Every finding on record at Accura Healthcare of Muscatine

Based on clinical record review, facility policy review, and staff interviews, the facility failed to prevent both verbal and physical abuse of a dependent adult resident, for 1 of 4 residents reviewed (Resident #1), that resulted in the resident's physical injury. The facility reported a census of 62 residents.Findings include:A Facility Reported Incident, dated 8/7/25, documented Resident is impaired for cognition, and has a BIMS (Brief Interview for Mental Status) of 11 (moderate cognitive impairment per the assessment scale) a staff witness reports that alleged perp (perpetrator) was being verbally and physically abusive with the resident. The witness reports seeing the alleged perp call the resident names, threaten her and then pull on the residents arm. No new injuries to the resident per the facility as she has scratches to her arms which were noted prior to the incident. The alleged perp reports that the resident was having behaviors all night and then when they went to get back to her room to get her changed, the resident had her finger and she and to pry her finger from the residents fingers as it hurt. The alleged perp reports that she didn't mistreat the resident. Review of Resident #1's Minimum Data Set (MDS) assessment tool, dated 5/15/25, a list of diagnoses which included diabetes, paranoid schizophrenia, anxiety, and depression. The BIMS score of 11 out of 15 points indicated a moderately impaired cognition. The MDS revealed Resident #1 had no potential indicators of psychosis such as hallucinations or delusions; and no physical or verbal behavioral symptoms towards others in the 7 days that preceded the assessment. The MDS described the resident with bilateral lower and upper extremity impairments. The resident required substantial to maximal assistance to reposition in bed, transfer to and from bed or chair, dressing, bathing and personal hygiene, frequently incontinent of urine and always incontinent of bowel. Review of the Care Plan, revised 10/05/23, revealed a Focus area to address [Name redacted, Resident #1] has a behavior problem related to schizo-affective disorder, paranoid schizophrenia, PARANOID PERSONALITY DISORDER, delusional disorder and hallucinations. Interventions included, in part: a. Assist [name redacted] to develop more appropriate methods of coping and interacting. Encourage [name redacted] to express feelings appropriately, initiated 10/3/19.b. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with [name redacted] as passing by, initiated 10/3/19.c. Explain all procedures to [name redacted] before starting and allow the resident several minutes to adjust to changes, initiated 10/3/19.d. If reasonable, discuss [name redacted] behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident, initiated 10/3/19.e. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed, initiated 10/3/19f. [Name redacted] often times believes that staff members are trying to hurt her, she needs redirected when she is having these thoughts, initiated 10/3/19.g. Know that resident frequently lifts up shirt, attempts to pull pants down in common areas. Staff to monitor and assist with redirecting behaviors when noted. Staff to complete 1:1 and offer resident activities. Staff to assist resident to room, when needed or request for privacy, initiated 11/4/24.h. Minimize potential for [name redacted] disruptive behaviors by offering tasks which divert attention, initiated 10/3/19.i. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes, initiated 10/3/19.j. Resident frequently refuses cares from staff, initiated 8/7/25.Review of a Behavior Note, transcribed by Staff A, Registered Nurse (RN) on 8/7/25 at 5:49 a.m., revealed Description of behavior: Resident has been up all-night exhibiting behaviors. Vocalizing loudly and being very disruptive to room-mate. Will not keep her clothes on while out in tv room. Non-pharmacological interventions used: Attempted to give food ad fluids. Assessment for Pain: No pain. What interventions was used and was it effective: Comfort interventions ineffective. Review of an Incident Note transcribed by Staff B, Licensed Practical Nurse (LPN) on 8/7/25 at 10:15 a.m. revealed On 8/7/25 at 7:47 a.m. ED (Executive Director) [name redacted, Administrator] was notified by staff at nursing home that a resident had allegedly been physically and verbally abused by third shift RN. Head to toe assessment completed by ADON (Assistant Director of Nursing) and documented. Resident continues to demonstrate self-inflicted scratches that have been noted in skin assessment. Resident was resisting cares and attempting to get out of bed during the HS (hour of sleep) hours. Resident was not easily redirected throughout the night and continued to have behaviors. CNA (Certified Nursing Assistant) at station 1 notified nurse of alleged abuse, statement collected and given to ED. Notified local Police Department, Officer (name redacted) arrived to facility to collect statements. Spoke to sister regarding investigation. Physician notified, will be in house today to see resident. Resident sitting in wheelchair in lobby resting. Review of a Skin Assessment form completed 8/7/25 at 10:08 a.m. by Staff H, ADON, included a Site Identification for #29. Site: Right hand (back); Type: Other, scratch; Length Width Depth (no entries); Stage: N/A. #30. Site: Left Hand (back); Type: Other, scratch; Length 3.2 cm (centimeters), Width 0.1 cm Depth 0.0 cm; Stage N/A. The assessment included the following Section E. Co-Morbidities. 1. Co-Morbidity Diagnosis: Paranoid Schizophrenia, Paranoid personality disorder, Schizoaffective disorder-bipolar type, Generalized anxiety disorder, MDD (major depressive disorder). 2. Other items that could effect healing: Resident has multiple self-inflicted scratches noted to lower abdomen, to under bilateral breast, scratch marks to lower back, with new scratches to back of bilateral hands. Resident continues to demonstrate self-inflicting behaviors. During an interview on 8/27/25 at 6:10 a.m., Staff C, CNA, stated she worked the 10 p.m. to 6 a.m. night shift that started on 8/6/25 with Staff A, RN, both assigned to Station 1, that included Resident #1. Staff C recalled on that night, the resident was in bed at the start of her shift, asleep, until sometime between 1:00 a.m. and 2:00 a.m. when the resident crawled out of bed, a normal behavior for her. When the resident does this, they have to put her in her Broda (specialized wheelchair that allows for a variety of positioning for comfort and safety) chair and bring her to a common area, as the resident would otherwise continue to crawl on the floor and potentially disrupt the sleep and safety of other residents. Another CNA, Staff E, assisted her to transfer to the Broda chair, the resident was wheeled to the family room common area, that she enjoys as she watches television while there. Staff C stated the resident continued to have behaviors while seated in the common area, that included removing her night gown. She explained either she or Staff A would put the resident's gown back in place, had also covered her with a blanket and the resident had removed the gown at least 6 to 8 times. Staff C stated during that time period she heard Staff A call the resident stupid and she was acting like a brat related to these behaviors. Around 3:00 a.m. the resident said she wanted to go to bed, Staff C explained to the resident she needed to stay where they could maintain her safety, then the resident attempted to throw herself on the floor from the Broda chair. Staff C stated Staff A clapped her hands loudly within 3 to 4 inches of the resident's face and said knock it off. They put the resident in bed between 3:30 a.m. and 4:00 a.m. Staff C stated between 4:30 a.m. and 5:00 a.m. Staff A noticed the resident was actively climbing out of bed. Staff C stated she thought they should provide incontinence care, dress the resident and get her up for the day. Staff C described the resident was seated upright near the foot of the bed, with her legs over the footboard, and as Staff C applied pants to the resident's lower legs, Staff A was next to the resident's left side, and had her right thumb under the resident's forearm, and all her fingers in contact with the top of the resident's forearm and appeared to be digging into her skin with her fingernails. Staff C stated the next thing she knew the resident had a hold of Staff A's left finger or fingers, the resident is strong and had a tight grip on her, Staff A said if you break my finger I'm going to break your jaw, and pried her finger loose from the resident's grip. Staff C stated at that point she asked Staff A to go get another CNA to help her to get Staff A away from the resident. Staff A returned within a minute or 2, then Staff D, CNA came into the room, Staff A remained in the room as they dressed the resident and transferred her to the chair. Staff A took the resident out to the common area where a couple other residents were seated, it was around 5:30 a.m. Staff C stated she had to finish cares on all her residents, and notified Staff B, LPN, assigned to Station 2, of what had occurred. Staff C stated she thought the resident was going to be bruised related to Staff A's actions, and she noticed a long red line/mark on the resident's left hand that she had not noticed before the incident, it appeared to her as a scratch, it was not bleeding at the time.During an interview on 8/27/25 at 7:34 a.m., Staff B, LPN, stated on the morning of 8/7/25, Staff C, CNA came to her, worried and reported an incident that had occurred with Staff A, RN and Resident #1. Staff B recalled Staff C reported the resident was awake much of the night with behaviors, and she [Staff C] thought Staff A had scratched and possibly bruised the resident when they tried to get the resident in bed, and Staff A told the resident if she broke Staff A's finger she was going to break the resident's jaw when the resident had a hold of Staff A. Staff B stated she assessed Resident #1 initially and reported the alleged incident to the Administrator before she arrived to the facility. The ADON also assessed the resident and documented the skin condition on a skin assessment form. Staff B stated she also notified the police, the resident's family and the physician. Staff B stated the resident has behaviors often, she is difficult to redirect at times, and when the resident is not redirectable staff should ensure the resident's safety, not further escalate the situation with continued interactions, walk away and continue to check on the resident, re-approach the resident later and the resident would often be calmer.During an interview on 8/28/25 at 11:19 a.m., Staff H, ADON, stated she completed a head to toe skin assessment on 8/7/25 related to the allegation, Resident #1 had scratches on the back of both hands, the right hand was short, about 1 cm long, the scratch on the left hand was longer, linear shaped, and had never seen scratches on the resident's hands before. Staff H explained the resident often scratches herself on her abdomen/chest area, it is one of her behaviors. The police officer took photos of the resident's hands when they were at the facility that day. Staff H stated the resident can have behaviors, resist care, sometimes staff can redirect her but there are times when she is not redirectable. When the resident is resistive staff should try other approaches, such as having another staff member attempt the care, direct the resident's focus to something else to divert attention if possible, or leave and re-approach the resident at another time when the resident was receptive to the care needed. During an interview on 8/27/25 at 6:40 a.m., the Administrator stated she was notified of the allegation by staff on the morning of 8/7/25 as she was on her way to the facility. She observed scratches on Resident #1's hands that day. The Administrator stated it was not acceptable or appropriate for staff to call the resident names, threaten a resident, or attempt to hurt a resident in any way as that was considered Dependent Adult Abuse and was not tolerated, Staff A, RN was terminated as a result of the allegation and the results of the facility's investigation of the incident.During an interview on 8/28/25 at 2:00 p.m., Staff A, RN, stated on the 8/7/25 night shift Resident #1 was awake most of the night, had behaviors, disrobed, scratched herself, wouldn't stay in bed, the resident heard voices at times. That night the resident said they are talking about you, she was restless, didn't know what she wanted, they had provided snacks and the resident wasn't redirectable. When they tried to get her up and dressed the resident got a hold of her left index finger, bent it backwards and it hurt. She'd asked the resident to let go several times but she wouldn't let go, Staff A had to pry the resident's finger/grasp away from her finger to get it away from her. Staff A denied that she had verbally abused the resident in any way, and had not attempted to hurt the resident during the care that was provided that night. Staff A stated the facility informed her the resident had scratches on her hands, and the resident scratches herself all the time, that was nothing new and not something Staff A had done.Review of the facility policy, titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting policy, updated 10/19/22, revealed a Policy Statement which declared, in part 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. This includes prohibiting nursing facility staff from taking acts that result in person degradation, including the taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and/ or recordings on social media or through multimedia messages. 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 clinical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were submitted timely for four of four residents reviewed for MDS submission (Resident #13, Resident #27, Resident #35, Resident #49). The facility reported a census of 53 residents. Findings include: Review of Resident #13's Significant Change MDS assessment with Assessment Reference Date (ARD) 4/1/25 revealed the following: MDS assessment completed on 4/15/25 and submitted on 5/4/25. Review of Resident #27's Quarterly MDS assessment with ARD 4/2/25 revealed the following: MDS assessment completed on 4/16/25 and submitted on 5/4/25. Review of Resident #35's Annual MDS assessment with ARD 4/2/25 revealed the following: MDS assessment completed on 4/16/25 and submitted on 5/4/25. Review of Resident #49's Admission MDS assessment with ARD 2/14/25 revealed the following: MDS assessment completed on 2/23/25 and submitted on 3/10/25. On 5/8/25 at 11:43 AM, the facility's MDS Coordinator explained she knew a few had not been submitted on time. On 5/8/25 at 12:58 PM, the facility's Director of Nursing (DON) explained went over what was due in the morning meeting, and did not recall was shared that going to be late on MDS. On 5/8/25 at 12:05 PM, the facility Administrator explained via email did not have a policy to address MDS.

Based on infection control data review, staff interview, and facility policy review the facility failed to ensure residents met the criteria for an infection per McGeer's criteria prior to antibiotic use for seven of twelve infections which developed in the facility per March 2025 infection control data review. The facility reported a census of 53 residents. Findings include: Review of the Infection Control Summary dated March 2025 revealed twelve infections developed in the facility. Review of the Infection Control Data Log dated March 2025 revealed out of the twelve infections, seven did not meet McGeer's criteria, and the residents received antibiotics. On 5/8/25 at 9:57 AM, the facility's Assistant Director of Nursing (ADON), who also was responsible for Infection Control at the facility, explained there was a Provider who liked to prescribe antibiotics, and facility had reached out to the Physician to speak with that Provider. On 5/8/25 at 12:55 PM, the Director of Nursing (DON) explained they knew that one of the Providers did not necessarily follow [criteria], so the facility always had someone on an antibiotic. Per the DON, she knew it was something that had talked about in the facility, and with the Administrator. Review of the Facility Policy titled Antibiotic Stewardship Program, updated 10/5/23, revealed the following: The Antibiotic Stewardship Program will optimize the treatment of infections by ensuring that residents who require an antibiotic are prescribed the appropriate antibiotic, reducing the risk of adverse side effects, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use, to improve resident outcomes.

Based on clinical record review, facility policy review and staff interview, the facility failed to notify the state ombudsman of the transfers out of the facility due to hospitalization for 2 of 3 residents reviewed (Residents #14 and Resident #19). The facility reported a census of 53 residents. Findings include: 1. A review of the Progress notes for Resident #19 revealed: a. Resident #19 transferred to hospital on 11/18/24 due to a urinary tract infection. The resident readmitted to the facility on [DATE]. b. Resident #19 transferred to the hospital on 12/16/24 for a procedure. The resident readmitted to the facility on [DATE]. c. Resident #19 transferred to the hospital on 1/3/25 for procedure, and admitted for treatment related to pyelonephritis (kidney infection). The resident readmitted to the facility on [DATE]. Review of the Notice of Transfer Form to Long Term Care Ombudsman did not include Resident #19's transfer on 11/18/24, 12/16/24, and 1/3/25. During an interview on 5/8/25 at 7:08 AM, the Social Services Director stated when a resident has been transferred to the hospital she fills out a transfer/discharge audit form, runs a report from the electronic health record and sends the information to the ombudsman office on the first of each month. The Social Services Director stated she verified the audit forms for November 2024, December 2024 and January 2025 but they did not include Resident #19. The Social Services Director stated she could not explain why this happened. Review of the policy titled Policy and Procedure Notifying Ombudsman of Discharges from Facilities, updated 4/30/21 revealed a Process section. Review of the section revealed The facility is responsible for notifying the Long Term Care Ombudsman of all transfers and discharges from the facility. 45338 2. Review of the resident's census revealed Resident #14 on hospital leave on 2/27/25. The Progress Note dated 2/27/25 at 2:19 PM revealed, in part, CNA (Certified Nursing Assistant) came and got this nurse and stated that resident is shaking uncontrollably and freezing cold. Upon assessment her skin was warm to touch, pallor to face and lips, nausea and dry heaving .[Name Redacted] office notified and gave order to send to ED (Emergency Department) d/t (due to) shaking and nausea . EMTs (Emergency Medical Technicians) called and arrived, report called to [Name Redacted] RN (Registered Nurse) at [Hospital Name Redacted]. Review of the Notice of Transfer Form to Long Term Care Ombudsman did not include Resident #14's transfer on 2/27/25. On 5/8/25 at 11:40 AM, the Social Services Director explained figured out that maybe had ran the wrong report, and explained had noticed similar situation for another resident who had been sent to the hospital.

Based on clinical record review and staff interviews, the facility failed to accurately code the Minimum Data Set to reflect a having Level II Preadmission Screening and Resident Review (PASRR) services for 1 of 1 (Resident #8) residents reviewed. The facility reported a census of 53 residents. Findings include: The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated the resident was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The Notice of PASRR Level II Outcome dated 7/22/24 revealed: a. PASRR determination: Approved with specialized services. b. PASRR determination explanation: You meet PASRR criteria for the diagnoses of Major Depressive Disorder and suspected Mild Intellectual Impairment which has led to significant symptoms that impact daily functioning and the need for intensive supports in the past. During an interview on 5/8/25 at 8:11 AM, the MDS Coordinator queried if she entered the resident's status for PASRR and she confirmed she did. The MDS Coordinator asked how she found the information to know what to code the PASRR and she stated the PASRR typically uploaded in the electronic record. During an interview on 5/8/25 at 8:20 AM, the MDS Coordinator stated she did some checking and Resident #8 had a Level II PASRR and it should of been coded on the MDS. During an interview on 5/8/25 at 11:49 AM, Director of Nursing (DON), confirmed if a Resident had a PASRR level II it needed coded as a Level II on the MDS. Per email on 5/8/25 at 12:21 PM from the Administrator, the facility does not have a policy related to accuracy of MDS assessments, and the facility follows regulations.

Based on observation, clinical record review and staff interviews, the facility failed to update a Care Plan to accurately identify the level of assistance 1 of 1 residents needed to complete the activities of daily living tasks of toilet use and bed mobility (Resident #7). The facility reported a census of 53 residents. Findings include: The Minimum Data Set assessment dated [DATE], revealed Resident #7 scored a 15 out of 15 on the Brief Interview for Mental Status exam, which indicated cognition intact. The MDS indicated the resident required substantial/maximal assistance to roll from left to right and dependent with toilet transfer and toileting hygiene. Review of the Care Plan, revised 4/11/23, revealed a Focus area to address The resident has an ADL (Activities of Daily Living) Self-Care Performance Deficit r/t (related to) confusion and fall. Interventions included, in part: a. TOILET USE: The requires assist x1 with assistance to wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet to use toilet. Revised on 11/6/24. b. BED MOBILITY: The resident is independent to reposition and turn in bed. Encourage the resident to participate to the fullest extent possible with each interaction. Revised on 11/6/24. During an interview on 5/6/25 at 12:40 PM, Resident #7 queried about positioning herself stated the staff assist her to reposition and sometimes put her on her side with a pillow behind her back. Resident #7 stated she preferred to be in bed, but staff do get her up and assist her into her chair. During an interview on 5/7/25 at 4:23 PM, Staff A, Certified Nurse Aide (CNA), stated Resident #7 could use the bed remote, but needed staff to assist with rolling over, and repositioning. Staff A stated she assisted the resident to reposition every 2 hours. Staff A stated the resident used an incontinent brief and was not always aware of when she needed to use the bathroom. Staff A stated Resident #7 preferred to stay in bed. During an interview on 5/8/25 at 7:28 AM, the MDS Coordinator stated Resident #7 is bed bound and required quite a bit of assistance with moving in bed. The MDS Coordinator stated Resident #7 is dependent with toileting. The MDS Coordinator confirmed the Care Plan needed updated for Resident #7 current level of assistance. During an interview on 5/8/25 at 11:43 AM, the Director of Nursing queried on Resident #7 level of care for her ADLs and she stated she didn't really know about Resident #7 except Resident #7 stayed in bed quite a bit and needed assistance. The DON asked about accuracy of the Care Plans and the DON stated when the old DON completed them, they were not always accurate and now the MDS Coordinator completed them. The DON confirmed the Care Plan needed to reflect the current ADL status of the resident. Per email on 5/8/25 at 12:21 PM from the Administrator communicated the facility does not have a policy regarding Care Plans, and follows regulations.

