Every finding on record at Algona Manor Care Center

Based on resident and family interviews, Resident Council minutes and a call light audit provided by the facility, the facility failed to timely answer the call lights for 1 of 2 residents reviewed (Resident #20). The call light audit dated 6/2/26 revealed that Resident #20 waited 35 minutes for a morning call light to be answered and 19 minutes for an afternoon call light to be answered. The facility reported a census of 40 Residents. Findings include: A Minimum Data Set assessment dated [DATE], documented Resident #20's diagnoses included multiple sclerosis and depression. A Brief Interview for Mental Status documented a score of 15 out of 15, which indicated intact cognition. It documented that Resident #20 was frequently incontinent and dependent for toilet hygiene and transfer. A Care Plan initiated on 5/14/26, documented that Resident #20 needed assistance with ADLs (Activities of Daily Living). It directed staff that Resident #20 was occasionally incontinent of urine. Please offer and assist her to commode upon rising in the morning, before/after meals and activities and at HS (hour of Sleep). Resident Council Minutes dated 5/4/26, documented under Old Business that call light response time is too slow and under Resident New Business call light response time taking too long. Under Staff new business: it was documented that resident council interview conducted. Only concerns noted during interview is call light response times. Resident Council Minutes dated 6/1/26, documented under Old Business that call light response time taking too long. Resident Council Minutes dated 7/7/26, documented that call light response time is too slow. Call lights are being shut off before needs are met, On 7/20/26 Resident #20 reported that call lights can take a long time to be answered. She stated she has had accidents before but sometimes she urinates right away after turning the call light on. However, she said, she then has to lay in the urine while she waits for staff to respond. She stated she has had to wait way longer than 15 minutes. Resident #20 added that she has called the front desk before to have someone come and help her as she had waited a long time for someone to respond to her call light and no one came. The call light audit dated 6/2/26 revealed that Resident #20 waited 35 minutes for a morning call light to be answered and 19 minutes for an afternoon call light to be answered. On 7/23/26 at 11:16 a.m., the Administrator stated that call lights should be answered within 15 minutes. She said they have been working on improving the call light response time. An undated Resolving Call Light Issues policy, documented that call lights are to be answered with (in) 15 minutes.

Based on record review, staff interview and policy review the facility failed to complete a background check for 1 of 6 current employees reviewed (Staff A, Certified Nurse Aide) (CNA). The facility reported a census of 30 residents. Findings include: Review of Staff A, CNA 's employee file documented a hired date of 9/20/24. Further review of the employee file lacked documentation of a background check in the file. During an interview on 6/10/25 at 2:06 PM, the Administrator reported the background check for Staff A, CNA was not completed. She reported the office manager just started around time of hire for Staff A and missed it but it should have been done. The facility Nursing Abuse Prevention, Identification, Investigation and Reporting Policy date October 2022 documented the facility will conduct a criminal record check prior to hire, in the manner prescribed under 481 Iowa Administrative Code 58.11(3).

Based on clinical record review and staff interview, the facility failed to complete a new Preadmission Screening and Resident Review (PASRR) for Level I on 2/27/25 for Resident #27. The facility reported a census of 30 residents. Findings included: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #27 showed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS documented diagnosis of anxiety, psychotic disorder (other than schizophrenia), and malnutrition. Review of the PASRR Level 1 Screening Outcome dated 8/12/24 for Resident #27 revealed PASRR Level I Determination No Level II Required. Review of the clinical chart revealed this PASRR came with Resident #27 from the hospital when admitted to the facility. The facility failed to submit a new PASRR due to the new diagnosis given on 2/27/25. The Progress Notes dated 2/27/25 for Resident #26 revealed the facility received a new diagnosis of delusions. Interview on 6/10/25 at 2:58 p.m. with the Social Worker, verified that she does the PASSAR's and that she does do them if there is a new medication started or new diagnosis. The Social Worker stated she is not sure what happened.

Based on observation, clinical record review, staff interview and a nursing assistant checklist form the facility failed to provide appropriate perineal cares for 1 of 3 residents reviewed, (Res #1). The facility reported a census of 31 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 9/24/24 indicated Resident #1 had diagnosis that included Non-Alzheimer's Dementia. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 (cognitively impaired), dependent on staff with toilet transfers and toileting and frequently incontinent of her bowels and bladder. A Care Plan indicated the resident had a Focus area of a requirement of assistance with activities of daily living (ADL's), revised 7/17/24. The Interventions/Tasks included the following as dated. a. Please assist me with toileting upon rising in the morning, before or after activities and at my hour of sleep (HS). Assist me with any incontinent cares as needed. I utilize adult incontinent pull ups.(revised 4.18.24) An observation on 10/8/24 at 12:55 p.m. revealed Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA as they toileted the resident whom Staff A confirmed as incontinent. Staff A removed the resident's soiled brief as the resident voided. Upon completion staff stood the resident as Staff A positioned herself behind the resident and cleansed her mid gluteal region times (x) 3 wipes and bilateral buttocks but failed to cleanse the resident anteriorly. During an interview at the same time Staff A confirmed she failed to cleanse the resident anteriorly. A Nurse Aide Skills Checklist form dated 2012 included the following directive: a. Wash and rinse the abdomen and anterior thighs (all areas in contact with urine/feces). Women - gently separate the labia and wash down one side then the other from front to back.

Based on observations, staff interviews and policy review, the facility failed to store food items according to professional standards and ensure food items were labeled with dates after opening. The facility identified a census of 35 residents. Findings include: 1. An initial kitchen tour conducted on 8/5/24 at 10:05 AM, of the kitchen revealed the following items were stored/opened in the kitchen's refrigerator ready for service and not labeled with a date after opening: a. American cheese slices in zip lock bag b. Container of ham salad c. Slices of smoked ham in zip lock bag d. Individual packed slices of Swiss cheese e. 46 oz Tomato juice f. 16 oz butter blend spread block- not sealed appropriately g. Cookies Mild salsa h. 1 gallon worcestershire sauce i. Heinz tomato ketchup j. 1 gallon tartar sauce k. 30 oz Mayonnaise l. 24 oz Hershey syrup m. 12 oz Dijon Mustard n. 12 oz honey mustard o. 1 gallon chocolate milk p. Two 1 gallon 2% milk q. Pint Half & Half cream and milk r. Half gallon Almond breeze s. Heavy whipping cream t. 7 servings cucumber salad in individual bowls u. Bag of hot dogs opened and dated 7/27/24. 2. The following items were stored/opened in the kitchen's freezer and not labeled with date after opening: a. Bag of frozen fish sticks- The bag was not sealed and freezer burn noted. b. Bag of frozen omelets c. Bag of frozen of chicken strips. 3. The following items were stored in the kitchen's dry storage area: a. Instant banana pudding mix- open, not dated b. 2nd bag of instant banana pudding mix- open, not sealed, dated 3/20/24 c. Dry gelatin mix- open, not dated d. Chocolate pudding mixture- open and dated 10/19/23 e. Raisin Bran cereal- open, not sealed, not dated. On 8/5/24 at 10:30 AM, The Dietary Manager reported he expected the dietary staff to label and date items when opened and left over food was good for 7 days after opening. The undated facility policy titled Dietary Services documented once the product was opened, the item will be dated with the date of which it was opened. The policy further directed to store, prepare, distribute and serve food in accordance with professional standards for food service safety and left over food items can be kept stored for up to 7 days.

Based on review of facility policy, staff interview and record review the facility failed to follow an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 resident (Resident #26). The facility reported a census of 35 residents. Findings include: The facility form named Nursing Home Physician Fax reported a new order for Resident #26 from the physician dated 1/11/23 for Methenamine 1 Gram, 1 tablet twice daily by prophylactic for urinary tract infection with no end date. The current Clinical Physician ' s Orders dated 8/8/24 for Resident #26 documented Resident #26 continued with the order for Methenamine 1 Gram, take 1 tablet by mouth twice daily related to urinary tract infections. The clinical record lacked documentation that the facility monitored the long term use of Resident #26 ' s antibiotic. An interview on 8/8/26 at 9:30 AM the Infection Preventionist (IP) stated they have a system in place to monitor long term use of antibiotics to assure they were still necessary. The IP revealed they generally review them once a year. An interview on 8/8/24 at 11:30 AM with the Pharmacy Consultant verified that she had addressed the prophylactic antibiotic in January 2023 but voiced she would have liked the facility IP to have followed up on it. The facility policy with an effective date of 12/26/2017 named Antibiotic Stewardship revealed the facility goal is to develop, promote, and implement an antibiotic stewardship system to monitor the use of antibiotics. Monitoring includes optimizing the treatment of infections by ensuring administering antibiotics only when needed, working collaboratively with the consulting pharmacy and provider to prescribe antibiotics only when clinically indicated, ordering the appropriate antibiotic, duration of administration for each infection.

Based on clinical record review, staff interviews, and policy review the facility failed to revise a Care Plan for 1 of 13 residents reviewed (Resident #21) for prophylactic antibiotic therapy. The facility reported a census of 35. Findings include: Resident #21 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #21 ' s MDS included diagnoses of coronary artery disease, hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD) and pulmonary embolism (blood clot in lungs) without acute cor pulmonale. The Care Plan with revised date of 7/24/24 identified Resident #21 required assistance with activity of daily living due to COPD. The Care Plan revealed Resident #21 had supplemental oxygen continuously. The Care Plan directed staff to update the Physician with any signs of respiratory distress such as a decreased oxygen saturation and complaints of new onset of shortness of breath. A Physician Order dated 5/15/24 directed staff to administer azithromycin (antibiotic) 250 mg (milligrams) one tablet every Monday, Wednesday and Friday related to COPD. A Pharmacy Consulting form dated 6/19/24 documented a physician order to continue the azithromycin 250 mg on Monday, Wednesday and Friday for 365 days due to COPD exacerbation, pneumonia and rehospitalization . Review of Resident #21 ' s Care Plan revealed the antibiotic medication, potential side effects and what to monitor for while taking the high risk medication was not addressed on the comprehensive care plan. On 8/6/24 at 11:28 AM, the Director of Nursing (DON) acknowledged and verified the antibiotic was not on the care plan. The DON reported she would expect the antibiotic to be addressed on the care plan. The undated facility policy titled Care Plan Development documented the facility will develop a comprehensive plan of care to include approaches, goals, and interventions that reflect the resident ' s preferences and choices. The policy further documented the plan of care will be reviewed periodically for the need for updating, modifying, or additions.

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow hand hygiene and gloving practices consistent with accepted standards of practice for 1 of 2 residents reviewed (Residents #1). The facility reported a census of 35 residents. Findings include: Resident #1 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #1 required supervision or touching assistance with rolling in bed and was dependent on staff to sit up or lay down in bed. The MDS identified Resident #1 required a mechanical lift and was dependent on staff for transfers and toileting. Resident #1 ' s MDS included diagnoses of anemia, hypertension (high blood pressure), multidrug-resistant organism, diabetes mellitus, malnutrition, right below the knee amputation, and left great toe amputation. The MDS coded Resident #1 had diabetic foot ulcers and received applications of dressings to feet. A facility form titled Non Pressure Sore Skin Conditions dated 6/7/23 revealed Resident #1 had an incision site to the left great toe from an amputation. The form documented on 8/7/24 the incision site measured 1.8 cm (width) (centimeters) x 1 cm (length) x 0.1 cm (depth). The wound appearance was light red and dark pink. The form revealed there was a small amount of bloody drainage from the incision site after the bandage was removed and the bleeding stopped after Resident #1 had a shower. A Physician Order dated 7/3/24 directed staff to cleanse the left great toe amputation site with normal saline, apply hydrofera blue (antibacterial foam dressing) ready dampened with normal saline to the wound bed, cover with foam and Mefix tape on Monday, Wednesday and Friday. On 8/7/24 at 9:28 AM, observed Staff A, RN (Registered Nurse) complete dressing change to left great toe amputation site. Staff A washed her hands and applied gloves. Staff A got wound care supplies ready using paper towels as a barrier. Staff A took a new bottle of saline, dampened a piece of gauze and placed it on the paper towel. Staff A then cut the hydrofera blue dressing with a pair of scissors, dampened the piece of hydrofera blue with the saline and placed it on the paper towel. Staff A with gloved hands searched through the pink bin of dressing supplies for a piece of foam. Staff A placed the piece of foam on top of the paper towels. Staff A carried the dressing supplies on the paper towel over to the bedside. Staff A cleansed the left great toe amputation site with the gauze pad while wearing the same gloves she had worn to gather supplies/touched multiple surfaces. After cleansing the wound, Staff A removed the gloves, took a new pair of gloves from the glove box on the wall and then sat the new gloves down on the sink. Staff A washed her hands and applied the gloves that were sitting on the sink. Staff A applied the hydrofera blue dressing to the amputation site, then covered the area with foam and secured the foam with tape. On 8/7/24 at 10:15 AM, Staff A, RN verified and acknowledged she should have completed hand hygiene and changed gloves before cleansing the wound. Staff A also acknowledged she should have washed her hands after removing gloves and before taking the gloves out of the box and not sat the gloves down on the sink. On 8/7/24 at 2:45 PM, the Director of Nursing reported she would expect staff to change gloves and complete hand hygiene between dirty and clean procedures. The undated facility policy titled Standard Precautions directed the following: a. Hand Hygiene- practice hand hygiene after touching blood, body fluids, secretions, excretions, or contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. b. Gloves- Wear gloves when touching blood , body fluids, secretions, excretions, or contaminated items. Put on clean gloves just before touching mucous membranes and non intact skin. Change gloves between tasks and procedures. Practice hand hygiene whenever gloves are removed.

