Every finding on record at Arbor Springs of West Des Moines L L C

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to protect residents from potential accidents and hazards by failing to prevent a mechanical lift from hitting a resident during a transfer (#10) and failed to lock the wheelchair while using a mechanical lift to transfer a resident to bed (#14). The facility reported a census of 47 residents.Findings include:1.Resident 10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severely impaired cognition. It included diagnoses of heart disease, heart failure, high blood pressure, and non-Alzheimer's dementia. It indicated the resident was dependent with all Activities of Daily Living (ADLs) and mobility. It also indicated the resident did not have any bruises in the seven (7)-day look-back period.The Care Plan revised 7/26/26 indicated the resident was a two (2)-person assist with transfers and directed staff to use two staff members and a mechanical lift for all transfers. It also indicated the resident would sometimes yell and grab for the lift. It revealed the resident required skin inspections per the facility policy and directed staff to observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse.On 8/12/26 at 9:05 AM, a Facility Reported Incident (FRI) indicated a mechanical lift component hit Resident #10 in the forehead after two (2) staff members transferred him from his bed to his wheelchair.A Health Status Note Progress Note dated 8/12/26 at 3:39 PM revealed the resident had a bruise on his forehead that had not been previously documented.On 8/13/26 at 9:16 AM, Staff F, Certified Nurse Aide (CNA) stated that when she and Staff G, CNA transferred the resident with a mechanical lift, she was holding his arm to stabilize him while lifting him and Staff G grabbed the same arm and moved it into the sling. Staff F stated, from her line-of-sight, she did not see the mechanical lift hit the resident.On 8/13/26 at 9:48 AM, Staff G, CNA stated she and Staff F were transferring Resident #10 from his bed into a wheelchair for breakfast. She stated she was on the resident's left side, facing him and trying to calm him down when Staff F brought the mechanical lift toward the resident. She stated the lift's sling hook hit the left side of the resident's forehead.On 8/13/26 at 10:30 AM, Resident #10 was observed sitting in the unit common area with a bruise on the left side of his forehead. Resident #10 was not able to answer questions regarding the bruise.On 8/17/26 at 8:33 AM, a document titled <Facility Name> Skill Fair 2026 revealed both staff members were trained on using mechanical lifts.On 8/17/26 at 2:05 PM, the Director of Nursing (DON) stated staff should have moved the mechanical lift to prevent it from hitting the resident's head.2. Resident #14's quarterly MDS dated [DATE] identified a BIMS score of 03 out of 15 which indicated severely impaired cognition. It included diagnoses of anemia, Alzheimer's disease, non-Alzheimer's dementia, and malnutrition. It revealed she required maximal assistance with eating and was dependent with all other ADLs and mobility. An Encounter Progress Note dated 3/27/26 at 00:00 indicated the resident's baseline was wheelchair bound and required a mechanical lift for transfers.The Care Plan revised 5/20/26 revealed the resident had impaired mobility, was non-ambulatory, used a wheelchair as her primary mode of locomotion, and was dependent on staff for wheelchair mobility. It also revealed she required a mechanical lift and 2-person assistance with transfers.During a continuous observation on 8/13/26 at 12:58 PM, Staff D, CNA and Staff E, CNA transferred Resident 14 from her wheelchair to her bed with a mechanical lift. Staff E positioned the mechanical lift in front of the resident's wheelchair. Staff D lowered the lift arm into position and both staff members connected the sling loops to the mechanical lift hooks. Staff E raised the resident from her wheelchair as Staff D held the resident steady to prevent swinging. Staff E moved the mechanical lift and positioned the resident over her bed and lowered her onto her mattress. The wheelchair wheels remained unlocked throughout the transfer process.At 1:05 PM, Staff D stated two (2) staff members are required for all mechanical lift transfers and the wheelchair should be locked when transferring a resident in or out of it. She also stated there was no specific reason the resident's wheelchair was left unlocked, she just forgot to lock it.At 1:09 PM, Staff E stated two (2) staff members are required for all mechanical lift transfers and the wheelchair should be locked when transferring a resident in or out of it. She stated the wheelchair should have been locked but she didn't notice it.On 8/17/26 at 2:05 PM, the DON stated staff should have locked the wheelchair while transferring the resident out of it.A policy titled Transfer/Lifts Policies revised 3/01/25 indicated the policy purpose was to ensure safe and appropriate transfer and lift techniques to ensure the highest quality of care and safety for residents and staff.

Based on clinical record review, and staff interviews the facility failed to follow physician's oxygen orders for 1 of 3 resident's (#10). The facility reported a census of 47 residents.Findings Include:Resident 10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severely impaired cognition. It included diagnoses of heart disease, heart failure, high blood pressure, and non-Alzheimer's dementia. It indicated the resident was dependent with all Activities of Daily Living (ADLs) and mobility. It also revealed the resident had not received respiratory treatments in the seven (7)-day look-back period.The Electronic Health Record (EHR) included a Physician's Order dated 1/06/26 to apply oxygen via NC (nasal cannula) at 2 L (liters per minute) and maintain oxygen saturation above 90%.The Oxygen Saturation Summary revealed the resident's oxygen saturation level was checked 7/07/26 at 1:23 PM, 7/10/26 at 1:00 PM, 7/21/26 at 11:41 AM, 7/22/26 at 12:38 PM, and 8/07/26 at 11:21 AM. There were no other documented oxygen saturation level checks since 7/01/26.The Care Plan revised 7/26/26 did not include the resident's supplemental oxygen therapy.On 8/17/26 at 12:50 PM, Staff A, Registered Nurse (RN) stated she would check the oxygen saturation level daily at the beginning of the shift and document it in the vital signs section of the EHR if a resident had an order for two (2) liters of oxygen to keep the resident's oxygen saturation above 90%.On 8/17/26 at 12:58 PM, Staff B, Licensed Practical Nurse (LPN) stated she would check the oxygen saturation level at least once per shift and document it in either the vital signs section or the Medication or Treatment Administration Record section of the EHR if a resident had an order for two (2) liters of oxygen to keep the resident's oxygen saturation above 90%.On 8/17/26 at 2:05 PM, the Director of Nursing (DON) stated staff should've monitored the resident's oxygen level.The facility did not have a policy specific to following physician's orders.

Based on clinical record review, staff interviews, and policy review, the facility failed to develop a personalized Care Plan that included resident specific target behaviors (TBs) or non-pharmacological interventions (NPIs) for 2 of 2 residents (#2, #1) who received psychotropic medications (medications that affect a person's mental state, emotions, and behavior). The facility reported a census of 47 residents. Findings include:1.Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderately impaired cognition. It included diagnoses of Alzheimer's disease and anxiety. It revealed the resident received antianxiety, antidepressant, and antipsychotic medications during the 7-day look-back period. It also revealed the resident required setup assistance with eating, supervision with sit-to-stand, chair-to-chair transfers, and ambulating, moderate assistance with toilet and shower transfers, maximal assistance with oral hygiene, upper body dressing, footwear, and bed mobility, and was dependent in all other ADLs and mobility.The Electronic Health Record (EHR) included Physician's Orders dated 2/27/26 for an antianxiety medication at bedtime for anxiety; an order dated 2/27/26 for an antipsychotic medication at bedtime for behaviors/hallucinations; and an order dated 7/29/26 for an antidepressant medication at bedtime for depression.An Encounter Progress Note dated 7/23/26 at 00:00 PM directed staff to continue to monitor for behavioral and mood disturbances but did not identify the behaviors or mood disturbances.A document titled POC Response History dated 4/10/26 - 8/11/26 indicated the resident was being monitored for frequent crying, repetitive movements, yelling/screaming, kicking/hitting, pushing, grabbing, pinching/scratching/spitting, biting, wandering, abusive language, threatening behavior, sexually inappropriate behavior, or rejection of care.The Care Plan revised 7/22/26 included the use of psychotropic medications and included the resident's recounting prior career experiences but did not identify the resident's specific TBs or NPIs.On 8/13/26 1:25 PM, Staff C, LPN stated she's never seen Resident #2 exhibit signs of anxiety but stated he self-isolates and verbalizes dreams into real-time hallucinations as signs of depression and psychosis; respectively.2. Resident #1's quarterly MDS assessment dated [DATE] identified a BIMS score of 00 out of 15 which indicated severely impaired cognition. It included diagnoses of Alzheimer's disease and non-Alzheimer's dementia. It revealed the resident received antianxiety, antidepressant, and antipsychotic medications during the 7-day look-back period. It also revealed the resident required moderate assistance with eating, required maximal assistance with walking 10 feet, and was dependent with all other Activities of Daily Living (ADLs) and mobility.The EHR included a Physician's Orders dated 4/23/26 for an antianxiety medication every four (4) hours as needed for agitation/restlessness; an order dated 3/31/26 for an antipsychotic medication for dementia with behavioral disturbance; and an order dated 4/14/26 for an antidepressant medication for difficulty sleeping.A Behavior Note Progress Note dated 8/09/26 at 10:10 AM revealed the resident was restless in his chair, displaying signs of agitation and discomfort, and swatted at staff who tried to help reposition him.A document titled POC Response History dated 4/10/26 - 8/11/26 indicated the resident was being monitored for frequent crying, repetitive movements, yelling/screaming, kicking/hitting, pushing, grabbing, pinching/scratching/spitting, biting, wandering, abusive language, threatening behavior, sexually inappropriate behavior, or rejection of care.The Care Plan revised 7/22/26 included psychotropic medication use and behavior symptoms but did not identify which behaviors were associated with each psychotropic medication. The Care Plan also did not include any of the resident's NPIs for staff to attempt.On 8/13/26 at 2:01 PM, Staff B, Licensed Practical Nurse (LPN) stated Resident #1's depression, anxiety, and psychosis are manifested by sleeping more frequently, crying, attempting to leave the facility, and has delusions of a local boy whom he must help; respectively. She located target behaviors in the resident's Care Plan but could not specify which behavior in the Care Plan was associated with each psychotropic medication. She also was not able to locate NPIs in the Care Plan.On 8/17/26 at 2:05 PM, the Director of Nursing (DON) stated Care Plans should be individualized to each resident.A policy titled Care Plan and Care Conference Policy revised 3/01/21 indicated each resident will have an individualized interdisciplinary plan of care in place and would be resident centered.

Based on clinical record review, staff interview, and the Resident Assessment Instrument User's Manual (RAI Manual) the facility failed to ensure a comprehensive Significant Change in Status Assessment (SCSA) was completed within 14 days of a resident admitting to hospice services for 1 of 3 residents (#5). The facility reported a census of 47 residents.Findings include:Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 01 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, psychotic disorder, and unspecified dementia without behavioral, psychotic, mood, or anxiety. It revealed she required supervision with eating, maximal assistance with oral and toileting hygiene, and all mobility except shower transfers, and was dependent with all other Activities of Daily Living (ADLs) and shower transfers. It revealed she received hospice care in the seven (7)-day look-back period.The Electronic Health Record (EHR) include a physician's order dated 7/20/26 for hospice to consult and admit as appropriate.An Encounter Note Progress Note dated 7/30/26 at 00:00 revealed a hospice consult was provided on 7/20/26 and the resident was admitted to hospice on 7/21/26.The Census tab revealed the resident's payer source transitioned to private hospice on 7/21/26.A Significant Change MDS dated [DATE] revealed the resident's MDS was completed on 8/06/26.The 2026 RAI Manual revealed a SCSA (significant change MDS) must be completed no later than 14 calendar days after determining that a significant change in resident's status occurred.On 8/17/26 at 10:58 AM, the MDS Coordinator stated she understood a SCSA was required to be completed 14 days after the Assessment Reference Date (ARD) and not the enrollment to hospice date.On 8/17/26 at 11:15 AM, the State RAI Coordinator stated a SCSA must be completed within 14 days after a resident enrolls in hospice because the resident's significant change in status has already been determined upon hospice enrollment.On 8/17/26 at 1:20 PM, the MDS Coordinator stated she misunderstood the ARD date reference to the 14-day timeline requirement in relation to hospice admission.On 8/17/26 at 2:05 PM, the Director of Nursing (DON) stated staff should've looked up the SCSA expectation.The facility did not have a policy regarding MDS (comprehensive) Assessments.

Based on clinical record review, staff interview, hospital record review, and facility policy review, the facility failed to assess and respond to residents change in bowel status and failed to perform physician ordered weekly weight checks for 1 of 1 resident's reviewed for bowel and bladder and weight loss or gain (Resident #4). This resulted in harm to the resident when she was hospitalized for constipation and required manual disimpaction of stool. The facility reported a census of 46. Findings include; The Minimum Data set (MDS) for Resident #4, dated 04/22/2026, documented the following diagnoses: hypertension (high blood pressure), diabetes Mellitus (diabetes), Alzheimer's Disease, Non-Alzheimer's Dementia, anxiety disorder, asthma or chronic obstructive pulmonary disorder (COPD). It documented her Brief Interview for Mental Status (BIMS) score as 03, indicating severely impaired cognition. It documented the resident was frequently/always incontinent of bowel and that she did not shows signs or symptoms of constipation. It documented she was not on a toileting schedule to manage her incontinence. The Care Plan for Resident #4, last revised 05/05/2026, documented the resident used psychotropic medications that can result in dehydration and constipation. It documented one of the potential side effects of these medications as constipation and impaction of stool. It further documented the resident was at risk for weight loss and altered nutritional status due to recent surgeries and her dementia status. It instructed staff to monitor the resident for weight loss/gain.The Order Summary Report for Resident #4 listed several medications that pose high risk for constipation. The medications include: Donzepil (Aricept), Ferrous Sulfate (iron supplement), Sertraline (Zoloft), Clonazepam, Risperidone (Risperdal), Hydrocodone (An Opiate), Lorazepam, and Midodrine. It also listed Milk of Magnesia and Polyethylene Glycol as needed constipation relief medications. An order was present for weekly weights on Resident #4. Review of Electronic Health Record (EHR) entries for weight tracking show only three tracked weights since 04/13/2026. Once on 06/01/2026 showing a weight of 130.6lbs, and once on 06/12/2026 showing a weight of 139.4lbs, showing a nearly 9lbs weight difference. Surveyor approached the Director of Nursing (DON) on 06/23/2026 and requested Resident #4 be weighed which produced a weight of 138.8lbs on 06/24/2026. Review of local hospital records dated from 05/21/2026 through 06/01/2026 document on 05/21/2026 Resident #4 entered a local hospital for evaluation for constipation. She was diagnosed with stercoral colitis, an inflammatory condition of the colon caused by fecal impaction, and was treated with a large volume fluid enema and manual disimpaction to remove the impacted stool. Review of Bowel and Bladder Elimination records revealed that from 05/02/2026 through 05/09/2026 Resident #4 had only a small bowel movement and no bowel interventions. On 05/10/2026 Resident #4 was given a PRN bowel intervention and produced a large bowel movement. Resident #4 produced a medium stool on 05/11/2026, a small stool on 05/13/2026, and no bowel movement recorded until 05/21/2026. Review of the May Medication Administration record revealed the following: On 05/06/2026 Milk of Magnesia was administered to Resident #4. It is charted as effective but no bowel movement is recorded. There are no further bowel interventions charted until 05/19/2026 when the physician was informed of the protracted constipation. On 05/19/2026 Resident #4 was prescribed Senna Plus and Lactulose Oral Solution to relieve constipation. These were ineffective. On 05/20/2026 resident #4 was given a Fleet Enema, this resulted in a medium bowel movement on 05/21/2026 but the resident remained constipated and was sent to a local hospital for evaluation. Review of Progress Notes from 05/01/2026 through 05/21/2026 documented the following: On 05/01/2026 Resident #4 was seen by a physician attempting to bear down and stated she was going to have a baby or two. Milk of Magnesia was administered on 05/06/2026 and was documented as effective. On 05/18/2026 it is documented Resident #4 is again having hallucinations about having a baby. She is attempting to bear down and squat. In an interview on 06/30/2026 at 09:14 AM with Staff N, Certified Nurse Aide (CNA), she stated she was unsure Resident #4 had been constipated, but she typically knows when residents are constipated because she goes to the bathroom with them and cleans them up when they are incontinent. She can tell if they are constipated because they struggle to go, or the stool that does come out will be hard. She stated they report if a resident had a bowel movement to the nurse and the nurses keep a sheet that tells the next shift if the resident has gone to the bathroom. In an interview on 06/30/2026 at 09:19 AM with Staff Q, Certified Medication Aide (CMA), she stated the CNAs track bowel movements and report them to nurses, the nurses keep a bowel tracking sheet that tells them if they have not had a bowel movement. She stated CMAs or nurses are to give bowel interventions three days after the last bowel movement, but further noted she does not pass medication for the facility. In an interview on 06/30/2026 at 09:59 AM with Staff O, CMA, she stated nurses track bowel movements and CNAs report who hasn't gone to the bathroom to the nurses. She stated after three days a bowel intervention is to be used, but noted the facility does not utilize CMAs to pass medications. In an interview on 06/25/2026 at 02:04 PM with Staff R, Licensed Practical Nurse (LPN), she stated the facility protocol is for CNAs to report who has had a bowel movement to the nurses. The nurses fill out a bowel tracking sheet if a resident has not had a bowel movement. She stated protocol is for them to give prune juice if it has been two days without a bowel movement, and a PRN bowel intervention if it has been three days. She stated on the fourth day they are required to contact the physician to give a suppository. She stated the next shift fills out a new bowel sheet and the previous bowel sheet is destroyed. In an interview on 06/30/2026 at 10:09 AM with Staff P, LPN, she stated the nurses use bowel tracking sheets based on CNA reports. The bowel sheet is passed on to the next shift and the bowel sheets go to the DON, or should, and she acknowledged sometimes they are just thrown away. She stated facility protocol is to give a PRN bowel intervention three days after last bowel movement to relieve constipation. In an interview on 06/25/2026 at 12:52 PM with the Nurse Practitioner, she acknowledged there had been a failure to give standard PRN bowel interventions to Resident #4 and blamed herself for not catching it. She stated she did not feel it posed significant risk to Resident #4, but noted the resident has been placed on a more aggressive constipation management regimen to prevent repeat issues. In an interview on 06/30/2026 at 09:00 AM with the Director of Nursing (DON), she clarified the facility protocol and her expectation is for bowel movements begin on the third day of no bowel movements. She stated Resident #4 does sometimes refuse medication but it should be documented on the Medication Administration Record (MAR) and acknowledged it was not. She acknowledged that based on charting it does not appear that Resident #4 was offered a PRN bowel intervention. Review of a facility provided document titled Bowel Management Policy stated the facility protocol to manage constipation is as follows: On day 2 if no bowel movement, give 120 ml of prune juice.On day 3 if no bowel movement, give milk of magnesia.On day 4 if no bowel movement, assess and then administer a suppository.On day 5 if no bowel movement, assess and then contact the physician for orders.

