Every finding on record at Accura Healthcare of Spirit Lake

Based on observation, and staff interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment for 8 residents (Resident #2, #4, #10, #12, #13, #14, #15, and #16). The facility reported a census of 72 residents.Environmental observations:On 4/14/26 at 2:12 p.m. Resident #4 upset her bedside table was sticky. Verified it felt sticky. Resident #4 unsure how long it had been that way. On 4/15/26 at 9:03 a.m. Resident #4 again complained of her table being sticky. The center of the table felt sticky. The toilet seat in the resident's bathroom had large areas discolored brown. On 4/20/26 at 8:56 a.m. Staff A Certified Nursing Assistant (CNA) and Staff B CNA assisted Resident #4 with cares. Staff B thought the toilet seat was stained due to loose stools. Staff A didn't know what caused it.On 4/14/26 at 2:15 p.m. Resident #12's bathroom had used washcloths on the floor.On 4/14/26 at 2:21 p.m. Resident #13's bathroom had clothes on the floor, and the toilet not flushed with a strong odor.On 4/15/26 at 9 a.m. Resident #14's bathroom had an open bag of incontinent pads spilling out onto the floor. On 4/15/26 at 9:12 a.m. Resident #10's bathroom floor had used paper towels on it, and a soiled pad in the trash can, with visible incontinence. On 4/15/26 at 9:16 a.m. Resident #15's bathroom had garbage on the floor (by the trash can), and a grip strip partially pulled up (in front of the toilet).On 4/15/26 at 9:19 a.m. Resident #16's bathroom had a used pad in the trash can, and used gloves on the floor. On 4/20/26 at 8:25 a.m. Resident #2's bathroom had a used incontinent pad in the garbage can, and a towel, an article of clothing, and a disposable glove on the floor. Resident #2 sat in her wheelchair in the room.On 4/21/26 at 9 a.m. the Assistant Director of Nursing (ADON) stated the CNA's should clean up (remove clothing that needed laundered, removing incontinent products) after assisting a resident with cares. The Administrator stated the toilet seat discoloration had been that way for a while. They could put a new seat on the toilet.On 4/21/26 at 1:50 p.m. the Environmental Services Supervisor stated the CNA's usually picked up linens and removed pads after they provided care. Clothing and linen should not be on the floor.The undated facility Handling Soiled Linen policy documented linen should be treated as potentially contaminated. Linen should not be allowed to touch the floor.

Based on observation, record review, and staff interview, the facility failed to ensure residents with a catheter received appropriate treatment and services to prevent infection for 3 of 3 residents reviewed (Resident #1, #7, and #8). The facility reported a census of 72 residents.1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had an indwelling urinary catheter. Diagnoses included neurogenic bladder.The Care Plan initiated 3/10/25 identified Resident #1 had a suprapubic (inserted through the abdomen to the bladder) catheter related to a bladder dysfunction. Resident #1 had the potential for urinary tract infections. The March 2026 Treatment Administration Record (TAR) included Resident #1 had the order to change the suprapubic catheter monthly on the 11th with a start date of 11/11/25, and change the urinary leg bag 2 times a month on the 12th and the 26th every month. The TAR documented the catheter was changed on the 11th, and the drainage bags were changed the 12th.The April 2026 TAR documented Resident #1 was in the hospital on the 11th and 12th so the catheter change and bag changes were not completed on those dates. The TAR documented monitor the catheter every 2 hours during the day, two times a day with a start date of 4/29/25. During an observation on 4/20/26 at 10:14 a.m. Staff A Certified Nursing Assistant (CNA) emptied resident #1's catheter leg bag, dated 3/26/26. Staff A stated they emptied the catheter bag about every 4 hours, and the resident let them know when it was full also.The clinical record lacked documentation Resident #1's catheter bag was monitored every 2 hours or who monitored it every 2 hours.On 4/21/26 at 9 a.m. the Assistant Director of Nursing (ADON) said Resident #1's family member wanted the catheter bag checked every 2 hours. She said the nurses were to monitor the leg bag every 2 hours to ensure it was getting emptied. The ADON verified the leg bag was not changed (since 3/26/26).2) According to the MDS assessment dated [DATE], Resident #7 scored 9 on the BIMS indicating moderate cognitive impairment. The resident had an indwelling urinary catheter. Diagnoses included a hip fracture.The Care Plan identified Resident #7 had a catheter due to urinary retention.On 4/14/26 at 1:53 p.m. Resident #7 slept in the recliner. The catheter bag hung from the trash can.On 4/15/26 at 10:02 a.m. Resident #7's catheter bag hung from the trash can, while the resident sat in the recliner The trash can contained garbage.On 4/21/26 at 9 a.m. the ADON stated the catheter bag could hang from the trash can if it was only used for that, and did not collect trash.3) According to the MDS assessment dated [DATE], Resident #8 scored 15 on the BIMS indicating no cognitive impairment. The resident had an indwelling urinary catheter, and diagnoses included a neurogenic bladder. The Care Plan revised 2/11/26 identified Resident #8 had an indwelling catheter related to neurogenic bladder. The resident had the potential for UTI's. At times the resident would empty his catheter bag himself.On 4/20/26 at 10:03 a.m. Staff A prepared to empty Resident #8's catheter bag. Staff A washed her hands and put on gown and gloves. She placed a graduate on a barrier on the floor. Staff A moved the resident's oxygen tubing that was on the floor, over with her gloved hand, and proceeded to handle the catheter bag and open the drain wearing the same gloves. Staff A completed the procedure before removing her gloves and doing hand hygiene. On 4/21/26 at 9 a.m. the ADON stated she would have changed gloves after touching the tubing on the floor.The Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) included ensuring that only properly trained persons who knew the correct technique of aseptic catheter insertion and maintenance were given the responsibility, and using Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system.

Based on observations, staff interviews and policy review the facility failed to ensure proper temperatures for foods served to residents. The facility reported a census of 66 residents. Finding Include: During observation on 10/1/2025 at 11:19 a.m., Staff D, [NAME] checked the temperature of the food in the steam table. Staff D checked the temperature of the mashed potatoes which tempted at 131.9 degrees fahrenheit (F). Staff D proceeded with meal service and served the residents the mashed potatoes out of the steam table and did not reheat the potatoes to an appropriate safe temperature. Review of facility provided policy titled Food Temperatures dated 2013 revealed the following information:All hot foods items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees F. Temperatures should be taken periodically to ensure hot foods stay above 135 degrees F. Interview on 10/1/2025 at 1:16 p.m., with the Dietary Manager (DM) revealed food in the steam table should be kept at least 135 degrees F if it falls below then should be reheated to ensure proper temperatures at meal service. The DM further revealed mashed potatoes should have been reheated prior to serving them to the residents.

Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was stored and prepared under sanitary conditions. The facility identified a census of 66 residents. Findings include: On 09/29/2025 11:21 a.m., during the initial walkthrough in the kitchen was conducted and following concerns were noted. Observations of the kitchen sinks labeled prep sinks were noted to have food debris in the bottom of the sinks and the far left sink was noted to have approximately 1/4 inch of water with food debris sitting in the bottom of the water. Observation of the floor by storage area was noted to have 3 straw wrappers laying on the floor in the walking path.Puree food preparation area noted to have dried food debris on the wall behind the food blender. Observation in the refrigerator of a flat of eggs ready for use with a cracked and empty egg shell on the flat of unused eggs. Observation in the refrigerator of a cart with meat thawing noted to have raw chicken on the bottom of the cart with a date of 9/23. Above the raw chicken was ham with a date of 9/25 and above the ham was raw ground beef with a date of 9/27. Review of the facility provided policy titled Food Storage Dated 2013 revealed food is stored in an area that is clean, dry and free from contamination. Food is stored, prepared and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Interview with the Dietary Manager at the conclusion of the initial walkthrough revealed the egg shell should not have been in the carton and should have been thrown away after the egg was used and the meat should not have been thawing in that order in the refrigerator and should have been in the correct order.

Based on clinical record review and staff interview the facility failed to notify the Long Term Care Ombudsman(LTCO) for 1 of 1 residents reviewed who transferred to the hospital (Resident #10). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #10 documented diagnoses of anemia, diabetes mellitus, and chronic kidney disease. The MDS showed the Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Review of Resident #10's census tab revealed:10/31/2024- hospital leave-unpaid11/1/24- active2/4/25- hospital leave-unpaid2/6/25- active Review of Resident #10's Progress Notes revealed; 10/31/24 at 5:21 p.m., resident being transferred to a larger hospital with diagnosis of Urinary Tract Infection (UTI) and tear in colon. 11/5/24 at 12:05 p.m., resident arrives back to facility. 2/4/25 at 1:30 p.m., Resident sent to the emergency department from doctor appointment to be evaluated for lethargy and UTI symptoms. 2/6/25 at 11:03 a.m., Resident arrived back to the facility. Review of the facility document titled Notice of Transfer Form to Long Term Care Ombudsman dated October, November and February lacked Resident #10's name. The facility does not have a policy regarding reporting to the LTCO office. The facility follows the federal guidelines. Interview on 10/02/2025 8:47 a.m., with Staff H, Social Worker revealed if a resident goes to the hospital then she would report that to the LTCO office. Staff H verified Resident #10 should have been reported to the LTCO office when she went to the hospital in October and February.

Based on observation, staff interview and facility policy, the facility failed to provide complete and appropriate incontinence care in a manner to prevent urinary tract infections for 2 of 3 residents observed (Resident #10 and #51). The facility reported a census of 66 residents.Finding include: 1.The Minimum Data Set (MDS) assessment dated [DATE] for Resident #10 documented diagnoses of dementia, Diabetes Mellitus. The MDS showed the Brief Interview for Mental Status (BIMS) score of 10, which indicated severe cognitive impairment. Observation on 10/1/25 at 9:57 AM revealed Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA completed hand hygiene, donned gloves, and lowered the resident's pants to complete perineal care. Staff B removed Resident #10's soiled briefs, removed gloves, then applied new gloves without performing hand hygiene. Staff A performed front perineal care using different areas of the same cleansing wipe. Staff A then cleansed the resident's buttock using different areas of the same cleansing wipe. Staff A failed to cleanse the entire surface area of the resident's buttock area. Staff A and Staff B removed gloves, failed to perform hand hygiene, then pulled up the resident's pants, arranged the blankets and bed controls. In an interview on 10/1/25 at 10:11 AM, Staff C, RN educated staff to perform hand hygiene after removing gloves, use a new cleansing wipe with every swipe of the skin, and to cleanse the entire buttock area including the hips. 2. Observation on 10/01/2025 at 9:57 a.m., with Staff F, CNA and Staff G, CNA assisted Resident #51 with incontinence care. Staff F and G entered the room and performed hand hygiene and applied gloves and explained to Resident #51 what they were going to do. Staff F with gloved hands lowered the side rail on the bed and assisted in removing Resident #51's clothing to get to incontinence brief. Staff F with the same gloves opened and lowered the incontinence brief and performed perineal care with the same soiled gloves. When finished with the incontinence care on the front of the resident Staff F with the same soiled gloves on assisted Staff G in turning Resident #51 to her side. Staff F with the same soiled gloves touched Resident #51's shoulder and hands with soiled gloves before continuing to perform perineal care. Staff F with a wipe used 3 wiping strokes over the hip area prior to turning the wipe. Staff F completed perineal care. Staff F removed the soiled gloves and performed hand hygiene and applied another pair of gloves. Staff F applied a clean incontinence brief and fastened the brief. Staff F assisted Staff G with pulling dressing Resident #51. Staff F removed her gloves and did not perform hand hygiene. Staff F assisted to cover Resident #51 up and used the bed controls to lower the bed and ensure the resident was comfortable. Staff F performed hand hygiene after finishing with the resident. Interview on 10/2/25 at 9:22 a.m., with the Director of Nursing (DON) revealed the facility does not have a policy on incontinence care. The facility follows standards of care and uses competencies for staff evaluations. Review of facility provided Competency for Peri Care with an updated date of 4/20/2021 revealed step 11 remove gloves prior to turning to their side unless using the buddy system. During an interview on 10/2/25 at 9:22 a.m., the DON revealed the staff should not have been touching everything with their gloves on and should have performed hand hygiene right away after removing their gloves. The staff received education yesterday after the completion of cares.

Based on observation, staff interviews and facility policy review the facility failed to ensure residents received the proper diet texture to meet the residents needs.The facility reported a census of 66 residents. Findings Include: During an observation on 10/1/2025 at 11:37 a.m., during meal service Staff D, cook dished up a puree meal for Resident #17. Staff D placed mashed potatoes on the plate and placed serving of puree beef tips with gravy over the potatoes. Observation of the puree beef tips revealed chunks of beef on the plate. Asked Staff D if that was a puree meal and was she serving that portion to Resident #17, Staff D replied yes. Asked the Dietary Manager (DM) if the plate can be served to Resident #17 and the DM replied no not with the chunks of beef like that. The DM removed the plate from service and remaining portion of puree beef tips from the steam table and pureed new portions for the residents. Resident #24 requested cottage cheese. Resident #24 is a puree diet and Staff D served regular consistency cottage cheese to the resident. Staff D stated the resident has an order for regular cottage cheese. Requested order from DM for Resident #24 to have regular cottage cheese consistency and not pureed consistency. Review of the facility provided policy titled Dysphagia Diets dated 2013 revealed the food service department will be responsible for prepping and serving the diet and fluid consistency as ordered. Interview on 10/1/1025 at 2:38 p.m., with Staff E, Dietician revealed if a resident is a puree diet then the food needs to be pureed properly when serving it to the resident. Staff E explained unless the facility had an order for the cottage to be regular consistency it should have been pureed prior to giving it to the resident. Interview on 10/1/2025 at 1:16 p.m., with the DM revealed she knows that the puree consistency during meal service was a concern and should not have been served. The DM explained the facility was unable to find an order for Resident #24 to have regular cottage cheese and she should not have served it.