Based on observations, record review, staff interviews and facility policy the facility failed to properly prevent a stage 1 pressure ulcer consistent with professional standards of practice for 1 of 2 residents reviewed (Resident #26). The facility reported a census of 35 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. The Minimum Data Set (MDS) assessment tool dated 5/7/24, for Resident #26 documented diagnoses that included malnutrition, diabetes mellitus, Non-Alzheimer ' s dementia, parkinson ' s disease, anxiety and depression. The MDS showed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS identified the resident as at risk for pressure ulcers. The MDS also identified the facility had placed a pressure reducing cushion in the resident ' s chair and pressure reducing device for the bed. Resident #26 ' s Care Plan revised on 5/10/24 contained the following information: Resident #26 is at risk for altered skin integrity and pressure related injury related to decreased mobility, age, diagnosis of type 2 diabetes, dementia, decreased meal intake and diagnosis of Parkinsons. The Care Plan directed staff to offer and encourage Resident #26 to utilize heel protectors, Resident #26 does refuse to allow staff to have these placed on her feet. To utilize a pressure relieving cushion in her wheelchair and pressure relieving mattress on bed. Nursing will complete a skin assessment each week to monitor for areas of concern updating the physician as needed. Please notify my charge nurse of any redness, new discoloration or concerns to my skin noted during care. Administer medications as ordered, monitor and document as needed for side effects and effectiveness Staff to apply moisture barrier cream with incontinent care. Staff to encourage me to lay down in the afternoon for pressure relief, at times I refuse and prefer to stay sitting in my recliner. Staff will assist with floating my heels while I am in bed to decrease my risk for injury or further injury to my heels while I am in bed. Staff will assist with re-positioning in bed every 2-3 hours for pressure relief. The resident's Care Plan lacked any new information related to the stage 1 pressure on the resident's left heel and any new interventions the facility put in place. The facility provided Braden Scale dated 8/1/24 showed Resident #26 scored a 12 which indicated a high risk for pressure ulcers. The facility provided Braden Scale dated 5/7/24 showed Resident #26 scored a 12 which indicated a high risk for pressure ulcers. The facility provided Braden Scale dated 2/6/24 showed Resident #26 scored a 15 which indicated risk for pressure ulcers. The Pressure Ulcer Documentation revealed the following information: the treatment is to apply a foam pad two times a week on shower days and as needed. The physician signed the Pressure Ulcer Documentation sheet on 7/19/24. The following are the measurements: 7/17/24 Left heel - is 2 centimeters (cm) x 1 cm (length x width) - area with brown discoloration 7/23/24 Left heel - 3 cm x 1.2 cm - area with brown discoloration 7/30/24 Left heel - 2.2 cm x 0.6 cm - area with intact brownish discoloration 8/6/24 Left heel - 2 cm x 0.4 cm - area with light brown discoloration 8/6/24 Right buttock - 0.3 cm x 0.2 cm x 0.1 cm - area with pink edges and wound bed is red 8/6/24 Coccyx - 1.5 cm x 0.3 cm x 1 cm - area is light red with pink edges The Treatment Administration Record (TAR) for July 2024 failed to reveal an order for a treatment to the left heel was being completed. The TAR for August 2024 failed to reveal an order for a treatment to the left heel was being completed. Review of Resident #10 ' s Progress Notes revealed the following: On 7/16/24 at 10:16 AM, During skin check today new pressure to left heel, Stage 1. On 7/19/24 at 2:18 PM, Received signed skin sheet regarding area to patient right heel. On 2/12/24 at 6:20 PM, Previous pressure ulcer on right heel resolved on 12/20/23. Preventative pressure relieving mattress on bed, cushion used when up on chair and purple booties on feet (except for transferring). Resident #26 has a history of pressure ulcers to her heels per Progress Notes dated 2/12/24. Observation on 8/7/24 at 1:19 PM with Resident #26 sitting in a recliner at this time with feet up. Resident #26 observed not sitting on a cushion or pressure reducing device. Resident #26 has slipper socks on and bilateral heels are not touching anything, heels are off the foot of the recliner. Observation on 8/7/24 at 3:17 PM with the DON. The DON went into Resident #26 ' s room, Resident #26 was sitting in a recliner with feet up with gripper socks to bilateral feet. DON pulled off the gripper sock to left foot, observed a white bandage on the heel, the DON then removed this bandage. The bandage failed to have a date of when it was applied. Observed left heel with brown discolored area, skin was intact. DON encouraged Resident #26 to wear heel boots and Resident #26 agreed at this time. Facility provided policy named Skin Assessment, Impaired Skin Integrity, Wound Care with an effective date of 12/5/16 revealed the goal of the skin assessment and reassessment is to maintain the resident at their highest practical physical well-being, early identification, implementation of interventions, registered nurse (RN) evaluation of effectiveness of interventions and timely revision of the resident care plan. Assessments are completed by an RN or licensed practical nurse (LPN), with evaluation of changes in assessment and review/revision of resident care plan by an RN. All staff are accountable for documenting interventions they complete. The RN is accountable for evaluating effectiveness of interventions and care. Notification of the resident, physician/nurse practitioner, family or representative will occur, upon discovery of a pressure ulcer, wound status is declining or shows no progress in one to two weeks. Interview on 8/7/24 at 3:17 PM with the DON, she acknowledged that the treatment was not put on the treatment sheet. The DON stated that the treatment is a standing order and the process would be for the nurse to put the order in the computer so it would be generated to the treatment sheet. DON acknowledged this should have been done when the area was found. Interview on 8/8/24 at 12:50 PM with the DON revealed there is no documentation when Resident #26 would refuse to wear the heel boots, the staff reported it to the nurses. The DON reported that there was not another intervention in place before the pressure ulcer to the left heel was found.

Based on clinical record review and staff interviews, the facility failed to provide assessment and interventions necessary for the care and services, to maintain the residents' highest practical physical well- being for 1 of 3 resident reviewed (Resident #13) for antibiotic therapy. The facility failed to monitor and complete urinary assessments/interventions for a resident who was diagnosed with a urinary tract infection. The facility reported a census of 35 residents. Findings include: Resident #13 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 04, indicating severely impaired cognition. The MDS identified Resident #13 was dependent on staff for toilet transfers and toileting hygiene. The MDS documented Resident #13 was frequently incontinent of urine. Resident #13 ' s MDS included diagnoses of coronary artery disease, hypertension (high blood pressure), urinary tract infection (UTI) in the past 30 days, and non-alzheimer ' s disease. The facility infection control logs from January 2024 to July 2024 revealed Resident #13 had been treated for a UTI with antibiotics on the following dates: -1/5 to 1/8 -1/16 to 1/23 -2/14 to 2/21 -5/1 to 5/8 -7/9 to 7/16 Review of the current Care Plan with target date 10/14/24 did not address Resident #13 was at risk for urinary tract infections, what signs and symptoms to monitor for and interventions to reduce the risk for UTI. The Care Plan revealed Resident #13 was incontinent of urine, was not always able to voice the urge to void and had a history of nocturia. The Care Plan directed staff to assist with toileting 2-3 times each night. A Progress Note dated 7/8/24 at 1:32 PM documented Resident #13 had been looking up to her right towards the ceiling, she thought she saw a blue car and that her son was picking her up. The note documented Resident #13 required more assistance at meals and was not aware she was going to spill her coffee. The note revealed Resident #13 has increased frequency and increased bladder incontinence. Resident #13 ' s urine was odorous and cloudy in appearance. A urine dip test was completed and results were positive for leukocytes, nitrates, protein and specific gravity was 1.010. A message was left at the Provider ' s office regarding Resident #13 ' s symptoms and urine dip results. The Progress Note lack documentation of a completed set of vitals signs (temperature, pulse, respirations, blood pressure) related to Resident #21 ' s change in condition. A Progress Note dated 7/9/24 at 1:42 PM documented a new order was received to obtain a clean catch urinalysis. A Progress Note dated 7/9/24 at 4:31 PM documented Resident #13 had a UTI and a culture was indicated. A new Physician Order was obtained to start Keflex (antibiotic/ATB) 500 mg (milligrams) TID (three times a day) for 7 days. Review of the July 2024 Medication Administration Record (MAR) revealed Resident #13 started Keflex on the evening of 7/9/24 for a UTI. A hospital microbiology report dated 7/10/24 at 7:16 PM revealed the urine culture grew out, greater than 100,000 cfu/ml (colony-forming unit per millilitre) escherichia coli (gram negative bacteria commonly found in lower intestine). Review of the Progress Notes from 7/9/24 to 7/16/24 lacked urinary assessments, monitoring of routine vital signs and documentation of any adverse drug effects while taking the antibiotic. Review of the July MAR revealed Resident #13 completed the Keflex at Noon on 7/16/24. The Progress Notes lacked documentation Resident #13 had completed antibiotic therapy. The documentation also lacked a full set of vitals signs and whether or not the ATB therapy was effective. On 8/7/24 at 4:00 PM, the Director of Nursing (DON) reported the first three days a resident was on an antibiotic for a UTI, she would expect the staff to document full set of vitals signs along with urinary symptoms, signs/symptoms of infection and any adverse drug reactions from the antibiotic therapy. She stated on the last day of the antibiotic she would expect full set of vitals signs and documentation if there was any improvement or not from the antibiotic therapy. The DON reported she could not locate any facility policies on what to document or monitor for when a resident was on an antibiotic.

Based on observation, resident interview, staff interview, Resident Council Minutes and facility policy review the facility failed to answer resident call lights within the allotted professional standards of 15 minutes for 1 of 3 residents reviewed. (Resident #3) The facility identified a census of 32 residents. Findings include: During an interview on 4/5/24 at 1:30 p.m. Resident #3 verbalized a concern related to wait times for her call light. The resident used the clock on her wall and timed the call light on for 30 minutes and even longer at times which made her feel like no one was there for her. Additionally, when staff toileted her and left her in the bathroom for long periods of time it caused pain. During an interview on 4/9/24 at 11:41 a.m. Staff B, Certified Nursing Assistant (CNA) confirmed observations of call lights on longer than 15 minutes on 2nd shift. The staff member indicated some of the reasons had been because some of the residents eat and ran back to room and wanted to go to bed right away. At 6 p.m. staff took breaks, nurse's change of shift and dietary served meals at different times of the evening which caused inconsistency. During an interview on 4/9/24 at 10:49 a.m. Staff A, CNA indicated staff answered resident call lights within the allotted 15 minutes however there had been times staff assisted residents longer than 15 minutes at a time because some residents took longer than others then staff failed to answer resident call lights timely. Review of the facilities Resident Council Minutes dated 1/19/24, 2/16/24 and 3/15/24 revealed residents voiced concerns with the wait times for their call lights. According to the facilities Call Light policy (not dated) all call lights should have been answered within 15 minutes.

Based on clinical record review, policy review, and staff interview, the facility failed to develop and implement a comprehensive and person-centered care plan that included all of the resident ' s medical and psychosocial needs for 3 of 12 residents reviewed (Residents #16, #24, and #29) who had orders for lower leg edema management and hearing aids. The facility reported a census of 36 residents. Findings include: 1. Resident #16 ' s Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognitive impairment. The MDS indicated that Resident #16 required extensive assistance of one staff with bed mobility, transfers, ambulation, dressing, personal hygiene and toilet use. The MDS included diagnoses of non-traumatic brain dysfunction, coronary artery disease, non-Alzheimer ' s dementia, right side hemiplegia and hemiparesis (paralysis and weakness), and stroke. Review of resident ' s clinical Progress Notes from April 2020 revealed that resident was first identified as having swelling to her left lower leg on 4/8/20. On 4/19/20 the resident complained of discomfort when ambulation due to edema. On 4/22/20 an order was received for compression stockings. Resident #16 ' s clinical record review of orders revealed that an order was written on 4/24/20 for the resident to have TED hose (support stockings for leg swelling) put on in the morning and removed at bedtime. Review of Resident #16 ' s Care Plan with a revision date of 9/12/23, lacked documentation of the resident having leg swelling or having an order for TED hose. 2. Resident #24 ' s MDS assessment dated [DATE] identified a BIMS score of 03, indicating severe cognitive impairment. The MDS indicated that Resident #24 required extensive assistance of one staff with bed mobility, transfers, ambulation, dressing, personal hygiene and toilet use. The MDS included diagnoses of non-traumatic brain dysfunction, diabetes, stroke, non-Alzheimer ' s dementia, and edema. Review of Resident #24 ' s clinical record review of orders revealed that an order was written on 12/21/22 to check the resident for having on knee high thromboembolic deterrent (TED) hose (support stockings) in the morning and off at bedtime. This order was discontinued on 1/4/23 and a new order was written for the resident to have All Cotton Elastic (ACE) wraps to be placed on the resident in the morning and taken off at bedtime. Review of the resident ' s Kardex, dated as of 9/28/23, revealed under Resident Care, that the Certified Nursing Assistant (CNA) was to put on and take off TED hose. Review of Resident #24 ' s Care Plan with a revision date of 9/11/23 lacked documentation of the resident having edema or needing to have TED hose or ACE wraps applied daily. 3. Resident #29 ' s MDS assessment dated [DATE] identified a BIMS score of 05, indicating severe cognitive impairment. The MDS indicated that Resident #24 required extensive assistance of one to two staff with bed mobility, transfers, ambulation, dressing, personal hygiene and toilet use. The MDS included diagnoses of atrial fibrillation (irregular heartbeat), coronary artery disease, non-Alzheimer ' s dementia, chronic obstructive pulmonary disease (COPD), and pulmonary fibrosis (thickening and stiffness of the lungs). Review of Resident #29 ' s clinical record review of orders revealed that an order was written on 9/6/23 to check the resident for having on TED hose in the morning and off at bedtime, and orders written on 9/7/23 and 9/8/23 to ensure the resident had hearing aids put in the morning and taken out at bedtime to charge. Review of resident ' s Care Plan with a revision date of 9/13/23 lacked documentation of resident having hearing aids or TED hose. Review of undated facility document titled Algona Manor Care Center Care Plan Development documented that the plan of care would be reviewed periodically for the need of updating, modifying, or additions. During an interview with Interim Director of Nursing (DON) on 9/27/23 at 4:00 PM, she stated that her expectation was that edema wear and hearing aids would be listed on the care plan.

Based on staff interviews the facility failed to have a qualified professional serve as the Dietary Manager for the facility. The facility reported a census of 36 residents. Findings include: During an interview with Staff A, Cook on 9/25/23 at 9:15 AM revealed there is currently not a Dietary Manager and the Administrator is overseeing the kitchen right now. During an interview on 9/25/23 at 2:48 PM with the facilities Administrator revealed they do not have a Certified Dietary Manager, they however do have an employee in the class, but she is not working right now.

