Every finding on record at Accura Healthcare of Milford

Based on employee file review, staff interview, and policy review, the facility failed to complete a criminal record check and dependent adult/child abuse registry check prior to an employee's hire date for 1 of 5 employee. The facility reported a census of 43. Findings include: Employee record review of Staff A, dietary aide, showed a hire date of 3/6/24. A Parental Consent for a Minor was signed by Staff A's mother on 3/7/24, which gave the facility permission to complete a criminal and abuse background check. Staff A's Single Contact License and Background Check was completed on 3/19/24 at 3:38 PM. Review of Staff A's time card revealed a total of five shifts worked prior to the completion of the background check (3/6/24, 3/10/24, 3/11/24, 3/13/24, and 3/16/24). The facility policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy states that the facility will conduct an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to residents, prior to hire, in the manner prescribed under 481 Iowa Administrative Code S 58.11(3). During an interview on 8/13/24 at 3:00 PM, the Administrator acknowledged that the criminal and dependent adult/child abuse registry check was not completed prior to Staff A's hire date nor prior to working shifts.

Based on clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch for in 4 out of 13 sampled residents reviewed for comprehensive care plans (Resident #9, #18, #25 and #32). The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 documented diagnoses of anxiety disorder, depression and Alzheimer ' s Disease.The MDS showed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Review of the May 2023 Medication Administration Record (MAR) revealed the following orders: Remeron (antidepressant medication) daily with an order date of 10/25/22. Risperidone (antipsychotic medication) daily with an order date of 12/26/22. Review of the MDS dated [DATE] revealed antipsychotic and antidepressant medication taken 7 out of 7 days in the look back period. Review of the Medication Review Report signed 3/28/23 revealed the following orders: Remeron daily with an start date of 10/25/22. Risperidone daily with an start date of 12/26/22. Review of the current care plan undated lacked information regarding the usage and side effects of antipsychotic and antidepressant medication. 2. The MDS assessment dated [DATE] for Resident #18 documented diagnoses of major depressive disorder, anxiety disorder and posttraumatic stress disorder.The MDS showed a BIMS score of 13 indicating no cognitive impairment. Review of the May 2023 Medication Administration Record (MAR) revealed the following orders: Duloxetine (antidepressant medication) daily with an order date of 1/26/23. Bupropion (antidepressant medication) daily with an order date of 1/26/23. Lantus (insulin) daily with an order date of 3/4/23. Review of the MDS dated [DATE] revealed antidepressant medication and insulin injections taken 7 out of 7 days in the look back period. Review of the Medication Review Report signed 3/28/23 revealed the following orders: Duloxetine daily with a start date of 1/26/23. Bupropion daily with a start date of 1/26/23. Lantus daily with a start date of 3/4/23. Review of the current care plan undated lacked information regarding the usage and side effects of antidepressant medication and insulin. 3. The MDS assessment dated [DATE] for Resident #25 documented diagnoses of major depressive disorder, anxiety disorder and hypertension.The MDS showed a BIMS score of 0 indicating severe cognitive impairment. Review of the May 2023 Medication Administration Record (MAR) revealed the following orders: Furosemide (diuretic medication) daily with an order date of 10/26/19. Sertraline (antidepressant medication) daily with an order date of 11/2/22. Tramadol (pain medication) twice a day with an order date of 2/21/23. Morphine Sulfate (pain medication) every 2 hours as needed with an order date of 5/3/23 with a discontinuation date of 5/12/23. Morphine Sulfate (pain medication) every 2 hours as needed with an order date of 5/12/23. Review of the MDS dated [DATE] revealed antidepressant medication and diuretics taken 7 out of 7 days in the look back period. Review of the Medication Review Report signed 3/28/23 revealed the following orders: Furosemide daily with a start date of 10/26/19. Sertraline daily with an order date of 11/2/22. Tramadol 2 times a day with a start date of 2/21/23. Review of the current care plan undated lacked information regarding the usage and side effects to watch for with antidepressant medication, diuretic medication and pain medication. 44475 4. The MDS for Resident #32 dated 3/10/23 revealed a BIMS score of 4 which indicated severely impaired cognition. The MDS revealed the resident had diagnoses of depression, anxiety, and dementia. The MDS revealed the resident took medications for depression and an anti-psychotic. The LTC (Long Term Care) Progress Note signed by a physician on 4/5/23 revealed orders for the following medications: a. Citalopram 20 mg PO (by mouth) daily. b. Lorazepam 0.5 mg PO BID (twice daily) PRN (as needed). c. Quetiapine 25 rng tablet PO bedtime. d. Trazodone 50 mg tablet PO bedtime. The Care Plan with an initiated date of 6/9/22 lacked side effects of the resident's high risk medications. In an interview on 5/16/23 at 2:26 PM, the Director of Nursing (DON) reported that she would expect side effects of high risk medications to be on resident's care plans. In an interview on 5/17/23 at 12:27 PM, the DON reported the facility does not have a policy regarding care plans, they follow regulations.

Based on observation, facility policy, and staff interview, the facility failed to transport linen in a manner to prevent contamination. The facility reported a census of 38 residents. Findings include: Observation on 5/17/23 at 11:53 AM of a cart in the 100 hall with resident clothing hanging on it, a staff person was delivering clothing from this cart into resident rooms. There was no cover on the cart or near the cart. Observation on 5/17/23 at 12:16 PM of a cart in the 200 hall with resident clothing hanging on it, a staff person was delivering clothing from this cart into resident rooms. There was no cover on the cart or near the cart. Observation on 5/17/23 at 1:47 PM of towels on an uncovered cart in the 200 hall. In an interview on 5/17/23 at 12:36 PM, the Environmental Services Supervisor (ESS) reported that she has had this position at the facility for 1 month, she had previously worked at the facility for the past 2 years in a different position and has never been told or observed laundry be covered while transported within the facility. In the same interview, the ESS reported that the only cart that is covered to transport clean laundry within the facility is used to deliver washcloths and hand towels to resident rooms. The Laundry Department policy with a revision date of 6/21/21 lacked direction on the transportation of clean laundry. In an interview on 5/18/23 at 11:19 AM, the facility's Infectoin Preventionist reported that the facility has never covered their clean laundry carts and agreed that they should be covered.

