Every finding on record at Accura Healthcare of South Des Moines

Based on clinical record review, resident and staff interview, the facility failed to maintain complete and accurate documentation of an ENT (Ear, Nose and Throat) referral for 1 of 3 residents' records reviewed (Resident #1). The facility reported a census of 82 residents. Findings Include: Review of Resident #1 Minimum Data Set (MDS) dated [DATE], documented Brief Interview for Mental Status score (BIMS) of 4, indicating severe cognitive impairment. Documented diagnoses included Alzheimer's Disease, Non-Alzheimer's Dementia, Anxiety Disorder, Depression, Bipolar Disorder, Obsessive Compulsive Disorder and behaviors including hallucinations and delusions. Review of an Emergency Department After Visit Summary dated 8/27/25 revealed Resident #1 was seen for a fall that resulted in a nasal fracture. Discharge instructions stated Resident #1 to be re-evaluated in the next week by ENT for nasal fracture. Review of Resident #1's Electronic Health Records failed to provide documentation of communication or referral to ENT. In an interview on 9/17/25 at 12:10 PM, Director of Nursing (DON), stated she was not able to recall the exact date, but thought the first week of September was the first call she had made to the ENT clinic about Resident #1's referral for nasal fracture. The DON informed ENT staff, Resident #1 was seen in the ER and a nasal fracture was noted and Resident #1 was to have a follow up with ENT. DON informed ENT staff that it is difficult for Resident #1 to be seen outside of the facility due to diagnoses and behaviors, requested the Doctor review Resident #1's x-rays. DON stated she called the ENT clinic again on 9/10/25 due to not hearing back and was notified Resident #1 only needed to be seen if there were issues related to the fracture. If repair is wanted or needed, Resident #1 would need to consult with plastic surgery. DON acknowledged at time of interview no documentation for ENT referral had been entered into Resident #1's EHR. Review of Resident #1's EHR, a Late Entry Progress Note was created by the DON on 9/17/25 at 12:13PM, with an effective date of 9/10/25 at 11:30 AM stated, received communication back from the ENT office. No follow up needed at this time, follow up if breathing issues develop. Resident's daughters were notified via email. In agreement with plan at this time.In an interview of 9/18/25 at 4:10 PM with the Facility Administrator and DON, DON acknowledged the failure to document the communication the ENT Clinic and Resident #1's family in Resident #1's chart and verbalized need for improvement with documenting these communications.

Based on observation, record review, staff interviews and policy review, the facility failed to use appropriate infection control practices and Enhanced Barrier Practices (EBP) during urinary catheter care for 1 of 3 residents reviewed (Resident #66). The facility reported a census of 74residents. Findings Include:Resident #66's Quarterly Minimum Data Set (MDS) assessment, dated 5/29/25, reflected a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS listed Resident #66 had an indwelling urinary catheter. The MDS included diagnoses of other neurological conditions, benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms and retention of urine. The Care Plan with a target date of 9/3/25 included the following Focuses and Interventions:a. Resident #66 had an SP catheter (suprapubic) and a history of urinary tract infection (UTI). The intervention directed staff to change catheter bag twice a month and PRN, monitor output every shift.b. Resident is at risk of colonization at Multidrug-Resistant Organisms (MDRO). The intervention directed staff to use Enhanced Barrier Precautions (EBP). Review of the Electronic Health Record (EHR) for Resident #66 revealed an order from the Primary Care Physician (PCP) dated 3/3/25 for Enhanced Barrier Precautions and an order to change the catheter bag to a leg bag in the morning for UTI prevention, dated 7/18/25. Review of the Medication Administration Record (MAR) for Resident #66 for July 2025 revealed an administration of Cefdinir Oral Capsule (antibiotic), 300 mg, give 1 capsule by mouth two times a day for UTI until 7/23/25.During an observation 7/23/25 at 9:10 AM of catheter care for Resident #66, noted two staff in the resident's room. Staff B, Certified Nursing Assistant (CNA), walked out of the room without a gown or gloves on, she carried a room tray. Staff B handed the room tray to the Assistant Director of Nursing (ADON). Then, without sanitizing or washing her hands, Staff B donned a gown outside of the room and then placed gloves on her hands. Staff B retrieved a 2nd gown out of the cart and a 2nd pair of gloves and brought them in to the resident's room and handed them to another staff in the room, Staff C, CNA. Staff C placed the gown and gloves on the sink counter in the room as she was holding the resident's catheter bag, standing in front of the resident, she did not have a gown on, she did have on gloves. The resident was in a wheelchair, the leg bag was attached to his leg. Staff C handed the catheter bag to Staff B and then donned a gown and removed her gloves, she sanitized her hands and put on new gloves. A barrier was already placed on the ground with a container on the barrier. Staff B removed an alcohol swab from a wrapper and cleaned the port to the catheter bag, she emptied the urine into the container and then used a clean alcohol swab to clean the port. The container was emptied into the toilet and cleaned. During an interview 7/23/25 at 9:25 AM, Staff C acknowledged she and Staff B already started catheter care for Resident #66 before the observation. Staff C stated neither she nor Staff B had their gowns on when they removed the catheter bag and attached the leg bag. When the observation started, Staff C stated she had already removed the catheter bag and attached the leg bag, without wearing a gown. Staff C stated an understanding of EBP and stated she and Staff B should have worn gowns during the entirety of catheter care. During an interview 7/23/25 at 10:21 AM, the ADON stated an expectation staff wear gowns during the entirety of catheter care and an expectation staff sanitize their hands or wash their hands prior to placing gloves on their hands. The ADON stated she talked to all of her staff this morning about EBP and infection control practices when completing catheter care. Review of the facility policies for Catheter Care and Enhanced Barrier Precautions, dated 5/11/21 and 11/13/24 respectively, documented to wash hands or use hand sanitizer and apply gloves prior to cleansing the access port with an alcohol pad and an order for enhanced barrier precautions will be obtained for residents with urinary catheters, gowns and gloves will be readily accessible to staff to use when performing high-contact care activities, which includes device care or use; urinary catheters.

Based on clinical record review, staff interview, and policy review, the facility failed to initiate nursing assessments of a surgical amputation site in a timely manner for 1 of 1 residents reviewed for surgical sites (Resident #39). The facility reported a census of 74. Findings include: The admission Minimum Data Set (MDS) Assessment, completed on 7/14/25, revealed a Brief Interview for Mental Status score of 14, which indicated intact cognition for Resident #39. Diagnoses listed on the MDS include presence of an above the knee amputation and hypertension. Pain was assessed as moderate. The After Visit Summary from Resident #39's hospitalization from 6/26/25 -7/8/25 indicated an above the knee amputation occurred. Discharge instructions listed a follow-up appointment with Vascular Surgery on 8/12/25. The admission Skin Assessment completed on 7/8/25 noted a left leg amputation incision. No Physician Orders identified regarding cares to the surgical site. The Baseline Care Plan initiated on 7/8/25 listed an incision site to Resident's #39's left knee. The Comprehensive Care Plan obtained on 7/22/25 identified Resident #39 with the potential impairment to skin integrity related to fragile skin. Interventions included following facility protocol for treatment of injury. The Care Plan identified Resident #39 with an infection of the surgical amputation site. Interventions included administering antibiotic as ordered, following facility policy and procedures for line listing and summarizing/reporting infections and to monitor/document/report to MD signs/symptoms of a urinary tract infection. After the admission Skin Assessment was completed, no further Skin Assessments identified either by paper, which would be located in the Skin/Wound Book, or electronically in the medical record. Review of Progress Notes in the electronic medical record revealed the first documented evaluation of the left leg amputation site occurred on 7/19/25. This was due to the start of Clindamycin (antibiotic) on 7/15/25. The Progress Note dated 7/21/25 documented communication with the vascular surgeon's office. Orders obtained to monitor the incision and to keep clean and dry. The surgical site was then evaluated as clean, dry, and intact with sutures in place. During an interview on 7/24/25 at 9:25 AM the Assistant Director of Nursing (ADON) acknowledge the Resident #39's recent surgical left leg amputation, which occurred on 6/27/25. The ADON acknowledged the lack of nursing surgical site skin assessments during the first nine to thirteen days of admission. The ADON noted the facility's wound care provider does not treat surgical wounds.The policy Weekly Skin Assessment and Documentation Process, updated 1/20/23, outlined the following: Skin ulcers and non-ulcers will be assessed and documented weeklyTreatment orders for all skin ulcers or non-ulcers will be implemented per the facility/corporate Skin Management ProtocolThe Nurse Leader will communicate appropriate wound treatment order per the facility/corporate Skin Protocol to the physician for approvalThe Care Plan will be updated and reviewed to ensure that the skin/wound alteration and appropriate interventions have been identified on the Care Plan.

Based on observation, clinical record review, staff interview, and policy review the facility failed to flush an enteral gastrostomy tube (g-tube)(tube surgically inserted into the stomach to provide nutrition and medication) per the physician order prior to administering medication thru the gastrostomy tube for 1 of 1 resident (Resident #7) reviewed. The facility reported a census of 74 residents. Findings include: A Annual Minimum Data Set (MDS) for Resident #7 dated 7/3/25, included diagnoses of Non-Alzheimer's Dementia and hemiplegia (paralysis of one side of the body). The MDS revealed the resident had a g-tube. Observation on 7/22/25 at 9:50 AM, Staff A, Registered Nurse placed crushed medications and liquid medications into a cup and added 30 milliliters (ml.) of water to the medications. Staff A proceeded to administer the cup of medications mixed with water to Resident #7 thru her g-tube, and then administered 30 ml. of water into the g-tube. Clinical Physician Orders for Resident #7 documented an order with start date of 7/22/25 for 30 ml of water before medication administration and 30 ml water after medication administration for g-tube. The facility's Medication Administration via Enteral Tube Policy revised 1/31/24 revealed to flush enteral tube with at least 15 ml. of water prior to administering medications, dilute the solid or liquid medication as appropriate and administer, and flush the tube with a final flush of at least 15 ml of water to ensure drug delivery and clear the tube. Interview on 7/23/25 at 4:05 PM, the Director of Nursing stated her expectation when administering g-tube medications is to flush the g- tube per physician's order with water only, then add water to dilute the crushed and liquid medications and administer the diluted medications mixed with water, and follow with a flush of water only.

Based on observation, policy review, and staff interviews, the facility failed to maintain hot holding temperatures above 135 degrees Fahrenheit for 1 of 1 meal observed. The facility reported a census of 79 residents. Findings include: On 2/12/25 at 11:09 a.m., the Dietary Services Manager placed plated food into two warming carts. When she completed filling the first cart, Staff B Dietary Aide took the cart to the Chronic Confusion Dementing Illness (CCDI) unit. At 11:19 a.m., she finished filling the last cart and the State Agency (SA) requested she place a test tray and a thermometer on the last warming cart. At 11:21 a.m., Staff B took the second cart to the CCDI unit. At 11:24 a.m., staff in the CCDI unit began to pass out trays to the resident. At 11:43 a.m., Staff C Restorative Aide stated they passed all of the trays with the exception of a few residents who were not in the dining room yet. The SA immediately obtained the following temperatures on the test tray: mixed vegetables 115 degrees Fahrenheit and tuna casserole 128 degrees Fahrenheit. The SA tasted the tuna casserole and it was warm but not hot. On 2/13/25 at approximately 2:00 p.m., the Dietary Services Manager stated she expected hot foods held above 140 degrees Fahrenheit. The facility policy Food Temperatures, dated 2021, stated foods will be transported and delivered to unit storage areas to maintain at temperature above 135 degrees Fahrenheit or above.

Based on clinical record review, policy review, and staff interviews, the facility failed to protect the resident's right to be free from physical abuse for 4 of 7 residents reviewed for resident to resident altercations (Resident #5, #6, #11, #13). On 7/20/24, Resident #4 scratched Resident #13. On 11/22/24, Resident #4 hit Resident #5 in the hand with an empty plastic pop bottle and shortly after hit Resident #6 in the back. On 2/4/25, Resident #4 hit Resident #11 on the head and shoulder and kicked her knees. The facility reported a census of 79 residents. Findings include: 1. The Quarterly Minimum Data Set(MDS) assessment tool, dated 10/10/24, listed diagnoses for Resident #4 which included non-Alzheimer's dementia, anxiety, and depression. The MDS stated the resident had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) for 1-3 days out of the 7 day review period and listed a Brief Interview for Mental Status(BIMS) score as 11 out of 15, which indicated moderately impaired cognition. The facility Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy updated 10/19/22, stated residents had the right to be free from abuse and must not be subjected to abuse by anyone, including other residents. The policy included assault as an example of Dependent Adult Abuse and defined Assault of a Dependent Adult as any act which was generally intended to cause pain or injury or which was generally intended to result in physical contact which could be considered by a reasonable person to be insulting or offensive. A 1/18/24 Care Plan entry stated the resident was at risk for alterations in her mood and behavior related to anxiety, depression, and dementia and directed staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Further entries on 1/18/24 directed staff to provide structured activities such as toileting, walking inside and outside, and reorientation strategies including signs, pictures, and memory boxes. A 7/20/24 Care Plan entry stated the residents were separated. The Care Plan lacked information regarding why the residents were separated. A 12/30/24 Care Plan entry directed the staff to implement 15 minute checks. The resident's Care Plan lacked documentation of the resident's history of resident to resident physical altercations and lacked direction for staff regarding how to prevent future incidences. a. Resident #4 and Resident #13 The Quarterly MDS assessment tool, dated 10/31/24, listed diagnoses for Resident #13 which included Alzheimer's, anxiety disorder, and heart failure. The MDS listed her BIMS score as 0 out of 15, which indicated severely impaired cognition. A 7/20/24 [NAME] Verbal Aggression Received report stated Resident #4 scratched Resident #13's arm. The facility separated the residents and initiated 15 minute checks. Health Status Note dated 7/20/24 at 9:29PM documented the following; Resident sitting in chair crying accompanied by staff states she scratched me look at my arm resident obtained red bruise to right forearm approximate 1 centimeter (cm) by 4 cm, clean area with soap and water took resident back to her room, performed head to toe assessment no other redness or bruises noted, temperature 97.9, pulse 89 blood pressure 144//88. Physician called, and family notified. Incident Note dated 8/11/24 at 4:20PM documented the following; This nurse summoned to resident hallway outside of Resident#13's room and noted resident yelling, please, somebody do something with her, she came in my room and slapped me! Resident then started pointing to her right, arm, and stated Right there, this is where she hit me! This nurse assessed resident's arm, and no redness or markings present upon assessment. Both residents were immediately separated to avoid further allegations. On call provider was informed. Statements provided by CNA's working that incident was not witnessed. The residents record lacked documentation of follow-up interventions, or review as to how to prevent futher similar incidents. b. Resident #4 and Resident #5 The Quarterly MDS assessment tool, dated 9/5/24, listed diagnoses for Resident #5 which included Alzheimer's disease, non-Alzheimer's dementia, anxiety, and depression. The MDS listed her cognition as severely impaired. An 11/22/24 5:31PM Alleged Abuse report stated Resident #5's tablemate(Resident #4) was upset and hit the resident in the right hand with a soda bottle in the dining room. c. Resident #4 and Resident #6 The Quarterly MDS assessment tool, dated 8/22/24, listed diagnoses for Resident #6 which included Alzheimer's disease, non-Alzheimer's dementia, and anxiety. The MDS listed a BIMS scores as 3 out of 15, which indicated severely impaired cognition. An 11/22/24 2:30PM Alleged Abuse report stated another resident(Resident #4) walked through the dining room and struck Resident #6 in the back/shoulder area with a pop bottle. d. Resident #4 and Resident #11 The Quarterly MDS assessment tool, dated 11/21/24, listed diagnoses for Resident #11 which included Alzheimer's disease, non-Alzheimer's dementia, and anxiety. The MDS listed her BIMS score as 6 out of 15, which indicated severely impaired cognition. A 2/4/25 at 7:00PM Physical Aggression Initiated report stated Resident #4 became rude, aggressive, and verbally abusive to a group of residents who sat at the adjacent dining room table. Resident #4 then hit Resident #11 on her head, shoulders, and kicked her knees. The facility initiated 15-minute checks. On 2/12/25 at 1:53 p.m. Staff E Certified Medication Aide stated (on 11/22/24) Resident #4 and Resident #5 argued and it became more aggressive. He stated Resident #4 reached across the table and hit Resident #5 with her plastic soda bottle. He stated they separated the residents but Resident #4 got ahead of the staff and hit Resident #6 in the left shoulder. Staff E stated the resident had always been explosive and they had to keep her corralled He said he tried to keep her away from certain tables and looked at verbal cues. He stated they were not always successful(in preventing her physical aggression with other residents) but they tried. On 2/12/25 at 2:18 p.m., Staff F Licensed Practical Nurse (LPN) stated(on 11/22/24) she heard Resident #4 screaming profanities at other residents and she pointed a soda bottle. She stated she went to get her out of the dining room but they had to walk past two tables and when they did so, she hit Resident #6 but did not hit her hard at all. Staff F stated she did not know why she did this as Resident #6 did nothing to provoke this. She stated she didn't know how to handle Resident #4 and she hit other residents. She stated she was not sure if she had triggers and stated she did not hear of any concrete interventions she could carry out to prevent these incidents. On 2/12/25 at 3:40 p.m., Staff G Registered Nurse (RN) stated Resident #4 was verbally and physically aggressive. She stated she lashed out at several residents and she could go from 0 to 360 in 2 seconds. She stated the other residents were fearful when she screamed loudly and that she was very impulsive. Staff G stated if they did not stand right next to her within a couple of feet, she did not feel they could stop a future physical altercation. On 2/13/25 at 8:25 a.m., Staff H LPN, Assistant Director of Nursing (ADON) stated Resident #4 was triggered easily. She stated her behaviors were very unprovoked and came out of nowhere. She would just go over and hit someone. She stated they tried several different interventions but it was difficult. She stated she didn't know if there was a way to 100% prevent her physical aggression towards other residents. On 2/13/25 at 3:12 p.m., the interim Director of Nursing (DON) stated the goal of the facility was for residents to be free from physical aggression. She stated with Resident #4, they tried their best to intervene but at times she got to the point where she picks on someone before they were able to intervene. She stated they did everything they could besides removing her from the facility.

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to implement resident centered care plan interventions to protect the resident's right to be free from physical abuse for 4 of 7 residents reviewed for resident to resident altercations (Resident #5, #6, #11, #13). The facility continued to use the intervention of resident separation, and implimentation of 15-minute checks, with additional follow up intervention. On 7/20/24, Resident #4 scratched Resident #13. On 11/22/24, Resident #4 hit Resident #5 in the hand with an empty plastic pop bottle and shortly after hit Resident #6 in the back. On 2/4/25, Resident #4 hit Resident #11 on the head and shoulder and kicked her knees. The facility reported a census of 79 residents. Findings include: 1. The Quarterly Minimum Data Set(MDS) assessment tool, dated 10/10/24, listed diagnoses for Resident #4 which included non-Alzheimer's dementia, anxiety, and depression. The MDS stated the resident had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) for 1-3 days out of the 7 day review period and listed a Brief Interview for Mental Status(BIMS) score as 11 out of 15, indicating moderately impaired cognition. The facility Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy updated 10/19/22, stated residents had the right to be free from abuse and must not be subjected to abuse by anyone, including other residents. The policy included assault as an example of Dependent Adult Abuse and defined Assault of a Dependent Adult as any act which was generally intended to cause pain or injury or which was generally intended to result in physical contact which could be considered by a reasonable person to be insulting or offensive. The facility policy Comprehensive Care Plans, revised 1/30/24, stated the facility would develop and implement a person-centered Care Plan for each resident. The policy stated the Care Plan would include measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs. A 1/18/24 Care Plan entry stated the resident was at risk for alterations in her mood and behavior related to anxiety, depression, and dementia and directed staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Further entries on 1/18/24 directed staff to provide structured activities such as toileting, walking inside and outside, and reorientation strategies including signs, pictures, and memory boxes. A 7/20/24 Care Plan entry stated the residents were separated. The Care Plan lacked information regarding why the residents were separated. A 12/30/24 Care Plan entry directed the staff to implement 15 minute checks. The resident's Care Plan lacked documentation of the resident's history of resident to resident physical altercations and lacked direction for staff regarding how to prevent future incidences. a. Resident #4 and Resident #13 The Quarterly MDS assessment tool, dated 10/31/24, listed diagnoses for Resident #13 which included Alzheimer's, anxiety disorder, and heart failure. The MDS listed her BIMS score as 0 out of 15, indicating severely impaired cognition. A 7/20/24 7:25PM [NAME] Verbal Aggression Received report stated Resident #4 scratched Resident #13's arm. The facility separated the residents and initiated 15 minute checks. b. Resident #4 and Resident #5 The MDS assessment tool, dated 9/5/24, listed diagnoses for Resident #5 which included Alzheimer's disease, non-Alzheimer's dementia, anxiety, and depression. The MDS listed her cognition as severely impaired. An 11/22/24 Alleged Abuse report stated Resident #5's tablemate(Resident #4) was upset and hit the resident in the right hand with a soda bottle. c. Resident #4 and Resident #6 The MDS assessment tool, dated 8/22/24, listed diagnoses for Resident #6 which included Alzheimer's disease, non-Alzheimer's dementia, and anxiety. The MDS listed a BIMS scores as 3 out of 15, indicating severely impaired cognition. An 11/22/24 Alleged Abuse report stated another resident(Resident #4) walked through the dining room and struck Resident #6 in the back/shoulder area with a pop bottle. d. Resident #4 and Resident #11 The MDS assessment tool, dated 11/21/24, listed diagnoses for Resident #11 which included Alzheimer's disease, non-Alzheimer's dementia, and anxiety. The MDS listed her BIMS score as 6 out of 15, indicating severely impaired cognition. A 2/4/25 Physical Aggression Initiated report stated Resident #4 became rude, aggressive, and verbally abusive to a group of residents who sat at the adjacent dining room table. Resident #4 then hit Resident #11 on her head, shoulders, and kicked her knees. The facility initiated 15-minute checks. On 2/12/25 at 1:53 p.m. Staff E Certified Medication Aide stated(on 11/22/24) Resident #4 and Resident #5 argued and it became more aggressive. He stated Resident #4 reached across the table and hit Resident #5 with her plastic soda bottle. He stated they separated the residents but Resident #4 got ahead of the staff and hit Resident #6 in the left shoulder. Staff E stated the resident had always been explosive and they had to keep her corralled He said he tried to keep her away from certain tables and looked at verbal cues. He stated they were not always successful(in preventing her physical aggression with other residents) but they tried. On 2/12/25 at 2:18 p.m., Staff F Licensed Practical Nurse(LPN) stated(on 11/22/24) she heard Resident #4 screaming profanities at other residents and she pointed a soda bottle. She stated she went to get her out of the dining room but they had to walk past two tables and when they did so, she hit Resident #6 but did not hit her hard at all. Staff F stated she did not know why she did this as Resident #6 did nothing to provoke this. She stated she didn't know how to handle Resident #4 and she hit other residents. She stated she was not sure if she had triggers and stated she did not hear of any concrete interventions she could carry out to prevent these incidents. On 2/12/25 at 3:40 p.m., Staff G Registered Nurse(RN) stated Resident #4 was verbally and physically aggressive. She stated she lashed out at several residents and she could go from 0 to 360 in 2 seconds. She stated the other residents were fearful when she screamed loudly and that she was very impulsive. Staff G stated if they did not stand right next to her within a couple of feet, she did not feel they could stop a future physical altercation. On 2/13/25 at 8:25 a.m., Staff H LPN, Assistant Director of Nursing(ADON) stated Resident #4 was triggered easily. She stated her behaviors were very unprovoked and came out of nowhere. She would just go over and hit someone. She stated they tried several different interventions but it was difficult. She stated she didn't know if there was a way to 100% prevent her physical aggression towards other residents. On 2/13/25 at 3:12 p.m., the interim Director of Nursing(DON) stated the goal of the facility was for residents to be free from physical aggression. She stated with Resident #4, they tried their best to intervene but at times she got to the point where she picks on someone before they were able to intervene. She stated they did everything they could besides removing her from the facility. On 2/17/25 at 10:57 a.m., Staff I MDS Coordinator stated she did not include specifics in Care Plans such as resident physical aggression and the details of the altercation.

Based on clinical record review and staff interview, the facility failed to follow physician's orders for a genetic testing referral for 1 of 3 residents reviewed for a physician's orders(Resident #4). The facility reported a census of 79 residents. Findings include: The Quarterly Minimum Data Set(MDS) assessment tool, dated 6/20/24, listed diagnoses for Resident #2 which included non-Alzheimer's dementia, seizure disorder, and diabetes. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. A 7/31/24 clinic Patient Encounter Form stated the resident had newly diagnosed breast cancer. The form listed a referral to genetic testing for history of ovarian cancer and now breast cancer with an extensive family history. The facility lacked documentation the resident completed genetic testing and lacked information regarding the resident's appointments and a reason she did not attend. On 2/11/25 at 10:06 a.m., Staff A Cancer Center representative stated Resident #2 had an appointment scheduled for genetic testing on 9/4/24 and the facility called and canceled the appointment right before the appointment time and stated they did not have a ride for the resident. She stated the resident had an appointment rescheduled on 10/8/24 but she did not show up. On 2/12/25 at 10:01 a.m. the interim Administrator stated the genetic testing was not completed. On 2/12/25 at 12:40 p.m., Staff D Staffing Coordinator stated she did not see an appointment for the resident on 9/4/24 when she reviewed the calendar. She stated she did have an appointment on 10/8/24 and she (Staff D) thought that another driver would take her to the appointment. She stated when she found out the other driver was not taking her she went to the resident's room and was going to rush to get her there. Staff D stated the resident did not want to rush to get to the appointment and also did not feel well. Staff D stated she did not document this anywhere. She stated no one at the facility rescheduled the appointment. On 2/12/25 at 12:43 p.m., Staff C Driver stated there were times when the facility had to reschedule appointments the day of the appointment if the nurse forgot to put a note in. On 2/13/25 at 3:12 p.m., the interim Director of Nursing (DON) stated the facility should follow physician's orders which would include referrals. On 2/17/25 at approximately 12:00 p.m., the Administrator stated the facility did not have a policy for physician's orders and they utilized the standards of practice as a guideline.

Based on observations, staff interviews, and policy review, the facility failed to provide a clean, comfortable and homelike environment. The facility identified a census of 71 residents. Findings include: Observations revealed the following: On 08/19/24 at 8:50 AM: a. A wooden pallet laid on the floor in the common area and smaller dining room across from the Station 2 nurse's station. The wooden pallet had boxes of flooring on it. b. The baseboard heaters on the 200 hall by the exit door had metal flaps that were bent up and torn away from the heater. c. The walls in the 100-400 hallways had missing baseboards (trim). d. A clear plastic bag of garbage contained a soiled brief, paper towels, and gloves, and a large black garbage bag laid on the floor by the doorway in room [ROOM NUMBER]. e. Soiled washcloths lying on the floor by the door in room [ROOM NUMBER]. A sign on the wall revealed the resident on enhanced barrier precautions. At 10:25 AM, the wooden pallet laid on the floor (between 2 recliner chairs) with boxes of flooring remained in the common area across from the Station 2 nurse's station. At the time, five residents (Resident #9, #20,#26,#29, and #68) sat in the same common area /smaller dining room across from Station 2 nurse's station. On 08/20/24 at 7:59 AM: a. The divider curtain in room [ROOM NUMBER] had a dried brown stain on it. b. The headboard on Resident #23's bed was loose and slanted downward on the bed. The headboard wood felt rough and had particles of wood showing. Multiple black ties were wrapped around the headboard and bedframe. c. The bathroom light in room [ROOM NUMBER] was not working. On 08/22/24 at 10:35 AM, the pallet with flooring remained on the floor in the Station 2 common area. At the time, 5 residents were seated in the area watching tv or sleeping. On 08/22/24 at 10:42 AM, the divider curtain in room [ROOM NUMBER] still had a brown stain. Resident #23's headboard on the bed still broken and had multiple black ties on it. In an interview 08/21/24 at 9:01 AM, Staff F, Maintenance Assistant, reported he fixed the beds and whatever else needed done at the facility. Staff put in a work order in the TELS system or verbally notified him when something needed repaired. He called the company if a bed wasn't the facility's bed and in need of repairs or checked. Staff F reported a remodel project completed in the Iris Unit and they have been doing renovations on Station 2. In an interview 08/21/24 at 10:14 AM, the Regional Maintenance Director stated he came to the facility about once a week. The new company took over around 4/2024 and they had been in the process of fixing things up. They removed the carpet in the halls and had been working on installing new flooring, and baseboards on Station 2. Some heater bases replaced but no plans to change out unless bad the heaters were badly damaged. In an interview 08/22/24 at 10:57 AM, Staff G, housekeeper, reported she took the divider curtains down to launder them whenever she saw they were dirty. In an interview 08/22/24 at 10:58 AM, Staff F, Maintenance Assistant, reported staff reported things that needed repaired or checked every day. He also checked the electrical remotes and fixed the beds about every day. Staff F reported Resident #23's headboard had been like that (slanted and loose) for awhile. He fixes the headboard but thought the resident knocked on it. At the time, Staff F observed the headboard on Resident #23's bed with the surveyor and stated the headboard needed repaired or replaced. In an interview 08/22/24 at 11:11 AM, the housekeeping supervisor reported they tried to clean the divider curtains in the resident rooms, and aimed to do a hall a week. In an interview 08/22/24 at 1:00 PM, Staff F reported he fixed the bed in room [ROOM NUMBER]. The surveyor verified the headboard attached to the bedframe and no longer slanted and loose, and the headboard no longer had multiple ties to hold the headboard to the bedframe. In an interview 08/22/24 at 1:30 PM, the Administrator reported a new company took over on 1/2024. The Administrator reported they tried to pull the manpower to lay the flooring and finish the trim by the nurse's station and common area. In an email dated 8/22/24 at 2:16 PM, the surveyor requested a policy for homelike environment. The surveyor's email also included to let the surveyors know if the facility had no policy. In an email 8/22/24 at 4:21 PM, the Administrator wrote we do not have policies for the other requests (homelike environment).

Based on observation, clinical record review, resident, family, and staff interviews, the facility failed to respect each resident's dignity throughout all cares provided or talk to residents with dignity and respect. The facility reported a census of 71. Findings include: 1. A direct observation on 08/19/24 at 11:30 AM revealed Staff K, Certified Medication Aide (CMA), on her cell phone at this time. From a period lasting from 11:30 AM until 11:42 AM Staff K remained on her phone while residents were seated and began to eat in the dining room. A direct observation on 08/19/24 at 12:06 PM revealed Staff K, CMA, return to her phone for a period lasting until 12:15 PM. During the observation a resident was observed needing comfort because she was afraid she did not have enough money to pay for lunch. Another staff member intervened. Staff K finally put her phone down when a resident spilled a portion of her lunch on the floor and attempted to clean it herself, at which point Staff K put her phone away and assisted other staff members in intervening. A direct observation on 08/20/24 at 12:23 PM revealed Staff L, Certified Nurse Aide (CNA), leave residents she was currently assisting in the dining room to position herself out of sight in the corner of the family room after receiving a cell phone notification. For a period of just over ten minutes, ending at 12:33 PM, Staff L continued to type on her phone without looking up or otherwise monitoring residents. A direct observation on 08/20/24 at 02:39 PM revealed Staff L, CNA, use her phone to start music over a blue tooth device for residents. Music played for residents until 02:49 PM, at which time a phone notification sound could be heard over the blue tooth speaker playing music. Staff L took her phone out of her pocket and began to type on her phone. The reply disrupted the music playing, replacing it with a typing sound. Staff L remained on her phone typing until 03:08 PM, at which time the typing sound ended and she used her phone to resume the music for the few residents remaining in the dining room. In a confidential interview on 08/19/24 at 10:42 AM a residents family member stated the staff are constantly on their phones, often seen ignoring residents. They stated they are in the facility almost daily and see staff members in the corners of the rooms on their phones, often while residents are eating. In an interview on 08/22/24 at 09:18 AM with the Director of Nursing (DON), she stated staff members are to refrain from using their phones while not on break. The expectation is for staff members to keep their phones turned off while on the floor unless they have an extenuating circumstance and an exception to policy discussed with their supervisor. She acknowledged she did not know of any staff member with a current exception to policy working in the Chronic Confused Dementia (CCDI) unit. Review of an undated facility policy titled Cell Phone Usage Policy documented all employees of the facility are expected to leave their personal cell phones in their vehicle or designated employee area. It further documented the use of cell phones during the work day is believed to negatively impact services provided to residents. 40905 2. During a confidential interview on 8/19/24 at 1:45 PM, a resident stated staff are talking on their personal cell phones even when in the resident's room assisting the resident with cares. The resident also reported some staff talk in another language than English when in the resident's room and the resident feels it's rude as the resident does not know if the staff are talking about the resident. 3. During a confidential interview on 8/18/24 at 2:16 PM, a resident stated staff are on their personal cell phones a lot, talking and texting, while in the resident's room assisting with the resident's cares. Resident also stated some other staff don't talk English language while in the resident's room and makes the resident feel uncomfortable.

Based on direct observation, family and staff interviews, the facility failed to appropriately supervise and have interventions in place to ensure the resident's individual safety in the Chronic confusion and dementing illnesses (CCDI) unit. The facility reported a census of 28 in the CCDI unit and a total census of 71. Findings include: In a confidential interview on 08/19/24 at 10:42 AM with a resident Family Member A, they stated they felt they had to take over many of the cares their family member received because the facility staff had a pattern of ignoring their loved ones needs. They stated they were performing several of their family members activities of daily living after discovering their family member soiled with dried feces on them. In a confidential interview on 08/19/24 02:22 PM with Resident Family Member B, they stated their loved one had been found on multiple occasions heavily soiled with dried feces on their body. They stated staff members often told them the resident had refused all cares, and had not showered in weeks as a result. A continuous direct observation that started on 08/20/24 at 10:32 PM of the CCDI unit revealed Staff N, Certified Nurses Aide (CNA), asleep in a chair positioned towards the center of the CCDI unit. A resident was actively having a behavioral episode that could be heard down the hallway and through the locked doors of the CCDI unit. Staff N resisted attempts from Staff O to wake her up by loudly clearing her throat and making loud vocalizations. She continued to sleep as the surveyor introduced himself, only waking up when Staff O directly addressed her by name. After waking up she continued to fall asleep until she requested to go on break at 08/20/24 11:28 PM. During the observation 08/20/24 at 10:48 PM, Staff N was approached by Resident #12 who asked for a glass of orange juice or hot chocolate. Staff N attempted to redirect Resident # 12, informing her they were out of orange juice and the kitchen was closed. Resident #12 continued to ask and be denied her request until Staff N stated fine and left the unit at 08/20/24 11:11 PM to get Resident #12 a hot chocolate. Upon receiving the hot chocolate, Resident #12 immediately returned to her bedroom. In an interview on 08/22/24 at 09:18 AM with the Director of Nursing (DON), she stated it was unacceptable for staff members to sleep during their shift. She stated it was explicitly against the code of conduct. Review of an undated facility document titled Work Rules, under section 5, records that staff members are prohibited from sleeping on the job.

