Every finding on record at Accura Healthcare of Pleasantville, LLC

Based on clinical record review, family, staff, and long term care ombudsman interviews, and facility policy review, the facility failed to complete a thorough and accurate discharge summary for one of two residents (Res #52) reviewed for discharge. The facility reported a census of 42 residents.Findings include: The Minimum Data Set (MDS) Assessment of Resident #52 dated 3/6/26 identified an admission to the facility date of 3/3/26. The MDS identified a BIMS score of 08 which indicated moderate cognitive impairment. The MDS documented the resident experienced delusions, and exhibited behavioral symptoms during the look-back period. The MDS documented diagnoses that included dementia with agitation, anxiety disorder and depression. The Care Plan reflected a Focus Area of Discharge Planning, dated 3/10/26. The Care Plan failed to reveal any discharge planning updates regarding the resident's discharge from the facility on 3/20/26.The Communication Note dated 3/19/26 documented a transport service would be transporting the resident to another nursing facility on 3/20/26.The Health Status Note dated 3/20/26 documented the resident discharged from the facility and the physician orders and face sheet were faxed to the receiving facility. The receiving facility was also called and given a report on the resident. The resident's Electronic Health Record (EHR) failed to reveal any documentation of discharge planning or the reason for the discharge.The resident's EHR additionally failed to reveal a recapitulation of stay.The form titled Resident Discharge Instructions dated 3/20/26 for Resident #52 documented the resident had orders for a dietary supplement twice a day and seven medications. A review of the Medication Administration Record for March of 2026 for Resident 52, when compared to the resident Discharge Instructions completed on 4/29/26 revealed the following discrepancies:Amlodipine 10 mg was included on the discharge summary, but no frequency or time of day was includedDonepezil, 10mg, was not included on the discharge summaryLisinopril, 5 mg, was not included on the discharge summaryResident #52 had orders for Memantine 20 mg, once a day. The discharge summary inaccurately noted 10 mg to be given twice a day. Buspirone, 10 mg twice a day, was not included on the discharge summaryResident #52 had orders for Seroquel, 50 mg, twice a day. The discharge summary inaccurately noted this to be given once a day. Several as needed medications for constipation were not included on the discharge summary. On 4/29/26 at 10:45 am, a family member of Resident #52 stated the family initiated the discharge process for the resident due to being unhappy with the care received at the facility. No documentation of the family member initiating the discharge was found in the resident's EHR.On 4/29/26 at 4:15 pm, the Administrator stated the resident transferred to a sister facility. The Administrator added the receiving facility had full access to the resident's EHR to see all orders and medications, etc.On 4/29/26 at 5:02 pm, the Regional Nurse Consultant stated the facility does have an assessment used for resident discharges in the EHR software. She verified the omission of this assessment in Resident #52's record and acknowledged the multiple medication discrepancies on the discharge summary form. However, she clarified the receiving facility used copies of the physician orders, not the discharge summary for the current medication list. On 4/30/26 at 12:05 pm, the Long Term Care Ombudsman reported she had not been aware of any concerns during Resident #52's stay at the facility and stated nobody had contacted her during the resident's stay. She did verify her office had received notice of the resident transferring. The facility policy titled Discharge Planning Process, revision date 2/23/25 documented the following: Policy: It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions.Definitions: Discharge planning is a process that generally begins on admission and involves identifying each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful discharge.Policy Explanation and Compliance Guidelines:Point 2: The facility will determine the resident's expected goals and outcomes regarding discharge upon admission, routinely in accordance with the MDS assessment cycle, and as needed. a) Initial information and discharge goals will be included in the resident's baseline care plan. b) Subsequent assessment information and discharge goals will be included in the resident's comprehensive plan of care. Point 6: An active individualized discharge care plan will address, at a minimum:a) Discharge destination, with assurances the destination meets the resident's health/safety needs and preferences. b) Identified needs, such as medical, nursing, equipment, educational, or psychosocial needs. c) Caregiver/support person availability and the resident's or caregiver's/support person's capacity and capability to perform required care. d) Resident's goals of care and treatment preferences.Point 7: The ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identify changes that require modification of the discharge plan, and updating of the discharge plan, as needed, to reflect the modifications.Point 9: The facility will update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.Point 11: The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record. Point 12: The results of the evaluation and the final discharge plan will be discussed with the resident or resident's representative. All relevant information will be provided in a discharge summary to avoid unnecessary delays in the resident's discharge or transfer, and to assist the resident in adjustment to his or her new living environment. Point 13: Education needs, as identified in the discharge plan, will be provided to the resident and/or family member prior to discharge.

Based on record review, and resident and staff interviews, the facility failed to ensure staff responded and answered residents' call lights within 15 minutes, and met residents' needs in a timely manner for one of two units. The facility reported a census of 45 residents. Findings include: Resident Council Meeting notes reviewed 2/2025 to 4/2025 revealed the residents voiced concerns about delayed call light response times, staffing shortages and delays in getting their laundry returned. The Grievance Forms dated 1/1/25 to 4/27/25 revealed: a. On 2/3/25, a resident complained about the shortage of staff. He waited a long time for his call light to be answered and also waited a long time to get coffee. Staff were reminded to answer call lights even if it is to tell the resident they will get someone to assist. b. On 3/3/25, a family member reported concerns about a resident's blood sugar not checked until after a meal and the resident received medications late. The staff had gone on breaks together. c. On 4/1/25, concerns voiced about rooms not cleaned for 2-3 days. During confidential resident interviews on 4/28/25 to 4/29/25, 4 of 7 interview able residents with a Brief Interview for Mental Status score of 13-15 (indicating cognition intact) reported it took staff 30 minutes to 2 hours before anyone responded to their call light and provided assistance. The residents reported the facility didn't have enough staff. One resident reported he had waited several hours to get the medication he requested and the treatments he needed. During an interview 4/29/25 at 11:30 AM. the Director of Nursing (DON) reported she had worked at the facility since 1/2/25. The DON reported she worked the floor usually when she took call over the weekend. The DON reported the number of staff during the week and on weekends included the following: a. On the 6 AM - 2 PM and 2 PM -10 PM shifts: Front hall - 2 Certified Nursing Assistants (CNA) and 1 nurse Back (Memory Care Unit) hall -2 CNA's, 1 Certified Medication Aide (CMA) or 1 nurse b. On the 10 PM - 6 AM shift: Front Hall: 2 CNA's and 1 nurse Back Hall: 2 CNA's

Based on facility abuse investigation, record review, staff interviews, and policy review, the facility failed to report allegations of abuse to the Iowa Department of Inspections, Appeals and Licensing (DIAL) within 24 hours for 3 of 3 residents reviewed for abuse (Resident #47, #9, and #30). The facility reported a census of 45 residents. Findings include: 1. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 47 had diagnoses of chronic respiratory failure and diabetes. Resident scored a 15 out 15 for the Brief Interview for Mental Status review, which indicated intact cognitive status. The resident indicated the care of personal belongings or things as somewhat important to her. The Admission Summary Progress Note dated 1/2/25 at 3:33 PM revealed Resident #47 admitted to the facility from the hospital on 1/2/25 and had diagnoses of weakness and urinary tract infection. The resident was alert and oriented to person, place, time, and situation, and responded to questions appropriately. An Inventory Sheet dated 1/2/25 signed by the resident and Director of Nursing (DON) listed the resident's belongings on the form. The inventory sheet lacked a purse or any money. An Incident Report revealed on 1/5/25 at 10:18 AM, Staff I (Registered Nurse (RN)) was summoned to the resident's room stating Resident #47 was missing $125 from her purse. The resident said she was unsure when she last saw the money. Resident #47 said she had $131 in her purse when she arrived at the facility but she only had $6 left. The Activities Director and the Administrator did a room search on 1/6/25. The Inventory Sheet of belongings reviewed upon admission had no purse listed on the form. Resident #47 admitted from the hospital on 1/2/25. The Administrator attempted to call family. Sheriff's dispatch was called on 1/10/25 at 2:42 PM. A Sheriff's Office Call for Service Record dated 1/10/25 at 11:01 AM revealed a resident was missing money. The record lacked a resident's name. A facility's investigation file revealed the Administrator filled out an abuse investigation on 1/8/25 at 1:41 PM for an incident that occurred on 1/5/25 at 10:15 AM. Resident #47 informed Staff I, RN, on Sunday 1/5/25 that she had $125 missing. An investigation was completed. The money was seen while the resident was at the hospital but no money was accounted for upon arrival to the facility. All staff were interviewed about whether they saw the resident's purse and money. No staff saw any money in Resident #47's room but staff reported they saw her purse. The purse had not been out of Resident #47's sight. A family member reported she had counted the money before the resident left the hospital. In an interview 4/30/25 at 11:50 AM, the Sheriff's Department reported the facility staff called for service on 1/10/25 at 11:01 AM about a resident missing money but the caller told them no officer was needed. In an interview 4/30/25 at 12:54 PM, the Activities Director (AD) reported she inventoried the residents' belongings whenever a resident admitted to the facility. She recorded the items on a paper inventory form including what was in a resident's wallet or purse/ bag, and the form was placed in the paper chart when completed. The AD reported she inventoried belongings for Resident #47 when she admitted to the facility. She did not have a purse at that time. The resident reported missing money a couple days later. The AD stated she was called in and asked about the purse. She didn't see a purse when Resident #47 first came in, but she saw she had a purse a few days later when she went out for an appointment. In an interview 4/30/25 at 2:25 PM, the Administrator reported Staff I, RN, called her on a Sunday (1/5/25) about missing money. She asked Staff I to look at the inventory sheet to see if Resident #47 came in with a purse. Staff I checked the form and told her no purse was listed on the inventory sheet. The Administrator told Staff I she would look into it the next day. The Administrator reported Resident #47 was confused when she admitted to the facility. She spoke with Resident #47 the following day on Monday (1/6/25). The resident reported she only had $6 in her purse. The Administrator asked her how much money she had. The resident said she had $125 but then changed her story on how much she had. The Administrator stated she tried to call the resident's family but the phone number she had did not work. She called the family for following week on a Wednesday after a case manager gave her a different number. The family member told her she counted the money at the hospital and thought the resident had $200 but she was not sure how much money was in the purse. There was a 12-hour gap between the time when the family member counted the money at the hospital and when the resident entered the facility. The purse and money were not listed on the inventory sheet when the resident admitted to the facility. The Administrator stated she reported the missing money to the DIAL after she spoke with the family member, and then she started an investigation. She asked staff that had worked during that timeframe about the resident's purse and money. She also called the police. In an interview 5/1/25 at 3:47 PM, Staff I, RN, reported Resident #47 reported a missing purse and money when she went into the resident's room. She looked around the room but couldn't find the purse. Staff I stated she couldn't recall the exact date of the incident. She recalled she called the Administrator on the date the resident reported the missing money. Staff I reported an incident report had been filled out. In an interview on 5/5/25 at 1:10 PM, Resident #47 reported she brought a purse with her when she admitted to the facility and hung the purse on the front side of the bed next to the window. She thought it would be safe there. One time she needed to get something out of her purse and placed the purse on the counter by the sink near the door. She found only six $1 bills inside the purse. There were no $20 bills inside her wallet. She had a total of $131 in her wallet that was inside the purse. The resident reported staff inventoried everything she had brought to the facility on the day she entered the facility but they did not inventory her purse or the contents inside her purse. She didn't think staff saw the purse and she had forgotten about it while staff inventoried her things. Resident #47 stated the Administrator came and talked to her the day after she reported the money missing. The Administrator told her she didn't have the purse with her because it wasn't inventoried or listed on the form. The Administrator tried to convince her she was wrong about having the money. Resident #47 didn't want to suspect who took the money. A lot of staff came in and out of her room, and she only left her room for meals and when she took a shower. During an interview 5/7/25 at 2:40 PM, the Administrator reported she didn't report the resident's missing money to DIAL right away because she wanted to get ahold of the resident's family to verify if the resident had the money. The Facility's Abuse Prevention, Identification, Investigation and Reporting policy updated on 10/19/22 revealed all Residents had the right to be free from abuse and misappropriation of resident property. All allegations of Resident abuse and misappropriation should be reported immediately to the charge nurse. The charge nurse immediately reported the allegations of abuse to the Administrator, or designated representative. All allegations of misappropriation shall be reported to the Iowa Department of Inspections and Appeals, no later than twenty-four (24) hours if the events that caused the allegation involved misappropriation, but did not result in serious bodily injury. 49698 2. Review of facility provided Abuse Investigation revealed on 12/9/24 at 7:01 PM, Staff I, RN reported to the facility Administrator she had received allegations that Staff R, former Assistant Administrator, had purchased items for herself using Resident #30 and Resident #9's trust. The facility's Abuse Investigation noted action taken by the facility included investigating the allegation by checking receipts. The credit card was not working at the time of the purchases, checks were used. The documented follow up actions taken by the facility noted when reviewing receipts and resident's room items were accounted for. The credit card was not used for transactions. The items that were supposedly purchased like a queen bed set and brown hair dye were not on the receipt, all hair [NAME] were accounted for. Checking account transaction statements and photo copies of three partial receipts were provided with the facility's Abuse Investigation documents. First receipt totaled $573.41 timestamped 11/30/24 at 10:32 PM, the second receipt totaled $124.61 timestamped 12/1/24 at 12:27 PM, and third receipt totaled $514.49 timestamped 12/1/24 at 12:26 PM. Review of the Checking account transactions statement indicated Walmart transaction 12/3/24 for $514.49, Walmart transaction 12/3/24 for $124.61, the transaction for $573.41 was not indicated on the transactions statement. The Summary/Conclusion of the investigation revealed the date of incident as 12/9/24, date of the follow up as 12/10/24, person involved as Staff R and nature of incident as possible theft. The facility's Abuse Investigation was signed by the facility Administrator on 12/10/24. On 4/30/25 3:21 PM, Staff Q reported in an interview, on 12/1/24 Staff R, former Assistant Administrator, used Resident #30 and Resident #9's trust to purchase items for both residents. Staff Q, verbalized concerns of purchased items being stolen by Staff R, reporting after Staff R purchased items for Resident #30 and Resident #9, bagged items were brought to the facility and placed under the nurse's desk, no receipt was provided to the CNAs for the purchased items to be checked in by comparing the items to the receipt and no signatures were provided on the receipt to validate purchased items were delivered to both residents. Staff Q also reported these items were still in bags at the nurse's station on 12/20/24. During an interview on 4/30/25 at 5:26 PM, the facility Administrator stated the provided investigation documents are the facility's completed investigation, it was an internal investigation and she did not report the abuse allegations to DIAL. Facility Administrator stated during her investigation, she had independently checked the receipts for Resident #9 (receipt total $124.61 and $573.41) with the items purchased and all items were there. In a follow up interview on 5/1/25 at 10:28 AM The facility Administrator stated she was notified at 7:00 PM on 12/9/24 that Staff I, was notified of allegations against Staff R, former Assistant Administrator. At the time of the purchases Staff R was doing the spend down for the residents (Resident #30 and Resident #9), she had previously been in the Activities Director position and was familiar with the resident's preferences. The facility Administrator confirmed the residents that were purchased for on 11/30/24 and 12/1/24 were not cognitively able to identify and express their wants and needs. She (facility Administrator) also stated the Police Department was not notified as there was no missing money. During an interview on 5/8/25 at 8:29 AM, the Clinical Nurse Specialist stated she was not familiar with the incident but would expect the facility to follow the corporate policies and CMS guidelines. Review of facility provided Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy updated 10/19/22 stated the following: Reporting: All allegations of Resident abuse shall be reported to the Iowa Department of Inspections and Appeals not later than two (2) hours after the allegation is made. All allegations of Resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections and Appeals, not later than two (2) hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury. If there is a reasonable suspicion that the allegation of abuse also constitutes a crime committed against the resident by any person, whether or not the alleged perpetrator is employed by the facility, the Elder Justice Act requires the matter must also be reported to law enforcement. While the federal regulations require all abuse allegations be reported to DIA within 2 hours, the Elder Justice Act has a different time frame for reporting to the police/sheriff. If the allegation of abuse (that results from a crime) results in serious bodily injury to a resident, a report must be made to law enforcement not later than two (2) hours after the allegation is made. If the allegation of abuse does not result in serious bodily injury, a report must be made to law enforcement not later than twenty-four (24) hours (See Elder Justice Act requirements on page 9). Failure to Report: A person required by this section to report a suspected case of dependent adult abuse who knowingly and willfully fails to do so within twenty-four hours commits a simple misdemeanor. A person required report a suspected case of dependent adult abuse who knowingly fails to do so or who knowingly interferes within the making of such report of applies a requirement that results in such a failure is civilly liable for the damages proximately caused by the failure. Elder Justice Act: If the incident prompting the investigation results in serious bodily injury to a resident and there is a reasonable suspicion that the incident was result of a crime committed by any person, whether or not the alleged perpetrator is employed by the facility, the Elder Justice Act requires the matter to be reported to law enforcement and DIA within two (2) hours by all persons having knowledge of the matter. Serious bodily injury is an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring surgery, hospitalization , or physical rehabilitation. In the absence of serious bodily injury, but with the reasonable suspicion that a crime has been committed by any person, the matter must be reported to law enforcement and DIA immediately, and in no event, more than 24 hours later, even on weekends and holidays, by all persons having knowledge of the matter. (Note: This does not eliminate the separate legal requirement to report all allegations of abuse to DIA within two (2) hours, even if there is no serious bodily injury).

Based on record review, observations, resident and staff interviews, and policy review the facility failed to carry out therapy recommendations and provide restorative exercises for 4 of 6 residents reviewed for restorative services and/or limited range of motion (Resident #3, #18, #33, and #37). The facility reported a census of 45 residents. Findings include: 1. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had diagnoses of multiple sclerosis, abnormal gait and mobility and muscle weakness. The MDS revealed the resident had impaired range of motion (ROM) to the upper and lower extremities. The MDS indicated the resident required substantial to maximum assistance for bed mobility, transfers and toileting. The MDS recorded the resident had no therapy services, and had a Restorative Nursing Program (RNP) that included passive range of motion (PROM) performed one day during the look-back period. The Quarterly MDS assessment dated [DATE] revealed the resident had dependence on staff for bed mobility, dressing, transfers and toileting. The resident had occupational therapy (OT) services 3/23/24 to 4/7/24, and zero (0) days of RNP during the look-back period. The Annual MDS assessment dated [DATE] revealed the resident had dependence on staff for bed mobility, dressing, transfers and toileting. The MDS recorded the resident participated in a RNP for 0 days during the look-back period. The Care Plan revised on 5/3/24 revealed Resident #3 had a self-care deficit in activities of daily living (ADL's) related to impaired mobility, multiple sclerosis and weakness. The Care Plan directed staff to perform PROM to the lower extremities 5 to 7 times a week to maintain his ROM. The OT Evaluation and Plan of Treatment dated 2/4/25 revealed Resident #3 referred for therapy for evaluation and treatment of contractures. The OT documented nursing was managing the resident's contracture impairment. The Documentation Survey Report revealed a restorative program for PROM to the lower extremities 5 to 7 times a week was documented on the following: 2/2025: 17 times. 8 days were left blank, and 3 days recorded as NA (not applicable) 3/2025: 20 times. 8 days were left blank and 2 days recorded as NA. 4/2025: 16 times. 5 days were left blank and 6 days recorded as NA. The Quarterly Nursing Assessment Progress Notes revealed the following: a. On 11/11/24 at 12:44 AM, resident does not participate in a RNP at this time. b. On 2/6/25 at 11:26 AM, resident does not participate in a RNP at this time. He had dependence on two staff for assistance. c. On 4/29/25 at 1:24 PM, the resident participates in a RNP. 2. The Quarterly MDS assessment dated [DATE] revealed Resident #18 had diagnoses of a stroke, hemiplegia and right foot drop. The MDS revealed the resident had impaired ROM on one side. The resident required supervision for transfers, toileting and dressing. He also required set up assistance for bed mobility, and had independence for eating. The MDS revealed the resident had participated in a RNP Active Range of Motion (AROM) activities for two days during the look-back period, and no therapy services. The Quarterly MDS assessment dated [DATE] revealed the resident had diagnoses of muscle weakness, right foot drop and hemiplegia. The MDS recorded the resident required set up assistance for eating, substantial to maximum assistance for toileting, dressing, bed mobility and transfers. The MDS indicated the resident had Physical Therapy (PT) services started on 1/16/25 and OT services started on 1/17/25. The Care Plan revised on 2/17/25 revealed Resident #18 had an ADL self-care deficit related to hemiplegia, right hand contracture, and muscle wasting. The Care Plan listed a PT and OT evaluation and treatment as ordered. AROM to the upper body for 15 minutes for one to seven times per week was added to the Care Plan on 4/24/25 (during the survey week). The PT Discharge Summary dated 2/13/25 revealed the resident had reached his maximum potential with skilled services and recommended a functional maintenance program (FMP) or group exercises. The Documentation Survey Report revealed a restorative program for AROM to the upper body for 15 minutes one to seven times a week documented for the following: 2/2025: 3 times 3/2025: 0 times 4/1- 4/13/25: not listed 4/14 - 4/28/25: 2 days; left blank 4 times, and NA recorded on 5 days. The Progress Notes revealed the resident participated in exercise seven times in 2/2025, 2 times in 3/2025, and 0 times in 4/2025. The Quarterly Nursing Assessment Progress Notes revealed the following: a. On 11/11/24 at 12:44 AM, resident does not participate in a RNP. He is totally dependent on two staff for physical assistance. b. On 2/6/25 at 11:26 AM, resident does not participate in a RNP. He is totally dependent on two staff for physical assistance and is non-weight bearing status. During observation on 4/29/25 at 10:16 AM, Resident #18 sat in a motorized wheelchair. The resident had a contracture to his right hand. 3. The Admission MDS assessment dated [DATE] revealed Resident #33 had diagnoses of arthritis and sciatica. The resident had dependence on staff for dressing, toileting, bed mobility, and transfers. The MDS recorded the resident had PT and OT services. The MDS assessment dated [DATE] revealed the resident required substantial to maximum assistance for transfers, and had dependence for toileting. The MDS recorded the resident participated in a RNP for 0 days during the look-back period. The Care Plan revised on 1/13/25 revealed Resident #33 had an ADL self-care deficit related to impaired balance. The Care Plan directed staff to encourage the resident to ambulate to and from meals (added 1/13/25) and perform AROM to the upper and lower body for 15 minutes one to seven times a week added on 4/24/25 (during the survey week). The PT Discharge Summary dated 3/6/25 revealed therapy recommendations for a RNP restorative. The PT documented a ROM program in place, and prognosis was good with consistent staff follow through. The resident required assistance of two staff and a walker for transfers. The Documentation Survey Report revealed the following documented on a restorative program for ambulation with a front wheeled walker and gait belt one to three times a day: 2/2025: 3 times. NA documented 8 times, and the box left blank 6 times 3/2025: 2 times. NA documented 8 times, and the box left blank 11 times 4/2025: 0 times. NA documented 8 times, and the box left blank 6 times. The Progress Notes revealed: a. On1/8/25 at 4:20 PM, resident participates in a RNP. b. On 3/20/25 at 11:21 AM, resident does not participate in a RNP at this time. He is able to ambulate in the corridor with a walker and assistance of one staff In an interview 4/28/25 at 1:01 PM, Resident #33 reported he needed therapy so he could walk. The resident reported he had a concern that he had gained weight. He thought walking would help get his weight down. In an interview 5/8/25 at 9:04 AM, the Regional Clinical Director reported staff told her Resident # 33 refused to walk at least since 1/2025. 4. The Admission MDS dated [DATE] revealed Resident #37 had diagnoses of spinal stenosis, repeated falls, and low back pain. The resident required partial to moderate assistance for bed mobility, toileting and transfers. The MDS recorded the resident participated in a RNP for 0 days. The Quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. The MDS indicated the resident required partial to moderate assistance for bed mobility, toileting and transfers. The MDS recorded the resident participated 2 days in a RNP during the look-back period. The Care Plan revised on 3/17/25 revealed Resident #37 had an ADL self-care performance deficit related to impaired balance and chronic pain. The Care Plan directed staff to ambulate the resident 25 to 50 feet with a gait belt one to three times a day, AROM to extremities for 15 minutes one to seven times a day and use the Nustep (bike) for 15 minutes one to seven times a week. These Care Plan directives were all added to the Care Plan on 4/24/25. A PT Discharge Summary dated 12/4/24 revealed Resident #37 referred for a Functional Maintence Program (FMP) such as walking and lower extremity exercises. The Progress Notes revealed on 3/2025 at 1:18 PM resident does not participate in a RNP at this time. The Documentation Survey Report revealed the following documented on a restorative program: a. Group Exercise Program 2/2025: 7 times 3/2025: 3 times 4/2025: 4 times. b. AROM to the upper and lower body for 15 minutes one to seven times per week: 2/2025: 11 times 3/2025: 7 times 4/2025: 4 times c. Ambulation 25-50 feet one to three times a day: 9:00 AM 2/2025: 19 times 3/2025: 26 times 4/2025: 24 times 1:00 PM 2/2025: 17 times 3/2025: 23 times 4/2025: 23 times 6:00 PM 2/2025: 3 times 3/2025: 3 times 4/2025: 5 times d. Nustep x 15 minutes one to seven days per week was added on 4/24/25. Observations revealed the following: a. On 4/30/25 at 1:30 PM, Resident #37 sat in wheelchair in the dining room by the Director of Nursing (DON's) office. b. On 04/29/25 at 1:49 PM, therapy room door closed. No staff in the room. Sign on door revealed for residents to ask for help if they needed weighed. A table and chair sat in the middle of the room. c. On 4/30/25 at 2:00 PM, Resident #37 sat in a wheelchair in the dining room. Dishes sat on the table in the Therapy Room. d. On 4/30/25 at 2:24 PM, therapy room door closed and lights off in the room. e. On 5/7/25 at 7:45 AM, Resident #37 sat in a wheelchair in the hallway outside of his room. In an interview 4/29/25 at 10:25 AM, Resident #37 reported staff walked with him from his room to the dining room but he felt like his legs may give out sometimes. He wanted to ride the bike to maintain his ability to walk but the staff won't let him unless the facility had staff available. The resident reported he went to the front area and waited until staff let him into the therapy room. In an interview 5/1/25 at 9:38 AM, Resident #37 reported he wanted to ride the bike in order to build up the strength in his legs, besides just walking. He reported he went down and sat in the dining room and waited for staff so he could go ride the bike in the therapy room. He watched staff go back and forth until someone got freed up and could be with him in the therapy room, but sometimes that didn't happen because staff were too busy or the facility did not have enough staff. On 5/7/25 at 7:45 AM, Resident #37 sat in a wheelchair in the hallway outside of his room. The resident reported he was waiting for someone to come and help him walk. Resident #37 stated he wanted to ride the bike for 10-15 minutes but he only got to ride the bike twice the week of 4/28/25. In an interview 4/30/25 at 1:23 PM, Staff K, certified medication aide (CMA), reported anybody at the facility did restorative. Therapy staff evaluated residents on how they should transfer. Staff K reported the restorative activities (RA) performed were documented in the computer. Staff K reported Resident #37 would go into therapy to ride the bike but staff had to be in the therapy room whenever a resident was in the therapy room. In an interview 5/5/25 at 12:01 PM, the Rehab Therapy Director reported he came to the facility whenever they had a resident on skilled therapy services. He sent emails to communicate with the Director of Nursing (DON) and the Administrator about therapy services ending and the therapist's recommendations. The Therapy Director reported it was his understanding the facility had a CNA lead restorative, but no actual RNP. No certain person was assigned as the restorative aide. The Therapy Director stated a RNP would be beneficial for the residents. The Therapy Director confirmed he had residents referred back to therapy due to a decline. The Therapy Director reported he expected nursing services to follow through on therapy recommendations whenever a resident had discharged from therapy. In an interview 5/6/25 at 9:47 AM, Staff D, Licensed Practical Nurse (LPN) reported the CNA's did the restorative exercises with the residents. The facility did not have an assigned restorative aide because the person did not last long after they were hired. The restorative aide got pulled to work as a CNA due to staffing needs. In an interview 5/6/25 at 11:30 AM, the DON reported the PT came up with tasks for the CNA to document RA in the computer. In an interview 5/7/25 at 10:20 AM, the MDS nurse reported no restorative program at the facility. She was told the CNA's did the exercises with residents. The ADON looked into putting tasks on the computer for the CNA to document walk to dine and other things. The MDS nurse reported she saw a decline in the residents' ADL's. The MDS nurse reported she expected to see residents up and moving more if they had a restorative person. In an interview 5/7/25 at 2:15 PM, Staff C, CNA, reported the facility did not have a designated restorative aide. The CNA was supposed perform ROM when they got a resident up or dressed the resident. Staff C reported only a few residents were on a walk to dine program. Staff C reported she did what she could but when she was the only aide working, it was all they could do to get residents up, provide showers, and feed residents. In an interview 5/7/25 at 2:40 PM, the Administrator reported restorative activity added in 2/2025 for staff to document things done. The Administrator reported some RA done last year but they had a lot of new staff since then. RA discussed and identified as an area to improve. In an interview 5/8/25 at 7:40 AM, the Regional Clinical Nurse reported she was assigned to the facility in 1/2025. She looked at systems such as restorative and what the facility had done for RA. She reviewed the resident's restorative and noted several of the programs were outdated or not applicable for residents so she discontinued or updated the computer so staff could document what they were doing and take credit for the things they were doing. The Regional Clinical Nurse reported the facility had been in the process of working on restorative. The facility did not have a designated restorative aide, the CNA's did the RA. A Restorative Program Process policy updated 10/26/21 revealed a restorative program ensured residents achieved and maintained their highest level of function. The nurse or therapy assessed the resident's level of function upon admission, quarterly and with significant changes. The licenses nurse developed a RNP with individualized interventions and goals for the residents. The nurse wrote a monthly restorative nursing summary to track the resident's progress.

Based on direct observation, facility record review, staff interviews, and policy review the facility failed to store and handle foods in a safe and hygienic manner, and failed to provide a clean and hygienic kitchen to cook and serve food. The facility reported a census of 45. Findings include: A direct observation on 04/28/2025 at 11:15 AM of the Kitchen and Dry storage revealed the following: A black residential style combination refrigerator and freezer with a note that states Freezer does not hold temps - Do not use contained three beef roasts that had been placed to thaw in the unit overnight. The thermometer inside of the refrigerator portion of the unit read 56 degrees Fahrenheit. The roasts were visibly bloated in their packaging, appearing ball-like. Staff A, Cook, stated he did not know how long the temperature in the refrigerator had been above 40 degrees for, but confirmed they were for dinner service that evening. It also revealed the following items were unlabeled, undated, and unsealed in the numerous chest style freezers: 1 bag of what appeared to be cooked eggs. 1 bag of what appeared to be French fries - these were spilled inside of the freezer. 1 bag of what appeared to be chicken or poultry meat. 1 bag of what appeared to be carrots. 1 bag of what appeared to be tater tots. The following items lacked a label or date: 2 bags of what appeared to be poultry meat. 1 bag of what appeared to be carrots. It also revealed significant buildup in the trap of the dish washing unit. A direct observation on 04/29/2025 at 03:40 PM revealed the dish washing unit trap had still not been cleared of the debris from the day before. It revealed a leaking sink pipe under the kitchen sink with a significant amount of black buildup and a large bucket of foul-smelling water with what appeared to be an organic film. Pictures were taken at this time. In a direct observation on 04/30/2025 at 12:33 PM Staff D, Licensed Practical Nurse (LPN), was observed picking up the garlic bread of a resident who required assistance eating with her bare hands, tearing it into multiple pieces, and placing the bites of food into the resident's mouth. Hand sanitation was not witnessed before or after. In an interview on 04/30/2025 at 10:25 AM with Staff A, Cook, stated he had reported the conditions of the space under the sink to management shortly after he first started - he believed this was towards the end of February 2025 or early March 2025. He was told it had been taken care of and that he did not need to worry about the space. In a further interview, at 02:30 PM of the same day, Staff A stated all kitchen staff are responsible or labeling, dating, and sealing items that are being put away. He stated bags should never be open to the air, and when items are spilled they are to be cleaned immediately. He stated that meats should be thawed at or below 41 degrees Fahrenheit and not above. He stated the dishwasher trap should be cleaned after every shift. In an interview on 04/30/2025 at 02:30 PM with Staff E, Dietary Aide, she stated the sink had been leaking for months, but she had been told it was taken care of and she was not in the habit of checking the area. She agreed they are all responsible for labeling, dating, and ensuring items stored in the freezer are properly sealed. In an interview on 04/30/2025 at 02:10 PM with Staff C, Certified Nurse Aide (CNA), she stated they are to avoid touching the lips of plates and utensils when serving residents. She stated they are never allowed to directly touch a resident's food bare handed, and if they do they should replace the food item. In an interview on 04/30/2025 at 02:16 PM with Staff B, Certified Medication Aide, she stated staff are to avoid touching food when serving residents. In an interview on 04/30/2025 at 01:53 PM with Staff D, LPN, she stated she knows she isn't supposed to touch resident food directly with her hand but was on autopilot and didn't think about it. In an interview on 04/30/2025 at 03:05 PM the Administrator, stated she believed the sink issue had been addressed on 03/12/2025, and acknowledged she had directed her staff to address it immediately. She confirmed this was the job of the maintenance department. She confirmed staff were not asked to clean this because she had thought the issue was resolved. In an interview on 04/30/2025 at 03:31 PM with the Clinical Nurse Specialist, she stated her expectation is for staff to never make bare hand contact with a resident's food. If they do, they are to replace the food and not allow the resident to eat it. In an interview on 05/05/2025 at 02:10 PM the Dietary Manager, acknowledged all foods require a label identifying the food and a date identifying when the item was opened. It should be resealed before storage. In a policy titled Food Storage with a date of 2021, it stated all foods should be covered, labeled, and dated. It also documented safe holding temperatures for refrigerated foods as 41 degrees or less. In a policy titled Bare hand contact with food and use of plastic gloves, with a date of 2021, it documented staff should use clean barriers, such as single-use gloves, when handling resident food.

Based on review of CMS-2567 reports, staff interview and facility policy review, the facility failed to have an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies to assist in the provision of quality care for residents and attain substantial compliance with Federal regulations and State rules. The facility had several repeat deficiencies identified on the facility's current recertification and complaints survey. The facility reported a census of 45 residents. Findings include: Review of the Department of Inspections, Appeals and Licensing (DIAL) website under the facility's visit history revealed repeated deficient practices identified during the facility's annual survey 3/20/23 and 6/24/24, complaint investigations completed 3/20/23, 2/20/24 and 9/30/24, and the current survey and complaint investigations. The repeat deficiencies cited included: F609 cited 3/30/23 and during the current survey. F610 cited 3/30/23 and during the current survey. F641 cited 9/30/24 and during the current survey. F656 cited 9/30/24 and during the current survey. F657 cited 6/24/24 and during the current survey. F684 cited 3/20/23, 2/26/24, 9/30/24 and during the current survey. F688 cited 9/30/24 and during the current survey. F725 cited 3/30/23, 2/26/24, 9/30/24 and during the current survey. F812 cited 3/30/23, 6/24/24 and during the current survey. F880 cited 2/26/24, 9/30/24 and during the current survey. The Payroll Based Journal (PBJ) Staffing Data Report for 10/1/24 to 12/31/24 (Quarter 1) revealed the facility had a 1 Star Staffing Rating. In an interview 5/7/25 at 2:40 PM, the Administrator reported she believed the PBJ 1-star rating was due to staff turnover. The facility had a high turnover in nursing leadership, including the Director of Nursing, the Assistant Director of Nursing, and the MDS nurse. On 5/7/25 at 3:15 PM, the Administrator reported the Quality Assurance Committee met quarterly and had identified areas they needed to work on. The Administrator acknowledged awareness of repeat deficiencies and stated the facility had a turnover of their entire nursing department in 1/2025. Prior to this, the previous ADON was part of the plan of correction in 9/2024, and it took a long time to fill the ADON position. The Administrator reported she had only worked at the facility since 4/22/24. The facility had worked on staff hiring and retention strategies, as well as staff education to address resident concerns. A Quality Assurance and Performance Improvement Plan (QAPI)) Plan updated 5/23/23 revealed the QAPI is a systematic approach for improving quality of care and services provided to the residents. The QAPI focused on systems and processes, identified system gaps, and identified root causes of concern as well as opportunities for improvement, which lead to improvement in the lives of residents, through continuous attention to quality of care, quality of life, and resident safety. The Root Cause Analysis was used to identify improvement opportunities and understand how to improve on them. The QAPI Committee monitored progress and ensured interventions or actions were implemented, and effective and sustained improvements were made.

Based on employee roster review, education transcript review and staff interviews, the facility staff failed to complete a minimum of 12 hours of regular in-service education for 3 of 4 Certified Nursing Assistants (CNAs) sampled who had worked at the facility greater than 1 year (Staff G, Staff M, and Staff N). The facility identified a census of 45. Findings include: 1. A CNA-CMA Roster revealed Staff G, CNA, had a hire date 5/20/21, Staff M, CNA, had a hire date of 10/9/23 and Staff N, CNA, had a hire date 7/6/22. The Relias Education Transcripts reviewed 5/2024 - 4/2025 revealed the education and number of hours completed for the following: Staff G =8.95 hours completed Staff M = 1.0 hours completed Staff N = 0 hours completed During interview on 5/6/25 at 11:30 AM, the Director of Nursing reported mandatory staff in-services held monthly and education courses set up on Relias for staff to complete. The DON reported staff needed to complete at least 12 hours of education each year. During an interview on 5/7/25 at 11:10 AM, the Administrator reported the staff who worked nights don't attend the staff meetings and in-service training. She tried to get the staff to attend the meetings/in-services but when they worked nights, it was hard.

