Every finding on record at Azria Health Winterset

Based on observations, staff interviews, and policy review, the facility failed to carry out appropriate food safety practices to prevent foodborne illness for 1 of 1 meal services observed. The facility reported a census of 51.Findings include:During a continuous lunch service observation on 6/24/26 from 11:30 AM to 1:30 PM, the following was noted: 1. Artificial nails were worn by both the Certified Dietary Manager (CDM) and Staff G, social services. Staff G seen prepping drinks for residents for the meal. The CDM completed various lunch tasks during the observation including prepping hot drinks and cooking hamburger patties for residents 2 .The hair net worn by the CDM did not entirely cover their hair as bangs were exposed. In addition to meal prep, the CDM also seen operating the dish machine (working with soiled and clean equipment) and prepping resident room trays 3. Staff H, Cook, seen preparing a cold meat and cheese sandwich with their bare hands. No gloves or utensils were used to obtain the bread, lunch meat and cheese from their respective packages and positioned on the breadIn an interview on 6/25/25 at 11:15 AM the Registered Dietitian (RD) voiced artificial nails are not acceptable in a food service or kitchen setting. The RD also voiced all hair, including bangs, need to be enclosed in hair nets.In an interview on 6/25/26 at 3:00 PM, the CDM acknowledged dietary staff should not be touching ready-to-eat resident food with bare hands.The policy Food Preparation and Service, version 2.1 (H5MAPL0333) 7 2022 10 2022 10 23, outlined the following: 1. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness 2. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks 3. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food 4. Food and nutrition services staff keep fingernails trimmed and cleanThe Food and Drug Administration Food Code 2022 noted the following: 1.2-302.11 (B) Unless wearing gloves in good repair, a food employee may not wear fingernail polish or artificial fingernails when working with exposed food 2.2-402.11 (A) Hair Restraints Effectiveness: Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, equipment, utensils, and linens and unwrapped single-service and single-use articles.

Based on clinical health record review, observations, resident interviews, staff interviews, and policy review, the facility failed to supervise resident medication administration for 2 of 3 residents reviewed (Residents #2 and #3). The facility reported a census of 51.Findings include: 1. The Minimum Data Set (MDS) Assessment completed on 3/12/26 revealed Resident #2 with a Brief Interview for Mental Status score of 11 out of 15, indicating moderate cognitive impairment. Diagnoses include aphasia (brain disorder affecting communication), asthma, and diabetes.Current Physician Orders noted the following medications for Resident #2: a.Asmanex 120 metered dose 2 puffs inhaled by mouth two times daily (treatment for asthma); b.Azelastine 137microgram/spray 1 spray in both nostrils two times daily (treatment for asthma); and c.Fluticasone 50 micrograms/act 1 spray in both nostrils two times daily (treatment for allergies). During an observation on 6/23/26 at 9:45 AM, Resident #2 seen self-administering two different nasal sprays in their room without nursing staff present. They then placed the two sprays in disposable cup which had an inhaler in it as well. Resident #2 explained staff will leave these medications in the room for him to administer when more convenient for him. The resident stated they self-administer with no issues. This is done two times a day, per the medication orders.Upon review, the clinical health record lacked a Physician Order for Resident #2 to self-administer medications. The record also lacked assessments to indicate Resident #2 not only safe to self-administer medications but can so accurately. The Care Plan lacked interventions indicating Resident #2 can self-administer medications.In an interview on 6/23/26 at 11:15 AM, Staff A, Licensed Practical Nurse (LPN), acknowledged leaving medications in Resident #2's room for them to self-administer. Staff A believes the resident is competent and reliable to take appropriately.In an interview on 6/24/26 at 10:20 AM, Staff B, Registered Nurse (RN), acknowledged leaving medications in Resident #2's room for them to self-administer. During the interview, Staff B excused themselves as this was a reminder to check and remove the nasal sprays and inhaler from the resident's room. The medications had been provided to the resident shortly before the interview. Staff B explained Resident #2 alerted and orientated and administers medications by themself. 2 .The MDS Assessment completed on 5/3/26 revealed Resident #3 with a BIMS score of 15 out of 15, indicating intact cognition. Diagnoses include coronary artery disease (heart disease), dysphagia (swallowing difficulties), and macular degeneration (eye disease that blurs vision).During an observation on 6/23/26 at 10:45 AM, a plastic medicine cup with a large green tablet in it was noted on Resident #3's bedside table. The resident explained it was Tums (antiacid) and had been there a couple of days.Upon review, the clinical health record lacked a Physician Order for Tums and for Resident #3 to self-administer medications. The record also lacked assessment to indicate Resident #3 not only safe to self-administer medications but can do accurately. The Care Plan lacked interventions indicating Resident #3 can self-administer medications.In an interview on 6/23/26 at 11:00 AM, Staff C, LPN, confirmed the green tablet on Resident #3's bedside table was Tums. When asked, the resident explained to Staff C a girl provided the medication (2 tablets) when they asked for it. They took 1 of the tablets and not the other. Staff C removed the remaining Tums from the room. Staff C explained the facility does not have any standing orders or protocols for medication use. All medications are ordered by the primary care providers. If the medication is not routine and used occasionally, the frequency is typically written as PRN (as needed).In an interview on 6/25/26 at 10:50 AM, the Director of Nursing, DON, stated assessments should be completed to ensure residents are physically and cognitively capable of self-administering medication. The DON also noted nursing staff should be present if residents self-administering medications to ensure the proper dosage is consumed.The policy Administering Medications, version 2.1 (H5MAPL0028), outlined residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.The policy Self-Administration of Medications, version 1.3 (H5MAPL0812) 1 2023, outlined the following: a. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident b. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is reassessed periodically based on changes in the resident's medical and/or decision-making status

Based on facility document review, resident interview, staff interviews, and policy review, the facility failed to ensure residents free from abuse for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 51.Findings include:The Minimum Data Set (MDS) Assessment completed on 5/19/26 revealed Resident #1 could not complete a Brief Interview for Mental Status (assessment of one's cognition). This is a decline from the previous MDS completed on 2/16/26 where the score was 6 out of 15 and indicated severe cognitive impairment. Diagnoses include cancer and non-Alzheimer's dementia.The Care Plan for Resident #1 indicated the need for staff assistance to complete daily tasks. This included the assist of 1-2 staff members to stand and pivot for transfers, which includes showers and toileting (initiated on 2/18/26). Resident #1 was independent with bed mobility from 9/3/24 through 6/3/26. The Care Plan noted Resident #1 at risk for falls due to confusion, anxiety, insomnia, and poor safety awareness. Interventions include to anticipate and meet resident needs. The Care Plan also noted an increased risk for alterations in comfort due to breast cancer, anxiety, and insomnia. Interventions include to monitor sleep/wakefulness and offer non-medicinal interventions for anxiety (initiated 11/28/23). The Care Plan directed nursing staff to anticipate and meet the residents needs, with documented start date of8/21/23. The Care Plan did not direct staff to keep the resident out of her bedroom to provide increased supervision.A 5-day investigation summary was submitted to the state agency after a facility self-report regarding abuse allegations was sent on 4/16/26. The document summarized Staff E, Licensed Practical Nurse (LPN) allegedly made Resident #1 stay up in a wheelchair, removed Resident #1's room identifiers, and unplugged Resident #1's personal phone.The census summary for Resident #1 showed an admission date of 8/15/23 to a room in the facility's south hall. On 3/13/26, the resident moved to a room located in the north hall. This move was to a different part of the facility and different staff providing cares.March and April 2026 Daily Assignment Sheets showed Staff E, Licensed Practical Nurse (LPN) was the scheduled nurse on the north hall for the 6 PM to 6 AM shift. Between 3/13/26 to 4/15/26, Staff E worked a total of 14 shifts on the north hall and directly with Resident #1.The facility document of staff statements detailed the interview with Staff F, former Director of Nursing. Staff F confirmed Staff E's actions towards Resident #1. This included removing name identifiers from the resident's room, unplugging the resident's phone at the start of their shift, and keeping the resident awake and up in her wheelchair with the nurse. Staff F stated these were fall interventions and were in place to protect the resident.The facility document of staff statement detailed the interview with Staff E on 4/16/26. When asked if they had refused to allow Resident #1 or any other resident to go to bed when asked, Staff E denied. Staff E explained Resident #1 was a significant fall risk if and had behaviors if goes to bed too early. If it is too early, Staff E will redirect and encourage the resident to follow them. Staff E noted the resident's safety awareness is bad and will have the resident hang out with the them until tired.Staff E denied forcing a resident to self-propel themselves in the halls to make them tired. Staff E answered Resident #1 would follow them down the halls but never forced.Staff E acknowledged removing Resident #1's room name plate after discussing with the Director of Nursing. Staff E felt it was effective as the resident would then ask staff for assistance. If it was too early to go to bed, the resident would be redirected. Staff E stated if they did not do this, Resident #1 would self-transfer and potentially hurt themselves. Staff E did not believe this caused increased sadness or anxiety.Staff E denied unplugging Resident #1's personal phone in their room. Staff E explained they would take the resident to the nurse's station to visit with family.Staff E noted Resident #1 with poor safety awareness and doesn't understand their fall risk. Staff E felt what they did was effective despite other employees not liking what was being done.The facility document of staff statements detailed an interview with Staff P, Certified Nursing Assistant (CNA). Staff P reported Resident #1 is discouraged from going to bed when Staff E works. Staff E will have the resident follow them around.The facility document of staff statements detailed an interview with Staff Q, CNA. Staff Q reported Resident #1 is in the wheelchair a lot overnight. Staff E keeps the resident with them in the hall.In a confidential resident interview on 6/22/26, a resident recalled seeing Staff E pushing Resident #1 around until tired despite the resident calling out. The resident noted when Staff E worked, Resident #1 stays up later when compared to other nurses. The resident explained staff typically will lay Resident #1 in bed around 7:30-8:00 PM. However they have observed Staff E pushing Resident #1 up and down the halls from 6:30 to 9:00 PM. Other staff members would try to intervene and help to assist Resident #1 and Staff E would decline. When this occurred the resident recalled Staff E responding with I got this. I know what I'm doing.In an interview on 6/23/26 at 11:15 AM, Staff A, LPN, voiced mornings where they had to replace Resident #1's room name plate due to it being removed. This started when the resident changed rooms to the north hall. Staff A was not aware if this was a Care Plan intervention.In an interview on 6/23/26 at 3:30 PM, Staff D, LPN, explained working overnights with Staff E frequently. Staff D had cared for Resident #1 prior to the resident's move to the north hall. From their understanding the move was to provide Resident #1 with a less stimulating environment as the south hall can be rather active.Staff D described an incident where they observed Resident #1 asleep in their wheelchair and starting to slide out. The resident was outside another resident's room while Staff E was in that room, with the door closed, providing cares. Staff D offered to have the CNA put Resident #1 in bed. Staff E declined stating the resident will stay there and may fall if placed in bed/room.Staff D recalled seeing Resident #1 up most of the night in their wheelchair. When they would walk by, the resident would grab their pant leg and ask to go to bed.In another incident Staff D noted Staff E pulling Resident #1 in their wheelchair while pushing a medication cart during evening medication pass.Lastly, Staff D detailed an incident, which occurred on 4/5/26 (Easter) around 8:00 PM. Staff D was in the north hall when Resident #1 reached out for their hand and said I don't have a room here. She told me I don't have a place to sleep. Staff D reassured the resident and took them to their room. Staff D noticed the room name plate removed and the phone had been unplugged. When trying to reconnect the phone, Staff E intervened and mentioned the resident is to receive calls at the nurse's station only. While in the room, Resident #1 wanted to lay down but Staff E took them out of the room. In an interview on 6/24/26 at 9:45 AM, Staff R, LPN, described Resident #1 as confused and always asking for help. However Staff R believes the resident able to alert staff of their immediate needs or discomfort. Staff R noted Resident #1's typical bed time is around 7:00 PM. In an interview on 6/24/26 at 11:05 AM, Staff I, CNA, explained Resident #1 would typically talk to family in their room around 7:00 PM and then in bed around 8:00 PM. One night, estimated to be 4/14/26 at 8:30 PM, Resident #1 was speaking out they wanted to go the bed. Staff I noted a sense of desperation to the request and offered to do so. Staff E declined the assistance and mentioned the resident needed to stay by them.Staff I reported seeing sticky notes covering Resident #1's room name plate with the door shut.In an interview on 6/24/26 at 2:20 PM, Staff J, CNA, explained Resident #1 historically yells out wanting to go to bed or help me. However, Staff J believes the resident able to alert staff for immediate needs (using bathroom, not liking something). Staff J acknowledged Resident #1 does try to get up on their own and attempt to self-transfer, which is not safe. When working with other nurses, the CNAs are able to intervene and assist with cares. Immediate needs were being addressed. When working with Staff E, CNA assistance is declined. Staff E would comment that the resident was going to stay with them. Immediate needs may not be addressed in a timely manner. Staff J feels Resident #1 became more desperate with requests for staff help. Staff J recalled an incident which occurred at approximately 8:30 PM. Staff J had assisted Resident #1 to the bathroom and then placed in bed. A short time later, Staff E asked where Resident #1 was. Staff J explained the resident was in bed, quiet and sleeping. Staff E stood in the resident's doorway, flipped on the light, and said to the resident I know what you're doing. You're getting up. The Resident #1 was removed from bed and placed back in the wheelchair.Staff J acknowledged observing Staff E removing Resident #1's room name plate. When the name plate is removed, Resident #1 seen actively looking for room and calling out Where's my room?.In an interview on 6/24/26 at 3:00 PM, Staff K, CNA, recalled an incident which occurred at approximately 8:30 PM. Resident #1 was in their wheelchair and asking to go to bed. Staff K attempted to care for the resident but Staff E said no. Staff K noted observations where Staff E was pushing Resident #1 down a hall with the medication cart. Other CNAs would offer to put the resident to bed but Staff E would not allow.Staff K observed Staff E removing Resident #1's room name plate and stating to the resident this isn't your room. Staff K also noted a mechanical lift in front of Resident #1's room to block entry.In an interview on 6/24/26 at 3:20 PM, Staff L, CNA, explained they typically work the overnight shift (10 PM to 6 AM) on the south hall. Staff L acknowledged Resident #1 does try to get up on their own. However, they believe there is a reason for it and that Resident #1 can alert staff to immediate needs. At times, they would see Resident #1 self-propelling in their wheelchair at night. On one occasion, Staff L heard Resident #1 say they were ready for bed and offered to put the resident in bed. Staff E intervened stating not right now as the resident would keep getting up. Staff L then offered to sit with the resident exclusively for a short time but Staff E declined stating I got this.Staff L recalled another situation where they heard Staff E say to Resident #1 You need to stay in the chair (recliner) despite the resident saying she wanted to go to bed.In an interview on 6/29/26 at 1:35 PM, Staff M, Registered Nurse (RN), recalled an incident, which occurred towards the end of March, when they were at the facility visiting. Staff E was completing the evening medication pass and had Resident #1 with them. Staff E would ensure the resident was with them and not wheel themselves away. Resident #1 was heard saying I want to go home and I want to go to bed. Staff E's response was No, you have to say here with me. Don't want you to fall. Staff M explained this continued for approximately an hour. Staff M described the situation as odd. In an interview on 6/29/26 at 2:30 PM, Staff N, CNA, described Resident #1 as restless and repetitive. However, they believe the resident could alert staff of immediate needs. Staff N had observed Staff E keeping Resident #1 from their room for safety reasons to prevent falls. This included removing the resident room name plate. Staff N noted Staff E would take resident up and down the hall, having the resident self-propel themselves in a wheelchair when able. Resident #1 would have their head down stating I'm tired. Take me back to my room. Staff N recalled a time when Resident #1 was sitting in a recliner located in near the nurse's station. The resident was calling out they wanted to go to bed to sleep. Staff E elected to keep the resident in the recliner to keep an eye on them. Staff N had not observed other nurses implanting these types of interventions; Staff E was the only one. In an interview on 6/25/26 at 3:50 PM, Staff O, RN/MDS Coordinator, acknowledged Resident #1 had progressively declined over the past 6-8 months. The move from the south hall to the north hall was in response to a cluster of falls the resident experienced. Staff O explained they oversee resident Care Plans. With regards to Resident #1, Staff O explained there were no Care Plan interventions which directed staff to remove the room name plate or any other room identifiers. Prior to changing rooms, it was encouraged to identify and assist Resident #1 in locating their room. There were no specific Care Plan interventions stating the resident would be self-propelling themselves around with nursing. Typically, when staff providing 1:1 care, staff will meet the resident where they are at. Staff O explained they attend morning meetings where falls and other resident-specific topics discussed. They do not recall any of these interventions being discussed.In an interview on 6/29/26 at 9:45 AM, Staff F, described Resident #1 as a high fall risk, anxious, and repetitive. The resident would often say they wanted to lay down and then immediately want up. Several interventions had been tried (medication adjustments, medical work-up for acute infections, staff providing 1:1 time). Staff F acknowledged different staff members had approached them regarding Staff E's treatment towards Resident #1 (keeping up in wheelchair, removing room identifiers, and unplugging personal phone). Staff F noted these were not Care Plan interventions as still trialing to see if effective. Staff F did not believe Staff E was mistreating the resident and instead providing alternative fall interventions. Staff E had a tendency to take tasks on themselves so as not to burden others. Staff F recalled a specific incident which occurred around 7:30 PM. Resident #1 was trying to enter their room as wanted to lay down. Staff E redirected the resident back into the hallway. Staff F did not believe the interaction was inappropriate nor was the resident mistreated. In an interview on 6/29/26 at 12:30 PM, the Chief Operating Officer (COO) acknowledged the regional corporate team was made aware of abuse allegation involving Resident #1 during a routine facility visit on 4/15/26. An investigation was then initiated. The COO interviewed Staff E as part of the investigation. When discussing the rationale of keeping the resident up/not putting to bed when asked, Staff E mentioned if Resident #1 goes to bed too early, they would fall. It was unclear what Staff E meant by too early or what time that was. The COO explained to Staff E that resident have the right to fall. However, Staff E did not believe the resident understood her fall risk. The COO did not feel the phone issue was a concern. When facility staff spoke to family, they reported never seeing it unplugged and was OK with the resident taking calls at the nurse's station. After the conclusion of the investigation, the COO did not believe there was mistreatment or abuse of Resident #1.The policy Resident Rights, version 1.2 (H5MAPL0768), noted the following: 1. Employees shall treat all residents with kindness, respect, and dignity 2. Federal and state laws guarantee certain basic rights to all residents of the facility, which include a. Dignified existence b. Treated with respect, kindness, and dignity c. Free from abuse, neglect, misappropriation of property, and exploitation d. Self-determination

Based on facility document review, staff interviews, and policy review, the facility failed to report to the state agency within the required time frame a suspected case of resident abuse and neglect for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 51.Findings include:The Minimum Data Set (MDS) assessment completed on 2/16/26 revealed Resident #1 with a Brief Interview for Mental Status score of 6 out of 15, indicating severe cognitive impairment. Diagnoses include cancer and non-Alzheimer's dementia.In an interview on 6/23/26 at 3:30 PM, Staff D, Licensed Practical Nurse (LPN), stated they sent a text message to the facility administrator and the Director of Nursing (DON) on 4/5/26. The text discussed questionable actions towards Resident #1 by Staff E. This included removing room identifiers (name plate, sign), unplugging their personal phone, and not allowing the resident to go to bed when asked. Staff D explained the DON responded to the text stating they did not believe Staff E was mistreating the resident. These were intervention the nurse put in place to keep the resident safe.The facility's self-report summary document, provided on 6/22/26, showed an allegation of abuse involving Resident #1 was reported and submitted to the state agency on 4/16/26.In an interview on 6/23/26 at 3:30 PM, Staff D, Licensed Practical Nurse (LPN), stated they sent a text message to the facility administrator and the Director of Nursing (DON) on 4/5/26. The text discussed questionable actions towards Resident #1 by Staff E. This included removing room identifiers (name plate, sign), unplugging their personal phone, and not allowing the resident to go to bed when asked. Staff D explained the DON responded to the text stating they did not believe Staff E was mistreating the resident. These were intervention the nurse put in place to keep the resident safe.In an interview on 6/25/26 at 3:30 PM, the Administrator acknowledged receiving a group text message from Staff D on 4/5/26. The DON was included on the group text. The Administrator explained they did not respond to the text as the DON was addressing. The Administrator does not recall discussing this further with the DON.In an interview on 6/29/26 at 945 AM, Staff F, former DON, acknowledged receiving the text message from Staff D and voiced the actions described where implemented as fall preventions. They did not believe the resident was being mistreated. Staff F also acknowledged other staff members approaching them with the same concerns previously.In an interview on 6/29/26 at 3:00 PM, the Chief Operating Officer explained the facility's abuse policy and protocol should be initiated when an allegation of potential abuse reported. This is regardless if the staff believe to be true or not. The COO stated the abuse protocol should have been initiated.The policy Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, revised Sept'22, outlined the following: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state laws 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility b .The facility's medical director c. The resident's representative and attending physician 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury

Based on facility document review, staff interviews, and policy review, the facility failed to investigate suspected resident abuse and neglect for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 51.Findings include:The Minimum Data Set (MDS) assessment completed on 2/16/26 revealed Resident #1 with a Brief Interview for Mental Status score of 6 out of 15, indicating severe cognitive impairment. Diagnoses include cancer and non-Alzheimer's dementia.In an interview on 6/23/26 at 3:30 PM, Staff D, Licensed Practical Nurse (LPN), stated they sent a text message to the facility administrator and the Director of Nursing (DON) on 4/5/26. The text discussed questionable actions towards Resident #1 by Staff E. This included removing room identifiers (name plate, sign), unplugging their personal phone, and not allowing the resident to go to bed when asked. Staff D explained the DON responded to the text stating they did not believe Staff E was mistreating the resident. These were intervention the nurse put in place to keep the resident safe.The facility's self-report summary document, provided on 6/22/26, showed an allegation of abuse involving Resident #1 was re ported and submitted to the state agency on 4/16/26.The facility document of staff statements detailed the interview with Staff F, former Director of Nursing. Staff E confirmed the questionable behaviors by a specific staff member towards Resident #1 were accurate. Staff F denied completing an investigation as the actions were fall interventions to protect the resident. There was not a need to report or investigate.A 5-day investigation summary was submitted to the state agency after the self-report was sent on 4/16/26. The document summarized the Administrator and the Director of Nursing (DON) were both aware of staff concerns surrounding a specific nurse's implemented fall interventions for Resident #1. The Administrator indicated the DON was investigating and concluded there was no mistreatment by the staff involving Resident #1.On 6/25/26, the Administrator was unable to locate documentation that a facility investigation was completed regarding potential abuse concerns involving Resident #1 prior to the one initiated on 4/16/26.In an interview on 6/29/26 at 9:45 AM, Staff F, former DON, acknowledged multiple staff approached them regarding concerns surrounding treatment of Resident #1. Staff F described themselves as a working DON (active on resident units, reviewing clinical records) and voiced constantly investigating. Staff F explained no formal investigation or documentation was completed. They did not believe mistreatment occurred and the suspected staff member continued to provide cares to Resident #1.In an interview on 6/29/26 at 3:00 PM, the Chief Operating Officer (COO) explained the facility's abuse policy and protocol should be initiated when an allegation of potential abuse reported. This is regardless if staff believes to be true or not. The COO stated the abuse protocol should have been initiated.The policy Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, revised Sept'22, outlined the following: 1. All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported 2. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents 3. The investigator consults daily with the administrator concerning the progress/findings of the investigation 4. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator

Based on observations, staff interview, and policy review the facility failed to sanitize a mechanical lift during use between 4 residents. In addition, the facility failed to transport linen in a manner to prevent contamination. The facility reported a census of 50 residents. Findings include:1. During a continuous observation that began on 3/16/26 at 1:45 PM, Staff A, Certified Medication Aide (CMA), exited a semi-private resident room after using a mechanical lift to transfer one resident and stored it against the wall in the hallway. They didn't sanitize the mechanical lift after the resident's transfer.Staff B, Certified Nurse Aide (CNA), took the mechanical lift into another semi-private resident room with Staff A and transferred one resident into a chair. Staff A brought the mechanical lift out of the residents' room and placed it in the hallway. They failed to sanitize the mechanical lift sanitized before or after the resident's transfer.At 1:50 PM, Staff A and Staff C (CNA) took the mechanical lift into another semi-private resident room and transferred a resident. The staff failed to sanitize the mechanical lift before or after the resident's transfer.At 1:52 PM, Staff C exited the residents' room with the mechanical lift. Staff C and Staff D, CMA, took it into another semi-private resident room. They failed to sanitize the mechanical lift before or after the resident's transfer.On 3/18/26 at 10:42 AM, Staff B stated she forgot to sanitize the mechanical lift between resident transfers on 3/16/262. On 3/16/26 at 2:44 PM, watched Staff E, CNA, transported linen (draw pads, gowns, blankets) on an uncovered cart down a resident hallway. A policy titled Laundry and Bedding, Soiled revised [DATE] indicated clean linen is protected from dust and soiling during transport and storage to ensure cleanliness.On 3/19/26 at 7:38 AM, the Director of Nursing (DON) stated staff should've cleaned the equipment between residents and they should've covered the linen during transport.