Based on observation, clinical record review, resident, family and staff interview and policy review, the facility failed to provide appropriate supervision for 1 of 3 residents reviewed for falls (Resident #3). The facility failed to provide a complete assessment and investigation to determine the root cause and failed to monitor and modify interventions in order to prevent further accidents for Resident #3. The facility also failed to utilize assistive devices per care plans to prevent bruising injuries for 2 of 2 residents (Resident #4 & #6). During the survey process, staff were observed to transfer residents by gripping forearms and hands. After alerting the facility, to prevent further injury, the staff were observed to place the gait belt then continue to grip the residents by the arms and not by the gait belt during transfers. The facility reported a census of 46 residents.Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #3 revealed the diagnoses of dementia, muscle weakness and abnormalities of gait and mobility. The MDS did not identify a pain medication regimen nor that Resident #3 identified the experience of pain. The MDS identified one fall with an injury, not a major injury. No prior orthopedic surgery identified. Resident #3 required moderate assistance from staff for dressing and ambulation. Resident #3 was incontinent of bowel and bladder and dependent on staff for toileting and personal hygiene. The Brief Interview for Mental Status (BIMS) score was a 4 which revealed severe cognitive impairment and no adverse behaviors were identified. The MDS dated [DATE] for Resident #3 revealed the diagnoses of dementia, anxiety, osteoporosis and fractured hip. The MDS identified two or more falls without injury. The MDS identified that Resident #3 underwent a surgical intervention for hip, required skilled care and surgical wound care. The MDS identified pain and the use of opioid pain medication. The MDS identified Resident #3 was dependent on staff for dressing, toileting, personal care, transfers and ambulation did not occur. The Care Plan with revision date of 5/4/26 directed staff to allow Resident #3 to express her frustration when she feels stuck here at (facility name). Encourage Resident #3 to discuss her feelings and concerns with long term care. Report, document and address episodes of anxiety, fear, and distress. Resident #3 loved to paint, attempt color therapy & any sorts of crafts. Activities of daily living plan of care directed staff to provide 1 person assist for transfers, ambulation with a front wheeled walker for short distances and a wheelchair for longer distances. Toilet Resident #3 frequently when awake as she was occasionally incontinent of urine, needed assistance with toilet hygiene. Document and report as needed any changes, potential for improvement, a self-care deficit or if declines in function. Resident #3 was identified as an elopement risk and directed staff to distract Resident #3 from wandering by offering pleasant diversions, structured activity, food, conversation, television, a book. Resident #3 enjoyed walking, conversation, reading. The care plan directed staff to identify a pattern of wandering, intervene and redirect as appropriate. Provide structured activities. The care plan identified Resident #3 as had dementia with behaviors therefore anticipate her needs, provide medication, allow time to express self and offer choices. Intervene before escalation. The care plan lacked any update or revision to the fall risk problem after the fractured hip was found on 3/4/26. During an interview on 6/23/26 at 10:13 am, Resident #3's husband stated his wife experienced two falls that resulted in a fractured hip that required surgical intervention within two months. The husband stated he was at the facility every day and after he would leave, the 2nd shift staff would call requesting him to talk to his wife. The husband stated he wondered why staff can't handle it when she gets upset and if Resident #3 was in her room by herself, the door had to be open so the staff could stick their head in the door to check on her. The husband stated in March 2026, he was notified Resident #3 had pain in her hip and right knee that increased over 3-4 days and an x-ray revealed she had a fractured right hip. The husband stated the staff was unaware of how it happened but stated she had osteoporosis. The husband stated two months later, he was notified she was bleeding from the back of her head from a fall and the emergency room physician reported that Resident #3 told him she had pain in her left hip. The husband stated the nursing staff told him the head injury was why they sent her to the hospital as she was on a blood thinner. The husband stated Resident #3 had a fractured left hip and a urinary tract infection (UTI). The husband stated he complained about the supervision and felt if she was properly supervised, it could have prevented the fall. The husband stated he was told two staff was present all the time but did not feel that was true since they go on breaks and only one was monitoring the residents. The husband questioned the report of her crawling out of the recliner in the common area, walked and hit her head on a door jam. The husband stated Resident #3 had not walked since she fractured the first hip and with both hospitalizations it was found that she had UTI's. During an observation on 6/23/26 at 10:13 am, Resident #3's room had an entryway and the bed was to the right. If you stick your head in the door, you cannot visualize Resident #3 in her bed or chair, if she was in her room, a person must enter the room and look around the wall of the bathroom. The common area had recliners with room to propel a wheel chair around both sides. Resident #3's room door was approximately 10 feet from the closest recliner. A sign on the door read, keep the door closed when resident in not in the room. Resident #3 was in a wheelchair with husband at bedside. emergency room notes dated 3/5/26 at 8:31 am revealed Resident #3 presented with a confirmed right hip fracture. There is no known history of trauma. Resident #3 had significant dementia; her husband was at bedside. Resident #3 complained of right groin and right knee pain. Apparently, the facility initially obtained an x-ray of the knee which showed arthritic changes and later noted that she had right hip pain which confirmed the fracture. She otherwise has no complaints at this time. She is not anticoagulated.Medical Decision Making This is a nontoxic-appearing [AGE] year-old female with a right hip fracture. I did discuss the patient's care with the orthopedic team. They plan for surgical repair tomorrow. I have independently visualized the patient's imaging and reviewed her lab testing. She and husband are agreeable to the plan. Hospital notes dated 3/6/26 at 4:45 pm for Resident #3 revealed: Reason for admission: Fracture of unspecified part of neck of right femur, initial encounter for closed fracture. Subjective: Patient was transferred here from (local hospital named) for surgical repair of right hip fracture prior to being seen by hospitalist there. Resident #3 was awake but not willing to answer questions. Daughter was at bedside and help provide some information. Resident #3 was not endorsing any acute symptoms currently.Urine: Turbid (cloudy) yellow with [NAME] Blood Cells (WBC's) 500 (normal 0-5). Urinary Tract Infection (UTI) Ceftriaxone 1 gram intravenous (IV) daily.Physical Therapy evaluation and treatment. Previous level of function: Skilled Care Facility assist with mobility per husband using Hoyer lift for all transfers few months and prior to that was using a walker. Results: decreased strength, endurance, balance, mobility, cognition and pain. The Progress Notes for Resident #3 revealed: On 2/26/26 at 5:09 pm, Staff C, Advanced Registered Nurse Practitioner (ARNP) documented visit for complaint of swelling right knee with pain. Resident #3 was resting in her chair, calm and at baseline. Staff reported Resident #3 and her husband reported left lower limb and upper limb pain. Resident #3's husband would like to keep her comfortable with some pain medication but not to keep her too sedated, concerned about the fact she was sleeping too much. We will consider a very small amount to ensure she is not in pain. Resident #3 was not very verbal so it was very hard to know what she was feeling.Resident #3 complained about the same symptoms on the February 9. The x-ray at that time, result negative. I do not think it is necessary to repeat an x-ray at this time. Staff reported: no recent falls, no change in appetite, no sleep disturbance, no change in behavior. On 3/2/26 at 10:09 am, Staff C, Advanced Registered Nurse Practitioner (ARNP) documented visit due to nursing and CNA were concerned about her severe pain. Resident #3 said it was on her hip, Resident #3 was shaking, displaying a lot of discomfort. Resident #3 had been put on a very small amount of tramadol on 2/27/26 and nursing staff said that observing the patient it is not enough. Resident #3 not always able to express what she felt as she has severe dementia. The husband agreed with the treatment course of increasing the tramadol. At the moment of the visit, Resident #3 was with physical therapist and occupational therapist. Staff C advised to work the upper body and assess and see how her hips. Staff C recommended an x-ray to exclude a possible fracture. On 3/3/26 at 8:52 am Resident #3 was sleepy with poor appetite. Possible Hospice recommendation. On 3/4/26 10:58 am, Husband notified of x-ray result and Staff C, ARNP expressed concerns as husband decided to send Resident #3 to hospital for an evaluation on 3/5/26. On 3/5/26 8:16 am Resident #3 was sent to the hospital emergency room with a right hip fracture. On 3/10/26, Resident #3 returned from the hospital utilized the mechanical lift for transfers and Oxycodone for pain management. On 3/12/26, Staff C, ARNP documented Resident #3 and husband were satisfied with the right hip repair. Staff C instructed the staff to be careful when they help Resident #3 to stand up from her wheelchair and when they change her in her bed as she was very frail due to her severe osteoarthritis. Staff reports: no recent falls, no change in appetite, no sleep disturbance, no change in behavior. On 5/2/26 at 9:36 pm, Staff G documented Resident #3 going toward her room and landed on the floor, apparently hit her head on her room door before staff tried to prevent fall. Resident assessed and complained of Right hip pain. A 0.3-centimeter, minor cut was noted to the back of Resident #3's head. The vital signs obtained was temperature 97.6, blood pressure 126/82, pulse 73, respirations18, SP02 (oxygen level in blood) 96%. The call provider was notified and advised Resident #3 should be sent to hospital for further evaluation. Resident #3's husband was notified. Fall Investigation dated 5/2/26 for Resident #3 revealed: 1. BIMS level 3. 2. Diagnosis Fractured neck of right femur, clot in deep veins right lower leg, lack of coordination, muscle weakness, restlessness and agitation. 3. Saturday May 2nd, 2026 approximately 7:15 pm Resident #3 was sitting in a recliner in the Birchwood Neighborhood living room following dinner with other residents. Staff Staff F, CNA was in the dining area coloring with another resident when she witnessed Resident #3 stand from the recliner and move towards her bedroom door. Prior to Staff F being able to get to Resident #3 she tripped and fell. Hitting her head on bedroom door causing a laceration. Resident #3 was assessed and complained of pain to right hip. Provider on call and family was notified and due to Resident #3 being on Eliquis (blood thinner) and hitting her head orders were given to have her sent to hospital. [NAME] was sent via ambulance. Prior to fall, Resident #3 was restless looking for husband with interventions such as toileting and offering food ineffective.4. On 5/4/26, the Director of Nursing (DON) followed up with Resident #3's husband. Resident #3 had a fracture to the left hip and was currently in surgery.5. Interventions: The family and physician were notified. Resident #3 was sent to emergency room via ambulance.6. Root Cause: Restless resident attempting to look for husband. A document titled Fall Investigation for CNA's dated 5/2/26 for Resident #3. Fall Description: Staff was watching everyone, went to assist another resident at the table coloring. When staff turned Resident #3 was walking to her room and before staff could get to her, she was on the floor. Before the fall: Resident #3 was in the recliner.Last seen: Sitting talking about her husband.Factors you think could have contributed to the fall?: Resident #3 wanted to see her husband, wanted to get her things earlier to go find him. The floor was dry. Last toileted 2 hours. Resident #3 was incontinent.Interventions in place at time of fall? Yes. Resident was safe. What do you think could have been done to prevent the fall from happening? Staff F documented: When Resident #3 would get upset about her husband, it was hard to redirect her, I walked her, offer food, toileted her with no effect. Signed: Staff F, CNA dated 5/2/26. On 5/4/26, Resident #3 was hospitalized for a fractured left hip. Hospital report dated 5/4/26 for Resident #3 revealed: Reason for admission: Left hip fracture and surgical repair. Resident #3 with a history of right hip surgical repair, dementia, mood disorder presented to the emergency room after unwitnessed ground-level fall. Resident #3 was diagnosed with Left displaced femur neck fracture.Urine Turbid 500 WBC's and 0.03 blood Staphylococcus culture. UTI: Ceftriaxone 2 gm IV daily for 3 days. Laceration of scalp.Occupational Therapy documented as an unwitnessed fall. Provider Progress Note: Follow-up Hospital discharge date d 5/7/26, Resident #3 was recently returned from hospitalization last month, status post-surgical intervention for right femoral head fracture. Unfortunately, Resident #3 had a fall during the weekend, fractured her left hip and had an open area to the back of her head. Resident #3 had been in the hospital and returned for post-operative care. Resident #3 was doing okay, administered oxycodone every 6 for pain. (provider wrote) I am concerned about these falls, Resident #3 broke her hip 6 weeks ago, the right side, and now she has broken the left side. Nursing staff was between 2 more creative ways in keeping the patient more supervised, maybe a chair alarm. Staff reported: no recent falls, no change in appetite, no sleep disturbance, no change in behavior. Documented by Staff C, ARNP. During an interview on 6/25/26 at 9:40 am, Staff F, Certified Nursing Assistant (CNA) stated she was made aware during a report from the other CNA's that Resident #3 fell and broke her hip in March 2026. Staff F stated she provided care for Resident #3 after that injury. Staff F stated she was not the same person and had increased anxiety during the evenings after her husband left. Staff F stated Resident #3's husband was at the facility every day. Staff F stated she informed the nursing that everything on Resident #3's care plan, give food, color, talk to her, did not work, saying she was a sundowner. Staff F stated every night Resident #3 had behaviors and overnight she would try to get up. Staff F stated she would assist Resident #3 into the recliner, held her hand and that worked. Staff F stated she arrived to work on 5/2/26 approximately 10:38 am and worked until 10 pm. Staff F stated when she arrived, Resident #3's husband had left for the day and she was very agitated, yelling she wanted him. Resident #3 refused to walk after the first fall so she would be propelled in a wheelchair. Staff F stated she assisted Resident #3 into the wheelchair and pushed her through the halls until it was supper time. Staff F stated Resident #3 calmed down until after supper when she wanted to go to her room. Staff F stated Resident #3's bedroom door was open and she could see her room. Staff F stated Staff H, CNA partner was going on break, so they assisted Resident #3 into the recliner in the common area. Staff F stated Resident #3 wanted to have her feet down and a blanket. Staff F stated Staff H went on break. Staff F stated she was helping another resident who was pacing around and was able to get him to sit at the table to color. Staff F stated it was calm for about 10-15 minutes then Resident #3 stood up, took a step, and before she could get up from the table, Resident #3 was on the floor. Staff F stated Resident #3 was in pain as she hit her head and said her hip hurt. Staff F stated she called on the walkie for assistance and Staff G, LPN responded, assessed Resident #3 and said to stand her up because she was ok. Staff F stated Resident #3 was not ok, her hip hurt, and informed Staff G to call 911. Staff F stated Staff G did not want to send Resident #3 out of the facility. Staff F stated Resident #3's husband would not like this so she called Staff E, LPN to assess Resident #3. Staff F stated Staff E responded and said she heard the earlier call for help, she checked Resident #3 and said she would call the husband. Staff F stated her partner returned from break and Resident #3 was sent to the hospital. Staff F stated she would report to the nurses that Resident #3 was anxious and yelling every night. Staff F stated Resident #3 tried to get up herself and when she was in a wheel chair, she would go to the door to try to leave. Staff F stated staff in the day shift was two CNA's, a float person and others to help. Staff F stated staffing during the 2-10 shift only and when a break was needed, she would walkie for supervision and would receive a slow response or didn't come. Staff F stated she was by herself when the other person went on breaks and at night time there was only one staff per unit. During an interview on 6/25/26 at 10:39 am, Staff H, CNA stated she worked on 5/2/26 with Staff F, CNA. Staff H stated Resident #3 was assisted to the recliner with her feet up. Staff H stated there was a male resident up and wandering and 4-5 other residents sitting in recliners. Staff H stated she went to break at approximately 6:30 pm. Staff H stated when she returned, Staff F stated that Resident #3 fell. Staff H stated she observed Resident #3 in a wheelchair and obviously in pain. Staff H stated she did not see Staff G, LPN perform an assessment but witnessed Staff G call Staff E, LPN on the walkie to come to assist. Staff H stated Staff E arrived, assessed the cut on Resident #3's head and the nurses called 911. Staff H stated she was not working the day Resident #3 broke her first hip but remembered no one was able to say how it happened. Staff H stated Resident #3 usually had the behaviors in the evening, asking for her husband and trying to get up out of the recliner to look for him. Staff H stated she would assist Resident #3 into a wheelchair and walk her, tried food, colored, none of the interventions worked. Staff H stated conversation helped Resident #3 for a little bit then she snaped back to the bad behaviors. Staff H stated she would tell the nurse, usually they come in observe and do things to calm her down. Staff H stated the nursing staff was aware of Resident #3's behaviors. During an interview on 6/25/26 at 10:54 am, Staff G, Licensed Practical Nurse (LPN) stated the 2-10 shift must be two staff at all time on each unit. Staff G stated the CNAs communicate on the walkie for supervision assist then they go on break and she will go supervise. Staff G stated she did not receive a call on the walkie in the evening of 5/2/26 until Resident #3 was on the floor. Staff G stated Resident #3 would get more confused in the evening and wanted her husband. Staff G stated she would have to call him often to calm his wife. Staff G stated if staff was not sitting right next to Resident #3, she will get up. Staff G stated when she arrived to the unit, Resident #3 was on the floor near her bedroom door. Staff G stated Staff F, CNA reported she was wiping down the dining table after supper and the other CNA was on break. Staff G stated she had told Staff F that she must be supervising residents. Staff G stated Staff F reported by the time she seen that Resident #3 was out of the recliner, she had fallen to the floor. Staff G stated Resident #3 could voice herself, but at that time she was quiet, not complaining of pain. Staff G stated Resident #3 could only walk a little if a staff was with her and used her walker, but she could not walk by herself. Staff G stated after her assessment, she assisted Staff F to lift Resident #3 to a wheelchair and then put her to bed. Staff G stated when Staff H, CNA returned to the unit, Resident #3 was in bed. Staff G stated Staff E, LPN entered the unit and received a report that Staff C, ARNP directed to send Resident #3 to the ER for the head injury and was on a blood thinner. Staff G stated she notified the husband. Staff G stated she was not aware Resident #3 had a fractured hip and was not aware of a urine infection. Staff G stated she remembered on the first of March 2026, Resident #3 had decreased mobility and the nurses couldn't figure out what happened to her. Staff G stated it was an unknown injury and the other nurses were concerned for 2-3 days. Staff G stated, we knew something was not right and requested an x-ray. Staff G stated the nurses were unaware Resident #3 had the fractured hip. During an interview on 6/29/26 at 1:39 pm, Staff E, LPN stated she had worked on 5/2/26 on the 2-10 shift. Staff E stated she was aware that Resident #3 was agitated as she had observed Staff F, CNA propelling Resident #3 by wheelchair in the halls to calm her. Staff E stated after dinner she heard a call on the walkie for a nurse then was requested by Staff G, LPN to go there. Staff E stated she found Resident #3 in a wheelchair in the common area with a laceration to her head. Staff E stated Staff G explained Resident #3 got up and fell. Staff E stated she assisted with the assessment of the laceration on the back of Resident #3's head and remembered it was deep. Staff E stated that Staff G had notified Staff C, Advanced Registered Nurse Practitioner (ARNP) who gave an order to send Resident #3 to the emergency room (ER) for further evaluation as she was on Eliquis (a blood thinner). Staff E stated the husband asked if it could be treated at the facility and explained it was a deep laceration and needed further treatment. Staff E stated the prior doctor would have the nursing staff complete neurological assessments for 72 hours and the new provider said if the resident was not symptomatic, but this was a head injury on a blood thinner. Staff E stated that Resident #3 was sent to the ER due to the head injury. Staff E stated Resident #3 was responding and her vitals were good so she returned to her own unit. Staff E stated all of the residents were in the common area and Staff F, CNA was the only staff in that unit as her partner was on a break. Staff E stated Staff F said she got up to put something in the trash and Resident #3 fell. Staff E stated breaks were based on the environment. Staff E stated in the evenings, the facility was not staffed with a float person and the nurse had to be the person responding to calls for supervision. Staff E stated Resident #3 had behaviors in the evenings and needed to be monitored closely. Staff E stated that same unit had another resident with wander behaviors and she voiced the need to have the extra person due to high behaviors in the evenings. Staff E stated the nurse had to respond to help supervise and that made the nurse late for passing medication. Staff E stated the Director of Nursing (DON) was new and replied you can handle it, but we can't. During an interview on 6/25/26 at 12:25 pm, the DON stated the facility was staffed to have two people on each unit ideally. The DON stated the staff are to call on the walkie to ask for supervision assistance when one of the two go on their break. The DON stated the expectation for nursing was to do complete assessments and when interventions are not effective to notify management. The DON stated a full investigation should have been completed for Resident #3 following the identification of the fractures. The DON stated she was aware that Resident #3 had a urinary infection identified on admit to the hospital from the fall in May 2026 and was planning to have her urine re-checked. During an interview on 6/25/26 at 1:08 pm, the Administrator stated the reason they staffed the units with two staff was in response to a supervision incident in the past but it was not made into a policy. The Administrator stated Resident #3's injury identified on 3/5/26 should have been reported and investigated. The Administrator stated he was not aware that Resident #3 had urinary tract infections when she was admitted to the hospital for the hip fractures on 3/5/26 and 5/2/26 and that could have contributed to the situations. The Administrator stated the investigation for the fall on 5/2/26 could have been more complete and more discussion to the need for more in-depth analysis with the Quality Assurance (QA) team to determine the true root cause. The Administrator stated the DON had been in her position for a short period of time and they were learning. Document titled Fall assessment dated [DATE] revealed: 1. To identify residents who are at risk for falls. 2. To implement interventions to prevent or reduce the incidence of further falls. Fall Risk Assessment: a. Residents will be assessed for fall risk on admission to the facility along with quarterly assessments and/or significant change in status. b. Residents identified as high risk for falls will have fall interventions implemented. c. Interventions for reducing the residents' risk for falls will be resident-specific and based on assessment findings. Protocol: a. When a resident was observed or discovered to have fallen, the staff present, if not the charge nurse, will immediately radio the Charge Nurse to the neighborhood. b. The charge nurse will assess the resident for injury and provide emergency first aid if needed. c. If there is suspected major injury, the charge nurse will notify the physician and the POA immediately. d. If the physician and the POA choose for emergency treatment, the charge nurse will facilitate transfer to the chosen acute care setting. e. If the resident has a known head injury, resident was observed hitting their head, or the fall was unwitnessed, neurological checks will be implemented as follows: Full vital signs, orientation, level of consciousness, pupil size and reaction, response to verbal commands, pain, and movement of extremities. Neurological Assessment are as follows: i. Initial ii. Every 15 minutes x2 iii. Every 1 hour x2 iv. Every 2 hours x2 v. Every 4 hours x2 vi. Every shift x6 d. If at any time the nurse assesses a change in neuro status the physician will be contacted. 2. The comprehensive MDS for Resident #4, dated 4/22/2026, documented the following relevant diagnoses: aftercare following joint replacement surgery, ataxic gait (unsteady walking), muscle weakness (generalized), cognitive communication defect, chronic obstructive pulmonary disease (COPD), Alzheimer's disease with late onset, dementia, bilateral primary osteoarthritis of knee (arthritis in both knees), difficulty in walking. It documented her need for assistance with transfers and walking as partial/moderate assistance and supervision/touch assist with ambulation. The Care Plan, last revised 04/16/2026, documented the resident suffers from a self-care deficit due to her right hip replacement and requires 1-2 staff for transfers. The Nursing Progress Notes from 04/03/2026 through 06/30/2026 document the resident's primary mode of transportation is her wheel chair and uses the assistance of two staff members for transfers. A direct observation on 06/23/2026 at 12:10 PM revealed Resident #4 being transferred by two staff members, identified as Staff K, CNA, and Staff L, CNA. During the observation Staff K placed a gait belt on Resident #4, then both Staff K and Staff L gripped the resident's forearms and pulled her out of her recliner and transferred her to a seated position in her wheelchair. During the transfer Resident #4 was observed to repeat Ow, ow, ow as staff members gripped her forearms, which ceased as soon as the transfer was complete. The resident was observed to rub her forearm after the transfer, though no injury was visible. 3. The comprehensive MDS for Resident #6, dated 05/26/2026, documented the following relevant diagnoses: unspecified dementia, chronic fatigue, ataxic gait, generalized muscle weakness. It documented her need for assistance with transfers and ambulation as being supervision or touching assistance. The June Medication Administration Record (MAR) documented the resident was on the following medications: aspirin 81mg (anticoagulant).The Nursing Progress Notes from 06/13/2026 note bruising to both arms/hands with an unknown origin. The Care Plan for Resident #6, last revised on 06/12/2026, documented the resident's need for an assist of one staff member when transferring and ambulating. A direct observation on 06/23/2026 at 10:13 PM revealed Staff M, CNA, assist Resident #6 to a seated position by using her forearm to ease her into her chair. Minutes later the resident requested to get out of her chair and Staff M placed the gait belt on the resident, then pulled her up by her forearm. Resident #6 is noted to have hand-shaped bruising present on her forearm where the staff member grabbed her to assist her to standing. A direct observation on 06/30/2026 at 08:45 AM showed Staff K transferring Resident #6 using her forearm to pull her up from a seated position. At 08:49 AM Staff K used the resident's forearm to lower her to a seated position from standing. In an interview on 06/30/2026 at 09:14 AM Staff N, CNA, stated the process for transferring a resident is to place a gait belt on the resident, then use the gait belt to pull them to a standing position or lower them to a sitting position. She stated she has been told not to pull the resident up by the forearm because it could injure them. She stated Resident #4 and #6 are not known to refuse use of the gait belt. In an interview on 06/30/2026 at 09:59 AM Staff O, CNA, stated she is supposed to put the gait belt on a resident then use it to help them transfer. She stated she never grips a resident by the forearms for transfers because she doesn't want to bruise or hurt the resident. She stated she is only allowed to hold on to the gait belt during transfers. In an interview on 06/30/2026 at 09:19 AM Staff Q, Certified Medication Aide (CMA), stated if a resident needs assistance to stand you first place the gait belt on the resident, then use the gait belt to assist the resident to their desired position. She stated she was instructed to avoid pulling on a resident's arms or forearms for transfers but she did not know why. She added she assumed it was because it could cause issues with skin integrity or break bones. In an interview on 06/30/2026 at 10:09 AM Staff P, Licensed Practical Nurse (LPN), stated that transfers with one or two assist for residents who don't use a mechanical lift require a gait belt. They are instructed to use the gait belt to assist the resident to a seated or standing position and not to grab other parts of the resident's body, as it is a high risk

Based on observations, staff interviews, facility record review, and manufacturer's manual review, the facility failed to ensure kitchen's mechanical dishwasher properly sanitized the dinnerware and kitchenware used by the dietary staff and residents to prepare and serve the resident meals. This failure posed the risk of food borne illness to the residents receiving food from the kitchen and eating in the facility's dining room. The facility reported a census of 46 residents. Findings include: Observation on 6/22/26 at 9:14 a.m. in the facility's kitchen revealed a mechanical dishwasher with a metal data plate that listed the manufacturer's specifics that included the model and the exact minimum temperatures for the wash and final rinse cycles. The data plate indicated the dishwasher's minimum wash temperature of 155 Fahrenheit (F) and minimum rinse temperature of 180 F. Further observation revealed the June 2026 Dish Machine Temperature Log was posted with temperatures recorded for both the wash and rinse cycles of each day's Breakfast, Lunch, and Supper mealtimes. Review of the June 2026 Log revealed of the rinse temperatures recorded to date, there were five times the recorded rinse temperature failed to meet the minimum rinse temperature of 180 F (on June 3, 4, 5, 17, and 18). Continuous observation on 6/22/26 from 9:25 a.m. to 9:52 a.m. revealed Staff I, [NAME] had operated the mechanical dishwasher to complete ten loads of dishes through the dishwasher's wash and rinse cycles. That observation revealed the wash cycle temperatures had reached the minimum wash temperature of 155 F or higher (155 F to 164 F). During that observation the rinse cycle temperatures failed to meet the minimum rinse temperature of 180 F with rinse temperatures ranging from 170 F to 172 F. In an interview on 6/22/26 at 9:52 a.m. Staff I, [NAME] acknowledged the temperatures of the observed rinse cycles had not met the required minimum rinse temperature of 180 F that assured the sanitation of the dishes that had been washed and rinsed in the mechanical dishwasher. In an interview on 6/22/26 at 10:02 a.m. with the Executive Director regarding the kitchen's mechanical dishwasher not reaching the required minimum temperature of 180 F for the rinse cycle, he acknowledged the problem and stated he would have the Maintenance Director address the problem. In an interview on 6/24/26 at 2:10 p.m. with the facility's Consultant Dietitian, she stated the facility had experienced some trouble with the mechanical dishwasher in the past. She was not sure of the exact dates but stated it was within the past year and that she had been informed that the business company who installed the dishwasher had fixed the problem. In an interview on 6/25/26 at 7:21 a.m. with the Maintenance Director regarding the mechanical dishwasher, he stated the kitchen had problems with the dishwasher in the past year. He stated the problem was with the dishwasher's solenoid part which was the electronic contacting switch for the dishwasher's two booster heaters. One booster heater was for the wash cycle and the other booster heater was for the rinse cycle. The Maintenance Director stated that on Monday, 6/22/26, after the low rinse cycle temperature had been reported to him, he had adjusted the booster heater which raised the rinse cycle's temperature. In an interview on 6/25/26 at 1:05 p.m. with the Executive Director, regarding the request for the policy regarding sanitation and the mechanical dishwasher, he stated the facility had no policy regarding the dishwasher. The Executive Director stated the facility followed the manufacturer's guidelines regarding the dishwasher's use to ensure sanitation. Review of the facility's Dish Machine Temperature Logs that had been requested for January 2026 through May 2026 revealed the bottom of form stated Report temperatures that are not in appropriate ranges to supervisor. There were no temperature ranges identified on the form.The wash and rinse temperatures recorded in January 2026 for the breakfast, lunch, and supper mealtimes were all above the required minimum temperatures for both the wash and rinse cycles. Review of the facility's Dish Machine Temperature Logs that had been requested for February 2026 through May 2026 revealed for: February 2026:4 recorded wash temperatures were below the required 155 F.7 recorded rinse temperatures were below the required 180 F.March 2026:12 recorded wash temperatures were below the required 155 F.23 recorded rinse temperatures were below the required 180 F.April 2026:6 recorded wash temperatures were below the required 155 F.18 recorded rinse temperatures were below the required 180 F.May 2026:No recorded wash temperatures were below the required 155 F.19 recorded rinse temperatures were below the required 180 F.For the months of February to May 2026, the mechanical dishwasher's: -Wash temperature failed to reach the required minimum temperature of 155 F for 7% of the recorded wash temperatures.-Rinse temperature failed to reach the required minimum temperature of 180 F for 19% of the recorded rinse temperatures.Review of the requested mechanical dishwasher's Dishmachine Owner's Manual Rev 2.08B revealed the Cycle Temperatures listed on Page 2 indicated the following temperatures: Wash- F (High Temp): 155 F-160 FRinse- F (High Temp): 180 F-195 FThe Dishmachine Owner's Manual page 4 documented The CMA-180 is a hot water sanitizing, single rack, door-type dishmachine. The Manual's instructions directed After the machine has warmed up for five to ten minutes (5 - 10 min.), observe the wash and rinse temperatures. The wash temperature must be 155 F minimum. The rinse temperature must be 180 F minimum . NOTE: Rinse water temperature must be observed during the rinse cycle.

Based on observation, staff interview, consultant dietitian interview, and facility job description review, the facility failed to designate a person to serve as the director of food and nutrition services who met the minimum qualifications to carry out the food and nutrition services. The facility reported a census of 46 residents. Findings include: During the initial kitchen tour on 6/22/26 at 9:14 a.m. the Dietary Manager's office door was observed to be closed and the light was off. Two cooks were observed and interviewed in the facility's kitchen Staff I and Staff J. Staff I, [NAME] stated he had worked at the facility for five years and when asked, revealed the facility currently had no Dietary Manager. Staff J, [NAME] stated she had been recently hired three months ago.Review of the Key Personnel list provided by the Administrator on 6/22/26 revealed there were 16 positions listed for the facility's Administration team, 14 of the positions had a name and phone number listed. There was no name or phone number listed for the Dietary Manager's position. In an interview on 6/23/26 at 1:02 p.m. regarding the facility's mechanical dishwasher, the Maintenance Director was asked regarding the Dietary Manager and he stated that the Executive Director was the acting Dietary Manager as the previous Dietary Manager had just resigned her position. In an interview on 6/23/26 at 2:13 p.m. with the Executive Director regarding the Dietary Department, he confirmed that the facility currently had no Dietary Manager. He stated the previous Dietary Manager had been employed a number of years and had resigned in May 2026. He was unsure of the specific day, but stated that her last day was at the end of May. He stated he was currently in the process of hiring a Dietary Manager. When asked about the facility's Dietitian, he stated the Dietitian was not employed full-time and was a Consultant Dietitian who visited the facility on a weekly basis. The Executive Director stated that he was currently serving as the acting Dietary Manager. Further interview on 6/24/26 at 10:07 a.m. with the Executive Director regarding his role as the acting Dietary Manager revealed that he stated he was not a certified dietary manager but had looked into completing an internet-based course for Certified Food Protection Manager. During an interview on 6/24/26 at 2:10 p.m. with the Consultant Dietitian she confirmed she visited the facility weekly to assist as a consultant for the facility's dietary department. She stated that the previous Dietary Manager had resigned and she was not sure what was happening with that position, but that the Executive Director was the acting Dietary Manager. She stated she completed an audit of the kitchen every other month, but was concerned that a Dietary Manager was not in place to supervise the daily operation of the kitchen and the multiple logs completed by dietary staff. Review of the facility's undated job description for the Dietary Services Manager revealed Under the general supervision of the Administrator and with guidance from the Contracted Dietitian, the Dietary Services Manager position assumes responsibility for residents receiving the highest quality nutrition and food service available within economic constraints, consistent with requirements identified on individual care plans and with applicable laws, regulations, and professional guidelines. The Manager plans, develops, directs and controls the activities of the Dietary Department. The qualifications listed included: a. Documented completion of State-approved Food Services Supervisor Course.b. High school diploma or equivalent.c. Certified Dietary Manager.The responsibilities included:- Implement of dietary and food service policies and procedures to meet residents' needs and in compliance with federal, state, and local requirements.- Implement a monitoring system for the dietary and food service department and make recommendations for implementation to assure compliance with federal, state, and local requirements.- Supervise the entire operation of the dietary department.

