Every finding on record at Accura Healthcare of Marshalltown

Based on review of the nursing schedule, staff interviews, Payroll Based Journal Data Report, and facility policy review, the facility failed to provide a Registered Nurse (RN) in the facility for eight (8) consecutive hours per day for 19 days between December 1, 2025 - March 8, 2026. The facility reported a census of 59 residents. Findings include: Review of the facility's nursing schedules for December 2025 lacked RN coverage for the following dates: 6th, 7th, 20th, 21st, 25th, and 31st.Review of the facility's nursing schedules for January 2026 lacked RN coverage for the following dates: 1st, 3rd, 4th, 17th, 18th and 31st. Review of the facility's nursing schedules for February 2026 lacked RN coverage for the following dates: 1st, 12th, 14th, 15th, 24th, and 28th. Review of the facility's nursing schedules for March from the 1st through the 8th lacked RN coverage on the 1st. The Email communication on 3/9/26 at 2:53 PM, the Facility Administrator acknowledged the lack of consecutive 8-hour RN coverage and stated, they typically didn't have RN coverage every other weekend.Review of Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report for Quarter 1 2026 (October 1 - December 31) triggered no RN hours, indicating four or more days within the quarter with no RN hours. No RN hours infraction dates included 10/11/25, 10/12/25, 10/25/25, 10/26/25, 11/8/25, 11/9/25, 11/22/25, 11/23/25, 11/27/25, 12/6/25, 12/7/25, 12/20/25, 12/21/25, 12/25/25.Review of the facility provided Nursing Services and Sufficient Staff Policy, updated 2/23/25, stated except when waived, the facility must use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week.

Based on observations, interviews and record review, the facility failed to report a resident-to-resident altercation for 1 of 3 altercations reviewed (Resident #10 and Resident #43). The facility failed to report when Resident #43 yelled at Resident #10 that she better not go into his room again or Resident #43 would give Resident #10 something to cry about. The facility reported a census of 59 residents.Findings include: 1. Resident #10's Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) documented a score was 6 out of 15, which indicated severely impaired cognition. The MDS listed Resident #10 as independent for mobility in a manual wheelchair. The MDS included diagnoses of Alzheimer's disease and non-Alzheimer's dementia, pseudobulbar affect (a brain condition in which a person experiences sudden, intense, and uncontrollable episodes of laughter or crying that are disproportionate or unrelated to their actual feelings), anxiety and depression.A Progress Note written on 3/5/26, at 9:56 a.m., documented Resident #10 sat in a recliner at the nurses' station, when another resident approached her. The staff reported she told Resident #10 to stay the f*ck out of their room or they would give her something to cry about. When asked if anything happened that day, Resident #10 replied that man accused her of going into his locker, he's a liar. She added that woman across the hall from him is an instigator. When asked if she was okay, she responded no. The note described Resident #10's response as a typical day to day response. The staff saw Resident #10 shortly after the conversation resting peacefully in the recliner at the nurse's station. A Progress Note dated 3/5/26 at 6:14 p.m., documented the staff monitored Resident #10 for a room change, as she moved to CCDI (unit for residents with chronic confusion or dementia related conditions). The note reflected she had no behaviors or complaints about her room change.On 3/12/26 at 12:20 p.m., Staff A, MDS Nurse, stated she talked with Resident #10 after the altercation. She described as tearful but added this was normal for her. 2. Resident #43's MDS assessment dated [DATE], documented a BIMS score of 14 out of 15, which indicated intact cognitive functioning. The MDS listed Resident #43 as independent for mobility in a manual wheelchair. The MDS included diagnoses of stroke, depression, and hemiplegia (one sided paralysis).On 3/9/26 at 1:11 p.m., Resident #43 stated that his wheelchair (w/c) was gone last week. He explained the facility allowed another resident to come into his room and take his w/c. They brought it back. Resident #10's roommate saw Resident #10 come out of his room with his w/c. Resident #43 described himself as kind since he's been at the facility. When he came out, he saw Resident #10 in the dining room. He told Resident #10, if they ever went into his room again, he would give her something to cry about. Resident #43 stated Resident #10 cried all the time. The facility told Resident #43 that he was a direct threat to Resident #10, and sent him to the hospital for an evaluation. Resident #43 gave the hospital a urine sample and it came up negative. The hospital should not tell people they are going to stick a catheter in them if they can't give them a urine sample. The only reason they hauled me away was the facility thought he was threatening (toward Resident #10). They brought him back the next day. They moved Resident #10 to another room down the hall. On 3/10/26 at 12:40 p.m., the Social Services Designee (SSD) stated the resident across the hall from Resident #43 told him Resident #10 went into his room and took his w/c. The SSD didn't know if Resident #10 really took Resident #43's w/c. They said to talk to the Business Office Manager (BOM) about that, as the SSD took vacation the last week. A Health Service Progress Note dated 3/5/26 at 9:29 a.m., the nurse noted sitting in her office at the time when the BOM approached her stating staff observed Resident #43 yelling at another resident to stay the f*ck out of his room or he would them something to cry about. The BOM stated she tried to intervene and redirect Resident #43, when he began to yell at her as well. They asked Resident #43 to please leave the nurses station, away from the Resident #10 who sat in the recliner unable to move without staff assistance. Resident #43 proceeded to enter the dining room, and had a conversation with another resident. During the conversation, the nurse heard a resident make several similar comments to a separate resident about how he would take care of her so they didn't have to get themselves into trouble. He added what are they going to do if he took care of it, kick him out? The staff reported the events to the Director of Nursing (DON) and ED at this time.A Progress Note dated 3/5/26 at 10:05 a.m., documented the facility received a verbal order to send Resident #43 to the emergency room (ER) for a psychological evaluation for behaviors.A Progress Note dated 3/5/26 at 10:16 a.m., documented Resident #43 left the facility via ambulance with police present. Resident #43 didn't have behaviors during transfer.A Progress Note dated 3/5/26 at 5:50 p.m., documented the facility received a report to follow up with psychology (psych) and his Primary Care Provider, with no additional orders. His urinalysis and lab work returned within normal limits.The Health Status Note dated 3/5/26 at 6:47 p.m., indicated Resident #43 returned from the emergency room (ER) via an ambulance with no new orders, except to follow up with provider and psych in next 2-3 days.A Care Plan for Resident #43 revised 11/20/26, documented Resident #43 had a potential for behavior/altered coping related to documentation of manipulative behaviors exhibited by this resident, directed towards staff, other residents, and guests/family that belong to other residents. Staff were to assess contributing factors for behavior, administer medications as ordered, move this resident to a quiet area to deescalate behavior, and redirection as indicated. In an email response dated 3/10/26 at 1:36 p.m., when asked if the facility reported the incident, the Administrator responded they didn't report the incident. Immediately after the incident, they spoke with Resident #10, and she didn't exhibit mental anguish, nor could she recall the events of the alleged incident. The Administrator responded to the question about if the facility did an internal investigation by sending an undated and untitled attachment of the internal investigation.In an email stream dated 3/11/26 starting at 10:27 a.m. and ending 3/11/26 at 10:59 a.m., the Administrator wrote there is no truth to Resident #10 taking Resident #43's wheelchair out of his room. Another resident told Resident #43 that Resident #10 probably took his wheelchair out of his room. When told Resident #43 had said he woke up and needed to use the restroom and his w/c wasn't in the room. Was his w/c taken out of his room at any point without giving him another one in its place? The Administrator responded: No, as far as they know, he had his wheelchair in his room the entire time. Often times it's between the recliner and his bed and he doesn't catch it there.An undated and untitled internal investigation documentation included the following:On 3/25/26, at approximately 9:45 a.m., the BOM overheard Resident #43 telling Resident #10 to stay the f*ck out of his room or he would give her something to cry about. The staff interviewed Resident #10 and questioned about the incident that had transpired a few minutes prior. Resident #10 stated that man accused her of going into his locker, he's a liar. She added that woman across the hall from her is an instigator. When asked if she was doing okay, Resident #10 replied no. Resident #10 could not recall the incident or exhibited any mental anguish regarding it. Resident #10 had diagnoses of pseudobulbar affect, dementia, Alzheimer's disease, and auditory hallucinations. Resident #10's provider provided an order to admit her into the CCDI unit for her benefit on 3/5/26. The facility started Resident #10 on social services visits 1 time a week for 4 weeks. Resident #43 voluntarily transported to the ER for a psychiatric evaluation on 3/5/26. Resident #43 returned the same day with no new orders and a new diagnosis of adjustment disorder with depressed mood. Resident #43 claimed he had no intention of harming anyone and was upset at that time because he claimed his wheelchair was stolen by Resident #10. He added another resident advised him Resident #10 probably took it. Resident #10 was not able to independently ambulate safely and there are no reports of Resident #43's wheelchair being missing. The resident's wheelchair is consistently found in his room next to his recliner, where he self-transfers. On 3/11/26 at approximately 10:15 a.m., the Administrator and the Nurse Consultant stated they discussed the incident with others including their corporation. They decided not to report as Resident #10 appeared to not be affected by the incident. They stated the documentation regarding her response in the progress notes when Resident #10 had said no after being asked if she was okay following the incident, was her typical response due to her disease process. Resident #10's ability to understand/impaired cognition was talked about as well as what a reasonable person's response would be in this situation. On 3/12/26 at 12:15 p.m., The Administrator and the Nurse Consultant acknowledged understanding of the reporting concerns. A Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy updated on 10/19/22, directed all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The Dependent Adult Abuse is defined under Iowa law, pursuant to Iowa Code Ch. 235E as:a) Any of the following as a result of the willful misconduct or gross negligence or reckless acts or omissions of a caretaker, taking into account the totality of the circumstances:Reporting: 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. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.

Based on observations, interviews, and record review, the facility failed to actively assist and plan a discharge from the facility for 1 of 2 residents reviewed (Resident #43). Resident #43 admitted to the facility for skilled care after a stroke, he desired to discharge from the facility. The facility could not provide documentation regarding active discharge planning with Resident #43 from 12/19/25 to 3/10/26. The facility reported a census of 59 residents.Findings include:A MDS dated [DATE], documented that Resident #43's diagnoses included stroke, depression, and hemiplegia (one sided paralysis). Resident #43 had a BIMS score of 14 out of 15, which indicated intact cognitive functioning. Resident #43 was independent for mobility in a manual wheelchair. Resident #43 was independent for eating, oral hygiene, toileting, upper and lower body dressing, putting on taking off footwear and personal hygiene. He was independent for rolling left and right, sitting to lying and lying to sitting on the side of bed, sitting to stand, chair/bed to chair transfer and toilet transfer. Resident #43 required partial to moderate assist for showering/bathing and transfer into shower/bath. The MDS documented that active discharge planning was not being done. It documented that a referral had not been made to the Local Contact Agency (LCA) and it documented the reason for the was his discharge date was more than 3 months away. A MDS dated [DATE] (admission MDS), documented that Resident #43's overall goal was to discharge to the community. A Census page for Resident #43, documented that Resident #43 admitted to the facility for skilled care. It documented that on 9/9/25, Resident #4 discharged from skilled care and started nursing home level of care where he has remained.A Care Plan initiated on 8/8/25, directed staff that Resident #43's goal was to return home. It directed to assist him by contacting outside resources he may need for a successful return home and to provide him with ongoing education in diet, medications, and safe activities to return home. A Social Services Progress Note dated 11/21/25 at 2:57 p.m., included the following documentation. A meeting was set up with therapy, Resident #43, Resident #43's friend, his wife, the MDS Coordinator, the Therapy Director and the Social Services Designee (SSD). They explained to Resident #43 and his friend that they were working with him at the wheelchair level for now because he had too much pain with his hip to continue working on trying to walk. Resident #43 had an appointment to see a vascular doctor to see if he qualified for any type of surgeries. His friend stated that would change the plans for discharge as the apartment they had found for him had stairs and wouldn't be doable for Resident #43 anymore. Resident #43 and his wife asked if he would be able to get his social security payment directly given to him a month before discharge, so he would have money to help pay for a deposit or rent. The SSD explained that typically that doesn't happen as he has to pay his client participation with the facility. The SSD explained that there was a waiver program that can assist with financial steps. The staff explained she would set up a meeting to see if Resident #43 qualified, but stressed that waiver programs could usually take up to 6 months, sometimes a year. The SSD had a phone meeting the following Monday with Resident #43's Medicaid Case Manager to start the waiver program process. On 12/19/25 at 12:27 p.m., a Social Services progress note documented the SSD sent a referral to another facility per Resident #43's request as he was not happy with the current facility. The other facility declined due to behaviors. The SSD let Resident #43 know and asked if there was anywhere (else) he would like to be referred too. Resident #43 declined and stated that he doesn't want to leave the area and that he wanted to go to a smoking facility. The SSD asked if he would like to go to a Veterans home. Resident #43 declined and stated that it was too long of a process and he didn't know where his [NAME] discharge paper was. The writer explained that she could assist him with it, and Resident #43 declined, stating, it was a waste of time.On 3/9/26 at 1:09 p.m., Resident #43 stated he had plenty to say. He stated he had a stroke 7 months ago and was put into the facility. He lost his apartment. He can no longer use his right side. Resident #43 stated he was pretty much stuck at the facility. It seemed to him that the facility was not doing anything to help him get an apartment. Resident #43 stood up, transferred to his wheelchair and shut his door (as there was noise out in the hallway). Resident #43 stated he doesn't ask staff for anything other than assistance with his shower, or to help open up something as his right side was almost shot. He stated the SSD still had not got an application in for him. Resident #43 stated he had been asking the SSD about it for months. He stated the SSD was right next door. He has tried to go see her. He said he just wanted out of the facility. Resident #43 stated he wanted a handicap apartment. He was able to shower himself. They might come in once a week to help me clean up or something like that. He stated that he is a smoker. A Social Services Note dated 3/10/26 at 11:23 a.m., documented the SSD and Resident #43 called different apartment complexes in the area. The SSD got a hold of a rental for an apartment. They required an application fee, and Resident #43 wanted to talk to his friend (Emergency Contact) about the application fee and potential security deposit fee. The SSD was going to follow up with Resident #43 again regarding the application fee and go from there. A Social Services Progress Note dated 3/10/26 at 11:46 a.m., documented Resident #43 reached back out to his Medicaid Case Manager to see if there was any type of waiver program that he may qualify for that would help him get an apartment, and receive some financial assistance. Resident #43 didn't currently have the appropriate amount of funds for an application fee, security deposit, or first month's rent. Resident #43 didn't want to try the waiver program for a group home or a host home. The case Manager is going to try to research to see if there was any type of government assistance, or waiver program that may help. The (SSD) informed Resident #43 that they can take some time, and itis not a fast process if there is a waiver program that can help. On 3/10/26 at 12:34 p.m., the SSD stated Resident #43 didn't want to live in a group home and didn't want to wait for placement. Resident #43's Emergency Contact was working on taking Resident #43 to his Emergency Contact's house. That was a couple of months ago. Then the Emergency Contact kind of backed out. The SSD stated that Resident #43's former roommate along with the Emergency Contact were trying to find a place for him. The SSD stated there's nothing we can do for him. He doesn't have any money. His debit card was negative. He didn't want to wait the for the time it takes. He doesn't want to do the waivers. He doesn't want to wait a year. It takes a while. He only wants to live in the town he is in and he doesn't want a group home or a host home. He wants the facility to pay for him to move out and for the facility to pay him his social security. He's not willing to wait out the time. He had an apartment before he came but had to let it go because he can't walk up the stairs. There's income-based apartments. He refuses as he does not like the owner. His Case Manager said they would assist with waiver programs and the money follows the person. The SSD stated she and Resident #43 have spoken about the before. He ends up leaving because he gets very upset. He wants the facility to stop taking his client participation but the facility can't do that. He's not always nice to his Case Manager. He has called the SSD a retard. The SSD stated she reached out to his Case Manager. He doesn't want to be here. The SSD stated her hands were tied unless he wanted to cooperate. He doesn't understand why he has to pay to stay at the facility. He won't fill out the paperwork to be waitlisted. The facility called about an apartment. The apartment needed $20 for an application fee. Resident #43's Emergency Contact did not have the money and Resident #43's debit card had a negative balance. He doesn't know his email or his password to check into the transactions, so they hit a wall with that. On 3/11/26 at 9:01 a.m., Resident #43 stated he had a roommate that was trying to help him get out of the place. His roommate was discharged from the facility and lived in an apartment right now. He stated the problem was that he needed his birth certificate and he's been waiting for 2 months. He stated he was born right here (in the town that the facility is located) and it shouldn't be a big deal to get it. He explained the real problem as, they take his social security money $1300 every month to live at the facility. That is plenty of money to live on outside of the facility. He stated if the facility wouldn't take it all he would be able to move out. He said he has gotten frustrated when the topic comes up. The SSD was supposed to be filling out the paperwork for help with the deposit and with getting his birth certificate. He stated she went to him yesterday to talk with him about things. He said he'd just see how long the was going to take. It's like he just sits there waiting. Resident #43 stated the SSD is the one that worked at the facility and she didn't talk with him. He didn't know what all things are available or how to go about doing them. On 3/11/26 at 9:53 a.m., the Administrator and Nurse Consultant stated that there has been work done with Resident #43 regarding his discharge. They were working with him to get his birth certificate. He didn't want it emailed because it cost money. He is supposed to get $50 a month but only gets $9/month as it goes to alimony or child care. So it's difficult to get him in to an apartment when he doesn't have the money for a down payment, processing, etc. The Administrator and the Nurse Consultant would look for the documentation that showed the facility worked with Resident #43 to get him discharged . On 3/11/2026 11:21 a.m., the Administrator stated that they cannot find specific information. That they have had conversations with him, and the conversations can take an hour to an hour and half. Sometimes after the conversations, a person can be exhausted and forget to document. He stated Resident #43's Emergency Contact took over trying to find Resident #43's placement. The Emergency Contact let the facility know he could no longer assist Resident #43 with discharging because the Emergency Contact had a new job. The Administrator stated that the happened approximately 2 weeks ago and at that time the SSD took the responsibility back over. There is no documentation of the change. On 3/12/26 at 10:06 a.m., Resident #43's Emergency Contact stated he tried to help Resident #43 with finding housing somewhere but he wasn't able to find any handicap accessible. The Emergency Contact said that at the time he had a conversation with the facility and they were going to take over. He said that has been a couple of months ago. The Emergency Contact stated he thinks it's ridiculous that Resident #43 is still at the facility. Resident #43 was supposed to be discharged after a month after entering the facility but he is still there. The Emergency Contact stated he was glad the was being looked into as Resident #43 should be able to live on his own with some services provided. A Discharge Planning Process Policy dated 2/23/25, instructed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Definitions: Discharge planning is a process that generally begins on admission and involves identifying each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful discharge. The Compliance Guideline directed the facility would: a) The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge. b) The facility will determine the resident's expected goals and outcomes regarding discharge upon admission, routinely in accordance with the MDS assessment cycle, and as needed. i) Initial information and discharge goals will be included in the resident's baseline care plan. ii) Subsequent assessment information and discharge goals will be included in the resident's comprehensive plan of care. c) If discharge to community is determined to not be feasible, the facility will document in the clinical record who made the determination and why. d) In cases where the resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the interdisciplinary team will treat the situation similarly to refusal of care: i) Discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location. ii) Offer other, more suitable, options of locations that are equipped to meet the needs of the resident. Document any discussions related to the options presented. iii) Document refusals of other options that could meet the resident's needs. iv) At time of discharge, follow policies regarding discharges Against Medical Advice, and refer to Adult Protective Services (or other state entity charged with investigating abuse and neglect), as necessary. e) If discharge to community is a goal, an active discharge Care Plan will be implemented and will involve the interdisciplinary team, including the resident and/or resident representative. The plan shall be. f) An active individualized discharge care plan will address, at a minimum: i) Discharge destination, with assurances the destination meets the resident's health/safety needs and preferences. ii) Identified needs, such as medical, nursing, equipment, educational, or psychosocial needs. iii) Caregiver/support person availability and the resident's or caregiver's/support person's capacity and capability to perform required care. iv) Resident's goals of care and treatment preferences. g) The ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identify changes that require modification of the discharge plan, and updating of the discharge plan, as needed, to reflect the modifications. h) The facility will document any referrals to local contact agencies or other appropriate entities made for the purpose of the resident's interest in returning to the community. i) The facility will update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. j) The facility will assist residents and their resident representatives in choosing an appropriate post-acute care provider (i.e., another SNF, HHA, IRF, or LTCH) that will meet the resident's needs, goals, and preferences. i) The Social Services Director, or designee, shall compile available data on other post-acute care options to present to the resident, including, but not limited to: A) Data on providers within the resident's desired geographic area, where available. B) Quality measure data, based on standardized patient assessment data, publicly available on the CMS Care Compare website. C) Data on resource use to the extent the data is available, such as number of residents/patients are discharged to the community, and rates of potentially preventable hospital readmissions. ii) The facility will ensure that the data used is relevant and applicable to the resident's goals of care and treatment preferences. iii) The facility will comply with the Federal Anti-Kickback statute when making referrals to other provider types. iv) The facility will present provider information to the resident and resident representative, if applicable, in an accessible and understandable format, and will answer any questions to assist in the resident's/representative's understanding. k) The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record. l) The results of the evaluation and the final discharge plan will be discussed with the resident or resident's representative. All relevant information will be provided in a discharge summary to avoid unnecessary delays in the resident's discharge or transfer, and to assist the resident in adjustment to his or her new living environment. m) Education needs, as identified in the discharge plan, will be provided to the resident and/or family member prior to discharge.

