Resident #4 had 2 dark red areas to the left of the original wound. Staff F stated the floor nurses only change the dressings and do not document on the Skin Sheets. During an interview with the Director of Nurses on 1/14/14 at 6:25 p.m. revealed that during the provision of cares earlier in the day (6:15 a.m.) for Resident #4, they noted the Duoderm to the resident's buttock appeared to be brown with feces with a date of 1/11/14 on the dressing. During an interview with Resident #4 on 1/14/14 at 9:45 a.m. indicated they have pain to the "sores" on their bottom when the staff clean and change/remove the dressing to their buttocks. Resident #4 stated they staff had not yet changed/removed their dressing to their buttock and placed a new dressing on that day.

Based on record review, resident and staff interviews, the facility failed to plan for and direct nursing services to ensure Resident #1 received adequate supervision with transfer equipment to protect against hazards in the environment. On 8/13/13 Resident #1 sustained a fractured knee when he/she slid off the slide board during a transfer from his/her bed to the wheelchair. Staff interviews established the standard of care during slide board transferred variety among staff with gait belt use or training received for slide board transfers. The resident's plan of care lacked necessary approaches to address his/her safety needs during the slide board transfer. The sample consisted of 1 of 16 residents with a facility reported census of 92 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had [DIAGNOSES REDACTED]. The resident scored a 15 of 15 on the Brief Interview for Mental Status indicating intact memory and cognition. The MDS documented the resident required extensive assistance of one staff member for bed mobility and transfers and that s/he did not ambulate or bear weight. The MDS documented the resident had a height of 67 inches and weighed 234 pounds. The care plan dated 8/13/13 instructed staff to transfer the resident with a slide board and 1 staff assist. The resident utilized a Hoyer mechanical lift with the assistance of 2 staff for transfers to the shower. The facility's Modified Lifting Policy and Procedure dated 1994 instructed staff to use gait belts 100% of the time. The policy instructed staff to utilize a mechanical lift 100% of the time for non-weight bearing residents. The use of mechanical lifts required 2 staff members. The policy also instructed staff on the use of lateral transfers but lack direction regarding gait belt use and/or the number of staff required to complete the transfer. The demonstration diagram showed one person using the slide board and a gait belt. The policy directed the slide board could be used for non-weight bearing through the lower extremities residents and allowed the resident to transfer without the use of a mechanical lift. The slide board section did not stipulate the use of the gait belt or the number of staff required to complete the transfer. The incident report dated 8/13/13 at 3:45 p.m. documented the resident slid off the slide board while doing a transfer with Staff P, certified nurse aide (CNA). The resident complained of right knee pain. Staff notified the physician and resident's responsible party. The nurse's notes dated 8/13/13 at 4:00 p.m. documented Staff P alerted Staff L, licensed practical nurse (LPN), that the resident slid off the sliding board during the transfer from the bed to the wheelchair. Staff L documented she entered the room and observed the resident sitting on the foot of the electric wheelchair. Staff L obtained vital signs and the resident had no complaints of pain. Staff used a Hoyer mechanical lift to assist the resident to the wheelchair. The resident complained of right lower knee pain and suggested an X-ray. The nurse's notes dated 8/13/13 at 4:20 p.m. recorded staff obtained an order for [REDACTED]. At 8:00 p.m. the resident transferred to the hospital. The consultation from the hospital dated 8/13/13 documented the resident had a comminuted bperiprosthetic tibia fracture (knee replacement). (A comminuted fracture means the bone is broke into several pieces.) During an interview on 8/21/13 at 5:27 p.m. Staff P, CNAs, stated on 8/13/13 she assisted the resident to transfer from the bed to the wheelchair using the slide board. Midway through the transfer, the resident got short of breath and leaned forward. The resident slid from the slide board onto the platform of the electric wheelchair for the resident's feet. Staff P attempted to assist the resident back onto the slide board by hugging the resident around the waist. The resident complained of back pain so Staff P lowered the resident. The resident's legs crossed and the right leg went under the platform of the wheelchair. Staff P stated she then called for help. Staff P stated she did not have training to use the gait belt for the slide board transfers. Staff P referred to the orientation as hurried and the training did not include a demonstration of a slide board transfer. When she orientated with the other CNAs on the resident transfers, they did not utilize a gait belt with the slide board. During an interview on 8/22/12 at 8:22 a.m. Staff M, LPN, stated on 8/13/13 Staff P informed her that she lowered the resident to the floor. Staff M entered the room with Staff L and observed the resident on the floor with their legs straight out in front. Staff M, Staff L, and Staff P tried lifting the resident to the wheelchair. Staff K stated the resident's leg did not look normal. Staff used the Hoyer mechanical lift to lift the resident to the wheelchair then to bed for an X-ray. Staff M stated she assisted the resident to transfer with the slide board and did not use a gait belt. Staff M stated she did have training to use a gait belt with a slide board transfer. During an interview on 8/21/13 at 1:55 p.m. Staff