Every finding on record at Bethany Lutheran Home

Based on Electronic Health Record (EHR) review, document review, staff interviews and policy review the facility failed to protect a resident from misappropriation of property when a resident's medication became missing from the facility for 1 of 3 residents reviewed (Resident #6). The facility reported a census of 86 residents.Findings include:The facility corrected the deficiency per past noncompliance through the following actions:All nurses and certified medication assistants were re-educated on the administration and disposal of controlled medications on [DATE]. Audits initiated on [DATE] of all narcotics delivered from [DATE] - [DATE] on all current, discharged and deceased residents. No further discrepancies found. Resident #6's prescription was replaced by the facility at the cost of the faciity. The Minimum Data Set (MDS) dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. The MDS documented Resident #6 received a scheduled and as needed pain medication. The MDS further documented Resident #6 had a diagnosis of intervertebral disk degeneration, lumbar region with discogenic back pain and lower extremity pain.Review of Resident #6's Medication Administration Records (MAR) documented a physician's order for Oxycodone / Acetaminophen 10/325 mg take 1 tablet by mouth twice daily for spondylosis, lumbar region with a start date of [DATE].Review of Resident #6's document titled, Individual Patient's Narcotic Record documented oxycodone tablet 10-325 take 1 tablet by mouth twice daily with a quantity of 30 received on [DATE] at 8:00 PM signed by Staff A, Certified Nurse Assistant (CNA) / Certified Medication Assistant (CMA) and Staff B, Registered Nurse (RN) for end of shift count signatures, on [DATE] at 6:00 AM count of 30 by Staff B and Staff C, CNA/CMA for end of shift count signatures, and on [DATE] at 2:00 PM count of 30 by Staff C only.Review of document dated [DATE] titled, Proof of Delivery documented Resident #6 had two prescriptions for oxycodone / acetaminophen 10-325 mg delivered with a count of 30 for each prescription signed as received by Staff D, Licensed Practical Nurse (LPN).On [DATE] at 12:45 PM Staff A stated on [DATE] she received 2 narcotics cards for Resident #6. Staff A explained the medication was oxycodone / acetaminophen. Staff A said Staff D was the nurse that night and she received the medications from the pharmacy. Staff A stated she rubberbanded the 2 cards of oxycodone / acetaminophen together in the cart. Staff A stated the oncoming nurse was Staff B and she counted the narcotics with her at 10:00 PM on [DATE] when she came in. Staff A stated at that time there were 60 tablets total with 30 on each prescription card. Staff A explained the narcotics count sheet for the medication had the pharmacy sticker on it. Staff A stated she came back in at 6:00 AM and worked the cart on Sunrise hall. Staff A stated before she left for the day at 2:00 PM she was asked about the narcotics sheet. Staff A stated she was asked if there was a sticker on it. Staff A stated there was a sticker in place and there were 60 when she signed it in. Staff A stated she then received a phone call from the Assistant Director of Nursing (ADON) and the Administrator asking her about her signature and she stated it was not her signature on the count sheet for Resident #6's oxycodone / acetaminophen either. Staff A explained the narcotics were missing from the Skyline hall. Staff A said Staff C was the CMA on the medication cart [DATE] on Skyline hall. Staff A stated when she was the CMA on the medication cart she would count the narcotics with the oncoming nurse. Staff A stated usually on Skyline hall on overnight to day shift it is a nurse to medication aide or medication aide to nurse. Staff A explained Staff B would have counted with Staff C. Staff A said the evening shift of [DATE] was Staff E, CNA/CMA and that was when she was called into the office. Staff A stated she did not know what had happened to the medications. Staff A said she told the ADON if there was a need for a new sheet she was working then she should have been called over to sign the sheet herself. On [DATE] at 3:07 PM Staff E stated she was working on [DATE] and [DATE]. Stated she was working on [DATE] and reported the missing narcotics for Resident #6. Staff E stated she completed the count with someone but did not remember who it was. Staff E stated the other CMA signed the narcotics sheet but she refused to sign it because it was not correct. Staff E explained the CMA that she counted the narcotic medications with said the count was correct and left to go home. Staff E stated she then went down to the ADON's office and told her the count was not right, it was off by a whole card of 30 narcotics. Staff E stated it was a twice a day medication and the box at the top of the sheet was not there. Staff E said it was hand written and not a sticker like normal. Staff E stated she asked why it was hand written. Staff E stated the CMA stated she spilled a liquid medication on it and had to write another one. Staff E explained the CMA that worked before her had written all the signatures on the narcotic sheet for all the staff. Staff E stated the ADON asked how she knew the count was off . Staff E stated the paperwork was different and the original paper said 60 as a count and there was not 60. Staff E stated the medication was twice a day and there should have been 2 medication cards. Staff E stated if the narcotic medication was twice a day or three times a day the pharmacy sends a 30 day supply. Staff E stated the ADON then checked all of the medication carts in the building and checked them again. Staff E stated they then checked the trash cans and the shred bins. Staff E stated it had been 24 hours and none of the trash had been picked up yet. Staff E explained the staff could not find the original count sheet or the medication cards. Staff E stated the CMA stated she had thrown the count sheet in the trash. Staff E stated the Administrator climbed through the dumpster and found nothing for the missing narcotics. Staff E stated she thought someone had to have taken the medications somewhere. Staff E stated the paperwork was gone that was why she knew it was staff that had taken the medications. Staff E stated when the count was completed one person looked at the narcotics book and one looked at the narcotic medication card. Staff E stated that was to make sure things are correct. Staff E stated if there was a CMA then she would count with a CMA. On [DATE] at 3:10 PM Staff B, RN stated she worked at the facility last in January working for an agency company. Staff B explained she worked the evening of [DATE]. Staff B said she counted the narcotic medications with Staff A that evening when she came in at 10:00 PM. Staff B stated Resident #6 had two cards of oxycodone / tylenol with 30 tablets. Staff B stated she did not know what the facility usually did but she said why not count both together on one sheet. Staff B stated there were 60 tablets of oxycodone / APAP total. Staff B stated they were counted all together on one narcotics count sheet. Staff B stated the sheet that came with the card had a sticker from the pharmacy with the name of the medication, resident's name and dose of the medication. Staff B stated in the morning on [DATE] she counted all the narcotics and then Staff C double checked the narcotics. Staff B explained the count was completed right there in the open area at the medication cart. Staff B stated there were no concerns and count was correct. Staff B stated Staff C looked at each narcotic medication card but did not count out loud. Staff B stated she was called later that day from the facility. Staff B stated the facility stated oxycodone / tylenol card and count sheet for Resident #6 were missing. Staff B stated she explained that both were there for Resident #6 when she left. Staff B stated she had destroyed narcotic medications once or twice but it was always with 2 nurses. On [DATE] at 12:15 PM Staff F, Registered Nurse (RN) stated she had worked together with Staff C maybe 2 or 3 times. Staff F acknowledged she worked the morning of [DATE]. Staff F explained on that day it was just a normal shift. Staff F stated Staff C went to lunch and returned from lunch. Staff F said at shift switch over time Staff C was filling out a narcotic count sheet. Staff F said Staff C said the narcotic count sheet was not filled out properly. Staff F explained Staff C had said she had spilled a liquid medication on the narcotic count sheet for Resident #6's oxycodone / tylenol medication's previous sheet. Staff F stated she could not remember if Staff C talked to her about an as needed medication that needed to be checked off. Staff F stated Staff C never told her that she was going to destroy any medication. Staff F stated there was a possible medication change that morning. Staff F stated a resident had a medication dosage change and that was why she could not click it off the effectiveness of the medication in the EHR system. Staff F stated the order in the EHR system was probably changed or discontinued and you could not check off the effectiveness for that medication afterwards. Staff F stated she did not remember the medication. Staff F stated when a CMA destroyed a narcotic there would have to be a second signature of the second staff present when the medication was destroyed. Staff F stated now the policy was management was the only person that could destroy a narcotic. Staff F stated it was not commonplace for anyone to destroy a narcotic without a nurse present. Staff F stated Staff C would have counted the narcotics with the previous nurse on the overnight shift, Staff B. On [DATE] at 11:56 AM Staff C said the narcotic medication oxycodone / acetaminophen was not missing and she accidentally destroyed them. Staff C stated [DATE] was like every other day. Staff C stated she did not count the narcotics with Staff B and would have noticed the medication cards were out of order if she did count them. Staff C stated before lunch there was a resident that had an as needed medication and when she tried to click the effectiveness off the EHR / MAR it would not let her do it. Staff C explained the EHR said the medication had been discontinued and she told Staff F, Registered Nurse (RN) that she was going to get rid of it. Staff C said the medications were out of order and she destroyed the wrong medication that day. Staff C stated it was close to lunch time and she was busy and did not tell Staff F that the medication had been discontinued. Staff C stated she forgot about destroying the medication. Staff C explained some time between lunch and 1:00 PM on [DATE] Staff E started doing count. Staff C said she was not doing count with Staff E and that was when she realized she did not tell Staff F. Staff C stated she was prideful and did not say anything until she had left. Staff C explained she told the ADON at that time what had happened. Staff C stated destroying narcotic medications without a nurse or second CMA present happened all the time. Staff C stated she had seen other nurses do the count sheet the same so she did the count sheet over. Staff C stated she did not have to write any signatures for anyone else. Staff C stated she did not [NAME] anyone's signatures on the oxycodone / acetaminophen count sheet she wrote on. Staff C explained she did not recall forging any signature. Staff C stated the new count sheet was a whole new paper. Staff C stated when she destroyed the narcotic she threw the bubble pack away in the garbage on her medication cart and put the top of the medication card with the resident's name in the shred bin. Staff C stated she did not remember if there were any required signatures for the destruction of the narcotic. Staff C said Resident #6's medication was destroyed. Staff C stated if she would have completed the count that morning with Staff B she would have noticed the medication cards were not together. Staff C stated she had worked as the main medication aide on skyline hall on [DATE] and that was the hall she normally passed medications on. Staff C stated she was aware the medication was twice a day, Resident #6 had 2 cards of oxycodone / tylenol, when new cards were brought in there might be 3 and the 2 were rubberbanded together. Staff C stated she did not remember if there were numbers written on the medication cards but the pharmacy always sent 2 cards for Resident #6 of the oxycodone / tylenol. Staff C acknowledged she did not do the 3 checks before destroying the medication. Staff C stated the 3 checks were right resident, right medication and right dose. Staff C explained she did not remember the medication that was popping up that required effectiveness that she thought originally was discontinued or the residents name. Staff C stated she did not know how that had resolved on the computer. Staff C said the as needed medication must have been given on the overnight or the PM shift. Staff C said upon further inspection she found out the dose had changed and had not been discontinued. Staff C stated she did not tell Staff F of her mistake. Staff C said she pulled the narcotic card out and put the tablets in the drug buster right next to where the printer would be in the medication room. Staff C stated she ripped off the top of the narcotic medication card and put it in the shred bin. Staff C stated she took the trash out right before lunch and if the Administrator, Director of Nursing (DON) or the ADON would have gone through the garbage sacks they would have found the count sheet. Staff C stated it was not uncommon for medication aides to destroy narcotics by themselves. Staff C explained she did not look at the name on the medication card and just destroyed the medication. Staff C stated the facility did not take her statement and she did not hear anything until she was terminated. On [DATE] at 12:38 PM the DON stated when narcotics were destroyed 2 nursing staff must be present. The DON stated the 2 staff will remove the medications, count the medication and dump them in the drug buster container. The DON stated the drug buster was kept in the medication room. The DON stated there is not a drug buster on the medication carts. The DON explained on [DATE] all the carts were checked and the ADON and her went back through all the medication cards to ensure the medication was not anywhere. The DON stated then the Administrator went through the trash can and the dumpster looking for any of the medication cards or the medication count sheet for Resident #6's oxycodone / acetaminophen. The DON explained Staff C said she had spilled liquid medication on Resident #6's oxycodone / acetaminophen count sheet, had falsified the signatures, then came back and said she destroyed the medication. The DON stated Staff C explained she had done by herself before which the facility had determined that was not true. The DON stated they searched the recycle bin and the top of the medication card was not anywhere in there. The DON said the medication card was not in the trash either. The DON explained Staff C had switched the count from 60 to 30 and that was why Staff E that had come on the shift noticed it. The DON stated Staff E was the CMA that found the difference in the medication count. The DON stated Staff E went to the ADON, reported the count difference, the ADON went to the narcotics drawer, called the DON, asked for more direction and asked when the oxycodone / acetaminophen was delivered for Resident #6. The DON stated the oxycodone / acetaminophen for Resident #6 had to have been removed from the facility. The DON stated she expected the medication would have been present with the appropriate quantity. On [DATE] at 12:40 PM the Administrator stated Resident #6's oxycodone / acetaminophen prescription was replaced by the facility at the cost of the facility. The Administrator stated Staff C was suspended immediately upon discovery of the discrepancy and later terminated after the incident was investigated. The Administrator stated she had searched all garbage at the facility including the dumpster. The Administrator stated the medication, the medication card and the medication countsheet for Resident #6's oxycodone / acetaminophen was never found. The Administrator stated the medication had to have been removed from the facility.Review of policy provided by the facility dated [DATE] titled, Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy documented all residents had the right to be free of abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Dependent adult abuse was defined under Iowa law. Any of the following as a result of the willful misconduct or gross negligence or reckless acts or omissions of a caretaker, taking into account the totality of circumstances. Exploitation of a dependent adult. Exploitation means a caretaker knowingly obtains, uses, endeavors to obtain to use or who misappropriates a dependent adult's funds, assets, medications, or property with the intent to temporarily or permanently deprive a dependent adult of the use, benefit or possession of the funds, assets, medication or property for the benefit of someone other than the dependent adult.

Based on observation, clinical record review, staff interviews, and policy review the facility failed to protect a resident from possible accidents and injuries for 1of 2 residents (Resident #38). The facility failed to provide adequate supervision to prevent elopement. On 7/20/25 between 4:30-4:40 PM the staff last saw Resident #38 standing by the front door where visitors were exiting. The door alarm sounded with Staff A responding to the alarm but he failed to locate Resident #38 and went back to his previous duties being unaware Resident #38 was outside. On 7/20/25 at approximately 5:00 PM Staff B looked out the dining room window and observed Resident #38 walking down the sidewalk past the facility, near the bridge over a creek, towards a high traffic 3 lane street with a speed limit of 35 miles per hour. The upcoming 3 lane street did not have a side walk on the side Resident #38 was walking towards. The State Agency informed the facility on 10/1/25 at 12:10 PM of the Immediate Jeopardy (IJ) that began on 7/20/25. The immediacy was removed on 7/21/25 when the facility completed the following: Door Alarm Response Policy (11/2/18) training.Missing Resident Policy (12/21/18) training. Elopement Response Drill training.The facility reported a census of 90 residents. Findings include: The Minimum Data Set (MDS) for Resident #38 dated 5/19/25 identified a Brief Interview for Mental Status (BIMS) score of 5/15 which indicated severe cognitive impairment. The MDS documented diagnoses that included: hypertension, renal insufficiency, thyroid disorder and Alzheimer's Disease. Resident #1 was independent with transfers and ambulation. The document disclosed the resident exhibited wandering behavior 1-3 days during the assessment period and wore a wander/elopement alarm.The Care Plan dated 9/15/25 identified a wandering focus area dated 5/14/25 with staff interventions to ensure a pathway for following, monitoring for signs/symptoms of urinary tract infection and use of a Wander Guard (5/14/25). Additional interventions of escorting the resident to and from activities and staff to attend all activities to redirect the resident when necessary was added on 7/21/25. The document contained a focus area for impaired cognition related to Alzheimer's dated 5/27/25 with interventions of keeping a consistent routine and escorting to/from activities revised 9/10/25. The Wandering Risk assessment dated [DATE] revealed Resident #38 had a score of 10/16 indicating a high risk to wander. The areas identified on the document included the resident was ambulatory, had a history of wandering, and a medical diagnosis of dementia/cognitive impairment. The document contained comments that on the date of the entry the resident had been wandering the halls today, almost went through a set of doors that set off alarms. Resident is independent with ambulation and could be mistaken for a non-resident and make her way out of the building in certain circumstances. The Morse Fall Scale dated 5/12/25 revealed a score of 60/125 indicating a high risk for falling. The document identified the resident had fallen within the past 3 months, did not use ambulatory aids, impaired gait (uses furniture as assistance, keeps head down when walking) and overestimates or forgets own limitations. A facility investigation revealed on 7/20/25 Resident #38 was assisted to the main floor chapel (resident resided on the lower floor) for church with no staff members present. At 4:30 PM staff were paged to the chapel to assist residents back from church. Between 4:30 PM - 4:40 PM Staff L, Dietary Aide, observed the resident standing by the front door and exit the building with visitors. Staff L stated an alarm did sound, but thought it was due to the visitors not entering the door code. Staff L stated she saw Staff A, CNA, respond to the door alarm. Staff A stated he only saw visitors outside. At approximately 4:45 PM Staff B, Certified Nurse Assistant (CNA), and Staff M, CNA, observed the resident walking along the sidewalk next to the facility parking lot. The staff were able to direct the resident back inside. The resident was wearing tennis shoes, scrub pants and a sweatshirt. All Wander Guards and door alarms were tested on [DATE]. A Progress Note entry dated 7/20/25 at 3:29 AM revealed the resident exhibited wandering behavior by walking the hallways on the first floor. Review of the weather on 7/20/25 using the World Weather revealed the temperature was +88 with a real feel +100 with 70% humidity.Review of the facility's Door Logs 6/30/25 to 10/1/25 revealed the following: The facility kept weekly logs of door checks.The facility consistently did not check doors on Sundays with the exception of 7/20/25 when the resident eloped and the doors were checked after the elopement.The door alarms were not checked on 7/19/25 the day prior to the elopement. The door alarms were not checked on 7/31/25 and 8/1/25. Observation on 10/1/25 revealed the facility was located on a residential east/west road on a hill with a speed limit of 25 MPH with a sidewalk that ran along the street in front of the facility. Going down the sidewalk along the street, one walked in front of the facility towards a 3 lane road with a speed limit of 35 MPH. Prior to reaching the road pedestrians were required to cross a bridge over a water flow way. The 3 lane road did not have a sidewalk closest to the facility. On 10/1/25 at 8:55 AM Staff B stated on 7/20/25 at approximately 5:00 PM she was in the lower dining room helping residents get ready for supper, when she looked out the window and saw Resident #38 walking down the sidewalk closest to the street near the fire hydrant and walking towards the 3 lane road. The staff stated she had Staff M go with her out the emergency door to get the resident. The staff stated the resident was near the fire hydrant when they reached her. The staff stated the resident indicated she was hungry and going for a walk to go to dinner. The staff stated they walked the resident back up the hill and came in the main door of the facility. Staff B stated she did not recall an alarm going off for the Wander Guard system prior to the resident's elopement. The staff stated when the Wander Guard alarm goes off it would go overhead on the call light system for the entire building for the specific door and what resident has exited. On 10/1/25 at 11:15 AM Staff E, Licensed Practical Nurse (LPN), stated on 7/20/25 he was working on the lower floor where the resident resided and was notified by staff of the elopement. The staff reported the church volunteers took the resident upstairs for the service and did not return her. The staff stated he did not observe the resident outside. Staff E stated he had checked her Wander Guard monitor and it was functioning. The staff stated the doors should lock when a resident was within 3 feet of the door and staff have to enter the door code and wander guard code to exit. On 10/1/25 at 11:35 AM Staff N along with the Receptionist demonstrated how the Wander Guard system worked with the main doors using a Wander Guard monitor. When the staff approached the main door with the monitor the doors would lock and the alarm wound sound. If the door code was entered with the monitor greater than 3 feet away the door would open without an alarm. If while the door was open and the monitor came closer to the door the alarm would sound and continue to sound until it was disarmed. On 10/1/25 at 12:35 PM Staff A stated he was working on the main floor on the date of the elopement. The staff stated the door alarms had been going off frequently that day due to visitors not entering the door code prior to exiting. The staff stated the alarm that went off when the resident eloped was the door alarm, not the Wander Guard alarm system. The staff stated he was not aware of a resident going out the door until much later. The staff stated when he came to the front door Staff L was attempting to shut the door alarm off. Staff A stated when the Wander Guard alarm went off a XD number code was revealed on the call light screen in the hallways indicating it was the Wander Guard. The staff stated when the alarm went off at the time of elopement the screen revealed R meaning right main door. On 10/2/25 at 8:00 AM the Administrator stated she would need the facility's policy regarding the frequency of doors to be checked. The Administrator expected staff to respond and follow the policies for door alarms and missing residents. The facility's Elopement Awareness Protocol, 7/21/22, provided door alarm checks and Wander Guard/Code alert checks were to be completed Monday through Saturday and Elopement Drills were to be completed routinely and documented. The facility's Door Alarm Response, 11/2/18, revealed staff were to immediately respond to the door that was sounding, walk outside, and scan the grounds to identify the source of the alarm. The document revealed if the source of the alarm was not identified, account for all residents and if a resident was unaccountable to initiate the missing resident policy.