Based on observation, interview, and clinical record review, the facility failed to ensure a nutritional supplement was increased per Dietician recommendation for one of one resident reviewed for nutrition (Resident #42). The facility reported a census of 53 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #42 dated 3/14/25 revealed the resident scored 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely intact cognition. Per this assessment, the resident had lost 5% or more in the last month or loss of 10% or more in the last 6 months, and was not on a prescribed weight-loss regimen. Review of the Care Plan dated 3/18/24, revised on 1/7/25, revealed the following: The resident has nutritional problem or potential nutritional problem r/t (related to) Dementia. Texture-altered diet r/t poor dentition. Has gradually decreased in weight x180 days. Review of the Physician Order dated 2/4/25 revealed, House Supplement 4oz (ounces) daily two times a day for weight loss. Review of Nutrition/Dietary Notes for Resident #42 authored by the Registered Dietician revealed, in part, the following: a. 3/2/25 at 11:45 AM: Significant Weight Loss Assessment .Recommendations: Recommend increase her house supplement to 120 ml 3x/day (three times a day) d/t (due to) significant weight loss and suboptimal po (oral) intake. b. 3/19/25 at 8:14 PM: Annual and Significant Weight Loss Assessment .Recommend increasing her house supplement to 3x/day since she had a significant weight loss. c. 5/4/25 at 5:37 PM: Significant Weight Loss Assessment . Recommend increase her house supplement to 120 ml 3x/day d/t significant weight loss and suboptimal po intake. On 5/05/25 at 11:18 AM, Resident #42 observed at a table in the dining room. The resident had pureed food in front of her, and observed to eat independently. Review of the resident's Medication Administration Record (MAR) for March 2025, April 2025, and May 2025 revealed the supplement ordered twice a day. On 5/7/25 at 9:51 AM, Staff B, Licensed Practical Nurse (LPN) queried who put in supplement orders, and responded when got doctor's order nurses would do. When queried as to process if came from the Dietician, Staff B responded she believed it needed to be signed off as doctor's order, and eventually made way to [staff]. Per Staff B, supplements were on the MAR, and nursing would give. On 5/8/25 at 9:36 AM, the Registered Dietician (RD) for the facility interviewed via telephone and explained, in part, the following about Resident #42: Per the RD, did put in notes to see if could bump up supplement due to continued weight loss, and explained last time she looked, hadn't seen it done. The RD explained she would put her notes in [electronic health record system], facility would print them off, and would bring them to the providers during the weekdays. The RD explained she had noticed the resident was losing weight. When queried if facility ever had RD put in her own supplement orders, the RD responded no, and further explained did not think she had those privileges. On 5/8/25 at 9:44 AM, the facility's Director of Nursing (DON) explained, in part, the RD would come in and meet with the facility and would go over every resident. Per the DON, the RD would email the facility her recommendations, from there DON would print them, and DON would give them to the doctor to look at. The DON further explained if any orders, recommendations in place, would put them on the chart and let the Dietary Manager and staff know. The DON not sure why recommendation in March was not addressed. On 5/8/25 at approximately 9:50 AM, the DON recalled the facility had not been getting the Dietician's emails. On 5/8/25 at 12:05 PM, the facility Administrator explained via email did not have a policy to address nutrition.

Based on record review, and staff and resident responsible party interviews, the facility failed to ensure the discharge needs of each resident were met when they transferred a resident to the wrong facility, a facility that had no knowledge of the resident, had not agreed to accept the resident's transfer, and did not have authorization to admit the resident because they were not a Veteran Administration (VA) contracted service provider, for 1 of 3 resident's reviewed for discharge coordination (Resident #1). The facility reported a census of 56 residents Findings include: The Minimum Data Set (MDS) Assessment tool dated 8/28/24 revealed Resident #1 admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of the rectum, depression, hypertension (high blood pressure), and a surgical wound present, scored 15 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated no cognitive deficits, and without symptoms of delirium. The assessment revealed the resident received analgesics on a scheduled and as-needed basis in the 5 days that preceded the assessment for frequent pain that impacted the resident's sleep and day to day function, rated at an 8 at the worst level with a 0 to 10 pain scale used, 10 was assigned to the worst pain possible, and required substantial staff assistance to reposition in bed, transfer to and from bed and chair, dressing, toileting, and bathing, and unable to stand or ambulate. The assessment revealed the resident received Physical and Occupational Therapy services (Skilled Therapy) with a goal of discharge to the community, estimated at 3 or more months away. A Notice of Medicare Non-Coverage (NOMNC) form dated 9/6/24 revealed 9/9/24 was the resident's last day of covered Skilled Therapy services. The resident was a Veteran, with long term care (LTC) benefits available through the Veteran's Administration (VA), continued LTC after 9/9/24 required authorization and approval by the VA, at a facility under VA contract, and the facility did not have a VA contract. Nursing Progress Note entries transcribed by Staff A, the facility's Social Service Designee (SSD) revealed: 8/28/2024 at 4:04 p.m. Care conference today with resident and family, plan is to discharge to home. If he should need more time, we will seek VA Nursing home. 9/9/24 at 12:19 p.m. Facility A (a LTC facility located 29 miles east of the facility) has accepted resident, They will call back and let SSD know transport time. 9/9/24 at 1:10 p.m. Non-Emergent Transport (NET) to transport resident. Pick up time is 2:30 p.m. 9/10/24 at 11:42 a.m. Discharge is set for 9/10/24 at 2:30 p.m. to Facility A. NET to transport. Pick up time is 2:30 p.m. 9/10/24 at 4:00 p.m. Facility B. (Facility B was a sister facility of Facility A, located 109 miles south west of the facility. Facility B had a VA contract, Facility A did not). A Nursing Progress Note transcribed 9/10/24 at 4:38 p.m. by Staff B, Registered Nurse (RN), stated: Resident left facility at 1:45 p.m. for transport to Facility A. Family not present. Resident left with discharge paperwork, including medication list and Medication Administration Record (MAR). Later when I called Facility A to ask if they needed information, the call was transferred to a nurses station, received a recording to leave a message and left message with my contact information if they had any questions. Additional Nursing Progress Notes transcribed by Staff A revealed: 9/11/24 at 8:25 a.m. SSD called resident's Power of Attorney (POA) to check on resident. He was admitted to Facility A for the night and transportation will be arranged to transfer to Facility B on 9/11/24. 9/11/24 at 8:27 a.m. SSD placed a call to Staff C, Regional Clinical Admission Specialist for the corporation that owns Facility A and Facility B). Left message waiting for callback. 9/11/24 at 1:56 p.m. Ambulance service to transport the resident from Facility A today. Ambulance service to callback and give estimated time of arrival. The facility's Transfer/Discharge - Outside the Facility policy dated 2/2015 directed: 1. The Director of Social Services or designee assists with the process of resident and family/responsible party notification and processing of transfers outside of the facility. 2. Transfers or discharges initiated by the facility and not by the resident/or the resident's physician or family/responsible party may require the completion of state specific process and documentation. 3. Review facility process for managing transfers out of the facility, as needed, with the resident and family/responsible party upon admission. 4. Verify physician order for transfer/discharge is obtained. 5. Assist nursing staff with notification of the resident and family/responsible party of the following: a. Reason for and effective date of transfer. b. Location of transfer. c. Name, address, and telephone number of the Ombudsman and other parties/agencies required by the state, as indicated. 6. Coordinate with the interdisciplinary team to provide information and education to prepare a resident to be discharged , as indicated. 7. Assist staff with coordination and communication with resident and family/responsible party. Staff interviews revealed: 9/12/24 at 1:56 p.m., Staff A, Social Service Designee (SSD) stated she had contacted the VA about the resident's continued care requirement, and spoke to Staff C, (Regional Clinical Admission Specialist) for Facility A's company. Staff C said she told me that Facility B had the VA contract, Facility A did not have a VA contract, but Staff A did not recall that, and believed the resident was supposed to transfer to Facility A, located 40 minutes away and accessible to the resident's family. She became aware the resident was transferred to the wrong facility late in the afternoon on 9/10/24 when she spoke to Staff C about it. Staff C told her they were going to get transportation for the resident to transfer to Facility B. She called her facility Administrator right away, who directed her to arrange transportation and bring the resident back to their facility. She spoke to Staff C again after that, who told Staff A that they were working on it. 9/12/24 at 2:17 p.m., Staff C, RN, Regional Clinical Admission Specialists stated she spoke with Staff A on 8/29/24, told her Facility A did not have a VA contract, but Facility B did, there was a bed available, and they would start the process for approval through the VA. She had more communication with Staff A over the phone about the approval for Facility B and the planned discharge/transfer date. On 9/10/24 she received a phone call at 4:45 p.m. from Staff D, RN, Director of Nursing (DON) at Facility A, who told Staff C that the resident was at their facility. Staff C called Staff A right after that, Staff A said she had made a mistake, she had been talking to too many different facilities. Staff C stated the initial plan was to transport the resident back to the facility then, but she was unable to reach anyone at the facility by phone. Staff D and the Administrator at Facility A had to make arrangements for the resident to stay there until the following day when other arrangements could be made. The resident was transferred to Facility B on 9/11/24. 9/12/24 at 9:50 a.m., Staff D, RN, DON at Facility A, stated the resident was dropped off at their facility around 4 p.m. on 9/10/24. Their facility had no knowledge of the resident's admission or information about the resident. Fortunately the resident's family was with the resident, and she was able to reach Staff C, who told her the resident was supposed to go to Facility B. Staff D was unable to reach anyone at the resident's facility by phone, contacted the VA and had to get Facility A's Administrator and Medical Director involved to get orders for his care at their facility overnight until transportation arrangements could be made the following day. Their facility did not have a VA contract, the resident's care would not have been covered by the VA and this situation was challenging and complicated by their inability to contact anyone at the facility' on 9/10/24. Due to the resident's rectal area wound and pain, he would not have been able to tolerate transport to Facility B in a wheelchair van and needed to transport by ambulance as Facility B was a 2 and a half hour drive. After several phone calls on 9/11/24, the resident did transfer to Facility B by ambulance, late in the afternoon. 9/12/24 at 10:31 a.m., Staff E, Care Coordinator at the VA, stated she spoke with the Administrator at Facility A, and Staff A on 9/11/24, and directed Staff A to make transportation arrangements by ambulance, to transport the resident from Facility A to Facility B, and the arrangements had to be made for that day. She received a phone message from Staff A at 2:10 p.m. on 9/11/24 that stated the resident would be transported by ambulance at 2:45 p.m. She then contacted Facility A at 3:30 p.m. to ensure the resident was transported, found out the resident was still there, and learned in later communication the resident did not leave Facility A until approximately 4:30 p.m. on 9/11/24. During an interview on 9/16/24 at 12:42 p.m., the resident's POA stated all the communication they had with Staff A about the resident's transfer was that he would go to Facility A, and that was acceptable. Staff A never discussed Facility B, and they would not have agreed for the resident to be placed that far away, that was a hardship to drive that far and they would have requested another facility closer to their location. They were at Facility A when the resident arrived there on 9/10/24, nobody at that facility knew anything about him, but they went above and beyond to try to do the right thing and make sure he was taken care of. The resident didn't arrive at Facility B until 7:00 p.m. on 9/11/24, it was a long day with a lot of phone calls going back and forth and waiting on information until they found out when the ambulance arrangements were finally made that afternoon.

Based on observation, staff interview, and facility policy review, the facility failed to maintain sanitary practices by improperly storing and serving food. The facility reported a census of 60 residents. Findings include: On 7/28/24 at 5:20 pm, an initial kitchen observation revealed: 1) An opened box of various yellow, green, and orange items in an opened blue plastic bag in the R-Plus freezer. 2) A shelf of opened, undated seasoning containers. 3) Two (2) pot roasts thawing out on a baking sheet on a tray cart beside the oven. During an interview on 7/28/24 at 5:30 pm, Staff C, Cook, stated the pot roasts were thawing out to use for dinner the following night. The manufacturer's thawing instructions direct staff to place roast in the refrigerator for 48 hours to thaw. During an observation on 7/28/24 at 5:45 pm, Staff C prepared a peanut butter sandwich with gloves on each hand. After making the sandwich, Staff C held the peanut butter container with her left hand and used her right hand to scoop some out on a knife. She spread the peanut butter on a slice of bread and repeated the process. She placed the knife on the food preparation table, put the lid back on the container, picked up the container and placed it on the shelf beneath the table. Without changing gloves or performing hand hygiene, Staff C picked up the sandwich with her gloved hands, placed it on a plate and put it on the serving counter. Another staff member served the sandwich to a resident. During a continuous observation on 7/31/24: a. At 11:35 am, Staff E, [NAME] touched kitchen utensils and equipment with gloved hands then placing her thumbs inside sandwich bags to dump the sandwich out. Each sandwich came in direct contact with the area where her thumb contacted. b. At 11:45 am, Staff E put on a pair of gloves and began placing slices of cheese on bread. She picked up a large, white bag of potato chips from under a food preparation table, placed the bag on the food serving counter, opened the bag and took some potato chips with the same gloved hands out of the bag and placed them on two (2) separate residents' plates. c. At 11:53 am, Staff C wore gloves and placed a resident's lunch ticket on a plate stacked on the food service counter. She rearranged other lunch tickets then moved the ticket off the plate. She picked up the plate, placed food for another resident on it, then served it through the food service window. d. At 12:07 pm, Staff C reached for a resident's tray to slide it back on a service rack and her ungloved fingers touched the resident's bread. She looked down at her hand, moved it from off the resident's bread, then covered the plate. Another staff member delivered the resident's tray to him. During an interview on 12:20 pm, Staff C stated the food preparation table used for pureeing residents' food was wiped with sanitizer and a rag. She identified the sanitizer bucket she used to clean the prep table. During an observation at 12:28 pm, Staff C performed a sanitizer solution test on the bucket she used to clean the prep table. She dipped the sanitizer test strip in the solution for 10 seconds, removed it and compared it to the color identifier on the test strip cartridge. She stated the solution did not change color which indicated 0 parts-per-million (ppm) of sanitizing solution was present in the sanitizer bucket. The Registered Dietitian stated the solution did not last as long as the manufacturer had indicated. A document titled Sanitation Storage dated 6/2015 directed staff to pour contents of opened canned goods into a plastic container with label and date. It also directed staff to place dry goods in plastic bags and sealed or plastic containers. It also indicated sanitizing solution may be maintained in a bucket or spray bottle if labeled and diluted according to manufacturer directions. A document titled Sanitation & Food Production dated 6/2015 directed staff to implement critical control points to prevent, reduce, and/or eliminate hazards related to food contamination such as: a) appropriate handwashing b) foods stored and thawed at proper temperatures c) food stored in appropriately labeled containers d) proper cleaning and sanitizing of surfaces and equipment On 8/01/24 at 12:11 PM, the Administrator stated staff should put a receive date, open date, and identifier on everything in the kitchen. She also stated staff should change gloves between food service and touching non-food items and should follow the facility's policies regarding the sanitizer solution.

Based on clinical record review, observation, family and staff interview the facility failed to provide a call light system within reach and met the needs of 2 of 20 residents (Resident #29, #49) reviewed. The facility reported a census of 60 residents. Findings include: The Minimum Data Set (MDS) of Resident #29, dated 5/29/24 identified a Brief Interview of Mental Status (BIMS) score of 00 which indicated severe cognitive impairment. The Care Plan of Resident #29 dated 7/16/24 revealed the resident deficit with Activity of Daily Living (ADL). The care plan informed the staff to encourage the resident to use bell to call for assistance. During an observation on 7/29/24 at 9:25 am, Resident #29 did not have a call device or bell sitting on him or with in reach. During an interview on 7/29/24 at 10:40 am, Staff B, CNA stated the resident has one on the bed. Staff B attempted to locate the call device or bell, no call device or bell found. Staff B obtained new call device and clipped the call device to the Resident #29 shirt. During an interview on 7/29/24 at 10:43 AM, a family member stated does not have a call device or bell to notify the staff when he needs something. Daughter stated when the resident first arrived to the facility he did have a call device. The family member stated they visit every other day, and is unable to describe what the call device or bell. During observations on 7/30/24 Resident #29 in room, and without a call device/bell at: 1:45 pm, and 3:35 pm. On 7/31/24 the resident without a call device/bell noted in room at 7:32 am. During an observation on 7/31/24 at 1:20 pm, Resident #29 had call device clipped to shirt. 2. The MDS of Resident #49, dated 6/13/24 identified a BIMS score of 3 which indicated severe cognitive impairment.

Based on employee file review, staff interview and facility policy review, the facility failed to ensure a current Dependent Adult Abuse certification for 1 of 5 staff members reviewed. The facility reported a census of 60 residents. Findings include: A employee file review on [DATE] revealed Staff G, Certified Nursing Assistant (CNA) revealed a hire date of [DATE]. The employee file lacked documentation of Iowa Department of Public Health (IDPH) approved Dependent Adult Abuse (DAA) Mandatory Reporter training at the time of review. The facility provided a DAA certificate dated [DATE], expired as of [DATE]. On [DATE] the facility provided a Dependent Adult Abuse Mandatory Reporter certificate dated [DATE]. A review of the nursing schedules for the time [DATE] to [DATE] revealed Staff G, CNA scheduled to work first shift on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 8:15 am the Administrator stated there had been a gap in Staff G's training. She stated the corporate office completes the verification check for new employees. The facility policy titled Abuse Prevention and Reporting Policy, issued ,d+[DATE], reviewed on ,d+[DATE] documented the following: Section IOWA Specific Instructions: Training of Employees: .Each employee shall be required to complete two hours of training relating to the identification and reporting of dependent adult abuse within six months of initial employment. Each employee shall complete at least two hours of additional dependent adult abuse identification and reporting training every three years.

