Every finding on record at Azria Health Prairie Ridge

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to provide incontinence care for Resident #10 (1 of 3 residents reviewed for incontinence care) after an episode of urinary incontinence and before dressing the resident in clean clothing. The facility reported a census of 53 residents.Findings include:Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE] showed diagnoses of non-Alzheimer's dementia and muscle weakness. The score of 5 out of 15 on the Brief Interview for Mental Status (BIMS) indicates severe cognitive impairment. Resident #10 is frequently incontinent of urine and requires partial/moderate assistance for toileting hygiene.The Care Plan for Resident#10 dated 7/13/2, directed the assist of one staff for toileting, and to clean the resident's peri-area with each incontinence episode.During an observation on 7/8/26 at 11:41AM, Staff A, Certified Nurse Aide (CNA) and Staff B, CAN, donned gloves and placed a gait belt around Resident #10 to assist with a transfer from her bed to the wheelchair. Resident #10's clothing and bed noted to be soaked with urine. Staff A and Staff C took the resident to the bathroom, while Staff B changed the bedding. Staff C, CNA removed all for Resident #10's clothing, and assisted the resident with putting on a clean brief and clothing. After the resident finished with using the toilet, Staff A offered to wipe the resident. Resident #10 attempted to wipe herself and then said she needed help. Staff A used dry toilet paper to wipe the residents back side. Without providing incontinence/skin care, staff assisted the resident with fastening her clothing and transferring the her back to the wheelchair. During an interview on 7/8/26 on 2:03 PM, Staff D, Certified Medication Aide reported staff are expected to complete incontinence care after each time a resident is incontinent. During an interview on 7/8/26 at 3:40 PM, the MDS Coordinator and current Interim Director of Nursing (DON) reported the Care Plan said staff needed to do incontinence care after each incontinence episodes. During an interview on 7/9/26 at 12:15 PM, Staff A, CNA reported the staff were expected to toilet residents every 2 hours or check and change them every 2 hours. Staff A said at times it can take longer. Staff A confirmed she did not provide incontinence care to Resident #10 after her clothing was changed due to being wet from urine incontinence. Review of the facility policy titled Perineal Care dated 3/2023, revealed a Purpose statement which declared: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.

Based on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to accurately assess and implement a physician order to prevent the worsening of a moisture associated skin damage (MASD) wound for 1 of 2 resident (Resident #18) with a history of MASD. The facility reported a census of 57 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #18, dated 10/14/25, identified an admission date of 10/8/25. The Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicated a moderate cognitive impairment. The diagnoses list included diabetes, incontinence without sensory awareness and morbid obesity. The assessment identified the resident had moisture associated skin damage (MASD).The BIMS completed for the 4/9/26 MDS indicated intact cognition based on a score of 15 out of 15.Review of Resident #18 Care Plan dated 10/31/25, revealed a Focus area to address I have frequent redness irritant to skin folds that require antifungal treatment as needed. Interventions initiated on 10/31/25 included, in part: Treatments as ordered.A review of the October 2025 Treatment Administration Record (TAR) revealed the following: Weekly skin assessments Q (every) Wednesday every day shift. Order Date: 10/8/25.Review of the electronic health record (EHR) revealed Skin Check notes with assessments occurred on the following dates.a. 4/8/26 - N Adv-Skin Check note.#001: New skin issue. Location: Left lower quadrant midline.Issue type: Abrasion. Progress: New wound. Wound acquired in-house. Length (cm): 0.6 Width (cm): 0.4 Depth (cm): 0 Granulation: 100%. Cleansing solution: Generic wound cleanser. Other primary dressing: border gauze.1. Review of EHR revealed a Nurses Note dated 4/8/26 at 1:13 PM: Order to keep skin ABD abrasion clean, dry and open to air.b. 4/15/26 - N Adv-Skin Check note.No new skin issues identified. #001: Skin issue is resolved. Location: Left lower quadrant midline.1. Review of EHR revealed a [name of clinic redacted] Office/Clinic Notes dated 4/16/26 which documented, in part: .History of Present Illness.She [Resident #18] expresses concern about a wound with steroids left.Physical Exam.SKIN: Warm, perfused, and dry. LLQ (left lower quadrant) abrasion, left inner thigh wound, moist, fluid filled intact blisters. Assessment/Plan.5. Open wound of left thigh, inner.I reached out [doctor name redacted] for treatment options, current treatment is marathon wound dressing, area constantly moist d/t (due to) incontinence.2. Review of a Physician Order dated 4/16/26 revealed: Left inner thigh wound: Clean wound with wound cleanser daily and if soiled; d/c marathon dressing; Start using Triad Cream BID and PRN if soiled; Make sure she is being check and changed frequently d/t MASD. 3. Review of the April and May 2026 Medication and Treatment Administration Record (MAR/TAR) revealed no order for left inner thigh wound cleansing daily and if soiled, or use of Triad cream BID and PRN if soiled. Marathon order discontinued 4/1/26. c. 4/22/26 - N Adv-Skin Check note.No new skin issues identified.d. 5/6/26 - N Adv-Skin Check note.No new skin issues identified.d. 5/13/26 at 8:41 AM- N-Adv Skin Check note.No new skin issues identified.1. Review of the EHR revealed a Nurses Note dated 5/13/26 at 2:02 PM: Resident has open area associated with MASD to right buttock and has scratched and reopened previous area on inner left thigh. Buttock measures 0.3 cm x 0.4 cm. Inner thigh measures 1.9 cm x 0.6 cm. Cleaned with wound cleanser and applied house zinc.On 5/13/26 at 7:49 AM, during an interview, Staff C, Registered Nurse identified herself as the facility wound care nurse. She explained the floor nurses were responsible for the resident's weekly skin assessment if the resident did not have any wounds. Staff C reported Resident #18 did not currently have wounds, but the resident did have a thigh wound that would come and go. On 5/13/26 at 9:14 AM, during an interview, Resident #18 reported two wounds, one on her left thigh and a sore on her bottom. She thought the wound on left thigh was getting better, and reported sometimes it was closed and sometimes the wound was open. Resident #18 thought both the wound on her bottom and upper left thigh were from wearing the smaller size incontinent briefs and the briefs rubbing against her skin. Resident #18 explained the facility did not order the right size brief in a previous order. Resident #18 reported the nurse had not been in that morning to assess her wounds. On 5/13/26 at 9:27 AM, during an interview, Staff L, Licensed Practical Nurse (LPN) reported she was the floor nurse this day for Resident #18. She reported the resident was due for a skin assessment today and she would get the State Agency (SA) when it was time. Staff L reported the Certified Nursing Assistants (CNA) were good about letting her know if residents had any skin issues, and nothing had been reported to her yesterday when she worked with Resident #18.During an observation on 5/13/26 at 10:11 AM, Staff L, Licensed Practical Nurse (LPN), entered the room to assess Resident #18's skin and donned gloves. Staff L identified two wound areas. Staff L measured an open upper right coccyx wound at 0.3 centimeters (cm) in length and 0.4 cm in width and had shallow depth in appearance. Staff L described there is a scabbed area above the open wound on the coccyx. Staff L measured the open left inner thigh wound at 1.9 cm in length and 0.4 cm in width. The left inner thigh wound had a scabbed area similar in size above the open area. Staff L then sprayed the wounds with wounds cleanser and applied zinc oxide to each area.Review of May 2026 MAR/TAR revealed the following orders for skin and wound care:a. Miconazole Powder (Miconazole) Apply to effected area topically as needed for redness BID. Order Date: 10/29/26. Administered on 5/1/26 and 5/6/26.On 5/13/26 at 3:34 PM, during an interview, Staff G, LPN, reported she had worked at the facility for 3 weeks and had provided wound treatment to Resident #18 in the last three weeks. Staff G reported the CNAs had reported wound concerns more than once regarding Resident #18. Staff G reported she would check out the concerns every time. Staff G reported the resident had wound to her thigh area. The resident complained about the wound and about it hurting her a lot. The wound looked like an old wound with scabs and open areas. Staff G reported she only saw one wound on the left upper inner thigh, and did not see any weeping from the wound. Staff G reported she gave the resident Tylenol one time for pain related to the wound. Staff G reported she did try to document in the progress notes when she looked at wounds. Staff G reported she did not notify anyone else that the wound was open. Staff G explained there was already ongoing wound treatment.During an interview on 5/13/26 at 3:24 PM, the Director of Nursing (DON) explained floor nurses were responsible for completing skin assessments on residents every week. Residents with wounds were seen by Staff C, RN, every Wednesday. The DON reported she reviewed Staff C's notes and compared the notes to the previous week. The DON reported if see saw that a wound was stalled, she would fax the resident's physician. The DON added the facility's ARNP came to the facility and reviewed wound documentation every Thursday. On 5/14/26 at 8:05 AM, during an interview, Staff C, RN stated that she had been treating Resident #18 left inner thigh wound off and on. Staff C, RN stated the wound would heal, and the resident would scratch the area and it would reopen. Staff C explained seeing fingernail marks from where the resident had scratched the left inner thigh on occasion. Staff C, RN, reported she did not consider a scab over a wound as healed. Staff C explained when she assessed the thigh wound had healed, the skin might have been discolored, but the skin was intact. Staff C reported the last time she had assessed the resident's left inner thigh was when the resident was getting the Marathon treatment. Staff C explained if the treatment was discontinued, then the wound was healed. Review of the April MAR/TAR revealed Marathon order discontinued 4/1/26. During an interview on 5/14/26 at 11:05 AM, Staff V, ARNP (Nurse Practitioner), reported she was one of a group of three nurse practitioners for the facility. They all worked together to share responsibility of the residents. Staff V reported she wanted to be notified as soon as nursing staff found a wound. Staff V explained there was a process for the facility to send a fax to the provider group, and the group would send a fax back. Nursing staff could also call if the resident had concerns that needed to be addressed that day. If a resident had a new open wound, or a change with a current wound, the ARNPs would give a new treatment order. Staff V explained it was not okay for nursing staff to do a wound treatment without an order first. Staff V did think it would be okay to use a PRN order for Zinc Oxide or barrier cream if a resident had some excoriation from incontinence. Staff V stated she would assess Resident #18 today. At 11:35 AM after assessing Resident #18, Staff V, ARNP reported the resident left thigh wound looked worse compared to the assessment on 4/16/26 completed by another ARNP. Staff V stated the Zinc Oxide treatment was not going to be effective. Staff V reviewed Resident #18 seen on 4/16/26 for a 60 day follow up visit and at that time was found to have one intact left inner thigh wound with fluid filled blisters. Staff V stated after the assessment the ARNP faxed a new order to the facility for: to discontinue the Marathon wound treatment, clean the wound with wound cleanser, apply Triad cream BID and PRN if soiled, and to make sure to check and change (resident's incontinent brief) due to maceration. Staff V reported she had not assessed the resident's coccyx wound on the visit today.Review of a document titled Final Report dated 5/14/26 revealed, in part: Chief Complaint: Acute Visit - Wound management. History of Present Illness: .The last wound treatment ordered on 4/16/26, which included cleaning the wound with wound cleanser daily and applying Triad twice a day. Upon assessment of the wound today, it was found to be larger with slough present. There was no redness or warmth noted in the area during today's assessment. I am changing the wound treatment orders to mupirocin and mometasone mixed 50-50 and applied to the wound bed covered with gauze and tape. Dressing to be done daily and as needed if soiled. On 5/14/26 at 11:52 AM, during an interview with the DON and Unit Manager, the Unit Manager reported they did receive the reports from the ARNP and physician visits via a fax system. The Unit Manager explained they usually received the reports the next day. The Unit Manager found the 4/16/26 visit note for Resident #18 in their electronic fax system. The visit and orders had not been pulled from the fax system.On 5/14/26 at 12:11 PM, during an interview, Staff C, RN, reported when she documented that she had assessed Resident #18 skin on 4/15/26, she would have done a full skin assessment and assessed the resident's left thigh. She explained the blisters could develop quickly and she did not see them on 4/15/26. Staff C did not remember doing the resident's skin assessment on 5/6/26. She explained that if she documented she did a skin assessment, then she did it. She then stated that she did the best that she could, and sometimes she could not see everything. On 5/14/26 at 4:22 PM, the DON reported she had been told by the wound nurse that Resident #18's left thigh wound had healed a couple days after the DON started to work at the facility, about six weeks ago. The DON reported she had only had access to the electronic faxes the last couple weeks, and the Unit Manager had showed her how to access them. Review of the facility policy, titled Medication and Treatment Orders dated July 2016 revealed a Policy Statement which declared: Orders for medications and treatments will be consistent with principles of safe and effective order writing. The Policy and Interpretation and Implementation section directed, in part:1. Medications and Treatments shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.Following Orders - Physician orders shall be followed, if unable to follow physician orders, notify Director of Nursing Services/ Designee and physician as appropriate. Review of the facility policy titled Wound Care dated October 2010, revealed a Purpose Statement which declared: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The Preparation order directed:1. Verify that there is a physician's order for this procedure.2. Review the resident's care plan to assess for any special needs of the resident.a. For example, the resident may have PRN orders for pain medication to be administered prior to would care.

Based on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to maintain a clean, odor free, comfortable and homelike environment in 31 of 32 resident rooms, 2 of 2 shower rooms, and 2 of 3 hallways throughout the facility. The facility reported a census of 57 residents.Findings included: 1. During a continuous observation from 8:26 AM to 12:30 PM on 5/11/26 a walk through completed for all resident rooms. The facility had a total of 32 resident rooms, with 16 rooms on the 100 Hall (East); 15 rooms on the 200 Hall (South) and one room on the 300 Hall (West). During the observation the following noted: a. Room entrances missing a transition strip, discolored yellow, brown and black with dirt particles embedded in rooms: 101,102, 103, 106, 107, 108, 109, 111, 112, 114, 117, 119, 202, 204, 205, 206, 207, 210, 211, 212, 214, 215 and 217. b. Black marks on and/or across the lower part of the resident room doors and frames in rooms: 104, 106, 107, 109, 111, 112, 115, 116, 117, 119, 201, 202, 204, 206, 210, 211, 214 c. Walls with scrap marks into the dry wall behind resident beds and/or chairs in rooms: 101, 102, 104, 105, 106, 107, 109, 111, 112, 114, 116, 119, 201, 204, 206, 208, 209, 215, 217 d. Stained and discolored flooring tiles in the resident rooms and bathrooms in rooms: 101, 103, 109, 111, 112, 115, 116, 119, 209, 210, 212, 215 e. Yellow, brown and black ring around the base of the toilet in rooms: 101, 103, 104, 105, 109, 111, 112, 115, 201, 202, 204, 207, 208, 210, 212, 214, 217 f. Missing basecoat (the foundational first layer of a coating system applied to seal the floor surface) on strip of flooring along the wall under the window leaving a dirt build up on the strip in rooms: 101, 102, 103, 104, 105, 106, 107, 109, 111, 112, 114, 115, 116, 117, 119, 202, 204, 206, 207, 208, 209, 210, 212, 215, 217 g. Dirt particles and particles of other unknown substances on floors in resident rooms, pieces of paper and/or tissue, and other trash items, and/or spiders/spider webs in rooms: 101, 102, 103, 104, 105, 106, 107, 108, 109, 111, 112, 119, 201, 204, 209, 214, 217 h. Persistent urine odors in the bathrooms of rooms: 202, 204, 207, 208, 212, 217; and in the 200-hall shower room. i. Dirt build up in corners of room and/or bathroom in rooms 101, 105, 107, 106, 109, 112, 117, 119, 202, 204, 206, 207, 208, 212, 214, 215, 217 j. Missing piece of floor tile in rooms: 101, 103, 104, 208 (bathroom), 212, 214, 215, 217 k. Holes in resident doors or in rooms: (bathroom door), 215 l. Broken dry wall on ceiling in rooms: 208, 210 m. Leaking/running toilets or faucets in bathrooms of rooms: 101, 109, 112, 114, 207 n. Conduit box hanging loosely and not secured in resident's wall in rooms: 109, 114, 217 o. Pieces of anti-slip strips peeling and missing in rooms: 101, 106, 112, 117, 204, 208, 212, 217 In addition, the 100 and 200 hallways noted to have multiple scraps and black marks above and below the handrails. The shower room in the 100 Hall had dirt and dust build up with a hair ball on floor near the entrance to the shower room and multiple stained/discolored tiles on the shower floor. The entrance to the beauty salon in the 200 Hall lacked a transition strip, and was discolored with yellow, brown and black stains and dirty in appearance. The shower room in the 200 Hall had scraps across the outside of the lower part of the door, several yellowish-brown discolored tiles, on the floor and around the lower edges of the shower, dirt particles on the floor near the entrance way, During an interview on 5/11/26 at 8:33 AM, Resident #13 reported housekeeping staff had only been cleaning the rooms once per week. She stated the facility had hired some new housekeeping staff, and she thought this was getting better and they were cleaning more often. The Minimum Data Set (MDS) assessment dated on 4/9/26 revealed Resident #13 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. During an interview on 5/11/26 at 8:49 AM, the Housekeeping Manager reported she had been working at the facility for one month. She explained that she worked 5 days per week, every other weekend. She explained there were two housekeepers working now, but the first two weeks she worked at the facility, she had to clean the resident rooms in the 100 and 200 hallways by herself. During an interview on 5/11/26 at 11:40 AM, Resident #7 stated the ceiling above his bed had needed repaired for at least 8 months. Resident #7 explained the roof had leaked at the facility and caused the damage to the ceiling. The ceiling noted to have a 2 foot in length by 1 foot in width opening into the dry wall with a piece of the dry wall hanging over the resident's bed. The MDS dated [DATE] revealed a BIMS score of 15 out of 15 which indicated intact cognition. During an interview on 5/11/26 at 12:07 PM, during an interview, Resident #20 reported she had been missing a piece of flooring and there had been scraps on the wall behind the bed for as long as she had been in the room; she was unsure how long she had been in the same room. The MDS dated [DATE] revealed a BIMS score of 15 out of 15 which indicated intact cognition. During an observation on 5/11/26 at 2:24 PM revealed: a. room [ROOM NUMBER] – the basecoat (top layer) of the flooring missing on a strip under the air conditioning unit and along the window leaving a buildup of dirt; a ring of discoloration noted around the toilet base; and a strong urine odor in the bathroom. b. room [ROOM NUMBER] – transition strip missing, floor discolored and dirty in appearance; trim board near the entrance with dried gray water marks present; grout and floor tiles discolored; discolored ring around the base of the toilet; and yellow & brown stains in sink. c. room [ROOM NUMBER] - the basecoat missing from the flooring on a strip along the wall under the window leaving a dirt build up and discolored appearance; a discolored ring around the base of the toilet with the caulk between the toilet base and floor cracked with pieces missing; and a buildup of dirt in the corners of bathroom floor. During an observation on 5/12/26 starting at 12:27 PM: a. room [ROOM NUMBER] – cover to the call light missing. b. room [ROOM NUMBER] - floor discolored at entrance; black marks across the lower part of the room door; a strip of flooring missing along the wall under the air conditioner unit; and discolored black ring around the base of the toilet. During an interview on 5/12/26 at 2:50 PM, the Maintenance Director reported she had started at the facility in September of 2025. The Maintenance Director explained she entered all repairs needed at the facility in an electronic tracking system. The Maintenance Director reported answering to a Regional Maintenance Manager. Upon reviewing the strip of flooring missing the basecoat in room [ROOM NUMBER] with the Maintenance Director, she reported the flooring needed a deep cleaning and that she had been aware of the concern existing in several of the resident rooms. The Maintenance Director reported the transition strips had been missing from the room entrances when she started at the facility and they were waiting on the hardware to install the strips. She reported being unaware of the discolored, stained appearance around the base of many of the resident's toilets. The Maintenance Director stated she did not know if there were any plans to replace flooring in residents' rooms. She stated she did not know there were some electrical conduit boxes not mounted in resident rooms. When asked if the boxes should be mounted into the resident's wall, the Maintenance Director said that was a good question. She had found a couple conduit boxes not secured and did secure them. The Maintenance Director had noticed the black marks on the walls. She explained she cleaned what she could and did patching and painting. She reported she planned to do another audit and paint and clean. The Maintenance Manager reported she had done two quarterly resident room inspections since starting at the facility in September of 2025. She explained she had done painting and dry wall patching. She stated that when a resident discharged , she tried to go into the room to get repairs done. The Maintenance Director reported she had redone the Administrator's and Director of Nursing's offices. On 5/13/26 at 7:42 AM, during an interview, the Administrator reported they had been using a contract company for housekeeping services, but they had problems with staff not showing up. The Administrator reported she had hired housekeeping staff and a manager for housekeeping and laundry. During an interview on 5/13/26 at 7:52 AM, Staff T, Housekeeping, stated she worked 5 days a week and every other weekend. Staff T reported during the week, she cleaned one hall, and another staff cleaned the other hall. On the weekends, Staff T reported she had to clean the whole facility. Staff T felt this was impossible, and she had too skimp. Staff T explained she had to do a quicker job and did not do as much. On the weekends she cleaned the resident's bathrooms, emptied their trash, cleaned any messes on the floor or tray table. Staff T clarified that she tried to mop the resident's floors, but did not have time to do the floor in every resident's room. She reported one of the housekeeping staff tended to call in when she was scheduled to work on the weekend. Staff T stated when she comes into the facility after the worker had called in, the trash would be over full, the rooms messy and there would be spills on the hallway floor. Staff T reported the facility was still hiring housekeeping staff and had hired a new manager. Staff T identified three resident rooms that smelled strongly of urine – rooms 202, 204 and 215. Staff T reported the facility was out of the chemical enzyme spray that they used to remove the urine smell, and they had been out of the spray for about a month. Staff T reported the facility just implemented a new daily and weekly cleaning schedule; housekeeping staff were supposed to start picking one room to deep clean daily. On 5/13/26 at 11:32 AM, during an interview, the Regional Maintenance Manager reported being in his position for about 3 years. He reported trying to make routine visits to the buildings, and had 9 buildings under his responsibility. He reported another Regional Maintenance person visited the facility about 3 weeks ago for him. The Regional Maintenance Manager reported being unaware of what had been identified as needed repairs and had not looked at the itemized list compiled by the facility's Maintenance Director. The Regional Maintenance Manager explained he had not done rounding for 6 months due to covering the maintenance position at one his buildings that did not currently have a Maintenance Director. On 5/18/26 at 4:00 PM, during an interview, the Administrator reported not having any control over when maintenance items would get replaced or fixed in the facility. During an observation on 5/12/26 at 8:35 AM, the 100 Hall and 200 Hall had a strong smell of urine. Housekeeping mopping floors in Hall 200 and housekeeping mopping the floor in a room on Hall 100. During an observation on 5/13/26 at 8:22 AM, walked the hallways (100 and 200) and the smell of urine strong to the point of taking one's breath away. During an observation on 5/13/26 at 12:56 PM, a strong urine smell in the 200 hallway between rooms 201 to 204. During an interview on 5/13/26 at 9:22 AM, a family member of Resident #6 stated the facility smelled of urine all the time. The family member stated she told the staff they were nose blind because they were at the facility all the time. She stated facility being dirty was her biggest concern and her mother's bathroom was always disgusting. During an interview on 5/13/26 at 1:06 PM, Staff J, Certified Nurse Aide (CNA) queried on the urine odor and Staff J stated some rooms it is worse like the bathroom in room [ROOM NUMBER]. Staff J stated she did notice the smell a lot. During an interview on 5/13/26 at 1:40 PM, Staff I, CNA asked if she noticed a urine odor and Staff I stated yes, it was a hit and miss and pretty much everywhere. Staff I asked what she thought caused the urine odor and Staff I stated not getting the facility cleaned very well. Staff I stated up until 2 weeks ago, the facility only had one housekeeper for the whole facility. During an interview on 5/13/26 at 2:04 PM, Staff H, CNA stated the urine odor was very bad and everywhere. Staff H stated certain rooms were worse, especially room [ROOM NUMBER] bathroom was really bad. During an interview on 5/14/26 at 9:48 AM, the Housekeeping Lead queried about the urine odors and she acknowledged the odor and stated when she mopped 200 Hall she took extra time so the smell was not so powerful. The Housekeeping Lead stated she also took extra time cleaning the floors and walls in 3 rooms on the 200 Hall. The Housekeeping Lead stated she cleaned the rooms daily and the aides would let her know if they needed cleaned again due to the smell being overpowering. The Housekeeping Lead acknowledged the smell got bad, but stated she can't stay in the rooms all day, and the staff tried their best. Review of the facility policy, titled Work Orders, Maintenance, dated 4/2010, revealed, in part, .Maintenance work orders shall be completed in order to establish a priority of maintenance service .Works order requests will be completed in a facility specific maintenance portal . Work orders will be prioritized and followed up as indicated .Emergency requests will be given priority in making necessary repairs.