Based on clinical record review, observation, staff interviews, and policy review the facility failed to utilize infection control techniques in order to prevent cross contamination for 2 of 3 residents reviewed for catheter care, treatments, and dressing changes (Resident #6 and #28). The facility also failed to ensure staff changed gloves and performed hand hygiene when contaminated for two of three residents observed. The staff failed to utilize a barrier and disinfect contaminated equipment and surfaces after use for 1 of 3 units observed. The facility staff also failed to don personal protective equipment on a resident on enhanced barrier precautions prior to catheter care for 1 of 3 units observed. The facility also failed to provide peri-care in a manner to prevent cross-contamination and infection for 1 of 3 residents observed for peri-care. The facility also failed to disinfect resident care devices when soiled for 2 of 3 residents observed during incontinence/catheter cares (Resident #6 and #41). The facility staff failed to rinse nebulizer equipment after use with hot water for 1 0f 1 treatments observed. (Resident#7). The facility reported a census of 71 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident#6 had diagnosis of neurogenic bladder, renal insufficiency, and urinary retention. The MDS indicated the resident had an indwelling catheter. The Care Plan revised 4/5/2024 revealed the resident had a suprapubic catheter and a history of UTI (urinary tract infection). During observation on 08/20/24 at 12:10 PM, Resident #6 lying in bed. An EBP sign sat on the counter by the sink. Staff C, certified nursing assistant, donned gloves, sat a graduate container on the floor by the resident's bed. Staff C unclamped and drained the catheter into the graduate container, the replaced the catheter port into the holder on the catheter bag. Staff C measured the amount of urine in the graduate then emptied the graduate into the toilet. Staff C then took toilet paper and wiped the inside of the graduate container and placed the graduate on the back of the toilet. Staff C removed her gloves. Staff C placed her hand under the soap dispenser but no soap came out. Staff C stated no soap in the soap dispenser and no soap in the resident's room for her to use. Staff C washed her hands with water. Staff C failed to follow enhanced barrier precautions and don an isolation gown prior to handling and care of the catheter. Staff C did not use a barrier to place the graduate container on, and did not cleanse the catheter port with alcohol after she emptied the catheter. Staff C failed to perform hand hygiene appropriately after she handled the urinary catheter. In an interview 08/20/24 at 3:40 PM, Staff A, Licensed Practical Nurse (LPN), reported EBP required for residents with a catheter. Gown and gloves worn during cares whenever a resident on EBP. In an interview 08/21/24 at 11:38 AM, the Infection Preventionist (IP) reported residents who had a catheter or any tubes coming out of the body placed on EBP. She expected staff to put personal protective equipment such as gown and gloves on whenever they entered the resident's room. At the time, the IP provided a list of resident on EBP. The IP confirmed Resident # 6 on EBP according to her EBP list. The IP reported an EBP sign placed inside the room above the light switch in the resident's room. The IP reported she expected staff used a barrier whenever they emptied a catheter. The IP reported staff needed to clean the catheter port with an alcohol swab after a catheter emptied. She expected staff rinsed the graduate with soap and water after the graduate emptied. The IP reported the housekeeping supervisor checked the soap dispensers in the resident rooms weekly and ensured they worked and had soap in them. Observation on 08/22/24 at 10:42 AM revealed the soap dispenser in room [ROOM NUMBER] still not working. In an interview 08/22/24 at 10:50 AM, Staff I, Licensed Practical Nurse (LPN) reported the housekeepers filled the soap dispensers and maintenance checked the soap dispensers to ensure they worked. In an interview 08/22/24 at 10:57 AM, Staff G, Housekeeper, reported she checked the soap dispensers. Staff let them know when soap dispensers ran out of soap. In an interview 08/22/24 at 10:58 AM, Staff F, Maintenance Assistant, reported staff reported things that needed repaired or checked every day. Housekeeping filled the soap dispensers but he fixed the soap dispensers and replaced the batteries. At the time, Staff F checked the soap dispenser in Rm 208. Staff F placed his hand under the dispenser but no soap came out or sound heard. Staff F reported the soap dispenser not working. Staff F opened the front of the dispenser, removed the batteries and put the batteries back in, then closed the front of the dispenser. Staff F stated the dispenser needed batteries. At the time, the EBP sign remained on the sink counter in the resident's room An Enhanced Barrier Precautions policy updated 5/6/24 revealed EBP implemented for the prevention of transmission of multidrug resistant organisms. A gown and gloves used during high contact resident care activities including handling and care of a urinary catheters. In an email dated 8/22/24 at 2:16 PM, the surveyor requested a policy for emptying the catheter bag. The surveyor's email also included to let surveyors know if the facility had no policy. In an email 8/22/24 at 4:21 PM, the Administrator wrote we do not have policies for the other two requests (homelike environment and emptying the catheter bag). 2. The MDS assessment dated [DATE] revealed Resident #28 had diagnosis of diabetes with foot ulcer, viral hepatitis, and a Stage 3 pressure ulcer on the right heel. The Care Plan revised 5/2/24 revealed Resident #28 had an unstageable pressure area on her right heel. The resident had potential for impaired skin related to diabetes and impaired mobility. The care plan staff directives included treatments per physician's orders The order summary revealed an order to cleanse the right heel wound with wound cleanser, apply Clobetasol 0.05% to periwound (surrounding around the wound), then apply collagen sheet to the wound, cover with ABD (large dressing) pad, and secure with a gauze roll daily and PRN (as needed) started on 07/18/24. During observations on 08/21/24 at 9:35 AM, Staff A, Licensed Practical Nurse (LPN), placed supplies on a towel on an overbed table by the bed. Staff A washed her hands, then donned a gown and gloves. Staff A reported Resident #28's right heel wound dressing off because therapy had just performed an ultrasound to the foot. Staff A reached into her uniform pocket, pulled out a pair of scissors and cut a roll of gauze. Staff A sprayed wound cleanser onto the resident's right heel, then took gauze and wiped the area. Staff A changed her gloves, then took a q-tip and applied Clobetasol to the skin around the wound area. Staff A applied Puracol collagen and an ABD dressing over the right heel wound. Staff A pulled and moved the yellow gown with her gloved hand, reached into her uniform pocket to get tape, and applied tape to the dressing. Staff A reached into her uniform pocket again, pulled out a pen, and wrote the date and her initials on the tape. Staff A removed one glove, then removed the yellow gown and her other glove, and rolled the gown up and placed the gown and glove into the trashcan. Staff A washed her hands, donned a glove, rolled the wound cleanser, tape, scissors, and hand sanitizer into the towel on the overbed table, tucked the towel and supplies against her uniform, opened the door to the resident's room with her gloved hand, then removed the glove, and took the towel with supplies rolled up inside to the soiled utility room. Staff F, Assistant Director of Nursing, stood in the room with the surveyor and observed Staff A during the procedure. In an interview 08/21/24 at 11:38 AM, the Infection Preventionist reported some residents with a wound placed on EBP. At the time, the IP provided a list of resident on EBP. The IP confirmed Resident #28 on EBP according to her EBP list. The IP reported she expected staff removed gloves and gown, and sanitized hands before they removed an item from their pocket, then wash or sanitize hands again, and reapply a gown and gloves to resume the treatment. The IP reported staff should plan accordingly and place supplies on barrier prior to a procedure. If staff forgot something, then they needed to remove the gown and gloves, wash their hands, obtain the supplies, re-sanitize hands, and reapply the gown and gloves. She expected staff to clean scissors with alcohol prior to and after use. Soiled linens should not be carried against the uniform due to infection control reasons. A facility's Dressing Change Competency updated 5/11/21 revealed the following procedural steps: 1. Gather necessary equipment: plastic biohazard bag, clean towel for clean field, dressing supplies, gloves, pen for making dressing, tape. 2. Wash hands, don gloves 3. Perform treatment: cleanse wound and perform treatment according to the orders 4. Apply dressing and date 5. Discard all waste into a plastic bag 6. Remove gloves 7. Wash hands 8. Discard waste into biohazard waste and return supplies (clean scissors) Enhanced Barrier Precautions policy updated 5/6/24 revealed EBP implemented for the prevention of transmission of multidrug resistant organisms. 3. During observation on 08/21/24 at 8:10 AM, Staff E, Licensed Practical Nurse (LPN) prepared and administered an albuterol treatment to Resident #17. Staff E placed the medication solution into the nebulizer chamber, then attached the chamber to a mask and applied the mask over the resident's face. Staff E turned the machine on and set a timer. At 08:26 AM, Staff E removed the nebulizer mask from the resident's face and placed the mask with nebulizer chamber onto the nebulizer machine holder on the bedside table. Staff E did not rinse the nebulizer chamber parts and mask after the treatment completed. In an interview 08/21/24 at 1:55 PM, the DON reported staff should pull the nebulizer chamber apart after a nebulizer treatment administered, rinse the nebulizer chamber and mask with water, and allow the pieces to dry. The facility's Nebulizer Treatment competency update 5/11/21 revealed after treatment administered, take the mouthpiece apart and rinse with hot water and allow to air dry after each use. 40905 4. The MDS assessment for Resident #41, dated 6/27/24, included diagnoses of diabetes and anxiety disorder and documented the resident had an indwelling catheter (tube into the bladder to drain urine). Observation on 8/20/24 at 12:53 PM, Staff P, Certified Nurse Aide (CNA) and Staff A, Licensed Practical Nurse (LPN) washed hands and applied a gown and gloves, then proceeded to transfer Resident #41 from the wheel chair to the bed, with a mechanical stand lift, hooking the resident's catheter bag to the arm of the lift during the transfer. Staff P, with the same gloves, proceeded to touch the lift, lift sling, bed and bed rail while transferring the resident and moving the catheter bag from the lift to the bed frame. Staff P, with the same gloved hands, got a graduate (container to empty and measure urine) from the bathroom and placed a paper towel on the floor under the graduate. Staff P proceeded with the same gloved hands and cleansed the tip of the catheter bag tubing with an alcohol swab, emptied the catheter, and cleansed the tip again. Staff P removed her gown and gloves, washed her hands, and placed the mechanical stand lift in hallway. Interview on 8/20/24 at 1 PM, Staff A confirmed the mechanical stand lift is used for other residents and expectation to wash hands and apply new gloves before emptying catheter bag after touching other items, to keep the catheter bag below the level of the bladder, and clean the mechanical stand lift after use. Interview on 8/22/24 at 10:21 AM, the Director of Nursing stated expectation to complete hand hygiene when going from dirty surfaces/items to clean and to clean equipment after use.

Based on clinical record review, observation, staff interview, and the facility policy review, the facility staff failed to provide complete incontinence care for one of three residents reviewed (Resident #23). The facility reported a census of 71 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had diagnoses of dementia. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. The MDS documented the resident had incontinence, and had dependence on staff for toileting hygiene. The Care Plan revised 2/8/24 revealed the resident had a self-care deficit in activities of daily living and had incontinence. The resident required maximum assistance for bed mobility and dressing. The care plan directed staff to clean the peri-area after each incontinence episode. During observation on 08/20/24 at 07:44 AM, Resident #23 [NAME] in bed while Staff C, certified nursing assistant (CNA), provided cares. Staff C donned gloves, removed the tabs on the resident's brief, then took a disposable wipe and cleansed the resident's groin bilaterally. Staff C then took one wipe and cleansed down the front (peri-area). Staff C pushed each wipe down and left the soiled wipes in place after she cleansed each area. Staff C rolled the resident onto her right side, removed the soiled brief and soiled wipes under the resident, then grabbed the trashcan and placed the items into the trash. Staff C took one wipe and cleansed the buttocks, then placed a clean brief under the resident. Staff C removed her gloves, donned a pair of shorts on the resident, and washed her hands. In an interview 08/20/24 at 8:05 AM, Staff C, CNA, reported Resident #23's brief was wet when she performed cares and provided incontinence care on 8/20/24 AM while the surveyor observed. In an interview 08/21/24 at 1:55 PM, the Director of Nursing (DON) reported she expected staff follow the policy whenever they provided peri-care. She also expected staff changed their gloves and sanitized their hands whenever going from a dirty to a clean area. The facility's Peri Care Competency revealed the following procedural steps: 1. Assemble equipment and supplies. 2. Wash hands and don gloves. 3. Gently separate the labia, wash one side then the other cleansing from front to back. 4. Wash the left and right inner thighs. Use a new wipe for each area and one swipe wipe technique. 5. Place soiled wash cloths into a plastic bag. 6. Remove gloves before turning the resident onto their side. 7. Wash the anal area front to back. 8. Wash the buttocks and both hips. 9. Remove gloves, wash hands, and roll the resident onto their side and onto a clean, dry surface. 10. Remove gloves and cleanse hands.

Based on observations, clinical record review, staff interview, and policy review the facility failed to assure a medication error rate of less than 5%. During observation of medication administration, the facility had 5 errors out of 37 opportunities for error resulting in an error rate of 13.51% (Residents #69). The facility identified a census of 71 residents Findings include: During observation on 08/20/24 at 3:28 PM, Staff A, Licensed Practical Nurse (LPN), checked the electronic health record (EHR) and obtained a Styrofoam cup with hot water. Staff A reported the hot water would help dissolve the pills better. Staff A prepared the following medication for Resident #69: 1. Amantadine (anti-seizure/tremor medication) 15 milliliters (ml) 2. Docusate sodium (stool softener) 30 ml 3. Atorvastatin (for cholesterol)10 milligrams (mg) 4. Eliquis (blood thinner) 5 mg 5. Metoprolol (for blood pressure) 25 mg Staff A crushed the pills (atorvastatin, eliquis, and metoprolol) and placed them into the liquid medication and warm water mixture in the Styrofoam cup. Staff A then stirred the contents together. At 3:37 PM, Staff A donned a gown and gloves, and placed the Styrofoam cup with medications on a table. Staff A checked placement of the Peg tube. Staff A attached a syringe to the Peg Tube, poured an unmeasured amount of water into the syringe, then poured the medication mixture into the syringe until the stryofoam cup emptied, and then poured 60 ml of water into the syringe. Staff A removed the syringe and plugged the Peg tube. An order summary report revealed Resident #69 on a mechanical soft diet. An active verbal order started on 04/29/2024 revealed medications may be given through the Peg tube as needed. The order summary lacked an order to cocktail medications whenever g-tube (gastrostomy) (a tube in the stomach) medications administered. The Medication Administration Record (MAR) dated 8/1/24 to 8/31/24, revealed amantadine, docusate sodium, atorvastatin, eliquis, and metoprolol administered by Staff A on 8/20/24 on the evening/PM shift. In an interview 08/21/24 at 1:40 PM, the Director of Nursing (DON) reported she expected staff followed the policy for g-tube medication administration. The DON stated g-tube medications given individually along with the amount of water flush per the physician's orders. At the time, the DON checked Resident #69's EHR and reported an order for medications may be given through the Peg tube as needed. The DON confirmed no order to cocktail the medications for Resident #69. In an interview 08/22/24 at 10:50 AM, Staff I, LPN, reported medications given one at a time whenever medications given through a g-tube. A facility's Medication Administration via Enteral Tube Policy revised 1/31/24 revealed each medication administered separately unless had a physician's written order that medications may be combined and given all together. The enteral tube flushed with at least 15 ml of water after each medication administered.

Based on clinical record review, resident, family, and staff interviews, the facility failed to appropriately provide assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well-being. Clinical record review revealed the nursing staff failed to provide thorough assessment, did not contact the resident's physician in a timely manner or provide treatment for 1 of 18 residents reviewed. (Resident#61). Findings include: The Minimum Data Sample (MDS) for Resident #61, dated 06/27/24, documented a brief interview for mental status score (BIMS) of 99, indicating the resident was unable to complete the interview. The MDS documented relevant diagnoses of Non-Alzheimer's Dementia, anxiety disorder, and bipolar disorder. The Care Plan, last updated on 07/15/2024, documented Resident #61 is dependent on staff to meet her emotional, intellectual, physical, and social needs. Review of a health status note dated 07/22/2024 documented a phone call between a resident family member and Staff M, Registered Nurse (RN), in which the family member states she had spoken to staff members over the course of two weeks about reported pain in Resident #61's right thumb. In an interview on 08/22/24 at 08:11 with Staff M, RN, she stated Resident #61 had mentioned pain in her right thumb for approximately two weeks before an order for an X-ray was received on 07/25/24. She assessed Resident #61 for impairment to the range of motion or swelling and didn't note anything. She stated she had provided as needed Tylenol after assessing the resident's thumb. In an interview on 08/22/24 at 08:35 AM with Staff K, Certified Medication Aide (CMA), reported Resident #61 had been complaining of pain in her right thumb and been more resistant to cares for at least two weeks leading up to the resident's X-ray on 07/25/24. She stated she did not believe she had reported the pain to anyone else or documented it in the electronic health record (EHR). She stated she had provided as needed (PRN) Tylenol on several occasions. In an interview on 08/22/24 at 08:53 AM with Staff L, Certified Nurse Aide (CNA), she stated Resident #61 had been reporting pain in her right thumb for days before receiving an X-ray on 07/25/24. Review of Resident #61's Medication Administration Record (MAR) dated from 07/01/24 to 08/22/24 documented that her as needed Tylenol had only been documented as administered on one occasion between 07/01/24 and 08/22/24, on 08/06/24. In an interview on 08/22/24 at 09:18 AM with the Director of Nursing (DON), stated the expectation is for staff members to take all newly reported resident pain seriously by informing nursing staff and document in the Electronic Health Record (EHR) to track. She acknowledged she expects nursing staff to use their best nursing judgement and to contact the physician if assessment reveals something abnormal. In an email sent by the facility administrator on 08/22/24 at 12:53 PM she stated the facility does not have a policy for assessment and intervention.

Based on clinical record review and staff interview, the facility failed to develop and implement a Baseline Care Plan that included anticoagulant (blood thinner), antipsychotic, and antidepressant medications and monitoring for one (Resident #76) of three residents reviewed. The facility reported a census of 71 residents. Findings include: A Minimum data set (MDS) assessment dated [DATE] for Resident #76, included diagnoses of heart failure, anxiety disorder, and mood disorder. Review of resident's order summary report dated 8/21/24, listed the following medications: 1. Apixaban (anticoagulant) 5 milligrams (mg)- 2 times daily. 2. Duloxetine(antidepressant) 40 mg. in the morning and 60 mg. at bedtime. 3. Risperdal (antipsychotic) 1 mg.- 2 times a day. Review of resident's Baseline Care Plan, dated 8/8/24, lacked documentation of the anticoagulant, antidepressant, and antipsychotic medications. Interview on 8/22/24 at 10:27 AM, the Director of Nursing stated expectation for the medications to be included in the baseline care plan. Interview on 8/22/24 at 1:00 PM, the Administrator stated there was no facility policy for the Baseline Care Plan, facility is expected to follow the regulations.

Based on clinical record review and staff interview the facility failed to provide the resident/resident representative notice of the bed hold policy at the time of transfer for hospitalization for two (Residents # 36 and #43) of three residents reviewed. The facility reported a census of 71 residents. Findings include: 1.A Minimum Data Set for Resident #36 dated 6/6/24, included diagnoses of heart failure and diabetes. A Brief Interview for Mental Status score of 15 indicated no cognitive impairment for decision-making. Review of resident's progress notes documented the resident was admitted to the hospital 5/26/24 and returned to the facility 6/3/24. Review of resident's clinical record lacked documentation of notification to the resident/ resident's representative regarding the bed-hold policy when transferred to the hospital. 2. Minimum Data Set for Resident #43 dated 8/8/24, included diagnoses of diabetes and cancer. A Brief Interview for Mental Status score of 15 indicated no cognitive impairment for decision-making. Review of resident's progress notes documented the resident was admitted to the hospital 5/9/24 and returned to the facility 5/14/24. Review of resident's clinical record lacked documentation of notification to the resident/ resident's representative regarding the bed-hold policy when transferred to the hospital. Interview on 8/21/24 at 3:26 PM, the Administrator confirmed no bed hold forms completed for Residents #36 and Resident #43. Interview on 8/22/24 at 10:40 AM, the Director of Nursing stated expectation for a bed hold to be completed with any hospital transfer.

Based on clinical record review, observation, staff interview, and policy review, the facility failed to follow the physician's orders and administer medications as ordered. Facility staff administered medications through a gastrostomy tube instead of by mouth as ordered for 1 of 7 residents observed during medication administration. The facility reported a census of 71 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had diagnoses of stroke, non-Alzheimer's dementia, seizure disorder, and dysphagia. The MDS documented the resident had impaired short-term and long-term memory and severely impaired decision making skills. The MDS indicated the resident on a mechanically altered diet and had a tube feeding. The Care Plan revised 5/3/24 revealed the resident had a Peg tube placed during hospitalization . The care plan directed staff to administer medications as ordered. The Medication Administration Record (MAR) dated 8/1/24 to 8/31/24, revealed Staff A, Licensed Practical Nurse (LPN) documented amantadine, docusate sodium, atorvastatin, eliquis, and metoprolol medications administered on 8/20/24 on the evening/PM shift. An order summary report revealed Resident #69 had physician's order to administer amantadine, docusate sodium, atorvastatin, apixaban (eliquis), and metoprolol by mouth. An active verbal order started on 04/29/2024 revealed medications may be given through the Peg tube as needed. The order summary lacked an order to cocktail medications whenever g-tube (gastrostomy) (tube in the stomach) medications administered. During observation on 08/20/24 at 3:28 PM, Staff A, Licensed Practical Nurse (LPN), checked the electronic health record (EHR) and obtained a Styrofoam cup with hot water. Staff A reported the hot water would help dissolve the pills better. Staff A prepared the following medication for Resident #69: 1. Amantadine (anti-seizure/tremor medication) 15 milliliters (ml) 2. Docusate sodium (stool softener) 30 ml 3. Atorvastatin (for cholesterol)10 milligrams (mg) 4. Eliquis (blood thinner) 5 mg 5. Metoprolol (for blood pressure) 25 mg Staff A crushed the pills (atorvastatin, eliquis, and metoprolol) and placed them into the liquid medication and warm water mixture in the Styrofoam cup. Staff A then stirred the contents together. At 3:37 PM, Staff A donned a gown and gloves, and placed the Styrofoam cup with medications on a table. Staff A checked placement of the Peg tube. Staff A attached a syringe to the Peg Tube, poured an unmeasured amount of water into the syringe, then poured the medication mixture into the syringe until the stryofoam cup emptied, then poured 60 ml of water into the syringe. Staff A removed the syringe and plugged the Peg tube. Removed her gown and gloves, and washed her hands. In an interview 08/21/24 at 1:40 PM, the Director of Nursing (DON) reported she expected staff followed the policy for medication administration. The DON stated g-tube medications given individually along with the amount of water flush per the physician's orders. At the time, the DON checked Resident #69's EHR and reported an order for medications may be given through the Peg tube as needed. The DON confirmed no order to cocktail the medications for Resident #69. In an interview 08/22/24 at 10:50 AM, Staff I, LPN, reported medications given one at a time whenever medications given through a g-tube. In an interview 08/22/24 at 10:24 AM, Staff H, Speech Therapist (ST), reported Resident #69 discharged from ST on 7/18/24. The ST stated she worked with the resident on diet texture and swallowing. The ST stated she was unsure if Resident #69 took pills orally or if nursing staff gave the medications through the g-tube. In an interview 08/22/24 at 12:55 PM, a family member reported the resident received medications through the Peg tube in her abdomen but he was not here all of the time to see if staff gave the medications another route. The family decided to leave the tube in place in case she had a seizure or something happened and she wouldn't be able to eat or take things orally. The resident had been eating with much encouragement from family members. In an interview 08/22/24 at 1:20 PM, Staff H, ST, reported she thought the nursing staff gave Resident #69's medications through the g-tube. The ST reported if a resident on a regular diet, the resident may be able to take medications orally. The resident went to the hospital after she had a seizure, and that's when the feeding tube was placed. Staff H reported Resident #69's tube got pulled out once and staff had concerns they couldn't replace the tube until the following week, and at that time, staff had a concern for making sure the resident got her medications. The ST stated the resident had receptive aphasia. She thought maybe the resident didn't understand fully and maybe staff wanted to ensure she got her medications so that is why the medications administered through the tube. A facility's Medication Administration via Enteral Tube Policy revised 1/31/24 revealed each medication administered separately unless had a physician's written order that medications may be combined and given all together. The enteral tube flushed with at least 15 ml of water after each medication administered.

Based on clinical record review, observations, staff interview, competency checklist, and a mechanical lift manufacturer user instruction manual, the facility staff failed to utilize safe transfer technique when they used a mechanical lift (Hoyer) transfer device for 1 of 3 residents observed for transfers and required a mechanical lift for transfers (Resident #23). The facility also failed to ensure adequate ventilation and temperature controls in a room that contained servers and electronic devices. The facility also failed to ensure bathroom call lights accessible for residents and staff for 1 of 3 units observed. The facility reported a census 71 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had diagnoses of dementia, muscle weakness, and anxiety. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severely impaired cognition. The MDS documented the resident had dependence on staff for transfers. The Care Plan revised 6/21/24 revealed the resident had a self-care deficit in activities of daily living related to dementia, impaired cognition, and impaired safety awareness. The Care Plan directed staff to use a Hoyer (mechanical lift) and two staff for transfers. During observation on 08/20/24 at 7:55 AM, Staff D, Certified Nursing Assistant (CNA), placed a sling under Resident #23 while the resident laid in bed. At 7:57 AM, Staff C, CNA, and Staff D attached the sling straps to a mechanical lift. Staff D moved the leg bars together, raised the resident up in the mechanical lift, and transferred the resident from the bed to a broda chair. Staff D opened the legs (outward) on the mechanical lift as she moved the lift under the broda chair in order for the lift legs to straddle around the broda chair. Staff D lowered the resident into the broda chair and removed the straps from the bar on the mechanical lift. Staff D then moved the mechanical lift legs together on the lift after she pulled the mechanical lift machine out from under the broda chair. In an interview 08/21/24 at 1:55 PM, the Director of Nursing (DON) reported the proper use of a mechanical lift. The mechanical lift legs should be in whenever the lift had no resident in it. The mechanical lift legs should be open whenever there was a resident in the lift and during the transfer of a resident so it is safe for the resident. The mechanical lift legs left open to prevent the resident from hitting their feet on the mechanical lift, and also in order to balance the resident and the machine so the lift doesn't tip. The facility's Hoyer Lift Competency updated 5/11/21 revealed the following: 1. Place sling under the resident 2. Position and secure the brakes on the bed or chair 3. Place the lift with the legs of the lift opened to the widest setting and the boom arm is centered over the resident. Lower the boom arm to hook the sling on the lift. 4. The lead caregiver uses the controls to raise the resident off the bed. The helper assures the sling is secured and may need to hold the resident's head. 5. The lead pulls the lift from the bed. 6. Ensure the resident's safety and properly positioned, then resume transfer. If possible, turning the lift should be avoided by moving the wheelchair to the lift. 7. Lower and position the resident into the chair. 8. Remove the sling An undated Hoyer User Instruction Manual revealed the mechanical lift is not intended to be a transport device. The legs on the Hoyer HPL 700 are electrically adjustable for width. The legs opened to enable access around chairs and wheelchairs. The lift legs should be in the closed position for negotiating narrow doorways and passages. 2. Observations revealed the following: On the Skilled Unit: a. On 08/19/24 at 2:22 PM, a folding chair propped the door open to the server room. A small fan sat on top of the folding chair and faced toward the server room. The air temperature in the hallway leading up to the server room and the server room felt extremely warm. b. On 08/21/24 at 7:41 AM, a folding chair propped the door open to the server room. A fan sat on top of the folding chair and faced toward the inside of the server room. A larger fan sat on the floor in the hallway near the door to the server room. The air temperature in the room and surrounding hallway continued to feel hot. c. On 08/22/24 at 10:20 AM, the folding chair continued to prop the door open to the server room. A fan sat on top of the folding chair and faced toward the inside of the server room. A larger fan sat on the floor in the hallway near the door to the server room. In an interview 08/22/24 at 10:33 AM, Staff J, certified medication aide (CMA) reported the door to the server room propped open and had a fan blowing (into the room) because the room got really hot. He was unsure what the temperature got up to in the room. Staff J reported IT checked the temperature and monitored things in the server room. At the time, two residents resided on the skilled unit. Staff J reported one resident independent and able to go outside of her room. In an interview 08/22/24 at 10:58 AM, Staff F, Maintenance Assistant, reported the server room got really warm. They ran the air conditioner (AC) in the room to help cool the room but it didn't seem to help. Staff F reported they kept the door to the server room open and used a fan to circulate the air. In an interview 08/22/24 at 12:49 PM, the Information Technologist (IT) reported he came to the facility about four times a month, but he had remote access to the VPN and the server. The IT reported the servers and electronic equipment such as the video and call systems in a small room on the lower lever and it had been that way since he started working for the company in 2015. The air conditioner (AC) unit in the server room had been a challenge because they no longer made parts for this AC unit . It was a challenge to keep the room cool so they put fans in there. The AC worked a month ago but then had problems with the AC again recently. The IT reported there is no way to vent the room into an open area due to the concrete floor and no subflooring under the room to do so. The IT reported there was not alot of server equipment or sensitive equipment hurt by the heat in that room. He kept the equipment clean and blew the units out regularly. He had replacement equipment and most generally could have things back up and running in an hour if something went down. On 08/22/24 at 1:10 PM, a Room Temperature app (application) revealed the temperature at 78 degrees Fahrenheit (F) in the server room. At the time, the IT reported the air conditioner wasn't working when he entered the room. The IT stated the AC unit was in the ceiling. He checked the thermostat on the wall behind the door and something had tripped so he called and got the thermostat reset. The IT reported the AC ran now but would take awhile to cool the area. 3. On 08/19/24 at 2:32 PM, Resident #75 reported an incident when staff left him in the bathroom. The bathroom had no call light for him to pull to let staff know he needed assistance. At the time, the surveyor observed a chrome cover with a small metal lever but no string or device to pull the call light in the bathroom. On 08/20/24 at 7:59 AM, the call light in the bathroom in room [ROOM NUMBER] had a very small metal level on it and no device for a resident or staff member to pull the call light.