Based clinical record review, staff interview, policy review and guidance from Resident Assessment Instrument (RAI) Manual, the facility failed to complete a Significant Change Minimum Data Set (MDS) Assessment within 14 days of a resident experiencing a fall with fracture, resulting in a decline in transfer and ambulation status and in increase in pain for 1 of 20 residents (Resident #50) reviewed for MDS. The facility reported a census of 60 residents. Findings include: The MDS of Resident #50, dated 3/20/24, assessed the resident independent in bed mobility, lying to sitting, sitting to standing, chair to chair transfers and toilet transfers. The MDS documented the resident denied having experienced any pain in the prior 5 days and had received no scheduled or as needed pain medications. The MDS of Resident #50, dated 5/2/24, revealed the resident sustained a major injury related to a fall since the prior MDS assessment. The MDS of Resident #50, dated 5/14/24, assessed the resident required substantial/maximum assistance independent in bed mobility, lying to sitting, sitting to standing, chair to chair transfers and toilet transfers. The MDS documented the resident received as needed pain medications, experiencing pain frequently over the last 5 days. On a scale of 1-10, 10 being the worst, resident rated pain at a 10. The Health Status Note, dated 5/2/24 at 11:08 AM, documented the resident found on the floor, her bed as high in the air as it could go, with no shoes or socks on, leaning against her bed and side table. The resident complained of severe left hip pain with any movement. The Active Diagnosis section of Resident #50's Electronic Health Record (EHR) documented a diagnosis, added on 5/8/24, of fracture of the unspecified part of the neck of the left femur. The Care Plan, dated 1/9/24, Focus Area addressed ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Trauma. With Intervention: The resident is independent with transfers/ambulation without the use of assistive devices. The Intervention, updated on 7/16/24: The resident is an assist x1 (one staff) with transfers utilizing a FWW (front wheeled walker) and gait belt. Resident utilizes wheelchair for mobility and is able to self-propel. Staff to assist resident with walk to dine utilizing gait belt, FWW and w/c (wheelchair) trail. The Care Plan, dated 5/21/24, Focus Area addressed acute/chronic pain r/t Unspecified part of neck of left hip fracture repair. The April 2024 Medication Administration Record (MAR) documented Resident #50 received acetaminophen 325 mg Give 650 mg (2 - 325 mg tabs) by mouth every 4 hours as needed for pain (PRN) a total of six doses. The May 2024 MAR documented starting on 5/10/24, the resident received 11 PRN doses of acetaminophen 625 mg every 4 hours as needed. The MAR for May of 2024 revealed the following new pain medication orders for Resident #50: a. On 5/8/24 tramadol HCL 50 mg by mouth every 6 hours as needed for pain per hospital discharge orders. The MAR documented 17 PRN doses administered for the month. b. On 5/14/24 oxycodone-acetaminiphen 5-325 mg 1 tablet by mouth every 6 hours as needed for pain per [doctor name redacted]. The MAR documented 20 PRN doses administered for the month. The MAR for July of 2024 revealed the resident rated pain as high as a 10 and continued to receive acetaminophen PRN (12 doses), and tramodol PRN (9 doses). During an interview on 7/30/24 at 9:26 am, the MDS Coordinator stated a significant change MDS should be done anytime a resident experiences a change in 2 or more areas, or if the resident enrolls or discharges from hospice. She stated Resident #50 should have had a Significant Change MDS completed and it was an oversight on her part. The Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October of 2023 documented the following: The Significant Change in Status Assessment (SCSA) is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. A Significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting ; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. The RAI additionally documented: An SCSA is appropriate when: a. There is a determination that a significant change (either improvement or decline) in a resident's condition from their baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments; and b. The resident's condition is not expected to return to baseline within two weeks. The facility policy, Resident Assessment Instrument (RAI)/Minimum Data Set (MDS), dated ,d+[DATE], Procedure section revealed: 6. Significant change .when identified as appropriate by the MDS Coordinator and interdisciplinary team following the guidelines, but not limited to as described in the current MDS/RAT manual. Within 14 days after the facility determines that there has been a significant change in the resident's status that will not normally resolve itself, which has an impact on one or more areas of the resident's health status and requires an interdisciplinary review and/or revision of the care plan. A significant change may be a decline or improvement that requires review or revision of the care plan. A Significant Change Assessment is completed when a resident either elects or revokes Hospice benefit even if no other change has occurred and regardless of when the last assessment was completed.

Based on observation, clinical record review, policy review, and staff interviews the facility failed to follow the care plan for 1 of 20 residents (Resident #35) reviewed. The facility reported a census of 60 residents. Findings include: The Minimum Data Set (MDS) of Resident #35, dated 6/11/24, identified a Brief Interview of Mental Status (BIMS) score of 12 out of 15 which indicated moderate cognitive impairment. The MDS documented diagnoses included: non-Alzheimer's dementia, Parkinson's Disease, and prior stroke. The MDS documented the resident experienced coughing or choking during meals or when swallowing medications, and had a mechanically altered diet. The Care Plan, initiated 12/14/21, revised 7/29/24, Focus Area for Nutritional Problem the resident to have a texture altered diet with choking episodes; requires cueing at times to slow down when eating and regularly coughs with meals. Interventions, dated 3/22/24, included: resident is to eat all meals in the assisted dining room; staff member to sit with resident during meals and assist with feeding and cue on taking small bites, chewing thoroughly/swallowing prior to giving a new bite. The Care Plan identified a Focus Area of ADL (Activities of Daily Living) Self Care Performance Deficit, initiated 2/16/24. Interventions included the following dated 6/7/24: staff educated to ensure they are sitting with resident at all meals, and assisted with feeding; staff to give resident cues to take small bites, chew and swallow prior to taking another bite; take a drink in between bites, slow down when eating etc.; resident is working with ST (Speech Therapy) requesting ST to eval, to determine if diet downgrade is appropriate for resident. The Active Diagnoses section of Resident #35's Electronic Health Record (EHR) documented a diagnosis of dysphagia, oropharyngeal phase (a difficulty moving food or liquid from the mouth to the upper esophagus during the oropharyngeal phase of swallowing) dated 8/30/22. The Orders Section of the EHR identified the resident had an order of regular diet, mechanical soft texture with no bread dated 2/8/24, and discontinued 6/7/24. The resident then received an order for Regular diet, puree texture on 6/7/24. The Weight Loss; Provider Notification Note dated 2/5/24 documented: Resident must be cued to slow down as he will continue to put food in his mouth before fully emptying mouth of previous bite. Resident regularly coughs at meals despite being on a texture-altered diet; SLP (Speech Language pathologist) aware. The Health Status Note, dated 3/21/24, documented the nurse paged immediately to the dining room, along with another nurse. Nurse informed Resident #35 choking on eggs. Nurse obtained the crash cart and ran to where the resident was sitting in his wheelchair. The resident was safely placed on the floor on his right side, and the nurse took over performing the Heimlich maneuver from another nurse. An additional nurse called 911. When emergency services arrived, the Heimlich successful and the resident was taken to the hospital for an overnight observation. The Health Status Note, dated 6/624, documented the resident in the dining room eating chili and choked. The Heimlich maneuver performed successfully on the resident. The note stated the nurse sat with the resident through the remainder of the meal. The Risk Management document #2816, dated 3/21/24, identified Resident #35 had a choking incident in the dining room. Note authored by Staff H, Licensed Practical Nurse (LPN). Root Cause Analysis identified as eating too fast, inhaled food and eggs got caught in throat. The Solution documented: Speech therapy, 1:1 during meals, assist with feeding, cues and reminders. The Risk Management document #2936, dated 6/6/24, identified Resident #35 had a choking incident in the dining room. Note authored by Staff I, Registered Nurse (RN). The Root Cause Analysis identified as eating too fast, not taking breaks between bites to chew/swallow. The Solution documented: staff re-educated to sit with the resident during all meals, assist with feeding, give cues to take small bites, chew/swallow prior to taking another bite. Taking drinks of fluid. ST working with resident, requesting to eval to determine if diet downgrade is appropriate. During an interview on 7/30/24 at 3:59 pm, Staff I, RN stated she saw the resident choking at the dining room table on 6/6/24. She stated a Certified Nurse Aide (CNA) was present at the table but was feeding someone else at the time and did not alert her to the episode. She stated staff should always be present at assisted tables. During an interview on 7/30/24 at 4:07 pm, Staff H, LPN stated during the incident on 3/21/24 she was at the back nursing station. She stated the resident was eating breakfast in the dining room. Staff J, LPN was monitoring the dining room. She stated a staff member came to her and told her help was needed immediately in the dining room. When she arrived, Staff J had all ready began the Heimlich. She stated she was not in the dining room at the beginning of the episode so she could not state if staff were at the table with the resident. During an interview on 7/31/24 at 7:17 am, Staff J, LPN stated she was supervising the dining room on 3/21/24. She stated Resident #35 had been served his food, and she was providing drinks to other residents. She stated she heard him cough, and turned to look at him and began to walk over to him. She stated he took another bite of food and she instructed him to stop and his coughing got worse. She stated a CNA was with her and the resident began to turn purple. She stated another staff member went to get the other nurse and 911 was called. She stated a CNA was present at the table but had not alerted her to the incident, she had heard him coughing and observed him in distress. During an observation which began on 7/31/24 at 12:00 pm, Resident #35 was observed sitting in the assisted area of the dining room eating a meal. Several staff were in the area, but no staff were sitting at the table with the resident. During the observation Staff K, Dietary Aide was passing out bowls of pudding for dessert. Resident #35 stopped her and asked if he could have a pudding. Staff L, Certified Nurse Aide (CNA) was sitting at the next table assisting another resident with their back turned to Resident #35. Staff K asked Staff L if it was ok for Resident #35 to have pudding. Staff L turned to look at the table, and told Resident #35 it was ok for him to have pudding. Staff M, LPN was also sitting at the same table as Staff L, CNA feeding another resident. She did not appear to be looking at or monitoring Resident #35. During an observation on 7/31/24 at 12:07 pm, Staff N, CNA brought food to the table of Resident #35 and then sat down at that time to feed that resident. Resident #35 was eating for at least 7 minutes without staff being at the table with him as directed in the Care Plan. During an interview on 7/31/24 at 1:14 pm, the Director of Nursing (DON) stated staff is always in the dining room when residents are eating. She stated per Resident #35's Care Plan, they should be sitting with him. She stated Dietary staff should not serve his meal prior to staff being present. She stated staff was present during his choking episodes and the Risk Management form stating re-education provided was given as an emphasis on the importance of it. During an interview on 7/31/24 at 1:16 pm, Staff L, CNA stated the resident has dysphagia and is provided cueing as needed and eats a puree diet. He stated as long as he is being observed, it is ok for him to eat without a staff member being at the table with him. During an interview on 7/31/24 at 1:36 pm, the Dietary Supervisor stated no resident who sits in the assisted area is to receive food until a nurse is present in the assisted area. During an interview on 7/31/24 at 1:38 pm, the Registered Dietitian stated for any resident in the assisted dining room, a nurse needs to be present and no food is served until a nurse is there. She stated the dining department had received no education or instruction that Resident #35 was not to be served unless a staff member was specifically present at his table. The facility policy Care Plan Development, dated August 2015 documented the following: Care Plan Development: An individualized, comprehensive care plan using the results of the RAI/MDS assessment, resident/family/legal representative and interdisciplinary input will be developed for each resident in the facility . and describe the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental and psychosocial well-being. Procedure: 4. The care plan is integral to the provision of care to the resident and will be available to team members who are responsible for providing care and services. The completed care plans will be maintained in the resident's clinical record. All team members are responsible for reporting any changes to the resident's condition to the primary/charge nurse and of any goals or objectives not being met. Any changes must be reported to the MDS coordinator for review. Documentation must be consistent with the resident's plan of care and revisions will be done on an as needed basis and can be done by any member of the Interdisciplinary team.

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to follow physician orders for 1 of 20 residents (Resident # 44). The facility reported a census of 60 residents. Findings include: The Minimum Data Set (MDS) assessment of Resident #44, dated 6/26/24, identified a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS listed diagnoses included: hypotension, diabetes mellitus, depression, and seizure disorder. The MDS revealed Resident #44 prescribed insulin and an antidepressant. The Care Plan, dated 3/18/24, Focus Area to address The Resident has impaired visual function r/t (related to) Diabetes. Interventions included: Arrange consultation with eye care provider practitioner as required. During on observation on 7/29/24 at 9:08 AM Resident #44 in room, lying on bed. The resident wore a blue and white eye patch on their left eye. During an interview on 7/30/24 at 8:20 AM Staff D, Registered Nurse (RN) stated the Resident #44 had LASIK eye surgery on 7/26/24. Staff D stated the eye patch is on at HS (at night) and off in AM only for protection. When queried regarding post operative orders, the Assistant Director of Nursing (ADON) presented Post -Operative Instructions, dated 7/27/24 . The instructions included orders: a. Neomycin (dark pink cap) - apply 1 drop to the operative eye four times a day for 1 week. Then you may discontinue the medication unless otherwise instructed. b. Atropine (red cap) - apply 1 drop a day to the operative eye (for sensitivity to light). c. Prednisolone acetate (light pink cap) - HOLD this drop the first week. Then, apply 1 drop to the operative eye on a taper as follows, unless otherwise instructed: 1 drop four times a day for 1 week; 1 drop three times a day for 1 week; 1 drop twice a day for 1 week; 1 drop once a day for 1 week; discontinue the drop. d. Wear eye protection such as glasses or sunglasses during the day, and a hard shield over the operative eye at night. A review of the July 2024 Medication Administration Record (MAR), and Treatment Administrator Record (TAR) revealed a lack of neomycin, atropine, and prednisolone acetate, and eye protection. During an interview on 7/31/24 at 12:20 pm, the Assistant Director of Nursing (ADON) stated eye drop orders were not initiated. The ADON stated staff completed a medication error report, and the eye surgeon notified. During an interview on 7/31/24 at 3:14 pm, the Administrator stated the facility follows industry standards for initiating/following physician orders.

Based on observation, clinical record review, staff and family interview, and policy review, the facility failed to provide supplemental oxygen as ordered for 2 of 2 resident reviewed for respiratory care ( Resident #22 & #163). The facility reported a census of 60 residents. Findings include: 1. The Minimum Data Set (MDS) listed diagnoses for Resident #22 included: heart failure, respiratory failure with hypoxia (low oxygen in body), and diabetes mellitus. The MDS revealed the residents BIMS score as 8 out of 15, indicating a moderate cognitive impairment. The MDS documented Resident #22 experienced shortness of breath, or trouble breathing with exertion (activity such as walking, bathing), when lying flat, and received oxygen therapy. A Progress Note, dated 7/6/24, revealed inpart, Hospice nurse from [hospice provider name redacted] came to facility, new orders for 1. Change current oxygen order to 1-4 liters/min via nasal cannula. A review Physician Orders revealed an order, dated 7/6/24 for Oxygen inhale 1 to 4 L/min (liters per minute) via nasal cannula (tubing in nose delivering oxygen from source) continuous. During an observation on 7/28/24 at 5:15 PM, Resident #22 wearing a nasal cannula connected to an oxygen tank. The gauge on the oxygen take noted to be on 0 (zero) which indicated the tank was empty. A review of Weights and Vitals revealed on 7/18/24 and 7/26/24 documented oxygen saturation taken by Room Air (no supplemental oxygen being used) method. The Care Plan, dated 5/2/24, Focus Area addressed The resident has COPD (chronic obstructive pulmonary disease). Interventions included: Give oxygen therapy as ordered by the physician. 2. The Admission MDS, dated [DATE], for Resident #163 identified a BIMS score of 10 out of 15, indicating a moderate cognitive impairment. Diagnoses listed included: heart failure, atrial fibrillation (irregular heartbeat), and chronic obstructive pulmonary disease (COPD). The MDS revealed the resident received oxygen therapy. An review of Physician Orders revealed a 7/9/24 order for Oxygen at 2 liters per minute via NC at bedtime (HS), and as needed (PRN) for dyspnea (difficulty breathing). It also included an order dated 7/24/24 which directed staff to keep oxygen saturation between 89-91% with avoiding excessive oxygenation and to monitor every shift. During an observation on 7/28/24 at 5:50 pm, Resident #163 noted to be connected to an oxygen tank via nasal cannula (NC). The oxygen gauge was noted to be on 0, indicating an empty tank. During an interview on on 7/29/24 at 9:09 am, a family member stated oxygen tanks were discovered empty a few times when the resident first admitted [admitted [DATE]]. The Treatment Administration Record (TAR) dated July 2024 included shift monitoring documentation but lacked documentation of oxygen saturation levels. During an interview on 8/01/24 at 12:11 pm, the Director of Nursing (DON) stated staff should ensure tanks are full and monitor and notify the nurse to change oxygen tanks that are low or empty. A policy, dated 6/15/21, titled Oxygen Administration Nasal Cannula Purpose: To provide the resident/patient with enhanced oxygen concentration of inspired room air. Procedure #14. Monitor the oxygen flow rate and oxygen saturation, as ordered.

Based on clinical record review, psychiatry progress notes, and staff interview the facility failed to attempt a gradual dose reduction (GDR) of psychotropic medications when the resident no longer exhibited behaviors for which the medications were prescribed for 1 of 5 (Resident #3) residents reviewed. The facility reported a census of 60 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score for Resident #3 of 6 out of 15, indicating a severe cognitive impairment. The MDS recorded 2-6 days of the resident reporting little interest or pleasure in doing things and no days of feeling down, depressed or hopeless in the 2 weeks prior. The MDS documented no physical or verbal behaviors directed towards others during the 7-day look back period. The MDS dated [DATE] documented the identical scores and documentation as the prior MDS. No change in cognitive status, depression or behaviors. The Care Plan identified a Focus Area, revised 5/1/2020 of socially inappropriate behaviors. The Care Plan identified a Focus Area, initiated 8/7/23 of use of anti anxiety medication related to anxiety disorder. The Care Plan identified a Focus Area, initiated 8/7/23 of use of antidepressant medication related to depression. The Treatment Administration Record (TAR) for the months of April, May, June and July 2024 r/t Behavior Monitoring lacked documentation of the resident having any negative behaviors. The Psychiatry Progress Note dated 2/22/24 noted: No changes to Paxil (an anti depressant medication) or Klonopin (an anti anxiety medication) at this time. Reducing any of the medications would not achieve the desirable therapeutic effects and the current dose is necessary to maintain the resident's function and quality of life. Staff will continue to redirect the resident. The note documented the resident has continued making inappropriate sexual comments but tends to stop when redirected. The Psychiatry Intake Note dated 4/2/24 noted: the resident was started on Paroxetine (Paxil) on 12/31/23 for hypersexual behaviors, particularly sexually oriented comments and discussions about his penis. This medication has seemed to help. Then he fell on [DATE] and sustained a subdural hemorrhage. Since then, staff have continued to notice a decrease in his hypersexual behaviors and no apparent adverse changes to his mental health. The Plan section of the Intake note stated depression, anxiety and hypersexual behaviors are stable on current medication regimen and no medication changes recommended. The Psychiatry Progress Note dated 7/12/24 noted: Collateral from nursing reveals no concerns about his mood. He is occasionally sexually inappropriate in his conversation but is fairly easily redirected. They report he just has no filter. He has not had any falls. The note further stated no psychiatric medication changes today. Patient is stable on current regimen with no adverse reaction noted. Dose reduction not indicated at this time as it could be detrimental to the stability of the patient's mental health. The Progress Notes from the Resident #3's Electronic Health Record (EHR) failed to reveal any documentation of any anxiety, depression or sexually inappropriate behaviors in a review of the notes for 2024. During an interivew on 7/30/24 at 1:20 pm, the Director of Nursing (DON) stated the resident still has some behaviors and they should be charted in behavior monitoring. She noted no behaviors had been charted recently and stated the facility could attempt a GDR. The facility policy, dated 5/2014, titled Behavior Management Procedures section indicated: 6. Develop goals and interventions on the care plan with input from the resident/patient and/or family/responsible party. Refer to the Care Plan Development Process in this program. Care plan to include, but not be limited to: a. Parameters for monitoring condition b. Non-pharmacologic interventions c. Dose reduction/elimination 10. Monitor and document behaviors and response to interventions in the resident/patient medical record. 11. Attempt a gradual dose reduction as ordered by the physician unless clinically contraindicated.