Based on clinical record review, staff interviews, and facility policy review the facility failed to maintain a Registered Nurse (RN) in the building for eight (8) consecutive hours a day. The facility reported a census of 46. Findings include: Review of a file titled Nursing Schedule Past 30 days, provided by the facility to surveyors on 06/23/2026 documented on 06/20/2026 five Licensed Practical Nurses (LPN) were in the building providing nursing coverage for the day, but no mention of RN coverage was present. In an interview on 06/25/2026 at 10:02 AM with the Director of Nursing (DON), she confirmed there was no RN present in the building on the 20th. She acknowledged this was a requirement. In an interview on 06/29/2026 at 03:43 PM with the Administrator he acknowledged there was no RN in the building on the 20th and stated it was because of a scheduling oversight. Review of the Facility Assessment, provided to surveyors on 06/30/2026, documented the following: The Facility follows current guidelines from CMS and DIAL regarding Provisions of care and staffing. Review of CMS State Operations Manual revisions implemented and effective on 12/13/2013 state the following: The requirements for long-term care facilities require that a skilled nursing facility provide 24-hour licensed nursing services, an RN for 8 consecutive hours a day, 7 days a week (more than 40 hours a week), and that there be an RN designated as Director of Nursing on a full time basis.

Based on clinical record review, staff interview, facility policy review, and guidance from the 2025 Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to develop and implement a comprehensive care plan for two of twelve residents (Res #1, #2) reviewed for Comprehensive Care Plan Development. The facility reported a census of 46 residents. Findings include:1. The Minimum Data Set (MDS) of Resident #1 dated 4/3/26 identified a Brief Interview for Mental Status (BIMS) score of 0, which indicated severe cognitive impairment. The MDS documented the resident exhibited physical behaviors directed toward others such as hitting, kicking, etc on 1 to 3 days of the 7-day look back period. The MDS documented diagnoses that included Alzheimer's Disease. The MDS documented the resident received antipsychotic, antianxiety and opioid medications during the lookback period. The MDS documented the resident was receiving hospice services. The Care Plan of Resident #1 revealed a Focus Area of risk for behaviors related to Alzheimer's Disease and dementia, dated 1/6/26. The Care Plan directed staff to administer medications as ordered, monitor and document for side effects and effectiveness. The Care Plan failed to address what behaviors the resident was at risk for or identify which medications to administer. The Care Plan identified an additional Focus Area of psychotropic medications related to behavior due to dementia, dated 1/6/26. It directed staff to administer psychotropic medications as ordered by physician. The Care Plan failed to identify the type of psychotropic medications or the target behaviors for which the medications were ordered. The Order Note dated 4/14/26 documented a new order placed for Res #1 for Trazodone (an antidepressant medication), give at bedtime for difficulty sleeping. The Care Plan failed to address the resident having any sleeping concerns or the order for a new antidepressant medication. The Medication Administration Record (MAR) of Res #1 for June of 2026 documented six administrations of Morphine (an opioid pain medication), directed to be given as needed for pain or shortness of breath. The Care Plan failed to address Res #1 having any pain or shortness of breath. The Census Line of Resident #1 identified he enrolled in hospice care on 3/31/26. The Health Status Note dated 3/31/26 documented the resident was admitted to hospice. The Care Plan failed to reflect a focus area of hospice care or an identification of which hospice contractor was serving him or the hospice contact information. The Care Area Assessment (CAA) section of Res #1's MDS was dated on page 54 of the MDS as being completed on 4/17/26. Page 38 of the MDS RAI Manual directs that the Care Plan Completion date must be no later than the CAA completion date + 7 calendar days. On 6/29/26 at 3:10 pm, the Director of Nursing (DON) stated her expectations for care plans include medication side effects to monitor for and interventions for those side effects. She stated target behaviors should also be on the care plan. She described how target behaviors are determined as primarily word of mouth along with nursing judgement and assessments for any new medications prescribed. On 6/29/26 at 3:28 pm, the MDS Coordinator stated some of the Res #1's medications were added after he enrolled in hospice for terminal restlessness. She reviewed his Care Plan and stated she knew he had a history of wandering but agreed the Care Plan was not personalized to his behaviors. She acknowledged the Care Plan did have a Focus Area of behaviors but stated it was not specific enough. The facility policy titled Care Plan and Care Conference Policy documented the purpose of the policy to be: Each resident will have an individualized interdisciplinary plan of care in place. 2. The quarterly review MDS of Resident #2 dated 6/15/26 identified a BIMS score of 11, which indicated the resident was cognitively moderately impaired. The MDS documented diagnoses that included Alzheimer's Disease and anxiety disorder. The MDS documented the resident received antipsychotic, antianxiety, and antidepressant medications during the 7-day look back period. The admission MDS of Resident #2 dated 3/5/26 documented an admission date of 2/27/26. The MDS documented the resident received antipsychotic, antianxiety, and antidepressant medications since his admission to the facility. The Care Area Assessment (CAA) Worksheet regarding Resident #2's psychotropic drug use dated 3/12/26 documented that the resident's psychotropic drug use would be addressed in the care plan and was signed by the MDS Coordinator on 3/12/26. The Care Plan of Resident #2 revealed a Focus Area of chronic confusion related to Alzheimer's Disease, dated 2/3/26. The Care Plan directed staff to administer medications as ordered, monitor and document for side effects and effectiveness. The Care Plan further directed staff to review the resident's medications and record possible causes of cognitive deficit. The Care Plan failed to identify a Focus Area for the resident's psychotropic medications that included the type of psychotropic medications, the target behaviors for which the medications were ordered, measurable goals, or person-centered individualized approaches to care, including non-pharmacological interventions. The MAR of Res #2 for June of 2026 documented daily administration at bedtime of: a. Seroquel (an antipsychotic medication), directed to be given for behaviors and hallucinations. b. Buspirone (an antianxiety medication) directed to be given for anxiety. c. Trazodone (an antidepressant medication), directed to be given for depression. On 6/24/26 at 3:21 pm the MDS Coordinator stated she was a Licensed Practical Nurse (LPN) and responsible for the interdisciplinary team's coordination and completion of the MDS assessments and resident care plans. She stated that a resident's psychotropic medications should be addressed on their individualized care plan by the type of medication (antipsychotic, antianxiety, and antidepressant) with an objective goal and person-centered interventions. When asked about Resident #2's psychotropic medications and his care plan, the MDS Coordinator acknowledged that Resident #2's psychotropic medications were not addressed on his care plan and stated that she had overlooked it. She stated she could improve on the residents' care plans. On 6/25/26 at 8:55 am the DON stated that the MDS Coordinator reported to her and that she signed the MDS assessments as the Registered Nurse (RN) Coordinator. The DON stated that the MDS Coordinator opened the MDS assessments, set the assessment reference date (ARD) date, and completed the assessments for the MDS. The DON stated that when the MDS Coordinator had completed the assessment, the DON reviewed and signed the MDS assessment. The DON stated her expectation was that the MDS assessment and further CAA assessments would follow the process that resulted in a comprehensive Care Plan. The DON stated that she had not always verified the CAA decision to care plan was followed through on the resident's care plan. The DON stated she was not aware that Resident #2's psychotropic medications had not been addressed on his care plan. The DON stated she was not aware of any other Care Plan issues. The facility's Care Plan and Care Conference policy dated 3/1/21 instructed the interdisciplinary team to continue to develop the care plan in conjunction with the RAI [Resident Assessment Instrument] (MDS 3.0) and CAAS . and provided guidance that the interdisciplinary team will develop and implement the Comprehensive Care Plan within 21 days of admission.

Based on clinical record review, staff interview and guidance from the 2025 Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to complete a significant change in status assessment (SCSA) that should have been completed within 14 days after it was determined the resident's status from baseline had occurred for 2 of 12 residents reviewed (Resident #3 & #1). The facility failed to complete a SCSA when Resident #3 experienced a decline in activities of daily living physical function after the return from hospital care for fractured hip repairs on 3/10/26 and on 5/6/26. The facility also failed to complete a timely significant change for Resident #1 when enrolled into Hospice care. The facility reported a census of 46 residents.Findings include: 1.The Quarterly Minimum Data Set (MDS) dated for 1/8/26 for Resident #3 revealed the diagnoses of dementia, muscle weakness and abnormalities of gait and mobility. The MDS did not identify a pain medication regimen nor that Resident #3 identified the experience of pain. The MDS identified one fall with an injury, not a major injury. No prior orthopedic surgery identified. Resident #3 required moderate assistance from staff for dressing and ambulation. Resident #3 was incontinent of bowel and bladder and dependent on staff for toileting and personal hygiene. The Brief Interview for Mental Status (BIMS) score was a 4 which revealed severe cognitive impairment and no adverse behaviors were identified. The Annual Assessment MDS dated [DATE] for Resident #3 revealed the diagnoses of dementia, anxiety, osteoporosis and fractured hip. The MDS identified two or more falls without injury. The MDS identified that Resident #3 underwent a surgical intervention for hip, required skilled care and surgical wound care. The MDS identified pain and the use of opioid pain medication. The MDS identified Resident #3 was dependent on staff for dressing, toileting, personal care, transfers and ambulation did not occur. The MDS dated [DATE] coded as an entry to the facility for Resident #3. The MDS dated [DATE] coded as a Medicare Part A 5-day scheduled assessment for Resident #3 revealed diagnoses of dementia, anxiety, age-related osteoporosis without current pathological fracture, repeated falls, hip fracture and muscle weakness. The MDS identified that Resident #3 underwent a surgical intervention for hip, required skilled care and surgical wound care. The MDS identified pain and the use of opioid pain medication. The MDS identified Resident #3 was dependent on staff for dressing, toileting, personal care, transfers and ambulation did not occur. The MDS identified a fall in the last month, a fall in the last 2-6 months and a fracture related to a fall in the 6 months prior to this assessment. The MDS failed to identify fall with major injury. During an interview on 6/24/26 at 3:21 pm, Staff D, Licensed Practical Nurse (LPN) MDS Coordinator identified significant changes with residents as increase in falls, behaviors, a decline in function with dementia and falls that resulted in hospitalization for a fracture with a return to the facility for skilled care. Staff D stated the hip fractures that Resident #3 experienced would warrant a significant change. Staff D stated the facility had completed a Medicare 5-day MDS assessment for Resident #3 on 5/12/26, but thought afterwards that should have been a significant change. She stated she had missed a Quarterly Review on Resident #3, the facility's QAPI team had identified and put a performance improvement plan (PIP) in place regarding the missed MDS assessment. Staff D stated she had discussed the missed MDS's with the Director of Nursing (DON) and the Administrator a couple of months ago. 2. The MDS of Resident #1 dated 4/3/26 documented the resident was receiving hospice services. Page 59 of the MDS documented the assessment completion date of 4/17/26. The Census Line of Resident #1 identified he enrolled in hospice care on 3/31/26. The Health Status Note dated 3/31/26 documented the resident was admitted to hospice. Page 38 of the MDS RAI manual directs the MDS completion date must be no later than the 14th calendar day after determination that a significant change in resident's status occurred (determination date + 14 calendar days). Pages 45-46 of the MDS RAI manual documents: A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. An SCSA (Significant Change in Status Assessmet) 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). On 6/30/26 at 11:10 am, the Director of Nursing stated the facility does not have an MDS policy. She stated they follow the CMS and RAI guidelines for when an MDS is due or indicated.

Based on clinical record review, family interview and staff interviews, the facility failed to appropriately supervise and maintain an environment free of potential hazards for 1 of 1 residents reviewed (Resident #2) after a resident made suicidal statements and self harmed. The facility reported a census of 49 residents. Finding include:According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated severe cognitive impairment. Resident #2 had diagnoses to include Non-Alzheimer's dementia and depression. The MDS documented the resident's current behavior status was worse compared to the prior assessment and the resident sometimes felt lonely or isolated from those around him. The Care Plan, revised on 6/18/25, documented Resident #2 used antidepressant medication related to a depression diagnosis and instructed staff under interventions to administer antidepressant medications as ordered by the physician and document/report an needed adverse reactions to antidepressant therapy, including social isolation and suicidal thoughts. Review of the Electronic Health Record (EHR) revealed the following Progress Notes:a. Progress Note dated 12/5/25 at 10:50 PM, titled Health Status Note: At HS (hour of sleep), it was brought to nurse attention that resident picked up a screwdriver and self-inflicted a small skin tear to his dorsal/the back of his left hand stating that he wants to un-alive (kill) himself. His family was notified immediately. He also refused to relinquish the screwdriver and threatened to harm anyone who try to take the screwdriver from his hand. He is currently sitting in the common area with the device in his hand while nurse and staff trying to deescalate the situation.b. Progress Note dated 12/6/25 at 10:01 AM, titled Health Status Note: Assisted Manager on Duty (MOD), Social Services Director (SSD) to search resident's room for any potential weapons to harm self or others from resident's room and removed call light to replace with bell to call for help. Removed items were placed in a basket and taken to the nurses station. 15 min check sheet initiated to monitor, direct care staff aware and verbalized understanding.c. Progress Note dated 12/6/25 at 12:00 PM, titled Social Services: Met with resident this morning to assess psychosocial needs and risk of self-harm. Resident was in the common area upon my arrival. He appeared in good spirits throughout my visit, with friendly mannerisms to include smiling and a pleasant tone of voice. He was alert to self only, was disoriented to time and place and spoke about how he's busy at work on his airplanes. He was asked if he had any safety concerns and he stated his line of work has several safety concerns because if he doesn't do his job correctly then others are placed at risk. Asked resident about events last night and gestured towards resident's laceration on the back of his hand. Resident stated, Oh, I was just playing around. I asked if he was attempting to hurt himself last night and he stated that a lot of people can be hurt if he doesn't do his job correctly. Validated the important work he does ensuring airplanes are operating correctly, agreeing this is a very important task. After speaking about airplanes for a little while I later oriented resident to facility and asked if he had any safety concerns regarding his living environment. He looked around the room before answering that no, he has no safety concerns. He stated he feels he's in a nice place. Resident was asked if he was having any current thoughts of hurting himself or anyone else and he denied this.During an interview on 2/4/26 at 1:45 PM, a family member stated a recollection of the night of 12/5/25, she received a call from the facility, from Staff A, Licensed Practical Nurse (LPN), at around 8:45 PM. Staff A advised her Resident #2 had a screwdriver and was upset and trying to harm himself, he hurt his hand with the screwdriver. She couldn't remember for sure, but he might have said he wanted to kill himself. She arrived at the facility approximately 30 minutes later. When she arrived, Resident #2 still had the screwdriver in his hand and did not want to release the tool. She noted he cut his hand with the screwdriver. Resident #2 was in his room with Staff B, Certified Nursing Aide (CNA), when she arrived. Staff B said Resident #2 did not want to let go of the screwdriver. She was able to get the screwdriver from Resident #2 and stayed in his room with him until he was calm. When she left the facility, around 10-10:30 PM, Resident #2 was not on a one on one watch and the facility had not taken any action yet, to her knowledge, to keep him safe. The facility did not tell her what they were doing to keep him safe until the next day. The facility did not go through his bedroom to remove potential hazardous items until the next day. A formal psychological evaluation was not completed, just an informal assessment with the facility Social Worker. She stated in May of 2025 Resident #2 was upset and might have made a comment of wanting to hurt himself, she believed he had a tool of some kind then as well. Resident #2 admitted to the facility in April of 2025, he did not have suicidal ideations prior to his admission. During an interview on 2/4/26 at 2:15 PM, Staff B, CNA, stated he recalled working on the 5th of December, 2025. He worked the 2:00 PM to 10:30 PM shift on the hall where Resident #2 resides. That night, after dinner, he noticed Resident #2 had something in his hand and had a cut on his hand. He had what appeared to be a small screwdriver in his hand. Resident #2 was yelling out and agitated. Resident #2 had been in his room after dinner, he then came out of his room with the screwdriver and said he wanted to kill himself. He did not want to let go of the screwdriver. Staff B stated he called the floor charge nurse, Staff A, LPN. Staff A came over to the unit within a few minutes. Resident #2 said he cut his hand with the screwdriver and said again that he wanted to kill himself. Staff A then called Resident #2's family who came to the facility and calmed the resident down. Staff B stated he believed the incident started around 7:30 PM and when he left his shift at 10:30 PM Resident #2 appeared to be calm. Staff B stated he remained with Resident #2 until the family arrived. Staff B stated he is not aware of any other steps taken that night, other than calling the family. During an interview on 2/4/26 at 2:30 PM, Staff C, LPN, stated she recalled working on the 5th of December, 2025. Her shift was from 10:15 PM to 6:15 PM and she was the charge nurse for the entire building, all 6 households. She received a verbal report from Staff A, LPN, as to how the residents were on the previous shift and Staff A advised her that Resident #2's family came to the facility to help with his routine at bed time. She did not receive a report and was not advised that Resident #2 had a tool or that he cut his hand with the tool. Staff A advised her Resident #2 was upset earlier in the night and made a statement of wanting to kill himself. Staff C stated the family was not at the facility with the resident when she arrived for her shift. Staff C stated Resident #2 slept through the night and she checked on him as often as she could. During an interview on 2/4/26 at 2:45 PM, Staff A, LPN, stated he recalled working on 12/5/2025 as the floor nurse. He worked the 2:00 PM to 10:30 PM shift, covering 3 units, including the unit where Resident #2 resided. Staff A recalled being at the nurse's station, which is located in the main hallway in between the 3 units, when Staff B called him and told him Resident #2 was upset. Staff A went to the unit where Resident #2 resided and Resident #2 had a short screwdriver in his hand and he said he wanted to kill himself. Resident #2 would not relinquish the screwdriver and was agitated. Resident #2 cut his hand with the screwdriver. Staff A stated he called the resident's family who came to the facility to help calm the resident down. The incident started after dinner, around 7:30 PM. Resident #2 still had the screwdriver in his hand and the family was able to get the screwdriver and helped him with his bed routine. When Staff A left the facility at 10:30 PM the family was no longer at the facility. Staff A stated he did not call management that night and did not implement any safety measures for Resident #2. Staff A stated he received a written reprimand for not contacting management that night and informing management of Resident #2's suicidal statement and self harm. Staff A stated safety measures were not put in place until the following day. Staff A stated he gave a verbal report to Staff C, LPN, when Staff C came on duty that night, he advised Staff C of the statement Resident #2 made of wanting to kill himself. Staff A advised he documented the incident in the Electronic Health Record (EHR) for Resident #2. During an interview on 2/4/26 at 3:30 PM, Staff D, LPN, stated she recalled working on 12/6/25, the 6:00 AM to 2:00 PM shift. She was the floor nurse for 3 units, including the unit where Resident #2 resided. Staff D stated when she started her shift, she received a verbal report from Staff C, LPN, about each resident. Staff D did not recall if the verbal report included Resident #2 making a suicidal statement or self harmed the night before. Staff D advised there were no safety precautions or measures in place for Resident #2 when she arrived for her shift. Staff D stated she read the 24 hour report for each resident when she came on duty. She could not recall if she learned of Resident #2's incident the night before through reading the 24 hour report or if it came verbally from Staff C. Staff D stated as soon as she became aware of the incident with Resident #2 she contacted management as it is their policy and procedure to contact management right away if a resident makes a statement of suicidal intention or if a resident self harmed. Staff D stated no steps were put in place to protect the resident after he self harmed and made a statement of wanting to kill himself. The steps that should have been taken immediately would have been to remove all dangerous items from his room and start 15 minute checks. Staff D stated she and the facility Social Worker, Staff H, started the interventions on 12/6/25, the day after the incident. Staff D advised Resident #2 was sleeping when she arrived for her shift at 6:00 AM on 12/6/25. Staff D stated Resident #2 made verbal comments previously about wanting to hurt himself, in May of 2025. The resident was placed on 15 minute checks immediately at that time.During an interview on 2/9/26 at 7:00 AM, Staff E, CNA, stated she recalled working on 12/5/25 from 10:15 PM to 6:00 AM the following day on the unit where Resident #2 resided. When she arrived for the start of her shift, she was advised Resident #2 made a suicide attempt earlier that night and had a screwdriver. Resident #2's family was there when she arrived for her shift and left by 10:30 PM. Staff E stated she was the only CNA working the overnight shift on the unit where Resident #2 resided, this is normal staffing for overnight shifts. Staff E stated no one told her Resident #2 was on 15 minute checks that night and she did not complete 15 minute checks. Staff E stated she checked on the resident as often as she could. Staff E stated she did try to keep an eye on him throughout the night. Staff E recalled the resident had a hard time falling asleep that night, she sat with him while he ate a snack and then he fell asleep. Staff E did not check on Resident #2 every 15 minutes, but did try to check on him often. During an interview on 2/9/26 at 9:25 AM, Staff H, Social Worker (SW), advised she worked a shift at the facility on 12/6/25 (Saturday), beginning at around 5:45 AM until around 2:30 PM. Staff H stated she was not informed of Resident #2's suicide statement or self harm when she arrived at the facility on 12/6/25, she became aware of the incident by reading the 72 hour report, a report pulled from Progress Notes for the past 72 hours for each resident. Staff H read in the report that Resident #2 was suicidal and inflicted an injury on his hand and wanted to kill himself. The Progress Note was written by Staff A, LPN. Staff H stated she went to check on Resident #2 at around 8:00 AM that morning. Resident #2 was at the breakfast table, Staff H asked the CNA on duty, Staff G, how he was doing. Staff G advised Staff H she did not know anything about what happened the night before. Staff H informed Staff G what she read in the 72 hour report. Staff H then went to find Staff D, the floor nurse. Staff D advised Staff H she did not know about what happened with Resident #2 the night before. Staff H told her what happened. Staff G advised the resident was fine that morning and there were no issues overnight that she was aware of. Staff G started her shift at 6:00 AM. Staff H stated she returned to her desk around 9:30 AM and reached out to the Director of Nursing (DON) to see if any staff had informed her of what took place the night before with Resident #2. Staff H stated the facility's policy and process is to contact the DON or the nurse on call to inform them of any suicidal attempt. The DON was not aware of what happened. The DON instructed Staff H to remove any hazardous items from the resident's room and start 15 minute checks. Staff H, along with Staff D, went into the resident's room that morning, around 9:45 AM, and removed hazardous items. The items removed included an iPhone cord, phone cord, his call light cord, his lamp, beaded necklaces, and a disposable razor blade located in his drawer. The resident had a bell to use as a call light. Staff H stated she talked to the resident later that morning after his nap and completed a safety/suicide assessment. Staff H observed marks on his left hand and asked him about the marks, he said he did that to himself, but did not know why. The resident was placed on 15 minute checks at around 10:00 AM on 12/6/25. During an interview on 2/9/26 at 9:55 AM, the Director of Nursing (DON) stated she was not aware of Resident #2 making a suicidal statement or self harm until Saturday morning, the 6th of December. The DON stated she read the 24 hour report that morning and saw the Progress Note, this was at around the same time Staff H called her, around 9:30 AM. She was on call that weekend as the DON. The DON stated she instructed Staff H to put the resident on 15 minute checks, go through his room and then talk to him. The 15 minute checks started that morning, and potentially harmful things were removed from his room. The DON stated when a resident makes a self harm statement the floor nurse should be notified right away. The floor nurse should notify the DON or Assistant DON (ADON) on call right away and the resident's Primary Care Physician (PCP). Residents should be put on 15 minute checks right away and their room should be emptied of anything harmful. The DON stated an expectation the floor nurse to have notified her immediately that night of Resident #2's suicidal statement and self harm. The DON stated an expectation the resident be put on 15 minute checks immediately and his room searched immediately and items that could be used to self harm be removed from the room. The DON acknowledged a delay in these steps to protect the resident from further self harm. The DON stated the facility does not have a policy on suicidal ideations/statements or resident self harm. During an interview on 2/9/26 at 10:35 AM, Staff G, CNA, stated she recalled working on 12/6/25 from 6:00 AM to 2:30 PM on the unit where Resident #2 resided. Staff G stated someone, she is not sure whom, informed her that morning that Resident #2 made statements of wanting to kill himself the night before. Later that morning items were removed from his room that could be dangerous to him and 15 minute checks were started later that morning. Resident #2 was sleeping when she began her shift, she was not aware at that time of the incident the night before. During an interview on 2/9/26 at 11:15 AM, Staff I, CNA, stated she recalled working on 12/5/25 from 2:00 PM to 10:30 PM on the unit where Resident #2 resided. She remembered after dinner Resident #2 coming out of his room with a screwdriver in his hand and he said he wanted to kill himself. He cut his hand with the screwdriver and did not want to give the screwdriver to staff. Staff B called the floor nurse, Staff A, and Staff A came to the unit. Resident #2 still did not want to release the screwdriver from his hand and was agitated. Staff A called the resident's family and the family came to the facility and helped to calm the resident. Staff I stated nothing was put in place that night to keep the resident safe from further self harm. Review of facility hard copy document titled 15-Minute Checks revealed 15 minute checks were not started on Resident #2 until 12/6/25 at 10:00 AM, the incident of self harm and statement made by Resident #2 of wanting to kill himself took place on 12/5/25 at approximately 7:30 PM. During an interview on 2/9/26 at 11:50 AM, the Administrator stated the facility does not have a policy on self harm or suicidal ideation, they use standard practice of care.