Based on observation, clinical record review, policy review, resident and staff interviews, the facility failed to carry out safety interventions to prevent the likelihood of further abuse perpetrated by Resident #2 for 2 of 2 residents reviewed for abuse (Resident #'s 1 and #3); the facility failed to carry out interventions to prevent a fall with a major injury for 1 of 3 residents reviewed for a fall (Resident #6). The facility reported a census of 72 residents. Findings include: 1. Resident #2 Minimum Data Set (MDS) assessment dated [DATE] documented a BIMS score of 3, which indicated severe cognitive deficits. The MDS included diagnoses of Alzheimer's disease, anxiety disorder, and depression. The MDS documented during the look back period the resident had both physical behaviors symptoms directed toward others and other behavioral symptoms not directed toward others that occurred 1 to 3 days. The MDS further documented the resident behaviors of wandering that occurred 1 to 3 days. It documented the resident's current behavior status was worse than the prior MDS. The Care Plan included the following Focuses: a. Revised 4/30/24: Resident #2 is at risk for increase in mood/behaviors diagnoses Alzheimer's with early onset, anxiety and depression. Resident #2 will wander in the hallways, he has times of inappropriate sexual behaviors and can easily be angered and become verbally and physically abusive. He will attempt to punch, kick and slap staff and other residents. The Interventions indicated the following: -Resident #2 to have a silent type alarm placed in the resident's chair. -Resident had an altercation with his roommate. The roommate was moved for his safety. -Observe for risk for harming others, increased anger, labile mood or agitation or feels threatened by others. -Redirect Resident #2 away from female residents when he is sexually inappropriate The Care Plan failed to direct new interventions for safety measures following the 4/23/24 sexual abuse incident and 5/23/24 physical abuse incident to protect the residents. An observation on 6/11/24 at 8:30 AM Resident #2 sat in at the nurse's station with no staff present around at the time. All the other staff assisted residents down the hallway and six minutes passed until staff came back to the area. An observation on 6/12/24 at 12:35 PM, revealed Resident #2 in his wheelchair with no alarm on sitting at the table within four feet of Resident #3 (female resident) in the lounge. No staff present at the time. At 12:42 PM, Resident #3 started yelled out and staff then came up the hallway and assisted Resident #3. During an interview on 6/12/24 at 9:50 AM, Staff K, Rehab Aide reported Resident #2 was to stay away from the women. Resident #2 had a chair alarm when in a recliner or wheelchair, bed alarm and motion sensor in the doorway. He reported Resident #2 had a history of sexually and physically abusive behaviors toward staff and other residents. During an interview on 6/12/24 at 9:54 AM, Staff L, CMA Resident #2 is to sit by himself in the dayroom and not be left in his wheelchair. Resident #2 had a chair alarm when in a recliner or wheelchair, bed alarm and motion sensor in the doorway. He reported Resident #2 had a history of sexually and physically abusive behaviors toward staff and other residents. During an interview on 6/12/24 at 9:57 AM, the DON reported Resident #2 was not to be put him in a wheelchair unless he was weak and unable to ambulate. She reports he had a chair alarm when out of his room and bed alarm and motion sensor when in his room. She reported he was not to be up in his wheelchair to move around and staff are to transfer him to a regular chair when at the table. Staff are to do frequent visual checks on him when he is out of his room. He is not to be close to any women. She reported staff were aware of those interventions due to being educated on them. During an interview on 6/12/24 at 10:05 AM, the Administrator reports Resident #2 had frequent checks on him and was not be close to any women. She reported he had a motion sensor and bed alarm in his room and when he was out to have a chair alarm on. She verbalized the staff were educated on these interventions. 2. Resident #1 MDS dated [DATE] documented that Resident#1 had diagnoses which included hypertension, anxiety, depression and psychotic disorder. The MDS revealed the resident with a BIMS score of 13, for which indicated no impairments with decision making or memory problems. The MDS documented that the resident had adequate hearing, was able to make self-understood, and had the ability to understand others. The MDS documented that the resident needed partial to moderate assistance with personal hygiene. The Plan of Care with an initiated date 7/28/21, revealed a focus area that resident was at risk for cognitive deficit with impaired thought processes as evidenced by diagnosis of Bi-polar II, depression, anxiety, delusional disorder. Intervention include: *prefers to have her door kept shut at all times. Date Initiated: 03/22/2024 During an interview on 6/11/24 at 1:50 PM, Resident #1 reported she had no further interactions with Resident #2 but is worried she might due to staff are not always present in the common areas when Resident #2 is present. She reported it bothers her a lot so she stays in her room most of the time with the door shut. She reported she had told staff about it but nothing changes so she quit telling them. 3. Resident #3 Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 5, which indicated severe cognitive deficits. The MDS documented the resident was moderate assistance with transfers and ambulation. The Plan of Care with a revised date of 2/08/24, revealed a focus area that resident has impaired cognitive function/dementia or impaired thought processes related to Dementia, Impaired decision making. Intervention include: *Monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Date Initiated: 10/25/2023 The Nursing Abuse Prevention, Identification, Investigation and Reporting Policy dated 10/01/2019 lacked safety directions to prevent the likelihood of further abuse perpetrated by a resident. 35434 4. The Minimum Data Set(MDS) assessment tool, dated 3/1/24, listed diagnoses for Resident #6 which included muscle weakness, unsteadiness on the feet and Alzheimer's disease. The MDS stated the resident required supervision or touching assistance for transfers and walking and listed her cognition as severely impaired. An 11/17/23 Incident Note stated a Certified Nursing Assistant (CNA) saw the resident open the door, walk across the hallway, and slide down the wall to sit on her bottom. The note stated she lost her balance and had a small red blood clot filling the right nostril. The resident required the assistance of 1 staff but ambulated on her own. The facility educated staff to assist the resident while she was up at all times. A 12/7/23 Care Plan entry stated the resident was at risk for falls related to impaired cognition and dementia. The Care Plan stated the resident required the assistance of 1 staff for transfers and directed staff to use Hand Held Assistance (HHA) if she refused the walker. A 1/16/24 Care Plan entry stated the resident would be free of falls through the review date and directed staff to follow facility fall protocol. A 2/7/24 Care Plan entry directed staff to encourage the resident to stay in common areas during anxiety. A 2/21/24 7:02 a.m. Incident Note stated staff walked the resident back to her room and when staff returned to the day room, they heard a crash and found the resident on the floor, having a possible seizure. The resident had no injuries. A 2/21/24 11:41 a.m. Health Status Note stated a nurse found the resident on the floor with her head bleeding. The resident transferred to the hospital. A 2/21/24 Hospitalist report stated the resident transferred to the hospital after she had a fall with head trauma with a scalp laceration(cut). A 2/26/24 Health Status Note stated the resident readmitted to the facility and had an additional fall at the hospital on 2/23/24. The note stated the resident would be an assist of 1 with hand held assist. A 2/27/24 Health Status Note stated the resident was on the floor. The Physical Therapy Discharge Summary, dated 3/8/24, stated the resident required the assistance of 1 staff with HHA. A 3/12/24 provider Encounter Note stated the resident fell and sustained a head laceration. There was a concern for seizure activity but the work up was negative. The resident had sutures in her head. A 4/24/24 8:15 p.m. Behavior Note stated staff found the resident in another resident's room at the end of Hall 700. The resident laid on her right side in the fetal position. The resident stated she hurt but would not allow the nurse to manipulate either leg. A 4/24/24 9:20 p.m. Order Note stated the resident had increasing pain when moving the right leg and the facility received an order for a portable x-ray of the right hip. A 4/24/24 9:41 p.m. Health Status Note stated the resident had increased pain and the facility called 911. A 4/24/24 10:29 p.m. Health Status Note stated the resident transferred to the hospital. The facility Nursing Schedule for 4/24/24 revealed the following staff members worked in the resident's unit during the evening: Staff B CNA 6:00 p.m.-6:00 a.m. Staff C Registered Nurse(RN) 6:00 p.m.-6:00 a.m. Staff D CNA 2:00 p.m.-10:00 p.m. Staff H Certified Medication Aide(CMA) 2:00 p.m.-10:00 p.m. Staff G CNA 2:00 p.m.-10:00 p.m. A 4/30/24 Hospitalist report stated the resident admitted to the hospital following a mechanical fall. She sustained a right hip fracture and underwent an open reduction and internal fixation (ORIF-a surgical repair procedure). The facility's undated untitled investigation of the resident's 4/24/24 fall stated Staff B observed Resident #6 sitting on another resident's bed. Staff B began picking up trash from the floor and the resident began walking toward the door. The resident then lost her balance and fell on the floor, landing on her right side before Staff A was able to provide assistance. The resident had pain and the facility transferred her to the hospital. The investigation did not include information regarding when staff saw the resident prior to her fall. A Witnessed Fall report, dated 4/24/24, revealed the following witness statements: Staff D witness statement. She walked down the hall and saw the resident exit another resident's room and fall to the ground. Staff B Witness statement: The resident was in another resident's room going through her trash. Staff B came in to the room and told the resident that she would show her to her room and the resident got mad that Staff B picked up garbage she put on the floor. The resident sat on the bed, then picked up a trash bag and headed out the door. She turned as she was going to say something to Staff B and fell outside the door. On 6/11/24 at 1:24 p.m. Staff A Physical Therapist(PT) walked with the resident with a gait belt and a walker. On 6/11/24 at 1:41 p.m., via phone Staff C Registered Nurse(RN) stated Staff D alerted her that Resident #6 fell and it was a hard hit. Upon assessment the resident had increasing pain and they decided to send her to the hospital. Since the fall she has had a decline. She stated the resident was a fall risk. On 6/11/24 at 1:58 p.m. Staff B CNA stated she was pulling down sheets to help other residents to bed when she found Resident #6 in another resident's room. She stated there was trash on the floor and the resident got up from the bed and Staff A made sure she would not trip on anything so she picked up the trash. She stated when the resident got up, Staff A did not touch her and she fell on her side. Staff A stated when the resident walked, they were not supposed to touch her per the family member's direction. She stated they were only supposed to follow her. Staff A stated she had just started her shift at 6:00 p.m. so she had not seen the resident prior to the fall. On 6/11/24 at 2:21 p.m., Staff A PT stated the resident required the assistance of 1 staff for transfer and if she refused a walker staff could use HHA. He stated he was not aware of a directive for staff not to make contact with her. On 6/11/24 at 2:29 p.m., Staff E RN stated prior to the resident's fall(on 4/24/24) the resident was an assist of 1. She would have used a gait belt or a hand hold. If she got up and walked on her own, staff would have rushed over to her. She stated the resident was unstable and they always needed to make contact with her and be hands on because she could fall. On 6/11/24 at 2:36 p.m. Staff F CNA stated prior to the resident's fall, staff did not use a gait belt or physical assistance with her when she walked. She explained that they just needed to stand behind her. On 6/12/25 at 6:33 a.m. Staff B clarified that when she found the resident in the other resident's room, she was sitting on the bed. Staff B started picking up the trash and asked the resident if she wanted to go to her room. The resident started walking to the door and Staff B followed behind her but not too close. Staff A reached for a piece of trash behind the door and that is when the resident turned around and fell . Staff A stated she did not know how far away she was from the resident when she fell but she was not within arms reach. She stated they could not hover over her and had to give her space. She stated when she fell she did not make contact with her because she fell too quickly. On 6/12/24 at 9:33 a.m., via phone Staff D CNA stated she worked on a different unit that night but happened to come up to the area when she saw the resident fall. She stated prior to the fall, the resident was an assist of 1. She stated if the resident started to get up on her own she would absolutely want to make contact with her. She stated at the time of the fall, Staff B was the only staff member she observed around the resident. On 6/12/24 at 9:58 a.m., Staff H CMA stated on the night the resident fell she did not remember seeing the resident as she may have passed medications both downstairs and upstairs. On 6/12/24 at 12:08 p.m., the Director of Nursing (DON) stated prior to the resident's fall, she was an assist of 1. She stated the resident needed physical stabilization. She stated staff should have checked on her frequently and they should have been watching her more closely. She stated Staff B informed her she had just laid her down in bed prior to the fall. She stated safety was first and was a priority over the trash. On 6/12/24 at 12:41 p.m., via email, the Social Services Supervisor stated the facility did not have a fall prevention policy. On 6/12/24 at 2:37 p.m., Staff G, CNA stated she did not see the resident the night she fell because she worked on another hall.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure staff protected and prevented resident to resident abuse for 1 of 1 resident reviewed (Resident # 3), when Resident # 2 slapped Resident #1 while in the lounge area. Resident #2 had a known history of resident to resident altercations and history of hitting staff, and the facility failed to evaluate the effectiveness of the interventions implemented to prevent harm to other residents. The facility reported a census of 72 residents. Findings include: 1. Resident #2 Minimum Data Set (MDS) assessment dated [DATE] documented a BIMS score of 3, indicating severe cognitive deficits. The MDS included diagnoses of Alzheimer's disease, anxiety disorder, and depression. The MDS documented during the look back period the resident had both physical behaviors symptoms directed toward others, and other behavioral symptoms not directed toward others, and wandering that occurred 1 to 3 days. The MDS further documented the resident behaviors of wandering that occurred 1 to 3 days. It documented the resident's current behavior status was worse the then prior MDS. The Care Plan included the following Focuses: a. Revised 4/30/24: Resident #2 is at risk for increase in mood/behaviors dx diagnoses Alzheimer's with early onset, anxiety and depression. Resident #2 will wander in the hallways, he had times of inappropriate sexual behaviors and can be easily angered and become verbally and physically abusive. He will attempt to punch, kick and slap staff and other residents. The Interventions indicated the following: -Resident #2 to have a silent type alarm placed in the resident's chair. -Resident had an altercation with his roommate. The roommate was moved for his safety. -Observe for risk for harming others, increased anger, labile mood or agitation or feels threaten by others. -Redirect Resident #2 away from female residents when he is sexually inappropriate An observation on 6/12/24 at 12:35 PM revealed, Resident #2 in his wheelchair with no alarm on sitting at the table within four feet of Resident #3 (female resident) in the lounge. No staff present at this time. At 12:42 PM, Resident #3 started yelling out and staff then came up the hallway and assisted Resident #3 The Facility Investigation dated 5/23/24 reflected Staff I, Certified Medication Aide (CMA) reported concerns to Staff J, Registered Nurse (RN), regarding Resident #2 slapping Resident #3. Staff J, RN reported to the Administrator and Director of Nursing. Staff I, CMA reported she was in view of the common area and witnessed Resident #2 in the common area, self-propelling in his wheelchair toward Resident #3. When Resident #2 reached Resident #3 he slapped her on the right side of the face. Staff I, CMA reported she continued to run over and immediately separate the two residents. Staff I, CMA reported she had witnessed Resident #2 sitting by himself at the table in the common area just five minutes prior to the incident. During an interview on 6/12/24 at 9:38 AM, Staff I, CMA reported she was down the 400 hallway passing medications and needed a blood pressure cuff and so proceeded to walk by the dayroom and saw Resident #2 sitting at the table by himself and Resident #3 was against the wall in the lounge/common area (around 12 feet away). She proceeded down to the end of 300 hallway to get the blood pressure cuff from the nurse working. When she turned around to head back up the hallway she saw Resident #2 self-propelling his wheelchair toward Resident #3. She started to run up the hallway but did not make it in time and witnessed Resident #2 slap Resident #3 on the right side of the face. She continued to run until she got to them and immediately separated them. She then reported it to the nurse. During an interview on 6/12/24 at 9:50 AM, Staff K, Rehab Aide reports Resident #2 is to stay away from the women. Resident #2 had a chair alarm when in a recliner or wheelchair, bed alarm and motion sensor in is doorway. He reports Resident #2 had a history of sexually and physically abusive behaviors toward staff and other residents. During an interview on 6/12/24 at 9:54 AM, Staff L, CMA Resident #2 was to sit by himself in the dayroom and not be left in his wheelchair. Resident #2 had a chair alarm when in a recliner or wheelchair, bed alarm and motion sensor in is doorway. He reports Resident #2 had a history of sexually and physically abusive behaviors toward staff and other residents. During an interview on 6/12/24 at 9:57 AM, the DON reported Resident #2 is not to be put in a wheelchair unless he is weak and unable to ambulate. She reports he had a chair alarm when out of his room and bed alarm and motion sensor when in his room. She reported he is not to be up in his wheelchair to move around and staff are to transfer him to a regular chair when at the table. Staff are to do frequent visual checks on him when he is out of his room. He is not to be close to any women. She reports staff are aware of these interventions due to being educated on them. During an interview on 6/12/24 at 10:05 AM, the Administrator reported Resident #2 was to have frequent checks on him and not be close to any women. She reported he had a motion sensor and bed alarm in his room and when he was out to have a chair alarm on. She verbalized the staff were educated on these interventions. Review of Resident #2 Progress Notes documented on these dates and times the following behaviors: *1/28/23 6:10 AM Health Status Note documented as follows; This nurse noticed resident going into another female resident's room. This nurse went into room and asked resident to leave. Resident stated Well aren't you going to help her?! This nurse assured resident that I would help her but he needed to leave the room. Resident stated You better you bitch Resident then left the room and this nurse assisted female resident. I left female resident's room and went to nurses desk, resident was noted to be sitting in a chair by the wall in the dining room. After a few minutes resident got up and started walking back to his room. This nurse was leaving the med room when I heard resident back in female resident's room. I went back into female resident's room and asked him to leave again when resident got angry and yelled at this nurse You shut your fucking mouth! This nurse was standing at the foot of female resident's bed with resident standing in between me and the door. This nurse told resident that he needed to leave the female resident's room immediately. Resident then got physical with this nurse hitting me three times in the chest, hitting me one in the face and grabbing and bending my right wrist back. This nurse yelled out for help but all the Certified Nurses Aide (CNA) CNA's were in other resident's rooms and could not assist. I told the resident that he needed to stop hitting me and leave the room. Resident stated I'll leave when you help her! This nurse assured resident that I would help her but he needed to leave as I couldn't do cares on her while he was in the room. Resident left room and went back to his room. On call manager [NAME] notified. On call Dr. also notified of situation. New Order (N.O.) obtain us with culture and sensitivity may straight cath if needed. Resident currently sitting calmly in chair in dining room. Will continue to monitor *3/21/2023 Health Status Note documented as follows; res. approached med-aide stating that he wanted a knife so he could cut his face. Res. redirected. will monitor *8/3/23 7:58 PM Health Status Note documented as follows; the resident being aggressive to another resident in lounge area. Verbal disagreement between this resident and a female resident. Resident#2 stood with walker and walked past another resident and said, What you gonna do about it? and ran his walker into the other residents' wheelchair. There were words between the two residents and then staff intervened to separate the resident. The incident was witnessed by CNA staff and this nurse. *3/22/24 at 3:43 p.m., Note Text: resident walking with staff in hall way. Resident made comment regarding breasts and attempted to touch staff member over clothes on her breast. Incident reported to this nurse and DON. *3/24/24 at 3:10 a.m., Note Text: CNA reported to this nurse that resident made sexually inappropriate comments to her. This RN reported to resident to inform him that comments like that were inappropriate. Resident stated I know I'm sorry. No other behaviors observed this shift. Will continue to monitor The Nursing Abuse Prevention, Identification, Investigation and Reporting Policy dated 10/01/2019 directed staff as follows: Policy Statement: All Residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking acts that result in person degradation, including the taking or using photographs or recording in any manner that would demean or humiliate a resident, and prohibits using of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep or distribute photographs and/or recording on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. -Physical abuse includes, but not limited to hitting, slapping, pinching, and kicking. It also includes corporal punishment when used to correct or control behavior, including but not limited to, pinching, spanking, slapping hands, flicking, or hitting with an object. - Resident-to-resident physical contact that occurs, which includes but is not limited to where residents are hit, slapped, pinched or kicked and results in physical harm, pain or mental anguish is considered resident-to-resident abuse. Resident-to-resident sexual harassment, sexual coercion, or sexual assault is also considered abuse. The facility will presume that instances of abuse caused physical harm, or pain or mental anguish in resident with cognitive and/or physical impairments which may result in a resident unable to communicate physical harm, pain or mental anguish, in the absence of evidence of the contrary. An example would be a resident slapping another resident who is physically or cognitively impaired, even though the resident who was slapped showed no reaction (e.g., yelp or grimace), it is presumed the resident experienced pain. 2. Resident #3 Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 5, which indicated severe cognitive deficits. The MDS documented the resident was moderate assistance with transfers and ambulation. The Plan of Care with a revised date of 2/08/24, revealed a focus area that resident has impaired cognitive function/dementia or impaired thought processes related to Dementia, Impaired decision making. Intervention include: *Monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Date Initiated: 10/25/2023

Based on observation, clinical record review, documentation from the facility self-report, staff interviews and facility policy the facility failed to provide an environment free from sexual abuse for 1 of 2 residents reviewed for sexual abuse. (Resident #1). Resident #2, the aggressor was well known for sexual behavior and comments toward other females. Resident #1 experienced unwanted sexual touching on 3/16/24. On 4/23/24, Resident #2 was observed sitting by Resident #4 who had poor cognitive status, and was unsupervised by staff for over two minutes. A serious adverse outcome was likely to occur as the facility failed to provide proper supervision of Resident#2, which put Resident#4 and any other vulnerable residents at risk for unwanted sexual advances. There was an immediate need for the facility to take steps to ensure all residents were protected from the risk of abuse. The facility reported a census of 78 residents. On April 23rd, 2024 at 5:45 p.m., the Iowa Department of Inspections, Appeals, and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy on April 24th after the facility staff completed the following: 1. On 4/23/24, a motion alarm was installed on Resident #2's door to ensure staff are notified when Resident exits the room. 2. On 4/23/24, staff education was initiated to ensure staff are aware of the motion alarm on Resident #2's door and to ensure the whereabouts are being monitored. 3. On 4/24/24, all interview-able residents will be interviewed by staff to ensure any abuse-related concerns have been addressed appropriately. 4. On 4/24/24, a silent alarm will be procured to place in Resident #2's chair while they are out of the room to ensure their activity is monitored. This intervention will be reviewed weekly for appropriateness. 5. On 4/24/24, a silent alarm will be procured to Resident #2 door to ensure staff are notified when exiting the room. Once the alarm sounds the charge nurse will be responsible to ensure resident whereabouts and summon nursing staff to provide intervention such as toileting, snacks, ambulation and activities. 6. On 4/24/24, Resident #1 and Resident #2 were moved rooms to decrease the potential interaction between Resident #1 and Resident #2. 7. The facility will continue with medication management and psychosocial services for Resident #2 as previously implemented. 8. The facility will continue with psychosocial services for Resident #1 as previously implemented. 9. Any concerns will be reported to the administrator immediately and addressed in facility Quality Assurance. The scope was lowered from an IJ to a G at the time of the survey. Finding include: 1. The Minimum Data Set (MD'S) assessment with a reference date of 12/29/23 for Resident #2 documented a score of 4 on the Brief Interview for Mental Status (BIMS) test which indicated severe cognitive impairment. The resident had diagnoses that included diabetes mellitus, Alzheimer disease, anxiety and depression and required supervision to touching assistance with transfers and ambulation with a walker. The MDS revealed the resident had no physical behavioral symptoms directed towards others (grabbing, abusing other sexually). Review of Facility Self-Report dated 3/16/24, Timeline of Incident: *On 3/16/24 at approximately 3:56 p.m., Executive Director, was notified by Infection Prevention and Quality Nurse, that Resident #1 had reported to Certified Nurses Aid (CNA), that Resident #2 had touched Resident #1 inappropriately. This was reported to Department of Inspections Appeals and Licensing (DIAL) on 3/16/24 at approximately 4:11 p.m. *On 3/16/24 at approximately 3:30 p.m., CNA had reported to Registered Nurse (RN) that Resident #1 wanted to speak with a nurse at Resident #1 bedside. The RN stated that Resident #1 reported that That man was in here and touched me. RN asked where and Resident #1 pointed to her private area under the covers and stated He went away and went to go sit on the bed over there. I then noticed Resident #2 was having trouble getting up, so I pushed the call light, and that CNA, came in here and helped him up. RN asked Resident #1 how she was feeling, and Resident #1 stated I am ok, I just want Resident #2 to stay out of my room. RN told Resident #1 that she would notify the management team, family, and providers and Resident #1 stated she was fine. The Care Plan with initiated date 4/8/22 documented a focus area of increase in mood/behavior as evidence by diagnoses of dementia without behavioral disturbances, anxiety, and depression. The resident would wander the hallways putting him at risk for elopement. The resident had times of inappropriate sexual behavior including verbal comments to females, and exposing himself. The resident could be easily angered, become verbally, and physically abusive. (The following documentation was removed with a revision of the Care Plan along with the words physically abusive on 4/20/22, and then added back to the Care plan on 6/16/23; The resident would attempt to punch, kick, slap staff and other residents). The following Care Plan interventions were in place at the time of the incident on 3/16/24; -Redirect the resident from female residents when he is sexually inappropriate. initiated 4/8/2022 -The resident is not able to give consent for sexual encounters. Monitor and redirect the other party immediately. Any encounter with another resident must follow resident to resident guidelines and be reported to the DON and or Administrator immediately along with a completion of an incident report 6/6/2022 -An attempt to conduct an evaluation for sexual consent was attempted with the resident on 6/6/22. Power of Attorney (POA) gave approval for the evaluation. The resident refused cooperation with the evaluation, and did not remember the sexual incident that took place with another female in his room on 6/5/22. A Care Plan intervention with initiated date of 4/8/22 documented as follows; Behavior management referral will be made to Deer Oaks Psychiatry and Bridges Community Services, this was discontinued prior to the incident, but another referral was made on 3/16/24. The Primary Care (physician visit notes) documented the following; -Visit dated 9/1/23, Seroquel (antipsychotic) added recently for hypersexual behaviors and delusions. The resident is oriented to place and time, but does have memory loss, becomes easily agitated. - Visit dated 10/27/23, Resident with increased hypersexual behaviors, exposes self to female resident, becomes agitated easily. -Visit 11/3/23, Depression. Takes sertraline and Cymbalta. Followed by Deer Oaks. Denies symptoms today. Seroquel for hypersexual behaviors and delusions. Dose recently increased, becomes easily agitated. -Visit 12/29/23, Depression. Takes sertraline and Cymbalta. Followed by Deer Oaks. Denies symptoms today. Seroquel for hypersexual behaviors and delusions. Dose recently increased, becomes easily agitated, but able to redirect. - Visit 2/12/24, Depression. Takes sertraline and Cymbalta. Followed by Deer Oaks. Denies symptoms today. Seroquel for hypersexual behaviors and delusions. Dose recently increased, becomes easily agitated, but able to redirect. Continue to monitor behaviors. -Visit 2/26/24, Seroquel dose decreased due to increased sleepiness and falls. Depression. Takes sertraline and Cymbalta. Followed by Deer Oaks. Seroquel for hypersexual behaviors and delusions. Dose recently decreased. No increase in behaviors at this time. Becomes easily agitated but able to redirect. Continue to monitor behaviors and follow up with Deer Oaks. Deer Oaks Psychiatric Subsequent assessment dated [DATE] documented the following; =Per staff on 1/5/23 resident asked another female resident to have sex, resident was redirected. Assessment/Plan directed staff to monitor mood and behaviors, provide supportive care and safe environment to meet resident's needs. =Deer Oaks Psychiatric Subsequent assessment dated [DATE] documented the following; Reason for referral at staff request the resident had aggressive behaviors difficult to redirect. Per staff resident seen in females' rooms- difficult to redirect, worsening agitation, verbally aggressive, physically aggressive, hit staff nurse, and roommate. Plan; Increase Seroquel, risk outweighs benefits as resident is danger to self and others. If Seroquel makes resident too sleepy, plan to cross taper Risperdal. Monitor mood and behaviors. Provide supportive care, safe environment to meet resident's needs. =9/28/23 Per staff resident makes inappropriate sexual comments at times. No behaviors. = 10/26/23 Per staff: Resident with recurrent falls. Resident inappropriate sexual behaviors and comments. Per chart on 10/24/23; resident found by CNA in a female resident room, with his pants around his ankles, and exposing his penis to the females in the room. Resident was made aware that it was inappropriate, assisted in pulling his pants, up, and was walked out of the room to a safe location. Resident had made in appropriate sexual comments toward staff. =3/5/24 Per staff resident impulsive and restless at time. Resident will change clothing multiple times per day, ambulates without walker, unsteady gait. No concern with inappropriate sexual behaviors. The Progress Notes documented on these dates and times the following behaviors: *6/5/22 at 5:40 p.m., Incident Note: Incident report complete due to inappropriate behavior with another resident. Physician notified, and family notified of incident. *6/6/22 at 8:44 a.m., Note Text: Message for, Advanced Registered Nurse Practitioner (ARNP) with Deer Oaks psych nurse manager regarding behaviors and incident on Sunday 6/5/22. She has sent over orders to increase med's and obtain labs. Noted in chart. Daughter to be notified by social worker when she contacts her regarding the incident. *6/6/22 at 2:09 p.m., Note Text: Administrator attempted to complete sexual consent assessment evaluation with resident to determine if resident is able to consent to sexual contact. Resident refused to answer questions asked by administrator. Administrator asked resident if he would prefer to be interviewed by a male staff member and he refused. Social Worker was present for attempted interview. *6/6/22 at 7:41 p.m., Note Text: resident observed sitting in lounge area trying to convince female resident, to come in to his room. This nurse reminded both residents that they cannot be alone in residents' room. *6/9/22 at 3:19 a.m., Note Text: Inappropriate behavior noted between resident and another resident. Educated on appropriate behavior and not to enter employee only exits. *6/10/22 at 12:25 p.m., Note Text: At the request of the family this writer attempted to do a second Sexual Consent; Assessment with the resident. The resident did agree to the assessment. This writer provided the resident with reassurance that all the information would be kept confidential and reminded him that the questions are sexually explicit. He voiced understanding and wanted to continue. This writer asked the first question, and the resident provided a yes answer but refused to provide the second part to those questions and asked to proceed to the next question. This writer asked him the second question he responded yes. Again, when this writer asked him the second part to that question he refused to answer and stated We are done with these questions. I am not going to answer any more. This writer asked the resident do you understand what that means, he stated Yes, and I do not want to talk about it. This writer voiced understanding and left the resident. *8/3/23 7:58 p.m. Health Status Note documented as follows; the resident being aggressive to another resident in lounge area. Verbal disagreement between this resident and a female resident. Resident#2 stood with walker and walked past another resident and said, What you gonna do about it? and ran his walker into the other residents' wheelchair. There were words between the two residents and then staff intervened to separate the resident. The incident was witnessed by CNA staff and this nurse. *10/24/23 7:13 p.m. Behavior Note documented Resident was found by CNA in a female resident room, with his pants around his ankles, and exposing his penis to the females in the room. Resident was made aware that it was inappropriate, assisted in pulling his pants up, and was walked out of the room to a safe location. The CNA then came and told this RN about the incident. *10/25/24 5:26 p.m. Behavior Note documented CNA assisting resident with hallway ambulation and resident made inappropriate sexual comments to female CNA. Physician office notified. *10/26/23 10:06 a.m. Health Status Note documented Fax received from physician related to exposing self to peer with no new orders, continue to monitor and report persistent behaviors. Provider to follow up with next visit. *3/16/24 at 5:25 p.m., Note Text: Certified Nursing Assistant (CNA), reported to nurse that a female resident is requesting nurse at bedside. This nurse at bedside. Nurse asked female resident how can we help her and she said, That man was in here and he touched me. She then said, He had trouble getting up by himself on that bed over there so I pushed my call light and the CNA girl came in and helped him up. Registered Nurse (RN) found resident's CNA and asked her if she helped resident up and staff member said, Yes, female resident called and said he needed help getting up. She then asked me to get a nurse. RN went to go see male resident next. RN found male resident laying down in his bed. RN asked male resident if he went into female resident room and male resident said, Yes, I went in there to say hi to her. RN asked male resident if he touched female resident at all and male resident said, No, I would not do that. RN assessed resident male resident head to toe and obtained vital signs. RN asked resident if he was having any pain, questions or concerns and resident said, No, I am fine. INTERVENTION: 15- minute checks started at 3:30 p.m. stat. RN stepped out of male residents' room and called On-call nurse to update her on recent incident, also notified Director of Nursing (DON) as soon as possible (ASAP). *3/22/24 at 3:43 p.m., Note Text: resident walking with staff in hall way. Resident made comment regarding breasts and attempted to touch staff member over clothes on her breast. Incident reported to this nurse and DON. *3/24/24 at 3:10 a.m., Note Text: CNA reported to this nurse that resident made sexually inappropriate comments to her. This RN reported to resident to inform him that comments like that were inappropriate. Resident stated I know I'm sorry. No other behaviors observed this shift. Will continue to monitor. Observation on 4/23/24 at 9:20 a.m., Resident #2 sitting in north lounge area in an armed chair with back against the east wall and Resident #4 in a wheelchair sitting next to Resident #2, for which Resident #4 was with in an arm's reach of Resident #2. No staff were in the area between 9:28 a.m.-9:30 a.m. Interview on 4/23/24 at 10:40 a.m., Staff D, CNA, recalled working on 3/16/24, and that Staff D witnessed Resident #2 ambulating independently with a walker, Staff D confirmed and verified that Staff D assisted Resident #2 to their room. Staff D stated that Resident #2 would make sexual comments to staff when cares where being performed. Resident#2 will do what Resident#2 wants to do. Staff D stated that staff were to keep an eye on Resident #2 when out of their room, but with the staffing status, that was not always being completed. Staff D reported that Resident#1 does not come out of her room as often as she did before the incident. Interview on 4/23/24 at 11:00 a.m., Staff E, CNA, recalled working on 3/16/24, and stated that Resident #1 had put on the call light, so Staff E went into Resident #1's room to answer the light. Resident #1 explained that Resident #2 had come into Resident #1 room and was sitting on the empty bed across from Resident #1 and that Resident #1 would like for Resident #2 to leave the room, and if Staff E would get the charge nurse. Staff E, remembered asking Resident #1 if there was something that Staff E could help with and Resident #1 said no. Staff E confirmed and verified that Resident #2 would make sexual comments during cares performed and Staff E would tell Resident #2 that those comments are not appropriate. Staff E reported that Resident#2 is well known for his sexual comments about wanting a kiss or wanting to relieve himself, and staff just ignore the comments or tell him that those comments are not appropriate. Staff E also confirmed and verified that Resident #2 needed to be supervised when out of their room but with our staffing numbers that was not always done. Interview on 4/23/24 at 12:50 p.m., Staff F, RN, recalled working on 3/16/24, and that Staff E came out of Resident #1 room and explained that the resident would like to speak with me. Resident #1 told Staff F that Resident #2 had touched Resident #1 in the private areas and that Resident #1 was scared of Resident #2 and did not know what to do. Staff F, confirmed and verified that Resident #2 is to be supervised when out of the room, but due to staffing issues that is not always done and Resident #2 can ambulate throughout the facility independently. Resident#2 can be by someone and you get up to do something, and then you look, and he is already up and walking away. Interview on 4/23/24 at 2:00 p.m., the DON confirmed and verified that Resident #2 needed to be kept away from female residents and it is the expectation of the staff to make sure that Resident #2 is not in the proximity of any female resident. The DON reported that even before the incident with Resident#1 it was well known that Resident#2 had made sexual comments, and staff were to report it to the nurse, and intervene. The DON reported that when she was a charge nurse on the floor, and Resident#2 made these comments, she then told the upper management about. She reported that upper management responded with the comment that it was just Resident#2 and he had not acted on those comments. The DON also confirmed and verified that staff were aware before the incident that Resident #2 needed to be kept away from other female residents. The DON reported that when she questioned staff for the 100 and 300 hallways of their whereabouts when the incident happened, staff responded to be down the 300 hallway assisting a resident, another staff member was in the dining room, and the nurse was down the 200 hallway passing medications, and that no one knew that Resident#2 came out of his room until Resident#1 put on her call light. The DON reported that she had directed staff to keep Resident#2 away from other residents, but they failed to follow that directive. The DON confirmed and verified that the Resident#1 did not come out of her room for a week after the incident, and wanted the door shut due to being scared of Resident#2. The DON reported that she had visited with Resident#1 frequently since the incident, and the resident is just now allowing the door to her room to be opened. 2. The Annual MDS dated [DATE] documented that Resident#1 had diagnoses which included hypertension, anxiety, depression and psychotic disorder. The MDS revealed the resident with a BIMS score of 13, for which indicated no impairments with decision making or memory problems. The MDS documented that the resident had adequate hearing, was able to make self-understood, and had the ability to understand others. The MDS documented that the resident and needed partial to moderate assistance with personal hygiene. The Plan of Care with an initiated date 7/28/21, revealed a focus area that resident was at risk for cognitive deficit with impaired thought processes as evidenced by diagnosis of Bi-polar II, depression, anxiety, delusional disorder. Interventions include: *3/16/2024 - frequent checks every shift for 72 hours. Date Initiated: 03/21/2024 *prefers to have her door kept shut at all times. Date Initiated: 03/22/2024 The Progress notes documented on the dates and times as follows: *3/16/2024 at 6:07 p.m., Note Text: This resident CNA reported to nurse that resident is requesting nurse at bedside. This RN went to bedside and asked how can we help. female resident said, That man was in here and he touched me near my private area. She then said, He had trouble getting up by himself on that bed over there so I pushed my call light and the CNA girl came in and helped him up. RN found resident CNA next and asked her if she helped resident male resident up and CNA said, Yes, female resident called and said male resident needed help getting up. She then asked me to get a nurse. RN performed assessments and obtained vital signs. Resident denied pain, questions or concerns. INTERVENTION: 15 MIN CHECK STAT. RN stepped out of resident room and went to males' room next. *3/25/2024 at 9:20 a.m., Note Text: Resident informed this writer that she would like to move to the other side of the room for multiple reasons. IDT in agreement with moving resident to the other side of the room. This writer notified maintenance; resident will be moved this morning. *3/27/2024 at 9:25 a.m., Late Entry: Note Text: SOCIAL SERVICES NOTE: This writer met with resident for her weekly visit. Resident stated that she is doing pretty good. *4/12/2024 at 2:16 p.m., COMMUNICATION - with Resident Late Entry: Note Text: SOCIAL SERVICES NOTE: This writer met with resident for her last weekly visit. Resident stated that she is doing well. Resident still prefers to have her door shut a majority of the time. Resident is enjoying her new recliner. Resident denied having any questions or concerns at this time. Social services to follow as needed. Interview on 4/23/24 at 9:45 a.m., Resident #1, confirmed and verified that Resident #2 came into the room and proceeded to touch Resident #1 private areas on 3/16/24. Resident #1 was scared and fearful of Resident #2. Resident #1 explained that after the incident with Resident #2, the door to her room was closed at all times. Resident #1 went on to say that Resident #2 would make comments to Resident #1 out in the dining room that Resident #1 felt was offensive and inappropriate comments about Resident #1 breast size. Resident #1 did not tell any staff about those comments, but did not go to the dining room to eat anymore. 3. The Quarterly MDS dated [DATE] documented Resident #4 had the diagnoses which included, hypertension, cerebrovascular accident, non-Alzheimer dementia, hemiplegia and depression. The MDS revealed the resident with short- and long- term memory problems and moderately impaired decision- making abilities. The MDS documented the resident, usually understood others, but missed parts of the intent of the message. The MDS documented the resident required substantial to maximal assistance with personal hygiene, and was dependent on staff for transfers and mobility. The Plan of Care with an initiated date 7/23/2019, revealed a focus area that resident is at risk for an ADL self-care performance deficit related to weakness, lack of coordination, difficulty walking, is at risk for alterations in mood/behavior as evidenced by diagnosis vascular dementia, depression, seizures and history CVA. She enjoys the attention of her male peers and will be observed holding hands and kissing her male peers. Interventions include: * TRANSFER: Assist x 2 with EZ-stand (mechanical lift to assist residents to stand and transfer). Ensure shoes always on when transferring. * Monitor resident when she is interacting with her male peers for sexual behaviors. Family is okay with resident holding hands, but no other inappropriate touching including kissing. * Notify Son, and nurse manager when if observed interacting inappropriately with another resident. This does not include hand holding. * Redirect and separate immediately and other resident when inappropriate sexual behavior is observed. This does not include hand holding. *On 3/16/24 at approximately 3:45 p.m., RN spoke with Resident #2 in his room and asked if he went into Resident #1 room to which Resident #2 replied. Yes, I went in there to say hi to her. RN asked Resident #2 if he touched Resident #1 and responded No, I would not do that. The Nursing Abuse Prevention, Identification, Investigation and Reporting Policy dated 10/1/2019 directed staff as follows; Policy Statement: All Residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking acts that result in person degradation, including the taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. = Sexual abuse is non-consensual sexual contact of any type with a resident [however, see Iowa Code definition of sexual exploitation above which provides that consensual contact between a resident and staff can be sexual exploitation]. Sexual abuse includes, but is not limited to: *Unwanted intimate touching of any kind especially of breasts or perineal area; *All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; *Forced observation of masturbation and/or pornography; and *Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g. posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. *Sexual contact is generally nonconsensual if the resident either: *Appears to want the contact to occur, but lacks the cognitive ability to consent; or * Does not want the contact to occur.