Based on observation, menu review, and policy review, the facility failed to serve appropriate diet for 1 of 1 residents (Resident #12) with a low sodium diet order, and 1 of 1 residents (Resident #5) with a double protein diet order. The facility reported a census of 60 residents. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated intact cognition. The diagnoses list included: atrial fibrillation (A Fib - irregular heartbeat), anemia, heart failure, and osteomyelitis (bone infection). The MDS indicated the resident had Stage 3 and Stage 4 pressure ulcers present on admission. A review of Physician Orders, dated 7/5/24, identified a Regular diet, Regular texture, Regular fluid, thin consistency. Directions included: DOUBLE PROTEIN. The Physician Orders revealed Double protein at all meals directions started on 12/23/23. A Pressure Ulcer Notification document dated 3/07/24 revealed the resident's blood albumin (protein in the blood used for tissue repair) level was 3.1 grams/deciliter (g/dL). A normal albumin level is 3.4 - 5.4 g/dL. The document indicated the resident ordered double protein with meals. During an interview on 7/29/24 at 10:53 am, Resident #5 stated he is supposed to get double protein for wound healing. The resident stated he is not always getting double protein. During a continuous lunch service observation that began on 7/31/24 at 11:20 AM, Resident #5's lunch tray was plated with one (1) serving of turkey & rice casserole and one (1) serving of green beans. During an interview on 7/31/24 at 12:55 pm, Resident #5 stated he did not get a double portion of protein. During an interview on 7/31/24 at 1:30 pm, the Registered Dietitian stated a double portion for Resident #5 would have been two (2) servings of the turkey & wild rice casserole. During an interview on 7/31/24 at 2:00 pm, the Assistant Director of Nursing (ADON) confirmed Resident #5's double protein at meals was due to his low albumin level and was for wound healing. 2. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated severely impaired cognition. It included diagnoses of anemia, heart failure, peripheral vascular disease, hypertension, renal failure, hyperlipidemia, and Non-Alzheimer's dementia. The Care Plan revised 7/29/24 directed staff to provide and serve 2 g Na+ (sodium) regular texture, thin liquids diet as ordered. A Physician Order dated 5/01/24 identified the resident's diet as two (2) gram sodium diet, regular texture, regular fluid, thin consistency. During a continuous lunch service observation on 7/31/24 at 10:55 AM, Staff C, [NAME] was observed plating a regular diet serving of turkey & rice casserole for Resident #12. On 7/31/24 at 1:30 PM, the Registered Dietitian stated the resident doesn't adhere to her diet. A document titled Menu Planning Guide updated 3/2022 indicated a low sodium diet is needed for controlling edema or hypertension. During an interview on 8/01/24 at 12:11pm, the Director of Nursing (DON) stated staff should check and ensure the correct diet is served to the resident.

Based on observation, record review, staff interview, and policy review, the facility failed to implement infection control practices to prevent cross contamination of invasive medical devices. The facility reported a census of 60 residents. Findings include: The Minimum Data Set (MDS) dated [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated severely impaired cognition. Diagnoses listed included: cerebrovascular accident ( stroke), non-Alzheimer's dementia, hemiplegia, and seizure disorder. The MDS identified Resident #13 used an indwelling catheter. During an observation on 7/29/24 at 11:56 AM, Resident #13's indwelling urinary catheter tubing observed lying on the floor and the drainage bag in a dignity bag lying partially on the floor. During an observation on 7/29/24 at 1:56 PM, Staff A, Certified Nurse Aide (CNA) emptied Resident #13's catheter drainage bag. She performed hand hygiene and donned gloves, no gown worn. Staff A unhooked the drainage bag from the bed rail, and laid the tubing and drainage bag on the floor with part of the bag exposed. She obtained a graduated cylinder (container for measuring urine) from the bathroom, returned to the resident's bedside and picked up the drainage bag. Staff A unclamped the spigot and drained the urine into the container. She clamped the spigot and secured against the drainage bag. Staff A emptied the urine in the toilet, and removed her gloves. Without completing hand hygiene Staff A walked to the nurses' station and threw the gloves in the trash. Without completing hand hygiene, Staff A picked up a pen and put it in her right pocket, walked down the hall and got a mechanical lift and entered another resident's room. The Care Plan dated 7/02/24 included the indwelling catheter and directed staff to check tubing for kinks each shift, after cares, and as needed and to position the catheter bag and tubing below the level of the bladder and away from the entrance door. The Electronic Health Record (EHR) included progress notes which indicated the resident complained catheter discomfort on 7/02/24; 7/04/24, and 7/08/24 and was changed on 7/08/24. It also included an order for Foley output every shift for Foley care. A document titled Catheter Care dated 01/13 directed staff to remove gloves and wash hands immediately after emptying the urine in the toilet and rinsing the collection container. On 8/01/24 at 12:11 PM, the Director of Nursing (DON) stated staff should remove gloves and perform hand hygiene prior to leaving the resident's room.

Based on clinical record review, observations, staff interviews, and facility policy review, the facility failed to follow Physician Orders for diuretic medication administration, failed to appropriately dispose of medications, and failed to prepare medications according to accepted standard of practice for four of fourteen residents reviewed for medication administration (Residents #13, #21, #26 and #49). The facility reported a census of 53 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #49 dated 8/9/23 revealed the resident scored 9 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderate cognitive impairment. Per this assessment, the resident received diuretic medication for 7 of the last seven days. The Care Plan dated 8/3/23 revised 10/23/23 documented, the resident had a nutritional problem or potential nutritional problem related to (R/T) morbid obesity; history (hx) of fluid overload, hypertension (HTN), edema, Parkinson s, muscle wasting, Chronic Obstructive Pulmonary Disease (COPD). Is on diuretic medication, so weight fluctuations anticipated, and has daily weights (wt). The Physician Order dated 3/10/23 documented, Daily Weights one time a day for congestive heart failure (CHF). Notify if wt change of 3 pounds (lbs)/24 hour (hr) or 5 lbs/week. The Physician Order active 4/20/23 documented, Metolazone (diuretic medication) Oral Tablet 5 milligrams (mg), with instructions to give 1 tablet by mouth as needed for weight gain - 5 mg for weight gain of 2-4 lbs/24 hr or 5 lbs in 48 hr, 2 tablets - 10 mg for weight gain of 4-5 lbs/24 hr or 5-7 lbs/48 hr. The Physician Order active 4/17/23 documented, Metolazone Oral Tablet 5 mg with directions to give 2 tablets by mouth as needed for weight gain ff gained 5 lbs or more in 1 week, administer and then notify Primary Care Physician (PCP). Review of weight documentation for October revealed, in part, the following dates when the resident's weights had increased by greater than or equal to two pounds, and Metolazone not documented as administered: a. On 10/6/2023 at 10:29 AM: 317.0 Lbs. b. On 10/7/2023 at 12:26 PM: 322.8 Lbs. c. On 10/11/2023 at 12:47 PM: 314.0 Lbs. d. On 10/12/2023 at 12:31 PM: 317.0 Lbs . e. On 10/16/2023 at 12:36 PM: 318.5 Lbs. f. On 10/17/2023 at 1:30 PM: 321.6 Lbs. g. On 10/21/2023 at 12:40 PM: 319.2 Lbs. h. On 10/22/2023 at 2:11 PM: 321.5 Lbs. i. On 10/23/2023 at 8:39 AM: 323.5 Lbs. On 10/11/23 at approximately 10:15 AM, above dates were provided to the Director of Nursing (DON) for follow up. On 10/26/23 at 10:40 AM, Staff B, Certified Medication Aide (CMA) explained weights were given to the nurse, and she would determine and ask Staff B to give the medication. When queried if the resident's weight had fluctuated and the resident needed the medication, Staff B responded yeah, and maybe yesterday he (resident) had one. On 10/26/23 at 12:13 PM, the DON explained it did appear the resident may have missed some doses, and explained they were reaching out to the physician. The Facility Policy titled Medication Administration dated 1/13 documented the following purpose: To administer the following according to the principles of medication administration, including the right medication, to the right resident/patient at the right time, and in the right dose and route. 45775 2. During an observation on 10/25/23 at 11:16 AM, Staff D, Licensed Practical Nurse (LPN) had already prepared medications for Resident #21, and Resident #26. Staff D then prepared medications for Resident #13. When queried about how she kept track of three medication cups to ensure she gave the correct medications to each resident, Staff D stated I can tell the medications apart because they are all different. She stated she has a lot to do, and she only prepares more then one medication at a time if she knows the medications. Staff D stated one cup contained an iron supplement for Resident # 21 ; one cup contained 2 acetaminophen (Tylenol) tabs and for Resident #26, and the last cup prepared was gabapentin for Resident #13. During an observation on 10/25/23 at 11:23 AM, Staff D offered Resident #13 2 tablets of acetaminophen for discomfort. The resident refused. Staff D discarded the medications in the trash bin on the medication cart. The trash bin lacked a lid or the ability to be locked. During an interview on 10/26/23 at 10:35 AM, Staff E, Certified Medication Aide (CMA) stated she only prepares medications for one resident at a time. She explained it is too easy to make a mistake if more than one resident's medication is prepared at the same time. Staff E stated if a resident refused a medication or the medication dropped on the floor it is to be wasted in the Sharps container (a container secured to the medication cart where sharp items are discarded after use. The container lid automatically closes and is unable to be easily accessed due to positioning of the lid.), or the Drug Buster container ( jug with a secured lid, and contains a chemical that dissolves medications). During an interview on 10/26/23 at 11:23 AM, the Director of Nursing (DON) stated she would expect a nurse or CMA to prepare medications for administration one resident at a time. She explained more than one at a time increases the risk of an error. The DON stated she would expect staff to waste medications in the Drug Buster container in the Medication Storage Rooms. She stated medications should never be wasted in a trash bin either on the medication cart or other trash reciprocal. The policy, dated 1/2013, titled Medication Administration does not address how many resident medications can be prepared at one time prior to administration.

Based on observation, staff interview, and record review the facility failed to ensure the kitchen was clean and sanitary. The facility reported a census of 53 residents. Findings Include: Observation on 10/23/23 at 11:40 AM of the initial kitchen revealed the following: a. The burners on top of the stove in need of cleaning, greasy build up and what appeared to be dried food particles were observed. b. The food mixer had dried build up and what appeared to be food particles on it. It was not cleaned after use from the previous day. c. The floor and walls throughout the kitchen and dish room observed with debris and build up. d. Food residue under the equipment, appliances, and shelving observed with debris and unknown substance with build up. e. The exterior door between the kitchen and delivery area observed with a small gap where undesirable pest could enter the building. During the initial observation and walk through the Dietary Manager advised a cook that she should have cleaned the mixer after use this morning and the worker responded, I didn't use that today. During an interview with the Dietary Manager, she explained she had only been with the facility for two weeks and was aware that a lot of changes needed to be made. She advised she removed the daily cleaning chart so she could add more cleaning tasks to it and had yet been able to complete it. A review of document from [Name Redacted] Pest Control and dated 9/06/2023 reported Action Required: Door does not close properly (Exterior). Repair or replace as needed. Door in between offices and the kitchen has gap large enough for rodents to fit through. Opened on 9/06/23. Action Required: Food residue under appliance/machinery/equipment (interior, Kitchen). Clean as needed. Food debris build up under dish area. This should be cleaned to prevent small flies and other pest activities. Opened on 9/06/2023.