Based on clinical record review, observation, staff interview, and policy review the facility failed to provide a homelike environment by not placing sheets on residents' beds for 2 of 5 residents (Resident #22 and #28) reviewed. The facility reported a census of 50 residents. Findings include:1. Resident #22's Minimum Data Set (MDS) assessment dated [DATE] revealed an admission date of 2/11/22 from a short-term general hospital stay. The MDS further indicated Resident #22 had diagnoses of stroke, non-Alzheimer's dementia, and hemiplegia (severe or complete paralysis on one side of the body).On 3/16/25 at 2:15 PM observed Resident #22 lying in bed without a sheet on the mattress. Resident #22 reported the facility did have a sheet, but just not on their bed.2. Review of Resident #28's MDS dated [DATE] revealed an admission date of 2/2/24 from a short-term general hospital stay. The MDS further indicated Resident #28 had diagnoses of pulmonary embolus (a sudden blockage in a lung artery), heart failure, non-Alzheimer's dementia, and a need for assistance with personal care.On 3/16/26 at 2:34 PM observed Resident #28 lying in bed without a fitted sheet, lying on top of the mattress.Interview 3/17/26 at 2:06 PM Staff G, Certified Nursing Assistant (CNA), reported they're not supposed to put fitted sheets on the air flow mattresses, but put a pad under the resident. Staff G confirmed Resident #28 should have a sheet on his mattress.Interview 3/17/26 at 2:09 PM Staff H, CNA, explained sheets should be on all beds unless it is an air flow bed. Staff H confirmed Resident #28 should have a fitted sheet on his mattress.On 3/17/26 at 2:27 PM Staff I, CNA, revealed she saw sheets not on beds, but they are beds with airflow mattresses. Staff I added those mattresses should have a bed pad under the resident. Staff I continued if it is not an air flow mattress then it should have a fitted sheet.On 3/17/26 at 2:55 PM the Director of Nursing (DON) said she expected the air flow mattress to not have a fitted sheet, only a pad placed under the resident. The DON added the other mattresses should have a fitted sheet as this would make it more homelike.Follow up interview on 3/18/26 at 11:05 AM the DON reported she believed it was best practice to not have sheets on low flow mattresses, and only to use a bed pad. The DON added something like this, the facility would educate the staff to have sheets on low flow mattresses.Review of a facility provided policy titled, Homelike Environment revised February 2021 directed:a. The facility staff and management maximize the characteristics of the facility that reflect a personalized, homelike setting which include clean bed and bath linens that are in good condition.

Based on clinical record review, staff interview, guidance from the October 2025 Resident Assessment Instrument (RAI) 3.0 User's Manual, and facility policy review, the facility failed to accurately reflect the status of 1 of 2 sampled residents on hospice care in the Minimum Data Set (MDS) Assessment (Resident #35). The deficient practice created the potential for the resident to not receive appropriate treatment and services. The facility reported a census of 50 residents. Findings include:The MDS of Resident #35, dated 2/11/26 was a significant change in status assessment. The MDS identified a Brief Interview for Mental Status Score of 14, which indicated intact cognition. The MDS coded the resident's prognosis, at section J1400, that the resident did not have a condition or chronic disease that resulted in a life expectancy of less than 6 months (hospice care is generally for patients with a terminal prognosis of six months or less to live, as certified by a physician). The MDS recorded that the resident was not receiving Hospice care, at section O0110K1. The facility's MDS Coordinator signed section J and O as completed on 2/25/26 certifying the document accurately reflected the resident assessment information for the resident. On 3/16/26 at 1:02 p.m. the facility provided the Resident Matrix which identified Resident #35 was currently receiving hospice services. Review of Resident #35's electronic medical record (EMR) revealed he returned to the facility from a hospital stay on 2/5/26 and the facility admitted him to hospice care that day. During an interview on 3/19/26 at 9:20 a.m., the MDS Coordinator said they completed the Resident #35's significant change in status MDS assessment due to his admission to hospice care. She acknowledged it was her error in failing to code the resident's prognosis accurately (section J1400) and failing to code that the resident was in a hospice program (section O0110K1). Review of the October 2025 RAI 3.0 User's Manual revealed a significant change in status assessment was required to be performed when a terminally ill resident enrolls in a hospice program. and remains a resident at the nursing home and the Manual directed to code:J1400: Prognosis as yes for the resident who was receiving hospice services and to code no if the resident was not receiving hospice services. O0110K1: Hospice care for residents identified as being in a hospice program. Review of the facility's policy Resident Assessments, revised December 2023, revealed the MDS coordinator was responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments. and .persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. To correct the passive past tense examples in the provided text, you can rephrase them to use the active past tense.

Based on observation, clinical record review, staff interview, and policy review the facility failed to provide adequate oral care for 1 of 3 residents (Residents #9) reviewed. The facility reported a census of 50 residents. Findings include:Resident #9's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was dependent on staff for oral hygiene, eating, and toileting hygiene. The MDS further Resident #9 had diagnoses of non-traumatic brain dysfunction, cerebral palsy, seizure disorder, and severe intellectual disabilities. Review of Resident #9's Care Plan with a revision date of 2/28/26 revealed an intervention for Resident #9 reveal dependency on staff for assistance with brushing teeth. On 3/16/26 at 2:45 PM witnessed Resident #9 with heavy plaque build up on their teeth. On 3/17/26 at 1:30 PM noted Resident #9's toothbrush in the medicine cabinet in an unopened and unused plastic wrapper. On 3/17/26 at 2:09 PM Staff A, Certified Nursing Assistant (CNA), explained it is very difficult to brush Resident #9's teeth. Staff A confirmed the staff haven't brushed Resident #9's teeth twice a day as they should. On 3/17/26 at 2:27 PM Staff I, CNA, verified the staff didn't brush the teeth twice a day on residents who needed assistance. Staff I confirmed Resident #9's toothbrush was still in the plastic, and that the residents' teeth should be brushed twice a day. On 3/17/26 at 2:33 PM Staff F, Licensed Practical Nurse (LPN), confirmed the staff didn't brush residents' teeth brushing twice a day as the staff get busy and forget to complete it. On 3/17/26 at 2:55 PM the Director of Nursing (DON) explained she expected the staff to do oral care twice a day. Review of a facility provided policy titled, Mouth Care revised February 2018 instructed the staff to provide oral care to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent oral infection.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to provide supplemental oxygen as ordered for 1 of 1 resident reviewed for respiratory care (Resident #48). The facility reported a census of 50 residents.Findings include:Resident #48's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #48 required setup assistance with eating, moderate assistance with showering, showering transfers, and lower body dressing, maximal assistance with footwear, and supervision with all other Activities of Daily Living (ADLs) and mobility. The MDS included diagnoses of anemia, chronic obstructive pulmonary disease (COPD), and syncope and collapse (temporary loss of consciousness caused by sudden drop in blood flow to the brain with rapid recovery). The MDS reflected she used supplemental oxygen within the 7-day lookback period.The Care Plan revised 11/26/25 directed staff to provide Resident #48 with 2 liters per minute (LPM) of continuous oxygen via nasal cannula ( tubing with 2 hollow prongs to fit into the nostrils).The Electronic Health Record (EHR) included a physician's order dated 1/12/26 for oxygen 1 L via nasal cannula (L/NC) every hour as needed (PRN) for shortness of breath (SOB)/comfort (low blood oxygen level).The Oxygen Saturation Summary indicated Resident #48's most recent documented pulse oximeter level (blood oxygen level - O2 sat) on 3/10/26.On 3/16/26 at 3:06 PM, observed Resident #48 using their oxygen. The oxygen concentrator set at 2 L/NC.On 3/17/26 at 3:22 PM, Staff F, Licensed Practical Nurse (LPN), stated the nursing staff administer Resident #48's oxygen based on the physician's order.On 3/17/26 at 3:29 PM, observed Resident #48 sitting in her wheelchair at the nurses' station wearing nasal cannula tubing connected to an oxygen tank that was turned off. Resident #48's EHR did not contain any documented O2 sat levels since 3/10/26.On 3/17/26 At 3:36 PM, Staff F stated he hadn't checked Resident #48's oxygen or tubing yet.A policy titled Oxygen Administration revised October 2010 directed staff to review the physician's order or facility protocol for oxygen administration. It also directed staff to assess the resident's vital signs and oxygen saturation while the resident is receiving oxygen therapy.On 3/19/26 at 7:38 AM, the Director of Nursing (DON) stated staff should have assessed Resident #48's need for more than 1 L/NC of oxygen. If needed, they should contact the physician to get the order changed. If the assessment indicated no need for an oxygen increase, then staff should've followed the physician's order.

Based on observations, clinical record review, policy review, resident, and staff interviews, the facility failed to provide non-pharmacologic pain management for 1 of 1 resident reviewed (Resident #7). The facility reported a census of 50 residents.Findings include:Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #7 required setup assistance with eating, moderate assistance with showering, showering transfers, and putting on footwear. The MDS listed she required supervision with all other Activities of Daily Living (ADLs) and mobility. The MDS included diagnoses of diabetes mellitus, heart failure, muscle wasting (when your muscles get smaller and weaker over time, often due to illness or not using them.), morbid obesity (excessive weight), and degenerative disc disease (condition in which spinal discs break down due to wear and tear causing chronic lower back pain). The MDS reflected she had constant pain that frequently affected her sleep. She received pain medication and non-medication interventions for pain in the 7-day lookback period.The Electronic Health Record (EHR) included the following physician's orders:a. 9/3/24: A scheduled 10 milligram (mg) narcotic (a powerful, often addictive, pain-relieving drug that affects the brain and body.) pain medication every 6 hours b. 12/24/25: 650 mg of Tylenol every 6 hours as needed for pain. c. 12/29/25: Directed staff to document non-pharmacological pain management intervention with the following information: 1 = Deep Relaxation 2 = Heat to the site 3 = Cold/Ice to the site 4 = Massage 5 = Meditation 6 = Music 7 = Going to bed 8 = Quiet Place 9 = Repositioning 10 = Aromatherapy 11 = Guided imagery 12 = Other/See progress NoteThe Care Plan Focus revised 11/19/25 indicated Resident #7 used pain medication therapy. The Intervention directed staff to manage pain per physician treatment orders.Resident #7's January - March 2026 Medication Administration Records (MAR) printed 3/17/26, documented the following: 4 daily doses of oxycodone administered between 1/1/26 - 3/17/26. Tylenol Administrations: January 2026: 15 dosesFebruary 2026: 8 doses March 2026: 5 doses.Pain ScoresJanuary 2026: 4 severe and 44 moderate documented pain scores out of 62 evaluations February 2026: 6 severe and 34 moderate documented pain scores out of 56 evaluationsMarch 2026 (1st - 17th): 2 severe and 23 moderate documented pain scores out of 34 evaluations No documented non-pharmacologic interventions between 1/1/26 - 3/17/26.On 3/16/26 at 2:24 PM, Resident #7 stated her oxycodone medication didn't help her pain as much as she'd like. The Tylenol didn't have an effect on her pain at all. She added the facility hasn't done anything non-pharmacological to help with her pain.A policy titled Pain Assessment and Management revised March 2020 indicated non-pharmacological interventions may be appropriate alone or in conjunction with medications. It also indicated pharmacological interventions may be prescribed to manage pain, however they do not usually address the cause of pain and can have adverse effects on the resident.On 3/19/26 at 7:38 AM, the Director of Nursing (DON) stated staff should've offered non-pharmacologic interventions and, if ineffective, should've contacted the physician for other options.

Based on clinical record review, document review, resident interview, staff interview, and policy review the facility failed to provide an adequate amount of nursing staff to assure residents safety by not responding to call lights in a timely manner for 3 of 6 residents reviewed (Residents #15, #20, and #22). The facility reported a census of 50 residents.Findings include:1. Resident #15's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS listed Resident #15 as dependent on staff for assistance with sitting to standing, chair/bed-to-chair transfers, and toileting.Interview on 3/16/26 at 1:49 PM Resident #15 reported the call lights often took longer than 15 minutes. Resident #15 added she could read a clock, and that is how she can tell. 2. Resident #20's MDS dated [DATE] revealed a BIMS score of 15, indicating intact cognitive functioning. Resident #20 required moderate assistance with sitting to standing, chair/bed-to-chair transfers, and toileting. Interview on 3/16/26 at 1:03 PM Resident #20 explained the call lights usually took 15 minutes or longer. Resident #20 added the call lights lasted up to 30 minutes. Resident #20 explained he watched the clock, and can tell time. 3. Resident #22's MDS dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment. The MDS listed Resident #22 as dependent on staff for assistance with toileting hygiene, personal hygiene, upper and lower body dressing. Interview on 3/16/26 at 2:14 PM Resident #22 reported the call lights could take longer than 15 minutes. Resident #22 added he watched the tv and could tell how long it took. Interview on 3/17/26 at 2:06 PM Staff G, Certified Nursing Assistant (CNA), said she saw call lights lasting longer than 15 minutes. Staff G added sometimes the staff don't see the lights on, when they are in the dining room. Interview on 3/17/26 at 2:09 PM Staff H, CNA, verified she saw call lights last longer than 15 minutes. Interview on 3/17/26 at 2:27 PM Staff I, CNA, reported she saw call lights last 15 minutes or longer. Interview on 3/17/26 at 2:33 PM Staff F, Licensed Practical Nurse (LPN), explained he saw call lights last longer than 15 minutes. Staff F reported the facility had a lot of 2 assist residents in the facility. The staff get tied up with assisting and call lights can last longer than 15 minutes. Interview on 3/17/26 at 2:55 PM the Director of Nursing (DON) revealed she expected the staff to answer the call lights in 15 minutes or less. A facility provided document titled, Device Activity Report dated 3/1/26 revealed several call lights ranging from 16 minutes to 52 minutes in length. A facility provided policy titled, Answering the Call Light revised September 2022 instructed the staff to answer the call system timely.

Based on observation, interview, facility policy review, and United States (US) Food and Drug Administration (FDA) 2022 Food Code review, the facility failed to serve food in a manner that complied with safe food handling practices during one of two observed meal services. The facility reported a census of 50 residents. Findings include: Observation on 3/16/26 of the noon meal started at 12:26 p.m. in the facility's Main Dining Room revealed:At 12:40 p.m. Staff J, Certified Nurse Aide (CNA), served Resident #50 their meal in a divided plate. After they placed the food in front of Resident #50, they left the table to return to the kitchen.At 12:41 p.m. Staff J ran through the dining room from the kitchen and picked up the meal they served Resident #50 and removed it from in front of him. Staff J then served that same meal to Resident #45, who sat at another table in the dining room.At 12:49 p.m. when asked if she removed Resident #50's plate she served to them and served it to Resident #45, Staff J agreed she removed the plate after she served it and then re-served that same meal to another resident. During an interview on 3/17/26 at 1:15 p.m. when inquired what should have happened if someone served a meal to a resident in error, the Dietary Manager replied she would remove the meal and provide the correct meal to the resident and inform the Director of Nursing (DON) of the error. When asked regarding the meal that had been served, she responded the meal that was served was contaminated and should not be served to another resident or returned to the kitchen, but should be disposed of in the trash. During an interview on 3/17/26 at 3:27 p.m. discussed the DON the noon meal service on 3/16/26 and the observation of Staff J serving a meal to Resident #50 and then removed the meal and re-served the same meal to Resident #45, due to serving by mistake. When asked what they should have done with the meal served by mistake, the DON replied they should have disposed of the meal. When inquired why they shouldn't serve that meal to another resident, the DON responded it was an infection control breach and they should have disposed of that meal in the trash. She stated she knew of the situation that had occurred at the noon meal service, she agreed Staff J made a mistake by serving that served meal to another resident. She stated the facility had a lot of newer staff and they recently hired Staff J.Review of the facility's Employee New Hires report revealed Staff J had a Hire Date of 1/20/26. Review of the facility's policy Food Preparation and Service, revised 10/23/22, directed employees to prepare and serve food in a manner that complies with safe food handling practices.Review of the U.S. Food and Drug Administration 2022 Food Code revealed regarding the re-service of food, Chapter 3, Section 306.14 stated regarding Returned Food and Re-Service of Food that . after being served. and in the possession of a consumer, food that is unused or returned. may not be offered as food for human consumption.