C, CNAs, stated she utilized the slid board to transfer the resident but the resident refused the gait belt. Staff C raised the bed about an inch above the wheelchair. The resident placed their feet on the platform of the wheelchair. Staff C stated she placed the slide board under the resident's buttocks, grabbed the back of the resident's pants and the resident grabbed the arm rest of their electric wheelchair to scoot across the slide board. Once in the wheelchair, the resident used the other arm rest to position in the wheelchair. Staff C stated the care plan did not indicate the resident refused the gait belt. During an interview on 8/21/13 at 2:00 p.m. Staff D, CNAs, stated she did not assist the resident with any transfers but knew to use a gait belt with the slide board. Staff D stated she knew the resident did not like the gait belt and would often refuse to wear one. During an interview on 8/21/13 at 2:12 p.m. Staff F, CNAs, stated she would put the bed higher than the wheelchair, the resident sat on the edge of the bed, she placed the slide board under the resident's buttocks and the resident would slide him/herself into the wheelchair using the arm rest of the wheelchair. The resident refused the use of the gait belt. Staff F stated she worked at the facility for 8 years and never had training to use the slide board with a gait belt. During an interview on 8/21/13 at 2:17 p.m. Staff G, CNAs, stated she put the bed higher than the wheelchair, placed the slide board under the resident's buttocks, assisted the resident's legs over to the wheelchair, and the resident would slide into the wheelchair. Staff G stated she always used the gait belt with the transfer. During an interview on 8/21/13 at 2:23 p.m. Staff H, CNAs, stated she assisted the resident to the edge of the bed, placed the slide board under the resident's buttocks and the resident would slide into the wheelchair independently. Staff H stated she would use the gait belt with the slide board transfer. During an interview on 8/21/13 at 2:05 p.m. Staff E, CNAs, stated when she assisted the resident to transfer with the slide board, she used the gait belt but the resident would often refuse at first. Staff E stated she put the bed higher than the wheelchair, placed the slide board under the resident's buttocks and the resident would complete the transfer mostly independently. Staff E stated facility policy directed staff to use the gait belt for any transfer except the Hoyer mechanical lift and the EZ stand mechanical lift. Resident #1 did not like using the gait belt. During an interview on 8/21/13 at 1:35 p.m. Staff A, restorative aide, stated she did not assist the resident with a transfer but knew the resident utilized a slide board. Staff A stated she would utilize a gait belt unless the care plan instructed not to or the resident refused. During an interview on 8/21/13 at 2:28 p.m. Staff I, CNAs, stated she assisted the resident to the edge of the bed, put the slide board under the resident's thigh, the resident would slid into the wheelchair grabbing the side rail and arm rest. Staff I stated she did not receive training to use the gait belt with the slide board and never observed any of the other CNAs using the gait belt with the resident's transfers. During an interview on 8/21/13 at 2:44 p.m. Staff J, CNAs, stated she raised the bed, sat the resident on the edge of the bed, and put the resident's feet on the platform of the electric scooter. The resident would slide over into the wheelchair using the arm rest. Staff J stated the resident refused the gait belt and would only use it with staff the resident knew. Staff J stated she worked at the facility for 8 years and did not receive training to use the gait belt with the slide board. During the interview on 8/21/13 at 3:14 p.m. Staff K, CNAs, stated to transfer the resident would raise the bed, place the slide board under the resident's buttocks, and the resident used the wheelchair arm rest to slide into the wheelchair. Staff K did not use a gait belt for the slide board transfer and did not receive training to use the gait belt with the slide board. On 8/13/13, she answered the resident's call light. She observed the resident on the floor with their legs crossed. Staff K stated she placed a gait belt around the resident and straightened the resident's legs. Staff K obtained Staff L, LPN, and Staff M, LPN. Staff P, CNAs, Staff L, and Staff M attempted to use the gait belt to raise the resident off the floor. Staff K stated the resident's leg bent in an awkward way so the staff set the resident on the floor and used the Hoyer mechanical lift to lift the resident to the wheelchair. Staff L obtained an order for [REDACTED]. During an interview on 8/21/13 at 3:30 p.m. Staff L, LPN, stated she had not assisted the resident with a transfer but knew the resident used a slide board. On 8/13/13 Staff P informed her, the resident slid off the slide board and she lowered the resident to the floor. Staff L observed the resident sitting on the foot platform of the wheelchair with legs straight. Staff L, Staff M, and Staff P attempted to lift the resident to the wheelchair with the gait belt without success. They used the Hoyer mechanical lift to transfer to the wheelchair then to the bed when the resident asked to have an x-ray. Afterward, Staff P stated she did not feel comfortable transferring the resident with one person. Staff L stated even if the resident wore a gait belt, it could not of prevented the fall. During an interview on 8/22/13 at 9:52 a.m. Staff Q, restorative aide from a sister facility, stated he completed the training of the new CNAs and goes through all the policies. Staff Q described a slide board transfer as a high risk transfer and staff needed to be trained by therapy. Staff Q stated staff do not need to utilize a gait belt for a slide board transfer but then stated staff needed