Based on observation, clinical record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices by not donning appropriate Personal Protective Equipment (PPE) or completing appropriate hand hygiene when personal care was completed and failed to provide appropriate infection prevention practices for waterborne pathogens for 5 of 24 residents reviewed (Resident #5, #8, #35, #89 and #77). The facility reported a census of 90 residents. Finding include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #8 documented a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. The MDS indicated Resident #8 had a stage 4 pressure ulcer. Review of Resident #8's Medication Administration Record (MAR) documented a physician's order to cleanse coccyx wound with wound cleanser, apply collagen rope or collagen strip to wound tunnel, lightly pack, once every 3 days and as needed for wound care. Review of Resident #8's EHR titled, Orders documented physician's orders to cleanse coccyx wound with wound cleanser, apply collagen rope or collagen strip to wound tunnel, lightly pack, once every 3 days and as needed for wound care. On 10/2/25 at 7:41 AM an observation revealed a dressing change completed on Resident #8 by Staff G, Wound Care Nurse. Staff G completed hand hygiene, applied gloves, lowered Resident #8's head of bed to comfortable position, removed saturated dressing from coccyx, serosanguinous drainage noted on old dressing, cleansed area with wound cleanser, a dime sized area right on tail bone measures 1cm x 1cm x 3cm, Resident #8 acknowledged no pain at the area, Staff G did not change gloves or complete hand hygiene, collagen rope packed loosely into wound, dressing applied over wound, removed gloves, and completed hand hygiene. On 10/2/25 at 3:23 PM the DON stated the facility's expectation was hand hygiene would have been completed and gloves would have been changed after the wound was cleansed before applying a new treatment and dressing. 2. Resident #5's (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12/15 indicating mild cognitive impairment and had an indwelling catheter for bladder elimination. The MDS listed the resident as dependent on staff for toileting and transfers. Observation and interview on 10/01/2025 at 2:58 PM, Staff Q, CNA and Staff R, CNA in Resident #5's room without PPE gowns on. Staff R exited the room, and stated Staff Q and she had transferred the resident with a full body lift from the recliner to his bed. Staff R stated she did not wear a gown while transferring the resident. Staff Q remained in the resident's room, touching bed linens and placing the call light on the resident's blanket, without a gown on. Staff R stated the resident was on EBP for his catheter, and would wear gown/gloves only if emptying the urinal and when queried about the Contact Precautions sign outside the resident's room, Staff R stated staff should wear PPE for any contact with urine. EBP and Contact precautions sign posted outside the resident's room. Resident #5's Order Summary Report revealed an order for EBP due to foley catheter with order date 9/26/25. Resident #5's Care Plan revealed the following: Focus: Resident has need for Enhanced Barrier Precautions related to indwelling catheter, multi-drug resistant organism (MDRO) colonization. Date Initiated: 8/25/25. Interventions: Gown and gloves to be worn for high contact activities, have PPE available for staff near the entrance to the resident's room, maintain signage on/outside resident's door regarding precautions needed, required PPE, and high-contact resident care activities. Date Initiated: 8/25/25. Interview on 10/1/25 at 12:30 PM, Staff T, LPN and Infection Preventionist stated EBP required when residents have MDRO, catheter, port/ fistula (under skin access to veins), and chronic wounds and EBP would require PPE of gown, gloves, and if possibility of fluids would need goggles and mask for direct care. Staff T further stated if staff were doing oral care for a resident and the resident had a catheter, she wouldn't expect staff to wear PPE and if the resident has a catheter, only need to wear PPE when doing catheter care. Staff T stated with contact precautions staff need to wear a gown and gloves before entering the room, and was unaware if a resident on contact precautions can go out to the dining room. Interview on 10/1/25 at 12:53 PM, Staff S, CNA stated with contact precautions any contact with the resident requires gloves, gown, and mask and with EBP for UTI, something/infections that can spread and catheters staff would need to wear a gown and gloves with any direct contact with the resident. 3. Resident #77's MDS list revealed the resident was admitted on [DATE] and the MDS was was in progress. Resident #77's Order Summary Report identified an order for EBP due to foley catheter dated 9/26/25. Resident #77's Care Plan revealed the following: Focus: Resident has need for Enhanced Barrier Precautions related to indwelling catheter. Date Initiated: 9/24/25. Interventions: Gown and gloves to be worn for high contact activities, have PPE available for staff near the entrance to the resident's room, maintain signage on/outside resident's door regarding precautions needed, required PPE, and high-contact resident care activities. Date Initiated: 9/24/2025. Observation on 9/29/2025 at 3:12 PM, Resident #77 in bed and a staff member, without a gown or gloves, entered the resident's room, answered the call light, touching covers on the resident, raised the resident's head of bed, and provided the resident a drink. 4. Resident #35's MDS dated 9/825 revealed a BIMS score of 15/15 indicating normal cognition. The document revealed diagnoses of a pressure ulcer of the left (L) buttock, Stage 4 and encounter for surgical aftercare for surgery of the nervous system, other fracture. The document disclosed the resident had a Stage 4 Pressure Ulcer meaning full thickness tissue loss with exposed bone, tendon or muscle and often includes undermining and tunneling. Resident #35's Care Plan dated 9/24/25 revealed a focus area of actual pressure ulcer related to moisture and present upon admission (initiated 8/27/25 and updated 9/9/25). Interventions included assess ulcer, and stage, treatment as ordered, repositioning, and pressure reduction cushion to chair initiated 8/27/25. A second focus area identified potential for nutritional problems due to Stage 4 Pressure Ulcer to L buttock (08/28/2025). Interventions for staff included supplements as ordered, notify the provider of any significant weight change and Pro Stat twice daily (BID) (8/28/25). A focus area identified EBP related to wound with wound vac (8/29/25) with the following interventions: gown and gloves to be worn for high contact activities, have PPE available for staff near the entrance to the resident's room and maintain signage on/outside resident's door (8/29/25). Resident #35's 9/25 Treatment Administration Record (TAR) revealed A. Vashe Wound Solution Therapy 475 ml use with a compress prior to dressing change on Monday, Wednesday and Friday - start date 9/27/25. B. Change wound vac on Monday, Wednesday and Friday. Vac to be set at 125 mm Hg every evening shift every Monday, Wednesday and Friday - start date 9/15/25. Observed on 9/29/25 at 10:24 AM signage for EBP outside Resident #35's room. Continuous observation began on 9/29/25 at 4:18 PM of Staff G performing wound care to Resident #35's Stage 4 Pressure Ulcer A. Staff G donned a gown in the hallway and sanitized bandage scissors at the treatment cart. B. Staff I, CNA, brought the resident into the room from a shower not wearing any PPE. The CNA donned gloves once in the room and assisted the resident with donning of non-slip socks for transfer from the shower chair to bed. C. Staff I did not don a gown or complete hand hygiene. D. Staff G stated she needed the Vashe Wound Solution from another cart and walked down the hall with the gown on to obtain supplies. E. Staff G entered the resident's room , placed the items on table donned gloves without hand hygiene and without changing gown. F. The staff transferred the resident to the bed using a Sit to Stand lift. G. Staff I remained in the room assisting with positioning the resident while wound care was completed. H. Staff G completed peri care with glove changes and hand hygiene. I. Staff G removed the dressing and packing, removed gloves, and washed hands. J. stated she did not have 4x4's and needed to go get them. The staff left the room wearing the gown to obtain the supplies and returned with 4x4's. K. Staff G donned gloves without hand hygiene or changing gown. L. Staff G applied the Vashe to the 4x4's and packed into the wound for 5 minutes, gloves changed without hand hygiene. M. Staff G completed peri care with glove changes and hand hygiene. N. Staff G applied Skin Prep, removed gloves, opened wound vac packaging, and donned new gloves. No hand hygiene. O. Staff I removed gloves, left the room, obtained a new bed pad, and donned new gloves with no hand hygiene. P. Staff G removed the gauze at 5 minutes with scant blood noted on the gauze, cut the foam packing to fit the wound, the wound vac dressing, touched her glasses, removed the wound vac tubing, completed the dressing, assisted Staff I with dressing the resident and then removed her gloves. No glove changes occurred during this sequence. On 10/1/25 at 5:45 AM Resident # 35 stated the staff did not wear gowns when assisting him with his personal care. On 10/2/25 at 12:34 PM the Infection Preventionist (IP) and MDS Coordinator, stated EBP would be used for anyone with chronic wound, catheter, any port - with direct care, wound care, changing linens, catheter cares. The IP stated EBP included the use of a gown, gloves and if there was fluid involved goggles and masks. The IP expected during wound care that glove changes would include hand hygiene. The IP stated staff should wash their hands before doing anything, apply clean gloves, provide a clean setup, change gloves with hand hygiene, and end with hand hygiene. The IP stated the expected staff to change their gown and not wear it outside the resident's room. On 10/2/25 at 1:17 PM the DON stated she expected staff to use a clean gown and gloves when entering a resident's room and to remove them when exiting a room. The staff stated a new gown and gloves were to be applied if returning to the room. The DON expected hand hygiene to be completed with glove changes. 5. Resident #89's MDS dated [DATE] revealed a BIMS score of 15/15 indicating normal cognition. The document revealed diagnoses of obstructive uropathy, Non-Alzheimer's Dementia, anxiety, hypokalemia and benign prostatic hyperplasia with lower urinary tract symptoms. The MDS indicated the resident had an indwelling catheter. Resident #89's Care Plan dated 9/24/25 revealed a focus area of requiring a urinary catheter related to diagnosis of obstructive uropathy (revision 5/28/25) with staff interventions of keeping a closed system as much as possible, measure and record output and catheter care BID and PRN (5/6/25). An EBP related to indwelling catheter for obstructive uropathy focus area (revised 9/24/25) contained interventions of gown and gloves to be worn for high contact activities (7/31/25), PPE available for staff near the entrance to the resident's room (7/31/25), signage on/outside of door (7/31/25), resident prefers to wear overnight foley bag and staff encourages resident to wear leg bag during the day and ask for assistance for draining (8/14/25). Observed on 9/29/25 at 10:31 AM Resident #89's catheter bag, no dignity bag, lying on the floor while the resident was sitting on his recliner. The resident had EBP signage outside of his door. Observed on 9/29/25 at 3:52 PM Resident #89 lying in bed with the catheter bag without a dignity bag lying on the floor. Continuous observation on 10/1/29 began at 6:11 AM of Staff J, CNA, completing catheter care on Resident #89. A. Resident #89 was lying on the bed with his catheter bag hanging in a dignity bag on the side of the bed. B. Staff J applied hand sanitizer prior to entering the room. C. Staff J went into the bathroom, sanitized hands, donned a mask, gown, gloves, and obtained a graduate cylinder. D. The staff placed the graduate cylinder on the floor without a barrier and obtained alcohol prep pads. E. The staff noted that they did not have all necessary items, removed PPE, and left the room. F. Upon return to the room, Staff J completed hand hygiene, and donned all PPE. G. Staff J completed wiping of the catheter tubing with an alcohol prep pad, emptied the catheter bag with splashing onto the floor, wiped the tubing with a new alcohol prep pad and closed the catheter. H. The staff completed peri care with correct techniques. I. The staff emptied the graduate cylinder, removed PPE and completed hand hygiene. Observed on 10/2/25 at 9:30 AM Resident #89 seated on the recliner with the catheter bag hanging off the trash can. On 9/29/25 at 10:31 AM Resident #89 stated staff do not wear gowns in his room while emptying his catheter or assisting him with care. On 10/2/25 at 12:34 PM the IP and MDS Coordinator, stated they expected the following during catheter care: a barrier to be used with the graduate cylinder, trash bag, graduate cylinder, alcohol prep pad to be used when the tubing was disconnected, empty the catheter, alcohol prep pad to wipe the tubing, reconnect the tubing, and carry the trash bag with the graduate cylinder to the bathroom to get a measurement and empty. The IP expected the catheter bag to not be on the floor or hanging off of a trash can. On 10/2/25 at 1:13 PM the DON stated she expected catheter bags to be kept in a privacy bag and not on the floor. 6. On 9/30/25 at 8:35 AM Staff K, Maintenance, provided the diagrams of water flow, the Legionella Policy, Water Temp Logs and Water Flush Logs. Review of the Water Temperature Logs with Staff K noted the logs were completed weekly; however the entire month of September did not have any logs present. Review of the Water Flush Log found the months of April and September were not present. Staff K stated he would follow up with the Maintenance Supervisor and the Administrator regarding the missing logs. On 9/30/25 at 9:25 AM the Administrator acknowledged she was aware of missing flushing logs for April and September and they were trying to locate them. On 10/1/25 at 6:08 AM the Administrator stated the missing logs were not located. The Administrator stated the Maintenance Director stated they had been completed but no one was able to locate them. On 10/2/25 at 7:02 AM the Administrator expected the Water Flushing Logs and Water Temperature Logs to be completed. The facility's Hand Hygiene - Center for Disease Control (CDC) Guidelines, updated 1/27/22, revealed staff should use an alcohol-based hand rub or wash with soap and water prior to touching a resident, before moving from dirty to clean task, after contact with blood/body fluids/contaminated surfaces and immediately after glove removal. The facility's Catheter Care Policy, revised 8/20/24, revealed staff should place a towel on the bedside table as barrier and set supplies on the work area, place a towel under the catheter tubing, tubing and bag should not touch the floor and the catheter bag must be covered with a dignity cover when visible. The facility's Transmission-Based Precautions (Isolation Precautions), updated 6/5/24, contained a reference to EBP indicating it was an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The document identified residents who had an infection or colonization with a CDC-targeted multidrug-resistant organism (MDRO), chronic wounds and indwelling medical device. PPE identified in the document included gloves and gown which were to be removed and hand hygiene performed prior to leaving the resident-care area. The document identified the following high-contact areas: dressing, bathing/showering, device care and wound care. The U.S. Department of Health and Human Services Centers for Disease Control and Prevention EBP sign outside of residents' rooms revealed providers and staff must wear gloves and gown during high contact resident care activities including dressing, bathing, transferring, hygiene, changing briefs or assisting with toileting, and wound care. The facility's Legionella Prevention Water Management Plan, dated 8/1/17, identified a risk management approach to identify control limits of water flow rate, temperature and disinfectant residual. The document indicated a member of the Water Management Team will monitor the control locations and limits routinely. A facility document, Hazards/Control Measures/Corrective Action Legend, in the Water Flushing Log Book revealed water temperature should be checked weekly at varying locations in hot water distribution 60 seconds after flushing. The document further revealed that for stagnation the facility should have a weekly flush at terminal ends unused for 7 days.