Based on observation, record review, resident, staff interviews, and facility policy review the facility failed to implement safety measures and interventions to protect residents on the CCDI (Chronic Confusion and Dementing Illness) unit from resident to resident physical abuse from Resident #2. On 11/26/23 during the lunch meal Resident #2 pushed a table into Resident #3 who responded by throwing cooled coffee on Resident #2. Later that same shift Resident #2 verbally threatened Resident #3 that she was going to get her. The facility separated the residents but failed to implement any measures to prevent further aggression. At approximately 7:00 p.m. that same day, a staff person responded to a commotion in Resident #3's room. Resident #2 and #3 were both in the room. Resident #3 was on the floor with blood coming from her head, and reported Resident #2 pushed me and caused to hit her head. Both residents were agitated and the staff person was unable to redirect Resident #2 from the room. Staff left the residents unattended and went to the nurse's station located in the middle of the unit to get help because there was no call light available in the room to summon help. Resident #3 required transfer to the local emergency room and 6 staples to repair a head laceration. These circumstances posed Immediate Jeopardy to resident health and safety. The facility was notified of the Immediate Jeopardy on 12/12/23 at 2:30 p.m. The facility took the appropriate steps to remove the Immediate Jeopardy on 12/12/23 at 4:11 p.m. This lowered the scope and severity from a K to an E. The facility identified 31 other residents reside on the CCDI unit. Findings include: 1. The Minimum Data Set (MDS) for Resident #2 dated 9/20/2023 documented severe cognitive impairment. The MDS documented no hallucinations or delusions and no physical or verbal behavioral symptoms directed towards others. The MDS also documented they wandered 1-3 days of the week during the observation period. The MDS documented the resident independent for bed mobility, transfer, toilet use, and walking. The MDS identified diagnoses that included Non-Alzheimer's disease, cerebral atherosclerosis, restlessness and agitation, and wandering. Resident #2's Care Plan, dated as initiated on 3/18/23, included a focus area: Resident has behavior problems as evidenced by exit seeking, verbal aggression toward staff and peers, and non-compliance with cares with a goal that residents behavior problems would not infringe on her care or the care of peers. Interventions included the following, dated as initiated on 3/18/23: Anticipate and meet needs, intervene as necessary to protect the rights and safety of others, approach in a calm manner, divert attention, remove from situation and take to alternate location. The Care Plan failed to direct new interventions following the 11/26/23 altercation to protect residents. Following surveyors' entrance on 11/30/23 a new intervention was added to monitor resident for agitation following family visits. Observation on 11/30/23 at 1:00 p.m. Resident #2 and Resident #3 were in the common dining. Resident #3 was seated at the table closest to the nurse's station and Resident #2 was seated at another table talking to a staff person and wandering about, and sitting down again. The two residents, displayed no non-verbal or verbal reaction to the other. Both residents appeared calm, and not agitated. 2. The MDS for Resident #3 dated 12/1/2023 documented a Brief Interview for Mental Status (BIMS) assessment score of 14. A score of 14 out of 15 indicating intact cognition. The MDS documented no physical or verbal behavioral symptoms directed towards others. The MDS documented the resident was independent for bed mobility, transfer, toilet use, and walking. The MDS identified diagnoses that included unspecified dementia, moderate, with agitation, and anxiety. During an observation and interview 12/5/23 at 2:10 p.m., Resident #2 voiced frustration that there are no activities going on. Responded that she doesn't like it here because there isn't anything to do. Denied that she felt unsafe, recalled that a lady had pushed her and she had hit her head. Can't recall who the lady was. Resident #3's Care Plan, dated as initiated on 8/19/23, included a focus area at risk for alteration in mood/behavior related to diagnoses of dementia with agitation, anxiety, and disorientation with a goal that residents safety will be maintained through the review date. Interventions included the following dated as initiated on 8/19/23: Distract from wandering by offering pleasant diversions, structured activities. The Care Plan failed to direct new interventions following the 11/26/23 altercation. Following surveyors' entrance on 11/30/23 a new intervention was added on 12/4/23 to place a stop sign and one-way arrow on patient door in an attempt to limit the number of residents wandering into her room. Review of a Progress Note dated 11/26/23 at 8:00 p.m. documented it had been reported to the nurse that Resident #3 had fallen and was bleeding. As the nurse entered room, Resident seated on floor with blood on hands and back of head bleeding. Cold compress applied. Resident Stated, she pushed me then I fell flat on my head. Order received to send to local emergency room to evaluate and treat. Further review revealed a note dated 11/27/23 at midnight that documented resident returned from the emergency room , accompanied by daughter. Resident returned to the facility with 6 staples to back of head, family member reported CT scan done with negative result. Review of an unwitnessed fall report dated 11/26/23 at 7:15 p.m., initiated by Staff A, Licensed Practical Nurse (LPN) documented nurse received call Resident #3 fell and bleeding. As nurse entered room, Resident seated on floor with blood on hands and back of head bleeding. Cold compress applied. Resident Stated, she pushed me then I fell flat on my head. 911 called and resident sent to local emergency room . Review of a facility document titled Clinical Follow Up for the time period 11/7/23-12/7/23 revealed no entry for behaviors or altercation for Resident #2 or Resident #3 on 11/26/23 to communicate the information between staff. In an interview on 12/5/23 at 3:14 p.m. Staff B, Certified Nurse Assistant (CNA) stated she had worked on Sunday 11/26/23. Reported she had witnessed Resident #2 push the table into Resident #3. Resident #3 responded by throwing cooled coffee on Resident #2. Residents were separated. When Resident #2 returned from getting her clothes changed she verbally threatened to get back at Resident #3. Staff B denied there was any direction for increased supervision, added that on Monday 11/27/23 Resident #2 was found wandering into Resident #3's room twice, and was able to be redirected out of the room. In an interview on 12/6/23 at 1:09 p.m. Staff C, Certified Medication Aide (CMA) stated she had witnessed an altercation at lunch on 11/26/23. Described Resident #2 had pushed a table into Resident #3, who had in response thrown cooled coffee. Had separated residents and took Resident #2 to her room to change wet clothes. Stated when Resident #2 returned to the dining room she threatened Resident #3 that she was going to get her. Staff C responded that she was not aware of any direction for increased supervision or interventions to prevent further aggression between these residents. Further stated at approximately 7:00 p.m. she was in the nurse's station with Staff D, CNA when Staff E, CNA entered to inform them Resident #3 was on the floor in her room bleeding, Resident #2 was also in the room, and Resident #3 had accused her of pushing her down. Staff C stated when they got to the room they heard Resident #2 continue to verbally threaten Resident #3. Reported staff were able to get Resident #2 out of the room, but she continued to try to re-enter. Additionally, reported she heard Resident #3 accuse Resident #2 of pushing her to the floor causing her to hit her head. Reported that Resident #3's head was bleeding, and there was blood on her shirt and the floor. Denied that following the fall she had been made aware of any direction for increased supervision or interventions to prevent further aggressive incidents other than what they normally provide on the unit. In an interview on 12/5/23 at 2:38 p.m. Staff E, CNA stated that she had reported to work at 6:00 p.m. and had not been informed of the earlier incident. Informed was in the dining room when she heard a commotion and yelling coming from the end of the hall where Resident #3's room was located, so responded. Described that she found Resident #3 on the floor, and Resident #2 standing in the room. Resident #3 had blood on her head and on the floor. Both residents were agitated and yelling at each other. Recalled that Resident #3 had specifically stated that Resident #2 had pushed her and caused her to fall and wanted her out of her room. Staff E stated there was no call light, walkie, or phone in the room to get help. Again, stated that she had not been made aware of the earlier incident and there was no direction for increased supervision. In an interview on 12/5/23 at 2:49 p.m. Staff D, CNA stated that she was in the nurse's station when Staff E, CNA reported that Resident #3 was on the floor in her room. Staff D reported she responded to the room, Resident #3 on the floor accused Resident #2 of pushing her down. Reported both residents were very agitated. Responded that she had heard something had happened earlier in the shift, but didn't know the details until after the incident where Resident #3 was on the floor. Staff D stated that she would have expected closer supervision after the earlier incident but was not aware of any intervention for increased supervision. In an interview on 12/5/23 at 3:39 p.m. Staff F, CNA reported she had worked on 11/27/23. Stated she had not been informed of the incident or any injury to Resident #3. Recalled that she had found Resident #2 in Resident #3's room and had redirected her out of the room. Stated that she had not been directed that Resident #2 was not to be in Resident #3's hallway. In an interview on 12/6/23 at 1:45 p.m. Staff A, LPN stated she had reported to work at 5:00 p.m. on 11/26/23 and had not been informed of the incident at noon, clarified that she had not been aware of the first incident until after the second incident had occurred. Was not aware of any increased supervision prior to the incident and denied putting any new intervention in place after the incident as Resident #2 was asleep in her room when Resident #3 returned from the emergency room with staples. Reported around 7:00 p.m. she received a call from the unit that Resident #3 was on the floor. Found Resident #3 on the floor in her room, touching her head, and bleeding. Stated Resident #3 alleged that she was pushed by Resident #2. In an interview on 12/6/23 at 1:20 p.m. the MDS nurse and supervisor of the day on 11/26/23 reviewed her text messages for the day and stated that she had been informed of Resident #3's fall at 7:30 p.m. Confirmed she was the on-call supervisor for the entire day, but had not been contacted or informed of the earlier incident where Resident #2 shoved the table into Resident #3, and Resident #3 threw coffee in response. Stated she would have expected to have been contacted and had she been contacted she would have instructed staff to initiate a 1:1. Further stated that she was unaware that no new intervention had been put in place when Resident #3 returned from the hospital. Would also have initiated a 1:1 if it hadn't already been implemented. Stated Resident #2 does hold a grudge and remembers so it would have been important to put a 1:1 in place right away to prevent further incident. Stated she is authorized to put a 1:1 in place and so is the charge nurse. In an interview on 12/5/23 at 2:00 p.m. the Interim Administrator stated that no new interventions had been implemented after the dining room incident, before Resident #2 entered Resident #3's room and allegedly pushed her to the floor. In an interview on 12/12/23 at 1:20 p.m. the Director of Nursing (DON) stated that she had not been the DON when the incident had occurred but has participated in the investigation. Stated the facility failed to communicate to the current and next shifts. Would have expected the nurse to chart the incident at noon where the table was shoved and coffee was thrown. Would have expected a risk management investigation, and as a part of this, new interventions to be put in place. That would also include notification of the on-call manager, and communicating by being placed on the nurse to nurse hot charting. Reviewed the hot charting and confirmed that had not been completed. Confirmed on her first day as DON, 12/5/23, had implemented a hall monitor and are staffing for this. Record review of a facility document titled Unusual Occurrence Protocol directed any time a resident is reported to have an unusual occurrence which included resident to resident altercation the following steps should be taken included: Nurse notified. Vitals and assessment. Separate resident from the source of any alleged abuse, neglect, or other resident involved in the altercation if applicable. Provide first aid if needed. Notify resident representative. Notify primary care provider. Notify the Director of Nursing and Administrator immediately. Initiate intervention to prevent further incident. Completed incident report in Risk Management section. Document. The Facility Policy Titled Abuse Prevention, Identification, Investigation and Reporting Policy dated 1/15/2020 defined, Resident to resident physical contact that occurs, which includes but is not limited to where residents are hit, slapped, pinched or kicked and results in physical harm, pain or mental anguish is considered resident to resident abuse. The facility will presume that instances of abuse cause physical harm, or pain or mental anguish in residents with cognitive and/or physical impairments which may result in a resident unable to communicate physical harm, pain or mental anguish, in the absence of evidence to the contrary. The policy further stated that all residents have the right to be free from abuse.

Based on clinical record review, hospital record review, staff interview, policy review and observations, the facility failed to ensure the safety of residents during a mechanical lift transfer (Hoyer lift) for 1 of 3 residents reviewed for safe transfers (Resident #1). On April 26, 2023 at 2:00 p.m., the State Survey Agency informed the facility the staff's failure to ensure the proper sling was used for a Hoyer transfer of a resident created an Immediate Jeopardy situation, which began on April 18, 2023. The facility staff removed the immedicacy on April 18, 2023, when the facility staff implemented the following Corrective Actions: a. Hoyer transfer education provided immediately to the staff involved in the transfer which resulted in a fall. b. Review of sling size signage and placement at the nurse's station and clean utility closet c. Hoyer and Easy Stand transfer education provided to nursing staff on 4/18/23 and ongoing. d. TELS education provided to all staff on 4/18/23 and ongoing e. Added hands on training for Hoyer and Easy Stand to orientation. Based on the actions taken by the facility prior to the start of the survey on 4/24/23 the event is considered past non-compliance. Findings include: The Quarterly Minimum Data Set (MDS) of Resident #1, dated 3/1/23, identified the presence of short and long term memory impairment. The MDS revealed the resident required extensive physical assistance of 1 staff member for bed mobility and revealed the resident totally dependent upon 2 person physical assistance for transfers. The MDS documented a height of 64 inches and weight of 288 pounds (lbs). The Care Plan revised 4/24/23 identified a focus area for Activities of Daily Living(ADL) self care performance deficit. The Care Plan directed staff the resident required assistance of 2 staff members with a mechanical Hoyer lift for transfers. The Progress Note, dated 4/18/23 documented Staff G, Registered Nurse, was called to the room of Resident #1 and observed the resident laying on her back with a laceration to her left temple which was bleeding. The resident had a delayed response to verbal stimuli and showed signs of head and neck pain. Staff G called emergency services. Resident #1 was transferred by emergency services to an acute care hospital. The Emergency Department notes dated 4/18/23 documented Resident #1 was seen in the emergency room due to a head laceration above the left eye brown obtained from falling out of a Hoyer lift sling at the nursing facility. The notes further documented the results from a Computerized Tomography (CT) scan that showed the Resident to have right side Cervical 6 and Cervical 7 facet fractures (a breakage of the spinal vertebrae). Additional injuries were documented as a large scalp hematoma (a pool of mostly clotted blood) measuring 6.8 x 4.4 x 2.1 centimeters (cm) extending over a larger area of the calvarium (the top part of the skull) measuring 10.3 x 10.3 x 11.2 cm. The Physician Transfer Order Report dated 4/24/23 documented the activity orders for Resident #1 upon readmission to the facility were for bedrest, rolling 20 degrees side to side, and needing to wear a Cervical Collar (C-Collar; a neck brace used to support the spinal cord) at all times. The Investigation Summary provided by the facility documented on 4/18/23 at approximately 7:15 am, Resident #1 fell out of the Hoyer sling that was the incorrect size. The resident sustained a C6-C7 fracture as a result. The investigation found that Staff H, Certified Nursing Aide (CNA) placed the wrong size sling under Resident #1. Staff I, CNA, attached this sling to the Hoyer lift and started the transfer process. Staff D, Certified Medication Aide (CMA) was getting Resident #1's wheelchair as Staff I began the transfer. As the resident was raised above the bed and the Hoyer lift was turned to transfer her into the wheelchair, one of the straps of the sling came off of the Hoyer and the resident fell to the floor. Observation on 4/25/23 at 1:00 pm, Resident #1 was lying in bed wearing a C-Collar. Her call light was sitting in a flower basket next to her bed out of reach. A small framed wheelchair with a purple Hoyer lift sling was parked in the room, on Resident #1 ' s side of the dividing curtain. On 4/26/23 at 11:08 am, Resident #1 was observed lying flat in bed with a C-Collar in place. On 4/25/23 at 10:27 am, Staff G, RN stated Resident #1 is a larger sized person. At the time she was summoned to the room for the fall, she looked up and noticed immediately the Hoyer sling hanging on the Hoyer was too small. She stated Resident #1 ' s roommate also is a Hoyer lift transfer and is a very petite person. She stated the larger Hoyer sling which should have been used for Resident #1 was noted to be in the roommate ' s wheelchair at the time of the fall. On 4/25/22 at 10:42 am, Staff D, CMA stated on the morning of the fall, she was passing medications on the hall where Resident #1 resided. She stated Staff I had entered the resident's room and she asked Staff D to assist as a 2nd person. She added when she entered the room, Staff I already had Resident #1 hooked up in the Hoyer and had already begun the transfer. Staff D stated she grabbed Resident#1's wheelchair and was looking down to guide it between the Hoyer lift legs. She stated the Hoyer lift legs were not fully open and she was concentrating on getting the wheelchair in place. She said she heard a pop noise and the resident fell to the ground and landed on the floor. Resident #1 hit her head on the floor during the fall. Staff D stated the sling in the Hoyer lift was purple. She voiced Resident #1 should be transferred with a larger sling colored green, blue or black. Staff D stated the normal protocol for a Hoyer transfer is to double check all the loops before beginning the transfer to ensure safety. When she entered the room, Staff had already had the resident in the air and was completing the transfer and her concern was to get the wheelchair in place since she was already up and out of the bed. She stated when the resident fell she questioned Staff I if she had double checked the loops and staff I responded she knew how to do her job. Staff D stated at that time she left to get help for the resident. On 4/25/23 at 3:31 pm, Staff H, CNA stated the day of the fall was his 4th day of employment at the facility. He said he began work at 6:00 am and began to get the residents ready for the day who were Hoyer lift transfers. He stated he got both Resident #1 and her roommate dressed. He said the sling he placed under Resident #1 was in the larger, taller wheelchair in the room which Resident #1 used. He stated the other larger Hoyer sling was on the roommate's side of the room. He felt because the sling was in Resident#1's wheelchair, that must have been the sling she preferred. He stated he had only worked at the facility a few days and he did not receive any training upon starting employment. After placing the sling under Resident #1, he went to answer call lights and did not care for the Resident any further that day. He was later called into the office and was told that Resident#1 had fallen and it was due to the Hoyer sling being too small. He stated he explained to them it was in her wheelchair and he put it under her, but he did not transfer the resident. On 4/25/23 at 4:00 pm, the Director of Nursing (DON) stated in the fall investigation, the facility had determined the way the sling popped off, the sling was not placed correctly on the Hoyer lift. The DON voiced the staff recreated the situation, having a staff member in the Hoyer lift suspended above a bed. They placed one loop only partially on the Hoyer lift instead of fully over the [NAME] and it popped off in the same fashion in that scenario as well. This recreation was done on 4/19/23, the day after Resident#1's fall. Additionally, the sling used for Resident #1 was too small. The DON stated as a result of this fall, Resident #1 is now on strict bed rest for likely 6-8 weeks. She stated the resident is to lie flat except for when being fed her head can be raised 20 degrees under supervision of the staff and she can be log rolled for care. Otherwise she is to be flat in bed. An undated document titled Mechanical Lift Transfer directs staff to follow manufacturer's instructions for the transfer procedure. The Via Health Services training packet for Staff I, dated 3/2/22 included training provided to Staff I for Hoyer lift transfers. Page 8 of the Transfer Audit & Training directs to place the straps of the sling over the hooks of the swivel bar. Match the corresponding colors on each side of the sling for an even lift of the patient. The unnamed document for Hoyer lift slings directs that the slings are color coded by size. Purple slings are medium with a recommended patient weight of 100-175 pounds Green slings are large with a recommended patient weight of 150-275 pounds Blue slings are extra large with a recommended patient weight of 200-400 pounds Black slings are bariatric with a recommended patient weight of 300-600 pounds. Photographs provided by the facility of the sling on the lift which Resident #1 fell out of show a purple sling was used. The Termination Report dated 4/19/23 documented the termination of employment for Staff I documented the description of the incident as Staff member did not place Hoyer sling onto lift correctly resulting in injury to resident. The Termination Report dated 4/19/23 documented the termination of employment for Staff H documented the description of the incident as Staff member placed wrong size Hoyer sling under resident prior to resident transfer which led to the injury of a resident.

Based on observation, record review and staff interviews the facility failed to safely transfer a resident who required a mechanical lift. The sample included 17 residents and a concern was identified for 1 of 17. The sling was connected unevenly and when Resident #6 wiggled the resident fell off the sling pad sustaining a laceration to the scalp requiring staples. The facility census was 60 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 0/15. A score of 0 indicated a severe cognitive impairment. The MDS indicated the resident had the diagnoses of depression, [CONDITION(S)] and dementia. The resident was dependent on staff for transfers. The MDS indicated the resident was 5 foot tall and weighed 195 pounds. The care plan revision dated 4/6/22 documented the resident had self care performance deficit related to weaknesses, impaired mobility and required transfer assistance of two staff with the use of a Hoyer lift. The care plan indicated the resident does not ambulate. The care plan indicated the resident was receiving Hospice services. The care plan also indicated the resident fell [DATE] and staff were to remind resident to keep arms crossed at all times during transfers and ensure all straps were even prior to transferring. The progress note dated 5/14/22 at 12:35 PM read Resident #6 was being transferred from bed into the broda wheelchair this morning for lunch. The resident had two certified nursing assistants assisting with transfer and had her in the sling hooked up to the Hoyer. When resident was transferring in the air, due to a number of factors, Resident #6 slipped out of the Hoyer sling and fell to the floor onto left side, hitting head on the garbage can causing a laceration and hitting her shoulder on the leg of the Hoyer machine. The facility was concerned with laceration and had resident transferred to emergency room . The progress note dated 5/14/22 at 2:45 PM read that Resident #6 returned from the emergency room with staples to back of scalp. There was also an abrasion to right elbow. The resident complained of pain to the back of the head. The progress note, dated 5/15/22 at 8:22 AM indicated that Tylenol 1000 mg given for pain. On 05/22/22 at 2:45 PM and 05/25/22 at 1:28 PM, Resident #6 was noted to have dark purple facial bruising on cheeks and chin. According to the facility investigation and interviews obtained at the time of the incident revealed the following: Staff B indicated they were transferring Resident #6 with the Hoyer left. The sling was connected and resident turned sideways when she began to wiggle and before Staff B could react, the resident slid out of the sling onto the floor. The resident hit head on garbage can and there was blood coming from back of head. Staff N reported the resident was hooked up to the Hoyer and the resident began to wiggle and the next thing the resident was on the floor. The resident hit head and told the staff she was OK. The ambulance was contacted and took to hospital. The incident report dated 5/14/22, indicated there were two staff in the room when the resident was transferred. The Hoyer sling was hooked to the Hoyer and staff were transferring to broda chair. The CNA indicated that Resident #6 does not get up into the broda chair very often only a few days a week and otherwise Resident #6 was usually in bed. The charge nurse had asked them to get Resident #6 up in chair for lunch. The resident was not wearing oxygen. One CNA moved the broda chair and the other CNA was moving the Hoyer sling and then the resident was sliding out on the left side onto the floor. The resident hit head on garbage can and blood coming out of her head. The resident said she was OK though head hurt a little bit. The ambulance was called and resident transported to the hospital. An interview on 6/2/22 at 1:30 PM, the DON stated she remembered the incident because she completed Hoyer transfer training that same day. An interview on 6/2/22 at 2:00 PM, the administrator verbalized she remembered the occurrence and conducting an investigation and training staff with Hoyer lift transfers. During the investigation it was determined the sling was not evenly attached to the Hoyer lift. On 5/14/2022, the facility provided education/instruction to staff to ensure when attaching a Hoyer sling to the Hoyer, make sure that all of the same colored loops were used. If the loops do not match, the sling will be unlevel and may cause the patient to fall out of the sling. The staff were to watch a video on how to properly attach a Hoyer ling to the Hoyer lift.