Based on record review and staff interviews the facility failed to document the use of oxygen on the Comprehensive Care Plan for 1 of 1 residents reviewed for oxygen use, (Resident #15). The facility reported a census of 35 residents Findings include The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/23/2022 for Resident #15 documented she was admitted to the facility on [DATE] and used oxygen. Record review of a document titled Discharge Documentation dated 2/16/2022 for Resident #15 showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on 4/27/2022 of Resident #15's current Care Plan lacked documentation and instruction to staff that Resident #15 needed oxygen. Record review of the facilities Policy for Safe Handling of Oxygen, dated 3/20/2020 lacked instruction to staff on the need to Care Plan oxygen use for residents. Record review of a undated policy titled, Care Plan Development instructed staff to complete the following: a. The Facility will develop a comprehensive plan of care to include the approaches, goals, end interventions that reflect the residents preference and choices. b. The interdisciplinary team will utilize a set of assessments, in combination with resident or resident representative interviews, and review of resident medical record. The facility will utilize the information obtained through these assessments and interviews for the development of such plan of care. c. The plan of care will identify quantifiable, measurable objectives with timeframe's to be able to assess whether the objectives have been met. d. The plan of care will be reviewed periodically for the need for updating, modifying, or additions. e. The plan of care process will be overseen by a Registered Nurse (RN) in good standing with the state of Iowa. Interview on 4/28/22 at 7:57 AM with the Director of Nursing (DON), revealed she would expect oxygen to be care planned on the comprehensive Care Plan.

Based on observations, record review and interviews the facility failed to follow physician's orders for diuretic medications for 1 of 12 residents reviewed, (Resident #9). Resident #9 suffered with [CONDITION(S)] and fluid overload. The physician's order for diuretic medication was dependent on daily weights and in the month of April, the lower dose was administered. The facility reported a census of 35 residents. Findings include: According to a Minimum Data Set (MDS) dated [DATE] Resident #9 had a Brief Interview for Mental Status (BIMS) score of 9 (moderate cognitive deficits). He required extensive assistance with the help of one with transfers, toileting, walking and hygiene. An MDS dated [DATE] showed the resident had a change in condition and required the help of two for transfers, walking and toileting. The Care Plan updated on 8/6/21 indicated Resident #9 was taking diuretics to manage hypertension and [CONDITION(S)] to lower extremities with a history of urine retention and acute kidney failure. Nurses were directed to monitor for fluid overload such as abnormal lung sounds and increase [CONDITION(S)] to the extremities. On 4/25/22 at 2:20 PM Resident #9 was sitting in his wheel chair in his room facing the recliner. He was leaning toward the recliner and said he wanted help to get into his chair. His feet and ankles were very edematous, rounded on the bottom and ankles swollen. He said he had trouble with swollen ankles and feet for a long time. According to the orders in the electronic chart, the resident had an order dated 2/24/22 at 2:24 PM for a diuretic medication; Tosemide 20 milligrams (mg) 3 tablets two times a day related to chronic kidney disease if weight was over 210 pound. Give 2 tablet two times a day if weight is less than 210 pounds. On April 7th, 9th, 10th, and 14th the resident was over 210 pounds and received just 2 tablets. On April 7th his weight was 213.4, on April 9th it was 211, on April 10th it was 213 and on the 14th it was 210.6 pounds. On 4/28/22 at 3:49 PM the Administrator said she would expect the nurses to review the resident's weight for the day and administer the mediation according to the provider's parameters.

Based on observations, record and policy review and interviews the facility failed to provide consistent treatment and monitoring to prevent the worsening of pressure ulcers for 1 of 3 residents reviewed, (Resident #9). Resident #9 suffered with chronic skin deterioration on his buttocks. The facility failed to complete weekly assessments and failed to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 35 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. According to a Minimum Data Set (MDS) dated [DATE] Resident #9 had a Brief Interview for Mental Status (BIMS) score of 9 (moderate cognitive deficits). He required extensive assistance with the help of one with transfers, toileting, walking and hygiene. An MDS dated [DATE] showed that he had a change in condition and required the help of two for transfers, walking and toileting. The Care Plan updated on 8/6/21 indicated Resident #9 was at risk for altered skin integrity and pressure related injury due to decreased mobility and a history of pressure area to the buttocks. The resident preferred to sleep in his recliner but staff were directed to encourage him to lay in his bed in the afternoon to decrease risk of pressures. Staff were to complete weekly skin assessments to monitor for areas of concern and update the physician. According to a document titled: Pressure Ulcer Documentation dated 6/7/21, the resident had a stage II ulcer on the left buttocks measuring 0.3 centimeters (cm) x 0.3 centimeters on 6/8/21. On 6/28/21 it measured 1 cm x 0.5 cm The Census tab of the electronic chart showed the resident had been discharged from the facility on 7/2/21 and readmitted on [DATE]. Upon readmission a document titled: Non-Pressure Skin Condition Documentation was completed with the following findings discovered on 8/5/21 at 1:30 PM; On the right buttocks, an excoriation a. On 8/7/21 measuring 4.8cm x 2.2cm. b. On 9/6/21 measuring 9 cm x 3 cm. c. On 9/29/21 measuring 10 cm x 4 cm. On the left buttocks, an excoriation a. On 8/7/21 measuring 4.5cm x 2.8cm reddened. b. On 9/6/21 measuring 7cm x 2cm. c. On 9/29/21 measuring 10cm x 3cm. The chart lacked documentation the physician had been contacted when the wounds worsened. According to the Orders tab in the electronic chart, the resident had an order dated 8/6/21 at 6:15 AM to apply [MEDICATION(S)] ointment to the areas of the right and left buttocks twice a day. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/27/22 at 11:50 AM Certified Nursing Assistant (CNA) Staff E and CNA Staff D assisted Resident #9 up out of the recliner chair and stated that he refused to get on the bed so they could provide incontinence cares. While the resident stood in front of the chair and held onto the walker, the aides pulled down his incontinence brief and gave him a urinal to use. The resident had feces on his buttocks and they used wash clothes to wipe him. As they wiped he said it hurt his bottom. He was found to have reddened areas on the left and right buttocks over the boney prominence of the intergluteal cleft. The Non-Pressure Skin Condition documentation showed each of the areas measured 4 cm. x 2 cm. on 4/25/22. According to facility document titled: Skin and Wound Care Protocol dated 11/28/16, once a wound is identified it should be assessed every 5-7 days and daily if deteriorating. Timely reassessment is a critical tool for nurse to evaluate to determine the effectiveness of physicians orders. On 4/28/22 at 9:04 AM the MDS/Care Plan Nurse said when the resident was readmitted to the facility in August of 2021, the areas of concern the resident had on his bottom were not identified as pressure areas but excoriation, therefore not documented as pressure ulcers. She said the difference in treatment was when there was an identified pressure sore they would consult with the wound clinic for treatment recommendations. She said they had not consulted with would care clinic on the residents' current skin concerns.

Based on observation, interviews and record review the facility failed to provide 2 staff assistance with transfers after a change in condition for (Resident #9). Resident #9 had a fall on 4/19/22 and the established intervention was to have 2 staff assist with transfers rather than just one. The facility reported a census of 35 residents Findings include: According to a Minimum Data Set (MDS) dated [DATE], Resident #9 had a Brief Interview for Mental Status score of 9 (moderate cognitive deficits). He required extensive assistance with the help of one with transfers, toiling, walking and hygiene. An MDS dated [DATE] showed he had a change in condition and required the help of two for transfers, walking and toileting. The Care Plan dated 4/19/22 showed the resident had a fall on that date and required two staff for transfers as his legs were weak and he had difficulty scooting himself back into his chair. On 4/25/22 at 2:20 PM Resident #9 was in his wheel chair facing his recliner and was leaning toward the recliner. He said he wanted some help to get into the recliner. Certified Nursing Assistance (CNA) Staff B came into the room and put a gait belt around him, helped him to stand and directed him to turn and scoot backward toward the chair. In a second observation on 4/27/22 at 7:52 AM, CNA Staff D transferred the resident from the recliner to the wheel chair without the help of a second staff. On 4/27/22 at 8:52 AM the Director of Nursing (DON) said they use a spread sheet to communicate changes in status from one shift to the next. The spreadsheet dated 4/19/22 had an entry that said the resident fell at 1:05 PM that day and he needed the assistance of 2 staff for transfers.

Based on observation, record review, staff interviews and policy review the facility failed to wash hands after emptying a catheter bag of urine and proceeded to touch door handles and drawers, and set a catheter bag on the floor for 1 of 1 residents reviewed for catheter care (Resident #15) and failed to complete hand hygiene after peri care ( Resident #29). The facility reported a census of 35 residents Findings include 1. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/23/2022 for Resident #15 documented she was admitted to the facility on [DATE] and used a catheter to assist with urination. Observation on 4/26/2022 at 1:53 PM of Staff C, Certified Nurses Assistant (CNA) emptying Resident #15's catheter bag into a hard hat (urine collection container) showed Staff C set the hard hat on top of a paper towel on the floor and proceeded to open two (2) alcohol pads from their packaging and lay them directly on on the rim of the urine collection container. Staff C then proceeded to pick the catheter bed bag (large bag that collects urine) up off of the floor and remove it from the bag it was contained in. Staff C emptied the catheter bed bag of urine into the hard hat and used the alcohol pads sitting on the hard hat to clean were the urine was emptied at. Staff C then preceded without removal of gloves or hand hygiene to insert the bed bag back into the bag it was contained in. Staff C then removed one glove, she then lifted the hard hat with the gloved hand and with the ungloved/unwashed hand opened the bathroom door and emptied the hard hat containing urine into the toilet. Staff C set the hard hat into the bathroom without cleaning for next use. Staff C exited the bathroom, she removed her other glove and threw them both into the trash. Staff C opened a drawer on the residents vanity and pulled out trash bags, she changed out the trash bags and returned the garbage bags to the drawer and shut the drawer. Staff C then preceded to wash her hands in the vanities sink. Record review of an untitled, undated policy provided on 04/28/22 regarding catheter cares instructed the facility staff to; a. Do not rest the catheter bag on the floor. b. Use Standard precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system. Interview on 4/28/2022 at 7:55 AM with the Director of Nursing (DON) revealed she expects staff to complete hand hygiene and change gloves immediately after completing a dirty task and prior to proceeding to the next task. 2) According to the MDS dated [DATE], Resident #29 had a Brief Interview for Mental Status (BIMS) score of 9 (moderate cognitive deficits). The resident required extensive assistance with the help of two staff for transferring, toileting and dressing. The Care Plan revised on 1/6/21 stated the resident needed assistant with activities of daily living (ADL) cares and mobility. He had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was continent of bowel but occasionally dribble urine and had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/25/22 at 1:38 PM Resident #29 was sitting in his recliner and Certified Nursing Assistant (CNA) Staff A and CNA Staff B put him on the commode with the use of a Sit to Stand mechanical lift. When the resident was done voiding, Staff A wiped his bottom with gloved hands. Without changing her gloves, she proceeded to transfer the resident to the recliner chair, unhooked the sling from the Sit to Stand and from the resident, touched the recliner chair and a blanket.

Based on observation, interview and policy review the facility failed to provide privacy and dignity with cares for 1 of 12 residents reviewed, (Resident #16). Resident #16 was transfered in a shower chair with his backside exposed. The facility reported a census of 35 residents. Findings include: According to Minimum Data Set assessment dated [DATE], Resident #16 had a Brief Interview for Mental Status score of 3 (severe cognitive deficits). The resident required extensive assistance with the help of two for dressing and transfers and was totally dependent for showers. The Care Plan updated on 5/31/18 showed Resident #16 required total assistance with toileting and was incontinent of bladder and bowel. On 4/27/22 at 6:23 AM Resident #16 was in a wheeled shower chair in the hallway and Certified Nursing Assistant (CNA) Staff C was pulling him backwards towards the shower room. The resident was wearing a hospital gown open to the back, he had a blanket on his lap and his backside was exposed. The resident held his bare feet up off the floor as they moved down the hall. According to the Resident Bill of Rights, page 7, the residents have a right to privacy and confidentiality. Personal privacy includes personal cares. On 4/28/22 at 1:52 PM the Administrator said she would expect residents were transferred from their room to the shower room with the body covered in a dignified and respectful manner.

Based on record review, staff interviews, and Resident Assessment Instrument (RAI) the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days of admission to hospice for 1 of 1 residents reviewed for hospice services, (Resident #18). The facility reported a census of 35 residents. Findings include: 1. Record review of Resident #18 Census dated 4/27/2022 documented the resident started hospice services on 2/8/2022. Record review of Resident #18's MDS completed documented an Assessment Reference Date (ARD) of 2/22/2022. Review of the MDS revealed it was not completed till 3/8/2022. Record review of the current RAI manual; Chapter 2, instructs facilities to follow the guidelines below: A Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing. Record review of the residents admission to hospice services on 2/8/2022 and the MDS completion date of 3/8/2022 revealed the facility took greater than 14 days to complete the assessment. Interview on 4/28/22 at 7:59 AM with the MDS Coordinator and Director of Nursing (DON) revealed training was provided by their facilities corporation that they have 14 days to set the ARD for the MDS and did not also have to have it completed by then as well.