to use a gait belt for all transfers with the exception of mechanical lifts. Staff Q stated Staff S, restorative aide, completed the demonstrations of the Hoyer and stand lift. Staff Q did not demonstrate a slide board transfer but stated the orientation materials contain a diagram of a slide board transfer. During an interview on 8/21/13 at 1:43 p.m. Staff B, Physical Therapist Assistant, stated he evaluated the resident after the resident fell and fractured vertebrae in the neck in his/her assisted living apartment. Staff B stated he used the slide board on the resident and trained the CNAs how to utilize the slide board, using a gait belt for the transfer. At the time, staff using the slide board represented the safest way to transfer to decrease pain and increase mobility. The CNAs' needed to cue the resident to lean forward to stay on the board. Staff B stated he demonstrated to the staff to raise the bed higher than the wheelchair, put the slide board under the buttocks and angle the board towards the bottom of the chair. The resident would grab the arm rest of the wheelchair and pull over onto the wheelchair seat. In regard to the incident that occurred on 8/13/13, Staff B stated the gait belt would not have prevented the fall. Once the resident's body weight leaned over the board, the CNAs would have to lower the resident to the floor. During an interview on 8/22/13 at 11:22 a.m. the Director of Nursing stated the facility utilized the same orientation material since 2007. New staff attends training at the sister facility then train with facility staff on site. The director of nursing stated Staff B, physical therapy assistant, would have completed the training for use of the slide board in 2011 when the resident admitted to the facility. Staff B no longer had records of staff attending the training. During an interview on 8/22/13 at 3:40 p.m. Staff N, CNAs, stated she helped orientate Staff P for a short time. Staff N stated she did not think she had to use a gait belt for a slide board transfer. Staff N stated the resident only required stand by assistance. During an interview on 8/21/13 at 3:50 p.m. Resident #1 stated a new girl transferred her/him from the bed to the wheelchair. The resident stated he/she did not think it was necessary to put that belt around their waist and usually did not wear the gait belt. The resident stated he/she started to fall forward and the girl tried to lift him/her up to the slide board, but could not and lowered her/him to the platform on the scooter.

Based on clinical record review, observation, facility policy review, and staff interview, the facility failed to prevent the development of pressure ulcers and assess the skin and provide treatment as ordered by the physician for 1 of 3 residents with pressure areas (Resident #6). The facility reported a census of 87 residents. Findings include: The Skin Care Program policy revised 7/30/10 provides the following guidelines: All individuals at risk or new admissions for the first week will have a systematic skin inspection at least once a day. Pay attention to bony prominences. Interventions and outcomes should be monitored and documented weekly. For new admissions, the policy directs staff to document any skin issues on the Admission Nursing Assessment, marking the body figure where any skin issues are present, Thereafter, skin will be assessed on a weekly basis and documented. Treatments will be completed as ordered by the physician. The Minimum Data Set (MDS) assessment tool dated 5/27/12 documented Resident #6 had [DIAGNOSES REDACTED]. The MDS documented the resident required moderate assistance with bed mobility, transfers, ambulation, and personal hygiene. The MDS documented the resident had no pressure areas. The MDS indicated the facility used pressure reducing devices for the chair and the bed but did not have a turning /repositioning program. The care plan dated 5/31/12 instructed staff to utilize a pressure reduction mattress to the bed, pressure relieving cushion to the wheelchair, and weekly skin assessments. The Braden Scale for Predicting Pressure Sore Risk dated 5/15/12 documented a score of 20 (incorrect score-should be 19) which identified the resident at a low risk for the development of pressure sores. On 5/31/2012 the scale identified the resident at risk with a score of 18. The Admission Nursing assessment dated [DATE] at 1:00 p.m. documented a red non-balanceable area to the spine which measured 2.4 by 10 centimeters (cm). The assessment indicated the area covered with Allevyn (adhesive foam dressing). The physician admission orders [REDACTED]. The TAR (Treatment Administration Record) for May 2012 documented an order for [REDACTED]. The treatment administration record lacked further documentation of skin inspections. The TAR dated June 2012 documented an order to inspect skin daily for 1st 7 days after admission and then discontinue. The TAR indicated the staff should inspect the skin weekly and on each Tuesday. The staff marked the skin was assessed on 6/5/2012 but crossed out as discontinued. The TAR for June 2012 documented an order for [REDACTED]. The clinical record lacked documentation of a physician order [REDACTED]. The non-pressure skin condition report dated 5/22/12 documented a pink area to the spine that measured 1.2 by .8 cm. The non-pressure skin condition report dated 5/29/12 documented a pink area to the spine that measured .5 by .5 cm. The non-pressure skin condition report dated 6/5/12 documented a pink area to the spine that measured .6 by .5 cm. The non-pressure skin condition report dated 6/9/12 documented a red open area that measured 12 by 2 cm. The nurse's notes dated 6/9/12 at 12:10 p.m. documented the resident complained of back pain. Upon inspection, staff observed a 12 by 2 cm open area to the spine. The nurse's notes documented the tissue as very red. Staff received new orders to apply [MEDICATION NAME] and cover. The nurse's notes dated 6/11/12 at 4:30 p.m. documented the open area had yellow slough with deep red surrounding tissue. Staff received an order for [REDACTED].