Based on observations, interviews, and record review, the facility failed to provide ongoing restorative services for 1 of 1 resident reviewed (Resident #2). Resident #2 did not receive Passive Range of Motion (PROM) on a consistent basis, nor did he receive PROM per his plan of care directions. The facility reported a census of 59 residents.Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] at, documented a Brief Interview for Mental Status (BIMS) documented a score of 15, indicating intact cognition. The MDS listed Resident #2 as dependent on staff for toileting, lower body dressing, and putting on and taking off footwear. diagnoses for included non-traumatic spinal cord dysfunction, paraplegia, pressure ulcer injury, and depression. This resident had a pressure reducing device for his chair and his bed. It documented he had 0 days of PROM provided during the lookback period. A Care Plan initially dated 10/16/25, directed staff Resident #2 had an active restorative program. The goal listed He would participate with his restorative program. The Intervention directed PROM to bilateral lower extremities (BLE) as he tolerated 1-3 days a week. On 3/9/26 at 1:26 p.m., observed Resident #2 lying in bed. He stated he didn't get up in his electric wheelchair and/or his manual wheelchair because he can't bend his knees well. When asked if staff assisted him with range of motion on his legs, Resident #2 stated they used to but people get so busy with things, they put the staff on something else. A Plan of Care (POC) Response History printed 3/10/26 at 2:47 p.m. for the past 30 days, directed to document the number of minutes spent providing Range of Motion (passive). The task question reflected the number of PROM to his bilateral lower extremities (BLE) 1-3 days a week or as he allowed. In the past 30 days, documentation reflected he received PROM on 2/9/25, 2/12/25, 2/17/25, 2/19/25, and refused PROM on 2/26 at/25 at 1:59 p.m. There were no refusals documented since 2/26 at/25. A Progress note dated 2/26 at/26 at 7:16 p.m., documented Resident #2 went to the Emergency Room. Resident #2's Clinical Census reflected he went to the hospital on 2/26 at/26 at and returned on 3/2/26 at. On 3/11/26 at 9:16 a.m., Resident #2 stated that he hasn't had PROM done since his return from the hospital. He said Staff B, Restorative Aide, stopped in the day before and said she would start it up again. Resident #2 stated he didn't know when that would be. On 3/11/26 at 3:01 p.m., Staff B stated she worked at the facility for about 7 or 8 weeks. She stated she frequently got pulled to work the floor. She stated normally she would start ambulating residents who needed assistance and then she would do a group activity with anyone who wanted to participate. She added she got pulled to the floor that day. She explained she went in to work with Resident #2 that day. She just did PROM on his lower extremities. He gets very dry skin and so afterwards she put lotion on him. She stated that she had to be very careful with him because of his heels. He's pretty easy going. Staff B stated that she felt bad because of the frequency she can't get in there to do his PROM with him. Staff B stated they told her to do what she could and she didn't know how to prioritize. Staff B assisted the residents in the bathroom to transfer and she also assisted residents to dine. She stated she worked with another CNA that day on the hall where Resident #2 lived and they ran around all day. Staff B stated normally when she is at the facility, she is the 5th person. Staff B stated the residents still received the care, it's just not as quick as when they have 5 there compared to 4. After Resident #2 returned from the hospital he had diarrhea. She stated she went in there and the girls would clean him up, he would say he had diarrhea. So, she left a few times that happened last week. Staff B explained she went in the day before and he said he didn't have diarrhea anymore so she told him she would start with him that day. Staff B stated she just finished doing PROM with him.On 3/12/26 at 12:02 p.m., Resident #2 stated he had some diarrhea for a couple of days. He stated Staff B came in yesterday. Prior to going to the hospital, she would come in and work with him when she could. However, because she got pulled to the floor often and couldn't work on his lower extremities. He stated the exercises really helped him, as he felt better after having them done. On 3/12/26 at 12:20 PM Administrator and Nurse Consultant acknowledged concerns. A Restorative Program Process policy updated on 10/26/21, directed to ensure the resident(s) achieve and maintain their highest level of function. The licensed nurse will monitor staff and resident(s) to ensure compliance with the restorative nurse program.

Based on clinical record review, resident and staff interviews the facility failed to provide to the resident or their representative a summary of the baseline care plan for 1 out of 2 residents reviewed (Residents #2). The facility reported a census of 54 residents. Findings include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure), chronic kidney disease, type 2 diabetes mellitus, chronic respiratory failure and chronic obstructive pulmonary disease (COPD).The Clinical Census revealed Resident #2 was admitted on [DATE]. A facility form titled Baseline Resident Care Plan dated 8/22/25 lacked documentation a copy of the baseline care plan was given or reviewed with Resident #2 or the resident representative. The baseline care plan lacked Resident #2 and/or the resident representative signature and date.On 11/20/25 at 9:30 AM, the MDS Coordinator acknowledged the baseline care plan lacked Resident #2's signature. She said she went over the care plan with Resident #2 but failed to get his signature, so she did not have proof she did it. On 11/20/25 at 10:46 AM, the Administrator reported the facility did not have a baseline care plan policy as the facility follows the regulations. On 11/20/25 at 1:45 PM, Resident #2 reported he did not get a summary of his baseline care plan. He reported the staff did not review his care plan with him.

Based on clinical record review and staff interviews, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 3 resident reviewed (Resident #2) for Physician orders. The facility reported a census of 54 residents. Findings includes: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure), chronic kidney disease, type 2 diabetes mellitus, bacteremia (blood stream infection), chronic respiratory failure and chronic obstructive pulmonary disease (COPD).The Clinical Census revealed Resident #2 was admitted on [DATE] for a Medicare Part A stay.The August Medication Administration Record (MAR) directed staff to administer Daptomycin 830 mg (milligrams) (a powerful antibiotic used to treat serious infections caused by gram positive bacteria) intravenously (giving medication into a vein) one time a day for bacteremia until 9/26/25. The Hospital Outpatient Infusion Physician orders dated 8/21/25 directed to hold statin medications while on the Daptomycin medication.The Hospital Discharge summary dated [DATE] documented Atorvastatin medication (statin medication used to lower cholesterol and reduce risk for heart disease) 80 mg was stopped. The discharge summary documented the Magnesium Oxide (supplement) was changed to 400 mg per day. The Hospital Post Acute Discharge Report printed on 8/22/25 did not include directions on when to restart the Atorvastatin or whether to keep the medication discontinued after the Daptomycin medication was complete. In addition, the discharge report lacked physician orders or directions for the Magnesium Oxide medication.The Clinical Record lacked clarification orders on admission for the Magnesium Oxide and Atorvastatin medications.Review of Resident #2's MAR from 8/22/25 to 10/8/25 revealed the Magnesium Oxide medication was not administered and the Atorvastatin was not restarted after the Daptomycin was completed on 9/26/25. The Progress Note dated 10/8/25 revealed Resident #2 requested that the Magnesium Oxide 800 mg twice a day and Atorvastatin 80 mg every day be restarted as he had always taken the medications prior to admission. The Progress Note dated 10/9/25 documented the Primary Care Physician had reviewed lab levels from that morning and gave new orders to start Magnesium 800 mg BID and Atorvastatin 80 mg daily at bedtime. On 11/19/25 at 2:50 PM, Resident #2 reported he had high cholesterol and he had always taken Magnesium Oxide and Atorvastatin at home. He reported it took the staff 3-4 weeks to get the medication orders taken care of.On 11/20/25 at 2:00 PM, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged the facility received several documents from the hospital with conflicting information/orders regarding the Magnesium Oxide and Atorvastatin. The ADON and DON said they would expect the clarification orders to be obtained.On 11/20/25 at 2:21 PM, the Administrator reported the facility does not have a policy regarding Physician orders. He reported the facility follows the standard regulation and procedure of care.

Based on clinical record review, staff interviews, hospital nurse interview and resident interview, the facility failed to administer oxygen per Physician orders for 1 of 1 resident reviewed (Resident #2) for respiratory services. The facility reported a census of 54 residents. Findings Include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure), chronic kidney disease, type 2 diabetes mellitus, bacteremia (blood stream infection), chronic respiratory failure and chronic obstructive pulmonary disease (COPD).The Care Plan with a target date of 2/13/26 documented Resident #2 had a diagnosis of COPD and hypertension and required the use of oxygen at 2 liters per minute. The care plan directed staff to make sure Resident #2 had the oxygen on and that he was using it correctly.The Physician Order dated 8/22/25 directed staff to administer oxygen at 2 liters per nasal cannula (n/c). Review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) from August to November 2025 lacked documentation of the physician order for oxygen (O2) at 2 liters per n/c.Review of the O2 Sats (percent's of hemoglobin in your blood carrying oxygen) Summary from August to November 2025 revealed O2 Sats documented on room air on the following dates: 8/22, 8/27, 8/29, 9/1, 9/3, 9/6, 9/7, 9/8, 9/9, 9/11, 9/15, 9/17, 9/20, 9/26, 9/30, 10/7, 10/8, 10/12, 10/18, 10/22, 10/28, 10/30, 11/1, 11/4, 11/13, and 11/18.The Skilled Progress Note dated 9/8/25 at 4:02 PM documented Resident #2 had his PICC line (peripherally inserted central catheter) replaced at the Emergency Room. On 11/19/25 at 2:50 PM, Resident #2 reported he had gone to the hospital in [NAME] Center in the facility van to have his PICC line replaced. He reported the staff did not send any oxygen with him when he went to the hospital. He said the hospital nurse had to send oxygen with him back to the facility. He reported he was breathing ok when he was without the oxygen. He reported he did not have a portable oxygen tank on his wheelchair at that time. On 11/20/25 at 8:31 AM, Staff A, Licensed Practical Nurse (LPN) reported she was not sure if Resident #2 had his oxygen on or not when he went to get his PICC line replaced. She reported Resident #2 was with it enough that he would have told the staff he needed the oxygen. She said he was on continuous oxygen so it should have been sent with him.On 11/20/25 at 9:30 AM, the MDS Coordinator verified the oxygen order was not on the MAR or TAR. The Assistant Director of Nursing (ADON) reported she thought the staff hit the wrong button on the electronic charting and made a mistake when documenting the oxygen saturations on room air. On 11/20/25 at 9:43 AM, the Hospital Infusion Registered Nurse (RN) reported Resident #2 came to the hospital with no oxygen. She said Resident #2 was pleasant, alert and reported that he wore oxygen continuously. She reported Resident #2 said the facility forgot the oxygen as they were in a hurry to get to the hospital. She said Resident #2's oxygen saturation was 88% on room air and that she placed him on oxygen as it was a necessity. She said she sent Resident #2 with an oxygen tank to use to get him back to the facility. She reported she did not recall any dyspnea or problems breathing prior to applying the oxygen. On 11/20/25 at 10:46 AM, the Administrator reported the facility did not have a formal oxygen policy as the facility follows the regulations. On 11/20/25 at 1:30 PM, the MDS Coordinator and Quality Assurance (QA) Nurse reported they would expect staff to follow the physician orders for the oxygen administration and would expect staff to send portable oxygen to physician appointments.

Based on clinical record review, facility policy review, and staff interview, the facility failed to protect the resident's right to be free from physical abuse for 1 of 1 resident reviewed for abuse (Resident #1). As a Certified Nurse Aide (CNA) finished giving Resident #1 his bath, the CNA turned the water to cold and purposely sprayed him. Resident #1 became angry, grabbed the shower head and slapped it against the wall. The facility reported a census of 46 residents.Findings included:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. Resident #1 required substantial/maximal assistance with showering. The MDS included diagnoses of Alzheimer's, non-Alzheimer's dementia, and anxiety disorder.The facility's Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, updated 10/19/22, stated all residents had the right to be free from abuse. The policy defined abuse as physical injury or assault of a dependent adult. The policy defined assault as the commission of any act generally intended to cause pain or injury to a dependent adult, or which generally intended to result in physical contact considered by a reasonable person to be insulting or offensive or any act intended to place another in fear of immediate physical contact which would be painful, injurious, insulting, or offensive, coupled with the apparent ability to execute the act. The Care Plan Focus dated 9/14/20 reflected Resident #1 had an altered thought process/cognition related to Alzheimer's disease. The Intervention directed to reassure Resident #1 in order to decrease frustration.The Care Plan Focus initiated 3/22/23 identified Resident #1 had the potential to be physically aggressive and throw things at staff.The Care Plan Focus revised 7/27/23 indicated Resident #1 had confusion due to the diagnosis of early onset Alzheimer's and dementia. The Interventions directed staff to remind him as needed due to being forgetful.The Health Status Note dated 6/17/25 at 5:00 PM indicated a staff member reported around 11:45 AM another staff member stated, watch this, then proceeded to spray Resident #1 with cold water. Afterwards, Resident #1 grabbed the shower head and banged it against the wall.A report entitled OnShift Time documented Staff A, Certified Nurse Aide (CNA) worked on the following days after 6/9/25: 6/13/25, 6/14/25, and 6/15/25.An Employee Corrective Action Form, dated 6/17/25, documented 2 CNAs witnessed Staff A intentionally spray a resident with cold water. The form identified the action as a direct violation of the facility's policy and the facility terminated Staff A.On 10/8/25 at 11:01 AM, via phone, Staff B, CNA, reported on 6/9/25, as she trained with Staff C, CNA, they helped Staff A with Resident #1 in the shower. Staff B described him as noncombative during the time. Staff B stated Staff A stood on Resident #1's right side and she (Staff B) stood behind her. Staff B had a clear view of Staff A and Resident #1. She explained at the end of the shower, Staff A stated, watch this and turned the shower to cold then sprayed Resident #1. She stated she did this for 5 full seconds and laughed at the time. Staff B stated she sprayed it on Resident #1's upper body and then he took the showerhead, he smacked it against the wall and it almost broke. Staff B stated after this, Resident #1 stated he didn't want his shower because it was cold. On 10/8/25 at 11:44 AM, via phone, Staff C verified being in the shower room with Resident #1, Staff A, and Staff B. Staff C described Resident #1 as aggressive as she (Staff C) put away towels. She reported she heard Resident #1 yelling; she turned around and saw Staff A spray him with cold water. Staff C stated Staff B and her told Staff A not to do that because it was rude, but she continued doing it for 10-15 seconds. Staff C stated she sprayed him on his back. She stated Resident #1 yelled, screamed, and told her to stop, as Staff A laughed. Staff C stated she knew it was wrong but, at first didn't think about it being abuse.On 10/8/25 at 3:38 PM, the Director of Nursing (DON) stated staff should treat residents with respect, dignity and, carry out cares correctly. She stated Resident #1 didn't like showering. She stated if staff witnessed potential abuse, she wanted them to report it immediately. She reported it didn't happen in this situation. As she completed competencies with a new CNA (Staff B), she hesitated to tell her at first but then reported what happened with Staff A and Resident #1.On 10/9/25 at 8:49 PM, the Assistant Director of Nursing (ADON) described Resident #1 as not easy to assist with showers and he only liked certain staff. She stated she didn't have any problems with Staff A prior to the alleged incident and stated she did not think Staff B and Staff A would make this up. She stated it was probably really hard for Staff C to report what happened because of being Staff A's cousin.On 10/9/25 at 9:33 AM, the Administrator stated he expected staff to treat residents with dignity and respect. He added, staff should report suspected abuse immediately. He explained if staff reported abuse, he would suspend the alleged abuser, conduct a formal investigation, and report to the State Agency (SA) within 2 hours. He explained the situation with Resident #1; he reported it to the SA when he found out. He stated the witnesses didn't realize it was abuse but there should have been no question.On 10/13/25 at 10:00 AM, Staff A stated on the day in question, she had no problems assisting Resident #1 with his shower. She described him as not combative that day, but he could be on other days. Staff A stated she didn't spray him with cold water intentionally but stated she could have accidentally sprayed him while turning off the water. She reported placing the shower head on the hook and when she turned off the water, the dial would have gone to the cold side before shutting off. She stated at this point, water could have sprayed him. She stated Staff B was training so observed Resident #1's shower. Staff A stated she would never intentionally spray a resident.

Based on clinical record review, policy review, and staff interview, the facility failed to report an allegation of abuse in a timely manner for 1 of 1 resident reviewed for abuse (Resident #1). The facility reported a census of 46 residents. Findings included:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. Resident #1 required substantial/maximal assistance with showering. The MDS included diagnoses of Alzheimer's, non-Alzheimer's dementia, and anxiety disorder.The facility's Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, updated 10/19/22, directed the facility to report allegations of abuse to the State Agency (SA) within 2 hours. The Health Status Note dated 6/17/25 at 5:00 PM indicated a staff member reported around 11:45 AM another staff member stated, watch this, then proceeded to spray Resident #1 with cold water. Afterwards, Resident #1 grabbed the shower head and banged it against the wall.An Employee Corrective Action Form, dated 6/17/25, documented 2 CNAs witnessed Staff A intentionally spray a resident with cold water. The form identified the action as a direct violation of the facility's policy and the facility terminated Staff A.On 10/8/25 at 11:01 AM, via phone, Staff B, CNA, reported on 6/9/25, as she trained with Staff C, CNA, they helped Staff A with Resident #1 in the shower. Staff B described him as noncombative during the time. Staff B stated Staff A stood on Resident #1's right side and she (Staff B) stood behind her. Staff B had a clear view of Staff A and Resident #1. She explained at the end of the shower, Staff A stated, watch this and turned the shower to cold then sprayed Resident #1. She stated she did this for 5 full seconds and laughed at the time. Staff B stated she sprayed it on Resident #1's upper body and then he took the showerhead, he smacked it against the wall and it almost broke. Staff B stated after this, Resident #1 stated he didn't want his shower because it was cold. She stated she would have reported this in a timelier manner, but she was new and Staff C was present in the room as well. On 10/8/25 at 11:44 AM, via phone, Staff C verified being in the shower room with Resident #1, Staff A, and Staff B. Staff C reported she heard Resident #1 yelling; she turned around and saw Staff A spray him with cold water. Staff C stated Staff B and her told Staff A not to do that because it was rude, but she continued doing it for 10-15 seconds, spraying his back. She stated Resident #1 yelled, screamed, and told her to stop, as Staff A laughed. Staff C stated she didn't report it to anyone that day. She stated Staff B and her talked about it, they thought should bring it to someone else's attention. Staff C stated she knew it was wrong but, at first didn't think about it being abuse.On 10/8/25 at 3:38 PM, the Director of Nursing (DON) stated if staff witnessed potential abuse, she wanted them to report it immediately. She reported it didn't happen in this situation. As she completed competencies with a new CNA (Staff B), she hesitated to tell her at first but then reported what happened with Staff A and Resident #1.On 10/9/25 at 8:49 PM, the Assistant Director of Nursing (ADON) reported it was probably really hard for Staff C to report what happened because of being Staff A's cousin.On 10/9/25 at 9:33 AM, the Administrator expected staff to report suspected abuse immediately. He explained if staff reported abuse, he would suspend the alleged abuser, conduct a formal investigation, and report to the SA within 2 hours. He explained the situation with Resident #1; he reported it to the SA when he found out. He stated the witnesses didn't realize it was abuse but there should have been no question.The facility lacked documentation they reported the allegation to the State Agency within 2 hours of the 6/9/25 incident.

Based on clinical record review, policy review, and staff interview, the facility failed to investigate an allegation of abuse and separate an alleged perpetrator of abuse from residents in a timely manner for 1 of 1 resident reviewed for abuse (Resident #1). The facility reported a census of 46 residents.Findings included:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. Resident #1 required substantial/maximal assistance with showering. The MDS included diagnoses of Alzheimer's, non-Alzheimer's dementia, and anxiety disorder.The facility's Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, updated 10/19/22, instructed the facility to implement measures to prevent further potential abuse such as suspending the employee. The Health Status Note dated 6/17/25 at 5:00 PM indicated a staff member reported around 11:45 AM another staff member stated, watch this, then proceeded to spray Resident #1 with cold water. Afterwards, Resident #1 grabbed the shower head and banged it against the wall.A report entitled OnShift Time documented Staff A, Certified Nurse Aide (CNA), worked on the following days after 6/9/25: 6/13/25, 6/14/25, and 6/15/25.An Employee Corrective Action Form, dated 6/17/25, documented 2 CNAs witnessed Staff A intentionally spray a resident with cold water. The form identified the action as a direct violation of the facility's policy and the facility terminated Staff A.On 10/8/25 at 11:01 AM, via phone, Staff B, CNA, stated she would have reported the incident sooner, but she was new and Staff C was present in the room as well. On 10/8/25 at 11:44 AM, via phone, Staff C verified being in the shower room with Resident #1, Staff A, and Staff B. Staff C described Resident #1 as aggressive as she (Staff C) put away towels. She reported she heard Resident #1 yelling; she turned around and saw Staff A spray him with cold water. Staff C stated Staff B and her told Staff A not to do that because it was rude, but she continued spraying his back for 10-15 seconds. She stated Resident #1 yelled, screamed, and told her to stop, as Staff A laughed.On 10/9/25 at 9:33 AM, the Administrator explained if staff reported abuse, he would suspend the alleged abuser, conduct a formal investigation, and report to the State Agency (SA) within 2 hours. He explained the situation with Resident #1; he reported it to the SA when he found out. He stated the witnesses didn't realize it was abuse but there should have been no question.The facility lacked documentation they separated Staff A from other residents and completed an investigation prior to 6/17/25.

Based on clinical record review, policy review, and staff interviews, the facility failed to store and/or handle controlled medications in accordance with professional standards to ensure medications were secure for 1 of 3 residents reviewed for the storage of controlled substances (Resident #2). The facility reported a census of 46 residents.Findings:Resident #2's Minimum Data Set (MDS) assessment, dated 6/5/25, identified a Brief Interview for Mental Status (BIMS) score as 14, indicating intact cognition. The MDS included diagnoses of anxiety disorder, schizophrenia, and hallucinations.The facility policy Controlled Substances updated 10/19/22, directed when a nurse received a controlled medication, the nurse needed to fill out the top of the controlled drug administration record including the first line on the section that counted the medications. They did this to indicate who signed in the medication from the pharmacy.Resident #2's August Medication Administration Record (MAR) listed an order dated 7/14/25 for lorazepam (used to treat anxiety) 0.5 milligrams (mg) twice daily for anxiety. A Packing Slip, dated 8/22/25, listed lorazepam 0.5 mg, quantity of 60, signed by Staff D, Licensed Practical Nurse (LPN). Above the signature, the document stated, by signing below, you acknowledge that the items above have been received.On 10/8/25 at 4:11 PM, Staff F, Registered Nurse (RN), stated on 8/23/25, she reordered Resident #2's lorazepam because they only had around 2 pills remaining. She stated the pharmacy faxed back they sent an entire card the day before. Staff F stated they searched every drawer of every cart but couldn't locate the medication. She stated when she checked in narcotics, she put them directly into the cart and filled out a sheet of paper with the medication quantity.On 10/8/25 at 4:21 PM, Staff E, LPN, stated (on 8/22/25), when she arrived for her shift, she received report from the Assistant Director of Nursing (ADON). About 10 minutes later, Staff D gave her 2 of Resident #2's medications, none of them narcotics. She placed the medications in the medication cart. She didn't receive any narcotic sheets.On 10/9/25 at 8:29 AM, Staff D stated the night in question, she checked in all of the medications individually, then gave Resident #2's medications to the ADON because she thought he moved to her hall. The ADON gave the medications to Staff E, who was actually Resident #2's nurse. She stated the next day, she got a call from the morning nurse who said they didn't have the medication there and the pharmacy said they delivered it the night before. Staff D stated they didn't have documentation she gave the medication to the ADON. She stated since the incident, if they hand medications to another nurse, they sign at that time.On 10/9/25 at 8:49 AM, the ADON stated Staff D accidentally gave her medications for the other hall. She gave them back to Staff D, then Staff E placed the medications in the correct cart. She reported the medications as Resident #2's clozapine (a sedative, not a controlled substance) and she didn't think Resident #2's lorazepam came in the pharmacy delivery.On 10/9/25 at 9:57 AM, the Director of Nursing (DON) stated she didn't know for sure what happened with the missing medication. She added that possibly the nurse was just nervous and accidentally checked the medication in. She stated after they checked in narcotics, they should place them in the locked box themselves. She stated after the incident, they now have 2 nurses sign in to receive narcotics.