Based on clinical record, facility policy, and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for 1 of 13 residents reviewed (Resident #24). The facility reported a census of 38 residents. Findings include: The MDS for Resident #24 dated 4/29/23 revealed a Brief Interview of Mental Status score of 7 which indicated severely impaired cognition. The MDS revealed the resident had diagnoses of stroke, diabetes mellitus, dysphagia (difficulty swallowing), dysarthria (difficulty speaking), and anarthria (inability to speak). The MDS revealed the resident required the extensive assistance of 1 person with eating. The MDS revealed the resident did not have have a feeding tube or a mechanically altered diet. The Medication Review Report signed by a physician on 3/28/23 revealed orders for: 1. Honey thick liquids. No solid diet at this time. Must be fully upright for all intake, liquids via spoon or cup. If resident is having trouble initiating swallowing or expressing pain with swallow, please stop intake for that meal. Start date 3/16/23. 2. Nutren 2.0 Oral Liquid (Nutritional Supplements) give 250 milliliters (mL) via g-tube (gastrostomy tube) 3 times a day for tube feedings. Water flush with 60 mL before and after feedings and/medications. The Rehab Communication on 3/20/23 revealed ST (speech therapist) recommends pureed solids and honey thick liquids. In an interview on 5/17/23 at 4:13 PM, the Director of Nursing (DON) reported that the Registered Dietician (RD) completed the section of the MDS in which the feeding tube or a mechanically altered diet were not correctly assessed. When asked if it is the responsibility of the nurse that signs the MDS assessment to ensure the MDS assessment was completely accurately, the DON reported it was. In the same interview, the DON reported the facility does not a policy regarding MDS assessments and that she would do a modification to the 4/29/23 MDS submission.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the PreAdmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 residents reviewed for PASRR requirements, (Resident #18). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #18 documented diagnoses of major depressive disorder, anxiety disorder and posttraumatic stress disorder.The MDS showed a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. Review of the clinical record revealed a Notice of Negative Level I Screen Outcome dated 1/25/23 revealed the PASRR level 1 screen remains valid for your stay at the nursing facility and should be transferred with you if you relocate. No further level 1 screening is required unless you are known to have or are suspected of having a major mental illness or an intellectual or developmental disability and exhibit a significant change in treatment needs. Further review revealed question #1- Check any or all of the following mental health conditions that are diagnosed or suspected for this individual now or in the past listed depression or depression disorder. Review of the MDS dated [DATE] revealed an active diagnosis of major depressive disorder, anxiety disorder and posttraumatic stress disorder. Review of the Medication Review Report signed 3/28/23 revealed the following diagnosis of major depressive disorder, anxiety disorder and posttraumatic stress disorder. Review of Resident #18 ' s chart lacked a follow-up and resubmission of a PASRR with the diagnosis of major depressive disorder, anxiety disorder and posttraumatic stress disorder. The facility revealed there is no policy on PASRR and they follow the PASRR recommendations. Interview on 5/17/23 at 2:34 p.m., wth the Social Worker revealed Resident #18 ' s PASRR will be redone to include the diagnosis.

Based on clinical record, facility policy, and staff interview, the facility failed to develop a care plan to include side effects of high risk medications for 1 of 5 residents reviewed (Resident #28). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) for Resident #28 dated 4/18/23 revealed a Brief Interview of Mental Status (BIMS) score of 4 which indicated severely impaired cognition. The MDS revealed the resident had diagnoses of hip and knee replacement, hypertension (high blood pressure), arthritis, asphasia (inability to speak), and low back pain. The MDS revealed the resident diuretic and opioid medications. The Medication Review Report signed by a physician on 4/13/23 revealed orders for: 1. Furosemide oral 20 milligrams (mg) give 20 mg by mouth one time a day related to essential (primary) hypertension with a start date of 4/12/23. 2. Hydrocodone-acetaminophen oral tablet 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for pain related to displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing with a start date of 4/11/23. 3. Hydrocodone-acetaminophen oral tablet 7.5-325 mg give 2 tablets by mouth every 6 hours as needed for pain related to displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing with a start date of 4/11/23. The Care Plan with an initiated date of 4/11/23 lacked side effects of furosemide and hydrocodone-acetaminophen. In an interview on 5/16/23 at 2:26 PM, the Director of Nursing (DON) reported that she would expect side effects of high risk medications to be on resident's care plans. In an interview on 5/17/23 at 12:27 PM, the DON reported the facility does not have a policy regarding care plans, they follow regulations.

Based on observation, clinical record, facility policy, resident interview, and staff interview, the facility failed to obtain a physician order for a medication and permitted a resident to self administer a medication without assessment or physician order for 1 of 13 residents reviewed (Resident #140). The facility failed to obtain a physician order for a mechanically altered diet for 1 of 1 resident reviewed (Resident #24). The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #140 dated 5/9/23 revealed the resident had a Brief Interview of Mental Status (BIMS) of 15 which indicated intact cognition. The MDS revealed the resident's primary medical condition was aftercare following explantation of shoulder joint prosthesis and had upper extremity impairment on 1 side. Observation on 5/15/23 at 12:25 PM of 2 bottles of over the counter eye drops in clearly visible on the resident's bedside table. In an interview on 5/15/23 at 12:25 PM, the resident reported that he brought the eyedrops into the facility and they (facility staff) know about it. The Clinical Record lacked an order for the eye drops and an order that the resident could self administer the eye drops. In an interview on 5/16/23 at 2:26 PM, the Director of Nursing (DON) reported that the eye drops were not in the resident's possession when he was admitted to the facility, if the resident's family brought them into the facility, they did not report it and the facility would have no way of knowing the resident had eye drops in his room. When asked if the resident told staff about the eye drops, the DON reported that she did not know anything about it. In an interview on 5/17/23 at 12:27 PM, the DON reported that the facility does not have a policy regarding self administration of medication, that they follow regulations. 2. The MDS for Resident #24 dated 4/29/23 revealed a Brief Interview of Mental Status score of 7 which indicated severely impaired cognition. The MDS revealed the resident had diagnoses of stroke, diabetes mellitus, dysphagia (difficulty swallowing), dysarthria (difficulty speaking), and anarthria (inability to speak). The MDS revealed the resident required the extensive assistance of 1 person with eating. The Medication Review Report signed by a physician on 3/28/23 revealed orders for honey thick liquids. No solid diet at this time. Must be fully upright for all intake, liquids via spoon or cup. If resident is having trouble initiating swallowing or expressing pain with swallow, please stop intake for that meal. Start date 3/16/23. The Rehab Communication on 3/20/23 revealed ST (speech therapist) recommends pureed solids and honey thick liquids. This Rehab Communication did not have a physician signature. The Clinical Record lacked a physician signed order for a pureed diet after 3/20/23. In an interview on 5/17/23 at 4:13 PM, when asked what the definition of a no solid foods order was, the Director of Nursing (DON) reported that it would mean the resident was to have a pureed diet and that puree food was not considered solid food. In the same interview, the DON reported that the process she had in place to ensure a resident's diet order was correct failed and that the facility did not have a policy regarding what different diet orders were defined as to know for sure what the definition of a no solid food diet was. In an interview on 5/17/23 at 4:19 PM, the Registered Dietician (RD) reported that in her time practicing as an RD, she has never seen an order for no solid foods, that if she saw an order written that way she would assume it meant the resident was to have a mechanically soft diet.