Based on record review and interview, the facility failed to properly monitor/assist a resident with a history of swallowing difficulties and failed to carry out appropriate procedures to assist a choking resident (Resident #273). A licensed nurse was not in the dining room during the lunch meal as the Director of Nursing had instructed and the care plan failed to identify and communicate Resident #273's eating and swallowing difficulties. The care plan failed to direct staff to cut the resident's food into bite-sized pieces, and cue the resident to swallow the food in his mouth before they offered him another bite. When the resident choked on a large piece of Polish Sausage, facility staff also failed to administer the [MEDICATION NAME] Maneuver in the dining room in a timely manner; instead, staff left the room to summon a nurse, wheeled the resident down the hall in his wheelchair, and had therapy staff perform the [MEDICATION NAME]. In addition, when the resident became unresponsive, CPR was initiated but the facility failed to have a system to rapidly communicate the resident's code status to staff. This failure necessitated a phone call to the resident's spouse to ascertain the resident's wishes while other staff administered CPR. The facility sent the resident to the emergency room via ambulance, and he passed away at the hospital. These findings constitute an Immediate Jeopardy (IJ) to the resident's health and safety. The sample consisted of 25 residents. The facility identified a census of 63 residents. Findings Include: 1. A Certificate of Death form, dated [DATE], indicated Resident #273 passed away [DATE] at 4:28 a.m. and listed the immediate cause of death as acute hypoxic (relating to low oxygen) [MEDICAL CONDITION] due to or as a consequence of [MEDICAL CONDITION] and acute respiratory arrest and listed the underlying cause as aspiration (a condition in which food or liquid is breathed into the airway) with the significant condition of [MEDICAL CONDITIONS] (a condition in which the brain did not receive enough oxygen). According to the MDS (Minimum Data Set) assessment tool dated [DATE], Resident #273 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assist of 1 staff for eating, and extensive assist of 2 staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS listed the resident's cognition as severely impaired. During an observation on [DATE] at 9:00 a.m., it was 92 steps from the fish tank in the 500 Hall to the ADR (Assisted Dining Room) and 48 steps from the front charting room to the ADR. A Speech Therapy Plan of Treatment, dated [DATE], documented the resident's referral to Speech Therapy was due to a swallowing assessment required for a chronic cough and staff reported the resident coughed at times when hurrying to swallow food. A Speech Therapy Discharge Summary, dated [DATE], documented the resident received Speech Therapy services from [DATE]-[DATE] for dysphagia therapy. The discharge recommendations directed staff to cue the resident to decrease oral residue and to check for clearance before offering another bite. A Progress Note entry, dated [DATE] at 12:48 p.m., documented the resident eating lunch at 12:10 p.m. and another nurse yelled the resident was choking. The resident was attempting to get food out as well as trying to get the air in. The writer (a nurse) began to rub his back vigorously due to not being able to get positioned to perform the [MEDICATION NAME] maneuver because of the wheelchair, and food began coming out of the resident's mouth and his lips turned blue. The staff lifted the resident onto the floor, turned him on the side and pulled food from his mouth. Another staff member dialed 911 and a PA (Physician's Assistant) who was present took over the code. The EMTs (Emergency Medical Technicians) arrived and transferred to the hospital via ambulance. A hospital report documented the resident admitted to the emergency department on [DATE] at 12:53 p.m. due to respiratory and [MEDICAL CONDITION] and listed the [DIAGNOSES REDACTED]. The report revealed the resident ate a hot dog and started choking. Staff performed the [MEDICATION NAME] which resulted in the removal of the hot dog. EMS (Emergency Medical Services) arrived and provided CPR (Cardiopulmonary Resuscitation) for a total of 25 minutes and then subsequently transferred the resident to the emergency room . A Progress Note entry, dated [DATE] at 12:45 p.m., documented the resident was in ICU (Intensive Care) and was on a ventilator. A Progress Note, dated [DATE] at 1:23 a.m., revealed the resident passed away on [DATE] at 4:30 a.m. According to the facility's week 1 lunch menu for Thursday (the day of the choking incident), the entree that day was Polish Sausage. A care plan entry, initiated [DATE], documented the resident required assistance at meals and was unable to feed himself. An entry dated [DATE] revealed the resident required total staff assist to eat and ate in the assisted dining room. The care plan did not include information regarding the resident eating rapidly or special direction to encourage the resident to eat more slowly. The care plan did not include information regarding the resident's swallowing difficulties or any special instructions for staff assisting the resident with meals. During an interview on [DATE] at 1:55 p.m., Staff D CNA (Certified Nursing Assistant) stated she was feeding another resident while Staff A fed Resident #273. She stated the residents were eating whole sausage and the resident began coughing like he was choking. She stated there was no nurse in the dining room at the time, so another CNA ran and summoned the nurse. Staff E LPN (Licensed Practical Nurse) entered and pushed the resident out of the dining room to the 500 Hall near the fish tank; Staff Q, PA (Physician's Assistant) directed them to place the resident on the floor. Staff Q then provided chest compressions while Staff D called 911. Staff D stated the resident ate quickly and reported there was supposed to be a nurse in the dining room at all times. During an interview on [DATE] at 3:01 p.m., Staff A stated she was feeding the resident on the day he choked. She stated the resident took a bite of sausage and then wanted milk, so she gave it to him. She then saw the resident was choking. Another CNA went to summon the nurse (Staff E) who was outside the dining room at the medication cart and Staff E came in and wheeled the resident to the 500 Hall near the fish tank. Staff A did not see anyone initiate the [MEDICATION NAME] maneuver in the dining room. She stated the resident was not able to feed himself, so staff cut up the food and fed him. During an interview on [DATE] at 10:31 a.m., Staff A stated she cut up the resident's Polish sausage and gave him a bite on the day of the choking. During an interview on [DATE] at 3:13 p.m., Staff E LPN stated she was in the charting room with the door open when a CNA came out of the dining room and called for her. When she arrived in the dining room, the resident had air exchange but food was hanging out of his mouth. She pulled some food out of his mouth, wheeled the resident away and started running with him in his wheelchair and yelling for help with Staff D accompanying them. When they arrived at the fish tank near the 500 Hall, they ran into Staff R LPN. Staff E stated she needed help and this was the reason she moved the resident out of the dining room and down to the 500 Hall looking for another nurse. A therapy staff member arrived and began doing the [MEDICATION NAME] and Staff Q PA (Physician's Assistant) moved the resident to the floor and continued the [MEDICATION NAME]. Staff E reported the crash cart did not have a suction machine on it or an ambu bag (a bag used to ventilate during CPR). She stated the computer listed the resident as a DNR (Do Not Resuscitate) but they could not locate the signed document, so someone tried to contact the resident's spouse in the midst of the situation to ascertain the resident's code status. Staff E reported there was no nurse in the dining room when the resident choked, although the 500 Hall nurse (Staff R) was supposed to be in the dining room. During an interview on [DATE] at 5:57 p.m., Staff R LPN stated when she was near the fish tank of the 500 Hall, she looked up and saw Staff E, LPN and Staff D, CNA wheeling the resident toward her. They leaned the resident forward and some food came out. Staff Q, PA arrived and instructed them to place the resident on the floor; Staff Q took over until the ambulance arrived. Staff R heard the DON (Director of Nursing) tell the ambulance crew she got a hold of the resident's spouse and the resident was DNR. Staff R stated she witnessed a large piece of hot dog come out of the resident's mouth during the incident. Staff R stated at the time the resident choked, it was her understanding Staff E was in the dining room. She stated the Friday before the incident the DON told her to get to the dining room during meals, but it was difficult for her to do so due to having to pass medications and complete blood sugars. During an interview on [DATE] at 2:22 p.m., Staff Q PA stated on the day the resident choked, she was in an office and heard someone call out for help. The resident was near the fish tank in his wheelchair. His skin was blue and he was not moving any air. She stated one of the PTAs (Physical Therapy Assistants) had attempted the [MEDICATION NAME] maneuver and they moved the resident to the floor when she arrived. Staff Q requested a crash cart, but there was a delay in getting the ambu bag because it was not on the cart. She reported she suctioned the resident and retrieved a large piece of Polish sausage. Staff Q commented the piece of meat was larger than an average bite and estimated it was ,[DATE].5 inches in length. She reported in the course of trying to assist the resident, the facility could not locate the resident's code status. Staff Q stated staff should have initiated the [MEDICATION NAME] maneuver immediately in the dining room because transferring a resident could lodge the piece of food in the throat even more. During an interview on [DATE] at 6:50 a.m., the DON stated when she got back from lunch on [DATE], the resident was unresponsive on the floor by the 500 Hall being assisted by other staff. She stated at the time of the incident, there was not an ambu bag on the crash cart and during the incident they were not 100% sure of the resident's code status. The electronic record indicated the resident was DNR, but they could not find the signed document. She reported they never did find it (the signed documented) after the incident. She stated staff called the resident's spouse during the emergency to inquire as to the resident's code status and the spouse informed them he was DNR. She stated the facility was trying to figure out a system where staff would know the resident's code status without having to go to the chart. She stated when staff fed residents they should cut up food in the appropriate sized bites and stated there should be a nurse in the dining room at all times; if a resident choked, staff should attempt to resolve the situation where the resident was located. During an interview on [DATE] at 1:00 p.m., the DON stated she would search for a policy related to what to do if a resident choked, but did not believe they had one. On [DATE], the facility abated the Immediate Jeopardy by implementing the following: 1. The Director of Nursing completed an audit of each resident's Code Status. 2. Facility staff completed an audit of the Code Carts to ensure all carts contained an adequate amount and type of supplies required in the event one of the residents suffered a [MEDICAL CONDITION] and or experienced a choking incident. 3. The Care Plan Coordinator conducted an audit of residents' care plans to validate each resident's care plan reflected the current needs of each resident. 4. All nursing staff were reeducated by the Director of Nursing regarding the requirements of immediately providing first aid including the [MEDICATION NAME] Maneuver. 5. All nursing staff were educated by the Director of Nursing regarding the requirements of maintaining the Code Carts in a fully stocked manner for immediate access to supplies in case of an emergency. 6. All nursing staff were educated by the Director of Nursing regarding the requirements of immediately calling for assistance in the event of an emergency and that assistance will be rendered at the place of occurrence. 7. All nursing staff were educated by the Director of Nursing regarding the elements of the facility's CPR policy. 8. All nursing staff were educated by the Director of Nursing regarding the requirements to assist resident with cutting foods to a size that is manageable by residents. 9. Licensed nursing staff were educated by the Director of Nursing regarding the requirement to maintain care plans to reflect the most current feeding assistance needs of the residents. 10. All therapy staff were educated regarding the requirement to complete therapy communication sheets with changes in resident care needs. 11. All staff were reeducated regarding the facility's policy for abuse. 12. All education began on [DATE] and continued until all staff were reeducated. The facility did not permit any staff to work prior to receiving all training required to abate the IJ. 13. The Director of Nursing placed a roster of resident wishes regarding CPR and stocked an additional Code Cart in the dining room for immediate use in the event of an emergency. II. Based on record review and interview, the facility failed to provide treatment and care in accordance with professional standards for 1 of 25 residents reviewed. The facility identified a census of 63 residents. Findings include: quality of care to promote the resident's highest According to the MDS dated [DATE], Resident #53 had [DIAGNOSES REDACTED]. The MDS documented the resident displayed cognitive impairment and required extensive staff assist with most activities of daily living. A review of the care plan for (MONTH) (YEAR) revealed no documentation of the potential for constipation with interventions if the resident did not have a BM (bowel movement) for more than 3 days. A review of nurse's notes revealed the following entries: a. On [DATE] at 11:55 p.m., Nurse assessed res for left leg pain related to [MEDICAL CONDITION] (blood clot). The resident appeared upset, displayed facial grimacing and stated pain was 2 or 3 on numeric scale and presented as infrequent, sharp, shooting pain to LLE (left lower extremity). The nurse documented a bruise across the resident's lower abdomen which measured 27 centimeters (cm) by 7 cm, perhaps from gait belt across abdomen. The resident complained of pain upon palpation of abdomen. The nurse notified the physician, who ordered an abdominal x-ray. b. On [DATE] at 07:07 a.m., staff called the physician's office to notify of new symptoms of pain and [MEDICAL CONDITION] (swelling) to the resident's leg c. On [DATE] at 00:40 a.m. Staff received fax regarding AND (abdominal) X-ray results. The physician's assistant asked if the resident continued with abdominal pain and also asked about bowels. The resident had last bowel movement on [DATE], so the physician assistant ordered staff to give [MEDICATION NAME] suppository now and if no results in 4 hours, give enema tomorrow. Staff administered suppository, awaited results, and passed information on to next shift. d. On [DATE] at 00:58 a.m. abdominal X-ray results: portable image of the abdomen demonstrated [MEDICATION NAME] distention of multiple loops of bowel throughout the abdomen with moderate volume stool in the colon. e. On [DATE] at 05:43 a.m. The resident did not have results with suppository, gave enema with results of formed soft medium BM. A review of (MONTH) (YEAR) MARs revealed the following: a. [DATE] [MEDICATION NAME] ordered daily b. FeSo4 (iron supplement) 325 mg(milligrams) twice daily c. Senna S 8.6 mg 2 tablets twice daily d. [MEDICATION NAME] suppository 10 mg once daily as needed for constipation - only one dose signed out on [DATE] e. Fleets enema one application once daily as needed for constipation - no doses signed out as given f. Senna Tabs 8.6 mg one tablet once every 8 hours as needed for constipation - no doses signed out as given During an interview on [DATE] at 8:33 a.m., Staff L, LPN reported if the resident had no bowel movement for more than 3 days, try least invasive interventions first, such as pushing fluids, then utilize standing order for Milk of Magnesia (MOM) and [MEDICATION NAME] suppository as the facility protocol. By day 3, assess bowel sounds, give suppository and if the suppository doesn't work, notify physician for additional orders. In an interview on [DATE] at 8:58 a.m., Staff F, LPN reported the facility protocol if the resident has not had a bowel movement for more than 3 days is to push fluids and initiate MOM. If MOM ineffective, repeat the MOM the following shift. If the second dose is ineffective, notify doctor via facsimile. During an interview on [DATE] at 9:07, Staff M, LPN reported the facility protocol if the resident has not had a bowel movement for more than 3 days: start with MOM on the third day, there is a section on the dashboard area (under the section with EMARs which will show alerts, i.e.: dietary intakes, if the resident has not had a BM for more than 3 days.) All nurses are educated to check the dashboard report at the beginning of the shift. The night shift nurse will usually tell first shift of residents that have gone for more than 3 days. In an interview on [DATE] at 2:26 p.m. Staff J, LPN reported the facility protocol: if resident has not had a bowel movement for more than 3 days is to initiate standing orders, listen to their bowel sounds, palpate their abdomen, ask the CNAs when the last BM was and if it has been 3 days, give MOM first, if ineffective, give [MEDICATION NAME] suppository. Staff J stated if the [MEDICATION NAME] suppository is ineffective, then give Fleets enema and if that is ineffective, call the prescriber and ask for their recommendations. She also reported Resident #53 had problems with constipation and had required MOM because she was on the 3 day list several times. Staff J stated the 3 day list is on our dashboard which means the resident did not have any documented BMs for 3 days. The nurses are to review the dashboards each shift. If a laxative is given, nurses should be checking for effectiveness at least every shift. Staff J reported if the resident had a BM, this would be documented in the nurse's notes and not necessarily if they did not have one. They should also check for bowel sounds, abdominal distention, decreased appetite. During an interview on [DATE] at 8:08 a.m., the director of nursing reported the facility protocol: if the resident had no BM for more than 3 days, staff placed the resident on the BM list. The nurses should ask the resident if she/he had a BM if they're cognitively aware and if they have, the nurse will document in the progress notes the day the resident had a BM. If they have not had a BM for 3 days, on the 3rd day, the facility had a standing order kept in the shift guides in each station at each hall. The nurse should start with MOM and if that doesn't work, give a [MEDICATION NAME] suppository and if that doesn't work, give a Fleets enema. If that doesn't work, the DON reported,we notify the doctor for further orders. She also reported that Resident #53 had chronic problems with her bowels. This problem should have been passed on in report. Shift reports are verbal and they are supposed to use 24 hour worksheets for nurses that don't work every day so they can get a picture of what has been going on with the past 2 weeks. The DON stated the facility kept a copy of the worksheets, but unable to produce a copy for the first week of (MONTH) (YEAR). She also reported the incident could have been prevented with better communication and follow-up. The DON added, if Resident #53 did have the history of constipation, I would not necessarily have expected the bowel protocol to be on her MAR because she had other interventions in place, such as the [MEDICATION NAME] and the Senna PRN A facility form titled: standards of practice directed: The below orders may be initiated by a nurse unless to do so is contraindicated by a resident's medical condition/history or allergies [REDACTED]. a. Milk of magnesia 30 cc (cubic centimeters) daily as needed for constipation. b. [MEDICATION NAME] suppository 10 mg daily as needed for constipation. c. Fleets enema one bottle daily as needed for constipation A review of the facility policy titled: bowel intervention policy with revised date of [DATE] had documentation of the following: All residents noted to have gone 3 days without a bowel movement, will receive the most non-invasive intervention they have ordered or allowed to take. This may include, but is not limited to Milk of Magnesia, [MEDICATION NAME] tablets or prune juice. The third shift nurse will run the no BM reports and perform and abdominal assessment on indicated residents. Documentation of the findings are to be documented. This will be included in their report to the first shift nurse. The first shift nurse will begin the first intervention, will receive a suppository starting on day 4 by the third shift nurse at 6:00 a.m. If the resident does not have results following a suppository intervention or the resident refuses any intervention, the physician must be called for further instructions. If the resident does not have a current PRN medication for bowel intervention, one must be written from the facility standing orders.

Based on observation, record review, staff interviews, and facility procedures, the facility failed to provide adequate nursing supervision, assistance devices, and individualized interventions for Resident # 47 after multiple falls which culminated in a fall and [MEDICAL CONDITION]. The facility reported a census of 63 residents. Findings include: 1. The Significant change Minimum Data Set (MDS) assessment tool dated 05/04/2018 indicated Resident # 47 demonstrated both long and short term memory deficits with severely impaired decision-making abilities. The MDS documented Resident # 47 required limited assist of one staff for ambulation (walking) and toilet use. The MDS also documented the resident experienced bowel and bladder and had [DIAGNOSES REDACTED]. The plan of care with a revision date of 12/19/2016 documented Resident # 47 as at risk for falls The plan documented the need for 2 staff to assist with transfers (12/19/16 and revised on 06/11/18), provide a low bed, body pillows (05/30/18), and clear pathways and call light (12/19/16). The care plan also directed staff to place a fall mat at bedside (05/30/18), and provide correct fitting shoes (04/24/18). The plan failed to provide any assistance with ambulation. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. From the beginning of (MONTH) (YEAR) until the fall and fracture on (MONTH) 26, (YEAR), Resident # 47 fell 15 times. a. 02/05/18 (10:00 PM) found sitting on the floor by couch yelling for help. b. The resident fell 8 times between (MONTH) and (MONTH) (YEAR); each time staff found the resident on the floor at the end of her bed. The fall on 05/26/18 resulted in a left [MEDICAL CONDITION]. c. 03/30/18 (5:24 PM) found on floor by station 1. d. 04/24/18 (2:28 P.M.) resident fell on face in hall. e. 05/01/18 (12:49 PM) ambulating in hall with sister and fell on the floor. 05/03/18 (9:40 PM) found on floor in 500 hall. 05/07/18 (2:45 PM) found on floor in 300 hall. 05/26/18 (12:15 A.M.) fall by bed and fall with fracture at 12:53 A.M. The facility failed to consistently identify appropriate interventions with each fall in order to prevent more falls from occurring. During an interview on 06/18/18 at 11:32 AM, Staff O, LPN (Licensed Practical Nurse) reported working the night of 05/26/2018 when Resident # 47 fell and fractured her left hip. Resident # 47 fell around 12:15 AM without any injuries found. Staff P, CNA (Certified Nursing Assistant) and Staff O placed the resident back in bed. Staff O stated it was not unusual for this resident to be up at night. Staff O noticed for the last 2 months Resident # 47 seemed to be slowly declining in stability when ambulating. Sometimes she would allow you to help her and other times she could be combative. Around 12:15 AM, Resident # 47's roommate came out into the hall and told staff the resident had fallen. Staff O and Staff P entered and found Resident # 47 on the floor at bedside with her legs out in front of her, holding her knee. The resident batted at the nurse to go away. Resident # 47 did not complain of any pain, so Staff P and Staff O helped the resident back to bed. Around 12:50 AM, the roommate came out again and said Resident #47 was on the floor. Staff O examined the resident who was not in pain until moved, then she complained of severe pain. The nurse called Hospice, the resident's daughter, and the ambulance. On 06/12/18 at 11:54 AM, the Director of Nursing stated had Resident # 47 incurred several falls prior to the [MEDICAL CONDITION] on 05/26/18. The DON stated this resident ambulated around the facility prior to the last fall. The DON stated this resident's dementia is advanced. She verbalized that interventions were put into place after each fall. A review of the plan of care revealed it failed to contain consistent, individualized interventions for every fall situation. On 06/13/18 at 02:29 PM, Staff P (Certified Nursing Assistant) verbalized being on duty the night Resident # 47 fell and fractured the left hip. She stated she worked 100/200 and part of 300 hall that night and when she made rounds, Resident # 47 was asleep in her bed. Staff P reported sometime after midnight, Resident # 40's roommate came out in the hall and said the resident was on the floor. Staff P called the nurse, went into resident's room and found her on the floor by the bed. Staff O checked the resident, found no injuries, and assisted her back in bed. Staff P stated the resident did not want to be bothered and yelled, get away, get away, but a short time later, the roommate came out told us Resident # 47 was on the floor again. This time Staff O checked and found the resident in pain when moved, she called the ambulance. When asked, Staff P verbalized the night shift helped Resident # 47 to the bathroom when she needed to go and they didn't use a mat by her bed. The facility Fall Risk Reduction & Management dated 12/2015 directed nursing staff to identify risk factors for falls and injuries, implement individualized interventions to minimize the fall risk, address the underlying causes, and evaluate the effectiveness of the interventions put in place.

Based on observation, record review and resident and staff interviews, the facility failed to have adequate staff in order to promptly respond to activated resident call lights which resulted in Residents #1, #3 experienced bladder incontinence and Resident #5 had ongoing chest pain. Resident #1 felt disgusted and embarassed due to the incontinent episode and Resident #5 felt scared becasue staff did not respond to the call light when he/she had chest pain. The sample consisted of 5 residents and the facility reported a census of 69 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 7/3/17. The MDS indicated Resident #1 had [DIAGNOSES REDACTED]. The Roster Sample Matrix document, provided by the facility on 7/28/17, identified Resident #1 as able to be interviewed. The MDS indicated Resident #1 required extensive assistance of two staff for bed mobility, transfers and toilet use. Resident #1 had frequent bladder incontinence. The current Care Plan initiated a problem with the resident at risk for falls due to gait and balance problems. The approaches directed the staff to be sure the resident's call light is within reach and encourage the resident to use the call light for assistance as needed. The approach directed the staff that the resident needed prompt response to all requests for assistance. Observation of Resident #1's room identified a Therapy Communication -Teaching - Training sheet, attached to the wall. The sheet dated 7/6/17 directed the staff to transfer/ambulate Resident #1 with assistance of one staff and a platform rolling walker. On 8/1/17 at 3:45 p.m. Resident #1 was interviewed and reported 2 weeks ago he/she asked the staff for assistance to go to the restroom. Resident #1 stated a staff person told him/her they would be back and then didn't return for almost an hour. Resident #1 stated she/he had an accident (urinated) in his/her pants. Resident #1 reported he/she felt a feeling of disgust and embarrassment and had to walk down the hallway with wet pants. Resident #1 stated she/he is in the common area most of the day and even sleeps in the common area. On 8/3/17 at 10:40 a.m. Staff B reported Resident #1 tells the staff when he/she needs to use the restroom. Staff B reported the residents may have to wait over 15 minutes for assistance if one of the staff is on break. 2. Resident #3 had a MDS assessment with a reference date of 6/16/17. The MDS indicated the resident had a BIMS (Brief Interview for Mental Status) score of 13. A score of 13 represented no cognitive problems. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had no urinary or bowel incontinence problems. The Care Plan directed the staff to provide assistance of two staff for transfers with a gait belt, place call light in reach and encourage use. On 8/1/17 at 3:00 p.m. Resident #3 was interviewed and reported he/she turned the call light on and waited up to 30 minutes every day for the last two weeks. Resident #3 stated he/she knows when needs to go (to the bathroom) and can make it there if the staff respond timely. Resident #3 stated he/she times the response on his/her wristwatch. An interview on 8/3/17 at 10:35 a.m. Staff A reported residents had accidents waiting for the staff to use the restroom. The residents reported to Staff A that they waited 20 minutes for the staff to respond to the call lights. (A reasonable person would not like to urinate in their personal clothing). 3. According to the Admission Record dated 8/1/17, Resident #5 had [DIAGNOSES REDACTED]. The MDS with a reference d ate of 7/13/17 indicated Resident #3 dated 7/13/17 identified Resident #5 required limited assistance of 1 staff person for transfers and toilet use. The MDS identified the resident had no cognitive problems and had a BIMS score of 15. The Care Plan directed the staff to keep the call light in reach, encourage to use it for assistance as needed and provide a prompt response to all requests for assistance. The Progress Notes dated 7/23/17 at 10:04 p.m. indicated Resident #5 called 911 (emergency number) because of chest pain. The note indicated when medics arrived; Resident #5 stated the chest pain had gone away. On 8/1/17 at 12:06 p.m. Resident #5 was interviewed and stated he/she had chest pain and put the call light on (activated). Resident #5 stated when the staff didn't respond after 30 minutes, he/she called 911. Resident #5 described the experience as scary. On 8/2/17 at 3:46 p.m. Staff D (licensed practical nurse) was interviewed and stated Staff E (Nurse) informed him/her someone called and reported Resident #5 called 911 and an ambulance was dispatched. Staff D went to Resident #5's room. Staff D did not recall if the call light was activated. Resident #5 reported the chest pain subsided. Staff D reported she was in Resident #5's room [ROOM NUMBER] minutes prior to this and administered medications to Resident #5. According to the Medication Administration Audit dated 7/23/17, staff signed out Resident #5's medications from 4:52 p.m. to 5:01 p.m. A phone interview on 5/2/17 at 4:10 p.m. identified the emergency services received Resident #5's call at 5:34 p.m. On 8/3/17 at 10:55 a.m. Staff C (certified nursing assistant) was interviewed and stated she reported the residents have complained about the staff's response to the call lights. Staff C stated she reported the residents had accidents in their pants while waiting for the staff to respond. Staff C stated the longest wait is when one of the staff is on break. Staff C stated the staffing is based on the census. Staff C reported the 500/600 Hall had 3 nurse aides instead of 4 for about a month because of the census. Staff C stated it is hard to answer the lights within 15 minutes. Staff C reported the staff is spread too thin. The CNA Orientation checklist, received on 8/3/17, identified a goal to respond to call lights in 10 minutes. The checklist directed the staff to never shut the call light off unless able to meet the resident's needs at that time. If the resident is the assistance of two staff, leave the light on and go ask for help.