-[MEDICATION NAME] level. The nurse's notes dated 6/15/12 at 3:00 p.m. documented the resident's physician examined the resident's wounds to the spine. The nurse's notes documented the total affected area measured 13 by 5 cm. The top wound measured .8 by 1.8 cm with yellow slough. The second wound measured 5.8 by 2 cm which included a top wound covered with 50% eschar and yellow slough. The lower part of the wound measured 2.4 by 1.1 and covered with eschar. The nurse's notes described the surrounding area as inflamed. The wound had serous drainage. The nurse's notes documented an intervention to put lamb's wool on the back of the wheelchair and obtain a physical therapy evaluation for wheelchair positioning. On 7/24/12 at 10:14 a.m. Staff D (Director of Nursing), stated the resident had an order for [REDACTED]. Staff R also failed to document the original area on a pressure area skin sheet instead of a non-pressure skin sheet stated Staff D. After the areas developed, the facility obtained an occupational therapy evaluation for wheelchair positioning and lamb's wool to the back of the wheelchair. The Director of Nursing and Quality Assurance Nurse have the skin assessment duties. The facility did not follow the physician's order [REDACTED].

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision to protect residents during a mechanical lift transfer (Resident #1) and failed to provide prompt safety interventions to prevent further falls from occurring (Resident #3,#4,#5). The sample consisted of 5 residents and the facility identified a census of 84 residents. Findings include: 1. Resident # 1 had [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment with a reference date of [DATE], reflected Resident # 1 rarely made self understood, and rarely understood others. The resident's long and short term memory were both impaired, and the resident had severely impaired decision making skills. The resident required at least the extensive assistance of staff for all cares, and was totally dependent on two staff for transfers. The resident was unsteady but able to stabilize during surface to surface transfers with assistance. The resident typically used a wheelchair, and had limited range of motion in both lower extremities (legs). The resident ' s care plan identified falls as a potential problem in regard to the need for assistance with all transfers and mobility. A hand written intervention dated [DATE] directed the staff to use a Hoyer lift and 2 staff members for all transfers for safety. The Nurse ' s Notes dated [DATE] at 1:20 p.m. reflected the nurse as called to the resident room and noted resident on the floor with head held by a CNA (Certified Nursing Assistant). The CNA informed the nurse the resident had fallen during a transfer and unable to prevent the injury. The resident had a 2 cm (centimeter) skin tear to the left parietal (side) of the head. Staff provided first aid, initiated neuro signs monitoring (pupil reaction, ability to move, and level of consciousness, etc.) and the resident denied pain. The physician was at the facility and was notified of the incident at 2:00 PM. The physician ordered staff to cleanse the area with a wound cleanser, apply bacitracin ointment and cover with a band-aide twice a day. An incident report dated [DATE] at 1:20 PM indicated staff transferred Resident #1 with a Hoyer Lift (mechanical device used with a sling/lift) and 1 of the 2 side/straps detached from the lift and the resident slid to the floor. An investigation of the fall document (not dated or signed) indicated on [DATE] at 1:20 PM, the resident was transferred to bed by staff J and O. Staff J was driving the Hoyer and Staff O was behind the resident's head. The left lower hook/sling detached from the Hoyer during the transfer. Staff J stated the resident's head hit the bottom right Hoyer leg, suffering a laceration to the left side of her head. The nursing assistants received disciplinary action for not checking placement of the hooks. The CNA staff were educated about proper transferring with the Hoyer lift. The resident expired on [DATE]. The physician progress notes [REDACTED]. The Modified Lifting Policy and Procedure (not dated) indicated staff were to be trained upon hire, on an annual basis, and as required to correct improper use/understanding of a safe resident and movement. Non weight Bearing residents were to be always transferred with a mechanical lift with 2 staff present. On [DATE] Staff J signed the Transfer Training-Lifting Protocols form which indicated she had received training to use a Hoyer lift. On [DATE], Staff J signed the Employee Warning and Discharge Notice. The offense was that a resident fell during a Hoyer transfer resulting in injury. The written statement dated [DATE] confirmed Staff J and Staff O were transferring Resident # 1 after lunch. Staff J moved the Hoyer lift (with the resident in the sling) towards the bed, and Staff O was positioned on the right side of the Hoyer. One of the left Hoyer straps slipped off of the device and the resident went out head first to the Hoyer stand. The staff tried to catch the resident. Staff J directed Staff O to get the nurse as Staff J stabilized the resident's head and placed pressure (to the laceration with a towel.) On [DATE], Staff O signed the Transfer Training-Lifting Protocols form which indicated Staff O had been trained to use the Hoyer lift. On [DATE], Staff O signed the Employee Warning and Discharge Notice, for the offense of a resident falling during a Hoyer transfer resulting in injury. Staff O provided a written statement (not dated) that Staff J and Staff O had hooked the sling to the Hoyer Lift. The staff started