Based on observation, clinical record, and staff interview, the facility failed to serve the correct consistency of food for 1 of 1 resident reviewed (Resident #24). The MDS for Resident #24 dated 4/29/23 revealed a Brief Interview of Mental Status score of 7 which indicated severely impaired cognition. The MDS revealed the resident had diagnoses of stroke, diabetes mellitus, dysphagia (difficulty swallowing), dysarthria (difficulty speaking), and anarthria (inability to speak). The MDS revealed the resident required the extensive assistance of 1 person with eating. Observation on 5/17/23 at 12:24 PM revealed the resident ate pureed food for lunch with visible pieces of corn in the puree. The Week 5 Wednesday puree menu for the noon meal revealed pureed cream corn was served. In an interview on 5/17/23 at 5:06 PM the Registered Dietician reported that pureed foods should be applesauce to mashed potato consistency with no pieces of food recognizable from its original form. She provided education to the Certified Dietary Manager (CDM) last week on the consistency food should be in for puree.

Based on observation, facility policy, and staff interview, the facility failed to store dishware, utensils, and cooking equipment in a sanitary manner; store canned food off of the storage room floor; maintain and clean the range and oven unit including hood and vents; store a scoop outside the container. The facility reported a census of 37 residents. Findings include: Observation on 1/31/22 at 10:57 AM revealed the majority of the dishware, silverware, and cooking equipment stored on open shelves throughout the kitchen stored with the serving side up, cooking equipment (pots and pans) not stored upside down, and silverware or utensils without coverings or lids. Observation on 1/31/22 at 10:57 AM revealed 2 flats of canned food with 12 cans per flat stored on the floor of a dry storage room. Observation on 1/31/22 at 10:57 AM revealed inside of the oven with brown or black grime, dried food crumbs covering the entire surface of the collection tray under the range, 2 layers of peeling paint on hood with the original metal of the hood exposed, and a black substance speckling the vents. Observation on 1/31/22 at 10:57 AM revealed a scoop stored inside a Thick and Easy Thickener container. Observation on 2/1/22 at 12:27 PM revealed no change in the observations from 1/31/22. The Kitchen Cleaning Checklist for 12/21 revealed the task for grill/stove pull out-change foil was performed by the DM on 12/31/21. The Cleaning Instruction: Hoods and Filters policy dated 2013 directed stove hoods and filters will be cleaned according to the cleaning schedule, or at least monthly and that hoods and filters should be cleaned professionally at least yearly. The Cleaning Instructions: Ovens policy dated 2013 directed ovens will be cleaned as needed and according to the cleaning schedule (at least once every two weeks). Spills and food particles will removed after each use. The Cleaning Instructions: Ranges policy dated 2013 directed the range will be cleaned after each use. In an interview on 2/1/22 at 12:48 PM, the Dietary Manager (DM) reported the items stored in the kitchen should be stored upside down to prevent debris from falling onto the food service or preparation areas; silverware and utensils should be stored covered or with lids on containers; canned food should be stored off the floor; the vents are cleaned by a contracted service every six months and that the vents look as usual to her, she has never worked in a kitchen with a painted hood and agreed that peeling paint could fall onto the range or flat top area, she cleans the range and oven monthly with the last cleaning performed between Christmas and New Year's; she agreed that scoops should not be stored inside containers.