Based on clinical record review, staff interviews, and facility investigation record review, the facility failed to protect residents from further potential abuse after receiving an allegation of abuse alleging a CNA treated Resident #71 roughly and threw her into her wheelchair. Staff reported Resident #71 had feared the staff member would answer her call light on 5/3/24. The resident reported the concern to a staff member who reported it to the charge nurse who reported it to the Assistant Director of Nursing (ADON). The ADON denied being aware of the situation. The situation occurred before breakfast and the facility didn ' t start to investigate until after 3:00 PM. This failure resulted in residents living at the facility to be exposed to the potential of abuse therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of March 3, 2024 on August 21, 2024. The facility staff removed the IJ on August 21, 2024 through the following actions: a. On 8/21/2024, staff member remains suspended and hasn ' t work since 5/3/24 b. On 8/21/2024, staff education was initiated to ensure all staff understand the facility abuse policy and reporting procedures. c. On 8/21/2024, All staff through the evening shift have been educated. Anyone not educated or not on the schedule will be educated on the vulnerable adult policy and reporting procedures prior to coming on shift. d. On 8/21/2024, All nursing leadership were educated by the Registered Nurse (RN) Nurse Specialist on their corporations investigation and allegation of abuse process and procedure. e. Any concerns will be reported to the Administrator immediately and addressed in facility Quality Assurance (QA). The scope lowered from a K to E at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 67 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #71 documented diagnoses of Bipolar disorder, hypertension and diabetes mellitus. The MDS showed the Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Review of Resident #71 ' s Progress Notes lacked documentation of the incident from the incident occurring on 4/3/24. Interview on 8/21/24 at 12:05 p.m., with Staff D, Certified Nursing Assistant (CNA) revealed Resident #71 ' s husband had been pushing her down the hallway that morning and she was waving at her to come to her. Staff D could see Resident #71 had been crying and asked her what was wrong. Resident #71 stated don ' t let her come back and take care of me and said the aide that got her up was rough with her. Staff D revealed Resident #71 ' s husband said the aide threw the gait belt across the room. Staff D further revealed she reported the incident to Staff E, Licensed Practical Nurse (LPN). Interview on 8/21/24 at 2:03 p.m., with Staff E, LPN revealed it was around breakfast time when Staff D told her Resident #71 ' s husband was upset and Resident #71 was crying. Staff E Staff explained to her Resident #71 told her the morning aide had been rough with her and she had been throwing things around in Resident #71 ' s room. Staff E explained Resident #71 had been tearful that morning when she saw her. Staff E stated she told Staff F, Registered Nurse (RN), Assistant Director of Nursing (ADON) what was going on when she came in approximately between 8:00 a.m. and 9:00 a.m Interview on 8/21/24 at 8:52 a.m., with Staff B, Social Worker revealed Staff A, Restorative Aide said Resident #71 was visibly upset and could see she had been crying and was still crying. Resident #71 explained the morning aide had hit her leg on the wheelchair when she was assisting her. Resident #71 kept saying she didn ' t want anyone to get into trouble but it wasn ' t right on how she had been treated. Resident #71 cried throughout the interview. After talking with Resident #71 Staff A and Staff B reported it to the Administrator. Interview on 8/21/24 at 10:57 a.m., with Staff A revealed she had seen Resident #71 at the breakfast table and could see she was crying at the table. Staff A revealed Resident #71 was talking to other people so she didn ' t want to interrupt at that time. Staff A revealed later in the day she heard staff members talking Resident #71 did not have a good day and had an altercation with an aide. Staff A asked Staff B to go and talk with Resident #71. Staff A explained Resident #71 was hesitant at first but explained to her there was an aide that came in her room in the morning and ripped her pajamas off of her and told her it was time to get up. Resident #71 further explained to her that she threw me into my wheelchair for breakfast and when we came back the aide stood her up and her foot got caught on her walker but she pushed her into her recliner. Resident #71 stated she didn ' t know what she did to make her mad but she didn ' t deserve to be treated like this. Staff A revealed she assured Resident #71 she was safe and reported it to the Administrator. Interview on 8/21/24 at 11:57 a.m., with Staff F revealed after she learned about the situation from the Administrator she went and talked to Resident #71. Resident #71 explained she felt the aide was rough and when she was transferring her into her wheelchair she felt like the aide had her over the wheelchair and just dropped her and was rough when she changed her sweatshirt. Staff F revealed she did an assessment and didn ' t find anything but didn ' t chart the assessment in the residents chart. Interview on 8/21/24 at 8:40 a.m., with the Administrator revealed he had been in the building and late that afternoon Staff A and Staff B came to him and stated Resident #71 was upset and after they talked to her it seemed like an allegation of abuse. The Administrator went and talked to Resident #71 and her husband. The Administrator further revealed Resident #71 revealed an aide pushed her walker away from her and she did a rough transfer. The Administrator further revealed he had the ADON talk with Staff C regarding what happened. The facility sent Staff C home pending an investigation. Review of the facility provided policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy update on 10/19/22 revealed the following information: a. 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. b. All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. c. Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: (1) suspending the employee; (2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility; and in rare instances (3) separating the employee accused of abuse from the resident alleged to have been abused, but allowing the employee to care for and have contact with other residents, only if there is a second employee who remains with and accompanies the employee accused of abuse at all times to supervise all contacts and interactions with the residents. Interview on 8/21/24 at 3:41 p.m., with the Administrator revealed the facility separated Staff C from all residents and sent her home and reported the allegation as soon as they were aware of it.

Based on temperature log review, observations, policy review, and staff interview, the facility failed to ensure food is stored, prepared, and served in a sanitary manner as well ensuring dishes and utensils cleaned in a sanitary manner to prevent foodborne illness. The facility reported a census of 67. Findings include: 1.Initial kitchen tour completed on 8/19/24 at 11:15 AM. The dry storage room had a container of oil sitting on the floor next to a storage rack. An unlabeled/dated container of what appeared to be sunflower seeds found on a storage rack. The walk-in cooler revealed the following: a.Two squeeze bottles, which appeared to be salad dressing, were not labeled nor dated; b.Outdated containers of food found (pork roast dated 8/9, potato salad dated 8/7, and fruit cocktail dated 8/6); c. A container of pickles, with torn aluminum foil as a cover, dated 8/6; d.A zip-loc bag with a used bag of shredded lettuce was not labeled nor dated; e.An unsealed zip-loc bag with an open bag of Heath candy pieces. 2.Follow-up kitchen tour completed on 8/21/24 at 8:10am. The walk-in freezer had an open bag of frozen browned chicken as well as an unlabeled/dated zip-loc bag of what appeared to be diced potatoes or meat. A container of pea salad, dated 8/13, found in the walk-in cooler. 3.Lunch service observation completed on 8/21/24 from 11:00 AM to 12:30 PM. Hand hygiene was not observed by Staff I, cook, during the continuous observation. Staff I observed wiping hands on her pants, rubbing her nose, and touching various kitchen equipment/handles with bare hands. Staff I observed spreading ice around a bin, with bare hands, which contained prefilled glasses of milk/juice for resident use. Staff I donned gloves prior to start of lunch service with no hand hygiene performed. During service, Staff I observed touching kitchen equipment/handles, food containers, and tray tickets with gloved hands as well as spreading ice around the bin holding prefilled glasses of milk/juice for resident use. With the same pair of gloves, Staff I seen deboning chicken for resident lunch plates. 4.Food temperature logs reviewed showed 8 meal temperatures were not recorded in August out of 62 meals, 33 meal temperature were not recorded for July out of 93 meals, 22 meal temperatures were not recorded for June out of 90 meals and 27 meal temperatures were not recorded in May out of a total of 93 meals. 5.Dish machine temperature logs reviewed showed 52 final rinse temperature readings were not recorded in August out of 62. No final rinse temperatures recorded for the month of July. Eighty seven final rinse temperatures were not recorded for the month June out of 90. No log located for the month of May. On 8/21/24 at 8:30 AM, Staff K, dining services personnel, reported not knowing which temperature gauge (out of 3 gauges) to look at to ensure the proper final rinse temperature reached. On 8/21/24 at 12:30 PM the Staff J, Certified Dietary Manager, interviewed. Staff J stated meal temperatures and dish machine final rinse temperatures are expected to be documented for each meal/three times per day. Hand hygiene and glove change should have been completed at key times during meal preparation/service. The undated policy Food Storage revealed: 1.Dry storage food items will be stored on shelves and all containers much be legible and accurately labeled and dated. 2.Refrigerated leftover food is stored in covered containers or wrapped carefully/securely and used within 3 days or discarded. 3.Frozen foods should be covered, labeled, and dated. 4.After engaging in other activities that contaminate hands. The undated policy Hand Washing revealed hands should be washed: 1.After touching bare human body parts other than clean hands and clean, exposed portions of the arm. 2.After handling soiled equipment or utensils. 3.During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. 4.Before donning gloves for working with food. The undated policy Food Temperatures revealed temperatures will be taken and properly recorded for each meal to ensure hot food is cooked to the appropriate internal temperature and cold food maintained and served at the appropriate temperature. The undated policy Dish Machine Temperature Log revealed: 1.Staff will monitor and record temperature to assure proper sanitizing of dishes. 2.Staff will be trained to record dish machine temperatures for the wash and rinse cycles at each meal.

Based on observations, staff interview, and policy review, the facility failed to provide food that is nourishing and palatable. The facility reported a census of 67. Findings include: 1.Breakfast test tray obtained on 8/21/24 at 8:30 AM. Temperature of the scrambled eggs recorded at 123 . The French toast edges were tough and dried out. 2.Kitchen lunch observation completed on 8/21/24 at 11:30 AM. The meatloaf on the steam table was seen with burned edges all around the pan. Staff observed having difficulty cutting the entree into individual pieces. 3.Resident meal round completed on 8/21/24 at 12:00 PM in the East Dining Room. Several residents voiced the meat loaf was burnt and unable to cut thru. Resident plates observed with hard, burnt, inedible meatloaf crust. 4.Lunch test tray obtained on 8/21/24 at 12:35 PM. The meatloaf received was burnt along the edges and crunchy when consumed. On 8/21/24 at 12:30 PM the Staff J, Certified Dietary Manager, interviewed and acknowledged the meatloaf was dried out. Staff J was not aware of the French toast quality nor the below standard temperature of the scrambled eggs. The undated policy Food Temperatures revealed that foods sent to the unit for distribution will be transported and delivered to maintain temperatures at or above 135 .

Based on observation and staff interview, the facility failed to provide infection control practices with the lack of enhanced barrier protection used during wound care treatment for 1 of 1 resident observed (Resident #53) and lack of hand hygiene when assisting residents to eat. The facility reported a census of 67. Findings include: 1.On 8/20/24 at 2:00 PM, Staff M, Licensed Practical Nurse (LPN) and Staff N, LPN, completed wound care to Resident 53's left lower calf. Upon room entry, no signage observed indicating resident placed in enhanced barrier protection (EBP). Staff M and Staff N performed hand hygiene and donned gloves prior to initiating treatment, which was completed as ordered. During interview with Staff N on 8/20/24 at 3:00 PM, it was reported EBP was not indicated for Resident #53 as the wound was not considered chronic. EBP would be initiated when classified as chronic, which is defined as greater than 30 days. The Enhanced Barrier Precautions policy updated 5/6/24, reported on order for EBP obtained for wounds (e.g. chronic wounds, such as pressure ulcer .) and/or indwelling medical devices. The Center for Disease Control (CDC) indicated EBP should be utilized with high-contact resident care activities such as wound cares whereas a wound is defined as any skin opening requiring a dressing (www.cdc.gov/hai/containment/PPE-Nursing-Homes.html). 2.During breakfast on 8/20/24 at 7:45 AM, Staff A, Restorative Aide (RA) observed assisting two residents at the same time to eat. On multiple occasions, Staff A seen rubbing the resident's arm and back to encourage them to eat (resident sitting on Staff A's left). Staff A then picked up eating utensils and/or drinking glasses to assist the other resident., who was sitting on Staff A's right. No hand hygiene was observed throughout. During the same meal period, Staff O, Certified Nursing Assistant (CNA), observed assisting two residents at the same time to eat. On two separate occasions, Staff O seen wiping a resident's mouth and nose with the clothing protector with no hand hygiene completed after the task. Staff O proceed to pick up eating utensils and or drinking glass to assist the other resident. The DON interviewed on 8/20/24 at 9:30 AM and reported there is no specific policy or procedure in place regarding hand hygiene for staff during meal assistance. The Hand Hygiene policy updated 5/6/24, indicated an alcohol-based hand sanitizer to be used: 1. After touching a resident or the resident's immediate environment. 2. After contact with blood, bodily fluids or contaminated surfaces.