Based on employee record review, facility policy review, and staff interviews, the facility failed to complete a thorough background check for 1 of 5 employees reviewed for background checks. The facility reported a census of 57 residents. Findings include: Review of the employee record for Staff A, Registered Nurse (RN) revealed a start date of 7/16/25. The Single Contact License & Background check (SING) dated 7/14/25. revealed: Child Abuse: Initiate record check evaluation process by completing form [PHONE NUMBER] and submitting to HHS (Health and Human Services) The employee file lacked documentation of any further documentation for the evaluation of child abuse. During an interview on 5/14/26 at 2:57 PM, the Business Office/Human Resource Manager queried on Staff A SING report and she stated she missed the child abuse section. She stated she reviewed the dependent abuse and sex offender sections. The Business Office/Human Resources stated the facility suspended Staff A and the facility submitted for the record evaluation and asked it to be expedited. The Business Office/Human Resource Manager stated she intended to review all staff SIGN to make sure nothing else missed. During an interview on 5/14/26 at 4:20 PM, the Administrator queried on Staff A SING and she stated she due to where the child abuse was located on the paper, her staff missed it, and the facility would go back and review all the staff files to make sure they didn't miss anyone else. Review of the undated policy titled Background Screening Investigations Policy revealed:a. The director of human resources, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated with offer of employment or contract agreement, and completed prior to employment.b. Should the background investigation disclose any misrepresentation on the application form or information indicating that the individual has been convicted of abuse, neglect, mistreatment of individuals, and/or misappropriation of property, the applicant is not employed or contracted.c. Any information (e.g., court actions) discovered through the course of the background investigation that indicates that the applicant is unfit for employment in a nursing home (for example, convictions involving child abuse, sexual assault, theft, assault with a deadly weapon, etc.) is reported to the individual's appropriate licensing boards.

Based on observation, facility policy review, resident and staff interview, the facility failed to maintain a safe and homelike environment by ensuring the metal guard was in place over the heating elements of a baseboard heater in the dining room and front sitting room located inside the main entrance of the facility and failed to ensure a the replacement of the molding trim at the base of a window in the dining room. The facility reported a census of 57 residents. Findings included: Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 3/12/26, revealed a Brief Interview for Mental Status score of 15 out of 15, which indicated intact cognition. During an interview on 5/11/26 at 12:07 PM, Resident #7 reported being upset about conditions in the dining room. Resident #7 explained that there was a piece of missing window trim molding for a window in the dining room and the guard was missing for the baseboard heater in the dining room. Per the resident, both items had been missing for more than a year. During an observation on 5/11/26 at 1:55 PM in the main dinging room, one window noted to missing the bottom piece of window trim molding. The outline from where the missing piece had been was visible. The baseboard heater located on the north dining room wall noted to be missing a metal guard and exposed heating elements. The baseboard heater located on the north wall in front main sitting area noted to have a bent metal guard which exposed the heating elements. The baseboard heaters were not operating during the observation.Review of the Work Orders, titled Open and in Progress Work Orders, dated 5/12/26, revealed no work orders related to the missing window trim in the dining room, or the missing metal guard on the baseboard heater in the north dining room, or the bent metal guard on the baseboard heater in the front entrance sitting area. During an interview on 5/12/26 at 2:50 PM, the Maintenance Director reported she had started at the facility in September of 2025. The Maintenance Director explained she entered all repairs needed at the facility in an electronic tracking system. She reported being unaware of the missing window molding trim in the dining room and missing metal guard for the baseboard heater in the dining room. The Maintenance Director reported the facility did use the baseboard heaters in the winter time and stated It's a safety risk to have the metal heating element exposed. She stated she had fixed the bent guard on the baseboard heater in the front sitting area in the past, but was unaware the guard was bent again. The Maintenance Director reported answering to a Regional Maintenance Manager.During an observation on 5/13/26 at 9:36 AM, the metal guard on the baseboard heater in the front sitting room baseboard heater bent back into place. The dining room baseboard heater had chairs, table and caution tape placed in front of the area with the missing metal guard for the baseboard heater.During an interview on 5/13/26 at 11:32 AM, the Regional Maintenance Manager reported being in his position for about 3 years. He reported trying to make routine visits to the buildings, and had 9 buildings under his responsibility. He reported another Regional Maintenance person visited the facility about 3 weeks ago. The Regional Maintenance Manager reported being unaware of what had been identified as needing repairs and had not looked at the itemized list compiled by the facility's Maintenance Director. The Regional Maintenance Manager explained he had not done rounding for 6 months due to covering the maintenance position at another one his buildings that did not currently have a Maintenance Director. During an interview on 5/18/26 at 4:00 PM, the Administrator reported not having any control over when maintenance items would get replaced or fixed in the facility.Review of the facility policy, titled Work Orders, Maintenance, dated 4/2010, revealed, in part, .Maintenance work orders shall be completed in order to establish a priority of maintenance service .Works order requests will be completed in a facility specific maintenance portal . Work orders will be prioritized and followed up as indicated .Emergency requests will be given priority in making necessary repairs.

Based on observation, record review, staff interviews, and the facility policy, the facility failed to ensure ongoing, personalized interventions for residents to address alcohol consumption by residents at the facility and to address alcohol being shared between residents at the facility for 4 of 4 residents reviewed (Resident #2, Resident #3, Resident #13, and Resident #19) for alcohol use; failed to keep a medication secured in a medication cart resulting in a resident accessing a topical pain relief medication with possible ingestion of the medication per facility staff for 1 of 4 residents reviewed for inadequate nursing supervision (Resident #10); and failed to conduct a smoking evaluation during admission for 1 of 4 residents reviewed for smoking (Resident #12). The facility reported a census of 57 residents. Findings include:1. The Minimum Data Set (MDS) assessment dated on 4/9/26 revealed Resident #13 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated resident independent with mobility. The MDS revealed medical diagnosis of depression, alcohol use unspecified, and revealed the resident took antidepressant medications. The Care Plan revealed a focus area revised on 2/16/26 revealed, in part, the following: The resident had alteration in mood and behaviors aeb (as evidenced by) yelling/cursing at staff and refusing cares at times. Is often noncompliant with plan of care. Resident often goes out of the facility and returns appearing to be intoxicated. It is suspected that she hides alcohol in her belongings as well as she frequently returns with bags full of clothing and grocery items.The Care Plan interventions dated 1/8/26 indicated if resident appeared to be intoxicated staff to monitor in order to keep her safe and keep other residents safe. Notify PCP (Primary Care Provider) and hold meds as needed. The interventions dated 2/16/26 revealed on 2/16/26 over the previous weekend resident noted to have consumed alcohol. PCP notified and medications held as ordered. The interventions dated 5/11/26 indicated resident sent to ER (Emergency Room) on 5/11/26 for treatment for being intoxicated, MD (Medical Doctor) notified with orders to obtain a blood alcohol and to hold medications. The Care Plan did not address interventions to try to prevent resident from drinking at the facility or bringing in alcohol. The Nurses Notes dated 2/16/26 at 12:02 PM revealed resident started drinking on Friday February 13th and continued to drink until Sunday February 15th. Medications were held throughout the weekend. Resident was stable and monitored over the weekend. No signs/symptoms (s/s) of distress. Was no disruptive with staff or peers. Sending this note over to PCP with copy of MAR (Medication Administration Record) to update with medications that were held.The Behavior Note dated 2/16/26 at 4:09 PM revealed writer met with Resident #13 today. She noted that she did consume alcohol over the weekend, and she did notify to nurse. MD (Medical Doctor) aware. She states that she does not want any other psychotherapeutic follow up. Re education provided, d/c (discharge) still in progress with [name redacted] regarding placement.The Nurses Note dated 3/12/26 at 2:54 PM revealed resident was observed pouring vodka into a drinking cup with red juice into it. This nurse explained to her we would be holding her medications while she would be drinking. Resident stated she thought she was still taking an antibiotic. This nurse stated if she was we would hold it and finish the antibiotic if that is what the provide wanted. Sending this note over to update provider on resident and current activities. Will re-start medications in AM if resident is no longer consuming alcohol.The Nurses Note dated 3/13/26 at 9:25 AM revealed medications held on 3/12 and 3/13. Nurse stated that he held her medications due to showing visible signs of being intoxicated. Resident denied drinking but was stumbling down hallways and being loud. Resident was laughing and her face was flushed. She was carrying around a cup he assumed to be a mixed drink. Resident is own POA (Power of Attorney). Sending fax to PCP. Nurse did say he called the PCP and notified. Just sending for follow up.The Nurses Note dated 5/11/26 at 5:15 PM revealed the resident was noticed to be stumbling while ambulating and slurred speech. able to move all extremities. Alcohol was smelled on residents' breath. MD was notified with orders to hold medications and send to ER for blood alcohol level. Ambulance was called, arrived and transferred resident to [name redacted hospital] for treatment. resident was noncompliant with a full assessment and upset with staff due to sending her out for evaluation. 2.The MDS dated [DATE] revealed Resident #3 scored a 13 out of 15 on the BIMS exam, which indicated cognition intact. The MDS indicated medical diagnoses of Type II diabetes mellitus (DM), alcoholic cirrhosis of liver without ascites, alcohol use, anxiety disorder, depression, and post traumatic stress disorder (PTSD). The Care Plan revealed a focus area dated 8/29/25 which revealed the resident had alcoholic cirrhosis of the liver. The interventions dated 8/29/25 indicated encourage alcohol cessation. The Care Plan revealed a focus area dated 2/16/26 for alteration in mood and behaviors aeb resident sometimes drink alcohol when she had provider orders to drink only non-alcoholic beer. The intervention dated 2/16/26 indicated to notify PCP and hold medications as ordered when it is believed resident has consumed alcohol. The Nurses Note dated 2/15/26 at 5:10 PM, revealed at 8:50 AM, this AM while this nurse was taking the resident's blood sugar (BS), the resident stated, I did something bad. This nurse asked the resident what they meant. The resident stated, I was bad and I drank. The nurse asked the resident what she meant. The resident stated, I drank alcohol the other day. The nurse asked the resident if the alcohol was in the resident's room. The resident stated it wasn't in the room. This nurse asked where the resident had gotten the alcohol from and the resident stated, I can't tell you, I'm not a snitch. This nurse educated the resident on the poor outcome of these behaviors if continued with current health conditions/diagnoses and how the current medications could have adverse reactions with the use of alcohol.The Nurses Note dated 2/15/26 at 5:22 PM, revealed at 4:40 PM, this nurse was approached by a staff member that the resident was leaned over in the wheelchair observed to be sleeping at the dining room table. This nurse brought the resident out of the dining room to do a focused assessment. The resident was slurring their words, their cheeks were flushed, and the resident could not stay awake during the conversation. This nurse asked the resident if they had drank any alcohol to which the resident stated no. This nurse took vitals, BP (blood pressure) 116/72, HR (heart rate) 93, Temp (temperature) 98.2, O2 (oxygen) 98% RA (room air), respirs (respirations) 16, BS 310. On call provider, [name redacted], notified of situation. On call manager, [name redacted] notified.The Nurses Note dated 2/16/26 at 12:08 PM revealed resident had a peer supply her with alcohol on Friday February 13th and they continued to drink until Sunday February 15th off and on. Medications were held throughout the weekend. Resident was stable and monitored over the weekend. No s/s of distress. Was no disruptive with staff or peers. Sending this note over to PCP with copy of MAR to update with medications that were held.3. The MDS assessment dated [DATE] revealed Resident #2 scored a 9 out 15 on the BIMS exam, which indicated moderately impaired cognition. The MDS revealed medical diagnoses of stroke, hemiplegia/hemiparesis, and diabetes mellitus. Per the MDS, the resident took antidepressant and hypoglycemic medication.The Behavior Note dated 12/21/25 at 3:33 PM revealed at 3:30 PM this nurse watched resident [Resident #19] hand [Resident #2] a cup of amber liquid and look down the hall at me and turn around as [Resident #2] was taking a drink. This nurse headed up the hall and asked [Resident #19] if he gave [Resident #2] alcohol, [Resident #19] stated I dont know what he has. I held my had out to [Resident #2] and he placed the cup in my hand and it smelled of Alcohol, at that time I had the CMA (Certified Medication Aide) confirm that it smelled of alcohol and was disposed of in the sink and witnessed by [name redacted, Registered Nurse]. I discussed with [Resident #2] that he should not be drinking alcohol while he is here at the facility and he can discuss that with his family when he leaves in a few days, he verbalized understanding. Family was called and he asked to talk to family member. This nurse heard [Resident #2] say I don't know what was in the cup PCP notified.4. The MDS assessment dated [DATE] revealed Resident #19 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed medical diagnoses for anxiety disorder, depression, alcohol dependence, and alcoholic cirrhosis of liver without ascites. Per the MDS, the resident took antidepressant, antianxiety, and opioid medication. The Care Plan revealed a focus area dated 11/25/24 which revealed the following: There are days [resident] may become physically and/or verbally aggressive towards others secondary to: Poor impulse control. Non- compliant with alcohol policy. The Physician Orders revealed the following:The Physician Order started on 6/19/24 and discontinued on 4/14/26 revealed, NO alcohol consumption while resident is taking pain medication- every shift for monitoring.The Orders Administration Note dated 12/13/25 at 8:37 PM, revealed resident may have non alcoholic beers 2 beers daily one at noon and one at bedtime.resident did not ask for beer. The Administration Note dated 12/13/25 at 8:38 PM, revealed no alcohol consumption while resident taking pain medication- every shift for monitoring- resident seems to be intoxicated. Resident's breath smells of alcohol and pupils are approx. (approximately) 7-8mm (millimeters). DON notified, PCP faxed, medications held.The Nurses Note dated 12/13/25 at 8:42 PM, revealed resident seems to be intoxicated. Resident is slurring words, their breath smells of alcohol, pupils are approx 7-8mm. Only medications received this shift were PRN (as needed) promethazine, scheduled tylenol, and scheduled guaifenesin, all other medications held per nursing judgement. DON, [name redacted] notified, PCP notified.The Behavior Note dated 12/21/25 at 3:30 PM, revealed @1530 this nurse watched resident [Resident #19] hand [Resident #2] a cup of amber liquid and look down the hall at me and turn around as [Resident #2] was taking a drink. This nurse headed up the hall and asked [Resident #19] if he gave [Resident #2] alcohol, [Resident #19] stated I dont know what he has. I held my had out to [Resident #2], and he placed the cup in my hand and it smelled of Alcohol, at that time I had the CMA confirm that it smelled of alcohol and was disposed of in the sink and witnessed by [name redacted, Registered Nurse]. I discussed with [Resident #19] that he should not be drinking alcohol while he is staying at our facility to which he shrugged his shoulders. PCP notified, Hold meds.The Behavior Note dated 12/28/25 at 2:54 PM revealed resident upset because d/t (due to) weather residents can not go out to smoke. Resident said he would just call up one of his friends to bring him some alcohol since he cannot smoke because there is nothing we can do about it.The Nurses Note dated 1/3/26 at 9:40 AM revealed resident was yelling this AM in hallway about having to have a roommate. This nurse explained there is no other open room and he would have to find a way to get along. He continued to be upset and returned to his room. CMA x 2 could smell alcohol on him. PCP stated to hold his narcotics for 12 hours due to alcohol consumption, but ok to give HTN (hypertensive) medications. Resident is his own POA and aware.During an interview on 5/13/26 at 1:06 PM, Staff J, Certified Nurse Aide (CNA) queried on the alcohol policy and Staff J stated knew some residents could bring in things they wanted, and some had brought in alcohol. Staff J stated she knew the facility had non-alcoholic beer. Staff J stated she didn't know the rules but she would think the facility would keep in locked in the medication room. During an interview on 5/13/26 at 1:40 PM, Staff I, CNA queried about the alcohol policy and Staff I stated as far as Staff I knew, residents couldn't bring it in, but staff were not allowed to take it out of the resident's room. Staff I stated Resident #13 brought it in and shared it with others. Staff I asked if where the alcohol was located and Staff I stated sometimes it would be out in the open and other times hidden. Staff I stated Resident #13 gave the cup to the staff and when staff took the lid off, they could smell alcohol. Staff I stated there was nothing they could do about it except alert the nurse. During an interview on 5/13/26 at 3:33 PM, Staff G, Licensed Practical Nurse (LPN) stated she was not clear on the alcohol policy. Staff G stated Resident #3 and Resident #13 drink at the facility and Staff G was told Resident #13 left the facility and brought back alcohol. Staff G stated she never seen the residents drinking. During an interview on 5/14/26 at 12:23 PM, Staff F, LPN stated it was reported to her Resident #3 and Resident #13 drinking over the weekend in February. Staff F stated a CMA saw Resident #13 pour it. Staff F queried if resident could bring alcohol into the facility, and Staff F stated officially Staff F got different information. Staff F stated Resident #13 could bring it, but we always encouraged her to turn it over to the nursing staff and the previous Administrator had several conversations with Resident #13 on not bringing alcohol into the facility. Staff F stated when Resident #13 would leave the facility, staff would go into her room and clean up the dirty dishes and find plastic pitchers with red [brand name] juice and when they took off the lid, it smelled like vodka. Staff F stated the only concern she had with Resident #13 drinking was when other staff were on call and didn't notify the provider and hold her medications. During an interview on 5/14/26 at 1:16 PM, Staff B, LPN/Unit Manager stated the alcohol policy was to notify the doctor and tell the staff to hold the medications. Staff B stated there was a fine line between resident rights and taking it, hard to explain, in his opinion. Staff B stated the policy was that the facility is their home, and if the residents BIMS is 15 would monitor their behaviors and notify the PCP. Staff B stated the residents he knew who drank in the facility were Resident #3, Resident #13, and Resident #19. Staff B stated he hoped the residents care plan were updated. Staff B stated he didn't agree with the alcohol policy, but it was breaching resident rights to confiscate. During an interview on 5/14/26 at 3:43 PM, the Director of Nursing (DON) stated the alcohol policy was the facility received an order from the physician and the pharmacy needed notified on what meds needed to be held. The DON stated residents should not be drinking in the facility, and if residents were drinking, their medications should be held. The DON queried what if a cognitive impaired resident got ahold of the alcohol, and the DON stated she didn't know, they hadn't had that happen.During an interview on 5/14/26 at 4:20 PM, the Administrator queried about the alcohol policy and the Administrator stated the policy was for a physician order and the resident needed to purchase it. The Administrator stated they were providing information often and encouraged Resident #13 not to drink because of the interaction with her medications. The Administrator stated Resident #13 wouldn't allow the facility to go through Resident #13's things. The Facility Alcoholic Beverages Policy dated February 2023 revealed: A physician's order must be received before any alcoholic beverage may be administered to a resident.Alcoholic beverages must be paid for by the resident, his family, and/or the resident's representative (sponsor).The Nurse Supervisor receiving the alcoholic beverage must label the bottle.Should you have any doubt concerning the administration of the beverage to the resident, contact the Director of Nursing Services.5. The MDS assessment dated [DATE] revealed Resident #10 scored a 4 out of 15 on a BIMS exam, which indicated severely impaired cognition. The MDS indicated the resident used a wheelchair. The MDS revealed medical diagnosis for unspecified dementia, severe with anxiety. The Nurses Note dated 3/12/26 at 11:51 AM revealed called to staff. She reported that she saw resident take off the cart & squirt some ActiveIce (topical pain-relief product) in a cup and possibly put some in her mouth. When evaluated her, she smelled like ActivIce. Vitals signs stable. Call made to [name redacted] w/ (with) instructions to call poison control. I was then instructed by them to give her some water or milk to drink. May irritate her lips some but she will be okay. She was gave water right away. NM (Nurse Manager) [name redacted] & Daughter [name redacted] notified. Resident is unable to say if she took any. She was making funny faces.During an interview on 5/14/26 at 1:54 PM, Staff B, LPN/Unit Manager stated he heard about the situation with Resident #10 but didn't know what interventions they did for Resident #10. Staff B stated a risk management was opened on it and the ActiveIce should of not been on top of the cart, it should of been locked up in the bottom of the cart. During an interview on 5/14/26 at 3:43 PM, the DON confirmed the ActiveIce should have been locked in the treatment cart so Resident #10 couldn't have access to it. The Facility Storage of Medications Policy revised November 2020 revealed, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.6. Review of Resident #12's Census information revealed the resident admitted to the facility on [DATE].The BIMS evaluation completed 5/5/26 at 4:31 PM revealed the resident scored a 15 out of 15, which indicated cognition intact. The Care Plan revealed a focus area dated 5/5/26 which revealed the resident continued to enjoy smoking. The intervention dated 5/5/26 indicated to instruct resident about the facility policy on smoking locations, times, and safety concerns. The Electronic Medical Record (EMR) Standard Evaluation page lacked documentation a Smoking Evaluation was completed. During an observation on 5/13/26 at 9:45 AM, Resident #12 went outside to smoke and took out his walker. Once he sat down, the portable oxygen concentrator turned off and the walker placed inside. During an observation on 5/13/26 at 9:57 AM, Resident #12 finished smoking and the CNA took off his apron and brought him his wheeled walker outside with his oxygen concentrator and turned it on as the resident walked back inside.Per Administrator email on 5/14/26 at 11:22 AM, Resident #12 was listed as a smoker. During an interview on 5/14/26 at 1:16 PM, Staff B queried on smoking evaluations and Staff B stated residents needed them done prior to going out to smoke for the first time. Staff B stated the MDS Coordinator was completing those and Resident #12 should have had one completed. During an interview on 5/14/26 at 2:16 PM, the MDS Coordinator queried on the smoking evaluation for Resident #12, the MDS Coordinator acknowledged Resident didn't have one completed, and should have. During an interview on 5/14/26 at 3:43 PM, the DON queried about Resident #12's smoking evaluation and she stated she didn't know until today he didn't have one. Resident #12 should have had one on admission. The Facility Smoking Policy-Residents revised on November 2022 revealed the following:a.Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: 1. Current level of tobacco consumption; 2. Method of tobacco consumption (traditional cigarettes; electronic cigarettes; vaping, pipe, smokeless tobacco etc.); 3. Desire to quit smoking; and4. Ability to smoke safely with or without supervision (per a completed Smoking Evaluation).