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facilities past surveys, and staff interview, the facility failed to correct their own deficiencies for 3 of 15 areas of concern. The facility reported a census of 56 residents. Findings include: The facility QAPI Plan dated 5/23/23 documented the purpose as to identify and correct quality deficiencies as well as opportunities for improvement in the lives of nursing home residents with a systematic approach. To do this, all employees will participate in ongoing QAPI efforts which support our mission. Principals of the QAPI system included, in summary: a. The outcome of QAPI is for resident quality of care and quality of life. b. Support performance improvement by encouraging our employees to support each other and be accountable for their own professional performance and practice c. Focus on systems and processes, emphasis to identify system gaps d. Make decisions based on data includes input and experiences of others e. Identify root causes of concerns, to monitor and evaluate activities f. To ensure timely services, clinically sound and based on current practices and technology g. Ensure resident confidentiality, services are compliant with regulations h. To establish a culture in which care partners are held accountable for their performance and do not fear retaliation for reporting quality concerns. The survey identified the following concerns cited previously in the past year at the facility: a. Dignity b. Infection Control c. Food Procurement Store/Prepare/Serve/Sanitation On 4/23/25 at 9:00 AM, the Administrator acknowledged the concerns with the repeated deficiencies and had a correction plan in place in regards to dignity however discovered the Staff A, previous Director of Nursing (DON), didn't follow through on audits as directed. Staff A no longer worked for the company. The Administrator acknowledged QAPI concerns with the repeated concerns reviewed included infection control and kitchen process.

Based on record review, resident interviews, staff interviews and policy review, the facility failed to be respectful and ensure residents' dignity for 5 of 21 residents reviewed (Residents #9, #13, #18, #22, and #28). The facility reported a census of 56 residents. Findings include: 1. Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. During an interview on 4/21/25 at 12:38 PM, Resident #9's reported Staff A, the previous Director of Nursing (DON), persisted and argued with her when she didn't want to take a shower. Resident #9's stated Staff A called another provider to convince her to shower and the provider didn't side with Staff A. 2. Resident #13's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. During an interview on 4/23/25 at 5:40 PM, Resident #13 recalled Staff A argued while at the nurse's station and told Resident #13 to go to their room. 3. Resident #18's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 14, indicating intact cognition. During an interview on 4/22/25 at 3:18 PM, Resident #18 explained they felt Staff A took advantage when a person felt down and weak. Resident #18 recalled Staff A worked many nights and described her as demanding. For instance, Resident #18 stated the staff directed them to get up and go to the toilet at night. When they responded no repeatedly, Staff A would not listen, she argued and had a superior attitude. 4. Resident #22's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. During an interview on 4/22/25 at 5:02 PM, Resident #22's explained Staff A said bluntly they were eating themselves to death and they wouldn't last long, with a family member present. Resident #22 reported they both got upset. Resident #22 reported Staff A would say, you know you could do it (referred to prolonged standing), even though they couldn't. Resident #22 reported they had poor communication, but they didn't need things sugarcoated. The staff didn't need to treat them rudely either. 5. Resident #28's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. During an interview on 4/21/25 at 12:35 PM, Resident #28's described the last DON as terrible. They talked down to the staff and would argue. Resident #28's recalled Staff A wanted their roommate to take a shower and they had a bandage that was not supposed to get wet. Staff A yelled they knew what they were doing. Resident #28 reported they heard Staff A tell residents to go to their room. During an interview on 4/21/25 2:43 PM, Staff P, Social Services, explained many didn't like Staff A due to her sergeant style of management. During an interview on 4/24/25 at 9:00 AM, the Administrator, explained they worked on the plan of correction which included staff education and audits regarding dignity. The Administrator indicated Staff A didn't comply with audits and continued to demonstrate dignity concerns. A Facility document titled, Self-Report outlined the allegations that occurred on 2/25/25, including investigative attachments. The report reflected the facility notified the Administrator that Staff A told Resident #22 he would eat himself to death and his family member witnessed the comment. Resident #22's reported Staff A talked to him as if he was a child. Following the allegations, the Administrator interviewed residents with intact cognition. The investigation indicated Resident #13 recalled Staff A yelled and directed them to go to her room. In addition, Resident #13 reported Staff A treated her family member on the phone rude. Resident #13's family submitted a concern to the Administrator. They reported Staff A repeated phrases and talked down them as if they were a child. The interview with Resident #28's identified Staff A wanted to argue all the time. They recalled Staff A yelled and asked, if they said Staff A was a liar. Resident #9 reported they heard Staff A say rude things to residents in the past but couldn't think of specifics. Resident #18 reported they felt Staff A didn't like her and treated her mean. The facility investigation attachments dated 2/26/25 documented the investigation revealed multiple complaints about Staff A regarding inappropriate and unprofessional conduct. The continued reports of inappropriate behavior demonstrated an unacceptable pattern of conduct that didn't align with the expectations of leadership in the facility. The paperwork reflected the facility terminated Staff A on 2/26/25. The facility Compliance policy, Employee Standards and Code of Conduct revised 9/1/23 directed the facility to make every effort to create and maintain a positive work environment, with the expectation to remain professional and respectful to one another with refraining from unbecoming behavior.

Based on clinical record review, Facility Assessment, Payroll Based Journal (PBJ) data, staff and resident interviews, the facility failed to provide enough staff to care for residents in a timely manner for 5 of 17 residents reviewed (Residents #13, #30, #34, #28, and #162). The facility reported a census of 56 residents. Findings include: 1. Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. On 4/21/25 at 2:45 PM, Resident #13's reported it can take staff 30 minutes up to an hour to answer her call light. She reported the second shift took the longest to answer her call lights. She added she used the clock on the wall to know the length of time. 2. Resident #30's Minimum Data Set (MDS) assessment dated [DATE] with Brief Interview for Mental Status score of 12 indicated moderate cognitive impairment. On 4/21/25 at 3:48 PM Resident #30 reported he liked to stay up late at night and some of the night staff try to get him to go to bed. He explained at night he could push his call light for staff to change him and it can take an hour before they show up. 3. Resident #34's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. On 4/22/25 at 8:39 AM, Resident #34's reported she had her call light on for at least an hour that morning before the staff answered it. She said she watched the call light times with the clock on the wall. She reported the day shift had the worse call light response times and thought the other shifts had their acts more together. She reported a time in the last 6 months that she had call light on for over 2 hours. 4. Resident #28's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. On 4/21/25 at 12:58 PM, Resident #28's reported his spouse needed assistance getting up and has waited a half hour at times up to an hour especially in the morning. Resident #28's voiced, staff say they are busy with getting showers done so they have to wait to get out of bed. Sometimes they bring the breakfast tray and she still didn't have anyone help her out of bed to eat. 5. Resident #162's Minimum Data Set (MDS) assessment dated [DATE] listed her admitted as 4/15/25 from the hospital. The assessment didn't have a BIMS score. On 4/21/25 at 11:54 AM, Resident #162's reported over the weekend, they were short staff. They thought it because it was a weekend and the Easter holiday. The staff said to give them 20 minutes and they would see if they could find someone to help them, but they didn't come back. A Grievance form dated 1/16/25 initiated by Resident #13's family documented call lights on 1/16/25 in the morning took a long time to answer and they didn't have their linens changed. The PBJ Fiscal Year (FY) Quarter 1 2025 (October 1-December 31) data reflected excessively low weekend staffing. The Daily Staff Posting dated reflected staff to include, on 4/20/25 the night shift included 1 Licensed Practical Nurse (LPN), and 2 Certified Nurse Aides (CNA's). The days shift included 1 Registered Nurse (RN), 1 LPN, 1 Certified Medication Aide (CMA) and lacked the number of CNAs. The evening shift included 3 LPNs and 5 CNAs with the census of 56. The Daily Staff Posting dated 4/22/25, listed the night shift had 1 LPN and 2 CNAs. The day shift listed 2 RN, 1 LPN and 5 CNAs. The evening shift included 1 LPN, 2 CMAs, and 4 CNAs with the census of 56 residents. The Daily staff Posting dated 4/23/25, listed the night shift had 1 LPN and 3 CNAs. The day shift listed 2 LPNs, 1 CMA, and 5 CNAs. The evening shift showed 2 LPNs, 1 CMA, and 4 CNAs with the census of 56 residents. The Daily Staff Posting dated 4/24/25, included the night shift had 1 LPN and 2 CNAs. The day shift had 2 LPNs, 1 CMA, and 5 CNAs. The evening shift had 1 LPN, 2 CMAs and 5 CNAs for the census of 56 residents. The Facility assessment dated [DATE], directed the facility needed the following staff per shift (adjust as needed): a. Night Shift included: i. RN: 1 full time employee to 53 residents ii. LPN/Licensed Vocational Nurse (LVN): 1 full time employee to 53 residents iii. CNA 4 full time employees to 53residents. b. Day Shift included: i. RN: 2 full time employees to 53 residents ii. LPN/LVN 1 full time employee to 53 residents iii. CNA 7 full time employees to53 residents iv. Med Tech 1 full time employees to 53 residents. c. Evening shift included: i. RN 1 full time employee to 53 residents ii. LPN/LVN 1full time employee to 53 residents iii. CNA 5 full time employees to 53 residents iv. Med Tech 1 full time employees to 53 residents During an interview on 4/24/25 at 9:46 AM, the Administrator reported they knew about the facility's staffing concerns and stated they needed to amend the Facility Assessment. 46513

Based on observations, staff interviews and policy review, the facility failed to label food and drinks with dates after opening, discard product after recommended date, ensure a male staff member wore a beard net, and failed to prepare and serve food under sanitary conditions to reduce the risk of contamination and food borne illness. The facility identified a census of 56 residents. Findings include: 1. An initial kitchen tour conducted on 4/21/25 at 9:45 AM, revealed the following items stored in the refrigerator ready for service: a. 1-quart tomato juice - open/not dated b. 1-quart silk soy milk - open/not dated c. 1-quart grape juice - open/not dated d. Container of open apricots - dated 4/13/25 e. Container of open ham salad - dated 4/13/25 f. Container of open mixed berries - dated 4/17/25 2. The kitchen's milk cooler revealed the following stored items: a. 1-gallon white milk - open/not dated b. 1-gallon chocolate mile - open/not dated c. 1-gallon orange juice - open/not dated On 4/21/25 during the initial kitchen tour, observed Staff I, Dietary Aide, with a beard and not wearing a beard net. Staff I said he didn't know if the facility had beard coverings and he hadn't worn one. He reported he worked at the facility for a couple of months. During the initial kitchen tour, observed Staff J, Cook, prepare sandwiches. Staff J wore blue colored gloves while making the peanut butter and jelly sandwiches. Staff J touched multiple items with her gloved hands while making the sandwiches which included the bread, knife, peanut butter jar, and jelly container. After spreading the peanut butter on the bread and squeezing jelly from the container, Staff J put the two pieces of bread together and put the sandwich in plastic baggies while continuing to wear the same gloves. On 4/21/25 during the initial kitchen tour, Staff J reported she thought food items remained good for 3 days after opening. She reported the staff should have discarded the apricots, ham salad, and mixed berries. On 4/21/25 at 10:15 AM, the CDM (Certified Dietary Manager) reported she expected the staff to label and date food items after opening. She reported after opening food items they should be discarded between 3 7 days depending on the type of food items. She verified they should have discarded the apricots; ham salad, and mixed berries after 3 days. The CDM reported she expected the male dietary aide to cover their beard and reported the kitchen had beard nets for him to use. On 4/23/25 at 11:30 AM, observed Staff K, Cook, wear gloves while serving lunch. She touched multiple surfaces with her gloves including the utensils, menus, and plates. While wearing the same gloves, Staff K took a cheese sandwich out of a plastic container and put the sandwich on the grill. After Staff K put the sandwich on the grill, she removed her gloves, washed her hands, and applied new gloves to continue to serve the food. A second time, Staff K went to make a grilled cheese sandwich, she removed her gloves, without hand hygiene she put on a new pair of gloves and took the cheese sandwich from the plastic container and put it on the grill. In addition, observed Staff L, Cook, on 2 occasions put on a pair of gloves without completing hand hygiene, use a spatula and her gloved finger to slide the peanut butter bars off the spatula on to the plates. On 4/23/25 at 12:15 PM, the CDM reported she expected the staff to use gloves for one task and change the gloves to prevent cross contamination. A facility policy titled Food Storage dated 2021 documented all foods should be covered, labeled, dated, and routinely monitored to assure consumption of foods (including leftovers) occur by their safe to use by dates, or frozen (where applicable), or discarded. A facility policy titled Food Safety and Sanitation dated 2021 required staff to wear beard nets with visible facial hair. A facility policy titled Bare Hand Contact with Food and Use of Plastic Gloves dated 2021 considered gloved hands a food contact surface that can become contaminated or soiled. If used, only use single use gloves for one task, for no other purpose, discard when damaged or soiled or when interruptions occur in the operation. The policy instructed to wash hands after removing gloves.

Based on clinical record review, staff interview and facility policy review the facility failed to supervise one out of two residents reviewed for elopement (Resident #161). The facility reported a census of 56 residents. Findings Included: Resident #161's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #161 walked independently with cane. The MDS included diagnoses of Alzheimer's dementia and heart failure. The Care Plan Focus dated 3/10/25, identified Resident #161's confusion related to Alzheimer's. The Interventions directed the following: a. Directed to monitor Resident #161's behavior, redirect him as needed (PRN). b. Remind him as needed as he forgets. The Care Area Assessment (CAA) dated 3/21/25, reflected Resident #161 admitted to the facility from home as the family could no longer care for him safely due to his diagnosis of Alzheimer's Dementia. He wandered and needed supervision to keep him safe. The CAA listed him as independent with all of his cares with the exception of bathing. He's ambulatory (able to walk) and walked freely around the facility. He is pleasant and cooperative with all of his cares, is alert, and oriented to self and family. Resident #161's Elopement assessment dated [DATE], reflected he had a moderate risk for elopement with a score of 2. The assessment listed Resident #161 as a new admission and he voiced being happy to be at the facility. He denied wanting to leave. Will monitor due to diagnoses of Alzheimer's, but the assessment reflected Resident #161 didn't have a risk for elopement at that time. The Health Status Note dated 3/15/25 at 8:46 AM written by Staff Q, Assistant Director of Nursing (ADON), identified Resident #161 as missing. Staff E, Licensed Practical Nurse (LPN), reported Resident #161 headed towards the dining room at approximately 7:55 AM, but when she went to the dining room she failed to see him in there. She immediately initiated a head count and 2 staff went outside to check parameters. The staff extended the search to the neighborhood. As Staff E went to call 911, Staff B, Certified Nurse's Aide (CNA), reported they found him. The staff found Resident #161 at approximately 8:05 AM. Resident #161 returned to the building at 8:13 AM. The facility notified the family and started frequent checks. The staff completed a head to toe assessment without no injuries observed. The nurse placed a wander guard to his right ankle. On 4/22/25 at 1:15 PM, Staff D, LPN, reported when Staff G, CNA, heard the door alarm she went to look why the door sounded. Resident #161 walked about 6 blocks away from the facility before staff found him and got him back to the facility. On 4/22/25 at 4:18 PM, Staff E, said she worked the medication cart on 3/15/25. She said she saw Resident #161 up the hall as he walked by she thought he went to breakfast in the dining room. She reported she continued doing her medication pass when she heard the front door alarm go off. She asked the Staff G to check the front door alarm. She reported Staff G said they didn't see anyone at the door or outside, and she failed to know why the alarm went off. She reported she went to the DR and looked for Resident #161, but she failed to see him. Staff E reported she walked down to Resident #161's room to make sure he didn't walk back there, but she failed to see him. Staff E reported she left the building to look around the front door area and didn't see Resident #161. She stated she alerted the staff to complete a head count of the residents and directed 2 staff members to go outside and search the neighborhood. Staff B called and reported she found him and they were on the way back to the facility. Staff E described Resident #161 as absent from the facility for around 15 minutes she thought. Staff E, confirmed Staff G turned off the door alarm and failed to go outside to look for reason the alarm sounded. On 4/23/25 at 11:30 AM, Staff Q reported Staff E called her when Resident #161 left the facility. Staff Q reported she was on her way to the facility and when she got there, Resident #161 already arrived back at the building. She said Staff E told Staff G to check the alarm. Staff G turned off the alarm, looked outside, but failed to see anyone. Staff Q revealed Staff G told the nurse she turned off the alarm and failed to see anyone. Staff Q reported Staff E said she went to the dining room (DR) to see if she could find Resident #161 because he'd walked towards the DR before the front door alarm sounded. Staff E told Staff Q, they didn't see Resident #161 in the DR, so she initiated the Missing Resident Protocol. Staff Q reported she directed Staff E to call the family and the policy, but staff brought him back just then and reported they found Resident #161 a few blocks away. On 4/23/25 at 9:58 AM, Staff G reported that on 3/15/25, she worked the 100-medication cart. She stated she went by the nursing station and Staff E told her to go check the front door alarm. Staff G said she went to front to door looked outside, walked around inside the dining room (DR) and she said she shut off the alarm. She reported she told Staff E she looked in the DR, looked out the door and failed to see anyone so she turned off the alarm. She reported about 5 minutes later Staff E sent Staff B and Staff D outside to look for him. Staff E told her she knew it was him because she saw him walk to the DR and when she went to the DR, she didn't see him there. Staff E reported she failed to go outside and look around for him after the door alarm sounded to see why the door alarm sounded. On 4/23/25 at 6:06 PM, Staff B stated she saw Staff E outside the front windows, she walked back and forth in front of the building. She told her Resident #161 left the facility and she needed to go look for him. Staff B reported she took off out of the building and called her son who lived in the neighborhood to help her look for the man. She reported they found him on 6th street and [NAME]. She reported they got Resident #161 in the car and brought him back to the building. On 4/21/25 at 1:19 PM the Administrator reported they had a resident with a BIMS of 13 leave the facility to see his brother a few blocks away, he came back so they didn't need to report it. On 4/24/25 at 2:25 PM, the Administrator provided the facility provided education to the staff after Resident # 161 left the facility it directed the staff to check for the reason the door alarm sounded and immediately tell the charge nurse and staff will conduct a head count. The facility provided a document that listed 6 wandering residents dated 12/26/24 through 3/26/25. The facility provided a policy titled Missing Resident/Elopement Process updated 10/29/2024, directed when a door alarm sounds the facility staff shall: a. Check the alarm panel to determine which door has been opened. Do not assume someone else has already done this. b. Check the exit door for any existing resident by means of a visual check. Visual check means observing the area around the exit and may require leaving the building. c. If a resident is discovered outside the facility inappropriately, staff will assist them back into the facility. d. Reset the door alarm after it is determined by visual check that no resident has exited the facility inappropriately or is returned to the facility. e. If for any reason, door alarms are turned off, the staff will continually visually monitor the door/doors. Ensure all residents are accounted for. f. If an alarm is discovered de activated, staff will perform an immediate head count to g. The nurse, Director of Nursing, or Executive Director will question staff to determine who de-activated the door alarm and reason for doing so.

Based on clinical record review, observations, staff interviews, and facility policy review the facility failed to maintain catheter tubing off the floor for 4 out of 4 days reviewed for one out of two residents reviewed (Resident #12). The facility reported a census of 56 residents. Findings include: Resident #12's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #12 required staff assistance of 1 with toileting hygiene and 2 staff with transferring. The MDS included diagnoses of neurogenic bladder (problems with the bladder as the nerves don't function properly), and diabetes mellitus (DM). The Care Plan Focus dated 8/21/23, identified Resident #12's used an indwelling urinary catheter due to wound healing. The Goal reflected she wouldn't develop a urinary tract infection(UTI). Resident #12's Urine culture dated 3/24/25, revealed greater than (>) 100,000 colony forming unit (CFU) per milliliter (ml) of Escherichia coli ESBL (extended spectrum beta lactamase) (happens when bacteria enters the urethra from another source) and 50,000 to 100,000 CFU per ml of pseudomonas aeruginosa (a type of UTI that occurs with catheters). Resident #12's March 2025 Medication Administration Record (MAR) listed an order for Levofloxacin (antibiotic) oral tablet. The order directed to give 500 milligrams (mg) by mouth one time a day for UTI until 3/31/25. On 4/21/25 at 12:36 PM, saw Resident # 12 sat in her wheelchair (w/c) in the dining room with 6 inches of the urinary catheter tubing sat on the floor under her w/c. On 4/21/25 at 1:54 PM, observed Resident #12 sitting at the nurses' station in her w/c, with 6 inches of the catheter tubing sitting on the floor under her w/c. On 4/22/25 at 5:39 PM witnessed 7 inches of Resident #12's catheter tubing drag across the floor as she wheeled herself up the hall. On 4/23/25 at 8:08 AM, saw Resident #12 sat in her w/c with 6 inches of her catheter tubing sitting on the floor under her w/c in the dining room. On 4/23/25 at 10:55 AM, observed Resident #12 sit in her room in her w/c with 6 inches of her catheter tubing sitting on the floor under her w/c. On 4/23/25 at 11:22 AM, witnessed Resident #12 sitting in her w/c in the dining room at the table with her catheter tubing sitting on the floor under her w/c. On 4/23/25 at 1:03 PM, watched Resident #12 sit in her w/c as she sat in the hall by the nurses' station with her catheter tubing dragging on the floor under her w/c . On 4/24/25 at 7:00 AM saw Resident #12 sit in the hall in the w/c while her catheter tubing sat on the floor under the w/c. On 4/24/25 at 8:17 AM, the Staff D, Licensed Practical Nurse (LPN), reported they expected the catheter tubing be kept off the floor. On 4/24/25 at 8:18 AM, Staff F, Certified Nurse Aide (CNA), reported the catheter tubing went in the dignity bag and clipped to the leg so the tubing is short and not on the floor. The facility provided a policy titled Catheter Care dated 11/13/24, failed to directed the placement of the catheter tubing off the floor.