Based on record review, staff and resident interview, the facility failed to notify the family of a change in condition for 1 of 3 residents reviewed (Resident #70). The facility reported a census of 70 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #70 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident was independent with eating. The resident had diagnoses including heart failure, atrial fibrillation, and long term use of anticoagulant. The Care Plan revised 11/16/22 identified the resident needed assistance with all of her activities of daily living (ADL'S) except for eating. She had a potential for dehydration related to medication use. The interventions included the nurse to observe her for signs and symptoms of dehydration such as poor skin turgor, decreased urinary output, and dry mucous membranes, and notify the doctor of any changes. The Clinical Resident's Profile page showed the resident had a #1 and a #2 emergency contact listed. The Progress Notes dated 7/1/24 at 1:31 p.m. documented communication with the Dr. after the nurse assessed the resident with a pulse reading in the upper 30's and low 40's with repeated checks both manually with stethoscope and with pulse oximeter readings. The resident more drowsy in the morning and needed fed breakfast when normally independent with eating. Last administration time of Diltiazem (med to treat high blood pressure/chest pain) at 9:30 a.m. and pulse 100 at that time. New orders received to send to the emergency room (ER) for evaluation and treatment. Family member called with no answer and message left on situation. The Progress Notes dated 7/2/24 at 2:50 p.m. documented staff updated the family member on the resident going to the ER, what they did for the resident, and that she had returned. The Progress Notes dated Sunday 7/7/24 at 10:51 a.m. documented a phone call placed to the resident's family member and gave an update on the resident's condition. The resident remained in bed with eyes closed and unresponsive at the time. The resident hadn't had much to eat or drink in the previous few days. The resident showed no signs/symptoms (S/S) of any pain, and rested with eyes closed. Vital signs (VS) within normal limits (WNL). Family said to keep the resident comfortable. At 10:57 a.m. the resident's family member called and after discussion with her family they would like the resident sent to the ER for evaluation. At 2:42 p.m. staff called the ER about the resident's status. The resident admitted for rapid ventricular response (RVR), A-Fib, and pneumonia. On 8/21/24 at 1:16 p.m. the resident's family member (contact #1) said she never received a call from the facility when the resident went to the hospital on 7/1/24. Someone called her on 7/2/24 and asked if she knew the resident went to the hospital the day before, what her condition was, and she had already returned. The family member said she didn't know. She said they called and told her on Friday evening the resident had some respiratory difficulty and they put her on oxygen. They did not call her on Saturday. On Sunday she received a call from the resident's friend asking if she knew the resident was unresponsive and hadn't been out of bed. She said the facility had not called her, and she had told them if they couldn't reach her to call another family member (contact #2). The resident's family member then called the facility. She didn't know what would have happened if she had not called the facility Sunday morning. At the hospital they determined the resident had a raging infection with a WBC of 19,000 (normal 4.500 to 11,000) and her heart rate 178 (normal 60-100) in the ER. On 8/22/24 at 12:34 p.m. the DON said if staff are unable to reach the 1st emergency contact they should call the next contact in the need to transfer a resident, or a change in condition requiring immediate attention. The facility policy Notification of Change of Resident's Health Status, updated 2/8/23 included the resident's physician the resident representative(s) would be notified of a change in status when there was a significant change in the resident's physical, mental, or psychosocial status for example a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications, a need to alter treatment significantly for example, a need to discontinue an existing form of treatment due to adverse consequences, or to start a new form of treatment, or a decision to transfer or discharge the resident from the nursing home.

Based on clinical record review, facility record review, staff interviews and facility policy the facility failed to appropriately implement interventions to protect 1 out of 3 residents reviewed from physical abuse, (Resident #71). The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #71 documented diagnoses of Bipolar disorder, hypertension and diabetes mellitus. The MDS showed the Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Review of the facility self report revealed the facility was made aware on 5/3/24 at 3:00 p.m., by Staff A, Restorative Aide and Staff B, Social worker Resident #71 reported Staff C, CNA was rough during a transfer. Interview on 8/21/24 at 12:05 p.m., with Staff D, Certified Nursing Assistant (CNA) revealed Resident #71 ' s husband had been pushing her down the hallway that morning and she was waving at her to come to her. Staff D could see Resident #71 had been crying and asked her what was wrong. Resident #71 stated don ' t let her come back and take care of me and said the aide that got her up was rough with her. Staff D revealed Resident #71 ' s husband said the aide threw the gait belt across the room. Staff D further revealed she reported the incident to Staff E, Licensed Practical Nurse (LPN). Interview on 8/21/24 at 2:03 p.m., with Staff E, LPN revealed it was around breakfast time when Staff D told her Resident #71 ' s husband was upset and Resident #71 was crying. Staff E explained to her Resident #71 told her the morning aide had been rough with her and she had been throwing things around in Resident #71 ' s room. Staff E explained Resident #71 had been tearful that morning when she saw her. Staff E stated she had told Staff F, Registered Nurse (RN), Assistant Director of Nursing (ADON) what was going on when she came in approximately between 8:00 a.m. and 9:00 a.m Interview on 8/21/24 at 8:52 a.m., with Staff B, Social Worker revealed Staff A, Restorative Aide said Resident #71 was visibly upset and could see she had been crying and was still crying. Resident #71 explained the morning aide had hit her leg on the wheelchair when she was assisting her. Resident #71 kept saying she didn ' t want anyone to get into trouble but it wasn ' t right on how she had been treated. Resident #71 cried throughout the interview. After talking with Resident #71 Staff A and Staff B reported it to the Administrator. Interview on 8/21/24 at 10:57 a.m., with Staff A revealed she had seen Resident #71 at the breakfast table and could see she was crying at the table. Staff A revealed Resident #71 was talking to other people so she didn ' t want to interrupt at that time. Staff A revealed later in the day she heard staff members talking Resident #71 did not have a good day and had an altercation with an aide. Staff A asked Staff B to go and talk with Resident #71. Staff A explained Resident #71 was hesitant at first but explained to her there was an aide that came in her room in the morning and ripped her pajamas off of her and told her it was time to get up. Resident #71 further explained to her that she threw me into my wheelchair for breakfast and when we came back the aide stood her up and her foot got caught on her walker but she pushed her into her recliner. Resident #71 stated she didn ' t know what she did to make her mad but she didn ' t deserve to be treated like this. Staff A revealed she assured Resident #71 she was safe and reported it to the Administrator. Interview on 8/21/24 at 11:57 a.m., with Staff F revealed after she learned about the situation from the Administrator she went and talked to Resident #71. Resident #71 explained she felt the aide was rough and when she was transferring her into her wheelchair she felt like the aide had her over the wheelchair and just dropped her and was rough when she changed her sweatshirt. Staff F revealed she did an assessment and didn ' t find anything but didn ' t chart the assessment in the residents chart. Interview on 8/21/24 at 8:40 a.m., with the Administrator revealed he had been in the building and late that afternoon Staff A and Staff B came to him and stated Resident #71 was upset and after they talked to her it seemed like an allegation of abuse. The Administrator went and talked to Resident #71 and her husband. The Administrator further revealed Resident #71 revealed an aide pushed her walker away from her and she did a rough transfer. The Administrator further revealed he had the ADON talk with Staff C regarding what happened. The facility sent Staff C home pending an investigation. Review of Resident #71 ' s Progress Notes lacked documentation of the incident from the incident occurring on 5/3/24. Review of the facility provided policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy update on 10/19/22 revealed 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. Interview on 8/21/24 at 3:41 p.m., with the Administrator revealed the facility seperated and reported the allegation of abuse as soon as they were aware of it.

Based on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 1 of 1 residents reviewed for abuse (Resident #71). The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #71 documented diagnoses of Bipolar disorder, hypertension and diabetes mellitus. The MDS showed the Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Interview on 8/21/24 at 12:05 p.m., with Staff D, Certified Nursing Assistant (CNA) revealed Resident #71 ' s husband had been pushing her down the hallway that morning and she was waving at her to come to her. Staff D could see Resident #71 had been crying and asked her what was wrong. Resident #71 stated don ' t let her come back and take care of me and said the aide that got her up was rough with her. Staff D revealed Resident #71 ' s husband said the aide threw the gait belt across the room. Staff D further revealed she reported the incident to Staff E, Licensed Practical Nurse (LPN). Interview on 8/21/24 at 2:03 p.m., with Staff E, LPN revealed it was around breakfast time when Staff D told her Resident #71 ' s husband was upset and Resident #71 was crying. Staff E said Staff D explained to her Resident #71 told her the morning aide had been rough with her and she had been throwing things around in Resident #71 ' s room. Staff E explained Resident #71 had been tearful that morning when she saw her. Staff E stated she had told Staff F, Registered Nurse (RN), Assistant Director of Nursing (ADON) what was going on when she came in approximately between 8:00 a.m. and 9:00 a.m Interview on 8/21/24 at 2:28 p.m., with Staff F revealed she did not know about the situation prior to the Administrator notifying her of what was going on around 3:00 p.m Review of the facility self report revealed the facility was made aware on 5/3/24 at 3:00 p.m., by Staff A, Restorative Aide and Staff B, Social that Resident #71 reported Staff C, Certified CNA was rough during a transfer. Review of facility intake information the facility submitted a self report on 5/3/24 at 5:04 p.m. Review of the facility provided policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy update on 10/19/22 revealed the following information: a. 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. b. All allegations of Resident abuse shall be reported to the Iowa Department of Inspections and Appeals not later than two (2) hours after the allegation is made. Interview on 8/21/24 at 3:41 p.m., with the Administrator revealed the facility reported the allegation as soon as they were aware of it.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the PreAdmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 resident reviewed for PASRR requirements, (Resident #57). The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #57 documented diagnoses anxiety disorder, psychotic disorder and delusional disorders. The MDS included a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment. The MDS revealed diagnoses of anxiety disorder, psychotic disorder and delusional disorder. Review of the active diagnosis list in the clinical record revealed the following diagnoses; a. Delusional disorders with an active date of 2/12/24 b. Anxiety disorder with an active date of 4/3/24. The Care Plan with revision date of 5/10/24 revealed the resident has dementia with behaviors, delusional disorder and anxiety. The clinical record lacked an updated PASRR to include updated diagnosis. The facility does not have policy on PASRR and follows the PASRR guidelines. Interview on 8/20/24 at 10:15 a.m., with the Social Services Director revealed the PASRR should have been redone with the updated diagnosis.

Based on record review, staff and family interview, the facility failed to provide adequate assessment and timely intervention for 1 of 3 resident's reviewed with a change of condition (Resident #70). The facility reported a census of 67 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #70 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident was independent with eating. The resident had diagnoses including heart failure, atrial fibrillation, and long term use of anticoagulant. The Care Plan revised 11/16/22 identified the resident needed assistance with all of her activities of daily living (ADL'S) except for eating. She had a potential for dehydration related to medication use. The interventions included the nurse to observe her for signs and symptoms of dehydration such as poor skin turgor, decreased urinary output, and dry mucous membranes, and notify the doctor of any changes. The Clinical Resident's Profile page showed the resident had a #1 and a #2 emergency contact listed. The Progress Notes included the following documentation: a. On 7/1/24 at 1:31 p.m. communicated with the Dr. after the nurse assessed the resident with a pulse reading in the upper 30's and low 40's with repeated checks both manually with stethoscope and with pulse oximeter readings. The resident more drowsy in the morning and needed fed breakfast when normally independent with eating. Last administration time of Diltiazem (med to treat high blood pressure/chest pain) at 9:30 a.m. and pulse 100 at that time. New orders received: Send to emergency room (ER) for evaluation and treatment. Family member called with no answer and message left on situation. b. On 7/1/24 at 2:05 p.m. the Director of Nursing (DON) assessed the resident with a low pulse and the DON was in contact with the doctor. Staff called for the ambulance around 1:25 p.m. and the ambulance left with the resident around 1:40 p.m. c. On 7/1/24 at 6:12 p.m. the resident returned, no new medications. The ER Nurse called to give report. The resident on Telemetry the entire ER visit with no changes in sinus rhythm. A computed tomography (CT) of the head performed with negative findings or abnormalities. A B-type natriuretic peptide (BNP, test to monitor heart failure) elevated, and 20 mg of Lasix intravenous (IV) given in the ER. Her physician would see her on Wednesday rounds. d. On 7/1/24 at 11:14 p.m. the resident took a pudding cup, was weak, tired, and had a cough present. e. On 7/2/24 at 2:50 p.m. updated family on the resident going to the ER, what they did for the resident, and she had returned. Vitals were good thus far but she had nausea, decreased energy, decreased eating, and crackles in the upper lungs. Notified the DON of the information and she stated the resident would be seen the following day on rounds and family notified. f. On 7/3/24 at 5:36 p.m. the Dr. assessed the resident on rounds. No new orders. g. On Friday 7/5/24 at 8:55 p.m. the nurse assessed the resident's oxygen at 86% on room air. The resident's head of the bed (HOB) elevated, and lung sounds diminished. After discussion with another nurse, noted the resident had an as needed (PRN) order for an albuterol inhaler, but did not have one in facility at the time. A call placed to the on call Dr. at 8:55 p.m. and he suggested Albuterol Nebs 2.5 mg/3 ml every 4 hours PRN, and oxygen to maintain saturation >90%. The resident's family member updated at 9:01 p.m. on the new order. The clinical record lacked follow up assessment of the resident's lung sounds. The Progress Notes dated Sunday 7/7/24 at 10:51 a.m. documented a phone call placed to the resident's family member and gave an update on the resident's condition. The resident remained in bed with eyes closed and unresponsive at the time. The resident hadn't had much to eat or drink in the previous few days. The resident showed no signs/symptoms (S/S) of any pain, and rested with eyes closed. Vital signs (VS) within normal limits (WNL). Family said to keep the resident comfortable. At 10:57 a.m. the resident's family member called and after discussion with her family they would like the resident sent to the ER for evaluation. At 2:42 p.m. staff called the ER about the resident's status. The resident admitted for rapid ventricular response (RVR), A-Fib, and pneumonia. The O2 Sats Summary showed the resident's O2 sat on 7/5/24 at 9:18 p.m. at 86%. The last recorded O2 sat documented on 7/6/24 at 5 a.m. at 94%. The Blood Pressure Summary showed the last recorded blood pressure on 7/3/24 at 10:51 a.m. The Respiration Summary showed the last recorded respirations on 7/3/24 at 10:50 a.m. The Temperature Summary showed the last recorded temperature on 7/3/24 at 10:50 a.m. The Nutrition - Fluids and Percentage eaten records showed the resident had no food or fluids since lunchtime on 7/5/24. A Transfer/Discharge Report dated 7/7/24 documented the last vital signs were from 7/3/24 and 7/6/24. The resident was not eating or drinking fluids, and started oxygen on 7/5/24, not normal for her, and that day non-responsive. A Prehospital Care (ambulance) Report dated 7/7/24 at 11:15 a.m. documented paged for a female unresponsive with a low heart rate. The resident laid pale and clammy in bed. The resident did not respond. The resident breathing around 40 per minute (normal 12-20). The resident connected to a monitor showing atrial fibrillation with (heart) rates 150- 210 (normal 60 to 100) but mostly on the 170 side. A History and Physical dated 7/7/24 documented the resident's assessment included pneumonia, atrial fibrillation with rapid ventricular response, sepsis (a life threatening response to an infection), congestive heart failure, acute kidney injury, and acute hypoxic respiratory failure. The resident presented with significant tachycardia (rapid pulse), hypoxia, elevated white blood count (WBC) at 19,000, and a chest x-ray concerning for pneumonia. On 8/21/24 at 10:10 a.m. Staff F Certified Nursing Assistant (CNA) stated they left the resident in bed on Saturday, she was tired not eating or drinking. On Sunday she again stayed in bed and she thought she may be opened her eyes. They took her meal trays to her room but she didn't think she ate or drank. The resident had been going downhill and they were concerned about her. They did notify the nurse. On 8/21/24 at 10:45 a.m. Staff G Registered Nurse (RN) stated the resident had not been feeling well for a few days. She had a cough, and not eating or drinking. She thought they had something going around at the time. She said she did try to call the family and could not reach them. They called her back later and she updated them on her condition. At the time they called she was unresponsive. The resident had visitors that morning and they also voiced their concerns with her condition. On 8/21/24 at 10:54 a.m. Staff H CNA stated the resident wouldn't eat or drink and they could tell she was going downhill. She talked with the nurse about her condition. On 8/21/24 at 12:35 p.m. Staff I CNA stated she had worked the days leading up to the resident's hospitalization . She said the resident had been going down hill. She said the CNA's talked to the nurses about it. On 8/21/24 at 1:16 p.m. the resident's family member (contact #1) said she never received a call from the facility when the resident went to the hospital on 7/1/24. Someone called her on 7/2/24 and asked if she knew the resident went to the hospital the day before, what her condition was, and she had already returned. The contact #1 said she didn't know. She said they called and told her on Friday evening the resident had some respiratory difficulty and they put her on oxygen. They did not call her on Saturday. On Sunday she received a call from the residents friend asking if she knew the resident was unresponsive and hadn't been out of bed. She said the facility had not called her, and she had told them if they couldn't reach her to call another family member (contact #2). Contact #1 then called the facility. She didn't know what would have happened if she had not called the facility Sunday morning. At the hospital they determined the resident had a raging infection with a WBC of 19,000 and her heart rate 178 in the ER. On 8/21/24 at 2:03 p.m. the friend of the resident stated they went out to see the resident every Sunday. She was always up in her recliner or her wheelchair. That last Sunday when they went to visit, the room was dark and she was in bed. She had a wet washcloth over her forehead. They went to the nurses station and asked what was wrong with her. Some staff members stated she was not feeling well. And the friend said she could see that and asked how long she had been that way. The staff members said since Friday. She asked if they had called contact #1 and they said they had tried but could not get a hold of her. The resident's friend stated she thought it strange they couldn't get a hold of her but she knew contact #1 had told them they could call contact #2 if they couldn't get a hold of her. The resident's friend called contact #1 and asked if she knew the resident's condition. Contact #1 said no and she had not received any calls from the nursing facility. The friend was very upset that they were leaving her lay like that and not doing something for her, or notifying some one. On 8/21/24 at 3:02 p.m. the DON stated the resident had been declining. She said if a resident continued to show declines nursing staff should assess their condition and report to the resident's physician and family regarding the declines. On 8/22/24 at 11:40 a.m. the Regional Nurse Consultant stated they had no policy on assessment, they went by the regulations and standards of practice.