Based on observations, resident and staff interviews, document reviews and policy review the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 6 of 27 residents reviewed (Resident #35, #42, #10, #30, #50 and #76). The facility reported a census of 90.Findings include: 1. Resident #35's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The document listed Resident #35 as frequently incontinent of bladder and bowel. The MDS listed the resident as requiring substantial/maximal assistance for toileting hygiene, bed mobility and transfers. Resident #35's Care Plan dated 9/24/25 revealed an Activities of Daily Living (ADLs) focus area, revised 9/9/25, with interventions of assisting with cares (9/3/25), bilateral bed rails (9/3/25), and reporting further deterioration to provider (9/3/25). The document included a urinary incontinence focus area dated 9/9/25 with interventions including incontinence care following each incontinence episode (9/9/25), report signs and symptoms of urinary tract infections (UTIs), and assist to toilet (9/9/25). On 9/30/25 at 2:46 PM Resident #35 stated call lights take a long time to be answered, sometimes longer than 15 minutes. The resident stated staff will come in at times, shut the call light off, say they will return and then do not. The resident stated he has been late to activities due to staff not answering his call light. On 10/1/25 at 5:45 AM Resident #35 stated he has been late to activities due to staff not answering his call light. 2. Resident #42's MDS dated [DATE] revealed a BIMS score of 15/15 indicating normal cognition. The document listed Resident #42 as frequently incontinent of bladder and bowel. The MDS provided the resident required substantial/maximal assistance with toileting hygiene, and transfers. Resident #42's Care Plan dated 9/25/25 revealed an ADL focus area (7/24/25) that included interventions with providing assistance with care, allowing extra time to complete ADLs and reporting further deterioration to the provided (7/24/25). The document contained a focus area of at risk for skin breakdown related to incontinence and impaired mobility (revised 9/25/25) with interventions of keeping areas clean and dry as possible, minimize skin exposure to moisture (7/24/25) and skin treatments as ordered (9/25/25). On 9/29/25 at 10:38 AM Resident #42 stated it would take 45 minutes or longer to answer call lights. The resident stated the staff would answer the call light and then leave with statements of takes 2 to get you up, can't get you up as we are assisting other residents either to or from the dining room, or we have reports to do. The resident stated assistance at night was limited. Resident #42 revealed she has had incontinence episodes due to staff not answering her call light and that it makes her mad and uncomfortable. 3. Resident #50's MDS dated 926/25, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The MDS identified a diagnosis of a stroke and dependent on staff for toileting and transfers. Interview on 9/29/2025 at 11:21 AM, Resident #50 stated he was at the facility receiving therapy after a stroke, was doing therapy daily, and it usually takes 30 minutes for the staff to answer his call light. 4. Resident #76's Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 15/15 indicating normal cognition. The document listed the resident as occasionally incontinent of bladder and required substantial/maximal assistance for toileting hygiene, bed mobility and transfers. Interview on 9/29/2025 at 3:41 PM, Resident #76 stated staff come in and talk to each other or look at their phone and can wait 1 1/2 - 2 hours for them to answer the call light, days and evenings are the worst, nights is better. Resident stated she times it with the clock on her wall. 5. Observation on 9/30/2025 at 4:27 PM, Staff U, Certified Medication Aide sitting at the Nurses' Station on a cell phone. Staff O, LPN instructed Staff U to go see if the other staff needed assistance. Review of document titled, Alarm Response Report provided by the Administrator revealed: a. room [ROOM NUMBER] had call lights with a response time of longer than 15 minutes from 9/24/25 - 10/1/25 on: 9/25/25 at 6:35 PM 24 minutes and 09 seconds. 9/27/25 at 6:50 PM 17 minutes and 25 seconds. 9/28/25 at 7:19 PM 18 minutes and 02 seconds. 9/29/25 at 8:46 AM 25 minutes and 04 seconds. 9/29/25 at 5:01 PM 19 minutes and 32 seconds. b. room [ROOM NUMBER] had call lights with a response time longer than 15 minutes from 9/24/25 - 10/1/25 on: 9/24/25 at 6:43 PM 27 minutes and 11 seconds. 9/25/25 at 4:51 PM 16 minutes and 55 seconds. 9/26/25 at 12:54 AM 23 minutes and 36 seconds. 9/26/25 at 4:30 PM 1 hour and 58 seconds. 9/26/25 at 7:20 PM 15 minutes and 39 seconds. 9/26/25 at 7:36 PM 30 minutes and 2 seconds. 9/28/25 at 7:07 AM 39 minutes and 27 seconds. 9/28/25 at 7:24 PM 21 minutes and 38 seconds. 9/29/25 at 7:10 PM 22 minutes and 47 seconds. c. room [ROOM NUMBER] had call lights with a response time of longer than 15 minutes from 9/24/25 - 10/1/25 on: 9/24/25 at 4:31 AM 44 minutes and 15 seconds. 9/24/25 at 6:53 AM 17 minutes and 49 seconds. 9/27/25 at 5:42 AM 17 minutes and 7 seconds. 9/27/25 at 6:38 PM 18 minutes and 51 seconds. 9/28/25 at 6:24 AM 18 minutes and 23 seconds. 9/28/25 at 6:28 PM 21 minutes and 15 seconds. 9/29/25 at 5:41 AM 17 minutes and 30 seconds. 9/30/25 at 4:20 AM 18 minutes and 44 seconds. 9/30/25 at 8:29 AM 18 minutes and 42 seconds. d. room [ROOM NUMBER] had call lights with a response time of longer than 15 minutes from 9/24/25 - 10/1/25 on: 9/30/25 at 1:38 PM 22 minutes and 22 seconds. 10/1/25 at 4:50 AM 24 minutes and 34 seconds. On 10/2/25 at 1:45 PM the DON stated the facility's expectation was that call lights would be responded to in less than 15 minutes. On 10/2/25 at 2:00 PM the Administrator stated she expected the call lights would be responded to in less than 15 minutes. The Administrator acknowledged on the Alarm Response Report there were several call light times that were reported longer than 15 minutes. Review of policy dated 10/31/24 titled, Call Light Response documented the objective was to ensure timely and efficient response to resident call lights, enhancing resident safety and satisfaction. Staff members were required to respond to resident call lights within 15 minutes of activation. Call light response data would be recorded and stored for a period of 7 days. This data would be reviewed regularly to identify patterns, improve response times and address any issues related to call light usage.

Based on observations, resident and staff interviews, record review, and policy review the facility failed to complete a significant change comprehensive assessment when a resident had a decline in condition for 1 (Resident #76) of 3 residents reviewed. The facility reported a census of 90 residents. Findings include:The Minimum Data Set (MDS) for Resident #76, dated 7/31/25, included diagnoses of heart and osteoarthritis. The MDS identified the resident was independent with eating, supervision or touching assistance with upper body dressing, substantial/maximal assistance with transfers, toileting and lower body dressing, and was occasionally incontinent of bladder. The MDS indicated the resident had a Brief Interview for Mental Status score of 15, indicating no cognitive impairment for decision-making. Resident's Care Plan, target date 11/7/25, identified the following: a. Focus: Is at risk for decline in activities of daily living (ADLs) with interventions of assist with dressing in the morning, at hour of sleep (HS), and as needed (PRN), assist with positioning PRN with left upper grab to bed to assist with repositioning, assist with toileting before and after meals, HS, and PRN, feeds self after staff set up and assist PRN, with latest revision date of 12/31/24 b. Focus: Is at risk for injury from fall related to impaired mobility with intervention of transfers via full body lift with 2 assist, revised 9/12/25. c. Focus: Resident experiences bladder incontinence related to diuretic (medication to decrease fluid in the body) use and impaired mobility, with interventions to assist to toilet before and after meals, HS and PRN, provide incontinence care after each incontinence episode with date initiated 8/6/25. Interview on 9/30/2025 at 9:41 AM Resident stated she has had a decline in her ADLs, she was moved to the assist to dine table in the dining room as staff have to feed her now due to she can't lift her arms high enough most of the time, she now requires a full body lift to transfer, is incontinent of bladder all of the time since using the full body lift as when they lift her up she goes every time as she is not able to control it anymore, and uses a bedside commode for bowel movements. The resident stated it has been a month or longer since her decline. Observation on 10/01/2025 at 7:40 AM, Staff P, Certified Nurse Aide (CNA) and Staff B, CNA transferred the resident from the recliner to the bed with a full body lift and completed incontinent cares with staff doing the turning for cares without any assist from the resident. Interview on 10/01/2025 at 7:48 AM, Staff P stated the resident has had a big decline since about 1 month ago. Staff P stated the resident has switched to a full body lift from a standup lift as the resident just went numb and wasn't able to stand and be safe, wears dentures and staff clean and give the dentures to her to put in and sometimes she can and sometimes not, moved to assist to dine table for meals and encourage her to feed self, but frequently needs staff to do, and was continent of bladder and bowel and would place on the toilet with the standup lift but is no longer continent of bladder. Staff P stated she is not aware of resident receiving any therapy. Observation on 10/01/2025 at 12:17 PM, Staff P assisting the resident to dine. Staff encouraged the resident to feed self by placing a curved spoon in the resident's hand and scooping food onto the spoon for the resident and the resident was not able to consistently get the spoon to her mouth and the food would fall off the spoon. Interview on 10/01/2025 at 12:41 PM, Staff C, MDS Coordinator stated she reads report every day to see resident changes and any differences with them. Staff C stated the staff have not reported a decline with the resident to her. Staff C stated with the resident changing from independent in the dining room to the assist table, continent to incontinent, and transfer changed from stand lift to full lift a significant change MDS should have been done that she should have noticed after 7 days and started a significant change with the expectation to start significant change 7 days after decline. Facility Comprehensive Assessment and Reassessment, effective 5/10/17, revealed the Resident Assessment Coordinator will ensure the MDS assessment is completed with 14 days of a significant change in status and a significant change in the resident's condition shall require a reassessment with changes in the plan of care reflecting the change of condition.

Based on clinical record review, staff interview, and policy review the facility failed to complete a Pre-admission Screening and Resident Review (PASRR) for 1 of 1 residents (Resident #6), who was diagnosed with new mental disorder diagnoses since admission to the facility. The facility reported a census of 90 residents. Findings include: Review of Resident #6's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7/15 indicating severe cognitive impairment. The document indicated the resident had hallucinations, delusions, verbal behavioral symptoms directed toward others, 1 -3 days during the reporting period, other behavioral symptoms not directed toward others daily, and the resident's behavior was worse than prior assessment. The MDS further revealed diagnoses of Non-Alzheimer's Dementia and psychotic disorder. The document provided the resident took antipsychotic medication. Resident #6's Care Plan dated 6/11/25 contained a impaired decision making focus area initiated 10/14/24 with interventions of explaining procedures and cares prior to initiating, provision of short/simple instructions, and task segmentation as needed initiated 10/14/24. An additional focus area of short term memory impairment and poor decision making abilities due to dementia initiated 3/12/25 provided interventions of assisting with decision making throughout the day and provision of verbal and visual reminders dated 3/12/25. The Care Plan anti-psychotic medication for diagnosis of delusional disorder and yelling out at times dated 3/12/25 referred to interventions of administration of antipsychotic medications, discussion of medications at Care Plan Conference, identification of target behaviors and non pharmacological interventions. The Care Plan failed to identify any PASRR focus area or interventions.The electronic medical record (EMR) Census indicated the Resident #6 admitted on [DATE].The EMR Medical Diagnoses for Resident #6 included:Unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (10/9/24),Delusional disorders (6/6/24)The Clinical Physician Orders printed 10/1/25 listed the following orders:Quetiapine 25 mg 1 tablet daily for delusional disorders, metabolic encephalopathy and unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Quetiapine 25 mg 1.5 tablets at bedtime for delusional disorders, metabolic encephalopathy and unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Target behavior: delusions (talking to people not present), verbally abusive towards staff, yelling/calling out.Review of a facility provided document titled, PASRR Notice of Nursing Facility Approval, dated 3/27/23 revealed a summary of findings indicating that Resident #6 that did not show evidence of a serious mental illness. an intellectual or developmental disability(IDD) or diagnosis of dementia/neurocognitive disorder that appeared to require PASRR intervention. The document included that if changes occurred or new information refuted the findings, a new screen must be completed. The EMR Patient Note for Mental Health dated 1/16/25 included a medical diagnosis of Metabolic Encephalopathy. The document included a psychiatric medication of Seroquel 25 mg.On 10/2/25 at 7:54 AM Staff H, Social Services, acknowledged there was only a Level I PASRR present in Resident #6's EMR and confirmed there was no other documentation related to a PASRR in the resident's soft chart. On 10/2/25 at 8:00 AM the Administrator concurred there was no documentation in the Path Tracker indicating a new PASRR had been submitted. The Administrator stated she thought the facility had fixed all of those, but must have missed this one. The Administrator expected if a resident had a new diagnosis or medication they needed to have new PASRR. On 10/2/25 at 9:01 AM the Administrator indicated the facility did not have a PASRR policy, but followed the regulations.

Based on clinical record review, staff interview, and policy review the facility failed to provide a comprehensive care plan related to high risk medications for residents with an order for diuretics for 1 of 5 residents (Resident #6) reviewed. The facility reported a census of 90 residents. Findings include: Review of Resident #6's Minimum Data Set (MDS) dated [DATE] revealed diagnoses of heart failure, hypertension, Non-Alzheimer's dementia, and psychotic disorder. The MDS further revealed that during the look back period Resident #12 received diuretic medication daily. Review of the Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order for Furosemide 20mg 1 tablet twice daily with a start date of 8/26/25. Review of Resident #6's Care Plan with a revision date of 3/12/25 revealed no documentation of diuretic medications usage.Interview 10/01/2025 at 2:40 PM with Staff C Licensed Practical Nurse (LPN) revealed that diuretics should be in the care plan. Staff C then confirmed that diuretics were not in Resident #6's care plan, and revealed that it should be. Interview 10/01/2025 at 2:42 PM with the Director of Nursing (DON) revealed that her expectation would be for diuretics to be on resident care plans if they were taking the medication. Review of a facility provided policy titled, Detailed Assessment and Reassessment dated [DATE] revealed:a. Detailed care planning will be documented on the resident's plan of care.

Based on observations, clinical record review, staff interviews, and policy review the facility failed to provide needed services in accordance with professional standards by leaving medications in a residents room for 2 of 8 residents (Resident #75 and #78). The facility reported a census of 90 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #75, dated 7/31/25 did not document a Brief Interview for Mental Status (BIMS). Review of EHR titled, Progress Notes dated 8/11/25 revealed a BIMS evaluation with a BIMS of 15. The MDS also documented a diagnosis of chronic obstructive pulmonary disease with acute exacerbation. Observation on 9/29/25 at 10:54 AM revealed a nebulizer machine with clear liquid present and a vial of albuterol sulfate 0.5mg/3mg per 3 mL lying full on Resident #75's bedside table. On 9/29/25 at 10:56 AM Resident #75 stated the nurses occasionally leave the nebulizer medication on the bedside table for the next dose. Resident #75 stated the nurses never clean the nebulizer or mask. Review of Resident #75's Medication Administration Record (MAR) documented a physician's order for ipratropium / albuterol to be inhaled 1 vial per nebulizer 4 times daily and a physician's order for levalbuterol 0.31mg to be inhaled 1 vial per nebulizer 3 times a day as needed (PRN). Review of Resident #75's Electronic Health Record (EHR) titled, Orders documented physician's orders for ipratropium / albuterol to be inhaled 1 vial per nebulizer 4 times daily and a physician's order for levalbuterol 0.31mg to be inhaled 1 vial per nebulizer 3 times a day as needed (PRN). On 9/29/25 at 11:13 AM Staff F, Licensed Practical Nurse (LPN) stated Resident #75 had 2 different breathing treatments. Staff F explained one breathing treatment was 4 times a day and the other was PRN 3 times a day. Staff F acknowledged she was the nurse that administered the breathing treatment this morning. Staff F acknowledged she did not clean the nebulizer. Staff F stated she liked to at least rinse the nebulizer out after every treatment. Staff F explained she administered the PRN treatment to Resident #75 that morning. Staff F stated Resident #75 refused the albuterol breathing treatment. Staff F acknowledged she left the albuterol on Resident #75's bedside table. Staff F stated she did not think that Resident #75 had any self administration orders. On 10/1/25 at 3:15 PM the DON stated during the incident with Resident #75's medication being left in the room she would like to have seen the mask cleaned after use. The DON stated the facility's expectation was the albuterol would have been returned to the medication cart as long as it had not been opened if the medication was refused and documented in the MAR. 2. The MDS for Resident #78, dated 8/14/25, included diagnoses of Non-Alzheimer's Dementia and depression. The MDS indicated the resident had a BIMS score of 12, indicating mild cognitive impairment for decision-making. Resident #78's Care Plan, revised 11/22/24, revealed10/01/2025 10:07 AM Care Plan, target date 11/14/25, identified a focus of: I have short term memory impairment and poor decision-making abilities at times with the goal to make daily decisions regarding my care with limited assistance or cueing from staff. The Care Plan lacked any documentation of self-administration of medications. Observation on 9/29/2025 at 1:47 PM, Resident #78 was lying in bed and a cup with 3 pills was sitting on the bedside table. The resident stated the pills were Tums and he needed them available for when he wants them. The resident stated the staff leave the pills for him. Interview on 9/29/25 at 2:15 PM, Staff O, LPN confirmed the 3 pills were Tums and stated she had observed the pills there the day before when she had worked 6 AM – 6 PM. Staff O stated she did not give them to the resident but thinks he has an order to have the pills. Staff O was unable to provide an order for the medications at bedside. Interview on 10/01/2025 at 9:53 AM, Staff I, Certified Medication Aide stated medications are to be given to the resident, observe until the resident swallows the medications, and would not leave any medications at a resident's bedside. Staff I confirmed the resident does not have an order to leave medications at the bedside. Staff I further stated she has observed Tums in a cup on the resident's table before, approximately 2 months ago but was not aware who left them for the resident. Facility Medication Administration policy, revised 6/30/23, revealed medications shall be stored in a locked medication cart and/or medication room with the procedure when administering to identify the resident, administer medication, assure resident has taken the medication.