Based on observation, clinical record review, facility policy review, resident and staff interview, the facility to ensure staff served food at a palatable temperature to residents who requested a room tray for 1 of 1 meal service observations. The facility reported a census of 57 residents. Findings included:Review of the Minimum Data Set (MDS) assessment for Resident #20 dated 3/19/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. During an interview on 5/11/26 at 12:07 PM, Resident #20 stated the food at the facility was horrible. Resident #20 described the food as cold and not tasting good. Resident #20 explained they ate their food in their room and always requested a room tray.During an observation on 5/12/26 that started at 7:55 AM, Staff R, Cook, started breakfast service, while Staff S, Cook, assisted with getting drinks, silverware and other requested condiments for residents and then handing the trays off to Certified Nursing Assistants (CNAs) and other facility staff in the dining room. Staff R identified the breakfast menu included one fried egg, Cream of Wheat for hot cereal, hot super cereal, 2 pieces of bacon, a muffin and ground sausage for residents required to have mechanical altered meat. During the course of meal service, Staff R, [NAME] served residents in the dining room first and then served residents that requested room trays. Staff R and Staff S, [NAME] placed a total of 6 residents meal trays per open service cart, and when the cart was full, staff in the dining room would take the cart to the residents rooms. Dietary staff sent a total of 2 carts to the 200 hall (South hall), the first with 6 resident meals and the second cart had 5 resident meals. Dietary staff sent 1 full cart and one additional cart with one resident meal and a test tray to the 100 hall. All meal plates leaving the dining room were covered with a plate lid. Timing of filling a cart with 6 resident meals was 6 minutes from start to finish.At 8:51 AM, Staff R and S added the test tray to the last cart. The Dietary Manager pushed the cart out of the kitchen, dropped the meal off for a resident in room [ROOM NUMBER], and pushed the cart with the test tray to the Administrator's office/conference room located between rooms 108 and room [ROOM NUMBER]. At 8:53 AM, the Dietary Manager tested the food temperatures with the following results: Eggs - 107.8 Fahrenheit (F); mechanical ground sausage - 96.8F; Cream of Wheat - 137 F. The eggs and sausage on the State Agency (SA) test tray were cold to the touch and not palatable. The Cream of Wheat was hot to the touch and had a good flavor. The Dietary Manager reported the food temperatures were too cold for the egg and sausage, and agreed the food would not taste good at those temperatures. During an interview on 5/12/26 at 2:40 PM, the Dietary Manager stated the facility needed to come up with better method to ensure hot delivery of food to rooms. Review of the facility policy, titled Food Preparation and Service, dated 4/2019, revealed, in part, .Proper hot and cold temperatures are maintained during food service.

Based on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to serve food based on resident preference for 1 out of 1 meals services observed (Residents #1, Resident #5 and Resident #7). The facility reported a census of 57.Findings included: 1. Review of the Minimum Data Set (MDS) assessment for Resident #1, dated 3/12/26, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. Diagnoses listed included diabetes, dementia, morbid obesity and abnormal weight loss.Review of the Care Plan for Resident #1, revised 6/19/25 revealed a Focus area to address I am at nutritional risk .MNA (Mini Nutritional Assessment): 10 (6/09): At Risk of Malnutrition. Interventions include, in part: Offer an alternate if dislikes food/fluids given/on menu and offer flavored beverages or water between meals within fluid restriction if resident is on fluid restriction. Date Initiated: 09/11/2024. 2. Review of the MDS assessment for Resident #5, dated 4/7/26, revealed a BIMS score of 15 out of 15, which indicated intact cognition. Diagnoses listed included diabetes, dysphagia (difficulty swallowing), and morbid obesity. The assessment identified the resident on a mechanically altered diet. Review of the Care Plan for Resident #5, revised 4/7/26, revealed a Focus area to address [name redacted, Resident #5] is at an increased nutrition risk r/t (related to) T2DM (diabetes), dysphagia, morbid obesity, constipation, lymphedema (fluid retention in lymphatic nodes), vit (vitamin) D deficiency, osteoarthritis, diverticulosis (pouches in the intestine), mixed HLD (hyperlipidemia), and age-related osteoporosis (bone loss). Interventions included, in part: Modify diet as appropriate according to Resident's food tolerances and preferences. Date Initiated: 2/6/26. Review of a Progress Note, titled Nutrition/Dietary Note, dated 5/10/26, revealed the following documentation: Note Text: Text: Significant Weight Loss noted of: (-) 5.1% X 1 mo (month) . RD/RDN (Registered Dietician) Observations: Wt (weight) - 169# (pounds) (5/02)[BMI = 29.9] (body mass index). Resident is on Consistent Carbohydrate Mechanical Soft and eats 75-80%. Furosemide (often called a water pill, used to treat fluid retention) 40 mgs (milligrams) was started on 3/14/26 and resident continues to use pneumatic compression pump to keep her leg swelling down. RD talked to resident on Thursday during noon meal and resident with no concerns expressed. Is eating well and intake should meet needs. Some weight loss due to the Furosemide started. RD wrote out fax for clinician to notify regarding significant weight change.Review of the Resident Matrix, dated 5/11/26, revealed the facility identified Resident #5 as an excessive weight loss.3. Review of the MDS assessment for Resident #7, dated 3/12/26, revealed a BIMS score of 15 out of 15, indicative of an intact cognition, and diagnoses of heart failure, diabetes, and dysphagia. The assessment identified the resident was on a mechanically altered diet. Review of the Care Plan for Resident #7, dated 5/8/26, revealed, in part, the following focus area and intervention: NUTRITION: I am at nutritional risk due past h/o dehydration prior to admit, CKD (chronic kidney disease), H/O CABG (coronary artery bypass graft), asthma, Type 2 DM, weakness, dysphagia(oropharyngeal), COPD (chronic obstructive pulmonary disease), spinal stenosis, Heart failure, GERD (gastroesophageal reflux disease), Depression, cognitive deficits; Offer an alternate if dislikes food/fluids given/on menu and offer flavored beverages or water between meals within fluid restriction if resident is on fluid restriction.On 5/11/26 at 11:40 AM, during an interview, Resident #7 reported concerns with not getting extra portions at meals when he requested it. During an observation on 5/12/26 starting at 7:55 AM, Staff R, Cook, started breakfast service. Staff R stated the breakfast menu included one fried egg, Cream of Wheat for hot cereal, hot super cereal, 2 pieces of bacon, a muffin and ground sausage for residents required to have mechanical altered meat. Staff R, [NAME] serviced the following trays:a. For Resident #1: One egg, a bowl of cold cereal with milk, and 2 pieces of bacon. Review of the resident's ticket for the 5/12/26 breakfast meal revealed a line drawn through the bacon and eggs, and identified the resident disliked eggs and bacon. The resident requested double portion of entree, cold cereal and a breakfast muffin. b. For Resident #5: One egg, a bowl of cream of wheat, and a 2 ounce serving of mechanically ground sausage. Review of the resident's ticket for the 5/12/26 breakfast meal revealed a line crossed through the ground sausage with gravy, and identified the resident disliked sausage and sausage gravy. The resident requested an egg and a muffin.c. For Resident #7: One egg, two bowls of cream of wheat, and a 2 ounce serving of mechanically ground sausage with gravy, a muffin and toast. Review of the resident's ticket for the 5/12/26 breakfast meal revealed the resident asked for 3 portions of eggs, 2 pieces of toast, 2 bowls of hot cereal, a muffin, and ground sausage.During an interview on 5/12/26 at 2:40 PM, the Dietary Manager reported she had noticed Staff R, Cook, had missed giving double or extra portions during breakfast service for some of the residents that morning. The Dietary Manager explained staff needed to read the meal tickets better, and she was working on different strategies to make dietary needs and preferences stand out. Review of the facility policy, titled Therapeutic Diets, dated 10/2017, revealed, in part, .Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes.

Based on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to ensure staff consistently used and re-ordered the appropriate size bariatric incontinence brief for resident comfort, and to ensure a bathroom faucet and closet were accessible for 2 of 4 residents (Resident #18 and Resident #3) reviewed for accommodations. The facility reported a census of 57 residents.Findings included:1. The Minimum Data Set (MDS) assessment for Resident #18 dated 4/9/26, revealed an admission date of 10/8/25. The Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicated intact cognition. The list of diagnoses included morbid obesity, incontinence without sensory awareness and need for assistance with personal care. The MDS identified: the use of a wheelchair; the resident required substantial/maximum assistance with toileting hygiene and bed mobility; dependent for lower body dressing, transfers and moving from sitting to lying and standing; and the resident always incontinent of bowel and urine.During an interview on 5/11/26 at 3:53 PM, Resident #3 stated the facility did not have enough size 5XL (extra-large) incontinent briefs for her roommate [Resident #18] and staff frequently used a smaller size brief. On 5/12/26 at 10:45 AM, during an interview, Staff O, Certified Nursing Assistant (CNA) stated Resident #18 wore a size 5XL incontinent brief. Staff O reported the facility did order 5XL briefs, but the briefs would get put on back order, and sometimes the resident had to wear size 4XL briefs. Staff O reported the size 4XL were too tight for the resident and caused rubbing sores on her inner thighs were the brief sat against the resident's skin. During an interview on 5/13/26 at 9:14 AM, during an interview, Resident #18 reported sometimes the facility had problems with running out the right size brief for her. She reported using a size 5XL brief. Resident #18 reported facility staff changed her brief every 2 to 3 hours. Resident #18 reported two wounds, one on her left thigh and a sore on her bottom. She thought the wound on left thigh was getting better, and reported sometimes it was closed and sometimes the wound was open. Resident #18 thought both wounds were from wearing the smaller size incontinent briefs and the briefs rubbing against her skin. Resident #18 explained the facility did not order the right size brief in a previous order. Until the next truck came in a week later, the resident reported she had to wear a smaller size brief. Resident #18 thought they had plenty of size 5XL briefs now. Review of a Nurses Note in the electronic health record (EHR) dated 10/8/25 revealed the following, in part: 3 skin issues upon admit.1) left inner thigh shearing of skin from incontinent brief measures 2 cm (centimeters) L (length) x 1cm W (width). 2) Right intragluteal cleft has MASD from incontinence measuring 1.5cm L x 1.5cm W. 3) Right hip has an abrasion circular in circumference measuring 1.5cm L x 1.5cm W.During an observation on 5/13/26 at 10:03 AM, Staff I, CNA prepared to complete incontinence care for Resident #18. Staff I, CNA reported the facility staff kept Resident #18's incontinent briefs locked in the medication room. Staff H, CNA, brought in several briefs into the room and put them in the drawer of the resident's dresser. Staff H reported they only had size 4XL briefs, and no 5XL available. Resident #18 visibly upset and expressed getting really angry about having to wear the smaller briefs. Staff I, CNA reported this had happened before. Staff I explained she had reported repeatedly to facility management about having the wrong size brief for Resident #18. Staff I stated management explained the 5XL brief was out of stock, they could not get the right size for the resident, it cost too much money, and at one point, they talked about making the resident buy her own briefs. During an interview on 5/13/26 at 1:10 PM, Staff M, CNA, reported she last provided incontinence cares to Resident #18 on 5/12/26 and there had been size 5XL incontinent briefs available. Staff M reported they were supposed to have a size 5XL for the resident and the kept the briefs in the nurse's office. Staff M reported there had been issues with the facility having the correct size incontinent brief. Staff M reported there were times when staff had to use a smaller brief when they were laying the resident down, because there weren't enough 5XL available. Staff M explained she had used size 3XL briefs on the resident, and the briefs did not fit. Staff M reported the resident did get upset and complain when having to wear the smaller briefs. On 5/13/26 at 3:34 PM, during an interview, Staff G, LPN, reported she had provided wound treatment to Resident #18 in the last three weeks. Staff G reported the facility had ordered a smaller incontinent brief size for Resident #18, and she thought the smaller brief size was causing skin irritation in the upper thigh area.On 5/14/26 at 9:28 AM, during an interview, Staff N, Medical Records and Central Supplies, reported Resident #18 used a size 5XL. She explained the truck came every week, and there had been times that the facility ran out of the 5XL briefs. Staff N explained last week when she placed the order for Resident #18's briefs, the company they place their order from (Regional Purchasing Agent for the nursing home) wanted them to try size 4XL due to the price difference between 4XL and 5XL. Staff N was not sure who spoke with the resident to see if the resident was in agreement with wearing a smaller brief. Staff N explained Resident #18 did tell her that the 4XL briefs were not working. Staff N reported she got 5XL briefs overnighted to the facility, and reported they had 5XL briefs in the medication room. Observation during the interview revealed a total of 11 5XL incontinent briefs were located in the locked medication room.On 5/14/26 at 12:49 PM, during an interview, the Unit Manager and Infection Preventionist reported he had ordered 5XL incontinence briefs for Resident #18 from the time he started in the Central Supplies position. He explained the order for supplies might be place once per week, but the order could arrive over multiple days. The Unit Manager reported that there might have been a small gap in availability of 5XL briefs, depending on the number of incontinence episodes that Resident #18 had. The Unit Manager reported there had been times when the facility ran out of 5XL briefs for Resident #18. When the facility has ran out, the Unit Manger reported they usually had size 4XL available. He explained the 4XL briefs were big and fit the resident, but they were not comfortable for her. The Unit Manager explained that supply orders went through an umbrella company that owned the nursing home. The regional umbrella company had to approve or deny purchasing requests. The Unit Manager reported there were times when he was putting the order in that the umbrella company asked the facility to use a smaller size brief for Resident #18. The Unit Manager reported they could message. He explained there was one time, closer to the end of February 2026, that he did order 4XL for Resident #18, because the umbrella company asked him to do it. Resident #18 reported being uncomfortable and having a problem wearing the size 4XL briefs. The Unit Manager reported he switched back to ordering size 5XL incontinent briefs. He reported the size 5XL briefs came in bags, 8 briefs to a bag.Review of the facility purchasing orders, dated from 5/1/26 to 5/14/26, revealed the following: the facility ordered 3 bags of size 5XL incontinence briefs and received the order on 5/6/26.On 5/14/26 at 3:43 PM, during an interview, Resident #18 reported she could not use the size 4XL incontinent briefs, and stated, they rub on my wound. The resident denied anyone had asked her if it was okay to use size 4XL briefs instead size 5XL. 2. Review of the MDS assessment for Resident #3 dated 3/27/26, revealed an admission date of 8/6/25. The BIMS score of 13 out of 15, indicated intact cognition. The list of diagnoses included diabetes, heart failure, and need for assistance with personal care. The MDS indicated Resident #3 used a wheelchair for mobility; set up assistance for oral hygiene; substantial or maximum assistance for upper body dressing, bed mobility, transfers and personal hygiene, dependent for lower body dressing, toileting and putting on/taking off footwear.Review of the Care Plan for Resident #3 dated 5/10/26, identified that the resident wished to return home and had a Focus area to address increased risk for actual/potential limitation(s) in ability to perform ADLs (Activities of Daily Living) related to impaired mobility and activity intolerance. Interventions included: Encourage the resident to participate to the fullest extent possible with each interaction; Personal hygiene/Oral Care: Ax1 (assist of 1); Dressing: Ax1 as needed with catheter and getting feet into leg holes.Review of an Occupational Therapy (OT) Discharge summary, dated [DATE] to 1/12/26, revealed a goal for Resident #3 to improve upper and lower body dressing tasks with minimal assist using compensatory strategies with reduced risks for falls. OT staff educated the resident on use of assistive equipment (AE) including a reacher and compensatory strategies to improve independence and safety with dressing. During an interview on 5/11/26 at 3:53 PM, Resident #3 stated an inability to turn the water faucet on in her bathroom. The resident reported she had to wait for staff to turn it on for her. Observation revealed a pull-up type handle on the faucet that would not pull up with multiple attempts by the State Agency (SA). Resident #3 reported an inability to reach her clothes in her closet. Resident #3 reported she would be able to get her clothes out herself if she could reach them. She reported frustration with having to wait for staff or else break the hangers by pulling on the bottom of her clothing. Resident #3 reported breaking 8 out of her last 10 hangers by yanking on the bottom of her clothes to get them out of the closet. During an observation on 5/13/26 at 9:11 AM, Resident #3 demonstrated how she was unable to reach the clothes in her closet from her wheelchair. The closet had 2 lower drawers with double doors above the drawers which stored hanging clothes. Resident #3 was able to reach the bottom of the hanging clothing from her wheelchair. Resident #3 reported the CNAs were aware that she couldn't reach her clothes.During an interview on 5/13/26 at 9:31 AM, Staff H, CNA reported she had assisted Resident #3 with getting dressed. Staff H reported she asked the resident what she wanted to wear for the day and got the resident dressed before the resident got out of bed for the day. Staff H denied Resident #3 had ever complained to her about not being able to reach the clothes in her closet. Staff H reported she had seen the resident get in the closet by herself. During an interview on 5/13/26 at 10:03 AM, Staff I, CNA reported she asked Resident #3 for her clothing preference and got the resident's clothes out for her. Staff I reported the faucet in the resident's bathroom was hard to pull to turn on. Staff H, CNA also present demonstrated turning on the faucet. The faucet stuck when Staff H pulled on it and she had to use some force to turn the faucet on. On 5/13/26 at 1:10 PM, during an interview, Staff M, CNA, reported there were a few other resident rooms with faucets like Resident #3's faucet. Staff M reported had observed Resident #3 have a hard time turning the faucet on. Staff M explained Resident #3 complained about not being able to wash her hands, and Staff M would turn the faucet on for her. Staff M reported she reported the concern with the faucet to a nurse. She did not remember how long ago, or which nurse she had reported it to. During an interview on 5/13/26 at 3:24 PM, the Director of Nursing (DON) reported that the Therapy Department was responsible for accessing room accessibility for all new residents to the facility. During an interview on 5/14/26 at 11:28 AM, the Therapy Department Program Manager and the Physical Therapy (PT)Supervisor stated they did do an initial evaluation of each resident and their ability to access things in their room. The Department Manager reported she believed she did the initial evaluation on Resident #3, but accessibility of the resident's clothes closet and her dressing herself would have been Occupational Therapy's (OT) part of the assessment. She thought Resident #3's main focus was bathroom use and transfers and trying to get her as independent as possible. She explained therapy should have assessed and done a maintenance request to make the closet accessible and order a different handle for the faucet. The Department Manager reported therapy ended because there was no definite discharge plan for the resident, and therapy had assessed the resident needed 24/7 care and assistance with toileting and transfers. She reported the resident could stand at a grab bar, but needed lowered countertops.During an interview on 5/14/26 at 4:22 PM, the DON reported that she never heard Resident #3 complain about her closet. The DON reported staff encouraged the resident to be more independent and confirmed it would be hard for Resident #3 to be more independent if she could not reach her clothes.During an interview on 5/18/26 at 12:46 PM, Staff P, OT, reported she had been working with residents at the facility for 2 years. She reported almost every resident, depending on insurance, received an initial evaluation that included an assessment of their room accessibility with a goal for the resident to be as independent as possible. Staff P reported she completed the initial OT evaluation on Resident #3, worked with her during her treatment and discharged the resident from OT services about 4 months ago (1/12/26). Staff P reported she assessed the closet accessibility for Resident #3, but closet accessibility was not a formal goal due to the resident wanting to discharge to home. Staff P explained they did work with the resident on dressing and being more independent, but they focused more on the resident sitting on the edge of bed to get dressed with use of the reacher. Staff P reported another option would have been for Maintenance to lower the clothing bar. Review of the facility's policy, titled Accommodation of Needs, dated 3/2021, revealed, in part, . the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis .In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility .In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes.

Based on clinical record review, facility policy review and staff interviews, the facility failed to notify a family of a missed medication in a timely manner for 1 of 1 resident (Resident #12) reviewed for family notification. The facility reported a census of 57 residents. Findings include: Review of the Minimum Data Set, dated [DATE], revealed Resident #12 admitted to the facility on [DATE]. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated intact cognition. Review of a Orders Administration Note entered into the electronic health record (EHR) on 5/2/26 at 4:34 PM, revealed an order for: famotidine oral tablet 20 milligram (MG)- Give 1 tablet by mouth two times a day related to gastro-esophageal reflux disease without esophagitis. Comments: on orderReview of a Nurses Notes dated 5/7/26 at 1:10 PM, revealed PCP (Primary Care Provider), POA (Power of Attorney) notified and acknowledged missed dose of famotidine upon admission on [DATE] due to not having medication available. No issues was noted from missed dose.During an interview on 5/13/26 at 3:33 PM, Staff G, Licensed Practical Nurse (LPN) confirmed she would notify the family when a medication is not available. Staff G stated she would try and call the family within 45 minutes to an hour.During an interview on 5/14/26 at 1:16 PM, Staff B, LPN/Unit Manager asked when the family notified and Staff B stated for pretty much everything and an example was when a medication not available. Staff B queried in what time frame the family would be notified and Staff B stated within 24 hours.During an interview on 5/14/26 at 3:43 PM, the Director of Nursing (DON) queried on when the facility notified the family and the DON named multiple examples to include medications not available. When asked if notifying the family 5 days later is appropriate, the DON stated no and it was an ongoing issue the DON was working to fix.Review of an undated facility policy titled Facility Change in a Resident's Condition or Status Policy revealed:a. Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).1. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.