Based on record review and staff interview the facility failed to add interventions after falls for Resident #1 with a history of falls and failed to provide assistance of 2 staff to prevent falls for Resident #4. The sample included 5 residents. The facility reported a census of 42 residents. Findings included: Resident #1's 3/14/17 Minimum Data Set (MDS) documented the resident had severely impaired cognitive function. The resident required extensive assistance of staff for transfers and ambulation in the room. The resident had a history of [REDACTED]. On 2/28/17 staff added an intervention to the Care Plan directing staff to apply pressure alarms to the resident's chair and bed. On 3/8/21 at 3:21 a.m. staff documented in the Nursing Progress Notes staff entered the room while doing rounds and found the resident sitting on the floor next to the bed. The 3/8/17 (Incident Report) Resident Assessment Form documented the resident had unhooked the pressure alarm. The resident's Care Plan lacked any new interventions related to the fall and did not direct staff to place the alarm box out of the resident's reach. On 3/9/17 at 3:11 p.m. staff documented in the Nursing Progress Notes the resident had been witnessed leaning over messing with his shoes when he slipped to the floor. The Care Plan lacked any new interventions related to the fall and did not direct staff to intervene if the resident leaned over in his chair. During interview on 9/12/17 at 12:22 p.m. Staff A, Registered Nurse (RN) stated they had added a Tabs (clip) alarm after that fall but confirmed it had not been added to the Care Plan. She stated the resident did not currently use a Tabs alarm. On 3/12/17 at 10:05 p.m. staff documented in the Nursing Progress Notes staff found the resident on the floor next to the wheelchair in his room. A hand written staff statement stated they had heard the resident's alarm and saw the resident leaning over doing something with his shoe but couldn't reach the resident before he slipped out of the wheelchair. The staff noted the resident still hanging on to a shoe lace after the fall. The Care Plan lacked any new interventions related to the fall, such as to keep the resident in a supervised area while awake or change to slip on shoes or slippers. On 3/13/17 at 7:30 a.m. staff documented in the Nursing Progress Notes the resident slid out of the wheelchair at the breakfast table. The Resident Assessment Form stated the resident had dropped a fork and was trying to pick it up. Staff added an intervention to place Dycem in the chair seat, but still did not direct staff to intervene when the resident leaned over in the chair. On 3/21/17 at 4:53 p.m. staff documented in the Nursing Progress Notes the resident had been reaching over to pick up Bingo Chips off the floor when the wheelchair tipped over and the resident fell on the floor. The Care Plan lacked any new interventions or directions to staff to intervene when the resident leaned over in the wheelchair. According to the MDS assessment dated [DATE], Resident #4 demonstrated long and short term memory problems and severely impaired skills for daily decision making. Resident #4 depended on staff for activities of daily living (ADL's) including bed mobility, transfer, dressing, toilet use and personal hygiene. Resident #4's [DIAGNOSES REDACTED]. An Incident Report, QA Investigation documented Resident #4 rolled out of bed on 6/30/17 at 4:15 a.m. The identified factors involved in the fall included the chucks pads slid easy, so when the resident rolled, if close to edge of the bed, he/she would slide right off the bed. An Incident Report QA Investigation documented on 7/3/17 at 11:30 a.m. a certified nursing assistant (CNA) provided care to Resident #4 while in bed. The CNA assisted Resident #4 roll over to provide further cares, then the resident rolled further independently causing feet and legs to roll off the bed, with her knees landing on the fall mat. The Fall investigation-Quality Improvement Document dated 7/3/17 11:30 a.m., recommended assist of 2 at all times with any cares in room. A Witness Statement dated 7/3/17 documented Staff F CNA had Resident #4 on her side changing her pad. She let go to grab gloves to provide incontinency care, and as the resident finished rolling onto her tummy her feet went off the edge causing her to slide off the bed onto her knees in a praying position. A Witness Statement dated 7/3/17 documented Staff C Registered Nurse (RN) walked into Resident #4's room to do a skin assessment and noted the resident 3/4 the way off the bed, with the CNA standing beside her to prevent her from falling further. The CNA stated she had Resident #4 on her side and went to get wipes from the sink area and noticed her sliding off the bed. The new intervention directed Resident #4 to have assist of 2 with all cares. Non Pressure Skin Conditions sheets documented the following on 7/3/17: a. 4 by 3 cm area of the right lateral thigh by the knee, reddish purple bruise. b. 1.3 cm skin tear of the left middle finger with 1.3 by 0.6 cm bruise with a small amount of bleeding. c. 0.5 by 0.5 cm purple bruise of right side of the cheek d. 3.5 by 1.3 cm purple bruise of the left medial thigh. e. 1 by 1.3 purple bruise of the right wrist. f. 1 by 0.5 cm light bruise to the left forehead. g. 1 by 0.3 cm purple bruise of the left foot by the 2nd digit. The Care Plan initiated 11/11/16 identified Resident #4 needed assist with ADL's related to a stroke placing her at risk for fall/injury. An intervention initiated 11/11/16 directed to assist Resident #4 with bed mobility with assist of 2. An intervention initiated 7/3/17 directed assistance of 2 staff for bed mobility and dressing. The September 17 Documentation Survey Report documented staff assisted Resident #4 with assist of only 1 for bed mobility on 7 shifts, and only 1 for dressing on 18 shifts. During an interview on 9/13/17 at 7 a.m. regarding the 7/3/17 incident, the Director of Nursing (DON) stated it was not good practice to leave the resident unattended on their side with a known history of rolling out of bed.