Based on clinical record review, staff interview and facility policy review, the facility failed to complete a gradual dose reduction (GDR) for an antipsychotic medication for 1 out of 5 residents reviewed for unnecessary medications. (Residents #10). The facility reported a census of 56 residents. Findings include: Resident #10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The MDS identified Resident #10's as independent for bed mobility and transfers. Resident #10's MDS included diagnoses of Alzheimer's disease, non Alzheimer's disease, cerebral palsy, psychotic disorder, and other sexual disorders. The MDS documented Resident #10 took an antipsychotic during the 7-day lookback period. The Care Plan Focus revised 12/18/24 reflected Resident #10 took antipsychotic medication for Alzheimer's dementia and sexual behaviors. The Interventions directed staff to send the Pharmacist's GDR recommendations to Resident #10's Physician. The Order Entry dated 4/29/24 included an order to administer haloperidol (Haldol) (antipsychotic) 2 MG (milligrams) QID (four times a day) related to psychotic disorder with hallucination due to known physiological conditions. Resident #10's Pharmacist's Recommendation to Prescriber dated 9/11/24, indicated he took the following medications: a. Haloperidol 2 MG QID (since April 2024) b. Leuprolide 3.75 MG IM once monthly (since March 2024) c. Medroxyprogesterone 300 MG IM once weekly (since April 2024) d. Sertraline 200 MG every day (since March 2024). The recommendation identified the medications as due for a GDR. The Pharmacist recommended to reduce Haldol to 2 MG three times a day (TID). The form included GDR recommendations for the three other medications. On the bottom of the form there was a hand-written note that documented sexual aggression protocol, leave dose alone. The recommendation lacked a signature from a provider regarding the documentation. Resident #10's Pharmacist's Recommendation to Prescriber dated 9/11/24, signed by an Advanced Registered Nurse Practitioner (ARNP) on 9/20/24 included an X for disagree for the response section. Under the Prescriber's comments section of the form included a new handwritten order to reduce Haldol to 2 MG TID and may hold if sleepy, keep other medications as is to help libido suppression. A Consultant Progress Note dated 9/25/24 documented the ARNP gave approval for a GDR for the Haldol from QID to TID. Resident #10's progress notes lacked documentation of the visit or the ARNP's order approval. Resident #10's September 2024 to April 2025 Medication Administration Records reflected the staff continued to administer Haldol 2 MG QID to him. Resident #10's clinical record lacked documentation or a request to clarify the Haldol order received in September2024. A Consultant Progress Note dated 12/20/24 documented the ARNP gave approval for a GDR for the Haldol from QID to TID, but the staff didn't want the dose changed. On 4/23/25 at 7:30 AM, the ADON (Assistant Director of Nursing) verified the facility didn't decrease Resident #10's Haldol in September. The ADON felt they had conflicting orders on the two pharmacy forms. She reported they had messy physician orders. She reported she couldn't find any documentation that the facility requested or received clarification on the orders. She reported she expected the nursing staff to clarify the physician order for Haldol. On 4/23/25 at 12:55 PM, Staff M, Regional Nurse Specialist, and the ADON reported they couldn't find any more information regarding the Haldol order from September 2024. Staff M said the facility would clarify the Haldol order on 4/23/25. Staff M acknowledged the facility should have clarified the Haldol order back in September 2024. On 4/23/25 at 1:09 PM, Staff M reported the facility didn't have a policy on following Physician orders. The facility followed the standard of care. A facility policy titled Medication Regimen Review Policy updated 10/19/22 instructed the consultant pharmacist to review the resident medication regimen including the resident's chart at least once per month. The consultant pharmacist would report in writing any recommendations and irregularities to the Attending Physician, the community Medical Director, and the Director of Nursing. In addition, if the Physician choose not to act upon the Pharmacy Consultant recommendation, the Physician must document rationale the reason they didn't indicate the change in the resident record. The DON and/or designee will clarify any discrepancies noted on the MAR and/or the Physician Order Summary with the ordering Physician.

Based on clinical record review and staff interviews, the facility failed to provide Occupational Therapy (OT) per Physician order and failed to start Physical Therapy (PT) in a timely manner for 1 of 1 resident reviewed (Resident #1) for therapy services. The facility reported a census of 56 residents. Findings include: Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS identified Resident #13 as independent with bed mobility. Resident #13 required supervision or touching assistance from 1 staff member with transfers, toilet use, and ambulation. The MDS described Resident #13 as ambulatory and could walk 10 feet. They required a wheelchair for locomotion. Resident #13's MDS included diagnoses of hypertension (high blood pressure), COPD (chronic obstructive pulmonary disease), diabetes mellitus, and muscle weakness. An Incident Report dated 1/11/25 at 10:25 AM reflected Resident #13 fell in her room when she walked from the bathroom. She had ahold of the end of her bed, when the foot board broke, and she landed on the floor. Resident #13 complained of left shoulder and ankle pain. The Health Status Note dated 1/15/25 at 8:00 AM reflected Resident #13 complained of left rib pain from a fall a few days ago. The note indicated the staff gave Resident #13 her regular scheduled pain medication. The Health Status Note dated 1/15/25 at 12:30 PM indicated Resident #13 continued to complain of left sided rib pain. The note documented the facility notified the DOP (Doctorate of Nursing Practice) of her pain. They reported they would see Resident #13 on rounds on 1/16/25. The Health Status Note dated 1/16/25 at 12:58 PM identified while at the facility, the DNP ordered a portable x ray to be completed as soon as possible. The Health Status Note dated 1/16/25 at 11:43 PM reflected Resident #13 had x rays completed. The results identified her as positive for acute (short-term or new) right posterior (back) 8 10 rib fractures. A Progress Note dated 1/28/25 at 1:20 PM documented the staff called the Provider regarding Resident #13's pain. The Provider gave a new order to encourage Resident #13 to use her as needed (PRN) Tramadol as ordered, with a PT/OT evaluation and treatment. The note documented the staff notified therapy of the new order. A Physician order dated 1/28/25 signed by the DNP on 1/30/25 directed PT/OT to evaluate and treat for increased pain. Resident #13's clinical record lacked documentation that she started OT services as ordered by the Physician on 1/28/25. In addition, Resident #13 didn't start PT services until 2/19/25. Resident #13's PT Discharge Summary listed she received services from 2/19/25 to 3/14/25. On 4/22/25 at 2:20 PM, the Administrator reported Resident #13 didn't have therapy notes for January as she didn't receive therapy at that time. On 4/23/25 at 12:50 AM, the ADON verified the facility didn't follow the order for PT/OT on 1/28/25 per facility protocol. She verified the facility didn't initiate OT as ordered and they didn't start PT until 2/19/25. She reported she expected the staff to follow Physician orders. On 4/23/25 at 1:09 PM, Staff M, Regional Nurse Specialist, reported she expected the staff to process Physician orders within 24 hours. She reported the facility didn't have a policy related to following Physician orders as the facility followed the standards of care.

Based on observation, staff interviews, the Centers for Disease Control and Prevention (CDC), and facility policy review, the facility staff failed to follow enhanced barrier precautions (EBP) while doing wound care by not wearing the required person protective equipment for 1 of 2 residents (Resident #15) observed for wound care. The facility reported a census of 56 residents. Findings include: Resident #15's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Resident #15 required substantial/maximal assistance with bed mobility. The MDS listed Resident #15 as dependent on staff for transfers. Resident #15's MDS included diagnoses of anemia (low iron levels in the blood), hypertension (high blood pressure), renal (kidney) disease, diabetes mellitus, and non Alzheimer's dementia. The MDS reflected Resident #15's had a diabetic foot ulcer. The MDS documented Resident #15 had a pressure reducing device in their chair/bed, nutrition and/or hydration intervention, application of ointments/medications and dressings to their feet. The Care Plan Focus revised 12/18/24 indicated Resident #15 had type 2 diabetes. He managed his diabetes with the use of hypoglycemics (medications to lower blood sugar). The Interventions reflected he had a diabetic ulcer to his right lateral foot. The Care Plan Focus initiated 1/8/25 indicated Resident #15 had an increased risk for colonization of multiple drug resistant organism (MDRO) related to wound. The Interventions directed staff to use EBP related to the wound. On 4/23/25 at 1:35 PM observed an EPB sign posted on Resident #15's door frame. The sign directed everyone must clean their hands, including before entering and when leaving the room. In addition, the sign directed providers and staff to wear gloves and a gown following high contact resident care activities, including wound care with any skin openings that require a dressing. On 4/23/25 at 1:40 PM observed Staff N, LPN (License Practical Nurse), complete a dressing change to Resident #15's right lateral foot ulcer. Staff O, CMA (Certified Medication Aide), assisted during the dressing change to help lift Resident #15's right foot. Staff N and Staff O did not put on gowns prior to the start of treatment and did not wear gowns during the treatment. Staff N acknowledged she didn't wear a gown during the treatment and reported she received education on the need to wear a gown. She said she got nervous and forgot to put the gown on. On 4/23/25 at 2:25 PM, the Administrator reported he expected the staff to follow the infection control policy and signage related to EBP. A facility policy titled Enhance Barrier Precautions updated 11/13/24 described the policy as to implement enhanced barrier precaution for the prevention of transmission of multidrug resistant organisms. The policy defined EBP as an infection control intervention designed to reduce transmission of multidrug resistant organisms that used targeted gown and gloves during high contact resident care activities. Examples of high contact resident care activities include wound care with any skin opening requiring a dressing change. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound.

Based on clinical record review, primary physician and staff interviews, the facility failed to ensure residents were given medications as prescribed by the physician, when a nurse administered the wrong medications to the wrong resident for 1 of 1 residents reviewed (Resident #52). The facility reported a census of 52 residents. Findings Include: The Admission Minimum Data Set (MDS) for Resident #52 dated 10/18/23 documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition for decision making. The MDS revealed he had diagnoses of atrial fibrillation, gastroesophageal reflux disease (GERD), arthritis, compression fracture, and neoplasm of the prostate. The resident received an anticoagulant, diuretic and opioid during the 7-day observation period. The Care Plan initiated 10/12/23 directed staff to medicate Resident #52 as directed by the doctor. Review of Resident #52's Medication Administration Record (MAR) dated October 2023, the resident received his morning medications on 10/31/23 as ordered by the physician by Staff K, Licensed Practical Nurse (LPN). The medications included: a. Calcitonin (Salmon) Nasal Solution - 1 spray alternating nostril one time a day. b. Lidocaine External Patch 4% - apply to lower back topically 2 times a day. c. Miralax Oral Powder 17 grams(gm)/scoop - give 1 scoop by mouth to times a day. d. Spironolactone oral tablet 25 milligrams (mg) - give 1 tablet by mouth 2 times a day. e. Acetaminophen - give 650 mg by mouth 3 times a day. f. Baclofen oral tablet 10 mg - give 1 tablet by mouth 4 times a day. Per the facility Incident Report dated 10/31/23 at 8:00 AM, the wrong medication was administered to the wrong resident. Staff C, Registered Nurse (RN) completed the Incident Report. She indicated on the report that she went to the dining room to give resident #50 his 4 medications that she could not find earlier. Resident #50 appeared to be sitting in his regular spot and had his hat pulled down low over his eyes. She told him she had his medications and administered them to him. He then opened his eyes and Staff C realized it wasn't Resident #50 but instead was Resident #52. She immediately found the Director of Nursing (DON) and advised her of the medication error. The physician was notified by Staff C, and Staff K notified the family. The Incident Report indicated the error resulted in the need for the resident to be transported to the emergency room (ER). Recommendations to prevent further reoccurrence noted on the report were to look at the resident's full face and relax. The incident description indicated Resident #52 received Resident #50's pills by mistake. Resident #52 received metoprolol 25 mg, Lasix 40 mg, spironolactone 25 mg, and Risperdal 2.0 mg. The Incident Report indicated Resident #52 was seated in the dining room where Resident #50 normally sits and was slumped like Resident #50 and had a hat on. Staff C, stated she said his name and gave him the medication and as he was swallowing she saw he did not have a mustache and that it was Resident #52. No injuries observed at the time. Per Resident #52's Progress Note dated 10/31/23 at 8:00 AM, the resident had a medication error this morning. The resident was currently in the dining room eating breakfast. His vital signs were as follows: temperature of 97.5 Fahrenheit (F), pulse of 76 beats per minute, respirations were 20 per minute and his blood pressure was 110/50. The resident's oxygen saturation was 96% on room air. The resident denies pain at this time. The DON was made aware of the situation. The resident finished breakfast and is being taken back to his room. Per Resident #52's Progress Note dated 10/31/23 at 8:12 AM, the resident's primary physician was notified of the medication error. An order was received to send resident to the ER for evaluation and treatment due to medications that resident was given. The physician wanted the resident to be monitored. Per Resident #52's Progress Note dated 10/31/23 at 8:25 AM, the ER Nurse was a given nurse to nurse report and 911 was called. Staff H, LPN notified the resident's family at this time. A bed hold was signed by the resident and hospital transfer paperwork prepared. The resident is in his room resting in his recliner and is aware of the situation. Denies pain at this time. Heart rate is regular and strong. No chest pains. Lungs clear bilaterally. No cough or shortness of breath noted. Per Resident #52's Progress Note dated 10/31/23 at 8:44 AM, the Emergency Medical Service (EMS) from the local hospital is in the room with the resident. Paper work given to the EMS staff. Resident left the facility with EMS. Per Resident #52's Progress Note dated 10/31/23 at 1:13 PM, the Social Worker from the hospital called with an update on the resident. He is being monitored and will be returning to the facility after 2:00 PM today. Nurse is to call with a nurse to nurse report. In an interview on 10/31/23 at 1:57 PM, the Administrator approached writer to inform her there had been a medication error this morning and they had sent the resident out to the hospital ER per Physician Order to be monitored. She reported the hospital called and said the resident would be returning today after 2 PM and they had reported the incident to the Department of Inspections, Appeals and Licensing. She did not feel this error was a reportable incident as the resident only needed monitoring. Per Resident #52 Progress Note dated 10/31/23 at 2:51 PM, the resident returned to the facility at this time via facility transportation. Per Resident #52's Progress Note dated 10/31/23 at 2:58 PM, per Hospital Discharge Orders: a. Hold the second dose of spironolactone today. Resume normal medications tomorrow. b. Orthostatic precautions/fall risk for 2 days (10/31/23 - 11/1/23) using extra precautions with transfers. The resident is aware of these orders and the MAR was updated at this time. Per Resident #52's Progress Note dated 10/31/23 at 4:38 PM, the resident reports double vision and lightheadedness at this time. Vital signs were as follows: temperature of 97.4 F., Respiration of 16 per minute, pulse of 82 to 100 beats per minute, and blood pressure of 143/80. Telephone call placed to the physician at this time. Order received for vital signs hourly until 6 AM. Continue to monitor. Treatment Administration Record (TAR) updated and resident made aware. Per Resident #52's Progress Note dated 10/31/23 at 8:07 PM, the resident has been resting in his recliner this evening. Awakens easily. Voices that he had a very busy day with having to go out to the hospital. He denies having a headache, dizziness, light-headedness, or double vision. He voices that has all gone away. His speech is clear and he is alert and oriented. Vital signs are stable with no irregularities noted. He ate his supper and took all of his medications without an issues. Per the Hospital After Visit Summary dated 10/31/23, the reason for the ER visit was accidental drug ingestion, initial encounter. Medications given were Acetaminophen 1000 mg at 12:15 PM and Sodium Chloride 1000 milliliter (ml) intravenous which was stopped at 11:43 AM. Vital Signs at discharge were: Temperature of 96.3 F, Pulse 82 beats per minute, respirations 15 per minute, blood pressure 144/78 and oxygen saturation 99% on room air. Orders included: a. Hold the second dose of spironolactone today. Resume normal medications tomorrow. b. Orthostatic precautions/fall risk for 2 days (today and tomorrow) use extra caution with transfers. ER Course on 10/31/23 included the following: a. At 9:05 AM - 12 lead Electrocardiogram (EKG) shows atrial fibrillation. No significant changes when compared to 3/3/23. b. At 10:11 AM - Potassium level of 4.2 (normal is 3.6 to 5.2), INR (international normalized ratio) (measurement of blood coagulation) of 2.7 (therapeutic range is 2.0-3.0). Will observe for hypotension, bradyarrhythmia until 2 PM. c. At 10:37 AM - Blood pressure 80/65. Sleeping in bed. Soft pressures are noted. No tachycardia but the beta-blocker would prevent that so we will give a liter of fluid and continue to observe. d. At 11:11 AM - Blood pressure 96/57. e. At 11:31 AM - Blood pressure 128/103. f. At 12:40 PM - Made a Mandatory Repot to the Department of Inspections, Appeals and Licensing regarding the accidental administration of another resident's medications to this resident at the nursing home. g. At 1:43 PM - Blood pressure 144/78, pulse 70-100 beats per minute in atrial fibrillation. He ate lunch, alert and wake indicating that he feels fine. Poison control recommended 6 hours tele-monitoring so we will continue for another 30 minutes or so. h. At 2:06 PM - Pulse in the 80's per minute and his blood pressure has vacillated from the 100's to 130's. He is asymptomatic. As long as we hold this evening's spironolactone he can resume normal medications tomorrow. In a phone interview on 11/1/23 at 3:50 PM, Resident #52's Physician stated he had been made aware of the medication error that occurred yesterday for this resident. He relayed he was quite concerned related to the resident's age being [AGE] years old and his age putting him at even greater risk of side effects. It was his understanding the resident had received his regular morning medications and then had been given another residents meds shortly thereafter. He stated the meds included an anti-hypertensive, diuretic and anti-psychotic medications. He was concerned with hypotension. He stated when he was called on the incident he considered having the facility monitor him closely but it would have required a significant amount of time by the staff and he didn't feel that was reasonable. He felt the resident would be better served being seen by the ER Physician and having the ER staff monitor the resident very closely. He reports he is very happy with his decision as the resident did experience hypotension and the ER was able to administer fluids to assist in raising his BP and he was able to return to the facility. Per review of facility documentation on 11/2/23 at 9:36 AM, Staff C, RN received a written warning for the incident on 10/31/23. Staff C also received the following corrective action in the past: A written warning - final - related to Trileptal 600 mg and Atenolol 25 mg being misplaced and not given to a resident during the evening med pass on 7/10/22. Medications were found the morning of 7/11/22 by a Medication Aide. The resident involved had a seizure on the morning of 7/11/22. Expectation moving forward: Staff C will always follow the 6 rights to medication administration. Staff C will also wait to sign off medications until the resident has been observed to have taken them. On 8/2/21 - Written Warning - Staff C had 2 medication errors in less than 2 weeks. Both of these errors included the drugs warfarin. Expectations moving forward - Staff C will follow the medication policy and observe the 6 rights of medication administration. On 11/2/23 at 10:18 AM, the Administrator reported she had spoken to Staff C and she reported she had given resident #50 all of his medication except for 4, metoprolol, spironolactone, Risperdal, and Lasix. It was the end of the month ([DATE]st) and there were no meds left in the cards for the 4 meds. She reported she gave the others and then went and got the November med cards and punched out the 4 she needed to still give. She punched them out from the 30th of November on each card. She then went to find Resident #50 to give him the rest of the meds and that is when she inadvertently gave them to the wrong resident (Resident #52). This was verified when this writer went to the November medication cards for Resident #50 and those meds had the medication removed from the 30th already. In an email dated 11/2/23 at 12:16 PM, the Administrator reported Staff C had not completed any competencies related to medication administration and the 6 rights of medication administration, however she would be receiving training before her next schedule day to work as part of her corrective action. In an interview on 11/01/23 1:50 PM, the Administrator stated it was the expectation all Medication Aides and nurses follow Physician Orders as written and ensure the right residents receive the right medications by using resident identifiers. In an email dated 11/02/23 10:16 AM, the Administrator reported the facility does not have a policy for medication administration or following the 6 rights of medication administration.