Based on observations, record review, staff interviews, and the facility policy, the facility failed to keep urinary catheter tubing and collection bags off of the floor in an effort to prevent an urinary tract infection for 2 of 2 residents (Resident #3 and Resident #14) reviewed with a urinary catheter; and failed to start an antibiotic in a timely manner to treat an urinary tract infection for 1 of 2 residents (Resident #3) reviewed for urinary tract infections. The facility reported a census of 57 residents. Findings include:1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated resident dependent with toileting hygiene and utilized a urinary catheter. The MDS revealed medical diagnoses for neurogenic bladder, type II diabetes mellitus, and a urinary tract infection (UTI) in the last 30 days. The Care Plan revealed a focus area dated 8/29/25 indicated resident had impaired urinary elimination pattern due to urinary retention resultant with need for a catheter. The interventions included: monitor/record/report to MD (medical doctor) for s/sx (signs/symptoms) UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Date Initiated: 08/29/2025Review of the Bacteriology Report dated 5/7/26 at 7:49 PM revealed verified date/time of 5/9/26 at 12:43 PM greater than 100,000 cfu/ml (colony-forming units per milliliter) Escherichia coli extended spectrum Beta Lactamase (ESBL) type organism. Review of the electronic health record (EHR) revealed:a. Nurses Note dated 5/11/26 at 9:52 AM: culture results received and faxed to PCP (primary care provider)b. The Nurses Note dated 5/11/26 at 2:05 PM: [name redacted] noted urine culture grew multidrug resistant e. coli, with orders for fosfomycin (an antibiotic). Resident aware and order was sent to pharmacy by provider.During an observation on 5/12/26 at 10:02 AM, Resident #3 catheter tubing and bag dragging on the floor. Resident #3 asked staff if her catheter was still dragging, and the CNA (certified nursing assistant) stated they couldn't get it better. The CNA stated she tried to fix it when they were outside. As Resident #3 self-propelled down the hall with the catheter bag dragging on the floor. During an observation on 5/12/26 at 12:22 PM, Resident #3 wheeled herself from one dining room table to the next and the catheter tubing and catheter bag dragging on the floor. The Orders Administration Note dated 5/12/26 at 6:34 PM revealed Hot Charting: Monitor residents' behavior, s/s (signs/symptoms) of a UTI every shift for monitoring Behaviors until 05/15/26 at 11:59 PM- no S/SDuring an observation on 5/13/26 at 9:18 AM revealed Resident #3 sat in her wheelchair and the catheter bag and tubing was off the floor. During an observation on 5/13/26 at 10:06 AM, Resident #3 self-propelled down the hallway and her catheter bag touched the floor as she went into the shower room. During an observation on 5/13/26 at 12:53 PM, Resident #3 self-propelled out of the dining room and the catheter bag has a large amount of urine in the bag and as she propelled one side of the bag touched the floor. During an interview on 5/13/26 at 3:33 PM, Staff G, Licensed Practical Nurse (LPN) stated catheter tubing/bags could not drag on the floor. Staff G queried if she was aware Resident #3 had a UTI and Staff G stated they send out for a urine analysis with a culture and sensitivity but didn't know the results and was not aware of an antibiotic order.Review of the EHR revealed a Nurses Note dated 5/13/26 at 4:16 PM: NOR (new order) from [name redacted] for one dose of fosfomycin 3G to be mixed with liquids and drink immediately DX (diagnosis): UTI. Resident awareReview of the EHR revealed an Orders Administration Note at 5/13/26 at 4:45 PM: orders for Fosfomycin Tromethamine Oral Packet 3 GM- Give 1 packet by mouth one time a day for Uti for 1 Day mix packet in 4-6oz of liquid and drink immediately- waiting on pharmacy to bring2. The MDS assessment dated [DATE] revealed Resident #14 scored a 15 out of 15 on the BIMS exam, which indicated intact cognition. The diagnoses list included: neurogenic bladder (nerve damage caused loss of bladder control). The MDS indicated resident independent with toileting hygiene and utilized an indwelling catheter.Review of Resident #14 Care Plan revealed Focus areas to address: a. I have impaired urinary elimination pattern d/t (due to) neuromuscular bladder dysfunction resulting in the need for a suprapubic catheter. Resident often has bladder spasms resulting in urine leaking around the catheter. Date Revised: 6/9/25.b. I have a Urinary Tract Infection. Dated Initiated: 5/11/26.During an observation on 5/12/26 at 11:07 AM, Resident #14 self-propelled down the hallway with the urinary catheter tubing dragging on the floor.During an observation on 5/12/26 at 12:44 PM, Resident #14 sat in her wheelchair in her room with the urinary catheter tubing resting on the floor under her wheelchair. During an observation on 5/13/26 at 9:44 AM, Resident #14 self-propelled out of the building to go to the smoking area with the urinary catheter tubing dragging on the floor. While in the smoking area, Resident #14 foot rested on top of the catheter tubing. Facility staff present. During an interview on 5/13/26 at 1:06 PM, Staff J, Certified Nurse Aide (CNA) stated urinary catheter tubing and the bag should not touch the floor. Staff J stated Resident #3 would slide down and usually drug on the floor and Resident #14 usually wore a leg bag but since coming back from the hospital used the large bag. Staff J asked why the catheter bag/tubing drug on the floor and Staff J stated she thought from the movement of the resident when in their wheelchairs. During an interview on 5/13/26 at 1:40 PM, Staff I, CNA stated the catheter bag/ tubing couldn't touch the floor for infection control. Staff I stated some of the wheelchairs sat low and didn't know if there was a way to avoid the catheter bag from touching the ground.During an interview on 5/14/26 at 3:43 PM, the Director of Nursing (DON) stated catheter bags/tubing should not touch the ground. The DON explained Resident #3's wheelchair was a little shorter. The DON stated they obviously needed to get Resident #3 a different chair and to make sure the bag is secured on the seat for Resident #14.The [NAME] stated Resident #3 antibiotic order had been faxed by the provider to the pharmacy and not the facility. She explained she talked to the providers and they were made aware of the need to inform the facility of the orders. Review of the facility policy titled Urinary Catheter Care, revised March 2023 directed: Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, clinical record review, facility policy review, and staff interview, the facility failed to ensure nursing staff locked an unattended medication treatment cart for 1 of 2 observations for medication storage. The facility reported a census of 57 residents. Findings included:Review of the Minimum Data Set (MDS) for Resident #22, dated 4/23/26, revealed a diagnosis of dementia; and Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated a moderate cognitive impairment. The resident utilized a walker to with supervision or touch assistance to ambulate. Review of the Care Plan for Resident #22, dated 2/19/26, revealed a Focus area to address elopement risk/wanderer related to the resident wandering aimlessly. On 5/12/26 at 3:18 PM, while on a walkthrough of the facility with the Maintenance Director, a 4 (four) drawer medication/treatment cart noted to be positioned across from the nurse's station by the medication room. The cart unattended by a facility staff and unlocked. Staff A, Registered Nurse (RN) at the nurse's station not watching the unlocked cart. Resident #22 sitting in a chair near the cart with his walker within reach. Staff Q, Certified Medication Aide (CMA) stationed at another medication cart next to the nurse's station with her back to the unlocked cart. At 3:19 PM, the Unit Manger/Infection Preventionist noted to be in the hall talking with another staff person. The Maintenance Director called the Unit Manger over and asked him to lock the cart.During an interview on 5/12/26 at 3:19 PM, Staff Q, CMA, reported the cart that had been unlocked was the insulin and wound treatment cart for the 200 hall. Staff A, RN, joined the interview and explained she had unlocked the cart to put some gloves in. She explained she went into the nurse's station to get a computer and forgot to the lock the cart. On 5/12/26 at 3:27 PM, Staff A, RN and the State Agency (SA) reviewed the contents of the unlocked cart. The following medications and supplies were in the unlocked cart: a. Top drawer of car contained: disposable needles, spare glucometers, 2 pairs of scissors and a package of empty syringes with needles. b. Second drawer from the top of the cart contained: 4-lispro insulin pens; 1-Ozempic pen; 7-lantus insulin pens; 2-novolog insulin pens; 1-Baqsimi Nasal Powder (medication used to treat low blood sugar); 1-glucagon pen of 1 mg per 0.2 ml; 1-glucagon pen of 1 mg per 1 ml.c. Third drawer from the top of the cart contained: 1-tube Proctomed cream; 1-tube Hydrocortisone cream 2.5%; 1-container Magic Butt Paste; 1-tube Mupirocin topical ointment (antibiotic); 2-tubes Zinc Oxide; 1-tube Santyl (type of wound treatment); 1-container of Mometasone Furoate cream 1%; 1-tube Ketoconazole cream 2%; 1-container of Fluorouracil 5% cream; 1-container Miconazole 2% powder; 2-containers Nystatin 100,000 units/gram powder; 1-tube of Triamcinolone ointment 0.1%; 1-bottle of Ketoconazole Shampoo 2%In addition the drawer included the following stock medications: 4 - Lidocaine 4% patches; 1-container antifungal powder; 1-16 oz (ounce) bottle Active Ice temporary pain relief spray; 1-container Diclofenac 1% topical gel; 1-container Nystatin 100,000 units/gram powder; 1-3 oz container VapoFreeze pain relief cream with menthol and camphor; 2 - tubes Triad Wound Dressing topical cream; 2 - tubes Triple Antibiotic Ointment; 2 - containers Zinc Oxide; 2 - containers Silicone cream; 1 - container Zeasorb powder; 1 - tube Hemorrhoidal ointment; 1 - 14 oz container Aquaphor healing ointment; 1 - 400-gram container Ascend Silver Sulfadiazine cream.d. The fourth drawer from the top of the cart contained the following stock medications: Lidocaine 5% patches; 1-16-oz bottle Active Ice temporary pain relief spray; 1-16-oz bottle Skin Integrity Wound Cleanser Wound Wash; 1-bottle mouthwash; 2-32-oz bottles Hydrogen Peroxide; 1-16-oz bottle Witch Hazel.During an interview on 5/14/26 at 12:49 PM, the Unit Manager/Infection Preventionist stated it was important to keep the treatment carts locked so someone did not ingest something or get a hold of sharps. Review of the facility policy, titled Storage of Medications, dated 11/2020, revealed, in part: .Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

Based on observation, facility policy review, resident and staff interviews, the facility failed to follow up after a report of food purchased by a resident was missing for 1 of 4 residents (Resident #12) reviewed for personal possessions. The facility reported a census of 57 residents. Findings include: Review of the electronic health record (EHR) revealed Resident #12 admitted to the facility on [DATE].The Brief Interview for Mental Status (BIMS) completed 5/5/26, indicated intact cognition based on a score of 15 out of 15. During an interview on 5/12/26 at 9:50 AM, Resident #12 stated he bought some lunchables (a pre-packaged make it yourself meal kit) because he gets sick every time he eats. He explained he bought some lunchables because he doesn't eat dinner, and an employee needed them more than I did and he took them. Resident #12 stated he asked the CNA (Certified Nurse Aide) to go and get him one and they came back and said he didn't have any. Resident #12 stated he told a manager and they said they would replace them, adding they took 3 of them. Resident #12 stated he is not upset about the money; he is upset about the lunchables. Resident #12 stated the lunchables were kept in a refrigerator in the hall and he did not know if the staff labeled the food. Resident #12 stated he is leaving tomorrow [5/13/26] for an appointment with another place. During an interview on 5/13/26 at 9:59 AM, Resident #12 stated a facility staff had not followed up with him about his missing lunchables.During an interview on 5/14/26 at 12:06 PM, Staff E, CNA queried on Resident #12 lunchables and Staff E stated she worked the day Resident #12 got the lunchables and recalled it was Mother's Day [5/10/26]. Staff E stated a lady also brought him in ice cream. Staff E stated she didn't put the food in the fridge when Resident #12 got it, but when Resident #12 asked for the lunchables, she couldn't find them in the fridge. Staff E stated when resident receive food items, the staff put the resident's name on them and places them in the fridge.During an interview on 5/14/26 at 1:16 PM, Staff B, Licensed Practical Nurse (LPN)/Unit Manager queried on Resident #12 lunchables and Staff B stated Resident #12 just reported the missing lunchables the day he left and Staff B would follow up with the Administrator. Staff B stated the Administrator would want staff to write up a grievance. Staff B stated he had not talked to the Administrator about Resident #12 lunchables yet. Staff B queried if he thought staff took them and Staff B stated no, and recently the lock on the beautician door where the resident refrigerator was located was broke and they recently changed the lock on it. Staff B stated the facility did not inventory the resident's food items; they just mark the resident's name on the items.During an interview on 5/14/26 at 4:20 PM, the Administrator queried on Resident #12 lunchables and the Administrator stated it was the first time she heard about them missing. The Administrator asked the process on missing items and the Administrator stated generally the facility replaced missed items. The Administrator stated Resident #12 lunchables should have been taken care of within that day it was reported.During an observation 5/18/26 at 8:55 AM, the resident refrigerator noted to have multiple food items labeled with resident names. The freezer contained an ice cream container labeled with Resident #12's name. No lunchables found in the refrigerator. Review of the facility policy titled Personal Property Policy dated October 2022 revealed:a. Resident belongings are treated with respect by facility staff, regardless of perceived value.b. The facility promptly investigates any complaints of misappropriation or mistreatment of resident property.Review of the undated facility titled Foods Brought by Family/Visitors Policy revealed:a. Foods brought by family/visitors for individual residents may not be shared with or distributed to other residents.b. Food brought by family/visitors that is left with the resident to consume later will labeled and stored in a manner that it is clearly distinguishable from facility-prepared food.c. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date.

Based on resident interviews, record review, staff interviews, and the facility policy, the facility failed to respect resident rights by not allowing residents to go out and smoke during the designated times for 3 of 4 residents reviewed for smoking (Resident #3, Resident #12 and Resident #13). The facility reported a census of 57 residents. Findings include: 1. The Brief Interview for Mental Status (BIMS) evaluation completed 5/5/26 at 4:31 PM revealed resident scored a 15 out of 15, which indicated cognition intact. Review of the Minimum Data Set (MDS) revealed Resident #12 admitted to the facility on [DATE]. The Care Plan revealed a focus area dated 5/5/26 for resident continued to enjoy smoking. Interventions dated 5/5/26, included: Instruct resident about the facility policy on smoking locations, times, and safety concerns and the resident requires supervision while smoking. During an interview on 5/12/26 at 9:45 AM, Resident #12 stated the facility allowed him to smoke three times a day except sometimes the staff didn't show up to allow the residents to smoke. Resident #12 stated yesterday and two days prior the residents were not allowed to go out and smoke at 7:30 PM. 2. The MDS assessment dated on 4/9/26 revealed Resident #13 scored a 15 out of 15 on the BIMS exam indicating intact cognition. The Care Plan revealed a focus area dated 1/9/26 for resident enjoyed smoking cigarettes. Interventions dated 9/25/25 included: Instruct resident about the smoking locations, times, and safety concerns and The resident requires supervision while smoking. Review of a Nurses Note dated 5/10/26 at 9:15 AM in the electronic health record (EHR), revealed resident was upset that staff was unable to take smokers out to smoke. Resident told other smokers to meet her at the front door and went to her room and retrieved a pack of cigarettes. Resident attempted to help smokers out of facility to smoke. Nurse and CNA (Certified Nurse Aide) notified residents that they are unable to leave the facility unassisted and staff is unable to take the smokers out. Residents became upset, redirection successful and resident went back to rooms. On call nurse notified of situation. 3. The MDS dated [DATE] revealed Resident #3 scored a 13 out of 15 on the BIMS exam, indicating intact cognition. The Care Plan revealed a focus are revised on 1/29/26 for resident continued to enjoy smoking. Interventions dated 8/9/25 included: Instruct resident about the facility policy on smoking locations, times, and safety concerns, and the resident requires supervision while smoking. Review of the Nurses Note dated 5/10/26 at 9:45 PM in the EHR, revealed nurse was alerted by CNA that resident wanted to speak to the nurse and resident was speaking to another resident. Upon entering the room with another CNA, the resident stated she was upset that she was unable to smoke and that she was dirty. Resident was informed that smoking is only to take place if staff is available and willing as the CNA/Nurse must volunteer to take the smokers out, resident was also informed that we were short staffed and unable to take the smokers out. During an interview on 5/13/26 at 3:33 PM, Staff G, Licensed Practical Nurse (LPN) queried on residents being able to go and smoke last weekend and Staff G stated no, the staff did not take the residents out for one of the smoking sessions. Staff G stated she didn't know if it was on Saturday or Sunday last weekend. Staff G stated the staff didn't have time to take the smokers out because the staff was shorthanded and they needed to take care of the residents. Staff G stated Resident #3 was very upset about not being able to go out and smoke. Staff G stated her understanding was staff had to volunteer to take the residents out to smoke. During an interview on 5/13/26 at 4:13 PM, Staff D, CNA stated she worked on Sunday and the residents didn't get their smoke break on second shift. Staff D stated the nurse said they didn't have enough staff to take off the floor. Per Administrator email on 5/14/26 at 11:22 AM, smoke times for residents was 9:30 AM, 1:30 PM, and 7:30 PM. Per email Resident #3, #12, and #13 were on the smoker's list. During an interview on 5/14/26 at 3:43 PM, the Director of Nursing (DON) queried about the residents not getting their smoke break on Sunday and the DON stated the facility spoke to the nurse on duty who was not an employee of the facility and let her know the residents need to be able to go out and smoke. The DON stated they were a smoking facility and had smoking times in place, and it was the facility policy to allow the resident smoke breaks. During an interview on 5/11/26 at 3:53 PM, Resident #3 reported the facility designated smoking times were 9:30 AM, 1:30 PM and 7:30 PM. Resident #3 voiced being upset due to not being able to smoke on 5/10/26 at 7:30 PM. She reported the resident's that smoke had been told that there wasn't enough staff available for them to smoke. Review of the facility policy titled Resident Rights Policy dated October 2022, revealed employees shall treat all residents with kindness, respect, and dignity.These rights include resident's right to exercise his or her rights as a resident of the facility.; be supported by the facility in exercising his or her rights. Review of the facility policy titled Smoking Policy -Residents dated August 2022 revealed in part: Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.

Based on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to serve a meal to meet the physician ordered dietary needs for 2 (Residents #9 and #16) out of 42 residents reviewed for diet orders during a breakfast service. The facility reported a census of 57.Findings included: 1. Review of the Minimum Data Set (MDS) assessment for Resident #9, dated 4/2/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Diagnoses included hip fracture, left tibia (lower leg) fracture, other fractures, and anemia (low red blood cell count).Review of the Care Plan for Resident #9, dated 4/24/26, revealed a Focus area to address I am at nutritional risk due to hospitalization.MNA (Mini Nutritional Assessment): 9/0 (4/2) At Risk for Malnutrition. Interventions initiated on 4/24/26 included:a. Diet: Consistent Carbohydrate with Double Protein portions to provide additional ~ 60 gms (grams) protein per [clinic name redacted].b. Meal Enrichments/Planned Snacks: Double protein at all meals per Ortho clinic recommendations.c. Monitor Meal Intakes.d. Offer an alternate if dislikes food/fluids given/on menu and offer flavored beverages or water between meals within fluid restriction if resident is on fluid restriction.e. Weigh at least weekly X 1 month(F692) after admit or per facility protocol then at least monthly or as recommended if more frequent than monthlyReview of Clinical Physician Orders for Resident #9 revealed a diet order dated 3/31/26, for a CCHO (consistent carbohydrate), regular texture, thin consistency. With direction for double protein portions at meals. During an interview on 5/11/26 at 3:34 PM, Resident #9 reported he was not getting enough to eat. Resident #9 reported all of his meal tickets stated he was supposed to get double. He explained sometimes he got double and sometimes he didn't. He explained he was supposed to get extra protein.2. Review of the MDS assessment for Resident #16, dated 3/12/26, revealed a BIMS score of 15 out of 15, which indicated intact cognition. Diagnoses included low back pain, weakness and spinal stenosis. Review of the Care Plan for Resident #16, last revised 2/10/26, revealed a Focus area to address I am at nutritional risk due to h/o (history of) falls and recent fractures in March of 2023 and again May 2024. I have h/o Breast CA (cancer), hypothyroidism, Left hip fx (fracture), UTI (urinary tract infection), low backpain. Interventions included, in part: Meal Enrichments/Planned Snacks: Extra egg when eggs are on the menu. Chocolate milk all meals. Revised on 4/3/25.Review of Clinical Physician Orders for Resident #16 included an order, dated 1/30/26 for a mechanical soft texture general diet and for dietary to give the resident an extra egg when on the menu.During an observation on 5/12/26 at 7:55 AM, Staff R, Cook, started breakfast service. Staff R stated the breakfast menu included one fried egg, Cream of Wheat for hot cereal, hot super cereal, 2 pieces of bacon, a muffin and ground sausage for residents required to have mechanical altered meat. During the course of the meal service observation, Staff R, [NAME] served food onto a tray for Resident #9. Staff R served Resident #9 one egg, a bowl of cold cereal with milk, a bowl of hot cereal and 2 pieces of bacon. Review of the resident's ticket for the 5/12/26 breakfast meal revealed the resident identified he did not like bacon, and the bacon had a line drawn through it. The resident's ticket identified the resident was to received double portion of protein all meals. During the course of the meal service observation, Staff R, [NAME] served food onto a tray for Resident #16. Staff R served Resident #16 one egg, 2 ounces of mechanically ground sausage, a bowl of cold cereal with milk and a muffin. Review of resident's ticket for the 5/12/26 breakfast meal revealed the resident had requested extra eggs. During an interview on 5/12/26 at 2:40 PM, the Dietary Manager reported she had noticed Staff R, Cook, had missed giving double or extra portions during breakfast service for some of the residents that morning. The Dietary Manager explained staff needed to read the meal tickets better, and she was working on different strategies to make dietary needs and preferences stand out. Review of the facility policy, titled Therapeutic Diets, dated 10/2017, revealed, in part, .Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet .A 'therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet .

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure nursing staff followed enhanced barrier precautions to prevent the spread of multi-drug resistant organisms to residents during when personal care and wound care provided for 1 of 1 resident (Resident #18) reviewed for infection control. The facility reported a census of 57.Findings included:Review of Resident #18's Minimum Data Set (MDS) assessment dated [DATE], diagnoses listed included diabetes, incontinence without sensory awareness and morbid obesity. The assessment identified the resident had moisture associated skin damage (MASD). The MDS listed an admission date of 10/8/25. Review of electronic health record (EHR) revealed a Nurses Notes dated 10/8/25 which documented: 3 skin issues upon admit. All need the application of Triad cream (type of topical wound treatment) to areas: 1) left inner thigh shearing of skin from incontinent brief measures 2 cm (centimeters) L (length) x 1cm W (width). 2) Right intragluteal cleft has MASD from incontinence measuring 1.5cm L x 1.5cm W. 3) Right hip has an abrasion circular in circumference measuring 1.5cm L x 1.5cm W.The MDS dated [DATE], revealed a BIMS score of 15 out of 15, which indicated Resident #18 had intact cognition. The assessment indicated the resident used a wheelchair and required substantial/maximum assistance with toileting hygiene and bed mobility and was dependent on staff for lower body dressing, transfers and moving from sitting to lying and standing. The resident was always incontinent of bowel and urine.During an observation on 5/13/26 at 10;11 AM, Staff L, Licensed Practical Nurse (LPN) entered the room to assess and treat the resident's wounds. Staff H, Certified Nursing Assistant (CNA) and Staff I, CNA also present to assist. Staff L, LPN, gloved, used the disposable measuring tape to measure an open upper right coccyx wound and open left inner thigh wound. Staff L reported there was a scabbed area above the open wound on the coccyx. Staff L measured an open lower left inner thigh wound at 1.9 cm in length and 0.4 cm in width. After spraying the wounds with wound cleanser, Staff L, LPN, without a change of gloves used a piece of woven gauze to clean the upper coccyx wounds. Using the same piece of gauze, Staff L then cleaned the wounds on Resident #18's left lower thigh. Without a change of gloves, Staff L, LPN, used her right hand to get zinc oxide out of the container, and then applied it to the coccyx wounds. Staff L proceeded to use the same gloved hand to get zinc oxide out of the container and then applied it to the wounds on the lower left thigh. Staff L, LPN, Staff H, CNA, and Staff I, CNA did not wear gowns during this observation. During an interview on 5/18/26 at 8:31 AM, Staff L, LPN, reported EBP (enhanced barrier precautions) should be used when doing personal cares on someone with a wound or catheter. Staff L explained staff needed to wear a gown and gloves for PPE when doing personal or wound cares for resident with a wound.During an interview 5/18/26 at 1:12 PM, the Unit Manager reported he started his role as Infection Preventionist and just obtained his certification. The Unit Manager reported EBP should be put in place when a resident had a catheter, wounds, ostomy or gastric tube. He stated PPE included a gown and gloves at a minimum and signs should be posted identifying the resident was on EBP. The Unit Manager explained the reason it was important for staff to follow EBP was to prevent the spread of infection. Review of the facility policy, titled Enhanced Barrier Precautions, dated 8/2022, revealed, in part, the following: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc. A peripheral intravenous line is not considered an indwelling medical device); and wound care (wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers).Review of the facility policy titled Wound Care dated October 2010, revealed a Purpose Statement which declared: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The Steps in the Procedure directed, in part: a. Establish clean field. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached.b. Wash and dry your hands thoroughly.c. Put on gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely.d. Use no-touch technique. Use applicators to remove ointments and creams from their containers.

Based on record review, staff interviews, and the facility policy, the facility failed to thorough document transfers to the hospital (Resident #2 and Resident #13); failed to provide the resident and/or the resident's representative a transfer notice, in writing, for 2 of 2 residents reviewed for hospitalization (Resident #1, Resident #11). The transfer notice also failed to include the resident appeal rights, the Ombudsman contact information, and the contact information for those agencies responsible for the protection of residents with intellectual, developmental, mental and related disabilities. This failure impacted all residents transferred to the hospital. The facility failed to notify the Ombudsman after resident sent to the hospital (Resident #10) for 5 of 5 residents reviewed for transfers. Findings include: 1. The Minimum Data Set assessment dated [DATE] revealed Resident #2 scored a 9 out 15 on the Brief Interview for Mental Status, which indicated a moderate cognitive impairment. The list of diagnoses included stroke, hemiplegia/hemiparesis, and diabetes mellitus.Review of the electronic health record (EHR) revealed the following:a. Orders Administration Note dated 12/7/225 at 5:43 PM: nitroglycerin tablet sublingual 0.4 MG (milligrams)- give 1 tablet sublingually every 5 minutes as needed for Chest Pain x 3 doses. If no relief, call MD (Medical Doctor). Resident c/o (complaints of) chest pain.b. Orders Administration Note 12/7/25 at 5:49 PM: . Administration was: Ineffectivec. eInteract Transfer Form V5 dated 12/7/25 at 5:52 PM, completed for transfer to hospital. The form lacked documentation of the change of condition and the forms sent with the resident.d. Nurses Note dated 12/7/25 at 9:22 PM: Resident returned from ED (emergency department) with no new orders. Arrived via wheel chair in a [company redacted] van. VSS Resident in a pleasant mood denies pain at this time. During an interview on 5/14/26 at 1:16 PM, Staff B, Licensed Practical Nurse (LPN)/Unit Manager asked what needed completed during a transfer and Staff B stated an eInteract Change of Condition if a change in a resident's behavior, contact the provider, get an order for transfer, put the order in and call 911. Staff B stated then the nurse started the transfer, and documents what time the provider called, family, and the ambulance. Staff B stated he printed the medication list, face sheet, transfer discharge sheet, and advanced directives. Staff B stated after the resident transported out of the facility, he notified the ED and gave report. Staff B stated the nurse could document in the eInteract Change of Condition or progress notes. Staff B queried on Resident #2 transfer on 12/7/26 and Staff B stated he might have missed doing the eInteract Change of Condition because he was PRN. Staff B confirmed he should have documented what he sent with the resident and what occurred prior to transport.2. The MDS assessment dated [DATE] revealed Resident #13 scored a 15 out of 15 on the BIMS exam, which indicated intact cognition. The MDS revealed medical diagnoses for depression and alcohol abuse, uncomplicated. The Care Plan revealed a focus area revised on 2/16/26 alteration in mood and behaviors aeb (as evidenced by) yelling/cursing at staff and refusing cares at times. Is often noncompliant with plan of care. Resident often goes out of the facility and returns appearing to be intoxicated. It is suspected that she hides alcohol in her belongings as well as she frequently returns with bags full of clothing and grocery items. The interventions dated 1/8/26 indicated if resident appeared to be intoxicated staff to monitor in order to keep her safe and keep other residents safe. Notify PCP (Primary Care Provider) and hold meds as needed. The interventions dated 2/16/26 noted over the previous weekend resident noted to have consumed alcohol. PCP notified and medications held as ordered. The interventions noted on 5/11/26 resident sent to ER (Emergency Room) for intoxication, MD (Medical Doctor) notified with orders to obtain a blood alcohol and to hold medications.An eInteract Transfer Form V5 dated 5/11/26 at 9:42 PM, revealed resident intoxicated and the last vital signs provided from 5/9/26. The transfer form lacked documentation of current vitals, events that occurred prior to transfer to hospital, and forms sent with the resident. The Nurses Note dated 5/11/26 at 5:15 PM (note put in by the Director of Nursing (DON) on 5/12/26 at 11:21 AM), revealed the resident was noticed to be stumbling while ambulating and slurred speech. able to move all extremities. Alcohol was smelled on residents' breath. MD was notified with orders to hold medications and send to ER (Emergency Room) for blood alcohol level. Ambulance was called, arrived and transferred resident to [name redacted] for treatment. resident was noncompliant with a full assessment and upset with staff due to sending her out for evaluation. During an interview on 5/14/26 at 3:43 PM, the DON queried on the process of a transfer and she stated nurses needed to do an assessment, vitals, call the provider, write down the times when called the ambulance, provider, and family. The DON stated a progress note needed completed with vitals and when the provider, ambulance, and family notified. The DON asked about her writing the progress note the following day after Resident #13 transferred out to the facility and the DON stated the situation with Resident #13 was a little messy and Resident #13 was intoxicated and Staff B called the DON and questioned if Resident #13 would go to the hospital, but it went pretty easily. The DON confirmed Staff B probably didn't document because Staff B was a new nurse and the DON was trying to get Staff B to put more progress notes in The DON confirmed a progress note needed completed with the change of condition and the forms sent with the resident. 3. The MDS assessment dated [DATE] revealed Resident #1 scored a 13 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed diagnoses for non-Alzheimer's dementia and difficulty walking. The Nurses Note dated 5/8/26 at 1:09 PM, revealed resident was moving around dining room in her wheel chair. CNA found resident lying on her belly. NP (Nurse Practitioner) stated that she would like to get her evaluated as it was unclear if it could be an obstruction or a bladder infection. Resident's pain continued at a 10 and became diaphoretic (sweaty). Resident was then transferred to the gurney via (by) the EMTs (Emergency Medical Technicians.The Bed Hold Authorization dated 5/8/26 revealed Resident #1 transfer out of facility on 5/7/26. The Bed Hold requested the facility hold the bed and above signature revealed per phone call with Power of Attorney (POA) dated 5/8/26. The Nurses Note dated 5/13/26 at 8:00 AM, revealed resident presented this AM with URQ (upper right quadrant) pain. Order to send to ED for eval and treat for severe abdominal pain.The Bed Hold Authorization dated 5/14/26 revealed Resident #1 transfer out of facility on 5/13/26. The Bed Hold requested the facility hold the bed and above signature revealed per phone call with resident representative dated 5/14/26. 4. The MDS assessment dated [DATE] revealed Resident #11 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The MDS revealed medical diagnosis for unspecified dementia. The Nurses Note dated 4/14/26 at 3:56 PM, revealed received a call from facility staff transporting resident to cardiology appointment, stated the cardiologist suggested taking the resident to the ER for abnormal vital signs. Facility staff transported to ER without incident. Resident was seen in ER and admitted to the hospital.The Bed Hold Authorization dated 4/15/26 revealed Resident #11 transfer out of facility on 4/14/26. The Bed Hold requested the facility hold the bed and above signature revealed per phone call with resident representative dated 4/15/26.The transfer notices above lacked documentation to include the resident appeal rights, the Ombudsman contact information, and the contact information for those agencies responsible for the protection of residents with intellectual, developmental, mental and related disabilities.During an interview 5/14/26 at 2:57 PM, the Business Office/Human Resources queried on bed holds and she stated the bed holds are done over the phone with a family member and have another staff member sign the bed hold with her. The Business Office/Human Resources stated she didn't provide a copy to the family/resident. The Business Office/Human Resources was not aware resident could appeal bed holds. During an interview on 5/14/26 at 4:20 PM, the Administrator queried on the bed holds and the Administrator stated she occasionally helped with the bed holds. The Business Office/Human Resources notified the family about the bed holds and didn't know if the family received a copy of the bed hold. The Administrator confirmed the family should receive a copy of the bed hold. 5. The MDS assessment dated [DATE] revealed Resident #10 scored a 4 out of 15 on the BIMS exam, which indicated severely impaired cognition. The MDS revealed medical diagnosis for unspecified dementia, severe with anxiety.The Nurses Note dated 4/25/26 at 11:27 PM, revealed at approximately 9:15 PM, CNA notified this nurse that resident was found on the floor. Upon entering the room resident was on the floor between her bed and wheelchair. Phoned [name redacted] on call number and they notified [name redacted. [name redacted] phoned back with verbal order to send to ED (Emergency Department) for evaluation.Phoned 911 at 9:41 PM, phoned report to [name redacted] ED at 9:37 PM. Resident left with EMS (Emergency Medical Staff) at 9:56 PM.The Notice of Transfer Form to Long Term Care Ombudsman for April 2026 lacked Resident #10 name for a transfer. During an interview on 5/14/26 at 4:20 PM, the Administrator queried on reporting hospital transfers to the Ombudsman and the Administrator stated she only reported if they discharged or were hospitalized and didn't know she needed to notify the Ombudsman if they went to the hospital and came back. Review of the facility policy, Transfer or Discharge, last revised 3/2025 revealed the following information: a. When the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider: The basis for the transfer or discharge;That an appropriate notice was provided to the resident and/or legal representative;The date and time of the transfer or discharge;The new location of the resident;The mode of transportation;A summary of the resident's overall medical, physical, and mental condition;Disposition of personal effects;Disposition of medications;b. Transfer or Discharge Appeals: Upon notice of transfer or discharge, the resident is provided with a statement of his or her right to appeal the transfer or discharge, including:The name, address, email, and telephone number of the entity which receives such requests;Information about how to obtain, complete, and submit an appeal form;How to get assistance completing the appeal process; andThe facility bed-hold policy.

Based on clinical record review, facility policy review, and staff interviews the facility failed to ensure that residents remained free from resident to resident altercations for 1 of 9 resident records reviewed (Resident #2). The facility reported a census of 62 residents.Findings include: Review of a Facility Reported Incident, dated 12/24/25 revealed (resident name redacted, Resident #1) was sitting in front of doorway to the nurses' station when (resident name redacted, Resident #2) was trying to pass by him. As Resident #2 passed by, Resident #1 swung back hitting her in the upper back twice. This was witnessed by Restorative Aide (name redacted, Staff A) and (name redacted, Staff B, Registered Nurse (RN)). When altercation started, (name redacted, Staff A) tried to stop (name redacted, Resident #1) from hitting (name redacted, Resident #2) by holding arm, (name redacted, Resident #1) then hit (name redacted, Staff A) in the shoulder and grabbed at her abdomen pinching it and causing a bruise. Immediately separated, head to toe skin assessment and pain assessment completed. Primary care provider, Power of Attorney (POA) and law enforcement notified.Review of the Minimum Data Set (MDS) assessment, dated 11/14/25 revealed a list of diagnoses for Resident #1, which included cerebrovascular accident (a stroke), hemiplegia (paralysis on 1 side of the body), aphasia (inability or difficulty with speech), adjustment disorder with depressed mood, and a history of falls and diabetes. The Brief Interview for Mental Status (BIMS) score 9 out of 15 indicted a moderate cognitive impairment. The MDS indicated the resident usually able to make himself understood, usually able to understand others, and had behaviors from 1 to 3 days of the 7 days that preceded the assessment date that did not impact the resident or others. The MDS indicated Resident #1 required substantial staff assistance to reposition in bed, transfer to and from bed or chair, dressing, toileting and bathing, unable to stand or ambulate and wheelchair used as primary mode of transportation.Review of Resident #1 Care Plan revealed a problem labeled I have alteration in mood and behaviors, I often do not want to have clothes on, I can be verbally aggressive, initiated 11/11/25. The plan directed staff to:a. Administer medications as ordered. Monitor/document side effects and effectiveness, initiated 11/11/25.b. Anticipate and meet the resident's needs, initiated 11/11/25.c. Assist the resident to develop the most appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately, initiated 11/11/25.d. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by, initiated 11/11/25.e. If reasonable, discuss the resident's behavior with them. Explain/reinforce why behavior is inappropriate and/or unacceptable, initiated 11/11/25.g. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm and controlled manner. Redirect. Remove from situation and take to alternate location as needed, initiated 11/11/25. A Nursing Progress Note transcribed by the Director of Nursing (DON) on 12/24/25 at 3:20 p.m. stated, in part: Resident watching another resident (name redacted, Resident #2) propelling self in her wheelchair around the nurse's station, as (name redacted, Resident #2) was trying to pass Resident #1 swung his arm back hitting (name redacted, Resident #2) in the upper back twice. A CNA (Certified Nursing Assistant) intervened holding Resident #1's arm and (name redacted, Resident #2) was able to get by. Resident #1 then hit the CNA in right shoulder and grabbed at her abdomen pinching her skin and causing a reddish/blue mark. Resident #1 was separated from (name redacted, Resident #2) and was placed on 1:1, Nurse Practitioner (NP) and law enforcement were notified.A Nursing Progress Note transcribed by the DON on 12/24/25 at 4:32 p.m. described the primary care provider was notified of Resident #1's transfer to the county jail by a Sheriff's vehicle.Review of Iowa Courts Online electronic records/data repository revealed Resident #1 arrested and taken into custody by the county Sheriff's office on 12/24/25, where he remained for the duration of the State Agency investigation. Resident #1 charged with assault on persons in certain occupations with bodily injury, and older individual assault.2. The MDS assessment for Resident #2, dated 12/18/25, revealed a list of diagnoses that included non-Alzheimer's dementia, cognitive communication deficit, adjustment disorder with mixed anxiety and depressed mood. The BIMS score of 6 out of 15 points indicated a severe cognitive impairment. The MDS indicated Resident #2 sometimes able to make herself understood and sometimes able to understand others. The MDS revealed Resident #2 unable to stand or ambulate, and used a wheelchair as primary method of transport.Review of the Care Plan revealed a problem labeled Resident has impaired cognitive function/dementia or impaired thought processes related to Dementia diagnosis, initiated 1/19/25. The plan directed staff to: a. Ask yes/no questions in order to determine the resident's needs, initiated 1/19/25.b. Cue, reorient and supervise as needed, initiated 1/19/25.c. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion, initiated 1/19/25.d. Present just one thought, idea, question or command at a time, initiated 1/19/25.A Nursing Progress Note in Resident #2's record, transcribed by the DON on 12/24/25 at 3:57 p.m. documented, in part: Resident was propelling self in her wheelchair around the nurse's station as per her routine every evening. When she was trying to pass (name redacted, Resident #1) he slung his arm back hitting her in the upper back twice. A CNA intervened and the resident was able to get by. Upon skin assessment no issues (redness, pain, or marks) were found, resident stated she had no pain.During an observation on 1/12/26 at 3:24 p.m., Resident #2 used her feet to self-propelled her wheelchair in the hallway near the Nurses Station area.During an interview on 1/12/26 at 12:20 p.m., Staff A, Certified Nursing Assistant (CNA) and Restorative Aide (RA) stated Resident #1 would become irritable if staff redirected him. On the afternoon of 12/24/25 Resident #2 self-propelled her wheelchair in the hall, and tried to get by Resident #1, while he talked on the phone at the nurse's station. Staff A stated she could not get to Resident #1 before he struck Resident #2 with his fist, twice on her back, as Resident #2 leaned forward in her wheelchair and continued to self-propel her wheelchair past him. Resident #1 then stood up and turned in the direction of Resident #2. Staff A stated she thought he was going to go after Resident #2, but was able to redirect him and asked him to sit down. Staff A stated that is when Resident #1 hit her with a closed fist on her right shoulder area, and then pinched her in the abdomen area. Staff A stated she was bruised on her shoulder and abdomen. During an interview 1/12/26 at 2:32 p.m., Staff B, Registered Nurse (RN) stated she worked on 12/24/25 and witnessed Resident #1 strike Resident #2 twice on the back. Staff B explained Resident #2 self-propelled her wheelchair around Resident #1 while he was on the phone at the nurse's station. Staff B stated Resident #1 then hit Resident #2 on her back. She stated it all happened so fast. She explained Resident #1 stood up, and Staff A, CNA/RA was able to stop him from hitting Resident #2 again. Staff B stated she then was able to direct Resident #1 to sit back down, and that is when he hit and pinched Staff A. Staff B stated they were able to get Resident #1 seated and separated from Resident #2, and notified the DON immediately. During an interview on 1/12/26 at 2:55 p.m., Staff I, CNA, stated Resident #1 had behaviors, explaining sometimes he was redirectable but other times he acted like he didn't understand staff and when redirected or a direction repeated, he would get agitated. Staff I stated she worked on 12/24/25 but did not witness the incident between Resident #1 and Resident #2.During an interview on 1/8/26 at 12:40 p.m., the DON stated Resident #1 had not had any physical altercations with any of the residents. She stated the resident planned to transfer to another facility on 12/29/25 to be closer to his family. The facility notified law enforcement of the incident on 12/24/25, county deputies arrived shortly after that and took the resident into custody and there were charges against him related to the incident. The DON stated they had re-assessed Resident #1's BIMS about 2 weeks before the incident and it was 13 at that time (indicated no cognitive impairment). The DON stated nursing staff assessed Resident #2 for injuries after the incident, and none were found. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention policy, dated 10/2023 directed staff:a. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.b. This policy consists of a facility-wide commitment and resource allocation to support the following objectives that include, but are not limited to:1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, and any other individual.c. Develop and implement policies and protocols to prevent and identify abuse, neglect, or mistreatment of residents, and/or theft, exploitation or misappropriation of resident property.d. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.e. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.f. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.g. Investigate and report any allegations within timeframes required by federal requirements.h. Protect residents from any further harm during investigations.