Based on record review and staff and family interviews the facility failed to provide adequate nutrition and hydration for 1 of 2 sampled (Resident #1) who had weight loss. The facility failed to implement effective interventions for Resident #1 disconnecting his tube feeding at night. The facility failed to carry out a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to adequately assess Resident #1 prior to hospitalization on [DATE]. Resident #1 admitted to the Intensive Care Unit with profound dehydration and an elevated sodium level of 175 (normal 135-145). The facility reported a census of 48 residents. Findings include: Resident #1's Minimum Data Set (MDS) dated of 3/5/21 listed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status (BIMS), documented a 4 out of 15 indicating severe cognitive impairment. Resident #1 required limited assist of one for eating. According to the MDS Resident #1 weighed 137 pounds, had a feeding tube and had a therapeutic diet. Resident #1 received 51% or more of his total calories and 501 cubic centimeters of fluids per day or more through a feeding tube. The Care Plan directed the staff to provide continuous enteral feedings, administer medications as ordered, if reasonable discuss why behaviors are inappropriate or unacceptable, monitor for pocketing of food, choking, coughing, drooling, refusal to eat, invite to activities that promote additional intake, obtain and monitor lab/diagnostic work as ordered, occupational therapy to screen for adaptive equipment for feeding as needed, Registered Dietitian to evaluate and make diet change recommendations and obtain weights per facility protocol. According to the Mini Nutritional assessment dated [DATE], Resident #1 weighed 136.5 pounds on 3/3/21, had a height of 71 inches on 1/12/21, moderate decrease in food intake, weight loss between 2.2 and 6.6 pounds, able to get out of bed/chair but does not go out, severe dementia or depression, body mass index 19 to less than 21. The assessment revealed a score of 7, indicating Resident #1 malnourished. The Care Plan failed to contain interventions to direct the staff how to address when Resident #1 disconnected his tube feedings during the night. The Care Plan lacked interventions to increase Resident #1's hydration and nutrition status. Review of Resident #1's Medication Administration Records and the Weights and Vitals Summary Sheet revealed the following: a. On 12/8/20, 141.3 pounds. b. On 12/23/20, 141.5 pounds. c. On 1/6/21, 141 pounds. d. On 1/14/21, 143.5 pounds. e. On 1/27/21, 142.5 pounds. f. On 2/2/21, refused weight. g. On 2/3/21, 137.5 pounds. h. On 2/9/21, refused weight. i. On 2/16/21, no documented weight. j. On 2/22/21, 134 pounds. k. On 2/23/21, 134 pounds. l. On 3/2/21, refused weight. m. On 3/3/21, 136.5 pounds. n. On 3/9/21, refused weights. o. On 3/16/21, 134 pounds. The Progress Notes revealed the following entries: a. On 1/6/21 at 11:30 a.m., the Interdisciplinary team (IDT) met to discuss residents weight. Care conference with wife scheduled for 1/7/21, to discuss future expectations for tube feeding and discharge home. Current weight 141 pounds. Remains on mechanical soft diet with nectar thick liquids. By mouth intake at meals fluctuate. Resident does disconnect tube feedings himself at times. Will continue to monitor weekly weights. b. On 1/12/21 10:50 a.m., IDT discussed the resident having increased oral intake, refusing tube feedings, removing from the feeding tube site or not allowing nursing staff to attach the feeding. c. On 1/14/21 at 2:14 a.m., Health status note - the resident pulled apart feeding and bed soaked with formula, feeding re-started. d. On 1/20/21 at 10:44 a.m., Health status note - IDT discussed the resident's improvement. Increase in weight, 2.5#. Oral consumption continues to increase, will review with dietician to decrease feedings. e. On 1/20/21 at 2:04 p.m., Nutrition/dietary note - Tube feedings: [MEDICATION(S)] 1.2 at 65 milliliters (ml) per hour for 24 hours with 200 ml water flush each shift plus 30 ml flush before and after medications. Provides: 1872 calories/87 grams of protein/1800ml of fluids per day. Body mass index (BMI) 20, low end of normal weight status. Current body weight (CBW) 143.5#. Increase of 2.2#/1.5% for 30 days and decrease of 2.1#/1.5% for 90 days. Ideal body weight (IBW) 172#. Estimated eternal needs (EEN, feeding needs): 1950 calories/day and 1950 ml fluids per day. Recommend decrease tube feedings to 12 hours overnight only and turned off during the day. f. On 1/27/21 at 11:24 a.m., Health status note - IDT met to discuss current weight loss, down 0.5# this week. Decreased frequency of feeding to night time and oral meals during the day. Will continue to follow. g. On 2/3/21 at 1:23 p.m., Health status note - IDT discussed current weight loss, 5# this week. Will continue to encourage to allow staff to assist, at times will not accept assistance. Will attempt to bring to dining room. Night time tube feedings continue. h. On 2/10/21 at 2:31 p.m., Health status note - IDT discussed 5# weight loss this week. Will continue to give magic cup three times a day, continue weekly weights, and if weight loss continues will increase tube feeding. i. On 2/17/21 at 11:16 a.m., Health status note - IDT discussed increased pain at this time. New order received, will assess after initiated and re-evaluate. j. On 3/8/21 at 12:17 p.m., Nutrition/dietary note - Quarterly review. CBW 136.5# (decrease of 1 pound for 30 days and decrease of 4.5 pounds 180 days). BMI 19, indicating lower end normal weight status. Diet with poor intake, less than 50% most meals. Resident requires assistance at meals. Tube feeding: [MEDICATION(S)] 1.2 @ 65ml/hour, totaling 936 calories, 43.3 grams of protein and 1040 ml of fluids. Reported resident will occasionally mess with and take tube feeding out during the night. Resident with gradual weight loss for 90 days and poor intake. Recommend 240 ml bolus of [MEDICATION(S)] 1.2 three times a day after meals if the resident consumes less than 50% of meal. k. On 3/16/21 at 3:17 p.m., Health status note - results on lab draw received, sent to the doctor with no new orders received. l. On 3/18/21 at 3:22 p.m., Health status note - the resident refused everything oral today including medications. Mucous membranes are intact but dry. m. On 3/19/21 at 5:10 a.m., Health status note - the resident disconnected tube feeding four times. Appetite poor and poor fluid intake. Tube feeding shut off after the 4th total bed change. n. On 3/19/21 at 11:38 p.m., Health status note - the resident on tube feeding, lethargic and tired. o. On 3/21/21 at 9:57 a.m., Health status note - the resident is lethargic and weak, will continue to monitor. p. On 3/22/21 at 1:00 a.m., Health status note - received call from the local hospital that the resident was being admitted for dehydration and high sodium. The Clinical record lacked documentation of the IDT review of the resident's weight after 2/10/21. The Clinical record lacked an assessment from the dietician until 3/8/21, following the weight of 134 pounds on 2/22/21. The Clinical record lacked documentation of an assessment prior to the resident being transferred to the hospital on 3/26/21. The Dietician Fax to Physician sheet dated 3/8/21 revealed the Dietitian recommended [MEDICATION(S)] 1.2 bolus of 240 milliliters three times a day after meals if Resident #1 consumed less than 50% of the meal. The Physician ordered the recommendation on 3/15/21. Review of the March 2021 Medication Administration revealed the facility failed to carry out the ordered Dietitian Recommendation dated 3/15/21 for the bolus feedings. The Clinical Laboratory Report collected on 3/16/21 revealed the following abnormal results: a. White blood count (WBC) - 13.0 (normal 4.0-11.0). b. Sodium (NA) - 160 (normal 132-146). c. Blood Urea [MEDICATION(S)] (BUN) - 38 (normal 9-23). d. Creatinine - 1.6 (normal 0.5-1.3). During an interview on 4/5/21 at 3:30 p.m., the Administrator confirmed the lab results were noted by two facility nurses on 3/16/21, Staff M (Licensed Practical Nurse) and Staff G (Licensed Practical Nurse). The Clinical record lacked documentation that the facility followed up with the physician on the abnormal sodium level of 160 on 3/16/21. Review of the Task Tab in the Electronic Record revealed the following intakes: a. On 3/15/21, breakfast 51-75%, lunch and supper 0-25%. b. On 3/16/21 - breakfast lunch and supper 26-50%. c. On 3/17/21, breakfast and supper refused, and lunch 0-25%. d. On 3/18/21, breakfast and supper refused. e. On 3/19/21, nothing by mouth breakfast, lunch refused, and supper 0-25%. f. On 3/20/21, breakfast refused and supper tube feeding. g. On 3/21/21, breakfast and lunch refused, and supper tube feeding. The ADL sheets dated 4/19/21 revealed Resident #1 refused to eat breakfast and supper on 3/17/21, refused breakfast and lunch on 3/18/21, refused lunch on 3/19/21, refused breakfast on 3/20/21, and refused breakfast lunch and supper on 3/21/21. The Emergency Department Provider Notes dated 3/21/21, identified Resident #1 presented to the emergency room by ambulance for [CONDITION(S)] (absence of enough oxygen in the tissues to sustain bodily function), with oxygen saturation in the 70's, and altered mental status. The nursing home reported the resident had not had any oral intake over the past 2 days. Physical Exam: mucous membranes dry, heart rate tachycardia (rapid), somnolent (drowsy), and weight 125 pounds. Labs revealed: WBC 18.12 and sodium 175, BUN 94, and Creatinine 4.49. Provider summary note: The resident presented with altered mental status from the nursing home, profoundly dehydrated and sodium level 175. The resident had an elevated white count, but no findings of an acute infection. Suspected the high sodium level is due to poor oral intake, intravenous infusion of fluids started and gave free water through the feeding tube. The resident was admitted to the Intensive Care Unit. During an interview on 3/29/21 at 3:30 p.m., the Director of Nursing (DON) was unaware Resident #1 had an order dated 3/15/21 for bolus feedings that the Dietitian recommended on 3/8/21. The DON confirmed the facility failed to implement the order for bolus feedings. The DON stated the order had been scanned into the resident's Electronic Health Record (EHR), however, had not been noted by a Nurse and therefore was not implemented. The DON stated she did not know how the order got missed. The DON stated either herself or another nurse would review the signed orders. The DON stated all orders are placed in the Assistant Director of Nursing (ADON) box, however, there is not currently a fulltime ADON. The DON stated once the orders are in the ADON box, they are sorted through and will be given back to the nurse if they need to be taken care of. The DON stated the Responsible Party is notified of all new orders that was the protocol with every order. The DON confirmed there was no assessment for Resident #1 prior to being transferred to the local emergency roiagnom on [DATE]. During an interview on 3/29/21 at 3:44 p.m., the Registered Dietician (RD) confirmed Resident #1 received enteral tube feedings overnight. The RD stated on 3/8/21 she completed dietary assessment. The RD stated Resident #1 was not eating and she recommended bolus feedings if he did not eat more than 50% at meals. The RD sent a fax to the resident's Primary Care Provider with the recommendations. The RD sent an email notification to the DON, MDS Nurse, and Dietary Manager with the information. The RD stated since Resident #1 had a feeding tube checked weights monthly they had weekly weights, then she would review them weekly. The RD stated Resident #1 had a gradual weight loss (December 141 pounds and March 16, 2021 131 pounds). The RD stated on 3/8/21 she did not visibly assess Resident #1 due to the pandemic and limiting exposure to the residents. On 3/16/21, she reviewed the weights, but did not specifically assess if the resident did not trigger as significant weight loss. The RD was not aware the bolus feedings were not implemented. During an interview on 3/29/21 at 3:51 p.m., Staff A (Licensed Practical Nurse) stated Resident #1, would refuse cares, especially his tube feedings. Staff A stated the resident would disconnect the feedings himself, and find him in the morning with formula running on the bed. During an interview on 3/30/21 at 9:13 a.m., Staff H (Licensed Practical Nurse) confirmed she had worked on 3/21/21, when Resident #1 was transferred to the local hospital. Staff H stated she had arrived at work approximately 5:30 PM and around 5:45 p.m., the staff had requested she check Resident #1, due to not doing well. Staff H stated the resident would not respond when his name was spoken, lips dry, eyes sunken, and mental status changed. Staff H stated she had asked the Certified Nurse's Aides (CNA) if they had checked the resident's vital signs and she was informed they were done on the day shift. Staff H stated she went to the nurse that was on duty at that time, Staff C (Registered Nurse) and requested she assess the resident, as she felt he had a change in condition. Staff H and Staff C confirmed the resident had a change in mental status and the LPN requested the RN transfer the resident to the local hospital. During an interview on 3/30/21 at 9:40 a.m., Staff C (Registered Nurse) stated she no longer worked at the facility, her last day was 3/24/21. Staff C confirmed she worked on 3/21/21 when Resident #1 transferred to the local hospital. Staff C completed an assessment on Resident #1 prior to his transfer. Staff C knew she documented the assessment in the Electronic Health Record. Staff C reported Resident #1 did not look good and had a full code status. Staff C called the physician and Resident #1's Responsible Party and he transferred to the hospital. Staff C reported Resident #1 refused his tube feedings and had increased behaviors since changing rooms. Staff C reported Resident #1 had difficulty swallowing on 3/19/21, when his decline started, and was seen by the speech therapist. Staff C had no knowledge of the facility notifying Resident #1's Physician or Responsible Party of the change in condition. During an interview on 3/30/21 at 11:35 a.m. Staff J (Certified Nurse's Aide) stated Resident #1 pulled the feeding tube out and refused to eat. During an interview on 3/30/21 at 11:45 a.m., Staff F (Certified Medication Aide) stated at times, Resident #1 would pull out his feeding during administration. Staff F stated Resident #1's intakes depend on his mood and what was served. During an interview on 3/30/21 at 12:26 p.m., Staff K (Certified Nurse Aide) stated Resident #1 had resistive and combative behaviors at times with cares. Resident #1 loved to drink water. However, when Resident #1 moved to the long term side of the facility, he did not drinking as much. Staff K recalled a day when Resident #1 had a swallowing issue. However, she was unable to provide the date. Staff K stated dietary staff had suggested the resident have an increase in tube feeding due to not eating. When Resident #1 moved to the long term care side the increase in tube feedings was not pursued. Resident #1 disconnected his feedings at times. Staff K stated when Resident #1 transferred to the hospital on 3/21/21, they discussed him being dehydrated and Staff A (Licensed Practical Nurse) administered fluids via Resident #1's tube. During an interview on 3/30/21 at 12:43 p.m., Staff L (Certified Medication Aide) stated the day prior to Resident #1 (3/20/21) being sent to the hospital he was not swallowing and she had informed Staff C. Staff L stated the Staff C informed her they would give Resident #1 everything through his feeding tube. Staff L stated the resident did not look right, thought he was in the dying process on 3/21/21. During an interview on 3/30/21 at 1:41 p.m., the Speech Therapist stated she went to see Resident #1 on 3/19/21, due to staff were concerned that he was coughing with the nectar thick liquids. The Therapist stated the resident was sitting up in his wheelchair, awaiting noon meal, and that he did take a drink of nectar thick liquids but would not take a bite of food. The Therapist stated the resident did not cough while drinking, however, his swallowing was delayed. The Therapist stated she talked to Staff A (Licensed Practical Nurse) and the Staff A informed her she was aware of the concerns as staff had informed her. The Therapist stated the resident was not himself, alert but drowsy and did not converse. The Therapist stated she had spoken with the Director of Nurses that she was unable to complete an evaluation due to the resident not being himself and would follow up on Monday 3/22/21. The Therapist informed the Director of Nurses if staff had trouble over the weekend, liquids could be advanced to honey thick consistency. During an interview on 3/31/21 at 8:50 a.m., Responsible Party for Resident #1, stated the resident was hospitalized at this time with hospice services. The family member stated she had not been notified the resident was having increased pain with changes to his pain medications, that he had weight loss, or that he had an open area to his buttocks. The family member stated she was unaware the resident had been disconnecting his feeding tube. The family member stated Resident #1 was admitted to the hospital on 3/21/21 due to dehydration and sodium level being high at 170. The family member stated the facility had called her after 6:00 PM, on 3/21/21, to inform her the resident was going to the hospital and she had inquired why so late in the evening with no response being given. The family member stated she had called the facility and spoke with Staff I (Social Worker) about is weight after he was hospitalized . The family member stated Staff I informed her the residents weight was 134 pounds, however, hospital weight upon arrival was 125#. The Responsible Party stated she had a window visit with Resident #1 on 3/19/21, and he would not respond to her, stated she was beating on the window to get him to look at her and this was not his normal. The family member stated on previous window visits, the resident would socialize and be rolling around in his wheelchair. During an interview on 3/31/21 at 12:53 p.m., Staff I (Social Worker) stated she had received a phone call from the Responsible Party after the resident was admitted to the hospital, regarding the resident's weight. Staff I informed the Responsible Party of Resident #1's most recent weight at the facility. Staff I stated the last Care Conference with the Responsible Party was 1/5/21, and weight was stable at that time, 141#. Staff I stated IDT meetings were held weekly, on Wednesdays, with dietary department, social services, Director of Nursing, the Director of therapy, MDS Coordinator, and Administrator. Staff I stated during these IDT meetings, residents would be reviewed as a whole with each department providing input. Staff I confirmed that Resident #1's weight was not reviewed on 2/17/21 and there was no IDT meeting regarding this resident after 2/17/21, documented in the resident's Clinical Record. During an interview on 3/31/21 at 12:30 p.m., the Director of Nursing (DON) stated she would expect the Dietitian to be more involved with Resident #1's weight loss. The DON stated she had a brief conversation with the Dietitian related to bolus feedings for Resident #1 due to him disconnecting his feedings at night, however, at times his oral intake was good and no changes were made. The DON stated the Dietitian would notify the resident's Physician of recommendations and once order was received, the family &/or responsible party would be notified of weight loss and new orders. The facility was notified of the Immediate Jeopardy on March 31, 2021 at 3:30 p.m. The facility removed the Immediate Jeopardy on April 1, 2021 by providing education to staff on supplemental feedings, weights, and lab values. The facility conducted an audit of weights and dietary interventions and conducted education on carrying out physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The scope lowered from J to D.

Based on observation, record review and staff & physician interview the facility failed to perform a Prothrombin Time (PT) and International Normalized Ratio (INR) lab draw for 1 of 2 residents (Resident #4) on an anticoagulant medication. PT & INR labs are done to determine blood clotting time when taking blood thinning medications. The Physician ordered a PT and INR on 3/15/21. On 3/26/21, Resident #4 transferred to the emergency room with a PT greater than 120 (normal 12.2-15.1) and an INR unable to be calculated due to the elevated PT value (normal 2-3). Resident #4 experienced bloody noses for 2 days prior to hospitalization without physician notification or intervention. Resident #4 admitted to the Intensive Care Unit on 3/26/21. The facility reported a census of 48 residents. Findings include: Resident #4's Minimum Data Set (MDS) with a completion date of 3/25/21, listed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status (BIMS), documented a 3 out of 15 indicating severe cognitive impairment. The MDS coded the resident had received an anticoagulant daily during the observation period. A Care Plan focus area with initiation date of 8/27/20 identified the resident on anticoagulant therapy related to [CONDITION(S)]. Interventions included: administer anticoagulation medications as ordered by the physician and monitor for side effects and effectiveness every shift (8/27/20), monitor/document/report as needed any adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headache, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, loss of appetite, sudden change in mental status, significant or sudden change in vital signs (8/27/20), review medication list for adverse interactions, avoid aspirin or non-steroidal anti-inflammatories (8/27/20). The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] 5 milligrams (mg) in the evening, with a start date of 3/3/21 and stop date of 3/8/21. Documented as given 3/4 - 3/7/21. b. [MEDICATION(S)] 4.5mg in the evening and re-check PT/INR in one week, with a start date of 3/9/21. Documented as given 3/9 - 3/25/21. c. Lab PT/INR one time only with a start date of 3/4/21. Documented as completed on 3/5/21. The Treatment Administration Record (TAR) dated March 2021 included the following: a. Draw blood for PT/INR on 3/8/21, one time only with a start date of 3/8/21. Documented as completed on 3/8/21. b. Draw blood for PT/INR on 3/15/21, one time only with start date of 3/15/21. Not documented as being completed, however, documentation on PT/INR flowsheet dated 3/8/21, with results. c. Monitor/document/report as needed adverse reactions of anticoagulant therapy: blood tinged urine or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden change in mental status, significant or sudden change in vital signs every day and night shift with a start date of 2/24/21. Initialed twice per day as being monitored from 3/1 - 3/25/21. The PT/INR/[MEDICATION(S)] Flowsheet revealed the following: a. On 3/8/21 at 4:30 PM, INR 3.5 and PT 32.9, current dose 5, resident not on an antibiotic, physician notified, dose changed to 4.5, and next INR 3/15/21. Nurse signature was blank. b. On 3/15/21, no entry, flowsheet blank. The Progress Notes revealed the following: a. On 3/8/21 at 6:39 PM, health status note, call placed to the physician with new order received to discontinue the [MEDICATION(S)] and decrease the [MEDICATION(S)] to 4.5mg every day and re-check in one week. b. On 3/17/21 at 3:49 PM, pharmacy review note, monthly medication regimen review completed. Requested nursing follow up on PT/INR that should have been draw on the 15th or 16th. c. On 3/25/21 at 4:40 PM, health status note, late entry: the resident more agitated today and yelling out randomly from room. The resident stated she did not know what she needed. The resident's physician was notified and order received to urinalysis (UA). Unable to obtain UA at this time. Fluids encouraged and will attempt again later. d. On 3/26/21 at 8:31 AM, health status note, the resident was weak and left side mouth drooping. The resident's face was symmetrical, exhibiting weakness and unable to drink or take food in. Blood pressure 102/97, pulse 88, respirations 18, temperature 98.0 degrees Fahrenheit. The physician and the resident's power of attorney was contacted, and the resident was transferred to the local hospital. The Occupational Therapy (OT) Daily Treatment notes revealed: a. On 3/24/21, the resident was wheeled to the bathroom and completed stand pivot transfer with maximum assist to toilet. The resident voided and blood was noted in her urine. The resident had a bloody nose and nursing was notified about both updates. b. On 3/26/21, the resident had dried blood on fingers and around nose. The resident was given warm wet cloth to clean hands and face. The Emergency Department Provider Notes dated 3/26/21 at 10:53 AM, revealed: a. Received consent for the patient to receive a blood transfusion due to a hemoglobin 5.1 (normal 11.0-17.0) b. Labs were notable for a urinary tract infection with associated hematuria (blood in the urine). INR is supra therapeutic, undetectable. Due to the resident's ill state, needing multiple infusions, K Centra (Prothrombin concentrate used as an urgent reversal of acquired coagulation factor deficiency induced by Vitamin K) was ordered. The resident needed the intensive care unit for close monitoring. c. Clinical impression: shock, severe [CONDITION(S)], acute [CONDITION(S)], and supra therapeutic INR. During an interview on 3/29/21 at 3:30 PM, the Director of Nursing (DON) confirmed Resident #4 last INR was 3/8/21, and there was no documented follow up. The DON stated she was only aware the resident had a bloody nose on 3/26/21, the day she was transferred to the hospital. The DON stated the facility staff had reported to her on 3/25/21, the resident was more agitated and she then notified the physician. The DON stated she was unable to obtain a UA as ordered and was going to attempt the following morning, however, the resident was transferred to the hospital. The DON stated she was not aware of any additional days when bleeding was reported by the therapy department to the nursing staff. During an interview on 3/29/21 at 3:51 PM, Staff A (Licensed Practical Nurse) confirmed she was working on 3/26/21, when Resident #4 was transferred to the hospital. Staff A stated the Nurse Aide requested she assess the resident and upon entering the room, the resident had blood on her arms and neck from scratching herself. Staff A stated she asked the resident if she was ok and the resident informed her she was, just itched. Staff A stated the Nurse Aides finished getting the resident up and then she went back to the resident's room. Staff A stated this time the resident had lip drooping and left hand was weak, however, able to follow all commands. Staff A stated since the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff A stated she was not aware the resident had needed a follow up INR. Staff A stated lab orders are placed in the lab book. During an interview on 3/30/21 at 10:40 AM, the Director of Nurses (DON) stated orders for labs are entered into the resident's electronic health record (EHR), placed on the calendar at the nurses station, and then the night nurse would make out lab requisitions. The DON stated the on staff phlebotomist is scheduled on Monday, Tuesday, and Fridays, however, she would also come in as needed. The DON stated she would also draw labs as needed. The DON stated Resident #4's INR had not been placed on the calendar and the order entered into the resident's EHR was not entered correctly, which did not prompt the task for completion. During an interview on 3/30/21 at 10:59 AM, Staff D (Certified Nurse Aide) stated she worked the morning on 3/26/21, that Resident #4 was transferred to the hospital. Staff D stated she had summoned Staff A (Licensed Practical Nurse) due to the resident not responding like usual. Staff D stated she assisted Staff E (Certified Nurse Aide) to transfer Resident #4 to her wheelchair with a gait belt. Staff D stated she summoned Staff A a second time, as Resident #4 kept her head down, not responding like usual, and had a runny nose with blood present. During an interview on 3/30/21 at 11:25 AM, Staff E (Certified Nurse Aide) stated she had dressed Resident #4 in bed on the morning on 3/26/21. Staff E stated Staff D (Certified Nurse Aide) then assisted with transferring the resident to her wheelchair with the gait belt. Staff E stated the resident did have a bloody nose while she was getting her dressed, and reported that to Staff A. During an interview on 3/30/21 at 11:45 AM, Staff F (Certified Medication Aide) stated he was aware Resident #4 had bloody noses and was reported to the charge nurses. During an interview on 3/30/21 at 2:32 PM, Staff G (Licensed Practical Nurse) stated she no longer worked at the facility, her last day of employment was on 3/28/21. Staff G stated Resident #4 would pick at her nose, causing it to bleed. Staff G stated she was unsure of the exact date, however, she had cleaned the resident 3 times due to having a bloody nose. Staff G stated the resident would bleed easily due to being on [MEDICATION(S)]. Staff G stated she knew the resident's INR was drawn on 3/8/21, however, unsure when was to be re-checked. During an interview on 3/30/21 at 4:06 PM, Staff B (Occupational Therapist) confirmed she had therapy sessions with Resident #4 on 3/25 & 3/26/21. Staff B stated the resident had a bloody nose off and on throughout the therapy session on 3/24/21, and had notified the nursing staff. On 3/26/21, she did not observe the resident having a bloody nose, however, found her with dried blood around her nose and fingers. Staff B stated the facility staff had asked her to check on the resident because she was being sent out. During an interview on 3/31/21 at 11:33 AM, Staff C (Registered Nurse) stated when she worked at the facility there was one staff person who drew labs and she was scheduled on Monday, Tuesday, and Fridays. Staff C denied the facility having an INR machine to perform the lab at the facility. Staff C stated she had initialed that the PT/INR lab had been done on 3/15/21, and that she had assumed it had been done. Staff C stated her initials were there as, assuming the lab had been done. Staff C stated the floor nurse would follow up to ensure the lab results were back and the physician was notified. There were times she was not working on the floor and she just signed things off on the MAR's because the Medication Aides were unable to do so. Staff C stated no one knows the correct protocols. During an interview on 3/31/21 at 12:20 PM, the Director of Nurses (DON) stated there was no PT/INR completed on 3/15/21. She called the hospital lab and the most recent PT/INR results were from 3/8/21. The DON stated the phlebotomist that is scheduled on Monday, Tuesday, and Fridays to do the lab draws always checked the calendar to see what labs needed to be drawn. The DON stated after the labs were drawn, the phlebotomist would give the nurse on duty and yellow copy of the lab requisition so the nurse would then document. The DON stated the facility does not have an INR machine to complete the testing in house. During an interview on 3/31/21 at 3:16 PM, Resident #4's Primary Care Physician stated he was unaware of the situation in the emergency room related to Resident #4's INR. The physician stated he remembered Resident #4's last INR reviewed was around 3 and the [MEDICATION(S)] had been decreased. The physician stated the INR should have been in the range of 2. The facility was notified of the Immediate Jeopardy on March 31, 2021. The facility removed the Immediate Jeopardy on April 1, 2021 by educating staff on following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The scope lowered from J to D.

Based on record review, staff, and resident interviews, the facility failed to ensure 1 of 4 residents were transferred in manner to prevent physical injury. Concerns were identified with Resident #1. The facility reported a census of 83 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 had [DIAGNOSES REDACTED]. The MDS noted the resident dependent on staff for activities of daily living, required extensive assistance of two for transfers. The MDS documented the resident's BIMS (brief interview for mental status) score 6 out of 15 indicating severely impaired cognition. The resident's Care Plan with a Target date of 4/28/18 identified the resident with a self care deficit related to confusion and dementia. The Care Plan directed nursing staff: a. Requires assistance of two staff for transfers. b. Provide peri care after each incontinent episode. c. Extensive assistance of one staff to turn and reposition in bed every 2 hours and as necessary. d. Dependent on one staff for dressing. e. Resident does not ambulate at this time. f. Dependent on two staff for toileting. g. Requires assistance of one staff for personal hygiene and oral care. h. Allow resident time to process new information. i. Do not rush during cares. j. Provide safe environment. l. Monitor for any signs and/or symptoms of pain. Anticipate the resident's need for pain relief and to respond immediately. A Nurse's Note dated 3/10/18 at 3:00 p.m. noted that staff observed Resident #1 on the floor near the nurse's station after they heard a thud at 7:15 a.m. The nurse noted that Resident #1 sustained a hematoma to her left temple which warranted being sent to ER for evaluation and treatment. The nurse also noted there were no other visible injuries at that time. Review of the Nursing Documentation and Fall Assessment Form dated 3/10/18 at 7:15 a.m. revealed Resident #1 sustained a hematoma (collection of blood under the tissue) to her left temple after staff observed her on the floor after they heard a thump. The Emergency Department (ED) Physician Note dated 3/10/18 at 8:38 a.m. noted Resident #1 presented with a head injury she sustained after she fell just prior to arriving. The report noted the resident did not know why she was there and had no complaints at the time. The assessment documented the resident attempted to stand and ambulate and fell striking the right side of her head. The physician's assessment revealed no tenderness, no swelling and no deformities. The CT scan ruled out any internal brain hemorrhage and the resident discharged back to the facility. The Nurse's Notes dated (MONTH) 11, 12, 14, 16, 17, 18, (YEAR) documented the resident denied pain or discomfort. The Nurse's Notes dated 13, 15, documented the resident had normal range of motion and denied pain. The Nurse's Note dated 3/19/18 at 3:50 p.m. noted the resident remained Hospice level of care without any changes. The Nurse's Note dated 3/19/18 at 10:00 p.m. noted the resident remained very agitated and an antianxiety medication [MEDICATION NAME] had been administered. The Nurse's Note dated 3/20/18 at 1:00 a.m. noted the resident remained very agitated, would not rest, wanted to leave and had delusions. The nurse noted that resident became combative and refused bedtime medication. The nurse tried antianxiety medication again at 1:00 a.m. The Nurse's Note dated 3/21/18 at 4:00 p.m. noted the resident complained of pain to her right leg when moved during transfers. Order obtained for an x-ray. An Incident/Accident Report dated 3/21/18 at 4:00 p.m. noted the resident had increased pain after a 3/10/18 fall. The Nurse's Note dated 3/21/18 at 8:30 p.m. noted the x-ray report revealed mildly displaced oblique (slanted or angled) fractures to the right distal (situated further away from point of attachment) tibial and fibular diaphyses (shaft of leg bones). Fractures right leg (tibula and fibula). The Nurse's Note dated 3/21/18 at 9:00 p.m. noted an order to: 1. Splint the right leg with an immobilizer for the night. 2. See an orthopedic Dr. tomorrow. The Patient Report date 3/21/18 revealed the right foot x-ray results noted a displaced [MEDICAL CONDITION] tibial and fibular diaphyses. The Major Injury Determination Form signed and dated 3/22/18 at 12:15 p.m. by the resident's physician documented the resident sustained [REDACTED]. The Nurse's Note dated 3/22/18 at 3:30 a.m. noted the resident tolerated the application of the immobilizer well. The nurse noted the right lower leg as swollen and slightly pink. The Nurse's Note dated 3/22/18 at 3:00 p.m. noted the ambulance transported the resident to her ortho appointment and noted the resident returned with a hard cast to her right lower extremity and should be rechecked in 3 weeks. When interview on 5/2/18 at 12:05 p.m. the Administrator reported their investigation concluded Staff B, CNA did an improper transfer. The Administrator believed Staff B scooped Resident #1 up in his arms, probably because of being in a hurry, and dropped her on the bed. The Administrator said the resident's roommate saw the whole thing. The Administrator said Resident #2 (Resident #1's roommate) can be kind of histrionic or dramatic, but they think there's nuggets of truth in what Resident #2 reported. The Administrator said Resident #2's is alert, oriented and has a BIMS of 15 out of 15 indicating (no cognitive impairment). The Administrator said Staff B's inappropriate actions caused the resident's injury and critical care had been withheld because Staff B did not come forward and report what occurred. An interview on 5/2/18 at 1:15 p.m. with Resident #2 (roommate of Resident #1) revealed that she witnessed the incident between Staff B and Resident #1 which took place in their room on 3/19/18 between 8:30 or 9:00 p.m. Resident #2, reported Staff B only pulled the privacy curtain about ¼ of the way closed so she still had a full view of what transpired. Resident #2 said she could see the entire room and all the way up to the edge of Resident #1's bed. Resident #2 said she could also see everything in a mirror that hung across from Resident #1's bed. Resident #2 said she became more attentive than she normally would have been because of how Staff B spoke to Resident #1. Resident #2 said Staff B did not yell at Resident #1, but said quit sassing me, why are you sassing me? I have not done anything to you, I'm just trying to put you to bed. Resident #2 said nobody else would have witnessed what happened because they were the only 3 people in the room at the time and the door to their room was closed. Resident #2 said Staff B placed Resident #1's wheelchair facing her bed, so she had a good view of Resident #1's right side and back. Resident #2 said Staff B forcefully pulled Resident #1's shirt over her head and arms so he could put her night shirt on her. Resident #1 screamed stop it, stop it. Don't touch me, get away from me. Staff B got Resident #1's shirt off and Resident #1 said g---it, stop touching me. Get someone else to help, get away from me. Staff B said don't sass me, I'm just trying to help get you into bed. You don't have any reason to sass me. Resident #2 said Staff B continued to forcefully pull Resident #1's night shirt on over her arms and head as she continued to object. Resident #2 said Staff B then pulled the curtain completely open again. According to Resident #2, Staff B came from behind Resident #1 put both of his arms under her armpits to lift her from the wheelchair. He then scooped her up and used one of his legs to move the wheelchair out of his way and caught Resident #1 under her legs with one arm, like cradling a baby, then used that momentum and threw Resident #1 onto her bed, all in one swift motion. Resident #1 landed on her back and hit so hard she bounced up off the mattress. Resident #2 said she repeatedly said dude stop. She doesn't want you touching her. Go get somebody else. Resident #2, described Staff B as a big guy that stood at least 6' tall. Resident #2 said she repeatedly said dude stop. She doesn't want you touching her. Go get somebody else. According to Resident #2, Staff B said nobody else could help him because they were so busy. Resident #2 said Resident #1 moaned in pain. Resident #2 said Staff B covered Resident #1, took her wheelchair and left the room. Resident #2 said she asked Resident #1 are you OK Grandma? after he left and she said yes, I'm OK. Resident #2 said Resident #1 did not sleep very well after that and had a bad night. Resident #2 said when Grandma is awake, I'm awake. Resident #2 said she did not notice Resident #1 having any pain the next day, but the day after that she did. Resident #2 said on the morning of 3/21/18 Staff G, CNA came in to dress Resident #1 as she laid in her bed. Resident #2 said she didn't notice Resident #1 had any pain while Staff G dressed her. Staff G went into the hall to find someone to help with the transfer, she re-entered the room and closed the door behind her. Resident #2 said Staff J, CNA entered the room and Staff G transferred Resident #1 from her bed to her wheelchair (alone) while Staff J put on gloves. Resident #2 said that is when Resident #1 complained that her leg hurt. Resident #2 said Resident #1 sat on the side of her bed, and Staff G bear hugged her, lifted her, spun her around and sat her in the wheelchair. Resident #2 did not know if Resident #1's feet touched the floor to stand/pivot/transfer or if Staff G literally picked her up. Resident #2 said they took Resident #1 to breakfast and she must have been complaining of pain at breakfast because most of the time Resident #1 sets by the nurses station in her chair but Staff G put her back in bed (alone) about 9:00 a.m. Resident #2 said those were the only times she saw people transfer Resident #1 alone. Resident #2 said Staff G did not bother to get Resident #2 up for lunch. Resident #2 said she asked Staff G if they were going to get her up and she said no, she's sleeping peacefully so I'm not going to bother her. Resident #2 said that Staff G left at 2:00 p.m. and she did not know if Staff G told anyone. Resident #2 said Staff F CNA came in at 2:00 p.m. and she told her about Resident #1's pain. Resident #2 said Staff F told someone and they got an orders for an x-ray. When interviewed on 5/9/18 at 3:50 p.m. with Staff G reported Resident #1 complained of leg pain when she got her up the morning of 3/21/18. Staff G said they usually transferred Resident #1 alone by giving her a hug and assisting her to stand/pivot transfer. Staff G said Resident #1 usually was able to stand and bear weight with assist of one. Staff G said she could not remember if she transferred her alone that day. Staff G said Resident #1 could not stand or bear weight that morning. Staff G said Resident #1 kept saying my leg hurts, be careful during the transfer. Staff G said Resident #1's roommate was in the room at the time and she could not see any physical signs of injury because the roommate did not want them to turn the lights on. Staff G said she and Staff J took Resident #1 to the shower room and she complained of pain. When they took the resident's blankets off and raised her gown they saw a nasty bruise on her right shin. Staff G described the bruise as purplish in color, kind of long and about 1 to 2 inches wide. She told Staff A about the bruise and said she needed to go look at it. Staff G said she finished getting residents up after telling the nurse about the bruise and Staff J stayed with Resident #1 in the shower. Staff G said she never received report from the overnight shift and no one said anything about a bruise. Staff G continued that she saw Resident #1 at the nurse's station between 9:00 - 10:00 a.m. and put her to bed with the help of another aid. Staff G said Resident #1 did not get out of bed for the remainder of her shift. She checked on her before lunch and she stayed in bed. Staff G said she believed one of the nurses said to leave her in bed because she was resting; but she did not remember who. Staff G said she checked on Resident #1 about 1:30 p.m. before she left and she was still sleeping. Staff G said she did not know if Staff A followed up on the report of Resident #1's pain and bruised leg. Staff G said she told Staff F about the resident's bruise and pain when she reported off at shift change. Staff G said she never noticed if Resident #1 was having any problems in the days before that. When interviewed on 5/7/18 at 2:05 p.m. Staff J, CNA stated she was not in Resident #1's room nor did she help get her up or put her to bed on the morning of 3/21/18. Staff J said Staff G brought Resident #1 to the shower room and the resident complained of her leg hurting. The resident wouldn't let her assist her in any way, even when she tried to console her. Staff J said she saw a bruise about 6 long and 1 wide on the resident's shin and she immediately reported it to Staff A, LPN as Staff G took Resident #1 to the nurse's station. During an interview on 5/3/18 at 12:05 p.m. Staff I, CNA stated Resident #2 ( Resident #1's roommate) knows what she is doing, she kind of supervises or oversees Resident #1's care when staff go in to help her. Resident #2 advocates for Resident #1, she informs staff of her observations of Resident #1, like she didn't sleep well last night etc. During an interviewed on 5/9/18 at 9:15 a.m. when asked what happened to her casted leg Resident #1 replied I ran into someone. When asked if her leg hurt, Resident #1 said yes, very much.