Based on observations, health record review, review of resident's trust statements, purchased items receipts, staff interviews, and policy review, the facility staff failed to properly handle resident's funds for 1 of 3 (Resident #30) residents reviewed. The facility reported a census of 45. Findings include: Review of Resident #30's Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment and diagnoses of hypertension, Non-Alzheimer's Dementia, Anxiety Disorder, Schizophrenia, and speech disturbances. Review of Resident #30's Electronic Health Record (EHR) indicated on 4/3/25 Resident #30's height measured 64 (5' 4) and weighed 183.2 pounds on 5/5/25. On 4/30/25 3:21 PM, Staff Q, Certified Nurse's Aide (CNA) reported in an interview, on 12/1/24 Staff R, former Assistant Administrator, used Resident #30's trust to purchase items for Resident #30. Staff Q, verbalized concerns of purchased items being stolen by Staff R, reporting after Staff R purchased items for Resident #30, bagged items were brought to the facility and placed under the nurse's desk, no receipt was provided to the CNA's for the purchased items to be checked in by comparing the items to the receipt and no signatures were provided on the receipt to validate purchased items were delivered to Resident #30. Staff Q also reported these items were still in bags at the nurse's station on 12/20/24. Review of facility provided Abuse Investigation revealed on 12/9/24 at 7:01 PM, Staff I, Registered Nurse (RN) reported to the facility Administrator she had received allegations that Staff R, former Assistant Administrator, had purchased items for herself using Resident #30's trust. The facility's Abuse Investigation noted action taken by the facility included investigating the allegation by checking receipts. The credit card was not working at the time of the purchases, checks were used. The documented follow up actions taken by the facility noted when reviewing receipts and resident's room items were accounted for. The credit card was not used for transactions. The items that were supposedly purchased like a queen bed set and brown hair dye were not on the receipt, all hair [NAME] were accounted for. Checking account transaction statements and photo copies of three partial receipts were provided with the facility's Abuse Investigation documents. First receipt totaled $573.41 timestamped 11/30/24 at 10:32 PM, the second receipt totaled $124.61 timestamped 12/1/24 at 12:27 PM, and third receipt totaled $514.49 timestamped 12/1/24 at 12:26 PM. Review of the Checking account transactions statement indicated Walmart transaction 12/3/24 for $514.49, Walmart transaction 12/3/24 for $124.61, the transaction for $573.41 was not indicated on the transactions statement. The Summary/Conclusion of the investigation revealed the date of incident as 12/9/24, date of the follow up as 12/10/24, person involved as Staff R and nature of incident as possible theft. The facility's Abuse Investigation was signed by the facility Administrator on 12/10/24. Review of Staff R's, former Assistant Administrator, Employee Record revealed the following: 1. Education Form: I have been presented with education. My signature verified that I have read, understand, and agree to abide by the Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy. Signed by Staff R on 9/25/24. 2. Background check document, background check completed as of 5/17/22 3. Iowa Department of Health and Human Services, Dependent Adult Abuse Mandatory Reporter Recertification Training completed on 2/12/24 4. Employee Corrective Action Form, Final Written Warning dated 12/18/24. Incident/Infraction on 12/11/24, an employee from Accura HealthCare of Pleasantville contacted Facility Administrator to share their concerns directly related to Staff R, Assistant Administrator, and text message between the two. In the provided text conversation, Staff R was identified as sending messaging indicating that Staff R was padding her paycheck as well as messages that are not professional and reflect negatively for Accura HealthCare of Pleasantville given the leadership position that Staff R upholds. During the investigation, it was also identified that Staff R broke confidentiality and shared information that should remain confidential. Expectations Moving Forward, Staff R is to remain respectful and professional when interacting with team members. Staff R needs to remember that she is in a leadership position and must conduct herself as such. She will maintain confidentiality in all areas including medical, personnel, and similar information. Document signed by Staff R on 12/18/24. In a confidential staff interview on 5/1/25 at 9:37 AM, staff member verbalized being aware of the facility's investigation related to Resident #30's and Resident #9's purchased items. Staff member stated the Walmart bags with resident's items sat at the nurse's station for weeks. Staff member stated, CNAs and nurses had asked multiple times for the receipts so the items could be given to the residents they were purchased for. Staff member verbalizes frustration with administrative staff due to the investigation being completed but the items that were part of the investigation were still in the Walmart bags under the desk at the nurse's station. Staff member was able to provide a picture on her phone that showed approximately 3-5 Walmart bags with items that appear to be clothes in them under the desk at the nurse's station. Staff member was able to show a time stamped date and time picture was taken revealing 12/13/24 at 10:04 PM. During an interview on 4/30/25 at 5:26 PM, the facility Administrator stated the provided investigation documents are the facility's completed investigation, it was an internal investigation and she did not report the abuse allegations to Iowa Department of Inspections Appeals and Licensing (DIAL). Facility Administrator stated during her investigation, she had independently checked the receipts for Resident #9 (receipt total $124.61 and $573.41) with the items purchased and all items were there. Review of facility provided trust statements, dated October 2024 through March 2025, for Resident #30 indicated a Resident Shopping transaction posted on 12/23/24 for $514.49. On 4/30/25, the facility Administrator provided a receipt for Resident #30's purchased that were made on 12/1/24 for $514.49, the receipt provided was the same copy provided in the facility's Abuse Investigation. The receipt failed to indicate where the purchases had been made (top portion of receipt), unable to identify if all purchased items were shown on copy of the receipt, and the copy of the receipt failed to indicate signatures of purchaser, resident and/or staff to validate items purchased. During an interview on 4/30/25 at 11:25 AM the Business Office Manager revealed the Activities Director goes shopping once a month for residents. The residents will let the Activities Director know their needs and the items are added to the list. If items are needed at other times of the month the Activities Director will try to get these items for them. When the items are purchased, the receipt is signed by the resident or two staff members as the items are identified and given to the resident. The Business office Manager, stated the only ones (residents) that spend money are the ones that are able to verbally let us know what they need. In an interview on 4/30/25 at 12:54 PM facility Activities Director stated she started working at the facility on 11/25/24. Her position also includes some Social Services duties, Activity Assessments for residents and inventory of resident belonging. When purchasing items for residents she takes the debit card to the store on the second Wednesday of the month to purchase for residents. She has a form that is filled out with the items residents are requesting. If a resident is non-verbal or or unable to communicate needs, the CNA's (Certified Nursing Assistants) will provide a list of items needed for that resident along with sizes. After purchasing items, the receipt is given to the Business Office Manager or the Administrator if the Business Office Manager is not available. When returning to the facility with the purchased items, they are distributed to the resident. The sheet and/or receipt is signed by the Activities Director and resident. If the resident is not able to sign, the CNA that helps distribute the items will sign. She has also shopped on Amazon with residents and their items are delivered to the facility. If making a purchase on Amazon, the Activities Director will sit with the resident to shop, print off the invoice, then give the invoice to the Business Office Manager. Often when residents need to spend down the resident will sit at the desk with the Activities Director and order on Amazon. When a resident has a guardian, Power of Attorney (POA) or representative that person is contacted, they will either purchase items for the resident and deliver to the facility or notify the Activities Director of items to purchase. Activities Director stated she does an inventory of resident's items on admission to the facility, inventories what she is able after purchases but items may be purchased or brought in by family members or visitors, if she is not made aware of these items they may not be added to the resident's inventory sheet. On 4/30/25 at 5:05 PM an email was sent to the facility Administrator requesting Resident #30's original receipt in the amount of $514.49, indicating where the items were purchased and providing the signatures of the employees and/or Resident #30 verifying the purchased items. During an interview 4/30/25 at 5:15 PM facility Administrator stated these purchases for residents, including Resident #30 were made as their trust accounts needed to be spent down and she was unaware of where the original receipts were but that she still communicated with Staff R and would try to contact her to see if she knew where the receipts could be located. On 5/1/25 at 6:51 AM the facility Administrator communicated via email stating, attached to the email were copies of receipts, including Resident #30's. With a new office manager, we were not sure where the originals were filed but I went to Walmart last night and they were able to reprint these for me. As per our communication last night, I mentioned we were doing spend downs for residents at this time. On 5/1/25 at 10:28 AM The facility Administrator stated she was notified at 7:00 PM on 12/9/24 that Staff I, RN was notified of allegations against Staff R, former Assistant Administrator. Staff R, was scheduled off the next day (12/10/24) and was not placed on suspension due to the investigation being completed at a time she was already out of the facility. At the time of the purchases Staff R, was doing the spend down for the residents, she had previously been in the Activities Director position and was familiar with the resident's preferences. Previously when spending down for residents that are unable to make their needs known, a meeting would take place with other staff members and CNAs to discuss the resident's needs and items residents would enjoy. The facility Administrator confirmed the residents that were purchased for on 11/30/24 and 12/1/24 were not cognitively able to identify and express their wants and needs. She (facility Administrator) also stated the Police Department was not notified as there was no missing money. In an interview with Staff R, former Assistant Administrator on 5/6/25 at 9:34 AM, Staff R verbalized her position at the facility as Business Office Administrative Assistant. She started working at the facility May 2022 and left January 2025, resigning due to family reasons. Staff R stated she was aware there was an internal investigation be conducted by the facility Administrator related to purchases for Resident #30 and Resident #9. She was made aware of the investigation when she got to work one morning in early December, but was unable to recall the exact date. Staff R, stated she was not suspended during the investigation and was in the facility, but couldn't have access to resident's trust accounts. She was not able to recall how long the investigation lasted but stated it was not the full day. Staff R revealed, during the investigation she was with the facility Administrator and helped go through the resident's belongings and helped identify the items. Staff R stated the facility Administrator and herself went through both Resident's (#30 and #9) and identified all items on the receipts. Staff R, stated she was not always the one to make purchases, it was normally done by the Activity Director. She couldn't remember, at the time of the purchases there either wasn't an Activity Director or she was new and not able to make the purchases. Staff R, stated the way she had always done the purchasing included making sure the funds for the resident were available, purchase the items, label the items with the resident' s initials, then bring the items to the facility and the CNA's would put the items away. The CNA's are supposed to inventory the items with the receipts and get two signatures, for Resident #30 and Resident #9 two staff signatures would have been needed. Staff R recalled purchasing the items on the weekend and keeping them in her car until she returned to work the following Monday. Staff R stated the items for Resident #30 and Resident #9 were brought in sacks labeled with the resident's initials to the nurse's station and she asked the CNA's to put the items away. Staff R stated she was not aware if the receipts had been signed by anyone. She was not able to recall clothing sizes purchased or identified during the investigation for Resident #30 or Resident #9. A follow up Interview 5/6/25 at 10:05 AM, facility Administrator stated while conducting the facility's Abuse Investigation she could not recall interviewing staff members related to the purchased items for Resident #30 or Resident #9. She stated when she conducted the investigation she reviewed all three receipts finding all the purchased items comparing them to the receipts independently without the help of any staff members. During the follow up interview, at 10:08 AM, the facility Administrator's personnel cell phone (sitting face up on her desk) started ringing with Staff R's name showing on the screen, but the facility Administrator declined the call and continued with the interview. Review of the facility provided, re-printed receipts from Walmart, revealed all purchased items were legible and Staff R, former Assistant Administrator's, authorization signature from time of electronic purchase were on the receipts. On 5/1/24 the provided receipts were uploaded by transaction number onto the Walmart website identifying the specific items, quantity, colors, and sizes purchased. Purchases on Resident #30's receipt totaling $514.49 included the following items: 1. Joyspun Women's and Women's Plus Plush Sleep Jogger Pants (gray, pink plaid, size Small) $9.98 2. Joyspun Women's Velour Notch Collar Top and Pants Pajama Set, 2-piece (red plaid, size 2X) $19.98 3. Joyspun Women's and Women's Plus Plush Sleep Jogger Pants (gray,pink plaid, size 2X) $9.98 4. Joyspun Women's Long Sleeve Tee and Jogger Pants Pajama set, 2-Piece (green top, gray Christmas pant, size 2X) $12.98 5. Joyspun Women's Long Sleeve Tee and Jogger Pants Pajama set, 2-Piece, (gray top, green Christmas pant, size 2X) $12.98 6. Joyspun Women's Long Sleeve Tee and Jogger Pants Pajama set, 2-Piece (black top, black with teddy bear pant, size 2X) $12.98 7. Time and [NAME] Women's High-Rise Ankle Knit Leggings, 27' inseam (black, size XL) $4.48 8. Time and [NAME] Women's High-Rise Ankle Knit Leggings, 27' inseam (black, size XL) $4.48 9. Time and [NAME] Women's High-Rise Ankle Knit Leggings, 27' inseam (gray, size XL) $4.48 10. Joyspun Women's Hacci Knit Jogger Sleep Pants, 29 inseam (pink, blue, yellow plaid, size Medium) $8.43 11. Time and [NAME] Women's High-Rise Ankle Knit Leggings, 27' inseam (gray, size XL) $4.48 12. Joyspun Women's Hacci Knit Jogger Sleep Pants, 29 (red, green, white plaid, size Small) $8.43 13. Time and [NAME] Women's and Women's Plus Zip up fleece jacket with hood (green, size XL) $13.00 14. Time and [NAME] Women's and Women's Plus Zip up fleece jacket with hood (navy, size XL) $13.00 15. Time and [NAME] Women's Quilted Fleece Pullover (dark green, size XL) $17.98 16. Time and [NAME] Women's and Women's Plus Zip up fleece jacket with hood (pink, XL) $13.00 17. Joyspun Women's Velour Notch Collar Top and Pants Pajama Set, 2-piece (gray, pink plaid, size Medium) $19.98 18 Time and [NAME] Women's Quilted Hoodie with Long Sleeves, (green, size XL) $17.98 19. Fruit of the Loom Women's Tank Style Cotton Sports Bra, 3-pack (white, black, gray, size 42) $14.94 20. Avia Women's Performance Cushioned Low-Cut Sock, 10 pack (black, size 4-9) $9.97 21. Avia Women's Performance Cushioned Low-Cut Sock, 10 pack (black/[NAME], size 4-9) $9.97 22. Gimme Fine Fit Ponytail Holder Hair Tie, Black 20ct $3.28 23. Scunci Mini Washable Scrunchie Hair Ties, Black, 6ct #3.46 24. [NAME] Fabric Covered Headbands, Assorted neutral colors, 3ct $4.48 25. Mainstay [NAME] Microfiber Quilt, Full/Queen- Reversible (blues, pink, cream floral) $24.97 26. Mainstay Cozy textured Plush Throw Blanket, Purple, 50x 60 $8.46 27. Dearfoams Cozy Comfort Women's waffle and [NAME] Moccasin Slippers (black, size 7/8) $14.00 28. Dearfoams Cozy Comfort Women's quilted jersey Clog (gray, size 9/10) $14.00 29. Reebok Women's and Women's Plus After Class Crewneck Sweatshirt (black, size Medium) $21.98 30. Reebok Women's and Women's Plus After Class Joggers (black, size Medium) $21.98 31. Reebok Women's and Women's Plus After Class Crewneck Sweatshirt (blue, size Large) $21.98 32. Athletic Works Women's Petite Stretch Cotton Blend Straight Leg Pants (black, size XL) $12.98 33. Reebok Women's and Women's Plus After Class Joggers (white, size XSmall) $21.98 34. Mainstays Cozy Plush Throw Blanket, Multicolor abstract Leopard 50x 60 $5.96 35. [NAME] Moisture Ribbons Women's body Wash, [NAME]+Lavender Oil, 18 fl oz (purple bottle) $6.97 36. [NAME] Moisture Ribbons Women's body Wash, [NAME] and Blue Lotus, 18 fl oz (blue bottle) $6.97 37. [NAME] Moisture Ribbons Women's body Wash, [NAME]+Lavender Oil, 18 fl oz (purple bottle) $6.97 38. [NAME] Moisture Ribbons Women's body Wash, [NAME]+Lavender Oil, 18 fl oz (purple bottle) $6.97 39. Mainstay 5 piece Reversible Bed in a Bag Comforter Set with sheets, Floral, Twin-XL (purple, orange,yellow,blue, pink flowers) $29.96 On 5/05/25 at 11:21 AM observation of Resident #30's room and closet, revealed clothing sized XL, a purple throw blanket and Bed in Bag bedding set in original packaging on the shelf of Resident #30's closet. On the floor a basket held multiple pairs of shoes, slippers were not observed but noted shoes size 8. Resident #30's bed was made with a red and white snowflake fleece blanket. During an interview on 5/5/25 at 1:24 PM Staff M, CNA stated she works with Resident #30 often and is familiar with her cares and needs. Resident #30 does walk with a walker and is confused most of the time. Staff M, CNA states she often assists Resident #30 with her showers and daily cares like getting dressed or changing her clothes. Staff M, CNA stated Resident #30's clothes are sized XL's and there might be a few random 2XL. Staff M, CNA stated she was not aware of Resident #30 having any slippers and that she does not wear slippers, she wears the gripper socks. During an interview on 5/5/25 at 1:43 PM Staff S, CMA stated Resident #30 wears sizes XL or 2XL clothes and is aware of bedding she had received including a Bed in a Bag set and a soft throw blanket. During an interview on 5/5/25 at 1:42 PM, Staff K, CNA stated she had worked at the facility on and off for the past [AGE] years and knows the residents very well. Staff K, CNA stated Resident #30 is a bit bigger on top and wears Xl-XXL size clothes. Resident #30 walks with a walker and tends to shuffle her feet when she walks so she wears gripper socks. If Resident #30 were to wear slippers, it wouldn't be safe. Since she shuffles her feet so much she could end up tripping or cause herself to fall. Staff K stated Resident #30 had not received any other blankets or throws she was aware of other than a bedding set and purple blanket she has not used. Staff K verified when items are purchased for a resident and brought back, somebody has to go through the bag, compare the items with the receipt, and sign the receipt to confirm all items were there. In a follow up interview on 5/8/25 at 10:05 AM, Staff R, former Assistant Administrator, stated her employment at the facility as the Activities Director in May 2022, due to family health concerns she took a leave of absence for a period of time then returned to the facility. When she returned to the facility her designated duty was staffing coordinator, from this position she became the Provisional Administrator in January 2023 until April 2024 when the current facility Administrator started. From the Provisional Administrator position she was assigned as the Business Office Manager. Staff R stated her duties as the Business Office Manager included helping with billing and resident trust statements, posting payments, staffing, new hire orientation, assisting with new resident admissions and helping the facility Administrator get started in her position. Staff R stated for the purchases made on 11/30/24 and 12/1/24, she had been designated to purchase items for residents as she had prior experience doing this in the Activities Director position and she had been notified by the Corporate Office of the residents that needed their trust account spent down. The Activities Director at that time had been hired, but had not started in her position yet. Staff R stated the process for purchasing items for residents was first to verify the funds are available, then go purchase the requested items. When purchasing for more than one resident the items need to be kept separate and paid for individually by the resident. At the time of these purchases the debit card had not been working, so Staff R returned to the facility to get the facility checkbook. After the items are purchased, the items are labeled with the resident's initials then the CNAs would assist with inventorying and putting the resident's items away. Staff R would keep the copies of the purchase receipts and post the charges to the resident's account. Staff R was able to recall she had shopped for Resident #30 and Resident #9 on Saturday 11/30/24 and Sunday 12/1/24. Staff R verified the re-printed receipts provided by the facility Administrator, indicating the electronic signature on the receipt was hers. Staff R recalled purchasing bedding, blankets, throws, night gowns, pajama sets, pants, and tops for the residents. She stated the sizes for Resident #30 and Resident #9 ranged from Large to XXL. After the items were purchased Staff R stated she had gone back home leaving the items in the trunk of her car. When she returned to work on Monday (12/2/24) the purchased items were brought into the facility. Staff R stated she had labeled the plastic bags with the resident's initials and delivered them to the nurses' stations. She stated not being able to recall the number of bags she had brought into the facility. Staff R, acknowledged the provided picture of the Walmart bagged items at the nurse's station, stating the items in the bag appeared to be the same color schemes of the items she had purchased for Resident #30 and Resident #9. Staff R stated she was off from work on Monday 12/9/24 but had worked from home due to being ill. On Tuesday 12/10/24 upon returning to work she was made aware of the investigation related to the allegation of items being stolen from residents she had purchased items for. Staff R stated on Tuesday 12/10/24 she assisted the facility Administrator with the investigation by physically pointing out the items that had been purchased compared to the purchase receipts and everything was accounted for. Staff R reviewed and verified the Walmart documents that indicated the items purchased with pictures, descriptions, quantity, sizes and prices. When reviewing the sizes of the items purchased, Staff R could not recall what size items she had purchased and stated she was not sure why there would have been the smaller sizes. Staff R stated after the purchased items were delivered to the resident, it was never brought to her attention of any items that may have not been to correct sizes. On 5/8/25 at 11:50 AM, Regional Director of Operations verbalized concerns related to the on-site investigation being conducted by the Iowa Department of Inspections Appeals and Licensing (DIAL) related to the items purchased and facility's Abuse investigation for Resident #30. Receipts indicating the purchased items with their sizes for Resident #30, and Resident #9 was reviewed by the Regional Director of Operations. She acknowledged the sizes indicated on Resident #30's receipt, stating the receipt may be inaccurate and would find the items indicated. Copies of the receipts with pictures, item description and sizes, as well as a list of the items that indicated discrepancies in the sizes Resident #30 wears was provided to the Regional Director of Operations and the facility Administrator. The provided list included the following items: 1. Joyspun Women's and Women's Plus Plush Sleep Jogger Pants (gray, pink plaid, size Small) 2. Joyspun Women's Hacci Knit Jogger Sleep Pants, 29 inseam (pink, blue, yellow plaid, size Medium) 3. Joyspun Women's Hacci Knit Jogger Sleep Pants, 29 (red, green, white plaid, size Small) 4. Joyspun Women's Velour Notch Collar Top and Pants Pajama Set, 2-piece (gray, pink plaid, size Medium) 5. Reebok Women's and Women's Plus After Class Crewneck Sweatshirt (black, size Medium) 6. Reebok Women's and Women's Plus After Class Joggers (black, size Medium) 7. Reebok Women's and Women's Plus After Class Crewneck Sweatshirt (blue, size Large) 8. Reebok Women's and Women's Plus After Class Joggers (white, size XSmall) Review of documents received on 5/12/25 at 1:04 PM, facility Administrator identified Residents #30 and Resident #9's items compared to purchase receipt, the Items of discrepancy (sizes xsmall, small, medium, large) identified for Resident #30 included the following: 1. Reebok jogger pants, cream size XL 2. Reebok crewneck sweatshirt, cream, size XL 3. Reebok crewneck sweatshirt, burgundy, size XL 4. Reebok jogger pants, dark gray, size XL Continued review of provided documents, received by the facility Administrator, revealed the following items listed on Resident #9's purchase receipt that the facility was unable to identify. 1. Reebok Women's and Women's Plus After Class Joggers (cream, size XL) 2. Reebok Women's and Women's Plus After Class Crewneck Sweatshirt (cream, size XL) 3. Reebok Women's and Women's Plus After Class Crewneck Sweatshirt (burgundy, size XL) 4. Reebok Women's transition jogger (dark gray, size XL) The reviewed documents failed to provide the items of discrepancy. Review of facility provided Job Description: Assistant Administrator, revision date 3/22/24, stated the following: Job Summary: The Assistant Administrator reports to and works collaboratively with the Area Executive Director or Executive Director (ED) supporting the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines and regulations that govern skilled nursing facilities to assure that the highest degree of quality care can always be provided to our residents. Follows all established policies and procedures to include nursing care procedures, safety regulations, human resources policies, departmental policies, and procedures, assuring that quality resident care and an effective operation can be Maintained. Essential Job Functions: 1. With the support of the ED, the Assistant Administrator leads the facility staff in developing and working from a business plan that focuses on all aspects of facility operations, including setting priorities and job assignments. 2. Monitor Human Resources to ensure compliance with employment laws, company policies, and to ensure practices maintain high morale and staff retention, including effective communication, prompt problem resolution, and a proactive work environment. 3. Develop positive relationships on behalf of the company with government regulators, residents, tenants, families, area healthcare providers, physicians, and the community. 4. Manage facility budgets and business practices to include labor costs, payables, and receivables. 5. Ensure a marketing strategy for the facility is developed and implemented that reflects service opportunities, completion, potential market area changes, and maximizes census, payer mix, and ancillary revenues. 6. Support the facility QA committee and ensure compliance with regulations for state of operation. 7. Monitor each department ' s activities, communicate policies, evaluate performance, provide feedback, assist, and observe, coach and discipline as needed. 8. Develop an environment that allows for creative thinking, problem solving, and empowerment in the development of the facility management team. 9. Oversee and conduct regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility, morale of the staff, and ensure resident and tenant needs are being addressed. 10. Exhibit positive customer service both to internal and external customers through the ongoing support and implementation of customer service initiatives and business objectives. 11. Utilize survey and customer satisfaction information to address areas of importance. 12. Ensure consultants and other support resources are appropriately utilized, all staff are appropriately trained, and a high level of interdepartmental teamwork is maintained. 13. Ensure the building and grounds are appropriately maintained and that equipment and work areas are clean, safe, and orderly, and any hazardous conditions are timely addressed. 14. Knowledge and adherence to safety/disaster preparedness plan. 15. In-person attendance is an essential function of this position. 16. All other duties as needed. Code of Conduct: Must adhere to the Company's Code of Conduct policy including documentation and reporting responsibilities. Review of facility provided Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy updated 10/19/22 stated the following: As members of the Accura team, we all embrace our mission statement .to be partners in care and family for life. As we strive to deliver on our mission, we will do this by adhering to our values of trust, integrity, accountability, commitment, and kindness. 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. 1. Exploitation of a dependent adult. Exploitation means a caretaker knowingly obtains, uses, endeavors to obtain to use or who misappropriates a dependent adult's funds, assets, medications, or property with the intent to temporarily or permanently deprive a dependent adult of the use, benefit, or possession of the funds, assets, medication, or property for the benefit of someone other than the dependent adult. 2. Misappropriation of Resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a Resident's belongings or money without the Resident's consent. This includes misappropriation or diversion of resident medications. Review of f

Based on interviews, review of the facility's abuse investigation, and policy review, the facility failed to take action to prevent further potential concerns by letting an employee with accusations of abuse continue to have contact with residents while the facility conducted an investigation for allegations of abuse. The facility reported a census of 45 residents. Findings include: Review of facility provided Abuse Investigation revealed on 12/9/24 at 7:01 PM, Staff I, RN reported to the facility Administrator she had received allegations that Staff R, former Assistant Administrator, had purchased items for herself using Resident #30 and Resident #9 's trust. The facility's Abuse Investigation noted action taken by the facility included investigating the allegation by checking receipts. The credit card was not working at the time of the purchases, checks were used. The documented follow up actions taken by the facility noted when reviewing receipts and resident's room items were accounted for. The credit card was not used for transactions. The items that were supposedly purchased like a queen bed set and brown hair dye were not on the receipt, all hair [NAME] were accounted for. Checking account transaction statements and photo copies of three partial receipts were provided with the facility 's Abuse Investigation documents. First receipt totaled $573.41 timestamped 11/30/24 at 10:32 PM, the second receipt totaled $124.61 timestamped 12/1/24 at 12:27 PM, and third receipt totalled $514.49 timestamped 12/1/24 at 12:26 PM. Review of the Checking account transactions statement indicated Walmart transaction 12/3/24 for $514.49, Walmart transaction 12/3/24 for $124.61, the transaction for $573.41 was not indicated on the transactions statement. The Summary/Conclusion of the investigation revealed the date of incident as 12/9/24, date of the follow up as 12/10/24, person involved as Staff R and nature of incident as possible theft. The facility's Abuse Investigation was signed by the facility Administrator on 12/10/24. On 5/1/25 at 10:28 AM The facility Administrator stated she was notified at 7:00 PM on 12/9/24 that Staff I, was notified of allegations against Staff R, former Assistant Administrator. Staff R, was scheduled off the next day (12/10/24) and was not placed on suspension due to the investigation being completed at a time she was already out of the facility. In an interview with Staff R, former Assistant Administrator on 5/6/25 at 9:34 AM, Staff R verbalized her position at the facility as Business Office Administrative Assistant. She started working at the facility May 2022 and left January 2025, resigning due to family reasons. Staff R stated she was aware there was an internal investigation be conducted by the facility Administrator related to purchases for Resident #30 and Resident #9. She was made aware of the investigation when she got to work one morning in early December, but was unable to recall the exact date. Staff R, stated she was not suspended during the investigation and was in the facility, but couldn't have access to residents' trust accounts. She was not able to recall how long the investigation lasted but stated it was not the full day. Staff R revealed, during the investigation she was with the facility Administrator and helped go through the resident's belongings and helped identify the items. Staff R stated the facility Administrator and herself went through both Resident's (#30 and #9) and identified all items on the receipts. Email communication dated 5/7/25 at 11:54 AM, facility Administrator revealed time cards were not available for Staff R for the dates of 12/9/24 and 12/10/24 as Staff R is a salaried employee with discretionary PTO (paid time off) so Staff R does not have clock in or outs and PTO is not logged in our system. A follow up interview on 5/8/25 at 10:05 AM, Staff R, former Assistant Administrator, stated she was off from work on Monday 12/9/24 but had worked from home due to being ill. On Tuesday 12/10/24 upon returning to work she was made aware of the investigation related to the allegation of items being stolen from residents she had purchased items for. Staff R stated on Tuesday 12/10/24 she assisted the facility Administrator with the investigation by physically pointing out the items that had been purchased compared to the purchase receipts and everything was accounted for. Review of facility provided Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, updated 10/19/22, stated the following: Investigation Protocols: Should an incident or suspected incident of Resident abuse (as defined above) be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident. Initial/Immediate Protection During Facility Investigation: Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: (1) suspending the employee; (2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility; and in rare instances (3) separating the employee accused of abuse from the resident alleged to have been abused, but allowing the employee to care for and have contact with other residents, only if there is a second employee who remains with and accompanies the employee accused of abuse at all times to supervise all contacts and interactions with the residents.

Based on clinical record review, facility abuse investigation, staff interviews and policy review, the facility failed to provide a thorough investigation into 2 of 2 allegations of misappropriation of resident's (Resident #30 and Resident #9) funds. The facility reported a census of 45 residents. Findings include: Review of Resident #30's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment and diagnoses of hypertension, Non-Alzheimer's Dementia, Anxiety Disorder, Schizophrenia, and speech disturbances. Review of Resident #30's Electronic Health Record (EHR) indicated on 4/3/25 Resident #30's height measured 64 (5' 4) and weighed 183.2 pounds on 5/5/25. Review of Resident #9's MDS dated [DATE] revealed a BIMS score of 2 indicating severe cognitive impairment and diagnoses of Renal insufficiency, Hemiplegia, Cerebrovascular Accident, Non-Alzheimer's Dementia, Anxiety Disorder, Depression, and Psychotic Disorder. Review of facility provided Abuse Investigation revealed on 12/9/24 at 7:01 PM, Staff I, RN reported to the facility Administrator she had received allegations that Staff R, former Assistant Administrator, had purchased items for herself using Resident #30 and Resident #9's trust. The facility's Abuse Investigation noted action taken by the facility included investigating the allegation by checking receipts. The credit card was not working at the time of the purchases, checks were used. The documented follow up actions taken by the facility noted when reviewing receipts and resident's room items were accounted for. The credit card was not used for transactions. The items that were supposedly purchased like a queen bed set and brown hair dye were not on the receipt, all hair [NAME] were accounted for. Checking account transaction statements and photo copies of three partial receipts were provided with the facility's Abuse Investigation documents. First receipt totaled $573.41 timestamped 11/30/24 at 10:32 PM, the second receipt totaled $124.61 timestamped 12/1/24 at 12:27 PM, and third receipt totaled $514.49 timestamped 12/1/24 at 12:26 PM. Review of the Checking account transactions statement indicated Walmart transaction 12/3/24 for $514.49, Walmart transaction 12/3/24 for $124.61, the transaction for $573.41 was not indicated on the transactions statement. The Summary/Conclusion of the investigation revealed the date of incident as 12/9/24, date of the follow up as 12/10/24, person involved as Staff R and nature of incident as possible theft. The facility's Abuse Investigation was signed by the facility Administrator on 12/10/24. During an interview on 4/30/25 at 5:26 PM, the facility Administrator stated the provided investigation documents are the facility's completed investigation, it was an internal investigation and she did not report the abuse allegations to Iowa Department of Inspections Appeals and Licensing (DIAL). Facility Administrator stated during her investigation, she had independently checked the receipts for Resident #9 (receipt total $124.61 and $573.41) with the items purchased and all items were there. On 4/30/25 3:21 PM, Staff Q, Certified Nurses Aide (CNA) reported in an interview, on 12/1/24 Staff R, former Assistant Administrator, used Resident #30 and Resident #9's trust to purchase items for both residents. Staff Q, verbalized concerns of purchased items being stolen by Staff R, reporting after Staff R purchased items for Resident #30 and Resident #9, bagged items were brought to the facility and placed under the nurse's desk, no receipt was provided to the CNAs for the purchased items to be checked in by comparing the items to the receipt and no signatures were provided on the receipt to validate purchased items were delivered to both residents. Staff Q also reported these items were still in bags at the nurse's station on 12/20/24. On 4/30/25, the facility Administrator provided receipts for Resident #30 and Resident #9's purchases that were made on 12/1/24 for $514.49 (Resident #30), 12/1/24 for $124.61 and 11/30/24 for $573.41(Resident #9) The receipts provided were the same copy provided in the facility's Abuse Investigation. The receipts failed to indicate where the purchases had been made (top portion of receipt), unable to identify if all purchased items were shown on copy of the receipts, and the copy of the receipts failed to indicate signatures of purchaser, resident and/or staff to validate items purchased. On 4/30/25 at 5:05 PM an email was sent to the facility Administrator requesting Resident #30 and Resident #9's original receipts for purchase dated 11/30/24 and 12/1/24, indicating where the items were purchased and providing the signatures of the employees and/or Residents verifying the purchased items. During an interview 4/30/25 at 5:15 PM facility Administrator stated these purchases for Resident #30 and Resident #9 were made as their trust accounts needed to be spent down and she was unaware of where the original receipts were but that she still communicated with Staff R and would try to contact her to see if she knew where the receipts could be located. On 5/1/25 at 6:51 AM the facility Administrator communicated via email stating, attached to the email were copies of three receipts. With a new office manager, we were not sure where the originals were filed but I went to Walmart last night and they were able to reprint these for me. As per our communication last night, I mentioned we were doing spend downs for residents at this time. Review of the facility provided, re-printed receipts from Walmart, revealed all purchased items were legible and Staff R, former Assistant Administrator's, authorization signature from time of electronic purchase were on the receipts. In a follow up interview on 5/1/25 at 10:28 AM The facility Administrator stated she was notified at 7:00 PM on 12/9/24 that Staff I, was notified of allegations against Staff R, former Assistant Administrator. At the time of the purchases Staff R was doing the spend down for the residents (Resident #30 and Resident #9), she had previously been in the Activities Director position and was familiar with the resident's preferences. The facility Administrator confirmed the residents that were purchased for on 11/30/24 and 12/1/24 were not cognitively able to identify and express their wants and needs. She (facility Administrator) also stated the Police Department was not notified as there was no missing money. A follow up Interview 5/6/25 at 10:05 AM, facility Administrator stated while conducting the facility's Abuse Investigation she could not recall interviewing staff members related to the purchased items for Resident #30 or Resident #9. She stated when she conducted the investigation she reviewed all three receipts finding all the purchased items comparing them to the receipts independently without the help of any staff members. During the follow up interview, at 10:08 AM, the facility Administrator's personnel cell phone (sitting face up on her desk) started ringing with Staff R's name showing on the screen, but the facility Administrator declined the call and continued with the interview. In a confidential staff interview on 5/1/25 at 9:37 AM, staff member verbalizes being aware of the facility's investigation related to Resident #30's and Resident #9's purchased items. Staff member stated the Walmart bags with resident's items sat at the nurse's station for weeks. Staff member stated, CNAs and nurses had asked multiple times for the receipts so the items could be given to the residents they were purchased for. Staff member verbalizes frustration with administrative staff due to the investigation being completed but the items that were part of the investigation were still in the Walmart bags under the desk at the nurse's station. Staff member was able to provide a picture on her phone that showed approximately 3-5 Walmart bags with items that appear to be clothes in them under the desk at the nurse's station. Staff member was able to show a time stamped date and time picture was taken revealing 12/13/24 at 10:04 PM. In an interview with Staff R, former Assistant Administrator on 5/6/25 at 9:34 AM, Staff R verbalized her position at the facility as Business Office Administrative Assistant. She started working at the facility May 2022 and left January 2025, resigning due to family reasons. Staff R stated she was aware there was an internal investigation being conducted by the facility Administrator related to purchases for Resident #30 and Resident #9. She was made aware of the investigation when she got to work one morning in early December, but was unable to recall the exact date. Staff R, stated she was not suspended during the investigation and was in the facility, but couldn't have access to resident's trust accounts. She was not able to recall how long the investigation lasted but stated it was not the full day. Staff R revealed, during the investigation she was with the facility Administrator and helped go through the resident's belongings and helped identify the items. Staff R stated the facility Administrator and herself went through both Resident's (#30 and #9) and identified all items on the receipts. On 5/1/24 the provided re-printed receipts were uploaded by transaction number onto the Walmart website identifying the specific items, quantity, colors, and sizes purchased. Review of purchases on Resident #30's receipt totaling $514.49 revealed discrepancies in clothing sizes. Items of discrepancy included the following: 1. Joyspun Women's and Women's Plus Plush Sleep Jogger Pants (gray,pink plaid, size Small) 2. Joyspun Women's Hacci Knit Jogger Sleep Pants, 29 inseam (pink, blue, yellow plaid, size Medium) 3. Joyspun Women's Hacci Knit Jogger Sleep Pants, 29 (red, green, white plaid, size Small) 4. Joyspun Women's Velour Notch Collar Top and Pants Pajama Set, 2-piece (gray, pink plaid, size Medium) 5. Reebok Women's and Women's Plus After Class Crewneck Sweatshirt (black, size Medium) 6. Reebok Women's and Women's Plus After Class Joggers (black, size Medium) 7. Reebok Women's and Women's Plus After Class Crewneck Sweatshirt (blue, size Large) 8. Reebok Women's and Women's Plus After Class Joggers (white, size XSmall) During an interview on 5/5/25 at 1:24 PM Staff M, CNA stated she works with Resident #30 often and is familiar with her cares and needs. Resident #30 does walk with a walker and is confused most of the time. Staff M, CNA states she often assists Resident #30 with her showers and daily cares like getting dressed or changing her clothes. Staff M, CNA stated Resident #30's clothes are sized XL's and there might be a few random 2XL. During an interview on 5/5/25 at 1:43 PM Staff S, CMA stated Resident #30 wears sizes XL or 2XL. During an interview on 5/5/25 at 1:42 PM, Staff K, CNA stated she had worked at the facility on and off for the past [AGE] years and knows the residents very well. Staff K, CNA stated Resident #30 is a bit bigger on top and wears Xl-XXL size clothes. Review of purchases on Resident #9's receipt totaling $124.61 revealed discrepancies in items purchased and documented findings by the facility Administrator's internal Abuse Investigation. Discrepancies include the following items: 1. Color oops Extra Strength Hair Color Remover $10.47 2.[NAME] Nutrisse Nourishing Hair Color Creme, 061 Light Ash [NAME] Mochaccino $8.47 3. [NAME] Nutrisse Nourishing Hair Color Creme, 42 Deep Burgundy Black Cherry $5.50 Discrepancies in items Resident #9's receipt totaling $573.41 included following items: 1.Splat Original Complete kit, Unisex Semi-Permanent Hair Dye with bleach, [NAME] Lavender $9.77 2.Splat Original Complete kit, Unisex Semi-Permanent Hair Dye with bleach, Pink Fetish $9.77 Indicating a total of five boxes of hair color or treatment were purchased, color remover, light ash brown mochaccino, deep burgundy black cherry, purple (lavender) and pink. In an interview on 5/6/25 at 10:30 AM, facility Administrator stated she did not recall interviewing staff related to the allegations while conducting the facility's abuse investigation. She (Administrator) stated she had reviewed all 3 receipts and found the items independently without the help of any staff members. The Administrator continued by stating when Staff I called and reported the allegation to her, Staff I asked to please specifically look for brown hair dye and queen bedding and the items were found when inventoried. Found items included 4 total boxes, three boxes were colored including pink, purple, and black cherry. The fourth box was a color toner. The Queen bedding set was found in Resident #9's closet. A follow up interview on 5/8/25 at 10:05 AM, Staff R, former Assistant Administrator, stated for the purchases made on 11/30/24 and 12/1/24, she had been designated to purchase items for residents as she had prior experience doing this in the Activities Director position and she had been notified by the Corporate Office of the residents that needed their trust account spent down. The Activities Director at that time had been hired, but had not started in her position yet. Staff R stated the process for purchasing items for residents was first to verify the funds are available, then go purchase the requested items. When purchasing for more than one resident the items need to be kept separate and paid for individually by the resident. At the time of these purchases the debit card had not been working, so Staff R returned to the facility to get the facility checkbook. After the items are purchased, the items are labelled with the resident's initials then the CNAs would assist with inventorying and putting the resident's items away. Staff R would keep the copies of the purchase receipts and post the charges to the resident's account. Staff R was able to recall she had shopped for Resident #30 and Resident #9 on Saturday 11/30/24 and Sunday 12/1/24. Staff R verified the re-printed receipts provided by the facility Administrator, indicating the electronic signature on the receipt was hers. Staff R recalled purchasing bedding, blankets, throws, night gowns, pajama sets, pants, and tops for the residents. She stated the sizes for Resident #30 and Resident #9 ranged from Large to XXL. After the items were purchased Staff R stated she had gone back home leaving the items in the trunk of her car. When she returned to work on Monday (12/2/24) the purchased items were brought into the facility. Staff R stated she had labelled the plastic bags with the resident's initials and delivered them to the nurse's stations. She stated not being able to recall the number of bags she had brought into the facility. Staff R, acknowledged the provided picture of the Walmart bagged items at the nurse's station, stating the items in the bag appeared to be the same color schemes of the items she had purchased for Resident #30 and Resident #9. Staff R stated she was off from work on Monday 12/9/24 but had worked from home due to being ill. On Tuesday 12/10/24 upon returning to work she was made aware of the investigation related to the allegation of items being stolen from residents she had purchased items for. Staff R stated on Tuesday 12/10/24 she assisted the facility Administrator with the investigation by physically pointing out the items that had been purchased compared to the purchase receipts and everything was accounted for. Staff R reviewed and verified the Walmart documents that indicated the items purchased with pictures, descriptions, quantity, sizes and prices. When reviewing the sizes of the items purchased, Staff R could not recall what size items she had purchased and stated she was not sure why there would have been the smaller sizes. During an interview on 5/8/25 at 8:29 AM, the Clinical Nurse Specialist stated she was not familiar with the incident but would expect the facility to follow the corporate policies and CMS guidelines. Review of facility provided Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, updated 10/19/22, stated the following: Investigation Protocols Should an incident or suspected incident of Resident abuse (as defined above) be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident. The administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident. a) Review documentation in resident record (including review of assessment if resident injury). b) Assess the resident for injury if the allegation involves physical or sexual abuse; c) Provide proper notifications to primary care provider, responsible party, etc. d) Attempt to obtain witness statements (oral and/or written) from all known witnesses e) If there is physical evidence that can be preserved, attempt to do so, and maintain in a safe location to minimize risk of evidence being tampered with. The facility will establish and enforce an environment that encourages individuals to report allegations of abuse without fear of recrimination or intimidation. Following investigation, the Administrator or designated agent will be responsible for forwarding the results of the investigation to the Department of Inspections & Appeals. This written report shall be forwarded to the Department within five days of the initial report.