Based on clinical record review, staff interviews and policy review, the facility failed to fully review and revise the comprehensive Care Plan for 1 of 3 residents (Resident #2) who were sampled for care plan review. The facility reported a census of 49 residents. Findings include:According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated severe cognitive impairment. Resident #2 had diagnoses to include Non-Alzheimer's dementia and depression. The MDS documented the resident's current behavior status was worse compared to the prior assessment and the resident sometimes felt lonely or isolated from those around him. Review of the Electronic Health Record (EHR) revealed the following Progress Notes:a. Progress Note dated 5/31/25, titled Health Status Note: Resident upset this AM due to unable to leave, and not safe to leave in room alone. Staff attempted to engage in activities, distract with meals and assist to converse with peers. When on the phone with his family, resident stated that he would just kill himself since he could not leave, overheard by staff in common room with phone on speaker. Resident on 15 minute checks following phone conversation at 1000 to family. Spoke with resident, no plan or attempts, and denies even saying the above. Primary Care Physician (PCP) made aware and advised to keep 15-minute checks until at least Monday and follow up with psychiatry, if family allows, to evaluate for depression. b. Progress Note dated 12/5/25, titled Health Status Note: At HS (hour of sleep), it was brought to nurse attention that resident picked up a screwdriver and self-inflicted a small skin tear to his dorsal/the back of his left hand stating that he wants to un-alive (kill) himself. His family was notified immediately. He also refused to relinquish the screwdriver and threatened to harm anyone who try to take the screwdriver from his hand. He is currently sitting in the common area with the device in his hand while nurse and staff trying to deescalate the situation.The Care Plan for Resident #2 lacked a focus area, goal and interventions for staff regarding the resident's suicidal statements, ideations and self harm. The Kardex Care Plan from the household where Resident #2 resided, a hard copy document for staff use to know the care plan for each resident, did not contain any information related to the resident's suicidal ideations or self harm attempt, or interventions for staff. During an interview on 2/9/26 at 9:55 AM, the Director of Nursing (DON) stated the suicidal ideations and what to do should have been in Resident #2's Care Plan and she expected the Care Plan be updated after each suicidal statement and self harm incident. The DON acknowledged the Care Plan was not updated. During an interview on 2/9/26 at 11:50 AM, the Administrator stated an expectation the Care Plan be updated and acknowledged the Care Plan was not updated in May of 2025 or in December of 2025 after Resident #2 made comments of suicidal thoughts and self harmed. Review of the facility policy Care Plan and Care Conference Policy, revised 3/1/21, documented the Comprehensive Care Plan will be reviewed and revised on a quarterly basis, with a significant change in condition and as needed.

Based on record review, observation, resident and staff interview, and policy review the facility failed to document follow up skin assessments for 1 of 3 residents reviewed for skin concerns (Resident #2). The facility reported a census of 53 residents. Findings include: The admission Minimum Data Set assessment (MDS) dated [DATE] revealed Resident #2 admitted to the facility on [DATE] and had diagnoses of a left femur fracture and Alzheimer's Disease. The MDS indicated the resident had a risk for pressure ulcers but had no skin issues. The MDS recorded the resident had a Brief Interview for Mental Status score of 11, indicating moderately impaired cognition. The Care Plan initiated on 5/6/25 revealed the resident had a stasis ulcer on the right outer ankle related to peripheral vascular disease. The Care Plan also documented the resident took aspirin post-surgically. The Care Plan directed staff to utilize a pressure reduction mattress and document adverse reactions of antiplatelet therapy such as bruising. An admission Skin Observation Tool dated 4/29/25 revealed Resident #2 had a skin tear on the left elbow, a surgical incision to the left thigh, and a stasis ulcer to the right ankle. The Skin Observation Tool lacked measurements of the wounds. The Skin & Wound Evaluations revealed the following: a. A right ankle arterial stasis ulcer 4/30/25 1.8 centimeter (cm) x 1.4 cm 5/24/25 1.8 cm x 1.6 cm The Skin and Wound Evaluations dated 4/30/25 and 5/24/25 lacked further information such as drainage, odor, and appearance of the wound. The resident's record lacked further documentation of skin assessments of the right ankle between 5/1/25 to 5/23/25. b. A skin tear to the left lateral calf and a bruise to the right upper (inner) arm on 5/28/25 but no wound measurements or documentation related to the wound appearance. The Treatment Administration Record dated 5/1/25 to 5/31/25 revealed orders for the following: a. Complete Skin and Wound Total Body Skin Assessment and update pictures every Thursday on the evening shift had a start date 5/1/25. b. Apply honey ointment and Mepilex dressing to the right ankle every 3 days, had a start date 5/6/25. The Progress Notes revealed the following: a. On 4/29/25 at 1:49 PM, the resident admitted to the facility and had a stasis ulcer to the right ankle. b. On 5/8/25 at 2:18 PM, ulcer on right ankle. c. On 5/27/25 at 3:00 PM, skin warm and dry. Stasis ulcer on right outer ankle. The Progress Notes lacked documentation of skin concerns or bruises to the resident's arms. Observation on 05/28/25 at 12:00 PM, Resident #2 had a large dark purple bruise to her left forearm. The right posterior arm had three small scabs. Resident #2 reported she told the staff to go slow and easy with her when they were changing and moving her because she had parts of her body that really hurt. In an interview 05/28/25 at 02:09 PM, the Director of Nursing (DON) reported skin assessments completed by the nurses. Weekly skin assessments were documented on the Medication Administration Record (MAR). The nurse documented the skin assessment on a Skin and Wound Assessment whenever a skin issue is found. The DON reported she had worked as the DON for only 3 weeks, and during this time, she had identified skin assessments were not getting done. In an interview 05/28/25 at 04:00 PM, the DON reported Resident #2's family member voiced concern about bruises to the resident's arms on Thursday 5/22/25. The DON stated she spoke with Staff K, Licensed Practical Nurse (LPN), and requested him to do a skin assessment. The DON reported she did not find any skin assessment documentation on Resident #2. She spoke with Staff K and told him he needed to document in the electronic health record (EHR). The DON reported she thought the bruises had occurred when staff transferred her. The resident also took medication that increased the chance of bruising. In an interview 05/29/25 at 08:12 AM, Staff N, Certified Nursing Assistant (CNA), reported she would report to the nurse if a resident had a change in condition or a skin concern such as bruises. Staff N reported she had not noticed any bruises on Resident #2 recently. She normally checked and changed the resident as needed during the night. Staff N reported when Resident #2 said they were hurting her. Staff N stated she stopped what she was doing, let the resident know what she was doing and asked her to turn so they could change her. Staff N stated she let the nurse know the resident thought staff were hurting her. The nurse directed the staff to have two staff whenever they performed cares with Resident #2. This intervention started approximately two weeks ago. In an interview 05/29/25 at 08:40 AM, Staff M, LPN, reported a Stop and Watch done whenever a resident had a change in condition. She did an assessment, notified the physician, placed the resident on a 24-hour watch (hot chart), and monitored the skin issue weekly until the area had resolved. Staff M reported the nurse assessed any skin concerns, took pictures and measured the area. Staff M confirmed skin assessments documented under the assessment tab in the EHR. The skin assessments were completed by the day shift nurse. Staff M stated she followed the facility's skin protocol and entered a Progress Note, but did not fill out an incident report whenever a skin concern was found. Staff M stated she did not remember Resident #2 having any skin issues, and indicated nothing flagged or popped up on the computer about something that needed attention. The resident used a mechanical stand lift. Staff M reported she did not notice anything when she assisted Resident #2 out of bed the last time she worked with the resident. In an interview 05/29/25 at 08:58 AM, Staff L, CNA, stated she reported to the nurse if a resident had a change in condition or skin concern such as a bruise or a wound. The nurse checked the resident's skin normally when the resident was in the shower. Staff L stated she had not noticed any bruises on Resident #2, except for a bruise on her hip when she first admitted to the facility. In an interview 05/29/25 at 12:53 PM, Staff K, LPN, reported he mainly worked the evening shift. Staff K stated he reported a change in the resident's condition to the DON and also documented an assessment or Progress Note about a change in the resident's health status. Staff K reported if he noticed a bruise on the resident, he tried to determine how the resident got the bruise. Staff K confirmed he observed Resident #2's skin the prior week. He was unable to open the phone app and therefore did not obtain skin measurements or document the skin assessment at that time. Resident #2 got irritated waiting and said she was getting cold. At that time, Resident #2 had bruises on her arms and legs. He documented a Total Body Assessment in the computer. Resident #2 didn't tell him how she got the bruises. Staff K stated he reported the resident's bruises and the inability to take pictures of the areas to the overnight shift. In an interview 05/29/25 at 09:41 AM, the DON reported she expected skin assessments completed weekly and whenever a new skin concern identified. She also expected the nurse to document a skin assessment under the Assessments tab in the EHR and fill out an incident report. In an interview 05/29/25 at 10:38 AM, Staff J, Registered Nurse (RN), reported skin assessments documented in the EHR on the MAR weekly, and on the Skin and Wound Assessment whenever a resident had a wound or skin condition. In an interview 05/29/25 at 12:21 PM, the DON reported Staff K documented the skin assessment on Resident #2 under the Total Body Skin Assessment. Staff K told the DON Resident #2 bruises were not measured because the camera wasn't working. A Self-Identification and Correction Form dated 5/27/25 revealed the facility's nurse consultant and interim DON self-identified skin concerns not being updated weekly on 5/19/25. Head to toe assessments completed on all residents. The Facility's policy titled A Use of Stop and Watch Communication Form dated 7/19/18 revealed a Stop and Watch form filled out whenever a change in the resident's condition identified including any new skin issues. The charge nurse completed a thorough assessment and put an intervention in place to address the Stop and Watch form. The DON/ ADON (Assistant Director of Nursing) reviewed the Stop and Watch form for accurate assessment and intervention.

Based on observation, staff interview, and policy review, the facility failed to follow Enhanced Barrier Precautions (EBP) practices for a resident with an open pressure injury for 1 of 3 resident reviewed for pressure ulcer/injury (Residents #14). The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) for Resident #14, dated 3/21/25, indicated that Resident #14 had a Stage #3 pressure ulcer. The Care Plan revised on 3/24/25, revealed that Resident #14 had a pressure area to the right 4th finger. The Care Plan lacked staff directives for for EBP. During an observation 5/28/25 at 9:25 AM, Resident #14's room did not have signage outside or inside the door to indicate that EBP was in use. During an observation 5/28/25 at 9:30 AM, Staff A, Licensed Practical Nurse (LPN), performed wound care for Resident #14. Staff A did not wear a gown during the entire wound care process. During an Interview 5/28/25 at 10:00 AM, Staff A stated that the facility followed EBP in the facility. She indicated that EBP is utilized for residents with catheters and Multidrug-resistant Organisms (MDROs) She then stated that if EBP was for wounds, she was not aware. During an Interview on 5/29/25 at 11:29 AM, Staff J Registered Nurse (RN) stated wound assessments and pictures are on the phone and in PCC. States Resident #14 has a Stage 3 pressure to right 4th digit. Staff J stated they use EBP at this facility and that catheters, wounds, and MDROs are included. Gown and gloves are utilized for cares. Staff J stated that skin tears and bruises are not included in EBP. Staff J stated that DON decides who will be in EBP. When questioned if Resident #14 should be in EBP, Staff J stated, He probably should be. During an interview on 05/29/25 at 12:05 PM The Director of Nursing (DON) stated that she made the decision about who is placed in EBP. The DON stated that indwelling devices, chronic wounds that can't be covered, and MDROs are placed in EBP. Questioned why Resident #14 was not in EBP based on our conversation and the current policy. The DON stated, That's a good question. I have no answer for that. Questioned if Resident #14 should be in EBP and the DON stated, He should be and I will get him into EBP right away. Review of document titled Infection Control Program does not mention EBP utilization. Facility's undated Enhanced Barrier Precautions policy revealed EBP should be used when a resident has a wound such as a pressure ulcer and during high contact care activities such as wound care. Gown and gloves worn during high-contact care activities. The Center for Disease Control and Prevention (CDC) directs nursing facility staff to implement EBP for residents with wounds and/or indwelling medical devices, regardless of MDRO status, during high contact resident care activities to include wound cares and device care or use (https://www.cdc.gov/long-term-care-facilities/hcp/ prevent).

Based on employee file review, staff interview, and policy review, the facility failed to ensure completion of dependent adult abuse training within six months of hire for 1 of 5 employee files reviewed. The facility reported a census of 53 residents. Findings include: Employee record review of Staff P, Certified Medication Aide, showed a hire date of 9/7/23. The file lacked documentation of Staff P completing dependent adult abuse training within six months of their hire date or annually. During an interview on 5/29/25 at 2:00 PM, the Director of Nursing (DON) confirmed the lack of dependent adult abuse training documentation for Staff P. The policy Abuse Prevention, Identification, Investigation, and Reporting Policy, revised 4/1/17, outlined the following: 1. Employees are required to complete two hours of training related to identification and reporting of dependent adult abuse within six months of initial employment 2. All nurses' aides will receive initial and annual resident abuse prevention training.

Based on direct observation, clinical record review, staff interview, and policy review, the facility failed to provide residents with prescribed therapeutic diets for 1 of 3 residents reviewed (Resident #30). The facility reported a census of 53 residents. Findings include: The significant change Minimum Data Set (MDS) for Resident #30, dated 02/14/2025, documented the following relevant diagnoses: gastroesophageal reflux disease (GERD), non-Alzheimer's dementia, seizure disorder, muscle weakness, and cognitive communication deficit. It documented the resident was rarely or never understood, and had severely impaired cognition skills. It further documented the resident was on a mechanically modified diet and required supervision and touch assistance while eating. The Care Plan for Resident #30, with a last revised date of 05/19/2025, noted the resident had a history of significant weight loss. It instructed staff to provide a therapeutic diet as ordered. It noted the resident's diet as being mechanically altered (mechanically soft diet), with soft or ground meat. A direct observation on 05/27/2025 at 12:26 PM, Staff C, dietary assistant, was observed bringing Resident #30 his lunch. He placed it in front of the resident, and Staff I, Certified Nurse Aide (CNA), began feeding Resident #30. While feeding the resident, it was observed Staff I looked confused before she began to feed the resident a bite of the soup. When approached, it was noted there were large chunks of what appeared to be beef and vegetables in the stew. Staff I was asked to take a piece of the meat out of the soup bowl and attempt to cut and mash it, to see if it was appropriate for a mechanically altered diet that requires soft and ground meats. Staff I attempted to cut the meat, and it did not cut easily. She attempted to crush the chunk of meat with the back of a spoon, and the meat resisted compression and slid out from under the spoon intact. A call was placed to the dietary manager. In an interview on 05/27/2025 at 12:33 PM the dietary manager confirmed the bowl of soup Resident #30 had been served was not approved for his diet. She confirmed it was regular diet, and provided the resident with the mechanically altered diet alternative. In an interview on 05/29/2025 at 09:03 AM with Staff I, CNA, she stated it is the kitchen's responsibility to plate the food, they include the appropriate diet and the CNAs pick up and serve the food to the residents. She stated the diet card for Resident #30 reflected he was to receive a mechanically altered diet, and that she was going to serve the soup to the resident. When asked why she looked confused she stated it was because she knows soup can be served to residents on mechanically altered diets, but the meat chunks looked far bigger than mechanically altered soups usually had. She confirmed the meat she cut for the resident was tough, not at all soft enough. In an interview on 05/29/2025 at 09:12 AM with Staff H, Certified Medication Aide (CMA), she stated the kitchen is responsible for plating the food and the CNAs are responsible for serving it to residents. She stated if a CNA notices the wrong diet has been served they are to report the issue to the kitchen and not serve the resident the incorrect meal. In an interview on 05/29/2025 at 11:04 AM with the Director of Nursing (DON), she stated CNAs are responsible for serving food to residents, dietary staff are responsible for plating food and matching it to the dietary card. Her expectation is that if a therapeutic diet is prescribed to a resident they received the correct therapeutic diet. In an interview on 05/29/2025 at 11:19 AM with the Registered Dietician, she stated Resident #30 had been on a mechanically altered diet for a significant period of time. She stated the resident does not have a diagnosis of dysphagia, but had been moved to a mechanically soft diet by hospice to promote intake and prevent weight loss. In an interview on 05/29/2025 at 11:32 with the Dietary Manager, she stated Resident #30 had been under the care of a different hospice provider at one point in time, and that the previous hospice provider had ordered a mechanically soft diet with pleasure feedings of normal textured foods. The resident had since switched hospice providers and the current order only recommended mechanically altered diet with ground meats. She stated she believed this is where the confusion had occurred. Review of a facility provided document titled Addendum to Simplified Diet Manual: Texture Altered Diets, with an effective date of 06/01/2024, stated the following: The Facility will offer the following diets for consistency alteration. The mechanical soft diet is designed to permit easy chewing. The general diet is modified in consistency and texture by cooking, grinding, chopping, mincing, or mashing. The diet includes foods soft in texture such as cooked fruit and vegetables, moist ground meats and soft bread and cereal products.

Based on direct observation, staff interview, and clinical record review, the facility failed to protect residents from potential accidents and hazards for 1 of 16 residents reviewed (Resident #46). The facility reported a census of 53 residents. Findings include: The quarterly Minimum Data Set (MDS) for Resident #46, dated 04/29/2025, documented the following relevant diagnoses: Alzheimer's disease and muscle weakness. It did not document the resident using a wheelchair. The Care Plan for Resident #46, last revised on 05/23/2025, documented the resident uses a wheelchair as his primary means of locomotion. It documented the resident is dependent on staff for locomotion with his wheelchair. A direct observation on 05/27/2025 at 11:03 AM revealed Staff E, Certified Nurse Aide (CNA), pushing Resident #46 in a wheelchair with his feet dragging on the floor in socks. The resident was pushed like this from the unit living room to the dining room. The resident was observed to kick his feet erratically, alternating from dragging under his wheel chair to kicking out in front of and to the side of his wheel chair. A direct observation on 05/27/2025 at 11:57 AM revealed a second improper transfer by Staff E, CNA. During the transfer, Staff E placed one of Resident #46's feet into a wheelchair foot pedal, but did not place the second foot in the pedal before pushing him from his place at the dining room table to another table. During the observation, Resident #46's foot was again visualized to be dragging under the wheel chair. A direct observation on 05/27/2025 at 12:15 PM showed Staff E, CNA, again moving Resident #46 in his wheel chair. This time with one foot still on the foot pedal and the other dragging under the wheel chair. During the observation, the resident's foot was nearly run over by the wheel chair wheels as it dragged. In an interview on 05/29/2025 at 09:03 AM with Staff I, CNA, she stated the proper procedure for pushing a resident in a wheel chair is to first ensure their feet are elevated on foot pedals. She stated she had mentioned the improper transfers to Staff E late in the day on 05/27/2025. She stated residents can fall and hurt themselves if their feet are not up during wheel chair locomotion. In an interview on 05/29/2025 at 09:12 AM with Staff H, Certified medication aide (CMA), she stated all residents undergoing wheel chair locomotion are supposed to have their feet up and in the foot pedals at all times. She stated they cannot push a resident without foot pedals. She stated she has seen residents injured in this way in the past. In an interview on 05/29/2025 at 10:03 AM with Staff G, CNA, she stated a resident has to have their feet up on pedals when being pushed or pulled in a wheel chair. She stated that if their feet drag on the ground it could cause abrasions, and residents have fallen in the past. In an interview on 05/29/2025 at 11:04 AM with the Director of Nursing (DON), she stated the proper technique for assisting a resident with wheel chair locomotion requires a resident's feet to be up on the foot pedals of the chair. She stated her expectation is that staff monitor residents to ensure their feet are on the foot pedals and not dragging. During the survey, a facility policy regarding wheel chair locomotion was requested but not provided.

2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had diagnosis of hypertension (high blood pressure). The Order Summary Report dated 5/28/25 revealed Metoprolol Succinate Extended Release (ER) 25 milligrams (mg) by mouth (PO) daily for hypertension. During observation on 05/28/25 at 07:59 AM, Staff O, CMA, prepared the following medications for Resident #1: Acetaminophen 650 mg PO Aspirin 81 mg PO Fluconazole 100 mg PO Furosemide 20 mg PO Metoprolol ER 25 mg PO Vitamin C 1000 mg PO Staff O crushed the pills, mixed the contents in applesauce, and administered the crushed medications to Resident #1. In an interview 05/28/25 03:18 PM, the Pharmacist reported an ER tablet or capsule should not be crushed. The Pharmacist reported the resident could receive too much of the medication at one time if an ER medication got crushed. Based on clinical record review, observations, staff interview, pharmacy interview, manufacturer recommendations, and policy review the facility failed to ensure a medication error rate of less than 5%. During observations of medication administration, the facility had 2 errors out of 30 opportunities for error resulting in an error rate of 6.67 % (Residents #1 and #21). The facility identified a census of 53 residents. Findings include: 1. The Order Review History Report dated 5/1/25-5/28/25 indicates Resident #21 has an order for Potassium Chloride Extended Release (ER) oral tablet 20 Milliequivalents (MEQ) one time a day with a start date of 10/26/24. It further indicates that medications may be crushed unless contraindicated by pharmacy with a start date of 2/15/23. During observation on 05/28/25 07:36 AM Staff F, Certified Medication Aide (CMA) prepared and crushed Resident #21's Potassium Chloride 20 MEQ ER with the rest of her medications. Staff F mixed the crushed medications with grape jelly and was preparing to give them to Resident #21. At that time, the surveyor intervened and instructed Staff F not to give the medications as the Potassium Chloride can not be crushed. At 07:40 AM Staff F discarded the medications, and attempted to dissolve the Potassium Chloride in water but it would not dissolve. During an interview on 05/28/25 07:40 AM Staff F, CMA stated that Potassium Chloride cannot be crushed. Staff F stated the rest of the medications would be given separately and Staff A would be notified that Resident #21 needs an alternate form of Potassium Chloride. During an interview on 05/28/25 09:30 Staff A, Licensed Practical Nurse (LPN) stated she contacted the doctor about an alternate form of Potassium Chloride. During a phone interview with the pharmacy on 5/28/25 at 3:18 PM the pharmacist reported crushing extended release medication depended upon the medication. Metoprolol ER capsule can be opened, sprinkled and given with pudding but the capsule or tablet are not able to be crushed. Can open capsules but don't crush the contents inside. Resident could receive too much of the medication at one time if ER/ Delayed Release (DR) medication is crushed. Also, there could be a delay in receiving medication if delayed release medication is crushed. Potassium chloride ER tablet should not be crushed. Potassium could be dissolved in water but some potassium is micro dispersible and will not dissolve. Facility's Administration of Medications policy dated 3/1/21 documents that if the medications are ordered to be crushed due to difficulty swallowing, use the pill crusher. Crush the pill and then mix with water, pudding, applesauce or other depending on resident's preference. In addition, the facility policy lacked information regarding what medications could be crushed such as extended release.