Based on observations and staff interviews, the facility failed to provide food prepared by methods that conserve nutritive value and flavor. The facility reported a census of 67. Findings include: On 8/21/24 at 11:00 AM, Staff I, cook, observed preparing four serving of puree meatloaf and carrots. Hot water utilized to thin out the items to achieve the correct puree consistency. When asked, Staff I reported water is mainly use when pureeing foods. During an interview on 8/21/24 at 12:30 PM with Staff J, Certified Dietary Manager, acknowledged that water is not the most appropriate liquid to use. Industry standards recommend liquids that add additional flavor, calories, or protein when pureeing to conserve nutritive value and flavor.

Based on clinical chart review, observations, staff interviews, and policy review, the facility failed to accurately care plan the use of Paid Nutritional Aides (PNAs), assess the appropriateness of PNA, and used a PNA for feeding assistance on a resident with swallowing difficulties for 1 of 2 residents who utilize a PNA at meals (Resident #27). The facility reported a census of 67. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #27 had a Brief Interview for Mental Status (BIMS) of 15 indicating an intact cognitive status. The MDS documented the resident had diagnoses including aphasia, depression, dyskinesia of esophagus, osteoarthritis (left and right hand), essential tremor, and dysphagia (pharyngoesophageal phase). The MDS reported Resident #27 complained of difficulty or pain with swallowing, coughs/chokes during meals or when swallowing medication, and loses liquids/solids from mouth when eating/drinking. Clinical record review revealed Resident #27 ordered a puree diet with regular consistency liquids. Quarterly Nursing Assessment Progress Note dated 8/1/24 indicated Resident #27 needs extensive staff assistance at meals and is dysphagic. Resident #27's Care Plan with a target date of 11/1/24 documented a focus area related to an alteration in nutrition due to chewing/swallowing difficulties related to dyskinesia of esophagus, dysphasia, and missing teeth. Intervention included resident will eat meals in the [NAME] dining room with staff assistance. The Care Plan did not address the specific use of PNAs with meal assistance. Further clinical record review lacked formal assessments addressing the use of PNAs for feeding assistance and whether or not a PNA is appropriate given Resident #27's dysphagia diagnosis. Lunch observation on 8/21/24 at 11:30 AM showed a PNA feeding Resident #27 a puree diet. Breakfast observation on 8/22/24 showed a PNA feeding Resident #27 a puree diet. Director of Nursing (DON) reported, on 8/22/24 at 10:15 AM, no regularly scheduled formal assessments completed on the continued use of PNAs. The DON stated if a resident coughing more than usual or having a bad day the PNA would be notified and not allowed to feed the resident. The facility does not allow PNAs to assist residents who receive thickened liquids. DON reported no further restrictions in place on PNA use. The facility's Speech and Language Pathologist (SLP) interviewed on 8/22/24 at 10:30 AM. The SLP reported Resident #27 is higher than normal aspiration risk given the medical diagnoses. SLP states they were not involved in the decision process of utilizing a PNA for Resident #27. The undated policy Paid Feeding Assistants (Nursing Facilities) outlined paid feeding assistants are not permitted to assist resident who have complicated eating problems such as difficulty swallowing. Nurses or nurse aides must continue to assist resident who require staff with more specialized training. Per policy, resident selection for PNA use must be based on the charge nurse current assessment of the resident's condition and the resident's latest comprehensive assessment and plan of care.

Based on record review, staff interviews and facility policy review the facility failed to provide accurate resident records for 1 of 19 residents (Residents #71). The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #71 documented diagnoses of Bipolar disorder, hypertension and diabetes mellitus. The MDS showed the Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Interview on 8/21/24 at 12:05 p.m., with Staff D, Certified Nursing Assistant (CNA) revealed Resident #71 ' s husband had been pushing her down the hallway that morning and she was waving at her to come to her. Staff D could see Resident #71 had been crying and asked her what was wrong. Resident #71 stated don ' t let her come back and take care of me and said the aide that got her up was rough with her. Staff D revealed Resident #71 ' s husband said the aide threw the gait belt across the room. Staff D further revealed she reported the incident to Staff E, Licensed Practical Nurse (LPN). Interview on 8/21/24 at 2:03 p.m., with Staff E, LPN revealed it was around breakfast time when Staff D told her Resident #71 ' s husband was upset and Resident #71 was crying. Staff E Staff D explained to her Resident #71 told her the morning aide had been rough with her and she had been throwing things around in Resident #71 ' s room. Staff E explained Resident #71 had been tearful that morning when she saw her. Staff E stated she told Staff F, Registered Nurse (RN), Assistant Director of Nursing (ADON) what was going on when she came in approximately between 8:00 a.m. and 9:00 a.m Review of the facility self report revealed the facility was made aware on 5/3/24 at 3:00 p.m., by Staff A, Restorative Aide and Staff B, Social worker Resident #71 reported Staff C, Certified CNA was rough during a transfer. Review of Resident #71 ' s Progress Notes lacked documentation of the incident from the incident occurring on 5/3/24. Review of facility provided policy titled Risk Management updated 10/25/2021 revealed all accidents/incidents involving residents will be reported, investigated and reviewed through the facilities QAPI Process to ensure residents receive the highest quality of care. Interview on 8/21/24 at 11:52 a.m., with the Director of Nursing (DON) revealed she was not sure if the incident should be documented in the resident's chart.

Based on observation, staff interview and record review, the facility failed to update the resident's care plan to accurately reflect the resident for 1 of 17 reviewed (Residents #14). The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #14 documented diagnoses of chronic kidney disease, acute pulmonary edema, and limitation of activities due to disability. The MDS showed a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment. Observation on 7/31/23 at 11:50 a.m., revealed a catheter hanging next to Resident #14. Observation on 8/2/23 at 11:01 a.m., revealed a catheter hanging under the wheelchair in the privacy bag. Review of Resident #14 ' s Care Plan with a revision date of 7/23/23 lacked information regarding residents having a urinary catheter and how to care for the catheter. Interview on 8/3/23 at 9:38 a.m., with the Director of Nursing (DON) revealed the catheter should have been on the care plan.

Based on observation, clinical record review, and interviews the facility failed to ensure one of three residents received adequate supervision to protect against hazards in the environment, ( Resident #2).The facility reported a census of 65 residents. Findings include: The Minimum Data Set assessment with a reference date of 7/4/19 for Resident #2 documented a score of 15 on the Brief Interview for Mental Status test which indicated no cognitive impairment. The resident had [DIAGNOSES REDACTED]. The resident had no falls since reentry. A PT (Physical Therapy)-Therapist Report dated 3/6/19 directed ambulation with CGA (Contact Guard Assist) of one to two staff. A Fall Risk assessment dated [DATE] documented a score of 11 which indicated a moderate risk of falls. A facility incident report documented a witnessed fall on 3/15/19. The report documented Resident #2 was walking with Staff B, Physical Therapy Assistant (PTA) in the main hallway with a front wheeled walker and a gait belt. The report documented Staff B let go of the gait belt to put on the brakes of the wheelchair, when the residents knees buckled causing him to lose his balance and fall forward. Staff B reported the resident landed on his left elbow and left side, hitting his head on the wall. Staff C, Registered Nurse (RN) documented the resident complained of pain to the left knee with notable swelling. A PT Daily Treatment Note dated 3/15/19, electronically signed by Staff B, PTA documented: Resident #2 ambulated 30 feet twice, CGA with one staff with wheelchair follow for safety. At the end of the second ambulation the resident had a fall. The resident reported he needed to sit down. Therapist let go of the gait belt to put on brakes on wheel chair. Resident's knees then buckled and he lost his balance falling forward. The resident landed on his left elbow and left side. A Major Injury Determination form dated 3/15/19 and signed by emergency room physician documented the resident was ambulating with therapy with assist of one and with a gait belt, lost balance and fell on left knee and left elbow. Diagnosis: [REDACTED]. Review of the emergency room Report dated 3/15/19 documented Resident #2 was seen for a left tibial fracture, and directed knee immobilizer on and non-weight bearing until can follow up with orthopedic specialist. Review of the 4/2/19 orthopedic consultation directed Resident #2 to remain in hinged knee brace for 4 weeks, with no weight bearing. A Fall Scene Investigative Report, signed as completed by Staff D, Registered Nurse on 3/18/19 documented the following conclusion: Resident working with physical therapy in main hallway with assist of one with gait belt and front wheeled walker. Physical therapy let go of resident to put the brakes on wheelchair. The report documented therapy staff had been educated on the proper technique while working with resident with wheelchair use. In a phone interview on 8/26/19 at 4:32 PM, Staff E, Clinical Director confirmed had provided in-service education on 4/2/19 following review of the fall. Staff [NAME] confirmed would expect hand to remain on the gait belt at all times with Contact Guard Assist of 1. In an interview on 8/26/19 at 3:25 PM, Staff F, PTA Rehabilitation Director stated she had reviewed the documentation and counseled/educated Staff B following the fall. Staff F confirmed would expect PTA doing assist of one with gait belt, when the resident reported needing to sit down, to keep hold of the bait belt while positioning the wheelchair. Further stated, would not have expected to release hold on the gait belt. Staff F provided a written statement dated 3/18/19 that documented she had reviewed the fall with Staff B immediately after the fall on 3/15/19. The written statement documented she had completed staff education about using assistance of 2 staff if resident is feeling weak or not transferring easily. Educated on always holding on to the gait belt, and locking the brakes from standing on the side of the wheelchair rather than letting go of the gait belt and going around the chair to lock the other brake. Interview with Staff B, PTA on 8/27/19 at 9:49 AM revealed Staff B does not routinely work at this facility. Staff B confirmed walking in hallway with Resident #2, using a gait belt and wheelchair to follow. Recalled the resident stated needed to take a break. Staff B stated she let go of the gait belt to place the brakes on the wheelchair. Staff B stated she knew her hand was to be on the gait belt at all times. In an interview on 8/27/19 at 10:04 AM, Resident #2 stated he remembered when he broke his left lower leg. Stated he was walking with therapy and getting stronger. He stated he started feeling weak and needed to sit down. She let go of my gait belt and I fell and broke my leg.

I. Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision and implement interventions to prevent injury for 1 of 14 active residents (Resident #1). Record review identified Resident #1 ' s care plan directed staff to use alarms for his/her safety. On 6/21/15, Resident #1 repeatedly pulled apart his/her alarm (canary alarm) and staff reattached the alarm leaving the alarm within his/her reach. Resident #1 removed his/her canary alarm and fell , sustaining a right hip fracture. Written statements & interviews established the resident's pad alarm and canary alarm did not sound when staff found the resident on the floor. The facility reported a census of 83 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 showed long/short term memory problems and cognitive impairments for daily decision making skills. Resident #1 required one staff assistance with activities of daily living (ADL's) for transfers, ambulation, and toilet use. The test for balance identified Resident #1 only able to stabilize his/her balance with staff assistance. Resident #1's [DIAGNOSES REDACTED]. A Fall Risk assessment dated [DATE] showed Resident #1 with a score of 20 indicating a high risk for falls. The Care Plan dated 06/12/14 identified Resident #1 with senile dementia and difficulty with understanding, attention and concentration. When awake, staff would help Resident #1 to the main living area so he/she would be with others. The Care Plan dated 06/09/14 identified Resident #1 with impaired thought process and difficulty with understanding, attention, and concentration. The interventions included Resident #1 required constant cues, reminders, and redirection. The Care Plan revised on 09/04/14 identified Resident #1 needed assistance with transfers and ambulation related to cognition and a history of falls. The interventions included a canary alarm at all times, and to check placement and functioning every shift (08/25/14); and a seat alarm at all times, checking placement and functioning every shift (12/05/14). Resident #1 needed assistance of 1-2, a gait belt and wheeled walker for all transfers and ambulation. The Care Plan revised 05/05/15 identified Resident #1 with a history of pain to his/her right arm. Resident #1 had fallen with a right shoulder fracture. The interventions directed staff that Resident #1 could not voice pain level (severity) and staff would assess him/her for non-verbal signs of pain such as facial grimacing, moaning, restlessness, etc. The Progress Notes dated 06/01/15 at 11:26 p.m. documented Resident #1 refused to go to bed. Staff redirect Resident #1 to rest now and the next morning he/she would see his/her family. Resident #1 continued to refuse and (staff assisted) him/her to the wheelchair (and took him/her to) the nurse's station. The Progress Notes dated 06/02/15 at 1:01 a.m. documented Resident #1 stated he/she was tired and assisted to bed. The resident rested there for 20 minutes and then (staff ) assisted him/her back into the wheelchair because he/she set off his/her alarm by crawling to the head of his/her bed to get up. Resident #1 refused to go back to bed. Resident #1 sat up in the wheelchair and sat at the nurse's station for 1 to 1 so the certified nursing assistants (CNA's) could do rounds. The Progress Notes dated 06/05/15 at 12:30 a.m. documented Resident #1 awake and set off the alarm while attempting to get out of bed. Staff assisted Resident #1 to sit in the wheelchair and gave him/her a stuffed animal to hold. Resident #1 wandered into the dining room and then back to the lounge by the nurse's station. Resident #1 talked to the stuffed animal and watched staff while they made rounds. The Progress Notes dated 06/14/15 at 10:35 p.m. identified Resident #1 had been restless and anxious. Staff found Resident #1 in bed standing beside his/her bed when the nurse answered the alarm. Resident #1 did not want to go back to bed and staff assisted him/her into his/her wheelchair and out to the nurse's desk. An Incident Report dated 06/21/15 at 1:05 p.m. documented Resident #1 took his/her canary alarm off his/her siderail and walked out of his/her room carrying the canary alarm. Resident #1 made it just outside his/her door and then fell to the floor. Staff found Resident #1 lying on his/her stomach with more weight on his/her left side. Resident #1 stated he/she wanted to get up, so he/she got up, and stated look what happened (now). Resident #1 stated he/she fell down on the hard floor and this was terrible. The report indicated Resident #1 had [DIAGNOSES REDACTED]. The Progress Notes dated 06/21/15 at 2:14 a.m. documented the nurse came out of another resident's room and found Resident #1 lying on the floor right outside his/her room. Resident #1 laid on his/her stomach with most of his/her weight on the left side. Resident #1 complained of right shoulder pain and his/her wrist hurt. Resident #1 could move both wrists very well and did not complain of pain when moving his/her wrist. No injuries noted. Resident #1 took his/her canary alarm off and carried it with him/her out of the room when he/she fell in the hallway. At 6:50 a.m. Resident #1 rested in bed quietly. During passive range of motion (ROM) to the right leg, Resident #1 complained of his/her right groin area hurting, and rubbed the area. Resident #1's right leg appeared shorter than the left and rotated outward. Resident #1 could not move his/her right leg by him/her(self). At 7:54 a.m. Resident #1 transferred by ambulance to the hospital. At 9:40 a.m. staff received a call from the hospital and Resident #1 admitted to the hospital with [REDACTED]. A hospital Consultation Report dated 06/21/15 documented Resident #1 resided at the nursing facility and sustained a fall early in the morning when he/she got up out of bed on his/her own and was unable to ambulate after the fall with evidence of right hip pain. The X-rays showed a right hip intertrochanteric fracture with subtrochanteric extension. The plan included to stabilize him/her medically and proceed with surgery the following morning. The Progress Notes dated 06/25/15 at 10:00 a.m. documented Resident #1 admitted to the nursing facility. Resident #1 dependent on staff for bed mobility and transfers. At 10:05 a.m. staff received a report from the hospital nurse at 9:52 a.m. Resident #1 had surgery to the right hip following a fracture after a fall. The incisions on Resident #1's right hip did not drain much, with staples and dressings in place. The Progress Notes dated 06/26/15 at 7:56 a.m. documented Resident #1 demonstrated facial grimacing during transfers. The Progress Notes dated 07/01/15 at 9:21 a.m. documented Resident #1 complained of right shoulder pain. Resident #1 grimaced and moaned when touched or moved, stating his/her shoulder hurt pretty bad. At 9:23 a.m. Resident #1 complained of shoulder pain more than the right hip and staff notified the physician. In a written statement dated 06/21/15 at 2:00 p.m. Staff D Certified Nursing Assistant (CNA) documented she came on duty at 10:00 p.m. and Resident #1 sat in his/her wheelchair by the front door going up and down the hall. Resident #1 had a seat and a chair alarm. Between 11:30 and 12:00 (midnight) Staff D toileted Resident #1 and put he/she to bed and both the alarms were functioning. Staff D was in another room and came out to find Resident #1 on the floor between 1:00 and 1:30 a.m. in the middle of the hallway. No alarm sounded. Resident #1 had removed the canary alarm from the bedrail and carried it with him/her. The seat alarm remained in the bed and did not sound. After signing, Staff D added Resident #1's side rail was up and the sheets off to the side. Before going to the other (resident's) room Resident #1 had attempted to get up. Staff D helped Resident #1 lie down, tucked him/her in, and reminded him/her of the time. During an interview on 06/30/15 at 5:58 a.m. Staff D stated she assisted Resident #1 to bed between 11:30 p.m. and 12 midnight. She said the pad alarm sounded when Resident #1 stood from the wheelchair and she pulled the canary alarm from the alarm box and it sounded, so she knew they were both functioning. On round between 1 &1:30 a.m. she and Staff B were going to assist another resident and Resident #1's alarm sounded. Staff D went to check on Resident #1 and stated he/she was sitting up in bed. Staff D stated Resident #1 had pulled the canary alarm apart when he/she sat up. Staff D velcroed Resident #1's alarm box to the (bed) side rail. Staff D reattached the alarm and had Resident #1 lay back down, with Staff D reminding him/her it was night time. Staff D and Staff B went to another resident's room. Staff D thought they were in the other resident ' s room for about 5 minutes. Staff D stated when they came out, they found Resident #1 on the floor in the doorway of his/her room. Staff D stated being unaware Resident #1 would take the canary alarm with him/her. Staff D stated she did know Resident #1 could be a night owl. She said after discovering Resident #1 on the floor, she checked the pad alarm and when she tapped it, it sounded. She did not know why it did not sound when Resident #1 got out of bed. She said it was turned on. Staff D stated the canary alarm had been Velcroed to the side rail within Resident #1's reach. In a written statement dated 06/21/15 Staff B Licensed Practical Nurse (LPN) documented at approximately 8-8:15 p.m. she documented and Resident #1 sat in his/her wheelchair by the nurse's station. Resident #1 visited with other resident's and the nurse. Resident #1's roommate asked for something and when Staff B went to the room, at approximately 11:00 p.m. Resident #1 rested quietly with his/her eyes closed. At approximately 12:45 a.m. the CNA and Staff B were on the way to another resident's room and as they passed by Resident #1's room, they heard a couple of beeps and Resident #1 talking. The CNA went into the room to check on Resident #1 and talk with him/her. The CNA came back out of the room and explained she tucked Resident #1 back into bed. The CNA and Staff B went to another resident's room to perform care. When they left that room they saw Resident #1 lying on the floor in the hallway. Resident #1 laid on his/her stomach with his/her weight mostly on the left side. Staff B assessed Resident #1. Resident #1 stated he/she wanted to get up, so he/she did, and look what happened. Staff B asked the CNA where the canary alarm was at, and Resident #1 responded he/she had it, and showed staff it was wound up in his/her left hand. During an interview on 06/29/15 at 2:43 p.m. Staff B stated she covered for another nurse and had worked a handful of night shifts. She did not know when Resident #1 last toileted (prior to the incident). At 12:45 a.m. she went to help Staff D in another resident's room. When they passed Resident #1's room she heard some beeps from Resident #1's alarm. Staff D went into the room and when she came out Staff D said she had tucked Resident #1 back into bed. Staff B did not know if Resident #1 tried to get up or (just) rolled in bed. She went to the other resident's room, and thought it may have taken 15 minutes in that room. Staff B stated then they came out and saw Resident #1 on the floor in the hallway. She asked about the canary alarm and Resident #1 had it in his/her hand. The other alarm was in the bed, but Staff B did not go in and check the alarm. Staff B said Staff D held it up and it sounded. Staff B stated if she had known Resident #1 tried to get up, she would have tried to find out his/her reason for getting up. During an observation on 06/30/15 at 7:49 a.m. Resident #1 laid in a low bed with a mat beside the bed and an alarm box on the left side rail (within Resident #1's reach). At 8:26 a.m. 1 alarm box remained on the left side rail, and 1 noted under the bed. During an observation on 07/02/15 at 7:07 a.m. Resident #1 laid in in the low bed with both alarm boxes hanging on the left (bed) side rail within Resident #1's reach. During an interview on 07/01/15 the Director of Nursing (DON) stated she talked to staff about the addition of the 2nd alarm in December and the only thing she could think was Resident #1 had agitation. The MDS Coordinator stated she did not recall why they added the 2nd alarm. During an interview on 07/01/15 at 12:00 p.m. when discussing the incident and concern with leaving the canary alarm within reach of the resident and not attending to/trying to ascertain what the resident needed when setting the alarm off prior to the fall, the DON shook her head in an up and down motion, in affirmation. During an interview on 07/02/15 at 7:12 a.m. the DON stated Resident #1 had not started therapy because he/she did not cooperate in the hospital. The DON stated Resident #1 started working with restorative and walking prior to the fall. At 8:15 a.m. when notified the alarm boxes were on the (bed) side rail, the DON stated she intended to deal with it that morning. II. Based on observation, staff interview and review of Material Data Sheet (MSDS) the facility failed to secure chemicals and medicine and provide an environment free from accident hazards for 26 cognitively impaired, independently mobile residents. The facility reported a census of 83 residents. Observation of an unlocked drawer in the hospitality area of the main dining room on 7/1/15 at 7:45 a.m. revealed a unopened box of Alka-Seltzer containing 24 tablets. b. Observation of the soiled utility room on Lakeland Hall on 7/1/15 at 11:25 a.m. revealed an unlocked door. Observation of a double door cabinet revealed the left door unlocked and a childproof latch on the inside of the right door. Without a key and without unfastening the latch, the right hand side of the cabinet could be accessed from the left side. The right hand side of the cabinet revealed the following chemicals with instructions to keep out of reach of children: 1-32 oz bottle of TMA Liquid Laundry Pre-spotter 1-16 oz bottle of Hollister M9 cleaner/decrystallizer 1- 15.5 oz bottle of Staph Ban disinfectant spray 2-1 quart bottle of Airlift Tropical Odor Eliminator 1- 1 quart bottle of Spartan Contempo Spotting Solution 2- 2 lb. container of Spartan Hard Surface Disinfecting Wipes 1- 1 quart bottle of HDQ Neutral Disinfectant 1- 1 quart bottle of DeVere One Step Quaternary Cleaner and Disinfectant 1- 1 quart bottle of Clorox Bleach and Water 10:1 c. Observation of the soiled utility room on the Transitional Care Unit Hall on 7/1/15 at 11:25 a.m. revealed an unlocked door. Observation of a double door cabinet revealed the left door unlocked and a childproof latch on the inside of the right door. Without a key, and reaching into the cabinet through the left door and unfasten the latch mounted on the inside which opened the right door. the right hand side of the cabinet could be accessed from the left side. The right hand side of the cabinet revealed the following chemicals with instructions to keep out of reach of children: 1- 1 quart bottle of HDQ Neutral Disinfectant 1- 32 oz. bottle of TMA Liquid Laundry Pre-spotter 1- 32 oz. bottle of Holmes Humidifier Water Treatment 1- M9 Hollister cleaner/decrystallizer 1- 2 lb. container of Spartan Hard Surface Disinfecting Wipes Review of a document provided by the Director of Nurses on 7/1/15 at 10:00 a.m. revealed 26 residents listed as cognitively impaired and independently mobile. During the environmental tour on 7/1/15 at 10:30 a.m., the Maintenance Supervisor stated the soiled utility room doors were always unlocked due to the presence of the childproof latches. During an interview on 7/1/15 at 11:30 a.m., the Administrator stated the soiled utility room doors should be locked and the child locks on the cabinets were not sufficient.