to raise the resident. As the resident was up in the air, the sling came off of the Hoyer lift device. Staff J was controlling the Hoyer device and Staff O stood by the resident's head. The staff tried to catch the resident, but could not. As soon as the resident hit the floor, Staff O obtained the nurse. On [DATE] at 1:30 PM, the Director of Nursing (Staff A) was interviewed and stated both Staff J and Staff O had been disciplined for the above incident as it was not certain the staff had properly attached the sling to the Hoyer lift device. The staff are trained to pull on the straps to insure the straps are properly positioned. On [DATE], at 8:55 am, the resident ' s physician was notified by telephone. The physician stated the resident had expired due to a change in the resident's condition. The physician was at the facility when the fall occurred, and saw the resident shortly after the fall. The resident was arousable after the fall. The physician voiced there was no correlation between the fall from the Hoyer lift and the resident's death. On [DATE] at 3:17 PM, Staff J was interviewed and stated she and Staff O planned to lay Resident #1 down in bed from the wheelchair. The resident was suspended in the Hoyer. Staff J started to turn the Hoyer. Staff O was on the other side of the resident. The left side of the Hoyer lift sling, by the resident's feet, came loose and the resident flipped out. The staff tried to grab the resident, but unable to so do. After the fall, the resident ' s left side of head was bleeding. Staff J moved the resident's head into better alignment, and asked staff O to summon help. Staff J thought that the resident had hit head on the foot bar of the Hoyer lift. Staff J had been trained during facility orientation to properly use a Hoyer lift. Staff J had tugged on the Hoyer lift to ensure the sling straps were properly secure. Staff J didn't understand how the lift sling slipped off of the Hoyer lift. Staff J stated if he/she was the second person doing a transfer, then would always have her hands on the resident Staff O had his/her hands up during the transfer, but was not touching the resident at the time. Staff J thought that while having hands on the resident wouldn't have prevented the incident, having hands on the resident would have made it possible to catch the resident when the sling strap slipped off of the Hoyer lift device. On [DATE], at 6:62 PM, Staff O was interviewed and stated she had been trained to use the Hoyer lift prior to the incident. Staff O stated when transferring a resident, she usually tugged on the Hoyer lift sling straps to ensure the straps were safely attached to the Hoyer device. During the transfer on [DATE], Staff O stated she had checked the sling straps to ensure they were safely on the Hoyer lift. Staff O stated obviously, she hadn't checked the straps "good enough" as the straps fell off of the Hoyer lift device. On [DATE], at 11:55 am, the Director of Nursing stated the facility staff were instructed during their initial training to tug on the straps to ensure the lift sling straps were appropriately and securely position on the Hoyer lift. During an interview on [DATE], at 1:50 PM, Staff D (Certified Nursing Assistant) stated had been trained to yank on the Hoyer lift sling straps to ensure the straps are properly attached to the device during Hoyer lift transfers. During an interview on [DATE] at 9:29 am, Staff G (Certified Nursing Assistant) stated he/she had been trained upon hire and periodically audited since then on Hoyer lift transfers. There were to be 2 staff doing the transfers. One ran the lift, and one managed the resident. The staff were to ensure that the lift straps were tight by tugging on the lift sling straps. This was to be done before elevating the resident. On [DATE] at 4:01 PM, Staff K (Certified Medication Aide) was interviewed and stated she was trained upon initial hire about Hoyer lift transfers. Staff K had also watched a movie within the last ,[DATE] months on transfers. There were to be 2 staff during transfers and the staff were to tug on the Hoyer lift sling straps prior to the actual resident transfer. 2. Resident # 5 had [DIAGNOSES REDACTED]. Review of the admission MDS with a reference date of [DATE], revealed Resident # 5 usually was understood by others and understood others. The resident had both long and short term memory problems, and severely impaired decision making skills. The resident transferred and ambulated independently. The resident was not steady, but was able to stabilize without human assistance walking, doing surface to surface transfers, moving from a seated to a standing position, moving on and off of the toilet, and while turning around. The resident did not have a history of falls. The RAP (Resident Assessment Protocol) dated [DATE] identified the resident at a very high risk for falls (score 18). The resident had poor balance, frequent agitation, and a high risk due to meds. Review of the [DATE] MDS revealed similar information, but Resident # 5 currently only sometimes understood others. The resident had a history of [REDACTED]. The care plan initiated on [DATE] and updated [DATE] identified Resident # 5 as independent with ambulation. The interventions directed staff to encourage the resident to lie down. The resident had a beveled (lipped) mattress. The resident had a history of [REDACTED]. Review of the undated neuro check sheet (assessment of a person's pupil size, pupils reaction, level of consciousness, pain response, ability to move extremities, and vital signs, all used to monitor a person for a possible brain injury) revealed that staff were to do neuro checks if there was a suspected head injury every 15 minutes times 4 , every 30 minutes time 2, every hour times 4 and every 8 hours times 2, and then every 12 hours for the remainder of the 72 hour follow up. The assessments