The Minimum Data Set (MDS) of Resident #35 dated 2/11/25 identified a Brief Interview for Mental Status (BIMS) score of 14, which indicated his cognition was intact. The MDS coded Resident #35 needed partial/moderate assistance to eat. The MDS listed Resident #35 as dependent on staff for hygiene tasks, dressing, transfers, to shower or bathe, and used a manual wheelchair. The MDS described Resident #35 as always incontinent of both bowel and bladder. The MDS included diagnoses of cerebral palsy, Cerebral palsy (CP) (a disorder of movement and posture caused by damage or abnormal brain development, usually before birth, resulting in varied impaired muscle control and coordination.), dysphagia (difficulty swallowing), diabetes mellitus, and cognitive communication deficit. The MDS failed to identify his terminal prognosis (J1400) and hospice care (O0110.K1).The Care Plan revised 3/5/26, identified the following Focuses:a. Resident #35 had an increased risk for limitations in his ability to perform Activities of Daily Living (ADL). The Interventions directed the following: i. Resident #35 needed supervision with meals and reminders to swallow. ii. Resident #35 needed the assistance of one to two staff with all his ADLs. b. Resident #35 had a potential risk for inability to maintain nutrition and identified the resident required a pureed diet (smooth, pudding-like foods that require no chewing) with honey thick liquids (modified fluids with a slow-pouring, syrupy consistency). c. Resident #35 had a terminal prognosis related to a stroke and received hospice care. The Interventions instructed staff to work effectively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met.The Care Plan failed to identify the following:a. Hospice provider and the specific services and functions they would provide in coordinating their services with those the nursing home would continue to provide. b. The structure of the Care Plan established between the nursing home and the hospice provider and that the resident's Care Plan was divided into two portions, one maintained by the nursing home and the other maintained by the hospice. c. The location of the hospice Care Plan. These failures created the potential for the coordinated Care Plan to be inconsistent and not current in meeting the needs of the resident for both his hospice care and nursing home care.Review of Resident #35's electronic medical record (EMR) revealed three scanned documents from his hospice provider:A one-page document, titled Hospice diagnosis code, dated 2/5/26, regarding patient billing.A thirteen-page document, titled Hospice reports, dated 2/25/26, that contained a Patient Fact Report and Medication Profile. This document included the hospice clinical team names, discipline, and contact information; Care Needs, Goals, and Interventions; and Medications prescribed. An eight-page document, titled Hospice records, dated 3/11/26, regarding physician orders and Care Plan. This document included the resident's hospice Care Plan and identified care needs, goals, interventions, and disciplines responsible (Registered Nurse, Licensed Practical Nurse, Hospice Aide, Social Worker, Chaplain, and Volunteer).During an interview on 3/18/26 at 3:45 p.m. the Director of Nursing (DON), reported the facility worked with three hospice providers. Some provided three-ring binders at the facility that kept resident specific information. Resident #35's hospice provider didn't provide the facility with a binder. The DON stated the facility received e-mails from the hospice providers that contained resident specific information. The facility scanned the information into the resident's EMR. She agreed they could make improvements with the hospice providers to facilitate the care coordination and communication with hospice and facility staff. During an interview on 3/19/26 at 9:20 a.m. the MDS Coordinator revealed she had worked at the facility for three years, and had the responsibility for developing and updating resident Care Plans. She stated that the hospice providers come to the facility weekly and the facility invited the hospice provider to the resident Care Plan conferences. She stated the services provided by the hospice provider varied by the needs of the individual resident. She agreed Resident #35's Care Plan didn't identify the structure of the Care Plan established by the nursing home and the hospice as divided into two portions. One maintained by the nursing home and the other maintained by the hospice. She agreed Resident #35's Care Plan didn't identify the location of the hospice Care Plan. Review of the Hospice Agreement with Resident #35's hospice provider reflected they would provide the most recent hospice plan of care specific to each patient. Which would include the names and contact information for hospice personnel involved in hospice care of each patient. The Hospice Agreement stated the plan of care will identify the care and services needed and must specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the plan of care. Review of the facility's Hospice Program policy, dated January 2024, revealed the facility designated the IDT [Inter-Disciplinary Team] to coordinate care provided to the resident by the facility staff and the hospice staff. Collaborating with hospice representatives and coordinating facility staff participation in the hospice Care Planning process for residents receiving these services. Coordinated Care Plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility in order to maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on observation, Electronic Health Records (EHR), Medication Administration Records-Treatment Administration Record (MAR-TAR), document review, policy review, and staff interview the facility failed to provide adequate sanitization to shower chair between residents, failed to provide influenza testing and communicate with public health during outbreak and failed to provide appropriate infection prevention practices during administration of medications to 2 of 7 residents reviewed (Resident #8, and #33), and contact with Resident#31 whom had a dressing. The facility reported a census of 50 residents. Findings include: 1. The Annual Minimum Data Set (MDS) dated [DATE] for Resident #31 documented a Brief Interview for Mental Status (BIMS) of 13 which indicated no cognitive impairment. Review of Resident #31's MAR - TAR a physician order to monitor scabbed areas to the left shin daily for wound care. Observation on 3/3/25 at 12:27 PM revealed Staff Q, Certified Nursing Assistant (CNA)/ Social Services entered Resident #31's room. Staff Q did not complete hand hygiene then touched the wound on Resident #31's left shin, then pulled a blanket down over the residents left shin. Staff Q then exited the residents room without performing hand hygiene. Observation on 3/5/25 at 7:50 AM revealed Staff N, Licensed Practical Nurse (LPN) prepared medication, no hand hygiene was completed, knocked on door, medications taken into residents room, medications given with sips of water and Miralax, trash taken to garbage can at medication cart. Staff N then pushed the medication cart down the hall to the next resident's room. Staff N stopped in front of room [ROOM NUMBER], medication cup obtained, keys removed from pocket, and started preparing medications. No hand hygiene completed by Staff N for this entire observation. A continuous observation on 3/6/25 from 7:32 AM to 8:45 AM revealed Staff E, LPN did not complete hand hygiene, gathered medications prior to entering a Resident#33's room, knocked on the residents door, entered the room, obtained gloves, applied Lidocaine patch to right hip, and applied Lidocaine patch to left hip. At 3/6/25 at 7:50 AM a CNA knocked on the door and asked for money for another resident. Staff E left room [ROOM NUMBER] A at 7:50 AM. Staff E walked to the medication cart and removed gloves. Staff E completed the task for the staff requesting money. Staff E returned to the room on 3/6/25 at 7:52 AM, knocked on the door and entered, no hand hygiene completed and applied gloves. Staff E administered an eye drop to the left eye, tissue utilized for the left eye, then administered an eye drop to the right eye and tissue utilized for the right eye. Staff E removed gloves, nurse obtained nebulizer, Ipratropium poured into nebulizer, nebulizer applied, nebulizer machine turned on, obtained blood pressure, gathered trash, returned to the medication cart, documented vitals on the computer, obtained keys to medication cart, unlocked the cart, returned blood pressure cuff to medication cart, locked cart pushed cart down to room [ROOM NUMBER] (Resident#8). Staff E obtained medications from the medication cart drawer, started removing medications from bubble packs and gathered medications for the resident in room [ROOM NUMBER] prior to entering the residents room. On 3/6/25 at 8:21 AM Staff E knocked on room the resident in room [ROOM NUMBER]'s door, entered the room, applied gloves, obtained alcohol wipe cleansed middle finger, obtained glucose strip, utilized lancet, obtained blood sample and blood glucose machine had a failure in functioning. On 3/6/25 at 8:24 AM Staff E left room [ROOM NUMBER], returned to the medication cart for another glucose machine, obtained a different glucose machine and obtained another lancet. Tasks were all completed by Staff E with gloves on. On 3/6/25 at 8:26 AM Staff E entered room [ROOM NUMBER], blood glucose machine placed on bedside table, blood sample obtained from left hand index finger, blood glucose machine placed on bedside table, blood glucose 108, scratched her face with the gloves on and obtained blood pressure. Staff E left room [ROOM NUMBER], returned to the cart to obtain another medication, unlocked the computer, unlocked the medication cart drawers, removed gloves, completed no hand hygiene, browsed the computer for orders, obtained insulin from medication cart, utilized an alcohol wipe to cleanse the rubber septum of insulin pen, 4 units drawn up, applied gloves, micro kill cleansing wipe obtained from medication cart drawer, glucose machine wiped down then wrapped and medication bubble pack card fell on the floor. Staff E picked up the medication bubble pack card off the floor with gloves on. Staff E returned the micro kill cleansing wipe to medication cart, removed gloves, obtained alcohol wipe, applied gloves, completed no hand hygiene, insulin taken into room, cap of needle removed, alcohol used to cleanse area on right thigh, insulin administered to right thigh, insulin taken back out to medication cart, Staff E returned to the computer, removed her glasses from face, removed the needle from insulin pen unlocked medication cart, insulin returned to the medication cart and removed gloves. Staff E pushed the medication cart down to the dining room and prepared medications for the next resident without performing hand hygiene. On 3/6/25 at 11:48 AM Staff T, LPN/Assistant Director of Nursing (ADON) / Infection Preventionist (IP) stated she would expect hand hygiene to be completed during medication administration, between residents, after removal of medications and with any glove changes. Staff T stated gloves are required with resident contact. Staff T stated hand hygiene should be completed prior to and after all resident contact. Staff T stated she would not expect a wound to be touched if not needed. Staff T stated if a wound was required to be touched gloves should always be worn. On 3/6/25 at 11:12 AM the DON stated hand hygiene should have been completed between residents. The DON stated the facility ' s expectation was hand hygiene would have been completed prior to and after resident contact. The DON stated depending on the surfaces the staff came in contact with without hand hygiene and the appropriate use of gloves the spread of bacteria or illness could happen. The DON stated she would like to have seen hand hygiene after every glove change. The DON stated the blood glucose machine should have been on a barrier. Review of policy revised 8/19 titled Azria Handwashing/Hand Hygiene documented the facility considers hand hygiene the primary means to prevent the spread of infections. Hand hygiene should be completed before and after direct contact with residents, before preparing or handling medications, before moving from a contaminated body site to a clean, after contact with a resident's intact skin, after contact with blood or bodily fluids, and after removing gloves. 47582 2. During an observation of the shower room on hallway 400 on 3/04/25 at 9:28 am revealed a brown-colored stain on the shower chair. At 9:41 am Staff S, Certified Nursing Assistant (CNA) observed taking a resident into the shower to provide bathing assistance. During an interview on 3/04/25 at 9:55 am Staff S, CNA revealed she gave a shower to the resident noted during 9:28 am observation mentioned above. When questioned if the shower seat was washed and sanitized prior to use for showering the resident, Staff S, CNA stated she did not. Upon inquiry on how she would typically sanitize the shower area during use, she demonstrated using a bottle of concentrated Clorox and wiped the shower chair using a washcloth with bare hands. She further stated she did not have to do anything else besides spraying the Clorox and wiping with the same rag and felt comfortable using the Clorox without wearing gloves as she was comfortable using the chemical because she used it at home as well. She confirmed Clorox was the only cleaner the facility provided to disinfect the shower area between and after residents' use. In an interview with the Housekeeping Manager on 3/04/25 at 12:04 pm, who held the role as a contracted company for the past 3 years, revealed the facility has used Clorox as a choice of disinfectant for shower rooms and shower equipment. She stated that the bottles labeled concentrated Clorox were actually diluted by her and all staff were able to dilute it as needed. She revealed the dilution process was completed by eye-balling the level of Clorox concentrate with water, and water making up the majority of the final product, then tested using a test strip but no documentation was completed measuring the strength of each bottle or dates. She also stated her department uses an actual disinfectant intended for healthcare use during once-a-day shower rooms deep cleaning. She could not provide an answer for the reason facility staff/CNAs were using Clorox and not the healthcare grade disinfectant. She stated that's how things have always been and didn't know who would direct which cleaning agent to use for CNAs but it was not her call. She agreed that the Clorox was not the proper chemical to use for this type of healthcare facility. She also stated she has not discussed this concern with the facility's Administrator or Director of Nursing about Clorox as being an ineffective cleaner. 49990 3. During a review of facility respiratory illness tracking and treatment from November 2024 through February 2025, questions arose as to the testing criteria for COVID-19 and Influenza. In November, 3 respiratory infections were documented. Testing was performed for COVID-19 but not for Influenza. In December, 2 respiratory infections were documented. Testing was performed for COVID-19 but not for Influenza. In January, 5 respiratory infections were documented. Testing was performed for COVID-19 but not for Influenza. In February, there were again 3 respiratory infections documented. COVID-19 testing was performed for all residents, and Influenza testing was performed on two residents after one resident tested positive for Influenza. In an interview on 03/04/2025 at 10:22 AM with the Infection Preventionist (IP), it was questioned what diagnoses the residents had been given, and she was asked why COVID testing had been performed but influenza testing had not. She stated the residents had been diagnosed with pneumonia, but only the Resident in February had tested positive for Influenza. She stated the facility does have influenza tests in the facility but they have a batch order for COVID testing and do not have a batch order for influenza testing. She stated they only test for influenza when they have had a resident or staff member test positive. That would prompt influenza testing for residents with respiratory symptoms. She stated she was unaware the surrounding areas were experiencing a large Influenza outbreak during the months reviewed. She stated she had last been in contact with [NAME] County Public Health sometime in October. Review of the Iowa Department of Health and Human Services Virus Surveillance Report, week 9, shows a large spike in influenza throughout the state from December through February. Review of the Centers for Disease Control and Prevention (CDC), regulations and recommendations for Long Term Care (LTC) state that residents residing in nursing facilities should be tested for both SARS-CoV-2 and Influenza when they show symptoms of respiratory illness.

Based on Electronic Health Records (EHR) review, observations, policy review, resident interview and staff interview the facility failed to provide the residents with a comfortable homelike environment by not repairing damages in resident rooms for 5 of 17 residents (Resident #11, #31, #33, #43 and #47). The facility reported a census of 50 residents. Findings include: 1. The Annual Minimum Data Set (MDS) dated [DATE] for Resident #31 documented a Brief Interview for Mental Status (BIMS) of 13 which indicated no cognitive impairment. Observation on 3/3/25 at 12:10 PM in Resident #31's room revealed drywall behind the head of the bed chipped with deep grooves and missing paint. Drywall to the left of Resident #31's bed under the window also had missing paint with grooves of missing drywall. On 3/3/25 12:15 PM Resident #31 stated he had never asked but would like the paint behind his bed and the area of dry wall fixed on the wall beside his bed. 2. The MDS dated [DATE] for Resident #33 documented a BIMS of 12 indicating mild cognitive impairment. Observation on 3/4/25 at 9:37 AM in Resident #33 ' s room revealed a quarter sized area of missing paint with several deep grooves that had been painted over behind the resident's chair. On 3/4/25 at 9:38 AM Resident #33 stated she would like to have the areas repaired but doesn't want to put the facility out. 3. The Quarterly MDS dated [DATE] for Resident #43 documented a BIMS of 05 which indicated severe cognitive impairment. Observation on 3/4/25 at 9:10 AM revealed paint missing on the wall to the left of the bathroom approximately 8 - 10 inches by 2 inches with a second quarter sized area of missing paint. Observation also revealed 4 areas about 3 inches by 1 inch above the light fixture on the wall. On 3/4/25 at 9:11 AM Resident #43 stated she used to have an old calendar to the left of the bathroom door. Resident #43 stated when she moved in a calendar was peeled off and the tape removed the pain. Resident #43 stated the missing paint bothered her a bit she had planned on covering the area because the missing paint is a bit of an eyesore. Resident #43 stated she would like it repaired but had not asked anyone to fix it. Resident #43 stated she had thoughts of covering the area with a picture or something. 4. The Admission MDS dated [DATE] for Resident #47 documented a BIMS of 14 which indicated no cognitive impairment. Observation in Resident #47's room on 3/4/25 at 10:45 AM revealed 2 large areas of different colored paint near the head of the bead under the window. Chipped paint behind the chair and near the light. On 3/4/25 10:47 AM Resident #47 stated she had entered the facility about 2 weeks ago. Resident #47 stated the missing paint is a bit of an eye sore but had been like that since she moved in. Resident #47 stated she thought they would have painted prior to someone moving in but the facility did not. On 3/5/25 at 4:46 PM Staff K, Certified Medication Assistant (CMA)/ Certified Nursing Assistant (CNA) stated she had turned in fix slips for broken remotes, when a bed would not move up and down and a pull shade was broken. Staff K stated maintenance repaired those issues. Staff K acknowledged that a few rooms up front and a few in the back have paint missing on the walls and grooves in the dry wall. Staff K stated she did not fill out the slips personally because she was told the paint and dry wall issues were already addressed. Staff K acknowledged there were some scratches on the wall in room [ROOM NUMBER]. Staff K stated she did not report the scratches in room [ROOM NUMBER]. Staff K stated she was told multiple people had written the concern up about scratches, missing paint, and grooves in the dry wall. Staff K stated she did not remember who stated they wrote the concerns up. On 3/5/25 at 5:11 PM Staff L, CNA stated she had reported environmental concerns to maintenance a couple of times. Staff L stated she could not remember what those concerns were but she had reported environmental concerns. Staff L stated she worked on all the halls. Staff L stated she had noticed missing paint and grooves in the drywall in resident rooms. Staff L stated papers had been filled out for the maintenance man. Staff L acknowledged those areas did not get repaired. Staff L stated she remembered reporting the 100 and 300 halls. Staff L stated she had not heard any of the residents complain about the paint or grooves. On 3/5/25 at 5:37 PM Staff M Maintenance Director stated the way that staff reported environmental issues are with fix it tickets. Staff M stated he does not get very many fix it tickets. Staff M stated he went through once every other month and touched up walls. Staff M stated he does not document repairs or touch ups. Staff M stated he saved the fix it tickets for so long and then threw them in the shred box. Staff M stated he kept them till the box was full and then shreds the tickets. Staff M acknowledged he knew the walls needed to be touched up and when he had a chance he went down the hall and tried to paint. Staff M stated the dry wall and paint is a constant thing. Staff M stated might not have filled the grooves but they got painted over. Staff M stated most of the time they try to have the rooms touched up or fixed prior to the residents moving into the room. Staff M stated that he heard concerns about paint all the time that is why he rotates through touching up the room. Staff M stated he does not repair a particular room usually repaired by hallway. Staff M stated he tried to repair each entire hall once every couple months. Staff M stated if the staff say that the resident has a concern about it then he would try to complete the repair faster. Staff M acknowledged the wall in room Resident #47's had grooves and were then repaired with drywall and primer paint. Staff M acknowledged the repair was prior to Resident #47's admission and entry into the room. Staff M stated he did not know how he missed repainting the area. Staff M stated the grooves are repaired about every six months but covers the grooves in paint until he can get back to them when he paints the hall. On 3/5/25 at 6:08 PM the Administrator stated the process for environmental concerns such as missing paint, grooves in the drywall, broken shades or window repairs is to fill out a fix it ticket. The Administrator stated if it is reported to her verbally she would just call Staff M and tell him. The Administrator stated when residents discharge they do a room readiness check and the rooms are checked frequently. The Administrator stated drywall and paint should be completed as needed. The Administrator stated there was not a procedure for checking rooms for repairs. The Administrator stated she had not had any residents report any concerns with paint or dry wall. The Administrator stated she would have expected that the paint would have been completed in Resident #47's room prior to the resident entering the room. The Administrator stated she would have expected that the trim would have been repaired in room [ROOM NUMBER]. Review of policy titled Maintenance Service revised 12/09 documented the maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe operable manner at all times. Maintenance personnel will provide routinely scheduled maintenance service to all areas. The maintenance director was responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. A copy of the maintenance schedule shall be provided to each department director so that appropriate scheduling can be made without interruption of services to residents. Records shall be maintained in the maintenance director's office. 47582 5. The Quarterly MDS dated [DATE] for Resident #11 documented a BIMS of 06 which indicated severe cognitive impairment and an admitted [DATE]. An observation of Resident #11 room on 3/3/25 at 3:37 pm revealed the majority of the wall by the bed had multiple areas of dented drywall, scratched and chipped paint and discoloration, including a taped piece of electrical wire that had no immediate purpose. The main window was missing an entire trim, exposing sharp edges of the drywall. During an interview with Resident #11 on 3/03/25 at 3:37 pm stated the wall looked damaged since she moved in there and she expected it to be fixed but it hasn't occurred to this day. During an observation of the 400 hallway on 3/4/25 at 9:45 am, the following rooms were noted to have less than homelike environment: room [ROOM NUMBER]. The right side window mesh screen hung loosely, not secured inside the window frame. The window to the outside was missing an entire trim, exposing sharp drywall edges. The privacy curtain divided the room in the middle and had multiple brownish splatter stains throughout the lower half area. The vacant bed had a broken electrical cord that was hanging loose with exposed wires. The vanity above the hand sink was wrapped with loose cable wires. The top of the shared clothing closet was cluttered with food rest devices. Several areas on the walls noted to have chipped paint. Rooms 406. The main window was missing an entire trim, exposing sharp drywall edges.

Based on Electronic Health Record (EHR) review, staff interview, policy, and Medication Administration Records - Treatment Administration Records (MAR-TAR) review the facility failed to provide needed services in accordance with professional standards by leaving medications in the residents room for self administration without visualization of the nurse for 4 of 12 residents (Resident #8, #31, #33 and #41). The facility reported a census of 50 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #8 documented a Brief Interview for Mental Status (BIMS) of 15 which indicated no cognitive impairment. Observation on 3/6/25 at 8:21 AM revealed Staff E, Licensed Practical Nurse (LPN) obtained medications, knocked on Resident #8's door, entered the room, applied gloves, placed medications on bedside table in front of Resident #8, returned to medication cart for new glucose machine on 3/6/25 at 8:24 AM, Resident self administered medications with sips of water outside of view of Staff E, LPN, obtained a different glucose machine, returned inside of Resident #8's room on 3/6/25 at 8:26 AM, performed a blood glucose level test, left Resident #8's room, and returned to the medication cart. 2. The Annual MDS dated [DATE] for Resident #31 documented a BIMS of 13 which indicated no cognitive impairment. Observation on 3/3/25 at 12:27 PM in Resident #31's room revealed white-colored cream on the bedside table in a medication cup. On 3/3/25 at 3:03 PM Staff H, LPN stated she had not put the magic butt paste on Resident 31 that day. Staff H, LPN stated she had not left the cream in there today. Staff H, LPN acknowledged there was no other cream besides the magic butt cream and the cream sitting on the bedside table was magic butt cream. Staff H, LPN stated she would not leave the medication in the room. Staff H, LPN stated if the medication was refused she would have disposed of it. 3. The Annual MDS dated [DATE] for Resident #33 documented a BIMS of 12 which indicated mild cognitive impairment. Observation on 3/6/25 at 7:43 AM revealed Staff E, LPN gathered medications prior to entering the residents room, knocked on the Resident #33's door, entered the room, obtained gloves, applied the Lidocaine patch to right hip, applied Lidocaine patch to left hip. On 3/6/25 at 7:50 AM a staff knocked on the door and asked for money for another resident. Staff E. LPN left the Resident #33's room with medications sitting on the bedside table and left room to obtain money for the staff member. Resident #33 self administered medications without visualization by the nurse. Resident #33 spilled a little water on her lap. Resident #33 asked the surveyor where the nurse went. On 3/6/25 at 7:52 AM Staff E returned to Resident #33's room. Staff E, LPN knocked on the door and entered, Staff E, LPN left the room again, Staff E, LPN refilled water from the medication cart and returned to the room. Staff E, LPN asked what happened when noticed the water in Resident #33's lap, Resident #33 stated that she wobbled a little with the medication and water and spilled a little, Staff E, LPN returned to the medication cart and documented vitals and threw away trash. On 3/6/25 at 11:12 am, the Director of Nursing (DON) stated the nurse administering medications should not have been turning her back to the resident while the resident was taking medications. The DON stated the nurse was required to monitor the resident while medications were administered. The DON stated medications should not have been left in the residents room. The DON acknowledged none of the residents in the facility have the ability for self administration of medications. The DON stated an self administration assessment would have to be completed, physician notified and she was not sure if the facility had a policy on resident self administration. Review of policy titled Administering Medications revised 4/19 documented medications were administered in a safe and timely manner, and as prescribed. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. Residents could self-administer their own medications only if the attending physician, in conjunction with an interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. 47582 2. The Quarterly MDS dated [DATE] for Resident #41 documented a BIMS of 13 indicating intact cognition. The MDS revealed Resident #41 had a diagnosis of non-Alzheimer's dementia and Grover's disease, also known as transient acantholytic dermatosis (a skin condition characterized by itchy, red, and raised spots, often on the trunk). During an interview with Resident #41 on 3/03/25 at 3:28 pm, this writer observed him applying a lotion to his trunk out of a medication cup while he was alone in his room. Resident #41 revealed it was a medicated cream that a nurse told him to apply himself and the staff only applied the cream to his back area since he couldn't reach it. A review of the clinical record for Resident #41 documented a physical order on 2/20/25 for Diclofenac Sodium External Gel 1%, topical, apply to back topically as needed for discomfort twice daily. In an interview with the Director of Nursing (DON) on 3/06/25 at 12:19 pm, she confirmed Resident #41 shouldn't have been self-administering a physician prescribed medication unless he had an order from a physician specifying it which there was no such order.