Based on clinical record review, staff interview, and policy review, the facility failed to accurately complete a resident's Minimum Data Set (MDS) assessment by not coding Hospice services and diagnosis of Dementia for 1 of 19 Residents reviewed in the sample (Residents #26). The facility reported a census of 45 residents. Findings include: Review of Resident #26's Census Report revealed Resident #26's admission to the facility on [DATE] and hospice level of care on 11/8/24. Review of Resident #26's Hospice Admission Plan dated 11/8/24 revealed admission to Hospice services with a diagnosis. of Dementia. Review of Resident #26 Significant Change MDS dated [DATE], revealed BIMS of 00, indicating severe cognitive impairment. The MDS section for special treatments, procedures, and programs indicated Hospice Level of care and active diagnoses including; Atrial Fibrillation, Heart Failure, Hypertension, Stage 4 Chronic Kidney disease, Diabetes Mellitus, Macular Degeneration, and Depression. Review of Resident #26's Quarterly MDS dated [DATE] revealed, Staff Assessment for Mental Status score of 2, indicating moderate impairment (poor decisions, cue/supervision required). Active diagnoses included; Atrial Fibrillation, Heart Failure, Hypertension, Stage 4 Chronic Kidney disease, Diabetes Mellitus, Macular Degeneration, and Depression. The MDS section for special treatments, procedures and programs indicated none of the above. Review of Resident #26's Quarterly MDS dated [DATE] revealed, BIMS of 99, indicating Resident #26 was unable to complete the assessment due to severe cognitive impairment. Active diagnoses included; Atrial Fibrillation, Heart Failure, Hypertension, Stage 4 Chronic Kidney disease, Diabetes Mellitus, Macular Degeneration, and Depression. The MDS section for special treatments, procedures and programs indicated none of the above. During an interview on 5/1/25 at 5:25 PM the Clinical Nurse Specialist acknowledged inaccuracies in the Significant Change MDS, Quarterly MDS dated [DATE] and Quarterly MDS dated [DATE]. During an interview on 5/07/25 at 10:20 AM, MDS Coordinator revealed she no longer worked at the facility. She started on 1/18/25 and left on 5/4/25. MDS Coordinator stated she had just started doing the MDS assessments, the regional nurse had been doing them prior and was training her. The previous MDS Coordinator started at the facility on 1/16/25 and left. MDS Coordinator stated she had been hired for a different position but after the previous MDS coordinator left she was moved into the MDS position MDS Coordinator stated Resident's Care Plans should be updated as needed, such as if there's new transfer status, falls, hospice services, and new interventions added. The MDS Coordinator stated the Regional Director of Operations had tried to keep up on the Care Plans, but they were not up to date as she (MDS Coordinator) would have expected. She (MDS Coordinator) asked nurses and nurse managers to let her know of things that needed to be updated, she continued by stating, the facility would let anyone go in and put things on the Care Plans, not best practice, but that's how they did it there. MDS Coordinator stated when she took over the Care Plans and MDS, she realized how much trouble they were in, Care Plans were not updated, MDS's were not accurate. Corporate was aware for a long time and anticipated they would receive tags. Review of Facility provide policy; Conducting an Accurate Resident Assessment, updated April 2025 Stated the purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident status at the time of the assessment, by staff qualified to assess relevant care areas.

Based on record review, staff interview, and policy review the facility failed to develop a comprehensive care plan for 2 of 19 residents reviewed for care plans (Resident #26 and #37). The facility reported a census of 45 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had diagnosis of diabetes. The MDS revealed the resident had no skin issues. The Care Plan revised on 10/30/24 revealed the resident had a potential for pressure ulcer development related to decreased mobility and incontinence. The Care Plan lacked information about a sore on top of the resident's head or information that pertained to a history of skin cancer or a chronic skin condition. The Progress Notes revealed: a. On 10/9/24 at 12:33 PM (Admission summary) included documentation as follows; resident admitted to the facility. Skin normal. b. On 1/9/25 at 9:16 PM and 3/20/25 at 7:24 PM, a dietary note documented the resident had a history of skin cancer. c. On 3/20/25 at 1:18 PM, (Quarterly Nursing Assessment) skin condition dry and had no abnormal skin coloring. d. On 5/6/25 at 12:08 PM, resident complaining again that the top of his head was hurting. Dermatology appointment set up for 5/15/25 at 1:10 PM. e. On 5/6/25 at 12:00 PM, a late entry created on 5/7/25 at 3:02 PM (after the surveyor spoke with the DON), revealed a 0.75-centimeter (cm) x 0.75 cm x 0 cm mole to the top of the resident's head today is inflamed and tender to touch. Area is intact with brown mole coloring. No active drainage. The resident reported he's had the mole for 4 or 5 years, and it was previously removed before admission to the facility. In an interview 4/28/25 at 2:28 PM, Resident #37 reported he had a sore on top of his head. The area came and went over the past 4-5 years. He saw a physician and got the area frozen a couple of times but the area had come back. He mentioned to a physician who saw him at the facility. The physician said he needed to see a dermatologist. The resident stated he had put Vicks on the sore on top of his head to help the pain. In a follow up interview on 5/1/25 at 9:38 AM, Resident #37 reported he told two physicians about the area on his head. They looked at if but that's as far as it went. He also spoke with nurse a month ago about it. She mentioned something about him going to see a dermatologist. He just hoped it was not cancer. In an interview 5/6/25 at 9:47 AM, Staff D, LPN, reported the MDS nurse, DON, and ADON completed the residents' Care Plan. Staff D reported Resident #37 had a skin area on his head removed before he came to the facility. The nurse put triple antibiotic (ATB) ointment or skin prep and a Band-Aid on the area whenever the area flared up. Staff D reported the physician saw the area but there had not been a referral to a dermatologist since the resident had been there. She checked the area and documented a progress note if she saw it looked more irritated. The resident was able to tell staff when it bothered him. In an interview 5/6/25 at 11:30 AM, the DON, reported Resident #37 had a chronic skin area on the top of his head for quite a while. She didn't think there had been any changes to the area since she had worked at the facility. Staff had let the physician know about the area and they had tried different treatments. The area had remained the same after the treatments were done. In an interview 5/7/25 at 10:20 AM, the MDS nurse reported the resident's care plan were updated whenever needed. The MDS nurse reported if a resident had a skin issue or wound, it should be included on the care plan along with the interventions. The MDS nurse reported she spoke with staff about the things that needed to be added to the care plan. The MDS nurse reported the residents' care plans were not updated as they should be. In an interview 5/8/25 at 1:30 PM, Staff D, LPN, she set up a dermatology appointment for Resident #37 the other day after she spoke with the surveyor. She spoke with the resident and then called the resident's family to inquire about the dermatologist he had seen previously. 49698 2. Review of Resident #26's Significant Change MDS dated [DATE], revealed BIMS of 00, which indicated severe cognitive impairment. The MDS indicated Hospice Level of care with active diagnoses including; Atrial Fibrillation, Heart Failure, Hypertension, Stage 4 Chronic Kidney disease, Diabetes Mellitus, Macular Degeneration, and Depression. Review of Resident #26's Census Report indicated Hospice care started on 11/8/24. Review Resident #26's paper chart included a signed Physicians order, dated 11/8/24, for Hospice services to evaluate and treat Resident #26. Review of Resident #26's Hospice Admission Plan dated 11/8/25 indicated diagnosis of Dementia and Senile Degeneration of the brain with Hospice services for end of life care. Review of Resident #26's paper chart included a signed Physician's order dated 3/20/25, requesting a signed order to admit Resident #26 to Hospice as of 11/18/24. Review of Resident #26's Care Plan revealed on 3/24/25 (date initiated) Resident #26 is on Hospice level of care. During an interview on 5/1/25 at 5:25 PM, the Clinical Nurse Specialist acknowledged the discrepancy in physician order dates, hospice admitted , significant change MDS, and failure to update Resident #26's Care Plan in a timely manner. During an interview on 5/07/25 at 10:20 AM, MDS Coordinator revealed she no longer worked at the facility. She started on 1/18/25 and left on 5/4/25. MDS Coordinator stated she had just started doing the MDS assessments, the regional nurse had been doing them prior and was training her. The previous MDS Coordinator started at the facility on 1/16/25 and left. MDS Coordinator stated she had been hired for a different position but after the previous MDS coordinator left she was moved into the MDS position. MDS Coordinator stated Resident's Care Plans should be updated as needed, such as if there's new transfer status, falls, hospice services, and new interventions added. The MDS Coordinator stated the Regional Director of Operations had tried to keep up on the Care Plans, but they were not up to date as she (MDS Coordinator) would have expected. She (MDS Coordinator) asked nurses and nurse managers to let her know of things that needed to be updated, she continued by stating, the facility would let anyone go in and put things on the Care Plans, not best practice, but that's how they did it there. MDS Coordinator stated when she took over the Care Plans and MDS, she realized how much trouble they were in, Care Plans were not updated, MDS's were not accurate. Corporate was aware for a long time and anticipated they would receive tags. Review of facility provided Comprehensive Care Plans Policy, updated April 2025, revealed the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need and ALL services that are identified in the resident's comprehensive assessment (MDS) and meet professional standards of quality. 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality and incorporate culturally competent and trauma-informed care as indicated. 2. The comprehensive Care Plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAA's) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. Comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse the treatment. 4. A comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on record review, resident and staff interview, the facility failed to ensure care conferences held at least quarterly for one of one residents reviewed for care conferences (Resident #33) and failed to document follow up on the concerns addressed. The facility reported a census of 45 residents. Findings include: The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had diagnosis of depression. The MDS recorded the resident had a Brief Interview for Mental Status score of 15 indicating intact cognition. The MDS indicated having family or a close friend involved in discussions about his care as very important. The electronic health record (EHR) revealed a Care Conference Meeting /Attendance note dated 10/24/24. Two family members attended, and as well as the resident. The EHR and paper chart lacked documentation of the care conferences held between 11/2024 - 4/30/25. In an interview 4/28/25 at 1:15 PM, the resident reported he had gone to a care conference meeting in the past several months but he felt it did not do any good to go to the Care Conference because nothing got done about the concerns or anything he mentioned. The resident reported the Administrator told him it took time to address things. In an email on 5/5/25 at 11:55 AM, the Administrator wrote that care conference notes were completed on paper. The Surveyor then requested the care conference notes for Resident #33. At 12:27 PM, the Administrator reported no Care Conference notes found for Resident #33. In an interview 5/6/25 at 9:47 AM, Staff D, Licensed Practical Nurse, reported the MDS nurse set up the Care Conference meetings. In an interview 5/7/25 at 10:20 AM, the MDS nurse reported she had worked at the facility 1/18/25 to 5/4/25. No care conferences were held during the time she worked at the facility but she was in the process of working on getting the care conferences set up. In an interview 5/7/25 at 2:40 PM, the Administrator confirmed no policy for care conferences. The Administrator reported they were trying to get on track for care conference meetings when the MDS nurse came on board. The Administrator reported she had a plan to catch up on the care conferences. The Administrator reported Care Conferences should be held quarterly. In an interview 5/7/25 at 2:45 PM, the Regional Clinical Director reported the MDS nurse arranged care conference but the MDS nurse had resigned. The Regional Clinical Director reported no Care Conference records or documentation found, including paper sheets.

Based on observation, record review, policy review, resident and staff interviews, the facility failed to complete an assessment and provide an intervention for 3 of 3 residents (Resident #12, #26 and #37). Resident #12 acquired a puncture wound to his right lower calf from a broken wheelchair and the nurse failed to make an assessment 12 or more hours after a CNA reported the incident. The facility failed to monitor Resident #26 after obtaining a burn. The facility reported a census of 47 residents Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #12 revealed a diagnoses of heart failure, renal insufficiency, diabetes mellitus, identified limited range of motion to both lower extremities and inability to walk 10 feet. The MDS failed to identify the use of a wheelchair as a mobility device. The MDS identified a risk for developing pressure ulcers or injuries of the skin and identified two venous/arterial ulcers present on the lower legs which required an application of nonsurgical dressings. The brief interview for mental status (BIMS) listed a score of 15 which indicated an intact cognition. Care Plan dated 4/11/25 for Resident #12 instructed staff to monitor skin with cares and alert the nurse of any red/open areas so the nurse can notify the physician. During an observation on 4/28/25 on 1:12 PM Resident #12 had bloody drainage on the wrap to the right leg that came from a small puncture wound to the back of his calf. During an interview on 4/28/29 at 1:12 PM Resident #12 stated when he returned from his appointment that morning, a screw on his wheelchair punctured the back of his leg. Resident #12 stated he had informed staff of the injury but no one had assessed it or fixed the wheelchair yet. During an observation on 4/29/25 at 9:10 AM, the dressing to Resident #12's right lower leg had dried drainage and fresh bloody drainage on the upper posterior calf. During an interview on 4/29/25 at 9:10 AM Resident #12 stated the nurse did not come yesterday to assess the puncture from the wheelchair. Resident #12 stated the dressing normally was changed every three days it would be completed by the night nurse. On 4/29/25 at 9:12 AM, the Department of Inspection, Appeals and Licensing Surveyor questioned the Assistant Director of Nursing (ADON) about the puncture wound to the back of Resident #12's right calf and the ADON stated the dressings to his lower legs get changed every three days and she was not aware of an injury to his right lower leg that was draining. During an interview on 4/29/25 at 9:17 AM, Staff P, Licensed Practical Nurse (LPN) stated the dressing order for Resident #12's lower legs was change on evening shift every three days and she was not aware that there was an injury from a wheelchair yesterday. Staff P stated the Certified Nursing Assistant (CNA) did not inform her. During an observation on 4/29/25 at 11:32 AM, the Director of Nursing (DON) assessed Resident #12's Right calf and received an order for a treatment. ADON assisted the DON to take measurements of the puncture wound. The dressing to Resident #12's right lower leg was saturated with drainage and was removed. The DON measured a small puncture wound to the back-lateral side of lower right leg .75 x .5 cm with dark colored skin (bruise) around it and cleaned with wound cleanser and had applied a large Telfa dressing. During an interview on 4/29/25 at 11:34 AM, the Assistant Director of Nursing (ADON) stated the maintenance director got the w/c pin replaced to the right pedal as that was why the wheelchair injured Resident #12's right leg. During an interview on 4/30/25 at 2:22 PM, Staff L, Certified Nursing Assistant (CNA) stated on 4/28/25 at 4 PM when he was administering Resident #12's medications, had noticed the dressing to Resident #12's right leg was saturated with blood and serum. Staff L stated he had informed Staff P, Licensed Practical Nurse (LPN). Staff L stated Resident #12 did not complain of pain, administered scheduled Tylenol. A document titled Non-Ulcer Skin Assessment that identified a puncture wound to Resident #12's right upper lateral calf that measured .75 centimeters (cm) long, .5 cm wide and a depth of 0.1 cm with small serosanguinous (serous fluid and blood) drainage from the wound. The assessment revealed the physician and family was notified on 4/29/25 and an order for zinc oxide, gauze pad and a wrap was applied. The document was signed by the Director of Nursing. A document titled New Skin Area dated 4/29/25 at 10:30 AM for Resident #12 revealed the resident related his right upper lateral aspect of his calf got poked by a broken piece on his wheelchair pedal. Resident had a .75 cm x .5 cm x .1 cm puncture that was draining clear fluid and saturated his Unna boot. Immediate action taken was that the maintenance repaired the broken piece, area assessed and orders received for treatment. The predisposing environmental factors was a malfunctioning of equipment. The physician order dated 4/29/25 directed staff to clean the puncture wound to Resident #12's right upper lateral aspect calf with wound cleanser, apply zinc oxide, ABD pad, and gauze roll on top, two times a day for wound care and as needed for soiling. During an interview on 4/29/25 at 1:37 PM, the Maintenance Director stated the Director of Nursing (DON) notified him today that Resident #12 had a problem with his wheelchair and had punctured his leg on it 4/28/25. The hinge pin to the right foot rest was completely missing and he didn't have one to replace it. The Maintenance Director stated someone had replaced the top pin with a bolt with a lock nut on it so he removed the bolt and turned it upside down to turn the tread down and put a bolt in the bottom side turned up so the treads were facing together inside the bracket. The Maintenance Director stated the one bolt in the top of the foot rest caused the locking lever to turn up when opened. The Maintenance Director stated he made sure the locking lever will not swing up and hurt Resident #12. The Maintenance Director stated he had not received a work order for that wheelchair and would expect that if there was an injury due to a piece of equipment then he would want the staff to call him immediately or as soon as he arrived the next business day. During an interview on 4/29/25 at 12:10 PM, the DON stated the expectation of a new wound assessment was that whomever took the report of an injury would tell the nurse and the nurse would then make an assessment, call the physician, fill out a skin sheet and a risk management form. 49698 2. Review of Resident #26 Quarterly MDS dated [DATE], revealed BIMS of 99, indicating Resident #26 was unable to complete the assessment due to severe cognitive impairment. Active diagnoses included Heart Failure, Hypertension, Diabetes Mellitus, Macular Degeneration, and Depression. MDS indicated Resident #26 is able to eat independently. Review of Resident #26's Care Plan, revision on 3/20/25, indicated risk of visual impairment related to Macular Degeneration with interventions to assess Resident #26's ability to function within limits of visual impairment and communicate where belongings are located. Care Plan also indicated, initiated date 8/30/24 Resident #26 had an ADL self-care performance deficit related to confusion with interventions including Resident #26 needing supervision at meals, such as assuring coffee cups have lids and the temperature of the coffee is checked. Review of electronic Health Status Progress Note dated 2/28/25 stated CNA reported Resident #26 spilled hot coffee on her chest. No redness or pain noted to the area. Faxed physician to notify, placed on Hot Chart (nursing charting system, focusing on documentation of resident's condition and progress) to monitor, representative notified. Review of Resident #26's paper chart revealed, faxed document to Resident #26's Physician dated 2/28/25, indicated Resident #26 spilled coffee on her chest this morning, no redness or pain from incident. Will monitor area. Resident #26's Physician responded on 3/6/25, noting the incident and requesting notification of any skin issues that occur. On 3/6/25 an RN signed the form indicating receiving Physicians response and direction. On 3/9/25 a second RN signed the form indicating second check and review of Physicians response. Review of electronic Health Status Progress Note dated 3/6/25 stated Resident #26's Physician noted the coffee incident on 2/28/25. Review of facility provided Incident Report dated 2/28/25 revealed, CNA reported Resident #26 spilled hot coffee on her chest. No redness or pain noted to the area. Resident #26's Physician was faxed and Resident #26 was placed on the Hot Chart to monitor. Mental Status indicated Resident #26 oriented to self, with confusion, impaired memory, weakness, and contributing diagnoses of 20/20 vision with correction. Incident Report Notes included on 2/28/25 Kitchen Manager to assure Resident #26's coffee cup has a lid and temperature of the coffee will be checked. Further review of Resident #26's Electronic Health Records (EHR) and paper chart failed to indicate nursing documentation or Hot Charting of assessments and/or monitoring of Resident #26's skin conditions in the area where the hot coffee had spilled. During an interview on 4/30/25 at 9:51 AM, DON revealed, Hot Charts are noted electronically in Point Click Care (PCC, Electronic Health Record), the process and expectation is that nurses monitor and assess the Hot Chart concerns and document these assessments and finding in a Nursing Progress Note in PCC. During an interview on 4/30/25 02:51 PM, Staff D, LPN showed this surveyor where Hot Charting is located in PCC. Stuff D, LPN stated when monitoring a resident that is listed on the Hot Chart, the nurse will document the resident's assessments and findings as a Nursing Progress Note in PCC or if the resident is Skilled Level of Care (LOC) it would be documented with the Skilled assessment. On 05/05/25 12:05 PM, the Facility Administrator provided a copy of Resident #26's Incident Report for the coffee spill on 2/28/25 and stated the Incident Report was the only documentation available, acknowledging if assessments and monitoring for Resident #26 had been completed; they were not documented. In an Email on 5/7/25 at 1:25 PM, the Administrator communicated the Facility did not have policies for Resident Assessments or Nursing documentation. 34817 3. The Quarterly MDS assessment dated [DATE] revealed Resident #37 had diagnosis of diabetes. The MDS revealed the resident had no skin issues. The Care Plan revised on 10/30/24 revealed the resident had a potential for pressure ulcer development related to decreased mobility and incontinence. The Care Plan lacked information about a sore on the top of Resident #37's head or information that pertained to a history of skin cancer or a chronic skin condition. The electronic health record assessments list lacked skin assessments. The Progress Notes revealed: a. On 10/9/24 at 12:33 PM (Admission Summary), resident admitted to the facility. Skin normal. b. On 1/9/25 at 9:16 PM and 3/20/25 at 7:24 PM, a dietary note documented the resident had a history of skin cancer. c. On 3/20/25 at 1:18 PM (Quarterly Nursing Assessment), skin condition dry and had no abnormal skin coloring. d. On 5/6/25 at 12:08 PM, resident complained again that the top of his head was hurting. Dermatology appointment set up for 5/15/25. e. On 5/6/25 at 12:00 PM, a late entry created on 5/7/25 at 3:02 PM (after the surveyor spoke with the DON), revealed a 0.75-centimeter (cm) x 0.75 cm x 0 cm mole to the top of the resident's head is inflamed and tender to touch. Area is intact with brown mole coloring. No active drainage. The resident reported he's had the mole for 4 or 5 years and it was previously removed before admission to the facility. The paper Shower sheets dated 4/2/25, 4/8/25, 4/11/25, 4/15/25, 4/18/25, 4/22/25, 4/25/25 revealed no skin concerns. The Non-Pressure Skin Assessments located in the paper chart revealed no information about a skin mole or sore on the top of the resident's head. Incident Reports reviewed 1/1/25 to 4/27/25 revealed no incident reports regarding any skin conditions or sore on the resident's head. The Order Summary dated 4/1/25 revealed no referral for dermatology listed. In an interview 4/28/25 at 2:28 PM, Resident #37 reported he had a sore on top of his head. The area came and went over the past 4-5 years. He saw a physician and got the area frozen a couple of times but the area came back. He mentioned a concern about the area to a physician that saw him at the facility. The physician said he needed to see a dermatologist. The resident stated he put Vicks over the sore to help the pain. In a follow up interview on 5/1/25 at 9:38 AM, Resident #37 reported he told two physicians about the area on his head. The physicians looked at if but that's as far as it went. He also spoke with nurse a month ago about it. She mentioned something about him going to see a dermatologist. Resident #37 stated he just hoped it was not cancer. In an interview 5/6/25 at 9:47 AM, Staff D, LPN, reported skin assessment done once a week on each resident. The nurses completed a skin assessment and filled out a skin sheet whenever they found a skin concern. They also placed the resident on the computer hot chart to document any follow-up notes. The DON, ADON and MDS nurse completed the skin assessments. Staff D reported Resident #37 had a skin area on his head removed before he came to the facility. The staff put triple antibiotic (ATB) ointment or skin prep and a Band-Aid on the area whenever the area flared up. Staff D reported the physician saw it but there had not been a referral to the dermatologist since the resident had been there. She checked the area and documented a progress note if she saw it looked more irritated. The resident could tell staff when it bothered him. In an interview 5/6/25 at 11:30 AM, the DON, reported she performed skin assessments weekly. The nurse filled out a skin assessment on paper if a new skin concern developed. Resident #37 had a chronic skin area on the top of his head for quite a while. She didn't think there had been any changes to the area since she had worked at the facility. Staff had let the Dr know about the area and they had tried different treatments. The area had remained the same after the treatments were done. In an interview 5/7/25 at 2:40 PM, the Administrator confirmed no policy for change in condition. In an interview 5/8/25 at 1:30 PM, Staff D, LPN, acknowledged she set up a dermatology appointment for Resident #37 the couple days ago after she spoke with the surveyor. She spoke with the resident and then called the resident's son to inquire about the dermatologist he had seen previously.

Based on record review, observations, staff interviews, and policy review the facility staff failed to change gloves when performed cares and then touched other objects for one of four residents sampled for cares (Resident #18). The facility staff also failed to disinfect a mechanical lift after use for one of three residents observed for transfers. The facility reported a census of 45 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had diagnoses of cerebrovascular accident (CVA)(stroke), hemiplegia (paralysis on one side of the body) and neurogenic bladder (loss of bladder control). The MDS recorded the resident had an indwelling catheter. The MDS documented the resident required partial to moderate assistance for toileting hygiene and substantial to maximum assistance for lower body dressing. The Care Plan revised 2/17/25 revealed the resident required Assistance with activities of Daily Living (ADL's) related to cerebral infarction and hemiplegia and had a catheter. The Care Plan revealed the resident transferred and moved in bed independently and required staff assistance as needed. The Care Plan directed staff to use enhanced barrier precautions related to the catheter. During observations on 5/1/25 at 10:25 AM, Staff G, Certified Nursing Assistant (CNA) and Staff B, Certified Medication Aide (CMA) washed their hands, then donned a gown, mask with a face shield, and gloves. Staff G removed Resident #18's brief tabs, then took disposable wipes as Staff B handed the wipes to her and cleansed the resident's peri-area and groin. Staff assisted the resident to roll onto his right side. Staff G changed her gloves, then took disposable wipes and cleansed the buttocks area. Staff B placed a clean brief under the resident and staff assisted the resident to roll onto his left side. Staff G continued to wear the same gloves and touched the back of the resident's shirt as she supported the resident and as Staff B cleansed the buttocks. The resident rolled onto his back and the brief tabs were attached. Staff G placed a blanket over the resident, placed the call light by the resident, then handed the resident a grabber device. Staff B picked up a beverage mug and offered the resident a drink of water. Staff G and Staff B removed their gown and gloves. Staff B then reached into her uniform pocket and applied hand sanitizer to her hands. The Assistant Director of Nursing stood in the room and observed staff with the surveyor. In an interview 5/6/25 at 9:47 AM, Staff D, Licensed Practical Nurse (LPN) reported gloves changed whenever staff did cares and went and did something else. In an interview 5/6/25 at 11:30 AM, the Director of Nursing (DON) reported she expected staff changed gloves before and after cares, and anytime staff went from a dirty to a clean task or area. In an interview 5/7/25 at 2:40 PM, the Administrator confirmed no other policy for glove changes found. A Using Gloves policy updated on 11/13/24 revealed gloves worn to prevent contamination of the employee's hands whenever services provided to the resident. Gloves must be replaced as soon as practical when contaminated. 2. During continuous observations on 4/30/25 at 2:01 PM, Staff H, CNA wore gloves as she pushed a mechanical lift out of room [ROOM NUMBER] into the hallway. Staff H parked the mechanical lift along the hallway railing, then told the resident to have a good nap. Staff H walked back into the room and removed the gloves from her hands. At 2:03 PM, a hospice CNA took the mechanical lift and pushed the lift into room [ROOM NUMBER]. The mechanical lift was not disinfected before or after use. In an interview 5/6/25 at 9:47 AM, Staff D, Licensed Practical Nurse (LPN) reported equipment such as a mechanical lift needed to be disinfected after use. In an interview 5/6/25 at 11:30 AM, the DON reported equipment such as mechanical lifts needed disinfected before and after use. An untitled facility policy updated on 11/13/24 under Miscellaneous revealed equipment cleaned and sanitized prior to using in other areas.

Based on clinical record review, facility document review, staff and family interview, the facility failed to meet a resident's need for corrective lenses by failing to schedule an optometrist appointment for replacement eye wear in a reasonable time frame for 1 of 16 residents assessed (Resident #34). The facility reported a census of 45. Findings include: The annual minimum data set (MDS) for Resident #34, completed on 03/27/2025, documented the following relevant diagnoses: Non-Alzheimer's dementia (dementia), and amaurosis fugax (temporary blindness). It documented the resident's brief interview for mental status (BIMS) score as 02, indicating severely impaired cognition. It also revealed the resident required corrective lenses for his vision. Review of a facility provided document titled Grievance form, with a reported date of 12/20/2024, documented that resident #34 was found wearing glasses that were not his. It documented the administrator searched for the glasses on 12/20/2024 but that they were not found. The grievance form also documented on 03/04/2025 Resident #34 had a doctor's appointment scheduled by the family, with the form being marked as resolved on 03/11/2025. In an interview on 04/28/2025 at 02:23 PM with a family member, they stated they had filed a grievance with the facility in December of 2024 regarding missing glasses. They stated they had reported this to facility staff earlier than the 12/20/2024 date but did not know exactly when. They stated they had requested a doctor's appointment to replace the eye glasses, but it did not get done. They stated they became upset with how long it was taking to schedule the appointment, so in late February of 2025 they scheduled the appointment themselves. They were unhappy with this, as Resident #34 had been without his glasses for over two months at the time of resolution. In an interview on 04/30/2025 at 03:05 PM with the Administrator, she acknowledged that she does not have any documentation as to why the facility did not schedule a doctor's appointment to replace Resident #34's eye glasses, but believed it was family preference

Based on record review, staff interview and policy review, the facility failed to provide the appropriate Center for Medicare Services (CMS) Notice of Medicare Non-Coverage (NOMNC) form to address service options and liability for payment for one of two residents reviewed for Advanced Beneficiary Notices (ABN) (Resident #99). The facility reported a census of 45 residents. Findings include: A review of the notice of non-coverage form for Resident #99 revealed the resident and/or significant other had been notified at least 48 hours prior to skilled services ended and provided information on the right to appeal (CMS form 10123) on 12/18/24. A review of the mandatory skilled nursing facility advanced beneficiary notice of non-coverage form for Resident #99 revealed CMS form #10124-DENC (detailed explanation of noncoverage) was provided to the resident and/or representative instead of CMS form #10055 to indicate the option to receive or decline continued skilled services. During an interview on 4/29/25 at 11:40 AM, the Administrator reported they did not have a social worker at the facility. The Administrator reported she took care of the ABN's. During an interview 4/30/25 at 2:25 PM, the Administrator reported she got the ABN forms in a packet from the Corporate home office. She received an email from Corporate at the beginning of the year regarding the forms to use for the ABN's. There were forms for Medicare Part A and another form for Part B. She thought she used the correct form for Part A for Resident #99. During an interview 5/7/25 at 2:40 PM, the Administrator confirmed the facility had no policy for ABN's.

Based on record review, staff interviews, observations, and policy review the facility failed to provide a safe environment to prevent the development and transmission of communicable diseases and infections by not appropriately wearing Personal Protective Equipment (PPE) and the facility not making PPE available to wear while caring for all Covid 19 residents at the facility leading to Resident #16 becoming positive for Covid 19. Resident #16 was transferred to the hospital related to shortness of breath with oxygen levels of 89 percent on 6 liters (L) of oxygen requesting to be sent to the ED. Resident #16 tested positive for Covid 19 on 9/6/24. Resident #16 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) as well as Congestive Heart Failure (CHF). Staff reported not having eye protection or gowns available until 9/23/24. Staff acknowledged appropriate PPE was not worn during Covid 19 outbreak at the facility. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of August 26, 2024 on September 24, 2024 at 4:50 p.m The facility staff removed the IJ on September 25, 2024 through the following actions: On 9/24/2024, all facility staff were educated or will be educated by next shift on the appropriate use of personal protective equipment in the facility. All residents on isolation have isolation carts stocked and available. On 9/24/2024, competencies were completed with all staff currently at the facility. All staff not present will have competencies completed prior to their next shift. The facility initiated on-going audits of isolation and personal protective equipment three times weekly on 9/24/2024. There have been no issues identified through these audits. Any concerns will be reported to the administrator immediately and addressed in facility QA. The facility did correct the deficiency surveyors ensured the facility implemented education and their policy and procedures. The facility was in compliance at that time. The facility identified a census of 45 residents. The scope lowered from K to E at the time of the survey after ensuring the facility implemented the education, auditsand their policy and procedures. Findings include: Review of document titled Resident Covid Positive documented 26 out of 45 residents tested positive for Covid 19 infection between 8/26/24 - 9/15/24. 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #9 had a Brief Interview for Mental Status (BIMS) of 9 which indicated moderate cognitive impairment. Progress Note dated 9/15/24 at 3:48 PM documented that Resident#9 tested positive for Covid. On 9/23/24 at 1:54 PM Staff J, Certified Nursing Assistant (CNA) stated Resident #9 did not have drawers or personal protective equipment (PPE) at the end of the hall near her room. Staff J stated Resident #9 was coming out for meals until 9/22/24. Staff J stated the day that she tested positive she questioned the DON about what the staff were wearing and the DON stated only N95's. On 9/24/24 at 7:30 AM Staff N, Occupational therapist stated she had worked with Resident #9. Staff N stated would not have known Resident #9 was Covid positive unless she did not look at the Resident #9's electronic health records (EHR). Staff N stated there was no sign for isolation precautions until surveyors entered on 9/22/24 gowns and eye protection were unavailable. Staff N stated N95 masks were present about 3 weeks ago. Staff N stated if there were signs they were very inconsistent. Staff N stated the only way staff knew for sure about Covid dx was to look in the resident's EHR. Staff N stated the first concern was reported to the administration last week with Resident #9. On 9/24/24 at 11:20 AM Staff F, CNA stated Resident #9 isolated only one day last week, maybe 9/20/24 for breakfast. Staff F stated Resident #9 was out for lunch that day though. Staff F stated the nurse told the CNA's that Resident #9 needed to be out for meals. Staff F stated Resident #9 was out for meals on all days but that 9/20/24 for breakfast. Staff F stated Resident #9 was symptomatic the whole time with a moist cough. On 9/24/24 at 1:53 PM Staff M, CNA stated she had brought Resident #9 up for meals when the resident was Covid positive. Staff M stated the nurse said Resident #9 had to come out for breakfast even when Covid positive. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #12 had a Brief Interview for Mental Status (BIMS) of 9 which indicated moderate cognitive impairment. MDS also documented Resident #12 utilized a catheter. Review of Resident #12's medication administration record (MAR) documented a physician's order for catheter change with 18 french instill 10 cc in balloon. On 9/23/24 at 5:07 PM an observation was made outside of room [ROOM NUMBER] Resident #12's room. Observation revealed garbage was removed from the room by Staff J, CNA and Staff L, CNA were exiting the room with garbage. Observation revealed no gowns in the garbage bag. Upon entering the room, observation of no gowns in the room's garbage. On 9/23/24 at 5:12 PM Resident #12 stated the staff just currently provided personal care to her, and did not wear any gowns. On 9/24/24 at 11:15 AM Resident #12 stated the staff frequently do not wear gowns when emptying her catheter. On 9/24/24 at 11:20 AM Staff F, CNA stated other staff frequently do care on Resident #12 without gowns. Staff F stated she had completed catheter cares for Resident #12 without a gown on. On 9/24/24 at 11:30 AM Staff J, CNA stated staff do not wear gowns with catheter cares. Staff J stated staff were supposed to wear gowns when completing care with feeding tubes or catheters. Staff J Stated staff rarely wear gowns when working with catheters. Staff J stated staff do not wear gowns when the gowns were unavailable to be worn. Staff J stated gowns were made available on 9/23/24. 3. The Minimum Data Set (MDS) dated [DATE] documented Resident #16 had a Brief Interview for Mental Status (BIMS) of 15 which indicated no cognitive impairment. MDS also documented use of oxygen, and diagnosis of COPD. Review of Resident #16's EHR on 9/6/24 Staff P, MDS Coordinator documented Resident with complaints of being more short of breath and not feeling well his chest feels heavier and congested, COVID tested - test came back positive, VS 124/78, 88, 98.0, 91% on 6L, 20 called on call provider and physician gave the following verbal orders: Doxycycline 100 milligrams (mg) twice a day (BID) x 7 days, Decadron 6 mg daily for 6 days, Paxlovid 300 mg BID for 5 days. Obtain a chest x-ray on 9/7/24. Resident #16 was aware. Review of Resident #16's electronic health records (EHR) Staff B, LPN documented on 9/10/24 at 11:41AM resident was having a hard time catching his breath with oxygen level 89% on 6 liters via nasal cannula. Resident was wheezing with a temp of 98.7. Resident stated he wanted to be seen at the emergency room . Physician gave an order to send Resident #16 via ambulance to the emergency room for evaluation and treatment. On 9/24/24 at 7:50 AM Staff B, Licensed Practical Nurse (LPN) stated Resident #16 was on 6 L and had COPD. Staff B stated she could not get Resident #16's oxygen saturation above 89% on 6L. Staff B stated Resident #16 was very scared and that is why he was sent out to the emergency room . On 9/24/24 at 11:40 AM the DON stated Resident #16 was Covid positive when he was sent to the emergency room . The DON stated Resident #16's primary complaint when sent out was shortness of breath. The DON stated Resident #16 was wheezing and wanted to be seen in the emergency room . The DON acknowledged Resident #16 remained in his room a lot. The DON stated professionally if the gown and eye protection was worn appropriately may have stopped Resident #16 from contacting Covid. The DON stated she was very skeptical as to the effectiveness of proper personal protective equipment (PPE) utilization in preventing the transmission of the Covid virus. The DON stated she would expect that appropriate PPE would be worn when completing care on anyone with enhanced barrier precaution (EBP). On 9/23/24 at 11:20 AM Staff O, Life Enrichment Director stated she did not see people wearing gowns appropriately with the Covid outbreak. Staff O stated Staff B was told she had to work while positive with Covid. Staff O stated Staff E, Staff J, Staff L, and Staff M were told they had to work Covid positive. Staff O stated when she bought it up in the meeting she was told that the staff were essential. Staff O stated a couple weeks ago corporate was at the facility. Staff O stated the cooperate gal was upset because there were no N95 masks and had witnessed a nurse giving a test to resident, after resident, after resident with no mask no gown no gloves. On 9/23/24 at 1:54 PM Staff J, CNA stated she caught Covid recently about 2 weeks ago. Staff J stated she was tested at the facility related to the outbreak. Staff J stated she was told to apply an N95 and keep on working. Staff J stated she was feeling fine and the Staff B tested positive as well. Staff J stated both of them worked with N95's on and kept working. Staff J stated staff was testing positive and just kept working. Staff J stated the facility did not always have N95's available. Staff J stated the facility was out of N95's. Staff J stated the N95's were in the basement or the garage. Staff J stated they did not isolate residents during the outbreak. Staff J stated there were no gown or eye shield available and they were not worn during the whole outbreak. Staff J stated the DON only wore a surgical mask when she was positive with Covid. On 9/23/24 at 2:25 PM Staff L, CNA Stated she and Staff C,CNA brought concerns to the Administrator about not having N95, gowns, and eye protection. Staff L stated she did not even know they had them available until 9/22/24. Staff L stated she had cared for Covid positive residents. Staff L stated residents were not isolated when they were Covid positive. On 9/24/24 at 7:50 AM Staff B, LPN stated when she had Covid she called in one day because she was horribly sick and had the next day off. Staff B stated the ADON stated she was going to have to work with symptoms and positive for Covid. Staff B stated in other departments the facility put staff off for 5 days. Staff B stated she was symptomatic when she was required to work. Staff B stated other staff had been required to work while positive with Covid as well. Staff B stated she brought her own N95. Staff B stated the facility had no gowns or eye protection provided until the survey team entered on 9/22/24. Staff B stated the facility did have gowns at one time but they were not available or utilized during the Covid outbreak. Staff B stated the lack of masks, gowns, and eye protection was brought to the management. Staff B stated the management told her they could just wear surgical masks. On 9/24/24 at 11:20 AM Staff F, CNA stated there were times when staff did not have gowns. Staff F stated there were no face shields available. Staff F stated this outbreak was not taken seriously at all. Staff F stated she had not worn gowns or face shields and no one wore PPE appropriately during the Covid outbreak. Staff F stated the Covid outbreak started in the back and came up to the front of the facility. Staff F stated she asked about going back and forth between the units. Staff F stated she did not know what EBP was. Staff F stated if the resident has a catheter or any infectious disease they were supposed to be worn. Staff F stated she would wear gowns if they were available. Staff F stated staff had to grab gowns from another room. Staff F stated the facility did not have gloves and masks in the hangers in the rooms on the back of the door. Staff F stated for a good portion of the Covid outbreak there were no gowns available. Staff F stated she told the ADON there were no gowns. On 9/24/24 at 11:40 AM the DON stated when Covid hit the facility she was one of the first that caught the virus. The DON stated she was off for a few days. The DON stated gowns were not being utilized for Covid and the facility did not have any eye protection. The DON stated N95 were available. The DON stated she brought N95's and gowns up from the basement. The DON stated she did not think that PPE was available before she brought it up from the basement. The DON stated there were boxes out on the station so they were available. The DON stated when staff call in and are sick if the staff were symptom free the staff were allowed to wear N95 and work. The DON stated she did see a concern with staff not wearing gowns or eye protection and entering rooms with Covid positive residents. The DON stated she could not answer why the staff didn't not wear appropriate PPE. The DON stated gowns were not available and had to get a few from another facility. The DON stated she reached out to another facility on 9/23/24 to get gowns the day that State entered the facility. The DON stated there were only gowns available in the rooms with the residents that had EBP. The DON stated #9 was positive on the 15th of September. The DON stated she found out after the fact that the staff were bringing Resident #9 out to the meals and the CNA's told her that she had been coming out to meals. The DON stated she did have a concern with Resident #9 being brought out to meals. The DON stated staff would have to help Resident #9 get to her wheelchair and Resident #9 would not have come to the dining room by herself. On 9/24/24 at 12:40 PM the Administrator stated there was PPE available for staff. The Administrator stated there were N95, gowns, gloves, and eye protection available. The Administrator stated the facility did recommend that everyone Covid positive would be isolated. The Administrator stated the facility tried making a table in a room that was just for Covid positive residents. The Administrator stated staff were told to isolate the residents who were positive. The Administrator stated she had witnessed Resident #9 in the dining room while she was Covid positive. The Administrator stated staff never brought it to her attention that they were out of gowns. The Administrator stated staff never brought it to her attention there was no eye protection available. The Administrator stated no one went to get gowns from another facility on 9/23/24. The Administrator stated gowns were obtained because the gowns were the gowns that the staff liked. The Administrator stated she had not made any observations of staff entering rooms without gowns on. The Administrator stated staff are probably supposed to wear gowns if the resident had EBP. The Administrator stated she is not the most up to date about EBP. The Administrator stated the corporation made observations of the staff wearing surgical masks instead of N95's. The Administrator stated staff with COPD were allowed to wear just surgical masks. The Administrator stated she did not require physician documentation of COPD. The Administrator stated the facility was in crisis mode and positive staff were required to work the floor as long as they were symptom free. The Administrator stated the staff were asked to test at the facility. On 9/24/24 at 1:53 PM Staff M, CNA stated there was never proper PPE available. Staff M stated there were gloves and N95 but no gowns or eye protection. Staff M stated she is not familiar with EBP. Staff M stated 9/20/24 or 9/21/24 she was in serviced on EBP with catheters. Staff M stated prior to in-service nobody used gowns in the room with residents that had catheters. On 9/25/24 at 1:00 PM Staff G, LPN / ADON / IP stated she does not do a lot with infection control and when she talked to the Administrator about what to have the staff do if they tested positive. Staff G stated the Administrator told her to have the staff wear an N95 and keep working. Staff G stated Staff J asked about the gowns being available and she was told there were gowns on the back of doors. Staff G stated she had seen staff working with residents that were positive with no gowns or eye protection. Staff G stated she in-serviced every time she observed staff not wearing gowns or eye protection. Staff G stated there were no disciplinary actions as a result of noncompliance of wearing PPE. Staff G stated all the write ups come from the Administrator. Staff G stated she had obtained her IP certificate and she had not been shown how to use the program that tracks trends, antibiotic usage, and infections. Staff G stated she just obtained her IP and had not completed any audits during her time as infection prevention. On 9/27/24 at 11:22 AM the Administrator stated Staff G was the IP and she was logging the infections on a log. The Administrator stated the log was kept on paper. The Administrator stated the logs should have been plugged into the facility's computer program that tracked trends, infections, and antibiotic use. The Administrator stated Staff G gives it to the DON and the DON plugs it in. The Administrator stated Staff G did not have access to the computer program and they are in the process of switching systems. The Administrator stated Staff G had been in the IP position since 2/19/24. The Administrator stated the DON was in charge of the training needed to run the program that tracked trends, infections, and antibiotic uses. The Administrator stated the DON had been tracking the trends. The Administrator stated when the DON saw trends she completed audits. The Administrator stated when the outbreak started August 26 trend was noticed that Covid outbreak started back in the CCDI unit. The Administrator stated would have expected more audits on PPE use and hand washing. The Administrator stated those audits were not completed that she was aware of. The Administrator stated Staff G was working most night shifts and the DON had Covid. The Administrator stated the MDS coordinator and herself should have completed audits based on the trends that were occurring with the Covid virus. The Administrator stated she recognized that Staff G had worked a lot of overnights but feels that Staff G should be able to complete IP work as well as nursing duties when working overnights. The Administrator stated staff G had not shared any concerns with inability to complete IP work or having access to the computer program that tracks trends, infections and antibiotic usage. The Administrator stated she has tried in the last month or so to have Staff G connect with the nurse specialist to be trained but Staff G always seemed to have to work overnights when training was available. The Administrator stated she did not know that IP having access to the tracking and trends of Covid would have affected the outcome of residents who develop Covid. The Administrator stated management failed with the Covid outbreak in education to the staff and identifying concerns with PPE usage. Review of policy titled, Infection Control General Guidelines updated 9/6/24 documented the purpose of the policy was to prevent and control the spread of communicable / contagious infection / diseases and establish guidelines to follow the implementation of isolation precautions. It was the responsibility of the Executive Director and / or DON through the (QAPI) Committee, to assure that all infection control policies and procedures are implemented and followed. The Infection Preventionist Nurse / DON shall be responsible for making periodic reports, both oral and written to the QAPI Committee concerning changes in established infection control practices. All staff shall be informed of the infection control policies and procedures through orientation program and regularly scheduled in-service training. Review of policy titled, Antibiotic stewardship Program updated 5/6/24 documented 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. The antibiotic stewardship program promotes the appropriate use of antibiotics and includes a system of surveillance, monitoring and preventative measures to improve resident outcomes and reduce antibiotic resistance. Antibiotic(s) will be prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms. When the nurse suspects that the resident has an infection, the nurses will perform an evaluation of the resident that includes: Complete set of vitals. Interview with resident for symptoms. Assessment of signs and symptoms. Nurses will utilize the appropriate Infection Criteria Protocol (GI, Skin/Soft Tissue/Mucosal,UTI, Respiratory) based upon the resident's signs and symptoms to determine if it is necessary to treat with antibiotics or if adjustments in therapy need to be made. The nurse will notify Physician/Practitioner of resident change of condition and evaluation information. The Nurse will communicate to the Physician/Practitioner the Infection ControlCriteria Protocol to treat the respective infection. Review of policy titled, Covid-19 outbreak updated 9/6/24 documented if the facility has one or more resident who test positive for Covid a N95 mask, gown, eye protection, and gloves are required in the presumptive and positive resident's room. When the facility has a staff member who has worked in the previous 48 hours and tests positive for Covid, that staff member will need to be off work for an isolation period. The resident with confirmed Covid infection will be placed in a single-person room, when possible. The door should be kept closed (if safe to do so). Ideally, the resident should have a private bathroom, if possible. Centers for Disease Control and Prevention website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), visited 7/11/24 and updated 7/12/22 revealed recent changes included, additional rationale for the use of Enhanced Barrier Precautions (EBP) in nursing homes, including the high prevalence of multidrug-resistant organism (MDRO) colonization among residents in this setting. Expanded residents for whom EBP applies to include any resident with an indwelling medical device or wound (regardless of MDRO colonization or infection status). Expanded MDROs for which EBP applies. Clarified that, in the majority of situations, EBP are to be continued for the duration of a resident's admission. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status and Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. 2. During an interview 9.25.24 at approximately 2 p.m. the Clinical Nurse Supervisor indicated the COVID-19 outbreak began 8.26.24. During an interview 9.25.24 at 1:50 p.m. the Executive Director confirmed the facility as out of outbreak status on 9.19.24. An observation 9.22.24 at 12:40 p.m. revealed Staff A, Dietary Aide wiped down/cleansed dining room tables in the main dining area without a mask. During an interview 9.22.24 at 1:21 p.m. with Staff B, Licensed Practical Nurse (LPN) indicated she had been unaware of the facilities current procedure with the use of PPE. During an interview 9.22.24 at 1:15 p.m. Staff C, Certified Nursing Assistant (CNA) indicated she had been unaware if staff were supposed to wear masks or not and that the COVID-19 outbreak had been over for three (3 )weeks but staff have not been directed as to the facilities expectations with PPE. During an interview 9.23.24 at 1:35 p.m. Staff C indicated the facility provided PPE when in outbreak status however the facility staff failed to use the equipment according to expectations ie. staff failed to wear gowns and shields and properly position their regular face masks to cover their nose and mouth. The staff member also confirmed facility staff cross contaminated the residents as they worked both the CCDI and South units on the same shift without the use of proper PPE, failed to utilize proper signage for visitors to educate them on the facilities outbreak status and/or screen the said visitors. During an interview 9.23.24 at 2:06 p.m. Staff E, CNA indicated when residents who resided in the CCDI unit tested positive for COVID-19 staff went back and forth from the unit to the front of the building when the worked their shifts on the same day. The staff member confirmed staff failed to wear masks, gowns and shields during the facility outbreak status and failed to screen visitors. 25854 During an interview 9.25.24 at approximately 2 p.m. the Clinical Nurse Supervisor indicated the COVID-19 outbreak began 8.26.24. During an interview 9.25.24 at 1:50 p.m. the Executive Director confirmed the facility as out of outbreak status on 9.19.24. An observation 9.22.24 at 12:40 p.m. revealed Staff A, Dietary Aide wiped down/cleansed dining room tables in the main dining area without a mask. During an interview 9.22.24 at 1:21 p.m. with Staff B, Licensed Practical Nurse (LPN) indicated she had been unaware of the facilities current procedure with the use of PPE. During an interview 9.22.24 at 1:15 p.m. Staff C, Certified Nursing Assistant (CNA) indicated she had been unaware if staff were supposed to wear masks or not and that the COVID-19 outbreak had been over for three (3 )weeks but staff have not been directed as to the facilities expectations with PPE. During an interview 9.23.24 at 1:35 p.m. Staff C indicated the facility provided PPE when in outbreak status however the facility staff failed to use the equipment according to expectations ie. staff failed to wear gowns and shields and properly position their regular face masks to cover their nose and mouth. The staff member also confirmed facility staff cross contaminated the residents as they worked both the CCDI and South units on the same shift without the use of proper PPE, failed to utilize proper signage for visitors to educate them on the facilities outbreak status and/or screen the said visitors. During an interview 9.23.24 at 2:06 p.m. Staff E, CNA indicated when residents who resided in the CCDI unit tested positive for COVID-19 staff went back and forth from the unit to the front of the building when the worked their shifts on the same day. The staff member confirmed staff failed to wear masks, gowns and shields during the facility outbreak status and failed to screen visitors.