could be discontinued at the discretion of the DON or ADON (Assistant Director of Nursing). Review of the Falls Risk Assessment identified a total score of 10 or above indicated the resident was a high risk for falls. Review of resident # 5's Falls Risk Assessment revealed the resident had the following scores on the following dates: [DATE] 16 [DATE] 20 [DATE] 17 The Nurse ' s Notes revealed the following falls: On [DATE] at 8:20 PM, the staff found the resident on the floor in a cradle position. The resident experienced no apparent injuries. The notes did not reflect vital signs had been checked and no documentation from [DATE] at 8:20 PM until the [DATE] 6 PM to 6 AM shift that the resident's ability to move either the upper or the lower extremities was assessed. On [DATE] at 5:15 PM, staff found the resident on the floor in front of the book case after the staff heard a noise in the resident's room. The resident cried and voiced pain in the left side of body area. The resident had no apparent injuries. On [DATE] 2:00 PM, staff found Resident # 5 on the floor at the foot of the bed. The resident had a nose bleed, which resolved. The resident had no other injuries. The resident was to be evaluated by Physical Therapy the next day. The [DATE] at 3:00 A.M. nurse's notes indicated the resident was up and down, and out of bed. The resident's gait was unsteady, and the resident required assistance. At 6:00 A.M., the resident was up independently with an unsteady gait. The resident was found in another resident's room/bed, and assisted back by staff to the resident's room. The resident's knees buckled, and the resident refused assistance at times. On [DATE], at 3:10 PM, Resident # 5 was noted to be sitting on his/her buttocks, with his/her hands holding self in the dining room. The resident had no noted injuries. On [DATE], at 9:00 A.M., the staff spoke to Resident # 5's next of kin (NOK) about the resident's recent falls. The staff recommended moving Resident # 5 off of the CCDI (Chronic Confusion and Dementia Unit). The NOK was in agreement with this, and the resident was to start a 3 day trial on the facility's East unit. On [DATE], at 10:45A.M., the resident continued to need ,[DATE] assist with ambulation at times. On [DATE], at 12:45 A.M., as staff entered the resident's room, the resident had attempted to stand, then tried to sit down and missed the bed. The resident went to the floor on buttocks and then fell to the right side up against the book shelf next to the bed. The resident had no apparent injuries. On [DATE] at 8:00 AM, Resident # 5 transferred to a room not on the CCDI unit. At 10:00 AM, the facility contacted the NOK regarding possible Physical Therapy's (PT) recommendation for a Merry Walker (a device similar to a toddler's walker that assists a resident with an unsteady gait to ambulate). On [DATE] at 3:52 PM, Staff E (Certified Nursing Assistant) was interviewed and stated Resident # 5 was prone to falls but the resident's ability to ambulate varied. As an example, the resident was not able to walk the previous Sunday ([DATE]). The resident usually had no falls when staff walked with him/her. On [DATE], at 10:38 am, Staff F (Licensed Practical Nurse) was interviewed and stated Resident # 5 was currently on another unit and used a Merry Walker. The resident had been moved off of the unit as the resident needed safer placement. The resident needed things such as a low bed, a mat on the floor, and an alarm. The unit residents typically didn't have alarms as the alarms often agitated the other residents. Resident # 5 walked slowly, was unsteady, and had had an increase in falls. At least 1, sometimes 2 staff would walk with the resident. On [DATE], at 9:29 am, Staff G was interviewed and stated Resident # 5 was often unsteady when ambulating. The resident had bad shakes, and tended to walk on his/her toes as though dancing. The resident needed reminders to walk more on the balls of his/her feet. Staff G had had to catch the resident to prevent falls at times. On [DATE], at 4:56 PM, Staff R (Licensed Practical Nurse) stated Resident # 5 was determined to do what the resident wanted to do. The resident often refused help, but did let her walk with him/her. During an interview on [DATE] at 1:55 PM, the Director of Nursing (Staff B) stated Resident # 5 had been moved out of the unit at the [DATE]. Also on [DATE] at 4:53 PM, she thought Resident # 5 was up independently in the unit at the time of the resident's last fall on [DATE]. During an interview on [DATE] at 9:37 am, the Director of Nursing confirmed there were no documentation of vital signs for the [DATE] fall. The Director of Nursing confirmed the PT evaluation was performed on [DATE]. The resident's ability to ambulate independently varied. Some days the resident was able to independently ambulate safely, and other days the resident could not safely ambulate independently. The resident had declined the end of January/first part of February. The staff was waiting to see if the decline was real. The resident's status had fluctuated up and down frequently. During a telephone interview on [DATE] at 2:15 PM, the resident's physician stated Resident # 5 had expired from complications of Alzheimer's disease. The resident had declined, and been on hospice. The fall on [DATE] did not contribute to the resident's death. Observation on [DATE] at 3:11 PM revealed Resident # 5 ambulating independently on the CCDI unit while holding onto the hand rail. The resident's gait was steady at that time. On [DATE], at 11:10 A.M., Resident # 5 stood in his/her room, holding onto a small dresser. The resident was able to balance self in an upright position, but the entire resident's body was shaking slightly. At 11:20 A.M., the resident ambulated with a gait belt and Staff G. The resident's gait was unsteady, but the resident did not fall. On [DATE], at 11:10 A.M., the resident was ambulating in the Merry Walker, with a personal alarm, by the East nurse's station. The resident had multiple falls and the facility did not implement prompt safety measures to prevent the occurrence of further falls. 