Based on record review, and staff and family member interviews, the facility failed to ensure the resident received adequate nursing supervision to prevent accidents during a surface to surface transfer for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 70 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 10/2/16, Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of 2 or more staff with transfers to and from the bed and chair, and also with bathing, dressing, toilet use and personal hygiene. The nursing care plan identified a self-care performance deficit related to limited mobility and left sided weakness/paralysis. The care plan directed staff to provide 2 staff assistance with gait belt for transfers, changed to 2 staff assist with mechanical lift for transfers on 11/2/16. An X-Ray of the left humerus (upper arm bone) obtained on 10/27/16 revealed a mildly displaced oblique fracture of the proximal humerus with interior subluxation/partial dislocation of the humeral head (ball and socket shoulder joint partially out of the socket). Nurse's Notes revealed the following: a. On 10/26/16 at 2:41 p.m. Staff A, licensed practical nurse (LPN) and unit manager documented the resident's family member reported the resident had significant pain in the left shoulder/arm at physical therapy. The physical therapist (PT) reported the resident demonstrated a significant amount of pain during therapy. Family members requested X-Rays of the resident's left shoulder and arm. Physician's office notified. b. On 10/26/16 at 3:14 p.m., Staff B, LPN documented the family stated the resident's arm popped out during therapy and requested X-rays. c. On 10/26/16 at 3:20 p.m., Staff A documented Staff B reported the resident demonstrated no signs of pain or discomfort and participated in cares per his/her usual self. d. On 10/26/16 at 11:32 p.m., Staff C, LPN documented Resident #1 had not voiced any complaints of pain or discomfort and had their left arm in a sling. e. On 10/27/16 at 3:16 a.m., Staff D, registered nurse (RN) wrote the resident denied any pain or discomfort, and required assist of 1 to 2 staff for repositioning in bed and personal cares. f. On 10/27/16 at 2:00 p.m., Staff B documented the physician assistant (PA) ordered x-rays of left shoulder, acetaminophen (Tylenol) 650 milligrams (mg) administered orally every 4 hours as needed for pain. The PA ordered staff to administer a dose at that time, then 3 times daily scheduled in addition to the every 4 hour as needed doses. g. On 10/27/16 at 3:37 p.m., Staff A documented the resident reported discomfort when certified nursing assistant (CNA) applied shirt in the morning, But no other reports of pain or discomfort the remainder of the shift; he/she participated in therapy per normal routine. A statement recorded by the PT, Staff E, on 10/28/16 revealed on 10/26/16 at 9:50 a.m., she transferred the resident from the wheel chair (WC) towards the right (the resident's unaffected side) to the NuStep machine (similar to an exercise bike). The resident used both legs and the right arm on the NuStep for 16 minutes. The PT supported the resident's left arm in a neutral position with her left arm and transferred the resident to the right side to the WC. At that time, the resident reported pain in the left shoulder and arm. PT assessed the left shoulder and noted some anterior and inferior subluxation of the left shoulder, and within expected limits of a [DIAGNOSES REDACTED] arm with paralysis. PT recommended use of a sling on the arm used with transfers and therapy activities. The resident's family member reported the resident had a sling at home and they would bring it to the facility for use. The resident's left arm was placed in an air splint for 15 to 20 minutes that promoted increased blood flow. Once removed, Resident #1 continued to complain of pain, but was less pain than before the application. A statement recorded by Staff B, obtained 10/31/16 documented on 10/26/16 at 12:05 p.m., the resident's family member stated they heard a pop in the resident's left shoulder at therapy, Staff B performed passive range of motion to left shoulder with findings within normal limits for the resident. The assessment did not reveal bruising or swelling, the resident denied pain to the shoulder at that time, and the nurse administered acetaminophen per the family member's request. At 2:45 p.m., another family member requested an x-Ray of the shoulder and the request was referred to Staff A at that time. A statement recorded by Staff F, CNA, obtained 10/31/16 documented on Thursday morning (10/27/16) the resident had a sling on the left arm when staff observed him/her before breakfast. The resident complained of pain in the shoulder with facial expressions that showed pain as staff dressed the resident at that time. When interviewed on 11/15/16 at 1:50 p.m., Staff B stated she worked the day shift on 10/26/16, and around lunch time the resident's family member talked about a pop in the resident's arm at therapy that day. Staff B wrote she assessed the arm at that time and it seemed within normal limits. She administered acetaminophen. Around 2:00 p.m. another family member requested x-Rays. Since it was the end of her shift, she turned the matter turned over to the unit manager (Staff A). During an interview on 11/16/16 at 1:16 p.m., Staff F stated she was off work on 10/26/16, but when she worked the day shift on 10/27/16, she saw a sling on the resident's arm. The nurse reported the arm was sore from therapy. Staff F remembered the resident winced with pain when they moved the arm and said his/her shoulder hurt when they transferred the resident 2 to 1 with a gait belt and pivot method that morning. Staff G, CNA, stated when interviewed on 11/16/16 at 1:30 p.m. that she was off work on 10/26/16, returned to work on day shift on 10/27/16, Resident #1 was usually the first resident they got up and had a sling on their arm that morning, the nurse said it was sore from therapy, the resident appeared in pain when they transferred him/her with 2 to 1 pivot method with gait belt, and appeared to have pain with movement. The employee stated she had not noticed the resident in pain prior to that date. Staff H, CNA, stated when interviewed on 11/16/16 at 11:38 a.m. that she assisted Staff H, CNA, with a 2 to 1 pivot transfer of Resident #1 from bed to WC on the morning of 10/26/16 with no abnormalities with the transfer identified. Staff I, CNA stated when interviewed on 11/16/16 at 11:47 a.m. she worked from 10:00 a.m. to 2:00 p.m. on 10/26/16, remembered something happened with the resident's arm in therapy and x-Rays wanted, she transferred the resident 2 to 1 and resident did not complain of pain. Staff J, physical therapy assistant (PTA), stated when interviewed on 11/15/16 at 9:55 a.m. that she usually worked with the resident as a co-treatment with occupational therapy (OT) in the morning and transferred the resident 2 to 1 with OT. Prior to 10/26/16 the resident would complain of pain in the left wrist/hand area after he/she exercised on the parallel bars and thought it was because the activity stretched muscles in that area. On 10/26/16 the employee worked with another resident in the therapy gym as the PT, Staff E worked with the resident, she saw Staff E transfer the resident to the NuStep, then back to the WC, Staff E had asked her where the slings were and applied an air splint to the resident's left arm, Staff J stated she thought she saw pain on the resident's face at that time, Staff E had identified the subluxation and showed the employee how to assess it when the air splint was on. Staff E, PT, stated when interviewed on 11/15/16 at 10:30 a.m. she had been a PT for 33 and 1/2 years, mostly in long-term care. She reported she was new to the facility and the first time she assessed Resident #1 was on 11/17/16 as the resident remained in bed. The 2nd time she worked with the resident was on 10/26/16, between 9:30 a.m. and 10:00 a.m. At that time she transferred the resident to their right side from WC to the NuStep, her knees locked around the resident's left knee, her right arm around the resident's left side. Staff E reported she held the gait belt at the resident's back area with her right hand, her left hand on the gait belt at the resident's right side area. After the resident completed the NuStep, with both legs and right arm, she transferred him/her to the WC (right). The resident complained of pain in the left shoulder/upper arm once in the WC. The PT assessed the subluxation assessed as moderate, 1 to 2 fingerwidths. She applied an air splint to the left arm at that time for 15 to 20 minutes, but a family member stated it was uncomfortable and asked her to remove it. Staff E stated upon removal the skin color of the area had improved and hand swelling was reduced. During an interview on 11/15/16 at 12:01 p.m., the radiologist that read the 10/27/16 the resident's x-rays reported the humerus fracture was acute (new), more than a few hours old and less than 6 days old. The radiologist could not identify the age of the subluxation. During an interview on 11/16/16 at 11:05 a.m., the physician assistant (PA) that assessed the resident on 10/27/16 stated she assessed the resident seated in a wheel chair on 10/26/16 between 10:45 a.m. and 11:00 a.m. The PA reported the resident was in obvious pain at rest; the pain was located in the left shoulder and upper arm and increased with any movement. She also reported she assessed the resident on 10/24/16 and the resident did not have an arm/shoulder injury or pain on that date. The PA stated the injury was acute. During an interview on 11/17/16 at 9:50 a.m., the orthopedic physician that assessed the resident on 10/31/16 and 11/15/16 stated when he assessed the resident on 10/31/16 the pain was localized at the upper arm area, the injury likely resulted from someone pulling up on the resident's arm. He reported and he had seen injuries of that type in his practice before, the long-standing [DIAGNOSES REDACTED] caused osteopenia (weakness of the bone) and the area at increased risk of injury but someone must have felt something or heard something when it happened. He stated it was an injury from force, but the subluxation was chronic and an anticipated finding on someone with a long history of [DIAGNOSES REDACTED].

Based on observations, clinical record review, and interviews, the facility failed to ensure each resident received adequate supervision to protect against hazards in the environment while being transported in the facility van. On 4/16/15, a staff member/van driver transported Resident #1 in his/her wheelchair to a doctor appointment when the equipment came unhooked and caused Resident #1 to fall on his/her right side. Interview with Resident #1 revealed he/she flew across the van and hit his/her head. Interview with a wheelchair van representative revealed if all the equipment had been connected, then the incident would not have occurred. The van driver stated the equipment had been disconnected after the incident occurred. Concerns were identified for 1 of 4 residents reviewed with a facility reported a census of 75 residents. Findings Include: 1. According to the Minimum Data Set ((MDS) dated [DATE], Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident with a Brief Interview for Mental Status total score of 14 which indicated the resident had intact memory and cognition. The MDS reflected Resident #1 required one staff assistance for bed mobility, transfers, dressing, and personal hygiene. The MDS documented the balance assessment indicated Resident #1 not steady and only able to stabilize with staff assistance. The MDS indicated the resident had no functional limitations in both upper and lower extremities and in range of motion. The MDS identified Resident #1 totally dependent on staff for locomotion on and off the unit. The MDS indicated the resident used a walker and a wheelchair for mobility devices. According to the Plan of Care with an initiated date of 4/6/15, Resident #1 had an increased risk for falls related to recent pneumonia, muscular decondition, fall history, generalized weakness, Polymyalgia Rheumatica (inflammatory disorder), Chronic Obstructive Pulmonary Disease (COPD) and anemia. The resident's plan of care specified he/she would have no falls that resulted in acute hospitalization throughout his/her stay. The interventions directed one staff to assist with transfers and ambulation, utilizing a 2 wheeled walker and gait belt. The Assessment of Risk For Falls dated 3/31/15, indicated Resident #1 at a low risk for falls. Review of Resident's #1's Nurse's Notes dated 4/16/15 at 9:00 p.m. revealed while Resident #1 left for a scheduled physician's visit around 2:00 p.m., the resident fell while in the facility van. Staff took the resident to the emergency room for treatment after the fall. The notes identified the resident's injuries to his/her left thumb with a laceration with 3 sutures, 2 lacerations to the right side of the head each containing 5 staples, a skin tear to right elbow, a laceration to the left middle finger and bruise to right 5th finger and right palm of hand. The notes documented new orders received for wound care to leave mepilex dressing on to right elbow, change in one week or if the dressing falls off then apply bacitrcin dressing twice a day; clean left thumb with soap and water, clean scalp laceration twice a day with soap and water. The resident returned to the nursing home at 5:30 p.m. Review of the Resident Incident Report dated 4/16/15 at 2:45 p.m. reviewed resident received lacerations in facility van while sitting in a wheelchair. Resident taken to emergency room for further treatment and evaluation. The emergency room notes dated 4/16/15 revealed Resident #1 sustained lacerations of multiple sites of scalp and neck, laceration of thumb, left, and a skin tear of right elbow ( without complication). The head CT (computed tomography) scan revealed no intracranial hemorrhage, no mass or mass effect, or no depressed skull fracture. The resident sustained [REDACTED]. The resident sustained [REDACTED]. The resident's wounds were sutured. The resident express concern that he/she would not be able to return to his/her home as planned on 4/19/15. According to the facility self-report, Staff C/van driver had been driving the facility van on 4/16/15 when Resident #1's wheelchair came loose on the left side, causing the resident to fall to his/her right side. Resident #1 hit his/her head and had been treated and released (from the emergency room ), back to the nursing home at 5:34 p.m. The Administrator investigated the incident and the van driver reported he/she had secured the wheelchair with the 4 straps and the seat belt. The Administrator re-acted the incident and all straps and binders functioned appropriately without incident. During an interview with Resident #1 on 5/28/15 at 3:37 p.m., he/she stated, the wheelchair came loose and he/she flew across the (van) and hit the lift. Resident #1 stated he/she was dazed after the incident and did not recall how he/she got to the emergency room . Resident #1 reported being in the wheelchair on its side on the floor. The resident reported he/she did not feel him/her (self) slide around before it happened and did not pay attention when the driver hooked him/her up. Interview on 6/10/15 at 9:00 a.m. with a representative from The Q'Straint & M-Series, Wheelchair & Occupant Securement System. The representative stated that if the floor anchorage are connected appropriately along with belts and hooks, and all equipment in good working order, then it would not have come undone by hitting a bump, suspension of the van, or going over a speed bump at 5-7 miles per hour. The representative stated these prior circumstances would not cause any of the wheelchair restraint to come undone or loose. The representative stated it would have to be both front and back of the same wheelchair restraints sides to either not be connected or connected inappropriately for the wheelchair to tip over. Interview on 5/27/15 at 9:45 a.m., Staff B, RN, wound nurse stated Resident #1 had an appointment to see the surgeon for staple removal of abdominal incision site. Staff B stated the resident had already been in the van and the lift door closed when she arrived but she witnessed Staff C connect the lap belt. Staff B did not observe Staff C secure Resident #1's wheelchair in the van. Staff B drove her own car to the appointment. Staff B stated she arrived to the doctor's office at the hospital before the van and called Staff C to find out why he had not arrived. Staff C stated she did not get an answer and then got a call from Staff C asking for help as Resident #1 had fallen in the wheelchair inside the van outside. Staff B stated she and another nurse from the clinic responded and found the resident sitting on the van floor completely out of the wheelchair with Staff C supporting the resident's back. Staff B stated the wheelchair was upright and pushed out of the way. Staff B stated she had seen straps used to secure the wheelchair on the floor but don't know if they were connected to anything. Staff B stated the resident requested to get up off the van floor and had been bleeding from their head and on his/her hands. Staff B stated she assisted the resident into the wheelchair and took him/her to emergency department around the corner of the hospital building. Interview on 5/27/15 at 10:13 a.m., 5/28/15 at 2:45 p.m. Staff C, Van Driver/Maintenance stated in his first interview that he had been driving for 6-8 months and received training by the Maintenance Supervisor. Staff C stated he assisted Resident #1 into the van via the wheelchair lift in the back of the van. Staff C stated he positioned the wheelchair, locked the break and then used the wheelchair restraints to secure the wheelchair in place. Staff C stated he used all four restraints and applied the lap belt. Staff C stated he checked the wheelchair after securing it, and shook the chair which did not move. Staff C stated he proceeded to the hospital where the doctor's office is located and turned the van to right instead of the usual left turn due to seeing a person lying on the sidewalk outside of the emergency room entrance. Staff C stated he stopped to ask the people if they needed help. Staff C stated then he drove the van around the back of the hospital. Staff C stated he stopped at the stop sign and then proceeded driving between 5-7 miles per hour over a speed bump. Staff C stated that is when he noticed in the rear view mirror the resident's leg up in the air and his/her shoe dangling off his/her foot. Staff C stated he stopped the van and went back to the resident who was alert and orientated. Staff C stated the wheelchair tipped to right side, but not all the way over, up against the van lift. Staff C stated the resident's head rested against the van lift and he/she had been bleeding from head. Staff C stated the resident remained in the wheelchair when it was tipped and he unhooked the resident's seatbelt. Staff C stated the front left floor anchorage was not connected or secured to the floor track, but the back left and back right and the front right were all securely connected to the wheelchair. Staff C stated they had ordered new straps not long ago but he had used these straps and they are identical to the old ones. Interview on 5/28/15, Staff C now stated the wheelchair fell completely to the right side of the van and the resident fell out of the wheelchair with the lap belt still connected. Staff C reported he took the lap belt off and unhooked the three remaining wheelchair restraints (the hooks that are connected to the wheelchair) and pushed the wheelchair out of the way. Staff C stated the left front floor anchorage was the only restraint not connected to the wheelchair when it tipped over. Staff C stated he is an EMT (Emergency Medical Technician). Observation of the van and interview on 5/29/15 at 9:30 p.m. with Staff C revealed now he recalls, the back left hook of the wheelchair must have been undone, or maybe came undone from hitting a bump. Staff C stated the right side wheelchair restraints were still connected. The surveyor tested whether the wheelchair could be tipped over as Staff C hooked up a wheelchair to the van restraints like he/she does all the time. Observation showed after the wheelchair restraints were securely in place, the wheelchair did not come loose or tip when pulled or pushed or lifted on. The surveyor asked Staff C to show how he found the front left floor anchorage after the resident tipped over in the wheelchair. Staff C, with effort, undid the floor anchorage and observation showed the hook-connected to the straps- of the left front still connected to wheelchair and tightened and locked positioned, with Staff C responding that was how he found it. The surveyor and Staff C attempted to move the wheelchair at that time and the wheelchair moved slightly. The front left wheel did not tip over due to the remaining 3 restraints still connected; nor would the wheelchair move backwards. However, when Staff C removed the left back hook restraint connected to wheelchair, (with effort ) it was noted once the left back hook had been disconnected along with the front floor anchorage the wheelchair easily tipped over to the right side. Staff C stated maybe the suspension of the van may have caused the restraints to come off. Staff C stated he/she was sure the resident had been secured correctly, in the wheelchair with the restraints before he left the facility. Interview on 5/26/15 at 3:00 p.m. with the Administrator revealed Staff C immediately reported the incident involving Resident #1 to him. The Administrator stated they have had no prior incidents with this van driver nor has the facility had an incident involving the bus or transportation in general. The Administrator indicated he did suspend the van driver until further notice. The Administrator stated he tested the floor binders using the resident's wheelchair and could not recreate the event. As all the straps and binders retained in position.