Based on record review, staff interview and policy review the facility failed to follow there Abuse Policy to assure an alleged perpetrator had been separate from the victim following allegation of abuse for 1 of 4 residents reviewed (Resident #1). The facility identified a census of 86 current residents. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE] Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident had short and long term memory problems and moderately impaired cognitive skills for daily decision making. According to the MDS the resident did not exhibit behavior problems and required extensive assistance with transfers and toilet use. The MDS identified the resident required two person physical assistance for bed mobility (moving to and from lying position, turning from side to side and position body while in bed). The MDS identified the resident always incontinent of urine.The MDS documented the resident did not have any physical behaviors directed towards others (no hitting, kicking, grabbing, pushing others). The care plan dated 11/13/14 directed staff to check and change the resident. The care plan did not identify the resident had behaviors directed towards others, (no hitting, kicking, grabbing, pushing others). Review of the Progress Notes dated 12/31/14 at 4:30 PM revealed the resident's family updated on occurrence from last PM. Review of Progress Notes dated 11/1/14 documented Resident #1 usually understands staff. A progress note dated 2/3/15 document on 11/15/14 Resident #1 had been uncooperative with cares when getting up for supper and this was the only occurrence of behavior this quarter. Review of the Investigation notes on 12/31/14 revealed that an incident reported about the overnight shift on 12/31/14 at 1:30 AM. Staff I, CNA (Certified Nursing Assistant) reported an incident that she had to Staff K, RN (Registered Nurse) at about 2:00 AM. Staff I reported that she did rounds with Staff L, CNA and went to the resident's room. Staff I went to get gloves and Staff L checked the resident to see if he/she voided and needed to be changed. The resident had his/her penis out of the brief and had voided all over him/herself. Staff L became upset and stated that the resident always did that. Staff L then flicked the resident's penis several times and called the resident a [MEDICATION NAME] bag. During an interview with Staff I, CNA on 2/20/15 at 3:00 PM she stated that she worked on 12/30/14 from 11:00 p.m., to 7:00 a.m., on 12/31/14. She did rounds on the resident's hall with Staff L, CNA. The resident had been incontinent, the bed had been wet and required a complete bed change. Staff L then stated that the resident had done that all night and Staff L then took the resident's brief off and flicked the resident's penis with her finger 2 to 3 times and called the resident a [MEDICATION NAME] bag. The resident then became very combative and angry and began cursing and hitting at Staff L. Staff I did not say anything to Staff L but did later tell the charge nurse. The nurse did not say anything to Staff L and Staff L did assist with the resident during 4:00 a.m. rounds. Staff L did go back into the resident ' s room during the 4 a.m., rounds and Staff I did most of the cares. Staff I reported Resident #1 had still been agitated during the 4:00 a.m., rounds and sat up in bed and cursed and struck out at Staff L. During an interview with Staff L, CNA on 2/20/15 at 10:50 a.m., she stated that she had worked both 2:15 p.m., to 11:00 p.m., on 12/30/14 and 11:00 p.m., to 7:00 a.m., on 12/31/14. She stated that no staff mentioned an incident during the shift and that she did work the entire shift. Staff L reported she showed up for work at approximately 2:15 p.m., on 12/31/14 and the DON came to talk with her about the incident. Staff L denied the alleged abuse allegation. The police report identified on 12/3/14, the DON spoke with the police department regarding an incident that occurred earlier in the morning at the nursing home. Two CNA ' s, Staff I and Staff L were working with Resident #1 around 1:30 a.m.. The resident had pulled out his penis and urinated on his bed/blankets. While in the room, Staff L flicked the resident ' s penis several times causing Resident #1 pain. The police report identified on 1/7/15, Staff I had been interviewed and stated Resident #1 had pulled his penis out and urinated on the bed/sheets. Staff I reported Staff L was upset and called Resident #1 a " [MEDICATION NAME] bag " then flicked his penis. Staff I reported Resident #1 became violent and angry and tried to get out of bed and attempted to punch Staff L. Staff I reported the resident was in pain and frustrated. During an interview with Staff K, RN on 2/23/15 at 5:00 p.m., she stated that Staff I, CNA had told her about an incident that she witnessed with Staff L, CNA towards the resident. She stated that she did not say anything to Staff L and that she continued to work on that hall during that shift. Staff K stated she waited for the Administrator and wondered why Staff I had not turned this in, she had seen it not her. Staff K stated this made her feel ill, she felt guilty. Staff K reported the other nurse (Staff A) told her to wait and tell the Administrator. Staff K reported the resident was louder than usual that time. Staff K called the surveyor back and reported she had not been sure of the time that Staff I reported the incident but thought it had been towards the end of the shift. During an interview with the DON (Director of Nursing) on 2/19/15 at 9:40 a.m. she stated that the Administrator reported the incident to her the morning of 12/31/14. She further stated that she questioned Staff L, CNA about the incident when she came in for her next shift on 12/31/14 at approximately 2:15 PM. Staff L denied the incident but admitted to using swear words and the DON then escorted Staff L out of the building. During an interview with the Administrator on 3/4/15 at 8:20 a.m., she stated that Staff K had told her that she had separated Staff L and the resident. Review of the Abuse Prevention, Identification, Investigation, Reporting Policy (not dated) directed staff to do the following: a. During the investigation, facility staff shall separate the affected resident from the person accused of abuse and maintain that separation until the abuse investigation is completed. If the investigation results in a reporting of the incident to the Department, the separation shall be maintained until the conclusion of the Department investigation. This separation may be maintained by suspending the accused employee to a shift or area of the facility so that no contact is made between the accused employee and the affected resident.

Based on observation, record review and staff interviews, the facility failed to ensure residents received adequate supervision against hazards for 1 of 4 residents (Resident #1). On 09/05/14 Resident #1 eloped from the facility without the facility staff aware of his/her whereabouts for approximately a half hour (1/2) after the door alarm sounded. Staff responded to the door alarm by turning the alarm off and no one checked the door/s. The Resident walked to a local store and a community member called the nursing home to alert them of a disoriented person had been observed leaving the store. Record review determined Resident #1 lacked the ability to make decisions about his/her safety and had a history of [REDACTED]. The findings constitute an immediate jeopardy to the resident's health and safety. The facility reported a census of 91 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had moderate difficulty hearing, no speech, was rarely/never understood, and sometimes understood others. Resident #1 could not complete the Brief Interview for Mental Status (BIMS) cognitive skills test. Resident #1 demonstrated long and short term memory problems and had severely impaired daily decision making skills. Resident #1 experienced signs and symptoms of delirium including fluctuating inattention and altered level of consciousness. Resident #1 required two staff assistance with activities of daily living (ADL's) including bed mobility, transfer, eating and toilet use. Resident #1's [DIAGNOSES REDACTED]. At the time of the assessment Resident #1 used a wheelchair for mobility. An Elopement Risk Assessments dated 07/21/14 and 7/28/14 identified Resident #1 at risk for elopement. The Care Plan revised on 08/11/14 identified Resident #1 had impaired mobility with a risk for falls and poor safety awareness. The interventions included : a. Ambulation independently throughout the facility. Resident #1 had a Wandergard on his/her left ankle, placed 09/03/14. Staff observed for mobility. The care plan identified Resident #1 demonstrated altered thought process related to advanced dementia evidenced by severely impaired thought process and he/she rarely spoke. The interventions included the following: a. Due to his/her inability to express needs, staff needed to watch for facial expressions and anticipate needs. b. Resident #1 no longer recognized his/her spouse, yet they visited almost every day. c. Resident #1 used facial expressions to express likes and dislikes, and staff to encourage him/her to respond to simple yes or no questions. The Progress Notes dated 09/03/14 at 2:45 a.m. documented Resident #1 acted restless and walked several times but tried to go out exits and into other residents rooms. The Progress Notes dated 09/03/14 at 3:56 p.m. documented Resident #1 had been independent throughout the facility with staff supervision. Staff closely supervised him/her due to walking without purpose and at times he/she went to other (residents) rooms and chairs, and to the doors. The Progress Notes dated 09/03/14 at 7:42 p.m. documented Resident #1 tried to escape the building, making it through the first set of doors. The CNA's redirected Resident #1 back in, then he/she went down the hall and attempted to go out another exit door. When the Certified Nursing Assistant's (CNA's) tried to redirect Resident #1, he/she started to push them away. The Progress Notes dated 09/03/14 at 8:48 p.m. documented Resident #1 went through the break room doors. Staff redirected him/her to the lobby. Resident #1 continued to try to go out the breakroom and kept setting off the door alarms. The Progress Notes dated 09/04/14 at 3:24 p.m. documented because of Resident #1's wandering and potential for elopement the DON and social worker met with Resident #1's spouse to discuss whether to look at him/her returning to the memory care unit where he/she admitted from. The Progress Notes dated 09/04/14 at 10:46 p.m. Resident #1 wandered the hallways. Staff found Resident #1 on another hall sleeping in another resident's bed. In a typed note regarding Resident #1 dated 09/05/14, the Director of Nursing (DON) wrote she was at the nurse's station talking on the phone when a CNA approached her and said Resident #1 went outside and walked down by the supply store. Staff found Resident #1 in a supply store and returned him/her to the facility. Upon investigation they noted at approximately 4:20 p.m. one of the door alarms went off and office personnel paged to check the north door. No one recalled any response to the page. The DON in serviced staff at 5:00 p.m. regarding protocol for answering all alarms. The note indicated Resident #1 did not give any indication of leaving; he/she just walked without purpose. A typed letter documented on September 5th, 2014 at approximately 4:50 p.m. the Activity Coordinator/Director (AD) answered a call from parts store. The female caller informed the AD that a person had walked in the store and appeared disoriented. All available staff proceeded to investigate and go to the area. They found Resident #1 at supply store at approximately 5:00 p.m. Resident #1 returned via the AD's car with 2 other staff persons at his/her side. They determined staff last saw Resident #1 at approximately 4:20 p.m. Office personnel heard a door alarm go off and announced to check the north door at approximately 4:20 p.m. No one replied or checked the north door, but staff turned the alarm off. Staff assessed Resident #1 and noted 2 small abrasions to the right knee, which they cleaned and treated. Upon the return of Resident #1 and finding him/her unharmed, the DON held a meeting with staff to educate them on the protocol for door alarms and the response protocol. Door alarms were to be checked immediately and visually assessed for persons leaving or coming to the building. If they visually saw the person, they were to announce all clear on the intercom. If they did not see a person, they were to go outside and check all directions. If they did not see a resident they were to complete a head count in the building to make sure all residents were in house. They were to announce all clear if applicable, or continue the search for the resident. The north door (which they determined Resident #1 went out) had a functional alarm checked daily. Maintenance placed an alarm on the interior door Friday evening (after the elopement) as an extra precaution. An Elopement Report form dated 09/05/14 documented Resident #1 was cognitively impaired with poor decision making skills. He/she ambulated independently. Resident #1 was identified as a wanderer, oblivious to physical and safety needs. Resident #1 had a Wandergard. Resident #1 may speak at times, but difficult to understand. Staff last saw Resident #1 at 4:15 to 4:30 p.m. The facility took action upon receiving a phone call at 4:50 p.m. Staff found Resident #1 at supply store at 4:55 p.m. After the elopement, staff noted Resident #1 with small knee abrasions to the right knee 0.2 by 0.5 centimeter (cm) and 1.1 by 0.3 cm. The potential for injury included uneven surfaces and blacktop road. The hazards present were light motor vehicle traffic. A facility layout showed Resident #1 resided on Manhattan hall in the mid-south portion of the building. The layout showed the north door on Lakeland Way on the northeast corner of the building. During an observation on 09/11/14 at 8:05 p.m. driving by supply store on Hi-way 71 noted a speed limit of 40 miles per hour, with 2 lanes northbound and 2 lanes southbound. Hi-way 9 to the north of the nursing home also had a speed limit of 40 miles per hour. At 5:15 p.m. noted moderate to heavy traffic on Hi-way 9 and 71. During an observation on 09/12/14 at 7:21 a.m. when going out the north door noted a ramp with a rail that ran west toward the facility back parking lot. The area beyond the parking lot grassy, sloped and uneven. A person could not walk a straight path to the parts store. Between the parts store and the supply store were a fast food restaurant, a salon, and 22nd Street. An observation of door alarm checks at the north door on 09/11/14 at 8:38 a.m. showed a pull apart alarm on the 1st of the 2 doors at that exit (a new intervention after the elopement). The 2nd door to the outside alarmed at the nurse's station. During an interview on 09/11/14 at 8:15 a.m. the DON stated Resident #1 went out the north door. Staff were out helping with the evening meal and the door alarm sounded. The DON stated the office manager/admissions coordinator (AC) staff used the intercom and asked staff to check the north door and then she shut the alarm off. The DON reported no one went to check the door. The DON stated they are supposed to check the door and say " all clear " , but no one did. According to the DON, the AC staff went back to the dining room and took resident's supper orders. The DON said Resident #1 must have walked down the driveway to a hardware store. The DON stated someone from the store called and said Resident #1 was there, but leaving. The DON reported Resident #1 crossed 22nd street to another store, and was inside when staff arrived. She said Resident #1 would answer questions if asked but would not make his/her needs known verbally. She said when they assessed Resident #1 he/she had abrasions on his/her knee, but had no indication of a fall. During an interview on 09/11/14 at 1:35 p.m. the Admission Coordinator (AC) staff stated the door alarm panel buzzed while she was in the front office. She went and checked the door alarm (panel) and it showed the north door had alarmed. She looked around the corner toward the north door and didn't see anyone. She went back to the office and paged overhead for staff to please check the north door. She shut the door alarm off before she paged. She went to the dining room and got busy, and did not hear a response back. She said whoever checks the door should do the all clear. She said she was taught to turn off the alarm and page; and staff were to respond. She said it's good if you can stay at the alarm panel. She said the person who checks the alarm panel can also go and check the door. She said if you check the door and don't see anyone, she thought you would go back and say all clear. She wasn't sure if you had to do any kind of a (head) count. During an interview on 09/11/14 at 3:11 p.m. the Activity Director (AD) stated about 4:50 p.m. she finished some documentation. She answered the phone and someone from a parts store said a disoriented person had been in there and described that person's outfit which made her think of Resident #1. She told a nutritional assistant to let the DON know what went on and left to find Resident #1. The community member from the parts store said Resident #1 headed for a restaurant. The AD told Staff A, Registered Nurse (RN) on the way out. She decided to get her keys and drive. In the mean time Staff A, the DON, and Staff L CNA went on foot in that direction. The AD drove to supply store and found Resident #1 walking down the aisle to the back of the store. Resident #1 cooperated with her, and mumbled something she could not understand. The AD stated prior to the elopement she saw a CNA walking with Resident #1. She tried to get Resident #1 to go with her, but he/she did not want to. The AD told the CNA Resident #1 was exit-seeking and she (the CNA) said she noticed that. The AD did not hear the announcement to check the north door. She said if the door alarm buzzed, you either paged or checked the door yourself. The alarm should be turned off after the all clear. She did not know about doing a head count if you didn't see anyone outside. She said Resident #1 had previously tried to go out the Haven Cove door and the front door. During an interview on 09/12/14 at 10:08 a.m. Staff A RN stated he worked the evening Resident #1 eloped. He did not see Resident #1 before the incident. He did hear the call to check the north door, while with a resident. There was not an all clear called. He said when they cleared the alarm, they should have waited to get the all clear. Someone should have checked the door. He said they should shut the alarm off, page overhead, wait for the all clear, then reset the alarm. If no one gave the all clear, they should go check it themselves. He said prior to the elopement there were times when staff would shut the alarm off without getting the all clear, assuming a family went out, which was completely against the rules. He said a couple days before the elopement, Resident #1 tried to go out the north door and Staff A redirected him/her. Staff A stated Resident #1's nurse knew, and he talked to the DON about putting an alarm on the 1st of the 2 doors at that exit, but they did not until after the elopement. During an interview on 09/11/14 at 3:27 p.m. Staff C CNA stated she worked the north hall. She saw Resident #1 wandering around so she asked if he/she still needed an alarm and they (other staff) said no. She said Resident #1 ambulated at the end of the north hall and she had to go answer a light. When she came back she did not see Resident #1, then she went to break. Staff C stated she heard to check the north door over the walkie. She did not hear all clear. She said that happened sometimes. Staff C said someone told her Resident #1 was exit-seeking, but she did not see him/her. During an interview on 09/11/14 at 3:35 p.m. Staff D CNA stated she saw Resident #1 earlier in the evening walking toward the front door. Someone stopped Resident #1 and he/she walked back to his/her area. Staff D did not recall hearing a page to check the north door. She said she would have checked the door, checked outside, and if she could not determine who went out, would say " not clear " so they would check the residents. She said she usually silenced the alarm. Whoever did the page was responsible to make sure they had an all clear. During an interview on 09/11/14 at 3:41 p.m. Staff E CNA stated she worked on Resident #1's hall. The last time she saw Resident #1 before the elopement, Staff I RN redirected him/her away from the front door, her way. She had him/her sit in the recliner and he/she actually followed her into a room. When Staff E came back out, Resident #1 was gone. Staff E knew of Resident #1's risk of elopement. They were to know Resident #1's location. She said she knew the resident ' s location, and then admitted she did not know until after the elopement; from approximately 3:30 p.m. to 5:00 p.m. She did not hear the call to check the north door. She said they were supposed to intercom door alarm checks. They were not to turn the alarm off until they got the " all clear " . They were to check the door, and check outside the door, and if they did not see anyone, say to check all residents. During an interview on 09/11/14 at 1:50 p.m. Staff F RN stated she worked Resident #1's hall the evening he/she eloped. Prior to the elopement, Resident #1 walked around in the hallway. Staff C came down the hall and asked if Resident #1 should be walking now, he/she had recently become independent. Staff F did not know if Resident #1 tried to get out (elope) before that. Prior to staff finding Resident #1 she heard someone say over the intercom to check a door. She did not hear anyone respond " all clear " . She said whoever was near the door should check the door. If no one was near the door, staff assigned (to that hall) should check the door. She said when she checked a door alarm, she looked around outside. If all clear, she went back and said door all clear. If no one outside, she probably would not do a headcount. During an interview on 09/11/14 at 2:08 p.m. Staff G CNA stated she worked on north hall the evening Resident #1 eloped. She heard the page to check the north door. Staff G responded to a personal alarm and could not leave. She did not hear the all clear. Until then she did not know what to do if she did not hear the all clear. She now knows if she does not hear the all clear, to go and check. She said when she heard a door alarm go off she checked the alarm panel and went and checked the door. If she did not see anyone at the door she would go outside and look both ways. If she did not see anyone she would call a Code Silver, which is a head count to make sure residents were accounted for. She thought whoever saw the alarm was responsible for making sure they got the all clear. She said this was not the 1st time they had not done the " all clear. " During an interview on 09/11/14 at 2:18 p.m. Staff H CNA stated she did not see Resident #1 prior to the elopement. She went to supper break and came back and saw staff bringing him/her back. She heard no calls to check the north door. She said if she responded to a door alarm she would go to the door and check it. She would go outside and make sure no residents went outside. If she did not see anyone she would let it be known it was okay over the walkies and shut the alarm off. She would not do a head count if she did not see anyone, she would just make sure no one went out. During an interview on 09/11/14 at 4:00 p.m. Staff I RN stated it was common sense to check outside and if did not see anyone keep looking. She said no one trained her what to do. She said Resident #1 tried going out the front door when she walked up there another time. She did not hear the page to check the north door. She saw Resident #1 prior to the elopement, hovering around the medication cart. She redirected Resident #1 back to his/her hall. During an interview on 09/11/14 at 2:26 p.m. Staff J CNA stated the evening Resident #1 eloped, he/she sat in the TV area at 4:10 p.m. when she went to break. When she returned (from break) everyone said Resident #1 went missing and they were looking for him/her. She did not hear an announcement to check the north door in the breakroom. She said when a door alarm went off they find out which door and either go to the door and check it or page for someone to check it. She said to check the door you would make sure no one walked around outside, turn the alarm off and say alarms okay over the walkie. Staff J stated she had never used the intercom. She said she did would not turn the alarm off until she checked (the door). She said when she came in that day, they said Resident #1 got out the Haven Cove door to the fenced in area and they had an additional alarm on that door. She said he/she kept going to that door when she worked 09/03/14. During an interview on 09/11/14 at 2:38 p.m. Staff K CNA (agency staffing) stated she worked the north hall the evening Resident #1 eloped. She thought she heard an announcement to check the north door. She was in a room getting people up. She had just started in the facility that week. She did not know the protocol for checking door alarms. The DON had training after the elopement. She said if alarm heard, announce it over the intercom, check the door and if you don't see anyone give the all clear. She said you do a headcount if a certain amount of time passes before the door was checked. During an interview on 09/11/14 at 2:45 p.m. Staff L CNA stated she worked on Resident #1's hall the evening of the elopement. Resident #1 came in another resident's room while giving care and she shoed him/her out, and he/she headed toward the dining room, around 3:30 p.m. She did not hear an announcement to check the north door. Staff L stated Staff A and the AD were outside. She went out and the AD told her to tell the DON Resident #1 went outside the building. Staff L ran to supply store with the DON. They found Resident #1 inside. She said Resident #1 mumbled. She said when they had walked with Resident #1 with assist of 2 he/she would go to the door. They were told he/she had a Wandergard bracelet because he/she was disoriented and confused. She said if she heard a door alarm go off on the panel, she would page to check the door. Normally they say clear, but not always, but assume it is clear. If she goes to check the door she goes outside and if doesn't see anyone she will complete a head count. She said she shuts the alarm off before they say all clear. During an interview on 09/12/14 at 9:20 a.m. the Human Resources (HR) Director stated she did orientation with all staff. She had a check off sheet and first on the tour was door alarms. She showed new staff the panel and set the front door off so they can see it light up and hear it. She showed them how to shut the alarm off. She told them if they were right there and knew who set the alarm off, they could shut the alarm off. If they did not know who set it off, they needed to step outside to look around and make sure there was not a resident out there. If not nursing staff (responding to the alarm) they were to tell a nurse. If they could not identify (who set the alarm off) they were to check residents assigned to work with. She said if it was a door they could not see they were to page over the loud speaker. She showed staff how to do that. She told them to wait there until they heard the " all clear " . If they stayed by the panel they could shut the alarm off and wait for the " all clear " . If they went to check the alarm (door) themselves they needed to leave the alarm sounding. During an interview on 09/11/14 at 1:24 p.m. the DON stated they had no policy/ (procedure) on checking doors when alarming. She said they taught staff what to do and had in-service on it. The HR taught staff during orientation. The facility abated the IJ on 9/14/14 when they implemented the following written training module for staff to follow: The Door Alarm Training Module identified the steps staff should follow when the door alarm goes off at the panel: Go to the panel & locate which door alarm is going off, then go to the panel. Leave the panel alarm " ON " and page for staff to check that particular door. If it is the front door, check it yourself. Wait at the panel for an " all clear " back from staff that had checked the door. If no response in 30 seconds, page again. If no response to the page, then go to the door yourself. After " all clear " , turn alarm off at the panel. Staff were reeducated on how to check the actual door that had alarmed. Staff should check to see if a resident is inside by the door, or outside. If the resident is found, return them to the building. Page all clear and notify the nurse of that resident exiting in order for the nurse to assess. If no one is seen, have the floor nurses implement a head count of residents. If resident is missing, implement the code silver procedure. Staff were showed the location of all door alarm panels at the nurse ' s stations. Staff were educated 1:1 by the Administrator, Human Resource Director and Maintenance Director on 9/12/14 to 9/14/14 on the written instructions for responding to door alarms. The facility added motion sensors before the Hill and Haven code exit doors and a tab alarm on the door immediately before the exit door on Lakeland exit door. Exit stopper door alarms were ordered and would be placed on Haven Cove exit, Hill exit and & Lakeland exit doors (by 9/15/14.) All exit doors are wired to the door alarm panel except Haven Cove exit door; which has a built in alarm at the door with the keypad. These actions lowered the deficiency from a scope and severity of J to D, with the need for ongoing monitoring of the staff responding to door alarms.