Based on observation, clinical record review, facility policy review, and staff interviews, the facility failed to ensure residents were free from significant medication errors for 1 of 6 residents reviewed (Resident #1). The facility reported census of 94 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 11/16/16, Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident demonstrated severely impaired cognitive skills and required extensive to total assistance from staff for all activity of daily living. The resident's plan of care with a goal date of 02/22/17 indicated the resident demonstrated behaviors and instructed staff to administer psychoactive medications as prescribed, to monitor for adverse reactions, and notify physician as needed. The facility medication administration policy with a revised date of 06/23/16 instructed staff to: *Identify the resident by pictures and check the Medication Administration Record [REDACTED]. Also look at the proper date and time column on the MAR indicated [REDACTED]. *Read the label 3 times before dispensing medication into the medication cup: 1. When taking the medication from the drawer 2. Before dispensing the medication 3. When putting the medication container back into the drawer *Remove the medication from the card; place the card over the cup so the medication falls into the cup. 1. Crush medications, if ordered. 2. Never administer medication that has been prepared by another person. A medication/treatment error report dated 11/30/16 at 8:00 a.m. documented staff gave Resident #1 his/her scheduled morning medications and also another resident's medications. According to the Medication Administration Records staff administered Resident #1 his/her normally scheduled morning medications at 6:58 a.m. The medications were as follows: 1. Calcium/D 600/400 mg 2. [MEDICATION NAME] 325 mg 3. [MEDICATION NAME]/APAP 10-325 mg 4. [MEDICATION NAME] 12 units 5. Magnesium oxide 400 mg 6. [MEDICATION NAME] 1000 mg 7. Senna 8.6 mg 8. Stress formula multivitamin 9. Xarelto 20 mg Staff gave Resident #1 the scheduled medications that belonged to Resident #5 as well. The medications were as follows: 1. [MEDICATION NAME] 100 mg 2. [MEDICATION NAME] 50 mcg 3. [MEDICATION NAME] 20 mg 4. Thera Beta [MEDICATION NAME] 5. [MEDICATION NAME] 100 mg 6. Mucus Relief 400 mg 7. Potassium Chloride 20 meq 8. [MEDICATION NAME] 100 mg 9. [MEDICATION NAME] 20 mg The facility investigation report dated 11/30/16 and signed by the facility Director of Nursing indicated staff gave Resident #1 another resident's medication (Resident 5's). Staff A, LPN had been preparing medications and Staff B, CMA (certified medication aide) was passing medications to residents when a misidentification occurred. Resident #5's pills were given to Resident #1 instead of the correct resident. The nurse immediately obtained Resident #1's vital signs and monitored him/her closely. The Primary Care Provider (PCP), was in the facility and treated the resident. The resident later transferred to the hospital for evaluation and treatment at 6:30 p.m. per family request related to the resident's continued lethargy (sleepiness). A Physician's progress note dated 11/30/16 revealed staff gave the patient given the wrong morning medications in addition to his/her scheduled morning medication. Nursing reported stable vital signs but lethargy. Upon entry to room, patient was unresponsive, gown saturated with drool. Audible gurgling, pulse oxygen level 70% on 4 liters per nasal cannula. All medications reviewed, multiple narcotics administered. [MEDICATION NAME] 0.4 mg IM (intramuscular) given at 11:10 a.m. and three drops of [MEDICATION NAME] 1% given sublingual given. Oxygen increased to 5 liters per nasal cannula. Respiratory Therapist called to assist. Oral suction and simple mask brought to bedside. Simple mask with 8 liters oxygen started, pulse oxygen level increase to 87%. Arouses slightly with sternal rub, cough elicited with oral suction, pulse oxygen level maintained at 88% via simple mask. Reassessed at 11:40 a.m., second dose of [MEDICATION NAME] 0.4 mg IM and [MEDICATION NAME] 1% three drops sublingual administered. Within minutes the patient showed increased resistance to the oxygen mask. Pulse oxygen level up to 95%. When suctioned, the resident stated, get that out of my mouth. Resident #1 reassessed at 12:00 p.m. Resident responds to touch although eyes closed: spontaneous cough, pulse oxygen 95% on 8 liters. Oxygen backed down to 5 liters per nasal cannula, maintained oxygen saturation at 95%. Oxygen reduced to 4 liters, continued to respond to gentle touch and verbal stimuli. Moist nonproductive cough present, able to partially clear airway independently. The emergency room history and physical information noted the resident admitted from care facility with altered mental status after receiving another patient's medications earlier in the morning. Notes from the facility indicated the resident became unresponsive and had been drooling, the facility assisted respiratory function and administered [MEDICATION NAME] twice, which brought up alertness status. The emergency room assessment and plan of care dated 11/30/16 at 11:40 p.m. noted toxic metabolic [MEDICAL CONDITION]ly secondary to inappropriate medication administration at care facility with [MEDICATION NAME], continue supporting the patient's respiratory status with oxygen administration and titration, hold [MEDICATION NAME] until mental status improves, nursing bedside swallow, fall and [MEDICAL CONDITION] precautions. On 12/6/16 at 12:50 p.m. Staff A, LPN stated she had started her first day on the floor as a floor nurse and also the first day on the medication cart. She stated the 400 hall had been a heavy hall with a large medication pass and the plan had been to have a CMA assist her. She stated Staff B, CMA came to help her. Staff A stated she had been setting up medications, popping the pills from the cards and Staff B had been taking stock medications and eye drops from the cart. Staff A reported the eye drops were still setting out when Staff B returned from delivering the medications to the resident. When Staff B noticed the eye drops with Resident #5's name had been on the medications, she stated Oh my gosh, those pills were supposed to be for Resident 5, and I gave them to Resident #1. Staff A told Staff B to get the Director of Nursing, who began to monitor Resident #1. Staff A reported Resident #1 stated to become more somnolent and blood pressure dropped. She also reported the PCP had been there with the Respiratory Therapist and they were in the room also to assess the resident. Staff A stated the resident's family came in later in the evening and had been upset, and Staff A had not been aware the resident had been sent to the hospital. Staff A stated she had not seen nurses set up medications and CMAs giving the medications prior to this incident, and reported she had not been comfortable with the practice, especially after the error occurred. On 12/06/16 at 11:35 a.m. Staff B, CMA stated she had come in on her day off to help out and not comfortable with being turned loose on her own to pass medications. Staff B stated she ended up helping Staff A. Staff B stated she had been taught not to pass pills that she had not set up herself. She stated Staff A had set up the pills and told her to go give them to Resident #1. Staff B stated she got back to the medication cart and noticed Resident #5's eye drops setting on the medication cart. She said she told Staff A these are Resident #5's eye drops, and Staff A stated the medications were also Resident #5's. Staff B reported she went to the unit manager to tell her about the medication error. Staff B stated she continued to watch Staff A for a while then went to monitor Resident #1's vital signs. Staff B stated when she went into Resident #1's room, the resident had been responsive but seemed drowsy, so she went to get one of the nurses and the unit manager. Staff B reported she went home after the nurses came into the resident's room. Staff B stated she was not been formally trained on setting up and passing medications at the facility, although she had done so during her CMA training.

Based on record review, staff and resident interviews, the facility failed to implement policies and procedures related to reasonable suspicion of alcohol or drug use and use of medication while on duty which impaired the employee ' s ability to perform work duties safely. Interviews and Staff A ' s personnel record identified concerns of impairment on 11/14/15, 5/4/16 and 5/7/16, and the Administrator ' s own recognition that Staff A had been impaired and possibly under the influence, however the facility failed to initiate it's policies which affect the employees ability to safely perform his/her job duties for residents. On 5/20/16 the facility documented Staff A was at risk for harming residents in her care, and moved her to the day shift. On 6/23/16, staff reported concerns to the Administrator about Staff A being impaired/possibly under the influence. The Administrator asked staff to keep an eye on Staff A, meanwhile Staff A continued to pass residents' medications. Interviews revealed residents did not get their morning medications on 6/23/16, and Staff A was observed removing medications without administering them to residents for the noon medication time. Later in the afternoon of 6/23/16, the Administrator sent Staff A home when suspecting Staff A had intentionally discarded residents ' medications. Staff A provided care and services as a nurse which potentially affected 29 residents on halls 100 and 300 on 6/23/16 or residents assigned to station 2 (including Residents #4, #3, #1). The findings constituted an immediate jeopardy to residents health and safety. The facility identified a census of 100 residents. Findings include: Facility Drug and Alcohol Substance Abuse Policy (undated) indicated employees may be subjected to testing when there is reasonable suspicion that an employee may be impaired while on duty. The policy also requires employees to inform the facility if an employee is taking a medication which may impair their ability to safely perform their job duties. The policy identified employees could not possess or use alcoholic beverages while on the property or perform work at the nursing home. The policy indicated if employees take any medication that affected their ability to reasonably and safety perform their job, the employee must inform the nursing home and discuss any reasonable accommodations necessary. Employee Record Employee record review found Staff A, Registered Nurse began employment with the facility on 8/26/15. Background checks completed at the time of her employment noted no dependent adult abuse, an active Registered Nurse license with history of disciplinary action and criminal background history. Criminal history noted two arrests for driving a vehicle while intoxicated on 7/25/09 and again on 12/27/14. Staff A's Registered Nurse license was suspended indefinitely on 12/2/10 pending receipt of a chemical dependency evaluation, treatment and aftercare and Staff A being able to verify 12 months of continuous sobriety. Staff A's license would then be placed on probation for 12 months upon fulfillment of the provisions noted above. Last known license issued date was 4/30/13. Record review noted Staff A received the following disciplinary actions during her employment: 3/10/16 for failing to administer medications at bedtime for 6 residents. 3/31/16 for failing to have another nurse verify a narcotic medication was removed from the e-kit. 4/14/16 for failing to complete an assessment on a new resident and administer medications to 3 residents. Record review found Staff A was involved in multiple incidents which questioned her ability to safely perform her job duties: On 11/14/15 at 2:00 a.m. Staff A was sent home when staff noted a change in her mental status. The facility completed interviews and a summary of that incident which noted Staff A was seemingly impaired and unable to maintain focus. Multiple staff indicated Staff A was seen carrying around a Star Bucks container with a pink liquid in it. Three staff members stated they could smell alcohol either from the container or on Staff A. Staff A admitted her impaired mental status was due to taking a [MEDICATION NAME] at 6:00 p.m. that evening related to tooth pain. Facility Drug and Alcohol Substance Abuse Policy indicated employees may be subjected to testing when there is reasonable suspicion that an employee may be impaired while on duty. The policy also requires employees to inform the facility if an employee is taking a medication which may impair their ability to safely perform their job duties. Record review of Staff A's personnel file found no disciplinary actions or actions otherwise related to Staff A's condition while on duty on 11/14/15. Despite Staff A's history of substance abuse, mental status change and several witnesses either smelling alcohol on Staff A or from the container, the facility failed to initiate it's policy related to Reasonable Suspicion Testing and failed to enforce policy related to required notification of an employee when taking a medication ([MEDICATION NAME]) which will affect the employees ability to safely perform job duties. On 5/4/16 at 4:45 a.m. Staff B, Registered Nurse, reported concern that Staff A was working while intoxicated. A summary of that incident noted Staff A seemed disoriented with poor balance and unfocused eyes. Staff A was noted in and out of the bathroom several times. The Administrator came in and questioned Staff A who stated she had had diarrhea due to an on-going medical condition. Staff A denied using alcohol and quickly changed the topic of conversation. The Administrator noted no impairments or odors of alcohol. In an interview on 7/12/16 at 6:52 a.m. Staff B stated on 5/4/16 at around 4:30 a.m. Staff J called her concerned that Staff A was intoxicated. Staff B noticed Staff A was in the bathroom a couple of times for 20 minutes, but otherwise noted no indications of obvious impairment such as an unsteady gait, slurred speech or smell of alcohol. Staff B contacted the Administrator who came in an evaluated the situation. In an interview on 7/12/16 at 5:13 a.m. Staff J, licensed practical nurse, stated she has observed Staff A impaired while at work. Staff A's speech has been slurred and walking impaired. Staff J noted these observations have been reported. Record review of Staff A's personnel file found no disciplinary action or actions otherwise related to Staff A's condition while on duty on 5/4/16. Despite Staff A's history of substance abuse, an earlier incident of impairment on 11/14/15 and Staff J's opinion that Staff A was intoxicated, the facility failed to initiate it's policy related to Reasonable Suspicion Testing. On 5/7/16 at around 5:30 p.m. Staff C, licensed practical nurse, reported concerns that Staff A might be intoxicated. A summary of the incident noted the Administrator was summoned when staff noticed concern that Staff A was acting unusual and may be intoxicated. The Administrator observed Staff A and found her to be unsure and unable to unlock the medication cart after multiple attempts. Staff A finally asked assistance of an aide to open a drawer. The Administrator spoke with Staff A and Staff A stated her lack of focus was due to her medical condition. Staff A sat in a chair to avoid standing. Staff A denied drinking. Staff A was informed she was being sent home. Staff A then disclosed she had taken a [MEDICATION NAME] before work. The Administrator asked that Staff A get a ride home as he didn't feel comfortable that she drive home. Staff A refused and the Administrator walked her out to her car and she left. The Administrator called 911 and reported concern that Staff A was possibly under the influence. In a statement written on 5/10/16 by Staff C, Staff C wrote that on 5/7/16 at 5:30 p.m. he noticed Staff A arrive at the facility with only a large cup from Jimmy John's. Staff A sat down at the desk as Staff C finished his medication pass. The other nurses and Staff C were having a conversation and Staff A's responses were slurred and not relative to the conversation topic. Staff A seemed to struggle for words. During report Staff A wrote chicken scratches on the report sheet. Staff C and Staff A then began the shift change narcotic count. Staff A was unable to open the medication cart, maintain balance or get the key in the hole to unlock the cart. When counting Staff A had trouble seeing the amount in the card and placing the card back into the drawer. At one point Staff C bent over to help Staff A and Staff C smelled a very potent odor of fruit flavor. Staff C waved over Staff O and noted he thought Staff A had been drinking. Staff C and Staff O then contacted the Administrator and Staff C took the keys from Staff A. In an interview on 7/11/16 at 5:50 p.m. Staff C, licensed practical nurse, stated on 5/7/16 at 5:30 p.m. Staff A arrived to work. Staff A was quiet and unable to maintain relevant conversation. As Staff C and Staff A began to initiate a shift change narcotic count, Staff C noticed Staff A was wobbling and unable to get the medication cart key into the cart. Staff C waved over Staff O to observe. The Administrator was contacted and sent Staff A home. Staff C stated he believed Staff A was impaired and was not going to allow her access to the medication cart keys. Record review of Staff A's personnel file found no disciplinary action or actions otherwise addressing Staff A's condition while on duty on 5/7/16. In an interview on 7/12/16 at 5:00 a.m. Staff K, certified nurse aide, stated she refers to Staff A as the drunk as she has often came into work smelling like alcohol. In an interview on 7/12/16 at 5:13 a.m. Staff L, certified nurse aide, stated we have all suspected Staff A might be drinking while at work. She had slurred speech and impaired walking. Staff L noted these observations haven been reported. In an interview on 7/12/16 at 5:13 a.m. Staff M, certified nurse aide, stated there has been a couple of nights which Staff A has come to work incoherent, slurred speech and impaired walking. When reported, the Administrator stated he couldn't tell and didn't do anything. Staff M noted Staff A has been known to sleep at the desk for upwards to 30 minutes and one time was in the bathroom for over an hour and a half. In an interview on 7/12/16 at 5:47 a.m. Staff N, certified nurse aide, stated there was a couple of nights in which Staff A came into work and appeared to be drunk. During those times Staff A was loud, nonsensical and smelled of alcohol. When reported it didn't seem as if anything was done, which frustrated the other nurses. Despite Staff A's history of substance abuse, two previous documented concerns of impairment (11/14/15 and 5/4/16), a clear indication of impairment (slurred speech, unsteady gait, lack of concentration, physical limitations), Staff C's opinion that Staff A had been drinking, the smell of a potent fruity odor and the Administrators own recognition that Staff A was impaired and possibly under the influence, the facility failed to initiate it's policy related to Reasonable Suspicion Testing and failed to enforce policy related to required notification of an employee when taking a medication ([MEDICATION NAME]) which will affect the employees ability to safely perform job duties. Review of Staff A's personnel record noted on 5/20/16 a summary note written by Staff H indicated a meeting was held with Staff A to discuss her employment going forward. The facility expressed concern with Staff A's previous incidents in which she claims her medical condition led to the impairments. Staff A was also reminded of the use of [MEDICATION NAME] prior to or during her shifts was not allowed. Staff A was given the option of a leave of absence, moving to the day shift or termination. Staff A chose to move to the day shift. An Employee Counseling dated 5/20/16 indicated a concern with Staff A's job performance noting staff reports of disorientation, impaired or unsteady gait, slurred speech, (when she came in or when leaving her shift) unusual behavior of disappearing for significant periods of time, throwing drink cups away as a member of management approaches and cups being left in file cabinets. A significant decline in attendance and dependability and the facility deeming it necessary to relieve Staff A of duty due to erratic behavior. The counseling note indicated the facilities' belief that Staff A is not in suitable mental or physical condition and at risk for harming patients in her care. The facility recommended Staff A accept a leave of absence so that these issues (medical and mental) can be addressed and resolved, but also provided an option for Staff A to move to day shift for increased monitoring and supervision. Staff A refused the leave of absence and agreed to the day shift. In an interview on 7/11/16 at 3:50 p.m. the Administrator indicated that no drug screens were requested of Staff A during the incidents noted on 11/14/15, 5/4/16 or on 5/7/16 as he had not received the training to make a determination of reasonable suspicion. In an interview on 7/12/16 at 1:34 p.m. Staff D, certified nurse aide, stated on the morning of 6/23/16 at around 5:30 a.m. she and Staff E were sitting in the parking lot prior to work and observed Staff A pull into the parking lot. Staff A got out of her car and had a Styrofoam cup in one hand. Staff A walked across the parking lot and was stumbling. During their lunch break (10:30 a.m. to 11:08 a.m. according to their time sheet) Staff D and Staff E were again sitting in Staff E's car in the parking lot. Staff A pulled into the parking lot and was driving erratically. Staff A pulled into a parking space and then backed up, almost striking Staff E' s vehicle. Staff A then pulled in and out of the parking spot several more times before finally putting her car into park while still moving (heard a grinding sound). Staff A' s car was not pulled in all the way leaving the rear end of the vehicle a few feet into the driveway. Staff A then got out of her vehicle and as she walked towards the facility she was stumbling and having difficulty standing. After their break, Staff D and Staff E reported their observations to the Administrator. In an interview on 7/12/16 at 6:33 a.m. Staff E, certified nurse aide, stated on the morning of 6/23/16 at around 5:30 a.m. she and Staff D were in her car prior to work when they saw Staff A pull into the parking lot. Staff A walked across the parking lot and was stumbling with a Styrofoam cup in her hand. During lunch break Staff E and Staff D were again sitting in her car in the parking lot when they saw Staff A drive into the parking lot. Staff A pulled into the parking spot fine and then for no apparent reason backed up across the parking lot nearly hitting Staff E's car. Staff A pulled forward, backed up and again pulled forward before finally parking her car with the rear end still partially out of the parking space. Staff A got out of her car and her shirt was wet mid torso. Staff A had a Styrofoam cup in one hand and a frappe in the other as she walked towards the facility. Staff A's gait was unsteady. After their break, Staff E and Staff D reported their observations to the Administrator. In an interview on 7/11/16 at 3:50 p.m. the Administrator stated on the morning of 6/23/16 at around 11:00 a.m. he was paged by Staff D. Staff D reported that morning that they had seen Staff A driving into the parking lot erratically, carrying a Styrofoam cup and stumbling as she crossed the parking lot. Staff D was outside during lunch break and again saw Staff A pull into the parking lot. Staff A was having difficulty parking her vehicle and again not in control. The Administrator spoke with the unit manager Staff F and asked that she keep an eye on Staff A. Staff F stated she was not familiar with Staff A, but noted she had had no concerns thus far that morning. About an hour later the Administrator again spoke with Staff F. Staff F had reported Staff A was not interacting with residents as she should be given the high volume of medications on the 100/300 hall. Staff F noted no impairments at that time. The Administrator then spoke with Staff G, registered nurse and asked if she had noticed anything unusual. Staff G stated she had not seen anything unusual. The computer was down awhile that morning, but seemed to be working now. Staff G stated some residents had stated they had not got their medications that morning, but when the medication administration records were checked, the medications had been signed out. At around 2:30 p.m. to 3:00 p.m. Staff F reported concern that Staff A was not interacting with residents as she should be and she discovered several medications discarded in the sharps container. The Administrator discussed these finding with Staff H, human resources at around 3:45 p.m. The Administrator and Staff H then met with Staff A and suspended her regarding the medication errors. Staff A was not happy and didn't understand why she was being suspended. The Administrator stated he did not recall Staff F stating Staff A smelled of alcohol and had slurred speech and it wasn't until the next day that he heard Resident #3 was claiming Staff A smelled like alcohol that day. The Administrator stated there were three previous incidents in which Staff A was suspected of being impaired during the overnight shift. Staff A was moved to day shift in May so she could be more closely monitored. Staff A stated he did not request a drug screen from Staff A. In an interview on 7/11/16 at 2:55 p.m. Staff F, unit manager, stated on the morning of 6/23/16, the Administrator asked her to watch Staff A as staff were concerned she was acting erratically. Staff F watched as Staff A stood at her medication cart and punched out pills, but didn't seem to leave the cart very often. Staff A appeared frustrated. Staff F stated this was the first time she had worked with Staff A and was not familiar with her. Staff F stated she noticed Staff A take multiple breaks and some long. Staff F knows Staff A has medical issues and thought the breaks might be related to her condition. Staff F stated she then watched the noon medication pass and noted Staff A was punching out pills, but not passing them. A couple of residents including Resident #3 insisted they had not received their morning pills, but when Staff A insisted they had, the resident changed their mind and agreed. Staff A admitted the medications were given late. Staff F stated Staff A was not comprehending well, her speech was slurred and she thought she smelled like alcohol. When Staff A took another break, Staff F looked at the sharps container and noticed several pills discarded on top. At this point Staff F reported her concerns to the Administrator and Staff A was sent home. Staff F admitted that she never witnessed Staff A discard medications into the sharps container, but found it odd that she was punching out so many and never left the cart. Staff F stated she spoke with several residents afterwards and all of them indicated they take what they are given and none of them could recall not getting their medications. Staff F also reviewed the Medication Administration Record [REDACTED]. Staff F stated Resident#3 had also informed her that she thought Staff A reeked of alcohol that day. Staff F stated the following day Resident #4 was having more than his/her usual pain. Staff F noted Resident #4 was visibly uncomfortable. By 6/25/16 his/her pain had resided. In an interview on 7/12/16 at 9:20 a.m. Staff G, registered nurse, stated on the morning of 6/23/16 she arrived to work and was preparing for the day. Staff A's computer was acting up and needed re-booted a couple of times. Staff A stated she was not familiar with the residents on 100/300 hall. Staff G offered her assistance as needed. Staff G stated that morning Staff A seemed scattered . Staff A was observed passing some medications to residents. Two residents, including Resident #3 came up to the nurse ' s station and stated they had not received their morning medications. Staff A assured them that they had. Resident 1's spouse also came up and asked if Resident #1 received his/her medications. During the noon pass, Staff G saw Staff A punching out medications, but never seemingly leaving her cart. Staff G stated she never witnessed Staff A passing a medication to a resident or discarding pills into the sharps container At some point Staff F asked Staff G to remove the sharps container from Staff A's medication cart. Staff G then noticed several pills scattered on top of the sharps debris. Staff G thought Staff A must have been discarding the pills rather than administering them to residents. Staff G stated she did not notice Staff A to be impaired that morning. In an interview on 7/13/16 at 8:05 a.m. Staff I, registered nurse, stated on the morning of 6/24/16, Resident #4 was complaining of severe pain, rating the pain level at an 8 of 10. Staff I provided Resident #4 with his/her routine [MEDICATION NAME] 100 mg as well as his/her [MEDICATION NAME] 30 mg. Staff I stated Resident #4's pain was well controlled and stable and it was very unusual that he/she would be in that much pain. Record review noted Resident #4 was [AGE] years old. He/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date of 5/8/16 indicated Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognitive status. Resident #4 required extensive assistance with transfers and toilet use and limited assistance with dressing and personal hygiene needs. The MDS indicated Resident #4 with occasional pain and a pain level of 7 of 10 in the last 5 days. Resident #4 ' s June 2016 Medication Administration Record [REDACTED]. Both medications are used to control pain. On 6/23/16 Staff A recorded the [MEDICATION NAME] 100 mg as given at 8:00 a.m. and [MEDICATION NAME] 30 mg as given at 9:00 a.m. and 1:00 p.m. Observations found 141 pills discovered in the sharps container on 100/300 hall medication cart that was removed on 6/23/16. In contrast all other sharps containers removed from other medication carts had anywhere from 4 to 8 pills discarded. Medications identified in the 100/300 hall sharps container included a [MEDICATION NAME] 100 mg pill. According to Staff F, Resident #4 was the only resident receiving [MEDICATION NAME] 100 mg on the 100/300 halls at that time. According to Resident #4's nurse's notes, there were no entries in the 10 days prior to 6/23/16 in which Resident #4 complained pain. On 6/24/16 at 2:50 a.m. and 2:00 p.m. Resident #4 was complaining of pain (8/10). During the next 10 days after 6/24/16 there were no further entries in which Resident #4 complained of pain. Resident #3 was interviewed on 7/12/16 at 8:00 a.m. Resident #3 stated he/she usually always gets his/her medications on time, however a couple of weeks ago, a blonde haired nurse (Staff A) came into his/her room and then left without giving him/her medications. At around 11:30 a.m. to 12:00 p.m. Resident #3 asked Staff F who his/her nurse was and stated he/she didn't get his/her morning medications. The blonde haired nurse insisted she gave the medications and then later gave him/her morning medications around noon. Resident #3 stated that same day the blonde haired nurse gave his/her 4:00 p.m. medications at 2:00 p.m. Resident #3 stated the nurse smelled like alcohol. In an interview on 7/13/16 at 3:00 p.m. Staff A stated she was scheduled to work 6:00 am. to 6:00 p.m. on 6/23/16. She had been recently moved from overnight shift to day shift and was not familiar with the residents on the 100/300 halls. Staff A stated it was taking a long time to get the medications passed and many were late. Staff A stated one resident refused their medications and she discarded the medications (12) into the sharps container. Staff A was unable to identify the resident who refused and stated she did not document the medications as refused on the medication administration record. Staff A denied discarding any other medications into the sharps container. When informed that 141 pills were discovered in the sharps container on her medication cart including Resident #4's [MEDICATION NAME] 100 mg, Staff A was adamant that she had passed Resident #4' s medication, but noted they were late. When asked how Staff A could explain 141 pills being discarded in the sharps container on her medication cart, Staff A responded, There is no proof that I did it . Staff A was questioned about being impaired that morning as two staff observed her driving erratically and staggering into the facility. Staff A denied being impaired and stated her gait is unbalanced due to her medical condition. Staff A admitted she is an alcoholic and noted her last drink was in December 2015. Staff A stated she attends AA meetings at a local church. When asked who her sponsor was, Staff A hesitated and then stated it was Sandy . Staff A did not have a last name or contact number. Despite Staff A's history of substance abuse, three previous documented concerns of impairment (11/14/15, 5/4/16 and 5/7/16), two witnesses noting erratic driving and staggering of Staff A on the morning of 6/23/16, Staff F noting Staff A with slurred speech and smelling like alcohol, one resident reporting Staff A smelled of alcohol and the Administrator sending Staff A home when suspecting Staff A had intentionally discarded several medications in the sharps container, the facility failed to initiate it's policy related to Reasonable Suspicion Testing. In an interview on 8/8/16 at 10:50 a.m. the Administrator stated Staff A had self terminated on 7/18/16. The Administrator stated there were plans to have all department heads receive training regarding the evaluation process of staff believed to be impaired and how to handle these situations. The Administrator stated there has been no corporate training yet and currently there is no scheduled training. The Administrator stated following the situation with Staff A, he feels better prepared to deal with these situations, while considering employee rights and employer responsibilities. The Administrator provided the new policy effective 8/8/16. The Administrator trained the employees on 8/8/16 of the new drug and alcohol policy. The facility abated the IJ on 8/9/16 when the Administrator received individual training and reviewed their drug and alcohol policy with the Human Service Director. The Drug and Alcohol Reasonable Suspicion Testing policy included multiple updates including the following: Reasonable suspicion testing is done to identify drug and alcohol affected employees who may pose a danger to themselves or others in their job performances. If any employee is suspected of alcohol or drug use, the trained supervisors will evaluate and determine reasonable suspicion based on logic and fact. Reasonable suspicion will include specific objective, articulated and reasonable inference drawn from observation concerning the employee's appearance or body odors, behavior, speech, direct observation of drug or alcohol use, or a report from a reliable source that the employee is using drugs or alcohol. No advance warning will be given to employee regarding the dates/times or random unannounced drug testing. The IJ was lowered from an L severity level to an E with ongoing monitoring of the policy being implemented by facility staff.

