Every finding on record at Accura Healthcare of Le Mars

Based on observations, interviews, and policies reviewed the facility failed to prepare, serve and distribute food in accordance with food service safety for general practices of mealtime service. The facility reported a census of 40 residents.Findings include: Observed on 7/13/26 at 10:05 during the initial kitchen walk through Staff B, Cook, and Staff C, Cook, with visible facial hair without beard nets, and the vent above the preparation table with dust fluff hanging from it. Continuous observation on 7/14/26 at 11:30 AM revealed the following:A. Staff B, Staff C, and Staff D, Cook, with visible facial hair without beard nets.B. Staff E, Cook, donned gloves without hand hygiene, opened a bag of lettuces, used the gloved right hand to reach in and put the lettuce on the plate. The staff closed the bag and placed it in a resealable plastic bag. C. During meal preparation and serving the serving utensils were placed on counters and the preparation table without barriers. D. Staff C donned gloves without hand hygiene and prepared room trays and served to the dining room with the use of serving utensils for the steam table foods. E. Staff C touched the bread packaging and removed sliced bread using the gloved left hand, placed it on the surface, held the bread in place while using the right gloved hand to butter the bread. The staff used either gloved hand to place the bread on the plates. On 7/15/26 at 8:48 AM the Dietary Services Manager (DSM) stated all staff with beards were expected to wear beard nets and the kitchen had them available. When discussing and looking at the vent over the prep table, the DSM stated maintenance assisted with that and a work order would be submitted. The DSM stated staff should be using a barrier of some sort on the counters/prep table versus placing the utensils on the counters/prep table. When asked about the use of gloves and hand hygiene, the staff stated the kitchen staff should wash their hands prior to donning gloves and gloves were worn with any ready to eat food. The DSM stated staff should not touch food with gloved hands when they had touched other items with gloves on; the staff should have used tongs/utensils for the bread and lettuce. The DSM stated the dietitian had provided education on use of tongs with bread rather than the use of gloves. On 7/15/26 at 10:05 AM the Administrator with the Regional Nurse Consultant present stated staff should be completing hand hygiene prior to donning gloves and they should use utensils with food preparation. The facility's Food Safety and Sanitation Policy, dated 2021, revealed employees were required to wear beard nets when facial hair was visible.The facility's Hand Hygiene Policy, updated 11/13/24, revealed hand hygiene should be completed before donning gloves and after removing gloves.

Based on clinical record review, facility documentation, and interviews with the resident's family and facility staff, the facility failed to implement necessary interventions to protect 1 of 12 sampled residents (Resident #21) from abuse. The facility reported a census of 39 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 documented diagnoses of Alzheimer's disease, depression, and diabetes mellitus (DM). The MDS recorded a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognitive impairment.During an interview on 7/15/26 at 12:25 PM, Resident #21's niece reported that on 3/5/2026, she was notified by the resident's banking institution regarding potentially fraudulent charges on the resident's personal account. According to the bank, these charges involved checks written by the resident's ex-stepdaughter. At that time, the ex-stepdaughter, identified as Staff F, served as the facility Administrator and was designated as one of the resident's [NAME] of Attorney (POA). The niece further reported concerns regarding medical decisions and care provided at that time. Additionally, the niece stated that she filed a protection order on behalf of Resident #21 against Staff F, which was served on 3/30/26.The Progress Note for Resident #21 on 3/9/26 at 10:15 AM documented the following:Adult Protection Services (APS) showed up on Saturday to see Resident #21 and asked for a medication list and said she would return on Sunday but did not come back on Sunday (3/11/26).During an interview on 7/15/26 at 3:25 PM, an Adult Protection Services Worker (APSW) reported that while at the facility, she informed Staff G, Executive Director of Operations, of the allegations of financial exploitation by Staff F regarding Resident #21 and concerns about the resident sleeping on the couch. The SW stated that when Staff G was informed, Staff G replied, They are allegations, we are going to leave them at allegations until APSW completes the report. The APSW noted that she would need to review her notes before providing the specific dates of her facility visit.During an interview on 7/15/26 at 2:15 PM, the current Administrator stated that Staff G, the Executive Director of Operations, was out of the office. While the Administrator was able to contact him by phone, he remained unavailable for the remainder of the day. The Administrator further reported that Staff F, the former Administrator, notified Staff G on 3/30/26, the day the court order was served, that she had received a restraining order regarding Resident #21. Staff F has not worked at the facility since 3/30/26, the date the protection order was served. The Administrator reported Staff G resigned on 5/19/26. During an interview on 7/15/26 at 3:37 PM, Staff H, former Director of Nursing (DON), acknowledged that Resident 21's niece had expressed concerns regarding financial and medical decisions made by Staff F, specifically involving hospice care and Power of Attorney (POA). Although Staff H could not recall the timing of this conversation, she reported communicating these concerns to Staff G, Executive Director of Operations. When asked whether the concerns should have been reported to the Department of Inspections, Appeals and Licensing (DIAL), Staff H stated, Until something is proven, there is nothing we can do. Staff H maintained that the allegations did not warrant reporting to DIAL, asserting that there were no issues with the resident's facility funds or billing. Instead of initiating an investigation or report, Staff H stated that Staff G instructed her to document and we will keep an eye on it.On 7/16/26 at 7:53 AM the APW provided the following via email:On 03/13/2026, the APSW contacted the Executive Director of Operations. He was informed of the concerns. He stated that Staff F will remain as the Administrator until the completion of the assessment. He stated that, to his knowledge, Resident #21 was being cared for and he had no concerns.The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy updated on 10/19/22 identified:All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. All allegations of Resident abuse shall be reported to the Iowa Department of Inspections and Appeals not later than two (2) hours after the allegation is made. All allegations of Resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections and Appeals, not later than two (2) hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury. If there is a reasonable suspicion that the allegation of abuse also constitutes a crime committed against the resident by any person, whether or not the alleged perpetrator is employed by the facility, the Elder Justice Act requires the matter must also be reported to law enforcement. While the federal regulations require all abuse allegations be reported to DIA within 2 hours, the Elder Justice Act has a different time frame for reporting to the police/sheriff. If the allegation of abuse (that results from a crime) results in serious bodily injury to a resident, a report must be made to law enforcement not later than two (2) hours after the allegation is made. If the allegation of abuse does not result in serious bodily injury, a report must be made to law enforcement not later than twenty-four (24) hours.During an interview on 7/16/26 at 10:05 AM, the Administrator, DON, and Regional Nurse Consultant were present. The Administrator confirmed that the facility was required to notify DIAL as soon as the abuse allegations were reported to the facility.

Based on clinical record review, facility documentation, and interviews with the resident's family and facility staff, the facility failed to implement measures to prevent further potential abuse, neglect, exploitation, or mistreatment for 1 of 12 sampled residents (Resident #21). The facility reported a census of 39 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 documented diagnoses of Alzheimer's disease, depression, and diabetes mellitus (DM). The MDS recorded a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognitive impairment.During an interview on 7/15/26 at 12:25 PM, Resident #21's niece reported that on 3/5/2026, she was notified by the resident's banking institution regarding potentially fraudulent charges on the resident's personal account. According to the bank, these charges involved checks written by the resident's ex-stepdaughter. At that time, the ex-stepdaughter, identified as Staff F, served as the facility Administrator and was designated as one of the resident's [NAME] of Attorney (POA). The niece further reported concerns regarding medical decisions and care provided at that time. Additionally, the niece stated that she filed a protection order on behalf of Resident #21 against Staff F, which was served on 3/30/26.The Progress Note for Resident #21 on 3/9/26 at 10:15 AM documented the following:Adult Protection Services (APS) showed up on Saturday to see Resident #21 and asked for a medication list and said she would return on Sunday but did not come back on Sunday (3/11/26).During an interview on 7/15/26 at 3:25 PM, an Adult Protection Services Worker (APSW) reported that while at the facility, she informed Staff G, Executive Director of Operations, of the allegations of financial exploitation by Staff F regarding Resident #21 and concerns about the resident sleeping on the couch. The SW stated that when Staff G was informed, Staff G replied, They are allegations, we are going to leave them at allegations until APSW completes the report. The APSW noted that she would need to review her notes before providing the specific dates of her facility visit.During an interview on 7/15/26 at 2:15 PM, the current Administrator stated that Staff G, the Executive Director of Operations, was out of the office. While the Administrator was able to contact him by phone, he remained unavailable for the remainder of the day. The Administrator further reported that Staff F, the former administrator, notified Staff G on 3/30/26, the day the court order was served, that she had received a restraining order regarding Resident #21. Staff F has not worked at the facility since 3/30/26, the date the protection order was served. The Administrator reported Staff G resigned on 5/19/26. During an interview on 7/15/26 at 3:37 PM, Staff H, former Director of Nursing (DON), acknowledged that Resident 21's niece had expressed concerns regarding financial and medical decisions made by Staff F, specifically involving hospice care, nursing care and Power of Attorney (POA). Although Staff H could not recall the timing of this conversation, she reported communicating these concerns to Staff G, Executive Director of Operations. When asked whether the concerns should have been reported to the Department of Inspections, Appeals and Licensing (DIAL), Staff H stated, Until something is proven, there is nothing we can do. Staff H maintained that the allegations did not warrant reporting to DIAL, asserting that there were no issues with the resident's facility funds or billing. Instead of initiating an investigation or report, Staff H stated that Staff G instructed her to document and we will keep an eye on it.On 7/16/26 at 7:53 AM the APW provided the following via email:On 03/13/2026, the APSW contacted the Executive Director of Operations. He was informed of the concerns. He stated that Staff F will remain as the administrator until the completion of the assessment. He stated that, to his knowledge, Resident #21 was being cared for and he had no concerns.The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy updated on 10/19/22 identified:Investigation Protocols:The administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident. If there is physical evidence that can be preserved, attempt to do so, and maintain it in a safe location to minimize risk of evidence being tampered with.Initial/Immediate Protection During Facility Investigation: 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. 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: (1) suspending the employee; (2) 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 (3) 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. Following completion of the facility investigation, if the facility concludes that the allegations of resident abuse are unfounded, the employee may be allowed to return to job duties involving resident contact, but the employee must maintain a separation and have no contact with the resident alleged to have been abused, by reassigning the accused employee to an area of the facility where no contact will be made between the accused employee and the resident alleged to have been abused. This separation must be maintained until the Department concludes its investigation and issues the written results of its investigation. Note: if the DIA determines there was abuse (even though the facility did not substantiate the abuse), there is risk that DIA could cite the facility with Immediate Jeopardy, for allowing an abuser to have access to other residents while the matter was being investigated.During an interview on 7/16/26 at 10:05 AM, the Administrator, DON, and Regional Nurse Consultant were present. The Administrator confirmed that the facility was required to separate and protect the alleged victim from the alleged perpetrator.

Based on clinical record review, interviews, and policy review the facility failed to develop and implement a program to maintain a resident's range of motion (ROM) and contracture management needs based on the comprehensive assessment and under the direct guidance of a Registered Nurse (RN) for 1 of 2 residents (Resident #1) reviewed. The facility reported a census of 40.Findings include:Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] disclosed the resident had short term and long term memory deficits, and severe impairment with daily decision making. The document revealed the resident had an impairment in movement of both arms and both legs. The document included diagnoses of arthritis, Cerebral Palsy, and contracture of an unspecified foot. The document coded 0 days of at least 15 minutes in the past 7 days of the assessment period for Restorative Nursing Programs (RNP).Resident #1's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had an impairment in movement of both arms and both legs. The document coded 0 days of at least 15 minutes in the past 7 days of the assessment period for Restorative Nursing Programs (RNP).Resident #1's Care Plan revised 6/13/25 disclosed a focus area of participation in a restorative nursing program with a resolved date of 7/13/26. Interventions for staff included participating in group exercises for the Restorative Nursing Assistant (RNA), Activities Department, and Certified Nursing Assistant (CNA), PROM for the upper and lower body to be completed by nursing, RNA and CNA. The document included a focus area for potential for pain due to limited mobility and contractures with interventions for pain medication, repositioning and observation for signs of pain. The clinical record's Clinical Medical Diagnoses included unspecified intellectual disabilities and quadriplegia (partial or total loss of sensory and motor function in all four limbs and torso). The clinical record's Point of Care documentation revealed no Restorative Nursing Program documentation. The clinical record's Plan of Care History revealed a program for passive range of motion (PROM) for lower body flexion and extension of hip and knees 1 set of 10 repetitions, 1 to 6 days a week with a resolved date of 2/27/26. The clinical record's Plan of Care History revealed a program for PROM for upper body flexion and extension of the shoulder and elbow 1 set of 10 repetitions, 1 to 6 days a week with a resolved date of 2/27/26. The clinical record's Progress Notes from 7/1/25 to 7/14/26 revealed the following entries:7/8/25 10:02 AM Restorative Nursing Note - resident completed 13 days and 3 evenings of restorative program with no documented refusals.8/26/25 4:29 PM Quarterly Nursing Assessment - resident had upper extremity functional limitation in ROM of both sides of the body, lower extremity functional limitation in ROM of one side of the body, and participated in a restorative nursing program.11/26/25 3:40 PM Quarterly Nursing Assessment - resident had upper extremity functional limitation in ROM of both sides of the body, lower extremity functional limitation in ROM of one side of the body, and participated in a restorative nursing program.12/4/25 11:38 AM Restorative Nursing Note - resident had a PROM program and was compliant with staff when offered in November with no signs of pain or discomfort.12/25/25 1:28 PM Restorative Nursing Note - resident showed no signs of pain or discomfort with PROM for upper and lower body.2/26/26 11:45 AM Quarterly Nursing Assessment - resident participated in a restorative nursing program.5/27/26 2:00 PM Quarterly Nursing Assessment - resident had upper extremity functional limitation in ROM of both sides of the body, lower extremity functional limitation in ROM of one side of the body, and did not participate in restorative nursing program.On 7/14/26 at 10:44 AM the Director of Nursing (DON) with the Regional Nurse Consultant present stated there was not a nurse in charge of the Restorative Nursing Program, and acknowledged the facility did not have a Restorative Nursing Program. The Regional Nurse Consultant indicated that was something they were working on. On 7/15/26 at 10:26 AM the Administrator and Regional Nurse Consultant acknowledged the facility did not have a restorative nursing program and could not explain why and when the program stopped. The Administrator reported that she and the DON were both new to their positions and are still learning/working to put systems back in place. 7/15/26 10:40 AM The DON with the Regional Nurse Consultant present, stated she had started her position as DON in the past 2 months, and had recognized there was not a Restorative Nursing Program in place. The staff stated she was working to address this by changing the scheduling and working to identify the staff for this program. The DON stated there was a position allocated in the budget for the Restorative Nursing Program. The Facility Assessment approved 6/6/26 revealed the facility provided mobility and fall prevention through restorative nursing and contracture prevention and care. The document disclosed the facility had 1 full time equivalent position for a Restorative Nursing Assistant.The facility's Restorative Program Process document, updated 10/26/21, revealed a resident's level of function would be assessed upon admission, quarterly or with a significant change by the licensed nurse or with collaboration of therapy. The document included the licensed nurse would develop a RNP with recommendations from therapy for strategy and adaptive equipment needs. The document disclosed the licensed nurse would educate the staff on the program, monitor the staff and resident(s) to ensure compliance daily, and write a monthly restorative nursing summary to track the resident(s) progress.