Based on record review and staff interview the facility failed to ensure residents free of significant medication errors that included the administration of blood thinner medication ([MEDICATION NAME]) according to the physician's orders [REDACTED].#4). Record review identified Resident #4's physician lowered the resident's [MEDICATION NAME] medication from 5.0 milligram (mg) to 2.5 milligrams on 9/3/14. The nurse failed to follow the physician's orders [REDACTED].#4 from 9/4/14 to 9/6/14. The resident's blood test on 9/8/14 revealed his/her blood clotting values were elevated and he/she transferred to the emergency roiagnom on [DATE]. The resident also had blood in his/her stools and bruising on his/her upper extremities. The facility had no medication policy to direct nurses when obtaining a new medication or discontinuation of medication. The findings constitute an immediate jeopardy to the resident's health and safety. The facility identified a census of 91 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated , Resident #4 had [DIAGNOSES REDACTED]. The MDS identified the resident with a Brief Interview for Mental Status (BIMS) score of 15, which revealed intact cognition. The Admission assessment dated [DATE] identified Resident #4 had been admitted after mitral valve replacement surgery (cardiac surgical procedure). The assessment noted Resident #4 was on an anticoagulant therapy (a class of medications used to prevent coagulation (clotting) of blood). The hospital Anticoagulant Therapy record dated 8/25/14 (prior to the nursing home admission) showed the resident ' s ([MEDICATION NAME]) [MEDICATION NAME] medication dosage (blood thinner medication) under rigid control as evidence by daily monitoring from 8/15/14 to 8/26/14 of his/her International Normalized Ration(INR), with a goal range of 2.5 to 3.5. (According to Heart Rhythm Society, the INR is useful in monitor the impact of the anticoagulant (blood thinner) medication. An INR can be too high ... and can indicate that blood is clotting too slowly, creating a risk of uncontrolled bleeding. ) Review of the physician's orders [REDACTED]. The physician's order [REDACTED]. On physician's order [REDACTED]. Review of the Medication Administration Record (MAR) dated 8/26/14 through 8/31/14 revealed the order for ([MEDICATION NAME] sodium) [MEDICATION NAME] 5 mg by mouth 1 time daily. The medication administered 8/27/14 through 8/31/14. Review of the MAR dated 9/1/14 through 9/29/14 revealed the [MEDICATION NAME] on hold 9/1/14 and 9/2/14. The MAR showed staff administered 2.5 mg of [MEDICATION NAME] on 9/3/14, 9/4/14, 9/5/14, and 9/6/14 and also administered 5 mg [MEDICATION NAME] on 9/3/14, 9/4/14, 9/5/14 and 9/6/14 (total 7.5 mg daily). On 9/7/14 the [MEDICATION NAME] 5 mg had been discontinued on the MAR and only 2.5 mg [MEDICATION NAME] had been administered. According to a 2 Facsimile (FAX) from the [MEDICAL TREATMENT] center dated 9/8/14, they informed the nursing home to HOLD Resident #4's [MEDICATION NAME] medication as the resident's INR was 10.5. Review of the Laboratory Specimen Report for the resident ' s blood clotting time showed his/her [MEDICATION NAME] ([MEDICATION NAME] time) (PT)/International normalized ration(INR) dated 9/8/14 revealed PT 125.3 and INR 10.50 (high). Review of the Medication Error Investigation Report dated 9/8/14 revealed medication [MEDICATION NAME] 5 mg given an extra 4 days (on 9/3/14, 9/4/14, 9/5/14, and 9/6/14). The physician had ordered on [DATE] to decrease the medication to 2.5 mg effective 9/3/14. The medication error report identified the medication error had been evident by the missing medication cassettes for [MEDICATION NAME] for 9/3/14 to 9/6/14. The reported noted Staff A had taken the physician's orders [REDACTED]. Review of the Progress Notes dated 9/9/14 at 9:00 AM revealed the resident had a nose bleed in the morning and large amount of blood in his/her bowel movement. Bruising noted over the bilateral upper extremities. The resident transferred to the emergency room for evaluation of condition. The progress note at 4:10 PM revealed a telephone call from the emergency room revealed no new orders and that the resident's PR/INR continued to be elevated. The Physician did not want to give vitamin K due to the resident's past heart history. The physician wanted an INR checked the next day and to no [MEDICATION NAME] given. The blood in the resident's ostomy to resolve. At 2:15 the resident returned to the facility. According to Health Net February 2005, the Scientific Rationale identified [MEDICATION NAME] must be taken maintained within the therapeutic range to minimize adverse events associated with excessive anticoagulation such as serious bleeding. During an interview with Resident #4 on 9/11/14 at 2:30 PM he/she stated that he/she went to the hospital and stayed there for 4 hours. He/she also stated that he/she felt very rough that day. The physician's orders [REDACTED]. A repeat PR/INR on 9/10/14 revealed PT 48.9 and INR 4.33. On 9/10/14 a new order to restart [MEDICATION NAME] at 2.5 mg. During an interview with the DON (Director of Nursing) on 9/11/14 at 1:30 PM she stated that the Medicare Nurse brought the medication error to her attention on 9/8/14. Staff A, RN (Registered Nurse) stated he had taken the order for [MEDICATION NAME] 2.5 mg and asked another nurse to remove the discontinued cassette that held 5 mg [MEDICATION NAME]. The medication cassette did not get removed (from the medication cart). Staff A had been educated to ensure that he needed to follow through with the order ' s that he received. During an interview with the Medicare Nurse on 9/12/14 at 8:10 AM she stated that during the resident's assessment, she looked back and saw the resident had two doses of [MEDICATION NAME] ordered. She looked and saw both medication cassettes remained. The [MEDICAL TREATMENT] center had already took the resident's PT/INR and called the facility. She then called [MEDICAL TREATMENT] back and explained the error. During an interview with Staff A, RN on 9/12/14 at 10:00 am he stated that he had put the new order for [MEDICATION NAME] 2.5 mg in the computer and did not discontinue the 5 mg entry. He stated also that he had asked another nurse to pull the medication cassette that held the 5 mg dose (of [MEDICATION NAME]) from the medication cart. He passed medications on 9/7/14 and saw the medication for [MEDICATION NAME] 5 mg come up to administer. Staff A stated he thought the [MEDICATION NAME] was on hold over the weekend. Staff A then discontinued the medication because he knew that he had taken the physician's order [REDACTED]. He did not look at the previous days to see if the 5 mg dose of [MEDICATION NAME] had been administered. He stated that he assumed the medication had been held since it was on hold previously. Staff A reported the Medication Nurse and another staff came to talk with him about it and that ' s when he realized it was a medication error. Medication Error Investigation Report dated 9/8/14 the DON identified the precautions taken to prevent similar errors included the nurse education to pull cassette themselves OR for the nurse to watch the other nurse remove it; and place it in the return bin; and then triple check medications prior to giving the medication. During an interview on 09/12/14 at 12:30 p.m. the DON stated they had no policy on medication administration or medication orders. She said they learned about these things in school and nurse's were oriented prior to working on their own. The facility abated the IJ on 9/14/14 when they implemented the following written medication training module as follows: New Medication Training Module identified the steps nursing staff to follow when a signed physician's order [REDACTED]. Enter a progress note that order was received and updated family, place the noted order in the resident ' s chart. Write on the 24 hour communication sheet and for the charge nurse to sign medication in when received from the pharmacy. To discontinue medication, staff should obtain a signed physician's order [REDACTED]. and write on the 24 hour communication sheet. Nursing staff were educated on 9/12/14 to 9/14 by the DON and Ancillary Nurse. These actions lowered the deficiency from a scope and severity of J to D, with the need for ongoing monitoring.