Based on observations, facility policy review, resident interviews, and staff interviews the facility failed to prevent the possible spread of infection by not performing hand hygiene for 5 out 5 residents reviewed, (Residents #3, #15, #16, #19, #20). The facility reported a census of 37 residents. Findings: 1.) The Minimum Data Set (MDS) assessment dated [DATE] for Resident #19 identified the presence of short and long-term memory impairment. The resident depended on staff for bed mobility, transfer, dressing, toilet use and personal hygiene. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan revised 12/9/21 identified Resident #19 had an activity of daily living (ADL) deficit. The Care Plan directed staff to use a restorative dining program for prompts and cues and assist the resident as needed to complete meals. On 1/31/22 at 12:35 PM, Staff D, Certified Nursing Assistant (CNA), was observed feeding Resident #19 bites of food and held her straw as the resident drank liquids. Staff D left the table to assist Resident #20 to cut food into bite sized pieces. Staff D then assisted Resident #3 and Resident #15 to take bites of food before she returned and continued to feed Resident #19. Staff D failed to use hand hygiene between residents. In an interview on 2/2/22 at 2:35 PM, the Administrator acknowledged Staff D should have performed hand hygiene before she assisted another resident. 2) According to the MDS assessment dated [DATE] Resident #16 scored 4 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident depended on staff for bed mobility, transfer, dressing, toilet use and personal hygiene. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The current Care Plan revised 11/19/21 identified the resident had an activity of daily living (ADL) deficit due to general weakness and declining mobility, changes in hands from arthritis, stiffness and contracture in fingers, and a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included assisting with peri-cares 2 times a day and as needed. On 2/1/22 at 12:45 p.m. Staff B CNA and Staff A CNA went the to resident's room to do care. Staff transferred the resident to bed with the total mechanical lift. Staff pulled the resident's pants down and rolled her to her left to get the lift pad out. Staff A did incontinent care in the front, then rolled the resident to her left and and wiped the anal area of some bowel movement (bm) smear. Staff B removed her gloves, then assisted putting a new pad on the resident, pulling the resident's shirt down, and touched the residents hands, before doing hand hand hygiene herself. The resident received no hand hygiene. 3) According to the MDS assessment dated [DATE] Resident #19 scored 00 on the BIMS indicating severe cognitive impairment. The resident required extensive assistance for transfer, toilet use and personal hygiene. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Care Plan identified the resident had an ADL deficit due to a history of [CONDITION(S)], dated 8/20/21. The interventions included assisting the resident to the toilet and transferring to her recliner after meals. On 2/1/22 at 12:58 p.m. Staff B and Staff A took the resident to her room. The resident said she had to go to the bathroom. They visited with the resident waiting for the the resident's roommate. When the roommate finished the 2 staff assisted Resident #19 to stand with a gait belt and walker, walked her to the bathroom, and assisted her to sit on the toilet. The resident's incontinent pad was wet, and she did go on the toilet. The staff assisted the resident stand and Staff B did incontinent care. Staff B changed her gloves with no hand hygiene and pulled up the residents incontinent pad, pants, and pulled her shirt down. The Nurse Consultant brought the geri chair to the bathroom door because the resident was tired. They wheeled the resident to her recliner and assisted her in the chair. On 2/2/22 at 9:45 a.m. Staff C Licensed Practical Nurse (LPN)/Infection Preventionist obtained the facility policy (for hand hygiene) which directed staff should always complete hand hygiene before donning gloves and after removing gloves. Staff C stated they should do hand hygiene after they removed gloves, before doing other tasks, and between glove changes. The facility Hand Hygiene policy updated 6/21/21 directed staff should always complete hand hygiene before putting on gloves and after removing gloves. The Center for Disease Control (CDC) Clean Hands Count for Healthcare Providers included doing hand hygiene immediately before touching a patient, after touching a patient or the patient's immediate environment, and immediately after glove removal. 4. Observation on 1/31/22 at 12:24 PM revealed Staff A, CNA, assist Resident #24 with lunch, then assisted Resident #17 to cut her food before assistance was resumed with Resident #24. Staff A did not perform hand hygiene in between assisting the 2 residents.

Based on observation, record review and staff interview, the facility failed to assure curtains were closed when providing personal care for 1 of 4 residents reviewed, (Resident #16). The facility reported a census of 37 residents. Findings include: According to the Minimum Data Set assessment dated [DATE] Resident #16 scored 4 on the Brief Interview for Mental Status indicating severe cognitive impairment. The resident depended on staff for bed mobility, transfer, dressing, toilet use and personal hygiene. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The current Care Plan revised 11/19/21 identified the resident had an activity of daily living (ADL) deficit due to general weakness and declining mobility, changes in hands from arthritis, stiffness and contracture in fingers, and a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included assisting with peri-cares 2 times a day and as needed. On 2/1/22 at 12:45 p.m. Staff B Certified Nursing Assistant (CNA) and Staff A CNA went the to resident's room to do care. Staff transferred the resident to bed with the total mechanical lift. Staff pulled the resident's pants down and rolled to her left to get the lift pad out. Staff A did incontinent care in the front, then rolled the resident to her left and and wiped the anal area of some bowel movement smear. The curtain to the window remained open to the parking lot. On 2/2/22 at 9:45 a.m. Staff C Licensed Practical Nurse (LPN) stated the curtains to the windows should be closed during personal care.

Based on clinical record and staff interview, the facility failed notify the resident or the resident's representative of the facility policy for bed hold, including reserve bed payment for 1 of 2 residents reviewed, (Resident #33). The facility reported a census of 37 residents. Findings include: The clinical record for Resident #33 revealed he was hospitalized on [DATE]. In an interview on 2/2/22 at 10:39 AM, the Administrator reported he was unable to locate the bed hold notification for the resident's hospitalization that occurred on 12/25/21.

Based on record review and staff interview the facility failed to provide Notice of Bed Hold Policy for one of one resident reviewed, (Resident #30). The facility reported a census of 44 residents. Findings include: According to the Minimum Data Set with assessment reference date 7/17/19 Resident #30 had a BIMS score of 15, cognitively intact skills for daily decsion making. The Progress Notes dated 7/30/19 showed the resident had been admitted to the hospital on [DATE]. Resident #30's clinical record lacked documentation to show the Notice of Bed Hold Policy had been provided. During interview on 8/20/19 at 2:30 PM the Administrator stated the facility did not have documentation to show the resident or the residents representative had received Notice of Bed Hold Policy for Resident #30's admission to the hospital on [DATE].

Based on observations, interviews, and record review the facility failed to provide appropriate and sufficient treatment for [REDACTED].#20). The facility reported a census of 44. Findings include: The Minimum Data Set with a completed Assessment Reference Date of 6/21/19 showed a Brief Interview for Mental Status score of 00, indicating severe cognitive impairment. The resident had [DIAGNOSES REDACTED]. The resident took antibiotics for seven of the seven days in the lookback period. Resident #20's Medication Administration Record [REDACTED]. On 8/19/19 at 2:22 PM, observed staff assisting the resident into a wheelchair, holding the catheter up into the air behind the resident's back to prevent the tubing from touching the floor. During an observation on 8/20/19 at 1:38 PM, noted the resident's catheter bag in a privacy bag hanging from the garbage container next to the resident's recliner. During an observation on 8/21/19 at 8:59 AM, observed the resident sitting in the recliner with feet reclined and catheter bag in a privacy bag hanging from the garbage can next to the recliner. On 8/21/19 at 10:59 AM, observed the resident sitting in his wheelchair in the front lobby area looking out the window. The resident's catheter was in a privacy bag hanging from the wheelchair. The privacy bag was sitting on the floor with the catheter tubing and clip to attach the catheter laying on the floor. During an interview on 8/21/19 at 1:05 PM Staff A, Certified Nurses' Aide, reported she would typically hang the resident's catheter gravity bag on the side of the recliner so it would be low. She stated she would not hang the catheter on the garbage can for storage. During an interview on 8/21/19 at 1:14 PM, the Director of Nursing reported the CNA's are to have the catheter off the floor. She stated sometimes they would hang the catheter from the recliner or the garbage can.