Based on electronic health records (EHR), resident interview, staff interviews, and policy review the facility failed to provide nursing staff to assure residents safety by not completing visual observations, providing cares, or offering assistance to a resident that required assistance for 1 of 6 residents reviewed (Resident #9). The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #9 had a Brief Interview for Mental Status (BIMS) of 9 which indicated moderate cognitive impairment. MDS also documented maximal assistance with dressing and moderate assistance with toileting. Progress Note dated 9/7/24 at 9:06AM for Resident#9 documented as follows by Staff B, Licensed Practical Nurse (LPN); Resident #9 was found on the floor with bloody tissues laid all around her, Resident #9 had a large purple bruise to the right side of the face (eye and eyebrow area). Resident #9 was dressed in blue jeans, blouse, shoes, and socks. Resident #9 was continent of bowel and bladder, resident indicated right hip pain when emergency medical transport staff tried to move Resident #9. The resident was able to move other extremities without pain. Review of facility investigation dated 9/7/24 documented Resident #9 was last seen at 3:30 AM and was found at 8:30 AM on the floor. Resident #9 was admitted to the hospital for pain but no fracture was found. At approximately 8:36 AM Resident #9 was observed in her bedroom by Staff B on her floor. Resident #9 had blood on her forehead. Resident #9 was immediately sent to the hospital where the hospital performed diagnostic testing. The hospital ruled out any new or acute fractures or injuries, however, the hospital did admit Resident #9 for acute pain. On 9/7/24, at approximately 8:36 AM the Administrator was notified by Staff B, LPN, that Resident #9 was observed in the sitting position in her bedroom on her floor with blood on her forehead. The hospital notified Staff B, that Resident #9 was admitted as inpatient for uncontrolled pain secondary to unwitnessed fall. At approximately 8:30 AM Staff B went into Resident #9's room to administer medications and ask her if she would like breakfast. Upon entry to Staff B observed Resident #9 sitting on the floor on her bottom with bloody tissues around her and a bruise on the right side of her face. Resident #9 stated to Staff B she had gone to turn off her lamp at her bedside table in the night and she fell and was unable to get up. Resident #9 was last observed by Staff K, Certified Nursing Assistant (CNA) at 3:30am on 9/7/24 resting quietly with eyes closed in bed. At approximately 8:40 AM Resident #9 was transported via ambulance to the hospital for treatment due to initial assessment indicated acute, new onset pain to right knee and right hip and limited range of motion to right knee and right hip. The hospital performed diagnostic testing including x-rays and a CT of head and spine. Results of completed x-rays and CT scans did not indicate any new or acute fracture or injury. Due to acute increase in reports of pain secondary to incident, Resident #9 was admitted to the hospital with a diagnosis of acute pain. Review of document titled, Discharge Summary dated 9/10/24 for Resident #9 documented on 9/7/24 Resident #9 was evaluated in the emergency room after a fall at the long term care facility. Resident #9 reported getting up to shut off a lamp right before going to bed. Resident #9 reported the floor was recently waxed and was slippery. Resident #9 reported falling to her knees on the way back to bed and did hit her head. Resident #9 stated she yelled for help all night and nobody checked on her until the morning. Wound on the forehead was sutured in the emergency roiagnom on [DATE]. On 9/24/24 at 7:20 AM Resident #9 stated she had fallen at night when she had the injury to her head and was on the floor yelling for help for a long time before anyone came into the room. Resident #9 stated that she could not reach her call light. Resident #9 stated she received stitches as a result of the accident. Resident #9 stated she tried to clean up the blood but kept on bleeding. Resident #9 stated they did not check on her until she was found on the floor by Staff B in the morning. On 9/24/24 at 7:50 AM Staff B, LPN stated she was the nurse that found Resident #9 on the floor. Staff B stated she came in at 6am on 9/7/24. Staff B stated she did not think the CNA's working that day did walking rounds and now CNA's have to sign off rounds were completed. Staff B stated she was taking am medications to Resident #9 was sitting next to her bed and had bloody tissues all around her. Staff B stated she was fully dressed in blue jeans. Staff B stated Resident #9 stated she was lying on the floor a good portion of the night. Staff B stated the blood on the tissues were still wet. Staff B stated Resident #9 stated she tried to go to the bathroom and then she fell . Staff B stated Resident #9 stated she yelled for quite some time but her voice is soft. Staff B stated the door was closed. Staff B stated there was a laceration on the left side of Resident #9's head. Staff B stated she immediately ran down and called 911. Staff B stated Resident #9 did have stitches for the laceration. Staff B stated the weekends are very short. On 9/23/24 at 2:25 PM Staff L, Certified Nursing Assistant (CNA) stated she was working the 9/7/24 that Resident #9 was found on the floor. Staff L stated Staff B, LPN and Staff M, CNA were the staff that attended the fall. Staff L stated Staff M and her had gotten a majority of the residents up that morning. Staff L stated Staff B yelled down the hallway their names. Staff L stated when she entered the room she saw Resident #9 on the floor. Staff L stated there was a big pile of dried up bloody tissues by Resident #9. Staff L stated Resident #9 was located by her bed. Staff L stated Resident #9 was awake and alert. Staff L stated the call light was lying on top of the bed. Staff L stated she had not completed rounds, maybe Staff K, CNA completed rounds. Staff L stated Resident #9 was found about 8 am. Staff L stated rounds were supposed to be completed about 6 am when they entered the facility. Staff L stated she went out for a smoke break at 7am. Staff L stated at times all of the nursing staff was out smoking together. Staff L stated Saff M helped Resident #9 off the floor and at that time Resident #9 was complaining about leg, hip, or both pain. Staff L stated she asked Resident #9 if her head hurts and she said yes. Staff L stated Staff B called 911 and the ambulance took Resident #9 to the hospital. On 9/24/24 at 1:53 PM Staff M, CNA stated she was familiar with Resident #9. Staff M stated she worked with Resident #9 the morning of 9/7/24. Staff M stated she walked into Resident #9's room with Staff B, LPN and found Resident #9 on the floor. Staff M stated there was blood on her head but was not bleeding very bad at all at that time. Staff M stated some of the blood was dry and some of the blood was wet and appeared with all the tissues that Resident #9 attempted to clean herself up. Staff M stated the call light was on her bed. Staff M stated she did not round on rooms that morning. Staff M stated she had not opened Resident #9's door or entered her room that day at all. Staff M stated Resident #9 was alert and not confused at all. Staff M stated Resident #9 stated she had been on the floor bleeding for a while. Staff M stated Resident #9 stated she fell at night and she had been yelling for help since. Staff M stated she did not hear Resident #9 yelling for help when she entered the room either. Staff M stated the facility was very short staffed and she works every Saturday and it is not enough staff with showers and the behaviors with most of the residents. Staff M stated the residents are not being properly cared for. Staff M stated some baths are completed in the afternoon. On 9/24/24 at 11:40 AM the Director of Nursing (DON) stated a CNA had not entered Resident #9's room from 3:30 AM till 8:30 AM when the resident was found. The DON stated she did the fall scene investigation. The DON stated she expected rounds would have been completed around 4:30 AM and at shift change at 6:00 AM. Stated change of shift rounds were being completed starting after the fall but was because of a lot of things. The DON stated what the facility would like is hourly rounding. Stated the facility's expectation would be rounding every 2 hours. The DON stated she would like to staff at least one more CNA on dayshift. The DON stated she had seen all of the nursing staff go out for cigarette breaks together. The DON stated the Administrator was aware of the nursing staff all taking breaks together. On 9/24/24 at 12:40 PM the Administrator stated she was familiar with the Resident #9. The Administrator stated there was no checks on Resident #9 between 3:30 AM and 8:30 AM the morning of the fall. The Administrator stated she would have absolutely expected an observation of the resident in-between these times. The Administrator stated the facility had implemented walking rounds to be completed with oncoming shifts. The Administrator stated she did not know how long Resident #9 had been on the floor in her room. The Administrator stated the blood was not dry. The Administrator stated she felt there was enough staff to provide appropriate care to the residents. The Administrator stated it had never been brought to her attention that all nursing staff is smoking at the same time. On 9/25/24 at 9:04 AM the Administrator stated staffing levels are determined by acuity and budget. The Administrator stated she never feels like there is not enough in the budget for the acuity level at the facility. The Administrator stated the acuity level is determined by the level of assistance the resident requires and treatments the residents need. The Administrator stated she felt the facility does have enough staff to care for the residents appropriately. The Administrator stated she would like some more but it's really hard to find nurses or CNA's. The Administrator stated the facility has ads to try to get more staff at the facility. The Administrator stated there are not a lot of people applying. The Administrator stated the facility is in a rural area and makes it difficult. The Administrator stated the facility does not use agency. The Administrator stated the facility has enough staff so has not been an issue that had to be brought to the corporate level. The Administrator acknowledged the facility had no policy that covered expectations on bed checks or rounds on residents. Review of document titled, Residents [NAME] of Rights with review date of 11/16 documented The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely. Review of document titled, Employee Resource Guide revised 8/24 documented smoking by employees should be limited to designated break times and is allowed only in designated areas and never in the corridors, living rooms, residents ' /patients ' rooms, nurse's stations, kitchen, and storage areas or near any room where oxygen is stored or is being administered. This policy also extends to all tobacco products, e-cigarettes and vaping. Review of undated document titled, Standards of personal Care documented overnight cares include routine rounds to assure safety; meet individual needs for those unable to sleep. 25854 2. During an interview 9.24.24 at 10:24 a.m. Resident #4 indicated he timed his call light on for up to 30 minutes as he used the clock on the wall in his room. After he waited for a lengthy period of time he went to find staff for assistance. The resident felt the facility failed to provide adequate staffing to meet his individual needs. During an interview 9.23.24 at 1:35 p.m. Staff C, Certified Nurse Aide (CNA) confirmed she had not been able to answer resident call lights within 15 minutes when she dealt with an emergent situation. During an interview 9.23.24 at 2:06 p.m. Staff E, CNA confirmed staff failed to answer resident call lights in a timely manner due to staffing issues. During an interview 9.24.24 (time unknown) Staff F, Certified Nursing Assistant (CNA) confirmed she provided baths to the residents scheduled two (2) times a week however there had been times she had been pulled to work the floor as a CNA with provision of direct cares. The staff member indicated 15-16 resident baths/showers had been scheduled every day for an eight (8) hour shift. When scheduled to provide baths her other responsibilities included assistance with meals and laying residents down after meals which took a total of 2-3 hours out of her 8 hour day. The staff member indicated she knew staff failed to provide showers on Saturdays due to staffing. During an interview 9.24.24 (time unknown) Staff F, CNA indicated the facility staffed two (2) CNA's to care for the residents who resided in the front of the building and half (1/2) of those residents required 2 staff assistance so that left the other residents unattended. The facilities Standards of Personal Care (Minimum) policy (not dated) included the following: a. Call lights placed within reach of the resident when n their rooms and answered promptly by staff.

Based on observation and staff interview the facility staff failed to maintain a locked and secured treatment cart for one of two med carts reviewed. The facility identified a census of 45 residents. Findings include An observation 9.22.24 at 12:47 p.m. revealed a treatment cart positioned along the wall in the nurse's station area beside the resident's paper chart rack unlocked and unattended accessible to all residents in the front of the building. During an interview 9.25.24 at 1:20 p.m. the Administrator indicated the facility referred to areas of the building as the front and the back with the back also known as the Chronic Confusion Dementing Illness (CCDI) unit. Additionally, she confirmed 30 residents resided in the front portion of the building. During an interview 9.23.24 at 1:35 p.m. Staff C, Certified Nursing Assistant (CNA) confirmed she observed unlocked, unattended med carts with the drawers left open including the narcotic drawer for any staff, visitors or residents to access. During an interview 9.23.24 at 2:06 p.m. Staff E, CNA confirmed she frequently observed unlocked and unattended medication carts.

Based on observation, record review, facility records, resident, family and staff interviews which determined, the facility failed to identify Resident #1 had a risk of elopement and proceeded to exit the facility on 7/10/2023. The front door alarm system failed to engage and the resident left unwitnessed. The resident attempted to leave the facility on 6/26/2023 by exiting the north door of the facility and on 7/3/2023 was exhibiting behaviors of wanting to leave. The facility identified 7 residents with Wanderguards and are at risk for elopement. This circumstance posed Immediate Jeopardy to the resident health and safety. The facility reported a census of 47 residents. The facility was notified of the Immediate Jeopardy (IJ) on July 26, 2023 at 1:00 p.m. The IJ was removed on July 26, 2023. The Facility Staff removed the Immediate Jeopardy through the following actions: 1. On 7/10/2023, back up alarms were placed on the front door to ensure alarms sound when opened. The door alarm system was also placed into night mode on 7/10/2023, to ensure the door alarms each time opened. The wanderguard remains active in night mode. A wanderguard was placed on Resident #1 on 7/10/2023. On 7/18/2023, the facility made a male bed open in the secure memory unit and Resident #1 was moved into this bed. 2. By 7/11/2023, all facility staff were educated on the missing resident process. An elopement drill was completed on 7/11/2023 with no concerns. By 7/13/2023, all nurses were educated on the door alarm system. 3. On 7/11/2023, all residents were reassessed for elopement risk and elopement book was updated as appropriate. 4. Immediately after the incident on 7/10/2023, [NAME] Healthcare was notified the alarm system malfunction. On 7/12/2023, 7/14/2023 and 7/18/2023, [NAME] Healthcare was onsite to investigate the malfunctioned alarm. They determined a new system will have to be installed. The facility continues with twice daily door alarm checks. 5. The facility initiated ongoing audit of the missing resident process via elopement drills three times weekly on 7/11/2023. There have been no issues identified through these audits. The facility also initiated an audit for door alarm checks three times weekly on 7/11/2023, with no concerns noted. 6. Any concerns will be reported to the administrator immediately and addressed in the Quality Assurance. The scope and severity was lowered from an IJ to and E at the time of the survey after ensuring the plan of correction was put in place and implemented. Observation on 7/25/2023 at 1:00 p.m., the facility administrator and this surveyor went to the front doors of the facility and on the north wall of the inside doors was a [NAME] Wanderguard Departure Alert System, model #0507-234, with a red light underneath the system a solid color. On the top of the frame on the inside doors were two clip/chair pull away alarms. This surveyor opened the inside door and the wanderguard alert system sounded/alarmed and the two pull away clip alarms were activated. This surveyor and administrator proceeded to open up the door to the outside of the facility, the following were observations on the outside of the facility. 1. Uneven side walk for which was slanted down to the road in front of the facility (north state street), with the edges of the side walk missing pieces of cement. 2. The speed limit sign in front of the facility stated 25 miles per hour. 3. Looking to the south of the facility was a orange sign stating Road Closed ahead, with two orange/white striped barricades across the road with a black sign and orange arrow with DETOUR written on it, and gravel in front of the barricades. 4. Looking to the north of the facility was Business Highway 5, with a speed limit sign of 35 miles per hour and a yellow sign with a black curve symbol on it. 5. The facility administrator confirmed and verified that Highway 5 is a busy highway for which there is lots of heavy traffic. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) quarterly assessment with a reference date of 6/29/2023 that documented Resident #1 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment. A score of 4 identified severely impaired cognition and decision making abilities. The MDS identified Resident #1 as limited assistance of one for transfers, walking in room and/or corridor, locomotion on and off the unit and a walker or wheelchair (WC) are used for mobility. The residents diagnoses included Alzheimer's Disease, Non-Alzheimer's dementia, asthma, respiratory failure, repeated falls and osteoarthritis of the knee. Review of Resident #1 Care Plan included the following: Activities of Daily Living (ADL) deficit due to my dementia, and Potential for Behavior/Altered Coping related to: altered mentation and desire to return home at time of admission. Interventions include: * I need assist of 1 for transfers * I need assist of 1 for locomotion * I need assist of 1, walker and gait belt or I use my WC * I use a walker/cane/wc for mobility. * Increased supervision as needed * Provide 1:1 activities as needed * Redirection as indicated Progress notes dated 7/16/2023 at 6:55 p.m., documented, Note Text: Resident attempted to get out of north door. This nurse stopped resident in which resident states you have no authority to keep me here! When this nurse explains why resident is here he states you're a god damn liar! get the police here to get me home!. This nurse was able to get resident back to nurses station to by telling him to call his son. He is now talking to his son and seems quite upset. Progress notes dated 7/10/2023 at 8:38 p.m., documented, Note Text: Resident back in facility accompanied by girl friend via personal vehicle. Head to toe assessment completed at this time. Wanderguard activated and applied to residents left wrist. 15 minute checks initiated. Progress notes dated 7/10/2023 at 8:20 p.m., documented, Note Text: Call received from Residents girl friend stating that Resident #1 was dropped off by a black SUV at her house. This nurse explained that staff was unaware of resident getting outside and has not stated anything about wanting to leave facility. Girl friend states she will bring him back to facility. Call placed to on call provider to inform of situation. Call placed to administrator. Progress notes dated 7/10/2023 at 7:33 p.m., documented Note Text: Resident has been up in dining area asking this nurse to call a certain phone number for him stating that it's a friends number. This nurse dialed number and automated system stated phone is no longer in service. This nurse explained this to resident when he asked to have that number dialed again. Resident is not directable at this time and is hyperfocused on that calling that number. This has continued since 6:00 p.m., when this nurse arrived for this shift. Progress notes dated 7/3/2023 at 2:50 p.m., documented, Behavior Note: for approximately hour after lunch resident up and down halls talking about leaving and trying to make multiple calls to same person. Progress notes dated 6/26/2023 at 8:45 p.m., documented, Health Status Note Text: Resident still at nurses station at this time arguing that he needs to leave. Resident family calling at this time and states resident called them and stated he was outside and was being locked out of the building. This nurse explained that at no time was resident outside of the building, but has been upset that we will not let him leave. Did explain to family that resident did open door to leave, but did not leave the facility. Family not wanting to talk to resident at this time, but seeked clarification. Progress notes dated 6/26/2023 at 8:40 p.m., documented, Health Status Note Text: Resident attempted to exit north side door and difficult to redirect. Resident states I have to get home! Let me leave! Resident assisted into w/c and assisted back to nurses station. Staff explained to resident that this is the nursing home and that he lives here. Resident denies this and states he will call the law if we don't let him out. Interview on 7/25/23 at 4:15 p.m., Staff C, Registered Nurse (RN), confirmed and verified that on 7/10/23, Resident #1 was propelling himself up and down the hallway when Staff C got to work at 6:00 p.m., and that the day shift staff explained that Resident #1 was on his roll again wanting to know why he was here. Staff C, kept a continues eye on Resident #1 during the supper meal and then while the staff were putting residents to bed for which Resident #1 was sitting underneath the television in the dining room and appeared to be sleeping. About 7:40 p.m., staff came and told Staff C that one of the resident had a catheter that was not draining properly and if the nurse could come and check it out. Staff C stated that Resident #1 was still sitting underneath the television in his w/c and that he looked like he was sleeping, Staff C, went down the hallway to the resident room to check on the catheter. Staff C, came back to the nurses station and seen that Resident #1 had moved a little in his w/c from underneath the television. Resident #1 appeared to be calm and content. Staff C went into the nurses supply room to get supplies to flush the catheter and laid eyes on Resident #1 who was still sitting in the w/c. Around 8:00 p.m., Staff C, came out of the resident room walked up to the nurses station to put the supplies away and noticed that Resident #1 was not in the dining room under the TV and no w/c. Staff C, started to walk down the hallway to Resident #1 room when the telephone rang. Staff C answered the telephone, it was Resident #1 girl friend, stating that she had Resident #1 in her car and if she can bring the resident back to the facility. Staff C went to the front inside doors and walked through them and the alarms did not sound. Staff C, stated that the resident returned to the facility around 8:40 p.m. Staff C, called the facility administrator who got to the facility between 8:50 p.m.-9:00 p.m., and placed two extra alarms on the top of the door frame to alert staff that someone was leaving or entering. Interview on 7/25/23 at 4:55 p.m., Resident #1 girlfriend explained that while watching television on 7/10/23, headlights appeared in the drive way around 8:30 p.m., she got up and proceeded to go out to the driveway and by the time she got out to the driveway, a black SUV had already assisted Resident #1 out of the vehicle and was backing out of the drive way and Resident #1 was in his wheelchair. The girl friend went and assisted Resident #1 in her vehicle, proceed to call the facility and returned Resident #1 to the facility. Interview on 7/25/23 at 11:20 a.m., the facility administrator explained that on 7/10/23, she got a telephone call from Staff C, RN around 8:40 p.m., that Resident #1, girl friend was bringing back the resident to the facility, that a couple in a black SUV came up into the girl friends drive way and assisted the resident out of the vehicle, put the resident into his w/c and then left. The administrator got to the facility between 8:50-9:00 p.m., went to the inside door of the facility and it was beeping and the light was flashing orange (for which means the alarm is not in activation mode). The administrator put in the code to reset the alarm and the light on the wanderguard system went to red, for which meant it was activated, for extra safety measures two clip/chair alarms were put on the frame on top of the front doors to ensure that the door alarms sounded if opened again. Interview on 7/26/23 at 9:15 a.m., Staff A, Certified Nurses Aide (CNA) and Staff B, CNA, confirmed and verified that on 7/11/23 at 6:00 a.m., they both came to work and the front door wanderguard alarm system was beeping and they stated that every once in a while when the generator or a surge would happen the alarm system would beep and that would signal that the wanderguard alert system needed to be reset, so they went over to the alarm and unplugged the system from behind the desk, waited a few seconds and plugged the alarm system back in and entered the code and the alarm system light went to a solid green, letting them know that the alarm system was activated. They confirmed and verified that the alarm system will continue to beep until you put in the code or unplug the alarm system to reactivate the wanderguard alert system. Interview on 8/1/23 at 11:00 a.m., Resident #1 denied leaving the facility at anytime and that if he did leave the facility he would of remembered being outside. Interview on 7/26/23 at 1:30 p.m., the facility administrator stated that the facility lacked a policy/procedure on how often to check the door alarms to make sure they function, but the expectation is for the staff to check the door alarms every shift and document on the Monthly Door Alarm log.

Based on clinical record review, hospital record review and staff interviews, the facility failed ensure staff followed safety interventions for 1 of 3 residents reviewed for falls (Resident #1). This resulted in harm to Resident #1 who suffered a traumatic fall leading to hospitalization . Resident #1 died 4 days following the fall. Findings include: The Minimum Data Set (MDS) of Resident #1 dated [DATE] documented the resident discharged to an acute care hospital as an unplanned discharge. The MDS revealed the resident required extensive assistance for transfers and did not walk. The MDS documented diagnoses that included Alzheimer ' s disease, dementia with behavioral disturbance and cerebrovascular disease. The MDS recorded the resident sustained a major injury related to a fall since the prior MDS assessment. The Care Plan updated [DATE] revealed the resident at high risk for falls related to confusion, psychoactive drug use and unawareness of safety needs. The Care Plan directed staff Resident #1 was to be the first resident to be assisted after meals to bed or recliner and the last one up prior to meals. The Fall Risk assessment dated [DATE] documented the resident scored a 23, indicating him to be at high risk for falls. The Progress Notes dated [DATE] at 3:39 pm documented the resident was in his room and was heard to call out. The Progress Notes further documented the resident was found lying on his left side with blood under his face. Upon assessment, the resident was observed to have three lacerations above his left eyebrow and two on his left temple. The resident was sent to the emergency room for evaluation and treatment. Trauma Surgeon Progress Notes dated [DATE] at 9:21 pm identified the resident as having presented to the hospital following an unwitnessed fall from a wheelchair found to have intracranial bleeding (bleeding inside the skull). The Note stated the resident had a poor prognosis with an injury that posed a direct threat to his life. A Surgery Progress Note dated [DATE] 11:51 pm Medical alert called to Intensive Care Unit room for destaurations and apnea. Upon arrival to the room, patient has agonal breathing, approximately ,d+[DATE] respirations a minute. Respiratory therapy was present and had placed a bite-block and was successfully bag-value-mask the patient with adequate saturations. Patient is nonresponsive, however this is not far off from the patients baseline on evaluation roughly ,d+[DATE] hours prior. We are aware that there has been interval increase in size of this hemorrhage. However, through conversation with neurosurgery, it is unlikely that this is a salvageable situation with any procedure. A computed tomography scan (CT scan) of the head on [DATE] at 10:05 pm noted a prior exam performed on [DATE]. In comparison, the CT scan noted an increase in a right parietal-occipital intraparenchymal hematoma (bleeding in the brain) from the prior exam and a large amount of intraventricular hemorrhage (bleeding around the ventricles of the brain) now present. The Physician Discharge Summary dated [DATE] documented the resident had active diagnoses in the hospital of fall and intraparenchymal hemorrhage of the brain. The Discharge Summary documented the resident passed away in the hospital on [DATE]. Hospital Progress Notes dated [DATE] at 11:36 am documented the direct cause of death the Resident #1 was respiratory depression and hypoxia likely secondary to traumatic intracranial hemorrhage which occurred as a result of fall. On [DATE] at 10:30 am, Staff C, Certified Nurse Aide (CNA) stated she and Staff, D, CNA provided cares for Resident #1 on [DATE] prior to his fall. She stated he was in bed, and she and Staff D provided incontinence cares and transferred him to his wheelchair. She said when cares were complete, they left him in his wheelchair in the doorway of his room. She stated there were still other residents they were getting up for dinner and went to another room. A few minutes later a nurse heard the resident call out and he was found on the floor of his room in front of his window. His wheelchair was backed against the wall as if he had pushed himself from the doorway straight back into the room. Staff C stated she carries a pocket care plan when on duty identifying fall interventions. On [DATE] at 10:34 am Staff D, CNA, stated on [DATE] she and Staff C assisted Resident #1 to get ready to go to dinner. She stated he was pushed in his wheelchair to the doorway of his room and she and Staff C proceeded to the room across the hallway to get another resident ready for dinner. She said approximately 5 minutes later the nurse heard the resident calling out and she called for Staff C and Staff D to assist. The resident was in his room near his dresser and it appeared he had propelled himself backwards in his wheelchair and fell over. She stated on the Resident Information Sheet (pocket care guide) safety interventions are listed on the right side of the paper. On [DATE] at 11:34 am via an email, the Administrator stated the facility does not have a policy regarding following care plan interventions. She stated they follow the standards of care related to this. On [DATE] at 11:57 am, the Regional Clinical Reimbursement Specialist stated her expectation is that all staff, regardless of appointment in the facility, would have knowledge of reading the care plan resident information sheet and abide by the safety standards to keep the residents safe.

Based on observations, clinical record reviews, staff and a Nurse Practioner (NP) interview, and facility policy review the facility failed to provide the necessary assessments for 1 of 4 residents reviewed for an acute/chronic illness. (Resident #3) The facility identified a census of 48 residents. Findings include: A Admission Minimum Data Set (MDS) assessment form dated 6/14/22 documented Resident #2 as admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented the resident without a Brief Interview for Mental Status (BIMS) score (not able to assess cognitive status based on this scale), with continuous inattention and with verbal, rejection of cares and other behaviors 1-3 days in the look-back period of (7 days). The assessment documented the resident required limited assistance of two (2) staff members with personal hygiene. Review of the facilities Progress Notes included the following documentation: a. 6/7/22 at 11:40 a.m. - Admission assessment: Ear status not addressed. b. 6/7/22 at 12:21 p.m. - Late entry: The resident arrived at the facility at 11:40 a.m. c. 6/7/22 at 3:10 p.m. - Late entry: Spoke with Newton West facility who described the resident with an ongoing issue with his right ear and green drainage. He had been on an antibiotic ear drops and oral antibiotics on the off of an undisclosed amount of time. d. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] e. 6/13/22 at 5:06 a.m. - The resident with a moderate amount of thick, green, and purulent drainage out of his right ear which he denied pain (the resident is cognitively impaired). f. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] g. 6/17/22 - A Note Text Form documented: Noted on rounds the resident with a moderate amount of bleeding and green drainage from inside his right ear. Resident denied any pain or ringing in ear. A Physician's Progress Notes form dated 6/17/22 at 10:30 a.m. documented the resident as seen for maggots in/on his external auricle(outer ear) and possibly inside his ear. A Physician's Progress Note form dated 6/18/22 at 5 p.m. documented the resident's right ear as red, hot, swollen, tender with copious (abundant supply) of purulent discharge and maggots in the ear canal. A Physician's Progress Note form dated 6/18/22 at 5:47 p.m. documented the resident's right ear as follows: a. Severe soft tissue [CONDITION(S)] (bacterial skin infection) of the right ear with subcutaneous gas (air became trapped in the tissue beneath the skin) . A large cavitory lesion (injury) with an air-fluid level which replaced the right external auditory canal measured up to 3 centimeters (cm). That finding appeared concerned for an abscess (a swollen area within the body tissue that contained an accumulation of pus). b. Evidence of [CONDITION(S)] (bone infection) with multiple areas of osseous (area turned to bone) destruction which predominantly involved the right external auditory canal. Osseous erosion/destruction of the mastoid (bony projection from the posterior section of the temporal bone) segment of the right temporal bone and the posterior floor of the right middle cranial fossa (shallow depression and/or hollow). c. Abnormal [NAME] enhancement involved the right middle cranial fossa which raised concern for meningitis ([CONDITION(S)] or bacterial infection). An Order Summary Report form dated 6/22/22 at 2:49 p.m. documented the resident received a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Order Summary Report form also documented the resident as on Augmenting 875-125 milligrams (mgs) one (1) tablet by mouth BID for an ear infection dated 6/17/22 thru 6/26/22 at 11:59 p.m. An Encounter Psych Progress Note dated 7/15/22 at 10:23 a.m. documented the resident as transferred from Accura Newton West in June and hospitalized 11 days after admission for an ear infection. Maggots were found in his ear and invasive undifferentiated [CONDITION(S)] of his right ear diagnosed . According to an email dated 9/16/22 at 12:52 p.m. the resident's Nurse Practitioner documented she expected facility staff to have assessed the resident's ear at least daily once the drainage was reported on 8/13/22 and the area could not have been prevented as the cancer had been most likely grown long before any signs were visible. According to a text message received 9/27/22 at 10:54 a.m. from the facilities Director of Nursing (DON) the NP text her a clarification of her note and documented she meant to say 6/13/22 on the above email rather than 8/13/22.