Based on Electronic Health Record (EHR), policy review, observation, and staff interviews the facility failed to protect residents from hazards, accidents and injuries by not securing 2 shower rooms with the presence of chemicals, sharp razors, and biohazard containers, inappropriate ambulation assistance and failed to secure the wheelchair while dining for 4 of 17 residents (Resident #16, #32, #39, and #43). The facility reported a census of 50 residents. Finding include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #43 documented a Brief Interview for Mental Status (BIMS) of 05 which indicated severe cognitive impairment. On 3/4/25 at 1:00 PM an observation revealed a wander guard present on Resident #43's walker. Review of Resident #43's EHR titled, Medication Administration Record and Treatment Administration Records (MAR-TAR) documented an order to check the placement and function of a wander guard (device that triggers an alarm at exits to alert staff that a resident is near an exit) each shift. Review of Resident #43's EHR titled Care Plan documented a risk for wandering/elopement identified. Review of EHR titled Progress notes dated 2/17/25 entered by Staff U, Licensed Practical Nurse (LPN) documented Resident #43 was ambulating by herself in the room and in the hallway with walker with an unsteady gait at times. Staff assisted as the resident would allow. Resident #43 yelled at staff I can do it and the resident wandered towards the exit doors. Staff redirected Resident #43 away from the exit doors. Resident #43 had become visibly upset with redirection. Resident currently in room talking to self and stuffed animals. Review of EHR documented Resident #43 resided in room [ROOM NUMBER]. Review of document titled Floor Plan revealed room [ROOM NUMBER] was across the hall from the shower room on hall 100. On 3/04/25 10:51 AM Staff O, Certified Nursing Assistant (CNA) stated she does only the baths at the front of the facility. Staff O stated she bathed residents in rooms on the 100 and 300 hall. Staff O, CNA stated if she was going to be away from the shower room for a while she was supposed to shut the door. Staff O, CNA stated if she went on break then she would shut the door. Staff O, CNA stated if she would be getting a resident up she would shut it. Staff O, CNA stated she did not always shut the door when she was going to the supply room. Staff O, CNA stated she does not know the rule on when to shut the door. Staff O, CNA stated she probably should shut it all the time. Staff O, CNA stated Resident #43 wanders and occasionally would come to her in or near the shower room and ask for her hair rollers. Staff O, CNA stated sometimes Resident #43' hair rollers are kept in the shower room. Staff O, CNA acknowledged the concentrated bleach was kept in the cabinet and acknowledged there was not a lock on the cabinet. Staff O, CNA acknowledged the shampoo, disinfectant wipes, razors, biohazard container, hair, and body products are not locked up in the cabinet. Staff O, CNA stated sometimes when she pulled the shower room door shut it would not latch. Staff O, CNA stated she had not brought that to the administrators attention because it just recently started doing that. On 3/4/25 at 11:02 AM Staff E, LPN stated she frequently found the shower room door open and would pull the door shut. Staff E, LPN stated one day Resident #43 was looking for her hair rollers in the shower room by herself without staff present. Staff E stated she was going through the cabinet and was where she found her hair rollers. Staff E, LPN stated the Director of Nursning (DON) came and talked to Resident #43 about not going into the shower room by herself. On 3/4/25 at 11:09 AM Staff P, CNA stated usually there should be a lock on the cabinet where all the supplies and chemicals are kept. Staff P, CNA acknowledged the shower room door was open currently, no staff was present, and it was not supposed to be. Staff P, CNA stated the cabinet used to have a lock. Staff P, CNA stated it had been a while since the cabinet had had a lock on it. Staff P, CNA stated there are residents that wander. Staff P, CNA stated Resident #43 would go in the shower room and look around in the shower room. Staff P, CNA stated she had found Resident #43 in the bathroom unattended. Staff P, CNA stated she had caught Resident #43 a time or 2 when she wasn't in showers. Staff P, CNA stated she occasionally forgot to shut the shower room door. Observation on 3/4/25 at 11:10 AM on 100 hall of bathroom door open. The DON entered the shower room on 3/4/25 at 11:13 AM. On 3/4/25 at 11:16 AM no staff returned to the bathroom Staff P, CNA shut the door once we exited the room. On 3/4/25 11:39 AM the DON stated the shower room door should be shut all the time. The DON stated the shower room door should be shut if there was no staff or residents in the shower room. The DON stated the shower room door is locked so the chemicals are not required to be locked up in the room because the door is locked. The DON stated she had never witnessed and staff have not brought to her attention that residents were in the shower room unattended. The DON stated on the 100 and 300 hall there are residents that wander. The DON stated she did not think there was a person on the 100 and 300 hallways that truly wandered. The DON stated the residents all have a purpose. The DON stated Resident #43 does not wander. The DON stated she did not remember if Resident #43 was in the shower room by herself and did not remember if the shower aide was in there with Resident #43. The DON stated Resident #43's hair rollers were put in the bathroom to prompt her to ask for assistance with them. The DON stated she did have a conversation with the staff. The DON stated the conversation was about Resident #43 entering the shower room. Stated had a conversation with Staff O about Resident #43 entering the shower room. The DON stated she told Staff O Don't leave the door open. The DON stated it was just an in the moment verbal conversation. The DON stated she was not sure but she may have followed Resident #43 into the shower room. The DON stated Resident #34 complains about the hair rollers being in the bathroom. Stated Resident #43 used a hair dryer with rollers and that is not safe. The DON stated it had not been brought to her attention that the shower room door does not latch appropriately. The DON stated the chemicals are a danger and water on the floor could cause a resident to fall. The DON stated she did not think Resident #43 would ingest something but you just never know. On 3/4/25 at 11:52 AM the Administrator stated she had not been informed that the shower room door did not latch appropriately. Review of policy titled Hazardous Areas, Devices, and Equipment revised 7/17 documented all hazardous areas, devices and equipment in the facility would be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. A hazard was defined as anything in the environment that had the potential to cause injury or illness such as open areas or items that should be locked when not in use. Any element of the resident environment that had the potential to cause injury and that is accessible to a vulnerable resident was considered hazardous. The safety committee would recommend measures to ensure that vulnerable residents cannot access hazardous areas in the facility (locks, alarms, supervision, etc.). The safety committee will periodically check for the implementation and integrity of measures intended to prevent residents from accessing hazardous areas. 47582 2. a. Observation on 3/4/25 at 9:24 am revealed a door to the shower room on hallway 400 was wide open and no staff present in the room. The shower room contained a bottle labeled concentrated Clorox and several shaving razors and 2 sharp containers. Other items noted in the room were gallon-size lotion containers. 2 cupboards storing various mentioned items were unlocked. One of the cupboards contained a key inside of it. b. During an interview on 3/04/25 at 9:55 am Staff S, CNA revealed Resident #16 resided on hallway 400 and had a history of wandering. She further stated if the door to the shower room was left open she could see Resident #16 going in there unsupervised due to a history of wandering behavior. The Quarterly MDS dated [DATE] for Resident #16 documented a BIMS of 06 which indicated severe cognitive impairment and a diagnosis of Alzheimer's disease. The MDS indicated Resident #16 used a wandering/elopement alarm device. A review of the Care Plan for Resident #16 documented a focus area for elopement risk and wandering related to impaired safety awareness, and memory deficit. Interventions directed staff to distract the resident from wandering, to provide a safe environment and to apply a wander guard. c. The Quarterly MDS dated [DATE] for Resident #32 documented a BIMS of 03 which indicated severe cognitive impairment and a diagnosis of Alzheimer's disease. The MDS indicated Resident #32 used a wandering/elopement alarm device. A review of the Care Plan for Resident #32 documented a focus area for risk of elopement and wandering. Interventions directed staff to apply a wander guard. The Care Plan indicated Resident #32 resided on 400 hallway where the shower door was observed to be left open with no staff supervision for periods of time. d. During a continuous observation on 3/04/25 at 10:29 am through 11:02 am, a staff member observed utilizing the shower room to provide baths to 2 residents. Between each resident, the staff member left the shower room for several minutes at a time leaving the door wide open and unsupervised. During this observation, at 10:46 am facilities maintenance staff went inside the shower room to clean the fire sprinkler with an air compressor and after exiting, the door remained open. At 11:02 am the staff member who gave baths exited the room and pulled the door closed. 49990 3. The Significant Change MDS for Resident #39, dated 12/30/2025, documented the BIMS score as 07, which indicated severe cognitive impairment. It documented the following relevant diagnoses: Non-Alzheimer's dementia, Huntington's Disease, and anxiety disorder. It documented the resident demonstrates difficulty making himself understood and his needs known. It also documented the resident was dependent upon staff for eating, personal hygiene and cares, dressing, and that he requires substantial support to walk. It did not document his use of a wheelchair. The Mayo clinic defined Huntington's disease as a progressive inherited neurological condition which causes those with the disease to lose control over their bodies as nerve cells in their brains die. This results in chorea - involuntary, rapid, jerky movements that may impact the hands, face, and limbs. These conditions worsen over time. In a direct observation on 03/04/2025 at 12:55 PM, Resident #39 was seen being pushed by Staff P, CNA in a wheelchair while wearing gripper socks. It was noted at this time the wheelchair lacked foot pedals, and Resident #39's feet were dragging on the ground and frequently jerking in the path of the chair wheels. Resident #39 was placed at the table, and the locks on his wheelchair were not engaged. The resident experienced near constant episodes of chorea impacting his legs, causing him to rock back and forth in the wheelchair and moving him away from the table while Staff P, CNA assisted him in feeding. At 12:59 PM Staff P finally moved Resident #39 closer to the table and engaged the wheelchair brakes. A direct observation on 03/04/2025 at 01:17 PM revealed Staff P, CNA again pushing Resident #39 in a wheelchair without foot pedals. Again, Resident #39's feet were dragging and experiencing spastic movements that placed his feet and legs in the path of the wheelchair wheels. In an interview on 03/10/2025 at 03:46 PM with Staff I, CNA, she stated they are instructed to never push a resident in a wheelchair without foot pedals. She was aware of Resident #39 and acknowledged she had seen Resident #39 being pushed without pedals before, and acknowledged he often used his wheelchair to get around the facility without pedals. In an interview on 03/10/2025 at 03:50 PM with Staff J, CNA, she agreed they are instructed to not push residents in wheelchairs without foot pedals. She was unsure of the reason why, but believed it had to do with potential injuries. In an interview on 03/10/2025 at 03:23 PM with Staff H, LPN she stated you should never push a resident in a wheelchair without securing their feet in foot pedals. This is to avoid injury to the resident. In an interview on 03/06/2025 at 11:14 AM with the DON, she stated the expectation was for staff to use foot pedals when assisting a resident in a wheelchair to avoid injury.

Based on observation, staff interview, and policy review the facility failed to store food in accordance with professional standards by not labeling and dating open food items, by not completing chemical sanitization checks appropriately for a low temperature dish machine, completion of hand hygiene by staff, completion of hand hygiene with the residents, and by not sanitizing surfaces in the kitchen with the appropriate chemical concentration. The facility reported a census of 50 residents. Findings include: 1. A continuous observation in the kitchen on 3/3/25 from 9:40 AM - 10:15 AM revealed in the 2 door stand up refrigerator a box of orange juice, apple juice, and cranberry cocktail all open and undated. In the Walk in freezer a box of chicken cordon bleu open to the air with bag open and box with 2 hamburgers open to the air with bag open. On 3/3/25 at 9:50 AM Staff A, Certified Dietary Manager (CDM) stated the dish machine service provider tested the chemicals for the low temperature dish machine once a month. Staff A stated test strip results are not recorded. Staff A acknowledged the facility had a low temperature dish machine. Staff A stated the facility did not test the chlorine dish machine. Staff A asked Staff B, [NAME] if the tear strips labeled QT40 were the strips to utilize for dish machine check. Staff A completed 4 strip tests in a row. Staff acknowledged no change in the test strips that were utilized for all 4 tests. Staff A acknowledged the test strip should not be 0 and there should have been a change in color. Staff A completed a test of the 2 sanitization buckets with the same strips labeled QT40. Staff A acknowledged both sanitization buckets revealed 0 and no change in color of the strip. Staff B acknowledged she had just made the sanitizing buckets and she was going to clean the serving table off first and then check the chemical in the bucket. Staff A stated the other sanitizing bucket was recently filled as well. Staff A checked that bucket also read 0 with no color change. Staff A acknowledged the test strip should not be 0 and there should have been a color change. Staff A left the kitchen at 10:00 AM and returned at 10:10 AM. Staff A returned and stated the staff had tested with the wrong test strips for the dish machine. Staff A repeated the test to the sanitizing bucket and again revealed 0 no color change in the strip. Staff A stated there was a kink in the line that filled the sanitizing buckets and that was the reason for a result of 0. Staff B revealed meal tables had been cleaned for after breakfast. Staff A stated corporate expected dish machine temperatures to be sent but not chemical test strips. Staff A repeated the test to the low temperature dish machine with correct test strips for chlorine with a result of 200 Parts Per Million (PPM). Staff A acknowledged the box of chicken cordon bleu and box of hamburgers should have had the bags closed with the box closed. Staff A acknowledged the orange, apple, and cranberry cocktail juice boxes should have open dates. Staff A stated then the dish machine was supposed to be checked daily. On 3/3/25 at 10:00 PM Staff B, [NAME] acknowledged the facility did not keep track of the low temperature dish machines chemical strip test results. Staff B stated she utilized the tear strips for dish machine checks and sanitizing bucket checks. On 3/10/25 at 12:07 PM Staff D, Technician for dish machine manufacturer acknowledged that the facility was one that he serviced. Staff D acknowledged the facility had a low temperature dish machine. Staff D stated he recommended daily chemical tests, follow the facility's policy, or to follow the regulations for that state. Staff D stated he did not know how often it should be checked. Staff D stated the test strips for the low temperature dish machine should read between 50 and 110 PPM. Staff D stated he would recommend that the sanitation tubs were checked as well per the regulations or the facility's protocol. Staff D stated he brought strips down to the facility on [DATE] or 3/7/25. Staff D stated the tear strips are labeled QT40 for the sanitizing bucket. Staff D stated the other strip was for testing the low temperature dish machine and that test strip tested for chlorine. Staff D stated the stick strip was supposed to be used in the low temperature dish washer and the strip test that tears off labeled QT40 was for the sanitizing buckets. Review of policy revised 11/22 titled Azria Sanitization documented Low-Temperature Dishwasher (Chemical Sanitization): Wash temperature (minimum 120 F); final rinse with minimum 50 parts per million (ppm) hypochlorite (chlorine) on dish surface in final rinse; and the chemical solution is maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Service area wiping cloths are cleaned and dried or placed in a chemical sanitizing solution of appropriate concentration. Review of policy revised 10/17 titled Azria Food Receiving and Storage documented all foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 49990 2. During a direct observation on 03/04/2025 at 10:57 AM, Staff B, Cook, was observed cutting vegetables at a preparation table. During the preparation, Staff B left the vegetables and began pulling several pans out from another the station behind her. She touched several surfaces before returning to chop the vegetables without performing hand hygiene. A direct observation on 03/04/2025 at 11:13 AM revealed Staff B stirring a large container of chicken pot pie filling with a slotted spoon, placing the slotted spoon on a visibly soiled surface without a barrier, and then picking up and using the same spoon to stir another container of the food item. During this observation, Staff B switched tasks twice, leaving the containers unattended and touching numerous other surfaces outside of the preparation area. She returned to food preparation without performing hand hygiene. Staff B then used a flexible rubber spatula to scoop the food item into a container to puree, placed the spatula on the same soiled surface without a barrier. She used the soiled spatula to puree the main entree before switching to a new spatula, which she also placed on a soiled surface and used multiple times. A direct observation of the dining room service on 03/04/2025 at 12:48 PM revealed Staff V, Certified Medication Aide (CMA), enter the kitchen and without performing hand hygiene begin to assist two residents with eating. Staff V went back and forth between both residents, on two occasions touching her face, and did not perform hand hygiene. At 1:09 PM, after both residents had finished eating, Staff V sanitized her hands after assisting a resident with washing his face. In an interview on 03/10/2025 at 03:46 PM with Staff I, CNA, she stated you should wash your hands or use hand sanitizer before she assisted a resident with eating. She stated you should only assist one resident at a time, and if you touched anything outside of the eating utensils you should wash your hands before resuming them with eating assistance. In an interview on 03/10/2025 at 03:50 PM with Staff J, CNA, stated she is expected to clean her hands before entering the dining room, and then before assisting residents with their meal. If you help another client or touch anything other than the utensil you use to serve them food you must also wash or sanitize hands. In an interview on 03/10/2025 at 03:23 PM with Staff H, Licensed Practical Nurse (LPN), She stated the process for assisting residents with eating is to first sanitize your hands, then verify the diet. If you are assisting two residents you should sanitize or wash your hands in between each resident. In an interview on 03/06/2025 at 10:10 AM with the Certified Dietary Manager (CDM), she acknowledged more hand sanitation and a barrier was required during the kitchen preparations. She also stated anyone who assists a resident with eating is required to sanitize their hands before they begin, if they touch anything outside of the dining table, and if they switch to another resident. In an interview on 03/06/2025 at 11:14 PM with the Director of Nursing (DON) stated her expectation is for staff to sanitize or wash their hands before assisting a resident and again after they touch anything outside of the dining table.

Based on clinical record review, facility policy review, and staff interview, the facility failed to provide the resident with proper notice when the facility initiated a discharge before the resident had exhausted their Medicare Part A benefit days for 1 of 3 residents reviewed (Resident #20). The facility reported a census of 50. Findings include: Review of the clinical records for Resident #20 show the resident's Medicare Part A began on 12/26/2024 when he entered the facility. The same record indicated the resident was discharged from skilled services on 02/11/2025. An Advanced Beneficiary Notification (ABN) CMS-10055 was present in the file, but no record of the required Notice of Medicaid Non-Coverage (NOMNC) CMS-10123 was found. An email was sent on 03/05/2025 at 12:27 PM from the state surveyor to the facility Administrator requesting clarification and asking for a copy of the NOMNC if there was one available. An email was received on 03/05/2025 at 01:03 PM from the Facility Administrator clarifying that the staff member normally responsible for providing proper notice was not in the facility at the time this was required, and as a result the NOMNC had not been provided to Resident #20 or his representative. In an interview on 03/10/2025 at 03:52 PM the Facility Administrator acknowledged the CMS-10123/NOMNC was required to be given to the resident or his representative at least two calendar days before a resident is to be discharged from skilled services. She acknowledged this was not done. Review of a facility provided document titled Notice of Covered and Non-Covered Services, with a last revised date in March of 2021, documented the following: If changes in coverage are made to items and services covered by Medicare or Medicaid, residents are notified in writing as soon as possible.