Based on record review, staff interviews and review of manufacturer ' s recommendations, the facility failed to provide adequate supervision to ensure against hazards from self and failed to ensure safety interventions, identified after an incident, are care planned and implemented for 1 of 4 residents (Resident #1). Finding include: 1. Resident #1 had a MDS (Minimum data set) assessment with a reference date of 07/02/13, which identified the resident had [DIAGNOSES REDACTED]. The MDS documented the resident had a BIMS (Brief Interview for Mental Status) score of 4 out of 15. A score of 4 identified the resident as severely impaired cognitively. The MDS identified the resident required extensive assistance of one staff member for the resident ' s activities of daily living (bed mobility, transfers, walking in room/corridor, dressing, and eating. The MDS reflected the resident depended on staff for toilet use and personal hygiene. The MDs reflected the resident had balance problems and could only stabilize with staff assistance. Review of the facility Fall Risk assessment dated [DATE] identified an assessment score of 10. A score of 7-18 represented a resident to be at high risk for falling. The Care Plan dated 12/23/13 listed a Problem/Need of the resident at risk for falls related to impaired balance and legal blindness. The approaches directed staff to: a. Resident is to have non-skid footwear on for all transfers and ambulation. b. Staff are to encourage and assist the resident to walk to meals. c. Staff are to ensure the resident's glasses are on, in good repair, and clean. d. Resident's bed to be placed in low positioned with wheels locked. e. Resident transfers/ambulates with the assistance of one (staff person), gait belt, and walker. f. Staff are to ensure the resident has in place a personal alarm, bed, chair, and floor alarm. g. Staff to ensure the resident's call light is in reach. h. Staff are to give the resident verbal safety reminders to not get up on own. i. Staff are to maintain the resident's environment free of clutter and safety hazards. j. Staff are to keep resident's frequently used items within reach. k. Implemented 2/10/14, body pillows (are to be placed) to the outer edge of the bed. Review of the Resident Incident Report Dated 4/16/13 at 1:45 a.m. revealed staff heard the resident calling out for help. Staff responded and found the resident sitting on the floor at the foot of the bed. The bed alarm and call light in use, however, there are no documentation of the alarm sounding or the call light on (activated), and staff responded to the resident yelling out for help. The staff assessed the resident and noted the resident sustained [REDACTED]. The staff documented the facility implemented staff education about alarm checks at the beginning of the shift and every two hours, staff are to keep the resident's call light in reach and educate the resident about the use of call light, floor alarm, bed alarm, personal alarm and chair alarm. Review of the Care Plan dated 12/23/13, lacked an indication the alarm checks and frequency of alarm checks were implemented. Review of the Resident Incident Report Dated 6/19/13 at 6:30 a.m. revealed resident's alarm sounded and staff responded and observed the resident on the floor in the bathroom floor. The resident stated she/he wanted to go to the bathroom. Staff assessed the resident and noted no injury. Staff documented the facility further implemented for the resident's safety that staff is to get the resident up first in the morning. Review of the resident's Care Plan, dated 12/23/13, lacked indication that getting the resident up first in the morning was implemented. Review of the Resident Incident Report dated 6/26/13 at 11:17 p.m. revealed (the staff) found the resident lying on left side at the foot of the bed with knees against the dresser and resident facing the bathroom. Bed in low position, bed alarm in place but not plugged in all the way, floor alarm positioned more towards the head of the bed. Staff assessed the resident and identified no injury. The staff documented the facility implemented that staff are to ensure alarms are on , place floor mat towards foot of bed, possible place floor mat alarm on other side of bed also, and to check with previous shift that all alarms are in place. Review of the resident's Care Plan dated 12/23/13, identified a lack of intervention implementation about how the floor mat is to be positioned on the floor or a floor mat placed on other side of the bed, and for staff to check alarms with the previous shift. Review of the Resident Incident Report dated 7/5/13 at 8:15 p.m., revealed staff responding to the resident's alarm and observed the resident sitting on the floor on the left side of the bed. The resident's personal alarm and bed alarm sounding. The resident reported he/she was trying to make it to the bathroom. The staff documented the facility further implemented for the resident to be placed on a toileting schedule. Review of the resident's Care Plan, dated 12/23/13, lacked indications of a toileting schedule had been implemented. Review of the Resident Incident Report dated 9/19/13 at 1:35 p.m., revealed staff responding to the resident's alarm and observed the resident lying on left side on the floor in front of recliner in the resident's room. Staff assessed the resident and noted a bruising to the left temple area. Staff documented the facility implemented the resident to be laid down in bed after lunch. Review of the resident's Care Plan, dated 12/23/13, lacked an intervention for staff to lay the resident down in bed after lunch. Review of the Incident Report dated 2/10/14 at 3:40 a.m., revealed the resident observed by staff sitting upright on the floor at the foot of the bed with legs extended out. The resident stated he/she had a bump on her head. Staff reported the resident's bed alarm had not been plugged in, floor alarm plugged in but not sounding, and the resident ' s personal alarm not on resident. The resident was assessed by the staff and was noted to have a 6 by 6 cm (centimeters) hematoma (bleeding under the skin) to the right side of head and an abrasion to the right shoulder. The staff contacted the resident's physician and family member and the resident was sent to the emergency room (ER) for further evaluation and treatment. Staff documented further interventions for the resident included staff to do alarm checks between rounds with two staff checking alarms, and body pillows to be placed to outer edge of the resident's bed. Review of the resident's Care Plan dated 12/23/13, revealed the body pillows implemented on 2/10/14; however the Care Plan lacked indications that the alarm checks are to be performed between rounds and two staff members are to check alarms had been initiated. The ER Visit Documentation reflected the resident transferred from the facility via ambulance. The resident apparently fell and hit her/his head. The resident was walking and slipped. The resident complained of severe pain of his/her head. The resident was described as quite confused and constantly asked where she/he is at. A CAT (computerized axial Tomography) scan of the head showed bilateral subdural hematomas. The hematoma on the right side measured 11 mm (millimeters). The hematoma on the left side measured 4 mm. The scan identified ethmoid sinusitis (inflammation of the mucous membranes of the sinus cavity). The physician documented he immediately notified the resident's guardian and spoke with another physician who is a neurosurgeon on call and presented the resident's case. The neurosurgeon stated the resident could be transferred to another hospital and could be made comfortable and if the resident survived for two weeks, they would do a treatment for [REDACTED]. The family did not want any surgery or referral to another hospital. The ER physician called the facility and discussed the case with the nurse manager. The nurse manager will place the resident on Hospice care. The ER physician notified the family of the dire situation. The resident states she/his is comfortable in the ER. However the resident continues to be confused. Review of the ER physician discharge orders dated 2/10/14 at 8:03 a.m. included: 1) Hospice Care if possible 2) Norco 5/325 mg (milligrams) 1 to 2 tablets every 4 hours as needed for pain. 3) Ativan 0.25 mg every 6 hours as needed for agitation. 4) Resume prior medications. Review of the Nurse ' s Notes reflected the following: The notes of 2/10/14 at 2:25 p.m. revealed the resident returned to the facility at 9:50 a.m. and neurological assessment continues. The resident continues to transfer with the assist of one as prior to 2/10/14 incident. Resident denies pain, ate meals with set-up assist only. Resident alert with confusion which is per his/her normal. Resident does make needs known. Resident resting in recliner with alarms in place and working at this time. The notes of 2/11/14 at 10:40 a.m., revealed staff called the POA (power of attorney)/family member and talked about the resident's condition and about Hospice care. The resident transfers with the assist of one (staff person) and gait belt per his/her normal, no change in cognition. Resident's only complaint is left shoulder pain which is not new and the resident is on a scheduled pain medication. The POA/family member says no to Hospice care at this time. The notes dated 2/12/14 at 10:33 a.m., revealed the resident's blood pressure measured 162/99, pulse 101 (normal 60-100, respirations 18 (normal 16-20), temperature of 100.0 degrees (normal 98.6) and oxygen saturation of 97 percent (normal 97-100). The CNA's (Certified Nurse Aide) reported to the nurse the resident noted to have slurred speech and weakness this morning with cares. The nurse administered the routine Tylenol (analgesic) as scheduled. The resident had a strong urine odor present. The resident needed assistance with eating and needed cues to swallow food. The resident's physician was telephoned at 10:34 a.m. and the nurse left a message. The nurse documented she would continue to monitor the resident. At 10:44 a.m. the physician office called the facility and gave new orders to obtain a urine sample and to send the specimen to the laboratory for a culture and sensitivity procedure. The notes dated 12/13/14 at 11:27 a.m., reflected the resident was receiving an antibiotic for a urinary tract infection. The resident's speech was better and resident feeds self with queuing for breakfast. The notes of 2/13/14, revealed the PA (Physician Assistant) as in the facility and saw the resident. The PA ordered x-rays of the resident's left shoulder and humerous (upper arm bone) due to [DIAGNOSES REDACTED]. The notes dated 2/23/14 at 10:15 a.m., revealed at 8:35 a.m.; the nurse was informed by the CNA that the resident seemed different. The nurse went to the resident ' room and identified the resident lying in bed with eyes closed but responsive to verbal, contact , and stimuli. Resident responded yes when asked if he/she is all right and denied pain. At 9:40 a.m. resident is partially responsive to verbal stimuli and touch, speech slurred and unable to squeeze with left hand. Call to POA and POA declined to have the resident sent to the hospital but to keep resident comfortable. At 2:30 p.m. POA/family came to see the resident and asked if for pain medications as they felt maybe the resident's head is hurting. Staff felt the resident in capable at this time to swallow medication and staff would call the on call physician for a liquid form of pain medication. The on call physician ordered for the resident to be sent to the ER for evaluation for the appropriate pain treatment. The resident's POA/family did not want further treatment at the hospital but wanted the resident comfortable. The resident sent to ER just for pain management. At 3:25 p.m. the resident returned with new orders for comfort medicine. The note dated 2/24/14 4:10 reflected the resident was admitted to Hospice care. The note dated 2/27/14 at 12:15 a.m. reflected the resident was pronounced dead. Review of the floor mat alarm system with DON (Director of Nursing) that had been in place for the resident when the fall occurred revealed model Secure SMA-120 alarm was used for the resident. Review of the manufacture recommendations for the Secure SMA-120 Alarm for Restraint-Free Fall and Wandering Prevention included features of always have alarm "ON" for resident safety and tamper resistant. The warnings to avoid possible injury included the Secure Alarm Safety Mat and Alarm must be tested prior to each use. Instructions for use included: a) If you want the alarm to sound in the room and at the nurse's station, slide the in-room sound Off/On switch to the "ON" position. If you do not want the alarm to sound in the resident's room, slide in-room sound Off/On switch to the "Off" position. b) Insert the pin of mat into opening marked "Sensor Mat". c) Carefully thread the mat cord and nurse call cable (if using) through the slot opening at the bottom of the alarm. d) Replace sliding tamper-resistant cover and tighten screw with Philips screwdriver to prevent tampering. e) Position the alarm box out of the reach of the resident but accessible to staff. f) The alarm and mat should be checked prior to each use for proper functioning. Test the alarm by stepping on the mat. The alarm will sound when stepping on the mat. The alarm will continue to sound and the flashing light will continue to flash for residents ' safety. To stop the alarm from sounding, press and release the Test/Rest button 3 times within 1.5 seconds. On 2/28/14 at 12:30 p.m., the DON stated the floor mat alarm had been missing the tamper-resistant guard cover on the alarm box. The DON stated the nurses are to check the alarms on all residents and document on the flow sheet that the alarm checked and functioning on all shifts. The DON stated the nurse who worked the 3rd shift the night/morning of 2/10/14 documented the alarm in place and working as reflected in the flow sheet. The DON stated since this incident, the facility has implemented all alarm boxes are to have the tamper-resistant guard in place and alarm boxes are to be kept out of the reach of the resident. The DON stated she is not sure how long the alarm boxes have been without the tamper-resistance guard. On 3/28/14 at 2:53 p.m., Staff C, CNA, was interviewed and stated she/he worked 2 p.m. to 2 a.m. on the night/morning of 2/10/14, and assigned to Resident #1. Staff C stated he/she assisted the resident to the bathroom around 12:30 a.m. to 1 a.m. Staff C stated prior to assisting the resident to the bathroom he/she unclipped the resident's personal alarm and after the resident sitting on the toilet Staff C went back to the resident's bed and turned off the floor mat alarm from sounding by putting the on/off switch to off position and the bed alarm Staff C pushed the button on the front of the alarm box 3 times to shut it off. Staff C stated he/she then assisted the resident back to bed and ensured the bed alarm, floor mat alarm, and personal alarm in place and working at that time. Staff C stated no tamper-resistant guard in place to the floor mat alarm box. Staff C stated since they started working for the facility several months ago, there has never been a guard in place on the alarm box that protected the on/off switch and unplugging the floor alarm box. Staff C stated that staff, at times, would turn the floor mat alarm off by switching the on/off button to "off", but staff just needs remember to turn the floor alarm box back to the "on" position again. Staff C stated the resident known to mess with the personal alarm; pull clip off, but never with any of the other alarms. Staff C reported he/she did not do rounds at 2 a.m. when Staff A, CNA, came into work. Staff C stated he/she asked Staff A about doing rounds and Staff A told Staff C to go ahead and leave and Staff A said he/she would do rounds. On 3/28/14 at 12:21 p.m., Staff A, CNA, was interviewed and stated she came into work at 2 a.m. on 2/10/14 and was assigned to care for the resident. Staff A stated she did not do rounds at 2 a.m. Staff A stated she went into the resident's room around 3 a.m. to place clean linens in the room and the resident was asleep at that time. Staff A stated she saw the resident's alarms in place but Staff A did not check the alarms for functioning. Staff A stated around 3:30 a.m. to 4:00 a.m. she assisted the resident across the hall from Resident #1 to the bathroom and then left the room. Staff A stated when she returned to assist the resident from the bathroom back to bed, Staff noted Resident #1 sleeping at that time. Staff A stated after she walked out of the resident's room across from Resident's #1, Staff A noted Resident #1 sitting on the floor at the end of the bed with legs out in front of her. Staff A stated no alarms sounded and staff noted the personal alarm attached to the bed but not the resident. The bed alarm was unplugged from the alarm box hooked to the bed to side rail but pressure alarm pad in place, the floor alarm box flashing red lights but not sounding and found the "On/Off" switched to the off button and the alarm box had no tamper-resistant guard in place. Staff A stated the resident said he/she needed to go to the bathroom. Staff A stated the resident does play with the personal alarm but she had never known or seen the resident mess with the other alarms. Staff A stated she did not know about the "On/Off" switch on the floor box alarm until after this incident. Staff A stated she called for the nurse when the resident was noted on the floor. On 3/28/14 at 3:25 p.m., Staff B, LPN (Licensed Practical Nurse), was interviewed and reviewed a written statement. Staff B stated she worked the 3rd shift ( 6 p.m. to 6 a.m.) on 2/10/14 and was assigned to care for Resident #1. Staff B stated she checked all the alarms of residents at 11:30 p.m. and Resident's #1 alarms were in place and functioning at that time. Staff B stated the resident is known to mess with the personal alarm string, but not any of the other alarms. Staff B stated around 3:30 a.m. she was called to the resident's room by a CNA (don't recall who) and noted the resident sitting on the floor at the foot of the bed with legs out in front and no alarms sounding. Staff B stated the floor alarm box had been in the chair next to the resident's bed, bed alarm box hooked to bed rail and personal alarm at head of bed but not clipped to the resident. Staff B stated she assessed the resident, notified the resident's physician and family and the resident transferred to the ER via ambulance. Staff B reported the resident's floor alarm was plugged in but not functioning.