3. Resident # 4 had [DIAGNOSES REDACTED]. Review of the [DATE] MDS revealed the resident's brief interview for mental status (BIMS) was 13 of a possible 15. The resident needed the assistance of 1 staff for cares. The resident was not able to balance during transitions and walking without human assistance. The resident used a wheelchair and walker. The resident did not have a history of falls. Review of the [DATE] MDS revealed Resident # 4's BIMS score was 12. The resident required the assistance of 1 staff for most cares. The resident was unable to balance during transitions and walking without human assistance. The resident now used only a wheelchair. The resident did not have a history of falls. The RAP dated [DATE] indicated the resident had a right wrist fracture. The care plan dated [DATE] indicated an intervention was initiated on [DATE] for a low bed with mats to each side of the bed. The Nurse ' s Notes dated [DATE] at 12:00 a.m. indicated Resident # 4 was found on the floor mat with the alarm sounding. The Major Injury form dated [DATE] at 2:30 p.m. indicated a portable x-ray revealed a fracture of the distal radial metaphysic (fractured right wrist). On [DATE] at 3:16 p.m. observation revealed the resident in a low bed with only the left mat present beside the bed. There was no mat to the right side of the bed. There was a mat folded up and against the wall near the resident's bed. Observation at [DATE] at 10:26 am revealed the resident in bed, with only the left floor mat in place. The right floor mat was not in place. On [DATE], at 2:58 PM, Resident # 4 was in the bed, with only the left floor mat in place. The other floor mat was folded up against the wall near the bathroom. Later on [DATE], at 4:35 PM, observation revealed Resident # 4 was again in the bed with only the left floor mat in place. 4. Resident # 3 had [DIAGNOSES REDACTED]. The admission MDS with a reference date of [DATE] identified the resident with a BIMS score of 3 (severely cognitively impaired). The resident ambulated and transferred independently, had no balance concerns, and used a cane/crutch to ambulate. The resident did not have a history of falls since admission. The RAP dated [DATE] indicated the resident ambulated independently with bilateral crutches. The resident was a high risk for falls (14, with a score of 10 or greater indicating a high risk). There was a home health aide note from [DATE] that the resident "continued to fall". The resident was a poor historian, but denied any recent falls. The MDS with a reference date of [DATE] continued to indicate a BIMS of 3 and now the resident required extensive assistance of 2 staff for transfers, and the limited assistance of 1 staff to ambulate. The resident now had a history of [REDACTED]. The care plan dated [DATE] directed staff to ensure the resident wore nonskid foot wear at all times while ambulating and transferring. The staff initiated a bed alarm on [DATE], and on [DATE] initiated a bed alarm under the resident's mattress. On [DATE], staff implemented an alarm on the dining room chair. The resident was independent with all facility ambulation and transfers until [DATE] when this was discontinued. On that date, [DATE], staff were directed to transfer the resident with a Hoyer lift and to use a wheelchair for mobility. Per the falls risk assessment, resident # 3 had the following scores on the following dates: [DATE] 14 [DATE] 19 [DATE] 19 [DATE] 16 The Nurse ' s Notes dated [DATE] at 6:15 A.M. indicted the resident ' s roommate called for assistance and informed the staff that Resident #3 had fallen in the bathroom and then crawled to the roommates bed. The resident reported that he/she walked to the bathroom, and slipped on the wet bathroom floor. Resident #3 had bumped his/her head. The only injury seemed to be right back discomfort. The resident did not have coverings onto the feet at the time of the fall. On [DATE], at 8:00 am, Resident # 3 ambulated in the hall without the use of the crutches. The resident fell , suffering an L shaped 3 cm laceration above the left eye. The resident went to a local hospital for evaluation, and returned at 2:20 PM with sutures. On [DATE], at 10:45 A.M. the resident ' s right crutch slipped and the resident fell to his/her knees. The resident was able to catch self on the wall railing. The resident had reopened an area on the left arm. On [DATE], at 12:15 PM, the resident was found on the resident's room floor; bleeding from an open area on the resident's left eye lid and right ear. The resident stated had slipped. The resident's right arm bled. The resident also talked about suicide. On [DATE], at 7:00 PM, the resident returned from being evaluated at a local hospital. The Physician order [REDACTED]. The resident had to have a bed alarm, and to not ambulate without 1:1 staff. There was no documentation that staff noted this order, except for the [DATE] alarm entry on the care plan. The Nurse's Notes on [DATE], at 2:40 am, reflected Resident # 3 hit the alarm on the floor and attempted to break the alarm. At 4:55 am, the resident was sent to a local hospital for evaluation. The resident returned at 10:30 am, with alarms in the bed and chair. The resident pulled the alarm out of the chair. On [DATE] at midnight, Resident # 3 was attempting to remove the alarms from under self and slammed the alarms on the floor. At 5:30 A.M., the resident attempted to self transfer. On [DATE], at 11:40 PM, Resident # 3 ambulated independently in the hall, and non compliant with the alarms. On [DATE], at 6:00 PM, the resident walked to the unit dining room. The crutch got stuck, and the resident fell to the floor, landing on