Based on observations, clinical record review, staff interviews, facility staff correspondence and policy review, the facility failed to provide a thorough assessment and timely intervention for 1 of 4 residents reviewed. (Resident #1). On [DATE] Resident #1 was lowered to the floor. Staff E, Certified Nurse Assistant (CNA) notified Staff A, Licensed Practical Nurse (LPN) who failed to complete a thorough assessment. The Assistant Director of Nursing (ADON) was notified at 9:15 AM on [DATE] that Resident #1 was in pain, the ADON failed to do an assessment until 3:15 PM and the Director of Nursing (DON) obtained an order for pain medication yet failed to ensure that it was administered. An x-ray on [DATE] revealed a displaced hip fracture that required surgical intervention. The facility reported a census of 53 residents. Findings are as follows: The Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed a diagnosis of a compression fracture of the thoracic spine at level T11 and T12 vertebrae due to repeated falls and a history of transient ischemic attacks (small blood clots) with cerebral (brain) bleed. Resident #1 required moderate assistance with care, toileting and dressing, and moderate assistance with sit/stand and ambulation. Resident #1 was frequently incontinent of bowel and bladder. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 2 which suggested severe cognitive impairment. The MDS documented the resident had vocal complaints of pain observed for 1 to 2 days. The Care Plan dated [DATE] for Resident #1 informed staff that she was a wander risk and a fall risk with walking and during toileting. The Care Plan identified that Resident #1 was evaluated by physical therapy and occupational therapy. The Care Plan directed staff to anticipate and meet needs, assistance of 1 staff for toileting, report and document physical, nonverbal indicators of discomfort or distress, follow up as needed and to report a decline in cognitive status, mood, or decline in activities of daily living (ADL). Resident #1 used disposable briefs, check and change frequently when awake. The Physician Orders for Resident #1 revealed the following pain medication orders: 1. Acetaminophen 325 milligram (mg) 2 tablets three times a day, ordered [DATE]. 2. Acetaminophen 325 mg, 2 tablets as needed (PRN), ordered [DATE] for pain/fever. 3. Diclofenac Sodium 75 mg, 1 tablet every 12 hours PRN, ordered [DATE] for pain. The Medication Administration Record (MAR) dated February 2025 for Resident #1 revealed: 1. Acetaminophen 325 milligram (mg) 2 tablets three times a day administered on: a. [DATE] at 8AM, 2PM, and 10PM. b. [DATE] at 8AM, 2PM, and 10PM. c. [DATE] at 8AM, 2PM, and 10PM. 2. Acetaminophen 325mg PRN administered on [DATE] at 3:07 AM. 3. Diclofenac Sodium 75 mg administered on [DATE] at 3:01 AM. 4. Oxycodone 5mg give 1 tablet every 6 hours for pain, initiated on [DATE] and discontinued on [DATE], that was not administered. The MAR for February 2025 revealed no PRN pain medications were administered on [DATE] or [DATE]. The Progress Notes for Resident #1 revealed: -On [DATE] at 3:10 PM, Resident #1 was admitted for physical and occupational therapy (PT/OT) following a T12 fracture. She was alert, confused, was to wear the back brace at all times and was to be assisted by 1 staff with walker for ambulation. Resident did have complaints of pain, PRN Tylenol given. - On [DATE] at 1:36 PM, is on skilled level of care due to PT/OT related to fracture. Has no complaints or concerns. Is wearing back brace and states no pain. - On [DATE] at 9:23 PM Residents pain controlled with PRN pain meds. Resident eating supper at the neighborhood table this evening with no complaints. Brace in place. - On [DATE] at 10:55 AM, Staff B, Medical Doctor, examined Resident #1, conducted a medication review to include the discontinuation of Oxycodone due to hyper vivid dreams. The son was present. - On [DATE] at 1:40 PM Resident has pain and relief with PRN meds and repositioning. Back brace in place. - On [DATE] at 10:36 AM, Staff C, Registered Nurse (RN) documented a skilled assessment that included no impairment of Range of Motion (ROM) of lower extremity, and was able to reposition self. Verbal complaints of pain rated at 1. Non-medication interventions provided relief. - On [DATE] at 3:17 PM, the DON documented that resident was in bed this shift, refused to get up, bear weight, or allow for cares. The resident called out and expressed pain with turns, legs were equal in length and ROM within normal limits (WNL). The resident called out in pain when attempted to sit resident up, and was unable to localize the pain. The DON notified Staff B, MD and will monitor through the evening then reevaluate in the morning. - On [DATE] at 3:45 PM, a late entry by the DON, Staff B, MD ordered Oxycodone every 6 hours prn pain, the point click care (PCC) was updated and the son notified. - On [DATE] at 2:23 PM, Staff D, LPN documented the resident was noted with increased pain to the left hip and no weight bearing. Notified the physician and received an order for an x-ray. - On [DATE] at 4:43 PM, the DON documented the x-ray result revealed a fracture of the left hip, discussed with the physician and was ok for a transfer to the Emergency Department or remain at the facility with hospice care as per family choice. The son was notified. - On [DATE] at 7:17 PM, the DON documented received call from 2nd son and after an update was given, chose to have resident transferred to a tertiary hospital. - On [DATE] at 12:47 PM, Resident #1's son called and stated the surgery took a little longer, more issues then they saw and resident will return to the facility. The Progress Notes lacked any documentation of any incidents or assessments related to any incidents that occurred on [DATE]. During an observation on [DATE] at 12:29 PM, Resident #1 was located in her room, in a bed that was low in the lower position, wearing a back brace and a foam wedge between her legs. Resident #1 was alert, confused and requested to have water. An untouched lunch tray was on her night stand. During an interview on [DATE] at 1:41 PM, Staff M, CNA revealed that she worked on [DATE] 6AM-2PM with the resident. She stated when she got report the aide did not say anything about Resident #1. Staff M stated she had to call the nurse because even when you touched the resident she screamed in pain. She stated she stayed in bed that day and refused food. She stated the nurse assessed her and gave her pain meds but she does not remember the nurses name. She stated when the pain meds wore off she started screaming again. She stated the resident usually walked around but that day she did not get up. During an interview on [DATE] at 10:12 AM, Staff H, Physical Therapy Assistant (PTA) stated Resident #1 was very alert, energetic, engaging and followed directions. Staff H stated the last encounter on [DATE], Resident #1 ambulated by hand hold assistance, due to unsteadiness and used a wheeled walker. During an interview on [DATE] at 10:34 AM, Staff I, Director of Rehabilitation stated during an encounter on [DATE] had found Resident #1 wandering around and required redirection to sit as she had complained of back pain. Staff I stated the next encounter on [DATE], Resident #1 was unable to sit on the side of the bed. Staff I stated Staff J, Speech Therapist (ST), attempted to assist but Resident #1 was yelling out in pain and rubbing both hips. Staff I stated Resident was soaked in urine and notified the CNA's and advised that they change her in the bed. Staff I stated they notified the ADON of Resident #1's change of condition and complaint of pain. During an interview on [DATE] at 10:52 AM, Staff J, ST stated she had a session in the gym on [DATE] with Resident #1, worked on sit to stand and reaching back to the chair. Staff J stated Resident #1 was independent 100 percent by the end of the session. Staff J stated on the morning of [DATE], she had assisted Staff I with Resident #1 who was very agitated, very distressed and cried when they attempted to sit her up onto the side of the bed. Staff J stated she consulted with the ADON to express her concerns and suspected pain. Staff J stated Resident #1 had medication changes and would be monitored. Staff J stated in the afternoon, attempts were made to work with Resident #1 but was unable to continue due to the extreme level of pain. During an interview on [DATE] at 11:57 AM, Staff F, CNA revealed that she had worked on [DATE] 6AM-10 PM and provided care for Resident #1. Staff F stated Resident #1 was running around and tried to put herself on the floor from a standing position and was going to fall. Staff F stated Staff G, CNA assisted her and they placed Resident #1 on the floor. Staff F stated she notified Staff A, LPN who failed to provide an assessment for Resident #1. Staff F stated at 9:15 PM, Staff G assisted to get Resident #1 off the floor, to the bathroom and to bed. Staff F stated Resident #1 always complained about pain. Staff F stated when she had returned to work on [DATE] at 2 PM, Resident #1 was in bed, therapy had recommended her to stay in bed, the DON conducted an assessment and ordered an x-ray. Staff F stated that Resident #1 was yelling out in pain and she was very wet with urine and did not want the day shift staff to touch her. Staff F stated Resident #1 had to be changed regardless and cried when she was turned during care. During an interview on [DATE] at 12:18 PM, Staff A, LPN stated she was the nurse on [DATE] evening shift and had been notified by Staff F, CNA that Resident #1 was sitting on the floor but did not follow through with an assessment or complete an incident report as she thought this was behavior that she had been doing on other shifts. Staff A stated she did not check the Care Plan to see if Resident #1 was allowed to be on the floor. Staff A stated she did not administer pain medication to Resident #1. During an interview on [DATE] at 12:48 PM, Staff K, LPN stated she had worked the over night shift on [DATE] to [DATE] and was not notified Resident #1 was on the floor during the previous shift and was not informed that Resident #1 had pain during the night shift. Staff K stated Resident #1 wandered but did not ever sit on the floor. Staff K stated the staffing on the night shift consisted of one CNA in each of the 4 neighborhoods and one nurse. Staff K stated the CNA would inform her if a resident experienced pain. During a follow up interview on [DATE] at 2:46 PM, Staff A, LPN stated if a resident received routine Tylenol and had increased pain, the expectation was to assess the pain and notify the physician. Staff A stated she remembered asking Resident #1 if she wanted to stay on the floor, she said yeah, but did not ask why she was on the floor. Staff A stated the CNA's did not inform her the resident was having pain when they got her off the floor. Staff A stated, I think there was a miscommunication. During an interview on [DATE] at 3:12 PM, the ADON stated if a resident was assisted to the floor it was to be considered as a fall and the expectation was that the staff would inform the nurse who would complete an assessment, including an assessment signs and symptoms of pain. The ADON stated she was unaware that Resident #1 was on the floor on [DATE] until she read an email from Staff L, Activities on [DATE] at 12:25 PM. Resident #1 was on the floor in the main living area on [DATE] at 3 PM, was unsure if the resident was care planned to be on the floor. Staff F, CNA was in a recliner with her feet up facing Resident #1 and Staff L did not inform the nurse at that time. The ADON stated she was informed by the Director of Therapy and Staff J, ST on the morning of [DATE] that Resident #1 was in pain when they attempted to get her out of bed. The ADON stated she went to Resident #1's room [ROOM NUMBER] hours later to assess her and found her to be in pain and was unable to lift her legs due to pain. The ADON stated the DON arrived and conducted an assessment. The ADON stated she asked the DON if they should get an x-ray and the DON told her no since she was unable to locate an origin of the pain. The ADON stated she was called away for a phone call and the next day, [DATE] after 8 AM, Staff D, LPN reported that Resident #1 continued to have pain and was unable to get out of bed. The ADON stated she had told Staff D to call the doctor and get an order for an x-ray. An email dated sent on [DATE] at 12:25 PM from Staff L sent to Department Heads documented the following: Hello, sorry that I am just getting this email sent now and looking back I should have alerted the nurse on this side rather than assuming the resident in question is care planned to be allowed to sit on the floor. I am concerned that something occurred yesterday afternoon during the 3PM hour. Several residents were in the common areas but the newest resident, Resident #1, was sitting on her behind on the floor in the middle of the sitting area just in front of the TV. I didn't see her walker or a chair near her. Staff F was sitting in a recliner with her feet up facing Resident #1. While I was in there, about half an hour, another aide (I don't remember who) joined the group in the main sitting area. Resident #1 did scoot around a bit on her bottom. I regret that I didn't inform the floor nurse yesterday. During an interview on [DATE] at 4:14 PM, Staff G, CNA stated she had worked on [DATE] at 2 PM till 6 AM. Staff G stated Resident #1 was running and was going to fall, then tried to get down to the floor. Staff G stated Staff F, CNA notified the nurse who did not do anything. Staff G stated she had assisted to get Resident #1 off the floor and she was screaming, but she always screamed. Staff G stated she had checked on Resident #1 during the night, Resident #1 did not get out of bed that night and was screaming a lot. During an interview on [DATE] at 4:45 PM, the DON stated she had received an e-mail from Staff L, Activities on [DATE] that Resident #1 was sitting on the floor and didn't know if she was care planned to be on the floor. The DON stated she had called Staff F, CNA whom stated Resident #1 was getting up without a walker, was fearful she would fall, and resident requested to be on the floor. The DON stated Staff A, LPN reported she did not know that Resident #1 was on the floor. The DON stated that Resident #1 complained of pain since admit and her son stated it was attention seeking behavior. The DON stated she assessed her at 3:15 PM, found Resident #1 to be in pain but was unable to replicate the pain. The DON stated she had called the physician who asked if she fell and was told no but she was on the floor. The DON stated the physician had ordered Oxycodone for pain and deferred if they transfer to the hospital to the family. The DON stated she did not give the Oxycodone but did call the son who wanted to confer with his brother. The DON stated the next day, on [DATE], Staff D, LPN had received an order for an x-ray and the 2nd shift nurse informed her that Resident #1 had a fractured hip. The DON stated the family was then informed and requested transfer to the hospital. During an interview on [DATE] at 1:47 PM, Staff B, Medical Doctor stated when he was informed on [DATE] that Resident #1 was on the floor the evening before, that she should be evaluated in the emergency department since it was too late for a mobile x-ray but felt the family delayed in decision. Staff B stated he ordered Oxycodone to be given and it was his expectation that it be given for pain. Staff B stated Resident #1 had osteoporosis and could have had a spontaneous fracture. Staff B stated on [DATE] the x-ray revealed a hip fracture and family agreed to a surgical intervention. Staff B stated that Resident #1 made it through surgery but she didn't bounce back and the result was death on [DATE] at 10:10 AM. A facility policy revised [DATE] and titled Fall Assessment revealed: Procedure: 1. Residents will be assessed for fall risk on admission and residents identified as a high risk for falls will have fall interventions implemented. 2. When a resident falls the Charge Nurse will complete the Fall Scene Investigation and create a Progress Note describing the event. Protocol: 1. When a resident is observed or discovered to have fallen, the staff present will immediately radio the charge nurse. 2. The charge nurse will assess the resident for injury. 3. If there is suspected major injury, the charge nurse will notify the physician and the power of attorney (POA) immediately. 4. Vital signs are taken every 8 hours for 72 hours with follow-up documentation charted on status of resident or as ordered by the physician.

Based on observation, clinical record review, staff interviews and policy review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 2 of 2 residents (Resident #26 and Resident #37) reviewed for nutrition. This failure resulted in harm due to Resident #26 experiencing a weight loss of over 17% in 6 months and Resident #37 experiencing a weight loss of over 10% in 6 months. The facility reported a census of 53 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 identified the presence of short and long-term memory impairment. The MDS revealed the resident required supervision with setup help from staff to eat. The MDS documented diagnoses that included: Non-Alzheimer's dementia, anxiety, depression and post-traumatic stress disorder. The MDS documented a height of 66 inches and weight of 129 pounds (lbs.). The MDS identified a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The Care Plan for Resident #26, revised 3/2/23, identified the resident at risk for altered nutrition. The Care Plan informed staff the resident had experienced significant weight loss at one, three, and six months. The Care Plan interventions documented by the Registered Dietitian directed the staff to provide and serve diet as ordered; utilize the nutritional intervention program ([NAME] started 11/5/21, revised 2/3/22), and that supplementation of 60 milliliters of house supplement twice a day between meals was recommended on 2/2/23 due to continued weight loss (2/2/23). The weights for Resident #26 were documented as follows: 1. 1/3/23 - 133.0 pounds 2. 1/29/23 - 128.2 pounds 3. 2/3/23 - 133.0 pounds 4. 2/16/23 - 127.0 pounds 5. 2/26/23 - 125.0 pounds 6. 3/1/23 - 122.2 pounds A Weight Change note authored by the Registered Dietitian (RD) dated 1/19/23 at 12:10 pm revealed Resident #26 had experienced a significant weight loss of 10.6% for 3 months and 9.3% for 6 months. Resident #26 received a [NAME]. The RD recommended adding to the weekly weight monitoring and for nursing to notify the provider of the loss. A Dietary Note authored by the RD dated 2/2/23 at 11:00 am revealed Resident #26 had experienced weight loss of 2.9% in 1 month, 10.5% in 3 months, and 13.1% in 6 months. The Registered Dietitian described Resident #26 as appearing thin and cachectic (loss of body weight and muscle mass) at the time of the note. The note continued to direct the [NAME] and weekly weight monitoring. The note further revealed the RD requested the nursing staff to notify the physician and the resident representative of the significant weight loss and to consider providing 60 milliliters of house supplement twice daily between meals to help reduce further weight loss. A Dietary Note authored by the Director of Nursing (DON) dated 2/2/23 at 3:19 pm revealed the DON notified the physician of Resident #26's weight loss. The note failed to lack documentation of the recommendation by the RD of the house supplement. A Dietary Note authored by the Director of Nursing (DON) dated 2/2/23 at 3:22 pm revealed the DON emailed Resident #26's sister/Power of Attorney requesting input regarding her favorite foods and handheld items that she could eat as she wanders. The note failed to include documentation of the Dietitian's recommendation of a house supplement. A Weight Change note authored by the RD dated 3/2/23 at 12:50 pm revealed Resident #26 continued to experience a significant weight loss. The note revealed a loss of 5.4% in one month, 11.6% in 3 months and 17.2% in 6 months. The note continued to inform that the RD recommended 60 milliliters of house supplement on 2/2/23 due to the noted weight loss at that time. The RD re-recommended this intervention. The RD requested the nursing staff to notify the physician and Resident #26's Representative of the continued weight loss. Observation on 3/6/23 at 12:25 pm, Resident #26 was served lunch at table with the other residents. She repeatedly walked away from the table. Staff took her food and her water glass (only drink offered) to the day room and was able to redirect and offer cues for her to eat approximately 75% of her meal. No drink other than water was offered and no ice cream was offered. On 3/7/23 at 3:37 pm, the DON also stated the facility has weekly meetings with the RD on Thursdays. The RD emails a summary of the meetings and then the nursing staff follows up on the concerns. She stated that she usually does those follow ups. The DON stated the supplement twice daily was not initiated because the Registered Dietitian only stated to consider it and did not officially recommend it. She further stated Resident #26 has a yellow dietary card, which indicates the [NAME] which means the staff are to provide fortified milk at meals and other additional snacks. On 3/8/23 at 8:00 am witnessed Resident #26 walking the unit rapidly. The staff attempted to direct her to the table but the resident resisted. On 3/8/23 at 8:10 am Staff L, Certified Nurse Aide (CNA), stated the staff prepares the food for Resident #26. She stated the CNAs cut the food up and sometimes the resident will grab some as she comes by. At times the staff is able to get her to sit down. She stated the resident drinks a lot of water. On 3/8/23 8:25 am observed Resident #26 came to the serving window and took 1 bite of egg, then walked away. On 3/8/23 at 8:29 am watched the staff move a plate of food with toast, an omelet, and a glass of water to the day room. Resident #26 sat with a staff member encouraging her to eat breakfast. No super cereal or milk was near her. Resident #26 sat for less than two minutes and walked away. The dietary aide did provide the super cereal for Resident #26. However, the nursing staff only took her plate and a glass of water to the day room to assist with providing meal supervision and cues. On 3/8/23 at 9:06 am the RD reported the super cereal is made in the kitchen and is brought to the kitchenettes ready to be served. She also stated when a resident is initially admitted to the facility, the staff will ask family members for lists of foods the resident likes or dislikes. She said in her weekly reports to the facility, she includes residents who would benefit from adding the house supplement for extra calories. She reported this has been discussed for Resident #26 a few times with nursing staff but it has never been addressed with the physician or the resident's family to her knowledge. The RD expected the nursing staff to bring this to the physician and the Resident's Representative. She reported that she has requested these follow ups be documented in the resident's progress notes and to record the response. She also stated if a resident does not like the fortified milk, other drinks like Breeze or Resource (juice like drinks) are available to offer as a replacement for the fortified milk. The Progress Notes lacked additional documentation of Resident #26's weight loss from the note completed on 3/2/23 at 12:50 pm until 3/8/23 at 10:12 am. A Weight Change note dated 3/8/23 at 10:12 am authored by the DON indicated the physician knew of Resident #26's weight loss. The note lacked documentation of the RD's recommendation of a supplement from the physician. The note stated that Resident #26's POA got contacted regarding the supplement. Resident #26's POA chose to decline and continue to attempt snacks. On 3/8/23 at 3:58 pm, the Administrator stated that the DON is to notify the medical director of recommendations from the RD. She stated the Dietary Manager is a part of the skin and weight meetings and is also aware of any recommendations made by the RD. The document titled Nutritional Intervention Program, updated 1/5/21 directs 6 oz of super cereal (oatmeal with added ingredients such as heavy cream to add additional calories), equaling 409 calories and 8 oz of fortified milk, equaling 230 calories are to be provided at breakfast. It further states that 8 oz of fortified milk (230 calories) and 4 oz of ice cream, equaling 125 calories are to be provided at lunch and dinner. Residents on the [NAME] program will have a yellow dietary card. The document continued to direct that the resident would be evaluated weekly during the weight meetings by the team and further intervention/removal from watch implemented as determined by the team. Should supplementation become necessary, the following guidelines apply to 60 ml of house supplement twice a day (2 calories per ml) and can increase per resident's needs. The Supplement will continue to be documented in the Medication Administration Record (MAR) Supplementation, weight concerns, and other nutritional issues are compiled in a report by the Dietitian weekly and findings shared with families and the resident's physician as appropriate. Resident #26's March 2023 MAR, Treatment Administration Record (TAR), Order Summary Report of all active orders lacked documentation of the house supplement. 2. Resident #37's MDS assessment dated [DATE] identified the presence of short and long-term memory impairment. The MDS revealed Resident #37 required supervision with setup help from staff to eat. The MDS documented diagnoses that included: Non-Alzheimer's dementia, depression, and coronary artery disease. The MDS listed a height of 62 inches and weight of 117 pounds. The MDS identified a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The Care Plan of Resident #37 revised February 2023 identified a risk for altered nutrition. The Care Plan informed the staff that Resident #37 experienced a significant weight change for one month in September 2022, and significant weight loss at six months in October 2022, December 2022, and February 2023. The Care Plan directed the staff to provide and serve diet as ordered; utilize the nutritional intervention program (11/5/21), and to provide supplementation as ordered by the physician. The weights for Resident #37 were documented as follows: 1. 8/5/22 - 128.1 pounds 2. 9/7/22 - 121.4 pounds 3. 10/5/22 - 120.4 pounds 4. 11/8/22 - 115.8 pounds 5. 12/5/22 - 117.0 pounds 6. 1/5/23 - 116.5 pounds 7. 2/8/23 - 114.6 pounds A Nutritional Note authored by the RD on 9/21/22 at 10:10 am documented Resident #37 had a weight of 121.4 pounds, indicating a 5.2% loss in 1 month, a 6.9% loss in 3 months, and a 9.7% loss since admission to the facility. The RD indicated the Nutritional Intervention Program initiated at that time. A Weight Change note authored by the RD on 10/13/22 at 12:35 pm noted Resident #37 had a weight of 120.4 pounds, indicating a significant weight loss of 10.5% in 6 months. The RD recommended nursing notify the physician of the weight loss. The note did not include additional recommendations at that time. A Weight Change note authored by the RD on 11/10/22 at 10:35 am identified that Resident #37 experienced a significant weight loss of 9.6% over 3 months and 11.6% over 6 months with an overall weight down by 14% since her admission to the facility. The note indicated no further supplementation provided at the time though the note suggested the resident could benefit from the addition of a house supplement to help promote weight stabilization. She stated to consider providing 60 ml of house supplement twice daily if the resident would accept it. The note continued to direct the nursing staff to notify the physician and the Resident's Representative of the weight loss. A Nutrition Note authored by the RD on 12/22/22 at 1:15 pm revealed Resident #37 experienced a 10.3% weight loss over the last 6 months and 13% since admission to the facility. Continuous observation on 3/7/23 beginning at 12:13 pm revealed eight residents of the neighborhood sitting at the dining table waiting for lunch, all having drinks. The table did not include Resident #37. At 12:24 pm the dietary staff arrived with the steam table. At 12:31 pm, the dietary aide made a lunch plate for Resident #37. Staff A, CNA, told the dietary aide Resident #37 was asleep. The dietary aide wrapped the meal in saran wrap to keep it warm. At 12:39 pm, the dietary staff left desserts for the residents at the serving window and left the unit. At 12:42 pm, Resident #37 observed awake and sitting up on the side of her bed. No staff were seen entering her room. At 12:45 pm, the staff began offering the desserts to the other residents. Overheard Staff A saying that she placed Resident #37's meal in the refrigerator. At 1:25 pm, all residents except Resident #37 had completed lunch, the tables were wiped off and the floors were swept. No staff was observed entering the room of Resident #37 to offer her a meal. On 3/7/23 at 1:26 pm, Staff M, CNA, stated that Resident #37 normally eats breakfast but often does not eat lunch or dinner. She stated they save her food for her. She said that she does not receive any food or snacks different from the rest of the residents. On 3/7/23 at 1:28 pm, Staff A, CNA, stated Resident #37 had no special dietary needs. She stated she is independent and comes out of her room when she wants to. She explained that when she wants to eat, she will come ask for it. On 3/8/23 at 7:57 am, Staff A reported a yellow meal card means the resident gets fortified milk at meals. On 3/8/23 at 8:25 am, Staff O reported a yellow meal card means the resident either eats finger food or pureed food. On 3/8/23 at 8:26 am, Staff N, CNA, reported a yellow meal card means thickened fluids, puree diet, or a mechanical soft diet. On 3/8/23 at 8:30 am, Staff P, CNA, stated a yellow card means a resident is on a mechanical soft diet. On 3/8/23 during an observation beginning at 12:23 pm, all of the residents sat in the dining area. Resident #37 sat at a separate table away from the rest of the residents. She had water as her only fluid at the table. At 12:35 pm, an observation of the freezer determined multiple cups of ice cream were available to serve the residents on the [NAME] after meals as per the [NAME] guidelines. At 12:49 pm Resident #37 finished eating, got up, and left the dining area. No ice cream was offered to her. At 12:52 pm, the other residents received the planned dessert. The observation revealed that no residents got offered ice cream. At 12:59 pm staff assisted the residents away from the dining room, to use the toilet or to rest in the common area. No observations of staff offering or serving ice cream to any resident. On 3/8/23 at 1:20 pm, Staff B, LPN, reported that he knew of the yellow diet cards and white diet cards but he did not know why the facility had different colors. He stated it had something to do with their diet order. On 3/8/23 at 1:24 pm Staff Q, CNA, stated a yellow card means the resident needs their food cut up or that the resident is on a modified diet. On 3/8/23 at 3:58 pm, the Administrator stated the DON is in charge of the majority of the education for the floor staff regarding the [NAME] program and the management team notifies the staff of any changes to the program.