Based on observation, document review, interviews, and policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs of residents by not following the approved menu for a meal. The facility reported a census of 40 residents.Findings include:Continuous observation of the meal service on 7/14/26 beginning at 11:30 AM noted the following:Staff C, Cook, removed 2 pork loins from the oven, placed on the prep table and proceeded to cut the meat into serving sizes. Staff C stated during serving of the goulash, he did not have a #6 scoop, but used the closest size he had and was using heaping servings to get to 6 ounces (oz.).Staff C prepared 3 pureed plates that consisted of goulash, cauliflower with cheese, mashed sweet potatoes, and twisted strawberry shortcake.Staff C stated he was not pureeing the asparagus as it was too difficult to modify due it being a stringy vegetable.Staff C pureed 3 servings of goulash with almond milk and after achieving the consistency divided the modified food onto the 3 plates. Staff C pureed 3 servings of cauliflower with cheese and after achieving the consistency divided the modified food onto the 3 plates. Staff C pureed 3 servings of twisted strawberry shortcake and after achieving the consistency divided the modified food onto the 3 plates.The facility's menu spreadsheet for the noon meal on 7/15/26 for regular diets provided the residents were to be served 3 oz. glazed pork loin, 1 baked yam, 4 oz. cauliflower with cheese, bread with margarine, and twisted strawberry shortcake. The pork loin was not weighed as it was cut or before plating, and consisted of varying sizes.The facility's menu spreadsheet for the noon meal on 7/15/26 for pureed diets provided the residents were to be served (1) 3 oz. serving of pureed pork loin, 8 oz. scoop of mashed sweet potatoes, (1) 4 oz. serving of cauliflower with cheese, pureed bread with margarine, and pureed twisted strawberry shortcake. The alternate pureed menu consisted of 6 oz of pureed goulash and 4 oz. serving of asparagus. The staff did not follow the menu for either the main option or the alternate option when preparing the pureed plates. The staff did not measure or refer to the serving size guide for portions following the modification of the goulash, cauliflower with cheese, and twisted strawberry shortcake. The facility failed to follow the menu for all residents on a regular menu who received the pork loin option due to the variance in portion sizes. The facility failed to serve and differentiate portion sizes for residents with therapeutic diets.On 7/15/26 at 8:48 AM the Dining Services Manager (DSM) stated the preparation for pureeing (3) serving sizes consisted of: obtaining 3 serving sizes of the food option, adding a liquid if necessary with the example of gravy, use the Robo Coup or hand immersion blender to achieve the desired consistency, use a measuring cup to measure how much food was modified, and refer to the guidance chart posted to obtain the correct serving size for the 3 residents. The dietary manager acknowledged by the staff serving the food directly onto the plates the residents did not receive the correct serving size. When asked about Staff C's statement of not having a #6 scoop so was heaping on the available scoop the DSM acknowledged the residents did not receive the correct serving size. When asked about the process for cutting the pork loin for serving the Dietary Manager stated the kitchen had a scale and the staff should have been weighing the meat to ensure 3 oz. servings. The staff stated she observed there was no scale present during the meal service preparation but did not want to disrupt the survey process. The DSM concurred the pork loin portions were not all the same size.When reviewing the items prepared and served to the residents on a pureed diet, the DSM stated the staff did not follow the menu for providing the necessary food items for the residents.On 7/15/26 at 10:05 AM the Administrator stated the staff should have used the appropriate serving scoop for serving the goulash. The Administrator stated residents were allowed choices for menu selection, but acknowledged for all pureed items to be the same combined with the cook's statement of not pureeing the asparagus due to it being a stringy vegetable and a mix of alternate and main menu items was possibly the cook's choice for modifying the diets for the meal. The facility's Portion Control Policy, dated 2021, revealed residents would receive the appropriate portions of food as outlined on the menu. The policy included menus should be posted at the tray line to allow staff to refer to the proper portions for each diet, scales should be used to weigh meat portions and scoops should be leveled off (not overflowing) for the most accurate portion size. The document revealed portions too small result in the resident not receiving the nutrients needed and portions too large provide the resident more food than needed.

Based on observation, interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility failed to provide food at a palatable, attractive, and a safe and appetizing temperature for 7 of 40 meals provided. The facility reported a census of 40 residents.Findings include:Continuous observation on 7/14/26 at 11:30 AM of noon meal service revealed the following:Staff C, Cook, prepared 3 pureed servings of goulash using almond milk, distributed them onto 3 plates, added pureed cauliflower and cheese, and mashed sweet potatoes.Staff C took the temperature of the goulash on the first plate and obtained a temperature of 119 degrees. The staff placed the loaded plate in the microwave, reheated the plate for 1 minute, removed, and took the temperature of the goulash. The temperature read 132 degrees. The staff moved the plate to the window for serving.The staff placed the second plate in the microwave for reheating for 1 minute, removed, and placed in the serving window without taking the temperature.The staff placed the third plate in the microwave for reheating for 1 minute, removed, and placed in the serving window without taking the temperature. During the course of the meal service Staff C warmed 4 individual cans of soup in the microwave by pouring each in a bowl, microwaving for 1 minute and serving them either to the dining room or room trays.The facility failed to achieve required serving temperatures and take temperatures for foods reheated in the microwave.On 7/15/26 at 8:48 AM the Dining Services Manager (DSM) stated the process for warming soup would be to pour the soup in a bowl, microwave it and take the temperature to ensure the correct temperature. The staff stated temperatures should be taken when warming soup to ensure it reached the correct temperature. The DSM stated at the end of the pureeing process the food's temperature should be checked to ensure it is at the correct serving temperature which the staff stated was 135 degrees. The staff stated if it was not 135 degrees it needed to be reheated in the microwave to reach the correct temperature. The DSM could not provide the temperature of what foods should be if they required reheating in the microwave. On 7/15/26 at 10:05 AM the Administrator acknowledged foods should be provided at the required temperatures.The facility's Resource: Minimum Cooking, Holding, and Reheating Temperatures Policy and Procedure, dated 2021, revealed the minimum cooking food temperature and holding time for reheating foods that are cooked, cooled, and reheated is 165 degrees for 15 seconds, and food that is taken from a commercially processed, hermetically sealed container or intact package is 135 degrees for no specific time.

Based on clinical record review, observations, staff interviews, and policy review, the facility failed to provide infection prevention measures with hand hygiene during wound care for 1 of 1 residents (Residents #20) reviewed. The facility reported a census of 40 residents.Findings include: Review of the clinical record's Minimum Data Set (MDS) tab revealed Resident #20's admission MDS Assessment and Medicare - 5 Day MDS assessment dated [DATE] were in progress.The in progress Care Plan revised 7/13/26 revealed a focus area of a pressure area on the left heel with interventions of reminding the resident to reposition every 2 hours as resident allows, pressure reducing mattress and monitoring of skin areas (identified on 7/3/26). The clinical record's Clinical Physician Orders contained an order to cleanse the left heel with saline, paint with Betadine and cover with a bandaid daily and as needed. Continue to off load heel at all times and notify the physician if the wound worsens. Observed on 7/14/26 at 11:05 AM Staff A, Licensed Practical Nurse (LPN), provide wound care to Resident #20 with the following noted:A. Staff A completed hygiene upon entering the room and placed supplies on a barrier.B. Staff A donned a gown and gloves.C. Staff A placed a barrier under the resident's foot, removed heel protector and sock. D. The staff changed gloves without hand hygiene.E. The staff cleansed the wound with saline, painted the wound with Betadine, allowed it to dry and placed a bandaid.F. Staff A changed gloves without hand hygiene. G. The staff gathered dirty supplies, placed them in the trash, secured the top, and gave it to housekeeping outside the door.H. The staff washed their hands and applied the resident's sock and heel protector.I. Staff A applied gloves without hand hygiene, obtained saline wash from table, placed on barrier at sink.J. The staff removed gloves and gown, washed their hands, and left the room with saline wash. On 7/15/26 at 10:15 AM the Administrator with the Regional Nurse Consultant present stated hand hygiene should be completed with glove changes. On 7/15/26 at 10:45 AM the Director of Nursing (DON) with the Regional Nurse Consultant present stated the expectation was for staff to complete hand hygiene with each glove change with either hand sanitizer or washing hands. The facility's Competency for Dressing Change (Non-Sterile), updated 5/11/21, revealed opportunities for hand hygiene with each glove change and glove changes to occur following removal and discarding of soiled dressing and performing of treatment. The facility's Hand Hygiene Policy, updated 11/13/24, revealed alcohol based hand sanitizers should be used immediately before putting on gloves and after glove removal. The facility's Using Gloves Policy, updated 11/13/24, revealed hand hygiene must be performed after removing gloves and did not replace hand hygiene. The document included gloves must be replaced as soon as practical when contaminated.

Based on observation, policy review and staff interview the facility failed to follow the menu and prepare food to meet the residents nutritional needs during lunch service. The facility reported a census of 39 residents. Findings include: Review of document titled, Week 3 Wednesday Diet Spreadsheets documented the noon meal of country fried pork tenderloin, mini baker potatoes, cream gravy, country trio vegetables, bread, margarine and flamingo cake was to be served. On 5/28/25 from 11:25 AM - 1:05 PM a continuous observation of lunch service revealed no bread or butter served to any resident during the meal. On 5/28/25 at 11:25 AM, 12:10 PM and 12:45 PM an observation of the residents' meals in the dining room revealed no bread or butter on the table. On 5/28/25 at 1:10 PM Staff A acknowledged bread and margarine was not served to the residents during the lunch service. Staff A explained the facility's menu should have been followed with bread and margarine being served to the residents. Review of policy, titled, Standardized Menus dated 2025 documented menus are revised by the Registered Dietitian and Dietary Manager based on resident food preferences. Reasons for change should be noted and kept on file. Menus should be approved and signed by the Registered Dietitian. Menus will be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy.

Based on clinical record review and staff interview the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications in 1 out of 5 sampled residents reviewed (Resident #34). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #34 documented diagnoses of hypertension, Alzheimer's Disease and muscle weakness. The MDS showed the Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. The MDS revealed resident #34 took antipsychotic medication during the review period. Review of Resident #34's May Medication Administration Record revealed the following orders: a. Quetiapine tablet (antipsychotic medication) daily with a start date of 4/25/25 b. Tramadol tablet (opioid medication) as needed for pain with a start date of 5/7/25. Review of Resident #34's Order Summary Report signed and dated 4/25/25 revealed an order for Quetiapine daily with a start date of 4/25/25. Review of the Care Plan with a revised date of 4/25/25 lacked non-pharmacological interventions to use prior to opioid medication usage and non-pharmacological interventions and targeted behaviors with antipsychotic medications. Review of the facility provided policy titled Comprehensive Care Plans dated April 2025 revealed the comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Interview on 5/28/25 at 3:34 p.m., with the Director of Nursing revealed the care plan should include non pharmacological interventions to use prior to medication and targeted behaviors the medications are being used for.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility for 1 of 1 residents reviewed (Residents #140). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #140 documented diagnoses of heart failure, Chronic Obstructive Pulmonary Disease (COPD) and hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Resident #140's Census tab revealed the following information: 10/18/24- hospital paid leave 10/22/24- active 5/16/25- hospital paid leave 5/19/25- active Review of Progress Notes revealed the following: 10/18/24 at 8:06 a.m., Resident admitted to the hospital for pneumonia and urinary tract infection. 10/22/24 at 1:32 p.m., Resident returns from hospital. 5/16/25 at 11:57 a.m., Resident admitted to the hospital with diagnosis of left sided pneumonia and urinary tract infection. 5/19/25 at 11:47 a.m., Arrived back at the facility via wheelchair van car. 5/19/25 at 1:22 p.m., Resident returns from hospital to facility Review of the Bed Hold dated 10/18/24 revealed verbal authorization from Resident #140 ' s representative but lacked a resident or representative signature. The bed hold lacked the amount per day the resident or representative agreed to pay. Review of the Bed Hold dated 5/16/25 revealed verbal authorization from Resident #140 ' s representative but lacked a resident or representative signature. The bed hold lacked the amount per day the resident or representative agreed to pay. Review of the facility provided policy titled Notice of Transfer or Discharge Process updated 4/21/2025 revealed copies of the notice will be sent to the resident representative and a copy will be placed in the resident medical record. Interview on 5/28/25 at 3:37 p.m., with the Director of Nursing revealed the bed holds should be filled out completely and have a physical signature attempted from the resident or resident representative.

Based on observation, resident interview, staff interview and policy review the facility failed to provide food at an appetizing temperature to 2 of 20 residents reviewed (Resident #25 and #190). The facility reported a census of 39 residents. Findings include: 1. The MDS dated [DATE] revealed Resident #25 had a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. On 5/27/25 at 11:40 AM Resident #25 stated the food is served cold when it should be warm quite often. Resident #25 stated she would like her food to be served warmer. 2. The MDS dated [DATE] revealed Resident #190 had a BIMS of 13 indicating no cognitive impairment. On 5/27/25 at 11:47 AM Resident #190 stated he had been there about 2 weeks. Resident #190 stated at times the food is served less than warm. Resident #190 stated he would like his food to be served warmer. Lunch service started at 12:15 PM on 5/28/25 with Staff B, [NAME] serving the food. The observation revealed room trays were served first. Room trays left the kitchen at 12:20 PM with arrival to the first residents room at 12:22 PM. The sample room tray was returned to the kitchen at 12:23 PM. Temperatures of the country fried pork tenderloin 130 degrees, temperature of the country trio vegetables 132 degrees and temperature of mini baker potatoes 120 degrees. Temperatures were obtained by Staff A, Kitchen Manager. On 5/28/25 at 8:34 PM Staff A stated the facility's expectation was that food served to the residents would have a temperature of at least 135 degrees. Staff A explained all of the food items on the plate did not meet her expectations for minimal temperatures. Staff A stated a whole new plate would be made at that time. Review of policy titled, Food Temperatures dated 2021 documented that food sent to the units for distribution such as meals would be transported and delivered to the unit storage areas to maintain temperatures at or above 135 for hot foods.