Based on observation, record review and interviews, nursing staff failed to appropriately assess and implement interventions for Resident #1 when he/she developed a wound on his/her right foot. The facility identified a census of 76 residents as the time of the investigation. Findings include: The Minimum Data Set (MDS) assessment tool for Resident #1, dated 2/19/13, revealed the resident had a BIMS (Brief Interview for Mental Status score of 10 out of 15. (A score between 8-12 on the BIMS equates to the individual having moderate cognitive impairments.) The assessment reveled Resident #1 had been totally dependent on staff for all activities of daily living (ADLs) except eating. The resident had [DIAGNOSES REDACTED]. The resident's plan of care with an onset date of 1/25/13 identified a potential for skin breakdown related to immobility/incontinence. The care plan identified Resident #1 on [MEDICATION NAME] medication and associated an increased risk for bruising/bleeding.The care plan instructed staff to alert physician of any significant changes in skin integrity and directed staff to use pressure relieving devices/equipment as needed. The care plan directed staff to turn and reposition the resident as needed. The care plan directed staff to assist with the resident's toilet needs before and after meals, at bedtime (hour of sleep), and as needed. The care plan directed staff to monitor daily the resident's skin integrity for impairment(s) and increased bruising during cares and biweekly with showers; and report findings to nurse. The care plan directed staff to refer (the resident) to the wound physician per doctor's orders. The care plan was updated to address a left heel deep tissue injury and a right 5th digit (toe) diabetic ulcer, with the nursing staff signature on 2/11/13. Review of Staff D, LPN (Licensed Practical Nurse) written statement (undated) indicated she was assigned to care for Resident #1 on 1/23/13 on 2nd shift. Staff D documented around 10 p.m. two CNA (Certified Nurse Aides)( Staff B and Staff C) reported to her (Staff D) that Resident #1 had a spot on his/her right little toe. Staff D documented she looked at the resident ' s foot and noticed a very small red spot on the side of the toe. Staff D documented she applied antibiotic ointment to area and covered with a band aid. Staff D documented the evening was hectic and she completely forget about it. The resident's skilled nursing observation assessment notes dated 1/23/13 revealed staff documented the resident had bruising and staff continued to monitor and complete treatment as ordered to the resident's abdominal folds. Further review of the resident's assessment notes dated 1/23/13 revealed no assessment completed of resident's right foot 5th digit toe wound or documentation of wound. The documentation lacked indication that the resident's physician had been notified of wound or treatment order's had been obtained. The skilled nursing observation assessment notes dated 1/24/13 and 1/25/13 (on all three shifts) revealed documentation of resident's skin condition of busing noted and treatment done to abdominal folds as ordered. The assessment notes lacked documentation of the resident's right foot 5th digit toe. Further review of the resident's assessment notes revealed the resident was transported to the hospital on [DATE] per family request and physician's orders [REDACTED]. Review of the hospitals Visit Summary dated 1/25/13 documented peeling of the epidermis of the right little toe; no significant bleeding or signs of inflammation. Also noted signs of excoriation of the waistline and multiple bruises in both his/her upper extremities. Further review of the Visit Summary revealed resident's [MEDICATION NAME] medication (blood thinner medication) was elevated (which increases bleeding risk and bruising). Resident #1 returned back to the nursing home with medication orders, but the discharge orders lacked a treatment order for his/her right foot 5th digit toe. Review of the resident's skilled nursing observation assessment notes dated 1/28/13 revealed the resident admitted back to the nursing home at 3 p.m. with busies noted to both hands and arms. The assessment identified a bandage on the resident's right small toe, left heel and dressing to the resident's coccyx area; and to monitor these areas. The resident's record lacked an assessment of the resident's wounds, or orders obtained for treatment initiated for the wounds. Review of the resident's Admission Skin assessment dated [DATE] documented no areas of concern to feet except "mushy heels". Review of the resident's Share sheet dated 1/30/13 indicated the resident received a shower and the only area of concern on the resident's skin was bruising to his/her bilateral arms. Review of the resident's assessment notes dated 1/29/13 at 7:01 pm revealed Skin Issues of bruising, left heel, right small toe and chest port. The notes lacked indication that the area to the right small toe was completed, physician notified, or treatment orders obtained. Review of statements given to the surveyor and interview with Staff G, LPN on 2/26/13 at 3:03 p.m. she reported, on 1/28/13 she documented in the Skilled Assessment Notes the resident's skin assessment on admission (when returing from the hosptial). Staff G stated she completed skin sheets and verbally reported the areas and gave the skin sheets to Staff F (the wound nurse). Staff G stated she failed to remove the right toe dressing that had been present on admission from the hospital and assess the area or the dressing on the resident's coccyx area. Staff G stated she failed to do this and knew that she made an error and did not follow policy or procedure. Staff G further stated she applied a dressing on 1/30/13 of antibiotic ointment to the resident's right 5th toe per request of the resident's family without checking for treatment orders. Review of the resident's Share sheet dated 2/2/13 indicated the resident received a shower and no areas of concern on resident's skin were noted. Review of written statement dated 2/7/13 and 2/8/13 of Staff E RN, (Registered Nurse) indicated she worked 2nd shift on 2/2/13 and 2/3/13 and was assigned to care for the resident. Staff E reported she was in the resident's room when the resident's family member asked her if she was going to do a dressing change on the resident's right foot 5th digit toe. Staff E stated she removed a dressing from the right 5th toe and inspected the wound. Staff E stated she washed the area and noted the wound had a small area that looked as if it had been open due to the drainage on the dressing that was removed and noted the dressing had been dated 1/30/13 and initialed by Staff G, LPN. Staff E reported she applied clean dressing to the wound that consisted of antibiotic ointment and covered with a gauze pad with supplies intended for a different area that had been healed. Staff E indicated that she then went through the treatment orders of the residents and thought she missed the order for the treatment for [REDACTED]. Staff E reported that she notified the physician that resident had an area to the right small toe and left heel and that they will treat with antibiotic ointment to both areas. Staff E indicated that she failed to fill out skin sheet assessment of area or write out standing orders. Review of Wound Nurse Notes dated 2/4/13 for Resident #1 revealed a wound to right 5th toe measuring 1.5 cm (centimeters) by 2.5 cm. Review of a fax to the resident's physician (not dated or timed) revealed new wounds to resident's right 5th digit toe, diabetic ulcer, and left heel. The nursing home received new orders for treatment to the right 5th digit toe (of skin prep and dry dressing to change daily, skin prep and cover with Allevyn to change every other day), and for a PA (Physician Assistant) to see the resident on Thursday. The fax had a date of 2/5/13 from physician's office. Review of the PA Transcription dated 2/7/13 documented Resident #1 had developed an open area to his/her right first toe. The chief complaint listed a lesion on the resident's right 5th digit toe. The PA documented apparently the area started as a blister and then became an ulceration, and now is darkened to eschar. The PA recommended a referral to a wound physician per family's request, no shoes until healed and new dressing treatment orders for wound. Review of the wound physician notes dated 2/8/13 indicated the resident had some [MEDICAL CONDITION] of both lower extremity. The examination of the left foot showed evidence of peripheral vascular insufficiency, and his/her left heel had small eschar present. The resident's right foot 5th digit toe showed eschar over anterior aspect, on the plantar aspect and evidence of tissue loss with some soft tissue infection, pedal pulses are not palpable bilaterally. The transcription text identified the resident reported no pain unless he/she bumps his/her right foot. The physician documented the resident had an infected fifth digit right foot with recommendations for treatment with wound care and antibiotics. The physician ordered an x-ray of the right foot today to make sure there was no underlying osteo[DIAGNOSES REDACTED], and obtained wound cultures. The physician educated the resident's family that the resident may end up losing the fifth digit toe of his/her right foot given the amount of tissue lost. Review of Wound Culture results dated 2/8/13 of the resident's toe revealed Staphylococcus Aureus-MRSA-large growth of the wound.

Based on observation, clinical record review, and staff and family interviews, the facility staff failed to provide adequate supervision and implement interventions intended to prevent falls for Resident #1. Resident #1 fell and fractured his/her wrist after staff left him/her unattended on the commode. The facility also failed to identify and remove the tubular brace from a bed in a timely fashion which was likely responsible for causing a significant skin tear to Resident #1's lower leg during a transfer. The resident sample consisted of 15 residents; the facility reported its census as 77 residents. Findings included: a) The facility admitted Resident #1 to the facility on [DATE] from the hospital after sustaining a cerebral vascular accident (stroke) at home. The resident's Minimum Data Set (MDS) assessment, with an assessment date of 6/1/2011, indicated the resident had severely impaired cognition, did not walk, and was totally dependent on 2 staff for bed mobility, ambulation, and toileting needs. The assessment further indicated the resident could not maintain balance when moving from a seated to standing position, moving on and off the toilet, and during surface-to-surface transfers without human assistance. A fall assessment dated [DATE] assessed the resident at high risk for falling (resident scored 14; a score of 7-18 represented high risk). The resident's care plan, with a problem onset date of 6/16/11, identified the resident had a history of [REDACTED]. The resident's care plan for activities of daily living (ADLs) indicated to keep the call light within reach. Nurses' notes dated 6/15/11 at 10:45 a.m. documented staff found the resident on the floor in his/her room with the call light pinned to his/her shirt. The resident indicated that he/she had tried to get into bed (from the wheelchair). Staff noted no resident injuries from this fall. The note stated staff implemented a bed and a chair alarm at that time. During an interview on 7/20/11 at 3:30 p.m., the Director of Nursing stated staff had moved the resident to a room closer to the nurses' station. A nurses' note dated 7/1/11 at 4:45 p.m. stated that Staff M, licensed practical nurse (LPN), had been called to the resident's room because the resident was lying on the floor. The nurse observed the following injuries to the resident: an abrasion on the forehead measuring 3 centimeters (cm) by 4.5 cm by 1 cm, a bruise on the left knee measuring 5 cm by 2 cm, and a skin tear involving the right hand and the right forearm measuring 15 cm by 15 cm. The physician and family were notified and orders for treatment were received. A Resident Incident Report, dated 7/1/11 at 4:45 p.m., indicated a certified nursing assistant (CNA) had left the resident unattended on the bedside commode when he/she left to get help (to transfer the resident back to bed). The resident fell from the commode and received the previously mentioned injuries. Staff N's written statement, dated 7/2/11, revealed that he/she left the resident unattended on the commode (in the resident's bedroom) to obtain help to transfer the resident back to bed. Staff N wrote that he/she had left the resident's room for 10 seconds; when she returned to the room the resident was lying on the floor. Staff N did not address why she did not use the resident's call light or her walkie-talkie to call for staff assistance in her written statement. The statement did not address whether or not the CNA had put a personal safety alarm on the resident, or whether the resident had the call light within reach prior to leaving him/her unattended. The CNA was unavailable for interview at the time of the survey. During an interview on 7/20/11 at 3:30 p.m., the DON indicated he/she had reprimanded Staff N for leaving the resident unattended on the commode on 7/1/11. A counseling report dated 7/1/11 revealed Staff N left an alarmed resident unattended on the bedside commode without a call light resulting in the resident falling with injuries. The plan of correction directed Staff N to never leave any alarmed resident alone and always give the call light to the resident. An interview with the DON on 7/20/11 at 11:00 a.m. revealed Staff N did not have his/her walkie talkie on his/her person 7/2/11 and had no response when the DON asked him/her why he/she did not activate the resident's call light. Nurses' notes, dated 7/2/11 at 7:45 a.m., documented staff noted that the resident's right hand as swollen and that the resident's left pupil had responded slowly during a neurological check. After notifying the physician of these findings, the facility transferred the resident by ambulance at 8:43 a.m. to the local emergency (ER) room for evaluation and treatment. The local ER subsequently transferred the resident to a university hospital due to a questionable neurological x-ray evaluation. Both hospitals had x-rayed the resident's right wrist. The university hospital discharge statement dated 7/2/11 revealed the resident had sustained a "small fracture of the right radius (wrist bone)". The discharge instructions recommended the resident wear a wrist splint for the next 4-6 weeks and to follow up with the resident's primary care physician if his/her symptoms worsened. The resident returned to the facility that same day. A sheet containing handwritten notes attached to the resident's care plan indicated that on 7/17/11 at 11:50 p.m., the resident's bed alarm sounded; the nurse responded to the alarm within 15 seconds and found the resident on the floor facing the bed and holding onto the side rail with the bedclothes wrapped around his/her body. Staff assisted the resident back to bed and assessed the resident had no injuries. Staff implemented a floor mat alarm at this time. Observation of the resident on 7/20/11 at 2:50 p.m. revealed he/she appeared to be sleeping in bed. Staff K stepped onto the alarmed floor mat next to the resident's bed several times and the alarm failed to sound. Further investigation of the alarm mechanism revealed it was in the off position. Staff K did not know who had failed to turn the floor alarm on. An interview with the Director of Nurses (DON) on 7/20/11 at 11:00 a.m., revealed it was the facility's policy to never leave a resident who has an alarm alone. The DON indicated Resident #1 required an assist of 2 staff for cares and had alarms on his/her bed and chair. b) According to nurses' notes dated 6/14/11 at 9:40 p.m., the facility transferred the resident to the local emergency room for evaluation and treatment after the resident sustained [REDACTED]. A second note dated 6/14/11 at 11:10 p.m. documented the resident returned to the facility with 14 sutures to his/her right lower leg. A late entry note dated 6/15/11 for the 2:00 p.m. to 10:00 p.m. shift indicated the resident had sustained the skin tear when he/she struck his/her leg on the metal bed frame. According to a laboratory report dated 6/29/11, a culture of the leg wound indicated that it was infected with methicillin resistant staphylococcus aureus (MRSA) for which the resident required antibiotic therapy and isolation. (See F441). During an interview on 7/21/11 at 9:00 a.m., the maintenance supervisor stated the facility had 64 beds that had the same tubular brace on the frame; this brace was necessary when adding a full bedrail to the frame. The supervisor indicated he would pad each one with foam; he further stated the facility was in the process of buying new beds but that it was a slow process. At 12:15 p.m. on 7/21/11, the maintenance supervisor indicated he had successfully removed the brace from the resident's bed and planned to do the same on all the other beds that had the tubular brace.

The following deficiency relates to mandatory # -M. Based on record review, staff interviews and review of the facility policy, the facility failed to ensure residents are free of any significant medication errors (Resident #5) when the facility allowed a certified medication aide to check residents ' blood glucose levels (Resident #5, #6, #7, #8, #9, #10, #11, #12) and administer insulin (Resident #5, #8, #9, #11, #12)). The facility reported a census of 76 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, with a reference date of 2/13/11, identified Resident #5 with a cognitive pattern score of 15. A score of 15 indicated no long or short term memory deficits and independent with cognitive skills for daily decision making. Resident #5 [DIAGNOSES REDACTED]. The physician ' s orders for March 2011 directed the facility to perform glucometer checks with each meal and at hour of sleep (HS). The order directed the facility to give an amount of Humalog insulin based on the checks with each meal. The order directed the facility to not give insulin at bedtime. The glucometer amounts were: 150 -200 then give 3 units of Humalog 100units/milliliter 201-300 then give 6 units of Humalog 100 units/milliliter 301-350 then give 12 units of Humalog 100 units/milliliter. The physician ' s order directed the staff to give [MEDICATION NAME] 100 units/milliliter 20 units subcutaneous each day. The Diabetic Monitoring Record SS (sliding scale) Insulin form for March 2011 indicated Resident #5 should receive sliding scale insulin (Humalog) in the a.m., 11:00 a.m. and at 4:00 p.m. and a blood glucose check at HS (bedtime) with no sliding scale insulin. On 3/25/11 at 5:30 p.m. Resident #5 received 6 units of Humalog insulin as ordered per sliding scale due to a blood sugar reading of 216. An nurse administered the insulin at 5:30 p.m. On that same date, Staff B recorded administering 12 units of Humalog at 8:00 p.m. under the HS portion of the form. In an interview on 3/31/11 at 8:30 a.m., Staff B (Certified Medication Aide, CMA) stated on the evening of 3/25/11 at around 7:00 p.m., she/he administered 12 units of Humalog to Resident #5 based on what she/he believed to be required sliding scale insulin. Staff B also administered the bedtime dose of 20 units of [MEDICATION NAME]. Staff B left the facility shortly after administering the medications and stated she/he informed the nurse about checking the blood glucose levels and administering the insulin. Staff B later admitted that she had made a medication error by giving Resident #5 12 units of Humalog on the evening of 3/25/11. Staff B admitted she knew checking blood glucose levels and administering insulin was out of her scope of practice, but insisted it as a problem until she made the medication error. In an interview on 3/30/11 at 5:00 p.m. Staff C (Licensed Practical Nurse, LPN) stated she/he arrived to work around 6:00 p.m. and was the nurse assigned to Station 1 which included 100, 200 and 300 halls. Staff B (CMA) was assigned to pass medications on the 200 hall. Staff C stated she/she became busy with multiple resident issues and at around 7:00 p.m., Staff B approached her and told her she/he was leaving and going home. Staff B was scheduled until 10:00 p.m. but insisted that she was only staying until the HS medication pass was completed. Staff B left. At around 10:00 p.m. Staff D arrived and asked what he could do. Staff C directed him to check Resident #5's blood glucose. Staff D soon returned and reported Resident #5's blood glucose level was 28. Staff C and Staff D looked at the Diabetic Monitoring Record SS Insulin to see what the glucose level had been. At that time they discovered sliding scale insulin (12 units Humalog) had been signed out at 8:00 p.m. by Staff B and recorded as given. Staff C then responded to the resident ' s room. Staff C observed the resident slumped over in the wheel chair and unresponsive to verbal or physical stimuli. Staff D entered the room and administered injectable [MEDICATION NAME] and eventually Resident #5 became increasingly alert and able to take oral sugars. Staff C returned to duties as Staff D remained with Resident #5. Staff C indicated she realized Staff B had made a medication error and she had passed insulin which was outside her scope of practice, but admitted she did not notify a supervisor of the incident until the following day. In an interview on 3/30/11 at 10:00 p.m. Staff D (Licensed Practical Nurse, LPN) indicated he/she arrived to work at around 10:00 p.m. Staff D was instructed by Staff C to check Resident #5's blood glucose level. Resident #5 sat in a wheelchair with head bowed down. Resident #5 was semi conscious and not responding to verbal stimuli. Staff D checked the glucose level and found it to be 28. Staff D informed Staff C and proceeded to administer [MEDICATION NAME] injectable. Minutes later Resident #5 became more alert and was able to swallow some jelly and drink orally. Staff D gave the resident half of a meat and cheese sandwich. Once Resident #5 was stable, Staff D checked the Diabetic Monitoring Record SS Insulin flow sheet to what the glucose level had been earlier. At that time it was discovered that Resident #5 had been administered 12 units of Humalog at a time he/she should not have received insulin. Staff C insisted she/he did not administer the insulin and it must have been Staff B, who had worked earlier. Staff D indicated he/she knew Staff B had made a medication error and had passed insulin which would be outside of Staff D ' s scope of practice, but admitted had not reported the incident until the following morning at shift change. In an interview on 3/31/11 at 2:35 p.m. Staff E (Registered Nurse, RN) indicated she/he arrived to work at around 6:00 a.m. on 3/26/11. Staff E stated Staff D reported that Resident #5 had a blood glucose level of 28 and Staff B had given sliding scale insulin in error at HS. Staff E gathered the documentation and later that evening the Director of Nursing came in on an unrelated issue and was provided the documentation. In an interview on 3/30/11 at 6:00 p.m. Staff F (Director of Nursing, DON) indicated she arrived at the facility around 8:00 p.m. on 3/26/11 (Saturday) on an unrelated staffing issue. Staff F was approached by Staff E and given a paper regarding the incident involving Resident #5. Staff F did not review the form at that time and instead placed it in her office. Staff F then went to the floor to help. On Monday (3/28/11), Staff F arrived to work and reviewed the papers given her on Saturday. At that time, Staff F realized the severity of what had happened and initiated an investigation. Staff F indicated certified medication aides are not to be checking glucose levels or administering any type of injectables, including insulin. Staff F indicated she was not aware of any other incidents involving Staff B checking glucose levels or administering insulin. In an interview on 3/31/11 at 2:00 p.m. Staff G (Licensed Practical Nurse, LPN) indicated she/he worked with Staff B on 3/15/11 and Staff B was assigned to pass medications on hall 6. Staff B informed Staff G she had passed medications that evening and wanted to leave the facility. Staff G stated she needed to check blood glucose levels. Staff B then stated she had already checked the glucose levels and administered the insulin. Staff G stated she/him had not instructed Staff B to check glucose levels or administer insulin to residents. Staff G admitted she/he failed to inform a supervisor that Staff B checked glucose levels and administered insulin which is out of her/his scope of practice. The facility policy for Insulin Administration indicated "Only appropriately licensed or certified personnel shall draw and administer insulin". The facility policy for Diabetic Monitoring indicated under procedure "Testing is performed by a licensed nurse". 2. Resident #6's Diabetic Monitoring Record SS Insulin form for March 2011 indicated Staff B checked the resident ' s HS glucose level on 3/25/2011. 3. Resident #7's Diabetic Monitoring Record SS Insulin form for March 2011 indicated on 3/15/11 Staff B checked the HS glucose level. 4. Resident #8's Diabetic Monitoring Record SS Insulin form for March 2011 indicated on 3/15/11 a glucose level was checked at HS and Staff B administered 4 units of Humalog and 28 units of [MEDICATION NAME] to the resident. 5. Resident #9's Diabetic Monitoring Record SS Insulin form for March 2011 indicated on 3/15/11 a glucose level was checked at HS and 6 units of [MEDICATION NAME] was administered by Staff B. 6. Resident #10's Diabetic Monitoring Record SS Insulin form for March 2011 indicated on 3/15/11 a glucose level was checked at HS by Staff B. 7. Resident #11's Diabetic Monitoring Record SS Insulin form for March 2011 indicated on 3/15/11 a glucose level was checked at HS and 4 units of [MEDICATION NAME] and 10 units of [MEDICATION NAME] was administered by Staff B. 8. Resident #12's Diabetic Monitoring Record SS Insulin form for March 2011 indicated on 3/15/11 a glucose level was checked at HS and Staff B administered 3 units of [MEDICATION NAME].