Based on clinical record review, family interview, staff interviews, and policy review the facility failed to ensure the residents were free of significant medication errors to 1 of 4 residents reviewed (Resident #38). The facility reported a census of 90 residents. Findings include: Review of Resident #38's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. The MDS further revealed diagnoses of hypertension, renal insufficiency, and Alzheimer's disease. Interview 9/29/25 at 3:25 PM with Resident #38's family member revealed that Resident #38 received another resident's medication in addition to Resident #6's own medications. The family member revealed that Resident #38 received another resident's blood pressure medication, magnesium, Tylenol, and a fourth medication. The family member stated that Resident #38 received more than twice their normal amount of blood pressure medication. The family member spoke with the Director of Social Services about what happened, and was told it was a new Certified Medication Aide (CMA) who had two cups of medications. The CMA put another resident's medications down, and provided Resident #38 with her medications. The family member further revealed that she was told the CMA turned their attention to something else, and when they turned back the resident had taken the other resident medications. Review of a facility provided document titled, Medication Error Report dated 9/4/25 revealed that a nurse had given another resident's medication to another resident. The document further revealed that the resident who received the wrong medication was administered fluids to maintain blood pressures. Review of a facility provided undated statement from Staff D Licensed Practical Nurse (LPN) revealed Staff D prepared Resident #38's medications. Staff E LPN asked who the medications were for, and Staff D replied that they were for Resident #38. Staff E then responded that he could give the medications to Resident #38. Staff D allowed this, and then prepared Resident #35's medications. Staff D then revealed that she became confused, and didn't realize/forgot that Resident #38's medications were already given by Staff E. Staff D further revealed that she then gave Resident #35's medications to Resident #38 thinking they were Resident #38's medications. Staff D revealed she did not realize what she did until later. Review of another facility provided undated statement from Staff E revealed that he administered Resident #38's medications, and Staff D who was training then proceeded to give Resident #38 another resident's medication.Review of Resident #38's EHR page titled, Progress Notes revealed an entry dated 9/4/25 at 9:50 AM that the floor nurse notified another nurse about administering the wrong medications to Resident #38. The nurse that was notified then notified the provider and the provider requested to have blood pressures completed every 30 minutes for the first 4 hours then hourly for the next 24 hours. Further review of the EHR Progress Notes revealed and entry 9/4/25 at 9:55 AM a new order was obtained from the Primary Care Provider (PCP) to hold Resident #38's blood pressure medications on the morning of 9/5/25, if Resident #38's systolic blood pressure was below 140. Another entry 9/4/25 in Resident #38's Progress Notes at 8:00 PM revealed a health status note documenting that Resident #38 was slightly hypotensive and bradycardic in relation to her previously recorded vital signs.Progress Notes dated 9/5/25 at 7:43 AM revealed that Resident #38's Lisinopril 40 mg tab and Amlodipine 2.5mg tab were held at that time related to Resident #38's blood pressure being 102/70. Progress Notes review of an entry dated 9/5/25 at 9:02 AM revealed Staff E obtained an order from the Nurse Practitioner (NP) for STAT subcutaneous saline fluids. Staff E further documented that the order was Saline fluids subcutaneous 1 Liter bag at 100 milliliters every hour for the rate. Progress Notes review of an entry dated 9/5/25 at 12:25 PM revealed Resident #38 had been exhibiting low blood pressures through the night and the morning and at 12:28 PM the subcutaneous infusion of 1000 milliliters was administered. Interview 10/2/25 at 10:10 AM with the Director of Nursing (DON) and the Administrator revealed that Staff D was passing the medications and Staff E offered to help. Staff E passed Resident #38's medications after Staff D prepared them. Staff D was then preparing another Resident's medications and gave them to Resident #38. Interview 10/02/2025 at 10:50 AM Staff E was in the dining room and was training Staff D. Staff E then revealed that Staff D got medications ready, and Staff E then passed the pills to Resident #38. Staff D then passed the medications of to Resident #38. Staff E then revealed that he and Staff D were unsure that they didn't pass Resident #28's medications until Resident #28 said something to them about 20 minutes later. Staff E then revealed that he did notify the physician. Staff E further revealed that Resident #38's blood pressure normally runs low, but when it got below the normal he called back to the physician and got an order for intravenous (IV) fluids. Staff E revealed that this was Staff D's first day out of nursing school, and she was performing the medication checks. Interview 10/02/2025 at 11:33 AM with the DON revealed that she would have liked to have seen the staff take their time when passing medications, and to only pass the medications that they have prepared. Review of a facility provided policy titled, Medication Administration with a revision date of 6/30/23 revealed:a. Medications shall be administered per physician order.b. Remove medication with labels facing the nurse. Check labels to Medication Administration Record (MAR). Verify resident, drug, strength, dose, route and hours of administration with MAR.

Based on clinical record review, facility policy review, staff interviews, and the provider interview, the facility failed to ensure the orders of 1 of 3 residents (Resident #2) were implemented after a 30-day review was completed by the ordering Nurse Practitioner. Resident #2 was ordered morphine sulfate (opioid used to treat severe pain) 15 milligrams (mg) twice a day (BID) for pain. The order was a durational order to be reviewed every 30 days by the Nurse Practitioner for continued use. During the Nurse Practitioner's visit with the resident on 3/20/2025 she noted to continue with the scheduled and as needed (PRN) orders for morphine. The Nurse Practitioner documented on 3/31/2025 that staff notified the provider the resident had not received her scheduled morphine since the March 18, 2025. Facility phoning pharmacy to see what occurred. Morphine was an active order on the Medication Administration Record (MAR). She ordered to give a dose now and order for one additional dose to be given to bridge until scheduled dose arrives. During the time Resident #2 was without her scheduled morphine she experienced withdrawal symptoms and was sent to the emergency room (ER) for evaluation. The facility reported a census of 88 residents. Findings include: According to Resident #2's Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 3/7/2025, she had a Brief Interview of Mental Status (BIMS) score of 3. A BIMS score of 3 suggested severe cognitive impairment. The MDS documented she received an antidepressant and an opioid 7 days of the 7 day review period. The MDS listed the following diagnoses: dementia, anxiety, depression, and restless leg syndrome. The Care Plan Focus Area with an initiation date of 8/15/2024 documented Resident #2 had chronic pain related to her diagnosis of osteoarthritis. The Care Plan encouraged staff to administer medications as ordered, monitor for signs and symptoms of narcotic overdose and report to the physician, and notify the physician if interventions are unsuccessful or if current complaint is a significant change from past experience with pain. Record review revealed an Order Summary Report for Resident #2 dated 3/6/2025, listed morphine sulfate (opioid used to treat severe pain) tablet 15 mg, 1 tablet BID for 30 days. A start date of 2/18/2025 was listed and an end date of 3/19/2025 was listed. The Order Summary Report was signed by the resident's physician on 3/19/2025. Record review revealed the following encounter notes completed by Staff H A Registered Nurse Practitioner (ARNP): a) 3/20/2025: continue morphine scheduled and PRN. b) 3/24/2025: Resident #2 was seen today after she had an emergency room visit for hypertension, vomiting and diarrhea. Diarrhea is still present however nausea has resolved. Spoke with the resident's daughter regarding aggressive bowel regimen resident is currently on and whether we should hold this with current diarrhea. She would like this not to be adjusted as she fears it may result in constipation. She does not appear to be in any distress or pain denies any current pain. Since returning from the ER, is currently on 2 liters (L) of oxygen (O2) via nasal cannula. Staff report diarrhea and no falls reported. Continue morphine scheduled and as needed. c) 3/31/2025: staff notified provider that the patient had not received her scheduled morphine since the 18th. Facility phoning pharmacy to see what occurred. Morphine is still on the Medication Administration Record (MAR) as active. Will give a dose x1 now and order for one additional dose to be given to bridge until scheduled dose arrives. Spoke with daughter regarding issue and plan moving forward. Hospice consult today. Review of Resident #2's March 2025 Medication Administration Record (MAR) revealed the following orders: a) morphine sulfate 15 mg, 1 tablet BID for 30 days, with a start date of 2/18/2025. The order was signed out as last given on 3/19/2025 at 7:00 PM. b) morphine sulfate 15 mg, 1 tablet BID for 30 days, with a start date of 3/31/2025 at 7:00 PM and end date of 4/2/2025 at 1:29 PM. The resident went 11 days without her scheduled BID morphine. Record Review revealed the following Progress Notes for Resident #2: a) 3/22/2025 at 9:52 AM at around 8:20 AM, staff reported to this nurse that resident has been, continuously vomiting and having diarrhea all morning and that it is bile. At 8:24 AM assessed the resident: blood pressure 229/97 (via right arm lying) pulse was 87 beats per minutes, respirations were 20 breaths per minutes, temperature 97.6, oxygen saturation was 92% on room air, unable to assess pain verbally with a number, but she does respond with, yes, when asked if she is in pain. Nonverbal signs of pain are present such as withdrawing extremities with movement, grimacing, moaning, generalized trembling, etc. Overall resident's color does not appear normal, she is red in the face and chest area and warm to touch. Trembling is consistent. Lung sounds are abnormal also upon auscultation. She is unable to respond with more than one word answers. This nurse did give report to emergency room nurse via telephone as well. Will get update from hospital at a later time. b) 3/22/2025 at 4:04 PM, Resident #2 returned from emergency room at 2:30 PM with no new orders. Resident received Zofran (antinausea), morphine, Lisinopril (treat high blood pressure), and contrast dye for a CT scan during her visit. Residents' daughter is aware and came to visit her mother when she returned. Resident's vitals taken upon arrival: temperature 97.8, respirations 18, oxygen saturations 95% on room air, blood pressure 135/69, and pulse 85. c) 3/24/2025 at 2:38 PM, referral sent to hospice. d) 3/29/2025 at 6:05 PM daughter reported that Resident #2 was unable to swallow liquids or solids at lunch today. That the resident said hungry but once her mouth opened food would tumble out. Great seems at peace at this time with this process. Made clear that she is not interested in a feeding tube and hospice is the way to go. e) 3/30/2025 at 2:23 PM unable to swallow medications today. Resident does open up mouth but is not swallowing. Did eat bites of food today only. Did have loose stool today. f) 4/1/2025 at 10:43 AM this nurse went into resident's room. Resident flaccid and lethargic. Blood pressure was 87/58 P 89 respirations shallow, oxygen saturations 62% on room air; 3 liters (L) of oxygen via nasal cannula applied. Blood pressure rechecked 120/75, oxygen saturations 100%. g) 4/1/2025 at 7:44 PM Resident #2 is non-verbal, arouses to verbal stimuli. She has mottling to bilateral hands, knees and feet. h) 4/2/2025 at 5:36 AM this nurse called to the resident's rooms, staff reported she has stopped breathing. Cessation of respirations, pulse and blood pressure at 2:27 AM. The Death Certificate dated 4/8/25 documented Resident #2's date of death as 4/2/25. The immediate cause of death documented as advanced dementia. Other significant conditions documented as one episode of opioid withdrawal that occurred and resolved more than one week prior to death. Likely physiological stress during that occurrence. On 5/29/2025 at 10:31 AM the Assistant Director of Nursing (ADON) was asked what happened when Resident #2 did not receive her morphine for 11 days, she stated the new order was not written on 3/20/2025 when Staff H rounded, which meant there was not a script at the pharmacy to fill. The order was just in her notes. Since then, they have put in place for staff to review orders with the physician's after they round to review and put the orders in place. She acknowledged the nurses should have noticed the order was not in place anymore. She added at that time they had a lot of different nurses working different halls, so the continuity of nurses was not there. When asked what should have happened after Staff H rounded that day, she stated the order should have been written for Resident #2's morphine and sent to the pharmacy. The notes that were written that day should have been glanced at and read through for additional orders. The ADON was not aware of the resident not receiving her morphine until hospice caught it during their evaluation. On 5/29/2025 at 11:35 AM the Director of Nursing (DON) stated her understanding on what happened with Resident #2's morphine order was it was a durational order that did not flag the pharmacy to send an e-script to be refilled like they do for the other narcotics. When they asked the pharmacy to investigate they determined the order was written for 30 days but they did not see an order for it to be refilled. Resident #2 had been on morphine for so long, someone should have noticed it was not ordered. When hospice came in for an evaluation, they noticed the order was not on her MAR. They got ahold of Staff H for a new order. The DON acknowledged Resident #2 did experience opioid withdrawal. On 5/29/2025 at 1:55 PM Staff H, the ARNP, stated normally the pharmacy would send a renewal request when medications are ordered for a duration. She was unaware the order had been stopped because when she looked at the MAR it was still an active order, so she never got a renewal request. She was unsure why the medication was stopped, she should have been active but they never got a refill from the pharmacy. When she was made aware of Resident #2 not receiving her scheduled morphine, she ordered for the dose to start that same day. The facility provided a policy titled Physician Visits, Medical Orders, Delegations of Tasks; with an effective date of 7/1/2021. The policy indicated all residents admitted to this facility must be under the direct supervision of a primary care provider. Only those primary care providers who are currently licensed by the state to practice medicine shall be allowed to do so. Medical orders shall be renewed and updated as applicable or needed. The policy stated members of the interdisciplinary team shall provide care, services, and treatment according to the most recent medical orders and according to laws, regulations and standards of practice.

Based on clinical record view, observation, staff and resident interviews, and facility policy review the facility failed to transfer 1 of 4 residents (Resident #3) in a way that would prevent an accident. The facility reported a census of 88 residents. Findings include: According to the Admission Minimum Data Set (MDS) assessment tool with a reference date of 4/11/2025 documented Resident #3 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented she utilized a walker for mobility and had an impairment on one side of her upper extremity. Resident #3 required supervision or touching assistance to go from a sitting to lying position, lying to sitting position and partial/moderate assistance to go from a sitting to standing position, chair/bed to chair transfer and toileting transfer. The MDS documented the following diagnoses for Resident #3: urinary tract infection (UTI), atrial fibrillation, depression, and toxic encephalopathy. The Care Plan Focus Area with an initiation date of 4/14/2025 documented Resident #3 was at risk for falling related to (what is causing the falls, what did you identify in your CAA documentation as contributing factors). The Care Plan documented a fall on 4/14/2025: her knee gave out during assistance with one staff. Resident #3's transfer status changed to the assistance of two staff with a gait belt. The Progress Notes for Resident #3 documented the following: On 4/30/2025 at 9:50 AM Resident #3 complained of her fourth toe on her left foot being hit; toe is red with a small bruise in the toenail. On 4/30/25 at 10:15 AM resident complaining of pain in her left 4th toe. Range of motion within normal limits for all toes. The 1st to 3rd toes were purplish in color which appeared from decreased circulation and resident's legs being dependent. 4th toe reddened with dark purple bruising noted to nail bed and 5th toe normal skin tone. Provider and family notified of resident's toe being bumped. On 5/27/2025 at 2:31 PM Resident #3 stated a staff member trained her with the mechanical lift alone. She was later told that staff are not to use those lifts alone, they needed to use two people. She was unsure if the staff member stepped on her toe, rolled the bedside table on it or what happened but her toe was hurting after the transfer that day. She indicated her toenail on that toe was still black. Observed her fourth toenail on her left foot to be black at the base and the tip of the nail was natural in color. She denied pain during the interview. On 5/27/2025 at 3:01 PM the Assistant Director of Nursing (ADON) stated Resident #3 was an assistance of two staff, pivot transfer or the use of two staff and a mechanical lift. On 5/27/2025 at 3:13 PM the Administrator stated the care sheet in Resident #3's room stated she was an assistance of one staff for transfers when it should have been updated to the use of two staff for transfers. Staff have since been educated on the use care plans, and they have implemented cheat sheets that are printed every morning and updated every day. On 5/27/2025 at 3:23 PM Staff A CNA stated she attempted to assist Resident #3 to her recliner but the resident had issues with standing up. She went to look for help but could not find another staff member. She got Resident #3 hooked up to use the mechanical lift but again could not find another staff to assist her. She unhooked the resident from the lift, placed it on the bathroom, stood Resident #3 up and assisted her to her recliner. Staff A stated she used the gait belt and walker when she assisted Resident #3 to her recliner. At the time the care sheet that was in her room stated she was an assistance of one staff with a gait belt and walker. When asked what her care plan stated her assistance level was at that time, Staff A stated she was not sure what it said in the computer. She stated she used the care sheet that was in her room for transfer assistance information. Staff A indicated she found out later she was an assistance of two staff with a gait belt and walker. On 5/29/2025 at 10:26 AM Staff B Certified Nursing Assistant (CNA), Staff C CNA and Staff D Certified Medication Aide) assisted Resident #3 from her wheelchair to the bathroom with an EZ stand (mechanical lift). On 5/29/2025 at 11:35 AM the Director of Nursing (DON) stated they do not have the care sheets in the resident's rooms anymore. When they were using them the Wound Care/Restorative Nurse was responsible for updating them. The have replaced the care sheets with a cheat sheet that gets updated daily as changes are reported through the therapy department. These sheets will tell the staff members how residents transfer, if they have a restorative program and if they are a priority lay down. When the CNAs come in for their shifts, they get a fresh copy for their shift. After their shift, they are to throw them away, not pass them off on to the next shift since they do change. The facility provided a policy titled Lift and Transfer Training with an effective ate of 11/17/18. The policy indicated all nursing staff shall be oriented to facility lifting and transferring techniques upon hire and on an ongoing basis. The facility provided a policy titled Comprehensive Care Plan with a revised date of 7/18/2022. The policy stated care, treatment and services shall be planned to ensure that they are individualized to the resident's needs. This facility shall provide an individualized, interdisciplinary plan of care for all residents that shall be appropriate to the resident's needs, strengths, results of diagnostic testing, limitations and goals