Based on observations, record review, staff interviews and policy reviews, the facility failed to provide proper hand hygiene during catheter care for 1 of 1 residents reviewed (Resident #16). The facility reported a census of 39 residents. Observation on 5/28/25 at 1:35 PM of Resident #16 showed Staff C, Certified Nursing Assistant, (CNA) performed hand hygiene, donned personal protective equipment then emptied urine from the catheter bag into a colander per policy. Staff C emptied the urine from the colander into the toilet, raised the colander and placed paper towels down into the colander. With the same soiled gloves Staff C placed the colander into the cupboard, placed the catheter bag into the privacy bag, moved the resident ' s blanket and clothing then hung the catheter bag onto the wheelchair. The Hand Hygiene policy last revised November 2024 identified staff should always complete hand hygiene after handling contaminated items and equipment such as, dressings, secretions, and excretions from residents In an interview on 5/28/25 at 2:57 PM, the Director of Nursing (DON), reported she expected staff to remove gloves and perform hand hygiene immediately after handling items contaminated with urine.

Based on clinical record review, observation, resident interview, staff interviews, and facility record review, the facility failed to provide adequate nursing supervision to prevent a fall that caused a distal femur fracture, need for hospitalization , pain control and decline in the resident ' s physical ability for 1 of 14 residents reviewed (Resident #29). The facility reported a total census of 41 residents. Past Noncompliance determined during the annual recertification survey of a facility incident that occurred on 1/22/24 regarding deficiency F689 with a scope and severity of a Level G. The facility provided evidence of education to the staff member directly involved in the facility incident that occurred on 1/23/24. The remainder of the nursing staff received education on 1/31/24. Findings included: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #29 documented diagnosis of hemiplegia, seizure disorder, traumatic brain injury (TBI). The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The MDS identified Resident #29 with limitation in movement and impaired range of motion to one side of the body, upper extremity and lower extremity. The MDS also showed Resident #29 dependent on a helper for all effort, or the assistance of two or more helpers is required for toileting hygiene. The Care Plan dated 10/26/23 for Resident #29 identified stand-pivot transfers with assistance of two staff and a gait belt. Do not use his bathroom, use the bedside commode. The Fall Risk assessment dated [DATE] for Resident #29 identified the resident to be a moderate fall risk. The Incident Report dated 1/22/24 at 7:18 PM for Resident #29 identified staff called the nurse to the resident ' s room. The nurse observed the resident laying on his left side with legs outstretched. The nurse noted the resident ' s pants were down. The resident reported he tried to pull up his pants while turning then lost his balance. The resident informed the nurse that he thought his leg was broken. The Progress Note dated 1/22/24 at 7:25 PM for Resident #29 identified staff witnessed a fall then called 911 to assist the resident. Resident #29 transferred to the emergency room (ER) by Emergency Medical Technicians (EMT). The emergency room Discharge Plan dated 1/22/24 for Resident #29 revealed an x-ray diagnosis of a left distal femur T-shaped fracture. Resident #29 transferred to a hospital with a higher level of care for orthopedic services. The Hospital Records dated 1/22/22 at 1:57 AM showed Resident #29 admitted for a left distal femur fracture. The History of Present Illnesses explained Resident #29 lost his balance and fell while he attempted to transfer. Resident #29 reported dull pain in the left leg. The Orthopedic Consultation dated 1/23/24 at 6:40 AM identified Resident #29 sustained a left intra-articular distal femur fracture. Resident #29 reported pain around the left knee. The orthopedic surgeon recommended surgical management. The Operative Report dated 1/23/24 at 5:28 PM for Resident #29 confirmed the diagnosis of a left intra-articular distal femur fracture, closed, displaced. The post operative plan included non-weight bearing left lower extremity of likely 8 weeks, gentle range of motion for the left knee as pain allows. Post surgery the resident received intravenous (IV) antibiotics and pain medication. The surgeon also ordered apixaban 2.5 mg by mouth twice a day for 30 days to prevent blood clots. The Final Report dated 1/29/24 for Resident #29 identified the discharge orders included the following: Mechanical lift for transfers. Bedrest. Gentle range of motion to left knee as pain allows. No weight bearing to left left for likey 8 weeks. Physical Therapy and Occupational Therapy consults. Foley Catheter. Surgical dressing instructions. The Discharge Summary dated 1/29/24 for Resident #29 indicated Tylenol and hydrocodone ordered for pain, and apixaban ordered to prevent a blood clot. The Physician Orders for Resident #29 the following pain medication ordered upon readmission to the facility on [DATE]: Hydrocodone-Acetaminophen 7.5-325 milligrams (MG) 1 tablet every four hours as needed for moderate pain. Hydrocodone-Acetaminophen 7.5-325 milligrams (MG) 2 tablet every four hours as needed for severe pain. The January 2024 Medication Administration Record (MAR) revealed Resident #29 received hydrocodone for pain as follows: 1/29- 2 times for a total of 2 tablets, 1/30- 2 times for a total of 2 tablets, 1/31- 3 times for a total of 4 tablets. The February 2024 Medication Administration Record (MAR) revealed Resident #29 received hydrocodone for pain as follows: 2/1- 1 time for a total of 1 tablet, 2/2- 1 time for a total of 2 tablet, 2/3- 2 times for a total of 4 tablets, 2/4- 2 times for a total of 4 tablets, 2/5-2 times for a total of 4 tablets, 2/6- 3 times for a total of 6 tablets 2/7- 4 times for a total of 8 tablets, 2/8- 1 time for a total of 2 tablet, 2/9- 3 times for a total of 6 tablets, 2/10-1 time for a total of 2 tablet, 2/11- 1 time for a total of 2 tablet, 2/12- 3 times for a total of 4 tablets, 2/13- 2 times for a total of 4 tablets, 2/14- 3 times for a total of 6 tablets, 2/15- 2 times for a total of 4 tablets, 2/16- 1 time for a total of 2 tablet. In an interview on 5/28/24 at 1:03 PM, Resident #29 stated, I was standing to use my urinal, one of my legs gave out from underneath me. Resident #29 reported that one Certified Nursing Assistant (CNA) hung onto him as he used the urinal. Resident #29 stated, I fell to the floor, had a dull pain that wasn ' t sharp. In an interview on 5/28/24 at 1:36 PM, Staff E, CNA reported she assisted Resident #29 to use the urinal while he stood at bedside. When Resident #29 finished urinating, Staff E assisted him to pull up one side of his pants. While Resident #29 attempted to pull up the other side of his pants, the resident leaned forward, causing him to fall in a forward direction. Staff E reported Resident #29 hit his head on the bedside commode and complained of left leg pain. Staff E reported to be the only CNA in the room at the time of the fall. When asked if there should have been two CNA ' s, Staff E replied, Yes, but my partner was on break and the nurse gets mad, so I didn ' t ask her. I usually ask for help. When asked if Staff E used a gait belt, she replied, No, he usually refuses, so I didn ' t ask. In an interview on 5/29/24 at 8:48 AM, Staff F, Licensed Practical Nurse (LPN) reported staff called her to Resident #29 ' s room. Staff F found Resident #29 lying on the floor, on his left side, in front of his nightstand. Resident #29 reported he tried to pull up his pants but fell and suffered from left leg pain. Staff F asked Staff E, CNA if she helped the resident. Staff E replied, Resident #29 insisted on pulling up his pants himself. Staff F reported Resident #29 lacked wearing a gait belt when she entered the room. Staff F then instructed Staff E to use the gait belt when getting the resident up. Staff F further stated, and I told Staff E to make sure she used it. When asked if Staff E assisted the resident to use the urinal alone, Staff F stated, yes. In an interview on 5/29/24 at 3:06 PM, the Director of Nursing (DON) reported the facility lacks policies related to gait belt usage and falls. The facility followed regulations and standard practices. In an interview on 5/30/24 at 8:10 AM, the DON reported Staff E failed to follow Resident# 29 ' s care plan by not waiting for another staff member before she provided Resident #29 with assistance for standing and using the urinal. The DON stated, Staff E was probably trying to help because the resident would have been in a hurry, and probably not wanting to wait for another staff member, but Staff E should have waited until someone was available. The DON reported that she planned to talk to the nurse about being more approachable, so that others can ask for help when needed. The DON also reported Staff E should have used a gait belt. The DON explained Resident #29 usually refused the gait belt because it was too tight. The DON has since ordered a larger gait belt and educated the resident regarding safety precautions. The DON stated, he ' s compliant now. The Comprehensive Care Plans policy last revised on 1/30/2024 identified The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative.

Based on clinical record review and staff interview the facility failed to appropriately inspect bed rails in the facility for 1 of 1 resident reviewed (Resident #8). The facility reported a census of 41 residents. Past Noncompliance determined during the annual recertification survey of a facility incident that occurred on 12/25/23 regarding deficiency F909 with a scope and severity of a Level G. The facility provided evidence of the bed being changed out with safe bed rails. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 documented diagnoses of diabetes mellitus, neurogenic bladder and hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Interview on 5/28/24 at 11:34 a.m., with Resident #8 revealed her bed rail had been loose and when she was being assisted the side rail broke off of the bed and she fell off of the side of the bed. Review of Resident #8 ' s Progress Notes revealed the following: a. On 12/26/23, Resident #8 being seen after going to the emergency room (ER) on 12/23/23 for left shoulder pain and returning to the facility on the same day. While in the ER an x-ray was obtained of the left shoulder which showed advanced degenerative change. Nursing staff also express resident fell out of bed yesterday. b. On 12/27/23 at 10:51 p.m., Resident #8 reports pain to the left shoulder and arm. As needed, tramadol has been effective. Resident #8 is lying in her new bed and it is in the lowest position. c. On 12/28/23 at 11:03 a.m., Resident #8 returns from doctor appointment with order for non-weight bearing to left shoulder. Follow-up with CT scan of left shoulder. d. On 1/17/24 at 1:11 p.m., CT results received impression: Acute intra-articular fracture of the anterior aspect of the glenoid with maximum distraction of fracture fragments in the order of 3 mm. e. On 3/28/24 at 10:54 a.m., Resident #8 returns after seeing the doctor with the following noted healed fracture no restrictions. Review of facility provided Incident Report dated 12/25/23 revealed while resident was being repositioned in bed, the side rail became disengaged and resident rolled off side of bed. Resident #8 states while trying to help them change me, I grabbed ahold of the rail as I was turning and I started falling. Review of the facility provided document titled Timeline of Incident revealed on 12/25/23 at 2:05 p.m., Resident #8 was lying in bed while she was being assisted by staff. Staff went to reposition her to her left side, Resident #8 went to grab her bed rail to hold on to and the bed rail broke apart from the bed frame causing Resident #8 to fall out of bed onto her left side. Staff brought in a replacement bed with functioning bed rails.On 1/17/24 the facility was notified by the physician Resident #8 had an acute fracture. Review of the CT shoulder imaging dated 1/8/24 revealed in the findings there is an acute appearing intra-articular fracture of the anterior aspect of the glenoid with maximum distraction of fracture fragments in the order of 3 mm. Interview on 5/29/24 at 9:53 a.m., with Staff A, Licensed Practical Nurse (LPN) was just coming onto shift when the staff called her down to Resident #8 ' s room. When Staff A entered the room Resident #8 was laying on the floor face down with the bed rail broke off of the bed. Resident #8 was assessed and assisted back into bed with the hoyer lift. Interview on 5/29/24 at 10:29 a.m., with Staff B, Certified Nursing Assistant (CNA) revealed she had assisted Staff C, CNA with Resident #8 into bed to change her brief. Staff B revealed when Resident #8 rolled onto her left side she grabbed the bed rail and the rail broke and Resident #8 fell to the floor. Staff B further revealed she had noticed the bed rail was a little loose but it had been that way for awhile and she didn ' t think it would break. Interview on 5/29/24 at 12:20 p.m., with Staff C, CNA revealed she had been assisting Staff B, CNA with Resident #8. Staff C revealed Resident #8 rolled onto her left side and the side rail on the bed broke and Resident #8 fell out of the bed onto the floor. Interview on 5/29/24 at 12:41 p.m., with Staff D, Maintenance Director revealed the beds have a tab on the rail that holds them in place and a pin that keeps them locked. The side rail was bad on both sides from what appears to have been bent from a bigger person pulling on the side rails on each side. The tab was bent so much that the pin that keeps the rail in place wasn ' t able to hold it any longer. Review of facility provided document titled Work History Report with created date of 5/29/24 revealed preventative maintenance with a due date of 11/30/24 and 12/31/24 under task completion revealed no action recorded. Review of the facility provided instructions titled Beds- Electric: Inspect Bed Rails dated 5/29/24 at 2:57 p.m., revealed items identified as poor condition should be removed from service. Maintenance check included ensuring that the rails engage and lock as specified and tighten, adjust or replace any parts such as end caps, knobs, bolts, screws, ect. that are loose, show signs of wear or are missing. Interview on 5/29/24 at 3:19 p.m., with the Administrator revealed the previous maintenance guy had been doing the bed checks and he retired at the beginning of November and the facility was without a full-time maintenance person. The bed rail inspections did not get done in November or December. After the incident happened, the facility realized the bed rail inspections were not being. The Administor further revealed he trained the new maintenance guy on how to do the bed rail inspections and they are now being completed.