Based on observation, clinical record review and staff interviews, the facility failed to ensure residents received adequate supervision against hazards and failed to direct nursing services to modify and or implement residents ' plan of care for two (2) of three (3) residents. While not visually monitored as the care plan directed, Resident #2 fell which resulted in fractures. Resident #1 did not receive adequate supervision and fell when staff could not respond to the resident's alarm due to being with another resident at the time Resident #1's alarm activated. The facility census was ninety-three (93) residents. Findings include: 1. A Minimum Data Set (MDS), with assessment reference date, 5/21/13 assessed Resident #2 with a brief interview for mental status (BIMS) score of "7" (severe cognitive impairment). The assessment revealed the resident had signs and symptoms of delirium displayed by his/her inattention (difficulty focusing attention, easily distracted or out of touch or difficulty following what was said). The resident had no behavior symptoms identified. The resident required extensive assistance of two staff with bed mobility, transfers, ambulation in room, dressing, toileting, personal hygiene and bathing. A balance test during transitions and walking identified the resident with a score of "2" in all areas of testing. A score of "2" identified the resident as not steady and only able to stabilize with staff assistance. The resident used a walker and wheelchair for mobility. The resident had functional range of motion limitations on one side of the lower extremities. The resident was frequently incontinent of bowel and bladder and not on a toileting program. The resident had [DIAGNOSES REDACTED]. The MDS identified one fall with no injury since the previous assessment. The resident was 59 inches tall and weighed 104 pounds. Resident #2 received PT (physical therapy) services from 4/16/13 to 5/20/13. The progress & discharge summary revealed he/she had shown progress with gait disturbance to 250 (feet) and would transition to walking and restorative program at the nursing home. The resident's care plan dated 3/13/13 revealed his/her mobility was impaired and he/she was at risk for falls. The care plan noted the resident had limited ROM (range of motion) to his/her right hip, right leg/hip pain and Meniere ' s disease (a disorder of the inner ear that can affect balance and hearing). The care plan indicated the resident required the assistance of one staff and gait belt to transfer with a FWW (front wheel walker). The care plan updated on 4/24/13 noted a seat alarm was used and should be on at all times for his/her safety. The care plan noted an intervention dated 5/15/13 which indicated do not leave resident unattended while in bathroom. Record review of falls revealed the following: The Record Fall form dated 5/21/13 at 8:15 a.m., revealed staff found the resident sitting on the floor by the couch with legs straight out in front of the resident. The resident's side rail remained up and the alarm did not sound. The intervention following the fall was: Staff replaced the seat alarm with a new one. The care plan noted the side rails were discontinued on 5/22/13. On 5/24/13 the care plan had been updated to assist the resident with two staff for transfers with a gait belt at bed time. On 5/28/13 the care plan now directed two staff to assist with ambulation with a gait belt for all transfers. The care plan intervention dated 5/28/13 directed staff not to leave the resident unattended in the dining room-bring the resident back to his/her room. The Record Fall form dated 6/16/13 at 1:45 a.m., identified the resident at the dining room table. The resident stood up and slid out of his/her chair. The intervention following the fall was: Be within staff sight at all times. A previous care plan intervention dated 5/28/13 directed staff not to leave the resident unattended in the dining room. On 8/26/13 at 10:10 a.m. Staff K (licensed practical nurse) stated the aides walked away and left the resident so the resident got up and fell . Review of the resident's care plan identified the intervention of "keeping resident in sight at all times" added to the care plan on 6/16/13. An incident/accident report, dated 7/4/13 at 1:20 a.m. revealed the resident deactivated his/her alarm when staff tried to lay the resident down to rest. The resident then got up on his/her own and fell over the floor mat and hit the floor. Staff assessed red areas to the resident's knees which dissipated after one hour. The care plan did not contain an intervention following the incident. The progress notes dated 7/7/13 at 9:50 p.m., revealed the resident was finally drifting to sleep after a long day of restlessness and he/she wakes up abruptly jerking his/her arms and legs. The Resident #2 reported to staff he/she was passing out. The nurse completed an assessment of the resident's vitals. The report documented the aide stated that earlier the same thing happened but the resident thought he/she was falling. The progress note dated 7/8/13 at 1:38 p.m., revealed the resident sits with nursing (staff) and startled during rests (jerking and calling out) and the staff was unsure what was happening. The resident had a room change for easier observation to dining room for meals. The resident attempted to self- transfer, ambulate in the hall with a walker; and two staff assisted the resident to return to his/her wheelchair close to nursing and other staff. An incident/accident report dated 7/11/13 at 5:25 p.m. identified the resident in the dining room. The resident stood up and fell over backwards and hit his/her head on the floor which resulted in a small lump on the back of the resident's head. The resident also had bruises to the left elbow that measured 1.8 centimeters (cm) by 1.3 cm.; right wrist measuring 1.5 cm. by 1.5 cm. and right elbow measuring 2 cm. by 1.2 cm. The incident/accident report indicated " everyone in (the) dining room " had witnessed the fall. The care plan did not contain an intervention following the incident. An incident/accident report dated 7/21/13 dated 12:15 p.m. identified the resident removed his/her shirt with alarm attached and stood up by the couch and lost his/her balance. The seat alarm activated and staff was in the resident room, heard it but could not reach the resident in time due to wheelchair in the way. The resident received a 2 cm. by 2 cm. bruise and a 0.3 cm. superficial abrasion to the left elbow and a 5 cm. by 0.2 cm. abrasion to the right elbow. The intervention following this incident was: Attach canary alarm to back waist of trousers. An incident/accident report dated 8/4/13 at 2:20 a.m. identified the resident's bed alarm sounding. Staff found the resident lying on the floor near the bedside table on top of a cushioned mat. Staff observed the resident's head close to the table leg. Staff did not identify injury after the incident. Following the incident, the August 2013 medication administration record (MAR) identified the following: 8/5/13 at 11:33 p.m. staff administered Tylenol (analgesic) for complaints of back pain and at 2:32 a.m. the resident rested quietly, 8/7/13 at 12:45 a.m., staff administered Tylenol for moderate back pain and at 1:58 a.m. the resident rested quietly, 8/8/13 at 12:10 a.m. staff administered Tylenol for complaints of back pain and at 2:38 a.m., the resident rested quietly. On 8/26/13 at 1:55 p.m., Staff F (nurse aide) stated she and Staff G were in a room with another resident when they heard the alarm sound. Staff G went out to check within a minute of the onset of the alarm activating and found the resident on the floor. An incident/accident report dated 8/8/13 at 5:05 p.m. and written by Staff C (registered nurse), stated staff found the resident on the floor in the hallway next to the north whirlpool room with alarms sounding. The resident stated he/she got up and turned around and fell . At that time, staff assessed a 2 cm. by 1 cm. skin tear to the right elbow. Progress notes dated 8/9/13 at 2:54 a.m., 10 a.m., 5:05 p.m. and 8/10/13 at 1:52 a.m., identified the resident rested quietly with no complaints of pain or discomfort. On 8/11/13 at 4:26 p.m. and 11:44 p.m. staff administered Tylenol at 4:26 p.m. due to resident grimacing with pain when moved by staff. Staff followed up after the 11:44 p.m. dose by documenting on 8/12/13 at 3:38 a.m. that staff rested quietly with eyes closed. On 8/12/13 at 4:10 p.m. progress notes identified the staff contacted the physician regarding the resident's pain while ambulating. The physician ordered an x-ray of the pelvis and lower lumbar region. Resident had facial grimacing when ambulating. X-ray arrived on the same date at 6:40 p.m. and performed the x-rays as ordered. On 8/13/13 at 8:40 a.m. the physician phoned with therapy orders for an evaluation and treatment due to pelvic fracture. The physician also ordered Norco (narcotic) 5/325 milligrams (mg) 1 to 2 tablets every 6 hours as needed. On 8/13/13 at 7:34 p.m. staff documented that the resident grimaced and moaned with pain so staff administered Norco. The X-ray Reports revealed the following: An x-ray report dated 8/12/13 identified an x-ray of the spine performed related to pain due to fall. The x-ray report identified a mild compression fracture of T12 which was possibly acute. An x-ray report dated 8/12/13 identified an x-ray of the pelvis performed related to pain due to fall. The x-ray report identified non-displaced bilateral pubis fractures. The x-ray reported the resident had osteopenia and arterial calcification. On 8/26/13 at 3:55 p.m. Staff C (registered nurse) stated she was in a room when the resident fell on [DATE]. She was with another staff and they took care of a resident when the resident fell . Another staff took residents to supper. Staff C stated all staff was busy with other residents so they could not keep the resident in their sight as the care plan directed. On 8/26/13 at 4:15 p.m. Staff D (nurse aide) confirmed everyone was busy when the 8/8/13 fall occurred. Observation showed, on 8/26/13 at 1:07 p.m. two staff transfer the resident from the wheelchair to the bed. The canary alarm was fastened to the back of the resident's slacks and the resident also used a seat alarm. The alarm activated when the resident stood with the two staff and gait belt. As the resident pivoted onto the toilet, he/she grimaced. 2. A Minimum Data Set (MDS) with assessment reference date of 7/6/13 assessed Resident # 1 with a brief interview for mental status score of "3" (severe cognitive impairment) The resident had the following signs and symptoms of delirium: inattention and disorganized thinking. The resident required extensive staff assistance with bed nobility, transfers, dressing, toileting, personal hygiene and bathing. The resident did not ambulate. A balance during transitions and walking test identified the resident as not steady and only able to stabilize with staff assistance when moving from a seated to standing position, moving on and off the toilet and surface to surface transfers. The resident did not perform the walking portion of the test. The resident had functional range of motion impairments of the upper extremities. The resident used a wheelchair for mobility. The resident had one fall with injury since the previous assessment. A care plan revised on 1/18/13 identified the resident with impaired physical mobility related to dementia, potential for falls due to history of falls and due to medication use. The care plan identified the resident used a seat alarm and canary alarm, the resident attempted self transfers and the resident's bathroom door also contained an alarm. The resident required the assistance of one to two staff and the EZ stand for transfers. An incident/accident report dated 6/27/13 at 4:45 p.m. revealed the resident attempted to transfer self to the toilet. Nurse aides were assisting another resident when Resident #1's alarms activated. Staff found the resident on the floor. The resident sustained [REDACTED].) by 0.5 cm. to the left shin. Staff phoned the ambulance at 6:45 p.m. due to the resident's elbow appearing out of place. The resident did not complain of pain. The right elbow was the site of an old previous fracture. Progress notes, dated 6/27/13 at 8:30 p.m. identified the resident returned to the facility with no new orders. The hospital performed an x-ray to the right elbow which showed the preexisting fracture that was not set. An emergency department (ED) record dated 6/27/13 identified the chief complaint as "fall". The physician documented the resident was found by staff in the bathroom, is not to get up per self and had done so and then was found in the bathroom. No complaints of pain or injury, but the right elbow appears somewhat swollen and not equal to the left. Able to move it but states it did hurt at first with movement but does have active range of motion to that arm. ED notes documented the right elbow was the site of a prior (long ago) fracture. The location of the pain or injury involved the right elbow. The severity of the pain was mild. The mechanism was injury that occurred from a fall. The right elbow x-ray was abnormal due to extensive old fracture. The ED sent the resident back to the facility, on the same date, with contusion instructions. Contusion instructions identified a contusion as a deep bruise which occurs when an injury bleeds under the skin. On 8/26/13 at 3:55 p.m. Staff C (registered nurse) stated she walked into the resident room after the resident fell and found the resident on the floor. She did not recall where the other staff were other than she documented they were with another resident at the time. She identified normal staffing as 3 staff, which would consist of 2 nurse aides and Staff C. On 8/26/13 at 12:15 p.m. the Director of Nursing confirmed the resident fell due to staff being tied up in another room so they couldn't get to Resident #1. On 8/26/13 at 3:50 p.m. the Director of Nursing stated the resident did not have a contusion or bruising. The resident had a nodule on the elbow from the old fracture. The arm remained functional and the resident could still use it.