Based on clinical record review, staff interview, employee file review, and policy review the facility failed to ensure two staff present while using a mechanical lift for a resident transfer, and staff failed to ensure sling straps removed from a mechanical lift when transferred a resident from the wheelchair to the bed for one of three residents reviewed for falls (Resident #3). The facility reported a census of 51 residents. Findings include: The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had diagnoses of cerebral palsy, deep vein thrombosis (DVT), and muscle weakness. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The MDS documented the resident required extensive assistance of two for bed mobility, and total dependence on two staff for transfers. The MDS indicated he had no falls. The MDS assessment dated [DATE] revealed the resident had a fall with an injury. The Care Plan revised 10/29/23 revealed the resident had a risk for falls related to cerebral palsy and impaired mobility. The care plan documented the resident had a fall out of bed on 10/19/23 and had an abrasion to the left forehead. A mechanical lift audit and sling inspections initiated 10/19/23 and added to the care plan. The care plan also directed staff to use two staff members for transfers with a mechanical lift. A fall risk evaluation dated 8/10/23 revealed a score of 9, which indicated the resident had a risk for falls. The Progress Notes documented as follows: a. On 10/19/23 at 8:02 PM, Staff M, Certified Nursing Assistant (CNA), called Staff O, Licensed Practical Nurse (LPN), and reported there had been a fall. Staff O was in another room on the 300 hall, and Staff M was in Resident #3's room on the 100 hall. Staff O found the resident on the floor, lying on his back with a cushion behind his head. The bed was in high position. Staff M stated he had used a Hoyer lift to transfer the resident to the bed. He tried to pull the lift away from the bed and there was resistance. The CNA was looking at the wheels as he continued to tug at the handles on the lift. Resistance then stopped and when the CNA turned to the resident, the resident was on the floor. Resident #3 stated he did not hurt anywhere. The resident was able to move all extremities freely. Five minutes later, the CNA reported the resident had a bruise at his left forehead. b. On 10/20/23 at 2:51 PM, no noted additional injuries post fall. Tylenol given as needed for general discomfort/soreness. Small hematoma (bruise) above left eye. Neuro checks within normal parameters. A skin evaluation dated 10/25/23 revealed the abrasion to the resident's forehead healed. An Incident Report dated 10/19/23 at 8:02 PM, revealed Staff M, CNA, told Staff O he used a mechanical lift per plan of care to move Resident #3 from the wheelchair to the bed. He placed the resident into bed and pulled the lift machine away from the bed. There was some resistance. The CNA checked to see if the wheels (on the lift) were stuck on something. When he turned to the resident, the resident was on the floor next to his bed. The chain on the lift next to the resident's left shoulder was still hooked up to the sling under the resident. The resident was unable to say accurately what happened. The resident denied injuries or pain, and able to move all extremities. Resident lying on the floor on his back with a cushion under his head. Vital signs included: blood pressure 188/95, pulse 70, respirations 24, pulse oximetry 91 percent on room air. Staff assisted the resident into bed. Five minutes later, Staff M alerted Staff O the resident had a swollen area to his left forehead. The area measured 2.5 x 2 inches. Neuro checks within normal limits. Resident #3 alert and answered questions appropriately except he stated the President (of the United States) was Bush. During an interview on 5/7/24 at 11:50 AM, Staff N, CNA, reported another staff person told her what residents needed for cares or she looked at the communication book to know how a resident transferred. During an interview 5/8/24 at 1:22 PM Staff M, CNA, reported he had worked at the facility 2 years. Resident #3 used a mechanical lift for transfers. Staff M reported he asked the resident what they needed done when he provided cares. On the day Resident #3 had a fall, Staff M reported he transferred the resident from the wheelchair to his bed. He unhooked the sling straps from the lift. He thought the straps were all unhooked but he apparently didn't push one strap off far enough. He was told after the incident to make sure he always had two people whenever he used a mechanical lift for transfers. The strap on the upper left shoulder was caught. He thought it was the wheels on the lift that were stuck or not working. When he pulled the lift back further, it finally came loose. When he looked down, he saw the resident on the floor. The resident ended up getting a bruise on his forehead. Staff M reported the nurse told him from that day forward to make sure he had a second person. He needed a spotter and never to put the resident in bed unless he had a second person. Staff M reported people don't show up for work or called in to work, and often times worked short. Staff M reported he received 1-2 weeks of orientation but also had experience prior to working at this facility. During an interview 5/9/24 at 10:45 AM, the Director of Nursing (DON) reported she didn't know if Staff M had an orientation checklist or if he completed competency for the mechanical lift during orientation. The ADON (Assistant Director of Nursing) did audits and new staff orientation related to infection control. The staffing coordinator may also do some competency checkoffs. The DON reported whenever a resident had a fall she did a root cause analysis to figure out what happened. When Resident #3 had a fall from the mechanical lift, the CNA thought he had the straps disconnected. It was the perfect storm with the roommate talking and caused distraction. She provided education, and went over (mechanical lift) competency after the incident with Staff M. During an interview 5/9/24 at 11:30 AM, the Staffing Coordinator reported she doesn't do anything with staff orientation. She completed lift audits until the ADON took over this task two years ago. The Staffing Coordinator confirmed she had not completed any audit or competency for use of mechanical lift devices within the past year. During an interview 5/9/24 at 11:37 AM, the ADON reported she went over donning/doffing PPE (personal protective equipment), hand hygiene, and employee health screening information with new employees. The ADON stated she doesn't go over use of mechanical lift devices or complete staff competency checklist with the CNA's. Staff M's employee file revealed a disciplinary action record dated 10/20/23 revealed: On 10/19/23, Resident #3 fell out of bed and was pulled to the floor due to the mechanical lift sling remained attached. CNA operated the mechanical lift independently. The corrective action included review of lift policy, as well as all lifts required two persons for transfers. Lift policy and education administered prior to Staff M returning to work. Employee Statement included the following: The resident's roommate was talking, and caused distraction. Staff M also thought the anti-rollbacks (on the mechanical lift) caused resistance. Staff M thought the sling was detached from the lift. Other staff was assisting another resident. It was an accident. Employee File reviewed on 5/8/24 revealed Staff M was hired on 2/1/22. The employee file/record lacked an orientation checklist or mechanical lift competency signed off by facility staff to deem the employee competent in use of mechanical lift. The employee file included a written statement by Staff M regarding fall 10/19/23 at 8 PM on Resident #3. Resident #3 was on the bed, Staff M believed the sling was disconnected from all 4 points of the lift, so the mechanical lift pulled away from bed. The mechanical lift had springy resistance to going further after lift about 3 feet away from the bed. CNA checked around the wheels as he continued to tug on the handles (on the lift). Resistance then stopped but when turned to remove the mechanical lift sling (under the resident), Resident #3 was on the floor next to the bed. The left shoulder strap was still connected to the lift. Nurse called and a cushion placed under the resident's head. The facility's policy for Using a Mechanical Lift Machine revealed at least two nursing assistants needed to safely move a resident with a mechanical lift. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. The procedural steps included: a. Slowly lower the resident to the receiving surface when the transfer destination is reached. b. Detach the sling from the lift once the resident's weight is released. c. Carefully remove the sling from under the resident. Be mindful of the resident's position and balance. A competency assessment for Using a Mechanical Lifting Machine revealed at least two nursing assistance needed to safely move a resident with a mechanical lift. A mechanical lift may be used when transferred a resident from the chair to bed. The procedural steps included: a. Attach sling straps to the sling bar b. Ensure sling attached to the clips and it is properly balanced c, Lift the resident 2 inches from the surface to check stability of attachments, sling and weight distribution. d. Slowly lift the resident. Only lift as high as necessary to complete the transfer. e. Slowly lower the resident to the receiving surface. f. Once the resident's weight is released, detach the sling from the lift. g. Carefully remove the sling from under the resident. Be mindful of the resident's position, balance and skin.

Based on interview and record review, the facility failed to implement CMS and CDC recommended infection control practices in order to control and prevent the potential spread of COVID-19 between residents and staff. The facility allowed staff to work and provide care to residents after they reported signs and symptoms of COVID-19 and subsequently tested positive for COVID-19. Additionally, the facility failed to ensure all staff were thoroughly screened before beginning their scheduled shifts, failed to ensure staff adhered to facility policy which prohibited staff from screening themselves, and failed to ensure all staff completed education regarding proper screening for COVID-19. These findings constituted an Immediate Jeopardy to resident health and safety. The facility reported a census of 43 residents. Findings Include: Record review of facility document titled COVID-19 Guideline, dated 9/9/20, documented the purpose of the guideline is to provide clarification for steps the facility will take regarding the Novel Coronavirus (COVID-19), minimize exposures to respiratory pathogens, and promptly identify residents with clinical features and risk for COVID-19. The objective is to decrease the prevalence and incidence of a resident coming into contact with anyone presenting with cold-like signs and symptoms as well as anyone who has traveled outside the country. In addition, the policy directed team members who become symptomatic during work hours, are required to immediately leave the facility and included a symptom-based strategy for determining when Health Care Providers (HCP) can return to work. HCP with mild to moderate illness who are not severely immunocompromised: At least 10 days have passed since symptoms first appeared and At least 24 hours have passed since last fever without the use of fever-reducing medications. Symptoms (e.g., cough, shortness of breath) have improved. A facility document titled Screening In/Out, date unreadable, documented: Everyone will be trained on screening in/out. An attached employee list for staff to sign related to education demonstrated 37 of 79 staff signed to indicate they were trained on screening in/out. The education directed: Everyone must push the doorbell and wait for someone to come to the door to screen you in the service hall. Once you have been screened in and the person screening you in had completed the screening in form and initialed it, you may enter the facility as usual. All the questions on the screening in form must be asked and answered. If someone answers yes to a question, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), or the MDS Coordinator must get involved to see if the person can enter the building. The person doing the screening in must initial to the right of the line info is entered on. In an interview on 1/7/21 at 7:35 AM, Certified Nursing Assistant, (CNA) Staff A reported she had tested positive for Covid-19 on 12/31/20 and experienced mild symptoms at that time. When asked if she had been restricted to any particular areas of the facility or is had any interaction with the only resident that still tested negative for Covid-19, she answered she had not been restricted from entering any areas and affirmed she had assisted Staff E to care for the only resident in the facility with a negative COVID-19 status. On 1/7/21 at 7:40 AM Staff AA, CNA reported Staff A and Staff E gave the resident with a negative COVID-19 test a bed bath. Staff AA reported she had tested positive for Covid-19 on 12/28/20 and she continued to work with a runny nose and headache. She added she had been told she could only work in the front hall with residents that had a Covid-19 positive status. In an interview on 1/7/21 at 2:20 PM, the DON was asked why Staff A provided care to the only resident that had tested negative for COVID-19 in the facility, the DON reported all of the staff that are here have tested positive for COVID-19. When the DON was informed that several staff members had been beyond the 10 day recovery period, the DON reported she would look into why that situation had occurred. In an interview with the DON on 1/7/21 at 2:30 PM, she said the facility had initially planned to put any residents with positive COVID-19 tests in the 500 hallway because it had 7 rooms (14 beds). However, so many residents tested positive on 12/23/20 that they decided to move them into the 100 hallway where there are 14 rooms (24 beds). A review of the Covid testing results and the electronic record census page revealed the following room changes: a. Resident #14 tested positive on 12/23/20 and moved to room [ROOM NUMBER]. The facility moved the resident back to room [ROOM NUMBER] after 8 days. b. Resident #15 tested positive on 12/23/20 and moved to room [ROOM NUMBER]. The facility moved the resident back to 405 after only 3 days. c. Resident #16 tested positive on 12/23/20 and moved to room [ROOM NUMBER]. The facility moved the resident back to room [ROOM NUMBER] after 5 days. d. Resident #7 tested positive on 12/23/20 and moved to room [ROOM NUMBER]. The facility moved the resident back to room [ROOM NUMBER] after 5 days. e. Resident #17 tested positive on 12/23/20 and stayed in room [ROOM NUMBER]. f. Resident #13 tested positive on 12/24/20 and stayed in room [ROOM NUMBER]. g. Resident #18 tested positive on 12/27/20 and stayed in room [ROOM NUMBER]. h. Resident #19 tested positive on 12/27/20 and stayed in room [ROOM NUMBER]. i. Resident #21 tested positive on 12/31/20 and stayed in room [ROOM NUMBER]. j. Resident #20 tested positive on 12/31. The resident stayed in room [ROOM NUMBER] and was in the 400 hallway with other residents who had not passed their 10 day recovery period. Resident #20 passed away from Covid-19 on 1/4/21. In an interview on 1/14/21 at 10:44 AM, Staff T, Business Office Manager (BOM) stated that she had been responsible for documenting the room changes during the Covid-19 outbreak. She said she entered the room change in the electronic record as soon as she either heard from the nurses or from the Assistant Director of Nursing (ADON). She added she also walked up and down the hallway at the end of the day to see if she had missed any changes and had several checks in place to keep on top of it. She explained that with the first positive residents, they had initially planned to put positive residents in the 500 hallway but because they had so many right away they chose the 100 hallway and kept the double doors closed. When asked if some residents had been moved to the 100 hallway when they tested positive and then back to the 400 hall within 3-5 days, she replied she thought that could be accurate. On 1/7/21 at 9:00 AM, Staff C, Certified Nursing Assistant (CNA), reported she screened herself and added that leadership checked the log daily. She also reported she had tested positive for COVID-19 and worked while she had symptoms: a headache and shortness of breath. In an interview on 1/7/21, the Director of Nursing (DON) stated COVID-19 positive staff could work if they were asymptomatic. She added that if staff circle yes on the screening log, they should notify the Infection Preventionist (IP) who would then explore whether or not the symptoms were new to them. The DON said staff are allowed to screen themselves at the start of their shift and should notify leadership with any issues. During an interview on 1/7/21 at 1:46 pm, Staff C stated nobody had told her to call in prior to work if symptomatic. She said a long time ago, the facility told staff to stay home, but most recently they instructed that staff could work with symptoms. Staff C reported she worked with symptoms because she did not want to let down the facility. During an interview on 1/7/21 at 2:11 pm, Staff B, Licensed Practical Nurse (LPN), reported she knew of staff that worked that had not only tested positive for COVID-19, but had also had symptoms. During an interview on 1/11/21 at 10:50 am, the Assistant Director of Nursing (ADON) and IP reported if staff circle yes on the screening log she spoke with them about the symptom, although she did not review the screening log daily or keep a log of staff signs/symptoms. She reported the Business Office Manager (BOM) reviewed the logs daily prior to scanning them to the corporate office. In an interview on 1/12/21 at 3:39 pm, Staff S, MDS Coordinator stated staff with symptoms of COVID-19 should not work, and added staff should not screen or temperature check themselves in prior to start of shift. On 1/12/21 at 3:51 pm, Staff T, BOM reported she screens herself in daily and also gathers screening logs daily to scan to the corporate office. She stated if staff circles yes she informs the ADON or DON, but does not keep a log. She said staff should not work if symptomatic of COVID-19 and added that facility nurses would not work if they were ill. During an interview on 1/13/21 at 9 am, with the Administrator, she stated staff were adults and they do not have enough staff to be at the door at all times, so they may screen themselves prior to start of the shift. The Administrator stated if staff have a symptom they need to have a nurse check them prior to working, and added that COVID-19 positive staff are separated from negative staff and if staff have symptoms they are to go home. The Administrator said she shares updates with staff verbally and does not talk to everyone. She said the IP follows up with staff if they circle yes on the Screening logs and Staff Q, corporate nurse, also receives daily Screening logs. During an interview on 1/13/21 at 11:08 am, the DON verified staff screen themselves in prior to start of shift. The DON stated when she was out of work status due to illness in December she realized a lot of things got missed, but did not know any staff that worked while ill. She stated she worked when ill with vomiting, diarrhea, headache, and shortness of breath on 1/3/21, 1/5/21, 1/6/21, and 1/7/21. She reported she was evaluated at Urgent Care and they told her they would still call her symptoms COVID, as she had tested positive on 12/11/20. The DON said Staff Q cleared her to continue working. During an interview on 1/13/21 at 1:09 pm, Staff Q, she reported the facility had staff stationed by the service entrance to screen staff into work, and they should notify nursing leadership if any staff circle yes. She stated staff can work if asymptomatic, but that did not mean the signs/symptoms would be completely gone, but they should be improved. Staff Q added they would send staff home with nausea /vomiting. Staff Q clarified she allowed the DON to work while ill because she had [MEDICAL CONDITION] and had started antibiotic therapy, and she allowed Staff C to work with headaches because she had a history of [REDACTED]. On 1/13/21 at 2:30 pm, Staff E, Shower Aide, reported she tested COVID-19 positive on 12/23/20 and had 12/24/20 off and returned on 12/25/20 because the facility said she could come back to work. She stated she had a headache on 12/26/20 and again did not work, but returned to work on 12/27 as she received a text that indicated the facility really needed her. She reported she had a headache, sore throat, loss of smell, and a backache while she worked. During an interview on 1/13/21 at 3 pm with Staff R, Scheduler, she stated staff that test COVID-19 positive must be symptom free for 10 days, or 14 days if they had symptoms, before they can work. She stated positive staff were approved by Staff Q, who received approval from Public Health before they can work again. Staff R said she did not maintain a log of positive staff. The facility form titled, Prevent COVID-19 Essential Visitor/Essential Vendor Screening log revealed prior to Entry, Staff C (positive COVID-19 test 12/28/20) recorded the following symptoms at start of her shift: a. On 12/30/20-headache and, new loss of taste and smell. b. On 1/3/21- cough or new shortness of breath, muscle pain, headache, sore throat, and new loss of taste and smell. c. On- 1/5/21- cough or new shortness of breath, muscle pain, headache, and new loss of taste or smell. She also documented she also had a COVID-19 exposure. d. On 1/6/21-cough or new shortness of breath, muscle pain, headache, new loss of taste or smell, and COVID-19 exposure. e. On 1/7/21-muscle pain, headache, and new loss of taste of smell. The Time Card Report for Staff C documented she worked the following dates after she documented in the screening log she had symptoms: 1/3/21, 1/5/21. The Time Card Report for Staff E, documented she worked on the following dates she reported she had symptoms from a positive COVID-19 test on 12/23/20: 12/27/20, 12/28/20, 12/29/20, and 12/31/20. The Prevent COVID-19 Essential Visitor/Essential Vendor Screening log showed that prior to entry, Staff K, Certified Nursing Assistant (CNA), documented symptoms (tested COVID-19 positive on 12/29/20) screened in with the following symptoms at start of her shift: a, On 12/29/20-cough or new shortness of breath, vomiting or diarrhea, headache, muscle ache, and sore throat. b. On 1/3/21-cough or new shortness of breath, vomiting and/or diarrhea, headache, and new loss of taste or smell. c. On 1/5/21- cough or new shortness of breath, headache, new loss of taste or smell. The Time Card Report for NA 2 documented she worked on the following dates when she documented symptoms: 1/3/21, 1/5/21. The Prevent COVID-19 Essential Visitor/Essential Vendor Screening log revealed Staff L, CNA documented the following symptoms at start of her shift on 1/4/21-headache, new loss of taste or smell, and COVID exposure. The Time Card Report for Staff L documented she worked on the following date: 1/4/21. The Prevent COVID-19 Essential Visitor/Essential Vendor Screening log revealed prior to entry, the DON documented the following symptoms at start of her shift: a. On 12/28/20- cough/new shortness of breath, vomiting/diarrhea, headache, and exposure to COVID b. On 1/3/21-vomiting/diarrhea, headache, exposure to COVID-19. c. On 1/5/21-cough/new shortness of breath, vomiting/diarrhea, headache, and exposure to COVID. d. On 1/6/21-cough, vomiting/diarrhea, and headache. e. On 1/7/21-cough, vomiting/diarrhea, headache, and exposure to COVID. The facility was notified of the Immediate Jeopardy on 1/14/21. The IJ was removed on 1/14/21 when the facility submitted an acceptable plan of correction. The scope and severity of the deficiency was lowered to an E after the IJ removal. The Plan of Correction the facility provided outlined the following actions: * The only resident without a positive COVID-19 test was assessed for COVID-19 and had no symptoms. The resident was also [MEDICATION NAME] tested again and remained negative for COVID-19. The facility identified an immediate need to implement a comprehensive COVID-19 infection control program to ensure the facility follows the CDC guidelines for mitigating staff shortages and develop a plan to care for negative residents. 1. Review and Revise Facility policies to meet the Strategies to Mitigate Healthcare Personnel Staffing Shortages as outlined by the CDC website including Crisis strategies. 2. Re-educate leadership staff regarding mitigation strategies 3. Re-educate facility staff with regard to the plan to care for the resident that has tested negative thus far. a. Daily assignments sheets will have staff denoted that MAY care for the negative resident which are negative staff or recovered staff within the 90 days post positive test. b. A visual reminder for staff permitted to care for the negative resident will be placed outside of the resident's room. 4. Re-educate staff on accurate reporting of any signs and symptoms on the employee screening log. 5. Ways of communication initiated on 1/14/21 - Survey Monkey for Winterset staff and Electronic Medical Record Secure for direct care providers.