his/her left hip and buttock. Prior to this fall, the resident ambulated with staff at the resident's side. On [DATE], at 11:45 PM, resident # 3 hit the bed alarm with a crutch. On [DATE], at 10:50 PM, the staff received an order for [REDACTED]. On [DATE], at 9:20 PM, the resident's alarm sounded and the resident was ambulating with crutches and almost to the bathroom. On [DATE], at 4:00 PM, Resident # 3 was found on the floor with his/her legs out in front of the resident. The resident suffered a skin tear to the left arm. The nursing documentation and fall assessment form indicated the resident was walking and neither the bed nor chair alarm sounded. On [DATE], at 2:45 PM, the resident went to a local hospital for evaluation for behaviors. On [DATE], at 6:30 PM, the resident returned from a local hospital after the evaluation. PT was notified of the earlier order to evaluate Resident # 3. On [DATE], at 9:40 am, Resident # 3 picked up the alarm out of the chair and threw it; breaking it. At 1:00 PM, the resident was up in the hallway without his/her crutches. Staff gave the resident the crutches. At 2:30 P.M. the resident ambulated in the hallway independently with crutches. On [DATE], at 4:30 PM, Resident # 3 ambulated in the hallway. The resident's canes (crutches) went one way and the resident went another and fell . The resident suffered a 2 cm skin tear on the left forearm. The nursing documentation and fall assessment form indicated the resident ' s alarms did not sound as the resident turned the alarms off and ambulated. The resident had a poor gait which may have contributed to the fall. The crutch tips needed replaced and had worn with metal exposed. The staff applied new tips. On [DATE], at 12:50 PM, the staff heard the resident fall in the bathroom. The bed alarm failed to sound, but worked when checked post fall. The resident complained of dizziness and had increased confusion. Resident # 3's hand grips were slightly weaker on the left side. The physician was contacted and the resident was sent to a local hospital for evaluation. The resident returned from the hospital on [DATE] at 3:00 PM. On [DATE], at 6:12 am, staff found Resident # 3 on the floor, sliding to the bathroom. The resident had no noted injury. The Nursing Documentation and Fall Assessment Form indicated the resident fell at 5:45 A.M. The bed alarm was on, but failed to sound. The tab was pulled on the alarm and it was at the end of the bed. The Physical Therapy Evaluation and Initial Plan of Care dated [DATE] 8:10 to 8:25 am revealed Resident # 3 was evaluated due to increasing right shoulder pain. The resident required increased assistance from staff to stand from a dining room chair and a bed. The use of the crutches increased the resident's risk for falls as the resident had to compensate for his/her history of polio affecting his/her legs. The resident was able to demonstrate that he/she could ambulate at his/her prior level of functioning/gait with the crutches or independently. Observation on [DATE] at 3:20 PM revealed Resident #3 self propelling down a hallway. The resident was using his/her right hand to pull him/herself down the hallway. The resident had an alarm, which was also attached to the back of the wheelchair. During an interview on [DATE] at 3:32 PM, Staff E stated that the alarms "drove the resident crazy". It was frustrating for the resident when staff helped the resident. The resident often thought the staff did things they didn't need to do. The resident refused a gait belt. The staff frequently checked the resident's crutches to ensure the bottoms weren't worn out. Most of the residents in the unit were entirely independently ambulatory, so resident presence was a surprise. The staff member thought Resident # 3 was on the unit for "trying to escape" out of the facility. On [DATE] at 10:38 am, Staff F stated Resident # 3 often ignored the alarms and/or threw them. The resident was to ambulate with at least 1 staff. However, the resident would try to hit staff, and take off without waiting for staff assistance. The staff couldn't get the resident to comply-the resident was used to being independent. The resident also didn't seem to want to take anything from the opposite sex staff. There was nothing to do but let the resident go. The staff were told by Staff C, the then administrator, to let Resident # 3 do what the resident wanted to do. This was what the resident did when the resident refused to comply with interventions. On [DATE], at 9:29 am, Staff G stated Resident # 3 had a lot of falls when getting up. If the resident let the staff, the staff member walked beside the resident and used a belt if possible. If the resident wouldn't let the staff walk with him/her, the staff tried to be close enough to grab the resident if needed. This would work if the resident didn't catch on to what the staff were doing. The resident knew if his/her safety alarm sounded, the staff would come. So, the resident would turn off the alarm and then get up independently. Staff had been monitoring the resident's crutch tips to ensure they were safe and not worn out. However, the staff had not documented this. The alarm failed to sound for the [DATE] fall. That type of alarm had a tab on it. If the tab was pulled out, the alarm wound not sound. The staff replaced the alarm post fall. For the [DATE] fall, the resident wasn't awake and didn't have any non skid socks on. That intervention was added to the staff's pocket care plan. The staff updated the pocket care plans frequently. No staff were with Resident # 3 at the times of the ,[DATE] and [DATE] falls. The alarm was working at the time of the [DATE] fall, but the resident had scooted to the edge of the bed, and the alarm failed to sound. The staff didn't know why the alarm failed to sound. The resident had had falls, but was screened by PT as still capable of being independently.