Based on clinical record review, policy review and staff interviews the facility failed to provide provision of assessment and timely interventions regarding an acute change in condition and safe transfers for 1 of 2 discharged residents reviewed (Resident #7). The facility reported a census of 43 during the survey revisit and a complaint investigation. Findings include: The quarterly Minimum Data Set (MDS) assessment tool dated 8/8/17 identified Resident #7 had [DIAGNOSES REDACTED]. The MDS reported that Resident #7 required extensive assistance of two staff for bed mobility, transfers, walking in their room and dressing and utilized the use of walker and/or wheelchair for locomotion. The MDS further reported that Resident #7's Brief Interview for Mental Status (BIMS) was a score of 3 out of 15, a score of 0-7 indicates sever impairment for daily decision making. Resident #7's Care Plan updated 7/31/17 included a focus area that the resident required staff assistance with activities of daily living related to [DIAGNOSES REDACTED]. Due to the heart failure the Resident becomes weak and is at risk for falling. The care plan included interventions to administer pain medication as ordered. For the residents safety please put shoes on with all transfers and to use assist of two staff members with all transfers and short distance ambulation with the use of a gait belt and front wheeled walker. The 10/8/17 updated to the care plan included the use of the Hoyer (mechanical lift) for all transfers. The care plan also included a focus area that included [DIAGNOSES REDACTED]. The interventions included the use of anxiolytic medication and to keep the environment as consistent as possible since the resident gets anxious and worried with changed, and offer reassurance if there is a change. The facilities Change in a Resident's Condition or Status revised (MONTH) 2006 Policy Statement that the facility shall promptly notify the resident, his or her attending physician and representative (sponsor) of changes in the resident's medical/mental condition and status ( e.g. changed in level of care, billing/payments, resident rights etc.) Under the policy interpretation and implementation list the following; 1. The Nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there had been: a. An accident or incident involving the resident. d. A significant change in the resident's physical/emotional/mental condition. The facilities Accident /Incident Prevention Monitoring System purpose to identify each resident as risk for accidents &/or falls and also adequately plan resident care and implement interventions to prevent accident/falls. The procedure listed the facility staff and or therapy staff will monitor resident's functional capacity/safety risk as needed but especially with any change of condition and as requested by the facilities quality assurance team. The Progress Note entered by Staff H Restorative nurse dated 9/15/17 at 9:25 a.m.reported the resident had been participating and completing her current restorative plan. No physical limitations hinder her participation and no referral needed. A late entry Progress Note entered by Staff I Registered Nurse (RN) for Resident #7 dated 10/2/17 at 8:59 a.m. entered at 1:03 p.m. reported the resident appears to be struggling with her air, oxygen saturation 48% on room air, skin color pale. The resident had wheezes bilaterally and diminished on expirations. Oxygen placed at 2 liters per nasal cannula and oxygen saturation at 91 %. No pedal [MEDICAL CONDITION] noted at this time. Resident refused to see a doctor, will ask later and suggested she think about it. Staff I entered a note at 9:25 a.m. reported they had asked the resident again about seeing a doctor the he would most likely put her on medication and she probably would not have to use oxygen later on. Resident still refuses to see doctor. The Progress note dated 10/2/17 at 10:55 a.m. reported Staff J RN updated the resident's emergency contact on her condition and that the resident is declining to be seen at this time. The emergency contact stated she would be out to speak with the resident. At 11:10 a.m. the emergency contact state resident is agreement to be seen. A 11:16 appointment set up for 1:30 p.m. today. The Physician Information Sheet dated 10/2/17 at 1:30 p.m. identified the present problem for the appointment as diminished expirations, inspiratory wheezes bilateral, shortness of breath and transferring poorly with assistance of two. The new physician orders [REDACTED]. The Progress Note entered by Staff J RN dated 10/3/17 at 11:15 a.m. reported the resident sleepy when in her room. Rhonchi noted to bilateral lungs and the oxygen saturation 97% on 2 liters per nasal cannula with no cough noted this a.m. A weight summary for Resident #7 recorded her weight on 9/27/17 at 1:37 p.m. at 179.5 pounds and the next weight on 10/4/17 at 8:32 a.m. to be 186 pounds. The Progress Note entered by Staff I RN dated 10/4/17 at 12:35 p.m. reported the resident's lungs clear to auscultation and diminished on expirations. No [MEDICAL CONDITION] noted and will continue to monitor. At 2:06p.m. Staff A Restorative Nursing Assistant (RNA) entered a note reporting she had attempted to get the resident to stand and get on the bike and the resident would not stand. The Progress Note entered by Staff C RN dated 10/5/17 at 2:40 p.m. reported the resident's oxygen saturation at 90% on 3 liters and the nurse checked the oxygen tubing and found it to be kinked. Oxygen saturation rechecked and at 95% on 3 liters per nasal cannula. The resident had labored breathing noted with exertion to talk or eat and her lung sound diminished throughout bilaterally and noted expiatory wheezes will continue to monitor. Staff A RNA entered a note at 3:46 p.m. reporting that the resident would not stand again today, very hard to get her to walk with walker to her wheelchair. At 11:50 p.m. a nurses note reported the resident's oxygen saturation 90% on 3 liters and her lungs were diminished with exploratory wheezes noted and will continue to monitor. The Progress Note entered by Staff H Restorative Nurse dated 10/6/17 at 10:47 reported the resident had not been feeling well had been seen at the clinic with a [DIAGNOSES REDACTED]. At 11:00 a.m. Staff C RN entered a nurse's note that reported the resident's oxygen saturation at 96% on 3 liters per nasal cannula. The resident had labored breathing noted with exertion to talk or eat and her lung sound diminished throughout bilaterally and noted expiatory wheezes will continue to monitor. At 2:45 p.m. Staff A RNA reported the resident had still not been feeling well and hard for her to stand and move to the wheel chair. A telephone clarification order from the physician dated 10/6/17 at 1:31 p.m. ordered supplemental oxygen at 3 liters per nasal cannula as needed to keep oxygen saturation above 90% one time a day related to heart failure and anxiety disorder. The Progress Note entered by Staff CRN dated 10/7/17 at 10:45 a.m. reported the resident's oxygen saturation at 92% on 3 liters per nasal cannula. The resident had labored breathing noted with exertion to talk or eat and her lung sound diminished throughout bilaterally and noted expiatory wheezes and the wheezes had improved since yesterday, will continue to monitor. The Progress Note entered by Staff B RN dated 10/7/17 at 10:23 p.m. reported the Certified Nursing Assistance (CNA) called this nurse to Resident #7's room. Upon entering room observed the resident sitting with her back against the bed facing the door and had gripper socks on. Per the two CNA's they were ambulating the resident to her bed and got near the bed going to sit down and the residents legs gave out. The two CNA's were not able to sustain her ups so the let her down slowly to the floor. The nurse and CNA's assisted the resident up to her recliner she had not been able to walk back to bed, so Hoyer lift used to the transfer. The residents range of motion (ROM) intact and within normal limits, no bruises noted at this time will continue to monitor closely. A Resident Assessment Form dated 10/7/17 at 9:00 p.m. completed by Staff B RN included the description of the above incident and the date and time stamp that the form had been faxed to the physician 10/8/17 at 1:24a.m. The form has an area to ask the resident what were you trying to do? Staff B entered referrer to CNA statement since the resident had been unable to answer. The CNA statement Staff [NAME] completed dated 10/7/17 explained he and Staff D were assisting Resident #7 from her recliner to the bed. The resident sat on the bed and Staff D lowered the bed in order for the resident to sit in safe positon. The mattress slipped and the resident was not able to hold by her own weight as her back slipped down the mattress and she fell to the floor. The Progress Note by Staff B RN dated 10/8/17 at 2:57a.m. reported the resident guarded the right hip area with position changes and yells ouch when doing ROM to the right leg, will reassess again when fully awake. At 6:30 a.m. Staff C entered a nurse's note reporting that with the assistance of Staff G CNA attempted to get the resident up to the commode. The Resident called out in pain it hurts, it hurts. The Staff C asked what hurts and the resident stated my right leg. Upon assessment of her legs that were extended out in front of the resident had no outward or inward rotation noted. The right hip area had a slight bump, no bruise noted. ROM intact, but caused the resident pain. After the assessment Staff C and Staff G using a gait belt attempted to transfer the resident to the commode and the resident would not bear weight on the right leg and minimal weight on the left leg. After the resident toileted, she had been transferred back to the bed calling out in pain the whole time. The Progress Note entered by Staff K RN dated 10/8/17 at 6:30 a.m. reported she assessed the resident in bed at this time. The resident's skin ashen-gray, and did report pain to her right hip and leg. No abnormal rotation or shortening of the right or left lower extremity at this time. A Hoyer lift and two assist with be used for all transfer at this time the Care Plan updated. The Progress Note dated 10/8/17 at 7:15 a.m. reported Staff C called Kossuth Regional Heath Center and physician made aware of the above notation and gave a telephone order to send the resident to the emergency room . The physician also okayed for the resident to eat since if she needed surgery it would not probably happen today. The Progress Note entered by Staff C RN dated 10/8/17 at 10:50 a.m. reported a telephone call had been received from a RN at Kossuth Regional Heath Center that informed the nurse that after x-raying the right hip the resident started to complaining of left leg pain so they x-rayed the left hip area. The resident had bilateral distal femur fractures and they were transferring her out to Mason City for surgery. During an interview on 10/24/17 at 8:30 a.m. with Staff B RN explained he had been called to Resident #7's room on 10/7/17 around 9:00 p.m. The CNA's were walking the resident to bed and had to lower her to the floor. ROM had been okay and resident stated she did not have pain. Staff B acknowledged he and the CNA's lifted the resident to the chair and then to bed. Later on in the night she grabbed her right leg when moving it, but stated she wanted to sleep. Staff B further explained he reported the incident to Staff C RN. Staff B wanted Staff C to do a better assessment to see if the resident needed to be sent out to the hospital for an x-ray once she is awake. During an interview on 10/24/17 at 9:13 p.m. with Staff D a care giver in training acknowledged she and Staff [NAME] had to lower Resident #7 down to the floor on 10/7/17 around 9:00 p.m. the resident could not stand. She explained once on the floor Staff [NAME] stayed with the resident and she went out to get the nurse. Staff B RN came along with Staff F CNA to the room with the ez-stand (mechanical lift to move from a sitting position to standing) and helped the resident up from the floor using the ez-stand. The resident complained of pain the whole time getting her up and stopped complaining once in bed. During an interview on 10/25/17 at 8:05 a.m. with Staff C RN confirmed she worked 10/8/17 at 6:00 am. During shift change report Staff B explained Resident #7 had fallen the night before and they used an ez-stand to get her off the floor. Staff B acknowledged she had a little pain. He further explained if you need to send resident to the emergency room you can. Staff C further explained her and Staff G CNA went down to the resident's room. Staff C completed ROM and the resident seemed fine, only had a small bump on her right hip. Staff C and Staff G attempted to get the resident up using a gait belt and two person pivot transfer and she would not bare weight. Staff C explained she called the on call doctor and he wanted her to send the resident to the emergency room . Staff C acknowledged that the resident seemed fine once sitting in her wheelchair. During an interview on 10/25/17 at 2:30 p.m. acknowledged the nurse's progress notes reported the resident's lungs clear and next day worsened with no doctor notification. She further acknowledged it had been reported in the progress notes by the restorative aide the resident had been having a hard time standing. The nurse explained she would have then look for restorative notes and doctor notifications. During an interview on 10/26/17 at 9:30 a.m. with Staff K acknowledged the only physician notification occurred 10/6/17 at 1:31 p.m. for clarification on oxygen and the fax sent 10/8/17 at 1:24 a.m. notifying the physician of the incident between the 10/2/17 doctor visit and the resident being sent out to the emergency room . During an interview on 10/27/17 at 5:30 p.m. with the emergency room physician from Kossuth Regional Heath Center explained in his opinion the bilateral distal femurs would not occur with a resident being lowered to the floor maybe possibly a unilateral fracture not both. He further explained he received a call from the facility and relayed the same information to them. This surveyor clarified in the physician's opinion the resident must have fallen and he replied yes. This surveyor asked the physician if the resident's lungs cleared after the [MEDICAL CONDITION] and then got worse should the physician be notified. The physician acknowledged if the resident had a change in condition he would expect the facility to notify the physician. He also explained if a resident with [MEDICAL CONDITION] had a 3 pound gain in 1 day or a 5 pound gain in 1 week the physician should be notified. Based on clinical record review, policy review and staff interviews the facility failed to provide provision of assessment and timely interventions regarding an acute change in condition and safe transfers for 1 of 2 discharged residents reviewed (Resident #7). The facility reported a census of 43 during the survey revisit and a complaint investigation. Findings include: The quarterly Minimum Data Set (MDS) assessment tool dated 8/8/17 identified Resident #7 had [DIAGNOSES REDACTED]. The MDS reported that Resident #7 required extensive assistance of two staff for bed mobility, transfers, walking in their room and dressing and utilized the use of walker and/or wheelchair for locomotion. The MDS further reported that Resident #7's Brief Interview for Mental Status (BIMS) was a score of 3 out of 15, a score of 0-7 indicates sever impairment for daily decision making. Resident #7's Care Plan updated 7/31/17 included a focus area that the resident required staff assistance with activities of daily living related to [DIAGNOSES REDACTED]. Due to the heart failure the Resident becomes weak and is at risk for falling. The care plan included interventions to administer pain medication as ordered. For the residents safety please put shoes on with all transfers and to use assist of two staff members with all transfers and short distance ambulation with the use of a gait belt and front wheeled walker. The 10/8/17 updated to the care plan included the use of the Hoyer (mechanical lift) for all transfers. The care plan also included a focus area that included [DIAGNOSES REDACTED]. The interventions included the use of anxiolytic medication and to keep the environment as consistent as possible since the resident gets anxious and worried with changed, and offer reassurance if there is a change. The facilities Change in a Resident's Condition or Status revised (MONTH) 2006 Policy Statement that the facility shall promptly notify the resident, his or her attending physician and representative (sponsor) of changes in the resident's medical/mental condition and status ( e.g. changed in level of care, billing/payments, resident rights etc.) Under the policy interpretation and implementation list the following; 1. The Nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there had been: a. An accident or incident involving the resident. d. A significant change in the resident's physical/emotional/mental condition. The facilities Accident /Incident Prevention Monitoring System purpose to identify each resident as risk for accidents &/or falls and also adequately plan resident care and implement interventions to prevent accident/falls. The procedure listed the facility staff and or therapy staff will monitor resident's functional capacity/safety risk as needed but especially with any change of condition and as requested by the facilities quality assurance team. The Progress Note entered by Staff H Restorative nurse dated 9/15/17 at 9:25 a.m.reported the resident had been participating and completing her current restorative plan. No physical limitations hinder her participation and no referral needed. A late entry Progress Note entered by Staff I Registered Nurse (RN) for Resident #7 dated 10/2/17 at 8:59 a.m. entered at 1:03 p.m. reported the resident appears to be struggling with her air, oxygen saturation 48% on room air, skin color pale. The resident had wheezes bilaterally and diminished on expirations. Oxygen placed at 2 liters per nasal cannula and oxygen saturation at 91 %. No pedal [MEDICAL CONDITION] noted at this time. Resident refused to see a doctor, will ask later and suggested she think about it. Staff I entered a note at 9:25 a.m. reported they had asked the resident again about seeing a doctor the he would most likely put her on medication and she probably would not have to use oxygen later on. Resident still refuses to see doctor. The Progress note dated 10/2/17 at 10:55 a.m. reported Staff J RN updated the resident's emergency contact on her condition and that the resident is declining to be seen at this time. The emergency contact stated she would be out to speak with the resident. At 11:10 a.m. the emergency contact state resident is agreement to be seen. A 11:16 appointment set up for 1:30 p.m. today. The Physician Information Sheet dated 10/2/17 at 1:30 p.m. identified the present problem for the appointment as diminished expirations, inspiratory wheezes bilateral, shortness of breath and transferring poorly with assistance of two. The new physician orders [REDACTED]. The Progress Note entered by Staff J RN dated 10/3/17 at 11:15 a.m. reported the resident sleepy when in her room. Rhonchi noted to bilateral lungs and the oxygen saturation 97% on 2 liters per nasal cannula with no cough noted this a.m. A weight summary for Resident #7 recorded her weight on 9/27/17 at 1:37 p.m. at 179.5 pounds and the next weight on 10/4/17 at 8:32 a.m. to be 186 pounds. The Progress Note entered by Staff I RN dated 10/4/17 at 12:35 p.m. reported the resident's lungs clear to auscultation and diminished on expirations. No [MEDICAL CONDITION] noted and will continue to monitor. At 2:06p.m. Staff A Restorative Nursing Assistant (RNA) entered a note reporting she had attempted to get the resident to stand and get on the bike and the resident would not stand. The Progress Note entered by Staff C RN dated 10/5/17 at 2:40 p.m. reported the resident's oxygen saturation at 90% on 3 liters and the nurse checked the oxygen tubing and found it to be kinked. Oxygen saturation rechecked and at 95% on 3 liters per nasal cannula. The resident had labored breathing noted with exertion to talk or eat and her lung sound diminished throughout bilaterally and noted expiatory wheezes will continue to monitor. Staff A RNA entered a note at 3:46 p.m. reporting that the resident would not stand again today, very hard to get her to walk with walker to her wheelchair. At 11:50 p.m. a nurses note reported the resident's oxygen saturation 90% on 3 liters and her lungs were diminished with exploratory wheezes noted and will continue to monitor. The Progress Note entered by Staff H Restorative Nurse dated 10/6/17 at 10:47 reported the resident had not been feeling well had been seen at the clinic with a [DIAGNOSES REDACTED]. At 11:00 a.m. Staff C RN entered a nurse's note that reported the resident's oxygen saturation at 96% on 3 liters per nasal cannula. The resident had labored breathing noted with exertion to talk or eat and her lung sound diminished throughout bilaterally and noted expiatory wheezes will continue to monitor. At 2:45 p.m. Staff A RNA reported the resident had still not been feeling well and hard for her to stand and move to the wheel chair. A telephone clarification order from the physician dated 10/6/17 at 1:31 p.m. ordered supplemental oxygen at 3 liters per nasal cannula as needed to keep oxygen saturation above 90% one time a day related to heart failure and anxiety disorder. The Progress Note entered by Staff CRN dated 10/7/17 at 10:45 a.m. reported the resident's oxygen saturation at 92% on 3 liters per nasal cannula. The resident had labored breathing noted with exertion to talk or eat and her lung sound diminished throughout bilaterally and noted expiatory wheezes and the wheezes had improved since yesterday, will continue to monitor. The Progress Note entered by Staff B RN dated 10/7/17 at 10:23 p.m. reported the Certified Nursing Assistance (CNA) called this nurse to Resident #7's room. Upon entering room observed the resident sitting with her back against the bed facing the door and had gripper socks on. Per the two CNA's they were ambulating the resident to her bed and got near the bed going to sit down and the residents legs gave out. The two CNA's were not able to sustain her ups so the let her down slowly to the floor. The nurse and CNA's assisted the resident up to her recliner she had not been able to walk back to bed, so Hoyer lift used to the transfer. The residents range of motion (ROM) intact and within normal limits, no bruises noted at this time will continue to monitor closely. A Resident Assessment Form dated 10/7/17 at 9:00 p.m. completed by Staff B RN included the description of the above incident and the date and time stamp that the form had been faxed to the physician 10/8/17 at 1:24a.m. The form has an area to ask the resident what were you trying to do? Staff B entered referrer to CNA statement since the resident had been unable to answer. The CNA statement Staff [NAME] completed dated 10/7/17 explained he and Staff D were assisting Resident #7 from her recliner to the bed. The resident sat on the bed and Staff D lowered the bed in order for the resident to sit in safe positon. The mattress slipped and the resident was not able to hold by her own weight as her back slipped down the mattress and she fell to the floor. The Progress Note by Staff B RN dated 10/8/17 at 2:57a.m. reported the resident guarded the right hip area with position changes and yells ouch when doing ROM to the right leg, will reassess again when fully awake. At 6:30 a.m. Staff C entered a nurse's note reporting that with the assistance of Staff G CNA attempted to get the resident up to the commode. The Resident called out in pain it hurts, it hurts. The Staff C asked what hurts and the resident stated my right leg. Upon assessment of her legs that were extended out in front of the resident had no outward or inward rotation noted. The right hip area had a slight bump, no bruise noted. ROM intact, but caused the resident pain. After the assessment Staff C and Staff G using a gait belt attempted to transfer the resident to the commode and the resident would not bear weight on the right leg and minimal weight on the left leg. After the resident toileted, she had been transferred back to the bed calling out in pain the whole time. The Progress Note entered by Staff K RN dated 10/8/17 at 6:30 a.m. reported she assessed the resident in bed at this time. The resident's skin ashen-gray, and did report pain to her right hip and leg. No abnormal rotation or shortening of the right or left lower extremity at this time. A Hoyer lift and two assist with be used for all transfer at this time the Care Plan updated. The Progress Note dated 10/8/17 at 7:15 a.m. reported Staff C called Kossuth Regional Heath Center and physician made aware of the above notation and gave a telephone order to send the resident to the emergency room . The physician also okayed for the resident to eat since if she needed surgery it would not probably happen today. The Progress Note entered by Staff C RN dated 10/8/17 at 10:50 a.m. reported a telephone call had been received from a RN at Kossuth Regional Heath Center that informed the nurse that after x-raying the right hip the resident started to complaining of left leg pain so they x-rayed the left hip area. The resident had bilateral distal femur fractures and they were transferring her out to Mason City for surgery. During an interview on 10/24/17 at 8:30 a.m. with Staff B RN explained he had been called to Resident #7's room on 10/7/17 around 9:00 p.m. The CNA's were walking the resident to bed and had to lower her to the floor. ROM had been okay and resident stated she did not have pain. Staff B acknowledged he and the CNA's lifted the resident to the chair and then to bed. Later on in the night she grabbed her right leg when moving it, but stated she wanted to sleep. Staff B further explained he reported the incident to Staff C RN. Staff B wanted Staff C to do a better assessment to see if the resident needed to be sent out to the hospital for an x-ray once she is awake. During an interview on 10/24/17 at 9:13 p.m. with Staff D a care giver in training acknowledged she and Staff [NAME] had to lower Resident #7 down to the floor on 10/7/17 around 9:00 p.m. the resident could not stand. She explained once on the floor Staff [NAME] stayed with the resident and she went out to get the nurse. Staff B RN came along with Staff F CNA to the room with the ez-stand (mechanical lift to move from a sitting position to standing) and helped the resident up from the floor using the ez-stand. The resident complained of pain the whole time getting her up and stopped complaining once in bed. During an interview on 10/25/17 at 8:05 a.m. with Staff C RN confirmed she worked 10/8/17 at 6:00 am. During shift change report Staff B explained Resident #7 had fallen the night before and they used an ez-stand to get her off the floor. Staff B acknowledged she had a little pain. He further explained if you need to send resident to the emergency room you can. Staff C further explained her and Staff G CNA went down to the resident's room. Staff C completed ROM and the resident seemed fine, only had a small bump on her right hip. Staff C and Staff G attempted to get the resident up using a gait belt and two person pivot transfer and she would not bare weight. Staff C explained she called the on call doctor and he wanted her to send the resident to the emergency room . Staff C acknowledged that the resident seemed fine once sitting in her wheelchair. During an interview on 10/25/17 at 2:30 p.m. acknowledged the nurse's progress notes reported the resident's lungs clear and next day worsened with no doctor notification. She further acknowledged it had been reported in the progress notes by the restorative aide the resident had been having a hard time standing. The nurse explained she would have then look for restorative notes and doctor notifications. During an interview on 10/26/17 at 9:30 a.m. with Staff K acknowledged the only physician notification occurred 10/6/17 at 1:31 p.m. for clarification on oxygen and the fax sent 10/8/17 at 1:24 a.m. notifying the physician of the incident between the 10/2/17 doctor visit and the resident being sent out to the emergency room . During an interview on 10/27/17 at 5:30 p.m. with the emergency room physician from Kossuth Regional Heath Center explained in his opinion the bilateral distal femurs would not occur with a resident being lowered to the floor maybe possibly a unilateral fracture not both. He further explained he received a call from the facility and relayed the same information to them. This surveyor clarified in the physician's opinion the resident must have fallen and he replied yes. This surveyor asked the physician if the resident's lungs cleared after the [MEDICAL CONDITION] and then got worse should the physician be notified. The physician acknowledged if the resident had a change in condition he would expect the facility to notify the physician. He also explained if a resident with [MEDICAL CONDITION] had a 3 pound gain in 1 day or a 5 pound gain in 1 week the physician should be notified.