Based on clinical record review, facility investigation file review, staff and resident interviews, and facility policy review the facility failed to treat 1 of 3 resident (Resident #3) with dignity during medication administration. The facility reported a census of 86 residents. Findings include: According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 1/16/2025 documented Resident #3 had a Brief Interview of Mental Status (MDS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented she refused care for 1-3 days of the 7-day review period. The following diagnoses were listed for the resident: chronic respiratory failure, atrial fibrillation, heart failure, and urine retention. The Care Plan Focus area with an initiation date of 1/15/2025 documented Resident #3 refused care such as medications at times. Staff were instructed to encourage the resident to take her medications as prescribed by her physician. Staff are to notify the physician/hospice provider. The following Progress Notes documented: a) On 2/9/2025 at 8:39 AM resident up to the nurse's station via walker, very confused. Resident denies any other complaints but pain, refused all medications this morning. No redirections are effective. Resident refused breakfast three times. b) On 2/9/2025 at 8:49 AM this nurse and other resident at the nurse's station discussing another matter with back turned to Resident #3. Resident #3 began yelling at this nurse and picked up a [NAME] cup; threw and hit this nurse's chair. Aide coming up hall stated what the heck is going on. Resident then picked up another [NAME] cup and began swinging it around, hitting this nurse in the outside of the left knee. This nurse assisted with sitting resident in a wheelchair and returning to her room. Continued being verbally abusive, accusing aide of killing babies. No redirection effective, medications given, provided safe distance reassurances, and call placed to Hospice. c) On 2/9/2025 at 9:06 AM Resident #3 continues to show agitation and yelling in room. Floor in room covered with water, seen pouring cups of fluid onto floor and into window sill in room. Noted water running in bathroom. Staff removing all objects except bed, recliner and oxygen from room to prevent injury to herself. Floor cleaned and resident is safe in wheelchair. Staff checking every few minutes. Review of the facility's investigative file revealed the following handwritten statements: a) Staff E Registered Nurse (RN) wrote: On 2/9/2025 at approximately 8:30 AM while this nurse was at the nurse's station documenting, Resident #3 approached the nurse's station, propelling her walker with her left hand as right hand was casted. This nurse greeted the resident and Staff B Certified Medication Aide. Offered a chair for the resident to sit in. Resident #3 refused as Staff E sat near the resident and offered a chair two times in the next 10 minutes. Staff B approached the resident and offered the resident an available meal tray and a chair to sit in; but she refused. Resident #3 spoke briefly to another resident discussing her broken arm and the resident stated yes it hurts. Staff E turned to continue charting while continuing to visit occasionally with Resident #3. At approximately 8:40 AM-8:42 AM Staff B approached the resident with a menu and offered to help chose the next day's meal. The resident refused and stated I don't want breakfast or lunch. The resident then took the menu from Staff B and threw it on the floor. Staff B left the area while Staff E remained in the area. At approximately 8:45 AM another resident approached the nurse's station to ask Staff E for a favor. Staff E turned to face that resident and began to discuss her need, taking notes. Immediately an object hit the back of Staff E's chair and she felt moisture. When she looked on the floor it was a [NAME] cup and the other resident stated oh my god, Resident #3 just threw that at us. Staff E stood up and at that time Staff F Certified Nursing Assistant (CNA) approached the nurse's station and stated what the heck happened. Resident #3 grabbed a second [NAME] cup and began swinging it, hitting Staff E on the left lateral knee. The cup was taken away and the resident continued to flail her casted arm at staff. This nurse approached the resident from behind, placed her arms under her upper arms and helped the resident upright without using her hands, just supporting arms and had Staff F placed in a wheelchair behind the resident and she sat down. This nurse instructed Staff F to take the resident to her room to prevent any further injury to property or others. This nurse obtained her as needed (PRN) Ativan and Morphine from the medication aide and returned to the resident's room. Resident #3 continued to kick and flail at staff. This nurse told the resident she was giving her medication to calm her down. Staff F held her head with her right palm on her forehead. This nurse inserted the medication syringes into her left cheek and administered. Staff E then instructed the CNAs that she was going to call the manager on duty and hospice. b) On 2/9/2025 Staff F wrote she was returning residents from the dining room back to their rooms. She passed Resident #3 by the nurse's station, she was to talking to the nurse, Staff E. Staff F passed with different residents twice on her back to the dining room and she saw Resident #3 pick up a [NAME] mug and threw it into the nurse's station where Staff E and another resident were sitting. Staff F said whoa whoa and picked up the [NAME] cup. Staff E stood up and went towards Resident #3 as she picked up another [NAME] mug winging it around and swung it into Staff E's knee. Staff E braced the resident and told Staff F to grab a wheelchair near by so Staff E could sit her down. Staff E asked her to take the resident to her room and she did. Staff E stood there not sure what to do once in her room. Resident #3 was yelling and stated I killed babies and T*** has camera in here watching. Staff E came in with 2 medications and said she had medication to help her calm down and be safe. Staff E took the medication in the syringes, held Resident #3's hands to her chest and told her to brace the resident's head for safety. Staff F used her arms to cradle the residents head while Staff E administered two medications. Staff E kept telling Resident #3 that it was her job to keep her safe. c) On 2/9/2025 Staff B was one of Resident #3's aides. After room trays had arrived some time after 8:30 AM. She stood at the nurse's station speaking with Resident #3 about breakfast and her menu. She asked why the resident did not want to eat breakfast and if she wanted to fill out her menu for tomorrow. She said no and then threw her menu on the floor. Staff B picked it up and told her that we would try later. Staff B then went to the dining room to grab other residents. When she arrived back to the hall, she came up on Resident #3's room where her things were in the hallway and Staff E stated she had been trying to flood her room and was throwing things. Staff B went to get a bath blanket and when she returned she saw Staff F behind the resident and Staff E in front of the resident. Staff F held the resident's head and Staff E just removed a medication syringe away from her. d) Staff C Certified Medication Aide (CMA) wrote on 2/9/2025 she was in the dining room during breakfast passing morning medications when Staff E approached her and said she needed morphine and Ativan for Resident #3. She needed it because she had thrown a [NAME] cup at her while she was talking to another resident. Staff C said she drew up the morphine in the syringe but Staff C did not have another one for the Ativan. Staff E took the bottle with her and returned it when she was done. Staff C asked Staff E if she was able to get Resident #3 to take her medications and Staff E stated she did not give her a choice. e) Staff A CNA wrote on 2/9/2025 while passing room trays, Staff E walked down the hall mad. Stated that Resident #3 was mad, throwing staff's cups at her and another resident. When Staff A was done passing trays she went down to check on Resident #3. When she walked in Staff F was holding Resident #3's head while Staff F was pulling out the medication syringe from her mouth. At that point her and Staff B got her calmed down. Resident #3 told them she can not have morphine due to her hallucinating. On 3/6/2025 at 3:37 PM observed Resident #3 lying in bed, sits up when greeted. When asked how staff were with her, she stated good. She added there was one nurse that got fired because she gave her morphine when she did not want it. She told her she did not want the medication because it made her hallucinate. It was in a liquid form not a pill like she thought it would have been. She denied anyone holding her head or hands during that time. When asked what nurse this was, she was unable to remember her name but knew she was no longer working at the facility. On 3/5/2025 at 11:25 AM Staff C stated on the morning of 2/9/2025 Resident #3 had refused that morning and she reported that to the nurse, the nurse attempted as well. This was normal for her to refuse medications. When Resident #3 first got to the facility she refused her medications and thought the hospital harmed her. Staff C went up to the dining room to work on her medication pass. After 8:00 AM Staff E came up to her at the medications cart stating she needed morphine (treatment pain) and Ativan (antianxiety) because Resident #3 was throwing [NAME] cups. Staff C drew up the morphine but she did not have enough syringes for the Ativan. Staff E took the bottle with her to administer the medication. Staff C stated she signed out the orders but was not present when they were given. When Staff E brought the medication back up to the medication cart, Staff C asked her if Resident #3 took the medications. Staff E stated she did not give her a choice, but that's all she said. Staff C was asked how Staff E sounded when she said she did not give Resident #3 a choice, she said it sounded awful; just in the wording. Staff C stated she knows they are not to force residents to take their medications, it's their right to not take them. On 3/6/2025 at 1:57 PM Staff F stated she had never worked with Resident #3 prior to 2/9/2025. She was assisting residents to their room after breakfast. Resident #3 was at the nurse's station, picked up a [NAME] cup; started to swing it then threw it in the middle of the nurse's station with another resident and staff member present. Resident #3 picked up a second [NAME] cup, swings it then threw it. It hit Staff E's leg. Staff E asked her to get a wheelchair and they assisted her to the wheelchair. Resident #3 said you killed your babies, random stuff. Once in the wheelchair, Staff E asked her to take her to her room as she yelled and threw her arms around. Staff F stayed with her until Staff E returned and she had two white boxes. Staff E told her to hold her head and a million things ran threw her mind and she knew she was not supposed to touch a resident on the other hand the nurse kept saying it's for her safety, it's for her safety. Staff F was torn because she has never been in the situation before. Staff F cradled Resident #3, her arms were not tight nor were they restricting. Staff F stated she did not know Staff E was going to force medications in Resident #3; she just kept saying it was for her safety. When asked if Resident #3 was given the choice to refuse the medications she sated there was no choice; she kept telling her its to keep you and everyone else safe. She added she felt like Resident #3's rights were stripped from her by not having a choice. On 3/5/2025 at 2:25 PM Staff B stated on 2/9/2025 she walked up to the nurse's station, after breakfast. She asked Resident #3 to fill out her menu and she threw it on the ground. She thought she was joking but Resident #3 was irritated at that point. Staff B went back to the dining room to assist other residents back from breakfast. As she walked down the hall, she noticed the furniture was out of Resident #3's room and she was throwing water on the floor. Staff B went to get blankets and towels to help clean up the water. When she walked around the corner she saw Resident #3 sitting in her wheelchair in her room as Staff F CNA stood behind the resident, holding the resident's head as she was thrashing around in her wheelchair. Staff E was standing in front of Resident #3 and was seen removing a medication syringe from the resident's mouth. Staff B stated she assumed it was Ativan. On 3/5/2025 at 2:39 PM Staff A stated on 2/9/2025 she was assisting with room trays. Staff A stated Staff E walked down the hall mad because Resident #3 threw a [NAME] cup at her. After she finished with room trays, Staff B asked her to go check on Resident #3 with her. Staff A stated Resident #3 was sitting in her room, irate. She walked away then went back in and saw Staff F had her hands on the resident's head and Staff E removed a medication syringe from the resident's mouth. Staff E was asked what she gave her, she indicated it was a pain medication and a medication to calm her down. Staff E and Staff F left the room. Staff B went in the room and was able to calm Resident #3 down. On 3/6/2025 at 12:11 PM the Administrator stated their investigation concluded Staff E did not allow Resident #3 the right to refuse the medications. Resident #3 had the right to refuse any of the medications. She believed Staff E should have contacted the resident's physician about what was going on. The Administrator added even in Staff E's statement she said she did not give her the option to not take the medications. On 3/6/2025 at 12:59 PM the Director of Nursing (DON) stated after they interviewed staff and got their statements, the nurse administered medications to Resident #3 that she did not want. She added if the staff would have stepped back and let Resident #3 decompress in a safe area it probably could have been avoided. Resident #3 needed space and time to calm down, to deescalate. On 3/6/2025 at 2:21 PM the Assistant Director of Nursing (ADON) stated during their interview with Staff E, she acknowledged Resident #3 tried to refused the medication. When asked why Staff E did not honor her wishes, she told them she felt Resident #3 was in pain and she was agitated. She was dumping water on the floor and threw a [NAME] cup at her. The ADON stated Staff E should have removed herself from the situation and brought someone else in. On 3/6/2025 at 3:02 PM Staff E stated immediately: I am not denying anything, I medicated Resident #3. She added she did not give her time to consent and she supported the fact that she was trying to keep Resident #3, other residents and herself safe. That morning she refused her medications when the CMA attempted to administer them. Staff E then attempted to administer her medications and she again refused. After breakfast Staff E was sitting at the nurse's station and Resident #3 came up to the desk, pushing her walker with her good hand. She was visiting with a resident that lived across the hall from her; they were having a pleasant conversation. Staff E asked the resident if she wanted a chair so she did not fall and she said no. Staff B then approached Resident #3 again to see if she wanted a chair because she was concerned about her falling. She declined the wheelchair offer. Resident #3 continued to talk with the other resident; they talked about her injured arm, how she injured it and if it hurt. Resident #3 was very oriented. They visited for about five minutes. Staff B came back down informed Resident #3 they have a breakfast tray for her and she could sit in a chair out at the desk to eat, allowing her to continue to visit with the resident. Resident #3 said no, I am not eating, it's probably poisoned. Staff B went on with another task. Staff E was charting and Resident #3 was talking with her, when another resident came down the hall and asked Staff E for a favor. She needed to leave a note for the medical supply nurse. Just as she started to write on the note pad, a [NAME] cup hit Staff E chair; in direct line of the other resident. Staff E stood up and Staff F walked down, asked what the heck happened. The resident said Resident #3 threw the [NAME] cup at us. Staff E stated let's get a wheelchair just as Resident #3 threw another [NAME] cup, that ended up hitting Staff E. Staff E assisted Resident #3 into a wheelchair and asked Staff F to take her to her room because she knows she has some medications she can have. Staff E went to Staff C and asked her to draw up morphine and Ativan. When Staff E got to Resident #3's room Staff F was behind the resident as she was throwing things off the dresser, pulled all her blankets on the floor. Staff F added at one-point Resident #3 was going crazy. The resident was pouring water in to the furnace that was on the wall and plugged in to an electrical outlet. Staff E felt Resident #3 was putting herself in danger so she asked Staff F to hold her head while she gave the resident her medications. Staff F had her right palm on the resident's forehead, not in a forceful manner. Staff E told the resident what she was doing, why she was doing it and that she was sorry it had to be done. She told Resident #3 she needed to calm down. Staff E and Staff F stayed in the room until she calmed down. Staff F left the room and called her charge nurse, called hospice and asked for them to come visit. Hospice told her to continue with the Ativan until her behaviors improved. Staff E was asked if Resident #3 was given the option to refuse the medications she gave, she indicated not at that point. She added she had thought about this repeatedly and it's the same when giving someone an as needed (PRN) Intramuscular (IM) injection when they are combative. Staff E stated she used the tools she had to stop the situations: had thrown a [NAME] cup in the direction of another resident, was pouring water into her furnace, and had turned on the water in her room allowing it to continuously run. She was trying to stop a million things and had the tools to do so. The facility provided a policy titled: Facility Responsibilities with a revised date of 3/1/2017. It documented it is the policy of this facility to uphold and comply with the facility responsibilities. The facility must ensure that staff members are educated on the rights of the residents and the responsibilities of a facility to properly care for it's residents. 1. Resident Rights. The resident has a right to a dignified existence, self-determination, and communication and access to person and services inside and outside the facility. a) The facility must treat each resident with respect and dignity, and care for each resident in a manner and environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individually. b) The facility must protect and promote the rights of the resident. 2. Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