Based on observation, record review and interviews, the facility failed to provide care and services to prevent the development of a pressure sore for 1 of 5 residents at risk for pressure ulcer development (Resident#4). The facility lacked assessments from 3/22/22 to 4/5/22 of a pressure sore on Resident #4's coccyx (tailbone). The area began as a purple, unopened, nickel to quarter-sized unopened area on 3/22/22. Facility staff assessed the area on 4/6/22, and by 4/13/22 the facility transferred Resident #4 to the hospital where the resident was diagnosed with [CONDITION(S)] secondary to an infected, unstageable, full thickness pressure sore that measured approximately 6 centimeters by 4 centimeters. The wound bed area contained black tissue and was tunneling (a wound that formed tunnels underneath the surface of the skin in Stage 3 or Stage 4 pressure ulcers). These circumstances constituted an Immediate Jeopardy to resident health and safety. The facility reported a census of 41 residents. Findings include: The Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident#4 had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also documented that the resident as at risk of pressure sore development but had no skin concerns during the lookback period. The MDS revealed Resident #4 required extensive assist of two staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene, was always incontinent of urine and was frequently incontinent of bowel. The MDS identified the definition of pressure ulcers: Stage I as intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II with partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. The Braden Scale for Predicting Pressure Sore Risk dated 11/21/22 documented the resident as at high risk for pressure sores. The Care Plan revised 1/15/22 identified Resident #4 had a potential for impaired skin integrity (such as a risk for development of pressure area related to immobility and poor nutrition) in addition to a risk for moisture associated damage related to incontinence. The care plan contained a goal revised on 3/18/22: the resident will maintain or develop clean and intact skin. On 4/26/22 at 12:34 p.m. Staff U, Certified Nursing Assistant (CNA) reported staff had transferred Resident #4 with an EZ-Stand until it broke; then staff transferred her with the Hoyer lift. Staff U stated the resident liked to sit in her recliner, but when the EZ-stand broke the staff would transfer her to bed so they could check her for incontinence and then change her as needed. Staff U recalled that a couple of weeks before 3/31/22, she noticed a quarter-sized, bright red, bloody open area on Resident #4's coccyx when she provided incontinence care. Staff U also recalled she had worked with Staff P, CNA that day and they had reported the open area to Staff X, Licensed Practical Nurse (LPN) at that time. On 4/21/22 at 1:49 p.m. Staff V, CNA reported that Resident#4 had anxiety about Hoyer lift transfers required education about the importance of skin care. Staff V reported she first saw a dime-sized, bruised, purple and blue area on Resident #4's coccyx during the weekend of 3/11/22 when she worked with Staff U, CNA and Staff Z, Certified Medication Aid (CMA). On 4/20/22 at 5:09 p.m. Staff W, CNA reported she had provided showers on day shift. She stated the day the staff notified the wound nurse (Staff I, RN) regarding the open area on the resident's coccyx, Staff I reported she had not known about the area (on 4/6/22). Staff W commented you could not have missed it - it had grown to the size of a tennis ball by the time the nurses had notified the wound nurse. Staff W reported she had not documented the area on the shower sheets because other staff told her the nurses were already aware of the area and added if the area was not new, then she did not have to document it on the shower sheet. Staff W stated she had just recently been told to continue to put the skin problems on the shower sheet until the area resolved. On 4/21/22 at 10:17 a.m. Staff W, CNA reported she first saw a quarter-sized, purple area on the resident's coccyx that was not open on 3/22/22. On 4/20/22 at 5:10 p.m. Staff P, CNA reported that on 3/6/22, the resident had a purple area about the size of a nickel on her coccyx. Staff P reported that Staff U, CNA had also reported the area to nurses on 3/6/22 and she and Staff U reported the area to nurses around 3/11/22. She added that on 4/13/22, the day Resident #4 went to the hospital, she saw the resident's coccyx area and it was black with tunneling and it had smelled really bad in the residents' room. On 4/21/22 at 10:24 a.m. Staff P, CNA reported that the resident had a quarter-sized, red, irritated area on her coccyx on about 3/20/22 to 3/26/22. Staff P reported that other CNA's had reported it to the nurses before that date. On 4/26/22 at 8:20 p.m. Staff Z, CMA reported that on 4/6/22, two staff members had reported a black, draining area on the resident's coccyx to her. Staff Z said she then notified Staff I, RN (wound nurse) and Staff AA, RN about the area. On 4/20/22 at 4:48 p.m. Staff A, LPN reported that on 4/6/22 Staff P, CNA and Staff W, CNA reported a skin concern on Resident #4's coccyx area. Staff A reported she had assessed the area, completed an initial assessment of the pressure area, called the doctor, and then notified Resident #4's contact person. Staff A added that it had been the first time she had been aware that the resident had anything on her coccyx and she was pretty shocked to see it - it did not happen overnight. On 4/21/22 at 9:26 a.m. Staff I, RN (former interim Director of Nursing, and wound nurse) reported that on 4/6/22 staff first notified her that Resident #1 had a wound on her coccyx. Staff I stated Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff I also reported the facility sent the resident to the hospital on 4/13/22 for low blood pressure and possible [CONDITION(S)]. Staff I described the pressure ulcer on Resident #1's coccyx area as an unstageable pressure sore with black eschar (a dark, dry, scab or falling-away of dead skin) with pink surrounding tissue and no tunneling at first. On 4/21/22 at 9:09 a.m. Staff X, LPN reported that if a CNA finds a skin issue they should tell the nurse. Staff X said there are shower sheets that contained a place for CNA's to document skin issues; the nurse will then look at the documentation and sign off on it. Staff X reported staff should document a new skin concern on a Note Assessment Risk Management Form in Point Click Care (PCC), fax the physician, and notify the wound nurse so the wound nurse could complete weekly assessments. Staff X reported she had completed the treatment to that wound and commented was not sure how it could have been missed. Staff X described the area as a black, tennis ball-sized area with foul-smelling drainage. On 5/3/22 at 2:45 p.m. the Director of Nursing (DON) reported that all staff should report any kind of skin issue to the nurse on the floor as soon as possible. On 5/3/22 at 3:26 p.m. Staff Y, Nurse Practitioner reported the DON first notified her of Resident #4's pressure sore on 4/8/22 via phone video. On 5/4/22 at 12:12 p.m. Staff Y, reported the wound center had a goal to heal the resident's coccyx wound to the point that the resident could have skin flap surgery to repair the area (flap surgery involves a piece of tissue that still receives blood supply because it's attached to the body by a major artery and vein or at its base. This piece of donor tissue is used in reconstructive surgery by being set into the injured area). A Skin Sheet- Ulcer Assessment (SSUA) dated 4/6/22 at 3:54 p.m. documented Resident #4 had a new, in-house pressure area described as a macerated area that measured 9 centimeters (cm) long by 4.5 cm wide that contained a black area of 6 cm by 3 cm with a pink and macerated outer area. Health Status Note dated 4/13/22 at 2:28 p.m. documented Resident #4 had vital signs this morning as follows: blood pressure 88/52, temperature 98.5 degrees Fahrenheit, pulse 118, respirations 20. Staff Y, Nurse Practitioner saw the vitals and ordered staff to transfer the resident to the emergency room for evaluation for possible [CONDITION(S)]. Staff transferred the resident via ambulance to the local hospital. A History and Physical-Consultation dated 4/14/22 from a large, metropolitan hospital documented Resident #4 seen in their local hospital emergency room then transferred to this hospital for evaluation by the surgery service who determined she had a large, full-thickness, decubitus ulcer with necrotic debris. The service recommended aggressive debridement and ultimately plastic surgery consultation for flap closure. A swab culture was obtained and deemed positive, so the resident had been put on intravenous antibiotics. The resident had presented with [CONDITION(S)] syndrome secondary to the infected decubitus. The large sacral wound approximately 6 centimeters by 4 centimeters tunneling eschar tissue of the wound bed. Observation on 4/25/22 at 3:15 p.m. revealed Staff T, LPN provided the ordered wound treatment to the large sacral wound with the approximate size of a softball that involved packing to the wound bed. On 4/25/22 at 3:15 p.m. Staff T, LPN reported that it had been their first observation of Resident #4's wound after the necrotic wound was debrided (when a doctor removed dead tissue to help the wound heal) at the hospital. Staff T reported she would classify the wound as a Stage 4 pressure wound and verified the current treatment order: Ascetic Acid dressing changes twice daily. Final Report Consultation from the wound treatment center dated 4/30/22 documented Resident #4 had surgical debridement of the wound on 4/15/22 with necrosis noted down to the level of the bone. The surgical report dated 4/15/22 documented surgical post-op debridement measurements of 8 cm long by 6 cm wide by 3.5 cm deep with debridement to the muscle and fascia. The Final Report dated 4/30/22 also contained a measurement for 4/28/22: length 7.3 centimeters, width 3.5 centimeters, and depth 5.0 centimeters. The Skin Management Protocol dated 10/14/211 directed facility staff to act in accordance with the Wound Notification Standards: 1. Notify the director of nursing and wound nurse of new skin alteration or skin ulcer 2. Complete incident report in risk management and skin sheet (non-ulcer or ulcer assessment) 3. All skin sheets, non-ulcer or ulcer assessment will be updated weekly in point click care in the assessment tab by designated wound nurse 4. The community will report to the physician if there is any deterioration or signs of infection is observed. 5. The community must remove a mechanical lift sling once transfer is completed. Slings may not be left under a resident at any time when not actively transferring. The Treatment Administration Record (TAR) dated 3/1/22 to 3/31/22 directed staff to apply [MEDICATION(S)] Ointment to Resident #4's buttocks topically every 24 hours as needed for skin breakdown prevention, beginning 8/10/21. The TAR lacked any documentation to show staff had applied the ointment to assist with prevention of skin breakdown. An Immediate Jeopardy (IJ) was identified on 4/21/22 and the facility was notified of the IJ at 1:00 PM that day. The IJ was removed on 4/22/22 when the facility developed and implemented the following corrective action plan: a. Head-to-toe assessments will be completed for all residents b. The facility will ensure any skin issues identified are assessed and treated as appropriate c. All nursing staff will be educated on the process of notifying charge nurses of any new or changing skin issues identified during routine cares. d. All charge nurses will be educated on the facility's process for assessing and treating any new or changing skin issues. e. The facility will initiate an ongoing audit on appropriate identification and reporting of new or changing skin conditions, as well as an audit on proper assessment and intervention by the charge nurse. Any concerns will be reported to the administrator immediately and addressed in the facility quality assurance process. The scope and severity level of the IJ deficiency was lowered from a J to an E at the time of the survey due to the need for continued monitoring after ensuring the facility educated staff regarding their policies and procedures related to identification and assessment of wounds.

Based on clinical record review, incident report, and staff interviews, the facility failed to ensure that staff placed foot pedals on a resident's wheelchair prior to pushing them from location to location for 1 of 6 residents reviewed (Resident #3). The facility staff transported a resident in a wheelchair without foot pedals to secure and protect her feet. The resident subsequently fell out of the wheelchair and sustained an injury that required transfer to a higher level of care for evaluation. The facility reported a census of 41. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had diagnosis of [CONDITION(S)] ([CONDITION(S)]) (stroke), dementia, [CONDITION(S)] (paralysis on one side of the body), anxiety disorder, depression, and psychotic disorder. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 7, indicating severely impaired cognition. The MDS documented the resident required limited assistance of one staff for locomotion on and off the unit, and used a wheelchair for mobility. Resident #3's care plan revised 1/16/22 revealed the resident had an ADL (activities of daily living) self-care deficit and a fall with injury. The care plan directives included the resident used a wheelchair for mobility and propelled herself with her legs. The care plan documented the resident was sent to the emergency room for evaluation and had head, spine and hip x-rays. An intervention included staff educated to ensure wheelchair steps in place whenever traveled with the resident (initiated on 3/28/22). An incident report dated 3/24/22 at 9:15 PM completed by Staff S, Licensed Practical Nurse (LPN), revealed Resident #3 pushed in wheelchair to her room by staff and she fell out of the wheelchair face down onto the carpeted hallway. Resident found on her stomach with her left arm up under her. The resident cried and yelled out saying her arm hurt. A purple and red bruise measured 7 centimeters (cm) by 9 cm around her left eye and a hematoma measured 2 cm by 5 cm on the left side of her forehead. 911 called. Neurological checks within normal limits (WNL). Ambulance arrived at 9:30 PM. Resident returned at 2:05 AM (on 3/25/22). CT (Cat) scan of head and spine, and hip x-ray negative. Progress note dated 3/25/22 at 2:42 PM revealed Resident #3 pushed to her room in a wheelchair by staff and the resident fell out of the wheelchair face down onto the carpeted hallway. Staff nursing assistant notified Staff S, Licensed Practical Nurse (LPN). Staff S documented she found resident on her stomach with her left arm up under her. The resident cried and yelled out saying her arm hurt and Staff S noted a bruise noted around Resident #3's left eye and a hematoma on left side of her forehead. Staff called 911 and initiated neurological checks and found them within normal limits. The ambulance arrived at 9:30 PM (on 3/24/22). Resident #3 returned to facility at 2:05 AM. A CT (cat) scan of the head and spine, and a hip x-ray were all negative. An emergency department (ED) physician's note dated 3/24/22 at 10:23 PM revealed Resident #3 presented to the ED from the care facility after a fall and concern for bruising on her forehead and around her left eye, and abrasions around the bruising and swelling around the left eye. The resident propelled in wheelchair, fell forward, and hit her head. The fall was witnessed and she had no loss of consciousness. The ED physician documented CT head and x-rays negative, Resident #3 discharged on [DATE] at 12:19 AM to the care facility. Skin sheet assessment dated [DATE] at 10:11 AM revealed purple bruising above the left eye measured 5 cm by 4.7 cm by 0 cm, and an abrasion 4 cm by 2 cm above the left eye first observed on 3/24/22. A skin sheet assessment dated [DATE] at 10:17 AM documented an abrasion 2 cm by 4 cm x 0 cm below the left eye first observed on 3/24/22. A telehealth psychiatric progress note dated 4/1/22 revealed the resident recently fell forward out of her wheelchair onto her face. Although she sustained no serious injury, the resident had severe bruising on her upper face, eyes, and forehead and her face still looked badly bruised. A staff person said the resident got upset and cried if anyone mentioned anything about her accident. In an interview 4/26/22 at 4:05 PM, Staff S, LPN, reported Resident #3 propelled herself in the wheelchair. The resident sometimes had behaviors and became dramatic. Staff S recalled Staff B, TNA (nursing assistant in training), came to her and said the resident had fallen out of the wheelchair. She walked down the hallway and found the resident on the floor. The TNA told her she pushed the resident in the wheelchair. She checked the resident. Since the resident could be dramatic and she wasn't sure if what she said was legitimate, she took the resident's word that she hurt as the resident had a bruise on the left side of her face and complained that her left shoulder hurt. She sent the resident to the ED and the x-rays showed no fracture. In an interview 4/26/22 at 4:15 PM, Staff B, TNA, reported she worked at the facility for 3 months. Resident #3 usually sat in her wheelchair in the hallway after supper. Staff B reported she pushed the resident in her wheelchair to her room but the wheelchair had no foot pedals on. The resident slid her feet on the floor as she pushed the wheelchair down the hall. Staff B reported she stopped and asked the resident not to slide her feet along the floor and to pick her feet up as she pushed the wheelchair. Staff B reported she resumed pushing the resident in the wheelchair and the resident went face first out of her wheelchair and landed on the floor in the hallway. Staff B stated she went and got the nurse and told her what happened. The nurse then contacted the hospital and sent the resident to the hospital to get checked. In an interview 5/3/22 at 9:45 AM, Staff N, Nurse Specialist, reported the facility had no policy or competency for transporting residents in wheelchairs. The facility followed standards of care, which meant whenever a resident pushed or transported in a wheelchair, the wheelchair needed wheelchair pedals on or the resident needed to propel themselves in the wheelchair. In an interview 5/3/22 at 2:45 PM, the Director of Nursing (DON) reported she expected staff to place foot pedals on the wheelchair whenever the staff pushed a resident in the wheelchair. If a resident wanted staff to push them in the wheelchair, the wheelchair needed to contain foot pedals.

Based on observations, record review and interviews, the facility failed to provide adequate supervision to prevent accidents for 4 of 4 residents reviewed for smoking, falls and elopement (Residents #9, #22, #26 and #29). The facility failed to assess resident for Resident #9 and #22 for safe smoking, allowed Resident #9 to carry smoking material on her person, allowed Resident #9 to smoke unsupervised, and allowed resident #9 and #22 to smoke in an unsafe environment. The facility failed to utilize a gait belt and front wheeled walker during ambulation for 1 of 3 residents reviewed for falls (Resident #26) which resulted in a femur fracture. The facility failed to provide adequate door alarm system to mitigate Resident #29's elopement. The door alarm contained modes to be set, one of which prevented the alarms from being activated at all times. On 10/14/21 at 1:30 a.m., Resident #29 eloped out the front door. At 2:40 a.m., staff found Resident #29 outside on the ground. This resulted in Immediate Jeopardy to the residents' health and safety. The facility identified 8 residents who demonstrated independent mobility and wandered on 10/14/21. Resident #29 was not one of the 8 residents identified by the facility. The facility reported a census of 43. Findings include: 1. SMOKING The MDS assessment tool, dated 9/28/21, listed Resident #9's BIMS as 14, out of 15, indicating intact cognition. Resident #9 had a diagnosis of asthma or [CONDITION(S)] ([CONDITION(S)]), oxygen dependent and incontinence. Resident #9 is independent with bed mobility, transfers, and toileting; she requires set up assistance with eating. She is at risk for pressure ulcers. Clinical Record review of Care Plan, dated 10/11/21, revealed Resident #9, smokes on scheduled staff supervised smoke breaks and will go outside unsupervised to smoke. The Care Plan failed to address resident safety for independently smoking and the possessions of cigarettes and lighter quarterly and annually. Facility policy titled, Safe Smoking Policy, with the following dates of 12/28/12, 1/7/13, 8/7/14, 10/29/14, and 2/3/15 indicate Resident #9 is able to smoke independently. The policies failed to document Resident #9 cigarettes and lighter kept in her possession. During an interview on 12/13/21 at 11:00 a.m., with Resident #9 revealed, she is able to smoke outside independently anytime and does not follow the posted smoking breaks the other residents follow. During an observation on 12/15/21 at 10:13 a.m., Resident #9 demonstrated a cigarette case with four cigarettes and lighter in her possession. Resident #9 stated she was unsure if she signed a facility smoking consent or not. During an observation on 12/15/21 at 10:30 a.m., Resident #9 exited the facility to the courtyard covered in leaves. A pile of leaves by the door was approximately 2 feet in depth and within the cigarette butts receptacle. Resident #9 stated the leaves have been present for the past 1-2 years. During an interview on 12/21/21 at 11:13 a.m., with Assistant Director of Nursing (ADON) revealed Resident #9 may keep her cigarettes and lighter with her, documented on her smoking assessment. ADON stated Resident #9 might smoke at any time. ADON stated she did not know who was responsible to pick up leaves. 2. SMOKING The annual MDS dated [DATE] for Resident #22 reported a BIMS score of 7 which indicated sever cognitive impairment. The MDS documented diagnoses of non- Alzheimer's Dementia, asthma, [CONDITION(S)] or chronic lung disease and [MEDICATION(S)] dependence (cigarettes). The MDS failed to document resident as a current tobacco user. Resident #22's Care Plan dated 11/16/20 included focus area of ADL (Activities of Daily Living) self-care deficit and potential respiratory abnormalities related to [MEDICATION(S)] dependence. Included interventions for smoker and go out for routine smoking times with supervision from staff and cigarettes and lighter are stored with the nursing staff. The Care Plan also included an area of confusion due to dementia, amnesia, symbolic dysfunction and mild cognitive impairment and directed staff to monitor behavior and redirect as needed. The last documented Smoking assessment dated [DATE] for Resident #22 included she had a cognitive loss, she smoked 2-5 times a day, she needed supervision and could not light her own cigarette and the facility stored her cigarettes and lighter. The facility failed to update the Smoking Assessment with the annual MDS. Observations revealed on 12/13/21 at 3:16 PM Resident #22 standing in the lobby to go outside to smoke. At 3:29 PM staff took residents out to smoke. Resident # 22 sitting in a chair spaced out 1 resident with apron on it. Staff have a lock box with the cigarettes in it. Area full of leaves by the fence and within feet of the red smoking receptacle. Observation on 12/14/21 at 9:42 AM, revealed the smoking area had fallen leaves swept off the patio area but piled up along the fence only about 3 feet from the red receptacle. During an interview on 12/27/21 at 1:44 PM with Staff A, Nurse Consultant, thought maintenance would be responsible for keeping the leaves out of the smoking area. During an interview on 12/27/21at 2:03 PM Staff G Maintenance stated he thought he was responsible for making sure the leaves were out of the smoking courtyard. He stated he had not moved any leaves for some time. The undated Resident Smoking Policy included the following: a. Smoking inside the facility is expressly prohibited. b. This policy applies to cigarettes, cigars, pipes and/or any other materials that requires fire. This also includes electronic or vapor cigarettes. c. A smoking evaluation with care plan interventions addressing safety issues must be completed upon admission quarterly, annually and for a change in condition assessments. d. A copy of this policy must be completed and signed by the resident and or the resident representative upon admission, and as needed which confirms understanding of the smoking policy and schedule. e. Following the completion of the smoking evaluation and acknowledgement of the policy, residents will be allowed to smoke in the designated smoking area with the supervision of a family member or other representative. No resident is authorized to smoke independently, they must be supervised by staff, family or another representative. When staff are providing supervision, smoking will only occur at times designated by the facility. f. The designated smoking area is the resident courtyard. g. All tobacco products including smoking tobacco, matches, lighters or other smoking paraphernalia will be kept by family members, or maintained by facility staff stored in a secure location. Residents may not sore smoking materials or supplies on person, in their belongings, or in their room, the reside [MEDICATION(S)] be reevaluated and may not be allowed to continue smoking privilege id deemed unsafe. The facility will provide lighters to be used so residents do not need to purchase lighters. Residents are responsible to purchase all other smoking materials. h. Oxygen is prohibited in smoking areas for the safety of residents. i. Administrative/Clinical staff may also deny resident s the privilege to smoke for any other safety concerns such as inclement weather. j. At any time this it is deemed unsafe for the resident to be smoking, even with the use of interventions, he/she will not be allowed to do so. 4. ELOPEMENT A MDS dated [DATE], documented diagnoses for Resident #29 included cancer, stroke, and non-Alzheimer's dementia. A BIMS score of 5 out of 15 indicated that resident had severe cognitive impairment. Limited assist of 1 was required for transfers, walking in room and corridor, and locomotion on and off the unit. A Witnessed Fall Report dated 10/14/21 documented that Resident #29 got up from the dining room table and walked to the front door and went outside. The CNA followed resident outside and tried to get him to come back inside. The resident refused and kept walking, stepped off the side of the concrete on to the grass where he fell , landing on his buttocks. CNA called for help via walkie and nurse went out to assess the resident. No hip rotation, no visible injuries. Resident denied pain or discomfort. After assessment completed, writer and CNA helped resident to stand up to his walker. Resident was able to walk with walker without reports of any discomfort. His range of motion was within normal limits. The resident was upset at staff for making him come back inside because he wanted to leave in his car. An Elopement Risk assessment dated [DATE] at 1:44 PM, scored resident at a 0 which indicated low risk for elopement. An Elopement Risk assessment dated [DATE] at 9:45 AM, scored resident at a 3 which indicated high risk for elopement. A Focus area in Resident 29's care plan, documented that this resident was an elopement risk related to an actual elopement on 10/14/21. The goal was that the resident would not leave facility unattended through the review date. Interventions included this resident wore a Wanderguard, to check placement and function of Wanderguard as ordered, and medication review by the primary care provider. A Progress Note dated 10/14/21 at 2:27 AM, labelled this entry as a behavior note and documented that a staff CNA reported that the resident got up from the table and walked to the front door and went outside. The CNA followed the resident outside and tried to get him to come back inside. The resident refused and kept walking, stepped off the side of the concrete on to the grass where he fell , landing on his buttocks. The CNA called for help via a walkie and the nurse went out to assess the resident. No hip rotation, no visible injuries. Resident denied pain or discomfort. After the assessment was completed the writer and the CNA helped the resident to stand up to his walker. The resident was able to walk with walker without reports of any discomfort. Range of motion was within normal limits. The resident was upset with staff for making him come back inside because he wanted to leave in his car. Fax was sent out to primary care provider and the Assistant Director of Nursing and administrator were aware. Progress Note dated 10/14/21 at 10:25 AM, documented that a Wander Guard was placed on resident's right ankle without any problems. This resident was friendly and compliant at the time. A Progress Note dated 10/14/21 at 10:30 AM, documented that a call was placed to this resident's daughter. She was made aware of the resident exiting the building and fell outside of the building. The resident was redirected into the building with staff assist and a FWW, without injury. No concerns voiced regarding resident exiting the building and fall. A Progress Note dated 10/15/2021 at 8:47, documented that resident's daughter returned a call to the facility and discussion was held regarding moving Resident #29 to the CCDI unit for elopement concerns per order from the primary care provider. The daughter was in agreement and voiced no concerns. A Progress Note dated 10/15/21 at 11:17 PM, documented that a call was placed to resident's daughter for further discussion regarding resident moving to the CCDI unit. Orders were received to discontinue resident transfer to CCDI unit after the Interdisciplinary Team reviewed. Resident's daughter was in agreement. On 12/13/21 at 1:26 PM, an observation revealed the CCDI (Chronic Confusion and Dementing Illness) unit door alarm sounded after the door was opened and before the door shut. Keypad on both sides of the door. The code was put in prior to the door being opened. On 12/14/21 at 3:30 PM, observation of exit doors revealed the following: a. A door alarm with an added pull string alarm was at the front door. Both Staff A and Staff D, stated the door alarm sounds differently for the WanderGuard then it does for people without a WanderGuard. The front door did not sound with the WanderGuard. Both the door and the pull alarm sounded but not a different sound for the WanderGuard. b. Checked doors at the end of the open unit hallways (north and south doors). Both sounded when opened. Both required a key code to disarm the alarm. c. Door to courtyard from the open unit was not locked nor did it alarm. The courtyard is enclosed. They leave the door unlocked year round. d. There was a door to a separate courtyard from the common area in the CCDI unit. This door was locked and would not open without entering a code. The code is written above the door. The door took some maneuvering by staff to get it to open after the code was put in. This courtyard was enclosed and paddle locks were noted on the gates. The fence is approximately 7 foot tall around both courtyards. e. The exit door down the resident room hallway on the CCDI unit sounded when opened. There was also a keypad on this door. f. There is a staff entrance door from the back parking lot. This required a code and will set off an alarm if door opened without the code. Staff D had a WanderGuard bracelet with her when checking the doors and this door sounded differently when the WanderGuard was close to the door. On 12/15/21 at 10:45 AM, Staff G, Maintenance Assistant, stated he was employed for 4 or 5 months. Staff G stated he was responsible for doing the checks on alarms, magnetic door locks, entries, exits, and the electric lock door in the infirmary. Staff G stated he had not had any issues with doors. He stated the doors had been getting a little old and finicky. Staff G stated they just went and replaced the alarms on the main door and the 2 North and South doors. A Work History Report printed on 10/14/21 at 8:51 PM, and provided by Staff G, showed the doors were check on 10/12/21 by Staff G. A Logbook Documentation, documented that on 10/12/21, Staff G tested the operation of doors and locks. The checks took 45 minutes. On 12/15/21 at 10:53 AM, Staff D stated the former NHA (Staff CC) had told Staff D that the front door alarm was set on the wrong setting. It was set to sound on day shift but not night shift. On 12/15/21 at 3:04 PM, voice message left for Staff CC, requested a call back. On 12/16/21 at 1:54 PM, Staff GG, CNA, stated she was working on the locked unit that night, so she was not working with Resident #29 but she heard about the incident. Staff GG stated there was only 1 CNA on the unlocked unit and that was Staff HH, CNA. Staff AA, Licensed Practical Nurse (LPN) was the nurse covering both units that night. Staff GG stated that Resident #29 had not tried to exit before when she had worked with him but she could see that he would do that, as at that time Resident #29 would walk up and down the hall. Staff GG stated she no longer works at the facility. Staff GG stated she had left the facility about 3 months prior to this interview. Staff GG stated there were a couple of resident who wore Wander guard in the front open unit. Staff GG was asked if she had heard an alarm go off that night, she was in the back (locked unit/CCDI) and didn't hear anything. She stated that there is usually an alarm that goes off and that was weird because there was not an alarm going off. The first story she heard was nobody knew how he got out there and the second story was that Staff HH had gone out there with the Resident #29. Staff GG stated the day before she had heard the front door alarm sound. She was working on second shift on that day, so it was working then. She did not know if someone messed with the alarm or not. 12/16/21 at 3:08 p.m., Staff II, [NAME] Technical Support (contracted), stated he was contacted by the facility as the facility had an elopement for a resident who was not wearing a tag. He stated a tag is a Wanderguard device. The alarm at the facility was set on day mode. Staff II stated that the day mode does not refer to the time of day or a shift nor does the night mode. Staff II stated that when an alarm is set on day mode it will only sound when a resident with a tag opens the door. He stated if a resident not wearing a tag opened the door, when it was set on day mode, the alarm would not sound. Staff II stated he remotely changed the alarm from day mode to night mode. He stated when the system is set on night mode the alarm will sound every time the door is open without a code being entered no matter if a tag is worn or not. He stated that staff, visitors or residents with or without a tag would cause the alarm to sound if the door is opened without the code being punched in prior to opening the door. Staff II remotely changed the mode from day to night. The facility provided an email to Staff CC from [NAME] Technical Support dated 10/14/21 at 1:59 PM which documented that this was a ticket update notification from [NAME] systems. The ticket is closed. Should we mistakenly closed the ticket you can simply reply to this email with your comment or call us. On 12/20/21 at 3:27 PM, Staff AA, LPN- Staff GG stated she was having behaviors on the CCDI unit. Staff AA went down there and when Staff AA was coming back up the hallway from the unit, Staff HH had locked himself outside with Resident #29. Staff HH went outside to get Resident #29, and went out the front door and the doors lock behind him and they could not get back inside. Staff AA went outside and Resident #29 had fallen into the grass near the building. Staff AA assumed this resident fell because he was on different ground as he would have walked off of the cement. Staff AA helped get this resident up. The way Staff AA understood it was that Resident #29 walked out with Staff HH and that's when this resident fell . Staff AA stated that Staff HH was hard to understand. Staff AA stated that later it came out that Staff HH had watched Resident #29 go out the doors, but Staff HH was not with this resident when this resident went out the front door. Staff AA stated that it had been so long since she had heard the alarm. She stated they do not have a lot of people trying to get out the doors. Staff AA believed housekeeping checks the doors daily. Staff AA stated she was told there were issues with the doors before this incident happened. Staff AA stated the issue was the doors were not alarming if a resident was near the door or pushed the door open they. Staff AA stated the only doors that should make noise are the inside doors with Wanderguard. She stated the doors should alarm no matter what. Staff AA had heard administration knew about the doors not working but she did not believe that. Staff AA thought it was one of those deals that they would work part of the time and the part time that the doors alarmed would have been when family would come in and they would screen them before they could get through the interior doors. Staff AA stated if family would try to come in, it would set the door alarm off. Staff AA mainly worked day shift and then she worked night shift. Staff AA stated that is when she heard Resident #29 would wander some at night and she observed Resident #29 wandering. Staff AA stated one reason she had have chosen to not work PRN anymore is because Staff HH should never work alone. He was a good worker. They told me they would never put Staff HH alone up front, then that night happened. Staff AA stated she has not been back there since. Staff AA stated that at nights the nurse may have to go back to the CCDI and that would leave one CNA out there alone. She stated it was too much responsibility. Staff AA stated there were approximately 35 residents up front. She stated only resident that she dealt with that wandered at night was Resident #29. She stated she wanted to put Resident #29 in the back (CCDI) prior to him going out the front door. Staff AA stated she got an order for him to transfer to the back. Staff AA stated she was told you really can't move him to the back because it could agitate him more and could cause aggression in the back. Staff AA stated she did not remember it being cold or anything outside that night. Staff AA supposed it was maybe jacket weather. On 12/20/21 at 6:16 PM, Staff CC, former NHA, stated she remembered the incident but did not have access to her notes. The NHA stated she remembered in the beginning of the day, getting a message that Staff AA had left for her. The message had said that Staff HH had gone out the door with Resident #29. Staff CC stated that she then got to the facility and notified Staff D. Staff CC stated then Staff AA sent text messages and said the door alarm wasn't working. Staff D found Staff HH's witness statement on the copy machine around 11:30 AM-noon. The witness statement looked like Staff HH didn't see the resident go out the front door. Staff CC believed it was within 15-30 minutes from the time Staff HH last saw this resident to the time Staff HH found this resident. Staff CC believed that Staff HH had searched the building twice. Staff CC and Staff D immediately went over to the door. Staff CC stated that sure enough the alarm was not working. Staff CC stated the alarm wasn't working from the time that Staff HH discovered it until Staff CC read Staff AA's text around noon. Staff CC stated they put Resident #29 on checks and an assessment was done. Staff CC stated they reached out to [NAME] who called back within a few hours. Staff CC immediately reset the door. It was on day mode and not night mode. Staff CC stated there was a difference about the day mode and night mode. Staff CC stated she set it on the night mode where it has a red button/light on it. Staff CC said their resource center had them call [NAME] to be sure the alarm was functioning at that time. Staff CC stated she made a decision at the time to change the code because before it was a 3 digit code to open the door and the code that goes to night code was a 4 digit code with only one number off between the 2 codes. Staff CC talked with [NAME] and Staff II checked and saw the alarm was working as designed. Staff CC could not change the 4 digit code per [NAME] but could change the 3 digit code, so she changed it to 3 completely different numbers. Staff CC stated that her intuitive thinking took me there. Staff CC thought someone accidentally hit the 4th number, changing it from night mode to day mode. Staff CC stated the day mode activates WanderGuard. If it's in night mode it goes off anytime anyone opens it inside and out. There is a 3 digit code you can touch to shut off the alarm to get in and out of the door. The day/night code had 1 number difference otherwise 3 numbers were chronologically the same, if she was remembering correctly. Staff CC stated it should be on day mode for the WanderGuard to work, but the facility had always kept the front door on night mode. Staff CC stated the door would have been on day mode when the resident eloped. The resident did not wear/was not care planned for a WanderGuard device at the time of the elopement. Staff CC stated she did not like the design. If the color is red on the alarm, that means it will always alarm when the door is opened (night mode). It won't detect a WanderGuard. It will just sound whether a resident or non-resident is wearing a WanderGuard or not. She stated the code is on the inside of the staff entrance (a different door), up high. This door is on day mode but is locked so a code is required to go through the door at any time and will alarm if the door is opened and the code wasn't punched in first. The day mode and night mode do not correlate to the time of day. 1/04/22 at 8:28 AM, Staff CC stated she submitted an email report to DIA initially within 24 hours for the elopement. On 12/21/21 at 10:02 PM, Staff HH stated Resident #29 sometimes came out of his room to hang out in the dining room. Staff HH stated Resident 29 would get up and sometimes sit in the couch or chair in the common area. Staff HH stated he did not have good peripheral vision. Staff HH got up to start rounds and Resident #29 was at one of the tables and he was walking toward the door and Staff HH thought he was going to one of the seating areas where Resident #29 sometimes sits. Staff HH was charting when Resident #29 was walking toward the seating. Staff HH stated it was about 1:30 or 2:00 AM. Staff HH wrote a little report so that should be more accurate. Staff HH was sitting at a table behind this resident when this resident walked toward the couch. Staff HH didn't even think Resident #29 would go out the door. Staff HH stated Resident #29 had never tried to go outside or never said he was going to go outside. Staff HH stated that Resident #29 was not exit seeking. Staff HH was charting and Resident #29 was out of Staff HH's line of sight. Staff HH stated that he was going to start his rounds but then intuition kicked in and he thought he'd better check on Resident #29. Staff HH stated Resident #29 was not over in either seating area. Staff HH stated he checked the halls and Resident #29's room and other resident's rooms and could not find Resident #29. Staff HH stated he did that twice. Staff HH stated he then walked outside to see if he had gone out there. Staff HH had his walkie with him. Staff HH stated that Resident #29 had walked down the side of the building and Staff HH found Resident #29 sitting on the grass. Staff HH stated he thought this resident was trying to stand up. Staff HH stated he tried the walkie a couple of times, but it must have been out of reach. Staff HH then tried to go inside but the door was locked. Staff HH stated he used his cell phone to call the facility and Staff AA answered the phone. Staff HH stated that Staff AA came out and she made sure the door was not going to lock on them. Staff HH stated that they both walked out and assessed Resident #29. Staff HH stated Resident #29 was rubbing his right knee a little bit and this resident's knee was slightly red. Staff HH then stated there might have been some redness. Staff HH stated they helped Resident #29 to stand up. Staff HH and Staff AA then walked Resident #29 inside and Resident #29 did say something about his car. Staff HH stated they told Resident #29 his daughter was taking care of his car, she had taken it to the shop and Resident #29 calmed down. Staff HH stated Resident #29 was just slightly agitated about his car and Resident #29 wasn't hurt. Staff HH stated that Resident #29 had never asked about his car before. Staff HH stated that he and Staff AA then realized the door alarm didn't work. Staff HH stated he and Staff AA took Resident #29 back to bed and he was totally fine the rest of the night. Staff HH stated that Resident #29 said he wasn't hurting. Staff HH stated he made sure Resident was still in bed as he kept peeking in there at this resident. Staff HH stated this resident fell where the concrete ended, where all the chairs are at when you turn right when you go out the front door. Staff HH stated this resident did not fall down the hill. Staff HH stated there is a little hill out there. Staff HH believed the nurse at least checked on the alarm to see why it didn't go off. Staff HH had asked her to check to make sure that he just didn't hear it go off. Staff HH was later told that he should have had the nurse initiate the search and not him. Staff HH stated he only started looking for Resident #29 because the nurse was in the back in the unit. Staff HH stated he understood why he should have had the nurse initiate the search as he had locked himself out. Staff HH stated he was hard of hearing. Staff HH stated it was just Staff AA, himself and then whoever was in the Lodge (CCDI) the night this resident went outside. Staff HH stated that back then he was normally working with just one nurse and then a CNA was in the back. He stated that now they normally have 2 CNAs. Staff HH the alarm has been working since then. A resident pushed on the door when she was wandering around and the alarm sounded. Staff HH stated he heard it. Staff HH stated that Resident #29 and another resident are up at nights. Staff HH stated that the weather was mild outside that night. He stated it wasn't like freezing, it wasn't cold because he would have grabbed a coat prior to going outside. Staff HH stated it was about 15 minutes from when he last saw Resident #29 walking toward the front seating area to when he found him outside. An Investigation Questions form documented the date/time of the incident was 10/14/21 at 1:30 PM, and documented that Staff CC and Staff D interviewed Staff GG. Staff GG had not heard anything about the incident until after the shift. What Staff GG heard was Staff AA had told her that while she was busy, Resident #29 was outside with Staff HH. Staff GG stated she did hear Staff HH paging, saying something like repeating Staff AA's name and saying best friend or buddy? He did not indicate an emergency. Staff GG was in the lodge (CCDI) unit doing rounds. She did not assist with the incident as at the time she did not know what was going on. Staff GG asked if Staff HH followed Resident #29 out the door, that wouldn't be an elopement, would it? Staff GG stated she had heard that Staff HH had followed the resident out the door. Staff B signed the form on 10/14/21 at 2:02 PM. Staff CC signed the form at 10/14/21 at 4:02 PM. An Investigation Questions form documented the date/time of the incident was 10/14/21 at 2:27 PM, and documented that Staff CC and Staff D interviewed Staff AA. Staff AA stated that Staff HH stated that a resident went out the front door. Staff HH stated he was right on his tail and Staff HH tried to get resident back into the building, resident was difficult to redirect and fell with his walker. Staff CC documented that Staff HH called the facility from outside the front door had been and that she did not witness the incident. Staff AA stated she walked to the front of the building from the CCDI unit and the phone was ringing. Staff HH was on the phone stating that he was out front of building with resident and they were locked out. Staff AA had been on the CCDI unit putting away medications from pharmacy delivery. Staff AA assisted resident back into the facility after identified there were no injuries. Staff AA completed a head to toe assessment and took vital signs. Staff AA notified Staff CC and the Assistant Director of Nursing of the incident and door alarm not sounding. Staff AA sent a fax to the primary care provider. Staff AA reported that Staff HH had told her that the resident got up from a recliner chair and went to the door. Staff B signed the form on 10/14/21 at 3:45 PM. Staff CC signed the form on 10/14/21. An Investigation Questions form documented the date and time of the incident was 10/14/21 at 1:30 AM, and documented that Staff B and Staff CC were the interviewers. Staff HH reported that he did not hear anything but noticed that Resident #29 had got up from the table and walked away. Staff HH thought the resident was going to sit on one of the couches and when he checked on the resident, the resident wasn't there. Staff HH reported he searched every room twice and went out the front door to look as he did not hear an alarm. When Staff HH checked outside he saw Resident #29 on the ground. Staff HH reported it to the charge nurse. Staff B and Staff CC did not sign or date the form. An email from the State Climatologist of Iowa and dated 12/21/21 at 9:29 AM, documented the weather in that area on 10/14/21 at 2:40 AM, was as follows: Temperature: 54 degrees Fahrenheit Relative humidity: 62% Winds out of the WSW at 6 mph Overcast skies No precipitation detected No wind chill temperature A Resident with Wander Guard list provided by the facility during the survey named the following residents to have Wander Guard devices and the date they were placed: a. On 10/9/21, Resident #12. b. On 4/30/21, Resident #41. c. On 1014/21, Resident #29. The facility provided