Based on record review, staff interviews and resident interview, the facility failed to ensure residents are free from mistreatment, neglect and misappropriation of property when they failed to provide adequate oversight and take appropriate action towards a nurse (Staff A) that had multiple incidents of suspected impairment while on duty and who eventually was discovered making significant medication errors on 6/23/16 by intentionally discarding multiple residents medications including. The facility failed to provide adequate supervision to residents when Staff A continued to work with residents on 6/23/16. Staff A provided care and services which potentially affected 29 residents residing on halls 100 and 300 on 6/23/16 including Residents #4 and #3. The findings constituted an immediate jeopardy to residents health and safety. The facility identified a census of 100 residents. Findings include: The facility abuse policy titled Dependent Adult Abuse Prevention revised 11/22/15 documented all resident had the right to be free from all types of abuse. The policy indicated the facility will not knowingly permit a Resident to be subject to these types of abuse from an employee. The policy identified neglect as the failure to provide the goods and services necessary to avoid physical harm, mental anguish or mental illness. The policy defined denial of critical care includes the failure to provide medical, mental health care and other care critical to maintain the resident ' s health. Observations during the onsite investigation showed 141 pills discovered in the sharps container on 100/300 hall medication cart that was removed on 6/23/16. Medications identified in the 100/300 hall sharps container included a [MEDICATION NAME] 100 mg pill. According to Staff F, Resident #4 was the only resident receiving [MEDICATION NAME] 100 mg on the 100/300 halls at that time. (In contrast all other sharps containers removed from other medication carts had anywhere from 4 to 8 pills discarded.) The 141 pills recovered included medications for residents with high blood pressure-heart failure ([MEDICATION NAME], losartan, [MEDICATION NAME] & [MEDICATION NAME]); heart failure medications ([MEDICATION NAME] & [MEDICATION NAME]); treatment for [REDACTED]. a. Record review noted Resident #4 was [AGE] years old. He/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date of 5/8/16 indicated Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognitive status. Resident #4 required extensive assistance with transfers and toilet use and limited assistance with dressing and personal hygiene needs. The MDS indicated Resident #4 with occasional pain and a pain level of 7 of 10 in the last 5 days. Resident #4's June 2016 Medication Administration Record [REDACTED]. Both medications are used to control pain. On 6/23/16 Staff A recorded the [MEDICATION NAME] 100 mg as given at 8:00 a.m. and [MEDICATION NAME] 30 mg as given at 9:00 a.m. and 1:00 p.m. According to Resident #4's nurse's notes, there were no entries in the 10 days prior to 6/23/16 in which Resident #4 complained pain. On 6/24/16 at 2:50 a.m. and 2:00 p.m. Resident #4 was complaining of pain (8/10). During the next 10 days after 6/24/16 there were no further entries in which Resident #4 complained of pain. b). Record review noted Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date of 4/17/16 indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognitive status. Resident #3 required extensive assistance with transfers and toilet use and limited assistance of one staff with dressing and personal hygiene needs. The MDS indicated Resident #3 with pain and received scheduled pain medication and as needed (PRN) pain medication. Resident #3 was interviewed on 7/12/16 at 8:00 a.m. Resident #3 stated he/she usually always gets his/her medications on time, however a couple of weeks ago, a blonde haired nurse (Staff A) came into his/her room and then left without giving him/her medications. At around 11:30 a.m. to 12:00 p.m. Resident #3 asked Staff F who his/her nurse was and stated he/she didn't get his/her morning medications. The blonde haired nurse insisted she gave the medications and then later gave him/her morning medications around noon. Resident #3 stated that same day the blonde haired nurse gave his/her 4:00 p.m. medications at 2:00 p.m. Resident #3 stated the nurse smelled like alcohol. The Daily schedule for 6/23/16 identified Staff A assigned to Station 2 as the nurse from 6: 00 a.m., to 6:30 p.m. In an interview on 7/12/16 at 1:34 p.m. Staff D, certified nurse aide, stated on the morning of 6/23/16 at around 5:30 a.m. she and Staff E were sitting in the parking lot prior to work and observed Staff A pull into the parking lot. Staff A got out of her car and had a Styrofoam cup in one hand. Staff A walked across the parking lot and was stumbling. During their lunch break (10:30 a.m. to 11:08 a.m. according to their time sheet) Staff D and Staff E were again sitting in Staff E's car in the parking lot. Staff A pulled into the parking lot and was driving erratically. Staff A pulled into a parking space and then backed up, almost striking Staff E' s vehicle. Staff A then pulled in and out of the parking spot several more times before finally putting her car into park while still moving (heard a grinding sound). Staff A' s car was not pulled in all the way leaving the rear end of the vehicle a few feet into the driveway. Staff A then got out of her vehicle and as she walked towards the facility she was stumbling and having difficulty standing. After their break, Staff D and Staff E reported their observations to the Administrator. In an interview on 7/12/16 at 6:33 a.m. Staff E, certified nurse aide, stated on the morning of 6/23/16 at around 5:30 a.m. she and Staff D were in her car prior to work when they saw Staff A pull into the parking lot. Staff A walked across the parking lot and was stumbling with a Styrofoam cup in her hand. During lunch break Staff E and Staff D were again sitting in her car in the parking lot when they saw Staff A drive into the parking lot. Staff A pulled into the parking spot fine and then for no apparent reason backed up across the parking lot nearly hitting Staff E's car. Staff A pulled forward, backed up and again pulled forward before finally parking her car with the rear end still partially out of the parking space. Staff A got out of her car and her shirt was wet mid torso. Staff A had a Styrofoam cup in one hand and a frappe in the other as she walked towards the facility. Staff A's gait was unsteady. After their break, Staff E and Staff D reported their observations to the Administrator. In an interview on 7/11/16 at 3:50 p.m. the Administrator stated on the morning of 6/23/16 at around 11:00 a.m. he was paged by Staff D. Staff D reported that morning that they had seen Staff A driving into the parking lot erratically, carrying a Styrofoam cup and stumbling as she crossed the parking lot. Staff D was outside during lunch break and again saw Staff A pull into the parking lot. Staff A was having difficulty parking her vehicle and again not in control. The Administrator spoke with the unit manager Staff F and asked that she keep an eye on Staff A. Staff F stated she was not familiar with Staff A, but noted she had had no concerns thus far that morning. About an hour later the Administrator again spoke with Staff F. Staff F had reported Staff A was not interacting with residents as she should be given the high volume of medications on the 100/300 hall. Staff F noted no impairments at that time. The Administrator then spoke with Staff G, registered nurse and asked if she had noticed anything unusual. Staff G stated she had not seen anything unusual. The computer was down awhile that morning, but seemed to be working now. Staff G stated some residents had stated they had not got their medications that morning, but when the medication administration records were checked, the medications had been signed out. At around 2:30 p.m. to 3:00 p.m. Staff F reported concern that Staff A was not interacting with residents as she should be and she discovered several medications discarded in the sharps container. The Administrator discussed these finding with Staff H, human resources at around 3:45 p.m. The Administrator and Staff H then met with Staff A and suspended her regarding the medication errors. Staff A was not happy and didn't understand why she was being suspended. The Administrator stated he did not recall Staff F stating Staff A smelled of alcohol and had slurred speech and it wasn't until the next day that he heard Resident #3 was claiming Staff A smelled like alcohol that day. The Administrator stated there were three previous incidents in which Staff A was suspected of being impaired during the overnight shift. Staff A was moved to day shift in May so she could be more closely monitored. Staff A stated he did not request a drug screen from Staff A. In an interview on 7/11/16 at 2:55 p.m. Staff F, unit manager, stated on the morning of 6/23/16, the Administrator asked her to watch Staff A as staff were concerned she was acting erratically. Staff F watched as Staff A stood at her medication cart and punched out pills, but didn't seem to leave the cart very often. Staff A appeared frustrated. Staff F stated this was the first time she had worked with Staff A and was not familiar with her. Staff F stated she noticed Staff A take multiple breaks and some long. Staff F knows Staff A has medical issues and thought the breaks might be related to her condition. Staff F stated she then watched the noon medication pass and noted Staff A was punching out pills, but not passing them. A couple of residents including Resident #3 insisted they had not received their morning pills, but when Staff A insisted they had, the resident changed their mind and agreed. Staff A admitted the medications were given late. Staff F stated Staff A was not comprehending well, her speech was slurred and she thought she smelled like alcohol. When Staff A took another break, Staff F looked at the sharps container and noticed several pills discarded on top. At this point Staff F reported her concerns to the Administrator and Staff A was sent home. Staff F admitted that she never witnessed Staff A discard medications into the sharps container, but found it odd that she was punching out so many and never left the cart. Staff F stated she spoke with several residents afterwards and all of them indicated they take what they are given and none of them could recall not getting their medications. Staff F also reviewed the Medication Administration Record [REDACTED]. Staff F stated Resident#3 had also informed her that he/she thought Staff A reeked of alcohol that day (6/23/16). Staff F stated the following day Resident #4 was having more than his/her usual pain. Staff F noted Resident #4 was visibly uncomfortable. By 6/25/16 his/her pain had resided. In an interview on 7/12/16 at 9:20 a.m. Staff G, registered nurse, stated on the morning of 6/23/16 she arrived to work and was preparing for the day. Staff A's computer was acting up and needed re-booted a couple of times. Staff A stated she was not familiar with the residents on 100/300 hall. Staff G offered her assistance as needed. Staff G stated that morning Staff A seemed scattered . Staff A was observed passing some medications to residents. Two residents, including Resident #3 came up to the nurse s station and stated they had not received their morning medications. Staff A assured them that they had. Resident 1's spouse also came up and asked if Resident #1 received his/her medications. During the noon pass, Staff G saw Staff A punching out medications, but never seemingly leaving her cart. Staff G stated she never witnessed Staff A passing a medication to a resident or discarding pills into the sharps container At some point Staff F asked Staff G to remove the sharps container from Staff A's medication cart. Staff G then noticed several pills scattered on top of the sharps debris. Staff G thought Staff A must have been discarding the pills rather than administering them to residents. Staff G stated she did not notice Staff A to be impaired that morning. In an interview on 7/13/16 at 8:05 a.m. Staff I, registered nurse, stated on the morning of 6/24/16, Resident #4 was complaining of severe pain, rating the pain level at an 8 of 10. Staff I provided Resident #4 with his/her routine [MEDICATION NAME] 100 mg as well as his/her [MEDICATION NAME] 30 mg. Staff I stated Resident #4's pain was well controlled and stable and it was very unusual that he/she would be in that much pain. An Employee Counseling dated 5/20/16 indicated a concern with Staff A's job performance noting staff reports of disorientation, impaired or unsteady gait, slurred speech, unusual behavior of disappearing for significant periods of time, throwing drink cups away as a member of management approaches and cups being left in file cabinets. A significant decline in attendance and dependability and the facility deeming it necessary to relieve Staff A of duty due to erratic behavior. The counseling note indicated the facilities' belief that Staff A is not in suitable mental or physical condition and at risk for harming patients in her care. The facility recommended Staff A accept a leave of absence so that these issues (medical and mental) can be addressed and resolved, but also provided an option for Staff A to move to day shift for increased monitoring and supervision. Staff A refused the leave of absence and agreed to the day shift. In an interview on 7/12/16 at 5:47 a.m. Staff N, certified nurse aide, stated there was a couple of nights in which Staff A came into work and appeared to be drunk. During those times Staff A was loud, nonsensical and smelled of alcohol. When reported it didn't seem as if anything was done, which frustrated the other nurses. Record review found Staff A was involved in multiple incidents which questioned her ability to safely perform her job duties: 1.) On 5/7/16 at around 5:30 p.m. Staff C, licensed practical nurse (LPN), reported concerns that Staff A might be intoxicated. A summary of the incident noted the Administrator was summoned when staff noticed concern that Staff A was acting unusual and may be intoxicated. The Administrator observed Staff A and found her to be unsure and unable to unlock the medication cart after multiple attempts. Staff A finally asking assistance of an aide to open a drawer. The Administrator spoke with Staff A and Staff A stated her lack of focus was due to her medical condition. Staff A sat in a chair to avoid standing. Staff A denied drinking. Staff A was informed she was being sent home. Staff A then disclosed she had taken a [MEDICATION NAME] before work. The Administrator asked that Staff A get a ride home as he didn't feel comfortable that she drive home. Staff A refused and the Administrator walked her out to her car and she left. The Administrator called 911 and reported concern that Staff A was possibly under the influence. In a statement written on 5/10/16 by Staff C, Staff C wrote that on 5/7/16 at 5:30 p.m. he noticed Staff A arrive at the facility with only a large cup from Jimmy John's. Staff A sat down at the desk as Staff C finished his medication pass. The other nurses and Staff C were having a conversation and Staff A's responses were slurred and not relative to the conversation topic. Staff A seemed to struggle for words. During report Staff A wrote chicken scratches on the report sheet. Staff C and Staff A then began the shift change narcotic count. Staff A was unable to open the medication cart, maintain balance or get the key in the hole to unlock the cart. When counting Staff A had trouble seeing the amount in the card and placing the card back into the drawer. At one point Staff C bent over to help Staff A and Staff C smelled a very potent odor of fruit flavor. Staff C waved over Staff O and noted he thought Staff A had been drinking. Staff C and Staff O then contacted the Administrator and Staff C took the keys from Staff A. In an interview on 7/11/16 at 5:50 p.m. Staff C, licensed practical nurse, stated on 5/7/16 at 5:30 p.m. Staff A arrived to work. Staff A was quiet and unable to maintain relevant conversation. As Staff C and Staff A began to initiate a shift change narcotic count, Staff C noticed Staff A was wobbling and unable to get the medication cart key into the cart. Staff C waved over Staff O to observe. The Administrator was contacted and sent Staff A home. Staff C stated he believed Staff A was impaired and was not going to allow her access to the medication cart keys. 2.) On 5/4/16 at 4:45 a.m. Staff B, Registered Nurse, reported concern that Staff A was working while intoxicated. A summary of that incident noted Staff A seemed disoriented with poor balance and unfocused eyes. Staff A was noted in and out of the bathroom several times. The Administrator came in and questioned Staff A who stated she had had diarrhea due to an on-going medical condition. Staff A denied using alcohol and quickly changed the topic of conversation. The Administrator noted no impairments or odors of alcohol. In an interview on 7/12/16 at 6:52 a.m. Staff B stated on 5/4/16 at around 4:30 a.m. Staff J called her concerned that Staff A was intoxicated. Staff B noticed Staff A was in the bathroom a couple of times for 20 minutes, but otherwise noted no indications of obvious impairment such as an unsteady gait, slurred speech or smell of alcohol. Staff B contacted the Administrator who came in an evaluated the situation. In an interview on 7/12/16 at 5:13 a.m. Staff J, licensed practical nurse, stated she has observed Staff A impaired while at work. Staff A's speech has been slurred and walking impaired. Staff J noted these observations have been reported. 3). On 11/14/15 at 2:00 a.m. Staff A was sent home when staff noted a change in her mental status. The facility completed interviews and a summary of that incident which noted Staff A was seemingly impaired and unable to maintain focus. Multiple staff indicated Staff A was seen carrying around a Star Bucks container with a pink liquid in it. Three staff members stated they could smell alcohol either from the container or on Staff A. Staff A admitted her impaired mental status was due to taking a [MEDICATION NAME] related to tooth pain at 6:00 p.m. Record review of Staff A's personnel file found no disciplinary action or actions otherwise addressing Staff A's condition while on duty on 5/7/16, 5/4/16 and 11/14/15. In an interview on 7/11/16 at 3:50 p.m. the Administrator indicated that no drug screens were requested of Staff A during the incidents noted on 11/14/15, 5/4/16 or on 5/7/16. In an interview on 7/13/16 at 3:00 p.m. Staff A stated she was scheduled to work 6:00 am. to 6:00 p.m. on 6/23/16. She had been recently moved from overnight shift to day shift and was not familiar with the residents on the 100/300 halls. Staff A stated one resident refused their medications and she discarded the medications (12) into the sharps container. Staff A was unable to identify the resident who refused and stated she did not document the medications as refused on the medication administration record. Staff A denied discarding any other medications into the sharps container. When informed that 141 pills were discovered in the sharps container on her medication cart including Resident #4's [MEDICATION NAME] 100 mg, Staff A was adamant that she had passed Resident #4' s medication, but noted they were late. When asked how Staff A could explain 141 pills being discarded in the sharps container on her medication cart, Staff A responded, There was no proof that she did it. Staff A was questioned about being impaired that morning (6/23/16) as two staff observed her driving erratically and staggering into the facility. Staff A denied being impaired. In an interview on 8/8/16 at 10:50 a.m. the Administrator stated Staff A had self terminated on 7/18/16. The Administrator provided the new policy effective 8/8/16. The facility abated the IJ on 8/9/16 when the Administrator received individual training and the facility staff were in-serviced on 8/8/16 of the revised Drug and Alcohol Reasonable Suspicion Testing policy which include new provisions to ensure residents were safe due to the continued employment of staff who had been reported under reasonable suspicion of alcohol. The reasonable suspicion testing is done to identify drug and alcohol affected employees who may pose a danger to themselves or others in their job performances. If any employee is suspected of alcohol or drug use, the trained supervisors will evaluate and determine reasonable suspicion based on logic and fact. The policy indicated if an employee refused, he/she would be subject to termination. As result of these provisions, the IJ was lowered from K severity to E with the need for ongoing monitoring to ensure resident would be free from possible neglect/abuse.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure one of four residents reviewed for resident to resident altercations was free from abuse (Residents #6 and #7). The facility reported a census of 100 residents. Findings include: The facility notification procedures posted at the nurse's station directed staff to notify the Director Of Nurse (DON) of Resident to Resident altercation and directed staff to notify the Administrator, when other department managers are not available. The facility abuse policy titled Dependent Adult Abuse Prevention revised 11/22/15 documented all resident had the right to be free from all types of abuse. The policy indicated the facility will not knowingly permit a Resident to be subject to these types of abuse from others. According to the Minimum Data Set ((MDS) dated [DATE] Resident #7 had [DIAGNOSES REDACTED]. The MDS identified Resident #7 with severely impaired cognition and documented the resident had behaviors that included; threatening others, screaming at others, cursing at others and indicated behaviors of this type occurred daily. The MDS indicated Resident #7 required extensive assistance of one staff for transfers, dressing, toileting, and personal hygiene. The Incident /Accident Report form dated 7/2/16 documented Resident #7 is unpleasant and uncooperative with roommate (Resident #6) and will not move when roommate wants to use the bathroom or exit the room. The Fall Investigation Tool dated 7/2/16 at 3:00 p.m., documented Resident #7 has always had a problem with roommates and an angry temper and easily combative. Nurse's Notes dated 7/2/16 at 4:05 p.m. Resident #7 slapped Resident #6 and pulled his/her hair when roommate (Resident #6) was attempting to exit the room. Resident #6 did not retaliate. Nurse's Notes dated 7/2/16 at 4:10 p.m. Resident #6 was slapped on the right arm and his/her hair pulled by Resident #7 (roommate) while he/she was attempting to exit their room. No injury was noted. When interviewed on 7/19/16 at 6:50 p.m. Staff F, Unit Manager, stated she was not made aware of the altercation between Resident #6 and #7 on 7/2/16 until 7/5/16. When interviewed on 7/19/16 at 6:55 p.m. the Director of Nursing (DON) stated the altercation between Resident #6 and #7 on 7/2/16 was not reported until 7/5/16. The DON stated once she was aware she promptly reported the incident to the Department of Inspections and Appeals.

This deficiency relates to complaints -C and -C : Based on observation, record review and staff interviews the facility failed to administer medications as ordered to ensure residents are free from medication error rates of 5% or greater and/or of any significant medication errors (Resident #4). The facility identified a census of 100 residents. Findings include: Record review noted Resident #4 was [AGE] years old. He/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date of 5/8/16 indicated Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognitive status. Resident #4 required extensive assistance with transfers and toilet use and limited assistance with dressing and personal hygiene needs. The MDS indicated Resident #4 with occasional pain and a pain level of 7 of 10 in the last 5 days. According to physician's order [REDACTED]. Both medications are used to control pain. Resident #4 ' s June 2016 Medication Administration Record [REDACTED]. Both medications are used to control pain. On 6/23/16 Staff A recorded the [MEDICATION NAME] 100 mg as given at 8:00 a.m. and [MEDICATION NAME] 30 mg as given at 9:00 a.m. and 1:00 p.m. In an interview on 7/11/16 at 3:50 p.m. the Administrator stated on the morning of 6/23/16 he was alerted to staff's concern that Staff A might be impaired. The Administrator spoke with the unit manager Staff F and asked that she keep an eye on Staff A. Staff F stated she was not familiar with Staff A, but noted she had had no concerns thus far that morning. About an hour later the Administrator again spoke with Staff F. Staff F had reported Staff A was not interacting with residents as she should be given the high volume of medications on the 100/300 hall. Staff F noted no impairments at that time. The Administrator then spoke with Staff G, registered nurse and asked if she had noticed anything unusual. Staff G stated she had not seen anything unusual. The computer was down awhile that morning, but seemed to be working now. Staff G stated some residents had stated they had not got their medications that morning, but when the medication administration records were checked, the medications had been signed out. At around 2:30 p.m. to 3:00 p.m. Staff F reported concern that Staff A was not interacting with residents as she should be and she discovered several medications discarded in the sharps container. The Administrator discussed these findings with Staff H, human resources at around 3:45 p.m. The Administrator and Staff H then met with Staff A and suspended her regarding the medication errors. The Administrator stated there were three previous incidents in which Staff A was suspected of being impaired during the overnight shift. Staff A was moved to day shift in May so she could be more closely monitored. In an interview on 7/11/16 at 2:55 p.m. Staff F, unit manager, stated on the morning of 6/23/16, the Administrator asked her to watch Staff A as staff were concerned she was acting erratically. Staff F watched as Staff A stood at her medication cart and punched out pills, but didn't seem to leave the cart very often. Staff A appeared frustrated. Staff F stated this was the first time she had worked with Staff A and was not familiar with her. Staff F stated she noticed Staff A take multiple breaks and some long. Staff F knows Staff A has medical issues and thought the breaks might be related to her condition. Staff F stated she then watched the noon medication pass and noted Staff A was punching out pills, but not passing them. A couple of residents including Resident #3 insisted they had not received their morning pills, but when Staff A insisted they had, the resident changed their mind and agreed. Staff A admitted the medications were given late. Staff F stated Staff A was not comprehending well, her speech was slurred and she thought she smelled like alcohol. When Staff A took another break, Staff F looked at the sharps container and noticed several pills discarded on top. At this point Staff F reported her concerns to the Administrator and Staff A was sent home. Staff F admitted that she never witnessed Staff A discard medications into the sharps container, but found it odd that she was punching out so many and never left the cart. Staff F stated she spoke with several residents afterwards and all of them indicated they take what they are given and none of them could recall not getting their medications. Staff F also reviewed the Medication Administration Record [REDACTED]. Staff F stated the following day Resident #4 was having more than his/her usual pain. Staff F noted Resident #4 was visibly uncomfortable. By 6/25/16 his/her pain had resided. In an interview on 7/12/16 at 9:20 a.m. Staff G, registered nurse, stated on the morning of 6/23/16 she arrived to work and was preparing for the day. Staff A's computer was acting up and needed re-booted a couple of times. Staff A stated she was not familiar with the residents on 100/300 hall. Staff G offered her assistance as needed. Staff G stated that morning Staff A seemed scattered . Staff A was observed passing some medications to residents. Two residents, including Resident #3 came up to the nurse s station and stated they had not received their morning medications. Staff A assured them that they had. Resident 1's spouse also came up and asked if Resident #1 received his/her medications. During the noon pass, Staff G saw Staff A punching out medications, but never seemingly leaving her cart. Staff G stated she never witnessed Staff A passing a medication to a resident or discarding pills into the sharps container At some point Staff F asked Staff G to remove the sharps container from Staff A's medication cart. Staff G then noticed several pills scattered on top of the sharps debris. Staff G thought Staff A must have been discarding the pills rather than administering them to residents. In an interview on 7/13/16 at 8:05 a.m. Staff I, registered nurse, stated on the morning of 6/24/16, Resident #4 was complaining of severe pain, rating the pain level at an 8 of 10. Staff I provided Resident #4 with his/her routine [MEDICATION NAME] 100 mg as well as his/her [MEDICATION NAME] 30 mg. Staff I stated Resident #4's pain was well controlled and stable and it was very unusual that he/she would be in that much pain. Observations found 141 pills discovered in the sharps container on 100/300 hall medication cart that was removed on 6/23/16. (In contrast all other sharps containers removed from other medication carts had anywhere from 4 to 8 pills discarded.) Medications identified in the 100/300 hall sharps container included a [MEDICATION NAME] 100 mg pill. According to Staff F, Resident #4 was the only resident receiving [MEDICATION NAME] 100 mg on the 100/300 halls at that time. According to Resident #4's nurse's notes, there were no entries in the 10 days prior to 6/23/16 in which Resident #4 complained pain. On 6/24/16 at 2:50 a.m. and 2:00 p.m. Resident #4 was complaining of pain (8/10). During the next 10 days after 6/24/16 there were no further entries in which Resident #4 complained of pain. Resident #3 was interviewed on 7/12/16 at 8:00 a.m. Resident #3 stated he/she usually always gets his/her medications on time, however a couple of weeks ago, a blonde haired nurse (Staff A) came into his/her room and then left without giving him/her medications. At around 11:30 a.m. to 12:00 p.m. Resident #3 asked Staff F who his/her nurse was and stated he/she didn't get his/her morning medications. The blonde haired nurse insisted she gave the medications and then later gave him/her morning medications around noon. Resident #3 stated that same day the blonde haired nurse gave his/her 4:00 p.m. medications at 2:00 p.m. Resident #3 stated the nurse smelled like alcohol. Record review noted Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date of 4/17/16 indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognitive status. Resident #3 required extensive assistance with transfers and toilet use and limited assistance of one staff with dressing and personal hygiene needs. The MDS indicated Resident #3 with pain and received scheduled pain medication and as needed (PRN) pain medication. In an interview on 7/13/16 at 3:00 p.m. Staff A stated she was scheduled to work 6:00 am. to 6:00 p.m. on 6/23/16. She had been recently moved from overnight shift to day shift and was not familiar with the residents on the 100/300 halls. Staff A stated it was taking a long time to get the medications passed and many were late. Staff A stated one resident refused their medications and she discarded the medications (12) into the sharps container. Staff A was unable to identify the resident who refused and stated she did not document the medications as refused on the medication administration record. Staff A denied discarding any other medications into the sharps container. When informed that 141 pills were discovered in the sharps container on her medication cart including Resident #4's [MEDICATION NAME] 100 mg, Staff A was adamant that she had passed Resident #4' s medication, but noted they were late. When asked how Staff A could explain 141 pills being discarded in the sharps container on her medication cart, Staff A responded, There is no proof that I did it .

Based on observation, clinical chart review, staff and resident interview, and policy review the facility failed to ensure that a resident entering the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable. Concerns were noted for three out of four sampled residents with pressure sores (Residents #2, #3, and #4). Appropriate physician ordered wound care was not provided for Resident #4 and Resident #2 and proper infection control techniques were not implemented during wound cares for Resident #4 and Resident #3. Staff did not provide appropriate intervention consistently for these residents. The facility reported census was 103 residents. Findings include: 1. A quarterly Minimum Data Set (MDS) assessment revealed Resident #4 had an intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14/15 points. Resident #4 required limited-extensive assistance from staff for all activities of daily living including bed mobility, ambulation, hygiene cares, and toileting. The MDS [DIAGNOSES REDACTED]. The MDS noted the resident did not have any pressure, venous, or arterial ulcers at the time of the assessment. The preventive items listed in the MDS Skin and Treatment Section noted a pressure reducing device for the chair and bed was provided for the resident and treatments included application of non-surgical dressings and ointments/medications other than to feet. The MDS reflected the resident was not on a turning or repositioning program or nutritional supplements aimed at prevention of skin issues. The Braden Scale (pressure sore risk assessment) is performed on all residents quarterly (every three months) to tract resident risk of developing pressure ulcers. The Braden scores for Resident #4 on 8/28/15, 11/5/15, and 4/25/16 were 15 . Staff neglected to document findings for an assessment due in February of 2016. The scale for the Braden scores is as follows: <9 =very high risk 10-12= high risk 13-14= moderate risk 15-18= at risk The plan of care noted Resident #4 had a self-care deficit related to [MEDICAL CONDITION] and decreased functional mobility. The interventions to prevent skin issues were initiated on 8/7/15 and staff was instructed to consult the wound nurse as needed, to float heels off the bed as requested, and to provide pressure relieving mattress and chair cushion. After identification of a pressure ulcer on the resident's heel on 4/25/16, float heels was written on the care plan. After identification of a second pressure ulcer on the resident's right heel on 6/6/16, Prafo boots (boot device that is worn on the calf and foot and is often used for patients to relieve pressure on the heel and prevent pressure ulcers) were implemented for the resident. Review of individual Wound/Skin Healing record for Resident #4 dated 4/25/16 revealed the identification of a stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough and may present as an intact or ruptured blister) on the left heel. The following entries were documented on the record: On 4/25/16- left heel wound measured 1.5 centimeters (cm) by 1.3 cm with scant drainage. Treatment was Triple Antibiotic ointment and the resident was not to wear shoes. On 5/2/16- wound measured 1.7 cm by 2 cm and was covered with eschar (dead tissue resembling a scab) and was deteriorating. Treatment changed to [MEDICATION NAME] (broad spectrum antiseptic for topical application in the treatment and prevention of infection in wounds) application. On 5/9/16- wound measured 3.2 cm by 4 cm and continued to deteriorate. Treatment apply heel lift boot to left heel. On 5/16/16- wound measured 4.5 cm by 5.5 cm and had drainage and a foul odor. The wound continued to deteriorate. Nurse's Notes Documentation revealed the following entries: On 5/17/16 (Tuesday) at 2:15 AM - the wound had significantly increased in size, was dark purple in color, and had a distinct odor present. The resident had been asked how his/her left heel felt and stated the heel did not hurt. The documentation did not state the physician had been notified of the change in the wound. On 5/19/16 (Thursday) at 5:30 AM - a new superficial open area with scant drainage was identified by staff on the resident's buttock. The area was cleansed and dried and left open to air. The doctor was notified and treatment orders were received. On 5/19/16 at 9:00 AM - the resident's left heel had deteriorated since 5/16/16 (Monday) and now had a foul odor and a brownish serosanquinous (fluid leaving a wound that is yellowish with small amounts of blood) drainage. Notification of the family was documented at this time. On 5/19/16 at 1:00 PM - the Advanced Registered Nurse Practitioner (ARNP) examined the heel wound and Resident #4 was sent to the emergency room for evaluation of the left heel pressure ulcer. On 5/19/16, a physician's order [REDACTED]. Record review of hospital Progress Notes dated 5/27/16 revealed the resident was admitted on [DATE] due to left heel wound which had been present for at least 3 weeks. Apparently a piece of tissue had fallen out of the wound which concerned staff. The resident had been complaining of a low grade fever. The reported identified a [DIAGNOSES REDACTED]. On examination the area was covered with black eschar but this was boggy and there was drainage and an odor. The resident reported pain in his/her left leg. The resident had a debridement (surgical removal nonliving tissue from pressure ulcers) while a patient in the hospital. Nurse's Notes Documentation revealed the following entries: On 5/27/16 at 1:45 PM - the resident returned to the facility and was admitted for skilled care. On 5/30/16 at 9:30 AM - the family noticed a new lesion on Resident #4's right heel and notified the staff. Review of an individual Non-Pressure Skin Condition Record for Resident #4 dated 5/30/16 documentation revealed a 3 cm by 5 cm area located on the right heel which appears to have dark fluid visible under intact skin. Review of individual Wound/Skin Healing Record dated 5/31/16 revealed the wound was unstageable and covered with eschar. The wound when opened, measured 3.5 cm by 2 cm. During observation of wound care for Resident #4 on 6/10/16 at 8:40 AM Staff A, Registered Nurse (RN), gathered supplies including tape, an unwrapped roll of gauze, a wrapped dressing, and a paper tape measure and placed the supplies on her clipboard. The top page on the clip board had Staff A's written notes on it. She entered the resident's room, placed the clipboard with supplies on a bedside table, washed her hands, and donned gloves. The Director of Nursing (DON) was in the room to observe the procedure. Staff A poked the wound bed with her gloved finger to check the surface of the ulcer on the right heel. The wound bed appeared to be slough tissue with a dark pink area surrounding the wound bed. A scant amount of serosanquinous drainage was noted. Staff A measured the wound with the paper tape (6 cm by 2.2 cm), soakeda square of gauze with [MEDICATION NAME], painted (applied) [MEDICATION NAME] on the wound, and elevated the right heel on a pillow to dry uncovered. Review of Resident #4's Treatment Administration Record (TAR) noted the treatment to the right heel was to cleanse the wound with wound cleanser, pat dry, dry paint with [MEDICATION NAME], and leave open to air once each day. Staff A neglected to clean the wound with wound cleanser prior to painting the heel with [MEDICATION NAME] and did not change her gloves appropriately during the procedure. Staff A continued with wound cares (from 6/10/16 at 8:40 a.m.) and washed her hands and changed gloves. She measured the wound on the Resident's left heel which had been debrided previously at the hospital. The wound measured 8 cm by 8 cm with a depth of 0.3 cm. Hard eschar covered the wound base and no drainage or foul odor was noted. She poked on the wound bed with her gloved finger and took [MEDICATION NAME] soaked 4 X 4 squares and placed the soaked squares on the wound bed. Securing the soaked 4 X 4 squares to the wound bed she wrapped the wound and 4 X 4 squares with the roll of unwrapped gauze which was still located on the clipboard. The [MEDICATION NAME] soaked through the outer wrapping and the wound nurse applied the Prafo lift boot to the foot. Review of Resident #4's TAR noted the treatment to the left heel was to cleanse the wound with wound cleanser, pat dry, dry paint with [MEDICATION NAME], and cover with a dry dressing daily (ordered on [DATE]). The treatment Staff A performed on the left heel during observation was an old order that had been discontinued on 6/2/16. Staff A again neglected to change her gloves appropriately during the procedure. During an interview with Resident #4 on 6/10/16 at 8:20 AM the resident stated the wound on the left foot became infected when it was not taken care of by staff. The resident stated his/her legs were not elevated off the mattress or her recliner footrest previously. He/she stated after the left foot wound was discovered a blue boot was placed on the left foot but not the right foot. The resident stated there now is a wound on the right heel and his/her bottom. The resident stated the physician told him/her the wounds were from pressure. During an interview with Resident #4's primary care physician (PCP) he stated with the resident's current [DIAGNOSES REDACTED]. When asked about the development of the wound initially he stated the facility staff is going above and beyond with the care of the wound but multiple factors are inhibiting wound healing. Nurse's Notes documentation revealed the following entries: On Tuesday 5/17/16 at 2:15 AM - the wound had significantly increased in size, was dark purple in color, and had a distinct odor present. The documentation did not state the physician had been notified of the change in the wound. Clinical record review of Resident #4's chart revealed the resident experienced an elevated temperature of 101 degrees on 5/13/16 prior to the 5/19/16 [DIAGNOSES REDACTED]. Documentation did not reveal the physician was notified of the resident's fever. During an interview with family members of Resident #4 on 6/16/16 at 1:00 PM in the resident's room one member stated he/she visits the resident at least twice a week or more. He/she recalled family was notified when the left heel ulcer was first identified on 4/25/16. The family member stated when visiting the resident he/she noted the blue boot on the left foot was not placed correctly. The resident's left heel was not centered in the open depression at the heel of the boot but was pressing on the padding above the hole. He/she stated he/she notified staff of this however when the member returned again to visit the boot still was not on correctly. The family member stated he/she did not see the resident's heels floated on pillows when in bed. The member stated the family was shocked when the resident was diagnosed with [REDACTED]. The family member stated the family thought the facility was updating them on changes in the resident ' s condition but were not notified of the wound deterioration, the resident's fever on 5/13/16, or the identification of a skin issue on the resident's buttocks on 5/19/16. The resident was observed to be sleeping in a supine position in bed while the family interview was taking place. The Prafo suspension boots were noted on both feet and the family members approved of the boots used now. The resident's calves were supported by pillows at this time. 2. A quarterly MDS assessment for Resident #2 dated 3/6/16 revealed the resident had an intact cognition as evidenced by a BIMS score of 15/15 points. Resident #2 required limited assistance from staff for all activities of daily living including bed mobility, ambulation, hygiene cares, and toileting. MDS [DIAGNOSES REDACTED]. The MDS noted the resident did not have any pressure, venous, or arterial ulcers at the time of the assessment. The preventive items listed in the MDS Skin and Treatment Section noted a pressure reducing device for the chair and bed was provided for the resident and treatments included application of ointments/medications other than to feet. The MDS reflected the resident was not on a turning or repositioning program or nutritional supplements aimed at prevention of skin issues. The plan of care noted Resident #2 had a self-care deficit and required assist of staff for bed mobility and ambulation. Interventions to prevent skin issues were initiated on 12/18/15 and staff was instructed to consult the wound nurse as needed, float heels off the bed as tolerated, to provide pressure relieving mattress and chair cushion. After identification of a pressure ulcer on the resident ' s left heel on 3/26/16 Heel-lift boots to be worn at all times-may remove for cares. Will refuse, was hand written on the care plan. The Braden scores for Resident #2 on 3/10/16 was 18 and on 6/7/16 was 17 indicating the resident was at risk for developing pressure ulcers Review of Resident #2's Wound/Skin Healing record dated 3/28/16 revealed the identification of a stage two pressure ulcer located on the left heel. The wound measured 2.1 cm by 2.3 cm with a depth of 0.2 cm and was noted to have purulent drainage (drainage consisting of pus). A second wound was identified on 4/11/16 on the medial aspect of the resident's left foot measuring 2 cm by 4 cm and was unstageable. Records revealed this wound was healed on 5/16/16. During observation of wound care for Resident #2 on 6/15/16 at 11:20 AM with the Director Of Nursing (DON) in the room to observe also, Staff B, Licensed Practical Nurse (LPN), gathered supplies, entered the resident's room, and placed the supplies on a clean barrier. Staff C, LPN, removed the resident's sock from the left foot and it was noted there was no dressing covering the wound. The resident stated at this time he/she had a shower last evening and staff did not re-dress the wound. The wound had a scant amount of drainage from the wound bed. Staff B provided appropriate wound care for the resident and maintained adequate infection control techniques. Review of Resident #2's TAR noted the treatment to the left heel was to cleanse the wound with wound cleanser, apply [MEDICATION NAME] AG (antimicrobial dressing) , and wrap with Kerlix (gauze wrap). Nursing staff neglected to provide appropriate wound treatment for [REDACTED]. 3. Resident #3 had a quarterly Minimum Data Set (MDS) assessment, dated 5/15/16, which revealed the resident had an intact cognition as evidenced by a BIMS score of 15/15 points. The MDS assessed the resident as independent with all activities of daily living except toileting. MDS [DIAGNOSES REDACTED]. The MDS noted the resident did not have any pressure, venous, or arterial ulcers at the time of the assessment. The MDS identified the resident at risk of developing pressure ulcers. The preventive items listed in the MDS Skin and Treatment Section noted a pressure reducing device for the chair and bed was provided for the resident and treatments included application of ointments/medications other than to feet. The care plan noted the method of ambulation and transfer was changed to staff assist with the mechanical Easy-Stand lift stand on 5/19/16. After identification of unstageable ulcer to the left heel on 6/5/16 Heel-lift boots, [MEDICATION NAME] (wound healing supplement) and Multi-vitamin to start was hand written on the care plan. The Braden scores for Resident #2 on 5/19/16, prior to his/her decline, was 20 indicating the resident was not at risk for developing pressure ulcers. Review of Resident #3's Wound/Skin Healing record dated 6/5/16 revealed the identification of an unstageable pressure ulcer located on the left heel. The wound measured 4.8 cm by 8.3 cm with an open area of 4.8 cm by 4.5 cm A moderate amount of serosanquinous drainage was documented. The record reflected Prafo boots were ordered for the resident. Observation on 6/10/16 at 8:00 AM revealed Resident #3 seated in a wheelchair in his/her room. The resident's feet were uncovered. The left foot had a dressing over the heel and the dressed heel was resting on the floor without a barrier. During observation 6/10/16 at 9 AM Staff A, RN, placed dressing supplies (unwrapped roll of gauze, 4 X 4 gauze squares sprayed with wound cleanser, and tape measure) on the clipboard and entered Resident #3's room to provide wound care. Resident #3 was seated in a wheelchair with his feet on the floor. Staff A noted the resident's feet did not have blue boots on and stated the resident was to wear the heel-lift blue boots at all times. Staff A washed her hands and gloved. She took the old dressing off the resident's heel and changed her gloves. The DON, present to observe the procedure, held the resident's leg up off the floor for Staff A to measure the wound (8.3 cm by 4.8 cm with a slough/eschar wound base measuring 4.5 cm by 4.8 cm). Staff A washed the wound with wound cleanser and took a [MEDICATION NAME] (non-stick) dressing out of the package. She placed the clean dressing directly on the floor and placed the resident's foot onto the dressing. She picked up the [MEDICATION NAME] dressing and heel and wrapped the foot with the gauze roll. Staff A did not apply Santyl ointment to the resident's wound and stated she would call the physician to ask if the Santyl should be continued since the wound was no longer completely covered with eschar. Review of Resident #3's TAR noted the treatment to the left heel was to cleanse the wound with wound cleanser, pat dry, apply Santyl, cover with dry dressing, and wrap with gauze twice daily and as needed. The TAR noted the resident was to float heels when in bed. The TAR did not instruct staff to place heel lift boots on the resident as noted the care plan. Review of a physician progress notes [REDACTED]. The resident was placed on [MEDICATION NAME] (antibiotic) - intramuscular injection daily for seven days. During an interview with Resident #3 on 6/10/16 at 9:15 AM the resident stated it was his/her understanding that the boots were to be on all the time. He/she stated staff did put the boots on last night. This morning when he/she was assisted to get up staff did not put socks or the boots on his/her feet and he neglected to tell them to. Observation of Resident #3 on 6/15/16 at 10:30 AM revealed the resident asleep in the wheelchair without boots on his/her fee which rested on the floor. Observation of Resident #3 on 6/16/16 at 9:00 AM revealed the resident asleep in the wheelchair with blue boots on both feet. Observation of Resident #3 on 6/17/16 at 9:20 AM revealed the resident asleep in the wheelchair without boots on his/her feet which rested on the foot pedals of the wheelchair. During an interview with Staff D, MDS/care plan nurse, on 6/15/16 at 10:20 AM she stated on admission all residents who are not independent with ambulation have interventions placed to float heels by placing pillows under their calves when in bed and pressure relieving mattresses and chair cushions. Residents assessed to be high risk for skin issues are placed on air alternating mattresses. The wound nurse, Staff A, then implements other preventative interventions as needed/ordered. During an interview with the Director of Nursing (DON) on 6/15/16 at 9:00 AM she stated all residents have weekly skin checks done by the nurse and on shower/bath days the Certified Nurse's Aides (CNAs) are responsible for checking the resident's skin and reporting to the nurse. The DON agreed that Staff A, Wound Nurse, did not provide the correct treatment for [REDACTED]. She stated Resident #4's left heel treatment had been changed on 6/2/16 and staff neglected to remove the older order from the TAR so two different treatments for the left heel were present on the TAR. She agreed Staff A, did not follow proper infection control techniques while providing wound cares to Resident #4 and Resident #3 and resident #2 should have had a dressing on his/her wound after his/her shower. She stated Staff A was new to the position of wound nurse and had requested additional training for wound care techniques. The DON stated she would arrange additional training for Staff A through the Hospital Wound Clinic. The DON stated she has been at the facility for one month and realizes she has education to provide for staff concerning preventative pressure ulcer interventions such as consistent heel floating and application of boots for residents at risk. The DON agreed that all residents should be thoroughly assessed for preventative skin interventions and appropriate interventions should be implemented. Review of the facility Skin Care and Early Treatment Policy, review date of 1/2013, noted residents who score 13-16 points on the Braden Scale (Resident #4) should have the following interventions placed: a. heel protectors b float heels/elbows with pillows c. weekly skin checks d. wheel chair cushion e. possible supplement and vitamin therapy