Based on clinical record review, facility policy review, and staff interviews the facility failed to ensure that residents are free from financial exploitation for 1 of 9 residents (Resident #3) reviewed. The facility reported a census of 62 residents.Findings include: Review of Resident #3 Minimum Data Set (MDS) assessment, dated 8/11/25 revealed a diagnoses list that included adult failure to thrive, type 2 diabetes with unspecified complications, alcoholic cirrhosis of liver without ascites (fluid accumulation in the abdomen), anxiety, and depression. The Brief Interview for Mental Status (BIMS) score of 10 out of 15 points indicated a moderate cognitive impairment. The MDS indicated Resident #3 always able to make herself understood and always understood others. The MDS identified the resident totally dependent on staff for substantial assistance to reposition in bed, transfer to and from bed or chair, and unable to stand or ambulate. Review of a Facility Self-Reported Incident, dated 12/7/25, revealed When having a discussion with Resident [name redacted, Resident #3], bims of 13. It was brought to the Administrators attention that [name redacted, Resident #3] let CNA [name redacted, Staff H, Certified Nursing Assistant (CNA)] her food stamp card to spend on herself.Review of Resident #3 Care Plan revealed a problem labeled I have actual and/or the potential for inability to cope with my lifestyle changes, limitations in my functional abilities and my husband no longer being able to act as my caregiver due to his own health complications, initiated 8/29/25. The plan directed staff to:a. Assist the resident to identify, access and use support systems of family, initiated 8/29/25.b. Encourage and allow me time to express my feelings re: difficulty coping with lifestyle changes. Allow me time to grieve, initiated 8/29/25.c. Encourage the resident to express feelings of anger, frustration and/or concerns, as appropriate. She likes 1:1 conversation, initiated 8/29/25.d. The resident needs assistance with problem solving, initiated 8/29/25.The Care Plan included a new problem labeled Involved in an allegation of misappropriation of funds by staff member, initiated 12/9/25, which directed staff to: a. Psychosocial wellbeing check in 2x a week for 2 weeks, then as needed, initiated 12/10/25.b. Resident education completed that only administrative staff will use personal money cards for personal items. Resident understood and agreed with education, initiated 12/9/25.During an interview 1/12/26 at 12:14 p.m., Resident #3 stated she had an EBT (Electronic Benefits Transfer) Food Stamp card for several years. She stated she received $171 monthly in benefits. Resident #2 stated she didn't always like the food served at the facility and wanted some snacks, so she asked Staff H, CNA to use her EBT Food Stamp card to purchase some snacks for her. She told Staff H that she could buy some things for herself with the card as well. Resident #3 stated she did not give Staff H an amount that she could spend and didn't know what she'd purchased for herself. Resident #3 stated she recalled the total purchased was for a little over $100, and Staff H returned the EBT Food Stamp card. Resident #3 stated she didn't think she did anything wrong, as she didn't think she had any way to get the food and Staff H was helping her. The resident stated she didn't want anyone to be in trouble over this and after it happened was when she found out there were staff at the facility that could have shopped for her.During another interview on 1/14/26 at 1:10 p.m., Resident #3 stated some of the items purchased required refrigeration, she didn't have access to the refrigerator and sort of lost track of those items. She stated Staff H, CNA gave her the receipt for the purchase but she didn't have it any more.During an interview on 1/8/26 at 12:40 p.m., the Director of Nursing (DON) stated they learned Resident #3 gave her EBT Food Stamp card to Staff H, CNA when a nurse reported the situation after a conversation with the resident. The DON explained Resident #3 stated she gave the card to Staff H to get food items for her and told Staff H she could get some food for herself. The DON stated Staff H was questioned and she stated she got food for the resident and for herself. DON stated Staff H didn't say what she spent on herself. The DON added that Staff H was terminated as a result and the facility reported the matter as required to the State Agency and the local police. During an interview on 1/14/26 at 10:30 a.m., Staff H, CNA, stated the resident wanted some snacks and asked her to take her [Resident #3's] EBT Food Stamp card to the store, purchase food for her [Resident #3] and said she [Staff H] could buy some food for herself as well. Staff H stated this occurred in October and she shopped at a grocery store located in [NAME]. Staff H stated she spent a little over $100 and used the resident's EBT Food Stamp card for the purchase. Staff H stated the resident checked the balance on the card before she gave it to her and it was $230 or $300. Staff H couldn't recall what she purchased for herself, then said it was a bag of chips, a 20-ounce soda and she couldn't remember what else, but was only a few items. Staff H stated she brought the resident's requested groceries to the facility in 4 or 5 grocery bags, refrigerated items were placed in the refrigerator in the beauty shop, and she returned the EBT Food Stamp card to the resident with the receipt. Staff H stated she had been a CNA since 2014, and had education on dependent adult abuse and didn't think she had done anything wrong because the resident told her she could purchase items for herself with the EBT Food Stamp card.During an interview on 1/12/26 at 12:20 p.m. Staff A, CNA and Restorative Aide (RA) stated she did not know about the situation with the resident's EBT Food Stamp card until after it occurred. She stated she was questioned by management staff. Staff A stated she knew it was wrong to use a resident's resources or accept gifts from a resident and that information was covered in the dependent adult abuse education that she received prior to employment at the facility. During an interview on 1/14/26 at 12:21 p.m., Staff L, [NAME] President of Operations for the facility's corporation stated they reimbursed the resident $25 for the items Staff H purchased for herself with the resident's EBT Food Stamp card, and would reimburse the total amount to the resident once known. Staff L stated the resident and staff were educated on dependent adult abuse that included financial exploitation, and there were designated staff at the facility that could shop for residents and who should shop for the residents when the need arose.A document received from Staff L, [NAME] President of Operations dated 1/30/26 described both she and the facility Social Worker met with the resident on 1/28/26, reviewed the purchases on the grocery store receipt dated 10/8/25 with the resident, the resident identified several items that she did not ask Staff H to purchase, those items totaled $115.96 and believed to be what Staff H had purchased for herself with the resident's EBT Food Stamp card.Review of a grocery store receipt dated 10/8/25, obtained by the State Agency on 1/22/26 revealed a total of 68 items purchased with Resident #3 EBT Food Stamp card for a total of $268.93.The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention policy, version 10/2023 directed staff:a. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. This policy consists of a facility-wide commitment and resource allocation to support the following objectives that include, but are not limited to:a. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, and any other individual.b. Develop and implement policies and protocols to prevent and identify abuse, neglect, or mistreatment of residents, and/or theft, exploitation or misappropriation of resident property.c. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.d. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.e. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.f. Investigate and report any allegations within timeframes required by federal requirements.g. Protect residents from any further harm during investigations.

Based on clinical record review, staff, resident and family interviews, the facility failed to make an attempt to meet resident needs prior to issuing emergency discharges for 2 of 2 residents (Resident #1 and Resident #5) reviewed. After a resident to resident altercation the facility issued emergency discharges to Resident #1 and Resident #5 upon their transfer to the hospital for an evaluation. The facility reported census was 57.Findings include: 1. According to a Minimum Data Set (MDS) with a reference date of July 17, 2025, Resident #1 had a Brief Mental Status (BIMS) score of 14 of 15, indicating an intact cognitive status. Resident #1 was coded independent to needing supervision assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnoses included coronary artery disease, atrial fibrillation and was always continent of bladder and bowel.According to the facilities Notice of Resident Transfer or Discharge form dated Sept. 16, 2025, directed to Resident #1's guardian, the form indicated Resident #1 was being discharged due to the safety of individuals in the facility being endangered due to the clinical or behavioral status of the resident. The form includes the placement facility and rights to appeal to the State agency with address and contact number along with other related advocacy agencies, addresses and numbers. The form was initialed by Resident #1.Clinical record review revealed Resident #1 was admitted on [DATE] and had a total of five recorded altercations with his peers. Altercations per the clinical record:a. On May 24, 2025 described as a disagreement with no threats of violence. Residents were moved to different rooms. b. On July 4, 2025 described as arguing about the TV being too loud. Residents were deescalated and volume turned down. c. On July 5, 2025 residents continued to argue and were moved to different rooms. d. On Sept. 12, 2025 arguing with roommate which escalated to both residents threatening to fight each other. The residents were separated and moved rooms. e. On Sept. 16, 2025 described as a verbal dispute with threats of violence leading to the facility doing an emergency discharge on both residents. 2. According to a Minimum Data Set (MDS) with a reference date of Sept. 16, 2025, Resident #5 had a Brief Mental Status (BIMS) score of 14 of 15, indicating an intact cognitive status. Resident #5 required maximal assistance with dressing and toileting hygiene and supervision with transfers, mobility and personal hygiene needs. Resident #5's diagnosis included coronary artery disease and atrial fibrillation. Resident #5 was coded as occasionally incontinent of bladder.According to the facilities Notice of Resident Transfer or Discharge form dated Sept. 16, 2025, directed to Resident #5's father or sister, the form indicated Resident #5 was being discharged due to the safety of individuals in the facility being endangered due to the clinical or behavioral status of the resident. The form includes the placement facility and rights to appeal to the State agency with address and contact number along with other related advocacy agencies, addresses and numbers. The form was initialed by Resident #5.In an interview on [DATE] at 5:30 p.m. the Administrator explained her reasoning to discharge Resident #1 and Resident #5 on Sept. 16, 2025. The Administrator stated there had been two resident to resident altercations days earlier involving Resident #1 and Resident #6 in a verbal and threatening altercation on Sept. 13, 2025 and Resident #5 and Resident #7 in a verbal and threatening altercation on Sept. 15, 2025. In both situations, the residents were roommates and the intervention were to separate by changing rooms, which eventually resulted in Resident #1 and Resident #5 becoming roommates and leading to the third verbal and threatening altercation on Sept. 16, 2025. The facility received orders for an emergency psychiatric evaluation and Resident #5 was the first to be sent out to the hospital #1 emergency department (ED), however the emergency room (ER) physician refused to complete an evaluation and wanted the resident returned to the facility. The Administrator stated she and the Director of Nursing (DON) decided to transport Resident #1 to a different hospital #2 emergency room. The Administrator explained what was happening and the ER physician stated they could do a psychiatric evaluation, but thought Resident #1 was fine. Hospital #2 staff then told the Administrator they could leave and they would be in contact with them. When Hospital #2 called the facility, the Administrator stated they had no more available rooms to accommodate residents with these behaviors and felt she had no choice but to discharge them. The Administrator stated Resident #1's guardian was called and informed and Resident #5's father and sister were called but never answered and the emergency discharge was explained to Resident #5 and signed by him.In an interview on Sept. 30, 2025 at 8:40 a.m. The Director of Nursing (DON) stated on the late evening of Sept. 16, 2025, she and the Administrator were called into the facility regarding a resident to resident conflict between Resident #1 and Resident #5. The two residents had gotten into a verbal argument which escalated into threats of physical violence. The DON stated they got an order for a psychiatric evaluation and began the emergency discharge process. They contacted emergency medical services (EMS) to have the residents transported to Hospital #1, but were told they would only take one. Resident #5 was initially sent. The Hospital #1 physician called the facility, refusing to do a psychiatric evaluation, noting Resident #5 was fine and they were discharging him back to the facility. The DON stated since Hospital #1 refused to complete a psychiatric evaluation on Resident #5, she and the Administrator would transport Resident #1 to Hospital #2 instead. When they arrived to Hospital #2, they explained why Resident #1 was there and the nurse began assessing him. There was a loud alarm going off and the DON and the Administrator were told they could leave and that they would call them with their evaluation. Sometime after 3:00 a.m. the facility received the call and was told Resident #1 did not meet the criteria to admit. The DON stated she was not aware of what else was discussed. The DON was then asked about family and guardian notifications and she stated she contacted Resident #1's daughter, guardian and informed her of their plans to discharge Resident #1 and depending on the outcome of the psychiatric evaluation, he may be readmitted . The DON stated she did not discuss the appeals process with Resident #1's daughter, guardian, noting she thought Resident #1 was his own person and had him sign the discharge papers. The DON was unaware that Resident #1's daughter was also his guardian. The DON stated they attempted to contact Resident #5's father and sister unsuccessfully, but explained the discharge papers to Resident #5 and had him sign the paper work. In an interview on Sept. 30, 2025 at 10:13 a.m. Resident #1's guardian, stated she received a call from the facility sometime after 10:00 p.m. on Sept. 16, 2025. The guardian stated the nurse was very kind and stated there was an altercation between her and another resident and they were doing an emergency discharge. The guardian stated she was half asleep and not clearly thinking as they told her they were taking him to Hospital #2. The guardian stated she questioned why Hospital #2 when there was a local hospital #1 and she was not provided a clear explanation. The guardian was asked whether the facility explained what an emergency discharge was and the appeals process should she disagree. The guardian stated that was never discussed and she was never provided any form to sign. The guardian stated her father is still in Hospital #2 and she has visited a couple times, but the distance is a problem. In an interview on [DATE]. 2025 at 9:00 a.m. The Social Worker at Hospital #2, stated Resident #1 was admitted on Sept. 17, 2025 following a verbal altercation at a facility. Resident #1 was found not to meet criteria for psychiatric admission. Hospital #2 reached out to the facility to try and have him return and the facility refused to take him back. Hospital #2 have now been forced to try and find placement for him. Hospital #2's social worker stated she thought Resident #1 was doing fine with no known reports of behavioral issues.In an interview on 9/30/25 at 3:46 p.m. Resident #5's sister, stated she received a call about 1:30 a.m. on Sept. 17, 2025 from Hospital #1 stating that her brother was in the emergency room (ER). That he had been in an altercation with another resident and the facility brought him there to be evaluated and now will not take him back. Resident #5's sister stated she called her father and together they went to the ER and picked him up. Resident #5's sister stated her brother has an apartment and his father took him there. The next morning her father went to the facility with Resident #5 to get his clothes. The facility refused to allow him into the facility and brought his clothes out to him. His father then took him to the grocery store and picked up some food. Resident #5's sister stated she thought her brother tried calling several people to arrange in home services, but noted her dad is pretty attentive. Resident #5's sister stated her dad is Resident #5's payee, but notes he can pay his bills. Resident #5 did not know about his medications and stated her brother probably mostly needs help with bathing, activities of daily living (ADL's), cleaning and cooking. Resident #5's sister stated she thought he was doing fine.

Based on observations, record review, document review, interviews, and facility policy review, the facility failed to ensure staff used safe and appropriate techniques to assist the resident in positioning on a bedpan for one (Resident #29) of one sampled resident reviewed for fractures. A facility Certified Nursing Assistant (CNA) pulled the resident's wrist while assisting the resident into an upright position on a bedpan, resulting in a fracture. The facility identified a census of 36 current residents. Findings include: A review of the facility's policy titled, Azria Safe Lifting and Movement of Residents, dated July 2017, revealed, In order to protect the safety and well-being of staff and residents and to promote quality care, this facility uses appropriate techniques and devices to life and move residents. The policy also indicated, Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. A review of Resident #29's Admission Record revealed the resident had diagnoses of hypertensive [CONDITION(S)] without heart failure, anxiety disorder, and other specified disorders of bone density and structure. A review of the quarterly Minimum Data Set, dated dated [DATE], revealed Resident #29 scored 14 on a Brief Interview for Mental Status, indicating intact cognition. Additionally, the MDS indicated the resident was dependent upon limited supervision for bed mobility was dependent on extensive assistance of at least one person for toileting and was dependent on moderate assistance of at least one person for rolling from one side to the supine (lying on back) position in bed. A review of the care plan, dated 03/10/2022, revealed the resident was at increased risk for actual and potential limitations in the ability to perform activities of daily living due to impaired mobility secondary to ankle stability. Interventions included one-person physical assistance and use of a grab bar and gait belt for toileting. A review of a, Skin Alteration Evaluation, dated 03/10/2022, revealed bruising was identified to Resident #29's left hand. [CONDITION(S)] and discoloration were also noted. Additional bruising was noted on Resident #29's left arm. Review of an undated DIA [Department of Inspections and Appeals] Report revealed there was dark purple bruising with swelling noted to the resident's left wrist and forearm. The resident denied pain unless the wrist was touched. The report indicated the resident was able to move the wrist freely with no discomfort voiced. Resident #29 reported the Certified Nursing Assistant (CNA) was trying to help the resident get up to go to the bathroom and pulled the resident by the hand. Resident #29 added, I said 'that hurts' and [CNA] let go and got me under my arms. An ice pack was provided to the resident, and the doctor was notified by the charge nurse. On 03/10/2022, an x-ray was obtained which identified a non-displaced fracture of the left wrist. According to the CNA, once the resident was on the bedpan like a toilet, the CNA stood on the left side of the bed and held Resident #29's left hand and upper back to provide support while hoisting them up to the resident's preferred position. Review of a signed interview dated 03/10/2022 from Resident #29 revealed the CNA (Staff E) was trying to help him/her get up to go to the bathroom and held the resident by his/her hand. Resident #29 added he/she said that it hurt, and the CNA let go and got the resident under his/her arm. A review of the Patient Report, dated and signed 03/10/2022, revealed three views of the left forearm. Findings included prominent soft tissue swelling at the level of the distal radius. The report indicated there was evidence of a small nondisplaced fracture. A review of a Progress Note, dated 03/11/2022 at 7:03 AM, indicated a visual inspection of the resident's left wrist revealed bruising and swelling. The nurse asked the resident if he/she was in pain and if the resident wanted any Tylenol. The resident declined and stated, no, it don't hurt unless I touch it. The resident denied pain. Review of the notes for the same day at 11:19 AM and 2:24 PM revealed the resident was sent to the doctor per the doctor's request. A note at 4:19 PM indicated new orders to keep the resident's arm elevated, use ice for pain or swelling, and follow up next Tuesday (03/15/2022). A review of a Final Report, dated 03/11/2022 and signed 03/12/2022, revealed a left wrist fracture. The report indicated recommendations for follow-up in three to five days for repeat x-rays and a splint to check alignment. A review of a Progress Note, dated 03/14/2022 at 5:39 PM, revealed new orders were received for x-rays in three days and repeat in 10 days. The note indicated the radiology provider was notified. Notes at 11:07 PM revealed the physician was doing the x-rays at the clinic, according to the transportation scheduler. A review of Staff E's signed statement, dated 03/16/2022, revealed Staff E noted that the resident rolled from side to side to get on the bedpan. She reported that once the resident was on the bedpan, the resident preferred to sit up, as if on a toilet, so the CNA stood on the left side of the bed and held the resident's left hand and upper back to provide support while hoisting the resident up to the resident's preferred position. A review of a Progress Note, dated 03/18/2022, revealed the resident's circulation, motion, and sensation to the left upper extremity was within normal limits. The left hand was edematous with bruising noted. During an interview on 07/06/2022 at 10:18 AM, Resident #29 stated he/she was needing assistance at night to use the restroom. Resident #29 preferred to use a bedpan. The CNA helping the resident grabbed Resident #29's wrist to help him/her get onto the bedpan. When this happened, Resident #29 said it hurt a little. Additionally, Resident #29 stated he/she was seen by the doctor. During an interview on 07/08/2022 at 2:14 PM, Staff E, CNA, revealed she was an agency CNA. When she helped Resident #29 use the bedpan, she knew Resident #29 used the bedpan in an unconventional way. The resident liked to sit on it as one would sit on a toilet. Because of this, Resident #29 used Staff E's arm for balance. Staff E stated Resident #29 would roll onto the bedpan from his/her side and use the staff's arms for balance to sit up. Staff E stated Resident #29 did not give any indication he/she was hurt during the process. The process was not really a transfer; however, Staff E went through all the normal transfer training for a resident during her CNA classes. During an interview with Staff D, CNA, on 07/08/2022 at 4:15 PM, she revealed there was continued communication between facility nurses, CNAs, and agency staff, regarding residents' status and needs related to transfers and residents' preferences. During an interview on 07/08/22 at 4:49 PM with the Administrator (ADM) and Director of Nursing (DON), they revealed they were not working in the facility when the incident occurred. Since their arrival, there was an expectation that agency staff had the same training as facility staff. When a new agency worker worked in the facility, if allowed, they were to come in to work an hour or two prior to their shift to shadow another staff member working with the residents they would be working with. Staff E's agency did allow staff to come in two hours before their shift. Since the ADM and DON arrived, they had implemented some new systems to help agency staff know the residents more. A KARDEX was now on the inside of the wardrobe of each resident. Their preferences and needs were outlined on this.