Based on record review and staff interview the facility failed to provide restorative services as planned for 4 of 7 residents admitted without limitations in range of motion and developed functional limitations (Resident #1, #6, #8, #10). Resident #1, #6 and #10 had range of motion declines in the lower extremities. The facility reported a census of 42 residents. Findings included: Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 4/17/17. The MDS indicated the resident had a severe cognitive impairment. The resident required extensive assistance of 2 staff members for transfers and ambulation in the room. The MDS indicated the resident had no functional limitations in range of motion of the upper and lower extremities. The MDS identified the following [DIAGNOSES REDACTED]. The MDS with a reference date of 5/30/17, documented the resident had no functional limitations in range of motion. The MDS indicated the resident required total dependence on staff for transfers and did not ambulate in room or corridor. The MDS, with a reference date of 8/21/17, documented the resident had functional limitations in range of motion to both lower extremities. The resident now required total assistance for transfers and did not ambulate. A form titled Walk-to -Dine/Restorative Therapy Order, written by physical therapy staff, dated 6/5/17, directed the nursing staff to assist the resident with seated lower extremity exercises, 15 to 20 repetitions 3 to 6 times weekly. The instructions directed if the resident did not follow instructions well to perform assisted/passive range of motion with gentle stretches to the legs, The resident's record lacked documentation that the resident received any restorative services. On 9/12/17 at 1:37 p.m. Staff E, restorative nurse, registered nurse, was interviewed and confirmed the facility had no documentation of any restorative treatment/cares. Staff E stated He slipped under my radar. 2. Resident #10 had a MDS assessment with a reference date of 11/8/16. The MDS documented the resident had short and long term memory impairments and moderately impaired with decision making ability. The resident required total assistance of staff for transfers and did not ambulate. The resident had no functional limitations in range of motion. The MDS with a reference date of 7/11/17 documented the resident's transfer and ambulation ability unchanged but now the resident had functional limitations in range of motion to both lower extremities. The MDS indicated the resident had [DIAGNOSES REDACTED]. The resident's Task Sheet directed staff to assist the resident with Active Range of Motion 3 to 6 times weekly. Staff documented in the electronic record assistance with the range of motion exercises provided only 5 times in July 2017, 7 times in August 2017 and on 9/13/17 assistance had only been provided one time in the month of September. 3. Resident #6 had a MDS with a reference date of 3/21/17. The MDS documented the resident had moderately impaired cognitive function. The resident required no assistance for transfers or ambulation and had no functional limitations in range of motion. The MDS with a reference date of 6/14/17 MDS (significant change in condition) documented the resident had severely impaired cognitive function and required extensive assistance of staff for transfers and ambulation. The resident had functional limitations in range of motion to both lower extremities. A Walk to Dine/Restorative Therapy Order written by Physical Therapy Staff directed nursing staff to assist the resident with seated lower extremity exercises for 2 sets of 10 repetitions and standing lower extremity exercises for 2 sets of 10 repetitions 3 to 6 times weekly. Staff documented in the electronic record assistance with the lower extremity exercises provided only 1 time in July 2017. The record lacked any documentation indicating staff assisted the resident with the exercises since 7/10/17. On 9/13/17 at 8:18 a.m. Staff G, restorative aide, was interviewed and stated she had not currently been doing any restorative treatment with the residents. Staff G stated she was a restorative aide for 2 months. Staff G stated she didn't do restorative services because she worked on the floor (as a nursing assistant) a lot and stated she didn't get to everyone every day 4. Resident #8 had a MDS assessment with a reference date of 1/10/17. Resident #8 scored 2 on the Brief Interview for Mental Status (BIMS) test. A score of 2 represented the resident had a severe cognitive impairment. Resident #8 required extensive assistance with activities of daily living (ADL's) including bed mobility, transfer, dressing, and personal hygiene. Resident #8's [DIAGNOSES REDACTED]. The MDS documented Resident #8 had no limitations in functional range of motion in the upper or lower extremities. The MDS with a reference date of 6/26/17, identified the resident had functional impairments of the lower extremities. The resident required extensive assistance of two or more people for transfers and ambulation in the room. A Tasks form printed 9/13/17 documented Resident #8's restorative included: a. Ambulation from the Nustep (mechanical device) with the walker and wheelchair to follow. b. Nustep 10-15 minutes workload 2 as tolerates, if resident able to walk or pivot to Nu-step 2x/week prn (as needed). c. Sitting exercises- wheelchair push-ups 5 times, 3-6 times a week prn. d. Standing exercises at parallel bars 3 times as long as possible as tolerates 2 times a week prn. e. Upper extremity exercises dowel rod with 1 pound weight chest press, circles forward and back, and elbow forward and back 10 times, 3-6 times a week prn. A Documentation Survey Report for January 2017 documented Resident #8 participated in restorative 6 times through 1/12/17, and only 3 times the rest of the month. The report showed 1 refusal. A Documentation Survey Report for February 2017 documented Resident #8 participated in restorative only 5 times the entire month. A Documentation Survey Report for March 2017 documented Resident #8 participated in restorative only 4 times the entire month. A Documentation Survey Report for April 2017 documented Resident #8 participated in restorative only 3 times the entire month. The report documented 1 refusal. A Documentation Survey Report for May 2017 documented Resident #8 participated in restorative only 5 times the entire month. A Documentation Survey Report for June 2017 documented Resident #8 participated in restorative only 1 time the entire month. A Documentation Survey Report for July 2017 documented Resident #8 participated in restorative only 5 days the entire month. A Documentation Survey Report for August 2017 documented Resident #8 participated in restorative only 1 time the entire month. On 9/13/17 at 2:45 p.m. the MDS Coordinator stated Resident #8 had not received any restorative services so far in September 2017. The resident had a [DIAGNOSES REDACTED]. Exercise can help with joint mobility and prevent muscle loss.

Based on observation, record review and staff interviews, the facility failed to provide timely interventions to prevent the development of pressure ulcers and failed to promote healing of sores for 2 of 10 residents reviewed (Resident #1 and #4) The facility reported a census of 42 residents. Findings included: Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 4/1717. The MDS documented the resident had severely impaired cognitive function. The resident required extensive assistance of 2 staff members for bed mobility and total assistance of 2 staff members for transfers. The resident did not ambulate. The Braden Scale dated 4/27/17 scored 16 which identified the resident at risk for the development of pressure ulcers. Resident #1 had a MDS with a reference date of 5/30/17. The resident required total assistance of 2 staff members for bed mobility and transfers. The resident did not ambulate. The Braden Scale, dated 6/12/17, indicated a score of 14. A score of 14 indicated the resident at moderate risk for the development of pressure ulcers. The MDS identified the resident had one Stage I pressure ulcer. The MDS described pressure sores as the following: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. A Pressure Ulcer Documentation form dated 5/3/17 identified the staff found a Stage I pressure ulcer (a non-blanchable [DIAGNOSES REDACTED] of intact skin) found on the coccyx area. The area measured 0.5 by 0.5 centimeters (cm.) According to the resident's Care Plan, staff did not add any pressure relieving device to the resident's bed until 5/23/17. On 5/23/17, the staff added a specialized overlay mattress. On 9/13/17 at 11:02 a.m. Staff A, Registered Nurse (RN) was interviewed and confirmed this to be the same alternating pressure air mattress currently in use. On 5/30/17 staff documented the area now measured 1 cm. by 0.4 cm. and described the pressure sore as a Stage II ulcer. The Pressure Ulcer Documentation form indicated the following: On 6/16/17, staff measured the ulcer to be 2 by 1 by 0.3 cm. and described the wound as Stage III (full thickness skin loss). On 6/23/17, staff measured the ulcer to be 2.4 by 2 cm. on the upper border and 1 cm. wide on the lower border. Staff documented the area unstageable due to 100% yellow slough (necrotic tissue). The Care Plan identified the interventions did not address pressure relieving devices to the wheelchair seat until 6/27/17. On 6/27/17 the staff added a gel cushion and then changed the cushion to a Roho cushion on 8/9/17. The Pressure Ulcer Documentation form indicated the following: On 6/29/17, the staff documented a 1 cm. by 0.5 cm callous found on the left heel with a slight brown center. The Progress Notes (Nurse's Notes) dated 6/29/17 at 3:57 p.m. identified the staff documented the Wound Nurse had stated the area resulted from rubbing rather than pressure. Staff documented the area resolved on 7/31/17. The Pressure Ulcer Documentation form indicated: On 7/3/17, the staff documented a 1.3 by 0.7 cm. callous/scab on the resident's right lateral heel. The area became progressively smaller but on 8/11/17 staff documented the area noted to be due to pressure and described the area as eschar (hard black/brown (dead skin cells) over the wound or parts of the wound which measured 0.4 by 0.4 cm. On 8/14/17 the area measured 0.5 by 0.3 cm. eschar with yellow exudate. On 8/21/17, staff measured the area 0.7 by 0.4 cm eschar. On 8/28/17 staff documented the area recently debrided and now measured 1.8 by 1.4 cm. On 9/11/17 the area measured 0.7 by 0.3 by 0.1 cm. With each measurement on and after 8/11/17 staff documented the resident grimaced and rated the resident's pain 4 to 6 on a scale of 10 with 10 being the worst. The resident's Care Plan directed staff to apply heel protectors to both feet anytime the resident laid in bed and to assist the resident to float the heels. Observation on 9/11/17 at 1:26 p.m. identified the resident lying on his back in bed with blue padded heel protectors in place without any pillow or device to float the heels. The resident had knees bent outward with the lateral aspect of the right foot/heel resting on the medial aspect of the left foot. Staff B, Certified Nursing Assistant (CNA) stated the resident should have the heels floated. She then placed a pillow under the lower legs and ankles to suspend the heels off the mattress. During interview on 9/11/17 at 2:04 p.m. Staff A (registered nurse) stated they had considered the padded heel protectors to be pressure relieving. At 2:51 p.m. she stated they had obtained new pressure relieving boots for the resident. During an interview on 9/13/17 at 11:29 a.m. She stated after the surveyor asked about the heel protectors they had did some research and determined they (blue boots) were not appropriate for pressure relief. On 9/12/17 at 10:48 a.m. observation identified the resident in bed while Staff C, RN and Staff D, CNA performed a dressing change on the resident's right lateral heel. Each time the registered nurse touched the ulcer to cleanse it, apply ointment and the new dressing; the resident said ow or grimaced and made grunting noises. When asked if the resident often had pain with the dressing change, the RN stated he/she usually did have some pain when they changed the dressing. When asked if they had ever administered Tylenol or other pain medication prior to the dressing change she stated, we could try that. We probably should. Staff documented on the Treatment Administration Record that the resident received daily dressing changes/treatments. 2. Resident #4 had a MDS assessment with a reference date of 02/20/17. Resident #4 scored 12 on the Brief Interview for Mental Status (BIMS) test. A score of 12 represented the resident had a cognitive impairment. Resident #4 depended on staff for activities of daily living (ADL's) including bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS identified [DIAGNOSES REDACTED]. Resident #4 had no pressure ulcer but had a risk for the development of a pressure ulcer. Resident #4 had a pressure reducing device for the bed and chair, but no turning/repositioning program. A Care Area Assessment (CAA) identified Resident #4 had a potential for pressure ulcer development due to frequent incontinence, total dependence with transfers and bed mobility, and the inability to make major body repositioning changes. The CAA documented pressure ulcer would not be addressed in the care plan. A Pressure Ulcer Documentation form dated 3/5/17 documented Resident #4 had a Stage 2 pressure area of the right inner buttock measuring 0.8 by 0.8 cm. The initial treatment or intervention implemented included Resident #4 to lie down between meals and repositioned off area every 2 hours. The area resolved 3/20/17. A Pressure Ulcer Documentation form dated 3/26/17 documented Resident #4 had a stage 2 pressure ulcer of the left heel measuring 5 by 3.2 cm. Initial treatment ordered or Intervention implemented included an air mattress placed on the bed and resident #4 to wear blue booties when in bed. The form documented the area resolved 5/2/17. According to the Minimum Data Set (MDS) assessment, dated 5/23/17, Resident #4 demonstrated long and short term memory problems and severely impaired skills for daily decision making Resident #4 depended on staff for activities of daily living (ADL's) including bed mobility, transfer, dressing, toilet use and personal hygiene. Resident #4's [DIAGNOSES REDACTED].#4 had a risk of developing pressure ulcers and had pressure reduction devices for the bed and chair. Resident #4 did not have a repositioning/turning program. An undated Provider Wound Care Orders for Resident #4's bilateral buttocks and lateral side left heel directed to clean the wound with mild soap and water or shower, and apply [MEDICATION NAME] to IAD (incontinence associated [MEDICAL CONDITION]) areas on the buttocks bilateral, and [MEDICATION NAME] to left heel DTI (deep tissue injury) area/blister daily. Wound Clinic Documentation dated 4/3/17 revealed the left lateral heel with deep tissue injury which staff applied [MEDICATION NAME] to. Interventions for healing included increased protein in diet, repositioning, support surface for bed/chair, extremity elevation, offloading foot, and incontinence management. The Care Plan dated 11/11/16 identified Resident #4 needed ADL assistance. The interventions included he/she wore pressure reduction booties when in bed, and if continued to kick them off, to float his/her heels, initiated 5/26/17, and revised 7/5/17. The Care Plan initiated 4/5/17 identified Resident #4 with impaired skin with scratched areas on his/her buttocks. The interventions included to offer good protein sources at all meals and be sure the meat and other proteins appropriate texture, offer pudding or magic cup with noon and evening meal, provide vitamin/mineral supplements as ordered. The care plan did not identify Resident #4's history of or risk for developing pressure ulcers. During an observation on 9/12/17 at 8:25 a.m. staff removed protective (not pressure reduction) boots from Resident #4's feet.