Based on observations, record reviews, and interviews the facility failed to complete assessments to determine continued usage of side rails or consents to use side rails for 3 of 6 residents reviewed (Residents #27, #2 and #29). The facility reported a census of 44. Findings include: 1. The Minimum Data Set (MDS) completed for Resident #27 with an Assessment Reference Date (ARD) of 7/12/19 showed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The resident had [DIAGNOSES REDACTED]. During an observation on 8/19/19 at 2:12 PM noted a side rail to the resident's bed. The chart lacked documentation of a side rail assessment. Resident #27's Care Plan lacked documentation of side rails. 2. The MDS completed for Resident #2 with an ARD of 8/9/19 showed a BIMS score of 00, indicating severe cognitive impairment. The resident had [DIAGNOSES REDACTED]. During an observation on 8/19/19 at 2:57 PM noted side rails bilaterally to the bed in the upright position. Resident #2's chart lacked documentation of side rail assessments and lacked documentation of consent to use side rails. 3. The MDS completed for Resident #29 with an ARD of 7/12/19 showed a BIMS score of 7, indicating severe cognitive impairment. The resident had [DIAGNOSES REDACTED]. During an observation on 8/19/19 at 1:38 PM observed a loop rail in an upright position to the resident's bed. Review of Resident #29's clinical record showed the last completed side rail assessment and consent for use was 3/16/18. During an interview on 8/20/19 at 3:36 PM, the Director of Nursing reported not all of the current residents had a side rail consent completed. She stated side rail assessments were not completed quarterly and she would be correcting that before the survey team leaves.

Based on interviews and record review the facility failed to complete a gradual dose reduction review for the [MEDICAL CONDITION] medication ([MEDICATION NAME]) for 1 of 5 residents reviewed (Resident #5). The facility reported a census of 44. Findings include: The Minimum Data Set completed with an Assessment Reference Date of 8/9/19 showed a Brief Interview for Mental Status score of 15, indicating intact cognition. The resident used antipsychotic, antianxiety, and antidepressant medications for seven of the seven days in the lookback period. The resident had [DIAGNOSES REDACTED]. The History and Physical form completed on 7/7/16 indicated the resident had [MEDICAL CONDITION]. The document showed the treatment for [REDACTED]. Resident #5's Medication Administration Record [REDACTED]. The chart lacked documentation regarding a gradual dose reduction review for [MEDICATION NAME]. During an interview on 8/20/19 at 1:43 PM, the DON reported the consultant pharmacist stated due to the medication being used to treat [MEDICAL CONDITION] the medicine did not require a GDR and the pharmacist would bring documentation on their next visit to the facility.

Based on observation and interviews with residents and staff the facility failed to assure milk served at safe temperatures. The facility reported a census of 47 residents. Findings included: During observation on 05/15/18 at 11:44 AM a cart sat in the kitchen with multiple glasses of milk and juices poured. The glasses sat without ice or refrigeration. At 11:49 AM staff brought the cart to the dining room and distributed the beverages among the tables. Three white milk and 1 chocolate milk were placed at seats with no residents present. At 12:12 PM 1 chocolate and 1 white milk remained on the tables with no residents present. At 12:12 PM Resident #33 came to the table with the white milk. On request the Dietary Manager measured the temperature of the milk 57.4 degrees Fahrenheit. She stated the temperature of the milk should be 40 degrees or less. During confidential group interview on 05/15/18 at 10:12 AM 4 of 4 residents stated they had occasions when milk and coffee had been placed at the table prior to their arrival. They stated the milk got warm and coffee cold. They agreed it would be better to serve them after residents arrived in the dining room.

Based on record review, interviews, and facility policy, the facility failed to immediately separate a staff after an allegation of alleged abuse and failed to report an allegation of abuse timely to the Department of Inspections and Appeals for 1 of 5 residents (Resident #5). The facility identified a census of 44 current residents. Findings include: According to Minimum Data Set ((MDS) dated [DATE] Resident #5 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs (brief interview for mental status) score of 0 which indicated severe cognitive impairment. According to the MDS the resident required extensive assistance with bed mobility, transfers, dressing, eating and toilet use. The care plan dated 3/19/15 directed staff to assist the resident with completing all daily cares and to provide with gentle distraction to let participate. During an interview with Hospice RN (Registered Nurse) on 12/9/16 at 2:10 PM she stated she received a call from the resident's family on Tuesday 12/6/16) evening after 6:00 PM. The family member reported an allegation of abuse that reported to her on 12/4/16. She stated she did not call the facility to report the allegation until the next morning at approximately 10:00 AM. She further stated she felt the resident had been safe and did not call due to the people to address it were not at the facility. Review of the Employee Schedule dated 12/6/16 revealed Staff P, CNA (certified nursing assistant) continued to worked the 2:00 PM to 10:00 PM shift on the West hall and had not been separated from residents. During an interview with the Director of Nursing on 12/9/16 at 2:30 PM she concurred Staff P had been on the schedule and worked the evening of 12/6/16 from 2:00 PM to 10:00 PM. Review of the Policy and Procedure titled Abuse Prevention, Identification, Investigation, and Reporting Policy dated 11/2016 directed staff to do the following: a. All allegations of resident abuse should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Director of Nursing, Administrator or designated representative. b. Should an incident or suspected incident of Resident abuse be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident. c. Upon receiving a report of an allegation of resident abuse, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: suspending the employee; segregating the employee to an area with no contact with any residents of the facility; separating the employee accused of abuse from the resident alleged to have been abuse. d. The staff member or employee shall immediately notify the person in charge or the person's designated agent who shall then notify the Iowa Department of Inspections & Appeals immediately, and in no event later than 24 hours of any allegation even on a weekend or holiday.