Based on clinical record review, staff interviews, and observations, the facility staff failed to safely transfer 1 of 6 sampled (Resident #2). Resident #2 moved while raised in a total mechanical lift and fell from the lift striking her head on the base of the lift. Resident #2 sustained a [MEDICAL CONDITION] which resulted in death. The lift failed to contain safety clips on the hanger bar to prevent the lift sling from detaching from the lift. The facility failed to properly train staff on the proper use of the lift and what to do in the event a resident moves while in the lift. The facility reported 10 residents required a total mechanical lift for transfers. The facility reported a census of 49. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 had [DIAGNOSES REDACTED]. Resident #2 had severe cognitive impairments and displayed behavioral symptoms directed towards others (like verbal symptoms or disruptive sounds). Resident #2 did not walk, required the assistance of two staff for transfers and used a wheelchair for mobility. The Care Plan revised [DATE] revealed Resident #2 unable to transfer effectively related to weakness and impaired cognition. The Care Plan instructed staff to assist Resident #2 to transfer with two staff with a total mechanical lift, to offer reassurance and talk with her throughout the transfer to ease fears/anxiety and provide clear instruction in regard to tasks. The Order Summary Report dated [DATE] documented orders to administer [MEDICATION NAME] Bisulfate (or [MEDICATION NAME], an antiplatelet medication) 75 mg (milligrams) once a day. Resident #2's MAR (Medication Administration Record) dated ,[DATE] - [DATE] documented she received [MEDICATION NAME] every morning. The Incident Report dated [DATE] at 7:00 p.m. authored by Staff A (Registered Nurse) documented a Nurse Aide notified her of the need to go to Resident #2's room and the resident fell from the Hoyer. Staff A entered the room and noted the Hoyer sling hung from the lift by the top two loops at the head and one bottom loop at the knee. The fourth loop was unhooked and hanging. Resident #2 lay on her side between the legs of the lift with her head laying partially on the leg of the Hoyer. The Incident Report documented Staff B (Nurse Aide) and Staff C (Nurse Aide) witnessed the fall. The Health Status Note dated [DATE] 8:27 p.m., revealed Staff A (Registered Nurse) noted all lift sling loops were intact. Staff A observed the resident bleeding, moved the lift and assessed the site of bleeding at the resident's right temple. Staff A instructed a Nurse Aide to apply pressure to the wound and summoned 911. Staff A then obtained vital signs and assessed the resident. Resident #2 had an emesis and bowel movement. Medics arrived and started to move Resident #2. Resident #2 had two more emesis and another BM. Medics applied a cervical collar and transferred Resident #2 on a back board and gurney. The note documented Resident #2 had not been lowered to floor. The note also documented Resident #2 received a laceration to the right temple, a hematoma (bruise) to the back right of her head and skin tears to her right shoulder, the sides of her right elbow and right knee and the back of her left hand near the thumb. Staff A documented Resident #2's blood pressure (BP) at ,[DATE], a pulse of 89, respirations at 18 and an oxygen saturation of 93% on room air. The Prehospital Care Report dated [DATE] documented the Fire Department responded following dispatch for a female who fell out of a lift. Staff reported they were transferring the resident with the lift and she fell on her head. The report described the lift as about three to four feet off the floor. Staff also reported the resident was unresponsive for a time prior to Emergency Medical Services (EMS) arrival. The resident did not normally talk or obey commands due to her dementia; she mumbled but did not verbalize any complaints. EMS staff documented a laceration to the resident's forehead that was difficult to access due to copious amounts of blood flowing from the wound. Resident # 2 transported directly to the hospital. During interview on [DATE] at 8:00 a.m., the Emergency Medical Service staff (dispatched on [DATE]) stated she saw the height of the lift when entering Resident #2's room and it must have been three to four feet in the air. The Emergency Department (ED) Physician Notes dated [DATE] at 8:21 p.m. documented Resident #2 presented following a fall just prior to arrival. The fall was described as three feet out of a Hoyer lift at the nursing home. The resident had swelling and bleeding to the head with risk factors of age and anticoagulation and with associated symptoms of nausea and vomiting. The records also documented Resident #2 experienced a hypertensive emergency (BP measurement of ,[DATE]) and she received treatment for [REDACTED]. The notes described Resident #2's condition as critical. A Computed Tomography (CT) scan of Resident #2's head on [DATE] at 8:58 p.m. documented findings of a large subdural hematoma overlying the right cerebral convexity. The hematoma measured 3.3 centimeters (cm) in the maximal dimension. The CT also showed a marked associated mass effect on the adjacent parenchyma (the brain's functional tissue) with an approximate 1.2 cm midline shift. The CT also showed effacement (narrowing) of the right lateral ventricle. The impression of the CT documented an associated mass effect on the adjacent parenchyma and resultant acute [DIAGNOSES REDACTED] (fluid accumulation in the brain). The hospital Discharge Face Sheet dated [DATE] at 3:20 p.m. recorded Resident #2 discharged back to the facility with Hospice and comfort cares. A Health Status Note dated [DATE] at 4:04 p.m. documented Resident #2 returned to the facility. Staff assessed the resident as nonresponsive; she would groan to a firm sternal rub (painful stimuli) but did not attempt to pull away. Resident #2 did not grip or pull (with her hands). Staff contacted Hospice who planned to discontinue the resident's current medications and begin comfort care medications. Observation of Resident #2 on [DATE] at 12:10 p.m. revealed Resident #2 on her left side in bed and with no response to her name. The observation revealed a right frontal/temporal bruised open area, very swollen in appearance and measuring approximately 3 x 5 cm. A Health Status Note dated [DATE] at 10:30 p.m. documented Resident #2 expired at the facility at 6:45 p.m. A Major Injury Determination Form signed by Resident #2's Physician on [DATE] revealed that after reviewing the circumstances, injury and prognosis of Resident #2, the physician believed Resident #2 sustained a major injury. The Certificate of Death dated [DATE] documented Resident #2's immediate cause of death as a traumatic head injury. The manner of death, accidental and a description of the injury as the patient struck head when dropped by nursing home personnel. During a phone interview on [DATE] at 10:57 a.m., Staff A remembered the incident on [DATE]. Staff A stated when she entered Resident #2's room, she saw her laying on the right side with her head partially on the leg of the lift and blood on the floor. Staff A lifted Resident #2's head, observed the laceration was a significant and asked Staff C to apply pressure while she dialed 911. Staff A stated that she asked the aides what happened afterwards. The aides reported the lift sling was not connected correctly. They tried to re-position the sling while the resident sat in the wheelchair, but the resident was positioned badly and fell . Staff A stated it was like they tried to blame positioning on the resident's fall. When asked about the elevation of the lift, Staff A stated the resident's bottom would have been three to four feet in the air. Staff A stated she took a photo right after the fall; the lift had not been lowered but it was moved away so she could care for the resident. Staff A sent the photo via text and asked to speak further. At 11:18 a.m., Staff A stated she is an advocate for patients and did not want to get anyone in trouble. Staff A stated the lift had very pronounced hooks and the sling was intact. Staff A thought the loops were not positioned completely on the lift hooks. When staff lifted Resident #2, her body weight caused the sling to come off the hooks, causing the fall. Staff A stated she sent the photo she took on [DATE] to the facility's Director of Nursing (DON). A review of the photograph received from Staff A revealed a total mechanical lift. The photograph revealed one loop hung free from the lift (lower right as the resident sat) and open-ended hooks at the end of the lift arms. The lift seat appeared to hang approximately three feet from the floor. The facility reported Resident #2's fall to the Department of Inspections and Appeals by telephone on [DATE]. The Incident Summary documented Resident #2 moved her lower extremities, which shifted her weight, during the transfer. When the resident's weight shifted, the loop closest to her right knee lifted off the loops of the lift basket. Resident #2 then slid out of the sling onto the floor, hitting her head on the leg of the lift. The User Manual showed illustrations of hooks at the ends of the lift's hanger bar which contained safety clips to close the end of the hooks where the lift sling loops connected. The illustrations showing the safety the clips were present on pages 1, 12, 17, 18 and 21. Page 26 of the manual instructed not to move the patient if the sling was not properly connected to the hooks of the hanger bar. Observation on [DATE] at 10:40 a.m. revealed no safety clips in place on the hooks at the end of the hanger bars on either the facility's total mechanical lifts. During interview on [DATE] at 10:00 a.m., Staff B stated after supper on [DATE], she assisted Resident #2 to her room and put the resident's pajamas on while Staff C obtained the lift. When Staff C arrived with the lift, Staff B noticed the resident positioned crooked in the lift sling, so she straightened her out. Staff B stated she ran the lift. Staff B started to lift the resident while Staff C stood behind the resident's wheelchair. Staff B stated the resident wiggled in the wheelchair before the transfer and in the sling during, so they stopped moving the lift. Resident #2 swung her leg and Staff B thought the right lower hook came out; Resident #2 fell to the floor. During the interview, Staff B stated the lifts are supposed to have safety clips at the top of the hooks to keep the loops in place. Staff B had never seen safety clips on the lifts. Staff B showed the surveyor her phone, which contained photos of the hooks without safety clips at the end of the Invacare hanger bar. Staff B stated she received the photos from another staff member (Staff D). During interview on [DATE] at 3:57 p.m., Staff C (Nurse Aide) stated the night of [DATE], Resident #2 had been kicking her legs over the edge of the chair more than once, beginning at 6 pm. The resident also kept trying to sit forward and she got more fidgety. About 6:30 or 7:00 p.m., she and Staff B assisted Resident #2 to her room. They noticed the resident curled sideways in her chair and the sling appeared crooked; they tried to reposition the sling multiple times. They started the lift; Staff B worked the controls and Staff C pulled the chair away. The next thing she knew, Staff C observed Resident #2 on the floor. It happened fast. Resident #2 turned right in the sling, her right and left legs crossed over each other. Staff C originally thought the loop snapped. Staff C stated she had never seen any safety clips at the hook ends of the lift hanger bar. She also had photos of the lift on her phone which showed no safety clips at the hook ends of the hanger bars. Staff C stated she wished the clips had been on the lift on [DATE]; they might have prevented Resident #2's fall. During interview on [DATE] at 5:15 p.m., Staff D (Certified Medication Aide) stated she had photos of the lift on [DATE] and provided the photos. Staff D stated she had worked at the facility for more than two years and the lifts failed to contain safety clips. Review of the photographs showed no safety clips at the hook ends of the hanger bar of the lift. Observation on [DATE] at 1:50 p.m., revealed the total mechanical lift 600 had safety clips in place to close the hooks at the end of the hanger bar. Observation at 3:00 p.m. revealed the total mechanical lift 450 lift also had safety clips in place to close the hooks at the end of the hanger bar. During observation and interview on [DATE] at 10 a.m., Staff E (Nurse Aide) observed the mechanical lift 600 and stated the safety clips were new. Staff E did not see the safety clips on the lifts the previous week and she thought they were placed on [DATE]. During observation and interview on [DATE] at 10:10 a.m., Staff F (Nurse Aide) observed the total mechanical 450 lift and stated she last worked the floor on [DATE] and did not see safety clips on the Invacare lifts then; today was the first day she'd seen them. On [DATE] at 10:10 a.m., the Maintenance Director stated he had worked at the facility since ,[DATE] and does monthly checks the lifts. He checks the wheels, clips, pulls hair out of the casters and checks the batteries. Observation of the total mechanical lift 600 occurred shortly after the interview. The Maintenance Director stated he did not order or install the safety clips. Review of Mobile Lift Inspection Logbook documentation dated [DATE], [DATE] and [DATE] contained instruction to inspect the boom (where the hanger bar connected) to check its hardware and swivel bar supports and inspect the swivel bar bolts/hooks for damage/wear and the sling hooks for bends or deflection. During an additional interview with the Maintenance Director of [DATE] at 10:00 a.m., he stated the items he mentioned on [DATE] were items he had problems with. He reviewed the Logbook documentation and stated he looked at all listed items. Upon observation of the lifts after the interview, he stated he was pretty sure the safety clips were on the end of the hooks, but not listed on the checklist he maintains. The Maintenance Director then stated he maintained three lifts at another facility and two lifts at this facility and it may be the other facility's lifts he remembered seeing the safety clips in place. During interview on [DATE] at 10:45 am, the Administrator reviewed the photograph taken the night of the fall and stated he had seen the photo before. The Administrator stated he placed the safety clips at the hook ends of the lifts on [DATE]. When asked if the clip's purpose would be to keep the loops on the lift's hooks, he stated he did not really know but it's not unreasonable to think so. An invoice from the facility's equipment supplier identified a purchase order for clips for the Invacare Spreader Bar as ordered on [DATE] and delivered on [DATE]. On [DATE] at 11:30 a.m., the Director of Nurses provided a list of residents who required mechanical lifts for transfers; the list contained the names of nine current residents and did not include Resident #2. The DON stated the facility had no bariatric residents and all nine residents could transfer in either the total mechanical lift 450 or the total mechanical lift 600. 2. During interview on [DATE] at 10:00 a.m., Staff B (Nurse Aide) stated she was [AGE] years old when she trained as A Nurse Aide and did not complete lift transfers during that training. Staff B stated that facility staff must be [AGE] years or older to use the mechanical lifts. Staff B stated the Director of Nurses knew she had observed transfers but she had no physical training on use of the mechanical lifts. Staff B turned 18 in June, 2020 and she thought everyone knew this because other staff told her she could use the lifts now. During further interview on [DATE] at 7:25 pm, Staff B stated she had been using both total mechanical lifts for all residents who required lift transfers since she turned 18 in June, 2020. She likely had transferred Resident #2 50 to 100 times. She stated Resident #2 could be fidgety with transfers but that night was really bad. During interview on [DATE] at 5:00 p.m., the Director of Nurses stated it is corporate policy that staff must be [AGE] years old or older to use the facility's mechanical lifts. At 3:30 pm, the Director of Nurses and the Administrator stated the facility had no policy regarding staff under the age 18 being prohibited from using mechanical lifts; it is the facility's practice though. On [DATE] at 11:10 a.m., the Director of Nurses provided Staff B's Staff Orientation Checklist - Transfer and Lifting Equipment, dated [DATE]. The Director of Nurses reported this was the most recent training Staff B had on mechanical lift transfers. Staff B had no additional training aside from watching other staff use the lift. 3. Staff B and Staff C both stated that Resident #2 fidgeted, moved her legs and attempted to turn sideways during the transfer on [DATE]. During an interview on [DATE] at 9:50 a.m., Staff G (Nurse Aide/Medication Aide) stated she had not received training regarding resident movement during a lift transfer. Staff G stated she worked in long-term care for a long time and if a resident moved during a mechanical lift transfer, she would stop the transfer and tell her charge nurse and try again later. On [DATE] at 10:20 a.m., Staff H (Nurse Aide) stated she received training on using the total mechanical lifts from another Nurse Aide. If a resident moved their legs or tried to roll during a transfer, she would not transfer the resident, would let them calm and try again later. The Nurse Aide who trained her told her that. She had not received an audit on safe use of the mechanical lifts prior to Resident #2's fall on [DATE]. During an interview on [DATE] at 10:40 a.m., Staff I (Nurse Aide) stated if a resident tried to move their legs or turn during a lift transfer, she would wait and try again later. It wouldn't be safe to move the resident. Staff I knew this based on her own experience, not from training at the facility. Page 7 of the Mechanical Lift 450 User Manual instructed to use common sense in all lifts. Special care must be taken with people with disabilities who cannot cooperate while being lifted. Review of the Staff Education for ,[DATE] document, with training beginning on [DATE], identified the following training items: a. User manuals for each lift are attached to the lifts themselves. Please utilize this as a user's guide to operation. Shower slings should be utilized for showers only b. In the event that any equipment fails, it needs to be removed from operation. A sign should be securely affixed to the equipment identifying it is out of operation. The equipment should be place in the vending machine area until it can be addressed. c. When assisting residents with Activities of Daily Living, reference the Pocket Care Plans to provide care as appropriate. The Pocket Care Plans are located at the designated nurse's station. The Staff Education for ,[DATE] also contained staff audits on safe use of the mechanical lifts. During interview on [DATE] at 10:45 a.m., the Assistant Director of Nurses (ADON) stated she conducted the staff education for ,[DATE]. The ADON stated she went through each item as documented and also went through the User Manual (pages ,[DATE], ,[DATE] and 31). She stated she watched as staff read the manual and use the lifts. The ADON stated the training did not specifically address what to do if a resident moved or squirmed during a lift transfer, but it did address the safety and comfort of the resident. On [DATE] at 2:45 p.m. the State Agency informed the facility of the Immediate Jeopardy. The facility abated the Immediate Jeopardy on [DATE] by educating staff on the proper use of lifts according to the manufacturer's instructions with return demonstration, educating staff on what to do in the event a resident moves while in the lift, installing clips to the lift hanger bar and implementing checks to ensure the clips are in place prior to use of the lifts. After corrective actions the scope lowered from a J to D.

Based on record review and interview, the facility failed to provide adequate supervision to protect one (1) of three (3) residents from hazards during transfers. Resident #1 fell and sustained a hip fracture on 10/12/16, two days after admission. Record review revealed Resident #1's care plan had not addressed how Resident #1 should have been transferred. Staff interviews revealed they previously transferred Resident #1 on multiple occasions with less assistance than the initial Nursing Assessment indicated and there transferred. The facility reported a census of 45 residents. Findings include: The discharge Minimum Data Set (MDS) assessment dated [DATE] noted Resident #1's admitted as 10/10/16, and listed the resident's [DIAGNOSES REDACTED]. The MDS indicated Resident #1 had either not walked in the corridor, or family and/or non-facility staff provided care 100% of the time during the assessment period. The MDS also indicated Resident #1 depended on the extensive assistance of staff to provide all ADLs (activities of daily living), which included weight bearing support to walk in the room. According to the MDS, staff assessed Resident #1 as having an altered level of consciousness, a memory problem, inattention, disorganized thinking and moderately impaired cognitive skills for daily decision making. The October TAR (Treatment Administration Record) from the previous facility where Resident #1 resided noted that upon admission, the resident required a wanderguard and pressure alarm safety device at all times. The Discharge Instructions dated 10/10/16 from the facility where Resident #1 previously resided, noted the resident required the assistance of 2 staff due to activity limitations. The Fall Risk assessment dated [DATE] indicated Resident #1 scored 22. According to the assessment form, a prevention protocol should have been initiated immediately for any resident that scored 10 or more. The initial Care Plan with a goal date of 10/30/16 noted the prevention of injury or harm had been the goals related to falls/safety risk, but only listed encourage to use call light and Physical Therapy referral as the interventions to attain that goal. The Quality Assurance Monitoring Tool dated 10/12/16 at 3:15 a.m. indicated Resident #1 attempted to transfer him/herself. A newly implemented intervention called for one on one monitoring of the resident until an alarm could be obtained. The Final Report document dated 10/12/16 indicated Resident #1 sustained a mildly displaced oblique intratrochanteric acute fracture proximal left femur (fractured upper thigh bone). The Final Report dated 10/13/16 indicated Resident #1 had undergone a surgical pinning of a left hip fracture. The initial Nursing assessment dated [DATE] indicated that Resident #1 required extensive assistance of 2 staff for bathing, dressing, transferring and toileting. The Nursing Assessment noted the resident had right and left lower extremity weakness, a history of falls which included the last 30 days, bladder incontinence and a lethargic level of consciousness. Though the initial care plan had not addressed how Resident #1 should have been transferred, staff interviews revealed they were not sure how Resident #1 should have been transferred, and admitted they had previously transferred Resident #1 on multiple occasions with less assistance than the initial Nursing Assessment indicated as follows: An interview on 11/16/16 at 9:35 a.m. with Staff F, LPN (licensed practical nurse), revealed that sometimes they only schedule one person on the memory unit, but believed they make every attempt to have two back there on overnights. She thought that had been their policy. According to the LPN, staff calls back and forth between the nurses ' stations as their way of corresponding, or they simply go to the memory unit and check on things. She stated the facility told them they could not carry their cell phones, but she told them she believed it was a safety issue by not carrying it. The LPN said they no longer use walkie talkies, so she relies on her cell phone in the event of an emergency. According to the LPN, if an only person in the memory unit could not reach someone at the nurses ' station and did not have a cell phone, they better hope they could leave the emergency long enough to get help, or hope someone came soon. An interview on 11/16/16 at 12:10 p.m., and subsequent interviews with Staff C, CNA/CMA (certified nursing aide/certified medication aide), revealed she worked on the memory unit from 10:00 p.m. on 10/11/16 until 6:00 a.m. on 10/12/16. She stated newly admitted residents are not typically equipped with alarms right away because they reserve the use of alarms as an intervention after a fall. According to the CNA, she had been told by the previous shift at report that Resident #1 should have been equipped with an alarm upon admission because he/she had been transferred from their corporate affiliate in Knoxville where he/she previously had an alarm. The CNA stated the resident had not been equipped with an alarm upon admission because the facility did not have an extra alarm. According to the CNA, if the resident had been equipped with an alarm, the fall might have been prevented because they respond so quickly when they hear an alarm sounding. When asked how she knew how to care for a newly admitted resident, the CNA stated, if it had not been passed on during shift report, she could not be sure how things were supposed to be done upon their arrival. In a subsequent interview, the CNA stated working shorthanded had been an issue approximately a month before. She said it had been common for only one staff member to be scheduled up front with the nurse and one on the memory unit. According to the CNA, the nurse came to the memory unit from time to time, but usually just called unless there had been problems. Staff C stated the night nurse spent the majority of her time up front, and staff on the memory unit called the nurses ' station up front if necessary. When two staff members are scheduled on the memory unit, she said they relieve each other for breaks. The CNA expressed concern about being left alone in the memory unit. She said sometimes residents get up in the night and go outside in the courtyard. According to the CNA, a resident might make a round out there, come back in and fall asleep on the couch or just roam around. Staff C mentioned the alarm sounded on the unit and up front when the door opened. She also stated that staff that work up front call the unit when they hear the alarm, and someone came to the memory unit if they were not able to reach someone. According to Staff C, the thought of a resident falling asleep outside while she assisted other residents concerned her the most. The CNA said the night Resident #1 fell , she took her 30 minute break about 1:30 a.m. and the other CNA on the memory unit took hers about 2:30 or 2:45 a.m. Both were left alone on the unit during their breaks. Fortunately, staff C said 15 minute checks on Resident #1 had just been implemented about 3:00 or 3:15 a.m. and the nurse had just gotten to the unit about 5 minutes before Resident #1 fell . Staff C said the nurse remained on the unit until about 4:00a.m., Staff A remained in the unit until she went up front about 5:00 a.m. to help Staff D and she remained on the memory unit for the remainder of that shift. She stated Staff D had been left alone up front while the three of them were back in the memory unit. Staff C said before the nurse left the unit, she told Staff C to administer Tylenol and call her if the resident complained of pain. Staff C said she attempted to call the nurse about 5:20 a.m., but had not been able to reach her. She said the phones at the nurses ' stations are the designated means of communication. The CNA/CMA said if she were alone in the memory unit during an emergency, she would just keep trying until she could reach someone. An interview on 11/16/16 at 12:40 p.m. with Staff D, CNA revealed she worked up front from 10:00 p.m. on 10/11/16 until 6:00 a.m. on 10/12/16. She stated she first realized Resident #1 had fallen when the nurse came to the front to get the equipment to do vital signs. According to the CNA, the nurse stated she would be tied up on the memory unit due to the fall. When asked about her opinion, the CNA stated they are adequately staffed. When the CNA had been informed that another staff member spoke of working short staffed, she became more open. She stated they did not take breaks back in July, August and September because there had only been one staff member scheduled up front, one scheduled in the memory unit and one nurse over the entire facility. She stated falls occurred simply because of being short staffed. The CNA said the facility did not have enough alarms to go around. She stated that she and other staff members heard that Resident #1 should have been alarmed, but due to a shortage of alarms, he/she had not. According to her, the facility has used safety alarms for a very long time. An interview on 11/16/16 at 1:30 p.m. with Staff B, CNA revealed that she worked on the memory unit from 6:00 a.m. to 10:00 p.m. on 10/11/16. According to Staff B, she relied solely on the previous shift to report details related to the care of a newly admitted resident. In a subsequent interview, the CNA stated she used her own judgment for the first couple days after the arrival of a newly admitted resident until the development of an initial care plan had been completed. She said she could not remember what the previous shift reported to her about Resident #1. The CNA said earlier in the day of 10/11/16, the resident had been lethargic, so they used 2 staff and a gait belt to transfer and walk with him/her. According to the CNA, the resident became more active during the evening and kept trying to self-transfer, so staff had to follow the resident around in an attempt to keep him/her safe. In an effort to describe how much better the resident walked that evening compared to that morning, the CNA said when he/she got up alone to walk to the bathroom; she reached out and assisted the resident by herself. When asked, she stated she did not think to put a gait belt on the resident, but also said she did not think a gait belt had been necessary based on a couple of factors. First, she stated the resident became agitated when she attempted to put a gait belt on him/her, and second, due to the resident's improved gait, she did not believe a gait belt had been warranted. The CNA said the resident had been so busy that evening, he/she fell asleep once he/she sat down. An interview on 11/17/16 at 9:45 a.m. and subsequent interviews with the DON, (Director of Nursing), revealed Resident #1 had been very lethargic when he/she arrived on 10/10/16. She stated initially the resident required transfer assistance of 2 staff and a gait belt, but had not been equipped with a safety alarm because of the resident's lethargic state and because their facility had a locked unit. She stated they do not necessarily resort to alarms if they are adequately staffed. According to the DON, the resident came from their affiliated facility in Knoxville, where he/she had required transfer assistance of 2 staff and had been equipped with a safety alarm because they did not have a locked memory unit. When asked if the change in the resident's activity level would have warranted the use of a safety alarm, the DON said the charge nurse would have been responsible to reassess the resident to see if an alarm would have been warranted. When this surveyor informed the DON that other staff interviews revealed the resident ' s lethargic state diminished and he/she became more active, she stated she had not been informed of the resident's change. Regarding the Fall Risk Assessment that instructed staff to immediately implement a prevention protocol if a resident scored 10 or more, the DON stated they did not have one. When asked what protocol they followed, she stated they do not follow a protocol. She stated they assess every resident on an individual basis. The DON revealed she expected everyone to follow the care plan. An interview on 11/22/16 at 2:40 p.m. with Staff E, LPN, revealed that she worked the overnight shift on the 10/12/16. According to the LPN, she arrived in the memory unit about 3:00 a.m. and saw Staff C coming out the 1st room on the right. She believed Resident #1 resided in that room. As she sat and charted, she said she heard a loud noise. According to the LPN, she went down the hall where she met Staff C. As they searched rooms, she stated she believed Staff C had been the one to find Resident #1 on the floor. The nurse said she went to get the equipment to do vital signs. She said she returned and attempted to check Resident #1's vital signs. She stated she had been unable to assess the resident because he/she became combative. She stated the resident denied having pain, so they stood him/her near the bed, and she had been able to check his head and arms. As they walked the resident from near the bed to the doorway, he/she lifted both legs and said put me down . The LPN said they lowered the resident to his/her knees. She went to get a wheel chair. When she returned, Staff A had been present, so she held the wheel chair while the LPN and Staff C put the resident in it. She stated they wheeled the resident to the dining room table where he/she sat for an hour and a half with the LPN as she charted. According to the LPN, the resident occupied him/herself by playing with her paperwork. Once she finished charting, the LPN said she told Staff C to give Resident #1 Tylenol and call her if he/she complained of pain. She stated Staff C attempted to call her, but she had been rounding up front with Staff D. Consequently, Staff E said she had been unaware that Staff C tried to call. The LPN said In the event of an emergency, Staff C would have had to keep calling until she reached her. The LPN said ideally an intercom would be nice, but believed that their current system worked fine. According to her, the doors are alarmed and they hear it up front. She stated they also carry their cell phones at night. The LPN stated Resident #1 had not complained of pain at any time. She stated another neuro assessment had been due for the Resident, so she returned to the memory unit about 5:40 or 5:45 a.m. She said Staff C informed her at that time the resident complained of pain and she had given Tylenol. The day shift nurses walked in right after that and she said she reported off to them. An interview on 11/23/16 at 6:55 a.m. with Staff A, CNA, revealed she worked on the memory unit from 10:00 p.m. on 10/11/16 until 6:00 a.m. on 10/12/16. According to the CNA, she had never met the resident, and he/she had been asleep on the couch in the lounge when her shift began. The CNA said between 1:00 a.m. and 2:00 a.m. on 10/12/16, Staff A's co-worker had gone on break, and she had been left alone on the memory unit. During that time, the resident woke up and got up off the couch on his/her own. The CNA said she approached the resident and applied a gait belt as she assisted him/her to the bathroom. According to her, the resident seemed very unsteady. Next, the CNA said she helped to transfer the resident to bed by herself. During shift report, the CNA said she heard the resident had been unsteady, very restless and did not like to stay in one place. According to the CNA, nobody told her how many people were required to transfer the resident. The CNA admitted that a reference sheet related to new admissions could be found in the ADL book, but she had not looked at it before her shift began. She did not think she needed to because typically only residents that require the assistance of one staff are on the memory unit. She agreed that obviously there are exceptions like in that situation. She said typically one person can deal with most of the residents, so they only ask for help when a resident becomes combative. Staff A stated that once she thought about it, she should have checked to see if the resident needed more assistance. She said it gets crazy sometimes, like when she arrived at 10:00 p.m. on the evening of 11/22/16. She stated there had been about 8 residents up walking around, and one of them had tried to get out the door. She stated that sometimes she cannot even get report due to the commotion. Staff A spoke of the early morning hours of 10/12/16 when the nurse, Staff C and she were all in the memory unit because of Resident #1's fall. Staff A stated that Staff D had been up front alone at that point and she would have been spread kind of thin since the 3 of them were in the memory unit. She said that some nights are wonderful, but other nights are horrible because the residents are climbing the walls. Staff A stated she thought at least 2 staff members were needed up front at all times. When asked what she would do if she were alone on the unit during an emergency situation, she stated she would call the nurses ' station up front. According to her, if nobody answered, she would keep trying until she got ahold of someone. She said that had never happened before, but she could see how it would be possible. According to Staff A, the Administrator and DON have changed 3 times in the 3 years she had worked at the facility, and most of the nurses are new again. She stated it seemed like a revolving door, and everyone had a different idea of how things should be done. According to her, because a communication barrier existed, it felt like she had to figure it out on her own once she hit the floor . The Daily Nurse Hall Assignments revealed between 10/1/16 - 11/12/16 on the 10:00 p.m. - 6:00 a.m. shift, only one staff member had been scheduled on the memory unit, one staff member over the rest of the facility and one nurse to supervise the entire facility on 10/1/16, 10/2/16, 10/3/16, 10/8/16, 10/9/16, 10/26/16, 10/31/16, 11/12/16.

Based on record review, emergency/hospital records, and interviews, the facility failed to administer all medications as ordered by the physician and failed to complete blood glucose monitoring for one of eight residents during his/her stay at the nursing home (Resident #6). On 5/27/15, the facility admitted Resident #6 to the nursing home and failed to administer medications, including insulin medication. On 6/8/15 Resident #6 became unresponsive and the nursing home staff finally checked his/her blood glucose level and transferred him/her to the emergency room with elevated blood glucose reading of greater than 700 (a normal range is between 70-100). Resident #6 subsequently lapsed into a diabetic coma and remained unresponsive and hospitalized until he/she passed away on 6/15/15. Interviews with the Director of Nursing (DON) identified she failed to verify the resident's physicians orders upon his/her admission. The facility did not have a written procedure to verify physicians orders were transcribed as ordered upon admission/re-admission. Record review revealed the facility failed to administer 14 physician's orders [REDACTED]. The findings constitute an immediate jeopardy to a resident's health and safety. The facility identified a census of 37 residents. Findings include: A physician order [REDACTED].#6 would be transferred to the facility on [DATE]. The order instructed staff to discharge the resident to the facility with current medications and treatment orders. The¿¿¿¿¿¿¿¿¿¿¿¿¿¿¿ Cumulative [DIAGNOSES REDACTED].#6 had [DIAGNOSES REDACTED]. The facility Tracking Assessment Flow Sheet for determining the Minimum Data Set assessment revealed the resident had an impaired cognitive status and needed staff assistance for all activities of daily living from 5/27/15 to 6/2/15. Review of the Nursing Admission Assessment for Resident #6 dated 5/27/15 revealed the admitting nurse noted the resident's [DIAGNOSES REDACTED]. The form identified the resident did not ambulate and used a Hoyer lift and wheelchair. The resident's initial care plan identified the resident as a Diabetic Alert with a goal to experience no complications. The interventions called for medications, diet & monitor for symptoms of hyper/[DIAGNOSES REDACTED], glucose scan as ordered, labs as ordered. On 5/27/15 at 12:12 p.m., the nursing home received the faxed physician's orders [REDACTED]. The facility faxed these three pages to the pharmacy at 5:53 p.m. Review of Nurse's Notes dated 5/27/15 revealed Resident #6 had been admitted at 5:20 p.m. on 5/27/15 from another nursing home. The resident arrived with a transfer form and 3 pages of physician orders [REDACTED].>Page 1: [MEDICATION NAME] 20 mg PO (by mouth) daily [MEDICATION NAME] 100 milligrams (mg) (2- 50 mg tabs) PO every morning [MEDICATION NAME] 10 mg PO daily [MEDICATION NAME] 40 mg PO daily [MEDICATION NAME] 2.5 mg PO every Wed and Sat Lisinipril 20 mg PO daily [MEDICATION NAME] HCL 0.2 mgs PO twice daily- hold if SBP (systemic blood pressure) < 110 Page 2: [MEDICATION NAME] 2% 1.5 inch every 12 hours topical ointment - hold if SBP <110. [MEDICATION NAME] 25 mg PO every evening hold if pulse is <60 or SBP < 100. [MEDICATION NAME] 5 mg PO BID. Senna S 8/6.5mg 2 tabs PO twice daily- hold loose stools. [MEDICATION NAME] 17 gram (gm) 1 packet PO twice daily. [MEDICATION NAME] 50 mg give 2 tabs PO twice daily in evening and bedtime. Hydralizine 50 mg give 2 tabs (100 mg) PO three times daily. Tylenol 325 mg 2 tabs PO three times daily. Page 3: [MEDICATION NAME] 400 mg one PO three times daily. [MEDICATION NAME] 0.4 mg PO every bedtime. [MEDICATION NAME] 0.3 mg/day topical patch change weekly on Thursday. [MEDICATION NAME] Suppository 10 mg Daily PRN (as needed) constipation. TUMS 1000 mg every 8 hours (hrs) PO PRN. MOM 30 ml (milliliter) daily PO PRN constipation. Halls cough drops 1 [MEDICATION NAME] PO every 2 hours PRN. Tylenol 325 milligrams (mg) 2 tabs PO BID PRN fever. [MEDICATION NAME] 2 mg PO PRN loose stools. [MEDICATION NAME] gtts (drops) 4 gtts to both ears X 4 days at bedtime, flush on day 5. [MEDICATION NAME] DM 10 CC every 4 hrs. PRN cough. Page 4: Tylenol 325 mg 2 tablets PO BID PRN pain [MEDICATION NAME] 1 mg emergency kit 1 ml SQ PRN for blood sugar (BS) less than (<) 50. Glucose tablet 20 gm PO PRN for [DIAGNOSES REDACTED]- give 5 tabs. [MEDICATION NAME] 100 units/ml inject 35 units SQ (subcutaneous injection) every day. Check BS PRN for hypo/[MEDICAL CONDITION] symptoms. Check BS once daily- notify Doctor if greater than (>)350. Page 5: Contained no orders Page 6: contained non-medication orders Review of the resident's Medication Administration Record [REDACTED]. The MARs and or Treatment sheets for May 2015 to June 2015 showed Resident #6 did not receive the following medications as ordered: Nitrogtlycerin 2% 1.5 inch every 12 hours topical ointment - hold if SBP <110. [MEDICATION NAME] 25 mg PO every evening hold if pulse is <60 or SBP < 100. [MEDICATION NAME] 5 mg PO BID. Senna S 8/6.5mg 2 tabs PO twice daily- hold loose stools. [MEDICATION NAME] 17 gm 1 packet PO twice daily. [MEDICATION NAME] 50 mg give 2 tabs PO twice daily in evening and bedtime. Hydralizine 50 mg give 2 tabs (100 mg) PO three times daily. Tylenol 325 mg 2 tabs PO three times daily. [MEDICATION NAME] 1 mg emergency kit 1 ml SQ PRN for BS< 50. Glucose tablet 20 gm PO PRN for [DIAGNOSES REDACTED]- give 5 tabs. [MEDICATION NAME] 100 units/ml inject 35 units SQ (subcutaneous injection) every day. Check BS PRN for hypo/[MEDICAL CONDITION] symptoms. Check BS once daily- notify Doctor if great than (>) 350. Review of a faxed report to the physician dated 5/27/15 revealed the resident had been admitted with history and physical and medications attached. The faxed noted the resident had [DIAGNOSES REDACTED]. Nurse' s Notes revealed the following entries: On 5/27/15 at 8:15 p.m. (late entry for 5:20 p.m.) resident admit to facility. Medications faxed to pharmacy. Weight 321.6 pounds. On 5/27/15 at 9:45 p.m. Resident polite and cooperative. Alert and oriented times 2-3. Pitting [MEDICAL CONDITION] to right lower extremity. On 5/28/15 at 5:50 a.m. Resident alert and oriented times 3. 5/29/15 at 6:00 p.m. Resident reported and observed to voice negative comments to staff. Continues to not use call light and [MEDICATION NAME] or yells help for staff assistance. On 6/1/15 at 8:00 p.m. Resident refuses staff cares and use of call light- yells out to staff. On 6/5/15 at 7:20 p.m. Resident refuses to eat meal, asking for just water. On 6/6/15 at 1:30 a.m. Resident has slept most of night except times 3. Not comfortable. On 6/8/15 at 3:00 a.m. Resident moans out when needs urinal or incontinency cares. On 6/8/15 at 1:50 p.m. (late entry for 7:30 a.m.) Resident observed on the floor with mechanical lift tipped to the side. The Certified Nurse's Aides (CNAs) reported the lift tipped to the side and Resident #6 had been braced by CNA's legs and lowered to the floor. The resident's vital signs were taken and no sign of injury. Resident verbally denies pain. On 6/8/15 at 9:35 a.m. a clinic orders to transport resident to emergency room for blood sugar as result of a hi (high) blood sugar reading on glucometer. In process of copying MARs and getting resident ready for transfer and noted orders from admitting facility for [MEDICATION NAME] daily and daily blood sugar checks were not done. On 6/8/15 at 10:00 a.m. the resident had been sent out of facility by ambulance. Review of a Medication Error Report dated 6/8/15 documented a transcription error had been made on admission. The duration of the medication error revealed from the date of admit (5/27/15) through discharge to the hospital (6/8/15). The [MEDICATION NAME] 100 units medication had not been given as ordered and the resident ' s blood sugar level/s were not monitored daily (during this time). Resident had a hi (high) glucometer reading of blood sugar. Upon review it was noted the faxed orders did not include all pages of the original orders. On 6/8/15 the facility notified the resident's physician that upon admission several physician's orders [REDACTED]. Review of an emergency room report dated 6/8/15 at 10:20 a.m. documented the resident as unresponsive when admitted to the emergency room and the initial blood sugar (blood glucose) reading of 739 with a normal range of 70-100. The admitting [DIAGNOSES REDACTED]. During an interview with the emergency room physician (ERP) on 8/5/15 at 12:43 p.m. he stated the resident was unresponsive during the course of treatment in the emergency room . He stated typically high levels of blood sugar in the brain causes swelling and this is why the resident was unresponsive to stimuli. The ERP stated the resident's high blood sugar (over 700) and the presence of [MEDICATION NAME] in the urine indicated the resident was in diabetic coma likely due to the omission of the resident's daily insulin over a 13 day period. The physician stated diabetic coma's can lead to (a person's) death, but could not say if this caused Resident #6's death. The physician reported Resident #6 left the emergency room and went to another hospital. Review of a physician discharge summary dated 6/9/15 revealed the resident ' s blood pressure dropped to 84/41. The resident ' s blood pressure improved with a [MEDICATION NAME] drip to 99/70, and then subsequently dropped to 69/40. The [MEDICATION NAME] drip and fluids bolus were restarted with improvements in blood pressure before he/she transferred to a higher level of care hospital. The physician notes revealed the resident was still unresponsive when transferred and the blood sugar level was at 347 at 8:00 a.m., and 12:05 p.m., the resident ' s blood sugar level read 298. The hospital discharge summary with an admission date of [DATE] and discharge date of [DATE] documented during transit the EMS (emergency medical service) found the resident obtunded, hypotensive and in respiratory distress. During the hospital stay, the resident would not wake up, and the family requested his/her (life) support be withdrawn. The resident ' s discharge [DIAGNOSES REDACTED]. Review of the death certificate for Resident #6 dated 6/15/15 stated the immediate cause of death was ischemic stroke (a stroke that develops when a blood vessel supplying blood to an area of the brain becomes blocked by a blood clot). Significant conditions identified included pneumonia,[MEDICAL CONDITION], and acute [MEDICAL CONDITION]. During an interview on 8/6/15 at 3:00 p.m. with Staff A, Licensed Practical Nurse (LPN), she stated on 6/8/15, she was the floor nurse for Resident #6. Staff A stated she completed a head to toe assessment of the resident and took vital signs after the mechanical lift incident. The LPN stated the resident verbalized complaints of pain in the back and arm. She stated she checked the resident's responsiveness a short time later (Staff A was unsure of the time) and the resident did not respond to any stimuli except a sternal rub and the response was to open his/her eyes. The LPN contacted the Director of Nursing (DON) and she instructed her to check the resident's blood sugar. The blood sugar glucometer read hi (high) and she reported this to the physician and sent him/her to the ER as ordered. Staff A stated she was unaware of the diabetic status of the resident. She stated if she had known the resident was diabetic upon admission she would have checked to see if there were orders for blood sugars or insulin. During an interview with Staff F, (LPN) on 8/7/15 at 11:30 a.m., she reported the LPNs don't do all the admitting orders. Staff F reported when she had transcribed medications orders, she always had the orders checked by another nurse. Staff F reported she would have looked for the blood sugar orders and if no orders would have called the physician. During interviews with the facility Director of Nursing (DON) on 8/4/15 at 2:00 p.m., 8/5/15 at 11:55 a.m., and 8/7/15 at 8:00 a.m., she stated she was the nurse who received 3 pages of faxed orders from the transferring nursing home on 5/27/15 for Resident #6. The DON stated she did not note at that time that the bottom section of three faxed pages which indicated there were 6 pages of physician's orders [REDACTED]. She stated Resident #6 brought the original orders with him/her at the time of transfer but she did not check the original orders against the faxed orders. The DON stated the insulin, as well as multiple other medications were omitted from the resident's MARs. The DON stated prior to the incident, the facility checklist for admission required a nurse to note and transcribed admission orders [REDACTED]. For Resident #6, the DON transcribed the orders herself and did not have a second nurse double check the orders. She stated she had never received orders before that were printed on both front and back of the pages and this was why she did not realize the orders were missing. She stated she should have double checked the original orders brought with the resident at time of transfer against the faxed orders. She stated the resident did not exhibit any symptoms of high blood sugar except a gradual increase in fatigue. The DON stated on 6/8/15 when Resident #6 had been lowered to the ground after mechanical lift tipped to the side she had been informed the resident experienced an altered level of consciousness. She instructed the charge nurse to check the resident's blood sugar. When the charge nurse checked his/her blood sugar with the glucometer, the reading indicated hi (high) which means the blood sugar is above 700. The resident was sent to the emergency room for evaluation. The DON stated she did not have a written policy for transcription of orders prior to 6/8/15. Instead staff used the Nursing Admission Checklist which listed tasks for the staff to complete at the time or soon after admission of a resident. One of the tasks on the list was to double check medications against the orders and to check accuracy of the MAR. Nurses were to document completion of this task by checking the task off on the flow sheet and by placing their initials by the checkmark. The DON acknowledged that the Nursing Admission Checklist for Resident #6 dated 5/27/15 revealed the above task was not completed as evidenced by lack of checkmark or initial on the flow sheet. The DON stated she had initiated a new written policy that requires all nurses to have another nurse double check all admission orders [REDACTED]. She stated she is revising the Nursing Admission Checklist to be more specific. The facility abated the IJ on 6/8/15, when the DON created a new admission order process to double check all admissions/re-admission orders [REDACTED]. The DON would now request another nurse validate the physician's orders [REDACTED]. On 6/8/15, a new written process indicated the following: effective 6/8/15, upon admission or re-admission a checklist shall be completed for each resident. Each item will be initialed by the nurse completing the task. The nurse who transcribed orders will sign off upon completion. The Director of Nursing or designee will perform a second check to review that the orders have been correctly transcribed and signed off on the checklist. This information had been shared with nurses. On 8/10/15, the facility also re-educated nursing staff (LPNs and RNs) at the in-service of this written procedure. These actions lower the immediate jeopardy from a J severity to a D with the need for ongoing monitoring of the admission/re-admission checklist to ensure orders are transcribed as ordered.