Based on clinical record review, observations and interviews the facility failed to provide adequate supervision to a high risk and cognitively impaired resident to prevent elopement for 1 of 3 sampled (Resident #1). Resident #1 exited the facility without staff knowledge on 12/28/19. This resulted in an Immediate Jeopardy. It was determined the wander device door alarm was unplugged and back up door alarm was silenced at the time of the elopement. The facility reported a census of 46. Findings included: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status score of 6, indicating severe cognitive impairment. Resident #1 required extensive assistance for transfers, dressing, toileting use, personal hygiene and utilized a wheelchair for mobility. Resident #1 had [DIAGNOSES REDACTED]. A Wander Risk assessment dated [DATE], identified the resident with a score of 15 indicating a high a risk for wandering. The Care Plan with a completion date of 9/27/19 failed to address the resident's risk for elopement and failed to address the use of a wander device. Review of the Progress Notes from 4/27/19 to 12/3/19 revealed the following behaviors: a.On 4/27/19 at 6:57 a.m., Resident #1 crawled out of bed, reported he needed to meet his brother and wanted assistance so he, could get out of here. b. On 5/1/19 at 1:56 p.m., Resident #1 propelled his wheelchair through the front door before staff could get to him. He thought his daughter's vehicle was in the parking lot and wanted to go meet her. Resident #1 had a wander device in placed to his left wrist. c. On 6/9/19 at 11:15 p.m., Resident #1 became quite confused and cantankerous, wanted his shoes and his wife called to come pick him up. d. On 7/22/19 at 4:06 p.m., Resident #1 returned from an appointment with a new order for [MEDICATION NAME] 5 milligrams by mouth once a day for confusion. e. On 8/21/19 at 5:37p.m., Resident #1 attempted to exit the facility multiple times throughout the day to go home. The staff redirected several times with good outcome, but only lasted a little while. f. On 11/18/19 at 5:42 a.m., Resident #1 talking of the need to get his truck to pick up grain. g. On 12/3/19 at 6:41 a.m., Resident #1 up and awake all shift wandering without purpose in the wheelchair throughout the front area of the facility. The December 2019 Treatment Administration Record (TAR) documented Resident #1 had a wander device on the left wrist. The TAR directed staff to check every shift for wandering. The TAR had 3 omissions on the night shift and 19 omissions on the day shift. A Door Alarm Testing Log documented a door alarm check on 12/27/19 at 11:00 p.m. which included testing the door alarm, modules mounted on the door frame, red/green light functioning, range of door satisfactory, cables secure, wires frayed and a comment section. An Incident Report Form, dated 12/28/19, completed at 4:00 p.m., documented a large group of people exited the building from a Christmas party with cooler and gifts. Resident #1 followed the group of people out the door. The Incident Report documented the following vital signs after the incident: Temperature 97.7 degrees Fahrenheit, Pulse 108 beats per minute, Respirations 20 breaths per minute, Blood Pressure 138/62. The Incident Report identified the severity level of the incident at a Level 3, indicating an occurrence type which is considered to be at risk in nature; with or without injury (i.e. elopement, abuse, etc.). The untitled and undated (Facility Investigation),provided by the facility, identified Resident #1 had [DIAGNOSES REDACTED]. On 12/28/19 at 3:45 p.m., another resident told Staff A (Nurse Aide) that he saw another resident in the front circle drive going out toward the street. Staff A responded and observed Resident #1 propelling his wheelchair down the street headed east. Staff A reached Resident #1 390 feet from the front door of the facility. Resident #1 had a t-shirt, long sleeve shirt, sweatpants, socks and shoes on. Resident #1 reported he was on his way home. Staff A returned to the facility at 3:52 p.m. with Resident #1. The outside had a temperature of 50 degrees. The Director of Nursing (DON) performed a head to toe assessment and no injuries were noted. The staff notified the family and physician. The staff completed a count of all residents. The Document identified about 3:30 p.m. to 3:40 p.m. there had been 15 -20 people leaving the building after celebrating a Christmas party with their family member. The door alarm had likely been silenced as the visitors exited the facility. The document identified the door alarms were checked and all were functioning. The wander device the resident had been wearing also functioned properly, but the wander device monitor (control box) on the front door had gotten unplugged so the wander device alarm did not sound when the resident exited the facility. During an interview, conducted by the facility on 12/28/19, Staff A (Licensed Practical Nurse) reported another resident reported they saw Resident #1 outside the facility heading toward the street. Staff A ran out the front door of the facility. Resident #1 was wheeling his wheelchair down the street, east towards his house. The resident stated he was going home. Staff A reported she redirected Resident #1 easily. During an interview conducted by the facility on 12/28/19, the Director of Nurses (DON) reported 15 - 20 visitors exited the facility between 3:30 p.m. - 3:40 p.m. following a Christmas party. They carried out coolers and packages. It was not determined who silenced the exterior front door alarm. The DON reported likely the door had been silenced so the group could exit without the alarm sounding. Resident #1 exited with or directly behind the group prior to the (front) door shutting. It would have been very hard for the resident to have opened the door himself if it had not remained opened after or when the group left. A member of the group may have assisted the resident out the door if he said they were just going out to the porch. When gathering information and checking the alarms, it had been noted the wander device had become unplugged from the wall (by the front door). It had been immediately plugged back in and activated appropriately when tested . During an observation on 9/1/20 at 2:45 p.m., Staff B (Registered Nurse) walked to the front door, front wander device door, dining room door, East hall exit door, South hall exit door, beauty shop/patio door, back hallway wander device door and rear facility exit door and checked the function of the door alarm system and the wander device system. Staff B opened all doorways to set the door alarm off and utilized the wander device pendant to test all the wander device alarmed doors. All tested doors alarmed appropriately. Observation on 9/2/10 at 2:55 p.m. revealed the front wander device system plugged tight into the socket and unable to be removed from the socket. The wander device plug is up high on the right side of the door frame and could not be accessed without a stool or chair. The automatic door opener system had the door openers approximately 4 feet high from the floor easily accessible on the side of the door frames. The rear employee entrance wander device has the plug on the left side of the door frame on the back side of the door, which can still be manually unplugged. During an interview on 9/1/20 at 3:06 p.m. the State Climatologist reported on 12/28/19 a temperature of 52 degrees Fahrenheit, relative humidity100%, winds out of the southeast at 12 - 16 miles per hour gusting, visibility at 2 miles, no wind chill, and rain before and after the time period the resident had been outside of the facility. During an observation and interview on 9/1/20 at 3:00 p.m., Staff A (Licensed Practical Nurse) walked out the front door, which had revealed a large horizontal crack in the cement with a small slope down into the facility front driveway, then into the street heading east to the intersection of Prairie Street and North(NAME)Street where staff found Resident #1 propelling his wheelchair on the right hand side of the road across from a nearby parking lot, approximately 390 feet from the front door of the facility. The right side of Prairie Street had uneven areas. Staff A reported on 12/28/19 at 3:10 p.m. she arrived to work at 2:00 p.m. and had Resident #1's section. Staff A reported Resident #1 had no agitation or exiting seeking prior to the elopement, but had been missing his spouse. Resident #1's spouse visited earlier that day. Staff A reported another resident pointed out the window and informed Staff A that Resident #1 was outside. Staff A looked outside and observed Resident #1 propelling his out onto the street. Staff A immediately ran outside to retrieve Resident #1 who was easily redirected. Resident #1 stated he was going home where his spouse lives a few blocks away. Resident #1 always talked about going to see his spouse or get his truck. Resident #1 had a t-shirt, long sleeve shirt, sweatpants, socks and shoes on. Staff A reported she did not recall hearing any door alarms go off around the time of the elopement. Someone unplugged the wander device on the door but she didn't know who. A red light at the Nurses Station plane indicates the door is alarmed. The staff received education after the elopement to ensure the door alarms are not silenced unless the door is checked to ensure a resident has not gone out. She said there had been a note placed not to unplug the wander device system on the front door, but the wander device system had been replaced shortly after the elopement. She reported the nurses now check the door alarms every shift right after report along with checking the resident's wander device pendants are working. She said she always looks to see if the residents have their wander device on and would let the nurse know if they did not have it on. During an observation and interview with the Administrator, 9/2/20 at 3:25 p.m., she reported she didn't know what more the facility could have done. She reported the facility took all the following steps immediately: a. The DON assessed the resident once back in the facility. b. A headcount had been done to ensure all resident's account for in house. c. The wander device on the front door plugged in and all the door alarms tested to ensure working appropriately. d. Immediate education provided on 12/28/19 right after the elopement for all shifts. e. Reporting to the Iowa Department of Inspection and Appeals (DIA) Hotline number to report the incident. f. The Administrator initiated 15 minute checks on the wander device plug on the front door to ensure plugged in and placed a note stating if you ever had to unplug this for any reason, it must be immediately plugged back in. g. A Posting placed on the front door reminding visitors not to assist resident out of the facility without consulting the nurse first. The Administrator reported they had taken appropriate actions. The Administrator pushed the button to silence the front door. The front door could be opened for a full 10 seconds in silence mode without the door alarm being triggered. The Administrator reported she did not realize the door remained silenced for that long. The Administrator also noted both sets of double front doors have a hold open option that can be set on the control box above the each door. This allows both sets of doors to automatically stay open, but she didn't know if that had been done the day of the incident. On 9/1/20 the facility provide a Care Plan Item/Task Listing Report that shower the facility had five resident's care planned as elopement risk and currently wearing wander device bracelets due to the risk of wandering. During an interview on 9/2/20 at 11:53 a.m., Staff C (Registered Nurse) reported she had not been working at the facility very long when the incident occurred. She had been scheduled on the South hall that day. She stated the resident usually sits by the Nurses Station. He had exit seeking and it had happened before. He is usually always looking for his truck or to go home. She didn't recall any door alarms going off prior to the resident being out of the facility. She reported she did not provide any care to him that day and couldn't recall if there were many visitors in the facility that day. She stated she did not recall silencing the door alarm system or anyone asking her if they could silence the door alarm system that day. During an interview on 9/2/20 at 12:00 p.m., Staff D (Nurse Aide) reported she remembered the incident happened. She had not been caring for him that day, but believed he had been found outside the facility down by the assisted living at the end of the block. When he came back he looked nervous and glad to be back. He appeared to be shaken up from being outside. Staff D could not recall hearing a door alarm go off or anyone asking to have the door alarms silenced. We received education on the door alarm system right after it happened. The resident always thinks he is going somewhere. He can push the front first (wander device) door open but it triggers the Wander device alarm so we can get him. Staff D reported she did not know if the resident would be able to get the outside entrance door open. During an interview on 9/2/20 at 2:03 p.m., Staff A (Licensed Practical Nurse) clarified she had seen Resident #1 15 minutes prior to the elopement. The resident had been in the middle of the East hallway by the shower room sitting in the wheelchair. He had been asking about having a snack. Staff A stated she would get him a snack. Staff A clarified when she looked out the window of room [ROOM NUMBER], she saw Resident #1 in the wheelchair by the side of the road down across from the other parking lot, by the intersection. He had gotten a few more feet down the road before she went out to get him, but hadn't gotten far. Staff A reported Resident #1 did not comment on being cold, but had been asking where his spouse had been. During an interview on 9/2/20 at 3:00 p.m., the Administrator reported she had talked with a family member of the resident having a Christmas party and the family member stated her daughter had seen Resident #1 sitting in the wheelchair on the sidewalk when she left the facility, but could not recall what time that may have been. During an observation on 9/2/20 from 3:20 p.m. to 4:00 p.m. the following observations were made regarding traffic on Prairie Street in front of the nursing home: a. At 3:35 p.m., one car drove down the alley and turned onto Prairie Street heading west. b. There were two cars parked in residential driveways that could back out onto Prairie Street by the location the resident had been found on 12/28/19. c. One house with a two vehicles that could pull directly onto Prairie Street by the driveway of the facility where the resident exit heading East onto Prairie Street. d. At 3:40 p.m. one truck and one car traveled down Prairie Street heading East right by where the resident had been found 12/28/19. At the same time a car pulled into the parking lot right across from where the resident had been found. e. At 3:45 p.m. two vehicles traveled East down Prairie Street in the same path the resident had been on 12/28/19. f. At 3:50 p.m. two trucks traveled down Prairie Street heading East on Prairie Street in the same path the resident had been on 12/28/19. During an interview on 9/3/20 at 9:45 a.m., the Administrator reported she would check to see if they had a written procedure on how the nurses were trained to check the door alarm system and if they had a written protocol prior to the 12/28/19 elopement. She stated the door alarm check includes checking both the hard wired door system and the wander device alarm system. She reviewed the prior door alarm documentation sheet with the Surveyor. The undated Door Alarm Testing Log listed to document and check the date, time, tested , are the door modules securely mounted to the door frame, are the door modules securely mounted to the door frame, is the red/green light, range of the door modules satisfactory, are the cables secure, and are the wires frayed. The Administrator verified the nurses were to check and document on the sheet. She noted the changes to the new form stating that the old door alarm testing log had been the recommended log from the wander device manufacturer. They had changed the form after the elopement. She stated that if any employee notices anything abnormal with the door system, they are to report it to maintenance. She reported the wander device panel at the nurses station shows a green light for all the areas unless a resident is near the door, then it would be yellow. If a resident goes out the door it would light up red. Regarding the hard wired main door alarm system, the panel is located at the nurses' station. All the doors should light up in red to show the doors are alarmed. If the light goes to green, the door is disarmed. She stated any staff member can disarm the alarm system or silence the alarm system as long as they check the door alarm and check to be sure that a resident has not exited the facility. During an interview on 9/3/20 at 10:03 a.m., Staff B (Registered Nurse) confirmed the Door Alarm Testing Log had been the form used for documentation of the door alarm checks prior to 12/28/19. She stated that she checks the doors by opening the door and using the wander device pendant to check the wander device system. She reported she does not checked the cables/wires that would be something that maintenance would probably do. As long as the door alarm sounds when checked, the system is functioning. She reported if the alarm did not sound, she would report to maintenance immediately. During an interview on 9/3/20 at 10:25 a.m., The DON reported she worked the dayshift on the South hall that day (12/28/19). The nurses had been checking the doors daily prior to 12/28/19, but had not been documenting the checks well. The nightshift nurse is responsible for checking the doors daily and documenting. She reviewed the Door Alarm Testing Log documentation sheet and verified that the 10-6 shift did check the door alarm 12/27/19 at 2300. The DON reported the door alarm system had been checked the morning of 12/28/19, but the check had not been documented. The DON reported a typical staffing pattern the day of 12/28/20 when the resident eloped. Another Resident had a Christmas party that day and there were a lot of people in the facility. We try to have residents in a more visual area by the nurses' station or dining area to keep an eye on them. We also use the WanderGuard to alert us if a resident tries to leave the facility. The nurses check the doors and the WanderGuard pendants every shift now, to ensure the pendants are on and functioning. The door alarm check is not assigned to a nurse, either one of the nurses' can do the check. The DON reported Resident #1 had a history of [REDACTED]. We never were able to find out through our investigation who unplugged the WanderGuard system. Someone would have to have gotten up on a chair to be able to unplug the WanderGuard on the front door. Stated she never gave any staff approval to disengage the hard wire alarm door for the front door. No one would have been at the nurses' station at that time when the resident went out the front door. During an interview on 9/3/20 at 11:05 a.m., Staff F (Maintenance Director) reported he has a wander device that he tests the wander device system with weekly and monthly. He checks the wander device sensors at shoulder height, waist height and knee height. In December 2019 and January 2020 the front door had been tripping often, the wander device people said it could be the front TV that was setting it off. He had checked the wander device plug as part of his checks, but unplugging the wander device plug is the only way to reset the wander device on the door when it acts up. Staff F stated it is possible that the wander device on the front door had been acting up and had been unplugged due to that reason. He stated he had never found the wander device door (control box) unplugged during his checks. The new wander device control box installed 1/7/20 had the plug screwed into the socket and cannot be unplugged. He reported due to the wander device on the back employee entrance area, being older, is not screwed in and can still be unplugged. There is another set of hard wired alarm doors beyond that set of doors. Staff F stated he would provide the door check documentation as he does it for the TELS system monthly. During an interview on 9/3/20 at 1:01 p.m., Staff G (Licensed Practical Nurse) reported the nurses have always checked the door alarm system right after report but had not documented the checks until after Resident #1's elopement on 12/28/19. She could not recall if she had been the one checking the actual doors (on 12/28/19) or if she had been in the nurses' station resetting the alarms as the doors were checked that morning. The nurses check the door alarm system together. One (nurse) goes around and opens the doors and uses the pendant to set off the wander device system, the other resets the hard wired alarms in the nurses' station. She felt the door alarm system had been silenced when a family had been bringing in food and gifts for a family Christmas party, but she did not give anyone permission for the doors to be silenced. She reported the door alarms had been checked that morning but they were not documenting the checks at that time. The December 2019 untitled documentation sheet supplied by the Maintenance Director documented Fire doors and windows with a title inspection - latch and gap. The documentation failed to address any documentation of the door alarm system or wander device control box being plugged in. On 9/3/20 at 1:25 p.m., the Maintenance Director stated the sheet didn't document that, but he did check the alarm function and the wander device being plugged in as part of the check. On 9/8/20 at 9:30 p.m., the DON, reported a checklist is used during the orientation of nurses. She takes the nurses to each door and shows them how to open the doors and check the wander device system with the pendant and check the resident wander device bracelets. The undated Orientation Checklist provided by the facility lacked documentation to show nurses are trained in the door alarm system. During an interview on 9/8/20 at 12:39 p.m., Staff A (Licensed Practical Nurse) reported she believes that the DON or Staff E took her around and showed her how to check both the hard wired alarm door system and the wander device system using the pendant. The door has to physically be opened to set off the alarm and then the tested with the wander device pendant as well. She stated the wander device doors have to be reset from the actual door. The hard wired door system has to be reset at the panel in the nurses' station. She reported she was not aware that if any of the nurses were checking the door alarm system daily prior to Resident #1's elopement. After the elopement on 12/28/19, the facility provided training and the nurses started checking and documenting the door alarm system checks every shift. During an interview on 9/9/20 at 10:40 a.m., Staff H (Nurse Aide) reported she had received training on checking the door alarm system right after the elopement on 12/28/19. She reported if a door alarm goes off, they check at the nurses' station to see which door has been triggered. They physically go to the door to check to see if a resident has gotten out. If they don't see anyone by the door or outside the door, they report to the nurse and a head count is done of all the residents. She reported the wander device cannot be unplugged from the front door. During an interview on 9/9/20 at 10:45 a.m., Staff A and Staff B reported if a door alarm goes off, the nurses check the panel in the Nurses Station, both the hard wired panel and the wander device panel to see which door is alarming. The red light on the hard wired door panel will be flashing if a door has been opened. If a resident wearing a wander device is by the door, the wander device panel will show a yellow light. If a resident with a wander device opens a door or goes out a door the light will go from green to red. Staff A reported there were issues with the front door wander device going off all the time prior to the elopement and to reset the system the wander device plug had to be unplugged at the control box and plugged back in. That is why the wander device had been replaced on the front door. Both Staff A and B reported they received training on the door alarm checks after the elopement on 12/28/19. Staff A reported she received training regarding the door alarm checks for both types of doors and how to do the documentation. If a door alarm sounds, she would check in the Nurse's Station to see which door triggered and she or another staff member would physically go to the door to see if a resident is by the door or has exited the door. The alarm is not to be cleared until the door is physically checked. If no one is seen, the staff go out the door and check outside. If no resident or anyone is seen, they do a head count to see if all residents are accounted for. The door alarms are checked right after report on every shift. The residents wander device pendants are checked as they do the morning medication pass to ensure all pendants are working. She stated there is a mirror outside the nurses' station that allows them to be able to see the access to the back employee doors that have a wander device on them. During an interview on 9/8/20 at 1:16 p.m., a Family Member reported she attended the Christmas party. When she arrived the door alarms were going off as they were bringing food and other items into the home for the family Christmas party. She stated she did recall the alarms were going off throughout the day and there were a lot of visitors in the facility. She stated that another family member left just a few minutes before them and she observed staff bringing Resident #1 into the facility. The door alarms were active when she left the facility around 3:45 p.m. to 3:50 p.m. During an interview on 9/8/20 at 2:38 p.m., the DON reported she expects all nurses to check the main door alarm and wander device system every shift and document that the alarms are functioning. She expects a door alarm or wander device will not be silenced unless staff have physically gone to the door and visually checked to be sure a resident has not gone out the door. If no one is seen, then nurses are to do a headcount of all residents to ensure safety. During a phone interview on 9/15/20 at 10:32 a.m., the Administrator confirmed she observed Resident #1 on 9/15/20 wearing the wander device on his right wrist. However, the September 2020 TAR documented the wander device checked by staff on the left wrist. Observations from 9/1/20 to 9/14/20 revealed the wander device on Resident #1's right wrist. During an observation on 9/1/20 at 4:18 p.m., Resident #1 propelled his wheelchair out of the shower room. Resident #1 had a wander device bracelet on his right wrist. During an observation on 9/2/20 at 8:03 a.m., Resident #1 propelled the wheelchair back from the dining room after breakfast. Resident #1 had a wander device bracelet on his right wrist. During an interview on 9/2/20 at 11:15 a.m., Resident #1 stated it all happened so long ago, he really couldn't remember. The Wandering and Elopement Policy, effective 7/1/20 revealed a purpose to provide a system for identification of residents at risk for unsafe wandering and elopement, provide a program of supervision and interventions to minimize risk of resident elopement, improve resident safety through timely investigations of elopements and elopement attempts, and provide staff education in effective wandering/elopement management through in-services and elopement drills. The following Definitions were defined in the policy: a. Wandering - the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specific course of known direction. Wandering may or may not be aimless. b. Unsafe Wandering - occurs when an at-risk resident, without supervision is exit seeking or attempting to leave the community/secured area but does not cross the threshold of a secured area. c. Elopement - when a resident (who is cognitively impaired) leaves the community/secured area without necessary authorization (i.e. an order for [REDACTED]. d. Elopement attempt - when a resident, without supervision is exit seeking or attempts to leave the community/secured area but does not cross the threshold of a secured area. The Policy included the following Environmental Control: a. Security devices on doors will be checked for function daily and documented. b. Alert devices, like wander device bracelets will be checked for replacement and function every shift and these checks will be documented in the medical record. The State Agency notified the facility of the Immediate Jeopardy on 9/9/20 at 12:05 p.m. During the survey initiated on 9/1/20 it was determined the facility abated the immediate jeopardy on 12/28/19. Past noncompliance was identified. On 12/28/19 the facility implemented testing of all door alarms for proper function, all wander device bracelets tested for proper function, educated staff to keep sight of disarmed doors, door alarm testing to be done every shift on all door alarms, fifteen minute checks for wander device plugged in, checks to continue until one keypad unit is replaced, new unit on order to arrive 1/7/20, note posted by wander device plug to never leave unplugged, and posted note on front door to visitors to never assist anyone out of the door without checking with a nurse first. The facility had the front door control module box for wander device system installed and sink screwed into outlet to prevent unplugging of the unit on 1/7/20.