Based on observation, interview and record review, the facility failed to adequately provide wound care to prevent worsening of ulcers for 4 of 5 residents reviewed (Residents #10, #12, #11 and #24.) The facility failed to implement a consistent system for communication between staff for monitoring wounds for residents of residents that were at risk or had developed ulcers and there were gaps in the record that failed to contain required information related to wound measurements, assessments, and descriptions. This situation constituted an Immediate Jeopardy to resident health and safety. The facility reported a census of 43 residents. The Minimum Data Set (MDS) Assessment tool identified the following descriptions of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. 1) The MDS staff completed upon Resident #10's admission on 10/1/20 revealed the resident scored 15 out of a possible 15 points on the Brief Interview for Mental Status (BIMS) test, which meant the resident demonstrated intact cognitive abilities The MDS documented the resident required extensive assist of 2 staff for bed mobility, transfers, ambulation (walking), dressing, and toilet use. The care plan dated 11/30/20 documented Resident #10 experienced physical limitations related to [DIAGNOSES REDACTED] and [MEDICAL CONDITION] femur, was at risk for falls, and had a Stage 2 pressure area on the right heel and left ankle. The care plan directed staff to administer treatments as ordered and monitor for effectiveness. A nursing note dated 11/30/20 at 2:39 PM, revealed Staff Y, Registered Nurse (RN) sent Resident #10 to the emergency room for an infected wound on the left ankle that measured 3 centimeters (cm) x 3 cm. The nurse documented the wound bed as necrotic with a hard scab and described the wound as red, warm to touch, with drainage that consisted of blood and pus. In an interview on 1/26/20 at 8:30 AM, the Physician's Assistant (PA) that saw the resident in the emergency room stated she had been very familiar with the resident because she had seen him in the clinic a couple of weeks earlier, and expressed surprise regarding his significant decline in health. She reported she called the nursing home to discuss her concerns about the wound on his left foot. She added staff said the resident had some areas on his left foot that were treated previously, but those areas had healed. Staff reported the nursing home had no current orders for a wound treatment for [REDACTED]. An emergency room note dated 11/30/20 at 1:19 PM documented the resident had a significant ulcer to left lateral foot; the PA suspected osteo[DIAGNOSES REDACTED], which an X-ray later confirmed. The note documented that blood cultures and lactic acid levels were concerning and the doctor made the decision to transfer the resident to a larger hospital due to the resident's unstable medical condition and the need for podiatry and infectious disease experts. According to a wound care note from the larger hospital dated December 11 at 2:20 PM, the resident had a partial 5th ray resection of the left foot and sharp excisional debridement of full-thickness skin, subcutaneous tissue, deep fascia, and left lateral malleolus ulcer. A review of the facility nursing notes and skin assessments for Resident #10 from 10/5/20 until his hospitalization on [DATE] revealed the following: a. On 10/15/20, skin assessments identified an area on the resident's left lower leg that measured 5.9 centimeters (cm) x 3.0 cm. b. On 10/15/20, the area on the left ankle measured 2.3 cm x 1.4 cm. c. On 10/25/20 at 12:44 AM, documentation of a head-to-toe assessment revealed the resident continued to have an area to back of the left calf, outer left ankle, and right heel with no measurements identified. d. On 10/25/20 at 5:44 PM, staff noted the resident experienced a new onset of confusion. e. On 10/28/20, the left lower leg ulcer measured 3 cm x 1.9 cm with no exudate or odor and the surrounding tissue remained normal. f. On 10/28/2, the left ankle ulcer measured 2.3 cm x 1.4 cm. g. On 11/4/20, Staff H, LPN sent a fax to the physician that documented the blister/open area on the resident's left heel and left calf healed/resolved. May we discontinue the [MEDICATION NAME] order? The area on the resident's right heel remains but is dry; continue with [MEDICATION NAME] until healed. The physician signed the fax on 11/4/20. h. On 11/4/20, a skin assessment to left lower leg documented the area had resolved. i. On 11/4/20, a skin assessment documented by Assistant Director of Nursing (ADON) revealed a left ankle area that measured 2.3 cm x 1.4 cm with no exudate, no odor, and the surrounding skin color remained normal. j. On 11/12/20 5:48 PM, staff documented the resident as confused and not wanting to eat or take medications. k. On 11/11/20, the left ankle measured 1.1 cm x 0.9 cm with no exudate, no odor, and normal skin color. l. On 11/18/20 5:15 PM, the left ankle measured 1.1 cm x 0.8 cm no odor, scant exudate, scabbed and dry. Normal skin color. m. On 11/25/20 at 3:29 PM, the left outer ankle again measured 1.1 x 0.8 cm area and remained scabbed with no noted exudate or odor. The area was left open to air. n. On 11/30/20 at 2:39 PM, the nurse transferred Resident #10 was transferred to the emergency room for an infected wound on the left ankle that measured 3 centimeters (cm) x 3 cm. The nurse described the area as warm to touch, [DIAGNOSES REDACTED]tous, with discharge that contained blood and pus and described the wound bed as necrotic with a hard scab. The electronic record contained an order that had been entered on 11/4/20 at 11:46 PM which directed staff to discontinue treatment to the left foot and continue [MEDICATION NAME] treatment to the right heel. In an interview on 1/26/21 at 1:30 p.m., Staff H, LPN reported before she contacted the physician to request the discontinuation of the treatment to the resident's left leg, she had discussed it with the Assistant Director of Nursing (ADON). On 2/4/21 at 8:30 a.m., the ADON stated she could not recall the (above) conversation. In an interview on 1/26/21 at 9:20 AM, Staff Y, RN reported she worked at the nursing home on an as-needed basis, and found Resident #10's cognition had declined since she had worked at the facility approximately a month before. She stated she worked two days in a row (11/29 and 11/30), and on the first day she applied the treatment to the resident's right heel as ordered and found the area almost completely healed with no open areas. She added the protective boot he wore contained a great deal of blood she had thought about that until the next day when she worked, so she checked his left foot. She found it inflamed with a black and swollen wound on the lateral (side) aspect and then called the doctor to request an order to send him to the hospital. She said she looked through the nursing documentation and orders and could not find any recent documentation of a wound on the left foot or any treatments ordered. Staff Y reported the emergency room nurses had called the facility several times after she transferred the resident with questions and seemed to be very irritated that there weren't more answers to explain the condition of the wound and his decline in health. Staff Y added she had experience with patients that became septic and it concerned her when Resident #10 displayed the same type of symptoms. According to the X-ray report from the emergency department on 11/30/20 at 2:17 PM, the resident had soft tissue swelling surrounding the 5th digit (toe) and distal 5th metatarsal (bones in the foot that connect with the toes) with erosive changes and osseous (bone) destruction involving the distal (end) of the fifth metatarsal. The area showed changes that involved the base of the proximal phalanx (toe bone closest to the foot) as well as at the proximal interphalangeal joint (closest toe joint to the foot) of the fifth digit with surrounding soft tissue swelling. The X-ray showed the resident had surgical screws present within the proximal first metatarsal as well as the bones of the hind foot. According to a (WOCN) Wound Ostomy Continence Nurse note from the hospital dated 12/1/20 at 10:10 AM, the X-ray of the left foot showed soft tissue swelling and 5th digit osseous erosion. Staff reported when given intravenous (IV) antibiotics, the resident showed increased confusion (not oriented to time, situation or location) compared to his baseline level of orientation upon arrival. The report documented a small necrotic ulcer of the distal left 5th digit and a lateral (side of) malleolus ulcer with purulent drainage and surrounding swelling. The malleolus is a bony projection with a shape likened to a hammer head, especially each of those on either side of the ankle. The note documented the surgeon planned to surgically remove the fifth metatarsal of the left foot. The resident had [DIAGNOSES REDACTED]. The operative report dated 12/8/20 at 7:29 AM, revealed the hospital put the resident's surgery on hold, pending medical stability of the resident as he received IV antibiotics. On 12/7/21, the surgeon amputated the resident's 5th metatarsal. The discharge plan dated 12/24/20 documented [DIAGNOSES REDACTED]. On 1/26/21 at 1:30, Staff H, Licensed Practical Nurse (LPN) reported at the beginning of November the computer showed a treatment for [REDACTED]. She said she reported her findings to the Assistant Director of Nursing (ADON) that there wasn't anything there and the ADON told her it was okay to ask for a discontinuation of the treatment at that time. The LPN said she sent a fax to the doctor with a request to discontinue treatments to the left foot. Staff H reported the nurses are discouraged from sending residents to the hospital and instructed to call the Director of Nursing first. When asked in an interview on 2/4/21 at 8:30 AM, why staff continued to document measurements on left foot areas after they were documented as healed, the ADON reported she sometimes continued to measure areas to try to see if there could be an infection under the surface she will continue to take measurements just to make sure there isn't some type of infection under the surface. The ADON could not recall a conversation with Staff H regarding an order change request on 11/4 to discontinue treatments to the left leg when asked during the interview. On 1/26/21 at 10:50 AM, Staff E reported she provided the residents baths and had worked with Resident #10 just a couple of weeks before he went to the hospital. She reported she told the nurses on at least 2 occasions the resident had wounds on the left ankle that were bleeding and getting worse. She recalled the resident had redness on the outer lateral ankle and the bottom of the left heel. She added the resident had displayed increased confusion and slept more often just prior to his hospitalization . On 1/26/21 at 1:07 PM, Staff B, LPN reported she thought the ADON or the Minimum Data Set (MDS) nurse completed wound assessments, but reported the areas were not measured consistently. In an interview on 1/26/21 at 11:45 AM Staff M, RN reported she thought either the ADON or the MDS nurse monitored wounds and added she had not worked with Resident #10 recently. In an interview on 1/26/21 at 10:50 AM Certified Nursing Assistant (CNA) Staff E said that she provided baths twice a week to the resident and she had worked with Resident #10 a couple of weeks before he went to the hospital. She said that on at least two occasions, she told the nurses the resident had bleeding wounds on his left ankle that had worsened. She did not know whether or not the nurses had checked the wounds after she told them about the areas. In an interview on 1/26/20 at 2:39 PM, the Physician Assistant that cared for Resident #10 in the emergency room said she would expect treatment orders for areas staff continue to measure. The facility was notified of the Immediate Jeopardy on 1/27/21. The IJ was removed on 1/28/21 when the facility submitted an acceptable plan of correction. The scope and severity of the deficiency was lowered to a D after the IJ removal. The Plan of Correction the facility provided identified the following: 1. Immediate Corrective Action for those affected by the deficient practice: Skin sweep of all current residents will be completed and documented by nursing by 1/28/21 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: a. All current residents Braden risk assessments will be reviewed by DON or designee by 1/28/21. If the Braden risk assessment is greater than 90 days old a new assessment will be completed. b. All current wounds will be reviewed by the IDT for interventions, effectiveness of interventions, and care plans updated by 1/28/21. c. Care plans for all residents identified as at risk for per the Braden will have their care plan reviewed and updated as needed by IDT by 1/28/21 d. All new admissions in the last 72 hours will be reviewed to ensure a risk assessment, care plan and interventions are in place as needed by 1/28/21. 3. Measures put in to place/systematic changes to ensure the deficient practice does not recur: a. Interdisciplinary Team (IDT) will be re-educated on Skin and Wound management policy by RNC on 1/27/21 and 1/28/21. b. Licensed Nurses will be re-educated on Skin and Wound assessment, document and communication by 1/28/21 or prior to next shift by Nursing Leadership. c. Delegation of duties for skin/wound alteration evaluation re-assigned effective 1/27/21 to DON. 4. Plan to monitor performance to ensure solutions are sustained: a. Administrator or designee will audit to ensure Skin interventions are in place 3 times a week for 2 weeks the weekly for 6 weeks with results taken to Quality Assurance Performance Improvement (QAPI) meeting. b. DON or designee will audit all wounds/skin alteration for weekly skin checks, skin alteration evaluations completed weekly with measurements, interventions, notification and care plan; 3 times a week for 2 weeks; weekly for 2 weeks then weekly for 4 weeks with results taken to QAPI. 3. Nurse Consultant will receive weekly skin alteration/wound measurements weekly from the DON or designee. 2) The MDS dated [DATE] documented Resident #11 had [DIAGNOSES REDACTED]. The MDS revealed the resident scored 15 of 15 possible points on the BIMS test, which showed the resident's cognitive abilities remained intact. The MDS also documented Resident #10 required extensive assist of one staff for ambulation, dressing, and hygiene, and extensive assist of 2 staff for transfers, toilet use, and bed mobility. The care plan dated 8/14/20 documented the resident as at risk for impaired skin integrity related to heart failure. The care plan directed staff to provide skin assessments per protocol with documentation of measurement of each area of skin breakdown, width, length, depth and type of tissue and exudate, and any other notable changes or observations. In an interview on 1/26/21 at 10:50 AM, Certified Nursing Assistance (CNA) Staff E said that she had some concerns about the wounds on Resident #11's lower legs. She reported she had mentioned her concerns to several of the nurses but was unsure if there had been any follow up. Staff E said that the resident had a lot of pain in her legs. In an observation on 1/27/21 at 2:00 PM, Staff M, RN unwrapped the dressings on the resident's lower extremities and revealed long excoriated areas on the back of both lower extremities. Each leg had two open wounds with a scant amount of drainage. Review of Resident #11's clinical record from 0/27/20 through 1/5/21 revealed no measurements and a lack of consistent, detailed descriptions of the resident's wounds. A nursing note on 12/6/20 at 5:11 PM documented two large open areas located on the lower left leg and a shallow area on the shin below the resident's knee. The lower left extremity had a long, narrow area on the back of the calf and a smaller open area above the resident's ankle with a large to moderate amount of slough and dark dried blood noted on old the dressing A nursing note on 12/15/20 at 5:35 PM recorded a bright red swollen area located on the outer aspect of the right ankle and an on open area to the posterior ankle previously being treated. Staff sent a fax to the doctor and notified the ADON. The nursing notes lacked any documentation related to the physician's response, orders, or guidance related to the area. In an interview on 1/27/21 at 10:55 AM, the ADON said she did not have any measurements or detailed descriptions of these wounds because they are venous stasis wounds and they changed constantly. When asked how she would know if/when there was a decline or the area showed any progress, she stated, I look at them. In an interview on 1/28/21 at 10:40 AM, the resident's attending physician reported that he obtained information regarding wounds and their progress from staff report. He also stated he looked at the wounds during visits, but with the barriers of telemedicine (due to the COVID-19 pandemic) he hasn't seen the wounds as often as he would like. He looked through his notes and said that he had a telemedicine visit on 1/21/21 but did not see the wounds at that time, but he did see the resident in person on 9/17/20 and he didn't have any concerns at that time. The doctor added the resident had chronic ulcers and did not like to get out of bed or move around much. He stated he had thought staff had been monitoring wounds weekly to include measurements and detailed descriptions and it was his expectation going forward that staff would complete detailed assessments on a weekly basis. On 1/29/21 at 11:48 AM, the Director of Nursing (DON) completed a skin alteration evaluation that identified the following areas: a. Right lower leg (rear) 12.3 cm x 4.9 cm x 0.3 cm deep with serosanguineous drainage, copious exudate, and pain. b. Right lower leg (rear) 1.3 cm x 1.9 cm x 0.3 cm deep with 100% granulation serous drainage, scant exudate, and pain present. c. Left lower leg (rear) 1.8 cm x 1.3 cm x 0.2 cm deep with serous drainage, scant exudate, and pain present d. Left ankle (outer) 1.8 cm x 1.3 cm x 0.2 cm deep with serous drainage, scant exudate, and pain. The document revealed staff sent a fax to the doctor regarding odor and [DIAGNOSES REDACTED]. The electronic record revealed the physician prescribed the following: a. On 1/29/21 at 7:30 AM, Keflex (antibiotic) four times per day for wound drainage b. 2/1/21 at 5:52 PM Calcium Alginate Miscellaneous apply to right leg wound topically one time a day for wound care right leg wound on outer medial lower leg to the upper portion of the wound apply calcium alginate after cleansing with normal saline cleanse lower portion of wound with normal saline an apply hydrogel cover both areas with super absorbent dressings and secure with Kerlix. c. On 2/1/21 at 6:15 PM, Left leg cleanses with normal saline. Apply collagen dressing to wound and cover with non-adhesive pad. Wrap with Kerlix change daily. 3) The MDS dated [DATE] documented Resident #24 scored 9/15 on the BIMS test which meant the resident demonstrated moderately impaired cognitive abilities. The MDS also documented the resident required extensive assist of 2 staff for surface-to-surface transfers, bed mobility, and toilet use, and extensive assist of 1 staff for ambulation and dressing. The care plan last updated on 12/31/20 documented [DIAGNOSES REDACTED]. The care plan revealed Resident #24 had limited ability to perform activities of daily living due to decreased mobility and identified him as at risk for impaired skin integrity. The care plan directed staff to monitor the resident's skin and report concerns to the physician. A review of the resident's medical chart revealed 13 skin assessments from 8/28/20 through 1/8/21. All of the assessments documented the resident's skin as intact. The chart lacked any skin assessments from 8/28 through 10/22. A treatment order dated 7/13/20 directed staff to apply house barrier cream to a stoma. The most recent assessment with any measurements of Resident #24's ulcer areas was dated 7/13/20. A nursing note dated 1/22/21 at 10:50 AM, documented an excoriated area to the left buttock after a shower. Staff sent a fax to the physician. A skin alteration evaluation dated 1/22/21 at 2:58 PM identified a new excoriated area on the (left buttock) that measured 8 cm x 5 cm width and documented staff notified the physician and initiated a treatment. A skin alteration evaluation dated 1/28/21 at 3:00 PM identified an excoriated site on the resident's left gluteal fold that measured 6 cm x 4 cm with no drainage, no pain and much improved. Review of the nursing notes and skin assessments during July 2020 - January 2021 revealed the chart lacked any documentation of the left gluteal fold or a description of any wounds. An order entered on 1/25/21 at 10:00 PM documented a treatment to the excoriated area on the left buttock twice daily until healed. 4) According to the MDS dated [DATE], Resident #12 had a BIMS score of 15 out of 15, which meant the resident demonstrated intact cognitive abilities. The MDS indicated that the resident required extensive assistance with the help of two staff for transfers and toileting and extensive assistance with help of one for dressing and bed mobility. According to the care plan dated 11/17/20 the resident had physical limitations related to a femur fracture. The care plan documented the resident as at nutritional risk related to diabetes mellitus and directed staff to monitor for signs and symptoms of infection to any open skin areas, redness, pain, heat, swelling or pus formation. The care plan recorded the resident had a risk for pressure ulcers related to limited mobility and had an actual area of impaired skin integrity related to a surgical wound. The care plan directed staff to follow facility protocols for treatment of [REDACTED]. to the physician. According to a nursing notes dated 11/6/20 at 4:35 PM, the resident admitted to the facility with physical therapy services after surgery to repair a left [MEDICAL CONDITION]. Skin assessments completed on 11/18/20 at 3:15 PM identified two surgical wound areas: an area to the left lower thigh that measured 2.0 cm x 2.4 cm x 0.2 cm depth and an area to the right trochanter (any of two bony protuberances by which muscles are attached to the upper part of the thigh bone)/ hip area that measured 16.0 cm x 2.8 cm x 0.5 cm depth. The admission orders [REDACTED]. According to a nursing note dated 11/30/20 at 4:53 PM, staff identified a wound to the inner, right upper thigh which had been present when the resident came from the hospital. The resident reported adhesive tape had caused the area and it had reopened. The nurse documented that there were no treatment orders for this wound and sent a fax to the physician to obtain orders for the area. The resident's medical record lacked wound measurements from 12/10/20 until 1/27/21 (when the DON had been alerted). In an interview on 1/27/21 at 10:30 AM, the DON said she had no other wound(s) measurement(s) for the areas and explained the facility assigned the wound nurse duties to the Minimum Data Set (MDS) nurse rather than the ADON. The DON reported the MDS nurse thought the floor nurses were assessing and measuring the areas. In an interview on 1/27/21 at 3:50 p.m., MDS nurse reported the facility was still discussing who would be responsible for monitoring the surgical wounds and she said that they were still in discussions about who would be responsible for that when notified that Resident #12's surgical wounds had not been measured since 12/10/20 and Staff N LPN was preparing to do change the resident's dressing next. She responded that the DON could come in and help with that so Staff N went to get the DON. Soon after, Staff N returned and reported the DON sent her back to get the MDS nurse to assist. By that time, the MDS nurse had closed her office door and did not respond to knocking. At 4:05 p.m., the DON entered the MDS office and at 4:10 PM, Staff N reported she would measure the areas herself. In an observation on 1/27/21 at 4:10 PM, the resident lay in bed on her left side. Staff N removed the bandage and found the open wound appeared green/gray. When asked, Staff N responded it did not look like healthy tissue and said she would document what she saw. A review of the chart on 1/28/21 reveled a nursing note entered by Staff N on 1/27/21 at 4:50 PM that documented she completed the resident's daily treatment and dressing change. She documented that the wound looked like it was healing with healthy granulated tissue. When asked in an interview on 1/28/21 at 9:45 AM why the documentation in the record differed from her statement at the bedside about the gray/green tissue in the wound and her description that it did not look like healthy tissue, Staff N stated she was not a doctor so she shouldn't say what is healthy or unhealthy tissue. She then commented that it didn't look good, although she said didn't want to put that in her note. In a skin alteration evaluation completed on 1/28/21 at 3:28 PM, the DON documented the wound as red and warm to the touch and the resident complained of pain, itching, and tingling to the site. A nursing note on 1/28/21 at 11:05 AM documented staff sent communication to the physician regarding the DON's assessment of the area and on 1/29/21 at 1:17 PM, the physician returned the fax with an order for [REDACTED].>The facility's Skin and Wound Management Program Overview dated 9/27/01 directed: All wounds are monitored daily as required by a licensed nurse, with documentation on the Daily Wound Review form that includes the date observed and; 1) Review of the pressure injury if no dressing is present 2) Review of the status of the dressing if present, whether the dressing is in tact 3) Whether dressing is intact 4) Whether drainage is present and is/is not contained in dressing 5) Review of the surrounding skin that can be observed without removing the dressing 6) Presence of possible complications such as sings of infection (redness, swelling, increased drainage, order, etc.) 7) Review if pain is present if present it is adequately controlled 8) Pain scale 0-10 All wounds are monitored at least weekly by a licensed nurse during rounds with documentation on the Weekly Wound Progress Review form that includes date observed and: 1) Location and staging (if pressure injury) 2) Size: measurement of greatest length and width as well as depth 3) Presence, location and extent of undermining or tunneling 4) Exudate/drainage: type (purulent, serous), color, odor, and approximate amount. 5) Paint if present; nature and frequency 6) Wound bed: color, type of tissue/character - including evidence of healing (granulation) or necrosis (eschar or slough). 7) Description of wound edge and surrounding tissue (rolled edges, maceration, induration, redness, etc.)

Based on observation, record review, and staff interview, the facility failed to assist and supervise residents that required dining assistance for 2 of 7 residents reviewed (Residents #1 and #3). The facility had identified Resident #3 as at risk for inability to maintain nutritional status and malnutrition due to a [DIAGNOSES REDACTED]. Meal observations on 1/6/21 and 1/7/21 revealed the resident lay in bed in her room with her unopened meal in front of her. Staff had not set up the meal or offered assistance during the meal. On 1/11/21, Resident #3 weighed 101.4 lbs. When staff weighed her again on 2/1/21, she weighed 92 pounds: a 9.2% weight loss. The facility reported a census of 43 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment tool dated 10/29/20, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0, indicating the resident experienced a severe cognitive deficit. The MDS documented the resident required supervision with set up for transfers, ambulation (walking) and meals and extensive assist of one staff for dressing and hygiene needs. The residents care plan dated 6/6/20 revealed she demonstrated limitations in her ability to perform activities of daily living and documented as at risk for potential inability to maintain nutrition related to dementia. The care plan also documented the resident could dine independently when provided cues and set-up assistance by staff. A nutrition evaluation dated 11/12/20 at 2:43 PM, indicated she required dining assistance and tray preparation/setup. A mini nutrition assessment dated [DATE] at 10:34 AM documented the resident as at risk of malnutrition. The weight summary documented the resident weighed 167.2 pounds on 9/2/20 and 162.3 pounds on 2/1/21. 2) According to the MDS dated [DATE], Resident #3 had a BIMS score of 15 out of 15 which meant the resident demonstrated intact cognitive ability. The MDS revealed the resident required extensive assistance with the help of one staff for dressing, hygiene and toilet use and extensive assistance of two staff for transfers and bed mobility. The resident dined with staff supervision and set up assistance. The MDS included [DIAGNOSES REDACTED]. The resident's care plan dated 11/9/20 documented the resident as at risk for inability to maintain nutrition related to [DIAGNOSES REDACTED]. The nutritional assessment dated [DATE] at 3:41 PM, documented Resident #3 as independent with meals and showed poor nutrition. The weight summary documented the resident weighed 101.4 pounds on 1/11/21 and 92 pounds on 2/1/21, which meant the resident had a 9.2% weight loss in the last month. The nursing notes revealed on 2/2/21 at 1:18 PM, the faxed a nutrition status update to the doctor. In an observation on 1/6/21 at 12:50 Resident #3 was in bed with a container of lunch on her bedside table. At 12:53 AM Resident #1 remained in bed with an open Styrofoam container that contained a fork in the meat, but the meal appeared uneaten and none of the staff assisted the resident in the room. In an observation on 1/7/21 at 8:30 AM, Resident #1 and Resident #3 remained in bed as staff served breakfast to residents in their rooms. At 9:00 AM, both lay in bed with unopened Styrofoam containers filled with breakfast on their bedside tables. At 9:15, 9:20, and 9:26 AM, the residents and meals remained in the same position with no staff visible in the 100 hallway or in any resident rooms in the 100 hallway. At 9:28 AM, Staff H, Certified Nursing Assistant (CNA) pushed a large garbage can down the hallway of the 100 hall and collected the Styrofoam containers from the resident's rooms. She reported another staff person had walked through the hallway 15 minutes earlier and had documented how much each resident had eaten. Meal Documentation entered into the Point of Care section of the electronic record at 9:51 AM listed that Resident #3 had eaten 26%-50% of her meal. An entry at 9:50 a.m. documented Resident #1 had refused her morning meal. In an interview on 1/25/21 at 8:55 AM, the MDS nurse provided a list of six residents that required assist with dining. The provided upon entrance only listed two residents. In an interview on 1/25/21 at 1:00 PM, Staff J said she did not know how to find out which residents required assistance with meals and named two residents from memory. In an interview on 1/25/21 at 9:25 AM, Staff H, CNA said she just tried to watch and be aware of which residents may not be eating much, but did not know where to find a list of residents that required assistance with dining. On 1/25/21 at 9:30 AM, Staff AA, CNA reported a communication book kept by the staff entrance contained changes and updates and she would check it to find which residents needed assistance at mealtime. An observation on 1/25/21 at 9:35 AM, revealed no communication book present in staff entrance area. On 2/1/21, the Administrator reported via email the facility did not have a formal policy related to caring for residents that required assistance with meals.