Based on clinical record review and staff interview the facility failed to develop care plans to address usage of high risk medications and side effects to watch for 3 out of 14 sampled residents (Resident #8, #15 & #32) and failed to include dialyis information for 1 of 1 sampled resident (Resident #2) reviewed for comprehensive care plans. The facility reported a census of 41 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 documented diagnoses of diabetes mellitus, neurogenic bladder and hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS revealed Resident #8 had taken insulin injections the last 7 out of 7 days in the review period and is currently taking diuretic medication and opioid medication. Review of the Order Summary Report signed by the physician dated 3/13/24 revealed the following orders: a. Belbuca Buccal Film (opioid medication) twice a day with a start date of 2/13/24, b. Furosemide Tablet (diuretic medication) daily with a start date 7/21/22, c. Novolog (diabetic medication) sliding scale injection with a start date of 8/18/23, d. Novolog (diabetic medication) 3 times daily with a start date of 1/24/23, e. Tresiba Subcutaneous Solution (diabetic medication) daily with a start date of 5/13/24, f. Tramadol (opioid medication) daily as needed with a start date of 7/20/22, g. Tramadol (opioid medication) daily with a start date of 1/12/24. Review of the May Medication Administration Record (MAR) revealed the following orders: a. Furosemide Tablet daily with a start date 7/21/22, b. Tresiba Subcutaneous Solution daily with a start date of 5/13/24, c. Novolog sliding scale injection with a start date of 8/18/23, d. Novolog 3 times daily with a start date of 1/24/23, e. Belbuca Buccal Film twice a day with a start date of 2/13/24 and discontinue date of 5/21/24, f. Belbuca Buccal Film twice a day with a start date of 5/23/24, g. Tramadol daily with a start date of 1/12/24, h. Tramadol daily as needed with a start date of 7/20/22. Review of the Care Plan with a revision date of 4/17/24 lacked information regarding usage of diuretic medication, insulin usage and opioid medication and signs and symptoms to watch for. 2. The MDS assessment dated [DATE] for Resident #15 documented diagnoses of diabetes mellitus, anemia and hypertension. The MDS showed the BIMS score of 13, indicating no cognitive impairment. The MDS revealed Resident #15 in the review period and is currently taking diuretic medication and opioid medication. Review of the Order Summary Report signed by the physician dated 3/13/24 revealed the following orders: a. Insulin Glargine with a start date of daily with a start date of 2/5/23, b. Hydrocodone-Acetaminophen daily as needed with a start date of 2/13/24. Review of the May Medication Administration Record (MAR) revealed the following orders: a. Insulin Glargine with a start date of daily with a start date of 5/14/24, b. Hydrocodone-Acetaminophen twice daily as needed with a start date of 5/15/24. Review of the Care Plan with a revision date of 2/6/24 lacked information regarding usage of diuretic medication, insulin usage and opioid medication and signs and symptoms to watch for. Interview on 5/29/24 at 2:43 p.m., with the Director of Nursing (DON) revealed she expected high risk medications and side effects to be on the care plan. 49056 3. The MDS assessment for Resident #32 dated 3/28/24 identified a BIMS score of 14, which indicated intact cognition. The MDS included diagnoses of atrial fibrillation, heart failure and hypertension. The MDS documented Resident #32 received the anticoagulation medication during the assessment period (last 7 days). Per the clinical Physician Order dated 5/18/24 directed staff to administer Warfarin (anticoagulant) 2 milligrams (MG), give 4 mg by mouth one time a day every Tuesday, Thursday, Saturday and Sunday for prevention of blood clot. Per the clinical Physician Order dated 5/17/24 directed staff to administer Warfarin 6 mg by mouth one time a day every Monday, Wednesday and Friday related to heart failure. Review of Resident #32 's Care Plan with an initiated date of 3/15/24 revealed the anticoagulant medication, potential side effects and what to monitor for while taking the high risk medication was not addressed on the comprehensive care plan. On 5/30/24 at 8:45 AM, the DON stated the expectation would be to have the warfarin addressed on the care plan. The facility policy titled Comprehensive Care Plans dated 1/30/24 revealed 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 and timeframes to meet a resident ' s medical, nursing, and mental and psychosocial needs that are identified in the resident ' s comprehensive assessment. 44420 4. The MDS assessment dated [DATE] for Resident #2 documented diagnoses of renal failure, arteriovenous fistula, stroke. The MDS showed the BIMS score of 13, which indicated no cognitive impairment. The Progress Note dated 3/15/24 at 10:24 PM revealed Resident #2 with a fistula in the left upper arm for dialysis with a dressing placed over the fistula. Review the Care Plan for Resident #2 failed to show the resident had a fistula for dialysis and lacked directions for assessments and fistula site care. In an interview on 5/29/24 at 1:27 PM, the Director of Nursing (DON) reported that the fistula should be on the care plan. The DON reported the resident returns to the facility with a dressing from dialysis but a dressing isn ' t needed, and the nurses know they have to assess the fistula. The DON stated, I do agree that the fistula should be on the care plan though.

Based on observations, staff interviews, and facility policy review the facility failed to ensure sanitary conditions where staff prepared and stored food. The facility identified a census of 41 residents. Findings included: The initial kitchen tour on 5/28/24 at 10:32 AM revealed the following: The bottom of refrigerators, and freezers contained an accumulation of food debris and dried liquid. The floor in the kitchen and dishwashing area contained a variety of scattered food debris and dried liquid. Open shelving beneath preparation tables contained food debris and dried liquid. The snack cart and vegetable storage bin contained a variety of scattered food debris. Handles on the snack cart with grime. Milk freezer with a thick layer of ice buildup. The Cleaning Schedules for May 2024 showed staff failed to complete cleaning tasks all the days of May except 5/3/24. Additional cleaning schedules for May 2024 showed the milk cooler cleaning task signed off by staff as completed. The Food and Nutrition Services in Healthcare Facilities policy date 2021 identified cleaning and sanitizing refrigerators on a regular cleaning schedule, and as needed. The kitchen will be thoroughly cleaned, and food preparation surfaces sanitized prior to closing each day. The director of food and nutrition services will assure that instructions for the food and nutrition services department are properly carried out, and that all local, state, and federal food, food safety and sanitation regulatory requirements are met. In an interview on 5/28/24 at 10:56 AM, the Dietary Manager (DM) reviewed the cleaning schedule. The DM stated, My staff obviously signed off that they cleaned the milk cooler but didn ' t defrost it. I' ll address it with that person. When asked if she expected all the cleaning tasks to be completed and signed by staff, the DM replied, yes. The DM explained that she recently had time off work and hasn ' t been able to follow up with staff.

Based on clinical record review and staff interview, the facility failed to refer one resident with a negative Level I result for the PreAdmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, and received Mental Health Services to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 resident reviewed for PASRR requirements, (Resident #19). The facility reported a census of 41 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #19 documented diagnosis of anxiety disorder, depression, psychotic disorder and hallucinations. Review of the clinical record revealed a Notice of Negative Level I Screen Outcome dated 3/29/21 revealed the PASRR level 1 screen remains valid for your stay at the nursing facility and should be transferred with you if you relocate. No further level 1 screening is required unless you are known to have or are suspected of having a major mental illness or an intellectual or developmental disability and exhibit a significant change in treatment needs. Further review revealed the following questions indicated the following: Mental health conditions diagnosed or suspected included: major depression, anxiety disorder. Has the individual received mental health services now or in the past? No. Review of the Care Plan last revised on 5/23/24 revealed Resident #19 used psychotropic medications (a drug that affects a person's mental state). Review of the Medical Diagnosis revealed Resident #19 with the following diagnosis: Delusion disorder, dated 3/11/21, Hallucinations, dated 3/24/23, Dementia, dated 3/31/23. Review of the Psychosocial Notes for Resident #19 revealed Telehealth services for medication management, behaviors, delusions, mood, sleeping patterns, confusion and appetite occurred on the following dates: 6/7/23, 6/26/23, 7/24/23, 8/14/23, 9/6/23, 11/13/23, 12/4/23, 3/11/24, 4/12/24. Review of the Telehealth notes, the first dated 7/28/22 for Resident #19 showed an updated assessment and reason for referral that included dementia, major depressive disorder, delusional disorder, hallucination disorder, and anxiety disorder. Telehealth visits occurred periodically, the last visit occurred on 4/12/24. Review of Resident #19 ' s chart on 5/29/24 showed the facility lacked a follow-up and resubmission of a PASRR with the additional diagnosis of delusional disorder, hallucination disorder and dementia. In an interview on 5/29/24 at 9:31 AM, the Director of Nursing (DON) reported the facility lacked policies related to PASRR. The facility followed regulations and standard practices. The DON reported the Social Worker (SW) did not resubmit Resident #19 ' s PASRR because of the dementia diagnosis. The DON reported she didn ' t know if this met regulations. In an interview on 5/29/24 at 9:45 AM, the SW reported she failed to resubmit the PASRR because she thought a resident diagnosed with dementia did not require a resubmission no matter if a change occurred in mental health diagnoses or mental health services. The SW reported she has since resubmitted the PASRR after the DON spoke with her.

Based on observations and diet orders the facility failed to update the care plan to reflect the current diet order of mechanical soft texture for 1 out of 14 residents (Resident #19). The facility reported a census of 41 residents. Findings Included: Observation of meal service on 5/29/24 starting at 11:55 PM, revealed Resident #19 ordered the scheduled therapeutic lunch for a mechanical soft diet which consisted of ground swiss steak, garlic mashed potatoes, waxed beans and bread with margarine. Staff G, Dietary [NAME] served the resident peas instead of waxed beans. The Physician's Order dated 4/22/24 for Resident #19 showed an order for mechanical soft diet texture. The Diet Type Report dated 5/29/24 showed Resident #19 as a mechanical soft diet. In an interview on 5/29/24 at 12:59 PM, the Dietitian reported peas could pose a choking hazard for Resident #19. The Dietitian reported that staff are required to follow the mechanical soft diet menu. Review of Resident #19 ' s chart on 5/29/24 at 1:32 PM showed no previous episodes of choking. Review of the Care Plan for Resident #19 on 5/29/24 at 12:52 PM showed the facility failed to update the resident ' s care plan to reflect the diet ordered on 4/22/24 of mechanical soft diet texture. The Comprehensive Care Plan policy last revised on 1/30/24 identified the care plan will be updated in a timely manner to ensure that services to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. In an interview on 5/29/24 at 1:47 PM, the Director of Nursing reported the plan of care should reflect the current diet order.

Based on clinical record review and staff interview the facility failed to address dementia care for 1 out of 1 residents reviewed (Resident #15). The facility reported a census of 41 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #15 documented diagnoses of diabetes mellitus, Non-Alzheimer ' s Dementia and hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment. The MDS revealed an active diagnosis of Non-Alzheimer ' s Dementia. Review of Resident #15 ' s Active Diagnosis List revealed a diagnosis of Vascular Dementia, unspecified severity with mood disturbance with a created date of 1/19/24. Review of the Care Plan with a revision date of 2/6/24 lacked information regarding dementia care. Interview on 5/29/24 at 2:43 p.m., with the Director of Nursing revealed the facility should have addressed dementia on the care plan. She further revealed the dementia diagnosis was a fairly new diagnosis for Resident #18.

Based on review of the planned menu, observation and staff interviews facility staff failed to follow the planned menu for 1 out of 41 residents observed (Resident #5). The facility identified a census of 41 residents. Findings included: The facility's Week 1 menu identified the following items as part of the planned menu for the pureed lunch meal on 5/29/24: Pureed swiss steak Mashed potatoes Pureed peas Pureed bread with margarine Pureed candy bar Milk Observation on 5/29/24 at 12:25 PM revealed Staff G, Dietary [NAME] failed to puree bread and margarine. Staff G plated the meal then handed the plate to staff to serve without pureed bread and margarine to Resident #5. The Food and Nutrition Services in Healthcare Facilities policy date 2021 identified food will be placed in bowls or on platters and delivered to the dining tables just prior to service. The food will: a. Be at the appropriate temperature for service and be covered if necessary. b. Have the appropriate serving size or serving utensil according to the planned menu In an interview on 5/29/24 at 12:59 PM, the Dietitian reported that she expected the pureed diets to be served per the menu.