Based on record review, staff interviews and review of the facility adult abuse policy/procedures, the facility failed to report and thoroughly investigate allegations of resident to resident abuse and provide interventions to keep the residents safe and others living in the CCDI (Chronic Confusion or a Dementing Illness) unit. Record review and staff interviews established Resident #1 had multiple incidents of physical aggression, combative behaviors or agitation towards other residents, however, the facility failed to thoroughly investigate theses incidents and implement interventions to protect other residents from abuse. The record identified Resident #1 as verbally and physically abusive to staff. Although there is no requirement to report resident to staff abuse, the facility staff were aware of the resident's capabilities to abuse other residents. Record review identified incidents of resident to resident abuse, however, the facility did not report these incidents to the Department until a 2/10/15 incident occurred. Concerns were identified but not limited to Residents #1. Other residents involved were Resident (#2, #3, #4, #5, #6, #7, #8, #9, #10 and #11). The findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 2/17/15. The MDS reflected Resident #1 had an admitted into the facility on [DATE] and had impaired short term memory and moderately impaired cognitive skills for daily decision making. Resident #1 was independently mobile in the facility and required supervision from staff when ambulating. The MDS reflected the resident required extensive assistance from staff for dressing, toilet use and personal hygiene and experienced incontinent episodes of bowel and bladder. The MDS identified the resident experienced behaviors of rejecting care 4-6 days a week and wandered each day. The MDS identified Resident #1's behavior did not include physical behavior directed towards others (e.g. hitting) or verbal behavior symptoms directed toward others (e.g. threatening, screaming, cursing) as indicated in his/her clinical record. Review of the Care Plan, with a start date of 10/8/14, identified a problem/need for behaviors/altered coping. The resident had resident to resident altercations, aggression, combative, wandering, verbalizing intent to harm self or others and threats to hit staff. The resident resisted cares, becomes combative, especially when toileting, changing clothes or showering, hollering and verbalizes an intent to elope. Review of the included interventions, directed staff to: Assess the resident for change in condition/function, notify physician, assess for contributing factors for behavior, obtain laboratory tests as ordered, administer medications as ordered, review medications, observe for side effects of psychoactive medications, move resident to a quiet area to deescalate behavior and involve family to assist with interventions effective in the past. The interventions also included and directed staff to obtain a psychological consult (none completed), provide diversion activities (none listed), provide 1 to 1 activities (no know activities scheduled), change room if indicated (no date or rationale listed), encourage increased activity involvement per the resident ' s preference, increased supervision (no date, no formal plan), stop signs on doorway (not used), report behavior to the physician daily until further notice (no start date or stop date). The nursing notes reflected the following: On 9/25/14 at 1:30 p.m. the resident arrived to the facility at 10:15 a.m. per personal vehicle and accompanied by spouse and daughter. The resident seemed pleasantly confused. At 12:50 p.m. (9/25/14) the resident had increased agitation and displayed wandering near the exits. The staff attempted to place a Wanderguard device on the resident. The resident became angry and grabbed the CNA (Certified Nursing Assistant) by both wrists. The nurse attempted to remove the resident's fingers from the staff ' s wrist. The resident yelled and kicked the staff member in the right shin. The resident let go and staff escorted the resident to the secured CCDI (chronic confusion or a dementing illness), referred to as The Lodge. On 9/26/14 at 3:30 p.m., 2 CNAs assisted the resident with a shower. The CNA's were yelling for help. The nurse and DON (Director of Nursing) entered the shower room to observe the resident holding both CNAs with extreme force by their arms. The resident had increased agitation. The resident was verbally and physically abusive to the nurse and other help trying to assist the resident with a shower. The resident did not receive a full shower due to the agitation. The notes reflected the resident received [MEDICATION NAME] ([MEDICATION NAME]) (the physician had ordered [MEDICATION NAME]-[MEDICATION NAME]) for the increased agitation. On 9/28/14 at 7:30 p.m. the resident had agitation and verbally and physically abusive towards staff due to the resident needing assistance with cares. The resident was not cooperative and cursed, hit, pinched and squeezed staff that tried assisting. The nurse administered IM [MEDICATION NAME] (antipsychotic) at 6:30 pm. And then IM [MEDICATION NAME] at 6:45 p.m. Resident to Resident Incident #1: On 9/30/14 at 4:50 p.m. Resident #1 had Resident #4 pinned forcefully up against the wall by holding his/her hands and pushing on Resident #4's abdomen. . A nurse intervened. The resident said verbal abusive words towards Resident#4 and the staff. The resident then let go of Resident #4 after prompting and grabbed the nurse around the neck for a brief second and then grabbed the nurse ' s both forearms and squeezed until the DON was able to detain the situation. Following the incident, the nurse contacted the family to discuss other placement, such as a behavioral unit. At 5:25 p.m., the physician determined medication adjustments could be done within the facility. The physician increased the [MEDICATION NAME] to 2 mg IM every ? hour and increased [MEDICATION NAME] to 50 milligrams twice a day if behaviors increase or becomes combative to send to the hospital emergency room for an evaluation and treatment. Resident to Resident Incident #2 On 9/30/14 at 8:30 p.m. the resident sat in the dining area wearing only a brief (inside out). The staff tried to assist the resident with this but was told if he did not leave him/her alone, would be popped square in the nose. On 10/1/14 at 1:30 p.m. (Late entry for 12:55 pm) the physician was notified of current condition. [MEDICATION NAME] decreased to 1 milligram every ? hour as needed for agitation. On 10/7/14 at 8:15 p.m. the resident paced, going in and out of resident rooms. At 9:55 p.m., the resident in another resident's room and staff removed the resident. On 10/10/14 at 5:15 p.m., the resident was in another resident ' s room closet. Staff tried to redirect the resident and the resident went to the bed where another resident laid. Resident #1 started moving the other resident ' s legs. At 8:30 p.m., the resident continues wandering in and out of other resident rooms. On 10/11/14 at 8:10 p.m. many other residents are getting upset due to the Resident#1 ' s agitation and complains concern for their and staff safety. On 10/14/14 at 6:05 p.m., the resident noted to be in another resident ' s room. The CNA attempted to assist resident and Resident #1 became agitated and started to forcefully grab the CNA ' s wrist and attempted to hit the CNA. Another nurse intervened. On 10/17/14 at 4:30 a.m., the resident wandered into another resident ' s room and awakened the resident. The CNA attempted to get the resident out of the room and he/she grabbed the CNA ' s left hand squeezing 3-5 digits and twisting. The CNA got away from the resident and started up the hall. The resident, naked, starting running after the CNA. A nurse entered the CCDI unit at that time and the resident grabbed the nurse ' s hand, squeezed and would not release. It took 3 staff to get the pull up (brief) on the resident. On 10/18/14 at 6:30 p.m., the resident wandering in halls, dining area and into other resident rooms. The resident only aggressive when needs to have brief changed. Resident to Resident Incident #3 On 10/20/14 at 6:05 p.m. the resident was aggressive with another resident and hit her on the right side of the face and neck. The staff removed the resident and the resident continued to wander and pace the hallways and unaware of what he had done. The staff notified the physician at 6:20 p.m. and the physician ordered [MEDICATION NAME] ([MEDICATION NAME]) 10 milligrams every a.m. At 6:50 p.m., the family did not want the medication ordered. On 10/23/14, the family agreed to have the medication. Resident to Resident Incident #4 On 11/3/14 at 7:00 p.m. Resident #1 was discovered in another resident's room patting and squeezing the head of the other resident as he/she slept. Resident to Resident Incident #5 On 11/20/14 at 6:15 p.m. Resident #6 reported to the nurse that Resident #1 had smacked him/her while in his/her room. Resident to Resident Incident #6 On 11/22/14 at 4:00 p.m. the nurse was called to the hallway at 3:00 p.m. and found Resident #1 lying on the floor. The staff reports a resident to resident altercation where Resident #7 claimed Resident #1 entered their room (107) and hit Resident #8 and Resident #7 shoved Resident #1 when he/she raised his/her fist. Resident to Resident Incident #7 On 12/5/14 at 4:55 p.m. Resident #1 laid on the sofa and Resident #9 stood over him/her. Resident #1 reached up and grabbed Resident #9's wrist and Resident #9 smacked Resident #1. The staff separated the resident. On 1/4/15 at 5:45 p.m. Resident #1 was observed as having increased agitation and rocking back and forth as another resident started to stand from a nearby recliner. The resident ' s seen pushing Resident #1's hands away. Staff separated the two residents without further incident. Resident to Resident Incident #8 On 1/17/15 at 6:45 p.m. Resident #1 was observed striking Resident #3. The residents were separated and there were no injuries noted. Resident to Resident Incident #9 On 1/18/15 at 2:05 p.m. indicated Resident #1 entered the room of Resident #2 and had a physical altercation. Resident #1 was found on the floor grabbing the resident's (Resident#2's) legs. Resident #1 sustained a contusion to his/her right eye area and bruising around the left temple area. The temple area measured 2.5 by 2.5. cm (centimeters). Inside the bruised contusion area measured .2 by .2 cm. Residents separated. Resident to Resident Incident #10 On 1/27/15 at 9:45 a.m., the resident became very upset this a.m. Resident ambulated down the hall after breakfast and another resident asked Resident #1 for a coat he/she was carrying. Resident #1 swung at the other resident. The other resident did not get touched and Resident #1 backed away. Resident #1 went on down hallway and tried to open a door when the nurse grabbed the door handle. The resident swung at the nurse but did not touch the nurse. At 4:45 p.m. Resident #1 had increased agitation and raised voice at other residents when the residents walked past Resident #1. Resident to Resident Incident #11 On 1/29/15 at 12:45 p.m. Resident #1 walked down the hall with a throw pillow. Resident #10 had a hold of Resident #1 ' s left and she/he yelled at Resident #1. Before the nurse approached the residents, Resident #1 had smacked the top of Resident #10 ' s head, palm down, three times before staff stopped the resident. The nurse separated the residents. No injury reported to Resident #10. Resident #1 sustained skin tears nail marks and bruising where Resident #10 had grabbed him/her. Resident to Resident Incident #12 On 2/1/15 at 12:15 p.m. Resident #1 was attempting to strike Resident #11, when Resident #7 pushed Resident #1 up against the wall. On 2/8/15 at 1:45 p.m., the staff awakened the resident because the spouse arrived at the facility to visit. The resident kicked the spouse in the abdomen, knocking the spouse back on feet. Staff walked the resident to the family room and now sat with spouse quietly. Resident to Resident Incident #13 On 2/10/15 at 10:00 a.m. Staff A heard yelling from Resident #2's room. Staff A discovered Resident #2 on top of Resident #1 in the closet. Staff A stated it appeared as if Resident #2 held Resident #1 down. The residents were separated. Resident #1 had abrasion on back which measured 5.5 cm. by 7 cm. and an area on side which measured 3 by 2 cm. and .3 by .2 cm. On 3/9/15 at 1:00 p.m. the Administrator was interviewed and stated she had not reported the resident to resident altercations to the Department until the event of 2/10/15. The previous resident to resident altercations were not reported. In an interview on 3/2/15 at 3:00 p.m. Staff A, Licensed Practical Nurse/Lodge Director, stated Resident #1 has dementia, is very confused and can become combative when staff attempt to provide cares. Staff A stated Resident #1 has also been in multiple altercations with other residents. Some altercations occur when other residents invade Resident #1's space and at other times when Resident #1 enter other resident rooms and gets confronted by residents in that room. Staff A noted either way, Resident #1 often becomes aggressive. Staff A stated excessive stimulation can also escalate Resident #1 and when they see him/her escalate they separate him/her from others and try to redirect. Staff A stated the staff have tried several medications, but most of them seemed to escalate his/her behavior. Since discontinuing the use of most of the medication, Resident #1 seems much better, especially in the last two weeks. Other interventions included placing him/her on 15 minute checks, moving him/her into a room where he/she tended to wander and the removing of two residents from the unit who tended to confront Resident #1 and create conflict. In a follow up interview on 3/3/15 at 1:20 p.m. Staff A stated there are only two staff assigned on the unit for 16 residents and feels this is inadequate to properly meet the needs of the residents and provide Resident #1 with proper supervision. Staff A admitted despite having Resident #1 on 15 minute checks, his/her whereabouts are often unknown in between checks as he/she wanders frequently throughout the unit and goes into other resident rooms. Staff A stated she does not take breaks because she feels it is unsafe to leave one person alone on the unit. If she does have to leave, she makes it brief and returns as quickly as she can. Staff A stated she has experience working in the dementia units and it takes three staff to adequately supervise and provide cares for residents. Staff A stated there are frequent times in which it takes two to three staff to provide cares for Resident #1 and during that time there is no one available to supervise the other residents. Staff A stated on the morning of 2/10/15, she had just sent the aide on break, just 5 minutes earlier when she heard yelling in Resident #2's room. Staff A ran to the room and found Resident #2 on top of Resident #1 in the closet. Resident #2 pinned Resident #1 on the ground. Staff A yelled at the housekeeper, on the unit at the time, to get help. Meanwhile Staff A attempted to separate Resident #2 and Resident #1, but was unable to given their size. Staff A stated she asked Resident #7 to help and together they were able to separate the residents. Staff A admitted that she was unaware Resident #1 had wandered into Resident #2's room. In an interview on 3/3/15 at 12:45 p.m. Staff B, Certified Nurse Aide, stated she works the day shift on the CCDI unit and finds the staffing to be inadequate. Staff B noted there are times (i.e.: meals, morning cares) in which two staff cannot provided adequate care and supervision for 16 residents. Staff B stated Resident #1 wanders in and out of resident rooms all day unnoticed by staff. Staff B admits they are to know his/her whereabouts, but it is not possible with two staff as other residents require care and assistance. Staff B stated Resident #1 is currently as good as he/she has ever been with regards to being calmer and easier to manage, but continues to wander in other resident rooms when staff ' s attention is elsewhere. Staff B also stated Resident #1 often requires two staff to provide cares, which then leaves no one to supervise the other residents. Staff B stated she does not take a lunch break and takes other short breaks, returning as fast as she can. In an interview on 3/3/15 at 2:20 p.m. Staff C, Licensed Practical Nurse, stated she has worked at the facility since September 2014 and is familiar with Resident #1. Staff C stated Resident #1 has always had behaviors, especially when staff are trying to provide cares. Resident #1 can become combative and aggressive quickly. Resident #1 has also been known to get in altercations with other residents. Staff C noted that all staff are to know his/her whereabouts and when he/she wanders into other resident rooms; staff are to redirect him/her from the room. Resident #1 is also on 15 minute checks. Staff C knew of no other interventions to keep Resident #1 supervised and other residents safe. Staff C stated there is one nurse and one aide on the evening shift and stated that was inadequate staffing to meet the needs of the residents. Staff C also stated that at least twice a shift, two to three staff are required to provide cares for Resident #1 and during those times there is no one available to monitor or supervise the other residents. Staff C noted Resident #1 has had fewer altercations lately, but continues to enter into other resident rooms. Staff C stated they try to take 30 minute lunch breaks and when they do it only leaves one staff available to supervise the residents. In an interview on 3/3/15 at 2:54 p.m. Staff D, Certified Nurse Aide, stated she is familiar with Resident #1. Resident #1 can become combative with cares and has had altercations with other residents. Staff D noted Resident #1 is on 15 minute checks and staff should know his whereabouts at all times. If Resident #1 goes into another resident room, he/she is to be escorted out. If Resident #1 becomes escalated, staff are to separate him/her from other residents and attempt to calm him/her. Staff D admits it often takes two to three people to change Resident #1, leaving no one to supervise the other residents. Staff D also admitted smoke breaks and meal breaks also leaves only one person to supervise. Staff D stated she believes it takes three people on the unit to provide adequate care and supervision. The facility policy/procedures titled: Resident has the right to be free from abuse from one another, dated 4/02, directed the staff if a resident strikes out, injuries another resident, or displays unpredictable, violent behavior that endangers the safety of others then the following steps should be taken: 1. The residents will immediately removed from each other to a safe area. 2. Monitoring of the resident at potential for harm to others will be monitored closely for the next 24 hours. 3. A head to toe assessment of each resident involved will be done and documented in each resident's clinical record. 4. The resident's physician and families will be notified and if an investigation is needed and will be again notified at the completion of the investigation. 5. Quality Assurance and a monitoring tools will be filled out and given to the DON (Director of Nursing). 6. The situation will be investigated in an attempt to determine the causative factors such as provocation, misinterpretation, etc. 7. If not already in place and assessment indicates need, psychiatric or psychological consultation/services will be requested. 8. The care plan team will update the care plan dealing with resident behavior and interventions. 9. As part of the overall plan of care, assessment of contributing factors should be explored: precipitating factors, pattern of behavior, environmental factors such as time of day, over or under stimulation, noise, staff, etc, and physical causes such as illness, infection, dehydration, constipation, medication toxicity or side effects, or pain. On 3/9/15 at 1:00 p.m. the Administrator was interviewed and stated she had not reported the resident to resident altercations until the event of 2/10/15. The previous resident to resident altercations were not reported. Note: At the time of the complaint investigation, the deficiency was coded at a "K", immediate and serious jeopardy. By 2/11/15, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the "E" level. Although the facility had not reported incidents of resident to resident altercations until the incident on 2/10/15, in which the facility reported on 2/11/15, the facility had policy/procedures in place for abuse investigation, notification, and interventions. As of the 3/12/15 exit conference, the facility needed to: ? continue to educate the staff and implement the facility abuse policy/procedures. ? continue to report incidences of abuse to the Iowa Department of Inspections & Appeals immediately (within 24 hours). ? monitoring of staff to ensure the facility abuse policy/procedures are being implemented.

This deficiency relates to self reported incident -I Based on observation, record review, staff and resident interviews, the facility failed to provide adequate supervision related to resident to resident altercations. Record review established Resident #1 showed aggressive behaviors including striking out to residents (#2, #3, #4, #5, #6, #7, #8, #9, #10 and #11) and staff members. The facility reported the census as 44 residents. The sample consisted of 11 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 2/17/15. The MDS reflected Resident #1 had an admitted into the facility on [DATE] and had impaired short term memory and moderately impaired cognitive skills for daily decision making. Resident #1 was independently mobile in the facility and required supervision from staff when ambulating. The MDS reflected the resident required extensive assistance from staff for dressing, toilet use and personal hygiene and experienced incontinent episodes of bowel and bladder. The MDS identified the resident experienced behaviors of rejecting care 4-6 days a week and wandered each day. The MDS identified Resident #1's behavior did not include physical behavior directed towards others (e.g. hitting) or verbal behavior symptoms directed toward others (e.g. threatening, screaming, cursing) as indicated in his/her clinical record. Review of the Care Plan, with a start date of 10/8/14, identified a problem/need for behaviors/altered coping. The resident had resident to resident altercations, aggression, combative, wandering, verbalizing intent to harm self or others and threats to hit staff. The resident resisted cares, becomes combative, especially when toileting, changing clothes or showering, hollering and verbalizes an intent to elope. Review of the included interventions, directed staff to: Assess the resident for change in condition/function, notify physician, assess for contributing factors for behavior, obtain laboratory tests as ordered, administer medications as ordered, review medications, observe for side effects of psychoactive medications, move resident to a quiet area to deescalate behavior and involve family to assist with interventions effective in the past. The interventions also included and directed staff to obtain a psychological consult (none completed), provide diversion activities (none listed), provide 1 to 1 activities (no know activities scheduled), change room if indicated (no date or rationale listed), encourage increased activity involvement per the resident ' s preference, increased supervision (no date, no formal plan), stop signs on doorway (not used), report behavior to the physician daily until further notice (no start date or stop date). The Nurse ' s Notes reflected the following: On 9/25/14 at 1:30 p.m. the resident arrived to the facility at 10:15 a.m. per personal vehicle and accompanied by spouse and daughter. The resident seemed pleasantly confused. At 12:50 p.m. (9/25/14) the resident had increased agitation and displayed wandering near the exits. The staff attempted to place a Wanderguard device on the resident. The resident became angry and grabbed the CNA (Certified Nursing Assistant) by both wrists. The nurse attempted to remove the resident's fingers from the staff ' s wrist. The resident yelled and kicked the staff member in the right shin. The resident let go and staff escorted the resident to the secured CCDI (chronic confusion or a dementing illness), referred to as The Lodge. On 9/26/14 at 9:00 p.m. the resident refused to be assisted with night cares and pacing. The physician was contacted. At 10:35 p.m. the physician ordered Haldol (antipsychotic) 1 mg (milligram) IM (intramuscular) injection every half hour but not to exceed 5 times in 24 hours and to notify the physician otherwise. The physician ordered Ativan (antianxiety) 1mg every 3 hours IM both for increased agitation/anxiety, Flomax (for urination due to prostatic hyperplasia (increased amount of cells growth) 0.4 mg twice a day and Lexapro (antidepressant) 5 mg tablet daily and Seroquel (antipsychotic) 25 mg twice a day. On 9/26/14 at 3:30 p.m., 2 CNAs assisted the resident with a shower. The CNA's were yelling for help. The nurse and DON (Director of Nursing) entered the shower room to observe the resident holding both CNAs with extreme force by their arms. The resident had increased agitation. The resident was verbally and physically abusive to the nurse and other help trying to assist the resident with a shower. The resident did not receive a full shower due to the agitation. The notes reflected the resident received diazepam (valium) (the physician had ordered Ativan-Lorazapam) for the increased agitation. On 9/28/14 at 7:30 p.m. the resident had agitation and verbally and physically abusive towards staff due to the resident needing assistance with cares. The resident was not cooperative and cursed, hit, pinched and squeezed staff that tried assisting. The nurse administered IM Haldol (antipsychotic) at 6:30 pm. And then IM Ativan at 6:45 p.m. On 9/30/14 at 4:50 p.m. Resident #1 had Resident #4 pinned forcefully up against the wall by holding his/her hands and pushing on Resident #4's abdomen. A nurse intervened. The resident said verbal abusive words towards Resident#4 and the staff. The resident then let go of Resident #4 after prompting and grabbed the nurse around the neck for a brief second and then grabbed the nurse ' s both forearms and squeezed until the DON was able to detain the situation. Following the incident, the nurse contacted the family to discuss other placement, such as a behavioral unit. At 5:25 p.m., the physician determined medication adjustments could be done within the facility. The physician increased the Haldol to 2 mg IM every ? hour and increased Seroquel to 50 milligrams twice a day if behaviors increase or becomes combative to send to the hospital emergency room for an evaluation and treatment. On 9/30/14 at 8:30 p.m. the resident sat in the dining area wearing only a brief (inside out). The staff tried to assist the resident with this but was told if didn ' t leave him/her alone, would be popped square in the nose. On 10/1/14 at 1:30 p.m. (Late entry for 12:55 pm.) the physician was notified of current condition. Haldol decreased to 1 milligram every ? hour as needed for agitation. On 10/2/14 at 8:00 a.m. the resident had increased aggressive behavior and combative with ADL ' s (Activity of Daily Living) cares. A variety of approaches attempted by 1 to 4 staff. Resident refused numerous times. Staff gave the Ativan IM to the resident. The Ativan was ineffective. The resident thrashes, kicking, spitting and hitting at staff. The resident head butted the CNA during cares. On 10/7/14 at 8:15 p.m. the resident paced and wandered in and out of resident rooms. At 9:55 p.m., the resident was located in another resident ' s room and staff removed the resident. On 10/8/14 at 1:30 p.m. a male CNA and 2 female staff attempted to put the shirt on the resident and he/she punched the male CNA in the mouth. The resident then laughed and said " I didn ' t hit you hard (expletive) " . At 2:10 p.m. a CNA gave the resident a snack and when she turned, the resident placed hands on the CNA ' s back. The resident stated " I ' m finishing what I started earlier " . At 2:25 p.m., the resident continued to be agitated and wandering around carrying a belt. The Administrator reported observing the resident placing the belt around his/her neck and tightening just prior to placing the belt on the table. On 10/10/14 at 5:15 p.m., the resident was in another resident ' s room closet. Staff tried to redirect the resident and the resident went to the bed where another resident laid. Resident #1 started moving the other resident ' s legs. At 8:30 p.m., the resident continues wandering in and out of other resident rooms. On 10/11/14 at 8:10 p.m. many other residents are getting upset due to Resident#1 ' s agitation and voices concern for their and staff safety. On 10/14/14 at 6:05 p.m., the resident noted to be in another resident ' s room. The CNA attempted to assist the resident and Resident #1 became agitated and started to forcefully grab the CNA ' s wrist and attempted to hit the CNA. Another nurse intervened. On 10/17/14 at 4:30 a.m., the resident wandered into another resident ' s room and awakened the resident. The CNA attempted to get the resident out of the room and he/she grabbed the CNA ' s left hand squeezing 3-5 digits and twisting. The CNA got away from the resident and started up the hall. The resident, naked, starting running after the CNA. A nurse entered the CCDI unit at that time and the resident grabbed the nurse ' s hand, squeezed and would not release. It took 3 staff to get the pull up (brief) on the resident. On 10/18/14 at 6:30 p.m., the resident wandered in the halls, dining area and into other resident rooms. The resident became only aggressive when needed to have brief changed by staff. On 10/20/14 at 6:05 p.m. the resident became aggressive with another resident and hit her on the right side of the face and neck. The staff removed the resident and the resident continued to wander and pace the hallways and unaware of what he/she had done. The staff notified the physician at 6:20 p.m. and the physician ordered Medroxprogesterone (progesterone) 10 milligrams every a.m. At 6:50 p.m., the family did not want the medication ordered. On 10/23/14, the family agreed to have the medication ordered and be administered. The Nurse ' s Notes continue to reflect the following: On 11/3/14 at 7:00 p.m. Resident #1 was discovered in another resident's room patting and squeezing the head of the other resident as he/she slept. On 11/11/14 at 7:25 p.m. a family member notified the facility and stated the facility needed to follow the medication list from the hospital (returned from hospital on [DATE]). The family member did not want any as needed medication administered and did not want the resident ' s physician to " mess " with the medication. On 11/20/14 at 6:15 p.m. Resident #6 reported to the nurse that Resident #1 had smacked him/her while in his/her room. On 11/22/14 at 4:00 p.m. the nurse was called to the hallway at 3:00 p.m. and found Resident #1 lying on the floor. The staff reports a resident to resident altercation occurred. Resident #7 claimed Resident #1 entered their room (107) and hit Resident #8 and Resident #7 shoved Resident #1 when he/she raised his/her fist. On 12/5/14 at 4:55 p.m. Resident #1 laid on the sofa and Resident #9 stood over him/her. Resident #1 reached up and grabbed Resident #9's wrist and Resident #9 smacked Resident #1. The staff separated the resident. On 12/29/14 at 6:40 p.m. the nurse received an order from the physician to discontinue the Lexapro and Seroquel medication. On 1/4/15 at 5:45 p.m. Resident #1 was observed as having increased agitation and rocking back and forth as another resident started to stand from a nearby recliner. The resident was seen pushing Resident #1's hands away. Staff separated the two residents without further incident. On 1/17/15 at 6:45 p.m. Resident #1 was observed striking Resident #3. The residents were separated and there were no injuries noted. On 1/18/15 at 2:05 p.m. Resident #1 entered the room of Resident #2 and had a physical altercation. Resident #1 was found on the floor grabbing the legs of Resident #2. Resident #1 sustained a contusion to his/her right eye area and bruising around the left temple area. The temple area measured 2.5 by 2.5. cm (centimeters). Inside the bruised contusion area measured .2 by .2 cm. Staff separated the residents. On 1/22/15 at 8:20 p.m., the resident went into another room and broke the toilet causing minor flooding of the room. Fifteen minute checks continue. At 10:15 p.m. the staff (CNA and Nurse) attempted to provide HS (bedtime) cares. The resident became agitated and kicked the nurse. Several more attempts by various staff resulted in an increase of violent behaviors toward staff. On 1/24/15 at 3:30 p.m. the resident had increased agitation and getting very close to other residents " in their face " and being very rude. Very aggressive with staff when tried to redirect several times and the resident seemed " angry " with other residents. On 1/27/15 at 9:45 a.m., the resident became very upset this a.m. Resident ambulated down hall after breakfast and another resident asked Resident #1 for a coat he/she was carrying. Resident #1 swung at the other resident. The other resident did not get touched and Resident #1 backed away. Resident #1 went on down hallway and tried to open a door when the nurse grabbed the door handle. The resident swung at the nurse but did not touch the nurse. At 4:45 p.m. Resident #1 had increased agitation and raised voice at other residents when the residents walked past Resident #1. On 1/29/15 at 12:45 p.m. Resident #1 walked down the hall with a throw pillow. Resident #10 had a hold of Resident #1 ' s left elbow and she/he yelled at Resident #1. Before the nurse approached the residents, Resident #1 had smacked the top of Resident #10 ' s head, palm down, three times before staff stopped the resident. The nurse separated the residents. No injury reported to Resident #10. Resident #1 sustained skin tears nail marks and bruising where Resident #10 had grabbed him/her. On 2/1/15 at 12:15 p.m. Resident #1 was attempting to strike Resident #11, when Resident #7 pushed Resident #1 up against the wall. On 2/8/15 at 1:45 p.m., the staff awakened the resident because the spouse arrived at the facility to visit. Resident kicked the spouse in the abdomen, knocking the spouse back on feet. Staff walked the resident to the family room and now sat with spouse quietly. On 2/10/15 at 10:00 a.m. Staff A heard yelling from Resident #2's room. Staff A discovered Resident #2 on top of Resident #1 in the closet. Staff A stated it appeared as if Resident #2 held Resident #1 down. The residents were separated. Resident #1 had abrasion on back which measured 5.5 cm. by 7 cm. and an area on side which measured 3 by 2 cm. and .3 by .2 cm. On 2/24/15 at 1:00 p.m. the resident ambulated up and down the hallway and in and out of rooms. On 3/1/15, the physician ordered an increase in Aricept (used to treat dementia/Alzheimer ' s disease) to 10 milligrams. In an interview on 3/2/15 at 3:00 p.m. Staff A, Licensed Practical Nurse/Lodge Director, stated Resident #1 has dementia, is very confused and can become combative when staff attempt to provide cares. Staff A stated Resident #1 has also been in multiple altercations with other residents. Some altercations occur when other residents invade Resident #1's space and at other times when Resident #1 enter other resident rooms and gets confronted by residents in that room. Staff A noted either way, Resident #1 often becomes aggressive. Staff A stated excessive stimulation can also escalate Resident #1 and when they see him/her escalate they separate him/her from others and try to redirect. Staff A stated the staff have tried several medications, but most of them seemed to escalate his/her behavior. Since discontinuing the use of most of the medication, Resident #1 seems much better, especially in the last two weeks. Other interventions included placing him/her on 15 minute checks, moving him/her into a room where he/she tended to wander and the removing of two residents from the unit who tended to confront Resident #1 and create conflict. In a follow up interview on 3/3/15 at 1:20 p.m. Staff A stated there are only two staff assigned on the unit for 16 residents and feels this is inadequate to properly meet the needs of the residents and provide Resident #1 with proper supervision. Staff A admitted despite having Resident #1 on 15 minute checks, his/her whereabouts are often unknown in between checks as he/she wanders frequently throughout the unit and goes into other resident rooms. Staff A stated she does not take breaks because she feels it is unsafe to leave one person alone on the unit. If she does have to leave, she makes it brief and returns as quickly as she can. Staff A stated she has experience working in the dementia units and it takes three staff to adequately supervise and provide cares for residents. Staff A stated there are frequent times in which it takes two to three staff to provide cares for Resident #1 and during that time there is no one available to supervise the other residents. Staff A stated on the morning of 2/10/15, she had just sent the aide on break, just 5 minutes earlier when she heard yelling in Resident #2's room. Staff A ran to the room and found Resident #2 on top of Resident #1 in the closet. Resident #2 pinned Resident #1 on the ground. Staff A yelled at the housekeeper, on the unit at the time, to get help. Meanwhile Staff A attempted to separate Resident #2 and Resident #1, but was unable to given their size. Staff A stated she asked Resident #7 to help and together they were able to separate the residents. Staff A admitted that she was unaware Resident #1 had wandered into Resident #2's room. In an interview on 3/3/15 at 12:45 p.m. Staff B, Certified Nurse Aide, stated she works the day shift on the CCDI unit and finds the staffing to be inadequate. Staff B noted there are times (i.e.: meals, morning cares) in which two staff cannot provided adequate care and supervision for 16 residents. Staff B stated Resident #1 wanders in and out of resident rooms all day unnoticed by staff. Staff B admits they are to know his/her whereabouts, but it is not possible with two staff as other residents require care and assistance. Staff B stated Resident #1 is currently as good as he/she has ever been with regards to being calmer and easier to manage, but continues to wander in other resident rooms when staff ' s attention is elsewhere. Staff B also stated Resident #1 often requires two staff to provide cares, which then leaves no one to supervise the other residents. Staff B stated she does not take a lunch break and takes other short breaks, returning as fast as she can. In an interview on 3/3/15 at 2:20 p.m. Staff C, Licensed Practical Nurse, stated she has worked at the facility since September 2014 and is familiar with Resident #1. Staff C stated Resident #1 has always had behaviors, especially when staff are trying to provide cares. Resident #1 can become combative and aggressive quickly. Resident #1 has also been known to get in altercations with other residents. Staff C noted that all staff are to know his/her whereabouts and when he/she wanders into other resident rooms; staff are to redirect him/her from the room. Resident #1 is also on 15 minute checks. Staff C knew of no other interventions to keep Resident #1 supervised and other residents safe. Staff C stated there is one nurse and one aide on the evening shift and stated that was inadequate staffing to meet the needs of the residents. Staff C also stated that at least twice a shift, two to three staff are required to provide cares for Resident #1 and during those times there is no one available to monitor or supervise the other residents. Staff C noted Resident #1 has had fewer altercations lately, but continues to enter into other resident rooms. Staff C stated they try to take 30 minute lunch breaks and when they do it only leaves one staff available to supervise the residents. In an interview on 3/3/15 at 2:54 p.m. Staff D, Certified Nurse Aide, stated she is familiar with Resident #1. Resident #1 can become combative with cares and has had altercations with other residents. Staff D noted Resident #1 is on 15 minute checks and staff should know his whereabouts at all times. If Resident #1 goes into another resident room, he/she is to be escorted out. If Resident #1 becomes escalated, staff are to separate him/her from other residents and attempt to calm him/her. Staff D admits it often takes two to three people to change Resident #1, leaving no one to supervise the other residents. Staff D also admitted smoke breaks and meal breaks also leaves only one person to supervise. Staff D stated she believes it takes three people on the unit to provide adequate care and supervision. On 3/3/15 at 11:00 a.m. Staff E, Administrator, was interviewed and stated from the initial resident to resident altercation involving Resident #1, she has discussed with the family and physician a need for psychiatric involvement. The physician was opposed stating he wanted to manage the behavior within the facility. Staff E stated the physician was notified of any altercations with staff or other residents. Staff E stated the staff were to monitor Resident #1's whereabouts and address escalating behavior by providing 1:1 or removing Resident #1 from the area. Resident #1's behaviors were primarily connected with staff needing to provide cares or other residents touching or confronting Resident #1 and Resident #1 responding aggressively. Staff E stated since admission, the reduction in medications have seemed to benefit Resident #1. Additionally Resident #1 is on 15 minute checks, was moved to room 101 where he/she tended to wander into and two residents were moved off the unit who were more confrontational and provoked Resident #1. Staff E noted since the changes, Resident #1 has had no further altercations with residents. Observation on 3/3/15 at 12:15 p.m. of Resident #1's whereabouts, found Resident #1 in room 103, unbeknownst to staff who were involved with assisting other residents during meal. Resident #1 later exited room 103 and entered rooms 108 and 109, again unbeknownst to staff. Resident #1 appeared calm and non- aggressive. Close Observation Flow Sheets reflected Resident #1 on 15 minute checks 11/4/14, 11/13/14, 11/15/14 thru 11/30/14 and 1/18/15 to present. The clinical record reflected during times in which Resident #1 was on 15 minute checks there were 4 incidents (11/20/14, 11/22/14, 1/18/15 and 2/10/15) in which Resident #1 entered the room of another resident and resulted in a resident to resident altercation. Note: At the time of the complaint investigation, the complaint was coded at a "K", immediate and serious jeopardy. By 3/10/15, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to "E" level. The Administrator transferred 2 residents from the CCDI unit into the general population. The 2 residents transferred caused Resident #1 to be agitation and to escalate. The facility added 1 staff member to the unit in order to provide 1:1 supervision to Resident #1 during awake hour and the facility added a pressure alarm during sleeping hours to alert staff that the resident is up and needs monitored. The resident was moved to the room that he/she gravitated towards and the resident received medication changes. As of the 3/12/15 exit date, the facility needed to: ? Continue to provide 1:1 supervison to Resident #1 and continue to have the 1 additonal staff member working in the unit. Continue the use of the pressure alarm during sleep hours in order to alert staff of the resident up and needing to be monitored. ? Continue to monitor behaviors and notify physician as needed. ? Monitor staff to assure compliance with the facility abuse policy/procedures. ? Continue to evaluate resident needs on a case-by-case basis and provide 1:1 supervision as behaviors warrant.