Based on clinical record review, staff interview, observation, fire department reports, hospital records, police reports, restraint information card instructions, employee file review, and facility record review, the facility failed to provide adequate nursing supervision and assistance devices to prevent accidents for 1 of 11 residents reviewed for adequate nursing supervision (Resident #1). On [DATE], during transport from a doctor appointment, the facility van driver failed to attach all 4 floor restraint straps/hooks to the wheelchair frame and buckle a shoulder-lap seat belt in the facility wheelchair transport van. As a result, Resident #1 tipped over in the van and fell out of her wheelchair, lay with her head in contact with the metal floor and blood present in her mouth, and went into cardiac/respiratory arrest requiring initiation of CPR (cardiopulmonary resuscitation) at the scene of the accident. Emergency personnel transported her to the hospital via ambulance, and she died in the hospital ER (emergency room ). This constituted an Immediate Jeopardy (IJ) to resident health and safety. The facility reported a census of 61 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented an admitted [DATE]. The MDS identified a Brief Interview for Mental Status (BIMS) score of 13 without signs/symptoms of [MEDICAL CONDITION]. A score of 13 indicated the resident demonstrated intact cognition. The MDS revealed the resident was totally dependent upon 2 persons for transfers, did not walk in the room/corridor during the 7 day look back period, and required extensive physical assistance of 1 person for locomotion on/off the unit. The MDS coded the use of a wheelchair as a mobility device and impairment on 1 side of the resident's lower body. The MDS documented [DIAGNOSES REDACTED]. The MDS recorded the resident received anticoagulant medication (blood thinners) on 7 out of 7 days of the look back period. The care plan focus areas dated [DATE] identified the resident: a. took an anticoagulant medication to manage her medical condition. b. had a potential/actual functional status limitation in ability to transfer and ambulate (walk) due to her left lower extremity non-weight bearing status related to her left ankle fracture. - required a mechanical lift (Hoyer) and assist by 2 staff to transfer - used a wheelchair and a walker - required the assistance of 2 staff for locomotion using a wheelchair - wore a cast on her left lower extremity c. had a potential/actual alteration in cardiovascular status specific to circulatory and hemodynamic (blood flow) balance. d. had an alteration in cardiovascular status requiring placement of a pacemaker or AICD (cardioverter) (a device designed to monitor the heartbeat that can deliver an electrical impulse or shock to the heart when it senses a life- threatening change in the heart's rhythm). e. at a risk for falls. - educate the resident/family/caregivers about safety reminders and what to do if a fall occurs The Medication Administration Record [REDACTED]. The Progress Notes dated [DATE] at 3:22 p.m. documented the resident went to a heart appointment that morning with a family member there. The entry recorded the facility received word of a medical incident when the resident left the appointment and later received word of the resident passing away. The City of Des Moines EMS (Emergency Medical Services) firehouse report dated [DATE] recorded the alarm sounded at 10:59 a.m.; the responders arrived on scene at 11:07 a.m., and the actions taken included advanced life support (ALS) and transport. The City of Des Moines fire department Patient Care Record, with assessment time of [DATE] at 11:12 a.m., recorded emergency response dispatched to 7th & Laurel street intersection for a fall in a white van. The report documented primary impression injury of head with secondary impression respiratory arrest with [MEDICAL CONDITION] protocol used. The report described the injury as fall from wheelchair 2 feet. The report included the following documentation: When the responders arrived on scene, the driver of the facility van stood outside at that rear of the wheelchair van and stated the patient fell out of the wheelchair when he turned from Laurel onto 7th. The driver said the wheelchair was secured but the patient was not. When the responders entered the wheelchair van, they found the patient prone (face down) with her head in the right rear corner, head hypo-extended (indicating head tipped down), and turned toward her left shoulder. The driver alleged the patient just talked to him prior to responders' arrival and at the time of responders' arrival the patient not responsive and possibly not breathing; responders called for [MEDICAL CONDITION] response. The responders rolled the patient to place a backboard; they noted the patient breathing on her own but breaths slow and shallow with blood in her mouth and on her teeth. At that time, the patient still unresponsive but had a weak carotid pulse. The responders loaded the patient into the squad and another crew of responders arrived on scene to start assisting with patient care. Initial vitals obtained but noted patient breathing rate more agonal (abnormal gasping for air considered inadequate breathing) and the monitor showed bradycardic rate (slow heart rate). The responders notified the hospital ER they were en route with [MEDICAL CONDITION] possible trauma. The hospital History and Physical Consultation report, signed [DATE] at 1:32 p.m., documented under impression and plan, injuries of cardiac and respiratory arrest, right temple laceration, and abrasion/bruising to bridge of nose. The hospital Trauma Services Discharge Summary dated [DATE] at 2:17 p.m. included the following documentation: The patient admitted [DATE] at 12:13 p.m. The history of present illness recorded the patient being transported in a wheelchair van when she fell out of the wheelchair as the van went around a corner and EMS called. Upon arrival of EMS, the patient reportedly laid in the corner of the van face down with her neck bent, pulseless, and apneic (not breathing). CPR initiated and a [NAME] LT airway placed (device used to secure the airway for mechanical ventilation); the patient arrived initially as a medical code but after the entire story obtained a trauma code called. The hospital course included: CPR in progress upon arrival; 2 doses of Epi ([MEDICATION NAME] medication used in emergencies to act quickly to improve breathing and stimulate the heart) used by EMS prior to arrival; paced rhythm with pulse upon arrival; and intubated with attempts to place central line which during that time the patient again went into [MEDICAL CONDITION]. After discussion with physicians and family, the resuscitation attempt was stopped. Time of death noted at 12:44 p.m. The body cam video of the 1st City of Des Moines Police Officer to arrive at the scene of the accident captured the following visual and audio documentation: *Minute 1:58 to 2:44 of the video Staff A, facility bus driver, stated the following to the officer: It's easier to show you. When Staff A transported he had to get them in 3 point harness, (indicated Resident #1's wheelchair in place to the far left of the back of bus behind the row of seats on the driver's side) this one here (physically demonstrated the floor latch on the left front of wheelchair) came loose from the floor and she leaned at the same time and ended up like this (showed the wheelchair tipped over to the right side to the floor) as turned the corner. She did not yell or nothing, Staff A thought like what the hell, pulled twice (indicated the left front floor latch) seemed to be there and came loose. The way the seat belts are can't seat belt anyone in that's behind the seats. Staff A had another patient he was picking up and he sits right here (indicated the spot in front of the ramp behind the passenger side row of seats). *Minute 4:05 to 4:18: Staff A stated he picked up (the resident) at Iowa Heart right here and Staff A checked that thing (pointed to the latch on the left front floor) and it was hooked. Staff A turned on 7th and heard a crash Minute 11:59: Resident #1's grandson arrived on scene. Minute 12:40 to 13:05 = Staff A stated to the grandson, made her fall this way so we don't know what's going on why it didn't, when Staff A had the Fire Chief in he did it then (indicated pulling out the left front floor latch/strap repeatedly) and it just came all the way out. The grandson asked, is she badly hurt, to which Staff A responded, she hit her jaw but they said she was okay other than that, that they could tell, but they wanted to take her over to get checked out due to her age. *Minute 15:43 to 15:55: Staff A stated (unintelligible vocalization) when the Fire Chief out Staff A pointed out (unintelligible vocalization) and all of sudden it just came loose, Staff A never had anything like that happen before. Minute 18:25 to 18:48: Staff A stated, like he said he never had that happen. Staff A couldn't believe it like he said he pulled on it and it just shot right out of there and not supposed to, supposed to lock. Staff A said his boss was freaking out because the maintenance guy and he both inspected the thing and he never had one do that. Minute 38:35 to 38:49: The 1st Police Officer stated, obviously he wasn't there when it happened so (the report) going to be pretty basic. Staff A responded, well it just came loose again while he (Crime Scene Investigation photographer) was in there photographing. Staff A reported the photographer asked, so it's supposed to catch and stay locked? Staff A said yes. *Minute 40:40 to 41:00: After the 1st Police Officer informed Staff A it was not criminal, report being made for injured person, Staff A clarified nothing going against the vehicle (no tickets), then stated, like he said that thing had never done that. *Minute 41:11: Staff A mentioned the grandson there when he strapped Resident #1 in and seen he did it right. Facility Investigation A written statement by Staff A dated [DATE] documented the following: Staff A picked up Resident #1 at Iowa Heart following her appointment where her grandson watched Staff A load and strap Resident #1 in the bus. Staff A left and went 2 blocks to the stop light at 7th & Laurel. As Staff A made the turn, he heard a loud crash, pulled over immediately, and found the resident on the floor. The left front strap had come lose allowing the resident to tip sideways. Staff A immediately called 911 for ambulance, stayed with the resident, and talked to her. Resident #1 bleeding from her mouth, breathing ok. Staff A called the facility to inform the Administrator of the event and waited for the ambulance to arrive. Once they got there, Resident #1 wasn't breathing very well. Staff A helped the 2 ambulance people get the resident loaded then waited for police to arrive. They checked the straps, it wasn't catching every time, took pictures, and released Staff A from the scene. No tickets were written or reports filed against Staff A or the facility. Staff A wrote a separate paper on how to secure passengers in the bus. Staff A wrote: If in a wheelchair and possible, a person should use 4 tie straps hooked to the steel frame of the wheelchair and once hooked, try to move the wheelchair to insure tie straps secured. Then set wheelchair brakes and place seat belt around the arms of the wheelchair, not the person. Make sure all the slack removed and the wheelchair then secured for transport. Facility Driver/Witness Interview On [DATE] at 11:00 a.m. Staff A replied he was hired for transport as a PRN (as needed) position in (MONTH) 2019 and recently worked 3 days a week. Staff A stated Staff B trained him when he first started. Staff A explained Staff B took him out for a driving test. Staff A commented he rode the facility bus before helping to volunteer so knew how to seat belt in residents. Staff A stated when he put someone on the bus, it was a different situation for everyone due to their size and where he had to place them. Staff A stated there was not a set standard or procedure that worked for every single person and no book on how to put residents in. Staff A said when he took people with full size geri-chairs (type of reclining wheelchair), he had to hook the resident all different because of all the plastic parts and it would not hold if hooked to plastic. Staff A commented that was an example of why he said every situation different. Staff A reported Staff B verbally trained him by walking him thru how to secure a resident, they did not have anyone on the bus for that training, and Staff B reminded him how to use all the restraints. Staff A clarified reminded meant when he helped to volunteer prior to hire; like going to the zoo when the facility needed to have 1 person for each resident. Staff A commented under the old administrator he could push residents around the zoo, just making sure a body with each resident, but no cares provided by him. Staff A stated when he volunteered he watched the staff connect the residents. Staff A said it was pretty simple and if a resident was in a seat, he just connected the lap belt. Staff A stated he would demonstrate once out in the bus, but there were not too many ways to hook up in the back. He said pretty much only thing is to hook to the structural spot of the chair, because PVC breaks. Staff A stated the biggest thing Staff B pushed was don't hook it to the person, hook it to the chair. Staff A denied he received any checklists on how to strap in a resident, only the checklist for driving the bus. Staff A said he took time on his own to look on the internet on how to strap in residents, but it wasn't accurate. Staff A agreed his employee file only showed the checklist, nothing on procedures or policies for driving the bus. Staff A reported he looked the bus up on the internet, but it was not 100% accurate, and it depended on type of wheelchair and how big a wheelchair was; there were so many variables. Staff A stated he had to do what fit the person to make them feel comfortable and safe. Staff A denied ever seeing the paper/information card for the Q'Straint floor latch. Staff A responded, like he said every situation different. Staff A commented he had transported a resident who had a seatbelt in his own chair so all Staff A had to do was secure that wheelchair. Staff A clarified he completed just 1 driving test and 1 walk thru with Staff B then was allowed to drive. Staff A said the facility asked him to drive because he had driven a semi and another list of vehicles; anything with wheels on it. Staff A then relayed what happened on [DATE] when Resident #1 tipped over in the transport bus. Staff A reported he picked Resident #1 up from her appointment. Staff A stated he went in to get the resident and her grandson stood outside of the lift gate. Staff A commented it was the 3rd time he transported the resident and had to put Resident #1 in the corner as another resident would board the bus later and needed to walk through. Staff A recalled he hooked the front 2 floor restraints and 1 floor restraint in the back. Staff A said he couldn't reach the other 1 (back floor restraint) as the resident was big with a broken foot and his arms were not long enough. Staff A commented with those 3 restraints, the wheelchair couldn't go anywhere. Staff A stated he showed the fire chief sat in the bus and rocked back and forth but couldn't go anywhere as 3 quarters of an X couldn't go anywhere. Staff A stated when he turned the corner at the stop light all he heard was a thud and he thought someone had hit him. As Staff A turned the corner with a left hand turn, he heard a big thud and immediately went to the side of the road as he thought someone hit him at the intersection of 7th and Laurel (in Des Moines). Staff A said he looked in the side mirrors, seen everyone still at the stop light except for him, he looked in the rearview mirror and the resident was gone, he couldn't see her. Staff A stated he immediately put the bus in park and saw the resident lay on the floor. Staff A said he called 911. Staff A reported a little pool of blood had been present by Resident #1's head, about the size of a large tomato spot and it looked as if it dripped out of the resident's mouth. Staff A stated the resident lay totally on her right side and he didn't move the resident; just let the blood drip out of her. Staff A said 911 told him they were sending an ambulance to him and asked if resident responded, said no still breathing. Staff A recalled Resident #1 was the type of lady who never talked anyway, and was not talking then, but was still there. Staff A stated he then called the Administrator to inform her what happened while it took forever for EMS to get there. Staff A stated just 2 ambulance people and he helped get the resident onto the back board and slid onto the gurney so they could do something with her. Staff A reported Resident #1 stopped breathing when she got on the gurney. Staff A said when they took the resident out of the bus her lips and nose were blue. Staff A reported the fire truck had not yet arrived. Staff A stated he did move the resident's wheelchair by sitting it up so EMS could get to her; the resident wasn't in the chair at that point and he knew he had to move it for them to get to her. Staff A responded he moved the wheelchair right before the ambulance got there and he waited until the last minute to do so. Staff A commented he thought he had to move it as she wasn't in it anymore. Staff A recalled Resident #1 lay on her side and when she breathed in she moaned; not in the chair at all. Staff A responded he did not have to unhook anything to set up the wheelchair because the 1 strap that came loose, the left front floor latch, and it allowed the wheelchair to be put back up. Staff A stated when he left the appointment, he shook the wheelchair back and forth to make sure it couldn't go anywhere. Once secured, Staff A reported he locked the wheelchair brakes, but where the wheelchair sat, he couldn't put on the back shoulder-lap belt (a safety belt fixed on the back wall of the bus that attached to a floor restraint/buckle). Staff A stated he couldn't put the shoulder-lap belt on because it was right in the middle of (the resident's) head and it would have been around her head. Staff A responded the shoulder-lap belt could be adjusted down but the strap still went right across the neck if he went across the resident. Staff A commented he showed all that to the Des Moines Fire Department and CSI (Crime Scene Investigations) and each time he showed them, the latch gave way and they said it was faulty equipment. Staff A stated, with those 3 straps he put on the wheelchair couldn't go anywhere. Staff A clarified the hook was still hooked to the wheelchair, but the ratchet part was broken. Staff A further clarified he had 3 straps on the wheelchair and was able to set it upright. Staff A explained the floor latch/restraint spring loaded to go back in but the stop that let it pull back out wasn't working. Staff A recalled the fire chief asked him if he hooked it and he said yes it was hooked. Staff A clarified he connected the left front floor, right front floor, and right rear floor latches; the left rear floor and the seat belt on the wall was not utilized as he couldn't get to them and the resident had a broken foot and was a good size. Staff A clarified Resident #1 never said anything. Staff A said he was legally deaf and couldn't hear what was said in the back of the bus. Staff A stated from the time of the thud on, Resident #1 never said anything that he could hear. Staff A reported the only way he watched what went on back in the bus was by the small rear view mirror. Staff A said it took quite a while for the fire chief to come as the ambulance needed to call and send the fire truck; about 10 minutes before the ambulance then called fire to be dispatched. Staff A responded he knew it was the fire chief he talked to, but did not know his name, he said he was there to control traffic, and said to walk him through what happened as he was standing there. Staff A stated he spoke to the police officer and the police sergeant and they called to see how to handle the situation, then waited for crime scene to come and photograph everything. Staff A responded Staff B taught him to use the belt strap on the wall attaching on the wheelchair not the person because when it went down the road it bounced and would keep tightening and cinching in until a resident couldn't breathe-there was no way to stop the cinching. Staff A stated Staff B taught him the floor latches were to be put in 4 point and always try 4 points, to the structure of the wheelchair; not plastic, not wheels, the wheelchair frame. Staff A again stated he did not use the 4 points on Resident #1's wheelchair as he couldn't reach. Staff A explained the problem was getting the belt unhooked (the left back floor latch). Staff A said he had to get the pin down to release the belt, he was a big guy, and couldn't get there to release. Staff A said he tried getting on the floor but if he couldn't later get it to release he couldn't hook it up. Staff A stated the only way he could see getting it hooked up and released would be to get a cane to push in there to release the belt. Staff A commented he never had any problems and he hauled a lot of people. Staff A confirmed Resident #1 had a cast on the left lower extremity that had been applied a week to 10 days prior to the accident. Staff A reported the resident could mover her legs very little and a lot of times she sat still when with him. Staff A responded it was not possible Resident #1's foot slipped off onto the red button (release) as the size she was she couldn't move. Staff A commented Resident #1 had been tall enough and big enough her feet were under the seat in front of her. Staff A stated he did not see it happen as his eyes were on the traffic when turning. On [DATE] at 11:40 a.m., Staff A re-enacted Resident #1's position before and after the accident in the facility bus and pictures were taken of the re-enactment. Staff A said as he walked to the back of the bus he couldn't see the resident's head. Staff A recalled the resident lay completely on her right side on the floor, head against the back wall between the floor lift vertical joist and the back door. Staff A said the pool of blood coming out of the resident's mouth was by the bottom of the vertical seat belt mounted on the back wall on the passenger side of the van. Staff A reported there had been no blood on the ramp at that time; the blood on the ramp was there later there from being smeared when paramedics moved her. Staff A said 3 straps were still hooked and 1 like this (indicated the left front floor strap still on wheelchair and should not have been extended). When asked if he thought the wheelchair would have stayed up with all 4 straps on and then the left front floor latch faulted, Staff A responded, yes but as long as 3 floor latches on it would have stayed upright. Staff A demonstrated being in the chair, rocked back and forth being hooked with the 3 floor latches, and he could not tip it over, then showed it could tip when he put his foot down on the latch (red button release). Staff A showed he couldn't use the wall seat belt on the back rear wall because it sat behind the resident. Staff A said the resident was in the corner with her arm against the window, and said he couldn't reach the left back floor latch with her wheelchair all the way back against the wall. Staff A showed with the wheelchair positioned all the way towards the left side of the vehicle, he couldn't even see that latch. Staff A stated Resident #1's wheelchair had been wider than the chair used for demonstration and wider than his arm. When asked, Staff A responded no, he never let anyone from the facility know that he couldn't reach that back and could only connect 3 straps. Staff A said he even got down on hands and knees but he couldn't reach that back corner to release the hook. Staff A again stated 3 points connection should have held. Staff A commented Staff B trained him to always hook on the post of wheelchair frame, not just the lower bar, as it was the strongest part of the chair. Staff A pulled and yanked vigorously on the left front floor strap several times and 2 times out of 5 the belt released tension and extended without depressing the red button. Staff A again yanked 3 more times and it failed once. Staff A then wanted to show how and why he could not use the back seat belt on the wall. Staff A showed pulling the seat belt across from right to left across his body and it went across his neck. When asked if it was adjustable, Staff A said yes it moves up and down to different locations but all locations would have the strap crossing a resident's neck. Staff A said when the strap on the resident each bounce of the road would cinch the belt tighter putting pressure on the neck of a resident. Staff A said the police sergeant had said it was a poor design. Staff A commented he would normally transport a resident in the center of the back of the bus, but he had to push Resident #1 over that day as another resident was to be picked up who used a walker and would need to walk on. Staff A stated in hind sight, he wished he had put Resident #1 in the middle then moved her when he picked the other resident up. Staff A stated the resident did have a cut on her finger so it could have been possible for some of the blood on the ramp to be from the finger. Staff A reported the resident had shallow breathing when the paramedics arrived and they stated it was so shallow she basically wasn't breathing. Additional Staff Interviews On [DATE] at 2:30 p.m., the Administrator reported the bus remained out of service with all keys secured. On [DATE] at 9:50 a.m., the Administrator stated the bus had been on was on lock down since the accident so nobody could access it. At 10:15 a.m., the Administrator unlocked the bus for observation. The Administrator said Staff A transported 2 persons that day, but had been at their appointment at the time of the accident so only Staff A and Resident #1 were in the bus at the time. The Administrator did not think the facility had the actual wheelchair used the day of the accident as it had been owned by Resident #1. The Administrator stated the wheelchair fell to the right according to the walk through conducted with Staff A, the Maintenance Director, and the Administrator. The Administrator stated monthly maintenance inspections had been completed prior to the incident and a checklist form completed. The Administrator said formal maintenance in a shop would be for procedures such as oil changes but the monthly inspections were completed by the Maintenance Director in the middle of the month. The last inspection had been completed sometime in mid-August. The Administrator stated in Staff A's account of the incident when the Maintenance Director and she had been present, Staff A did not report attaching the left back floor restraint or the seatbelt that went across the body. Observation revealed a shoulder belt on the back wall of the bus, behind the area where a wheelchair would be placed with the resident facing forward. When asked about documentation of training for Staff A on attachment of the wheelchair, the Administrator said she thought she already provided it. She stated Staff A had been trained by Staff B, Central Supply Clerk, who had been the former bus driver. The Administrator said the facility investigation included a statement from Staff B regarding how she trained Staff [NAME] The Administrator reported 3 staff members were trained on being able to drive the bus other than Staff A: Staff B (currently only working in Central Supply due to health reasons), Staff C, CNA, and the Maintenance Director. On [DATE] at 11:20 a.m., the Maintenance Director provided a demonstration from start to finish on how to properly load a resident into the facility bus with the surveyor acting as said resident. The Maintenance Director started the bus to be able to lower the lift ramp located on the passenger side towards rear of the bus. The Maintenance Director pulled the wheelchair onto the ramp backwards, locked brakes on wheelchair, connected a belt strap across the ramp approximately at shoulder height, then went into bus, elevated the lift, unlocked the wheelchair brakes, and pulled the chair backwards into the bus. Once in the bus, the Maintenance Director maneuvered the wheelchair to turn toward the left side so the wheelchair and surveyor faced the front of the bus, behind the driver's side, in the back of the bus. The Maintenance Director stated he would connect in that position as Resident #1 in that position per Staff A's report due to 2 residents transported that day. The Maintenance Director showed he connected the floor restraint straps to both sides of the front wheelchair frame and not the wheels. The Maintenance Director said it didn't matter where it connected as long as it was connected onto the frame of the wheelchair. The Maintenance Director then connected the back straps, left and right on the floor underneath the wheelchair to the bottom frame bars. The Maintenance Director placed the seat belt that connected from the back wall of the van, thru the arms of the wheelchair, across the surveyor's lap, and to the belt strap connector secured on the floor on the right side of the wheelchair. The Maintenance Director tested the tension on all 4 straps by tugging on them to ensure they were secured and the wheelchair brakes locked as well. The Maintenance Director stated that was the proper way to connect it. The Maintenance Director said Staff A reported he did not connect the back left strap onto the wheelchair as he could not reach it. The Maintenance Director acknowledged the back door of the bus could be opened and a person could reach inside the bus to get to the back connection if needed, but he would expect a driver to get down on hands and knees and reach underneath to connect the strap. The Maintenance Director said Staff A did not mention anything about securing the seat belt onto the resident. The Maintenance Director said on [DATE], as soon as Staff A returned with the bus after the accident, Staff A, the Administrator, and himself completed a verbal walk-through and demonstration of what occurred that day. The Maintenance Director and the surveyor tried many scenarios to try to tip the wheelchair. With all 4 straps secured with the seat belt, the chair had been difficult to even budge when empty. Even with an unfastened seatbelt, it had still been difficult, even when pushing on the left side of the bus wall when in the wheelchair to tip over the chair. It did not tip over. The Maintenance Director undid the left back strap and still the chair only leaned approximately 5 to 10 degrees to the right side at most with the entire strength and force of the surveyor tugging on the wheelchair. The only way to tip over the chair 40 degrees to the right was to undo the left side back and front floor straps. Even with the seat belt connected, the chair could only go so far if attached through the arms of the wheelchair. However, without the seat belt or the left side floor straps front and back, the chair tipped with a lot of effort to pull it over. The Maintenance Director stated Staff A reported the police officer and he identified the left front floor latch as faulty that day, but could not recreate the failure. The Maintenance Director reported Staff A indicated the latch did not catch