Based on observations, clinical record review, facility policy review, and staff interview the facility failed to provide adequate supervision for resident's at risk for elopement for 1 of 3 (Resident #1) residents reviewed. On 7/20/22, Resident #1 admitted to the facility & identified at a high risk of elopement and a history of wandering. On 8/25/22, the facility staff opened an alarmed exit door leading out to the backyard of the facility, and left the door opened & unattended. Resident #1 exited the facility through the opened door and had been gone approximately 10 minutes without staff aware until a fell ow resident observed the resident outside the facility in the unsecured backyard. This resulted in immediate jeopardy to resident health and safety. The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) for Resident #1 dated 8/5/22, identified the resident admitted to the facility on [DATE]. The MDS identified the resident with a Brief Interview for Mental Status (BIMS) score of 8, which indicated mild cognitive impairment. The MDS documented the resident exhibited verbal behavioral symptoms directed towards others daily and significantly interfered with the resident's participation in activities or social interactions, and significantly disrupted the care or the living environment. The MDS identified the resident had wandering behavior 1 to 3 days during the 7 day look back period. The MDS coded the resident independent with bed mobility, transfers, ambulation, and locomotion on and off the unit. The MDS identified the resident steady at times with ambulation or turning around, and used a walker with ambulation. The MDS revealed the resident had not been assessed for ambulating 10 feet on uneven surfaces or the ability to go & down 1 step or a curb. The MDS documented diagnosis of hypertension and non-alzheimer's dementia. The Baseline Care Plan with a start date of 7/20/22, identified Resident #1 at risk for elopement with hourly checks until the resident would allow wander guard bracelet alarm to be placed. The Baseline Care Plan identified the resident alert & orientated to self with forgetfulness & confusion. Resident # 1 identified being independent with ambulation, transfers and mobility with the use of a walker. The Care Plan with date initiated 8/24/22, identified Resident #1 with potential for ADL (activities of daily living) deficit due to diagnosis of dementia. The Care Plan interventions included: a. Independent with ambulation & transfers. b. Ambulate independently without assistive devices. (8/19/22) The Care Plan with date initiated 8/24/22, identified Resident #1 with the potential for elopement. The Care Plan interventions included: a. Close observations to verify location 32 times a shift. (9/6/22) b. Have wandered near the neighbor's yard, encouraged to stay in the courtyard. (8/24/22) c. Refused to wear a wander guard bracelet alarm. (undated) The Care Plan with revised date of 8/26/22, identified Resident #1 with altered thought process/cognition related to diagnosis of dementia and short term memory. The Care Plan interventions included: a. Assess the resident upon admission, quarterly, or with a significant change to identify decline/further decline in cognitive status. b. Educate the family or the responsible party regarding changes. c. Reassure the resident to decrease frustration. The Elopement Risk assessment dated [DATE], identified Resident #1 at a high risk for elopement with a score of 5, due to: independently mobile, history of wandering, episodes of disorientation/confusion, episodes of non-acceptance of placement, and recent multiple changes in room/caregiver/family. Identified the resident considered to be at risk for elopement and the care plan current to the resident's elopement risk. Comments included: the resident care planned to have a wander guard bracelet alarm for safety. The Fall Risk assessment dated [DATE], identified Resident #1 at moderate risk for falling with a score of 10, due to: admission less than 3 months, difficulty with memory & recall ability, occasional incontinence, daily or more agitated behavior (included wandering), and with gait analysis required use of assistive device and decreased muscle coordination. The document titled Follow-up Question Report for Resident #1 dated 7/18 - 9/12/22, identified the following behaviors: a. 7/20/22 at 1:59 PM - yelling, screaming, abusive language b. 7/21/21 at 8:59 PM - abusive language, threatening behavior c. 7/22/22 at 1:59 PM - abusive language d. 7/22/22 at 11:21 PM - grabbing e. 7/23/22 at 1:42 PM - wandering f. 7/24/22 at 1:59 PM - yelling & screaming g.7/25/22 at 5:42 AM - yelling, screaming, threatening behavior h.7/26/22 at 1:56 PM - yelling, screaming, wandering, abusive language, threatening behavior, & refused care i. 7/27/22 at 1:59 PM - wandering j. 7/31/22 at 5:59 AM - wandering k. 8/6/22 at 1:26 PM - wandering l. 8/7/22 at 10:26 AM - wandering m. 8/11/22 at 12:34 AM - yelling & screaming n. 8/12/22 at 1:35 AM - wandering o. 8/13/22 at 11:23 PM - wandering p. 8/17/22 at 10:45 PM - threatening behavior q. 8/19/22 at 1:26 PM - abusive language & sexually inappropriate r. 8/20/22 9:59 PM - wandering s. 8/22/22 at 1:39 PM - wandering t. 8/23/22 at 5:20 AM - wandering u. 8/24/22 at 11:42 AM - wandering v. 8/25/22 at 9:59 PM - yelling & screaming The Progress Notes for Resident #1 revealed: a. On 7/20/22 at 9:27 AM, an Admission Summary Note revealed the resident admitted to the facility from another facility. The resident alert and orientated to person, place, time, & situation, and able to respond to questions. b. On 7/23/22 at 5:53 AM, Nurses Note (NN) revealed the resident continued to adjust to the nursing home and had been awake wandering the hallways and visiting with the staff. The resident talkative and pleasant until the staff unable to do exactly what the resident asked. The resident became upset & went to the room, and slammed the door. The resident returned to the dining area in a few minutes, visited with staff and had forgotten about previous encounter. c. On 7/24/22 at 9:40 PM, NN indicated the resident had behaviors and upset unable to wander to the front area of the building. The resident re-directed and calmed self after a short period of time. d. On 7/26/22 at 12:31 PM, Behavior Note (BN) revealed the resident refused bath and called the facility staff a witch. During lunch the resident told another resident to shut their mouth and placed fist in the air & asked if wanted to fight. The staff re-directed the resident and explained not allowed to speak to other residents that way. The resident returned to the room and slammed the door. e. On 7/26/22 at 12:40 PM, NN revealed the resident had many behaviors; rude & verbally abusive to the staff and verbally abusive to the residents. f. On 7/27/22 at 5:43 PM, NN indicated the resident had outbursts and would swear at the staff. The resident refused to eat supper and wandered occasionally. g. On 8/8/22 at 2:33 PM, NN late entry indicated the resident had care conference with nursing, dietary, activities, and social services. The resident indicated would like to go outdoors. BIMS 8, one to one's as needed, and care plan updated. h. On 8/21/22 at 2:37 PM, BN revealed the resident had been outside, siting in the patio area. The staff observed the resident wandering over by the garden and asked the resident to return to the patio with staff view. The resident became upset with the staff and refused to return to the patio. The resident remained within staff vision and another staff approached the resident. The resident stated not going to leave and just looked at the watermelon in the garden. The resident returned inside the facility and complained about being bored and nothing to do. The interventions: re-educated the resident to stay in staff's site and changed the staff approaching the resident due to agitation. The interventions were effective and the resident calmed down and returned into the facility. i. On 8/25/22 at 9:35 AM, BN revealed the resident observed outside in the courtyard at 9:30 AM, unattended by the facility staff. The staff approached the resident and requested to return inside the facility and reminded the resident could not go outside alone. Head to toe assessment completed, noted bruising to the right forearm and back of the left hand, and vital signs taken. The resident educated on staff being present when outside and the resident re-stated to the nurse must have staff to go outside. The facility document titled Elopement dated 8/25/22 at 9:35 AM, identified Resident #1 and the incident location outside. Incident Description: a. Nursing: the resident had gone outside the facility without staff and noted by another resident. The facility staff approached the resident & returned to the facility. b. Resident: the resident stated had just gone for a walk. Immediate action taken: a. Description: the resident asked to return inside the facility and agreed. A head to toe exam completed and vital signs. b. Resident taken to hospital: No. Injuries observed at time of the incident: No injuries observed at time of the incident. Level of Pain: no pain. Mental Status: orientated to person, place, situation, and time. Injuries reported post incident: no injuries noted post incident. Predisposing environmental factor: blank Predisposing physiological factors: confused. Predisposing situation factors: used cane. Witness: no witness found. The facility document titled Self-Report, undated contained the following: Timeline of incident: On 8/25/22, at approximately 9:39 AM, the Administrator notified by Staff A Universal Worker, that Resident #1 had been found outside the facility in the courtyard walking on the sidewalk. On 8/25/22 at approximately 9:30 AM Resident #1 observed by Resident #4 outside walking on the sidewalk in the courtyard in the middle of the facility, and alerted Staff A. Staff A immediately went outside through the patio sliding door and escorted Resident #1 back into the facility. A head to toe assessment completed at approximately 9:38 AM by the nurse on duty. Resident #1 noted to have bruise to the right forearm and the back of the left hand. The resident dressed for the day in red t-shirt, tan shorts, and slipper/shoes with rubber soles. The resident used cane to assist in ambulation. Upon initial investigation identified the Maintenance man tested the patio door alarm and proceeded to leave the door open to ventilate & provide fresh air. The Maintenance man then left the area, leaving the patio door unattended. On 8/25/22 at approximately 9:20 AM, the Administrator had conducted a tour of the facility and transitioned down the center hallway to the back dining/living/recreational area and had passed Resident #1. Resident #1 had turned around and the Administrator stepped to the side to allow Resident #1 to pass & proceed to the area where the patio door located. At approximately 9:30 AM the Administrator returned for the management meeting following the facility tour and alerted at 9:39 AM that Resident #1 returned back in the facility after observed by Resident #4 through the patio screen door out in the court yard, on the sidewalk. Resident #1 Care Plan at the time of the incident indicated the resident had potential for elopement and the intervention in place was to provide a wander guard bracelet alarm. Resident #1 refused to wear the wander guard after several attempts by the staff. The exterior doors in the facility are alarmed in attempt the resident should exit seek. Plan of Action: the facility continued to follow the current care plan for Resident #1 and added 32 checks per shift for 72 hours and then as needed by staff to continue to verify the resident's location. On 8/29/22 the Maintenance man added an additional alarm to the glass door and an additional coded alarm to the screen door, as additional layer of alarms to the patio as means of notification. Education provided to the maintenance man regarding leaving any alarmed door unarmed and unattended on 8/29/22. All staff educated regarding leaving doors unalarmed and unattended to be completed by 9/2/22 or next scheduled shift. The facility document titled Missing Resident/Elopement process updated 7/12/21, identified: Assessment and identification of wandering residents: a. An elopement risk assessment will be completed upon admission, readmission, quarterly, annually, and with any significant change MDS. b. Care Plan will be modified as needed on the risk assessment. c. Complete a missing resident identification form - activities will be in charge of having a missing resident identification form completed for each resident on admission and annually Residents identified at risk for elopement: a. Alarm bracelet may be placed on the resident to audibly alert the staff of the attempts by the resident to exit the facility. b. The residents care plan shall address behaviors using the resident specific goals &/or approaches as assessed by the IDT (Interdisciplinary team). c. A current picture of the resident will be maintained in the facility. d. Facility staff will ensure that all exit alarms are responded to immediately. e. Staff will encourage activities which the resident enjoys in order to occupy/distract the resident. When the door alarm sounds the facility staff shall: a. Check the alarm panel to determine which door opened. Do not assume someone else already did this. b. Check the exit door for any existing resident by means of visual check. Visual check means observing the area around the exit and may require leaving the building. c. If a resident discovered outside the facility inappropriately, staff assist them back into the facility. d. Reset the door alarm after it determined by visual check that no resident exited the facility inappropriately or returned to the facility. e. If for any reason, door alarms are turned off, the staff will continually visually monitor the door/doors. f. If an alarm is discovered de-activated, staff will perform an immediate head count to ensure all residents are accounted for. Elopement Process (missing resident): a. When determined a resident is missing the following will occur: i. Alert the nurse in charge and all shift personnel to search the facility. If the resident is not located a grounds search will be instituted. ii. If the resident is unaccounted for after a thorough grounds search of the building and grounds immediately notify: Executive Director/DON, family &/or legal representative, attending physician, and police. b. A complete description of the resident will be given to the police along with a current photo of the resident. Provide law enforcement the Missing Resident Identification form. When the resident is located, the following procedure will be followed: a. Head to toe assessment of the resident will be completed to determine if medical attention is required. Document in the nurses notes the head to toe assessment completed and findings. b. After the assessment completed, the attending physician will be notified and the results of the assessment reported. The phsycian's plan of care will be documented in the resident's record. c. The resident's family/legal representative shall be notified of the resident's condition. d. The resident's condition will be monitored every shift x 72 hours. e. A detailed incident report will be completed. f. An Elopement/Missing Resident Investigation form will be completed by the DON &/or designee. g. The Incident Report will be reviewed at the Monthly Safety Committee meeting and each quarter with the QA (quality assurance) Committee. Education and Training: a. All staff will be educated on proper identification, assessment, and treatment of the resident's identified as an exit seeking risk. This education will occur during orientation and annually thereafter. b. Missing Resident Drill will be completed on all shifts quarterly On 9/7/22 at 12:21 PM, the Maintenance man stated the exit door alarms and the wander guard alarms checked one time a week. The Maintenance man stated no resident had a wander guard bracelet alarm in place. Observation of the exit doors and the wander guard alarms with the Maintenance man revealed: a. The front door with an alarm in place, with the alarm sounding when the door opened. The door alarm reset at the front nurses station panel. The second front door, inside the vestibule revealed and wander guard alarm, with alarm sounding with the door opened. A code entered at the door to reset the wander guard alarm. b. The dining door with an alarm & wander guard in place, with the alarms sounding with the door opened. The two different alarms with 2 different distinct sounds. The door alarm reset at the front nurse's station panel and code entered at the door for the wander guard alarm. c. The North hallway exit & South hallway exit doors with alarm in place, sounded when the door opened & reset at the front nurse's station. A secondary back alarm present at the top of the door with a turnkey reset. d. The television room exit and the basement exit doors with alarms, sounded when the door opened and reset at the back nurse's station. e. North 2 hallway exit & South 2 hallway exit with door alarms, sounded when the door opened and reset at the back nurse's station panel. f. The sliding glass patio door exit alarmed & sounded when opened, being reset at the back nurse's station panel. A second alarm added to the patio door for back up if the 1st alarm not activated, sounded when the door opened and reset on the glass patio door. An additional alarm added to the screen door. The screen door alarm activated and deactivated on the screen door. The Maintenance man opened the screen door 4 times before an alarm sounded. The Maintenance man stated the facility staff had residents outside this morning and did not activate the alarm. On 9/7/22 at 12:46 PM, the Maintenance man stated the facility nurses had been in the back dining room on 8/25/22, and assisted the residents with breakfast. The Maintenance man stated between 7:00/7:30 AM, noted the back dining room had musty urine smell and wanted to open the sliding glass door for fresh air due to being cool outside. The Maintenance man stated thought the nurses and the aides being present in the dining room, would watch the open sliding glass door. The Maintenance man stated Resident #1 opened the screen door and walked outside, and no facility staff noticed the resident leaving the facility. The Maintenance man stated the new policy was not to leave the glass patio door open. The Maintenance man stated he had opened the sliding glass door and left the back dining room area, and had not informed the nursing staff to door left open. The Maintenance man stated went about his work and did not return to the back dining room area. On 9/7/22 at 12:48 PM, the Administrator stated had been with a potential resident and their family on the morning of 8/25/22, for a facility tour. The Administrator stated at approximately 9:15/9:20 AM, had passed Resident #1 in the hallway by the back nurse's station (located across from the back dining room) and the resident headed to the MDS nurse's office as the resident did routinely in the morning. The Administrator stated Resident #1 had turned around and headed back to the dining room, back by the Administrator, and headed to the bird aviary, and the Administrator stated had turned back to the resident at that time to return down the hallway with the potential resident and family. The Administrator stated went to the morning managers meeting that had started at 9:30 AM and at 9:39 AM, received a text message that Resident #1 outside of the facility. The Administrator stated Resident #1 was unaccounted for approximately 15-20 minutes. The Administrator stated the Maintenance man had opened the sliding glass patio door in the morning to allow fresh air into the facility. The Administrator stated not aware of the sliding glass door to the patio being opened during the morning tour with the potential resident. The Administrator stated not able to observe the patio doors from where stood in the hallway by the back nurse's station due to the bird aviary. The Administrator stated before the new alarm could be placed on the patio door, Resident #1 had gotten upset due to wood being used to keep the door closed. The Administrator stated residents allowed to go outside independently and stay on the patio, after an assessment completed, however, most residents had to be assisted out of the patio doors and the facility staff aware the residents were outside. The Administrator stated the residents had their own personal cell phones to call for assistance if needed when outside in the patio area independently. The Administrator stated the residents allowed outside without staff are not at risk for elopement. The Administrator stated no residents allowed outside the front of the facility without the facility staff or family members present, only out the back patio. The Administrator stated awaiting to have sensor driveway alarms to be installed across the patio doors as additional alarms. The Administrator stated had gone outside with Resident #1 multiple times, would go out the front door and around to the garden. The Administrator stated Resident #1 would check out the lawnmower and the garden, and sit on the bench for a short time before ready to return inside the facility. The Administrator stated the resident previously lived by a state park in a neighboring town and liked to be outside. On 9/7/22 at 12:50 AM, observation with the Administrator of the outside area from the sliding patio door revealed an open back yard, unsecured. Ambulated from the patio to the garden approximately 77 feet of uneven ground. To the left of the garden a 5 foot cement wall and to the right of the garden approximately 150 feet away on uneven ground & partial sidewalk, a busy residential street. The Administrator stated Resident #1 had been found standing beside the garden. On 9/7/22 at 1:00 PM, Resident #1 stood in the doorway of the room, well-groomed and non-skid footwear on. The resident asked the Administrator about going outside for a walk and informed would go out later in the afternoon and the resident agreed. Resident #1 stated was supposed to have someone with him when he went outside, stated when moved to the facility had been promised the facility had an outside area to go to. Resident #1 then changed the subject to the refrigerator that needed to be stocked with the snacks the staff had bought. The resident repeatedly stated had too many snacks and nowhere to put them. Resident #1 stated never went outside by self, however, technically could because did not have one of those wander guard bracelets on, and pointed to the wrist. The resident stated the facility had removed the wander guard from the ankle, that had been placed at the previous facility a long time ago and a new wander guard had never placed on. The resident then stated the biggest problem, the ice box needed filled. Resident #1 then stated the facility staff go with when went outside and that should work anyway. The resident stated could go anywhere he wanted with the Administrator, as he was the one that made the decisions. The resident stated the Administrator and himself had a plan on going outside. The resident again talked about the concern with the snacks. On 9/7/22 at 1:15 PM, Staff A Universal worker stated had previously worked at the facility where Resident #1 had been transferred from and had been familiar with the resident. Staff A stated the residents that transferred to this facility from the other facility had behavioral issues and provided one to ones. Staff A stated on the morning on 8/25/22, had been in the back dining room facing the TV area with 2 other residents who were finishing breakfast. Staff A stated unable to recall the time, however, stated breakfast served around 8:20/8:30 AM and the resident took 30-40 minutes to eat. Staff A stated Resident #4 pointed outside to the backyard and asked what Resident #1 was doing outside. Staff A stated turned around and Resident #1 stood by the tree, walking back towards the facility. Staff A stated went outside and asked the resident what doing, and stated gone for a walk. Staff A stated the screen door had been shut, but the glass patio door had been open all day. Staff A stated didn't believe Resident #1 tried to escape, the resident liked to go outside and look at the garden and then return inside the facility. Staff A stated Resident #1 had a wander guard bracelet alarm while at the previous facility, as the resident did tend to wander. Staff A stated Resident #1 not allowed to go outside of the facility, to the garden, by himself. Staff A stated if a resident is independent and makes their own decisions, can go outside on the patio independently as long as the facility staff made observations of the patio. Staff A stated the residents not cognitively with it, had to have the facility staff go outside with them. Staff A stated prior to the incident on 8/25/22, the patio doors were not usually open because the Maintenance man would yell at the staff because of the air conditioning being on. Staff A stated the Maintenance man had left the sliding glass patio door open that day because it was cool outside and letting fresh air in. Staff A stated did not think the Maintenance man ever came back to shut the sliding glass door. Staff A stated when Resident #1 admitted to the facility would not allow the wander guard bracelet to be placed and wouldn't allow the facility staff to remove the wander guard from the previous facility for a long time. Staff A stated the resident always told the staff he was federal and did not need a wander guard, not going anywhere. Staff A stated unaware of any other residents who had left the facility unattended without the staff being aware. Staff A stated when the facility placed a new alarm on the patio door, the facility reviewed with all the staff. Staff A stated when the glass patio door opened, an alarm sounded at the back nurse's station and had to be reset at the panel at the nurse's station. Staff A stated the new alarm placed could be reset at the door. On 9/7/22 at 2:40 PM, Resident #4 stated the residents not allowed to go outside of the facility without the staff. Resident #4 stated had been in the dining room on the morning of 8/25/22, finishing breakfast, unable to recall the time, did not look at the clock. Resident #4 stated did not observe Resident #1 go out the patio door, stated just observed the resident when already outside. Resident #4 stated the glass sliding door had already been open and Resident #1 had to just walk out, but did not see the resident go out. Resident #4 stated Resident #1 had not been trying to run away or anything, just went out to the tree and looked around. Resident #4 stated Resident #1 had on a t- shirt & shorts, however, unsure of the weather. Resident #4 stated did not observe Resident #1 by the garden, only by the first tree, just looking at the ground. Resident #4 stated never observed any other resident's outside without the staff being present. Resident #4 stated Resident #1 had not been outside long, as soon as observed him, informed Staff A and went right out and got the resident inside the facility. On 9/7/22 at 2:50 PM, Resident #5 stated Resident #1 had not been in danger when outside the facility unattended on 8/25/22. Resident #5 stated Resident #1 observed the opened patio door and went outside, the resident didn't go anywhere. Resident #5 stated the facility staff had the resident go to the front dining room and removed the tables from the back dining room, not allowed to eat in the back dining room. On 9/7/22 at 3:19 PM, the Director of Nursing (DON) stated the facility did not have residents with wander guard bracelet alarms in place. The DON stated a resident would go to the door, however, not strong enough to open the door and did not make an attempt to leave the facility. The DON stated the facility had no residents with exit seeking behaviors or wandering. The DON stated Resident #1 just walked, did not wander, looked for entertainment. The DON stated Resident #1 did wander, however, did not try to get out the front doors. The DON stated two residents admitted from another facility had wander guard bracelets in place on admission and removed the wander guards last week due to not being at risk for elopement. The DON again stated the facility did not have any residents are at risk for elopement. On 9/7/22 at 4:00 PM, the Assistant Director of Nursing (ADON) stated a temporary nurse had admitted Resident #1 on 7/20/22, and the facility staff unaware the temporary nurse assessed the resident being at high risk for elopement. The ADON stated attempted to place a facility wander guard on Resident #1 upon admission to the facility and the resident attempted to kick the ADON in the face. The ADON stated removed the old wander guard bracelet from the previous facility, from the resident a couple of days after admission. The ADON stated Resident #1 refused to allow a new wander guard to be placed and the facility staff attempted x 1 week and caused the resident increased agitation. The ADON stated the facility staff keep close observations on the resident due to refusal of the wander guard bracelet, however, did not document the close observations, the staff just did them. The ADON stated the resident did not have any exit seeking behaviors. Jointly reviewed the close observation logs completed by the facility staff 8/25-8/30/22. On 9/12/22 at 1:39 PM, Staff B Registered Nurse (RN) stated worked the day shift at the facility for 4 months. Staff B stated when Resident #1 admitted to the facility, aware the resident at risk for elopement. Staff B stated the exit doors alarmed & secured with codes. Staff B stated initially worked the front section of the facility & recently started to work the back section. Staff B stated when an exit door alarm sounded, would show at the nurse's station panel where the door located that had been opened. Staff B stated the facility attempted to place a wander guard on Resident #1 and the resident refused. Staff B stated prior to the elopement on 8/25/22, the facility completed 15 minute checks on the resident, however, unsure if those were documented. Staff B stated had not actually worked the back with Resident #1 until after the elopement. Staff B stated knew the staff tried to be aware of where the resident was located. Staff B stated any time Resident #1 went outside of the facility, had to have staff with. Staff B stated no way could the resident have gone outside the facility on own. Staff B stated would not have felt safe letting Resident #1outside on own. Staff B stated not aware of Resident #1 attempting to elope prior to the day being outside. Staff B stated the facility had no residents that had wander guard alarms on and not aware of any residents that are at risk for elopement. Staff B stated the doors alarmed. Staff B stated a new admission to the facility with a high risk for elopement stated maybe initiate 15 minute checks, however, the management would determine the need for wander guard. On 9/12/22 at 1:48 PM, Staff C Certified Nurse's Aide (CNA) stated worked the day shift at the facility for 3 years. Staff C stated worked the morning of 8/25/22 when Resident #1 had eloped from the facility. Staff C stated worked in the back, however, had not been in the dining room at the time the resident went outside. Staff C stated had been in a room with another resident. Staff C stated the last time observed Resident #1, while eating breakfast, between 8:00/8:30 AM. Staff C stated Resident #1's morning routine was the resident up at 7ish, went to the dining room for breakfast. Staff C stated the resident either stayed in room until breakfast or would walk up front and back unti