Based on clinical record review, observation, facility document review and staff and physician interviews, facility staff failed to ensure a resident received transfer assistance as directed by her care plan and facility directives for one of five residents reviewed (Resident #2). On 6/16/20, Staff A ambulated Resident #2 without the use of a gait belt, contact guard assistance or with a wheelchair following the resident which resulted in the resident falling and suffering injuries related to the fall. The facility identified a census of 42 current residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 had [DIAGNOSES REDACTED]. The assessment documented she required the assistance of one staff during transfers and while walking. Resident #2 showed unsteady balance while walking, could stabilize only with the assistance of staff and used a walker and a wheelchair as mobility devices. The MDS also documented she had a fracture related to a fall within the last 6 months, but no falls since the prior MDS assessment. Resident #2's Care Plan, updated on 4/15/20, instructed she required the assistance of one staff for transfers and ambulation, using a front-wheeled walker. The resident should have a wheelchair for transport for longer distances and staff must push it. On 4/15/20, staff added the intervention to follow Resident #2 with a wheelchair for all ambulation. On 6/16/20, staff updated the care plan to instruct 2 staff to assist the resident with a stand/pivot transfers and not walk the resident at this time per therapy. On 7/1/20, staff were directed to use a gait belt at all times and provide the assistance of one to stand/pivot transfers from the wheelchair, recliner, toilet and bed only. A Fall Scene Investigation form dated 6/16/20 at 8 am documented Resident #2 had an intercepted fall, she lost strength and appeared to get weak while walking. The investigation form documented staff lowered the resident to the floor and staff followed the care plan. The form documented she suffered no injuries. A Fall Summary dated 6/17/20 revealed Resident #2 careplanned to have a wheelchair follow with all ambulation. Staff A, CNA/CMA (certified nursing assistant/certified medication aide) ambulated the resident with no wheelchair follow and no gait belt. The resident's legs gave out and she fell face forward onto the floor. The resident voiced no initial complaints. However, later in the shift she had significant [MEDICAL CONDITION] and bruising to the left knee. An X-ray was done without fracture or injury noted. The CNA received a written immediate education regarding not following the care plans. The Assistant Director of Nursing (ADON) completed the Fall Summary and also obtained witness statements related to the fall. The witness statements obtained at the time revealed Staff A did not place a gait belt on Resident #2 during ambulation nor did she use a wheelchair to follow behind the resident. The Immediate Education and Correction Required form contained in the fall investigation documented Staff E, LPN (licensed practical nurse) educated Staff A the resident needed a wheelchair follow for all ambulation, Staff A did not follow the care plan and this resulted in the resident falling. The Fall Scene Investigation form documented the resident had no injuries following the fall. However, Resident #2's Skin Condition Forms documented the following injuries noted on 6/17/20: a. A dark purple bruise to her left thumb, measuring 2 x 2 centimeters (cm) documented as healed on 6/30/20. b. Two dark purple bruises to her left bicep, one measuring 6 x 8 cm and the second measuring 2 x 3 cm. Both bruises, documented as healed on 7/8/20. c. A light reddish purple bruise to the left shin, measuring 4 x 4 cm, documented as healed on 7/8/20. d. A dark purple bruise to her right elbow, measuring 6 x 3 cm, documented as healed on 7/8/20. Resident #2's Health Status Notes documented the following: a. 6/16/20 at 3:55 pm - She had no visible signs of discomfort at the time. Her left knee to upper thigh showed swelling and discoloration. She could move the knee and staff applied ice. b. 6/16/20 at 4:32 p.m. - Staff spoke with the resident's physician who ordered a 3-view X-Ray to her left knee. c. 6/17/20 at 6:16 am - Resident #2 had increased swelling to her left knee and it remained bruised from the fall. d. 6/18/20 at 6:13 - The resident's left knee remained swollen and bruised and painful to touch per the resident. e. 6/18/20 at 9:41 pm - Her left knee/thigh remained at various stages of healing. The knee remained slightly swollen. f. 6/22/20 at 8:05 am - Resident #2's left knee had a water filled blister measuring 3 x 3 cm. The knee was swollen, red and painful to touch. Staff contacted her physician who ordered a second portable X-ray. A Skin Condition Report dated 6/30/20 documented the resident's left knee now had a dark hard scab measuring 5 x 4 cm. On 7/6/20, staff documented the presence of 3 eschar/dry scab open areas measuring 4 x 5.5 cm, 1.5 x 2 cm and 2.5 x 3 cm. On 7/13/20, staff documented the areas measured 3.5 x 5.5 cm, 1 x 2 cm and 1.5 x 2.5 cm with a dark brown wound bed and no redness. X-ray reports dated 6/16/20 and 6/22/20 documented no evidence of fracture. Review of Resident #2's Medication Administration form for 6/20 documented she received as needed [MEDICATION NAME] medications on 6/20/20 (Tylenol and [MEDICATION NAME]) and 6/30/20 (Tylenol). The resident received routine administration of Tylenol, a [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME] for chronic pain per physician's orders [REDACTED]. Review of the Service Report dated 7/13/20 by the resident's physician documented seeing her for a wound to her left knee, which had a prior total left knee replacement. The resident had a history of [REDACTED]. She likely had [MEDICAL CONDITION] disease on top of the trauma, which caused a significant eschar. The physician documented resolving ecchymoses (bruising) below the left knee. The wound is now significantly smaller with healing in the central aspect, dry eschar that is unstageable and with the edges dramatically improved in terms of turgor and skin growth. Assessment revealed left knee presumptive [MEDICAL CONDITION] and family requests to go to a wound center. Interview with the physician on 7/22/20 at 10:25 am revealed he did not know if the open area to the resident's left knee would have occurred without the trauma. She had a left knee replacement and COVID-19 three - four months prior. It was likely the knee would have had less swelling without the coagulopathy from COVID-19. The resident had a remarkable amount of swelling. The physician did not think the wound was a deep tissue injury. A wound consult report dated 7/14/20 documented the resident was seen for a wound on the left knee which had been present since a fall 6/16/20. She had Covid 5/9/20. The wound originally started as a blister and stayed about the same. treatment for [REDACTED]. She had a X-ray, but notes from nursing home indicate it was negative for fracture and she saw the PCP the next day. Wound care included application of [MEDICATION NAME] paint. The clinician did not recommend debridement at the time. On 7/22/20 at 10:25 a.m. the resident's physician stated he did not agree with the 7/14/20 [MEDICATION NAME] order. Review of physician orders [REDACTED]. Review of the July 2020 treatment administration record revealed the facility implemented the orders as the physician directed. Observation on 7/14/20 at 9:55 at the facility revealed Resident #2 sat in the recliner in her room with wound care beginning by a CMA. The resident's left knee showed 3 areas of black eschar measuring approximately 4 x 2 cm. The entire knee appeared swollen and greenish in color. On 7/14/20 at 9:35 am, Staff B, Cook stated on 6/16/20 during breakfast, she saw the resident on the floor after she fell . Staff B stated the resident was not wearing a gait belt when she saw her laying on the floor. Staff A then ran and got a gait belt and placed it on the resident while she lay on the floor. Staff B then saw and heard Staff A call the nurse for help on the walkie-talkie and Staff B returned to her duties. During an interview at the facility on 7/14/20 at 11:15 a.m., Staff C, CNA stated on 6/16/20 she worked in the kitchen during the resident's fall and it was the first time she'd worked on Resident #2's neighborhood. Staff C stated Staff A insisted on getting the resident up. She saw Staff A walk the resident out of her room without use of a gait belt and without a wheelchair following behind the resident. Resident #2 fell while Staff A walked beside her; she did not see Staff A touching the resident while the resident ambulated. The resident went face down, hit her face and glasses but did not have injury to her face. The resident complained of pain to her left knee later and the knee appeared swollen and bruised up; Staff A told Staff C later in the shift that the resident might have hit her knee, but Staff C did not see that. During the interview, Staff C wore a gait belt draped over her shoulder; she stated she uses a gait belt whenever she walked with any resident. Staff C concluded that she didn't know Resident #2 could walk as she sat in the wheelchair the times she had seen her. During a re-enactment of the fall with Staff C on 7/16/20 at 10:30 am, she stated and demonstrated she saw the fall from the kitchen window. Staff C saw Staff A walk to the right of the resident, without touching her, without use of a gait belt and without a wheelchair following behind. The resident pushed a walker; her legs gave out, she fell straight down and did not hit the walker. Staff C repeated she saw Staff A put a gait belt on the resident before the nurse arrived. Staff C concluded that she normally worked on the Evergreen neighborhood and she's been trained to always use a gait belt while walking with a resident During a phone interview on 7/14/20 at 5:50 pm, Staff D, CNA stated she made breakfast in the kitchen on 6/16/20 when she saw Staff A walk Resident #2 out of her room. Staff D stated she knew the resident should walk with a gait belt and with a wheelchair following. Staff A did not use a gait belt or a following wheelchair while walking with the resident. Staff D stated she did not see the fall because it happened so fast; the resident was just on the floor. Staff D concluded that staff uses gait belts whenever staff walk residents. During a phone interview on 7/14/20 at 6:30 p.m., Staff E LPN stated on 6/16/20, she remembered Resident #2 assisted with a gait belt and lowered to the floor. However, her injuries were not consistent with being lowered to the floor. Then other witnesses came forward. They learned that Staff A did not lower the resident to the floor and she landed pretty hard on her left knee. Resident #2 did not have swelling or open areas to the left knee and no complaints of pain initially. The resident complained of left knee pain near the shift change from days to evenings; the evening shift nurse assessed the knee further and an X-Ray was done. Staff E stated the resident walked with physical therapy after the fall and her knee seemed to get worse as time went on. Staff A informed Staff E at the time of the fall the resident was really strong during care that morning, so Staff A decided to walk her. When Staff E saw the resident, she wore a gait belt, a walker nearby and no wheelchair. Residents, including Resident #2, should wear a gait belt with all transfers. The next day, Staff E stated she learned that others saw Staff A get a gait belt and put it on Resident #2 while she lay on the floor. Staff E stated she educated Staff A on following care plan direction for transfers after the fall on 6/16/20. During interviews at the facility with the Administrator and Director of Nursing on 7/15/20 beginning at 11:30 am, both stated they did not know of staff statements that Staff A put a gait belt on Resident #2 while the resident lay on the floor. The Administrator stated she talked with Staff A after the fall, who described how she held the resident (contrary to witness statements). The Administrator stated the facility did not have a policy on resident ambulation, but used a check list instead. It is the facility's policy for all resident to wear a gait belt during transfers and ambulation unless a resident walked independently or became agitated or refused gait belt placement. The facility's Competency: Ambulation skills checklist directed that placement of and contact with a gait belt is required during resident ambulation. The facility's Competency: Ambulation skills checklist directed that placement of and contact with a gait belt is required during resident ambulation. During a phone interview on 7/15/20 at 9:15 am, Staff A stated on 6/16/20, she walked Resident #2 to breakfast and she used a gait belt on the resident, and it seemed like her legs gave out. The resident did fine and then just got weak. Staff A stated Resident #2 usually required the assistance of one staff to transfer and walk. Staff A stated she used care plans and therapy recommendations to learn how to walk and transfer residents, she did not use a wheel chair to follow the resident on 6/16 and did not remember receiving any additional education on transfers and ambulation following the resident's fall. Staff A was then informed that other staff remembered the resident did not wear a gait belt when she fell and they saw Staff A place one while the resident lay on the floor. When asked why their recollections differed from hers, Staff A stated she did not know why. During an in-person interview on 7/21/20 at 3:05 pm, Staff A stated she walked right behind the resident, holding on the waist of her pants. She did not hold onto a gait belt and did not use a wheelchair to follow behind the resident. Staff A stated she did not know of the care-planned intervention to have a wheelchair behind the resident while she walked. Staff A stated the resident walked to the bathroom before that without problems and seemed strong. When asked if the resident wore a gait belt at the time, Staff A stated she did not work the floor often and usually worked as a CMA. She thought she placed a gait belt on the resident, but maybe she took it off once she seated the resident in the bathroom. Staff A stated she knew the resident did not walk much and needed a heavier gait belt to support her. It was possible Staff A forgot to put the gait belt back on. Staff A did not remember the last skills day she had and no longer worked at the facility. Review of Staff A's personnel file revealed a hire date of 4/3/13 and a position title of CNA/CMA. The file showed a Competency Form for Ambulation dated 2/12/20, in which she successfully demonstrated step #4 (placing a gait belt properly around a resident's waist) and step #9 (which included to never let go of the gait belt when walking the resident). Observation on 7/15/20 at 1 p.m. revealed Staff F, OT (Occupational Therapist) in Resident #2's room. Staff F placed a gait belt and walked the resident using a walker 4 steps from a straight chair to a recliner. Staff F stated Resident #2 could only ambulate with OT and Physical Therapy oversight. CNA's could pivot transfer the resident only.

Based on facility records, policy, Paramedic and Staff interviews, the facility failed to initiate CPR (Cardiopulmonary Resuscitation) to 1 out of 3 Residents (Resident #1) reviewed at the time they witnessed her death. The facility reported a current census of 46 residents. Findings included: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had [DIAGNOSES REDACTED]. The MDS also noted Resident #1's Brief Interview for Mental Status (BIMS) score as 3 out of 15 (severely impaired cognition) with inattention and disorganized thoughts. The MDS indicated that people usually understood Resident #1 and she usually understood them. According to the MDS, Resident #1 needed limited to extensive assistance of one or two staff members for activities of daily living (ADLs). The [DATE] Care Plan noted Resident #1's code status (whether or not to be resuscitated at the time of death) as being a full code (elected to receive CPR). Policy: An untitled undated policy document titled with facility name revealed the following: Determine the circumstances when Cardio-pulmonary resuscitation must be initiated, pursuant to Federal law requirement to carry out a Resident's advanced directives. Procedure: Upon determination that a Resident is in cardiopulmonary or respiratory arrest, CPR will be immediately initiated by the Charge Nurse and 911 will be called for advanced cardiac life support unless one of the exceptions applies: When the Resident or responsible party has indicated that resuscitation is not desired and the attending Physician has issued a written do not resuscitate (DNR) order that is maintained in the facility's clinical record; or When there is the presence of obvious signs of irreversible death defined as rigor mortis (stiffening of the body a few hours after death) or dependent lividity (blood settling after a significant amount of time without circulation); or When a Physician states do not do CPR. 3. If CPR is required, it will be immediately initiated by the Charge Nurse 4. If CPR is initiated, it will be continued until a Physician directs staff to stop or paramedics arrive and take over the CPR 6. If a Nurse's assessment concludes that the Resident exhibits signs of irreversible death leading to nursing judgement not to initiate CPR, complete documentation of the Nursing assessment shall be documented in the clinical record. Record Review: A document titled Iowa Physician order [REDACTED].#1 should receive CPR at the point she no longer had a pulse and respirations. The IPOST was signed by her Spouse/Durable Power of Attorney for Health Care to indicate Resident #1's known preference. A Health Status Note dated [DATE] at 12:03 p.m. noted that Resident #1 refused to get out of bed that morning, had difficulty breathing, coarse lung sounds throughout and refused to cough. The nurse also noted that Resident #1 had a temperature of 100.8 F. The physician ordered a portable chest x-ray and lab work. A Medication Administration Note dated [DATE] at 3:10 p.m. noted Resident #1 cried and showed signs of discomfort. Staff administered Tylenol ([MEDICATION NAME]) to the resident at her husband's request. A Health Status Note dated [DATE] at 5:12 p.m. noted the physician ordered an antibiotic twice a day for 10 days for an upper respiratory infection. A Health Status Note dated [DATE] at 6:21 p.m. noted that Resident #1 with a slight fever. A Health Status Note dated [DATE] at 7:25 p.m. and documented by Staff C RN (registered nurse) noted that Staff D CNA (certified nurse aide) and Staff [NAME] CMA (certified medication aide) summoned Staff C to Resident #1's room at about 7:10 p.m. Staff C documented that Resident #1's color changed and identified the resident with difficulty breathing. Staff C ordered Staff [NAME] CMA to check vital signs immediately and raise the head of the resident's bed. Staff C noted that she went to get an O2 concentrator and stopped at the Nurse's station to check the resident's code status; which was specified as a full code. Staff C noted that she then called the physician to obtain an order to send Resident #1 to the hospital. Staff C called 911 for transportation due to the resident's full code status. Staff C also noted that she used the mobile phone to dial Resident #1's husband before quickly returning to the resident's room. According to Staff C's documentation in the health status note, EMS arrived and followed about 20 feet behind her to the resident's room. As Staff C entered the room she noted Resident #1's skin color notably changed to paler, jaw dropped without respirations. Staff C noted that she did not hear any breath or heart sounds after she listened for several seconds. EMS (emergency medical services) entered the room and also did not detect any heart sounds after they listened. Staff C pronounced Resident #1 dead at 7:18 p.m. According to Staff C, EMS stated that the medical examiner did not need to be called once Staff C told them the facility was a skilled and intermediate care facility. EMS report and interviews: The EMS Incident Detail Report dated [DATE] noted that Staff C, RN, called at 7:12 p.m. for emergency assistance of a full code resident with breathing problems. They arrived at 7:18 p.m. and completed their objective at 7:22 p.m. The EMS Patient Care Report dated [DATE] noted EMS arrived at the facility at 7:18 p.m. after being summoned for Advanced Life Support related to breathing problems. According to the document, Resident #1 was deceased and they made no effort to resuscitate her. The EMS Narrative noted that EMS responded in emergent mode immediately after being dispatched to the facility for a report of difficulty breathing. According to the Paramedic, facility staff informed them upon arrival that Resident #1 just passed. The Paramedic noted that she confirmed that Resident #1 had DNR orders. She also confirmed that Resident #1 did not have a pulse or respirations. The facility Nurse pronounced Resident #1 dead at 7:18 p.m. An interview on [DATE] at 2:18 p.m. with Paramedic 2 revealed that they were dispatched because of a resident having breathing problems. According to Paramedic 2, the Facility Nurse met them outside Resident #1's room when they arrived and said the Resident just passed. Paramedic 2 said she entered the room and observed while Paramedic 1 checked the Resident and determined she did not have a pulse or respirations. Paramedic 2 stated the facility nurse told them Resident #1 did not need resuscitation. According to the Paramedic, they would have initiated resuscitation efforts; a heart monitor, rescue breathing and CPR if the resident was a full code. The Paramedic said they would have also requested extra crew members for help too. She said their protocol dictates that CPR should be continued on site for a minimum of 10 minutes. An interview on [DATE] at 2:40 p.m. with Paramedic 1 revealed that the facility nurse met her outside of Resident #1's room when she first arrived and said the Resident just passed. Paramedic 1 said she entered the Resident's room and confirmed that she did not have a pulse or respirations. When asked, Paramedic 1 said she did not see the appropriate paperwork so she confirmed with the nurse that Resident #1 should not be resuscitated/DNR. According to the Paramedic, the nurse said Resident #1's spouse visited earlier in the day and he felt Resident #1 would probably die that night. When asked how they received information from their dispatcher, the Paramedic said they get it verbally over the radio and updates on the computer in the cab of their transport vehicle. The Paramedic remembered the dispatch report saying Resident #1 had shortness of breath and difficulty breathing. The surveyor asked the Paramedic to address the information on the report that said full code. According to Paramedic 1, nursing homes use terminology more loosely than they do, so they have to wait until they arrive to assess the situation for themselves. The Paramedic said she starts gathering more information by asking facility staff. She said typically they have the paper work there with them; but Staff C did not. The Paramedic said she did not ask to verify what the nurse told her by looking at the order; she took her word for it. According to the Paramedic, they would have started CPR, asked for additional assistance and for transportation to the hospital if she knew Resident #1 was a full code. The Facility Death Record identified Resident #1's immediate cause of death on [DATE] at 7:18 p.m. as from dementia and cardiopulmonary arrest. A document titled Investigation of Charge Nurse Staff C and Resident #1 on [DATE] revealed that the co-Director of Nursing (DON) received a call from Staff C at about 7:30 p.m. stating Resident #1 passed away. Staff C RN informed the co-DON that a CNA called her to Resident #1's room. Staff C noticed Resident #1's labored breathing when she arrived. The co-DON documented that Staff C told her she left the room to get oxygen (O2) and had Staff [NAME] CMA stay and get the resident's vital signs. Staff C told the co-DON that Resident #1 was not breathing when she returned to her room. The co-DON's documentation noted that Staff C told her Resident #1 was a full code and the paramedics arrived right after she died . The co-DON asked Staff C if she started CPR and Staff C said she did not. When asked why she did not start CPR, Staff C replied I don't know, I just don't know. The co-DON noted that she informed Staff C that Resident #1's full code status meant staff initiates CPR even if the resident died . According to the co-DON, Staff C's response was we have to do CPR even if the Resident is already gone? The co-DON replied yes. A QAPI (quality assurance performance improvement) Action Plan dated [DATE] documented: Concern: CPR not initiated on Resident indicated as a full code. Root Cause Analysis: RN failed to follow Resident's wishes to be a full code. Action items: re-educated Staff C on appropriate time to initiate CPR. Facility investigation/interviews: The co-DON documented a subsequent interview she had with Staff C on [DATE] at 10:40 a.m. Staff C told the co-DON that a CNA called her to Resident #1's room on [DATE] at 5:30 p.m. According to Staff C, Resident #1 breathed like someone sobs when they cry at the time she arrived. Staff C informed the co-DON that Resident #1's spouse and private caregiver sat next to the resident's bed at the time. Staff C said Resident #1's eyes were closed and the resident did not respond to verbal stimuli. According to the co-DON's documentation, Staff C said she left the Resident's room and told Staff [NAME] CMA to administer Tylenol to Resident #1 per the spouse's request. Staff C said she faxed an order another nurse received at about 5:00 p.m. to the pharmacy. Staff C told the co-DON she went back to Resident #1's unit to inform her spouse about the order, but realized that he and the Resident's caregiver left. According to the co-DON, Staff C told her that a CNA called her to Resident #1's unit about 7:10 p.m. Staff C told the co-DON that she found Staff D CNA and Staff [NAME] CMA in Resident #1's room. The Resident had difficulty breathing and her color had changed to ashen/pale. The co-DON noted that Staff C told her she instructed Staff [NAME] CMA to check Resident #1's vital signs, but Staff [NAME] CMA had to leave the room to get the equipment. The RN told the co-DON she left Staff D CNA with the resident as she left the room to get O2 (oxygen). According to the co-DON's documentation, Staff C stopped at the Nurse's station after she went to the O2 storage room; at which time she realized Resident #1 was a full code. The RN called the physician to notify him; at which time he authorized her to send Resident #1 to ER(emergency room ). Staff C then called 911 and also attempted to call Resident #1's spouse on the portable phone. According to what Staff C told the co-DON, she headed back to Resident #1's unit and saw EMS coming down the hall. Once inside of Resident #1's room, Staff C told the co-DON that Staff [NAME] CMA was shaking her head. The RN listened to the resident's chest with the stethoscope and concluded there were no respirations or labored breathing. Staff C told the co-DON that EMS listened to Resident #1's heart too; at which time Staff C pronounced the resident's death at 7:15 p.m. According to the co-DON, Staff C thanked EMS for coming and asked if there were any charges for coming. The co-DON asked Staff C if she told the paramedics if Resident #1 was a full code. The RN told the co-DON she did not tell them the Resident was a full code or a DNR. After further questioning, Staff C RN told the co-DON she never performed CPR before. When asked by the co-DON why she did not initiate CPR, Staff C RN told her she realized Resident #1 was a full code and she needed to call 911. According to the co-DON, Staff C stated looking back, I should have started CPR for those 11 seconds. The co-DON noted that she asked Staff C RN again why she did not start CPR. Staff C said at that moment I was down the hall. EMS was behind me and I didn't think it made a difference at that point. Staff C also told the co-DON that when she walked into Resident #1's room and saw signs of death, she did not call time of death for 30 to 60 seconds after being in the room. The co-DON documented her interview on [DATE] at 12:00 p.m. with Staff D, CN[NAME] The co-DON noted that Staff D told her she went into Resident #1's room with Staff E, CMA on [DATE] at about 4:00 p.m. with the Resident's caregiver present. Staff D said she went in the room again at about 5:00 p.m. Staff D CNA told the co-DON the caregiver left around 6:30 p.m. and she peeked in on Resident #1; at which time she called Staff C to look at the resident. Staff D told the co-DON that Staff [NAME] checked Resident #1's vital signs and Staff C went to get O2; which she left in the resident's room before Staff C left again to go to the nurse's station. Staff D said she radioed Staff C RN again; who responded by saying she was on the phone with the ambulance. Staff D said she went to the Nurse's station to get Staff C; at which time they returned to the resident's room together. Staff D told the co-DON she looked at Resident #1 and thought it's not good. Staff D said Resident #1 was still breathing. She watched Staff C listen to the Resident's heart and EMS walked in. The CNA told the co-DON that one of the paramedics also listened to Resident #1, but nobody started CPR. The co-DON documented her interview on [DATE] at 1:40 p.m. with Staff [NAME] CM[NAME] Staff [NAME] reported that she first went into Resident #1's room about 3:00 p.m. with the resident's husband and private caregiver present. Staff [NAME] told the co-DON she overheard Resident #1's spouse tell the caregiver that she would have to bring him back later because the resident was going to die tonight. Staff [NAME] CMA told the co-DON she went back into the resident's room with Staff D CNA at suppertime to give her an antibiotic. Staff [NAME] told the co-DON that Resident #1 seemed to be in distress, her mouth was wide open, her eyes were shut and she had a rattle in her throat. Staff [NAME] CMA said Resident #1 usually responded by saying OK when she told her she had some medicine, but the resident did not respond this time. Staff [NAME] CMA said she told Staff D CNA to call the nurse. Staff [NAME] told the co-DON she left the room to get her vital signs kit and returned right away. According to Staff E, she could not get any vital sign readings despite her attempts. Staff [NAME] CMA told the co-DON she even told Staff D to check Resident #1's pulse, but Staff D could not feel it either. Staff D left and returned to the resident's room with Staff C. Because Staff D did not understand what Staff C RN wanted when she told her to go get O2, Staff C left the room to retrieve the O2 herself. Staff [NAME] told the co-DON that Staff C returned with the O2; followed closely by paramedics. Staff [NAME] told the co-DON a paramedic listened, but could not hear Resident #1's heartbeat. An Affidavit dated [DATE] verified Staff C's vital signs assessment of Resident #1 late in the morning on [DATE] after another staff informed her that the resident had not gotten out of bed yet. Staff C indicated she only documented Resident #1's temperature of 100.8 F in the electronic health record, but hand wrote the remainder of her vital signs assessment on the 24 hour report; which she provided. Besides the 100.8 temperature, the Nurse recorded Resident #1's blood pressure of ,[DATE], 22 breaths per minute, pulse of 96 beats per minute and 90% O2 level. Staff interviews with staff working when the incident occurred: An interview on [DATE] at 12:45 p.m. with Staff D CNA revealed that she entered Resident #1's room with Staff [NAME] about 7:00 p.m. According to Staff D, Resident #1 not only looked different, she breathed slower than she normally did. Staff D said her color changed too, she appeared somewhat pale. Staff D said she worked since 6:00 a.m. that day and Resident #1 did not want to get out of bed that day. The resident acted differently and they did a chest x-ray during the day. Staff D said she called over the radio for Staff C to come and she responded right away. According to Staff D, Staff C RN looked at Resident #1 and told Staff [NAME] to get vital signs and then Staff C RN left to get O2. Staff D said Staff C RN returned shortly with the oxygen. When asked, Staff D said she thought Resident #1 was still breathing at that time, but did not know for sure. Staff D CNA said Staff C left again to go to the nurse's station. Staff D said she radioed for Staff C RN to come back because Resident #1 had more difficulty breathing. Staff D said Staff C radioed back and said she was on the phone with the ambulance. Staff D said Resident #1 still had respirations at the time Staff C returned. Staff D CNA said Staff C checked the resident with her stethoscope when the ambulance arrived. Staff D said she thought Resident #1 was still alive when EMS arrived; but could not say for sure because of how stressful things were. According to Staff D, EMS checked the Resident and did not detect a pulse. Staff D said neither Staff C nor the Paramedics initiated CPR. Staff D said the facility talked to her about the situation. She told them nobody started CPR. Staff D said she did not know if Staff C knew whether or not Resident #1 should receive CPR. When asked, the CNA said her CPR certificate expired. An interview on [DATE] at 1:05 p.m. with Staff [NAME] revealed that she and Staff D entered Resident #1's room at about 7:00 p.m. Staff [NAME] said the resident had a very funny sound coming out of her mouth. The CMA said Staff D used a term that described breathing noises people commonly make right before they die. Staff [NAME] said Resident #1 stopped breathing at times. Staff [NAME] CMA said the resident did not look good; her color changed and she appeared to be a bit pale. Staff [NAME] CMA said she told Staff D to call the nurse while she checked Resident #1's vital signs. Staff [NAME] said she put the blood pressure cuff on the resident's arm and the pulse oximeter (checks pulse and O2 level) on her finger but they did not register anything. Staff [NAME] said that although she still heard rattling, she no longer felt any breaths coming out of Resident #1's mouth. Staff [NAME] said Resident #1 did not respond to her as she tried to speak to her. When asked, Staff [NAME] said she did not have CPR certification. Staff [NAME] CMA said Staff C arrived and they informed her that they could not get any vital sign readings. According to Staff [NAME] CMA, Staff C wanted Staff D to get the O2 concentrator; but Staff D said she did not know what she meant. Staff [NAME] said they were afraid due to it being such a crazy moment. Staff [NAME] CMA said Staff C went to get the O2 and called the paramedics. Staff [NAME] said Staff C did not put the O2 on Resident #1 when she returned, instead she immediately attempted to get vital signs. According to Staff [NAME] CMA, EMS arrived at that time. She said a paramedic used a stethoscope to listen, but said she could not hear Resident #1's heart or anything. Staff [NAME] CMA said at that point, I think Staff C told EMS to initiate CPR, but neither Staff C nor the paramedics tried. Staff [NAME] said she and Staff D left the room at that time. Staff [NAME] CMA said the facility provided education to staff working the next morning. According to Staff E, they said CPR should be started immediately and the nurse should be notified immediately in the event of a similar situation. Staff [NAME] said they also told them that anyone could call the ambulance. Staff [NAME] CMA said they thought a nurse had to call the ambulance. Staff [NAME] said she was in Resident #1's room earlier when her husband and sitter were visiting. Although Resident #1 did not make the same rattling noise, she had some difficulty breathing then too. Staff [NAME] said Resident #1's husband was a physician. Staff [NAME] said she overheard him saying the sitter would have to bring him back to the facility later because his wife was not going to make it. An interview on [DATE] at 1:35 p.m. with the co-DON revealed that she would expect Staff C to start CPR at the point when Resident #1 no longer had respirations or a heartbeat. The co-DON believed Staff C panicked and did not know what to do. According to the co-DON, Staff C should have started CPR when she went back into the room and assessed Resident #1. She said EMS should have relieved Staff C and assumed responsibility when they arrived. When asked, the co-DON said Staff C, who was certified in CPR, should have stayed with the resident in distress at all times and delegated the errands/tasks to other staff members. Other staff: An interview on [DATE] at 3:30 p.m. with Staff G, RN revealed that she knew to look in the Resident's paper chart and the electronic chart to find the resident's code status. According to Staff G, if a resident requested to be a full code, staff needed to begin chest compressions if the resident stopped breathing and no longer had a heartbeat. Staff G said staff should call 911 and apply O2 on a resident with a pulse and no respirations. Staff G said staff should monitor the resident and begin chest compressions if/when the resident no longer has a pulse. According to the RN, none of those interventions apply if a resident has a DNR code status. An interview on [DATE] at 4:05 p.m. with Staff H, RN revealed that she had CPR certification. Staff H RN said resident's charts are either labeled with DNR or full code and their code status is also located in the electronic health record. When asked, Staff H said staff should initiate CPR at the point when the resident no longer has a pulse or respirations. Staff H said staff should continue CPR until the physician directs staff to stop or a paramedic takes over. She said rescue breathing should be started if they are not breathing but still have a slight pulse. An interview on [DATE] at 8:30 a.m. with Staff F, LPN, revealed that she knew to look in the paper or electronic chart to find a resident's code status. According to the LPN, compressions should be started if a Resident is unresponsive, not breathing and without a pulse while someone else calls 911. Staff F LPN said she would stay with a Resident in distress if she was the one certified in CPR. Staff F said she would utilize an uncertified person with knowledge of CPR to relieve her under her supervision and guidance. According to Staff F LPN, that would be better than becoming completely fatigued and ineffective. Staff F said staff needed to continue CPR until EMS arrived or until the Resident becomes responsive, has a pulse, and can breathe on their own. Staff C RN interview: An interview on [DATE] at 3:10 p.m. with Staff C revealed that she started her shift on [DATE] at 1:30 p.m. According to Staff C, the nurse that reported off to her said Resident #1 had a slight fever and they did a chest x-ray and lab work on her. When asked, Staff C said nobody told her Resident #1's spouse said earlier that he did not think his wife would make it until Staff [NAME] relayed that information sometime between 3:15 and 5:00 p.m. Staff C said she first went to Resident #1's room when someone called her there at about 3:10 p.m. The RN said she assessed Resident #1, but she did not check her vital signs. Staff C stated Resident #1 would not open her eyes or respond to the questions. Staff C RN said she documented her assessment in the electronic health record. Staff C said she returned to Resident #1's room to inform the resident's husband that staff would administer Tylenol to his wife at his request. Staff C RN said she returned to the unit where Resident #1 resided another time to inform the resident's spouse that they obtained an order for [REDACTED]. Staff C said she never returned to Resident #1's room until a CNA called her back at 7:10 p.m. Staff C stated neither Staff D or Staff [NAME] informed her they did not get a reading when they attempted to check the Resident's vital signs, nor did they tell her Resident #1 stopped breathing intermittently and would not respond to them when they attempted to interact with her. Staff C RN said she, Staff D and Staff [NAME] went into Resident #1's room together after Staff D said Resident #1 wasn't looking good. Staff C RN said she observed Resident #1 with difficulty breathing and her color had changed to ashen. Staff C said she asked Staff [NAME] to check Resident #1's vital signs and asked Staff D to raise the head of her bed. Staff C said she left the room and went to the other side of the building to get O2. Staff C said she stopped at the nurse's station to check Resident #1's code status on the way back. She stated she immediately called the physician to get the order to for Resident #1 to go to the hospital when she realized the resident was a full code. Staff C then called 911 and told them they had difficulty getting Resident #1's vital signs, she had difficulty breathing and she was a full code; they should come with sirens on and lights flashing. Staff C said she grabbed the mobile phone and attempted to call Resident #1's husband on her way back to the unit. She entered Resident #1's room; at which time Staff [NAME] informed her she could not get a reading of Resident #1's vital signs. Staff C described Resident #1's color as being even more ashen and the resident's jaw dropped. Staff C RN listened to the resident's heart and lungs with her stethoscope and could not hear anything. When asked, Staff C said she did not start CPR at that point because EMS was literally right there. She said a paramedic assessed Resident #1 also and could not hear anything. Staff C said the Paramedics did not start CPR either. Staff C said she did not tell them to start CPR, she assumed they would just do it. She said she did not meet EMS outside of the room and tell them Resident #1 already expired and she was a DNR. Staff C said she called the co-DON at 7:29 p.m. to report Resident #1 expired. Staff C RN said the facility called her on [DATE] and said not to come to work due to investigation of the incident. They called her again later and told her to come in on [DATE] at 10:00 a.m.; at which time she met with the Administrator, the co-DON and their Attorney for about 1 ½ hours. Staff C said the Administrator asked why she did not start CPR. Staff C said she responded by telling her EMS was right behind me; it was their job. When asked about her response to the co-DON asking why she did not start CPR, Staff C said she could not say whether or not she told the co-DON I just don't know, I just don't know. Staff C RN also said she did not remember asking them do you mean you're supposed to start CPR once they're dead?, but could not deny she said it because there was so much going on. Staff C said it did not seem strange that EMS did not start CPR knowing Resident #1 was a full code; it didn't dawn on me to question why they didn't. Review of Staff C's personnel file revealed it contained active American Red Cross certification for Staff C to perform CPR. Staff C completed the training [DATE]. Abatement: Following the incident on [DATE] involving Resident #1 not receiving CPR the facility completed the following: The facility reeducated nurses on the facility CPR policy completed [DATE] The facility reeducated Staff C on [DATE]. The facility audited all resident charts to ensure all charts had signed IPOST orders completed [DATE]. The facility audited all charts to ensure they contained labels with correct stickers to identify resident code status completed [DATE]. The facility audited point click care (electronic records) accurate code status for each resident completed [DATE]. The deficient practice detailed above resulted in an immediate jeopardy situation for the facility. This abatement resulted in past noncompliance for the facility.