Based on record review and interview, the facility failed to provide adequate supervision to protect one (1) of four (4) residents from hazards. Resident #1 fell and sustained a hip fracture. Staff interviews the resident had been left unattended in his/her room in the wheelchair and no staff acknowledged they assisted the resident back to his/her room. Staff interviews and record review revealed Resident #1 had a history of [REDACTED]. The facility reported a census of 59 residents. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had [DIAGNOSES REDACTED]. The resident had impaired cognitive ability with a BIMS (Brief Interview for Mental Status) score of 7/15. Resident #1 required supervision of 1 staff for transfer, ambulation, toileting, and dressing. A balance during transitions and walking test identified the resident as not steady and only to stabilize with staff assistance when moving from seated to standing, walking, turning around while walking, moving on and off the toilet and surface to surface transfers. The MDS revealed Resident #1 had a fall with no injury since the prior assessment. Review of the Care Plan, dated 9/26/16, identified Resident #1 at risk for falls related to weakness, psychotropic medications, poor judgement and safety awareness. Interventions included but not limited to the following: a. Assure the floor is free of glare liquids, and foreign objects. b. Encourage resident to assume a standing position slowly. c. Give the resident verbal reminders not to ambulate/transfer without assistance. d. Keep a call light in reach at all times. e. Keep personal items and frequently used items within reach. f. Observe frequently and place in supervised area when out of bed. g. Offer toileting assistance after rising, before and after meals, at bedtime and when doing rounds. h. Provide proper, well maintained footwear. i. Provide resident an environment free of clutter. The Care Plan included an intervention dated 10/15/16 that directed staff assist the resident from the dining room and do not leave in wheelchair in his/her room. A review of previous falls indicated the following Incident Reports : a. 9/28/16 at 6:00 p.m. Resident #1 was found on the floor near the bed. Staff educated the resident to call for assistance prior to transfer. The resident demonstrated use of the call light. b. On 10/4/16 at 5:00 p.m. Resident #1 was found up without his/her walker. The resident was lowered to the floor after his/her legs gave out. A room change was implemented to allow higher staff visibility. Additionally, a sign was placed in the resident's room with pictures to remind use of call light prior to self-transfer. c. On 10/13/16 at 5:00 a.m. Resident #1 was found on the floor near his/her bed. A floor mat was placed near his/her bed as an intervention. d. On 11/12/16 at 1:10 p.m. Resident #1 voiced self-transfer from wheelchair to recliner when he/she slipped during self-transfer. Staff were directed to assist the resident from the dining room following a meal. Nurses notes dated 11/15/16 at 3 a.m., and 1:15 a.m., documented the resident reported no pain. The Incident Report dated 11/19/16 at 9:30 a.m., identified Resident #1 attempted to self-transfer from wheelchair to recliner and fell on the floor. Resident #1 complained of left thigh pain. The form noted the staff (Staff A) had been counseled on pushing Resident #1 ' s (wheelchair) back to room and not leaving him/her in the hallway. The nurse ' s notes dated 11/19/16 documented Resident #1 had been assessed after the self-transfer which resulted in a fall. Resident #1 complained of pain of left thigh pain and the physician had been notified. Staff would continue to monitor. The fax dated 11/19/16 documented Resident #1 attempted to self-transfer and fell and complained of pain 9 out of 10 (high) in left thigh. The physician had spoken with staff at 9:45 a.m., to continue neurological checks for six hours then per shift; and call the physician if his/her pain worsens. Nurses Notes included the following documentation: On 11/20/16 at 3:3o a.m., Resident #1 complained of pain to left lower extremity and staff administered pain medication. At 10:40 a.m., Resident #1 complained of left hip pain with movements; and the resident walked with walker to bathroom. The resident ' s gait was slow and unsteady at times. Staff assess the resident with no shortening or internal rotation, and no sign/symptoms of pain with ROM (range of motion); Staff administered prn (as needed) pain medication. On 11/21/16 at 12:15 a.m. ROM was identified as normal and the resident denied pain. At 2:30 p.m., Resident #1 complained of pain on the top of right thigh. Resident walked with front wheeled walker with the assistance of one staff. The physician reported to call if resident needed an x-ray or needs to be seen. On 11/22/16 at 11 a.m., resident continued to complain of left hip pain and refused pain medication. ROM showed no shortening or internal rotation of left lower leg. At 5:30 p.m., Resident has been the assist of two for transfers this shift and continues to complain of left leg pain. Staff documented the resident will have an x-ray tomorrow. On 11/23/16 at 3:30 a.m. Resident #1 denied pain when questioned and no indication of pain. At 9:45 a.m., Resident went to the physician ' s office for evaluation of right thigh pain. Nurse's Notes dated 11/23/16 at 11:30 a.m. revealed Resident #1 was transferred for surgical repair of a fractured left proximal femur fracture. The physician ' s history dated 11/23/16 documented the resident had fallen over the weekend and now complains of left hip pain and will not stand; wearing bearing up until yesterday. The resident has a history of dementia and schizophrenia. The reported noted the resident had refused treatment over the weekend and refused. The report noted past right hip surgery of some sort. The operative procedure report dated 11/23/16 documented the resident is found to have a minimally displaced femoral neck fracture. The resident had pinning of his/her fractured hip on 11/23/16. Staff interviews as follows: a. On 12/28/16 at 10:29 a.m. Staff A, certified nursing assistant (CNA), stated Resident #1 finished his/her meal so she helped him/her to the hall. Staff A took Resident #1 for treatment in the hall, and she pushed Resident #1 to Staff D. Staff A requested Staff D, a CNA take Resident #1. Staff A then provided assistance to another resident. Staff A was aware Resident #1's Care Plan directed staff to not leave Resident #1 unsupervised in his/her wheelchair in his/her room. Staff A stated Staff D and Staff E, CNA, provided assistance to Resident #5, Resident #1's roommate, so she thought they would provide assistance to Resident #1 also. Staff A could not recall who took Resident #1 back to his/her room and had passed him/her off to Staff D. Staff A reported she got blamed for the incident. b. On 12/28/16 at approximately 10:00 a.m. Staff D, CNA, stated on 11/19/16 Staff AA, CNA, oriented her. Staff D provided toilet assistance to Resident #5 before breakfast. She stated cares were not provided by her prior to Resident #1's fall. Staff D stated Resident #1 fell because someone left the resident unattended in his/her room in the wheelchair. c. On 12/28/16 at 11:01 a.m. Staff E stated she recalled she was the float aide on 11/19/16. Staff E stated care was not provided for Resident #1 or Resident #5. Staff E thought Staff A propelled Resident #1 from the dining room into his/her room and left the resident unattended in the wheelchair. Staff E was aware Resident #1 was not to be unattended in the wheelchair in his/her room because he/she frequently attempted to self-transfer. d. On 12/28/16 at 1:25 p.m. Staff F, CNA, stated she fed Resident #1 breakfast. After breakfast Staff A propelled Resident #1 out of the dining room. Staff F remained in the dining room with residents, and assisted other residents. Staff F was aware Resident #1 was to be transferred from the wheelchair after meals because of self-transfer attempts which resulted in falls. On 12/27/16 at 2:38 p.m. the Administrator stated prior to Resident #1's fall and fracture staff were directed to transfer Resident #1 from the wheelchair after meals while in his/he room because he/she attempts to self-transfer.

Based on record review and staff interview, the facility failed to plan for and direct nursing care and services to ensure one (1) of five (5) residents received adequate supervision from hazards (Resident #1). Resident #1 attempted to self- transfer from his/her wheelchair to bed when he/she fell and fractured his/her hip. The facility used alarms to alert staff of residents needs to self transfer and at the time of Resident #1's fall, staff interviews acknowledged the alarm did not sound. Staff interviews determined the alarm had not been plugged into the pad and staff had not checked the resident's alarm during prior transfers. The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 with a Brief Interview for Mental Status (BIMS) test score of 5 out of 15, which revealed the resident had severe cognitive impairments. Resident #1's speech appeared unclear with slurred or mumbled words, and he/she could sometimes be understood (and sometimes understood others). The MDS identified Resident #1 had impaired vision and experienced periods of inattention and disorganized thinking. Resident #1 could not stabilized his/her balance except with staff assistances during surface to surface transfers (transfers between bed and chair or wheelchair). The MDS identified Resident #1 required two staff for transfers and for toilet use and one staff assistance for bed mobility. The Care Plan dated 12/20/13 revealed Resident #1 was at risk for falls due to his/her cognitive (impairments) and poor safety awareness. The care plan directed staff to equip the resident with a device that monitored rising (alarm). The plan also directed staff to give verbal reminders to not ambulate/transfer without assistance; to observe frequently; and place the resident in a supervised area when out of bed. The plan also directed staff to check Resident #1 when doing rounds and in between and ensure chair/bed alarms were in place and working at all times. Nurse's notes dated 12/27/13 at 9:30 p.m. documented an aide entered resident's room and found him/her lying on the floor. The resident denied hitting their head. Staff obtained vital and completed a neurological check. Resident #1 could not tell the nurse if he/she felt hurt and moaned and grimaced during cares. The nurse questioned the resident again if in pain and asked resident to touch the painful area. The resident placed his/her hand on the left ribcage, but could not rate pain on a pain scale. Staff administered PRN (as needed) Tylenol, notified physician and received orders to send to ER (emergency room ) for possible fractured ribs. Staff also notified the resident's power of attorney. The fall investigation form dated 12/27/13 documented the resident had been found on the floor lying on his/her left side. The Incident Report Form dated 12/27/13 at 9:30 p.m. documented Resident #1 found on the floor by Staff F, CNA and Staff C, CNA when they entered the resident's room. Staff D, Licensed Practical Nurse, (LPN) assessed the resident. The resident went to the hospital and the evaluation determined he/she sustained a hip fracture. All staff who entered the room at the time of the fall reported no alarm sounding. The physician's orders [REDACTED]. Interview with Staff M on 1/13/14 at 3:41 p.m. revealed Staff M went to Resident #1's room with Staff C (on 12/27/13) and they stood the resident up to change his/her brief and then assisted the resident to sit down in a (wheel) chair. Staff M did not recall checking to see if the alarm was plugged in. Staff M reported then they took the resident to supper at 5:00 p.m. Staff M noticed Resident #1 still eating in the dining room around 6: 00 p.m. Staff M reported all staff should check the alarms any time they transfer a resident from one level to another such as chair to bed or bed to wheelchair. Staff do not record when they check alarms. Staff M stated the alarms make a screeching/beeping sound when the battery is low. A light will blink when the alarm had been activated. Staff M reported now after attending an in-service, she will check the alarm twice now and reported she had learned a lesson and always check (alarms) now. During an interview on 1/13/14 at 4:05 p.m. with Staff C revealed she came in sometime before supper and got Resident #1 up from his/her recliner. Staff C reported together with Staff M they put a new brief on Resident #1 and then assisted the resident into his/her wheelchair. Staff C reported seeing the alarm on the wheelchair but did not check to see the alarm was working. After supper Staff C reported the resident's door had been closed as the resident's family had been with him/her. Staff C went to break around 8:20 p.m. and then assisted another resident. According to Staff C, around 9:30 p.m. Staff F mentioned she had to put Resident #1 to bed. Staff C stated Staff F requested assistance with Resident #1. When Staff F and Staff C entered Resident #1's room they observed the resident on the floor. Staff C reported she did not check the resident's alarm like she should have. Staff C reported when the alarm is connected, the light will blink (white light). An interview with Staff D on 1/13/14 at 4:42 p.m. revealed she worked as the charge nurse on 12/27/13 when Resident #1 fell out of the wheel chair. Staff D stated about 8:15 - 8:30 p.m. a relative of Resident #1 stopped at the nurses' station to advise staff that she was going home. The relative informed Staff D that Resident #1 had been very tired and needed to go to bed right away. Staff D directed Staff F to assist Resident #1 to bed. Staff F turned and walked away and Staff D assumed Staff F was going to Resident #1's room. (Staff D later discovered that did not happen.) Staff D reported she heard another CNA asked Staff F if all residents were down (in bed) around 9:15-9:30 p.m. About 9:15 - 9:30 p.m. she heard Staff C yelling to come to Resident #1's room. When Staff D arrived in the resident's room she observed Resident #1 sort of on the floor, the resident had been in the wheelchair. Staff D confirmed no alarm sounded. Staff D reported the resident had pulled the bed linens off the bed. Staff D reported Resident #1 could not tell them what he/she had been doing. Staff D assessed Resident #1 and then with Staff C's help, Resident #1 had been transferred into bed. Resident #1 then transferred to the hospital. Staff D did not know why Staff F did not assist Resident #1 to bed when she received the directive to do so. Staff D also stated alarms should be checked when a resident had been moved from one position to another. Staff D reported some residents might be able to turn off their alarms, but Resident #1 could not have turned off his/her alarm. Interview with Staff F on 1/16/14 at 10:49 a.m. reported working even fewer hours when she moved away to go to college. Staff F reported the night that Resident #1 fell she was on her way to get additional linens when Staff D directed her to put Resident #1 to bed. Staff F did not tell Staff D she was in the middle of assisting another resident. Staff F reported she told her (nurse) she would put Resident #1 to bed when she finished (assisting the other resident). Staff F did not change Resident #1 since the resident's family had been visiting. Staff F stated her shift started at 6:00 p.m. on 12/27/13. Resident #1 was assigned to Staff F on 12/27/13. She did not think it was her fault that the alarm had not been connected when Resident #1 fell . Staff F felt the staff that got the resident up at around 4:00 p.m. should have checked the alarm. Staff F reported she was busy that evening and did not have direct contact with Resident #1 until 9:30 p.m. Staff F reported all alarms should be checked anytime a resident had been transferred. The task of checking the alarms was not recorded. Staff F stated they were educated on alarms during orientation. Staff F confirmed the Hall Sheets listed which residents had alarms and what kind of care they required. The CNAs read the sheets then signed them at the end of their shift. Staff F stated that signing off on the Hall Sheet didn't mean they had done anything listed on the sheet, just that they had read the sheet. An interview with Staff L, Scheduler on 1/15/14 at 2:10 p.m. revealed the expectation that alarms are checked at the beginning of every shift. The alarm chirps when the battery is low. Staff L reported the CNAs had Hall Sheets that list which residents use alarms and the Hall Sheets are kept at the nurse's station. Staff L did not know if the CNAs record when they checked alarms, but suggested it might be noted on the Hall Sheets. Staff L stated staff received training on alarms during orientation. Interview with Staff K, Central Supply on 1/16/14 at 12:19 p.m. revealed she checks/repairs nonfunctioning alarms. Staff K revealed she did not know the manufacturer's directions for the alarms. There is a picture on the pads of the alarms; Staff K first changes the battery and then they are checked by switching the plug in other functioning. The equipment is checked until the alarm works. Any totally nonfunctioning alarm will be returned to the company. Interview with Staff A, Human Resources on 1/13/14 at 2:20 p.m. and on 1/15/14 at 1:35 p.m. revealed CNAs are provided training on alarms at the time of orientation. Staff A provided a copy of the orientation for Staff F, CNA. A review of Staff A's Competency Checklist: Orientation" noted on 3/10/13 she had been trained on falls and alarms. An additional interview with Staff L on 1/15/14 at 2:10 p.m. confirmed the facility's expectation that staff check the alarms at the beginning and at the end of each shift. She reported the alarms chirp when the battery is low. CNAs have Hall Sheets indicating which resident had an alarm. Staff L reported she thought the only place alarms are recorded on a daily basis is the Hall Sheet. She confirmed staff received training on alarms during orientation. Interview with Staff E, LPN on 1/15/14 at 1:20 p.m. confirmed alarms are checked anytime a resident had been moved from one surface to another; such as bed to chair, chair to wheel chair. Staff E reported alarms are checked at shift change during rounds. Staff E reported it is everyone's responsibility to check alarms. Interview with the Director of Nurses (DON) on 1/16/14 at 10:08 a.m. revealed CNAs are trained/orientated by another CNA and the facility conducts annually in-services on falls. The DON reported alarms are part of the in-service training. The facility held the most recent in-service on falls on 1/6/14. The DON provided copies of the material presented which includes education on alarms. The DON provided the facilities policy for Chair Alarms. The DON confirmed the policy indicates on weekly reassessment form. The DON reported they do not reassess or document weekly. The only reassessment occurs at the care plan meeting quarterly. The DON reported the CNAs do have Hall Sheets. The DON reported they are to carry and sign them at the end of the shift. The DON provided the Hall Sheets for 12/27/13. Alarms are noted on the Hall Sheets, noting which resident had alarms. The DON reported staff read the Hall Sheets and then sign them at the end of their shift. The DON confirmed that their signatures on the sheets did not mean staff had checked the alarms or residents. The DON reported their signature acknowledged they read the Hall Sheet and signed it. She reported her expectation was that staff checked the alarms every shift and after all transfers. The expectation was presented to staff during orientation/training and in-services. The DON reported Resident #1's alarm was not plugged into the pad at the time of his/her fall. The DON reported the resident's family member had been interviewed by the ADON and reported not knowing whether the alarm in his/her wheelchair was plugged in or not. The chair alarm (motion sensor) policy (number IRF-IDT-5131 NERH) documented the purpose was to alert staff of residents transfers who require assistance or at high risk for falls. A phone interview with the facility's Medical Director on 1/17/14 at 1:23 p.m. revealed he expected Resident #1 to eventually return to his/her same level of functioning as prior to the fall. The resident displayed minimal activity before the fall. The resident did not walk prior to the fall and only did toe touch transfers with the assist of staff. The physician declined to comment on the issue of alarms within the facility.