Based on clinical record review, observations, staff interviews and facility policy review, the facility failed to accurately reflect the needs for 1 out of 3 residents reviewed in regards to supervision and care (Resident #1). Resident #1 was found outside lying on the ground unsupervised in hot weather wearing sweaters. Resident #1 required hospitalization related to heat exhaustion and dehydration. The resident's cognition had declined and the Care Plan was not updated to direct staff on how to keep Resident #1 safe. The facility reported a census of 51 residents. Findings Include: A Minimum Data Set (MDS), dated [DATE], documented diagnoses for Resident #1 that included early onset Alzheimer's disease, abnormalities of gait and mobility, and heart failure. A Brief Interview of Mental Status (BIMS) revealed a score of 3 out of 15, which indicated severely impaired cognition. The resident required supervision of 1 for locomotion on and off the unit, dressing and toileting. An MDS dated [DATE], documented that this resident's BIMS score was a 10 out of 15, which indicated moderately impaired cognition. A Care Plan with a Focus Area dated 10/9/19, documented that Resident #1 had an Activity of Daily Living (ADL) deficit due to Alzheimer's disease. An intervention date 6/28/21, directed staff that Resident #1 was now allowed to go out (to) the courtyard with his forward wheeled [NAME] (FWW) independently. The edge of the sidewalks had been painted yellow to show his boundaries. This resident had been educated on the use of his walkie talkie and to call for assist on channel 6 if he should need help outside. He was to check in with nursing prior to going outside and getting his walkie talkie and then when he came back in, he was to report to the nurse and turn his walkie talkie back in. The above Care Plan Focus Area and intervention were discontinued on 7/5/23. Review of Progress Notes for Resident #1 documented the following: a. On 7/2/23 at 3:43 p.m., another resident went to nursing staff and said that someone was outside with their pants down. Resident #1 was standing at the tree with pants to his knees. Staff went outside and noted this resident's wheelchair was in the grass. Staff advised Resident #1 that he could not be outside. They were able to get his pants on and get him inside. Resident #1 had his coat on and his 2 shirts. Water was given and resident was alert and smiling. This resident's skin was pink, warm, and dry. There was no cyanosis (blueness to skin related to decrease in oxygen) noted. Staff advised this resident not to go outside without help. b. On 7/2/23 at 4:00 p.m., staff had a conversation with this resident about not urinating outside. This resident verbalized understanding and used the restroom indoors. c. On 7/4/23 at 6:00 p.m., Resident #1 found outside in the courtyard when staff were looking for the resident because he did not come out for supper. Staff A, Certified Nurse Aide (CNA), found Resident #1. The resident was lying face down on his right side with feet stretched out in front of him with 1 shoe on and 1 shoe off. Resident #1 was wearing his dress shoes and noted outside for approximately 40 minutes. Staff did not move the resident and Staff B, Licensed Practical Nurse (LPN), stayed with Resident #1 until the Emergency Medical Services (EMS) arrived. Staff were unable to obtain vital signs. When the resident was turned over it was found he vomited and soiled himself. EMS moved and assessed the resident. The resident was lying on the right side of his body with his face on the concrete and his feet stretched out in front of him with the wheelchair behind his head. Resident #1 was unable to give a description of what had happened. Resident #1's range of motion was not checked until EMS arrived. Resident #1 told the nurse that he was having pain but wouldn't tell the nurse where it was located. The resident's skin was warm and he was wearing a coat and 2 shirts on with pants and dress shoes. The resident was to be an assist of 1 with walker and or wheelchair. Resident #1 had an order to go outside to the courtyard with a walkie talkie but didn't have one on him today. The resident was sent to the emergency room (ER) for evaluation and treatment. d. On 7/4/23 at 9:50 p.m., staff spoke with the ER nurse. He voiced that Resident #1 was being admitted related to unresponsive episode. The ER nurse voiced that they needed to run more tests so they could figure out what happened. The Director of Nursing (DON), was informed of the resident's admission to the hospital. e. On 7/5/23 at 5:34 p.m., received a call from the hospital and they are keeping the resident for another day. The hospital staff stated they are reporting this incident to the Department of Inspection and Appeals (DIA). Advised the DON was going to also. f. On 7/8/23 at 9:53 p.m., an Admission Assessment documented Resident #1 admitted to nursing facility in a wheelchair from the hospital. Resident #1 was oriented to facility meal times, visiting hours, room and staff. The resident's ADL needs were extensive assist from staff for bed mobility, transfers, dressing, toileting and limited staff assist to complete personal hygiene. Resident #1 was oriented to person and disoriented to place, time, and situation. A Hospital Summary Report dated 7/8/23 documented the following diagnoses were noted on 7/4/23 and resolved on 7/8/23: a. Encephalopathy acute (a disease that affects brain structure or function and causes altered mental state and confusion). b. Rhabdomyolysis (a breakdown of skeletal muscle due to direct or indirect muscle injury, if not treated immediately if can lead to kidney damage). c. Heat exhaustion. d. Dehydration. e. Lactic acidosis (condition where there is too much acid in the body). The Summary of hospitalization documented that an [AGE] year-old male with advanced Alzheimer's dementia was apparently found down in the courtyard of the facility on a hot day wearing winter clothing for an unknown period of time. Upon arrival to the ER the patient was minimally responsive and febrile to 101 (degrees Fahrenheit). Responsiveness improved once the patient was cooled and given intravenous (IV) hydration. The resident was unable to provide any history due to his dementia and thought he was still at the nursing home. The resident did not remember going outside wearing winter clothing at all. Initial Vital Signs (VS) were positive for fever and mild hypoxia (low oxygen level) with the resident needing oxygen at 2 liters per a nasal cannula. Review of an email sent on 7/25/23 at 12:16 p.m., the State Climatologist of Iowa reported the following weather conditions in response to a request for the weather on 7/2/23 at 3:45 p.m. and for 7/4/23 from 4:00 p.m. to 6:00 p.m.: On July 2, 2023: a. Temperature: 85 degrees F. b. Relative humidity: 48%. c. Heat Index: 86 degrees F. d. Winds out of the Northwest (NW) at 14 miles per hour (mph). e. Mostly cloudy with no rainfall detected. On July 4, 2023: a. Temperature: 86-88 degrees F. b. Relative humidity: 48-53%. c. Heat Index: 92 degrees F. d. Winds out of the South-Southwest (SSW) to [NAME] 7-12 mph. e. Fair conditions with no rainfall detected. On 7/10/23 at 9:30 a.m., no residents were noted to be outside. The Nursing Home Administrator stated they put a Facility Self-Report in today for an incident that happened last week involving Resident #1. She said there was some confusion regarding whether he was in observation at the hospital or not, but they found out he was admitted . When asked how long can a resident be in the hospital before they are considered admitted ? The Administrator stated it depends-sometimes 24 to 48 hours. She said that Resident #1 had fallen outside and went to the hospital. On 7/10/23 at 12:10 p.m., Staff C, Restorative Aide, stated the door alarm sounds at the Nurse's Station. She stated about 2 years ago she had to go outside to get a resident who went outside. She knew about the resident going outside, because of the call light system and she went to check, then saw the resident outside. Staff C reported she has had no other residents that she has had to retrieve since then. On 7/10/23 at 1:00 p.m., the DON stated that there are no residents in the facility that currently use the Wander guard system (a system that has residents wearing a bracelet which will alert staff when a resident is near an exit door). She stated no other residents have been outside that they have had a concern with. The DON reported she would get the timeline for Resident #1's fall outside. When asked if the door alarm sounded alerting the call light system and staff, the DON stated it would have. The DON stated at that time Resident #1 was able to go outside, so staff would have seen him go out and would not have had a problem with that. She stated that on the day he went outside and fell , Resident #1 had a supplement drink around 4:30 and after passing trays, staff noticed he wasn't in the dining room, so went to find him and found him outside, lying on his side. The DON said they wondered if there was something else going on with him like a potential urinary tract infection (UTI), because he was trying to pee outside and he normally didn't do things like that. The DON said he always wears a coat outside and is one who can get combative if you would try to remove his coat. She said he needs help getting over the hump and outside the door usually but on that day, he must have gone over the hump by himself because they could not find any staff that reported they helped him outside. The DON stated he no longer was able to go outside on his own after this incident. Throughout the survey, Resident #1 noted lying in bed with all observations so far of him. On 7/10/23 at 1:22 p.m., Staff A, CNA stated she had got to work a little late so she didn't take report from anybody (on the day of the incident). She stated her partner had taken report. That day Resident #1 was in bed around 3:00 p.m. He usually was in bed for lunch and supper. She stated that day she arrived to the facility about 2:10 p.m. or 2:15 p.m. Staff A stated she was supposed to leave that day at 6:00 p.m., so she was giving report to another CNA and was telling her what happened during the 4 hours Staff A had worked. Staff A stated she was ready to leave, in the breakroom when a staff member who worked in the kitchen, asked about where Resident #1 was. Staff A stated she then went back to his room. Staff A told the other CNA to walk with Staff A so she could finish giving report. Staff A stated that Resident #1 was not in his room and he was not in his bed. Staff A stated a resident across the hall had her curtains open and Staff A saw a wheelchair out in the courtyard. Staff A stated they then went outside, saw Resident #1 on the ground, had the other CNA go check on him while Staff A ran to get a nurse. Staff B, LPN was the nurse on the other side and she came right away. Staff A stated this resident's nurse and his other nurse were arguing about who was going to take care of him. When asked how Resident #1 seemed to be doing, Staff A stated that Resident #1 was lying on the ground. She stated he responded to them. Staff A stated she thought Resident #1 was hot because it was hot outside. Staff A stated Resident #1 usually wore about 5 jackets. Staff A reported Resident #1 could go outside by himself. She stated she had seen him go outside by himself before, but she did not see him go outside by himself on that day. She said he was lying on the cement area without any obvious injuries. Staff A stated the Paramedics removed Resident #1's jacket after responding quickly after they called the Paramedics. Staff A stated she ended up leaving around 8:00 p.m. Staff A stated that she wasn't sure what time Resident #1 left the facility. She stated the Paramedics cut off Resident #1's clothes and they were out there for about 10-20 minutes. Staff A stated that because Resident #1 was laying like facing the cement, Staff B had said she did not want to move him because of the way he was lying. Staff A stated that half of his face was facing the ground and his arm was under him, so they didn't know if he had a broken arm or anything like that. Staff A stated when she said Resident #1's name he said yes, but he was moaning like he was in pain. Staff A stated that Resident #1 was in his room when she had seen him earlier and had heard the (door) alarm. Staff A did not know if anyone saw him and she did not know who shut off the alarm. Staff A stated that it was very busy that day and she was used to working on the other side. It was different because they have new residents. She stated they have another resident who was trying to open the door. Staff A repeated that they did not know who shut off the main box that is at the Nurse's Station. Staff A said the facility had a few residents who go outside without asking and the nurse that is usually behind the desk is supposed to be checking the box. When asked about a walkie talkie, Staff A stated that Resident #1 used to carry a walkie talkie when he was walking but it had been a long time since he walked. Staff A stated she worked as needed (PRN) so she did not know for sure how long it had been since he was walking, thought it had been a few months. Staff A stated she had not seen Resident #1 carry that walkie talkie for a long time. Staff A repeated that she last saw him about 3 something that day, it was probably 3:30. Staff A reported that supper was served at 5:00/5:30 p.m. On 7/10/23 at 2:00 the Administrator stated Resident #1 did not have a walkie talkie on him. She stated Resident #1 probably hadn't used a walkie in a long time. The Administrator stated Resident #1 used to go up to the Nurse's Station and ask for a walkie. The Administrator stated everyone should be aware of the alarms. We all know what times the smoke times are. The Administrator stated if staff do not see anyone at a door that triggered an alarm then staff are to go down the hall to find who went out. She stated that if staff aren't able to see who went out the door, then staff should go into the facility's Elopement Protocol and make sure all residents are accounted for. She stated that the facility needed to get clarification on if anyone saw him go outside. Initially Staff D, Registered Nurse (RN), stated she did see him go outside but then when the DON asked her the next day, Staff D stated she did not see him go outside. The Administrator stated that Staff D was coming in later that day and they were trying to get down to the bottom of it, whether or not Staff D let him out. When asked about him being outside on 7/2/23, the Administrator stated she was unaware of this incident. The Administrator stated that Resident #1 has had to be redirected before when he had urinated inappropriately outside. The Administrator stated that was when Resident #1 was walking. The Administrator stated that she was unaware of him urinating inappropriately since he's been using a wheelchair. The Administrator stated she wanted to say it had been 3 to 6 months since Resident #1 had been using a wheelchair. She stated Resident #1 was starting to use his walker unsafely so the facility switched him to a wheelchair. The Administrator stated that Resident #1 could still transfer and pivot. On 7/10/23 at 2:24 p.m., Staff F, RN, stated that (on 7/2/23), another resident had come to Staff F and said that Resident #1 was outside by a tree peeing. Staff F stated she went out and sure enough he was peeing and had his pants down. She stated they were able to get his pants back up and get him back on to the hard surfaces as he was on the grass. Staff F stated that Resident #1 had not gone outside for the longest time. Staff F stated she did not know if he had recently gone outside before that. Staff F said Resident #1 used to bring a walkie talkie with him. Staff F stated she got Resident #1 all checked out and made sure he had clean clothes on. She said he was acting fine. She stated it happened around midafternoon. Staff F stated she did look at his Care Plan and it did say he could go outside with a radio. Staff F stated she reported it on to the Night Nurses on the 24-hour report. Staff F stated that Staff E, Quality Assurance Nurse, had to come in because someone called in sick on the night shift. Staff F stated Staff E came in and Staff F told Staff E what had happened. Staff F stated she had no idea about whether the alarm had sounded. Staff F stated she had just sat down and was getting ready to chart when the other resident came up and told her about a Resident peeing outside. Staff F stated she just finished passing the 2:00 p.m. medications. Staff F stated there was no alarm going off then. Staff F stated that originally Resident #1 would go out with people that would go out smoking, but that was a long time ago. Staff F stated she worked 3 days a week. On 7/10/23 at 3:15 p.m., Staff G, LPN, stated that she had only been working at the facility for a short while and mostly worked days. Staff G stated that Resident #1 did not really go outside much during the day hours. Staff G stated when she worked a 2nd shift a couple of weeks prior and Resident #1 went in and out a few times on that shift, he would let himself out and then let himself back in. Staff G reported that staff told her that Resident #1 does that all the time. Staff G reported that Resident #1 opened the door safely when she saw him. On 7/10/23 following the above conversation, Staff H, CNA, stated she had worked at the facility for over a year. Staff H stated she had just recently come back to the 2-10 shift from nights about a week prior. Staff H stated that she heard about Resident #1 falling. Staff H stated that Resident #1 used to have a walkie and she wouldn't have thought anything about him going outside because he did that all the time last year. Staff G stated she had not seen him go outside this year though. On 7/10/23 at 3:44 p.m., Staff I, LPN, stated that she was not working either day this resident was found outside but it was something he would do fairly regularly. Staff I reported she had not seen him go out lately, but he had gone out and sat in the courtyard. Resident #1 was out for a classic car show. She stated if she would have saw him going out it would not raise an alarm to her. Staff I stated Resident #1 would go outside with another resident as well. Staff I stated Resident #1 wears his coat constantly. Staff I stated when this resident was out at the car show she tried to get him to come in. Staff I stated Resident was wearing a hat and gloves and he refused to take them off. She stated this resident sleeps all day and gets up at night. He wakes up during the day and will ask for a supplement drink. Staff I stated Resident #1 would be awake during the day, you can go in and talk with him. Staff I stated as far as getting out of bed this resident would wait to get up until after supper. Then he would go down and play cards. On 7/10/23 at 4:08 p.m., Staff J, CNA, stated she wasn't working when Resident #1 was found outside. Staff J stated she worked full time on 2nd shift, and Resident #1 would normally go outside so she wouldn't have thought twice about him going outside. Staff J stated she had worked at the facility for 9 years. Staff J stated that Resident #1 was able to get in and out of the door without any issues. Staff J reported that she knew one time he went out with the jacket on and it was in the 70's. Staff J stated that she made a comment to the nurse and Resident #1 came right back in though. Staff J explained Resident #1 used to use a walkie talkie outside with him but that had been a while ago. She stated he used to come up to the Nurse's Station and get the walkie talkie. Staff J stated the last time she saw him do that was a few months ago. Staff J stated the resident stopped telling us he was going out recently. Staff J stated she hadn't seen a change cognitively. He still takes care of himself. Staff J stated that she personally did not know if the wheelchair was something Resident #1 wanted to be in. On 7/10/23 at 4:23 p.m., the DON stated she had received a text message saying to call the facility. The DON called the facility back and was told that Resident #1 was on the ground outside and was told what was going on. The DON came in around 7:40 p.m. to 8:00 p.m., and started her investigation on what had happened. The DON stated that Staff B, LPN said she had seen this resident around lunchtime. The DON stated that Staff D said she saw him around 4:30 p.m., at the desk when this resident received a supplement and then around the 5:40ish p.m., staff went to look for him and that's when they found him outside. The DON stated she was not aware of the incident of him urinating outside. The DON stated she looked at the Care Plan and had gotten it all updated. The DON stated she understood the concerns. On 7/10/23 at 4:31 p.m., Staff D, RN stated she had worked the dayshift when Resident #1 had fallen. Staff D stated she had seen Resident #1 when he came up for a Boost (dietary supplement). She stated that 4:30 p.m. was probably the right time as this resident wants a Boost before supper. Staff D stated she honestly did not know what time it was, but was afternoon before supper. Staff D reported Resident #1 did not show up for supper and one of the girls was going and getting the residents up for supper. Staff D stated that Staff B, LPN was working also and Staff B ended up going out and taking care of him. Staff D stated that both she and Staff D were getting ready to leave. Staff D stated she did not see Resident #1 go outside. Staff D stated she honestly did not remember the alarm going off on the door and added that it gets so noisy and the alarm goes off all day long. She stated 2 other residents go out all the time and they were care planned to go out. Staff D stated that if she was at the Nurse's Station and heard the alarm go off, she would see who was going out and if it's okay, then she would shut the alarm off. Staff D stated that if they staff did not know where the alarm was coming from they would go and check to see if someone accidentally went out. Staff D did not think any of these people have any business going in or out. She stated the facility did not have enough staff to ensure that the residents are safe. Staff D stated she did not think a resident could be Care Planned to go out there safely. Staff D stated that the last she knew, Resident #1 was care planned to go in and out by himself. Directly following this interview, the Administrator and the DON stated they understood the concerns with the level of this resident's impaired cognition and the facility allowing him to independently go outside. They acknowledged that the Care Plan should have been updated to reflect his changing needs. The facility reported they did not have policies on Care Plans, Nursing Supervision, or Rounding and Resident Checks. The facility reported they follow regulations and Nursing Standards of Practice. Review of the Missing Resident/Elopement Process policy revised on 7/12/21, directed staff under the Assessment and Identification of Wandering Residents Section: 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 based on risk assessment. c. You will complete a missing resident identification form. d. Activities will be in charge of having a missing resident identification form completed for each resident on admission and annually by the end of the first quarter (March 31st). Under the Residents identified at Risk for Elopement Section: a. Residents whose assessment identifies them at risk for elopement, the following steps will be taken: i) An alarm bracelet may be placed on the resident to audibly alert the staff of attempts by the resident to exit the facility. ii) The resident's Care Plan shall address behaviors using resident specific goals and/or approaches as assessed by the Interdisciplinary Team (IDT). iii) A current picture of the resident will be maintained in the facility. iv) Facility staff will ensure that all exit alarms are responded to immediately. v) 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 has been opened. DO NOT assume someone else has already done this. b. Check the exit door for any existing resident by means of a visual check. Visual check means observing the area around the exit and may require leaving the building. c. If a resident is discovered outside the facility inappropriately, staff will assist them back into the facility. d. Reset the door alarm after it is determined by visual check that no resident has exited the facility inappropriately or is returned to the facility. e. If 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. The Nurse, DON, or Executive Director will question staff to determine who de-activated the door alarm and reason for doing so. If the Nurse, DON, or Executive Director in advance did not approve the de-activation, the person responsible for de-activating the alarm may face disciplinary action. Disciplinary action issued for such occurrence shall be maintained by the DON or Executive Director. Elopement Process (Missing Resident): 1) When it is determined that 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, institute a grounds search. ii) If the resident is unaccounted for after a thorough grounds search of the building and grounds, the following will be immediately notified: a) Executive Director/ Director of Nursing b) Family and/or Legal Representative c) Attending Physician d) Police A complete description of the resident will be given to police along with a current photo of the resident. Provide law enforcement the Missing Resident Identification Form. When the resident is located, the following procedures will be followed: a. Head to toe assessment of the resident will be completed to determine if medical attention is required. Document in Nurse's Notes - Head to Toe Assessment completed and findings. b. After assessment is completed, the attending physician will be notified, and results of assessment reported. The Physician'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 and/or designee. g. The Incident Report will be reviewed at the Monthly Safety Committee meeting and each quarter with the QA Committee. Education and Training: a. All staff will be educated on proper identification, assessment, and treatment of residents 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. Attachments: a) Missing Resident Identification Form. b) Elopement/Missing Resident Investigation. c) Missing Resident Drill.

Based on observation, clinical record review, staff and resident group interview, resident rights and facility policy review, the facility failed to assure 2 of 4 residents were free from abuse (Resident #2 and #3). The facility also failed to ensure each resident was treated with respect and full recognition of their dignity and individuality. A staff member sent humiliating photographs of Resident #2 and #3 via a social media app called, Snapchat. Staff B admitted she sent the photos of the residents via Snapchat. Record review revealed the residents displayed cognitive impairments and required staff assistance for personal hygiene and toilet use. A reasonable person in today's society would be embarrassed and feel degraded if his/her care provider humiliated him/her in this manner. The facility identified a census of 74 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 5/3/17 indicated Resident #2 had [DIAGNOSES REDACTED]. The assessment indicated the resident experienced severe cognitive impairment, required assistance of 2 staff with bed mobility, transfers, toilet use and personal hygiene. The MDS documented the resident as non-ambulatory (did not walk) and with an indwelling catheter for urinary elimination. Review of the resident's Care Plan revealed the resident had focus areas that included an impaired ability to perform activities of daily living (ADL's) related to [MEDICAL CONDITION] diagnosis, [MEDICAL CONDITION], weakness, memory loss, hypertension, [DIAGNOSES REDACTED], hospice status and [MEDICAL CONDITIONS] (initiated 9/29/14) and with a catheter (initiated 5/15/17). The Care Pan described the resident as forgetful and directed staff to provide catheter care two times a day (BID) and as needed (PRN). An Order Entry form dated 4/20/17 directed the staff to place a 16 French (FR) 10 cubic centimeter (cc) Foley catheter changed monthly and PRN. an order for [REDACTED]. An MDS assessment form dated 5/10/17 indicated Resident #3 had [DIAGNOSES REDACTED]. The assessment indicated the resident experienced severe cognitive impairment and required extensive assistance of 2 staff with personal hygiene. A Care Plan with a focus area initiated indicated the resident had a [DIAGNOSES REDACTED]. During an interview 7/19/17 at 8:40 a.m., the resident indicated he/she could not recall anyone having taken a picture of him/her. Snapchat is a video messaging application that enables the user to take photos and record videos and add text and drawings to them. Staff A, Certified Nursing Assistant (CNA) provided the following written statement: On my first day while I walked the halls doing rounds Staff B, CNA opened a Snapchat of what seemed to have been Resident #2 with a Snapchat filter on his/her face. Then on April 25, 2017 around noon, I received a Snapchat from Staff B which had been of video of Resident #2 as he/she lay in bed on his/her side with no brief in place. The caption of the Snapchat was F---ing third shift! Staff B explained in the video how the catheter would not function properly positioned over the resident's hip in that way. She then proceeded to show the bypass positioned on the chuck (bed pad) located under the resident. In the Snapchat, I could see the resident's butt cheek, but not his/her genitalia, rectum or face. I could hear the resident mumbling in the back ground. I turned this in to the Administrator while I worked at around 4 p.m. I then went on break right about that time and when I checked my phone, I had received another snap of the staff member with another resident. That picture had been of the staff member with a fully clothed resident and a face swap of the resident's face but his/her body and the face of staff C, CNA. When Staff A looked at Staff B she said Don't tell. The Administrator provided the following typed statement as dated: On April 25, 2017 at 4:05 p.m. Staff A came to my office and spoke to me. She reported she witnessed Staff B open a Snapchat that had a video of what appeared to have been a resident with a Snapchat filter over his/her face. She also reported she received a Snapchat from Staff B with a video of Resident #2. I asked her how she knew it had been Resident #2 and she said I could just tell by his/her catheter because he/she had been the only resident on that hall with a catheter. She reported that in this video you could not see the resident's face but the video was depicting the improper placement of his/her catheter tubing with a message that said stupid f (explicit) night shift. When interviewed I asked her if you could see the resident's, face or genitals and she indicated no but she could see the resident's right butt cheek. At the time of this report Staff B had no longer been in the facility or in contact with any residents. On the same day, while I interviewed Staff A she received an additional Snapchat from Staff A with a picture of Staff A and what appeared to have been a resident in a wheelchair with the face of Staff C over the resident's face. Based on the positioning of the resident in the wheelchair and his/ her stature it appeared to have been Resident #3. I took a written statement from Staff A at that time. I called Staff B at home to discuss this matter. Staff B denied having received any Snapchat with a resident in the video. She did however acknowledge that she sent the Snapchat video with the catheter placement for the purpose of showing that the night shift had been stupid. She also acknowledged having taken and sending the Snapchat photo of her and a resident with the face swap of Staff C. I asked her if Staff C had been present for that photo and she said no, the photo she used of the Staff C had been her phone already. I asked both Staff A and Staff B what their personal relationship had been and they both indicated that they were merely classmates. I asked Staff B if she recalled the education that I provided to her on 4/20/17 regarding dependent adult abuse and the taking and/or distributing of photos or videos of residents. She said yes and that she didn't know why she sent the picture and video. During an interview 7/18/17 AT 3:56 P.M., Staff B confirmed she worked 4/25/17 from 6 a.m. until 2 p.m. That morning while her partner Staff C, CNA gave another resident a shower she entered the room of Resident #2 to get him/her up for the day and found him/her awake and trying to get out of bed as she thought the resident's foot had been on the ground with the catheter tubing around an unknown leg and under him/her pulled tight with no urine in the catheter bag. The resident wore a shirt or gown but no pants and/or a brief. At that point she opened Snapchat on her telephone because she wanted to show the Quality Assurance (QA) nurse and took a picture and a 2 second video of the resident's leg however she had been 99.9% sure the residents bottom had not been exposed in the photo. The staff member indicated she could not recall who she sent the Snapchat to and that she could not recall having sent it however she recalled having typed a capture about the night shift but could not recall exactly what had been said in the capture. The staff member indicated the resident had not been aware she took the picture. The staff member also indicated around 1:55 p.m. the same day there had been nothing much to do so she went to the room of Resident #3 to chat with him/her and performed a grooming procedure at which time the staff member put Snapchat on her telephone and took a picture of the resident. The staff member then covered the resident's face with a picture of Staff C and sent it to Staff A and nobody else. The staff member felt the resident had been aware the picture had been taken. During an interview 7/19/17 at 8:40 a.m., Resident #3 indicated he/she had not recalled anyone taking a picture of him/her. A Resident's Bill of Rights form updated 11/28/16 included the following information: a. Each resident had the right to considerate and respectful care and to have been treated with honesty, dignity, respect in a manner and in an environment that promoted maintenance or enhancement of his/her quality of life and with reasonable accommodation of individual needs expect where the health, safety, or rights of the resident or other individuals in the facility would have been endangered. b. Each resident had the right to have been free from exploitation, physical, verbal, sexual or mental abuse, corporal punishment and involuntary seclusion. A Hawkeye Care Centers Employee Handbook form revised 1/1/14 included the following information: a. Unless authorized by management, use of personal cell phones had been prohibited at work and on work facilities, except during break times and in the companies designated break room (s). b. Use of cameras or video recording devices had been prohibited at work at all times. Pictures and video could not have been taken at work or on work premises. c. You may not post resident, vendor or co-worker information which would have been otherwise prohibited from release by state or federal law. Review of an Abuse Prevention, Identification, Investigation, and Reporting Policy form revised 4/1/17) included the following information: a. All Residents had the right to have been free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraints not required to treat the resident's medical symptoms. That included prohibiting nursing facility staff from taking or using photographs or recordings in any manner that would have demeaned or humiliated a resident and prohibited using any type of equipment (e.g., cameras, smart phones and other electronic devices) to have taken, keep or distribute photographs and/or recordings on social medial or through multimedia messages. b. The transmission, display or taking of electronic images of the unclothes breast, groin, buttock anus, pubes or genitals of a dependent adult by a care taker for a purpose not related to treatment, care monitoring, assessment or [DIAGNOSES REDACTED]. c. Personal degradation of a dependent adult meant a willful act or statement by a caretaker intended to shame, degrade, humiliate or otherwise harm the personal dignity of a dependent adult or where the caretaker knew or reasonably should have known the act or statement would cause shame, degradation, humiliation or harm to the personal dignity of a reasonable person.