Based on record review and staff interview the facility failed to provide timely and complete assessment for residents with change in condition for 1 of 5 residents reviewed. (Resident #4) The facility identified a census of 44 current residents. Findings include: 1. According to MDS (minimum data set) dated 10/2016 Resident #4 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs (brief interview for mental status) of 13 which indicated intact cognition. According to the MDS the resident required extensive assistance with bed mobility, transfers, dressing and toilet use. Review of the care plan dated 10/13/16 directed staff to monitor lung sounds, vital signs and report any abnormal findings to the Doctor. The care plan also directed staff to the resident requested cardiopulmonary resuscitation and to keep the Doctor and family informed of changes in health and to respect the health care choices. Review of the Progress Notes dated 10/28/16 at 5:51 PM revealed the resident displayed increased weakness. When administered the evening medication, the resident had difficulty sucking water through a straw. With continued encouragement, resident eventually able to complete task. The resident also required increased assistance for transfers and cares during the shift. Mechanical lift utilized by the CNAs (certified nursing assistant) Resident noted to have difficulty supporting own weight while sitting in the recliner and falls to the right side. Pillows placed to support the resident. Resident refused to drink supplemental shake or eat anything despite multiple attempts with encouragement. Resident's speech quiet and indiscernible. Eyes shut the majority of the shift. Spoke with resident's daughter earlier in the shift regarding condition. Will continue to monitor and notify family and physician if condition changes. Vitals signs: T (temperature) 96.4, P (pulse) 81, R (respirations) 24, O2 (oxygen saturation) 96% and BP (blood pressure) 156/87. At 7:05 PM staff documented a call received from the Hospice nurse and will come to the facility tomorrow (10/28/16) between 8:00 and 10:00 AM. Review of the Progress Notes dated 10/29/16 at 3:35 AM revealed the resident had mild dyspnea on moderate exertion. No transfer or ambulation occurred during the shift. Incontinent of bladder and speech incoherent at times. Review of the Progress Notes dated 10/29/16 at 10:19 AM revealed the resident awake at 8:00 AM with his/her eyes fixed and not blinking. He/she did not verbally respond but grunts. Arms flaccid bilaterally and pupils reactive and equal. Vital signs: T 98.6, P 65, R 22, O2 98% and BP 124/76. Bowel sounds times 4 quadrants and wheezes on expiration. At 8:45 AM hospice arrived and assessed the resident and vital signs stable. Family requested the resident go to the hospital for testing. At 9:40 AM paramedics leave the facility with the resident by ambulance. Review of the Weights and Vitals Summary revealed the facility failed to further document vital signs or assessment from 10/28/16 5:51 PM through 10/29/16 at 8:00 AM. When interview on 12/8/16, at 4:30 PM Staff F, RN (Registered Nurse) stated she was not real familiar with Resident #4 and she had received report the hospice nurse was coming to evaluate Resident #4 for admit. At approximately 7:00 AM the CNAs reported the resident acting different than normal. She stated she went to the resident right away and assessed the resident's vital signs; the resident's vital signs were normal but the resident did not respond. Staff F stated she called the family and told them the resident was not responding and the hospice nurse was coming and they may went to come. The hospice nurse assessed the resident and stated the resident not a candidate to admit and she called the Doctor. The resident transported to the hospital. During an interview with Staff K, RN on 12/9/16 at 9:14 AM she stated the resident had been off and had sunken checks and pale. The resident had difficulty suctioning a straw. She did vital signs and had been normal, lung sounds were full, which had not been a new finding. She talked to family, Director of Nursing and hospice. She stated the resident responded very soft and tracked with his/her eyes just fine. She further stated she did not feel the resident had an acute change and family was looking into hospice.

Based on observation and staff interview the facility failed to assure food is prepared and served in a manner to minimize the risk of food borne illness. The facility reported a census of 48 residents. Findings include: On 4/21/15, observation of the prep and serving of the noon meal revealed Staff C washed her hands at the handwashing sink three times. a. The first 2 time Staff C lathered her hands and rinsed her hands, got paper towels from the automatic dispenser, turned the water off with the paper towel and then dried her hands with the contaminated paper towel. b. The third time Staff C washed her hands she turned the water off with her bare hands and then dried her hands with the contaminated paper towel. Staff C pureed one serving of broccoli, she turned the machine on with her hand. Staff C used a spatula to push the button to turn the machine off and then used the spatula to spoon the broccoli out into a bowl. During the meal service Staff C opened a drawer with her hand and grabbed an 8 ounce ladle by the bowl, Staff C then placed the contaminated ladle into the soup container on the steam table. When interviewed on 4/22/15, at 3:10 p.m., the Dietary Manager stated she would expect staff to dry their hands with the paper towel prior to turning off the faucet.