Based on record review, interviews and observation the facility failed to provide adequate nursing supervision resulting in a [CONDITION(S)] due to a fall for 1 out of 3 residents reviewed, (Resident #125). The facility reported a census of 25 residents. Findings Include: The Minimum Data (MDS) with an Assessment Reference Date of (ARD) of 11/11/20 for Resident #125 showed a Brief Interview of Mental Status Score (BIMS) of 08 which indicated moderately impaired cognitive skills. The MDS showed the resident had diagnoses of dementia, disorientation, weakness, [CONDITION(S)], and anxiety. The resident required limited assistance with one staff for transfers, dressing and ambulation. Review of Progress Note dated 9/6/2020 at 10:26 PM stated Resident #125 was found sitting in the hallway in front of room 45 sitting on buttocks holding on to side rail in hallway. The Resident stated, I just wanted to get out of bed. I wasn't tired yet. Intervention at time of fall was to educate staff on alarm use. Review of the Incident Report dated 9/6/20 stated the immediate action taken was staff to ambulate resident with walker and gait belt, lay resident back down in bed, alarm activated. Certified Nurse's Aides (CNA) educated on making sure alarm box is turned on. Review of the Progress Note dated 11/29/20 at 3:45 PM noted the resident was resting in a recliner in the lounge area of the commons room. The Nurse had seen the resident about 30 minutes prior to the incident. The two CNA's were down a hall helping another resident when they heard a thump from the commons room and found the resident lying on the floor on her right side. The Progress Note stated it appeared the resident got up on her own and started waking to the piano in the dining room. There was a chair alarm placed in the recliner but it was not turned on. The resident was complaining of pain in her right leg and was sent to the emergency room for evaluation. On 12/14/21 at 10:22 AM observation made of the area with Director of Nursing (DON). The DON showed the resident was sitting in the commons area with the recliners and TV and was found on the floor by a piano which was located about 50 feet from where she was seated. Review of the Incident Report dated 11/29/20 prepared by Staff C, Registered Nurse (RN) stated the resident was sitting in a recliner in the front lounge area, got up unassisted and fell on her right side. Alarm was in place but was not turned on. Review of the facilities investigation stated at approximately 3:15 PM Staff C RN conducted vitals on the resident while in the recliner and then went on to obtain other residents vital signs. At approximately 3:30 PM Staff D CNA noticed the resident laying on the floor from a distance after hearing a noise. Staff D CNA noted the pad alarm was not sounding. Staff C RN then called the emergency room and Emergency Medical Team arrived on site at 3:40 PM. Plan of action taken was to reeducate all nursing staff to ensure proper alarm utilization by the end of day 12/2/20. Review of the Progress Note dated 11/29/20 at 5:27 PM showed the facility was notified by the hospital Resident #125 sustained a dislocated trochanter and a [CONDITION(S)]. Review of the Progress Note dated 12/1/20 at 1:51 PM stated the facility was informed by the hospital Resident #125 had surgery on 11/30/20. Review of the Respiratory Surveillance Form showed Resident #125 tested positive for Covid-19 on 11/29/20 at the hospital. Review of the Progress Note 12/2/20 at 12:54 PM showed the resident returned to the facility Review of Progress Note dated 12/11/20 at 5:18 PM Resident #125 was admitted to hospice with diagnosis of Covid-19 and comorbidities of right hip fracture repair. The Progress Note dated 12/12/20 at 6:00 PM noted the resident had passed away. Review of the Care Plan stated a personal alarm was to be on at all time with an initiation date of 6/10/20. Review of the Fall Risk assessment dated [DATE] stated resident was a high risk for falls with a high fall risk score of 18. Interview on 12/14/21 at 1:50 PM the DON stated the facility does not have personal alarms any more, it has been about a year since they have used alarms, she stated she does not like to use alarms and expects staff to observe residents.

Based on record review and staff interview, the facility failed to provide adequate assessment and timely intervention for 1 of 3 residents reviewed for hospitalization s, (Resident #6). The facility reported a census of 36 residents. Findings include: According to the Minimum Data Set assessment dated [DATE], Resident #6 scored 6 on the Brief Interview for Mental Status, indicating no cognitive impairment. The resident's [DIAGNOSES REDACTED]. The Progress Notes dated 8/29/19 at 4:47 p.m., documented the resident complained of a hard time breathing. The resident's oxygen (O2) saturation (sat) at 63% (94-100 normal). Staff got a new concentrator and an O2 mask because the resident wouldn't deep breathe through the nasal cannula. The O2 sat rose to 90%. The resident not happy about the mask, but asked to leave it on because effective. They would continue to monitor. The clinical record lacked any documentation of an assessment of the resident other than the O2 sat or any follow up of O2 sats. The Progress Notes dated 8/30/19 at 8 a.m., documented the resident complained of shortness of breath. A check of the O2 sat revealed 71% on 2.5 liters per nasal cannula, with a heart rate of 144 (normal 60-100). O2 applied at 4 liters per mask. At 8:15 a.m. they finally got a hold of the family with the okay to send the resident to the emergency room (ER) for evaluation. At 8:30 a.m. the resident transferred by ambulance. The O2 sat at 90% with a mask and heart rate 134 and irregular. Report called to the hospital. A Transfer/Discharge Report dated 8/30/19, documented the resident complained of trouble breathing, face swollen and flushed, O2 sat 82%, pulse 120, and respirations 32 (12-20 normal). The report also documented the resident complained of difficulty breathing during the night and O2 sat 62% during the night. The hospital record dated 8/31/19, documented the resident's [DIAGNOSES REDACTED]. The resident remained critically ill. A [MEDICAL CONDITION] Consult Note dated 8/31/19, documented the resident came to the ER from the nursing home with complaints of increased shortness of breath for 1-2 days. When the resident came to the ER her O2 sat registered in the 70's on 6 liters of O2 and the resident admitted to the intensive care unit. The resident then on 12 liters of O2, and received diuretics and antibiotics the day before. The resident had a proBNP level of 3800 (normal less than 150) a test to detect and evaluate heart failure. During an interview on 12/10/19 at 10:27 a.m., the Assistant Director of Nursing (ADON) stated she documented, on the 8/30/19 transfer sheet, the resident had difficulty breathing with O2 sats in the 60's (during the night) because that's the report she received. She said Staff H, Registered Nurse (RN) asked her if she would assist her with the resident. During an interview on 12/10/19 at 3:10 p.m., Staff H stated on 8/30/19 she came on and during report the night nurse, Staff I, RN reported the resident had difficulty breathing and (O2) sats were in the 60's. Staff H immediately went down and assessed the resident and then called the hospital house supervisor and the family to see about transferring to the hospital. She did not know if the night nurse took any other vital signs. She said she thought the night nurse said she turned the O2 up and put a mask on her. She did not know what she turned the O2 up to. Staff H stated the resident also had a rapid heart rate. The Progress Notes lacked any documentation regarding the resident's condition, an assessment or any intervention related to difficulty breathing on the night shift and the resident's vital signs record lacked any documentation. During an interview on 12/12/19 at 5:50 a.m., Staff I stated she did not remember the night shift prior to the resident transferring to the hospital on [DATE]. During an interview on 12/12/19 at 7:40 a.m., the Resource Nurse concurred they had no follow up after the resident's low O2 sat (8/29/19 at 4:47 p.m.). She said they had instituted checking O2 sats routinely. During an interview on 2/12/19 at 12:42 p.m., the resident's personal physician stated if someone had a low O2 sat he would expect a nursing assessment, and if determined accurate, he expected the resident to go to the next level which would be the ER, immediately. He said if the facility had assessed the resident and sent her to the ER sooner she may not have become so critically ill.