Based on record review, staff, family and resident interviews, the facility failed to assess suicide ideations and depression for 2 of 5 residents reviewed (Resident #1, #3). The facility reported a census of 100 residents. Resident #1 committed suicide by placing a string around her/his neck and hung self from the bed rail. The resident had expressed statements of death and had experienced emotional turmoil with grown children, sale of home and personal belongings and not wanting to live at the facility. The resident had a history of [REDACTED]. Resident #3 expressed wanting to die and had negative thoughts. The staff had not implemented psychosocial interventions to assist Resident #1 and #3 during times of depression. Findings include: 1. A MDS (Minimum Data Set) assessment with a reference date of [DATE] identified Resident #1 had no cognition, mood or behavior problems. The resident ambulated independently in room and only required limited assistance with dressing, supervision with personal hygiene. The active [DIAGNOSES REDACTED]. A Nurse's Notes dated [DATE] at 12:30 p.m. noted resident talked about discharging from the facility and the resident informed the social worker if he/she was not discharged that day, he/she would kill him/herself. The resident was placed on 15 minute checks and the nurse placed a call to the resident's physician. The physician ordered [MEDICATION NAME] 50 mg. daily. At 5:00 p.m. the resident left with family for a visit at a friend's house. At 7:00 p.m. the resident's family called and reported the resident would not get into the car to return to the facility and the resident would be spending the night at the family's home. On [DATE] at 2:00 p.m. the resident's family came to the facility and picked up all the resident's belongings and reported the resident would not be returning to the facility. At 2:30 p.m. the staff called the resident's physician and reported the resident left the facility. At 4:40 p.m. the physician gave a new order to discharge the resident from the facility. The nurse called the resident's medication into the pharmacy of the family's choice. A Pre-Admission Screening and Resident Review dated [DATE] noted the resident was admitted to an acute hospital from his/her family's home, where the resident lived for 7 days after moving from the nursing home. The resident was unable to return to his/her family's home. The hospital was seeking nursing home placement. The resident continued to receive his/her home dose of [MEDICATION NAME], 50 milligrams (mg) daily. The resident had no listed mental health [DIAGNOSES REDACTED]. An admission Resident Data Collection form dated [DATE] reflected an admission [DIAGNOSES REDACTED]. The resident experienced daily, distressing pain in his/her back and neck. The psychological aspects/family relationships section noted DHS (Department of Human Services) and police involved. A Nurse's Note dated [DATE] (no time given) reflected Resident #1 was admitted with [DIAGNOSES REDACTED]. The Social Worker was notified of the admission and the ongoing DHS/Police investigation. A Hospital Transfer Order Report dated [DATE] noted the resident's problem list included [MEDICAL CONDITION], mass in abdomen, fall, facial injury, tremor and homelessness. The physician medication orders included an anti-depressant medication, [MEDICATION NAME] at 50 mg daily. The hospital records dated [DATE] noted the resident's family history included the resident lost his/her entire family during a grenade attack. A Social Service Assessment, completed by the skilled unit social worker, Staff E, dated [DATE], reflected the resident ' s speech could be difficult to understand due to language, resident alert and oriented, resident cheerful during initial visit, [MEDICATION NAME] for depression, and the resident's psycho- social needs included depression and family issues. The recommendations included the Department of Human Services investigation report for possible dependent adult abuse. Review of the Nurse's Notes revealed the nursing staff documented resident was friendly and cooperative on [DATE] and resident calm, cooperative, pleasant, in good spirits and very social on [DATE]. A Minimum Data Set (MDS) assessment, with a reference date of [DATE] identified the resident was unable to complete an interview for the cognitive patterns assessment. The MDS identified no memory problems, good recall, made independent consistent/reasonable decisions, and showed no [MEDICAL CONDITION]. The MDS reflected a Resident Mood Interview should be conducted, however all portions of the mood section remained blank and not completed. The staff assessment of mood revealed the resident displayed no symptoms of feeling depressed or hopeless and was short-tempered and easily annoyed. The MDS also identified the resident's behavior did not place the resident at risk for physical illness or injury. The MDS reflected no behaviors including rejection of care and evaluations. The MDS revealed the resident required limited assistance with locomotion on and off the unit and dressing. The resident weighed 140 pounds and stood 5 feet tall. The MDS reflected the resident did not receive [MEDICAL CONDITION] medications including antidepressant medications. The MDS also reflected neither the resident nor the resident's family participated in the assessment. The MDS reflected psychosocial well-being, mood state, or behavioral symptoms were not necessary and were not care planned. A Care Area Assessment Documentation (CAA) dated [DATE] noted the resident was readmitted to the facility after a brief attempt of discharge and lived with his/her family. The resident refused to participate in a restorative program. The record revealed the facility did not write a new plan of care for the resident after the resident discharged from the facility and returned after a brief hospitalization . The resident's plan of care dated [DATE] and dated again on [DATE] identified the resident's problems/strengths included: a. Impaired decision making related to [MEDICAL CONDITION] as evidenced by fluctuations in cognition, b. Self-care deficit related to weakness as evidenced by need for assistance with ADL's (cares), c. Altered nutrition related to [MEDICAL CONDITIONS], GERD, history of a stroke and depression, d. Alteration in comfort related to disease process as evidenced by use of an as needed medication. The Plan of Care interventions for Impaired decision making related to [MEDICAL CONDITION] as evidenced by fluctuations in cognition included: cognition varies from day to day and over the course of the day, resident was encouraged to make independent decisions as long as appropriate, family was encouraged to be active with cares and decision making as they were able, and social service consult as needed, psych consult as needed. An addition dated [DATE] to the Impaired decision making problem noted mood state related to disease process and depression. The goal noted resident would voice feelings to staff if sad or depressed and the intervention dated [DATE] noted resident became easily annoyed, give time to voice feelings. On [DATE] at 3:00 p.m. the resident's physician saw the resident and discontinued medications including the resident's antidepressant medication (gradual discontinuation process). On [DATE] at 2:00 p.m. resident seemed alert and pleasant. Review of the clinical record revealed no documentation in the nurse's progress notes of the resident becoming easily annoyed. Social Service Progress Note: [DATE] Resident requested a room change due to he/she did not like the smell that comes from the roommate when the roommate went to the bathroom. The social worker showed the resident two empty rooms, after the resident chose one, the social worker explained to the resident that the other room would be a better fit for her. The resident stated he/she understood but would like the other room. [DATE] Spoke to resident in the dining room today and the resident stated he/she changed his/her mind about changing rooms. (Review of the clinical record revealed a lack of follow up regarding the resident's wishes to change rooms due to the smells of bowel movements and the family's request that the resident be brought out of the room due to the smells of bowel movement from the roommate). [DATE] Resident scored a 15 out of 15 on the cognitive testing. No signs of [MEDICAL CONDITION]. Mood assessment completed. Resident indicated sleeping too much. No behaviors, no concerns. [DATE] The resident voiced a desire to move to another state to live close to family. The resident's family voiced agreement with the resident's desire to move. The social worker called the resident's financial power of attorney and informed him of the resident's desire to move out of state to be closer to family. The POA stated there was some bad family dynamics and dysfunction. Review of the clinical record revealed a lack of documentation, assessment or care planning due to the family dysfunction and/or resident's desire to discharge to another facility out of state. On [DATE] The Social Worker spoke with a real estate agent about working on the selling of the resident's home. The agent would come to the facility and have the resident sign the agreement to sell the home. On [DATE], the resident talked about moving to a facility out of state and requested his/her medical records be sent to another facility to be approved of a move at the beginning of October. On [DATE] The social worker spoke to the out of state facility who approved of the resident's admission and waiting for the transportation. On [DATE], the social worker spoke to the resident's family who validated [DATE] would be the resident's last day. The social worker verified the resident had given the facility a verbal 2 week notice and all that needed to be down was discharge paperwork. On [DATE], the social worker spoke with the resident who reported the mortgage man (agent) came to the facility on [DATE] and stated the resident needed to stay in Iowa in order to close the house. Review of the clinical record revealed a lack of documentation on any follow up of the necessity for the resident to remain in Iowa until after the closing of the house and lacked documentation on the plan of care regarding the resident's plan to discharge and/or the delay. The note reflected turmoil with family regarding living at the facility. On [DATE], the resident seemed unhappy about being in the facility and stated the family sold the house and now the resident had nowhere to go. The resident claimed the family kept the money from the sale of the house. The resident voiced a desire to discharge and live with a friend and wanted the family to sign him/her out of the facility. The social worker called the financial POA and the resident's family about the resident's plan. The resident was agitated and stated if the family did not sign him/her out of the facility, the resident would kill him/herself and go to hell. The social worker asked the resident if he/she had a plan to kill him/herself. The resident denied a plan and stated he/she would just kill him/herself. Social Service informed the Assistant Director of Nursing, Staff A. Review of the clinical record revealed a lack of documentation of the resident's statements of suicidal ideation's either in the plan of care and/or the nurse's progress notes On [DATE], the resident requested social service witness his/her wishes that if when he/she passed, that any funds left would go to his/her family. The social service told the resident she could witness the resident's wishes, however the resident would need to have an attorney draw something up. The resident was adamant that someone other than his/her family witness that and he/she wanted any money left after his/her passing, that some of the money go to the grandchildren. On [DATE] the social worker called the resident's friend to see if the resident was going to live with the friend and if the friend would be the resident's 24-hour care giver. The friend stated he/she informed the resident last weekend that he/she could not care for the resident. The social worker then called the resident's family. The social worker informed the resident's family the resident planned on discharging from the facility on the 18th. The social worker then informed the resident what the friend stated. On [DATE] the resident told the staff he/she was going home to live with a friend. Resident got very angry and used profanity and stated if he/she did not leave that day, he/she was going to kill him/herself. The social worker asked the resident if he/she had a plan and the resident stated he/she would kill him/herself. The social worker inform the director of nursing (DON) and the ADON of the resident's suicide ideations. The DON approved 15 minute checks for 72 hours and the ADON was going to check into an antidepressant medication. On [DATE], the resident ' s family came to the facility. The social worker suggested Assisted Living or if the resident was not happy with the facility, then another nursing home. The family stated they would take the resident to the friend for a visit. The resident had some belongings and stated he/she was going on a vacation. The family then signed the resident out to go on a visit. On [DATE] the ADON, Staff A reported the resident's family called last night and reported the resident refused to come back to the facility. The social worker called the resident's family. The family would look into Assisted Living and in the meantime, the resident would live with the family. On [DATE], the resident was admitted to the facility. This social worker was unable to fully understand the resident due to language. The resident reported a family member drug him/her by the ankles to the front door, the police were called, the resident was taken to the emergency room , and a DHS (Department of Human Services) report was filed by the hospital social worker. On [DATE] A ICF (non-skilled) bed became available and the resident was notified and will move to Station 2 today. Addendum: Resident very upset with being moved, does not want to relocate to Station 2. Informed resident that was the only bed available and 48-hour notice provided. On [DATE], Staff C documented the resident was very angry with her/social worker due to the discharge in December and Staff C calling the resident's friend and family. The staff assessment was done due to the resident did not want Staff C in his/her room. The staff reported resident easily annoyed on mood assessment. No behaviors noted. The Social Worker will assist as much as resident will allow or will refer to other Social Worker on Station 1. On [DATE], Resident #1 expired in the facility. The entry directed staff to see nursing notes. Review of the clinical record review on [DATE] revealed a lack of any documentation regarding the resident's death on [DATE]. A physician's orders [REDACTED]. A physician's progress note dated [DATE] indicated the physician saw the resident on a routine visit. The resident informed the physician he/she wanted all medications, except Tylenol stopped. A Nurse's Progress Note dated [DATE] at 3:00 p.m. reflected the physician order. The nurse's note lacked an assessment of the resident regarding mood and/or signs or symptoms of depression. Review of the clinical record revealed a lack of ongoing assessment of the resident's mood and/or signs or symptoms of depression due to the discontinuation of [MEDICATION NAME]. When interviewed on [DATE] at 10:48 a.m. the resident's primary physician stated he discontinued the resident's antidepressant due to the resident stated he/she wanted his/her medications discontinued and he felt if the resident was going to refuse the medication it was better to stop the medications as requested. He stated he would have expected the staff to closely monitor the resident for a change in mood and/or signs of depression. The physician stated he was not informed of the resident's continued statements of wanting to kill him/herself and that the resident's family no longer visited the resident. The physician stated he would have expected the facility staff to inform him of these factors. When interviewed on [DATE] at 4:00 p.m. the Director of Nursing stated it is the facility ' s policy and she would have expected any time a resident is put on an antidepressant medication or the medication is discontinued, the resident ' s record be placed on the "Hot Chart" list. The staff would document every shift on the resident and the reason for the medication, such as depression. The staff did not follow the facility policy and did not document every shift assessment. The facility did not document signs/symptoms of depression when [MEDICATION NAME] was started and when it was decreased and discontinued. Review of the Food Intake Record, this resident did not eat or drink anything for the evening meal on [DATE]. The record also indicated the resident did not eat or drink anything for the breakfast or noon meals on [DATE], [DATE] and on [DATE]. When interviewed on [DATE] at 9:30 a.m. Licensed Practical Nurse, Staff F stated she was working the overnight shift one night back in either [DATE] or [DATE] when about midnight, the resident informed her he/she wanted to die. The resident told the nurse he/she wanted to die due to he/she was sad. The nurse stated she did not ask the resident if he/she had a plan. The nurse thought she had documented this incident in the nurse's notes and told the ADON Staff A and thought she had sent a fax to the physician. Staff F stated this incident was a couple months before the resident died . The nurse also stated back in December the resident kept saying he/she wanted to go live with his/her family. Staff F stated they (staff) all told the resident that would be a bad idea due to the resident had [MEDICAL CONDITION] and he/she would be a burden to his/her family. The resident stated he/she did not care. The resident also stated his/her family had beaten him/her up and left him/her in a snow bank. When asked how the resident responded when the nurse informed him/her, he/she would be a burden to the family, Staff F stated the resident would respond he/she did not care, he/she just wanted to go home. Staff F stated she worked 6:00 p.m. on [DATE] to 6:00 a.m. on [DATE]. She stated on [DATE] she went to the resident's bedroom about 6:30 p.m. to give the resident his/her bedtime medication. The resident was walking from the bathroom to his/her wheelchair. The resident took the medication. The nurse stated she did not see the resident again on her shift. She stated she had no reason to enter the resident's room again that night. She stated the resident did not have any treatments and/or any other medications. When interviewed on [DATE] at 1:50 p.m. a certified nursing assistant (C.N.A.) Staff G stated she was working 6:00 a.m. to 2:00 p.m. on [DATE]. She went down the hall and noted this resident's curtain was pulled closed, which was unusual and the light was off, which was also unusual. She knocked and turned on the light. She then pulled back the curtain and saw the resident's body, face down by the bed. She observed the bed in a high position, so high the resident could not have gotten into the bed at that height. At first she thought the resident had fallen. She called out for the nurse. Together they rolled the resident over and saw a string doubled and tied to the top of the elevated side rail and the other end tied around the resident's neck. Staff G stated normally the resident was happy and would laugh and joke around, however the resident would say he/she did not want to be in the facility. The resident had talked to Staff G about how his/her parents were killed in front of him/her. Staff G also stated the resident had talked to her about how his/her spouse was physically abusive to him/her. The resident had informed Staff G that when his/her children grew up, they were mean to him/her and did not want anything to do with him/her. The resident informed Staff G his/her children refused to let him/her live with them. After the resident came back to the facility [DATE], Staff G went to talk with the resident, at which time she witnessed scratches and bruises on the resident. The resident informed her, he/she did not want to stay in the facility and if he/she had to stay here, he/she wanted to die. Staff G told the resident it was not bad living in the facility and they all cared about him/her. The resident told her, he/she knew that but he/she did not want to stay in the facility. A week or so later the resident again told Staff G that if he/she had to stay in the facility he/she wanted to die. Prior to Christmas, the resident shared a room with Resident #7. Resident #7 had a lot of belongings and the resident did not like sharing the bedroom with Resident #7 due to Resident #7 took up so much of the room and Resident #7 hung up her bras to dry. When interviewed on [DATE] at 1:05 p.m. a C.N.A. Staff H stated prior to the resident's discharge in [DATE] other staff had informed her the resident had told them he/she would rather die than to live in the nursing home. The resident was very joyful, fun loving and would always laugh and joke around. The resident was also stubborn., When the resident wanted something, he/she wanted it his/her way. The resident would get into fights with the social worker. The resident was independent. The resident only required their assistance if he/she was in pain or something. Staff H had not seen the resident's family visit since return to the facility last December. The only time Staff H saw the resident in a bad mood was when he/she wanted to go home. The resident would tell Staff H he/she did not want to live in the facility. Normally the resident was up and dressed by 6:00 a.m. and would be out in the hallway by 6:30 a.m. to 6:45 a.m. On [DATE] at 6:10 a.m. the off-going C.N.A. did not give her the normal report. The night C.N.A. informed her everyone was fine and then left. On [DATE] at 1:40 p.m. Staff I, certified medication aide, (CMA), was interviewed and stated the resident was always pleasant and kind. The resident was independent and did not use the call light. The resident was independent with dressing, propelling wheelchair and toileting. The resident's bed was always made. The resident slept while sitting sideways on the bed and leaned against the wall. The resident always had 3 to 4 pictures of his/her family on the bed. Prior to his/her discharge in [DATE] the resident would say he/she wished he/she would die. The resident would say he/she did not want to be in the nursing home. The resident would say he/she could not wait for it to be his/her turn to die. The resident would tell Staff I that his/her family sold his/her house, got rid of all his/her personal belongings and gave all his/her clothing to the thrift store. On [DATE] at about 6:45 a.m. she heard a page for all staff to report to the resident's bedroom. She went to the resident's room and observed the resident's body on the floor. The nurse rolled the resident over. She then noticed the string around the resident's throat. There was a pool of blood on the floor, by the resident's head. The resident's face was swollen, huge and dark purple in color. She noted the resident's bed was completely empty, no pictures. The pictures were in a plastic bag in the top drawer. Normally the pictures never left the bed. On [DATE] at 12:00 noon, Staff J, registered nurse, was interviewed and stated she was employed at the facility for about 3 weeks. She noted the resident was normally happy, smiley and pleasant. The resident was always cooperative with medications. Staff J had worked the day shift on [DATE] at which time the resident was his/her normal happy self. The resident was not a complainer. On [DATE] she reported to work at 6:00 a.m. Normally the resident was up and dressed before Staff J would come to work. On [DATE] at 6:00 a.m. the resident was not up out of bed. She went to the resident's room and walked behind the privacy curtain. She saw the resident's body lying face down on the floor by the side rail of the bed. At first she believed the resident had fallen. She knelt down beside the resident and then saw the string around the resident's neck. She cut the string from around the resident's neck. The resident's body felt warm and pink. The resident's face was dark blue. She heard no heart beat and the resident was not breathing. She felt no pulse and the resident did not respond to painful stimuli, a sternal rub. She began chest compressions. She asked staff to find out the resident's code status. She then ceased chest compressions. Observation revealed the string was double thickness and wrapped around the side rail several times with several knots and tied in a knot around his/her neck. The nurse observed everything in the resident's room was gone except for a plastic disposable cup with orange peels. The resident normally had pictures out. The resident normally had a newspaper on the bed. Normally the room was cluttered and at that time everything was gone, even the television remote control was out of sight. Paramedics came and instructed her not to touch anything in the room. The nurse stated she also observed a pool of blood on the floor under the resident's head, from the resident ' s nose. On [DATE] at 1:14 p.m. Staff K, CNA was interviewed and stated the resident was very sweet. Staff K rarely ever assisted the resident due to the resident was independent. Occasionally the resident would request assistance pushing his/her wheelchair to or from the dining room. Normally the resident would be up by 6:00 a.m. The resident had stated his/her desire to move out of state to be with family. The resident had stated he/she wanted to go home. Prior to [DATE], Staff K had heard from staff and residents that the resident stated he/she would rather die than to live in the nursing home. Staff K stated everyone heard those statements. Residents #7 and #8 told Staff F, prior to [DATE] of the resident ' s statements of wanting to die. After the resident returned to the facility in December of 2013, the resident would say he/she would rather die than to live in the nursing home. On the morning of [DATE], she heard Staff G yell for the nurse. Staff K went to the resident's room and saw the nurse on the floor by the resident. She also saw blood on the floor. Staff K paged for a full code (to initiate Cardiac [MEDICAL CONDITION] Recessitation (CPR)). She then assisted the resident's roommate out of the room. When interviewed on [DATE] at 4:45 p.m. another resident, Resident #7 stated he/she used to share a room with the resident. The resident was a pleasant gentleman/lady. Resident #7 stated the resident was sad, and would say how he/she wanted to die and kill him/herself. The resident used to talk about how abusive his/her family was to him/her. When interviewed on [DATE] at 12:00 noon, another resident, Resident #8 stated he/she used to sit at the dining room table with the resident. The resident would state how he/she wanted to go home and would rather die than to live in the facility. The resident talked about wanting to move to another state to live near his/her family. When interviewed, the Assistant Director of Nursing, Staff A, stated the resident was pretty pleasant. The resident did not attend activities. The resident would leave his/her bedroom for meals. The resident had talked of moving out of state. The resident believed he/she was going to live with his/her children. The children were going to place the resident in a nursing home, so the resident did not go. The resident was mad a few days. The resident stated he/she was going to live with a friend. The social worker then called the friend and then the resident got mad at the social worker, so the resident would not talk to the social worker. The resident's family did not attend the care conference meetings. On [DATE] the resident stated he/she would hurt him/herself. The resident stated he/she would rather be dead. They called the physician and placed the resident on 15 minute checks. Staff A did not talk to the resident. The family came to take the resident to the friend's house for a visit. The resident was packed up. The family was not sure if the resident would stay with the friend. The resident refused to come back to the nursing home and stayed with the family. The family reported they were looking into assisted living placement for the resident. The family informed Staff A the resident would not be returning to the facility so they discharged the resident from the facility the day after he/she left for a visit. The resident then returned to the facility after a hospitalization . The resident reported the family member hit him/her. The resident's family no longer called or visited. Staff A denied ever planning for or assessing the resident for assisted living. On [DATE], Staff A came to the facility at approximately 7:45 a.m. She went to the resident's room after the resident's body had been removed from the facility. Staff A noted the resident's bed was in a high position. The resident was really short and he/she liked the bed low so his/her feet could touch the floor. She noted the resident's items were all packed. When interviewed on [DATE] at 12:00 noon, a family member/medical power of attorney for this resident stated the resident had been manipulative to get out of the nursing facility last December. The resident began taking [MEDICATION NAME] on [DATE] and he/she was informed it would take 6 to 8 weeks to take effect. The family found multiple pills (unknown what pills they were) in the carpet in his/her home after the resident was taken to the hospital on Christmas Day, 2013. The resident was totally out of control. The family member talked to the police, the lawyer and the social worker. The family member stated the resident was not stable mentally and could not stay at his/her home any longer due to the resident would not follow direction. The resident was depressed and was not taking his/her medications. The family told the resident he/she could leave, but no one wanted him/her so the resident began to destroy items in the family member's home. After the resident returned to the facility, the family refused to have any contact with the resident. The family stated the resident had tried to kill him/herself in the past, however he/she did not give any details of this history. The family stated the resident ' s first attempted suicide occurred 2 ,[DATE] years ago and was unhappy the family had saved him/her. On [DATE] at 2:10 p.m. the Social Worker, Staff C was interviewed and stated she began work as the social worker on Station 2 in October of 2013. Staff C stated the former social worker had been arranging for the resident to go and live with his/her family in another state. The resident believed he/she would be living with the family members and the family was planning on placing the resident in a nursing home, so the resident became angry. Then the resident wanted to go and live with a friend. The friend did not want to be a care giver. When the social worker told the resident the friend could not be a care giver the resident stated he/she might just as well kill him/herself. The resident wished to move out of the facility on [DATE]. The 18th came and the resident was not happy. The resident then began to make suicidal statements. She then informed the ADON and they placed the resident on 15 minute checks. The resident's family member came in that day and took the resident out for a visit. The family then called and stated the resident refused to return to the facility. The 18th was the date of the closing of the sale of the resident's home. The resident then ended up in the emergency room and claime

Based on observation, clinical record review, and staff interviews, the facility failed to provide adequate supervision during transfers to ensure against hazards for one (1) of six (6) residents. Resident #1's care plan directed staff to use a mechanical lift to support and transfer the resident. Staff interviews determined training had been provided, however staff continued to provide unsafe transfers to residents. Two facility staff transferred Resident #1 without the lift and subsequently the resident sustained [REDACTED]. Findings include: 1. Resident #1's Minimum Data Set (MDS) with the assessment reference date of 7/15/12 identified a Brief Interview for Mental Status (BIMS) score of 7; which indicated Resident #1 had cognition deficits. The assessment indicated Resident #1 usually had the ability to understand others and comprehends most conversations. The assessment revealed the resident required extensive assistance of one staff person for transfers, bed mobility, dressing, and for personal hygiene. The assessment indicated Resident #1 totally dependent on one staff to use the bathroom. The assessment revealed Resident #1 had been unable to perform the balance test related his/her ability to walk or transition during transfers. The MDS identified the resident used a wheelchair for mobility. The MDS identified Resident #1 with [DIAGNOSES REDACTED]. The ADL Functional Rehab care plan dated 7/19/12 identified Resident #1 required the assistance of two (staff) with all Hoyer transfers. (A Hoyer is a mechanical lift used with a sling to support/transfer non-weight bearing individuals.) The Pocket Care Plan used by the CNA (Certified Nurse Aides) dated 7/20/12 revealed Resident #1 required two (2) staff assistance with Hoyer lift transfers and to use a purple color sling. The Incident/Accident Report dated 7/21/12 at 7 a.m., documented a CNA (Staff A) reported when she lifted Resident #1's right arm, she felt and heard a popping sound. The assessment identified the resident had been able to move his/her right hand and fingers. The incident happened in the shower room and the physician and family were notified. Resident #1 had been transferred in ambulance for X-rays. The CNAs were disciplined and then terminated. The Nurse's Notes dated 7/21/12 at 7:15 a.m., revealed Staff A reported when she lifted Resident # 1's right arm, the CNA felt and heard a popping sound. The resident was pale (in color) but alert. The resident stated his/her arm hurt and asked if he/she could have breakfast. Staff received an order for [REDACTED]. The X-ray exam dated 7/21/12 showed the resident had a right shoulder mid-shaft fracture. The X-ray revealed the injury represented an acute fracture. Another exam of the right humerus identified there was a mildly comminuted fracture of the midshaft of the humerus. (A comminuted fracture is a fracture in which the bone has been broken into several pieces.) Nurse's notes dated 7/21/12 at 2:30 p.m., revealed the resident returned from the emergency room with a sling and prn (as needed) pain medication. The physician's progress notes dated 7/30/12 revealed the [AGE] year old resident had a non-operative fracture and would wear sling for (approximately) 2 months. An undated and untitled summary of the incident on 7/2/1/12 described 2 aides were attempting to do a 2 person (no mechanical transfer device being used) from the shower chair to the resident's wheelchair when the aid raised the resident's right arm to place the CNA's arm behind the resident's back. The summary described the resident suffered a fractured right humerus and the physician determined the resident's injury was not a major injury and he/she would return to their previous level of care. The facility identified Staff A and staff B, both CNAs, as the 2 staff involved in the incident. The personnel record of Staff A verified the facility had taken time to train and audit the employee and also encouraged her to get into the habit of using the pocket care plan or the communication board to verify a resident's proper transfer status. Staff B ' s personnel record indicated she had been trained and audit on transfer technique. A handwritten statement from Staff A dated 7/21/12, at 7:05 a.m., she wrote she was in the shower room with Staff B. They planned to lift Resident # 1 from the shower chair to the resident's wheelchair (without the Hoyer lift). When Staff A lifted the resident's right arm to place it on the CNA's shoulder, the CNA felt and heard a popping sound. The CNA carefully put the resident's arm down, and told the nurse. Before the incident, the 2 staff had transferred Resident # 1 out of bed with the Hoyer lift. The resident had no complaints of pain at that time. Below the CNA's signature, was the following information in different handwriting: did 2 person "transfer from the wheelchair to the shower chair. " The staff did the 2 person transfer to save time, and knew that this was not an excuse. Staff B's signed statement dated 7/21/12 indicated Staff A and B transferred Resident #1 with the Hoyer (from bed to chair). After the resident's shower was done, Staff B half-dressed the resident. Staff A and B then attempted to 2 person transfer using the gait belt. Staff B noted she heard a pop sound when the resident's arm was raised. The staff obtained the nurse. Under Staff B's signature were hand written notes in a different handwriting which read: Staff B knew about transfers and Hoyer use. Staff B felt pressured to get Resident #1 done, but knew better. Staff B was the shower aid that day. On 8/16/12 at 3:10 p. m. Staff A reported she had worked as a Registered Nurses (RN) in England, and started working as a CNA at the facility 5/27/09. Staff A reported the 2 staff used the Hoyer lift to transfer the resident to the wheelchair, and took the resident to the shower room. The 2 staff then transferred Resident #1 using a 2 person transferred without a gait belt, to the shower chair without incident. Staff A stated the staff used an arm under arm technique. Staff A then left the shower room. After the resident ' s shower, the resident was almost all dressed. Staff A planned to give the resident a hug, and lift up the resident. Staff B would then pull up the resident's pants. Staff A lifted Resident #1's arm to put his/her arm on Staff A's shoulder. Staff A then felt and heard a pop-similar to stretching and then releasing a rubber band. Resident # 1 stated "oof", and held his/her elbow. Staff A then got another staff member (perhaps staff Q). Staff A held the resident's legs, Staff B had the resident's left arm, and Staff Q then pulled up the resident's pants. The staff then transferred the resident to the wheelchair. Resident #1 was not crying out. Staff A took Resident # 1 to see the nurse; Staff J. Staff J asked the resident several questions. The resident was more interested in having breakfast. The resident had breakfast. The X-ray man came did the X-ray and stated that it looked as though Resident #1 had a fracture. Staff A stated the staff did not use a gait belt with Resident #1 for transfers as the resident could not walk. Staff A knew resident # 1 was to be a Hoyer transfer per the resident's care plan. Staff A stated it was always a battle against the clock to get things done. Staff A had not transferred the resident in the shower for a long time and the previous shower aid had always used a fireman's lift to transfer Resident #1 in the shower. During a telephone interview with Staff B on 8/21/12 at 10:42 she reported she usually did not work with Resident #1. Staff B had never showered the resident before and she was the shower aid that day. Staff B reported Staff A wanted Resident # 1 to have a shower before breakfast, and helped Staff A transfer the resident via Hoyer lift to the shower chair. Staff B reported after the shower the 2 staff attempted to transfer Resident #1 to the wheelchair. Staff A lifted the resident's arm up and it popped. Staff A told the nurse about this. The 2 CNAs got an unknown third person to help transfer the resident to the chair. Staff B stated she was not familiar with Resident #1, and assumed that the staff that worked with the resident all of the time knew how to transfer them. Staff B knew she should have followed her first judgment and used the Hoyer lift. Staff B suspected that Resident #1 was a Hoyer lift as there was a pad (sling) in the resident's room. Staff B did not get a Pocket Care plan that morning, but knew the pocket care plans were available. Staff B had been a CNA for [AGE] years, and knew how to do transfers. Staff B was trained on doing transfers when starting at the facility. During an interviewing with Staff J (RN) on 8/17/12, at 10:12 a.m. she reported being alerted of the incident when Staff A brought Resident #1 to her. Staff A informed Staff J of what had happened and Staff J began to assessed Resident #1 who could move his/her fingers, but could not lift his/her arm away from his/her body. Staff J stated the resident had a strong radial pulse and did not have any pain as long he/she did not move the right arm away from the body. Staff J contacted the physician for an X-ray order and alerted the resident's family. After the X-ray, Resident #1 was sent to the hospital for evaluation. The resident returned to the facility with a fractured humerus and a sling. During an interview with Staff R on 8/20/12 at 1:10 p.m. she reported being counseled for transferring a 2 assist resident independently. (Staff R stated a different resident, Resident #6 had sustained an injury of unknown origin (skin tear on 6/11/12). During the investigation, Staff R stated she had been transferring Resident #6 independently (approximately on 6/11/12-6/12/12) and had been written up for this. Staff R stated she had not caused the injury, nor been transferring the resident when the injury occurred.) Staff R reported other staff had also been independently transferring residents that were to be 2 person assists. Staff R reported after she was written up, the other staff stopped doing this-they also learned their lesson. Staff were told in orientation that they could be written up, receive verbal counseling, or fired for not following facility policy. Staff could look at the board in the resident's room, or read the pocket care plan to know how to transfer a resident. Physical therapy determined how a resident transferred. On 7/21/12, the facility held a mini in-service and instructed staff to transfer residents according to their care plans, and the pocket care plan. Staff were told they could provide more assistance but not less during a transfer. The training advised staff if a resident was Hoyer lift, the resident must always be a Hoyer lift. Observation on 8/16/12 at 13:32 p.m., Staff P observed Staff G and H transferred Resident # 1 using a Hoyer lift from the resident's wheelchair to the bed without incident. The resident wore a sling on his/her right arm. The facility policy titled Modified Lifting directed staff to use a mechanical lift 100 % (percent) of the time with two staff completing the transfer. This included transfers in and out of the bathing area/chair.