Based on observation, clinical record review, and interviews with staff, family and resident, the facility failed to ensure one of four residents received adequate supervision and implement interventions for safety (Resident #1). Record review identified the resident's care plan intervention for safety had been discontinued on 2/20/13. Record review determined the resident required assistances out of bed and his/her balance not steady. On 2/25/13, Resident #1 received his/her medication from a nurse who left before ensuring the resident had swallowed his/her medications. The resident stood up to pick up a pill he/she thought had dropped and lost his/her balance and fell to the floor. The resident sustained [REDACTED]. The resident's family stated his/her safety intervention should not have been discontinued and observation showed the care plan intervention not implemented. The facility reported a census of 44 residents. Findings include: 1. A hospital History and Physical (H&P) dated 11/13/12 noted Resident #1 was taken to the emergency room after being found unresponsive outside his/her home. The resident was found on the driveway after suffering a syncopal episode. The local hospital identified two small areas of subarachnoid bleeding in the brain. The medical history included a resection of a glio[DIAGNOSES REDACTED] (cancer) of the brain in 2002. The resident received chemotherapy and radiation therapy following the craniotomy; then developed subsequent epilepsy. The H& P noted the resident's family reported the resident had progressive forgetfulness and episodic disorientation over the past year. The family identified the resident's gait seemed less steady and he/she had fallen at least 2 to 3 times in the past six months at home. The family felt the resident had deteriorated neurologically. A CT scan identified intracranial hemorrhage, subdural hematoma, hemorrhage and chronic ischemic changes. The physician's assessment included a history of progressive memory deficit and episodic confusion as well as balance and gait instability for the past year and a half. A hospital Progress Note dated 11/20/12 included the following [DIAGNOSES REDACTED]. This resident's admission record revealed an admitted to this facility on 11/23/12. A Nursing assessment dated [DATE] noted Resident #1 required the assistance of two persons with transfers and walking, a history of falls, injuries related to falls and cognitive impairment. Record review identified Resident #1 did not have a physician's orders [REDACTED]. The Admission Care Plan dated 11/23/12 noted he/she required the assistance of two persons, a gait belt and a walker for transfers and walking. The plan of care instructed the staff to use a person alarm at all times. A communication report to this resident's physician on 11/28/12 reported on 11/28/12 at 9:58 p.m. staff responded to the sound of this resident's personal alarm sounding. Staff found this resident on the floor with the call light and personal alarm attached to the resident's shirt. The resident stated, "I was trying to get into my chair and didn't make it. I'm not hurt I just want to get in my chair." The nurse provided education and explained the resident should wait for the staff to assist him/her with transfers for good safety measures. The resident stated, "I'm ok I feel fine. I will try to wait next time." A CAA (Care Area Assessment) dated 12/6/12 noted this resident had a recent fall with a brain bleed, the resident responds and moves slowly, the resident transfers with staff assistance, gait belt and walker, the resident experienced generalized weakness, poor balance, and impulsiveness. A Rehab Communications report dated 12/17/12 instructed the staff to provide minimal assistance of one person, a walker and a gait belt for walking and personal cares in the bathroom. A hospital Consultation report dated 1/9/13 noted this resident sustained [REDACTED]. A CT approximately two weeks ago showed continued increasing size of the subdural hematomas. The resident admitted for evacuation of these with burr holes of these hematomas. The resident noted fatigue that had been going on longer than November. The resident had minimal exercise capacity secondary to deconditioning. He/she noted chronic difficulties with deconditioning following his/her glio[DIAGNOSES REDACTED] surgery about 10 to [AGE] years ago and again acute illness in November, An Operative Report dated 1/10/13 noted the subdural hematoma was enlarging in size and measured 13 mm (millimeters) in thickness. An Admission Care Plan dated 1/14/13 noted the resident required the assistance of two persons for walking and instructed the staff to use a personal alarm for the resident. A communication sheet sent to this resident's physician on 1/24/13 updated the physician of his/her poor participation or improvement with therapies, the resident's increased lethargy, increased edema in both legs, back pain, redness between the legs and a weight of 212.4 pounds. A Rehab Communications report dated 1/24/13 noted the resident required moderate assistance of one person for walking and transfers. An Occupational Therapy note dated 2/1/13 identified the resident continued to require assistance with dressing, toileting and cues for safety. The therapist identified precautions were necessary to address falls, the resident's impulsive, slow processing, confusion and shortness of breath. A Communication Sheet sent to the resident's physician on 2/4/13 informed the physician he/she continued to receive Hydrocortisone cream to upper legs twice a day for redness since 1/24/13. The resident diagnosed with [REDACTED]. No improvement with redness and continues to be tender. A Communication Sheet sent on 2/5/13 to the resident's physician noted because of the resident's medical condition he/she was not progressing with therapies. The physician discontinued skilled nursing services and ordered the resident to return to skilled therapy services when medical condition allowed increased participation. A Physical Therapy note dated 2/5/13 identified Resident#1 required contact guard assistance with sit to stand transfer. The resident walked sixty feet three times with some shortness of breath, elevated heart rate and a drop of oxygen saturation rate to 88%. The therapist noted the resident became very pale and short of breath. The therapist wrote, "I do not feel safe ambulating the resident with bilateral blood clots." A Physical Therapy Progress Discharge Summary dated 2/7/13 noted Resident #1 had been removed from skilled care due to bilateral blood clots and decrease oxygen saturation. The note identified the resident had shown minimal gains due to increased edema and blood clots which prevented them from achieving their rehab goals. The precautions noted he/she had been at risk for falls, elevated heart rate, confusion and impulsive. This resident's plan of care dated 2/14/13 noted the resident's recent hospitalization after a fall at home and the return to the hospital for evacuation of chronic subdural hematoma. The interventions instructed the staff to use a personal alarm at all times. An Occupational Therapy Plan of Care dated 2/18/13 noted this resident required moderate assistance with cares and contact guard assistance due to unsteadiness. Precautions listed included falls, impulsive, slow processing, confusion and shortness of breath. The care plan noted on 2/18/13 staff discontinued this resident's oxygen use. On 2/19/13 staff wrote to encourage increased independence as able. On 2/19/13 staff wrote to provide standby to contact guard assistance for completion of cares, have resident ambulate to closet, obtain clothing and complete dressing with assist as needed. An updated plan of care noted on 2/20/13 staff discontinued the use of this resident's personal alarm. Milford Nursing Center Progress Notes included the following: 1/25/13 at 6:51 p.m. This resident had 1 plus edema to lower extremities, the resident refused to walk due to pain in the thigh area, the resident required extensive assistance with transfers. The resident was alert, but had some confusion with time. 2/4/13 at 10:02 p.m. The resident had 2 plus edema in both lower legs, the resident was alert and forgetful. 2/11/13 at 9:02 a.m. a Social Service progress note included the resident completed the mood assessment with a score of 10 which showed a decline for this resident. The resident had been removed from therapy, which upset the resident. The resident stated he/she felt bad about him/herself almost everyday, he/she wanted to be able to jump out of bed and dress him/herself. 2/18/13 at 10:17 p.m. resident required assistance for transfers, walking, dressing and was alert and forgetful. 