Based on observation, record review and staff interviews the facility failed to prevent and document complete assessments on pressure sores for 2 of 2 residents reviewed with pressure sores. (Residents #7 and #12). The facility reported a census of 54 residents. Findings include: The Minimum Data Set (MDS) identifies the following stages of pressure ulcers: Stage I intact skin with non-blanchable redness of a localized area usually over a bony prominence. Stage II partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also be an open or intact blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Stage IV Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed and often includes undermining and tunneling. 1. Resident #7's Minimum Data Set (MDS) admission assessment completed 9/21/16 had documentation of the following Diagnoses: [REDACTED]. It also identified the resident required extensive staff assistance with most activities of daily living and with one unstageable pressure sore. The care plan with the short term goal target date of 12/26/16 identified the resident with an actual pressure ulcer to the right heel and directed staff to: a. Heel offloading boot with transfers and when working with therapy b. Heels up cushion when in bed c. Inspection of area daily with cares d. Reduce pressure to area as much as possible e. Treatments to area per orders f. Weekly assessment per nurse, noting size, characteristics, surrounding tissue, drainage. Report progress or lack of progress to the physician. A review of the physician orders [REDACTED]. 9/24/16 use heels up cushion in bed offloading boot during therapy and transfers. 10/19/16 heel protectors on at all times A review of the Braden Scale completed 9/14/16 identified the resident at risk for developing pressure sores with a score of 19. A review of the admission data collection tool completed 9/14/16 at 3:00 p.m. had documentation the resident did not have pressure sores only bruises from IVs. A review of the Initial Wound Review form dated 9/19/16 identified a facility acquired stage I pressure sore to the right heel with measurements of length of 5.5 centimeters (cm) and width of 4.5 cm, wound edge light purple and wound bed with white rim. A review of the September 2016 Daily Wound Review Form progress notes had documentation of only one entry dated 9/19/16 of the entire wound which measured 7 cm by 5.7 cm bright red with 1 cm purple area around the cavity and 6 cm by 4.7 cm middle. A review of the Orthopedic Office Clinic Note dated 9/23/16 had documentation the resident presented with the chief complaint of a right heel blood blister with discoloration of the right posterior heel. Presents from the nursing home with no documentation as to when this appeared. The right lower extremity examination revealed skin noted with 5.5 cm by 4.5 cm flat stage I pressure blister to the posterior heel, retrocalcaneal region. A review of the Daily Wound Review Form for October 2016 and the nurse's notes revealed assessments of the pressure sore to the right heel not adequately assessed. Observation on 12/8/16 at 6:15 a.m., at 6:30 a.m., at 6:45 a.m., at 7:00 a.m., at 7:30 a.m. as the resident slept in bed with the heels up cushion underneath both calves, however, both heels rested directly on the mattress and no heel protectors to both feet. During an interview on 12/6/16 at 2:53 p.m., the Director of Nursing (DON) reported she did not know how the pressure sore developed and verified the admission assessment completed 9/14/16 at 3:00 p.m. identified the resident with only bruises from IVs. She also reported the assistant DON (ADON) completed the assessments on the wounds every week and there had been another form the ADON documented on. She also verified the daily review form did not have complete weekly measurements documented weekly. In an interview on 12/6/16 at 3:07 p.m., the Assistant DON (ADON) reported she had taken vacation after 9/19/16, that she did have measurements documented on her QA sheets for 9/26/16, but could not explain why she did not document in the resident ' s chart. During an interview on 12/6/16 at 3:45 p.m., the ADON provided a copy of an orthopedic surgeon ' s consult dated 9/23/16 with documentation of measurements of the wound, ( which would explain why we did not have documentation that week). In an interview on 12/8/16 at 6:42 a.m., Staff C, RN reported the resident has an offloading boot, has a cushion to float heels and heel protectors to prevent further pressure sores. In an interview on 12/8/16 at 7:45 a.m., the ADON reported the resident should have heels floated when in bed, heels should not be touching the bed, should be wearing prafo boots when in bed. During an interview on 12/8/16 at 10:26 a.m., the DON reported the resident did move around a lot in bed and it had been difficult to keep the heels up cushion in place. 2. Resident #12's MDS quarterly assessment completed 9/8/16 had documentation of the following Diagnoses: [REDACTED]. It also identified the resident as cognitively impaired and required limited assistance with bed mobility, personal hygiene and eating. The resident required the assistance of 2 staff persons for transfers toilet use and dressing. The MDS identified the resident had one Stage II pressure ulcer The care plan with a goal date of 12/15/16 identified the resident with impaired skin integrity related to the open area on the left second toe and bunion on the left foot. It directed staff to: a. Due to bunion resident to use blue boot and no shoe on the left foot b. Treatment to area per orders c. Weekly assessment of area noting size and characteristics. Notify the physician of progress or lack of progress A review of the Admission/Readmission Skin Review sheet completed on 6/22/16 identified the resident with a pressure ulcer to the second digit of the left foot with measurements of length of 0.6 cm and width of 0.5 cm. A review of the skin review sheets for the pressure ulcer to the second digit of the left foot revealed: a. June 2016 - no documentation of assessments after 6/22/16 b. July 2016 - only documentation on 7/6/16 c. August 2016 - no documentation from 8/18/16 through 8/16/16 and from 8/17/16 through 8/31/16 d. September 2016 - documented as healed on 9/11/16 e. October 2016 - no documentation until 10/14/16 (no initial worksheet to show when the area opened up again), only 2 assessments documented on 10/19/16 and 10/26/16 f. November 30, 2016 measurements length of 0.7 cm and width of 1.2 cm A review of the initial wound evaluations revealed the resident developed the following pressure sores after admission on the following dates: 10/14/16 to the right second toe with measurements of 0.5 cm by 0.5 cm 11/5/16 to the bony area to the left great toe with measurements of 0.6 cm by 0.6 cm 11/22/16 to the coccyx with measurements of 12 cm by 1 cm A review of the December 2016 Daily Wound Review Form progress notes identified the following pressure sores on 12/7/16: a. Left second toe (labeled as wound #1) measured 0.3 cm by 0.3 cm, b. Left side of the foot (labeled as wound #2) measured 3.6 cm by 1.4 cm with a black area which measured 0.4 cm by 0.2 cm, c. Right foot bunion (labeled as wound #3) measured 2.8 cm by 2.5 cm with a black area with a dipped area and some tan tissue which measured 0.8 cm by 2.2. cm. In an interview on 12/8/16 at 7:45 a.m., the ADON reported she did not know how the resident's wound developed, only that she knew the resident had the wound to the left second toe on admission. In an interview on 12/8/16 at 6:20 a.m., Staff A, LPN reported the ADON measured pressure sores weekly, nurses assessed daily and documented on the wound sheet. The ADON kept her measurements in a different book. During an interview on 12/8/16 at 6:35 a.m., Staff B, LPN reported nurses should document on pressure sores daily on the skin sheets. In an interview on 12/8/16 at 6:42 a.m., Staff C, RN reported nurses should document on pressure sores daily on the skin sheets and the ADON measured pressure sores weekly.

The following relates to # -I Based on observation, record review and staff interview, the facility failed to provide adequate supervision and implement interventions identified to prevent accidents for 2 of 4 residents reviewed (Residents #1 & #2). The facility reported a census of 48 residents. Findings include: 1. According the MDS (Minimum data set) assessment tool with a reference date of 09/19/13, Resident #1 had [DIAGNOSES REDACTED]. The MDS documented a BIMS (Brief Interview for Mental Status) score of 3 out of 15. A BIMS score of 3 identified the resident had severe cognitive impairments. The MDS identified Resident #1 required the assistance of two staff for bed mobility, transfers, ambulation, dressing, and toilet use. The MDS documented the resident had no prior fall history since last assessment being completed. The MDS documented the balance assessment during transition and walking indicated the resident not steady and only to stabilize with staff assistant. The Care Plan with a start date of 9/25/13 listed the resident had a potential for falls related to weakness and his/her fall history. The care plan directed staff to : a) Assist the resident to the restroom as needed every two hours while awake. b) Orientate the resident to room, call light system, instruct resident to call for assist with transfers and ambulation. c) Therapy to evaluate and treat as indicated. d) Use pull alarm to w/c (wheelchair) mat on floor when in recliner or bed, dated 9/25/13. (discontinued on 11/20/13). Change to string alarm to wheelchair, dated 11/20/13. e) On 11/15/13, transfer to the emergency room . f) Remove mat alarm on 11/15/13 for inspection by maintenance. g) Use motion sensor on each side of bed initiated on 11/20/13. h) Ambulate with two assist of staff, using wheeled walker and gait belt, dated 11/20/13 and 12/4/13. i) Transfer with assist of two staff and staff to be using a gait belt, may use Hoyer lift, as of 12/4/13, or Sara lift, as of 11/26/13 (mechanical lift). j) Weight bearing status. k) Use string alarm when up in wheel chair or chair. Review of the facility's Incident Report Form, dated 11/15/13 at 9:10 p.m., revealed staff heard the Resident #1 yell "help, help!" and staff found the resident sitting up with head against bathroom door, in room, with right leg on top of wheeled walker and left leg tucked under right leg. The form documented there had been equipment related to the resident's fall and identified the type of equipment as a floor mat alarm. Resident transferred to the emergency room for further evaluation and treatment. The floor mat alarm had been removed from resident's room by staff for maintenance inspection. Review of the Nurse's Notes dated 11/15/13 at 9:50 p.m., revealed staff heard Resident #1 yell "help, help!". Resident found sitting up with head against bathroom door and right leg on top of wheeled walker and left leg tucked under right leg. The assessment revealed the resident complained of severe left leg pain. The resident's physician called and resident transferred to the emergency room (ER) for further evaluation and treatment and resident's family notified. After resident transported to the ER staff inspected the resident's floor mat alarm. The document revealed the pressure floor mat alarm had been found with the alarm box in the on position and alarm plugged into mat, however the pressure floor mat did not sound as the nurse stood on it. The resident's bed had been in low position. Staff took mat and alarm box out of room for further inspection. Review of the nurse's notes dated 11/16/13 at 5:45 a.m. revealed staff called the ER to check on the resident's status. The ER reported to the facility that the resident admitted to the hospital with [REDACTED]. Review of the hospital history and physical dated 11/16/13 identified Resident #1 had been transferred to the emergency after a fall at the nursing home. The hip x-ray and pelvis x-ray showed evidence of a left hip fracture (displaced intertrochanteric hip fracture). The report documented Resident #1 had been given pain medication while in the emergency room . The hospital consultation report dated 11/16/13 revealed Resident #1 had very limited mobility and the x-ray identified he/she had a left hip fracture. Due to the resident's memory loss, he/she was described as a poor historian for reporting his/her medical history. The resident stated his/her left hip hurts. The report revealed the resident would need surgical repair for the fracture. A social progress note dated 11/21/13 identified the resident had been readmitted to skilled care at the nursing home for left hip fracture. Review of the facility's Investigatory Interview Form dated 11/18/13, Staff B, Certified Nurse Aide (CNA), identified Staff B had been the first staff member into the resident's room after hearing the resident yelling help. Staff B checked the resident's floor alarm along with Staff F, Registered Nurse (RN), and after pushing on the pressure floor mat alarm connection to the alarm box the floor pressure alarm sounded when pressure applied by staff. Review of the facility's Investigatory Interview Form dated 11/18/13, revealed Staff F, Registered Nurse (RN) and Staff B, CNA, went to check the resident's pressure floor mat alarm that had been in place after the resident had been transferred to the emergency room . Staff B reported the alarm did not sound when she/he stepped on it. Staff B reported he/she followed the alarm box cord which had the switch in the on position, and light responded as on. Staff F indicated the connection at the pressure floor mat alarm cord at first glance appeared to be connected. Staff F reported when the connection was pushed together snapped tighter into position, the pressure alarm mat then sounded when pressure had been applied to it. Staff F indicated the pressure alarm mat and alarm box had been removed from the resident's room for further inspection. The surveyor observed the alarm box and pressure alarm mat on 12/12/13, with the Director of Nursing (DON) and Administrator present. The alarm box had been identified as the one in place at the time of Resident#1's fall. Observation revealed an alarm box labeled and the manufacture information for the floor pressure alarm called Direct Supply Attendant. The alarm box revealed a connection to the box with a cord that leads to a connection to the Direct Supply Attendant alarm floor mat. The connection from the floor mat was approximately 4 inches in length (that was connected to the alarm box.) This was noted to be torn at the mat connection with the covering of the wires torn and wires could be visualized. The Administrator demonstrated and stated that staff are to turn on the alarm box, with the on and off switch located at the bottom of the alarm box, and staff are to hear a click, and see lights on the alarm box flash, and that is how staff check the alarm is turned on and working. Further observations revealed the alarm box when not connected to the floor pressure mat would make the same chirp and lights would flash, however when pressure applied to the mat pressure alarm, it would not sound. Observations revealed when the alarm connected to the pressure floor mat alarm, the alarm box would chirp, lights would flash. When pressure applied the mat would sound, indicating it was connected correctly and the alarm tested to be working. The DON stated the company where they purchase the floor mat and alarm box did not send the Owner's Manual when the mat was purchased. The DON stated staff are to check alarms beginning of each shift and throughout shift and document they checked the alarms and they are in place and working. Review of the manufactures recommendations of the Direct Supply unit, including the economy alarm model, included testing the system of the alarm box by applying pressure to the pad to activate it, to always test the device before use. Review of the Direct Supply Attendant Protector Bedside Mat-Owner's Manual noted the mat when used in conjunction with an Attendant Pad Alarm/Alert, the Attendant protector will notify caregivers when the resident steps or falls on the fall mat. Safeguards instructions included to inspect the product for damage before each use and do not use it if it appears to be damaged or not functioning properly. A Safeguard Warning also included instructions to insure all staff members are familiar with facility's policies for working with residents where fall mats are used. The manual included directions to verify that the Attendant Protector cord is plugged securely into the Attendant Alarm/Alert, and to inspect and test before every use. Interview on 12/12/13 at 9:58 a.m., Staff B, CNA, stated he/she was assigned to care for Resident #1 on 11/15/13 on second shift. Staff B stated he/she assisted the resident with toilet use and night time cares around 8:00 p.m. Staff B further reported she/he then assisted the resident to bed. Staff B reported she turned on the alarm box that was connected to the pressure mat on floor, and heard the alarm box chirp, which Staff B indicated to him/her as the indicator the alarm was on and working. Staff B indicated he/she had been in another resident's room across from Resident #1's room around 9:00 p.m. or a little after when Staff B heard Resident #1 yelling out "help me". Staff B reported he/she immediately went to the resident's room and found the resident sitting on the floor with back against the closed bathroom door and resident had right foot on the wheeled walker (which had been still standing up right). Staff B reported Resident #1 ' s left leg had bent under his/her right leg. Staff B reported the resident had their shoes on the wheeled walker's seat and the shoes were on the resident's chair when Staff B assisted the resident to bed earlier. Staff B stated the resident had been wearing his/her normal night clothes of a tee shirt and briefs. Staff B stated he/she did not hear any alarm sounding prior to the resident yelling out for help. Staff B reported Staff A, RN, came into the resident's room right behind him/her and Staff F, RN, also came into room. Staff B stated she/he did not see the resident between the time he/she assisted the resident to bed and finding the resident on the floor. Staff B reported the resident's pressure floor mat alarm did not sound and the resident's call light was not turned on. Staff B further stated after she/he turned the alarm box on and heard the chirp, he/she never stepped on the pressure pad alarm to check the alarm. Staff B reported this was how he/she had always checked the pressure mat (floor) alarm. Staff B stated he/she now turns alarm on and steps on the pressure pad alarm to ensure it was connected and working properly. Staff B stated that after the resident's fall the connection between the alarm box and pressure alarm met was not fully connected and not sounding when pressure had been applied to it. Staff B stated after fully connecting the pressure alarm mat to the alarm box the mat would sound when pressure applied. Interview on 12/11/13 at 3:45 p.m., Staff A, RN, stated he/she had been at the nurses station on 11/15/13 around 9:00 p.m. when Staff A heard someone yelling out "help". Staff A indicated Staff B, CNA, went into Resident#1's room and Staff A right behind Staff B. Staff A stated resident found sitting on the floor with back against closed bathroom door. Staff A indicated no alarm had been sounding prior to finding resident on floor. Staff A reported the resident complained of pain to the hip. Staff A stated she and Staff F assessed the resident and called the resident's physician. Staff A indicated the resident's pressure floor mat alarm had been in place when Staff A entered the room but had not sounded. Staff A reported after the resident transferred to the emergency room , Staff B checked the connections of the alarm box and the pressure alarm mat pad and after Staff B wiggled the connection into place between the mat and the alarm box, the alarm sounded when pressured applied. Interview on 12/12/13 at 2:35 p.m., Staff F, RN, demonstrated how staff knew the pressure floor mat alarm is connected by turning the alarm box on at bottom of the box and hearing chirp and lights flash. Staff F stated he/she was not aware of stepping on mat or any other staff stepping on mat to check and see it is connected and working. Staff F further stated that Resident #1's fall he/she checks all floor mat alarms by also stepping on it to make sure the alarm will sound. Staff F reported on the day of the fall, when she/he went to the resident's room, the resident was sitting on the floor with back against closed bathroom and complaining of hip pain. Staff F stated she and Staff A assessed the resident, called the resident's physician and sent the resident to the emergency room via ambulance. Staff F indicated that no alarm sounded prior to the resident's fall. Staff F reported after the resident left for the emergency room , Staff B and Staff F went in the resident's room & checked out the alarm box and pressure alarm mat. Staff F stated the alarm box turned on but when pressure applied to the mat it did not sound. Staff F stated the connections were checked and the pressure alarm mat connector to the alarm box not fully connected to the alarm box. Staff F stated the connections were fully connected and the pressure floor alarm mat sounded when pressure applied. Staff F further stated the resident would make several attempts to get up unassisted and alarm would sound alerting staff of the resident ' s attempts to get up unassisted. Staff F indicated the resident would not use call light to summon for assist. Interview on 12/12/13 at 10:42 a.m., Staff C, CNA, reported she/he knows from experience that pressure floor mat alarms (like what Resident #1 had), that you will hear a chirp when the alarm box is turned on and to then apply pressure to the mat and it will sound if properly connected. Staff C stated he/she checks all alarms when first coming onto duty to ensure they are working and in place and continues to check throughout shift. Staff C indicated that he/she has come into work on the night shift before, a few months back, and found Resident #1's pressure floor mat not connected to the alarm box. Staff C stated he/she connected it and ensured the alarm box and pressure floor mat were turned on, connected, and working. Staff C stated he/she reported this to the nurse in charge. Staff C stated he/she had found on other occasions, alarms were not turned on, and she/he would immediately correct and report this to the charge nurse. Interview on 12/13/13 at 11:32 a.m., Staff D, CNA, stated he/she learned from their own experience, how/when to turn on an alarm box, (like Resident #1's), and that staff had to step on the floor mat to ensure it sounds. Staff D stated all types of alarms need to be checked and documented for residents' safety. Interview on 12/13/13 at 11:15 a.m., Staff E he/she demonstrated how to check the floor pressure alarm that Resident #1 had in place. Staff E reported he/she learned how to check the alarm by their own experience working with the alarm. Staff E demonstrated the alarm box was to be turned on and then Staff E stepped on the pressure floor mat to sound it off. The alarm box and mat connected were working. Staff E stated he/she knows that all alarms are should be checked each shift and documented. 2. According the MDS (Minimum data set) assessment tool with a reference date of 06/06/13, revealed Resident #2 had [DIAGNOSES REDACTED]. The MDS documented the resident with a BIMS (Brief Interview for Mental Status) score of 10 out of 15. A BIMS score of 10 revealed the resident had moderate cognitive impairments. The MDS indicated Resident #2 required limited assist of one staff for bed mobility, transfers, ambulation, and dressing, and extensive assist for and personal hygiene and toilet use. The MDS documented the resident had no prior fall history since last assessment being completed. The MDS documented the balance assessment during transition and walking indicated the resident not steady and only to stabilize with staff assistant. The Care Plan with a start date of 11/28/13 identified the resident had a potential for falls related to his/her impaired mobility. The care plan directed staff to: a) Provide the assistance of one staff for transfers, ambulation and wheeled walker. b) Instructed the resident to call for assistance with transfers and ambulation. c) Use a bed chair alarm while resident was in bed. d) Use pad alarm to chair while resident was in his/her room. e) Use mat alarm on the floor while the resident was in the recliner or bed. f) Use a string alarm to chair while resident was in dining room. g) Contact physician about increased drowsiness with resident the start of Neurontin. h) On 11/26/13 transfer resident to the emergency room and staff education. Review of the facility's Incident Report Form, dated 11/26/13 at 5:10 a.m., revealed CNA, Staff H, assisted Resident #2 with ambulating to the bathroom. Resident #2 started to lose his/her balance and fell backwards. Staff H had been unable to prevent the resident from falling. Staff G, RN assessed Resident #2 and he/she complained of left hip pain and unable to bear weight. Staff G notified the resident's physician and the resident had been sent to the emergency room for further evaluation and treatment. Review of the Nurse's Notes dated 11/26/13 5:50 a.m. revealed the CNA reported to this nurse that she/he had been ambulating the resident to the bathroom from the bed and that the resident lost his/her balance and started to go backwards. The CNA stated that he/she attempted to catch the resident but was not able to steady the resident and the resident went to the floor. Staff assessed the resident and assisted the resident off the floor to stand and noted resident not able to not bear weight. Staff assisted resident to a lying position in bed and called the resident's physician and received orders to transfer the resident to the emergency room for further evaluation and treatment. At 10:35 a.m. the emergency room called and reported the resident to have a fracture and, UTI (urinary tract infection) and elevated blood pressure. Review of the Medicare Daily Skilled dated 12/3/13 revealed the resident readmitted to the facility at 2:00 p.m. on skilled level of care with [DIAGNOSES REDACTED]. Review of the facility's Investigatory Interview Form: Employee Interview, dated 11/26/13 revealed the DON interviewed CNA, Staff H. The DON documented Staff H assisted the resident to stand with wheeled walker and shoes on. The resident's bed alarm sounded and Staff H shutting off the alarm when the resident started leaning. Staff H grabbed the resident as she/he falling to the floor and Staff H reported she/he kept the resident from hitting their head during the fall. Staff H indicated the gait belt had been sitting in the resident's recliner next to Staff H. Review of the facility's investigatory Interview Form: Employee Interview dated 11/26/13, revealed Staff G, RN, interviewed Staff H, CNA. Staff G documented Staff H reported the resident ' s call light had not been on. Staff H reported he/she had been ambulating the resident to the bathroom, and resident had shoes on. Review of the facility's investigatory Interview Form: Employee Interview, dated 11/26/13, documented the DON interviewed Staff G, RN. The DON documented Staff G reported approximately 5:50 a.m. she/he had been at the nurses' station when Staff G heard a crash. Staff G went to Resident's #2 room and found CNA, Staff H, kneeling on the floor next to the resident. Staff G reported the resident's door to be slightly open when he/she entered the resident's room. Staff G reported the resident on the floor between the front of the bed and end table. Staff G stated that Staff H, CNA, reported that she/he prevented the resident from hitting their head during the fall. Staff G, RN, reported that Staff H, CNA told her/him that Staff H had been helping the resident to the bathroom. Staff G assessed the resident and noted resident to have pain to left hip and unable to bear weight. Staff G reported she/he along with Staff H assisted the resident to the bed. Staff G called the resident's physician and ambulance to transport the resident to the emergency room . Interview on 12/16/13 at 10:10 a.m., Staff H, CNA, stated he/she had been assisting Resident #2 to transfer to the bathroom. Staff H stated the resident had been in bed and he/she assisted the resident up to a sitting position. Staff H stated he/she put the resident's shoes on and placed the resident's walker in front of the resident. Staff H stated she/he had been on the right side of the resident and the resident's alarm boxes on Staff H left side. Staff H reported the resident stood him/her (self) up and took a couple steps when Staff H instructed the resident to wait a minute. Staff H reported she/he thought the resident had been steady standing with a walker. Staff H then turned away to shut the alarm box off and Resident #2 lost his/her balance and fell . Staff H stated he/she tried to prevent the resident from falling but was unable to and Staff H and the resident went to the floor. Staff H reported he/she was able to prevent the resident from hitting their head on the floor or wall. Staff H stated he/she did not have a gait belt on the resident. Staff H reported the gait belt was on the resident's recliner. Staff H stated he/she should had the gait belt on prior to the resident standing and/or applied after the resident stood. Staff H indicated he/she was aware the resident was not always compliant with waiting for staff assistance and Resident #2 makes frequent attempts to get out of bed without staff assistance. Interview on 12/2/13 at 2:26 p.m., the Director of Nursing (DON), stated all staff are trained on proper gait belt use when hired. The facility submitted via a fax on 12/13/13, a Five Minute Meeting for Employees dated 9/26/13 regarding gait belt use and that Staff H had signed that he/she attended the meeting. Review of the facility Transfer instructions dated 1/1/01, included Procedure including: a) Using a transfer belt during activities. b) Use transfer belt when transferring resident from bed to chair. c) The resident should wear a transfer belt whenever he or she is being transferred. d) The transfer belt is used for the following reasons: to provide a firm grasping surface for the staff person, to protect the resident from accidental trauma to skin, to give the resident a sense of security, and to allow the staff person to lower the resident gradually (to floor if necessary) without injury to either party. e) Use the transfer belt in the following manner: - explain the procedure to the resident - apply the transfer belt snugly around the resident's waist - pull gently on the transfer belt, and assist the resident to a standing position - after the resident is standing, use the belt to assist in stabilizing and transferring the resident - if the resident begins to fall: draw the resident close to own body using the transfer belt - slowly lower the resident to the floor, watching the resident's head during descent - reassure the resident and call for assistance.