Based on clinical record review, facility investigation file review, staff and resident interviews, and facility policy review the facility failed to report an allegation of abuse involving Resident #3 within 2 hours of the allegation. The facility reported a census of 86 residents. Findings include: According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 1/16/2025 documented Resident #3 had a Brief Interview of Mental Status (MDS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented she refused care for 1-3 days of the 7-day review period. The following diagnoses were listed for the resident: chronic respiratory failure, atrial fibrillation, heart failure, and urine retention. The Care Plan Focus area with an initiation date of 1/15/2025 documented Resident #3 refused care such as medications at times. Staff were instructed to encourage the resident to take her medications as prescribed by her physician. Staff are to notify the physician/hospice provider. The following Progress Notes documented: a) On 2/9/2025 at 8:39 AM resident up to the nurse's station via walker, very confused. Resident denies any other complaints but pain, refused all medications this morning. No redirections are effective. Resident refused breakfast three times. b) On 2/9/2025 at 8:49 AM this nurse and other resident at the nurse's station discussing another matter with back turned to Resident #3. Resident #3 began yelling at this nurse and picked up a [NAME] cup; threw and hit this nurse's chair. Aide coming up hall stated what the heck is going on. Resident then picked up another [NAME] cup and began swinging it around, hitting this nurse in the outside of the left knee. This nurse assisted with sitting resident in a wheelchair and returning to room. Continued being verbally abusive, accusing aid of killing babies. No redirection effective, medications given, provided safe distance reassurances, and call placed to Hospice. c) On 2/9/2025 at 9:06 AM Resident #3 continues to show agitation and yelling in room. Floor in room covered with water, seen pouring cups of fluid onto floor and into window sill in room. Noted water running in bathroom. Staff removing all objects except bed, recliner and oxygen from room to prevent injury to herself. Floor cleaned and resident is safe in wheelchair. Staff checking every few minutes. Review of the facility's investigative file revealed the following handwritten statements: a) Staff E Registered Nurse (RN) wrote: On 2/9/2025 at approximately 8:30 AM while this nurse was at the nurse's station documenting, Resident #3 approached the nurse's station, propelling her walker with her left hand as right hand was casted. This nurse greeted the resident and Staff B Certified Medication Aide. Offered a chair for the resident to sit in. Resident #3 refused as Staff E sat near the resident and offered a chair two times in the next 10 minutes. Staff B approached the resident and offered the resident an available meal tray and a chair to sit in; but she refused. Resident #3 spoke briefly to another resident discussing her broken arm and the resident stated yes it hurts. Staff E turned to continue charting while continuing to visit occasionally with Resident #3. At approximately 8:40 AM-8:42 AM Staff B approached the resident with a menu and offered to help chose the next day's meal. The resident refused and stated I don't want breakfast or lunch. The resident then took the menu from Staff B and threw it on the floor. Staff B left the area while Staff E remained in the area. At approximately 8:45 AM another resident approached the nurse's station to ask Staff E for a favor. Staff E turned to face that resident and began to discuss her need, taking notes. Immediately an object hit the back of Staff E's chair and she felt moisture. When she looked on the floor it was a [NAME] cup and the other resident stated oh my god, Resident #3 just threw that at us. Staff E stood up and at that time Staff F Certified Nursing Assistant (CNA) approached the nurse's station and stated what the heck happened. Resident #3 grabbed a second [NAME] cup and began swinging it, hitting Staff E on the left lateral knee. The cup was taken away and the resident continued to flail her casted arm at staff. This nurse approached the resident from behind, placed her arms under her upper arms and helped the resident upright without using her hands, just supporting arms and had Staff F placed in a wheelchair behind the resident and she sat down. This nurse instructed Staff F to take the resident to her room to prevent any further injury to property or others. This nurse obtained her as needed (PRN) Ativan and Morphine from the medication aide and returned to the resident's room. Resident #3 continued to kick and flail at staff. This nurse told the resident she was giving her medication to calm her down. Staff F held her head with her right palm on her forehead. This nurse inserted the medication syringes into her left cheek and administered. Staff E then instructed the CNAs that she was going to call the manager on duty and hospice. b) On 2/9/2025 Staff F wrote she was returning residents from the dining room back to their rooms. She passed Resident #3 by the nurse's station, she was to talking to the nurse, Staff E. Staff F passed with different residents twice on her back to the dining room and she saw Resident #3 pick up a [NAME] mug and threw it into the nurse's station where Staff E and another resident were sitting. Staff F said whoa whoa and picked up the [NAME] cup. Staff E stood up and went towards Resident #3 as she picked up another [NAME] mug winging it around and swung it into Staff E's knee. Staff E braced the resident and told Staff F to grab a wheelchair near by so Staff E could sit her down. Staff E asked her to take the resident to her room and she did. Staff E stood there not sure what to do once in her room. Resident #3 was yelling and stated I killed babies and T*** has camera in here watching. Staff E came in with 2 medications and said she had medication to help her calm down and be safe. Staff E took the medication in the syringes, held Resident #3's hands to her chest and told her to brace the resident's head for safety. Staff F used her arms to cradle the residents head while Staff E administered two medications. Staff E kept telling Resident #3 that it was her job to keep her safe. c) On 2/9/2025 Staff B was one of Resident #3's aides. After room trays had arrived sometime after 8:30 AM. She stood at the nurse's station speaking with Resident #3 about breakfast and her menu. She asked why the resident did not want to eat breakfast and if she wanted to fill out her menu for tomorrow. She said no and then threw her menu on the floor. Staff B picked it up and told her that we would try later. Staff B then went to the dining room to grab other residents. When she arrived back to the hall, she came up on Resident #3's room where her things were in the hallway and Staff E stated she had been trying to flood her room and was throwing things. Staff B went to get a bath blanket and when she returned she saw Staff F behind the resident and Staff E in front of the resident. Staff F held the resident's head and Staff E just removed a medication syringe away from her. d) Staff C Certified Medication Aide (CMA) wrote on 2/9/2025 she was in the dining room during breakfast passing morning medications when Staff E approached her and said she needed morphine and Ativan for Resident #3. She needed it because she had thrown a [NAME] cup at her while she was talking to another resident. Staff C said she drew up the morphine in the syringe but Staff C did not have another one for the Ativan. Staff E took the bottle with her and returned it when she was done. Staff C asked Staff E if she was able to get Resident #3 to take her medications and Staff E stated she did not give her a choice. e) Staff A CNA wrote on 2/9/2025 while passing room trays, Staff E walked down the hall mad. Stated that Resident #3 was mad, throwing staff's cups at her and another resident. When Staff A was done passing trays she went down to check on Resident #3. When she walked in Staff F was holding Resident #3's head while Staff F was pulling out the medication syringe from her mouth. At that point her and Staff B got her calmed down. Resident #3 told them she can not have morphine due to her hallucinating. On 3/6/2025 at 3:37 PM Resident #3 was lying in bed, sits up when greeted. When asked how staff were with her, she stated good. She added there was one nurse that got fired because she gave her morphine when she did not want it. She told her she did not want the medication because it made her hallucinate. It was in a liquid form not a pill like she thought it would have been. She denied anyone holding her head or hands during that time. When asked what nurse this was, she was unable to remember her name but knew she was no longer working at the facility. On 3/5/2025 at 11:25 AM Staff C stated on the morning of 2/9/2025 Resident #3 had refused meds that morning and she reported that to the nurse, the nurse attempted as well. This was normal for her to refuse medications. When Resident #3 first got to the facility she refused her medications and thought the hospital harmed her. Staff C went up to the dining room to work on her medication pass. After 8:00 AM Staff E came up to her at the medications cart stating she needed morphine (treatment pain) and Ativan (antianxiety) because Resident #3 was throwing [NAME] cups. Staff C drew up the morphine but she did not have enough syringes for the Ativan. Staff E took the bottle with her to administer the medication. Staff C stated she signed out the orders but was not present when they were given. When Staff E brought the medication back up to the medication cart, Staff C asked her if Resident #3 took the medications. Staff E stated she did not give her a choice but that's all she said. Staff C was asked how Staff E sounded when she said she did not give Resident #3 a choice, she said it sounded awful; just in the wording. Staff C stated she knows they are not to force residents to take their medications, it's their right to not take them. On 3/6/2025 at 11:41 AM Staff D RN stated a couple of CNAs told her about an incident between a nurse and another CNA the day prior. Staff D stated she was working that day. The CNAs told her when they walked in they saw a CNA holding Resident #3's head and a nurse was removing syringes from the resident's mouth while in her room. When asked who reported this to her, she stated Staff A and Staff B. She told her Staff E was administering the medications and Staff F was the one holding Resident #3's head. After she was told this information, she told her boss as soon as she got to work. She was asked to write a statement and had the CNAs write theirs. On 3/6/2025 at 1:57 PM Staff F stated she had never worked with Resident #3 prior to 2/9/2025. She was assisting residents to their room after breakfast. Resident #3 was at the nurse's station, picked up a [NAME] cup; started to swing it then threw it in the middle of the nurse's station with another resident and staff member present. Resident #3 picked up a second [NAME] cup, swings it then threw it. It hit Staff E's leg. Staff E asked her to get a wheelchair and they assisted her to the wheelchair. Resident #3 said you killed your babies, random stuff. Once in the wheelchair, Staff E asked her to take her to her room as she yelled and threw her arms around. Staff F stayed with her until Staff E returned and she had two white boxes. Staff E told her to hold her head and a million things ran threw her mind and she knew she was not supposed to touch a resident on the other hand the nurse kept saying it's for her safety, it's for her safety. Staff F was torn because she has never been in the situation before. Staff F cradled Resident #3, her arms were not tight nor were they restricting. Staff F stated she did not know Staff E was going to force medications in Resident #3; she just kept saying it was for her safety. When asked if Resident #3 was given the choice to refuse the medications she sated there was no choice; she kept telling her it's to keep you and everyone else safe. She added she felt like Resident #3's rights were stripped from her by not having a choice. After this took place she went to her charge nurse and was told to write a statement. On 3/5/2025 at 2:25 PM Staff B stated on 2/9/2025 she walked up to the nurse's station, after breakfast. She asked Resident #3 to fill out her menu and she threw it on the ground. She thought she was joking but Resident #3 was irritated at that point. Staff B went back to the dining room to assist other residents back from breakfast. As she walked down the hall, she noticed the furniture was out of Resident #3's room and she was throwing water on the floor. Staff B went to get blankets and towels to help clean up the water. When she walked around the corner she saw Resident #3 sitting in her wheelchair in her room as Staff F CNA stood behind the resident, holding the resident's head as she was thrashing around in her wheelchair. Staff E was standing in front of Resident #3 and was seen removing a medication syringe from the resident's mouth. Staff B stated she assumed it was Ativan. When asked how Staff F was holding the resident's head, she sated she caught the tail end of it but she was holding her head at the resident's temples. The resident was still able to trash around. She was not sure if the medications were given or not. When Staff B was asked if she reported what she saw to anyone, she acknowledged she did not. On 3/5/2025 at 2:39 PM Staff A stated on 2/9/2025 she was assisting with room trays. Staff A stated Staff E walked down the all mad because Resident #3 threw a [NAME] cup at her. After she finished with room trays, Staff B asked her to go check on Resident #3 with her. Staff A stated Resident #3 was sitting in her room, irate. She walked away then went back in and saw Staff F had her hands on the resident's head and Staff E removed a medication syringe from the resident's mouth. Staff E was asked what she gave her, she indicated it was a pain medication and a medication to calm her down. Staff E and Staff F left the room. Staff B went in the room and was able to calm Resident #3 down. When asked if she reported this to staff, she stated she reported it to the on-call manager as soon as she came upstairs. She came upstairs after Staff E called her that same day. On 3/6/2025 at 12:11 PM the Administrator stated their investigation concluded Staff E did not allow Resident #3 the right to refuse the medications. Resident #3 had the right to refuse any of the medications. She believed Staff E should have contacted the resident's physician about what was going on. The Administrator added even in Staff E's statement she said she did not give her the option to not take the medications. The Administrator stated the incident took place on 2/9/2025 and management was informed on 2/10/2025. Staff were educated on reporting if they feel something is not right. There also educated on reporting allegations of abuse, misconduct or if something is questionable. She advised if they have to question anything to call her, they have her cell phone number. On 3/6/2025 at 3:02 PM Staff E stated immediately: I am not denying anything, I medicated Resident #3. She added she did not give her time to consent and she supported the fact that she was trying to keep Resident #3, other residents and herself safe. That morning she refused her medications when the CMA attempted to administer them. Staff E then attempted to administer her medications and she again refused. After breakfast Staff E was sitting at the nurse's station and Resident #3 came up to the desk, pushing her walker with her good hand. She was visiting with a resident that lived across the hall from her; they were having a pleasant conversation. Staff E asked the resident if she wanted a chair so she did not fall and she said no. Staff B then approached Resident #3 again to see if she wanted a chair because she was concerned about her falling. She declined the wheelchair offer. Resident #3 continued to talk with the other resident; they talked about her injured arm, how she injured it and if it hurt. Resident #3 was very oriented. They visited for about five minutes. Staff B came back down informed Resident #3 they have a breakfast tray for her and she could sit in a chair out at the desk to eat, allowing her to continue to visit with the resident. Resident #3 said no, I am not eating, it's probably poisoned. Staff B went on with another task. Staff E was charting and Resident #3 was talking with her, when another resident came down the hall and asked Staff E for a favor. She needed to leave a note for the medical supply nurse. Just as she started to write on the note pad, a [NAME] cup hit Staff E chair; in direct line of the other resident. Staff E stood up and Staff F walked down, asked what the heck happened. The resident said Resident #3 threw the [NAME] cup at us. Staff E stated let's get a wheelchair just as Resident #3 threw another [NAME] cup, that ended up hitting Staff E. Staff E assisted Resident #3 in to a wheelchair and asked Staff F to take her to her room because she knows she has some medications she can have. Staff E went to the Staff C and asked her to draw up morphine and Ativan. When Staff E got to Resident #3's room Staff F was behind the resident as she was throwing things off the dresser, pulled all her blankets on the floor. Staff F added at one-point Resident #3 was going crazy. The resident was pouring water in to the furnace that was on the wall and plugged in to an electrical outlet. Staff E felt Resident #3 was putting herself in danger so she asked Staff F to hold her head while she gave the resident her medications. Staff F had her right palm on the resident's forehead, not in a forceful manner. Staff E told the resident what she was doing, why she was doing it and that she was sorry it had to be done. She told Resident #3 she needed to calm down. Staff E and Staff F stayed in the room until she calmed down. Staff F left the room and called her charge nurse, called hospice and asked for them to come visit. Hospice told her to continue with the Ativan until her behaviors improved. Staff E was asked if Resident #3 was given the option to refuse the medications she gave, she indicated not at that point. She added she had thought about this repeatedly and it's the same when giving someone an as needed (PRN) Intramuscular (IM) injection when they are combative. Staff E stated she used the tools she had to stop the situations: had thrown a [NAME] cup in the direction of another resident, was pouring water in to her furnace, and had turned on the water in her room allowing it to continuously run. She was trying to stop a million things and had the tools to do so. The facility provided a document titled Nursing Facility Abuse, Prevention, Identification, Investigation and Reporting Policy. The policy documented all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking part in acts that result in person degradation, including the taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It shall be the policy of this facility to implement written procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. These procedures shall include the screening and training of employees, protection of residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, mistreatment, and misappropriation of property, without fear of recrimination or intimidation. Reporting: All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. All allegations of Resident abuse shall be reported to the Iowa Department of Inspections and Appeals not later than two (2) hours after the allegation is made.