2/19/13 at 12:55 p.m. therapy is recommending resident is to ambulate to closet, obtain clothing and complete dressing with assist as needed to increase independence. Encourage self care tasks and provide direct supervision for safety. Provide supervision and assist if needed for dressing, toileting and transfers. A Physical Therapy Plan of Care dated 2/19/13 noted the resident's therapy necessity included therapy necessary for lower extremity strengthening, gait training, endurance training. The plan identified without therapy the resident was at risk for falls and decreased mobility. The precautions included fall risk, chronic subdural hematoma and balance impairments. The resident ' s cognition and safety awareness were minimally impaired. Milford Nursing Center Progress Notes included the following: 2/20/13 at 1:13 p.m. resident had 2 plus edema in both legs, walked with assistance, transferred with assistance, resident needed skilled services to regain strength to perform ADLs (cares of daily living.) 2/24/13 at 3:40 p.m. resident had 2 plus edema in lower legs and ankles, resident had stress incontinence of bladder, resident needs minimal assistance pushing off chair for transfers. A Minimum Data Set (MDS) assessment tool dated 2/24/13 noted this resident scored a 15 out of 15 for cognition. Signs and symptoms of delirium revealed this resident experienced psychomotor retardation such as sluggishness, staring into space, staying in one position, moving very slowly, and this symptom fluctuated. The resident felt tired or had little energy. The resident required limited assistance with transfers and walking. The resident required extensive assistance with dressing, toilet use, personal hygiene and bathing. The resident's balance was not steady, but the resident was able to stabilize without staff assistance. The resident was occasionally incontinent of bladder. The resident experienced occasional pain and rated his/her pain at a six on a scale of one to ten. The resident had a history of [REDACTED]. The Milford Nursing Center Progress Notes dated 2/25/13 at 10:27 p.m. identified the following: resident was found on the floor in the hallway. Resident lying on left side. Incident occurred shortly after nurse had taken the resident his/her medications. The resident stated he/she stood up to pick up a pill he/she thought he/she had dropped. He/she ran into the doorway and fell . The resident wanted to go to the supper meal in the dining room. After supper he/she had difficulty standing and applying weight to the left leg. The resident rated the pain at a ten (10) on a scale of one to ten. This resident's spouse transported the resident to the emergency room . At 10:45 p.m. the spouse called the facility and reported the resident was being transferred to the hospital for treatment of [REDACTED]. A Fall Investigation report dated 2/25/13 at 5:05 p.m. noted identified factors involved in fall: Resident thought he/she saw a pill on the floor. The report identified the call light was in reach, but not turned on. A hospital Consultation report dated 2/26/13 at 2:00 a.m. noted resident fell when he/she got up from his/her chair to look for a pill that he/she thought he/she dropped this evening. The resident informed the physician of his/her history of frequent falls and poor balance. He/she fell on to his/her left side and sustained a left hip fracture. The resident also sustained a contusion to the left ribs and chest wall. Past Medical History included mild cognitive impairment following closed head injury and chronic subdural hematoma. A hospital Transfer Order sheet dated 2/28/13 listed left hip fracture as the primary diagnosis. The resident required moderate to maximum assistance with transfers and cares. When interviewed on 4/2/13 at 11:20 a.m. a registered nurse, the MDS/Care Plan Coordinator, Staff D stated she was the one who discontinued the use of the personal alarm after discussing it with the Director of Nursing/Provisional Administrator. She stated she discontinued the use of the alarm on 2/19/13. Staff D stated she discontinued the alarm due to the Rehab Communication Sheet from therapy on 2/18/13 which instructed them to provide supervision and assistance if necessary. She stated they were trying to get the resident more involved with his/her cares. Staff D stated the resident was steady on his/her feet. She stated this was the first time they had removed this resident's alarm since his/her original admission last year. Staff D stated she had never passed medications or worked as a nurse at this facility. She stated she relied on reports for her information. The Rehab Communication sheet that Staff D reference to documented the following: dated 2/18/13 instructed the staff to provide supervision and assistance if needed for dressing, toileting, transfers and grooming. Provide standby assistance to contact guard assistance. The communication identified the resident is to ambulate to closet to obtain clothing and complete dressing with assistance as needed to increase independence. Encourage independence with self care tasks. Provide direct supervision for safety. The typed statement by the Director of Nursing/Provisional Administrator, noted on 2/25/13 she was informed the resident was on the floor. She went to this resident's hall and saw the resident on the floor. The resident did not complain of pain. The resident stated he/she wanted to go to the dining room for the evening meal. After the incident she visited with the charge nurse, Staff A. She asked her what happened. Staff A stated she had given the resident his/her pills and the glass of water. She had been paged for a phone call and went to answer it. Staff A apologized profusely and was instructed to wait until residents have finished their medications before leaving them. When interviewed on 4/2/13 at 11:00 a.m. the Director of Nursing/Provisional Administrator stated it was the therapy department who made the decision to discontinue the use of the personal alarm. When interviewed on 4/1/13 at 4:10 p.m. Resident #1 stated one afternoon he/she was sitting in his/her chair when he/she had dropped something and he/she thought he/she would just pick it up. He/she stated he/she lost their balance and reached for the door frame but missed the door frame and fell out into the hallway. He/she stated he/she did not feel pain right away. He/she stated they must have hit his/her ribs due to he/she had pain in his/her ribcage. The resident's spouse joined the conversation on 4/1/13 at 4:30 p.m., and stated they never should have discontinued his/her alarm. The typed statement by Staff A noted on 2/25/13 at 5:05 p.m. she took this resident's medications to his/her room. The resident had been napping and was confused as to the time of day. The nurse handed the resident the medications. The nurse was paged for a phone call and left the resident's room. The resident's walker was in front of his/her bed. The resident was in his/her chair. After finishing with the phone call she was informed the resident had fallen in the hallway. She found the resident laying on his/her left side on the carpet with his/her feet outside his/her doorway. When asked why he/she got up unassisted the resident stated he/she was looking for a pill he/she thought he/she had dropped. After the evening meal, the resident had increased pain and difficulty bearing weight on the left leg. The resident stated his/her left rib cage hurt worse. The typed statement by Staff D, a registered nurse, noted on 2/25/13 she looked down the hall and noticed Resident #1 on the floor with staff assisting him/her. The resident stated he/she though he/she had seen a pill on the floor and was reaching to get it and fell forward from his/her chair. An Employee Warning and Discharge Notice dated 2/25/13 noted Staff A left medications at a resident's bedside and left the room to answer the phone. Resident thought a pill dropped. The notice reported the resident got up to see (if he/she dropped a pill), lost (his/her) balance, fell and broke a hip. The facility completed a Self- Identification & Correction Form dated 4/4/13 which identified the charge nurse failed to watch the resident swallow his/her medication. The facility educated all charge nurses to not leave a resident until the medications had been swallowed. The facility identified to the Department the nurse had been educated for leaving the resident before ensuring his/her medications were swallowed. A physician's orders [REDACTED]. Observation on 4/1/13 at 5:35 p.m. revealed Resident #1 seated in the dining room in a regular dining room chair at the table. Alarm not attached to this resident. Observation revealed the alarm on the resident's walker and not attached to the resident. Observation also revealed no staff in the immediate area of this resident. When interviewed on 4/1/13 at 5:40 a.m. a certified nursing assistant, Staff F stated she had walked this resident to the dining room and had failed to attach this resident's alarm after assisting the resident into the dining room chair. Staff F stated they were aware this resident was to use the alarm at all times and that she had just forgotten to apply it.