Based on record review, hospital records, and interviews with staff, physician, pharmacist and family, the facility failed to adequately monitor anticoagulant medication for one (1) of two (2) residents reviewed. Resident #7 returned from the hospital on [DATE] with a physician order's to monitor his/her INR (International Normalized Ratio)/test for blood clotting) on 10/1/13. The nursing staff continued to administer [MEDICATION NAME] (blood thinner) medication without monitoring the impact of the anticoagulant medication until the resident had been transferred to the emergency room with bleeding gums on 10/15/13 with his/her INR elevated to high critical level of 23.9 (with a therapeutic INR range between 2.0-3.5.). The resident required 10 units of Vitamin K therapy to promptly reduce the elevated INR. The findings constitute an immediate jeopardy to the resident's health and safety. The facility reported a census of 94 residents. Findings include: The Minimum Data Set (MDS) assessment tool dated 10/4/13 documented Resident #7's active medical [DIAGNOSES REDACTED]. The MDS identified the resident scored 12 out of 15 on a cognitive test. The resident exhibited no behaviors or refusal of cares during the assessment period. The resident required two staff assistance with bed mobility, transfers, dressing and toilet use. The resident did not walk. A Computerized Progress Note dated 9/22/13 at 9:33 a.m. identified Resident #7 struggling to breath and reported shortness of breath. The nursing home obtained a physician's orders [REDACTED]. The progress note identified the resident's vitals as : blood pressure: 108/64, heart rate: 113, oxygen saturation rate: 64% on room air. The Hospital History and Physical dated 9/22/13 documented the [AGE] year old resident of the nursing home arrived at the emergency room with shortness of breath. On arrival to the emergency room Resident #7 was found with a varying kind of arrhythmia's (an alteration in rhythm of the heartbeat) including PVC's (premature ventricular contraction an abnormal heart rhythm), PAC's (premature [MEDICAL CONDITION] contraction, also an abnormal heart rhythm and some [MEDICAL CONDITION] (rapid heart rate). He/she received [MEDICATION NAME] IV (intravenously) followed by [MEDICATION NAME] to control heart his/her rate. The resident received oxygen for the treatment of [REDACTED]. The physician's assessment included: acute [MEDICAL CONDITIONS], flash [MEDICAL CONDITIONS], with a very high possibility of acute [MEDICAL CONDITION] infarction or [MEDICAL CONDITION] embolism. The cardiology consultant documented the resident was unaware of any history of [MEDICAL CONDITION] and should be on anticoagulation therapy long term. The Hospital Discharge Summary dated 9/29/13 noted during the resident's hospital course ( 9/22/13 to 9/29/13), he/she received [MEDICATION NAME] ([MEDICATION NAME] is a blood thinning medication used to treat [MEDICAL CONDITION]) and his/her International Normalization Ratio (INR) was therapeutic then got elevated. (The INR is a blood test used to monitor the clotting tendency of the blood when on anticoagulation ([MEDICATION NAME]) therapy. The resident's [MEDICATION NAME] was held a few days and on the morning of 9/29/13 his/her INR was 2.1 (The therapeutic INR range is between 2.0 to 3.0.) and the [MEDICATION NAME] medication was restarted at 4 milligrams (mg) daily. The summary identified the resident had problems including [MEDICAL CONDITION] and [MEDICAL CONDITION] The discharge instructions included: [MEDICATION NAME] 4 mg daily and to check the resident's INR level in 2 days and he/she will need monitoring and adjustments of his/her [MEDICATION NAME] dosing from there on. The resident's discharge [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment tool dated 10/4/13, the staff failed to identify the resident's [MEDICAL CONDITION] and shortness of breath on the MDS. Physician orders [REDACTED]. The Consolidated Orders Report dated 9/29/13 also instructed the staff to obtain PT/INR-one time only on 10/1/13. The Discharge Orders dated 9/29/13 identified a lab test for [MEDICATION NAME], to be completed on Tuesday October 1, (2013). Admission Nursing assessment dated [DATE] at 11:45 a.m. documented skin pale and dry. Computerized Progress Notes dated 9/29/13 at 12:31 p.m. identified the resident returned to facility by ambulance. At 2:02 p.m. resident on skilled services due to post hospitalization . The resident to receive therapies due to profound weakness from immobility of hospitalization and recent cardiac changes with goal of returning to former level of activity. The note identified the resident's skin color pale, warm and dry. Computerized Progress Notes dated 9/30/13 at 3:16 a.m. identified the resident's skin condition as warm and dry. Resident had bruise on abdomen. Review of computer files and hard clinical record revealed the lack of assessments of these newly documented bruises of unknown origin. Computerized Progress Notes dated 9/30/13 at 10:22 a.m. identified the staff nurse called this resident's family member(s) to report the resident's spouse reported resident more confused and talking about getting the car washed. All antihypertensives held that morning due to low blood pressure 90/62. The nurse faxed report to physician regarding resident status. At 1:22 p.m. new orders received for dietary supplement, continue treatment to the resident's head, continue ear drops, and heat/ice packs and Biofreeze to areas of pain. At 2:32 p.m. nurse documented Skin Condition: p/w/d (pale, warm, dry) abdomen bruised, buttocks red. At 9:50 p.m. a licensed practical nurse, Staff C documented Skin Condition: warm and dry pale in color intact. At 10:36 p.m. Staff C documented new orders received and noted to draw laboratory work CBC (complete blood count) and CMP (comprehensive metabolic panel) tomorrow. The communication sheet sent to the resident's physician dated 9/30/13 at 10:30 a.m. informed the resident's physician of increased confusion. The nurse documented the resident's primary [DIAGNOSES REDACTED]. The nurse documented medication changes in the last week included [MEDICATION NAME], Potassium and [MEDICATION NAME]. The communication sheet did not list the newer medication ([MEDICATION NAME]) and/or [DIAGNOSES REDACTED]. The resident's Plan of Care updated on 10/14/13 failed to identify the new onset of [MEDICAL CONDITION] and [MEDICATION NAME] use. The plan of care noted the resident had a skin wound. The interventions instructed the staff to monitor his/her skin for any redness or breakdown. The plan of care failed to instruct staff to monitor this resident as ordered regarding the [MEDICATION NAME] use and his/her [MEDICAL CONDITION]. Continued Progress Notes included the following: On 10/1/13 at 12:34 p.m. a nurse documented the resident's skin condition as: warm, dry, pale and thin. At 1:29 p.m. a nurse documented the resident's skin condition as stable. On 10/1/13 at 11:18 a.m. a licensed practical nurse, Staff A documented upon readmission, new order received for PT/INR to be drawn on 10/1/13. The lab draw done this morning from left hand without incident. The nurse failed to address the physician's orders [REDACTED]. On 10/1/13 at 10:58 p.m. Staff C documented resident's PTT (a blood draw to test levels of [MEDICATION NAME]) received and noted with no new orders at this time. The laboratory blood report dated 10/1/13 documented PTT tested high 36 with normal being 21.5 to 35. This form read **For Patients on [MEDICATION NAME] Therapy** Critical High greater than 100. On 10/3/13 at 12:41 a.m. a nurse documented the resident's skin condition as scattered bruising. The nurse failed to document the location of the bruising and a description/assessment of the bruising. At 5:16 a.m. another nurse documented the resident's skin condition: as warm, pink and dry. At 12:13 p.m. a third nurse documented the resident's skin condition as intact. At 3:04 p.m. a nurse documented the resident's skin condition as: abdomen and arms have scattered bruising in various stage of healing. The large bruise on right abdomen that was purple in the center, green and yellow on the outside. On 10/4/14 at 4:43 a.m. a nurse documented the resident's skin condition as skin intact with multiple bruises in various colors and stages. Extremities and torso; front and back. Review of this resident's clinical record and computer files revealed a lack of physician notification and thorough assessment of these newly documented bruises of unknown origin. On 10/4/13 at 12:02 p.m. a nurse documented Skin Assessment: intact. At 9:19 p.m. a nurse documented Skin Assessment: warm and dry pale in color area on buttock remain same. On 10/5/13 at 1:35 a.m. a nurse documented the resident's skin condition as warm, dry. Bruising present to upper extremities and abdomen. At 1:47 p.m. another nurse documented the resident's skin condition as warm, dry, buttocks raw and irritated treatment. On 10/6/13 at 2:32 a.m. a nurse documented the resident's skin condition as pink, warm and dry with various bruises on torso and extremities. On 10/7/13 at 2:10 a.m. a nurse documented the resident's skin condition as pink in color, warm and dry with multiple old bruises in stages of healing especially to torso and extremities. At 11:59 a.m. a nurse documented Skin Condition: intact. On 10/7/13 at 3:49 p.m. the Social Service Designee documented staff reported resident was cooperative and pleasant. The cognitive test revealed a score of 12 indicating moderate impairment. On 10/7/13 at 4:48 p.m. a nurse documented a new physician's orders [REDACTED]. On 10/8/13 at 10:58 p.m. a nurse documented Skin Condition: intact, but dry and fragile. On 10/9/13 at 4:22 p.m. a nurse documented Skin Condition: cool and dry. Buttocks are being treated. On 10 10/10/13 at 3:24 a.m. a nurse documented Skin Condition: warm and dry. Treatment to buttocks in place for redness. On 10/11/13 at 4:22 p.m. a nurse documented Skin Condition: warm and dry. At 1:58 p.m. another nurse documented Skin Condition: Intact and no open sores. At 10:36 p.m. another nurse documented the resident's skin condition as intact. On 10/12/13 at 4:20 a.m. a nurse documented the resident's skin condition as pale pink, warm and dry. Skin intact with various bruises in stages of healing. At 3:34 p.m. another nurse documented Skin Condition: skin intact but does have some bruising to extremities. On 10/13/13 at 4:19 a.m. a nurse documented the resident's skin condition as warm and dry. Scattered bruising to extremities and abdomen. On 10/14/13 at 4:26 p.m. a nurse documented Skin Condition: intact, no open sores. At 10:19 p.m. another nurse, Staff C documented Skin Condition: warm and dry pale in color large purple bruise noted on left hip and another one behind knee also has a bruise on right hip yellow purple in color. Staff C also documented resident ate independently in the dining room. Resident pleasant and cooperative. Resident voiced no pain complaints this shift. On 10/15/13 at 12:07 a.m. Staff C documented the resident's mouth began to bleed after supper. Resident bleeding from the front four bottom teeth. Ice applied and mouth rinsed out. Call placed to this resident's physician. New orders received and noted to hold [MEDICATION NAME] 10/15/13 and roll up gauze and place in front of teeth to put pressure on the area also need to draw labs in morning, a CBC, BMP, and a [MEDICATION NAME] in the morning. Resident notified of new orders, will have day nurse contact family. The next entry dated 10/15/13 at 12:48 a.m. Staff C documented new order received and noted to send resident to emergency room to evaluate and treat mouth bleed. Ambulance here to pick up resident, his/her family notified. Family to meet resident at the hospital. The medication record for October 2013 showed Resident #7 received 4 mg of [MEDICATION NAME] every day from 10/1/13 to 10/14/13. The medication record also identified Resident #7 received 81 mg of Aspirin every day from 10/1/13 to 10/14/13. Interviews: When interviewed on 10/23/13 at 5:15 p.m. Staff C (LPN) stated she had worked at this facility for the past [AGE] years. She stated on 10/14/13 the resident was a little confused at supper time. After supper staff reported the resident was bleeding from his/her gums. She had the resident rinse out his/her mouth. She noted the resident's teeth were bleeding. She stated the resident began bleeding about 7:00 p.m. She stated she could not get the bleeding to stop. She then called the physician who ordered special gauze to pack along the resident's gums to stop the bleeding. Staff C denied recalling the name of the special gauze the physician ordered. She stated she did not have the item the physician ordered so she just rolled up regular gauze. Staff C stated due to this resident was on Skilled Care they completed assessments every shift. She assessed this resident on the afternoon shift (2:00 p.m. to 10:00 p.m.). She noted the resident had bruises to the right hip and behind the knee and the left hip. She informed two other nurses, Staff A and Staff B of the bruises. They looked at the bruises and decided the bruises were from the lift they used to transfer this resident. Staff C denied ever seeing this resident's lab/blood work results on 10/1/13. Staff C then reviewed the progress note for 10/1/13 and then she stated when she received the PTT results, she thought it was a PT/INR. Staff C stated it never occurred to her to look to see if the blood work was for what the physician ordered. Staff C stated on 10/4/13 she documented this resident's skin was pale in color. The nurse stated she documented the resident's skin condition based on what the nursing assistants told her. Staff C stated on 10/14/13 she performed this resident's skilled assessment about 10:00 p.m. and she failed to document anything about this resident's bleeding mouth. When interviewed on 10/23/13 at 5:40 p.m. Staff A stated she was in charge of making sure all lab work was drawn as ordered. She stated she did not work the floor as a nurse, her duties included lab work, MDS assessments and care plans. She stated she was informed Resident #7 needed an INR drawn on 10/1/13. Staff A stated she filled out the lab slip and she may have checked the PTT in error (verse PT/INR). She denied having any system in place to check to see if what lab was drawn matched what the physician ordered. Staff A stated it never occurred to her that this resident was on [MEDICATION NAME] and required his/her INR monitored and his/her [MEDICATION NAME] regulated according to the INR results. Staff A stated she was informed of this resident's bruising on 10/14/13. She stated before supper she looked at the resident's bruising. She stated she knew he/she was on [MEDICATION NAME] and she believed the bruising was caused from the lift sling they used to transfer the resident. Staff A stated she was first aware that she had failed to draw the correct test, the INR when she was completing her assessment for the resident's 5-day MDS assessment. She was reviewing the resident's record. She knew it was the wrong test, however she saw where the physician wrote no new orders on the PTT results so she did not believe she needed to notify the physician of her error. When interviewed on 10/24/13 at 11:55 a.m. a licensed practical nurse, Staff B stated she was in the building on 9/29/13. She assisted with the readmission for Resident #7. She knew he/she was on [MEDICATION NAME]. They had received word from the hospital on [DATE] of this resident's pending re-admission to the facility on [DATE]. She called the hospital on [DATE] and asked the hospital to fax the resident's readmission orders [REDACTED]. She then informed the charge nurse that she had entered the resident's new orders. Staff B stated she could not recall what she did about the resident's new order for lab work INR to be drawn on 10/1/13. Staff B stated protocol would be for her to make out a lab slip for the order, however she denied recalling if she made out a lab slip or not. She stated that is why the nurses double check orders. She left it up to the charge nurse to double check her work to ensure she noted the new orders correctly. Staff B went on to say that on 10/14/13 another nurse asked her to come and look at this resident's bruises. The resident had a bruise on the right hip, a bruise on the right leg, and the left side. A purple bruise that extended from the hip to the mid-thigh on the right. The resident also had a bruise that went from the side of the hip to the middle of the abdomen. She did not check the resident's torso, chest or back, or the knee. She did not think these bruises were significant. She just thought they needed to be more careful. She never thought about the fact the resident was on [MEDICATION NAME]. They did not discuss the [MEDICATION NAME]. On a scale of one to ten with ten being the most severe, she rated the bruises at a six. They did not discuss calling the physician. She observed these bruises around 3:00 p.m. When interviewed on 10/24/13 at 10:00 a.m. Staff A stated on 10/1/13 she was not aware of the physician's orders [REDACTED]. A Hospital History and Physical (H & P) dated 10/15/13 noted this resident's gums began to bleed after supper. The nursing home tried ice, pressure and gauze, however continued to ooze. The resident had not had this before but it was persistent. The H & P noted because the resident was on [MEDICATION NAME] and bleeding, he/she was sent to the emergency room . The resident had been discharged from the hospital (previously) on 9/29/13 after having [MEDICAL CONDITION] and flash [MEDICAL CONDITIONS] and was to have an INR in two days (10/1/13) after discharge. For some reason this did not occur. He/she was on [MEDICATION NAME] for [MEDICAL CONDITION]. The resident had two large bruises on the hips. The patient, a very pleasant, alert and oriented elderly patient was in no acute distress. The assessment documented the following: initial blood pressure: 170/100; diffuse ooze of blood in mouth; heart irregular with a murmur. He/she had numerous petechiae and purpura on his/her upper extremities. He/she had a very large bruise on left iliac crest which was old but it had an indurated, firm area that measured 7 by 4 centimeter (cm). He/she had more fresh bruises on right thigh extending nearly to the knee. Laboratory and diagnostic studies included: INR of 23.9. Assessment: inadvertent over-anticoagulation [MEDICATION NAME] toxicity. For whatever reason, he/she did not have his/her safety check of the [MEDICATION NAME], although it was requested to do so on discharge instructions from the last hospitalization . Plan: will give him/her Vitamin K, follow the INR, follow hematocrit. Will hold off fresh frozen plasma given recent history of flash [MEDICAL CONDITIONS]. Hospital Laboratory dated 10/15/13 at 1:30 a.m. revealed this resident's [MEDICATION NAME] registered 231.6 Critically High with reference range of 9.30 to 10.70. The INR registered 23.9 with preferred ranges of 2.0 to 3.0 and 2.0 to 3.5 for Acute [MEDICAL CONDITION] Infarction. laboratory results dated [DATE] at 12:54 a.m. revealed HGB (hemoglobin) low at 13.1, HCT (hematocrit) low at 39.2%. No standards provided on this report. Laboratory comparative report included: INR tested 16.8 on 10/15/13 at 9:40 a.m., and 5.4 on 10/16/13 at 5:20 a.m. [MEDICATION NAME] tested 163.8 10/15/13 at 9:40 a.m., 53.6 on 10/16/13 at 5:20 a.m., 16.4 on 10/17/13 at 5:05 a.m., 14.2 on 10/22/13 at 5:05 a.m. with reference range 9.3 to 10.7. Hospital Physician Progress Record dated 10/16/13 noted this resident received second dose of Vitamin K on 10/15/13 due to INR 16.8. The decision was to give Vitamin K over fresh frozen plasma due to recent history of flash [MEDICAL CONDITIONS]. Bleeding of the gums had slowed down somewhat. Assessment: [MEDICATION NAME] ([MEDICATION NAME]) toxicity causing over-anticoagulation. Hospital Physician Progress Record dated 10/17/13 documented this resident more confused. Blood pressure 79/29 in one arm and 76/26 in the other. Heart rate 96, irregularly irregular. Assessment: hypertension. The physician documented he/she thought the resident was bleeding somewhere. The resident still had very large bruises. The report revealed the resident's primary physician stated he/she would not put this resident on any anticoagulation therapy due to the risk far outweighed the benefit. Hospital Physician Progress Record dated 10/18/13 included urine test was negative, irregularly irregular heart rate with a 2 to 3 systolic murmur. Patient required significant fluids and 2 units of blood on 10/17/13. Assessment included: [MEDICATION NAME] toxicity, treated with Vitamin K. Acute blood loss [MEDICAL CONDITION]. [MEDICAL CONDITION] ischemia. The events of yesterday did strain his/her heart. Hospital Physician Progress Record dated 10/19/13 included resident more confused. The patient continued with diffuse bruising noted throughout. Assessment included: [MEDICAL CONDITION] ischemia secondary to cardiac strain. Plan: continue monitoring in ICU (intensive care unit). There was a question about whether to restart the [MEDICATION NAME] however the physician did not feel comfortable with that due to all the bleeding the resident had. The resident's potassium continues to be low, will add a potassium supplement and will check a urine test to rule out any underlying infection. Hospital Physician Progress Record dated 10/20/13 noted the resident had a rough day 10/19/13 and a rough night. The resident was very agitated and almost belligerent to the staff he/she was so upset. More problems with confusion. Family is concerned about the confusion. Physician believed it was likely ICU [MEDICAL CONDITION]. Assessment: [MEDICATION NAME] toxicity, acute blood loss, ICU [MEDICAL CONDITION], chronic systolic heart failure, [MEDICAL CONDITION] and elevated heart rate. Plan: due to continued heart rates in the 110's and 120's will keep resident in the ICU. Hospital Physician Progress Record dated 10/21/13 the resident did not have a good night. His/her heart rate went up to the 140's. Having more ectopy. He/she did not tolerate Nitro at all. He/she became diaphoretic, more trouble breathing, mottled to the waist. He/she was mottled to the knees. The assessment documented it appeared that the resident had a cardiac event. Hospital Physician Progress Record dated 10/22/13 the resident's family reported the resident stated he/she wanted to go. The resident's prognosis was grave. The family was leaning towards comfort measures, oxygen, [MEDICATION NAME] if needed. Family would like the resident and spouse to be together. The physician documented he/she would try and arrange getting the resident and spouse together. The spouse was also hospitalized . A hospital physician order [REDACTED]. Hospital Physician Progress Record dated 10/23/13 noted they transferred the resident to another floor for comfort care and to share a room with his/her spouse. The resident was pretty much unresponsive however when they put his/her spouse's hand in his/hers, the resident woke up and was able to talk, family members were present. The resident required [MEDICATION NAME] and had a quiet night. Assessment: He/she is frankly moribund. He/she had the large hematomas from over-anticoagulation. He/she had [MEDICAL CONDITION] with rapid ventricular response, [MEDICAL CONDITION] infarction, flash [MEDICAL CONDITIONS]. After discussion with family, he/she changed to comfort care. Will continue oxygen, [MEDICATION NAME] if needed, good local care. Not going to do routine vitals. No further labs. The physician did not expect resident to regain consciousness. Hospital Death Summary dated 10/23/13 noted the resident admitted to the hospital due to over anticoagulation. The patient was admitted to the intensive care unit, given Vitamin K, and monitored carefully. The bleeding had stabilized. He/she unfortunately developed [MEDICAL CONDITION] with rapid ventricular response, [MEDICAL CONDITIONS], after a cardiac event. This progressed. He/she became less responsive. After discussion with the family, determination for comfort care was made on 10/22/13. He passed away very peacefully on the morning of 10/23/13. When interviewed on 10/23/13 at 1:30 p.m. the resident's family member(s) stated the facility did not inform them of the resident's bruising. When the resident came to the hospital they went to give him/her a shot in the hip when they found the very large bruise on the hip. They would have wanted to know about the bruises right away. The nursing home called them the day after the resident was admitted to the hospital and told them it was all a human error. The family stated they had concerns about the resident's increased confusion and they had asked the facility to obtain a urine test one week before they got it. The family believed everything that happened to the resident, occurred due to the [MEDICATION NAME] and the facility's failure to check the INR, assess the resident and keep the physician updated. When interviewed on 10/24/13 at noon, this resident's primary physician stated when this resident left the hospital, the cardiologist ordered the facility to obtain an INR on 10/1/13. The facility got a PTT instead. The physician stated he/she asked the hospital to take pictures of this resident's bruises due to they were horrible. The physician stated the facility called him/her on 10/15/13 about the bleeding in the mouth at about 12:30 a.m. The physician stated the nurse who called did not know if the resident was on [MEDICATION NAME] or not, she had to go and check. The nurse did not tell the physician the resident's mouth had been bleeding since 7:00 p.m.. The physician would have expected the facility to call him/her if the bleeding did not stop in 30 to 60 minutes. The physician stated he/she had never seen an INR that high. He/she would have expected the facility nurses to call him/her right away when the resident began to have bruising. The physician also would have expected the nurses to inform him/her of the error in obtaining the INR. The physician believed this resident's INR was probably going up right away and was probably elevated when he/she first began to show signs of bruising. The physician stated the resident's death was a direct result of the [MEDICATION NAME] toxicity and the stress it caused on the heart. The stress caused a multi-system failure. When interviewed on 10/22/13 at 11:45 a.m. the facility's consultant pharmacist stated he/she had never seen any [MEDICATION NAME] or INR as high as this resident's. He/she also stated PTT tests for blood clotting with use of [MEDICATION NAME] and PT/INR tests for patients on [MEDICATION NAME] and they are not interchangeable. When interviewed on 11/6/13 at 11:30 a.m. a registered nurse, Staff I stated she normally worked the day shift, 6:00 a.m. to 2:00 p.m. She was assigned to Resident #7 on 10/11/13. Review of the computerized Progress Notes for 10/11/13 Staff I documented at 1:58 p.m. Skin Condition: intact and no open area. During this interview, Staff I stated she did not perform a skin assessment that day. She stated the only skin she observed would have been what skin was exposed such as face and hands. The computerized Progress Note for 10/14/13 at 2:46 p.m. noted Staff I documented Skin Condition: Intact, no open areas. During this interview, Staff I stated on 10/14/13 she did not do a skin assessment prior to documenting this skilled nursing assessment. Staff I stated her normal routine for documentation on skilled nursing residents was not to complete skin assessments. She stated normally she would ask the nursing assistants if there were any concerns she needed to be aware of. Staff I stated she worked the day shift on 10/14/13. A certified nursing assistant came to her and stated the resident had a bruise. She went to the resident's bathroom and noted a bruise from the resident's left hip down to the knee and purple areas on the arms. The resident informed her he/she was having pain in his/her shoulder and the lift sling caused pain in the shoulder. When interviewed again on 11/6/13 at 4:07 p.m. Staff I stated she continues to not look at residents skins prior to documenting skin assessments. She also stated it was the day shift aides who informed her of the resident's bruise on 10/14/13. When interviewed on 11/7/13 at 7:35 a.m. a registered nurse, Staff J stated the first time she took care of the resident after his/her hospitalization she noticed his/her abdomen and hip were bruised. The resident returned from the hospital with flash [MEDICAL CONDITIONS] and on [MEDICATION NAME]. The resident's condition had deteriorated, he/she was not as cooperative, he/she no longer put on their call light to summon assistance to the bathroom and required check and change every two hours. She noticed the abdominal bruising and assumed it was due to Levonox injections. She never measured the bruising, she never completed skin assessment sheets and she never filled out physician notification sheets or notified the physician of these new bruises. She stated he/she had a couple bruises on the abdomen, maybe the size of a fist and the hip had a bruise that was maybe 8 inches by 3 inches. Review of the computer Progress Notes revealed on 10/6/13 at 2:32 a.m. Staff J documented Skin Condition: pink, warm and dry with various bruises on torso (main part of the body) and extremities. On 10/7/13 at 2:10 a.m. Staff J documented Skin Condition: pink, warm, dry and intact with multiple old bruises in stages of healing especially to extremities (arm and legs) and torso. On 10/12/13 at 4:20 a.m. Staff J documented Skin Condition: pale pink, warm and dry. Skin intact with various bruises in stage of healing. When interviewed on 11/7/13 at 8:30 a.m. a certified nursing assistant, Staff K stated she worked the day shift on 10/14/13. She noticed a bruise on the resident extending from the hip to the thigh. Another staff member told her it was a bruise from a fall. She was worried about the bruise due to it appeared to be spreading. It was dark purple in color at the top of the bruise and then turned green on the lower end. She also noted bruising on the abdomen and on the arms. She stated nurses did not normally ask her about resident skins, however there was an area on the computer where the nursing assistants document skin conditions such as bruises. According to a reference article titled, National Medical Policy, by Health Net, updated January 2013; the Scientific Rational Initial section revealed the following; "[MEDICATION NAME] is an oral compound of significant medical importance ...It decrease the tendency of the blood to clot, and is very potent in doing so. However, it is a medication that must be taken maintained within the therapeutic range to minimize adverse events associated with inadequate or excessive anticoagulation such as serious bleeding or [MEDICAL CONDITION] events. Monitoring of the PT or INR is recommended to ensure that the dose levels remain within the therapeutic range." According to another reference, INR by the Heart Rhythm Society, " The higher the INR, the longer it takes for blood to clot. If the INR is too high, there is a risk of uncontrolled bleeding. Report any unusual bleeding or bruising to your prescribing physician. " A typed statement dated 10/15/13 with the DON (Director of Nursing) name revealed the following: It was brought to my attention that Resident #7 had been admitted to the hospital due to [MEDICATION NAME] toxicity. Upon investigation it was discovered that Resident #7 returned to the facility on [DATE] with new orders for [MEDICATION NAME] 4 mg daily and orders to check a PT/INR on 10/1/13. On 10/1/13, a PTT was drawn and results were sent to the physician and returned with no new orders. Resident #7 continued to receive [MEDICATION NAME] 4 mg daily. On the night of October 14, 2013, the resident was noted with