Based on observations, staff interviews, clinical record review, and policy review the facility failed to review and revise the Care Plans for 2 of 7 residents reviewed (Resident #5 and Resident #6). The facility failed to revise the interventions for a resident who sustained falls and a resident who had a significant change. The facility reported a census of 86 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #5 scored 5/15 on the Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The document revealed diagnoses of heart failure, benign prostatic hyperplasia, and urinary tract infection (UTI) in the last 30 days. The document revealed the resident had an indwelling catheter and was always incontinent of bowel. The MDS indicated the resident received hospice care services. Observed on 3/7/2025 at 11:30 AM Resident #5 asleep in bed, catheter bag at foot of bed on the right side with a dignity bag over it, and the call light with reach. Observed on 3/11/25 at 1:30 PM the resident lying in bed semi-alert with the head of the bed and knees elevated with foot protectors in place. The catheter bag was on the right side of the foot of the bed and the call light was within reach. Continuous observation on 3/12/25 at 7:40 AM Staff G, Certified Nursing Assistant (CNA) completing a bed bath with Resident #5. Staff G wore personal protective equipment (PPE). Staff A, CNA, and Staff H, CNA knocked and entered the room to ask if they could be of assistance. Staff A and Staff H offered to complete catheter care for Staff G. Staff A and Staff H completed hand hygiene and donned PPE. While Staff A was preparing for catheter care, Staff G and Staff H repositioned Resident #5 in bed. Staff A placed a barrier on the floor and the graduated cylinder on the barrier. Staff H completed the emptying of the catheter with Staff A providing the alcohol wipes. Staff H and Staff A completed the task with removal of the cylinder, and bagging the linens. Staff H and Staff A completed hand hygiene and removed bagged trash and linens from the room. Staff G remained in the room and completed the clean up from the bed bath. The resident had no complaints of pain during the observation, and no signs of redness or skin irritability. Resident #5's Care Plan, dated 3/3/25, revealed the resident received hospice care (initiated 2/25/25). A focus area identified the resident's ability to complete activities of daily living (ADLs) initiated 2/18/25 with interventions of physical therapy/occupational therapy for strengthening/endurance (2/18/25), and to report further deterioration in status to the physician (2/18/25). The Care Plan failed to identify the resident's transfer status, and positioning needs. The document failed to have revisions regarding the need for therapy services and reporting deterioration to the physician. The Care Plan failed to identify the resident had a catheter. The Electronic Medical Record (EMR) Progress Notes revealed on 2/23/25 Resident #5 was admitted to the hospital with a UTI with hematuria. An entry dated 2/25/25 revealed the resident was readmitted to the facility from the hospital and was meeting with hospice. A Progress Note dated 2/26/25 revealed the resident had a Foley catheter in place and was patent. An entry dated 3/3/25 revealed the resident required a Significant Change Assessment as the resident was no longer on skilled services and was on hospice care. On 3/6/25 at 1:16 PM the Director of Nursing (DON) stated Resident #5 was in the hospital with a deep vein thrombosis. The DON reported she was not sure if the resident had any compromised skin on his buttocks. The DON indicated she thought the resident was compliant with care. On 3/6/25 at 2:36 PM the Assistant Director of Nursing (ADON) stated the resident had a fall prior to coming to the facility and had bruising to his face and arms. The ADON reported Resident #5 had an excoriation in the brief area. The ADON stated the resident was pleasant, cooperative, and had not voiced any concerns with being at the facility. On 3/12/25 at 9:15 AM Resident #5 stated he had no concerns with his care. The resident stated he appreciated the staff; the staff were doing a very good job and were always pleasant. Resident #5 stated he had no concerns with his care. On 3/12/25 at 12:30 PM Staff A stated the resident had a 5 day stretch of bed rest and that had ended on 3/10/25. Staff stated they tried to get Resident #5 up earlier this week and the resident has significant complaints of pain and asked to go back to bed. Staff reported they ask the resident if he wanted to get up and he declined. The staff stated the resident requires the use of a dependent mechanical non-weight bearing lift for all transfers. Staff A stated the resident will feed himself when positioned upright in bed. On 3/12/25 at 12:55 PM the DON stated the staff responsible for Care Plans was not in the building and was a full time student. The staff stated Resident #5 should have positioning and transfer interventions on the Care Plan. The DON reported there was a Care Sign in each resident's room on their closet door for an at a glance reference for staff reference. Review of Resident #5's Care Sign on his closet door with the DON revealed transfers with assistance of 2 with a front wheeled walker. The DON acknowledged it was incorrect and corrected it to Hoyer (dependent mechanical non-weight bearing lift) for transfers. 2. According to the MDS assessment dated [DATE] Resident #6 scored 15/15 on the BIMS indicating normal cognition. The document revealed diagnoses of Non-Alzheimer's Dementia and a wedge compression fracture of the thoracic vertebrae. The document revealed the resident was frequently incontinent of bowel and bladder. The MDS indicated the resident required substantial assistance for rolling and sitting to/from lying positions. The document revealed sit to/from stand and transfers required partial moderate assistance. The document revealed that it was unsafe for Resident #6 to ambulate 10 feet. Observed on 3/6/2025 at 11:23 AM the resident in recliner asleep with a sling under him, call light within reach, gripper socks on, and a wheelchair (w/c) at the foot of his bed, not within reach. Observed at 1:46 PM the resident asleep in his recliner, sling under him, and call light within reach. Observed on 3/7/2025 at 11:37 AM the resident asleep in his recliner, feet elevated, pillow under his legs, sling behind him, and the call light within reach. Observed on 3/11/25 at 1:45 PM Resident #6 sleeping in a recliner with his lower extremities elevated on a pillow and gripper socks on. The resident had a call light within reach. The resident was seated on a pressure relief cushion and a dependent lift sling. Continuous observation on 3/12/25 at 6:50 AM with Staff I, CNA, and Staff K, CNA, providing care to Resident #6. Staff I and K knocked, entered the resident's room, asked the resident if he was ready to get up, and the resident agreed. The staff proceeded to go into the bathroom, completed hand hygiene, and donned PPE. Observed the resident positioned in bed in the low position and a sign posted reminding the resident to use a call light for assistance. Staff K assisted the resident with rolling and positioning in bed while Staff I completed peri care. Staff K completed peri care with technique of maintaining separate dirty and clean hands. Staff K noted Resident #6's bandage on the buttock had been dislodged and required nursing assistance to change. Staff J, Licensed Practical Nurse (LPN), knocked, entered the room, completed hand hygiene, and donned PPE. Staff J completed wound care with good technique. Staff J completed hand hygiene, donned new gloves, and assisted the staff with positioning and rolling the resident for donning a new brief and pants. Staff I and Staff K proceeded to place a dependent mechanical lift sling in place and prepared to transfer Resident #6 to his recliner. The staff positioned the resident in the recliner on a pressure relief cushion with his legs elevated, a pillow under his legs, and the call light within reach. The staff completed hand hygiene, and removed the trash and dirty linens. Observed on 3/12/25 at 11:25 AM Resident #6 seated on the recliner with legs elevated, pressure relief cushion present, gripper socks on, and the call light within reach. CNA K was exiting the room with the dependent mechanical lift. Observed on 3/12/25 at 12:35 PM CNA K feeding the resident while positioned in bed in the lowered position with head of bed elevated. Observed on 3/12/25 at 12:43 PM Resident #6 was resting in a lowered bed, pressure relief cushion on the recliner, and no Dycem (non-slip material) present on the recliner. Resident #6's Care Plan dated 2/10/25 revealed a focus area identifying the resident as having a risk for injury from falls dated 12/18/24. The interventions for staff included non-skid socks when shoes were not on (1/4/25), anti-rollbacks to w/c (1/27/25), keep walker within reach (2/3/25), Dycem on recliner with a sign reminding the resident to use a call light (12/18/24), restorative nursing walking program 3 times/day with assistance of 1 with w/c to follow (1/27/25), and transfers with assistance of 1 with front wheeled walker (FWW) (initiated 12/18/24 and revised 1/24/25). The Care Plan failed to identify the change in transfer techniques, the use of a pressure relief cushion on the recliner, the bed in a lowered position, and enhanced barrier precautions. The EMR Progress Notes reviewed from 2/6/25 to 3/7/25 revealed entries of the resident self transferring in his bedroom and bathroom, waking up in the night and sitting on the edge of his bed, and falling with and without injury. A Progress Note dated 2/28/25 revealed the resident sustained an unwitnessed fall in his bedroom, transferred to the hospital, and admitted with a right hip fracture. On 3/11/25 at 3:05 PM Resident #6 stated he fell when he was getting up to go shave as his spouse was wanting to go shopping. The resident remained in the mindset that he had been at home when the fall occurred. The resident was seated on a pressure relief cushion on the recliner with his legs elevated and on a pillow, gripper socks on, dependent mechanical lift sling present, and call light within reach. On 3/12/25 at 7:10 AM Staff I stated Resident #6 had previously resided in another part of the building and had provided care to the resident. The staff stated the resident required frequent walk [NAME] as the resident had a strong history of getting up without assistance and was a high fall risk. On 3/12/25 at 10:55 AM Staff J stated a fall intervention for Resident #6 included moving the resident to a room close to the nurses station (the current room is across from the nurses station). The staff stated the resident moved to this room on 2/4/25. The staff stated when the resident was in the previous room the bed was put in the low position as a fall intervention. On 3/12/25 at 11:25 AM Staff K stated fall interventions for the resident included putting a pillow under legs to prevent sliding forward in the recliner, and the bed lowered when the resident is in it. The staff stated they could not speak to interventions when the resident used the wheelchair as the resident does not use the wheelchair that often. On 3/12/25 at 12:47 PM the DON stated the staff responsible for Care Plans was not in the building and is a full time student. The staff stated Resident #6 should have Dycem under the cushion on the recliner as it was still a fall intervention. The DON acknowledged the pressure relief cushion should be on the Care Plan if it was not. The staff reported the pillow under the legs was used as a positioning aid to prevent skin breakdown due to the resident's risk for compromised skin. The DON reported the bed being lowered was not a fall intervention for the resident. The DON stated the transfers on the Care Plan should be the same as what the resident is doing. The staff reported there was a Care Sign in each resident's room on their closet door for an at a glance reference for staff reference. Review of the Care Sign in Resident #6's room with the DON revealed interventions including the use of a Hoyer lift, keep walker in reach, non ambulatory, and Dycem on recliner. The DON discontinued the reference to keep the walker within reach of the resident. The DON acknowledged the bed was in a low position and there was no Dycem present on the recliner. The DON stated the facility had been completing Care Plan Audits, but needed to do more as there were still areas to improve as things were being missed. The DON also indicated staff education needed to be completed on positioning aids. On 3/12/25 at 3:20 PM Staff L, CNA, stated she worked the overnight shift and had not witnessed the resident attempt to get out of bed in the middle of the night. Staff L reported the resident would wake up at night, but would then go back to sleep. The staff stated the resident would have complaints of pain when rolling and repositioning in bed. Staff L stated she saw Resident #6 seated on the edge of the bed on 2/28/25 around 5:30 AM, and assisted him with dressing, transferred him with a gait belt and walker to his recliner, and provided him with the call light. The staff stated she had not witnessed the resident attempt to sit on the edge of the bed since returning from the hospital with a fractured hip. On 3/12/25 at 1:45 PM the Administrator expected that the Care Plans were updated to match the resident needs. The Administrator stated the facility had been working on processes to ensure the Care Plans were updated, but admitted there was still work to be done The facility policy, Comprehensive Care Plan, revised 7/18/22 revealed the Care Plan shall be appropriate to the resident's needs, strengths, limitations, and goals. The policy disclosed there should have regular reviewing and revising of the plan for care, treatment and services.

Based on clinical record review, facility investigation file review, staff interviews and facility policy review the facility failed to use professional standards while administering Resident #3's medications. The facility reported a census of 86 residents. Findings include: According to the admission Minimum Data Set (MDS) assessment tool with a reference date of 1/16/2025 documented Resident #3 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented she refused care for 1-3 days of the 7-day review period. The following diagnoses were listed for the resident: chronic respiratory failure, atrial fibrillation, heart failure, and urine retention. The Care Plan Focus area with an initiation date of 1/15/2025 documented Resident #3 refused care such as medications at times. Staff were instructed to encourage the resident to take her medications as prescribed by her physician. Staff are to notify the physician/hospice provider. The following Progress Notes documented: a) On 2/9/2025 at 8:39 AM resident up to the nurse's station via walker, very confused. Resident denies any other complaints but pain, refused all medications this morning. No redirections are effective. Resident refused breakfast three times. b) On 2/9/2025 at 8:49 AM this nurse and other resident at the nurse's station discussing another matter with back turned to Resident #3. Resident #3 began yelling at this nurse and picked up a [NAME] cup; threw and hit this nurse's chair. Aide coming up hall stated what the heck is going on. Resident then picked up another [NAME] cup and began swinging it around, hitting this nurse in the outside of the left knee. This nurse assisted with sitting resident in a wheelchair and returning to room. Continued being verbally abusive, accusing aide of killing babies. No redirection effective, medications given, provided safe distance reassurances, and call placed to Hospice. c) On 2/9/2025 at 9:06 AM Resident #3 continues to show agitation and yelling in room. Floor in room covered with water, seen pouring cups of fluid onto floor and into window sill in room. Noted water running in bathroom. Staff removing all objects except bed, recliner and oxygen from room to prevent injury to herself. Floor cleaned and resident is safe in wheelchair. Staff checking every few minutes. Review of Resident #3's March 2025 Medication Administration Record (MAR) revealed the following orders: a) Ativan (antianxiety) constitute 2 milligrams(mg)/milliliters(mL), give 0.75 mL sublingually as needed (PRN) for anxiety with a start date of 1/16/2025 and end date of 2/9/2025. The order was signed out as being given by Staff C Certified Medication Aide (CMA) on 2/9/2025 at 8:49 AM. b) Morphine (treatment of pain) solution 20 mg/mL, give 0.75 mL sublingually every 1-hour PRN for moderate to severe pain, with a start date of 2/8/2025 and end date of 2/10/2025. The order was signed out as being given by Staff C on 2/9/2025 at 8:49 AM. On 3/5/2025 at 11:25 AM Staff C stated on the morning of 2/9/2025 Resident #3 had refused meds that morning and she reported that to the nurse, the nurse attempted as well. This was normal for her to refuse medications. When Resident #3 first got to the facility she refused her medications and thought the hospital harmed her. Staff C went up to the dining room to work on her medication pass. After 8:00 AM Staff E came up her at the medications cart stating she needed morphine (treatment pain) and Ativan (antianxiety) because Resident #3 was throwing [NAME] cups. Staff C drew up the morphine but she did not have enough syringes for the Ativan. Staff E took the bottle with her to administer the medication. Staff C stated she signed out the orders but was not present when they were given. When Staff E brought the medication back up to the medication cart, Staff C asked her if Resident #3 took the medications. Staff E stated she did not give her a choice but that's all she said. On 3/6/2025 at 12:59 PM the Director of Nursing (DON) stated Staff C acknowledged she drew up the morphine, gave Staff E the box that had the Ativan medication in it, signed out the medication but did not administer them. Staff E administered the medications. The DON stated she spoke to Staff C about this and educated her on it after she acknowledged she was not supposed to do that. The DON stated Staff C should have let Staff E draw up the medications, sign them out and administer them or Staff C should have drawn them up, sign them out and administer them. On 3/6/2025 at 3:02 PM Staff E stated immediately: I am not denying anything, I medicated Resident #3. Resident #3 had behaviors that morning and told another resident she was in pain. Staff E went to Staff C and asked her to draw up morphine and Ativan. When Staff E got Resident #3's room Staff F was behind the resident as she was throwing things off the dresser, pulled all her blankets on the floor. Staff F added at one-point Resident #3 was going crazy. The resident was pouring water in to the furnace that was on the wall and plugged in to an electrical outlet. Staff E felt Resident #3 was putting herself in danger so she asked Staff F to hold her head while she gave the resident her medications. Staff F had her right palm on the resident's forehead, not in a forceful manner. Staff E told the resident what she was doing, why she was doing it and that she was sorry it had to be done. She told Resident #3 she needed to calm down. Staff E and Staff F stayed in the room until she calmed down. Staff E acknowledged Staff C drew up the morphine in the dining room and Staff E drew up the Ativan in Resident #3's room. Staff C signed out the medications as being given. The facility provided a document titled Medication Administration with a revision date of 6/30/2023. The policy read that medications shall be stored in a locked medication cart and/or medication room. Medications shall be administered per physician order. Procedure: -open medication cart, -remove medication, check labels with MAR, -dispense medications, -return medications to cart, close and lock the medication cart, -identify the resident. Administer the medication. Assure resident has taken the medication. Sign medication on the MAR, -Whenever medications are administered on an as needed (PRN) basis, the staff administering the dose is responsible for documenting the administration. CMA's must check with the licensed nurse prior to administering a PRN medication. The nurse will be responsible for assessing the need and effectiveness of the PRN medication.

Based on video review, electronic health record (EHR) review, document review, resident, and staff interviews the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 24 resident reviewed (Residents #10, #22, #54 and #289). The facility reported a census of 85 residents. Findings include: 1. Resident #54's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS listed Resident #54 as frequently incontinent of urine and of bowel. On 10/28/24 at 11:55 AM Resident #54 stated one day last week on 10/20/24, 10/21/24, or 10/22/24 it took until 8:00 AM before they answered her call light. Resident #54 reported she wanted to get up, use the restroom, and go to breakfast that day. Resident #54 explained the facility had call-ins that day. Resident #54 added it could take up to an hour for them to answer the call light, and has in the last 2 weeks. The Alarm Response Report for dates 9/29/24 10/29/24 reflected call lights with response times longer than 15 minutes as: a. 9/29/24 call light turned on at 6:36 AM and cleared at 7:09 AM for a total of 33 minutes. b. 9/30/24 call light turned on at 6:35 AM and cleared at 7:09 AM for a total of 34 minutes. c. 10/1/24 call light turned on at 6:55 AM and cleared at 7:12 AM for a total of 16 minutes. d. 10/4/24 call light turned on at 6:35 AM and cleared at 6:52 AM for a total of 17 minutes. e. 10/6/24 call light turned on at 6:33 AM and cleared at 7:04 AM for a total of 31 minutes. f. 10/8/24 call light turned on at 6:23 AM and cleared at 7:10 AM for a total of 47 minutes. g. 10/8/24 call light turned on at 9:53 AM and cleared at 10:18 AM for a total of 24 minutes. h. 10/10/24 call light turned on at 3:04 PM and cleared at 3:26 AM for a total of 22 minutes. i. 10/12/24 call light turned on at 9:54 AM and cleared at 10:12 AM for a total of 17 minutes. j. 10/13/24 call light turned on at 6:26 PM and cleared at 6:44 PM for a total of 18 minutes. k. 10/18/24 call light turned on at 9:54 AM and cleared at 10:11 AM for a total of 16 minutes. l. 10/19/24 call light turned on at 6:22 AM and cleared at 7:08 AM for a total of 45 minutes. m. 10/20/24 call light turned on at 6:24 AM and cleared at 7:10 AM for a total of 46 minutes. n. 10/22/24 call light turned on at 6:23 AM and cleared at 7:06 AM for a total of 42 minutes. o. 10/26/24 call light turned on at 6:25 AM and cleared at 6:53 AM for a total of 27 minutes. p. 10/27/24 call light turned on at 6:36 AM and cleared at 6:54 AM for a total of 18 minutes. q. 10/28/24 call light turned on at 6:25 AM and cleared at 6:43 AM for a total of 18 minutes. On 10/29/24 at 2:27 PM Staff D, Certified Nursing Assistant (CNA), explained the facility had a chime that alerted the staff when a resident turned on a call light. Staff D stated they had a screen hanging from the ceiling that showed what room turned on the call light. Staff D stated sometimes it took longer than 15 minutes to answer the call lights. Staff D stated it frequently took longer on Sunrise hall because they have more 2-person lifts. Staff D stated any response longer than 10 minutes is too long. Staff D stated she thought the facility's expected call light response times as between 10- and 15-minutes. On 10/29/24 at 2:54 PM the Administrator acknowledged the call light concern. The Administrator stated the staff sometimes forgot to shut off the call light. The Administrator stated the management had monitored the call light length. The Administrator acknowledged call lights lasted longer than 15 minutes. The Administrator stated call light response should be 15 minutes or less. On 10/30/24 at 2:00 PM the Administrator stated the facility didn't have a policy for call light response. The Administrator stated the facility followed federal regulations. 44420 2. Resident #22's MDS assessment dated [DATE] identified a BIMS score of 15, indicating no cognitive impairment. The MDS listed Resident #22 as dependent or required partial assistance for toileting hygiene, bathing, and lower body dressing. In addition, Resident #22 required supervision or touching assistance for personal hygiene. The MDS included diagnoses of polio (a viral infection that can lead to partial or full paralysis), lack of coordination, muscle weakness, abnormalities of gait and mobility. In an interview on 10/28/24 at 12:34 PM, Resident #22 reported it took staff 45 minutes to answer his call light that morning. Resident #22 stated, they didn't have enough help. Resident #22 explained it took staff 20 to 30 minutes to answer the call light. Resident #22 added, he urinated in his chair because it took so long. It pissed him off when he had to urinate in his own chair. The Care Plan Focus revised 2/13/22 indicated Resident #22 had a risk for injury from falls related to diagnoses of post-polio syndrome, psychotropic medications, and impaired mobility. The Interventions instructed Resident #22 had a sign in his room as a reminder to use his call light. Resident #22's Call Light log for dates from 10/7/24 through 10/28/24 reflected response times greater than 15 minutes: a. On 10/7/24 at 9:56 AM the call light response time took over 29 minutes. b. On 10/10/24 at 6:24 PM the call light response time took over 17 minutes c. On 10/11/24 at 11:38 PM the call light response time took over 23 minutes. d. On 10/12/24 at 8:49 AM the call light response time took over 19 minutes. e. On 10/17/24 at 9:01 AM the call light response time took over 18 minutes. f. On 10/16/24 at 7:36 AM the call light response time took over 20 minutes. g. On 10/28/24 at 7:26 AM the call light response time took over 42 minutes. In an interview on 10/28/24 at 1:54 PM, Staff A, Registered Nurse (RN), reported the facility answered the call lights after 15 minutes when a shift didn't have enough staff. Staff A reported the facility had 2 to 3 times a week they didn't have enough staff. In an interview on 10/28/24 at 2:15 PM, Staff B, CNA, reported they didn't answer the call lights within 15 minutes when they had a shift short staffed. Staff B stated, when they are short staffed they can't answer all the call lights within 15 minutes, especially around meal times. In an interview on 10/28/24 at 2:22 PM, Staff C, CNA, said when they are short staffed they can't answer the call lights within 15 minutes, or properly toilet residents every two to three hours. They have to rush routine cares and staff get burned out. 49628 3. Resident #289's MDS assessment dated [DATE] listed as in progress reflected an admitted as 10/24/24. The completed portion identified a BIMS score of 13, indicating no cognitive impairment. Resident #289 required substantial/maximal assistance for toileting hygiene, bathing, or lower body dressing. In addition, Resident #289 required substantial/maximal assistance for sit to stand movements, and toilet/bed/chair transfers. The MDS portion related to medical diagnosis remained incomplete. Resident #289 Medical Diagnoses included a diagnosis of unspecified fracture of the upper end of the left humerus (upper arm). On 10/28/24 at 11:50 AM Resident #289 reported it sometimes took a long time, over 15 minutes, for the staff to answer call lights. The resident stated it happened a couple of times since coming into the facility the previous week. Resident #289's Baseline Care Plan, dated 10/24/24, indicated they required 1 assist for transfers, continent of bowel, and bladder. Resident #289's Call Light Log during the one week look back period of 10/24/24 through 10/29/24 reflected the following times greater than 15 minutes: a. On 10/26/24 at 12:31 PM the call light response time took over 19 minutes. b. On 10/27/24 at 6:07 PM the call light response time took over 21 minutes 4. Resident #10's MDS assessment dated [DATE] identified a BIMS of 15, indicating no cognitive impairment. The MDS listed Resident #10 as dependent or required partial assistance for toileting hygiene, bathing, and lower body dressing. In addition, Resident #10 required partial or moderate assistance for sit to stand movements, chair, bed, and toilet transfers. The MDS included diagnoses of end stage renal (kidney) disease, muscle weakness, and pulmonary hypertension (a type of high blood pressure that affected the lungs and the right side of the heart). The Care Plan Focus revised 3/13/23 indicated Resident #10 had a risk for injury from falls related to a diagnosis of end stage renal disease. The Interventions revised 10/7/24 directed to transfer with full body lift with 2-person assist. On 10/28/24 at 12:43 PM observed Resident #10 seated in a wheelchair with the call light attached to a lamp behind them, out of their reach. Resident #10 stated she didn't have a way to contact staff, and wanted to get out of her wheelchair into her recliner. Resident #10 reported the staff take a while to answer her call light. Observed an unidentified CNA walk past her room without looking in at Resident #10. At 12:55 PM witnessed the Activities Director enter Resident #10's room to deliver mail, and heard her ask for the call light as she wanted to get into her recliner and had no way to get help. The Activity Director gave Resident #10 her call light and went to get CNA assistance. Resident #10's Call Light log during the three weeks look back period of 10/7/24 through 10/28/24 reflected call light response times greater than 15 minutes: a. On 10/8/24 at 7:25 AM the call light response time took over 28 minutes. b. On 10/8/24 at 10:53 AM the call light response time took over 46 minutes. c. On 10/8/24 at 11:25 AM the call light response time took over 27 minutes. d. On 10/8/24 at 12:04 PM the call light response time took over 17 minutes. e. On 10/8/24 at 1:38 PM the call light response time took over 26 minutes. f. On 10/10/24 at 5:58 AM the call light response time took over 25 minutes. g. On 10/10/24 at 6:50 AM the call light response time took over 24 minutes. h. On 10/10/24 at 11:20 AM the call light response time took over 26 minutes. i. On 10/10/24 at 1:22 PM the call light response time took over 20 minutes. j. On 10/12/24 at 3:59 AM the call light response time took over 28 minutes. k. On 10/12/24 at 7:16 PM the call light response time took over 27 minutes. l. On 10/12/24 at 6:41 PM the call light response time took over 31 minutes. m. On 10/13/24 at 7:59 PM the call light response time took over 19 minutes. n. On 10/14/24 at 11:15 PM the call light response time took over 28 minutes. o. On 10/21/24 at 4:36 PM the call light response time took over 20 minutes. p. On 10/22/24 at 4:52 PM the call light response time took over 19 minutes. q. On 10/22/24 at 5:47 PM the call light response time took over 59 minutes. r. On 10/26/24 at 10:11 AM the call light response time took over 22 minutes. s. On 10/28/24 at 6:04 PM the call light response time took over 18 minutes. t. On 10/6/24 at 8:36 AM the call light response time took over 17 minutes. On 10/30/24 at 10:30 AM, Staff F, CNA, stated call lights might run longer than 15 minutes when residents are having behaviors or cares that require longer times. Staff F added one hall had several residents with behaviors which take increased time. On 10/30/24 at 10:35 AM, Staff G, CNA, stated call lights may be longer when residents turn their call light back on immediately after staff answer their call light, and they have to wait while staff attend to other resident(s) who had been waiting. Staff stated some residents have behaviors which may cause a staff member to remain in a room to meet the resident needs, leading to call lights for other residents to run long. On 10/29/24 at 2:30 PM the Director of Nursing (DON) stated they expected the staff to answer call lights within 15 minutes. The DON stated the facility completed morning reviews of call lights, and then asks staff about the reason for the extended call light response times. The DON reported the facility started trialing the use of walkie talkies to enhance communication.