Based on observation, staff interview and record review the facility failed to implement measures to ensure adequate supervision to prevent falls and major injury for three of six residents reviewed. (Resident #6, #35, and #136) The facility reported a census of 37 residents. Findings include: 1. Resident #6 had a Minimum Data Set (MDS) assessment with a reference date of 7/10/18 that documented a score of 5 of 15 on BIMS (brief interview for mental status) indicated severely cognitive impairment. According to the MDS, the resident required the extensive assistance of two staff for transfers, bed mobility, walking, dressing and toilet use. A balance during transition and walking test identified the resident as not steady and only able to stabilize with staff assistance when walking, turning around, moving from a seated to standing position, and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. The resident had had no falls since the prior assessment. Review of the Fall Risk assessment, dated 7/10/18 identified the resident scored a two (2) or above in the following areas which required review for possible interventions: Mental Status, Balance and Gait, Ambulation status, Medications, and Predisposing diseases and scored a 12 which represented a high risk of falls. The Fall Risk assessment identified a score of 10 or abouve represented high risk. The Interdisciplinary Working Plan of Care, dated 12/2/15 identified the resident at risk for falls related to forgetfulness and unsteady gait. A care plan directive dated as revised on 2/13/17 directed one-two assist of staff with gait belt and front wheeled walker for transfers and ambulation. A fall incident report dated 10/6/18 at 9:00 p.m. reflected the staff transferred Resident #6 from his wheelchair to the bed and he slid to the floor. The nurse assessed the resident and implemented new intervention identified to prevent recurrence, two staff to assist resident at all times According to a document titled Preliminary Radiology Report dated as completed 10/7/18 reflected an x-ray of the right hip with pelvis was completed after fall on 10/6/18. The findings included a proximal right femoral fracture (hip). The resident was admitted to the hospital and remained at the hospital. During interview on 10/9/18 at 2:45 p.m. Staff A, certified nursing assistant (CNA), stated on 10/6/18 at approximately 8:30 p.m. transferred Resident #6 from his wheelchair to bed. Staff A, CNA confirmed she transferred the resident with assist of one and a gait belt, stated is a one to two on the care plan. Staff A clarified that a one to two on the care plan meant that the resident required the assistance of one or two staff, depended on the day. Staff A further explained that she determined if the resident required one or two based on if the resident had a normal day. Staff A confirmed that in the process of standing from wheelchair to transfer became weak and slid to ground, Staff A stated was unable to keep from falling, and observed the resident fall, landed on buttocks. Staff A stated the resident normally stands pretty well but sometimes, like this time is too weak. In an interview on 10/08/18 at 1:26 p.m. the Director of Nursing,( DON) confirmed the resident fell as transferred with one staff person on 10/6/18. Confirmed the care plan directed one to two person transfer, based on how the resident is doing. The DON further stated staff CNA's are responsible to determine if the resident required one or two to transfer based on the time of day, if tired, and how doing. The DON admitted CNA's should not have been responsible for assessing if the resident required one or two staff to safely transfer. Further admitted that should have had a second staff person for the transfer. 2. Resident #35 had a Minimum Data Set (MDS) assessment with a reference date of 6/12/18 that documented a score of 9 of 15 on BIMS (brief interview for mental status) test which indicated moderately impaired cognitive and memory impairment. According to the MDS, the resident required the extensive assistance of two staff for transfers, bed mobility, walking, and toilet use. A balance during transition and walking test identified the resident as not steady and only able to stabilize with staff assistance when walking, turning around, moving from a seated to standing position, and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. The resident had had one fall with no injury since the prior assessment. Review of the Fall Risk assessment, dated 7/10/18 identified the resident scored a two or above in the following areas which required review for possible interventions: Mental Status, History of falls, Balance and Gait, Ambulation status, Medications, and Predisposing diseases and scored a 18 which represented a high risk of falls. The assessment identified a score of 10 or above represented high risk. The Interdisciplinary Working Plan of Care, identified the resident at risk for falls related to confusion, gait/balance problems, and unaware of safety needs. A care plan directive dated as revised on 6/20/18 directed two assist of staff with front wheeled walker and gait belt for transfers and ambulation, and further directed offer to go to bathroom if restless and attempting to self-rise. A fall incident report dated 7/19/18 at 1130 (11:30 a.m.) documented kitchen staff witnessed the resident self-rising frequently while waiting for lunch, resident fell on floor unwitnessed, and was sent to the emergency room for evaluation and treatment. The nurse further documented educated other department not to leave restless resident alone and find nursing staff as an intervention taken to prevent recurrence. According to a hospital discharge summary dated 10/10/18 the resident was admitted after she fell at the nursing home and was unable to stand or walk. The document further revealed the resident sustained [REDACTED]. According to a diagnostic imaging report dated as completed 7/19/18, x-ray of the left hip with pelvis was completed after an unwitnessed fall. The findings included a [MEDICAL CONDITION] femoral neck with angulation and displacement (left [MEDICAL CONDITION]). During interview on 10/9/18 at 9:05 a.m. Staff E, Registered Nurse (RN), stated on the date of the incident, 7/19/18 she was the nurse on duty and responded to notification that the resident was on the floor in the dining room. Further revealed Staff F, Dietary aide had been talking to the resident in the dining room and reported after the fall that the resident had been anxious, but Staff F had left her alone to return to the kitchen. Staff E, RN reported she counseled Staff F, would expect to notify nursing and stay with resident when observed to be agitated. Staff E, RN confirmed Staff F failed to stay with the resident and failed to report concerns to nursing. Staff F, Dietary aide confirmed observed the resident sitting in the dining room, and no nursing staff were within sight. Confirmed observed Resident #35 wiggling in wheelchair, made a rocking motion, and repeated attempted to self-rise. Reminded the resident to stay seated, and returned to the kitchen, further stated was unaware the resident had fallen until later. Confirmed her supervisor the Dietary Manager had educated if resident is agitated and there are no nursing staff in the area would expect to stay with the resident. Confirmed should have stayed with the resident. In an interview on 10/09/18 at 1:45 p.m. the Dietary Manager confirmed after the fall had educated Staff F, dietary aide would have expected to stay with the resident until could get assistance from nursing. Further clarified Staff F should not have left when she knew the resident was agitated. 3. A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/7/2018 identified Resident # 136's mental status as fully intact, revealed the resident required extensive assistance from (1) staff with toileting and ambulation in her room and documented the resident as only able to stabilize her balance with assistance from staff. A Hospice Physician's Plan Of Care/Certification Of Terminal Illness Hospice form identified the Resident as admitted to Hospice services as of 5/1/2018, due to a terminal [DIAGNOSES REDACTED]. Review of a Hospice report form dated 5/23/18, included a medication list for [MEDICATION NAME] 0.5 milligrams (mg),with a start date of 5/4/18, every 4 hours as needed (PRN) for anxiety and [MEDICATION NAME] 0.5 mg, with a start date of 5/10/18, every evening at 9:00 P.M. A care plan, with a initiation date of 5/16/18 and revision date of 8/15/18, identified the resident with a potential for a psychosocial well being concern, related to a history of feeling depressed and anxious, particularly in the evening. The same care plan included a goal for the resident to feel less anxious after 1:1 time with staff, family or friends when she felt worried or depressed. Care plan interventions for nursing included the following: a. Allow resident to make choices whenever possible. b. Assist with calling family as needed. c. Monitor for medication side effects in regards to [MEDICATION NAME] and [MEDICATION NAME]. d. Provide active listening as needed. e. Provide reassurance as needed. f. Resident has many relatives and friends that visit. A facility Fall Assessment Policy and Protocol dated 2/2012, included the following direction: At the time a resident falls, the charge nurse will complete a Fall Assessment Form and Incident Report with a purpose to identify specific information about the circumstances surrounding a fall and any precipitating events. The Director of Nursing (DON) or designee needed to review the fall assessment form within 72 hours and reviewed by the Quality Assurance Team monthly. Changes to the resident's plan of care needed to be made. According to a Nurses Note dated 5/21/18 at 7:39 P.M., staff documented the Resident's neighbor's family reported Resident #136 had been making a loud noise in her bathroom and staff found the resident on the bathroom floor. The resident told staff she hit her head on the toilet at the time of the fall and sustained a 1.8 centimeter (cm.) by 1.8 cm. lump on the back of her head. Further review of the resident's record lacked a fall investigation and/or incident report in regards to the fall 5/21/18. Review of the resident's care plan revealed the resident at risk for falls and included an intervention dated 5/24/18 (after the resident's fall on 5/21/18) for 1-2 staff to assist the resident with a four wheeled walker when transferred or ambulated. The facility failed to implement intervention on her care plan related to the staff transfer issue. According to a Nurses Note dated 7/15/18 at 7:23 P.M., staff heard the resident calling from her room at 4:45 P.M. and found the resident on the floor on her left side. The resident reported she self transferred herself from her bathroom and fell . The resident was transferred to an emergency room at a local hospital, via ambulance. A Radiology report dated 7/15/18 confirmed the resident sustained [REDACTED]. Further review of the resident's record lacked a fall investigation and/or incident report in regards to the fall 7/15/18. Review of the resident's care plan in regards to falls, revealed staff documented an intervention dated 7/15/18 (following the fall), for activity as tolerated. Again, the care plan lacked intervention in regards to supervision re: getting up on her own and the potential for falls. A Fall Risk assessment dated [DATE], identified the resident at high risk for falls. According to a MDS with an ARD of 8/17/18, staff identified the resident's mental status as moderately impaired, and required extensive assistance of 2 staff with transfer and walking in her room. Further review of Nurses Notes revealed staff documented the following: 7/28/18 at 1:09 A.M.- Very restless, makes many phone calls, wants someone to sit with her all night. 7/30/18 at 6:23 A.M. - At 8:00 P.M., the resident was restless, attempted to crawl out of bed. 8/14/18 at 3:00 P.M. - Having a lot of anxiety about bedtime and being left alone. Resident wanted staff to sit with her. 8/14/18 at 4:00 P.M. - Continues to be anxious about being left alone. 8/15/18 at 1:48 A.M.- Very restless and climbing out of bed. 8/15/18 at 3:00 P.M.- Having lots of anxiety today about being alone tonight. Staff tries to distract resident by sitting with her, but she asks continuously if staff can stay in her room with her. 8/21/18 at 3:00 A.M. - Very anxious 8/29/18 at 9:20 P.M. - Was up on her own several times in the hall looking for Certified Nurse Aide (CNA), or anyone. She wanted to make sure staff knew she was still there. 8/31/18 at 6:20 P.M. - Anxious and unable to redirect. 8/31/18 at 7:13 P.M. - PRN [MEDICATION NAME] ineffective. 8/31/18 at 8:04 P.M. - At 7:20 P.M., the resident was found on the floor in her room. The resident told staff she was going to the bathroom, lost her balance and fell on the floor. Complained of intense pain in her left shoulder and transported to the local hospital. 8/31/18 at 9:50 P.M. - Staff received a telephone call from the local hospital, reported the resident sustained [REDACTED]. Even though the resident reported to staff a fear of being left alone and exhibited increased anxiety, staff failed to update the resident's care plan for staff approaches in regards to her increased anxiety and need for increased supervision. Further review of the resident's record lacked a fall investigation and/or incident report in regards to the fall 8/31/18. Review of a Hospitalist History and Physical (completed at the out of town hospital) dated 8/31/18 at 11:59 P.M., a Physician documented the resident sustained [REDACTED]. The Physician documented the resident required admission to the hospital for inpatient services. Review of a Nurses Note dated 9/2/18 at 2:00 P.M. revealed staff documented the resident returned to the facility following hospitalization . Further review of Nurses Note revealed the following: 9/3/18 - 12:02 A.M.- Crying out in shoulder pain while in bed. 9/3/18 - 4:49 A.M. - Yelling out in shoulder and arm pain and restless. 9/4/18 at 8:04 P.M. - On comfort measures for hospice care. 9/5/18 at 2:34 P.M. - Resident passed away. During interview on 10/10/18 at 7:20 A.M., the DON confirmed no investigations into the resident's falls on 5/21/18, 7/15/18 or 8/31/18. She identified the past DON as being in charge at the time of the falls and could not speak for the past DON as to why the investigations had not been completed. The DON confirmed fall investigations and incident reports had been completed in the past. She identified the resident's bedroom as in the back of the facility and one of the last rooms at the end of the hall. She stated the resident preferred a private pay larger room, and that was the location of those rooms. The DON stated if an anxious resident received a PRN [MEDICATION NAME] and was ineffective, she expected staff to then attempt 1:1 supervision, snack, toileting, assess for pain etc. She reported Resident #136 had not liked to be in her room alone and always wanted someone with her in her room. During interview on 10/10/18 at 7:30 A.M.- Staff D, CNA identified Resident #136 as always anxious and not able to ambulate steadily. She reported the resident hadn't liked to be alone. During interview on 10/10/18 at 8:30 A.M., Staff D Registered Nurse (RN), reported being on duty at the time of the resident's fall on 8/31/18. He described Resident #136 as routinely overly anxious and got worked up about being alone. He stated prior to the resident's fall on 8/31/18, she exhibited increased anxiety and confirmed he administered the resident a PRN of [MEDICATION NAME] at 6:29 P.M. Staff D confirmed the PRN [MEDICATION NAME] had been ineffective when he assessed the resident again on 8/31/18 at 7:13 P.M. and the resident continued to be anxious. Staff D stated in the past the staff would need to provide 1:1 attention to the resident if continued to be anxious, or her friends or family would sit with her. Staff D confirmed the resident's friends or family had not been in the facility at that time and stated the staff may not have provided 1:1 attention to the resident prior to finding her on the floor on 8/31/18 at 7:20 P.M., as that was a busy time of the evening and staff had been busy with other residents. During interview on 10/10/18 at 2:20 P.M., the DON stated she had not been aware if anyone had talked to the resident and/or her family in regards to moving her to a room closer to the nurses station due to her not liking to be alone and in order for staff to provide closer supervision. Observation on 10/10/18 at 2:40 P.M. revealed the resident's room had been approximately 46 paces from the nurses station in the back of the building. During interview on 10/11/18 at 8:25 A.M., the facility DON confirmed if Resident #136 received a PRN of [MEDICATION NAME], and it had been ineffective, staff needed to provide interventions such as 1:1 supervision etc.