This deficiency relates to self reported incident -I Based on observation, clinical record review, staff interviews and review of the facility abuse policy/procedures, the facility neglected to timely develop strategies to prevent Resident #1 from mistreatment or abusing other residents. Record review established Resident #1 showed physical aggression and mistreatment of [REDACTED]. Concerns were identified for 1 of 11 residents (Resident #1). The facility reported a census of 44 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 2/17/15. The MDS reflected Resident #1 had an admitted into the facility on [DATE] and had impaired short term memory and moderately impaired cognitive skills for daily decision making. The MDS identified Resident #1 as independently mobile in the facility and required supervision from staff when ambulating. The MDS reflected the resident required extensive assistance from staff for dressing, toilet use and personal hygiene and experienced incontinent episodes of bowel and bladder. The MDS identified the resident experienced behaviors of rejecting care 4-6 days a week and wandered each day. The MDS identified Resident #1's behavior did not include physical behavior directed towards others (e.g. hitting) or verbal behavior symptoms directed toward others (e.g. threatening, screaming, cursing) as indicated in his/her clinical record. Review of the Care Plan, with a start date of 10/8/14, identified a problem/need for behaviors/altered coping. The resident had resident to resident altercations, aggression, combative, wandering, verbalizing intent to harm self or others and threats to hit staff. The resident resisted cares, becomes combative, especially when toileting, changing clothes or showering, hollering and verbalizes an intent to elope. Review of the included interventions, directed staff to: Assess the resident for change in condition/function, notify physician, assess for contributing factors for behavior, obtain laboratory tests as ordered, administer medications as ordered, review medications, observe for side effects of psychoactive medications, move resident to a quiet area to deescalate behavior and involve family to assist with interventions effective in the past. The interventions also included and directed staff to obtain a psychological consult (none completed), provide diversion activities (none listed), provide 1 to 1 activities (no know activities scheduled), change room if indicated (no date or rationale listed), encourage increased activity involvement per the resident ' s preference, increased supervision (no date, no formal plan), stop signs on doorway (not used), report behavior to the physician daily until further notice (no start date or stop date). Review of the Nurse's Notes reflected the following: On 9/30/14 at 4:50 p.m. Resident #1 had Resident #4 pinned forcefully up against the wall by holding his/her hands and pushing on Resident #4's abdomen. The nurse intervened and Resident #1 turned his/her aggression towards staff. Following the incident the staff consulted with family and physician to have resident evaluated for psychological unit. The Physician determined medication adjustments could be done within the facility. On 10/20/14 at 6:05 p.m. Resident #1 became aggressive with Resident #5 and hit him/her on the side of the face. The resident's were separated. On 11/3/14 at 7:00 p.m. staff discovered Resident #1 in another resident's room, patting and squeezing head of the other resident as the resident slept. On 11/20/14 at 6:15 p.m. Resident #6 reported to the nurse Resident #1 had smacked him/her while in his/her room. On 11/22/14 at 4:00 p.m. the nurse was called to hallway at 3:00 p.m. and found Resident #1 lying on the floor. Staff reports a resident to resident altercation where Resident #7 claimed Resident #1 entered their room (107) and hit Resident #8 and Resident #7 shoved Resident #1 when he/she raised his/her fist. On 12/5/14 at 4:55 p.m. #1 laid on the sofa and Resident #9 stood over him/her(Resident #1). Resident #1 reached up and grabbed Resident #9's wrist and Resident #9 smacked Resident #1. Staff separated the residents. On 1/4/15 at 5:45 p.m. Resident #1 was observed as having increased agitation and rocking back and forth as another resident started to stand from a nearby recliner. The staff saw the resident pushing Resident #1's hands away. The staff separated the two residents without further incident. On 1/17/15 at 6:45 p.m. Resident #1 struck Resident #3. The staff separated the residents. On 1/18/15 at 2:05 p.m. Resident #1 entered the room of Resident #2 and had a physical altercation. The staff found Resident #1 on the floor and grabbing the legs of Resident #2. Resident #1 sustained a contusion to the right eye area and bruising around the left temple area. Staff separated the residents. On 1/29/15 at 12:45 p.m. Resident #1 walked down the hall with a throw pillow. Resident #10 had a hold of Resident #1 ' s left and she/he yelled at Resident #1. Before the nurse approached the residents, Resident #1 had smacked the top of Resident #10 ' s head, palm down, three times before staff stopped the resident. The nurse separated the residents. No injury reported to Resident #10. Resident #1 sustained skin tears nail marks and bruising where Resident #10 had grabbed him/her. On 2/1/15 at 12:15 p.m. Resident #1 attempted to strike Resident #11, when Resident #7 pushed Resident #1 up against the wall. On 2/10/15 at 10:00 a.m. Staff A heard yelling from Resident #2's room. Staff A discovered Resident #2 on top of Resident #1 in the closet. Staff A stated it appeared as if Resident #2 was holding Resident #1 down. The residents were separated. In an interview on 3/2/15 at 3:00 p.m. Staff A, Licensed Practical Nurse/Lodge Director, stated Resident #1 has dementia, is very confused and can become combative when staff attempt to provide cares. Resident #1 has also been in multiple altercations with other residents. Staff A stated some altercations occur when other residents invade Resident #1's space and at other times when Resident #1 enter other resident rooms and gets confronted by residents in that room. Staff A noted either way, Resident #1 often becomes aggressive. Staff A stated excessive stimulation can also escalate Resident #1 and when they see him/her escalate they separate him/her from others and try to redirect. Staff A stated they have tried several medications, but most of them seemed to escalate his/her behavior. Since discontinuing the use of most of the medication, Resident #1 seems much better, especially in the last two weeks. Other interventions included placing the resident on 15 minute checks, moving him/her into the room where he/she tended to wander and the removal of two residents from the unit who tended to confront Resident #1 and create conflict. In a follow up interview on 3/3/15 at 1:20 p.m. Staff A stated there are only two staff assigned on the unit for 16 residents and feels this is inadequate to properly meet the needs of the residents and provided Resident #1 proper supervision. Staff A admitted despite having Resident #1 on 15 minute checks, his/her whereabouts are often unknown inbetween checks as he/she wanders frequently throughout the unit and goes into other resident rooms. Staff A indicated she does not take breaks because she feels it is unsafe to leave one person alone on the unit. If she does have to leave she makes it brief and returns as quickly as she can. Staff A indicated she has experience working on dementia units and it takes three staff to adequately supervise and provide cares for residents. Staff A stated there are frequent times in which it takes two to three staff to provide cares for Resident #1 and during that time there is no one available to supervise the other residents. Staff A stated on the morning of 2/10/15 she had just sent the aide on break 5 minutes earlier when she heard a yelling in Resident #2's room (101). Staff A ran to the room and found Resident #2 on top of Resident #1 in the closet. Resident #2 was pinning Resident #1 on the ground. Staff A yelled at the housekeeper, on the unit at the time, to get help. Meanwhile Staff A attempted to separate Resident #2 and Resident #1, but was unable to given their size. Staff A stated she asked Resident #7 to help and together they were able to separate the residents. Staff A admitted that she was unaware Resident #1 had wandered into Resident #2's room In an interview on 3/3/15 at 12:45 p.m. Staff B, Certified Nurse Aide, indicated she works the day shift on the CCDI unit and finds the staffing to be inadequate. Staff B noted there are times (i.e.: meals, morning cares) in which two staff cannot provided adequate care and supervision for 16 residents. Staff B indicated Resident #1 wanders in and out of resident rooms all day unnoticed by staff. Staff B admits they are to know his/her whereabouts, but it is not possible with two staff as other residents require care and assistance. Staff B indicated Resident #1 is currently as good as he/she has ever been with regards to being calmer and easier to manage, but continues to wander in other resident rooms when staffs attention is elsewhere. Staff B also stated Resident #1 often requires two staff to provide cares, which then leaves no one to supervise the other residents. Staff B indicated she does not take lunch breaks and takes short cigarette breaks, returning as fast as she can. In an interview on 3/3/15 at 2:20 p.m. Staff C, Licensed Practical Nurse, indicated she has worked at the facility since September 2014 and is familiar with Resident #1. Staff C indicated Resident #1 has always had behaviors, especially when staff are trying to provide cares. Resident #1 can become combative and aggressive quickly. Resident #1 has also been known to get in altercations with other residents. Staff C noted that all staff are to know his/her whereabouts and when he/she wanders into other resident rooms, staff are to redirect him/her from the room. Resident #1 is also on 15 minute checks. Staff C knew of no other interventions to keep Resident #1 supervised and other residents safe. Staff C indicated there is one nurse and one aide on the evening shift and stated that was inadequate staffing to meet the needs of the residents. Staff C also stated that at least twice a shift two to three staff are required to provide cares for Resident #1 and that during those times there is no one available to monitor or supervise the other residents. Staff C noted that Resident #1 has had fewer altercations lately, but continues to enter into other resident rooms. Staff C stated they try to take 30 minute lunch breaks and when they do it only leaves one staff available to supervise the residents. In an interview on 3/3/15 at 2:54 p.m. Staff D, Certified Nurse Aide, stated she is familiar with Resident #1. Resident #1 can become combative with cares and has had altercations with other residents. Staff D noted Resident #1 is on 15 minute checks and staff should know his whereabouts at all times. If Resident #1 goes into another resident's room, he/she is to be escorted out. If Resident #1's behavior becomes escalated, staff are to separate him/her from other residents and attempt to calm him/her. Staff D admits it often takes two to three people to change Resident #1, leaving no one to supervise the other residents. Staff D also admitted smoke breaks and meals breaks also leaves only one person to supervise. Staff D stated she believes it takes three people on the unit to provide adequate care and supervision. In an interview on 3/3/15 at 11:00 a.m. Staff E, Administrator, stated from the initial resident to resident altercation involving Resident #1, she has discussed with the family and physician a need for psychiatric involvement. The physician was opposed stating he wanted to manage the behavior within the facility. Staff E stated the physician was notified of any altercations with staff or other residents. Staff E stated the staff were to monitor Resident #1's whereabouts and address escalating behavior by providing 1:1 or removing Resident #1 from the area. Resident #1's behaviors were primarily connected with staff needing to provide cares or other residents touching or confronting Resident #1 and Resident #1 responding aggressively. Staff E stated since admission, the reduction in medications have seemed to benefit Resident #1. Additionally Resident #1 is on 15 minute checks, was moved to room the room where he/she tended to wander into and two residents were moved off the unit who were more confrontational and provoked Resident #1. Staff E noted since the changes, Resident #1 has had no further altercations with residents. Observation on 3/3/15 at 12:15 p.m. of Resident #1's whereabouts, found Resident #1 in room [ROOM NUMBER], unbeknownst to staff who were involved with assisting other residents during the meal. Resident #1 later exited room [ROOM NUMBER] and entered rooms [ROOM NUMBERS], again unbeknownst to staff. Resident #1 appeared calm and non aggressive. Close Observation Flow Sheets reflected Resident #1 as checked by staff every 15 minutes on 11/4/14, 11/13/14, 11/15/14 thru 11/30/14 and 1/18/15 to present. The clinical record reflected during times in which Resident #1 was on 15 minute checks there were 4 incidents (11/20/14, 11/22/14, 1/18/15 and 2/10/15) in which Resident #1 entered the room of another resident and resulted in a resident to resident altercation. The facility policy/procedures titled: Resident has the right to be free from abuse from one another, dated 4/02, directed the staff if a resident strikes out, injuries another resident, or displays unpredictable, violent behavior that endangers the safety of others then the following steps should be taken: 1. The residents will immediately removed from each other to a safe area. 2. Monitoringof the resident at potential for harm to others will be monitored closely for the next 24 hours. 3. A head to toe assessment of each resident involved will be done and documented in each resident's clinical record. 4. The resident's physician and families will be notified and if an investigation is needed and will be again notified at the completion of the investigation. 5. Quality Assurance and a monitoring tools will be filled out and given to the DON (Director of Nursing). 6. The situation will be investigated in an attempt to determine the causative factors such as provocation, misinterpretation, etc. 7. If not already in place and assessment indicates need, psychiatric or psychological consultation/services will be requested. 8. The care plan team will update the care plan dealing with resident behavior and interventions. 9. As part of the overall plan of care, assessment of contributing factors should be explored: precipitating factors, pattern of behavior, environmental factors such as time of day, over or understimulation, noise, staff, etc, and physical causes such as illness, infection, dehydration, constipation, medication toxicity or side effects, or pain. Note: At the time of the complaint investigation, the deficiency was coded at a "J", immediate and serious jeopardy. By 3/10/15, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the "D" level. The facility implemented 1:1 with staff to resident when awake. During sleeping hours, a pressure alarm will be utilized to alert staff when the resident is up and to be monitored. The facility added a staff member to the unit and staying within eyesight of the resident at all times. The resident received medication changes and moved to a room which he/she tended to gravitate towards. Two higher functioning residents living in the dementia unit were moved off the CCDI unit. As of the 3/12/15 exit conference, the facility needed to continue: ? 1:1 supervision with Resident #1, ? Continue to have the additional staff member in the CCDI unit to monitor the resident ? Continue to use the pressure alarm during sleep hours so staff are alerted when the resident is up and needs monitored. ? Continue to monitor behaviors and inform the physician when necessary. ? Monitor staff to ensure the facility abuse policy/procedure is being implemented in order to prevent the abuse of residents.

Based on record review, observations, and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and failed to supervise the implementation of the written health care plan. The facility care plan interventions for Resident #6, #8 and #12 had interventions to prevent or minimize potential injury to residents at risk of falls. The staff did not utilize the planned alarm interventions. This occurred for 3 of 8 residents reviewed with recent falls. The facility reported a resident census of 50. Findings include: 1. Resident #8 had a quarterly MDS (Minimum Data Set) assessment, with a reference date of 1/3/13, which identified the resident had the following [DIAGNOSES REDACTED]. The MDS identified the resident with both short and long term memory impairments and severely impaired cognitive function related to daily decision making skills. The MDS reflected the resident demonstrated behaviors of pacing or wandering on a daily basis. The MDS indicated the resident required extensive staff assistance for bed mobility, transfers, ambulation, dressing, personal hygiene, and toileting needs. The MDS reflected the resident had sustained falls on a prior assessment 1 fall with no injury and 1 fall with an injury determined not to be major in nature. The MDS indicated the resident used no type of physical restraint during the assessment period. The resident care plan, reviewed by the facility on 1/10/13, identified the resident at risk for falls and had a history of [REDACTED]. The Care plan interventions included the resident used of a Merry Walker (a device that encloses a resident in with a strap between the legs and a bar across the entrance of the walker which allowed independent ambulation without the resident being able to exit the device with assistance. The device also provided a seat for the resident to sit on when tired of ambulating but did not allow exiting the device), use of a personal safety alarm when in the Merry Walker only, use of a chair and bed pressure pad alarm, hipster pants on at all times, gripper socks on when shoes are off, and directed staff to not put the resident to bed at 7:00 p.m. but to keep up later. The resident ' s care plans identified restraint use due to the resident ' s frequent attempts to self-transfer or ambulate. The resident utilized a Merry Walker when up to promote independence with ambulation while providing safety. A Fall Risk assessment dated [DATE] scored the resident with a composite score of 21. A Fall Risk assessment dated [DATE] scored the resident with a composite score of 20 (A total score of 10 or above represents High Risk for fall). A Quarterly Multidisciplinary Screening, completed on 1/19/12, identified the resident with no recent decline in activities of daily living or mobility/transfers so deferred the need for any Physical or Occupational Therapy interventions. The Quality Assurance Monitoring Tool dated 1/25/13 at 9:10 a.m. revealed the resident had been found lying on the floor in the T.V. area with a large laceration to the left side of the forehead. The assessment tool indicated no safety devices in place at the time of the fall. The Assessment tool identified interventions in place prior to the occurrence included a PSA (Personal Safety Alarm) to be on while in the Merry Walker and a Pressure pad chair alarm when seated in the recliner or regular chair. A Physician Communication and Progress Note for new symptoms, signs and other changes in condition form dated 1/25/13 indicated staff reported to the resident ' s primary physician the resident sustained [REDACTED]. The form documented the resident transferred to a local area hospital for evaluation and treatment. A Hospital History and Physical dated 1/26/13 documented the resident sustained [REDACTED]. The resident remained hospitalized for [REDACTED]. Observations made on 2/11/13 at 11:45 a.m. revealed the resident seated in a dining room chair in the dining room with a pressure pad alarm on. At 2:40 p.m. the resident ambulated around the unit in the Merry Walker with a PSA alarm on. Observations made on 2/12/13 at 7:10 a.m. revealed the resident ambulating independently in the Merry Walker with the PSA alarm on. At 9:00 a.m. the resident remained in the Merry Walker while receiving Physical Therapy exercises. At 11:20 a.m. Staff C, CNA ( Certified Nursing Assistant), released the resident from the Merry Walker and with a gait belt ambulated the resident into the bathroom and them to the dining room table. A pressure chair alarm in place as the resident sat at the table for lunch. At 2:00 p.m. the resident ambulated independently while in the Merry Walker with a PSA alarm on. An interview conducted on 2/12/13 at 9:50 a.m. with Staff C revealed she worked with Resident #8 on 1/25/13. Staff C stated the resident required the use of a chair pressure alarm when up in a chair, used a bed alarm when in bed, and used a PSA alarm when up in the Merry Walker. Staff C stated on the morning of 1/25/13, she brought the resident to the dining room table for breakfast but found no pressure alarm pad on the resident ' s chair. Staff C stated she found no additional alarms available so sat the resident in the dining room chair anyway knowing the resident needed to have a pressure pad alarm on while seated in the chair. Staff C stated she continued to bring other residents out for breakfast; it ' s a very busy time around meals and did not ever obtain a pressure pad alarm for Resident #8. Staff C stated after breakfast another resident continually stood up and would self-transfer so she decided to take the resident to their room and toilet them. Staff C stated as she assisted the resident to the room, she looked back and saw Resident #8 trying to stand up independently so she called to Staff B, LPN (Licensed Practical Nurse) to alert her of Resident #8 attempting to transfer self. Staff C stated she called to Staff B twice to inform her of Resident #8 ' s activity and thought Staff B heard her. Staff C stated as she brought the other resident back to the dining room, she observed Resident #8 seated on the couch in the lobby area. She stated she thought Staff B assisted the resident to sit there and did not check to see if an alarm had been applied though stated she should have checked. Staff C stated she then made resident beds and while in another resident room, she heard a resident yell the resident had fallen. Staff C stated she heard no alarms sounding to alert her of the resident ' s activity. Staff C stated as she came down the hallway, she observed StaffA, LPN (Licensed Practical Nurse), with the resident and questioned what happened. Staff A replied she didn't know as she last observed the resident seated on the couch. Staff C stated she then held pressure to the resident ' s left forehead as Staff A called for more staff assistance. Staff C stated at this point, Staff B returned from the front of the building and asked Staff C where the resident ' s alarm was. Staff C stated she replied she thought Staff B applied it when she transferred the resident over to the couch. Staff B replied she did not hear Staff C tell her of Resident #8 attempts to self-transfer from the dining room table. Staff C stated she should have applied a pressure pad chair alarm immediately after she brought the resident out for breakfast. Staff C stated it is her responsibility to ensure all of the residents had alarms in place according to the pocket care plan information. Staff C stated she received disciplinary action after this incident and she felt the disciplinary action fair. Staff C stated she did not omit the alarm to cause any harm to the resident. Staff C stated she got busy and didn ' t go back to obtain one (an alarm) when she should have done so immediately upon realizing one was not on the chair. On 2/12/13 at 10:10 a.m., Staff B was interviewed and revealed she worked the day of the fall on 1/25/13. Staff B identified Resident #8 as a fall risk. Staff B explained according to the CNA ' s pocket care plans, the resident required a PSA alarm when ambulating in the Merry Walker, a pressure pad chair alarm when seated in a chair, and a bed alarm when in bed. Staff B stated she and Staff A, LPN frequently updated the pocket care plan information and the CNAs had access to the care plans for every shift and any updated information was immediately added to the care plans to keep it current. Staff C stated she passed medications and then stopped to assist with feeding residents at breakfast. Staff B stated she exited the unit at around 9:00 a.m. and notified Staff B of her exit. Staff B stated she recalled observing the resident seated in the dining room chair but couldn ' t state if the pressure alarm was on at this time. Staff B stated the resident made no attempts to transfer self from the chair. Staff B stated she got called back to the unit due to a report that a resident had fallen. Staff B stated she did not recall having any conversation with Staff C regarding not having enough alarms for all of the residents requiring them earlier that morning. Staff B stated as she entered the unit she observed Resident #8 on the floor lying on her/his left side with blood on the floor. Staff B stated as she began assessing the resident she noted a laceration above the left eye. Staff B stated she called the resident ' s physician and requested transport the resident to the hospital for evaluation and treatment. Staff B stated later that morning, she telephoned the hospital to check on the resident ' s status and was told the resident sustained [REDACTED]. She stated the resident remained hospitalized until 2/4/13. Staff B stated prior to this fall the resident required to have safety alarms on at all times and should have had a pressure pad alarm on her dining room chair. Staff B stated at the time of her assessment she asked Staff C why the resident didn ' t have an alarm sounding at the time of the fall. She stated after the incident, she told Staff C she needed to have the required safety devices on the residents as directed on the care plans. Staff B stated she did not believe Staff C omitted the application of the chair alarm that morning on purpose and stated possibly Staff C just didn ' t ' t think the situation through at the time. Staff B stated the staff received education about the importance of the safety device application after the incident. 2. A quarterly MDS dated [DATE] identified Resident #6 with the following [DIAGNOSES REDACTED]. The resident scored 5/15 on the Brief Interview for Mental Status and indicative of memory and cognitive impairment related to daily decision making skills. The MDS reflected the resident required total staff assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The MDS identified the resident with impairment on one side for both upper and lower extremity function related to range of motion. The MDS coded the resident with no falls on a previous assessment. The resident Care Plan identified a history of falls related to impaired mobility and Alzheimer ' s Dementia. The care plan interventions directed staff to use a personal safety alarm at all times ( PSA) , a bed alarm with low bed, a floor mat alarm, and a chair alarm ( Discontinued on 1/27/13). A Fall Risk Assessment completed on 1/10/13 scored the resident with a composite score of 17 (Total Score of 10 or above represents High Risk). The nursing note documentation dated 1/31/13 at 10:50 a.m. identified the resident was found on the floor in the resident room seated with the legs out stretched in front of body. The documentation noted no alarms sounded at the time of the fall. The note indicated no injuries noted. The Quality Assurance Monitoring Tool dated 1/31/13 at 10:10 a.m. identified the resident sustained [REDACTED]. The documentation indicated the resident slid out of the Geri- chair onto the floor landing on bottom area. The document indicated no safety devices in place at the time of the incident. Interventions used prior to the occurrence included bed alarm and Personal Safety alarm. Interventions implemented post occurrence included education for the aides to apply alarms. An observation made on 2/12/13 at 7:35 a.m. revealed the resident assisted into the Broda Geri-chair via the Hoyer lift assisted by Staff D, CNA (Certified Nursing Assistant), and Staff E, CNA. The resident had in place a pressure pad alarm on the seat of the Broda Chair and a PSA alarm connected to the back of the resident ' s shirt. On 2/13/13 at 11:35 a.m., Staff D was interviewed and stated she had gotten the resident up and out of bed on 1/31/13 prior to the resident ' s fall. Staff D stated she did not realize the resident required alarms when up from the bed. Staff D stated she failed to apply either the pressure pad alarm to the chair or the personal safety alarm to the resident after she had gotten the resident up in the chair for lunch. Staff D stated as soon as she heard of the resident ' s fall; she went immediately to the administrator and informed him of her error. Staff D stated she had not been aware of the pocket care plans that provided this information as she had only worked at the facility for a few weeks prior to this fall. Staff D verified this did not excuse the fact that she did not apply the alarms needed to ensure the resident ' s safety at all times. She stated she felt the facility probably mentioned the use of pocket care plans sometime during her initial orientation. 3. A quarterly MDS dated [DATE] identified Resident #12 with the following [DIAGNOSES REDACTED]. The MDS identified the resident scored 3/15 on the Brief Interview for mental Status indicative of the resident with both memory and cognitive impairment associated with daily decision making skills. The MDS reflected the resident required extensive staff assists with bed mobility, total staff assistance with transfers and toilet use. The MDS indicated the resident with no prior falls. The resident care plan identified the resident with a history of falls. The care plan directed staff to use the following interventions: personal alarms, bed and chair alarm, and floor mat beside the bed when in it, and lip mattress on the bed. A Fall Risk assessment dated ,[DATE]//12 and 12/3/12 scored the resident with a composite score of 14 (Total Score of 10 or above represents High Risk). The nursing note documentation dated 6/16/12 at 10:20 a.m. revealed at 9:30 a.m. the staff found the resident in the bathroom sitting on the footboard of the wheelchair. The documentation indicated the resident attempted to self-transfer to the toilet in the bathroom. A Quality Assurance Monitoring Tool dated 6/16/12 at 9:30 a.m. revealed the staff found the resident sitting on the footboard of the wheelchair while attempted to self-transfer from the wheelchair to the toilet. The document indicated the resident had a pressure pad alarm on the seat of the wheelchair but no alarm box connected to it and no PSA alarm connected to the resident. Interventions used prior to the occurrence included the use of a bed and chair pressure pad alarm and PSA alarm on at all times. A care plan intervention added to the care plan after the fall included to ensure new clips on alarms and make sure alarm box is on. The staff also received a 5 minute in-service related to the placement of alarms. On 2/14/13 at 9:11 a.m. Staff A, LPN, was interviewed and revealed verification of the documentation related to the fall incident on 6/16/12. Staff A stated at the time of the resident ' s fall, the resident should have had in place a personal safety alarm and a pressure pad alarm while seated in the wheelchair. On 2/14/13 at 9:15 a.m., the facility Administrator was interviewed and revealed the facility had no specific policy regarding the use of safety alarms. The Administrator stated each resident is reviewed by the nurses and the Quality Assurance team who then make the decision as to what safety devices needed to be put into place to ensure the resident remained as safe as possible. The Administrator explained on 1/25/13, the facility held a mandatory staff in-service related to Safety Compliance - Placing of Alarms on all residents.

Based on observation, record review and interviews, the facility failed to assure one (1) of three (3) residents received the necessary intervention to promote healing for his/her wound (Resident #7). The facility reported a census of 41 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment Tool dated 11/24/11 identified Resident #7 with [DIAGNOSES REDACTED]. The MDS identified Resident #7 with short and long-term memory impairment and severely impaired with cognitive skills for daily decision making. The MDS documented the resident required total dependence of two staff for bed mobility and transfers. The MDS further revealed the resident experienced impairment of range of motion on one side of the lower extremity. The MDS documented Resident #7 received hospice care while a resident in the last 14 day look back period. The MDS documented Resident #7 had infection of the foot, ([MEDICAL CONDITION]) and had a bed pressure reducing device. The Braden Scale -for predicting pressure sore risk dated 9/8/11 and 11/23/11 documented the resident at high risk for pressure sores due to a score of 11 (Total score of 12 or less represents high risk). Record review of Resident #7's prior skin integrity concern established the following: a. Nurse's notes dated 01/31/11 at 9:40 a.m. documented a follow up of antibiotic for [MEDICAL CONDITION], vitals. Right lower leg healed and not open, area with no drainage, skin prep applied per doctor's order. b. Nurse's notes dated 02/23/11 documented that the hospice nurse here with a new order to discontinue laboratory orders and discontinue the L'nard boot to right lower extremity: clarifications. c. Nurse's notes dated 04/10/11 at 10:45 a.m. documented a red area to the resident's right lower extremity, small scab that measured 0.5 centimeters by 0.5 centimeters (cm) on the ankle. Received new order for Keflex (antibiotic) 500 milligrams (mg) three times daily for seven days. d. Nurse's notes dated 04/12/11 at 3:30 p.m. documented a new order for a bunny boot to the right lower extremity to help [MEDICAL CONDITION] heal. Then when healed to keep protected from happening again. e. Nurse's notes dated 04/13/11 and 04/14/11 identified the bunny boot on the right lower extremity. f. Nurse's notes dated 04/18/11 at 1:45 p.m. revealed vitals, follow up on antibiotic for right lower extremity [MEDICAL CONDITION], area remains red with small scabbed area. Resident denies/displays no pain/discomfort. Skin prep applied as ordered and leg afloat on pillow with bunny boot on, however, the resident continues to kick off bunny boot. g. Nurse's notes dated 06/09/11 at 1:45 p.m. revealed a new order received for Keflex 500 mg three times daily for one week for [MEDICAL CONDITION] of the right ankle. h. A non-pressure skin condition report dated 7/7/11 documented the area healed. A physician encounter form dated 8/22/11 documented Resident #7 with a history of contact [MEDICAL CONDITION]. CARE PlAN: A care plan dated 4/7/11 documented Resident #7 with [DIAGNOSES REDACTED]. The care plan identified the L'nard boot to right lower extremity at all times had been discontinued on 2/23/11 and then discontinued again 3/23/11.The interventions called for floating right lower extremity while in bed at all times. The care plan documented bunny boots on right lower extremity while in bed. The Careplan dated 09/15/11 through current identified a problem/need for potential injury due to [MEDICAL CONDITION], impaired mobility and chronic area of cellulites on right ankle. A goal for the resident to remain safe till next quarter. Intervention of bunny boots to right lower extremity at all times while in bed. Nurse's notes dated 08/14/11 at 1:10 p.m. documented that a Certified Nurse's Aide (CNA) called this nurse to resident's room where CNA's found resident sock to have serosanguineous drainage on it. Resident area to inner right ankle open. One centimeter in diameter, denies pain to area on palpation. Obtained order for different treatment. Right ankle has been opened other times and then also closed multiple times. A non-pressure skin condition report dated 08/14/11 identified Resident #7 with a chronic open area that closes and reopens located at the right inner ankle. The wound measured 1 centimeter (cm) in diameter with a small amount of serosanguineous exudate, a wound bed with [MEDICATION NAME] tissue, and surrounding skin pink. The non-pressure skin condition report revealed the following weekly assessments of the inner right ankle wound: a. Dated 08/14/11 a one centimeter (cm) wound with a small amount of serosanguineous exudate (fluid that filters from the circulatory system into [MEDICAL CONDITION] or areas of inflammation-fluid-sap-blood), wound bed with [MEDICATION NAME] tissue, surrounding skin color pink, and surrounding tissue/wound edges normal for skin. b. Dated 08/25/11 a scab that measured 0.5 cm by 0.4 cm with normal surrounding skin. Progress checked as improved. c. Dated 09/01/11 a scab that measured 0.5 cm by 0.4 cm with normal surrounding skin. Progress checked as improved. d. Dated 09/08/11 a scab that measured 0.5 cm by 0.4 cm with progress checked as not changed. e. Dated 09/15/11 an area described as one centimeters in diameter and no further description documented. f. Dated 09/22/11 a scab that measured 0.7 cm by 0.5 cm with the progress checked as improved. Nurse's notes dated 09/23/11 at 4:00 p.m. revealed a response to the right ankle culture; new order for [MEDICATION NAME] (antibiotic) 300 mg by moth twice daily for ten days. g. Dated 09/29/11 a scab that measured 1.2 centimeters in diameter with the progress checked as deteriorated. h. Dated 10/06/11 a soft scab that measured 1.5 centimeters in diameter with the progress checked as deteriorated. i. Dated 10/13/11 a soft scab that measured 1.25 centimeters in diameter with the progress checked as improved and continue treatment. j. Dated 10/20/11 a soft scab that measured 0.8 cm by 0.6 cm with normal surrounding skin, a progress checked as improved and continue treatment. k. Dated 10/27/11 a soft scab that measured 0.6 cm by 0.5 cm with normal surrounding skin and a progress checked as improved. l. Dated 11/03/11 a soft scab that measured 1.0 cm by 0.5 cm with normal surrounding skin and a progress checked as deteriorated. m. Dated 11/10/11 a soft scab that measured 1.0 cm by 0.3 cm with normal surrounding skin and a progress checked as improved. The physician's orders [REDACTED]. n. Dated 11/17/11 a scab that measured 1.0 cm by 0.3 cm with normal surrounding skin and a progress checked as not changed. o. Dated 11/24/11 a scab that measured 1.4 cm by 1.0 cm with a scant amount of serosanguineous exudate, wound bed normal, surrounding skin color pink, and surrounding tissue/wound edges normal for skin. p. Dated 12/01/11 a slight open area that measured 1.2 cm by 1.0 cm with a small amount of serosanguineous exudate, wound bed with [MEDICATION NAME] tissue, surrounding skin color pink, and surrounding tissue/wound edges with peripheral tissue [MEDICAL CONDITION]. The assessment documented a culture sent and a progress as slight improvement. q. Dated 12/07/11 a soft scab that measured 1.0 cm in diameter with a scant amount of serosanguineous exudate, normal wound bed, surrounding skin color pink, and surrounding tissue/wound edges as normal. The assessment documented the progress as not changed. r. Dated 12/14/11 an area that measured 1.5 cm by 1.0 cm with a moderate amount of serosanguineous exudate, wound bed with [MEDICATION NAME] tissue, surrounding skin color pink, and surrounding tissue/wound edges as normal. The assessment documented the progress as deteriorated. s. Dated 12/21/11 an area that measured 1.3 cm by 1.0 cm. The nurse' s notes dated 12/27/11 at 6:30 a.m. documented a fax had been sent to the physician requesting a new treatment for [REDACTED]. The nurse's notes dated 12/27/11 at 2:10 p.m. documented a new order for [MEDICATION NAME] to right medial ankle, change every 3 days. t. Dated 12/28/11 a area that measured 1.3 cm by 1.0 cm with a moderate amount of serosanguineous exudate, wound bed with [MEDICATION NAME] tissue, surrounding skin color pink, and surrounding tissue/wound edges as normal. The assessment documented the progress as deteriorated. A physician visit dated 01/05/12 identified Resident #7 with a history of and open [MEDICAL CONDITION] and fibula of the right leg. The documentation revealed Resident #7 with an infected abrasion of the ankle. Noted a plan for [MEDICATION NAME] and [MEDICATION NAME] to the wound twice daily and wrap with gauze, notify of worsening of signs and symptoms of infections, and pressure off the area as much as possible. u. Dated 01/05/12 an area that measured 2.0 cm by 1.0 cm and a depth of 0.1 cm with a moderate amount of serosanguineous exudate, box blank for wound bed, surrounding skin color pink, and surrounding tissue/wound edges as macerated. The assessment documented the progress as deteriorated. Noted area larger, [MEDICATION NAME] left off side at present with dry dressing applied to contain drainage. Well have doctor exam in a.m. when in house. v. Dated 01/11/12 an area that measured 2.0 cm by 1.0 cm with a small/scant amount of serosanguineous exudate, box blank for wound bed, box blank for surrounding skin color, and surrounding tissue/wound edges as peripheral tissue [MEDICAL CONDITION]. The assessment documented the progress as deteriorated and treatment change. Observations: Observation on 01/10/12 at 12:50 a.m. revealed Resident #7 up in his/her geri chair, noted the resident's legs crossed down at ankles. Observation revealed the resident with a gauze wrap around his/her right ankle/foot and gripper socks on. Observed no foot or ankle protection boots on to prevent pressure at location of the crossed ankles. Observation on 01/10/12 at 2:47 p.m. revealed Resident #7 lay in bed on his/her back and noted one bunny boot lay at the end of the bed (not on the resident's foot). Observation on 01/11/12 at 9:48 a.m. revealed Staff J, Certified Nursing Aides, provided incontinence care for Resident #7. Staff J completed cares and failed to place a bunny boot on the right foot. Observation on 01/12/12 at 9:43 a.m. revealed Resident #7 in bed and observed no bunny boot or heel protector to the resident's foot. Staff J, Certified Nursing Aide, attempted to locate the bunny boot, and found the bunny boot under the resident's bed. Observation revealed the bunny boot had a strap across the boot, although lacked the Velcro area for the strap to fasten on to foot (ensure the placement). Staff J reported that she places the bunny boot on when the boot is available/not dirty. Staff J reported the resident did not really kick the boot off, just that it would slip off his/her foot when he/she moves. Staff J further searched other hall linen closets and found only one functional bunny boot. Staff N, Restorative Aide, reported that she does not keep track of the bunny boot. Staff N reported that she overheard today that hospice was bringing some new ones (protective boots). Observations during the survey revealed the resident up in his/her geri chair before and after meals, noted legs crossed at the ankles with no protection boot on to relieve pressure between the ankles. Nurse's notes dated 01/13/12 at 7:30 p.m. documented the hospice nurse delivered moon boots today for resident. TARs (Treatment Administration Record) updated. Record review of the nurse's notes from 04/18/11 through 01/16/12 revealed only the following entries of the bunny boot kicked off: a. Dated 01/12/12 at 4:30 a.m. the resident continues to kick boots off. Pillow under bilateral (both) feet but moves legs off. b. Dated 04/18/11 at 1:45 p.m. documented the area remains red with small scabbed area. Skin prep applied as ordered and leg afloat on pillow with bunny boot on , however, resident continues to kick off bunny boot. The Careplan lacked documentation of a problem with the bunny boots kicked off or any other interventions attempted in regard to protect the resident's ankle/foot.

Relates to facility reported incident # Based on record review, and staff interviews, the facility failed to provide the necessary provisions to ensure Resident #1 received adequate supervision from hazards in the environment. As the door alarm activated, Resident #1 left the nursing home without being noticed. The facility staff failed to determine which door alarm had been activated and or account for residents at risk for elopement. The findings constitute an Immediate Jeopardy situation. The facility identified eleven residents at risk for elopement with concerns identified for Resident #1 and Resident # 6. The facility reported a current census of 27 residents. Findings include: According to the admission face sheet, Resident #1 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had suffered from shortness of breath and had an unsteady gait when walking. The MDS documented the resident required supervision with his/her ambulation and had fallen in the past 31-180 days. The assessment identified the resident's mental function varied over the course of the day. The assessment identified the resident had long and short-term memory deficits. The assessment identified the resident without any cognitive deficits for daily decision making skills (the facility staff determined this was an error during an interview). According to Nurses Notes dated 10/31/10 at 4:10 p.m., Staff C, Licensed Practical Nurse, documented a family member had come into the facility and reported that a resident (Resident #1) had been down the road on the next block. Staff C documented he/she exited out the front door and headed south one block and then turned west and Resident #1 had been at a truck visiting with a community member. Staff C documented the wanderguard sounded when the resident returned to the nursing home. Staff C documented a door alarm had sounded and the staff called the Lodge unit and Staff D went to look outside to see if someone went out the door. Staff C charted he/she turned the alarm off since no resident(s) were found. Staff C documented they returned to completing resident tasks and did not consider the north or south (exit) doors. An assessment completed after the elopement, identified no changes in the resident's condition. Record review for Resident #1 identified the following: A Care Plan dated 9/2/10 identified the resident at risk for elopement or verbalized his/her intention for elopement.The care plan intervention documented a wanderguard device had been placed on the resident's walker. A Mini Mental Status Exam dated 8/26/10, documented a score of 13 which determined an apparent abnormal cognitive status for Resident #1. An Elopement Risk Assessment form dated 8/26/10, documented a score of 18. A score of 5 or more points meant the resident had been at risk for elopement. Review of Social Progress Notes dated 8/31/10 at 2:30 p.m. acknowledged that when Resident #1 showed confusion, he/she would attempt to exit the back door of the facility to locate his/her car. The progress note inferred the resident's confusion about his/her car located in the parking lot of the nursing home. A quarterly Care Plan Assessment form dated 8/31/10 at 3:15 p.m., documented the resident had been confused at times in addition to long and short term memory deficits. The assessment acknowledged the resident will try to exit the back door to go home. Review of Nurses Notes dated 6/3/09 at 3 p.m., documented the resident had tried to exit the back door of the facility to watch for his/her family member. The nurse documented after some convincing, the resident finally returned in the nursing home. The nurse made the decision to place a wanderguard device on the resident's walker. Interviews: During an interview 11/16/10 at 11:40 a.m., Staff C, Licensed Practical Nurse, confirmed that on 10/31/10 the south door alarm sounded and he/she went to look at a panel at the nurse's station in the main unit of the facility. The staff member noted a red light had been illuminated and assumed it had been a door located in the Lodge area in the facility (locked unit). At that point Staff D, Certified Nursing Assistant, called back to the Lodge and the staff member had requested his/her assistance to check the door. Staff D, Certified Nursing Assistant, went to the Lodge and had checked outside for any resident(s) that may have gone outside but no resident had been found. Staff C, Licensed Practical Nurse, then shut off the alarm on the panel in the main unit of the facility. Approximately 10-15 minutes later a family member had entered the facility and told him/her that a resident (Resident #1) had been down the road without a jacket on. The staff member then went to the resident's room and noticed that he/she had not been there. The resident had then been found down the street and brought back to the facility. The staff member did confirm the door alarms had been labeled "N", "S" and "W" for north, south and west doors. During an interview 11/16/10 at 1:25 p.m., Staff D, Certified Nursing Assistant, confirmed that on 10/31/10 at approximately 3:30 p.m., he/ she had checked on Resident #1 who had been resting in his/her room. The staff member then continued with some work duties when an alarm sounded. The staff member stated he/she went to the alarm panel at the nurse's station and pushed the reset button without looking at the panel which had been covered by a lamp shade and papers that were hanging down from a bulletin board. The staff member then called the "Lodge", assuming a door had been opened in that unit.The staff member working in the "Lodge" requested that he/she come to the Lodge to check the doors. Staff D, Certified Nursing Assistant, went to the Lodge and noticed the doors had been clear so he/she silenced the alarm in the "Lodge" and went back to the main unit and resumed working. The staff member then stated at approximately 4:10 p.m. a family member had entered the facility and stated Resident #1 had been down the road walking. The staff member stated that he/she went to the resident's room and confirmed the resident had not been there and followed through and went outside to bring the resident back to the facility. The staff member stated Resident #1 had been wearing overalls, a short sleeve shirt and no coat when he/she re-entered the nursing home and his/her skin felt cold. During an interview with Staff A on 11/18/10 at 2:46 p.m. he/she stated the assessment from 8/26/10 had the incorrect cognition information and had been corrected (on 11/18/10). The assessment now documented Resident #1 made poor decisions and required cue or supervision. Review of a 24 Hour Nursing Report form dated 10/31/10, documented the door alarms had been checked on all 3 shifts. A written statement dated 11/18/10, documented the Administrator had witnessed a small decorative lamp at the nurse station on a couple different occasions but had since purchased a new lighting device for the staff members. (Staff interview revealed the door light panel had been covered by the lamp shade). The facilities policy on "Walk Away/Missing Resident documented the following information: In the event that a wandered door alarm would sound; or, if facility staff are unable to located a particular resident, the following procedure will immediately be implemented: 1. If a door alarm sounds, identify the door that caused the alarm to activate. Proceed to that door and attempt to verify the cause of the alarm activation. Should a resident be found exiting the door or outside the door, return the resident into the facility and follow up appropriately. 2. Should staff be unable to determine the cause of the alarm activation, all known potential elopement risk residents should be immediately accounted for. If all are accounted for, a further accountability of all residents is warranted. The facility policy also addressed additional protocols for missing residents and specifics on who to notify, etc. The facility abated the immediate jeopardy on 11/1/10 by re-educating staff to check the alarm panel when door alarm(s) are activated. From November 1 to 15, 2010, the facility completed individualized training for all nursing staff of how to respond to activated door alarms. In addition, the facility purchased a different style alarm that sounds different from other alarms and installed these on both halls, with a five minute in-service provided to staff. These alarms on the north and south halls require staff to manually turn off the active alarm at the 2 emergency exit doors. The facility completed mock elopement drills on 11/4/10. The facility in-serviced all nursing staff of their policy. These actions lowered the deficiency from a scope and severity level J to an D level. At the time of the exit conference, the facility had not determined routine monitoring of proper response from staff when door alarms are activated. 2. A Record of Admission sheet dated 7/09, documented Resident #6 had [DIAGNOSES REDACTED]. A MDS assessment dated [DATE], documented Resident #6 with short and long term memory deficits, moderately impaired cognitive skills and wandered 1 to 3 days in the past 7 days. The MDS assessment documented the resident required supervision when he/she ambulated. A Care Plan dated 9/22/10, documented the resident had a problem with a history of behaviors/altered coping and wandering with interventions that included the use of a wanderguard device. The Treatment Record for November 2010 showed no documentation that staff checked the resident's wanderguard device every shift from 11/1/10 to 11/18/10, until the surveyor identified the lack of documentation. According to the facility document titled, "wanderguard system" dated 11/18/10, the charge nurse each shift will now check the wanderguards.