Based on observation, clinical record review and staff interviews, the facility failed to direct nursing services to ensure three of four residents received adequate supervision with equipment to protect against hazards and failed to implement care plan directives to meet residents safety needs. Concerns noted for Residents #1, #2 and #4. The facility reported a census of 97 residents. Findings include: 1. Review of the Admission Record for Resident #1 revealed an admission date of [DATE]. The admission [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment tool dated [DATE] scored this resident a 9 out of 15 on a cognitive test. The resident experienced hallucinations and delusions. The resident rejected care and wandered. The resident walked and transferred him/herself independently. The resident required limited assistance with personal hygiene and bathing. Active [DIAGNOSES REDACTED]. This assessment noted this resident experienced falls while in the facility. This resident weighed 170 pounds. The assessment documented Resident #1 used a walker when walking. A Psychiatrist note dated [DATE] identified Resident #1 left the nursing home for a walk on his/her own. The staff believed he/she was a little more confused than usual. A Psychiatrist note dated [DATE] indicated staff reported the resident had been out walking around the facility late at night looking for his/her baby. The resident admitted to occasional hallucinations and seeing their deceased spouse. The psychiatrist's assessment revealed the resident had episodic psychosis particularly at night. The Psychiatrist identified he's concerned these episodes of nocturnal agitation could cause (him/her) to injure (him/herself) inadvertently. The resident's [DIAGNOSES REDACTED]. A Social Service Progress Note dated [DATE] at 9:18 a.m. documented Resident #1 as alert and oriented. BIMS score of 9 reflecting a decline from 11, still indicating moderate cognitive impairment. The resident continued to have intermittent confusion with disorganized thinking. The resident stated he/she was unsure why he/she had trouble falling. Staff report resident's delusions continue about spouse still being alive, his/her going home and working and about his/her children doing things for him/her. Resident #1's Plan of Care noted he/she moved to the nursing home after falling at home and suffering a traumatic brain injury. The care plan goal noted Resident #1 sometimes experienced intermittent disorientation and his/her neuropsychologist recommended that he/she not live independently. The interventions directed staff to allow independence as possible in the facility. This intervention was revised on [DATE]. Another intervention dated [DATE] directed staff when he/she showed signs of increase confusion please remind him/her to ask staff for assistance. The resident ' s goal dated [DATE] noted he/she had an increased risk for falls related to his/her history of falls and some of the medications he/she takes and the interventions directed staff to remind Resident #1 to use his/her call light for assistance if needed. The Plan of Care listed Resident #1's falls under the word " Incident". The list included the following falls and interventions: a.) [DATE] fall with injury; a new intervention dated [DATE] instructed the staff to provide this resident assistance of one person as resident allows. b.) [DATE] fall without injury; intervention non-skid footwear on when up as allows. c.) [DATE] fall without injury; a new intervention dated [DATE] instructed the staff to educate the resident to use the call light. d.) [DATE] fall without injury; intervention to check through the night. e.) [DATE] fall without injury; intervention to reposition lamp to left side of chair so he/she can reach the lamp. f.) [DATE] fall without injury; a newer intervention dated [DATE] instructed the staff to utilize a pressure alarm on this resident when in bed or up in chair. g.) [DATE] fall with major injury; the intervention identified sent to ER for evaluation and treatment. The plan of care also noted a problem with memory deficits due to a head injury. Another problem read, "I suffered a traumatic brain injury." One intervention for this problem dated [DATE] read "Please continue to allow me to be as independent as possible." One intervention dated [DATE] read, "Please continue to reassure me and reorient me when I am confused." Another intervention dated [DATE] read, "When I am showing signs of increased confusion please offer me assistance." One problem listed on this plan of care read," I have intermittent confusion at times and occasionally have delusional thinking. My confusion increases with infections." Review of the nursing Progress Notes revealed the following: [DATE] at 8:55 p.m. resident found on the floor in bedroom. Resident lost balance, fell backwards, and complained of right wrist pain. The nurse assessed Resident #1's and determined rotation of his/her wrist caused pain. On [DATE] 12:01 a.m. resident's family member arrived at 9:30 p.m. and took resident to the hospital for an x-ray. On [DATE] at 12:06 a.m. nurse called the hospital for a report of Resident #1. The hospital nurse reported this resident had a fractured wrist. On [DATE] at 12:34 a.m. resident returned to the facility. Encouraged resident to call for assistance with transfers or needs. [DATE] at 1:47 p.m. resident walks independently with walker. [DATE] at 10:12 p.m. resident elevated right arm on pillows most of the shift. Resident needs assistance with dressing, toileting and walking. Resident cannot walk safely without assistance due to he/she cannot hang onto the walker. [DATE] at 1:17 p.m. resident continues to walk throughout facility. [DATE] at 1:42 p.m. resident returned from physician with new orders. These orders included: keep cast dry, keep right hand elevated above the elbow daily to relieve swelling, okay to move right fingers as tolerates and do simple cares but no lifting, no work, no vigorous activity, be careful and avoid repeat falls/injuries. [DATE] at 4:46 a.m. resident has been observed up with walker independently to walk about several times during the night. Encouraged to call for assistance. [DATE] at 6:19 p.m. resident confused, states going home. Sat out in dining room with coat waiting for family to come. Insistent that he/she is leaving, becomes agitated if try to reason with him/her. [DATE] at 10:12 p.m. continues to walk independently with his/her walker, even though it has been discouraged and to use wheelchair. [DATE] at 3:24 p.m. returned from physician visit with a new order for resident to use the walker for short distances, use wheelchair for longer distances. [DATE] at 8:20 a.m. resident found sitting on floor in bedroom. [DATE] at 4:52 a.m. resident non-compliant using call light to request assistance from staff and has been observed several times out walking in the hall. [DATE] at 6:21 p.m. resident complained of increased discomfort on left side above hip. [DATE] at 11:49 p.m. resident complains of left side pain and had a four inch by one inch faint bruise below ribs. [DATE] at 11:59 p.m. resident remains on skilled level of care post aspiration pneumonia, resident requires assistance with cares, is on a walk to dine program and other times uses a wheelchair. (When interviewed on [DATE] at 11:00 a.m. the Administrator stated this entry must be a mistake due to this resident was never on skilled services and she believes this must be a mistake.) [DATE] at 12:29 a.m. resident complained of left rib pain and mild right wrist throbbing. Encouraged resident to use call light and resident complied. [DATE] at 7:28 a.m. resident does not use call light to summon help and gets up and walks by self to bathroom. [DATE] at 4:55 a.m. resident out in hallway with walker several times during the first part of the night, talking about going home. Resident accepted a narcotic medication, Vicodin for right arm discomfort and encouraged to call for assistance when needing to get up. Cast to right arm intact. [DATE] at 3:06 a.m. resident noted sitting in room-mates recliner chair with closet open. When questioned stated is packing to leave. Encouraged resident to rest a little more due to it being in the middle of the night. Using walker without difficulty though does so independently without asking for help. [DATE] at 12:13 p.m. resident refused breakfast, lunch, noon medication and shower thus far, resident lying in bed. [DATE] at 12:02 a.m. resident up independently throughout facility with walker. On [DATE] at 1:22 a.m. resident was found on the floor in his/her bedroom. Resident #1 reported he/she got on his/her knees to straighten his/her pad on his/her bed and then just had to sit down. The resident denies hitting his/her head or bumping his/her cast. The nurse assessed the resident and noted no skin tears, bruises or bumps. [DATE] at 3:55 p.m. Resident #1 up per usual routine, no complaint of pain or discomfort. [DATE] at 11:04 p.m. at 7:30 p.m. roommate called nurse to room. Found resident on the floor. Stated he/she tried to turn off reading light, was too far away, and lost balance. [DATE] at 5:38 p.m. resident able to dress self and walks about facility independently. [DATE] at 9:25 p.m. resident complains of low back pain and right abdominal pain from fall yesterday. [DATE] at 7:10 a.m. resident rested well after pain pill and warm pack given for complaint of right arm and lower back discomfort. Resident up independently with walker. [DATE] at 4:10 a.m. resident up wandering the halls occasionally through the night. Needing to be reminded and redirected back to room. [DATE] at 4:02 p.m. Staff A documented she visited with Resident #1 in his/her room regarding his/her new pressure alarm. Staff A documented the alarm was sounding when she entered and Resident #1 had been standing at his/her beside table. Staff A documented she explained the reason for the alarm and Resident #1 informed her, "You don't think I know how to turn that damn thing off, I sure as hell do. Staff A documented Resident #1 has been noncompliant with the alarm, turning it off, walking in room frequently this early p.m. Staff reported they are checking Resident #1, and when the alarm was off, they turn it back on. [DATE] at 6:35 p.m. Staff A documented when checking on resident the alarms were off. Staff turned the resident's alarm back on prior to going on their break. The other nursing assistant was in another resident's bedroom. A nurse heard a sound and saw this resident sitting on the floor outside of the bedroom door. [DATE] 4:30 p.m. (Late Entry by Staff A) when it was noted that this resident was turning off his/her alarms this nurse spoke with the resident, explaining that alarms were for his/her safety and protection. The nurse alerted hall staff (nursing assistants) that the resident was able to turn off his/her alarms and needed closer monitoring through the shift. [DATE] at 5:26 p.m. Staff B documented resident found lying on the floor in bedroom doorway, was unresponsive to verbal and painful stimuli. Resident assisted to the floor and in a supine position with neck immobilization maintained due to the fall was unwitnessed. Resident then opened eyes and complained of hip pain. [DATE] at 10:58 p.m. Late entry for 7:30 p.m. call from the hospital, this resident had a hip fracture and is to have surgery in the morning. Review of the Incident/Accident reports for this resident, revealed he/she fell eleven (11) times in his/her bedroom from [DATE] through [DATE]. A review of the following Incident/Accident Reports identified the following: [DATE] at 8:00 p.m. staff summoned to this resident's bedroom, by the resident's roommate. Resident on the floor. Resident reported he/she lost his/her balance and fell to the floor. [DATE] at 8:30 p.m. this resident's roommate came to the nurse and reported Resident #1 had fallen. The report identified Resident #1 had been found on the floor. Resident reported losing his/her balance while pulling down bedcovers. Complains of right wrist pain. New Intervention dated [DATE]: One assist with transfers and walking. A Major Injury Determination Form dated [DATE] noted this resident sustained [REDACTED]. A Doctor/Facility Communication Form dated [DATE] noted this resident sustained [REDACTED]. A second Doctor/Facility Communication Form dated [DATE] gave new orders/instructions. These new orders included: no lifting/no strenuous work, he/she can use a walker for transfers/ambulation for shorter distances and use a wheelchair for longer distances. [DATE] at 11:41 a.m. resident found sitting on the floor in his/her room by the bed. A communication sheet sent to the resident's physician dated [DATE] noted the resident fell on [DATE] and began complaining of increased discomfort on the left side above the hip. The resident had a four inch bruise at the site. [DATE] at 1:22 a.m. staff found the resident on the floor in his/her room. [DATE] at 7:30 p.m. resident fell in his/her room. New Interventions: Bed and Chair Pressure Alarm a note added to this report dated [DATE] read, "wrong report" [DATE] at 3:00 a.m. staff found this resident on the floor in his/her bedroom. Review of the clinical record revealed no documentation of this fall, and/or any assessment of the resident at the time of this fall in this resident's clinical record and/or the nurses' progress notes. When interviewed on [DATE] at 11:00 a.m. the Administrator verified the lack of any documentation of this fall in this resident's clinical record, only on the incident report. [DATE] at 4:30 p.m. found this resident on the floor in this resident's bedroom doorway. Injury noted: questionable fractured hip. Left leg rotated outward. Resident stated, "My hip hurts." A History and Physical dated [DATE] noted this resident's medical [DIAGNOSES REDACTED]. The hospital Surgical Center Operative/Procedure Note dated [DATE] documented Resident #1's preoperative [DIAGNOSES REDACTED]. The note identified the resident had postoperative complications. The note identified the [AGE] year-old resident had been falling a lot over time. The resident had fallen at the beginning of February 2013 and fractured his/her right wrist. The resident fell again on [DATE]. He/she was able to stand and walk on the left hip. The resident then arrived in the emergency room . X-rays of the left hip revealed a left hip fracture that was comminuted, angulated and displaced. The resident was placed in the ICU (intensive care unit) and then subsequently coded and CPR (cardio-pulmonary resuscitation) and resuscitation were started. Two physicians had reviewed with the resident's family members who then understood the next step would be a ventilator. The family members requested no ventilator be applied. The resident then went on showing deterioration without the ventilator and without further CPR resuscitation with the family's request of DNR (do not resuscitate). After approximately one hour, the resident passed away. The hospital Surgical Center Discharge Summary dated [DATE] noted the resident came through his/her surgery okay and really did not have any problems until the end of the surgery when his/her blood pressure abruptly dropped. Two units of blood products were infused as well as some intravenous vasopressors to try and help the blood pressure. He/she was taken to the intensive care unit where he/she lost his/her pulse and code was started. CPR was done including multiple doses of epinephrine and CPR was stopped. He/she did regain a pulse for a short time. Intubation was successful. The resident had an established DNR and the family agreed he/she would not want to be on a ventilator nor aggressive measures done. Therefore, he/she was extubated, and intravenous fluid and blood product infusion was stopped. A Major Injury Determination Form dated [DATE], the Director of Nursing noted Resident #1 resident fell in his/her bedroom and sustained a fractured hip. The resident had gotten up from his/her bed and turned off his/her own alarm. The Director of Nursing documented this resident's previous functional ability included one assistance with staff with walker, at times was independent with walker when non-compliant. The physician documented on [DATE] this incident was a major injury. When interviewed on [DATE] at 3:25 p.m. the Director of Nursing stated this resident had prior falls including a fractured wrist. The resident was pretty independent. He/she needed assistance but would not let people help him/her. The Director of Nursing stated they care planned for this resident to be assisted to prevent other/further falls. Care Plan interventions to decrease this resident's risk for falls included to turn down this resident's bed, walk with this resident with the use of a gait belt. She stated this last intervention was added after the resident fell and broke his/her wrist. Additional interventions included: non-skid strips on the floor, made him/her assistance of one person and frequent checks. The Director of Nursing stated she expected the staff to check on this resident every fifteen to thirty minutes. The Director of Nursing stated she first learned of this resident's 3:00 a.m. fall on [DATE] when she reported to work. They discussed this resident and his/her falls at their QA (quality assurance) meeting that morning and determined an alarm was necessary. They planned to use an alarm on this resident to alert staff should this resident stand up unassisted. The Director of Nursing stated she observed this resident several times that morning in his/her room laying diagonally on the bed and/or sitting on the side of the bed. The Director of Nursing stated she never entered this resident's room and did not check to see if the alarm was turned on or off. The Director of Nursing denied being informed this resident knew how to, and was turning off his/her own alarm. The Director of Nursing left the facility approximately 3:50 p.m. that day. This resident exhibited signs of sundowning. The Director of Nursing noted this resident showed signs of increased confusion in the evenings. The Director of Nursing stated when a resident turns off their own alarm, her expectations would be for the staff to provide closer supervision and remind the resident he/she needs assistance. The Director of Nursing was asked when would she expect the staff to utilize a lock box, a plastic tube, with a lid that locks in place. The Director of Nursing stated she would expect the staff to place a resident's alarm box in one of these lock boxes when they notice a resident either can or does turn off their own alarm. The Director of Nursing stated the staff failed to notify her when they learned this resident was turning off his/her own alarm. She also stated further interventions the staff could have implemented for this resident would have been to notify herself of this resident's ability to turn off the alarm and to move this resident to a public area for closer supervision. When interviewed on [DATE] at 5:40 p.m. a registered nurse, Staff A stated on [DATE] Resident #1 told her he/she knew how to turn off his/her own personal alarm. Staff A found Resident #1 standing unassisted in his/her bedroom on [DATE]. Staff A explained the reason of the alarm to the resident. She then informed the nursing assistants Staff E and Staff J to be very mindful. She stated Staff E and Staff J were busy. She again found this resident standing up unassisted in his/her bedroom. The alarm was not sounding. The resident told her, "I told you." The resident had turned off his/her own alarm. This was approximately 2:30 p.m. Staff A believed the alarm was not effective for this resident, due to the resident knew how to turn the alarm off. Staff A then turned this resident's alarm back on. Staff A reported the alarm used on this resident was easy to turn on and off. Staff A denied implementing any new interventions after she determined this resident could turn off the alarm. Staff reported this resident could be compliant approximately fifty percent of the time. Staff A stated at this time both of the nursing assistants were busy. She instructed the C.N.A.s (certified nursing assistants) to watch the resident closely. Staff A then went to the main/front nurses station to file paper work. Later, approximately 4:00 p.m. she saw another resident standing down this resident's hallway, waiting for the nurse to complete a blood sugar test. Staff A then walked down the hallway. She saw Resident #1 sitting on the floor. She knew right away Resident#1 needed to go to the hospital so she called 911. The resident complained of hip pain. When interviewed on [DATE] at 6:35 p.m. a registered nurse, Staff B stated she was present at the QA meeting on [DATE] when they discussed Resident #1 and his/her falls. Staff B stated they had done everything possible for this resident's safety except to wrap him/her up in bubble wrap. She stated the interventions put in place for this resident prior to this fall was to put safety strips on this resident's bedroom floor, floor mats next to this resident's bed and the use of a pressure alarm on this resident's bed. Staff B stated she was working in her office on [DATE] when she heard something and went to the hallway where she saw Resident #1 standing by his/her bedroom doorframe. No alarms were sounding. No walker in sight. Staff B approached Resident #1 and eased the resident to the floor. Resident #1 was not responding. The resident opened his/her eyes and his/her eyes flipped back and the resident was shaking. No alarms were sounding. She covered the resident with a blanket. The resident's left leg was externally rotated. The resident began to come around. The ambulance crew arrived. Staff B stated prior to this fall, when she would check on this resident, the resident would tell her, she did not need to check the alarm due to she knew how to turn it off. When interviewed on [DATE] at 5:25 p.m. a registered nurse, Staff C stated Resident #1 was pleasantly confused. Staff C stated Resident #1 was on frequent checks due to the resident would attempt to leave the building. This resident had fallen in February and fractured his/her wrist. The resident then used a platform walker. The resident would get up unassisted in his/her bedroom due to their memory loss. The resident could not remember to use a call light. The resident rarely used the call light. Prior to fracturing his/her wrist the resident was independent with cares and walking. The resident could undo the alarms. Interventions they had implemented to decrease this resident's falls were: strips on the floor, new slippers, routine toileting, fifteen minute checks, snacks and the use of different alarms. The resident learned how to turn off the alarms. Staff C stated they were running out of interventions. When interviewed on [DATE] at 7:35 p.m. a licensed practical nurse, Staff D stated Resident #1 was kind of spunky and a little sassy. The resident had a dry sense of humor. The resident was more confused at times. The resident liked to stay in his/her bedroom. Staff D denied remembering if this resident utilized alarms prior to the fall on [DATE]. Staff D stated the facility staff had utilized locked cages to secure alarm boxes on residents who knew how to turn off their alarms. She stated these boxes prevent the residents from turning off their alarms. Staff D denied knowing where these boxes were stored. Staff D stated she would use one of these lock boxes on any resident who knew how to turn off their alarm. When interviewed on [DATE] at 6:10 p.m. a certified nursing assistant (C.N.A.) Staff E stated she was assigned to care for Resident #1 on [DATE]. Staff E stated Resident #1 was a spunky, forgetful resident. The resident had dementia. Prior to fracturing his/her wrist, this resident was independent. They had utilized a pressure alarm on this resident's bed at night. They used the alarm that was easily turned off by sliding a switch over. Staff E stated if residents saw the staff do this over and over, they (the residents) could figure out to turn them off for themselves. Staff E reported to work on [DATE] at 2:00 p.m. On that day, Resident #1 was more confused. The resident was very stubborn. On [DATE] she was very busy assisting residents to the bathroom, answering call lights, and helping residents to the dining room for the evening meal. Resident #1 was turning off his/her alarm. Staff E found the resident in his/her bedroom with the alarm turned off about three times between 3:00 p.m. and 4:00 p.m. Staff E went on her fifteen minute break from 3:45 p.m. until 4:00 p.m. After she returned from break her partner went on her break. Staff E went into another resident's bedroom to assist the other resident. Staff E stated they had five or six residents on that hallway that night who used alarms. That evening there were two C.N.A.s assigned to Resident #1's hallway. At 4:00 p.m. she was assisting another resident, her partner was on break and the nurse was busy. When she came out of the other resident's bedroom she saw Resident #1 lying on the floor in the hallway. The resident was complaining of his/her leg hurting. No walker was in sight. Staff E stated Resident #1 required one on one supervision that evening due to he/she would not leave the alarm turned on. Staff E had reported her concerns regarding Resident #1 to the charge nurse, prior to this fall. The nurse told her, "I don't know what we are going to do with (Resident #'1 first name), (he/she) is so ornery." Prior to this fall the resident needed assistance due to he/she was unsteady on his/her feet. When interviewed on [DATE] at 8:10 p.m. a C.N.A. Staff F stated prior to this fall, Resident #1 walked independently in the hallways. They provided supervision of this resident, due to the resident would try to leave the facility. Staff F stated a few other residents use a yellow circular cage they lock the alarm box in to prevent the resident from turning off their alarm. Staff F denied knowing where they store these alarm box cages. Staff F stated if she were caring for a resident who knew how to turn off an alarm, she would try a different kind of alarm. Some alarms turn off by sliding a switch over and some you have to push a button three times. When interviewed on [DATE] at 2:15 p.m. a C.N.A. Staff G stated she cared for this resident on [DATE]. She recalled asking another staff member if they needed to walk with this resident or was the resident independent. The day of this fall, Staff G was assigned to this resident's hallway, however she did not care for this resident. Staff G stated if a resident can turn off an alarm, they put the alarm box in a locked box/cage. When interviewed on [DATE] at 1:40 p.m. a C.N.A. Staff H stated she was assigned to care for Resident #1 the day shift on the day the resident fell . Staff H stated Resident #1 was a little challenging to care for due to he/she would not follow directions. She was informed this resident had fallen during the night. At 6:00 a.m. when she came on duty no alarms were in place for this resident. She was informed they were to walk with this resident. She entered the resident's room. The resident denied needing her assistance, however Staff H stayed in the room and assisted the resident with his/her morning cares. She asked the Director of Nursing what they were to do for this resident, regarding the resident's fall. The Director of Nursing informed the C.N.A., "You know (first name) is not going to be compliant but just watch (him/her). The Director of Nursing informed Staff H they were going to use an alarm on this resident. Staff H then went to the maintenance man and obtained an alarm for this resident's bed and chair. Staff H denied knowing how the resident transferred to and from the dining room that day. After applying the alarms that morning, at approximately 9:00 a.m., Staff H cannot recall caring for this resident again that day. When interviewed on [DATE] at 1:20 p.m. a C.N.A. Staff I stated Resident #1 still tried to be independent even after his/her fall with fractured wrist and still while wearing a cast. Resident #1 was confused on some days. This resident was very adamant and was hard to redirect. Staff I worked as a med aide the day of this fall, on the day shift. Staff I stated no alarms were used on Resident #1 prior to the day of this fall. Staff I does believe this resident was capable of turning off his/her alarm. When residents are known to be able to turn off their alarms, Staff I will report her concern to the Director of Nursing and/or the charge nurse. They have different kinds of alarms to try and they have a yellow cage/box to lock the alarm box up. Staff I stated these yellow lock boxes have saved a lot of falls. When interviewed on [DATE] at 6:50 p.m. a C.N.A. Staff J stated Resident #1 was a very sweet resident, but was very, very hard headed. Resident #1 did not like having an alarm placed on him/her and wanted to be independent. Staff J worked the second shift, 2:00 p.m. to 10:00 p.m. the day Resident #1 fell . The day shift staff informed her Resident #1 now used an alarm. At approximately 2:30 p.m. Staff J checked on this resident. The resident was in his/her room without an alarm on. The resident had taken off his/her alarm and turned the alarm off. She then turned the alarm back on. About four or five times that afternoon, she found Resident #1 four or five times up walking independently in his/her bedroom with the alarm turned off. The resident told Staff J he/she did not need the alarm and he/she did not care if he/she fell and got hurt. Staff J stated she went on her fifteen minute break and when she returned from her break, she saw Resident #1 on the floor in the hallway. The resident's walker was in the resident's bathroom. No alarms were on or sounding. Staff J stated other resident use other types of alarms and some residents utilize a yellow cage to lock up the alarm box to prevent the resident from turning off their own alarm. When interviewed on [DATE] at 8:28 a.m. a C.N.A. Staff K stated she had been assigned to care for Resident #1 on the day shift that the resident had fallen, however she was pulled to work on another hall. Resident #1 wanted to do things for him/herself. Resident #1 was confused. On that day, Resident #1 remained in bed all day, on the day shift, 6:00 a.m. through 2:00 p.m. Staff K stated in the past when residents would turn off their own alarm they would implement other interventions including to place the alarm where the resident could not reach it, to use a seatbelt alarm or to place the alarm box in a yellow cylinder with a lock on it to prevent the resident from turning off the alarm. 2. Review of the Admission Record found in the clinical record revealed Resident #4 admitted to this facility on [DATE]. A Facility Transfer Form dated [DATE] noted this resident transferred from the facility to the hospital due to a fall, pain in right hip and right leg internally rotated. A Care Plan Conference Summary dated [DATE] noted this resident required staff assistance for cares, was incontinent of bowel and bladder, had sustained no falls and utilized a pull away alarm. A Care Plan Conference Summary dated [DATE] noted this resident required staff assistance for cares, was incontinent of bowel and bladder, had sustained falls on 12/