Based on clinical record review, observation and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from hot coffee and harming self (Resident #4). The facility identified a census of 48 residents and the sample consisted of 4 residents. Findings include: 1. Resident #4 had a MDS (Minimum Data Set) assessment with a reference date of 5/24/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMs (Brief Interview for Mental Status) of 00. A score of 00 identified the resident as severely cognitively impaired. According to the MDS, the resident required extensive assistance with bed mobility, transfers, dressing and supervision with eating. The Care Plan dated 6/1/16, directed staff to place the resident at the assisted table. Assist and/or cue as needed. The Old End Hall Sheets identified pocket Care Plans dated 7/22/16. The pocket Care Plans identified no direction for hot liquids. Staff identified the hall sheets in effect prior to the incident. On 7/15/16, the pocket care plan were updated to direct no hot liquid and hot liquids must be cooled off prior to giving (to the resident). Review of the facsimile to the physician dated 7/12/16 revealed the resident spilled hot coffee to the stomach and groin area. Cold water applied immediately. The area bright red. The resident complained of pain and stated it had been tolerable. The new order included Silvadene (burn antibiotic cream) to the affected areas 2 times a day until healed. Review of the Skin Tear/Bruising/Abrasion/Rash Incident Report dated 7/12/16 at 4:00 PM, revealed resident spilt coffee on him in dining room cold water applied in shower room immediately. The interventions included cold water applied immediately with shower and cool residents hot liquids down with cool water. Review of the Weekly Assessment of Other Skin Conditions dated 7/12/16 revealed redness on the following areas: a. Abdomen 7 cm (centimeters) by 4 cm. b. Left thigh 2.7 cm by 2.5 cm. c. Right thigh 3.1 by 2.5 cm. On 7/14/16, the area on the left thigh identified a 2.4 cm by 4 cm reddened area with a small intact blister. No drainage and no signs or symptoms of infection. Review of the Nurse's Notes dated 7/12/16 at 4:00 PM revealed the resident spilled hot coffee to the groin/abdominal area. Staff immediately applied cold water per a shower. Areas of bright red, diminishing after the shower. The resident complained of pain that had been tolerable. The area to the stomach measured 7.0 cm by 4 cm. The area to the left inner thigh 2.7 cm by 2.5 cm and the area to the right inner thigh 3.1 cm by 2.5 cm. At 6:50 PM, the nurse received a new order for Silvadene (cream) to the affected areas 2 times a day until healed. Review of the Dietary Communication sheet dated 7/14/16, directed staff to please cool resident ' s hot liquids with cool liquid prior to giving to the resident. Review of the posted note (not dated) directed staff to do the following: a. When giving residents hot liquids it is VERY important to cool it down prior to serving it. b. As an intervention for the resident ' s coffee burns, he/she MUST ALWAYS have hot liquids cooled down. Observation on 7/15/16 at 1:00 PM indicated Staff B, CNA (certified nursing assistant) and Staff J, CNA transferred the resident from the wheel chair to the bed. Observation revealed no reddened areas to the abdomen or right thigh. The left inner thigh with 3 reddened lines approximately 2 cm in length and each line had an intact blister approximately 0.5 cm in size. During an interview with Staff D, Dietary Aid on 7/15/16 at 1:30 PM she stated that she served all of the residents that requested coffee for the noon meal. She further stated that she did not add anything or any cold water to any of the resident ' s coffee and had not been instructed to do so. During an interview with Staff B, CNA on 7/15/16 at 1:00 PM she stated that she had not been made aware of the incident and did not know of interventions to cool the hot liquids. During an interview with Staff J, CNA on 7/15/16 at 1:00 PM she stated that she had not been made aware of the incident and did not know of interventions to cool the hot liquids. During an interview with the Director of Nursing on 7/26/16 at 10:15 AM, she stated in her opinion it had been general knowledge to dilute coffee for all residents. The Care Plan did not direct staff to dilute hot liquids prior to the incident. Since the incident, notes are placed at the nurse ' s station and kitchen to direct staff to dilute the coffee with cool liquid before serving. The resident ' s Care Plan was updated to reflect addition of cool liquid. On 7/18/16, the manufacturer turned the temperature down on the coffee machine. The Director of Nursing stated she added additional notes for staff direction and provided staff instruction. The Director stated she performed a safety screen for all residents that requested coffee hot and determined it safe if not diluted. All other residents require diluted coffee. On 7/26/16 at 2:15 PM, Staff K (CNA) was interviewed and stated she gave the resident the coffee. The resident sat alone at the dining room table for a snack. Staff K stated she did not dilute the coffee. Staff K stated she saw the resident had spilled the coffee on his/her pants and the Administrator assisted her to take the resident to the shower room to cool the skin. Staff K identified she saw a little redness but saw no blisters. She had not been trained on certain rules for any resident ' s coffee. Staff K further stated she did not see any other staff dilute the resident ' s coffee. Staff K stated she did have the resident's Care Plan and it did not identify special precautions for hot liquids.

Based on observation, record review and staff interviews, the facility failed to plan for and direct nursing services to ensure each resident received adequate supervision from hazards for one of four residents reviewed. Staff interviews identified Resident #1 was known to detach the alarm clip from his/her clothing. On 4/22/14, staff found Resident #1 on the floor with the alarm clip detached from his/her clothing, and not sounding. The resident fractured his/her right tibia/fibula resulting in a hospitalization , pain and increased debility. The facility identified a census of fifty-five (55) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 2/24/14, assessed Resident #1 with short and long term memory impairments. The resident required two staff to assist with transfers, toileting and bed mobility. The resident did not ambulate. The resident used a wheelchair for mobility. A "balance during transitions and walking" test identified the resident as unsteady and only able to stabilize with staff assistance when moving from seated to standing position, moving on and off the toilet and surface to surface transfers. The resident was frequently incontinent of bowel and bladder. The resident had [DIAGNOSES REDACTED]. The resident did not have a history of falls. A fall risk assessment dated [DATE] assessed the resident with a score of "12". A score of 10 or above represented high risk. A pain evaluation dated 3/22/14 (before the incident) revealed the resident with a PAINAD (pain assessment in advanced dementia) score of "0" (no issues with pain). An incident/accident report dated 4/22/14 at 5:45 p.m. identified staff found the resident lying on the bathroom floor in the prone position. The resident complained of right leg and knee pain and a burning feeling in the right foot. A fall assessment form dated 4/22/14 at 5:45 p.m. revealed the resident stated he/she bent over in the wheelchair to pick something up from the floor and fell forward out of the wheelchair. The resident transported to the hospital for evaluation where the resident was diagnosed with [REDACTED]. An emergency room (ER) report dated 4/22/14 identified the resident with a closed fracture of the upper third of the fibula and tibia. The resident also suffered a contusion to the head and cervical spine. A hospital consultation dated 4/23/14 revealed the resident was nonambulatory and transferred from bed to chair. The resident fell out of the wheelchair sustaining an injury to the right lower extremity last evening. No one witnessed the fall. The resident transferred to the emergency room (ER) where they found a minimally displaced proximal tib-fib fracture and admitted the resident for further evaluation and treatment. X-rays showed advanced osteopenia which resulted in the resident not being a candidate for open reduction and internal fixation because the severe osteoporosis would not hold the hardware. The treatment for [REDACTED]. Nurse ' s notes identified the resident returned to the facility on [DATE] at 10:45 a.m. with orders to wear a brace to the right leg at all times. Staff could remove the brace for baths. The resident grimaced when staff moved the right leg. The resident returned with a new order for Norco (narcotic) for pain every 4 hours as needed for pain. A telephone order dated 4/29/14 bat 10:40 a.m., identified staff received an order to administer Norco three times a day routinely for pain control. A pain evaluation dated 4/24/14 (after the incident) revealed the resident with a PAINAD (pain assessment in advanced dementia) score of "6" (probable pain issues). On the fall assessment form dated 4/22/14 reviewed by the Director of Nursing (DON), staff was asked if the resident's chair, bed alarm had been used and was it functioning; and responded "yes". The changes made to the care plan noted an EZ lift with the assistance of two, and the alarm would be attached to the center of the shirt on the resident's back. On 5/21/14 at 1 p.m. the Director of Nursing stated the alarm functioned when staff checked it after the fall, but it did not function when the resident fell . Care Plan: A care plan, dated 3/5/14 identified the resident as at risk for falls related to weakness and requiring assistance with transfers. The care plan directed staff to ensure the resident had a magnetic release alarm (MRA) in place and functioning at all times. The care plan did not contain alterations in the plan of care since the resident was known to try and manipulate the alarm until after the fracture incident. An addendum dated 4/24/14 (after the fall/fracture incident) directed staff to hook the clip to the center of shirt on back when up. On 5/20/14 that intervention was discontinued and a new intervention dated 5/20/14 directed staff use an exit pad (sensor) alarm on the resident and functioning at all times. Staff Interviews: On 5/20/14 at 10:20 a.m. the Director of Nursing (DON) stated Staff K (nurse aide) found the resident on the floor. The round disc from the clip that attached to the magnetic alarm was on the floor. The DON stated she assumed the resident took the alarm clip off and fell . The alarm did not sound. Staff C (nurse aide) took the resident to the toilet one hour prior to the fall. The DON stated the resident was not known to manipulate the alarm in the past. The alarm box remained on the wheelchair handle with the magnetic piece still attached to the box. The blue clip that staff attached to the resident was off with the disc piece of the clip on the floor. The DON stated she asked staff if the resident removed his/her shirt and staff said no, the resident's shirt was on when they found him/her. Staff working when the incident occurred: On 5/20/14 at 1:50 p.m. Staff C (nurse aide) stated the day of the incident, he was in the process of getting residents up for supper. He got Staff K to assist him with a transfer when they heard yelling from the south hall. Staff K investigated and found the resident in the whirlpool room with the door shut. Staff C stated the resident wheels self around and used an alarm but Staff K found the disc portion of the alarm clip on the floor. Staff C stated he thinks the resident took the clip off. He stated the resident has removed the alarm before when he/she was in bed and when in the wheelchair. The resident pulls his/her clothing forward and then unfastens it. He stated he has reported this information to the nurse. He stated he took the resident to the toilet shortly before the fall and he had also just seen the resident wheeling around on the north hall when he and the DON ambulated a resident. After toileting the resident, he attached the box to the wheelchair handle and attached the blue clip to the resident's back low by the shoulder. On 5/20/14 at 10:25 a.m. Staff K (nurse aide) stated Staff C came and got him to assist with a transfer and heard the resident yell. He stated he found the resident in the whirlpool room with the door shut. He asked the resident how he/she got on the floor and the resident stated he/she dropped something and bent over to pick it up and tumbled out of the wheelchair. Staff C stated the resident may have unpinned the alarm clip because the disc/wheel portion of the clip laid on the floor. He stated the resident was known to do it. The resident must have pulled the clip around and popped the disc/wheel out of the blue clip. On 5/20/14 at 1:20 p.m., Staff K viewed the area where the incident occurred with the surveyor. Staff K reported the bathroom door was shut and the resident had been in the whirlpool room in Hall 37-46. Staff K reported the clip should be placed between the resident's clothes with it snapped to the wheel to hold it in place. When Staff K found the resident on the floor, the wheel portion of the clip laid on the floor. A document dated 4/23/14, noted Staff K reported he found Resident #1 in the whirlpool room the door shut. Staff K heard the resident yell as he got closer (to the room). The alarm was hanging on the chair and the disk was lying on the floor between the resident's legs. Staff K reported there was nothing else on the floor except the disk to the alarm. Staff K reported he stayed with the resident and Staff C was coming down the hall. On 5/20/14 at 1:27 p.m. Staff G (licensed practical nurse) stated she worked when the resident fell . She was passing medications when a nurse aide came and told her the resident was lying on his/her back on the floor in the whirlpool room. The resident kept saying his/her leg hurt. The resident told Staff G he/she tried to pick something up from the floor and fell . The only thing on the floor was the blue disc from the alarm clip. Staff G stated she thought the resident tried to take the clip off and the disc popped out so the resident tried to get it. Staff G stated she had not seen the resident manipulate the alarm in the past and no one told her they had seen it. On 5/20/14 at 2:05 p.m. Staff D (nurse aide) stated she was on break when the incident occurred She stated she had not seen the resident manipulate or remove the alarm. Other Staff On 5/20/14 at 11:55 a.m. Staff H (nurse aide) stated the resident would reach back and pull clothing around to remove the alarm clip or the resident would take his/her shirt off. Staff H stated staff usually got the resident's shirt back on before the resident could remove it. The resident also usually sat in a recliner in the lounge or in the wheelchair in the lounge so staff could watch the resident and intervene if they saw the resident manipulate the alarm clip. Staff H stated she didn't report the resident's actions to anyone. Staff H just took care of the problem when she saw it. On 5/20/14 at 11:50 a.m. Staff I (nurse aide) stated the resident removed the alarm clip before the incident. The resident would take his/her shirt off. The resident got the clip off before by reaching back or pulling the shirt forward and then taking it off. Staff I stated she reported the information to nurses. On 5/20/14 at 2:12 p.m. Staff E (nurse aide) stated the resident will try to take the alarm off in bed by moving clothing around to get to the alarm clip. She had not seen the resident actually remove the alarm. One time the resident tried to remove it when in the wheelchair. The resident moved his/her shirt forward to get the alarm clip but Staff E saw it and intervened. Staff E told the resident to leave the alarm clip on. Staff E stated she told the nurse on the occasions when she saw the resident try to remove the alarm. On 5/20/14 at 10:42 a.m. Staff J (registered nurse) stated about a year ago she saw the resident remove the alarm clip when he/she was in bed. She also saw her manipulate and try and get it and then, after the fact, seeing that the resident did take it off. She stated she thought management knew the resident did this because from time to time they replaced clips. The more worn the clip is, the easier it is to remove. She stated people have informed her the resident took the alarm clip off. Observation: On 5/20/14 at 12:55 p.m. observation showed the resident wheeling his/her wheelchair leaving the dining room At that time, the resident went to his/her room and two staff transferred the resident to bed via mechanical lift. The alarm clip was attached to the center of the resident's back just above the back of the wheelchair seat. The alarm activated when the magnet pulled away from the alarm box and the blue clip remained attached to the resident's shirt. Staff supported the resident's right leg during the transfer. Observation showed a brace on the right leg that extended from the upper thigh down to the ankle. The DON provided a staff meeting noted dated 4/29/14. The note documented the following: Resident #1's fall had been discussed and staff were educated on hooking up the alarms to the center of the back of the resident's shirt where the resident can't reach it; and keep the box out of the resident's reach. (The DON did not provide any other documentation prior to 4/22/14 of interventions or changes to Resident #1's services.) On 5/20/14 at 3 p.m., the surveyor reported to the DON and Administrator what staff stated during interviews about the resident attempting to and actually removing the alarm prior to the incident. After the discussion, the DON stated she would switch the blue clip alarm to an exit sensor pad on bed and wheelchair based on the knowledge that the resident removed the blue clip in the past. The DON stated the resident wears "slinky" material blouses so it would be easy for the resident to move his/her shirt around.