Based on clinical record review, policy review and staff interviews the facility failed to provide provision of assessment and timely interventions regarding an acute change in condition and safe transfers for 1 of 2 discharged residents reviewed (Resident #7). The facility reported a census of 43 during the survey revisit and a complaint investigation. Findings include: The quarterly Minimum Data Set (MDS) assessment tool dated 8/8/17 identified Resident #7 had [DIAGNOSES REDACTED]. The MDS reported that Resident #7 required extensive assistance of two staff for bed mobility, transfers, walking in their room and dressing and utilized the use of walker and/or wheelchair for locomotion. The MDS further reported that Resident #7's Brief Interview for Mental Status (BIMS) was a score of 3 out of 15, a score of 0-7 indicates sever impairment for daily decision making. Resident #7's Care Plan updated 7/31/17 included a focus area that the resident required staff assistance with activities of daily living related to [DIAGNOSES REDACTED]. Due to the heart failure the Resident becomes weak and is at risk for falling. The care plan included interventions to administer pain medication as ordered. For the residents safety please put shoes on with all transfers and to use assist of two staff members with all transfers and short distance ambulation with the use of a gait belt and front wheeled walker. The 10/8/17 updated to the care plan included the use of the Hoyer (mechanical lift) for all transfers. The care plan also included a focus area that included [DIAGNOSES REDACTED]. The interventions included the use of anxiolytic medication and to keep the environment as consistent as possible since the resident gets anxious and worried with changed, and offer reassurance if there is a change. The facilities Change in a Resident's Condition or Status revised (MONTH) 2006 Policy Statement that the facility shall promptly notify the resident, his or her attending physician and representative (sponsor) of changes in the resident's medical/mental condition and status ( e.g. changed in level of care, billing/payments, resident rights etc.) Under the policy interpretation and implementation list the following; 1. The Nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there had been: a. An accident or incident involving the resident. d. A significant change in the resident's physical/emotional/mental condition. The facilities Accident /Incident Prevention Monitoring System purpose to identify each resident as risk for accidents &/or falls and also adequately plan resident care and implement interventions to prevent accident/falls. The procedure listed the facility staff and or therapy staff will monitor resident's functional capacity/safety risk as needed but especially with any change of condition and as requested by the facilities quality assurance team. The Progress Note entered by Staff H Restorative nurse dated 9/15/17 at 9:25 a.m.reported the resident had been participating and completing her current restorative plan. No physical limitations hinder her participation and no referral needed. A late entry Progress Note entered by Staff I Registered Nurse (RN) for Resident #7 dated 10/2/17 at 8:59 a.m. entered at 1:03 p.m. reported the resident appears to be struggling with her air, oxygen saturation 48% on room air, skin color pale. The resident had wheezes bilaterally and diminished on expirations. Oxygen placed at 2 liters per nasal cannula and oxygen saturation at 91 %. No pedal [MEDICAL CONDITION] noted at this time. Resident refused to see a doctor, will ask later and suggested she think about it. Staff I entered a note at 9:25 a.m. reported they had asked the resident again about seeing a doctor the he would most likely put her on medication and she probably would not have to use oxygen later on. Resident still refuses to see doctor. The Progress note dated 10/2/17 at 10:55 a.m. reported Staff J RN updated the resident's emergency contact on her condition and that the resident is declining to be seen at this time. The emergency contact stated she would be out to speak with the resident. At 11:10 a.m. the emergency contact state resident is agreement to be seen. A 11:16 appointment set up for 1:30 p.m. today. The Physician Information Sheet dated 10/2/17 at 1:30 p.m. identified the present problem for the appointment as diminished expirations, inspiratory wheezes bilateral, shortness of breath and transferring poorly with assistance of two. The new physician orders [REDACTED]. The Progress Note entered by Staff J RN dated 10/3/17 at 11:15 a.m. reported the resident sleepy when in her room. Rhonchi noted to bilateral lungs and the oxygen saturation 97% on 2 liters per nasal cannula with no cough noted this a.m. A weight summary for Resident #7 recorded her weight on 9/27/17 at 1:37 p.m. at 179.5 pounds and the next weight on 10/4/17 at 8:32 a.m. to be 186 pounds. The Progress Note entered by Staff I RN dated 10/4/17 at 12:35 p.m. reported the resident's lungs clear to auscultation and diminished on expirations. No [MEDICAL CONDITION] noted and will continue to monitor. At 2:06p.m. Staff A Restorative Nursing Assistant (RNA) entered a note reporting she had attempted to get the resident to stand and get on the bike and the resident would not stand. The Progress Note entered by Staff C RN dated 10/5/17 at 2:40 p.m. reported the resident's oxygen saturation at 90% on 3 liters and the nurse checked the oxygen tubing and found it to be kinked. Oxygen saturation rechecked and at 95% on 3 liters per nasal cannula. The resident had labored breathing noted with exertion to talk or eat and her lung sound diminished throughout bilaterally and noted expiatory wheezes will continue to monitor. Staff A RNA entered a note at 3:46 p.m. reporting that the resident would not stand again today, very hard to get her to walk with walker to her wheelchair. At 11:50 p.m. a nurses note reported the resident's oxygen saturation 90% on 3 liters and her lungs were diminished with exploratory wheezes noted and will continue to monitor. The Progress Note entered by Staff H Restorative Nurse dated 10/6/17 at 10:47 reported the resident had not been feeling well had been seen at the clinic with a [DIAGNOSES REDACTED]. At 11:00 a.m. Staff C RN entered a nurse's note that reported the resident's oxygen saturation at 96% on 3 liters per nasal cannula. The resident had labored breathing noted with exertion to talk or eat and her lung sound diminished throughout bilaterally and noted expiatory wheezes will continue to monitor. At 2:45 p.m. Staff A RNA reported the resident had still not been feeling well and hard for her to stand and move to the wheel chair. A telephone clarification order from the physician dated 10/6/17 at 1:31 p.m. ordered supplemental oxygen at 3 liters per nasal cannula as needed to keep oxygen saturation above 90% one time a day related to heart failure and anxiety disorder. The Progress Note entered by Staff CRN dated 10/7/17 at 10:45 a.m. reported the resident's oxygen saturation at 92% on 3 liters per nasal cannula. The resident had labored breathing noted with exertion to talk or eat and her lung sound diminished throughout bilaterally and noted expiatory wheezes and the wheezes had improved since yesterday, will continue to monitor. The Progress Note entered by Staff B RN dated 10/7/17 at 10:23 p.m. reported the Certified Nursing Assistance (CNA) called this nurse to Resident #7's room. Upon entering room observed the resident sitting with her back against the bed facing the door and had gripper socks on. Per the two CNA's they were ambulating the resident to her bed and got near the bed going to sit down and the residents legs gave out. The two CNA's were not able to sustain her ups so the let her down slowly to the floor. The nurse and CNA's assisted the resident up to her recliner she had not been able to walk back to bed, so Hoyer lift used to the transfer. The residents range of motion (ROM) intact and within normal limits, no bruises noted at this time will continue to monitor closely. A Resident Assessment Form dated 10/7/17 at 9:00 p.m. completed by Staff B RN included the description of the above incident and the date and time stamp that the form had been faxed to the physician 10/8/17 at 1:24a.m. The form has an area to ask the resident what were you trying to do? Staff B entered referrer to CNA statement since the resident had been unable to answer. The CNA statement Staff E completed dated 10/7/17 explained he and Staff D were assisting Resident #7 from her recliner to the bed. The resident sat on the bed and Staff D lowered the bed in order for the resident to sit in safe positon. The mattress slipped and the resident was not able to hold by her own weight as her back slipped down the mattress and she fell to the floor. The Progress Note by Staff B RN dated 10/8/17 at 2:57a.m. reported the resident guarded the right hip area with position changes and yells ouch when doing ROM to the right leg, will reassess again when fully awake. At 6:30 a.m. Staff C entered a nurse's note reporting that with the assistance of Staff G CNA attempted to get the resident up to the commode. The Resident called out in pain it hurts, it hurts. The Staff C asked what hurts and the resident stated my right leg. Upon assessment of her legs that were extended out in front of the resident had no outward or inward rotation noted. The right hip area had a slight bump, no bruise noted. ROM intact, but caused the resident pain. After the assessment Staff C and Staff G using a gait belt attempted to transfer the resident to the commode and the resident would not bear weight on the right leg and minimal weight on the left leg. After the resident toileted, she had been transferred back to the bed calling out in pain the whole time. The Progress Note entered by Staff K RN dated 10/8/17 at 6:30 a.m. reported she assessed the resident in bed at this time. The resident's skin ashen-gray, and did report pain to her right hip and leg. No abnormal rotation or shortening of the right or left lower extremity at this time. A Hoyer lift and two assist with be used for all transfer at this time the Care Plan updated. The Progress Note dated 10/8/17 at 7:15 a.m. reported Staff C called Kossuth Regional Heath Center and physician made aware of the above notation and gave a telephone order to send the resident to the emergency room . The physician also okayed for the resident to eat since if she needed surgery it would not probably happen today. The Progress Note entered by Staff C RN dated 10/8/17 at 10:50 a.m. reported a telephone call had been received from a RN at Kossuth Regional Heath Center that informed the nurse that after x-raying the right hip the resident started to complaining of left leg pain so they x-rayed the left hip area. The resident had bilateral distal femur fractures and they were transferring her out to Mason City for surgery. During an interview on 10/24/17 at 8:30 a.m. with Staff B RN explained he had been called to Resident #7's room on 10/7/17 around 9:00 p.m. The CNA's were walking the resident to bed and had to lower her to the floor. ROM had been okay and resident stated she did not have pain. Staff B acknowledged he and the CNA's lifted the resident to the chair and then to bed. Later on in the night she grabbed her right leg when moving it, but stated she wanted to sleep. Staff B further explained he reported the incident to Staff C RN. Staff B wanted Staff C to do a better assessment to see if the resident needed to be sent out to the hospital for an x-ray once she is awake. During an interview on 10/24/17 at 9:13 p.m. with Staff D a care giver in training acknowledged she and Staff E had to lower Resident #7 down to the floor on 10/7/17 around 9:00 p.m. the resident could not stand. She explained once on the floor Staff E stayed with the resident and she went out to get the nurse. Staff B RN came along with Staff F CNA to the room with the ez-stand (mechanical lift to move from a sitting position to standing) and helped the resident up from the floor using the ez-stand. The resident complained of pain the whole time getting her up and stopped complaining once in bed. During an interview on 10/25/17 at 8:05 a.m. with Staff C RN confirmed she worked 10/8/17 at 6:00 am. During shift change report Staff B explained Resident #7 had fallen the night before and they used an ez-stand to get her off the floor. Staff B acknowledged she had a little pain. He further explained if you need to send resident to the emergency room you can. Staff C further explained her and Staff G CNA went down to the resident's room. Staff C completed ROM and the resident seemed fine, only had a small bump on her right hip. Staff C and Staff G attempted to get the resident up using a gait belt and two person pivot transfer and she would not bare weight. Staff C explained she called the on call doctor and he wanted her to send the resident to the emergency room . Staff C acknowledged that the resident seemed fine once sitting in her wheelchair. During an interview on 10/25/17 at 2:30 p.m. acknowledged the nurse's progress notes reported the resident's lungs clear and next day worsened with no doctor notification. She further acknowledged it had been reported in the progress notes by the restorative aide the resident had been having a hard time standing. The nurse explained she would have then look for restorative notes and doctor notifications. During an interview on 10/26/17 at 9:30 a.m. with Staff K acknowledged the only physician notification occurred 10/6/17 at 1:31 p.m. for clarification on oxygen and the fax sent 10/8/17 at 1:24 a.m. notifying the physician of the incident between the 10/2/17 doctor visit and the resident being sent out to the emergency room . During an interview on 10/27/17 at 5:30 p.m. with the emergency room physician from Kossuth Regional Heath Center explained in his opinion the bilateral distal femurs would not occur with a resident being lowered to the floor maybe possibly a unilateral fracture not both. He further explained he received a call from the facility and relayed the same information to them. This surveyor clarified in the physician's opinion the resident must have fallen and he replied yes. This surveyor asked the physician if the resident's lungs cleared after the [MEDICAL CONDITION] and then got worse should the physician be notified. The physician acknowledged if the resident had a change in condition he would expect the facility to notify the physician. He also explained if a resident with [MEDICAL CONDITION] had a 3 pound gain in 1 day or a 5 pound gain in 1 week the physician should be notified. Based on clinical record review, policy review and staff interviews the facility failed to provide provision of assessment and timely interventions regarding an acute change in condition and safe transfers for 1 of 2 discharged residents reviewed (Resident #7). The facility reported a census of 43 during the survey revisit and a complaint investigation. Findings include: The quarterly Minimum Data Set (MDS) assessment tool dated 8/8/17 identified Resident #7 had [DIAGNOSES REDACTED]. The MDS reported that Resident #7 required extensive assistance of two staff for bed mobility, transfers, walking in their room and dressing and utilized the use of walker and/or wheelchair for locomotion. The MDS further reported that Resident #7's Brief Interview for Mental Status (BIMS) was a score of 3 out of 15, a score of 0-7 indicates sever impairment for daily decision making. Resident #7's Care Plan updated 7/31/17 included a focus area that the resident required staff assistance with activities of daily living related to [DIAGNOSES REDACTED]. Due to the heart failure the Resident becomes weak and is at risk for falling. The care plan included interventions to administer pain medication as ordered. For the residents safety please put shoes on with all transfers and to use assist of two staff members with all transfers and short distance ambulation with the use of a gait belt and front wheeled walker. The 10/8/17 updated to the care plan included the use of the Hoyer (mechanical lift) for all transfers. The care plan also included a focus area that included [DIAGNOSES REDACTED]. The interventions included the use of anxiolytic medication and to keep the environment as consistent as possible since the resident gets anxious and worried with changed, and offer reassurance if there is a change. The facilities Change in a Resident's Condition or Status revised (MONTH) 2006 Policy Statement that the facility shall promptly notify the resident, his or her attending physician and representative (sponsor) of changes in the resident's medical/mental condition and status ( e.g. changed in level of care, billing/payments, resident rights etc.) Under the policy interpretation and implementation list the following; 1. The Nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there had been: a. An accident or incident involving the resident. d. A significant change in the resident's physical/emotional/mental condition. The facilities Accident /Incident Prevention Monitoring System purpose to identify each resident as risk for accidents &/or falls and also adequately plan resident care and implement interventions to prevent accident/falls. The procedure listed the facility staff and or therapy staff will monitor resident's functional capacity/safety risk as needed but especially with any change of condition and as requested by the facilities quality assurance team. The Progress Note entered by Staff H Restorative nurse dated 9/15/17 at 9:25 a.m.reported the resident had been participating and completing her current restorative plan. No physical limitations hinder her participation and no referral needed. A late entry Progress Note entered by Staff I Registered Nurse (RN) for Resident #7 dated 10/2/17 at 8:59 a.m. entered at 1:03 p.m. reported the resident appears to be struggling with her air, oxygen saturation 48% on room air, skin color pale. The resident had wheezes bilaterally and diminished on expirations. Oxygen placed at 2 liters per nasal cannula and oxygen saturation at 91 %. No pedal [MEDICAL CONDITION] noted at this time. Resident refused to see a doctor, will ask later and suggested she think about it. Staff I entered a note at 9:25 a.m. reported they had asked the resident again about seeing a doctor the he would most likely put her on medication and she probably would not have to use oxygen later on. Resident still refuses to see doctor. The Progress note dated 10/2/17 at 10:55 a.m. reported Staff J RN updated the resident's emergency contact on her condition and that the resident is declining to be seen at this time. The emergency contact stated she would be out to speak with the resident. At 11:10 a.m. the emergency contact state resident is agreement to be seen. A 11:16 appointment set up for 1:30 p.m. today. The Physician Information Sheet dated 10/2/17 at 1:30 p.m. identified the present problem for the appointment as diminished expirations, inspiratory wheezes bilateral, shortness of breath and transferring poorly with assistance of two. The new physician orders [REDACTED]. The Progress Note entered by Staff J RN dated 10/3/17 at 11:15 a.m. reported the resident sleepy when in her room. Rhonchi noted to bilateral lungs and the oxygen saturation 97% on 2 liters per nasal cannula with no cough noted this a.m. A weight summary for Resident #7 recorded her weight on 9/27/17 at 1:37 p.m. at 179.5 pounds and the next weight on 10/4/17 at 8:32 a.m. to be 186 pounds. The Progress Note entered by Staff I RN dated 10/4/17 at 12:35 p.m. reported the resident's lungs clear to auscultation and diminished on expirations. No [MEDICAL CONDITION] noted and will continue to monitor. At 2:06p.m. Staff A Restorative Nursing Assistant (RNA) entered a note reporting she had attempted to get the resident to stand and get on the bike and the resident would not stand. The Progress Note entered by Staff C RN dated 10/5/17 at 2:40 p.m. reported the resident's oxygen saturation at 90% on 3 liters and the nurse checked the oxygen tubing and found it to be kinked. Oxygen saturation rechecked and at 95% on 3 liters per nasal cannula. The resident had labored breathing noted with exertion to talk or eat and her lung sound diminished throughout bilaterally and noted expiatory wheezes will continue to monitor. Staff A RNA entered a note at 3:46 p.m. reporting that the resident would not stand again today, very hard to get her to walk with walker to her wheelchair. At 11:50 p.m. a nurses note reported the resident's oxygen saturation 90% on 3 liters and her lungs were diminished with exploratory wheezes noted and will continue to monitor. The Progress Note entered by Staff H Restorative Nurse dated 10/6/17 at 10:47 reported the resident had not been feeling well had been seen at the clinic with a [DIAGNOSES REDACTED]. At 11:00 a.m. Staff C RN entered a nurse's note that reported the resident's oxygen saturation at 96% on 3 liters per nasal cannula. The resident had labored breathing noted with exertion to talk or eat and her lung sound diminished throughout bilaterally and noted expiatory wheezes will continue to monitor. At 2:45 p.m. Staff A RNA reported the resident had still not been feeling well and hard for her to stand and move to the wheel chair. A telephone clarification order from the physician dated 10/6/17 at 1:31 p.m. ordered supplemental oxygen at 3 liters per nasal cannula as needed to keep oxygen saturation above 90% one time a day related to heart failure and anxiety disorder. The Progress Note entered by Staff CRN dated 10/7/17 at 10:45 a.m. reported the resident's oxygen saturation at 92% on 3 liters per nasal cannula. The resident had labored breathing noted with exertion to talk or eat and her lung sound diminished throughout bilaterally and noted expiatory wheezes and the wheezes had improved since yesterday, will continue to monitor. The Progress Note entered by Staff B RN dated 10/7/17 at 10:23 p.m. reported the Certified Nursing Assistance (CNA) called this nurse to Resident #7's room. Upon entering room observed the resident sitting with her back against the bed facing the door and had gripper socks on. Per the two CNA's they were ambulating the resident to her bed and got near the bed going to sit down and the residents legs gave out. The two CNA's were not able to sustain her ups so the let her down slowly to the floor. The nurse and CNA's assisted the resident up to her recliner she had not been able to walk back to bed, so Hoyer lift used to the transfer. The residents range of motion (ROM) intact and within normal limits, no bruises noted at this time will continue to monitor closely. A Resident Assessment Form dated 10/7/17 at 9:00 p.m. completed by Staff B RN included the description of the above incident and the date and time stamp that the form had been faxed to the physician 10/8/17 at 1:24a.m. The form has an area to ask the resident what were you trying to do? Staff B entered referrer to CNA statement since the resident had been unable to answer. The CNA statement Staff E completed dated 10/7/17 explained he and Staff D were assisting Resident #7 from her recliner to the bed. The resident sat on the bed and Staff D lowered the bed in order for the resident to sit in safe positon. The mattress slipped and the resident was not able to hold by her own weight as her back slipped down the mattress and she fell to the floor. The Progress Note by Staff B RN dated 10/8/17 at 2:57a.m. reported the resident guarded the right hip area with position changes and yells ouch when doing ROM to the right leg, will reassess again when fully awake. At 6:30 a.m. Staff C entered a nurse's note reporting that with the assistance of Staff G CNA attempted to get the resident up to the commode. The Resident called out in pain it hurts, it hurts. The Staff C asked what hurts and the resident stated my right leg. Upon assessment of her legs that were extended out in front of the resident had no outward or inward rotation noted. The right hip area had a slight bump, no bruise noted. ROM intact, but caused the resident pain. After the assessment Staff C and Staff G using a gait belt attempted to transfer the resident to the commode and the resident would not bear weight on the right leg and minimal weight on the left leg. After the resident toileted, she had been transferred back to the bed calling out in pain the whole time. The Progress Note entered by Staff K RN dated 10/8/17 at 6:30 a.m. reported she assessed the resident in bed at this time. The resident's skin ashen-gray, and did report pain to her right hip and leg. No abnormal rotation or shortening of the right or left lower extremity at this time. A Hoyer lift and two assist with be used for all transfer at this time the Care Plan updated. The Progress Note dated 10/8/17 at 7:15 a.m. reported Staff C called Kossuth Regional Heath Center and physician made aware of the above notation and gave a telephone order to send the resident to the emergency room . The physician also okayed for the resident to eat since if she needed surgery it would not probably happen today. The Progress Note entered by Staff C RN dated 10/8/17 at 10:50 a.m. reported a telephone call had been received from a RN at Kossuth Regional Heath Center that informed the nurse that after x-raying the right hip the resident started to complaining of left leg pain so they x-rayed the left hip area. The resident had bilateral distal femur fractures and they were transferring her out to Mason City for surgery. During an interview on 10/24/17 at 8:30 a.m. with Staff B RN explained he had been called to Resident #7's room on 10/7/17 around 9:00 p.m. The CNA's were walking the resident to bed and had to lower her to the floor. ROM had been okay and resident stated she did not have pain. Staff B acknowledged he and the CNA's lifted the resident to the chair and then to bed. Later on in the night she grabbed her right leg when moving it, but stated she wanted to sleep. Staff B further explained he reported the incident to Staff C RN. Staff B wanted Staff C to do a better assessment to see if the resident needed to be sent out to the hospital for an x-ray once she is awake. During an interview on 10/24/17 at 9:13 p.m. with Staff D a care giver in training acknowledged she and Staff E had to lower Resident #7 down to the floor on 10/7/17 around 9:00 p.m. the resident could not stand. She explained once on the floor Staff E stayed with the resident and she went out to get the nurse. Staff B RN came along with Staff F CNA to the room with the ez-stand (mechanical lift to move from a sitting position to standing) and helped the resident up from the floor using the ez-stand. The resident complained of pain the whole time getting her up and stopped complaining once in bed. During an interview on 10/25/17 at 8:05 a.m. with Staff C RN confirmed she worked 10/8/17 at 6:00 am. During shift change report Staff B explained Resident #7 had fallen the night before and they used an ez-stand to get her off the floor. Staff B acknowledged she had a little pain. He further explained if you need to send resident to the emergency room you can. Staff C further explained her and Staff G CNA went down to the resident's room. Staff C completed ROM and the resident seemed fine, only had a small bump on her right hip. Staff C and Staff G attempted to get the resident up using a gait belt and two person pivot transfer and she would not bare weight. Staff C explained she called the on call doctor and he wanted her to send the resident to the emergency room . Staff C acknowledged that the resident seemed fine once sitting in her wheelchair. During an interview on 10/25/17 at 2:30 p.m. acknowledged the nurse's progress notes reported the resident's lungs clear and next day worsened with no doctor notification. She further acknowledged it had been reported in the progress notes by the restorative aide the resident had been having a hard time standing. The nurse explained she would have then look for restorative notes and doctor notifications. During an interview on 10/26/17 at 9:30 a.m. with Staff K acknowledged the only physician notification occurred 10/6/17 at 1:31 p.m. for clarification on oxygen and the fax sent 10/8/17 at 1:24 a.m. notifying the physician of the incident between the 10/2/17 doctor visit and the resident being sent out to the emergency room . During an interview on 10/27/17 at 5:30 p.m. with the emergency room physician from Kossuth Regional Heath Center explained in his opinion the bilateral distal femurs would not occur with a resident being lowered to the floor maybe possibly a unilateral fracture not both. He further explained he received a call from the facility and relayed the same information to them. This surveyor clarified in the physician's opinion the resident must have fallen and he replied yes. This surveyor asked the physician if the resident's lungs cleared after the [MEDICAL CONDITION] and then got worse should the physician be notified. The physician acknowledged if the resident had a change in condition he would expect the facility to notify the physician. He also explained if a resident with [MEDICAL CONDITION] had a 3 pound gain in 1 day or a 5 pound gain in 1 week the physician should be notified.