Based on observation, staff and family interview and clinical record review the facility failed to ensure interventions were followed to prevent the development or worsening of pressure sores. The facility reported a census of 86 residents. (Resident # 2, #7 & #9) Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident # 2 had [DIAGNOSES REDACTED]. The MDS also indicated the resident required extensive assistance of one for bed mobility, and at risk for pressure ulcers with no stage one or higher pressure ulcers. A wound clinic care instruction sheet dated 12/7/10, directed the facility to make sure nothing touched the residents heel when in bed, and heel has to be suspended at all times in bed. A podiatry note dated 1/28/10, documented the resident had a left posterior heel decubitus ischemic ulceration (pressure sore) to the posterior heel. A physician order [REDACTED]. A wound clinic recommendation noted 5/24/11, directed the facility to suspend the residents heel whenever he/she would allow, and keep close watch on the right heel as well. A physician order [REDACTED]. A routine physician notification dated 9/14/11, requested a treatment change to the left heel of Safegel wound gel and cover with [MEDICATION NAME], change every three days. The order had been signed by the physician, and noted 9/15/11. The care plan dated 9/19/11 identified a problem of altered skin integrity related to an open area on the left heel. The following interventions directed staff to: a. Remind and encourage to elevate feet. b. Alternating pressure mattress on bed. c. Consult with Registered Dietician as needed. d. Encourage to take in adequate amount of food and fluids. e. Apply treatments as ordered. f. Encourage to allow staff to push in wheel chair. g. Have the wound nurse monitor skin weekly while has open area. h. Follow any treatment/recommendations made by the wound clinic. During an initial tour of the facility on 10/4/11 at 9:48 a.m., Staff O, Registered Nurse, identified the resident as having a vascular ulcer (caused by poor circulation) on the left heel. A skin assessment documented on a non-pressure skin condition report dated 10/5/11, that the resident had a 1.0 cm by 1.0 cm hard calloused area with a 0.5 cm by 0.4 cm depth open area in the center of a wound on the left heel. The form indicated the area had been first observed on 11/25/09. A skin assessment documented on a non-pressure skin condition report dated 10/5/11, indicated the resident had a 1.0 cm by 0.6 cm white hard calloused area with a 0.4 cm by 0.3 cm dark brown area in the center on the right heel. The form indicated the area had been first observed on 9/2/11. On 10/5/11 at 8:25 a.m., observation revealed a large dry erase board with numerous directives for the residents care and routine, which included to turn the resident every two hours. The board also included an entry written on it stating the resident had a red spot on his/her bottom. During the observation, Staff F, Certified Nurse Aide and Staff D, Certified Nurse Aide provided morning cares and positioned the resident in bed on his/her back, with a pillow under his/her feet. On 10/5/11, observation revealed the following; a. At 9:42 a.m., the resident remained on his/her back in bed. b. At 10:10 a.m., the resident remained on his/her back in bed. c. At 10:35 a.m., the resident laid on his/her back in bed. At 10:55 a.m., the resident laid supine (on his/her back) with a pillow under the calves and the bilateral heels resting on the bed. At 11:17 a.m., Staff D entered the room and positioned the resident on his/her left side. On 10/6/11 at 6:45 a.m., the resident laid in bed lying supine as Staff D finished morning cares. Observation revealed the resident had no dressing on the left heel. Staff D positioned the resident on his/her back with a pillow under the calf's and the bilateral bare heels resting on the bed. At 8:30 a.m., the resident remained supine in bed. At 9:40 a.m., the resident remained supine in bed. At 10:00 a.m., Staff B, Registered Nurse, entered the residents room upon the surveyor request to examine the residents heels. Staff B verified the resident had no dressing on the left heel, with both heels bare and resting directly on the bed and a pillow under the calves. Staff B verified the resident should have the heels elevated and should have had a dressing on the left heel. Staff B stated that for all he/she knew the dressing could have been off since the previous evening. Staff B stated the nurse aides were to report to the nurse if a dressing fell off. After retrieving a measuring device, Staff B obtained the following measurements; a. Left heel, 1.2 cm by 1.3 cm white area with a 0.5 cm by 0.6 cm open area in the center, 0.1 cm by 0.1 cm in depth. b. Right heel, 1.7 cm by 1.0 cm white area with a 0.2 cm by 0.3 cm dark area in the center. Upon completing the assessment, Staff B left the resident on his/her back and elevated the bilateral heels on two pillows. At that time the surveyor questioned Staff B if he/she had been assessing the resident ' s bottom as related to the note of a red area written on the dry erase board. Staff B stated they had not been aware the resident had a red area on the coccyx and stated the surveyor should talk with Staff C for information related to this. At 10:12 a.m. on 10/6/2011, Staff B asked Staff R, Licensed Practical Nurse, if he/she had been aware of the fact the resident did not have dressings on the left heel. Staff R reported he/she had not known the resident should have had dressings on, and had not worked on that wing for a long time. During an interview on 10/6/11 at 10:28 a.m., Staff C, Quality Assurance Registered Nurse, stated he/she did not know anything about a red area on the resident ' s bottom. At that time Staff C entered the resident ' s room to assess the coccyx. Staff C measured a 7.5 cm by 15 cm bright red area over the coccyx with 0.1 cm by 0.1 cm open area on the coccyx. Upon completing the assessment the resident had been positioned in a supine position again. Upon exiting the room, the surveyor informed Staff C of the observations of the resident remaining in a supine position, and asked Staff C what the expectation would be for positioning the resident. Staff C replied the resident should be turned from side to back to side. Staff C then gave directives for staff to return to the room and position the resident on his/her side. Review of documentation from the 10:28 a.m. coccyx assessment of the open area on 10/6/2011 revealed it to be documented on a non-pressure skin condition report, but on the sheet indicated the condition to be pressure related. A separate non-pressure skin condition report dated the same day also revealed documentation of the large red area on the resident ' s coccyx. During a family interview on 10/6/11 at 11:30 a.m., the family member stated he/she had noticed a red area on the resident ' s coccyx which had been about the size of a quarter on the evening of 10/4/11, and had reported it to nursing staff. The family member stated the directives had been written on the dry erase board after noting the red area on that evening. The family member stated the resident had no open areas on the coccyx at that time. On 10/7/11 at 1:59 p.m., Staff A, Director of Nursing, indicated he/she had spoken to the nurse who had been on duty the evening of 10/4/11. Staff A provided the surveyor with a written statement from the nurse who indicated the resident had a red area on the right buttock that evening but had no open areas at that time. 2. The Minimum Data Set (MDS) with an assessment dated [DATE]; documented Resident #9 had [DIAGNOSES REDACTED]. The MDS documented the resident had a brief interview for mental status of a score of 10, required extensive assistance with bed mobility, transfers and personal hygiene, and functional limitation in range of motion to lower extremity. The MDS documented resident with an unhealed pressure ulcer and at risk for developing a pressure ulcer. A routine Physician notification form dated 09/15/11, documented area to right bunion healed, to have an order for [REDACTED]. A non-pressure skin condition report with a date first observed 02/09/11, documented medial right foot area, with measurements on these dates: a. 09/22/11 measures 0.1 centimeters (cm) by 0.2 cm, with a scab wound bed. b. 09/28/11 measured 0.1 cm by 0.2 cm, light brown scab with light pink outer edge. c. 10/05/11 measured 2.2 cm by 1.2 cm pinkish, brown, dry scaly area with 0.4 cm by 0.8 cm dark purple area on proximate end and 0.3 cm by 0.5 cm brown intact scab at distal end of wound. The Care plan with a review dated 10/11/11, documented resident with good chance of having skin breakdown due to weight loss, ongoing decline with my dementia and my Parkinson and don't move well anymore. The Approaches: a. Please encourage me to drink the house supplement that the nurses give me every day. b. Please put my blue boots on my feet when I am not walking or when I am resting in my room. c. Please be careful of my right foot. It hurts at times. d. Please talk with the dietician sometimes to see if there is something to help heal my sore. Observation on 10/04/11 at 1:29 p.m., revealed resident sitting in wheelchair in room with tennis shoes on. Observation on 10/04/11 at 3:02 p.m., revealed resident sitting in wheelchair in room with tennis shoes on. Observation on 10/05/11 at 6:30 a.m. Staff P, put white tennis shoes on resident feet and placed on foot pedals. Observation on 10/05/11 at 12:01 p.m., revealed resident sitting in wheelchair at dining room table with tennis shoes on. Observation on 10/05/11 at 1:40 p.m., revealed resident sitting in wheelchair in room with tennis shoes on feet. Observation on 10/06/11 at 1:14 p.m., revealed Staff I and Staff B proceeded to change dressing to resident ' s right medial bunion. Staff I removed the dressing and Staff B stated that the area is worse and there is a dark area that was not there before. Interview on 10/06/11 at 2:00 p.m., Staff B stated that the resident had the tennis shoes on all week and that the area to the right medial bunion only had a scab and that having the tennis shoes on all the time contributed to the bigger area and the bunion getting worse. 3. The minimum data (MDS) for Resident # 7 completed 9/20/11, indicated [DIAGNOSES REDACTED]. The MDS included a cognitive pattern assessment that identified the resident had a behavior described as psychomotor [MEDICAL CONDITION] that included sluggishness, staring into space, staying in one position, and moving very slowly. The MDS revealed the resident required total dependence for bed mobility, transfers, dressing, eating, toileting and hygiene needs. Review of facility skin condition reports from 5/4/11 to 6/22/11 revealed the following assessments of a stage 2 pressure area on the resident's left heel: a. 5/4/11-- Left heel 4 centimeters (cm) by 5 cm purple boggy fluid filled heel b. 5/5/11-- Left heel 4.4 cm by 5.1 cm fluid filled blister appearance c. 5/13/11--Left heel 4.2cm by 5 cm red wound bed d. 5/20/ 11--Left heel 3.1 cm by 2.9 cm dark purple/closed/ intact DTI (deep tissue injury) e. 5/27/11--3.4 cm by 3.0 cm [MEDICATION NAME] ordered 5/24/11 appears DTI/unstageable f. 6/1/11-- 2.3 cm by 3.5 cm DTI/ unstageable/ boggy/ brown/ red skin intact Change orders to leave open to air and relieve pressure g. 6/8/11-- 2.7 cm by 3.6 cm brown/ red/ DTI/ remains unstageable h. 6/11/11-- 2.9 cm by 2.7 cm with 0.7 by 0.9 cm center with small serosanguineous exudate. Wound bed slough i.. 6/22/11-- area healed- will apply skin prep daily to help maintain skin integrity. The resident's plan of care reviewed 7/5/11, included the following approaches: a. Please make sure that I have my prevalon boots on my feet at all times. b. Please make sure that my heels are suspended off of the mattress or recliner with a pillow under my ankles. The resident's treatment record for 10/11, included the following treatments: a. Prevalon boots: on at all times b. Left heel: apply skin prep daily to maintain skin integrity The resident's physician orders [REDACTED]. Observations of the application and use of prevalon boots and usage of pillow to elevate the heels as follows: a. 10/5/11 at 10:50 a.m.--- Provalon boots not on. Resident up in wheelchair. Resi- dent wearing slipper socks with feet on wheelchair pedals. b. 10/5/11 at 3:30 p.m--. Provalon boots not on. No pillow under resident's ankle. Heels resting directly on mattress. c. 10/6/11 at 7:15 a.m.---Provalon boots not on. Resident up in wheelchair. Resident wearing slipper socks with feet resting on pedals. d. 10/6/11 at 8:03 a.m.-- Provalon boots not on. Up in wheelchair. e. 10/6/11 at 9:40 a.m. -- Provalon boots not on. Resident sitting up in recliner. Residents heels resting on recliner footrest. No pillow under resident's ankles. f. 10/6/11 at 10:25 a.m.--Provalon boots not on. Resident sitting up in recliner. No pillow under ankles. Resident's heels resting on recliner footrest. g. 10/6/11 at 11:50 a.m.-- Provalon boots not on. Resident up in wheelchair. Feet resting on wheelchair pedals. h. 10/6/11 at 1:25 p.m.-- Provalon boots not on. Resident up in wheelchair. Feet resting on wheelchair pedals. i. 10/6/11 at 2:20 p.m.--Provalon boots not on. Resident up in recliner in room. Socks on feet and feet resting on recliner footrest. No pillow present under the ankles. j. 10/6/11 at 4:15 p.m.--Provalon boots not on. Resident up in wheelchair with feet resting on wheelchair pedals. Resident wearing socks only. j. 10 /7/11 at 7:20 a.m.--Provalon boots not on. Resident up in wheelchair with bare feet resting on wheelchair pedals. An interview with Staff C (Quality Assurance Registered Nurse) on 10/7/11, at 8:50 a.m., indicated the expectation would be for the Provlone boots to be on according to the care plan.