Based on clinical record review, observation, staff interview, and facility record review, the facility failed to develop a systemic approach to lock exterior courtyard gates to ensure gates locked at all times for 1 of 3 residents reviewed for wandering/elopement (Resident #17). The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS documented [DIAGNOSES REDACTED]. The MDS recorded no behavioral symptoms present during the 7 day assessment reference period. The resident displayed independence with bed mobility, transfers, walking in the room and corridor, and locomotion on the unit. The Plan of Care dated 7/26/18 identified the following: a. Specific Behaviors - at times the resident may ask to be let off the neighborhood on 2-10 (p.m./afternoon shift). The resident may be exit seeking, or ask to go upstairs. b. Extra Things to Know - the resident had an elopement risk and his picture is on the elopement risk poster. d. Bed and Mobility Devices - the resident may be up overnight when exit seeking, pounding on exit doors 2-10/10-6 (evening and overnight shifts). e. Transfers and Ambulation - the resident is independent in transfers and ambulation; supervise with ambulation in the hallway; and on 9/1/18, 15 minute checks. The poster titled Residents at Risk for Elopement dated 7/6/18 included a picture of Resident #17 with his room number. The Elopement Risk Tool dated 7/26/18 identified Resident #17 as at risk for elopement. The Progress Notes dated 8/1/18 at 9:56 p.m. documented the resident as restless and anxious at 3:00 p.m. The note recorded the resident asked for his anxiety meds, as not exit seeking, and less agitated and more easily redirected than the day before on 2-10. The Progress Notes dated 8/2/18 at 7:32 p.m. documented the resident exhibited minor exit seeking behaviors in the early afternoon and he wandered on and off most of the evening. The Progress Notes dated 9/1/18 at 5:50 p.m. documented the CNA (Certified Nurse Aide) reported Resident #17 exited the courtyard gate when she assisted other residents to return from the courtyard. The resident returned immediately and safely from the parking lot. Staff notified the resident's daughter, the Administrator, and doctor via phone. At 7:00 p.m. staff documented checking on Resident #17 every 15 minutes and the resident appeared agitated and sought to exit the facility after talking to his brother on the phone. Resident #17 asked for his car keys so he could drive home. Staff attempted redirection unsuccessfully, turned the TV to the baseball game for distraction, and gave him a non-alcoholic beer. The Progress Notes dated 9/2/18 at 9:15 p.m. documented at 8:15 p.m. the resident requested to go out and find his bike to ride to his car; the resident wanted to see his mother and father. The nurse documented distracting him with stories of the heavy rains. The note documented at 8:50 p.m. the resident continued to request to go outside, staff offered a cup of water and a cookie, then the resident fell asleep in the chair. The facility identified a census of 9 residents on 9/1/18 who resided on the Maple neighborhood and indicated 5 of those residents as self mobile (Resident #26, Resident #13, Resident #3, Resident #27, and Resident #17). Review of the Shift Assignments dated 9/1/18 identified the following staff assigned to the Maple unit where Resident #17 resided: Staff G, CNA and Staff F, CNA, for the 6 a.m. to the 2 p.m. shift Staff D, CNA, and Staff E, CNA for the 2 p.m. to 10 p.m. shift. Staff C, Registered Nurse (RN) for the 2 p.m. to 10 p.m. shift The undated, signed, written statement by Staff E contained a fax stamp of 10/1/18 at 1:45 p.m. Staff E wrote the following: Staff E pool staff assisted residents out of the dining room after dinner. Staff E's co-worker decided to open the patio door for residents that wanted to get some fresh air outdoors. Then Staff E's co-worker told her to watch the residents in the commons (TV) area while Staff D watched the residents outside on the patio. Resident #17 was one of the first residents to take advantage of the patio experience and the last time Staff E saw him at that particular time was after dinner with Staff D on the patio. The undated, unsigned, written statement by Staff D contained a fax stamp of 10/1/18 at 1:45 p.m. Staff D wrote the following: After dinner around 5:40 p.m. Staff D took Resident #3, Resident #17, and Resident #48 outside into the courtyard. They were outside for only a few minutes when Resident #3 went back inside with Resident #17, Resident #48, and Staff D still outside. Staff D called to her partner to come help stand Resident #48 up so she could shake off crumbs from his clothing; Resident #17 stood right next to them. At that point, Resident #27 walked into the dining room and sat on the arm of the chair, which was wobbly. Staff D's partner couldn't get him to sit down properly so she assisted her in sitting him down. Staff D went back out, brought Resident #48 into the living room, right after that Staff D went out to her car. On Staff D's way out, Resident #26's daughter then walked Resident #17 back in. Staff D went out to her car around 5:50 p.m. Staff D believed Resident #17 got out while she assisted her partner with Resident #27 (it only took 2 minutes with Resident #27). Staff D thought Resident #17 got out through the courtyard gate because it was not locked. Usually the first thing Staff D did after getting report would be to always check iPods, iPad, and gate, and if they checked the courtyard cameras they would see her checking gates. When Staff D started her shift that day it was very hectic between Resident #37 and Resident #17 being anxious, Resident #48 having visitors, and having an agency aide. Staff D got distracted and didn't fill out her shift sheet which meant she didn't check the gate. Observation on 10/8/18 at 11:53 a.m. revealed Resident #17 stood up from a straight back chair independently and Staff A, CNA, redirected him from the doorways. At 12:24 p.m. Resident #17 wandered out of the dining room and informed staff he was looking for the outside. Staff T, Certified Medication Aide (CMA), redirected Resident #17 and told him they had his lunch ready first. Resident #17 could not exit the main neighborhood doors when he attempted to push on them as the doors were locked with the keypad code required to exit the neighborhood. Observation on 10/8/18 at 3:04 p.m. revealed Staff B, Licensed Practical Nurse (LPN), demonstrated how the Maple unit courtyard gate locked. Staff B reported the gate must be unlocked by a key and then they push the button for a latch to unhook to be able to open the door. Observation on 10/10/18 at 7:47 a.m. revealed Resident #17 attempted to get into the locked dining room. Resident # 17 asked Staff A to unlock the door, she did, and staff were present in the dining room with the patio doors locked. Resident #17 went straight to the table and sat down to drink. In an interview on 10/08/18 at 1:50 p.m., Staff C recalled working on 9/1/18 when Resident #17 eloped. Staff C stated after dinner Staff D had several residents out in the courtyard that day. Staff C reported Staff D turned to push one of the wheelchairs into the dining room and one of the other residents started to sit on the arm of a chair. Staff D turned to help that resident with the chair and when she stepped back through the door she didn't see Resident #17, so she thought she missed him coming back in. Staff C stated Staff D knew that Resident #17 went outside (to the courtyard). Staff C reported another CNA, Staff E, took other residents from the dining room to the commons area while she was in the nurses station. Staff C received notice that Resident #17 had been out of the facility when Staff D told her he had gotten out and she saw him coming back into Maple unit. Staff C completed an assessment and the resident had no injuries. Resident #17 stated he was looking for his car, this was a common theme for the resident and at night time he wanted to look for his car. Usually if Resident #17 wanted to go out, they went out with him to the courtyard, he would see no cars, and then go back inside. Staff C had never heard of any difficulty getting him back inside or of any other elopements. Staff C said the CNAs had keys for the gates, they are supposed to check at the beginning of each shift, and sign off the gate check on paper. Staff C said she did not talk to the family member who found Resident #17 outside the building and Staff D reported the family member as the daughter of a different resident who resided on Maple. Resident #17 did not seem upset and she thought he was only outside just a few minutes. It was a nice day with no inclement weather. Staff C called the Administrator to report immediately. Staff C thought the failure someone unlocked that gate at some point in time. Staff C stated Staff D reported the shift change chaotic that day and at shift change Staff D did not check the gate. The pool aide (CNA from temporary staffing agency) would not know, that it would be one of the facility's staff responsibility unless they had worked there a lot. Staff C had not met Staff E before so expected Staff D to check the gate. Staff D admitted to not checking the gate and felt really bad. Staff C said she immediately had all the units check their gates and do a head count as soon as she looked at Resident #17 and made sure he was okay. In an interview on 10/8/18 at 2:30 p.m. Staff F recalled she heard about the incident with Resident #17 when she got back to work the next day. Staff are supposed to check the gate when they get on the neighborhood and they had 30 minutes to complete it, so it's done on rounds. Staff F said the partner could also check. Staff F recalled being asked if they checked that morning and her partner (Staff G) said she checked the gate. Staff F responded you should check the gate by pushing on it then push a little button but you have to have the key to unlock it. If it's unlocked, you push down on the button to push open. Staff F stated she documented the checks on the shift change sheets with her initials. Staff F did not know how it got unlocked. Staff F stated the Education Director trained her by having her unlock and lock the gate. Staff F had never seen the gate unlocked unless by the mower but they announce that and she did not recall the lawn being mowed that day. On 10/9/18 at 12:36 p.m., Staff D recalled working the night Resident #17 eloped. Right after supper she took Residents #17, #48, and #3 outside while her partner, Staff E, worked inside in the commons area. Resident #3 walked back in and Staff D either wheeled Resident #48 back in or was getting ready to, she couldn't recall. Staff D stated Resident #27 tried to sit on the arm of a chair in the dining room and Staff G could not redirect him, so Staff D stepped in and got Resident #27 to sit down properly. Staff D reported the entire incident all happened within 5 minutes. Staff D said she informed her partner she was going to her car to grab something. Staff D said she then saw Resident #17 in the hallway walking with one of Resident #26's daughters. Staff D stated Resident #17 had left and been found in five minutes or less; she thought he slipped out about 5:50 p.m. to 5:55 p.m. Staff D said at 5:45 p.m. they got done with supper, about 5:50 p.m. she took the residents outside, and at 5:55 p.m. Resident #17 walking back in; he did not appear upset at all or dirty. Staff D stated she asked Resident #17 where he had been and he responded just right here; she did not think Resident #17 knew what he was doing. Staff D thought it was a nice day. She reported working for the facility for 8 months, hired (MONTH) (YEAR), and she resigned the previous month. Staff D stated Resident #17 always was exit seeking to want to go home or go upstairs but he gave no signs before it happened; he did not say he wanted to leave. Staff D commented she did not get a chance to check the gate at 2:00 p.m. The unit was hectic, chaotic, they just got new resident (#48) and he tried to climb out of bed. There were 2 CNA's assigned to the unit and the Administrator present (at the beginning of the shift). Staff D got a quick report and she had Staff E with her who hadn't worked there before, so had to walk her through everything. Staff D stated she always checked the gate, it just happened that day she didn't. Staff D reported the morning shift signed the sheet as locked and the facility had no lawn care that day, so the gate had to be unlocked on the morning or overnight shift. Staff D did not see Resident #17 walk out and there would be no way he could get under the gate. Staff D confirmed the gate as unlocked when she went to check it after Resident #17 came back into the unit. Staff D thought people really were checking the gate, signing the sheet, and when she worked with her partner they always checked and signed. In a follow-up interview on 10/10/18 at 11:42 a.m., Staff D responded she did not know exactly when trained or who trained her on the gates but she knew she had received training. Staff D said after the incident she was trained to press the black button to check the lock. In an interview on 10/9/18 at 1:11 p.m. the Education Director stated the staff training reiterated not to check the gate by pulling on the door as they could pull with all their might and the door won't open due to the style of latch, but the door may still be unlocked. The Education Director stated the staff are also trained not to check with the key in the lock as it may inadvertently unlock. The facility's expectation of staff is to use the palm of their hand to push on the button style key lock and ensure the gate is locked. In an interview on 10/9/18 at 2:35 p.m. the Administrator and the Assistant Director of Nursing, (ADON) stated gates were to be checked by the facility CNA's at a minimum of 3 times a day, at the beginning of each shift. The ADON and the Administrator had reeducated staff on the proper way to check the gates, completed elopement drills, and department heads checked the gates daily at random times after the elopement. The ADON responded the staffing level as normal with 2 CNA's for the Maple unit. Staff planned Resident #17 to be supervised while outside but Staff D assisted Resident #27 from sitting on the edge of the chair as well as assisted her partner to keep Resident #27 from escalating with behaviors. The ADON felt staff chose the safety of one and turned back to the courtyard. The ADON stated there were no cues for Resident #17 to elope and it would not be normal for him to wander away from the group. Resident #17's usually went to all activities, ice cream socials, John Deere outings, and often stood outside his room located directly next to the dining room which leads to the patio. The ADON stated Resident #17 went out to the patio before and he walked independently without supervision or an assistance device. The ADON event occurred at approximately 5:50 p.m. and he was outside for approximately 5 minutes. In an interview on 10/9/18 at 3:20 p.m., Staff G stated she worked for the facility since the beginning of the year and only worked on the Maple unit. Staff G recalled she checked the gate and she stated she did not know that gate to ever open. Staff G stated the guy she worked with the day before, Staff H CNA, double checked the door with her and said they must check it every day when doing rounds. Staff G said the first thing she did was go to lock the door. She used the key to unlock, lock again and then jiggled to make sure not open. Staff G said it was the first time she ever had to check the gate as she had never taken anybody outside; she worked every other weekend and didn't like to go outside as a group because Resident #17 could sundown (get confused) quickly. Resident #17 would start asking for the keys to the car and when she heard him say that, she redirected him to have a beer to try to distract him. Staff G stated that day the resident acted very calm and she expressed surprise that he went outside. They checked that gate so she thought it impossible Resident #17 exited; someone had to let him out because the gate locked. Staff G reported she gave the keys to the permanent girl. Staff G stated she received training on gates by the Education Director who covered everything and got training after the elopement too. Staff G stated the Administrator came and had her sign a paper that it's their responsibility to check, they must shake the gate to make sure it locked, and check all your residents. Staff G stated the staff just needed to keep a close eye and be observant with Resident #17. In a follow-up interview on 10/10/18 at 11:31 a.m., Staff G clarified she put the key in the door how Staff H showed her and tested to make sure the gate fully locked. Staff G said after she locked it she took the key out, pushed on the button, and shook it a little bit to make 100% sure the gate door locked. In an interview on 10/10/18 at 10:03 a.m. the Administrator reported the first 6 days in staff orientation, staff are assigned a trainer who is another CNA who went through the trainer course. The Education Director stated Staff H is not a trainer. The Education Director responded she did not think the facility had a written procedure to check the gate but she would look at the education. The Education Director stated after the incident, they facility listed the gate check as a separate line on the CNA checklist and before this incident the trainer trained the CNA's. The Education Director met with the trainers yearly as a group and small informal meetings were conducted approximately every 6 months and they had no documentation of the meetings. The Education Director confirmed Staff D as trained by Staff I, CNA, on 2/27/18 for the task sheet, also known as CNA Nurse Communication Sheet on the checklist. The Education Director stated the other place the checklist would reflect training on gates would be the change of staff and rounds which Staff R, CNA, had signed training provided to Staff D and that Staff R also a trainer. The Education Director stated the hand written gate training written on Staff D's checklist was written the night before to highlight for the surveyor where the gate locking would have been covered. The Education Director stated now after the incident, the locking the gate covered on days 1 and 2 of orientation. The Education Director stated if they found a problem, they would expect to activate their QA process and go back to retrain staff. Prior to the incident they relied on CNA's to initial on the task sheet. The Administrator said on 9/2/18 she spoke to both aides, (Staff G and Staff F) and neither put the key in the lock. The Administrator said numerous times she told them to push the button. The Administrator stated she worked on 6 to 2 shift (9/2/18) so she educated them. The Education Director stated she went out with Staff G, who said the Administrator had already retrained her, and asked her questions; she still wanted Staff G to show her how she checked the gate and she did not put the key in the lock at that time. The Administrator reported Staff G had been off on maternity leave for 3 months and returned 8/19/18, so 9/1/18 would have been Staff G's second weekend to work. The Education Director thought it doubtful Staff G retrained upon return from maternity leave. The Education Director stated she trained the trainers and before the incident there were variations in how staff checked the lock: some put the key in the lock and then jiggled the door and some hit the lock and wiggled the door. In a follow-up interview on 10/10/18 at 10:30 a.m. the Education Director said Staff H received training from Staff J, CNA (a trainer currently out of the country) and also by Staff U, CNA, who also was a trainer at that time. The Education Director stated she had a trainer meeting on 7/19/18 and changed the checklists/definitions to update. The Education Director changed staff rounds to refer to the checklist. The Education Director stated the Shift Checklists used for training the trainers and used as a reference for them to train the CNA's. The Education Director showed it listed to check the courtyard gates and the task sheet listed to check the lock itself. She retrained staff on 7/19/18 after she made changes to the format and had the trainers demonstrate locking the gate and checking the gate. The Education Director stated the trainers had access to the definitions of what to say like a tutorial for the trainers, not passed out to everyone. At 1:50 p.m., the Education Director stated she first learned of variations in how the staff checked the gate after the elopement when they expected each staff member to complete return demonstrations. With the current training they had staff do return demonstrations initially and after the incident. The Education Director said after the elopement when the staff showed her, some showed they pushed on the button with a hand and some locked and relocked it but as long as they knew how to lock and secure the door that's what she looked for. The Trainer Definitions prior to 7/19/18 for Change of Staff Report/Rounds documented the check should be done at the beginning of the shift and staff should refer to the checklist. The Shift Checklists/Staff Cleaning for Oncoming Shift included direction to check the courtyard gate for security and initial the check on the task sheet. For CNA/Nurse Communication Sheet (Task Sheets), the gates should be checked during report and rounds - check the lock itself to make sure it is locked. The Trainer Definitions updated on 7/19/18 for CNA/Nurse Communication Sheet documented Gate Check - Check the lock itself on the gate that it is locked and secure. Do not just wiggle the door. For Locking and Unlocking Courtyard Gates - Orientee should demonstrate how to unlock/open gate in an emergency and lock/secure gate. Additional staff interviews revealed the following information: On 10/10/18 at 11:00 a.m., Staff K, CMA (certified medication aide) stated she checked the gates every shift and had been trained to push on the button. If not locked, it opens and you need to lock it by putting the key in the lock. On 10/10/18 at 11:02 a.m., Staff L, CNA, stated she was trained to push on the button and to push door too as it could be unlocked. About 2 months ago, she received training to push the button when she checked to gates. On 10/10/18 at 11:04 a.m., Staff M, CNA, stated she started work on 7/6/18 and the Education Director trained her to put the key in and shove the lock and door afterward. On 10/10/18 at 11:06 a.m., Staff N, CNA, stated she was trained to check the gates where they put the key in: push on it, push on the gate and its locked if the button will not go in. Staff N said she never put the key in to check if locked. Staff N started working (MONTH) (YEAR) and received training on the first or second day. Staff N stated that sometimes the Education Director did assessments of them and once a month they got new people she trained because she worked as a trainer. In an interview on 10/10/18 at 11:08 a.m., Staff O, CNA, stated she worked for the facility since (MONTH) (YEAR) and received locked gate training when she first started. She received more training 2 months prior due to some confusion on how to know if the gate locked or unlocked. Staff O said she was trained to push on the button and if the button pushes in, it's not locked. You should push and shake the door. In an interview on 10/10/18 at 11:10 a.m., Staff P, CNA, stated she worked for the facility since (MONTH) (YEAR). Staff P stated she was trained on gate checks a couple times by the Education Director; first on the Dogwood neighborhood then a second time on the Cottonwood neighborhood. Staff P learned each shift to take the keys out to turn to the lock and to push it and see if the gate moved. A paper with a fax date of 10/1/18 as documented by the Administrator recorded: At approximately at 2:00 p.m. the Administrator spoke with Staff F, CNA, and Staff G, CNA, both CNA's worked Maple on the 6 to 2 shift on 9/1/18. Both aides stated that they checked their gate in the morning and that the gate was locked. Both aides reported that no one used the courtyard on their shift. The Administrator documented the following internal investigation: On 9/1/18 at approximately 6:15 p.m., Staff C, RN, called the Administrator and informed her that Resident #17 was out in the courtyard with a staff member and a couple of other residents. A resident in the dining area needed immediate assistance, she assisted that resident and came back out. She assisted the other two residents inside and under the impression the other resident walked himself back in. As she entered the common area a family member walked in with Resident #17. The CNA immediately checked the gate for proper function and made sure it locked. She also did head count on the neighborhood to ensure all residents were accounted for. The Administrator instructed Staff C to immediately start 15 minute checks on Resident #17 and to add him to their hot list for the next 7 days. On 9/2/18, the Administrator documented at approximately 10:00 a.m. she checked all gates to ensure they functioned properly and locked. All gates were locked. The Administrator started immediate education with nursing staff on expectations of when checks are to be done on the courtyard gates. The Administrator also created a log of random checks that would be done on courtyard gates by department heads. The lack of supervision and systematic gate checks resulted in Immediate Jeopardy for facility residents. The facility abated the Immediate Jeopardy situation on 10/10/18 by educating staff on a consistent system to check the gate lock and requiring return demonstration at the time of that training.