Based on record review and staff interviews, the facility failed to provide adequate supervision to protect one of two residents from hazards (Resident #2). The facility reported a census of 41 current residents, 2 of which transferred per mechanical lift (Hoyer). Findings include: Resident #2 had a Minimum Data Set (MDS) assessment dated [DATE] documented a score 11 of 15 on BIMS (brief interview for mental status) test which indicated cognitive impairment. The resident had [DIAGNOSES REDACTED]. The resident was dependent upon two staff for transfers, bed mobility and toilet assistance and dependent upon one staff for dressing, hygiene and bathing. The resident did not ambulate. A balance during transitions and walking test identified the resident did not complete tasks such as walking, turning around, moving from seated to standing position, and surface to surface transfers. The resident had bilateral lower extremity impairment and utilized a wheelchair for mobility. The Care Plan updated 6/15/16, identified the resident unable to ambulate or transfer without assistance. A Care Plan intervention dated 5/12/16 directed two staff to transfer per Hoyer lift (mechanical lift) and two staff. A Resident Assessment Form dated 8/1/16 at 9:30 a.m. reflected Resident #2 fell out of the Hoyer lift sling during transfer. The nurse assessed the resident and identified a bump to his/her head. Resident #2 was transferred to the emergency room for evaluation. The physician information sheet identified on 8/1/16 Resident #2 had acute pain after he/she had a fall from the Hoyer. The resident had been diagnosed with [REDACTED]. According to a Follow Up Fall/Incident Investigation dated 8/1/16 revealed Staff P and Staff O, both certified nursing assistants (CNA), were educated to wait until both staff members were ready to transfer a resident by Hoyer before lifting the resident in the air. Staff interviews as follows: a. On 10/20/16 at 10:51 a.m. Staff P, CNA, stated she was near the middle of Resident #2's bed preparing for Hoyer transfer when she heard Resident #2 yell and fall onto the floor. Staff P stated she informed Staff O she was not ready to transfer the resident before Staff O lifted the resident in the Hoyer lift. Staff P did not assist Staff O with the Hoyer transfer. After the resident's fall, Staff P observed the resident lying on the floor with his/her face up. The resident complained of pain but did not lose consciousness. She notified the Director of Nursing (DON). Staff P stated Resident #2 required cueing for hand placement during Hoyer transfer because he/she would hold the Hoyer straps during transfer. Staff P was trained to encourage resident ' s to give a bear-hug during transfer to ensure safety. b. On 10/20/16 at 12:23 p.m. Staff K, licensed practical nurse (LPN), stated on 8/1/16 Staff O notified her Resident #2 fell . Upon entry to the resident's room she observed Resident #2 lying face up on the floor with his/her head near the door. Staff K stated Staff P told her she informed Staff O she was not ready to transfer the resident, however Staff O continued. Staff O attached the lift sheet to the Hoyer lift then transferred the resident without assistance from Staff P. Staff P informed Staff K that the loop on the lift sheet was not attached all the way and Resident #2 fell . Staff K completed a nursing assessment and noted Resident #2 complained of shoulder pain. Resident #2 was transferred to the emergency room for evaluation. Staff O did not return the surveyor's requests for interview. According to a written statement attained by the DON regarding the incident, Staff O stated Staff P was preparing the bed for transfer, and Staff O attached the lift sling to the Hoyer and lifted Resident #2 higher in the air because his/her bed was higher. Staff O closed the legs of the Hoyer lift, then heard the straps snap off the Hoyer lift hook which caused the resident to fall. Resident #2 landed on his/her left shoulder and head. His/her right foot was caught on the lift sling. Staff O stated Staff P was in the room at the time of transfer. After a resident is elevated in the Hoyer lift, the Hoyer lift is pushed by staff to the desired destination. Prior to lowering the resident, staff close the legs of the mechanical lift to fit under the frame of the bed. On 10/20/16 at 1:18 p.m. Resident #2's family member confirmed Resident #2 fell from the Hoyer during transfer. The family member stated upon notification, his sibling contacted the facility and asked if the fall was the result of personnel or equipment. The DON informed the family member it was personnel. The DON informed the family member Resident #2 was not hooked up correctly and was dropped after he/she was lifted in the Hoyer lift. On 10/20/16 at 1:32 p.m. Resident #2's contact/ family member confirmed she received a telephone call from the facility and was informed Resident #2 was transferred to the hospital for evaluation after he/she fell out of the Hoyer during transfer. Staff O sent her a text to check on Resident #2. Staff O told the family member two staff were in the room at the time of Hoyer transfer, one near Resident #2's bed straightening linens when Staff O lifted Resident #2. During transfer, one of the hooks came off and Resident #2 fell on to his/her head on the floor. The family member stated the floor at the facility is concrete. The family member asked Staff O if they check hooks prior to lifting residents. She then asked why staff were not with Resident #2 when he/she was lifted, to which Staff O responded Staff P was near his/her bed. Observation on 10/19/16 at 7:10 a.m. revealed Staff AA, CNA, and Staff BB, CNA, transfer Resident #2 per Hoyer lift. After the lift sheet was attached to the mechanical lift, Resident #2 placed his/her hands on the lift sheets near the straps. All 4 straps were attached to the lift appropriately. Neither Staff AA nor Staff BB directed Resident #2 of proper hand placement prior to or during the transfer. On 10/19/16 at 9:57 a.m. the DON stated she investigated the resident's fall during Hoyer transfer. The DON confirmed Staff O transferred Resident #2 per Hoyer without assistance from Staff P. She always tells the residents to give a hug prior to/during Hoyer transfer for safety. The DON stated two staff are to assist with Hoyer transfers at all times.