Based on observation, staff interviews, document review, and resident record review, the facility failed to provide adequate supervision to ensure against hazards from self and the facility failed to ensure the assignments and work schedules for health service personnel met the needs of the resident when a unit was left unattended by staff members (Resident #1). The facility reported a census of 55 residents. The sample consisted of 4 residents. Findings include: 1. Resident # 1 had [DIAGNOSES REDACTED]. Review of the same document revealed the resident ' s Brief Interview for Mental Status (BIMS) score was 6, which indicated the resident was severely cognitively impaired. The resident required the limited assistance of 1 staff for transfers, and supervision to ambulate (walk) both in and out of the resident ' s room. Resident # 1 was steady both while moving from a seated to a standing position and while walking. The resident had no functional limitations with range of motion, and used a walker. The resident had a history of [REDACTED]. The resident's 12/19/12 care plan revealed the resident as independent with ambulation but required a walker. The care plan also directed facility staff to provide stand by assistance with ambulation and transfers as needed; remember the resident often needed cuing and reminders to use his walker, encourage the resident to leave the door open at all times; ensure there was Dicem to the resident's chair; and on 1/1/13 to do 15 minute checks for 24 hours. Review of the resident's July-Jan falls sheet revealed that resident # 1 had the following falls and injuries on the following dates: 7/3/12 - hematoma and abrasion to the forehead 8/14/12 - no injury 9/24/12 - no injury 10/2/12 - no injury 10/11/12 - no injury 10/14/12 - abrasion to the forehead, right knee, right shoulder, and skin tear to the right elbow 11/21/12 - abrasion to the left buttock and back/blood blister to the left hand 1/1/13 - no injury 1/2/13 - fractured left femur and left patella (knee cap) Per the same document, the intervention after the 1/1/2013 fall was 15 minute checks for 24 hours post fall. According to the 1/1/13 10:15 p.m. Incident/Accident report, staff heard a noise and found Resident # 1 on the floor on the resident's right side, with the resident's walker on top of the resident. The resident could move all extremities, had normal range of motion, and no apparent injuries at this time. The changes to the resident's plan of care were to do visual checks every 15 minutes for 24 hours. Per a document labeled with resident # 1's name, staff documented performing both the 5:00 a. m. - 5:15 a. m. check and the 5:15 - 5:30 a. m. check. Per the 1/2/13 5:15 a. m. Incident/Accident report, the Birch aide found the resident on the floor. The Aspen aide (Resident # 1's unit) was helping the nurse in Cottonwood. The resident wore shoes and told the staff she/he tried to get to the breakfast table. The resident went to toilet at 5:00 a. m. The resident was on 15 minutes checks, but the aide was checking resident # 1 more often due to the resident being more restless during the night. The changes made to the care plan were the staff posted a sign on the bathroom door, the room door, and the bedside table to remind the resident to use the walker. Per the 1/2/13 nursing notes, at 5:15 a.m., the nurse was called to the resident's unit, Aspen, by the aide from another unit, Birch. The aide on the resident ' s unit, Aspen, was assisting the nurse and the aide on Cottonwood at the time. The resident was found on the floor between the resident ' s room and the kitchen. The resident did not have their walker, as the walker was in the doorway of the resident's room. The resident appeared to have no injuries. The staff faxed the resident's doctor, and planned to continue the every 15 minute checks for the next 24 hours. Per the 1/2/13 9:00 a.m. nursing notes, the resident complained of left knee pain. There was no redness, swelling, or discoloration. The resident complained of pain while bending the knee, and could not put a lot of weight on the knee during transfers. The staff gave the resident acetaminophen (Tylenol) at this time. At 10:00 a. m., the Tylenol was ineffective. The staff transferred the resident to bed, but the resident continued to complain of pain with transfers. The staff notified the resident's family. At 10:05 a.m., the staff notified the resident's physician. The physician ordered an X-ray due to the increased pain, and internal rotation (twisting towards the inside) of the resident's left leg. At 11:20 a. m., the X-ray tech confirmed Resident #1 had a left hip fracture, and a possible tibia (lower leg bone) fracture. The staff notified the resident's physician and family. The resident then went to the hospital for further evaluation. Per the 1/2/13 Portable X-Ray, Inc, report, Resident #1 had a nondisplaced (in proper bone alignment) transverse (straight through) patellar (knee cap) fracture. The resident also had an intertrochanteric fracture of the proximal left femur (left hip). During an interview on 1/14/13 at 1:40 p.m., Staff A (Certified Nursing Assistant) stated he was assigned to Aspen at the time that Resident #1 had fallen. The resident was very restless that shift, and had had a fall shortly prior to the early morning one. The resident had been talking about a cable - Staff A thought the resident was referring to the resident ' s call light. Staff A confirmed that he had performed the every 15 minute checks, and he had initialed the 5:00 a. m. to 5:15 a. m. check and the 5:15 to 5:30 a. m. check. Staff A had spent most of the shift sitting at the table so he could see Resident # 1 as the resident was so restless. Staff A had toileted resident # 1 perhaps 15 minutes earlier, and put the resident back to bed. Staff A thought Resident # 1 had the call light. Then the nurse, Staff C, called and requested Staff A come and help on Cottonwood. The resident appeared to have been asleep when Staff A left the unit and so he went to Cottonwood. Staff A had been the only person working on the unit. Staff A thought he had been gone about 3 minutes. When Staff A came back to the unit, Resident # 1 was on the floor. Staff A stated the nurse knew Staff A had left Aspen and Staff A didn't expect Resident # 1 to get up. During an interview on 1/4/13, at 10:20 p.m., Staff B (Certified Nursing Assistant) stated she had not cared for Resident #1 prior to this night shift. Staff B was charting on the adjoining unit, Birch. Staff B didn't know that staff A had been pulled from Birch - no one had told her. Staff B heard yelling, and walked through the shared kitchen area to the Birch unit. Staff B called for Staff A as Staff B didn't know that Staff A was not on the Birch unit. Staff B saw a man on the floor and used the walkie talkie to call for Staff C, the nurse. Then, both Staff A and Staff C walked through the door. Staff C said that Staff A had been pulled to another unit. Staff B told Staff C that Staff B did not know that. The staff did vitals. The resident had trouble moving his/her right leg and walking. Staff B asked Staff A if the resident was ok, then returned to Birch. Staff B stated that staff weren't often pulled off one unit to go to another unit. On nights, usually one staff member worked on each unit. It was not usual to pull staff on nights. If that happened, the staff were usually told someone was being pulled. That way, the staff could watch the residents. Staff B had started working nights on January 1st. Birch and Aspen shared the same kitchen, while Cottonwood was a totally separate unit. Staff could stand in the kitchen and see both units. On nights, the staff could call the nurse to come and cover the unit if the staff member had to leave briefly. The staff could communicate via the walkie talkies. There were different channels, so the staff could alert all the staff, or call each unit individually. Staff C, Registered Nurse (RN), was interviewed on 1/14/13 at 10:31 p.m. Staff C could not be sure of the date of the incident, but thought it had occurred around 5 to 5:15 a.m. Staff C had been called to Cottonwood to assist with a combative resident. The aide on Cottonwood had a gait belt on the resident, and was trying to keep the resident from falling. The resident refused to help the staff. Staff C used the private walkie talkie channel to call Staff A for assistance. Staff A came and was able to help the other two staff transfer the Cottonwood resident to the wheelchair. Staff C thought Staff A was off of Aspen for perhaps 2-3 minutes before Staff B called. As Staff A and C were leaving Cottonwood, Staff B called and said that Resident # 1 was on the floor. The resident could move everything, and initially seemed ok. Then, the resident said she/he couldn't move their right leg. Staff C thought she had told Staff A to make certain that Resident # 1 was safe before coming over. At the time, Staff C thought that the resident was in bed. This was the first time that Staff C, who was new to the facility, had pulled staff to come and help on another unit. Staff C stated she had been told in orientation what to do, but didn't think things through to tell Staff B to watch both units, Birch and Aspen. Staff C thought that Staff A had told Staff B that he was leaving the unit. Staff C should have called and told Staff B that Staff A was being pulled to another unit. It was a tough night shift. Staff C stated she had been counseled about this incident. The counseling was to be certain that the aides knew that someone was being pulled off of the assigned unit to ensure that it was covered. This was the first time that Staff C had been in a situation of needing to have a staff member leave a unit to cover an emergency. The DON (Director of Nursing) was interviewed on 1/22/13 at 3:48 p.m. The DON stated the expectation would be staff to be on each unit at all times. Birch and Aspen were connecting units. If staff were pulled for an emergency from one unit, the expectation was that the staff on the other unit would play "center field " during the emergency. The staff could stand in the kitchen, and see both units. This should happen only in emergencies and the nurse should coordinate all of this. It was the nurse's job to make sure all staff knew that a unit was unattended. After the incident with Resident # 1, the facility had a mandatory in service unit coverage on 1/5/13. Staff that could not attend were expected to watch the video within 7 days. The expectations that all units would be covered were reiterated. Staff were originally trained on this during their initial facility orientation. All of the staff carried walkie talkies. There was an alarm group, in which one staff could page all of the staff. Staff C failed to notify Staff B at the time of the incident with Resident # 1. Staff C didn't use the alarm group to notify all of the staff. Staff C felt she needed emergency help, and called Staff A. However, Staff C didn't call Staff B. The situation was a "perfect storm". Staff C received counseling about this incident. Per the in-service training and attendance record, on 1/4/13, the facility DON and Administrator led a Certified Nurse's Aide (CNA) meeting. The topics included the overall facility standards, supervision of neighborhood, peer to peer interactions and communication during shift exchanges. Thirty one staff members attended. On 1/14/13 at 1:49 p.m. observation revealed Resident # 1 sitting in a recliner in the unit living room. The resident was dressed appropriately for the season. The resident had a long (thigh to lower leg) immobilizer (a splint to keep the resident from bending the knee) on the left leg.

Based on record review, observation and staff interviews, the facility failed to provide adequate supervision to ensure against falls (Resident #13), and hazards (Resident #5 and Resident #7). The Director of Nursing failed to plan for and conduct the training of nursing assistants and ensure the work schedules for all health services personnel so the resident ' s needs are met. The facility identified a census of 54 residents. The sample consisted of 10 residents. Resident #13 was transferred to the bed by a new nursing assistant employee and another employed nursing assistant. The staff did not adequately supervise the resident while the resident sat on the side of the bed. When the trained employee left the resident to obtain a pillow near the bed, the resident fell forward and hit the wheelchair which resulted in a subdural hematoma (bleeding in the brain). The Director of Nursing stated she would have expected the new nursing assistant to just observe on the first day of employment. The new employee should have worked with the planned mentor instead of the nursing assistant at the time of the resident ' s fall. Resident #7 requested a whirlpool bath. Two nursing assistants bathed the resident. The chair belt needed repaired and the staff continued to use the whirlpool. The resident attempted to stand while seated in the whirlpool chair. One of the nursing assistants walked away from the resident to obtain a towel and the other assistant could not prevent the resident from falling forward onto the floor. Resident #5 had a bladder drainage Foley. A nursing assistant attempted to thread the bag and tubing underneath the chair. The tubing was coiled around the resident ' s foot and impeded the bag from going under the chair, however, the nursing assistant continued to push the bag underneath the chair. The facility Director of Nursing and the Surveyor intervened and prevented an injury to the resident. Findings include: 1. Resident #13 had a quarterly MDS (Minimum Data Set) assessment, with a reference date of 1/13/2012 which identified [DIAGNOSES REDACTED]. The MDS reflected both long and short term deficits and severely impaired decision making skills. Resident #13 required the assistance of two people for transfers, walking in the room, and toilet use. Resident #13 required human assist to stabilize when moving from a seated to standing position, when walking, when moving on and off of the toilet, and for surface to surface transfers. The MDS documented that Resident #13 had 2 falls with no injury and 1 fall with injury since the prior assessment. Review of the Unusual Event Flow Sheet dated 3/23/12 at 2:00 PM indicated Resident #13 had been transferred to bed and then the resident slid out of the bed and hit head on the wheelchair. The nurse was summoned to the room. The resident on floor on left side by the bed. The nurse assessed the resident. The resident had a temperature of 97.8 degrees Fahrenheit, pulse 80 (normal 60-100), respirations 14 (normal 16-20) and blood pressure lying 220/102 (elevated). The resident had pulse oxygen of 70% (per Mayo clinic.com, under 90% is considered low). The resident had a 2 centimeter found red area on the right side of face and a 4 centimeter long area on the left side of face. At 2:15 p.m. the neurological check flow sheet revealed the blood pressure to be slightly lower at 184/96 (still elevated), pulse 70 and respirations 14. The neurological check flow sheet identified the resident as lethargic and responded slowly to verbal stimuli. The resident ' s pupil sizes and reaction were identified as normal. The resident had clear speech. The facility transferred Resident #13 to the hospital for an evaluation. A CT (Cat Scan) was performed at 4:40 p.m. The findings report revealed a massive right subdural hematoma (a collection of blood as a result of vessel damage) ranging up to 2 centimeters in thickness. The right lateral ventricle of the brain had a 14 mm (millimeter) shift of the midline to the patient's left. A Major Injury Determination Form was completed by the ARNP (Advanced Registered Nurse Practitioner) on 3/26/2012 at 12:20 P.M. The ARNP documented the resident had a negative CT scan on 3/13/2012 and had been experiencing changes in mental status prior to the fall. The ARNP identified the resident sustained [REDACTED]. On 4/4/12 at 10:30 AM Staff I, CNA (Certified Nursing Assistant) was interviewed and stated 3/23/12 had been her first day working at the facility and had been orienting to the job. Staff I and Staff J, CNA decided to lay Resident #13 down so they transferred Resident #13 from the recliner to the wheelchair and took the resident to his/her room. Staff I and Staff J then transferred the resident from the wheelchair to the bed with the resident sitting on the side of the bed. Staff I stood on the left side facing the resident beside the bed side rail. Staff J stood to the right side when facing the resident. The staff noticed the resident did not have a bed pillow. Staff I stated they were looking for the pillow and not paying attention to the resident. Resident #13 then leaned forward and fell to his/her left side falling between the bed and wheelchair landing on the left hip with his/her head on a Love Sack pillow located on the floor near the bottom of the bed. On 4/4/12 at 11:05 AM, Staff J (Certified Nursing Assistant) was interviewed and stated she and Staff I decided to transfer Resident #13 from the wheelchair because the resident had been lethargic, squirming around and slipping down in the wheelchair. Staff J stated that after transfer to bed, she noticed no pillow on the bed. She located the pillow on the floor by the wall and took 1 large step away to grab the pillow. When Staff J turned back toward the resident, he/she started falling off the bed. Staff J went toward the resident but the resident had fallen to the floor. Staff J stated if she had been on the resident's other side and not the one to pick up the pillow, she would have made sure to keep in contact with the resident while seated on the side of the bed. Staff J made a drawing of the room and the position of the staff at the time of the resident ' s fall. On 4/4/12 at 2:35 PM, Staff E (Certified Nursing Assistant) was interviewed and stated he had cared for Resident #13 and the resident could move real fast. Staff E stated the resident had declined and moved slower but he would keep his eyes on Resident #13. On 4/4/12 at 2:40 PM Staff F (Certified Nursing Assistant) was interviewed and stated she had cared for Resident #13 on the late night shift. Staff F stated that Resident #13 liked to get up and down and she would keep her eyes and a hand on him if sitting on the edge of the bed. On 4/4/2012 at 2:45 P.M. Staff G, LPN (Licensed Practical Nurse) was interviewed and stated she would stick right with Resident #13 or would sit on the bed with the resident. Staff G stated Resident #13 sometimes swayed and she would put her hand on his back. Staff G stated she would also expected a CNA working with Resident # 13 to watch him/her as the resident could be pretty fast. An interview with Staff H, CNA on 4/4/12 at 2:55 PM revealed she had worked with Resident #13 on the 2 PM-10 PM shift and would just stay beside him unless the resident tried to get up and would expect other CNA's to watch the resident also. On 4/4/2012 at 3:00 P.M. the Director of Nursing (DON) stated she would have expected the CNA to keep a hand on Resident #13 knowing the resident had been agitated and squirming in the wheelchair. The DON stated she would have expected the CNA to have read the Behavior Protocols but since it was the first day of work for Staff A, she probably had not had time to read these. When questioned about whether she felt that this had been a lack of supervision, the DON agreed that it amounted to lack of supervision because Staff A did not pay attention to Resident # 13 but watched the other CNA. An additional interview with the DON on 4/4/12 at 4:05 PM revealed a CNA should receive 6 days of orientation, 2 days of which are suppose to be with a mentor. The DON identified Staff B not to be a mentor. The DON stated she would have expected Staff A to just watch on the first day. The DON did not know if anyone had told Staff A to only watch. The DON stated there is nothing in writing that directed the new CNA to watch only. 2. According to the MDS assessment dated [DATE] Resident #7 had [DIAGNOSES REDACTED]. The review of the MDS dated [DATE] revealed the resident required extensive assistance of 2 person physical assistance or transfers, limited assistance of 1 person physical assistance for hygiene, and extensive assistance of 1 person physical assistance for part of the bath. Review of the care plan dated 2/2/12 revealed the care plan directed the staff to assist the resident with baths to provide cues and encourage for the resident to wash him/herself. The care plan directed the staff the resident required 1-2 assist with transfers and always use 2 in the bathroom. Review of the facsimile dated 12/25/11 to the resident's physician that the resident had a witnessed fall. The resident hit his/her head. The resident had reddened areas which included a 3 centimeter (cm) by 3 cm. area to the right forehead, a bruise on the right palm, and the left knee. Review of the Unusual Event Flow Sheet dated 12/25/11 at 7:00 a.m. revealed the resident slid off the whirlpool seat when being lowered out of the tub. The interventions put in place after the fall revealed the staff would not use the whirlpool until the seat belt to the seat got fixed. The screw had become missing for the belt to latch to the seat. Review of the Fall Investigation for CNA ' S dated 12/25/11 revealed the resident slid out of the whirlpool chair and landed face forward on the floor. The fall was witnessed. The thing that could have been done to prevent the fall from happening was if the whirlpool chair had a working lap belt. Review of the Nursing Notes dated 12/25/11 at 11:00 a.m. revealed the resident had a witnessed fall that morning. The resident hit his/her head and obtained a 3 by 3 area of redness to the right forehead. The skin stayed intact and the resident also received bruising to the left knee and the right palm (near thumb) became slightly bruised. The resident complained of pain. On 4/4/12 at 9:28 a.m. Staff D (Certified Nursing Assistant stated that she and another CNA (Z), took the resident to the restroom. The resident saw the whirlpool and wanted to take a bath. Staff C and Staff Z undressed the resident and transferred the resident from the wheelchair to the whirlpool seat. The staff saw the belt would not buckle and the resident really wanted a bath so both the staff decided to go ahead and give the resident the whirlpool bath. Staff D stated when they were transferring the resident out of the whirlpool and when the seat became positioned midway down to the floor, the resident's feet did not touch the ground and the resident became confused and began to lift him/herself up to stand, Staff Z put his hand on the resident to try to stop the resident from falling. Staff D stated she stood approximately 3 feet away to get a towel for the resident. She stated Staff Z could not stop the fall and the resident fell forward out of the whirlpool seat. Staff D stated she tried to tell the resident he/she could not have a whirlpool, the resident wanted one, and at that time Staff C stated she was passive and wanted to make the resident happy. The review of the facility's whirlpool Preventive Maintenance Procedures revealed the procedures instructed the staff that the safety belts are subject to wear and deterioration over time and required periodic replacement. The staff needed to check the condition of the seat belt and beat buckle for signs of damage or wear especially at the grommet area. The staff needed to replace the belt at the first sign of deterioration or separation of the coating material from the webbing. 3. According to the MDS assessment dated [DATE], Resident #5 had [DIAGNOSES REDACTED]. The assessment documented the resident displayed total dependence on staff for transfers and utilized an indwelling urinary catheter. The resident's care plan dated 2/2/12 directed staff to transfer him/her using a Hoyer lift. Observation on 4/2/12 at 4:45 p.m. revealed Staff A (certified medication aide or CMA) and Staff B, CNA transferred Resident #5 from his/her bed to the wheelchair. During the transfer, the resident's catheter tubing became coiled completely around his/her left foot. Once the resident sat in the wheelchair, Staff A took the resident's catheter bag and pushed it under the resident's wheelchair seat towards the back of the chair. The tubing, coiled around the resident's foot, impeded the movement of the bag, but Staff A continued to attempt to push the bag through. At that point, the surveyor and DON (observing in the room) intervened and notified Staff A of the tubing coiled around the resident's foot. During an interview on 4/3/12 at 2:45 p.m., the DON stated that with placement of a Quality Assurance Nurse, the facility would be doing more audits and monitoring of resident transfers.