Based on the facility staff report and interviews the facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours a day for 7 days a week. The facility census was 85. Findings include: The September 2024 and October 2024 Nurse Schedule reflected the scheduled RN called to quit on 9/21/22, then walked out on 9/22/24. The document didn't include any other scheduled RNs on those dates. In an interview on 10/30/24 at 2:15 PM the Staff Coordinator stated on 9/21/24 and 9/22/24 she didn't have the on call phone, but knew about the situation. The Staff Coordinator stated the scheduled RN called in sick on 9/21/24 after being at work less than 30 minutes. On 9/22/24 the RN walked into the facility, looked at the schedule, and walked out. The Staff Coordinator stated they didn't fill the position with a RN for the empty shifts. The Staff Coordinator reported during the weekends they had limited RNs on the schedule/available, during the work week the acting DON may cover the RN position if necessary. In an interview on 10/30/24 at 2:25 PM the Administrator with the Nurse Consultant present acknowledged they didn't have RN coverage on 9/21/24 and 9/22/24. The Administrator stated the scheduled RN called in on 9/21/24 and walked in 9/22/24, looked at the schedule, and walked out. The Administrator said she didn't know about the call in on 9/21/24, but knew on 9/22/24 of the staff walking out. The Administrator stated the facility followed regulations for staffing.

Based on observation, staff interview, and facility policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility reported a census of 85 residents. Findings include: During an observation on 10/28/24 at 9:55 AM Staff H, Cook, completed modification of the entree to mechanical soft consistency. Staff H obtained cooked turkey measured prior to the modification. Without performing hand hygiene, Staff H donned (applied) a glove to the right hand. They said they would use the gloved hand for placement of the turkey in the processor while the left hand would run the food processor. Staff H picked up the turkey with the gloved hand and placed it in the food processor. Staff H then placed their gloved hand over top of the processor, while the left hand managed the controls of the processor. Staff H used the non gloved hand to pour the contents into the measuring cup while the gloved hand used a scraper and moved the contents into the measuring cup. Once completed with the scraper Staff H used their gloved hand to compact the turkey in the measuring cup to obtain the correct measurement. They poured the turkey into a warming pan. Staff H proceeded to repeat the process for the mechanical soft turkey for the second dining room. Staff H picked up the turkey from the premeasured container for processing with the gloved hand and placed it in the processor. Staff H continued to use the gloved hand to cover the processor, use a scraper and compacted the food in the measuring cup. When completed Staff H removed the glove and threw it away. Without completing hand hygiene, they covered the food and placed it in the steam oven. On 10/28/24 at 11:28 AM observed Staff H prepare the noon meal including temperatures and preparation of buttered bread. Staff H removed food items from the steam oven for distribution to the kitchenette and main steam table. Observed Staff H on 3 of 8 instances of stabbing the thermometer through the aluminum foil covering creating large holes in the top. For the remaining 5 instances Staff H uncovered the food for temperatures and then recovered the food. During the preparation of buttered bread, Staff H, donned a single glove on the left hand, opened the package of bread, obtained a slice of bread, used the ungloved hand to apply butter to the slice of bread while the gloved hand held the bread, and then used the gloved hand to place the bread on a serving tray. Staff H repeated the process several times using the gloved hand to touch the bread wrapper and bread. Observed serving tongs beside the bread. Staff H did not wash their hands prior to glove application, but did wash after they removed their glove. In an interview on 10/30/24 at 10:45 AM the Dining Services Manager stated staff shouldn't touch other items when using a gloved hand for food management. The Dining Services Manager explained using tongs would be the best option for touching food items. The Dining Services Manager stated staff should complete hand hygiene immediately after removing gloves. The Dietary Policies and Procedures related to Use of Gloves dated April 2017 instructed to use gloves only for a single task and discard them when interruption occurs in the operation. The Hand Hygiene CDC Guidelines facility document, updated 1/27/22 directed to complete hand hygiene immediately after glove removal.

Based on clinical record review and staff interviews the facility to notify the Long-Term Care (LTC) Ombudsman of a transfer to the hospital for 1 of 6 residents reviewed (Resident #26). The facility reported a census of 85 residents. Findings include: Resident #26's Clinical Census reflected she had an unpaid hospital leave from 6/2/24 - 6/10/24. Review of the facility document, Notice of Transfer Form to LTC Ombudsman, for the month of Jun 2024 lacked notice of Resident #26's hospitalization . During an interview on 10/29/24 at 2:25 PM the Director of Nursing (DON) stated Social Services typically handled the bed holds and notification to the LTC Ombudsman. She added the document would be in the chart. During an interview on 10/30/24 at 10:55 AM the Social Services Director stated Resident #26 didn't have a signed bed hold or notification to the LTC Ombudsman when she admitted to the hospital. During an interview on 10/30/24 at 11:00 AM the Administrator acknowledged the facility didn't do a bed hold or notify the LTC Ombudsman for Resident #26's hospitalization starting on 6/2/24.

Based on record review, staff interviews, and policy review the facility failed to offer the resident, the Resident's Representative, and/or the Power of Attorney (POA) of a bed hold for 1 of 6 residents reviewed (Resident #26). The facility reported a census of 85 residents. Findings include: Resident #26's Clinical Census reflected she had an unpaid hospital leave from 6/2/24 - 6/10/24. Resident #26's electronic and paper clinical record lacked a bed hold for the hospitalization from [DATE] - 6/10/24. During an interview on 10/29/24 at 2:25 PM the Director of Nursing (DON) stated Social Services typically handled the bed holds and notification to the LTC Ombudsman. She added the document would be in the chart. During an interview on 10/30/24 at 10:55 AM the Social Services Director stated Resident #26 didn't have a signed bed hold or notification to the LTC Ombudsman when she admitted to the hospital. During an interview on 10/30/24 at 11:00 AM the Administrator acknowledged the facility didn't do a bed hold or notify the LTC Ombudsman for Resident #26's hospitalization starting on 6/2/24. The facility document, Bed Hold Policy, dated 3/9/19 instructed when a resident transferred to a hospital or goes on therapeutic leave, the facility will provide the Bed Hold Notice form to the resident or the resident's representative.

Based on clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to prevent 1 of 3 residents (Resident #1) from sustaining an injury while assisting them with positioning in their bed. Resident #1's care plan documented she required the assistance of two staff with repositioning in bed. On 7/20/24 Resident #1 wanted to be repositioned in bed. Staff A Certified Nursing Assistant (CNA assisted Resident #1 by herself with repositioning in bed when she rolled out of bed and landed on the floor. Resident #1 complained of pain to her hip, left arm and indicated she did hit her head. Resident #1 was taken to the emergency room (ER) and found to have a closed displaced fracture of her left femoral neck that required surgical repair on 7/22/24. The resident returned to the facility on [DATE]. The facility reported a census of 84 residents. Findings Include: According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 6/11/24 documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS documented she was frequently incontinent of bowel and had no falls since her admission/entry, reentry or prior assessment. The MDS listed the following diagnosis: spina bifida, seizure disorder, anxiety, opioid use, insomnia, and chronic pain syndrome. The Care Plan focus area with an initiation date of 6/13/2023 documented Resident #1 was at risk for decline in her activities of daily living (ADLs) related to her diagnoses of spina bifida and seizures. The care plan documented the following intervention with a revision date of 7/15/2024, the resident required total assistance of two staff to reposition in bed. The resident had bilateral grab bars to assist with repositioning. The Progress Notes documented the following: a) On 7/20/24 at 1:21 AM resident had turned on her call light and wanted help from the Certified Nursing Assistant (CNA) to roll to the other side. Resident tolled to right side and was too close to the edge of the bed, air mattress in place and rolled off the bed landing on the floor. b) On 7/24/24 at 5:05 PM resident returned from hospital stay at approximately 11:00 AM. Resident required two-person assistance with a mechanical lift. Her incision site was covered with dressing post op with orders to leave dressing intact until follow up with Orthopedics on 8/7/24. Review of a document titled Hospital Discharge Summary with a date of service of 7/23/24 documented a primary discharge diagnosis of closed displaced fracture of the left femoral neck. The resident had surgery to repair the fracture on 7/22/24 with the plan to return back to the facility. Review of the facility's investigative file included the following: a) On 7/22/24 Staff A Certified Nursing Assistant (CNA) stated Resident #1 had her call light on. She went into her room and the resident had requested that she be moved to her right side. Resident #1 grabbed the grab bar on her bed and Staff A assisted with rolling the resident to her right side. Resident #1's slipped off the grab bar and started to fall to the floor. Staff A went to grab for Resident #1 but was unable to stop her from falling. Staff A called for assistance from other CNA's and nurses on the floor. Resident #1 was complaining of pain, so they did not move her. Staff A placed a pillow under her head and stayed with her until the ambulance crew arrived and transported her to the hospital. b) Staff documented on the Fall Scene Investigation Report that assistance per care plan was being provided. c) Staff documented the root cause of the fall as the resident being too close to the edge of the air mattress when trying to roll over. The initial intervention put in place to prevent future falls was to ensure staff pull Resident #1 over before rolling to one side. d) Investigation determined that Resident #1 had an air mattress on her bed that may have shifted during repositioning, as well as her hand slipping from the grab bar. The bed had brakes engaged and both grab bars were in position. On 8/12/24 at 2:06 PM the Director of Nursing (DON) stated Resident #1 had always been able to use the grab bars to assist with repositioning. At the time of the fall, she got too close to the edge of the bed, with her momentum she just kept rolling and fell . The aide that was with her at that time could not get to her quick enough to help. The DON acknowledged there was just one staff assisting her with repositioning at that time. She acknowledged the care plan at that time stated to reposition with two staff assistance and Staff A should have had another staff member with her. Some staff say the resident can assist by using the grab bars but the care plan does state to use two staff with repositioning. She stated they initiated education to all staff on two persons assist, lifting and moving residents in bed. The education went to all CNAs and nurses. On 8/9/24 at 11:15 AM Staff C Certified Medication Aide (CMA) stated while she assisted Resident #1 with positioning in bed, she would have another staff member present. Staff C stated Resident #1 can roll to each side by herself but it's hard to assist her by yourself. Resident #1 will try to assist by using the grab bars but she can't hold on to them for that long because she has limited strength. On 8/9/24 at 1:48 PM Staff B CNA stated prior to Resident #1's fall she would have another staff member in the room to assist with repositioning her. Staff B indicated that was her own preference so she would not hurt Resident #1. On 8/12/24 at 12:07 PM Staff D CMA indicated she would assist Resident #1 with repositioning with another staff member present. She indicated Resident #1 is heavier, having that second person makes it easier to reposition her in bed. She indicated the resident can use the grab bars but was unsure why someone would reposition her in bed alone. On 8/12/24 at 2:59 PM Staff A stated she had assisted Resident #1 with repositioning the night she fell out of bed. She stated she assisted the resident by herself because at that time she was an assistance of one. Staff A stated she did not know anything about being an assistance of two staff for repositioning. When Staff A was informed of the care plan stating at the time of the fall, the resident required the assistance of two staff for repositioning, she stated she did not know that otherwise she would not have gone in there alone to help her. The facility provided a policy titled Comprehensive Care Plan with a revision date of 7/18/2022. The policy documented the facility shall provide an individualized, interdisciplinary plan of care for all residents that shall be appropriate to the resident's needs, strengths, results of diagnostic testing, limitations and goals. The facility provided a policy titled ADL Services with an effective date of 6/28/17. The policy documented residents shall receive assistance with ADL's every shift, as appropriate.

Based on clinical record review, staff interviews, transportation driver interview, clinic staff interview, family interviews, facility document review and facility policy the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice. A nurse failed to complete an assessment and intervene with a significant change. The resident was unresponsive prior to leaving for an appointment, after Oxycodone a schedule 2 opiate (narcotic) was given. At the clinic appointment the resident was found to be unresponsive with a blood pressure of 62/38 and a faint pulse. Narcan, an opiate antagonist was given. Primary diagnosis at appointment was unresponsiveness. Resident #1 was transferred to the emergency room from the clinic via ambulance. Vitals signs from that morning at the facility indicated a blood pressure of 96/63, pulse of 58 and an oxygen saturation of 90% on room air for 1 of 5 residents reviewed (Resident #1). The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 20, 2023 on November 1st, 2023 at 3:50 P.M. The Facility Staff removed the Immediate Jeopardy on November 1, 2023 through the following actions: a. On 11/1/23, the Director of Nursing and Assistant Director of Nursing began re-education of nurses on facility policies for Comprehensive Assessment and Reassessment and Physician Notification of Change in Condition. All licensed nurses not scheduled will be educated via phone by the end of the day on 11/1/23 by the Director of Nursing or the Assistant Director of Nursing. Any nurses on leave, as needed (PRN) status, or agency will receive this education prior to their next scheduled shift. These policies will be reviewed with new nurses upon hire by the Director of Nursing or their designee. b. On 11/1/23, the Director of Nursing and Assistant Director reviewed the Interact Change in Condition: When to report to the MD/NP/PA with all nurses. All licensed nurses not scheduled will be educated via phone by the end of the day on 11/1/23 by the Director of Nursing or the Assistant Director of Nursing. Any nurses on leave, as needed (PRN) status, or agency will receive this education prior to their next scheduled shift. These policies will be reviewed with new nurses upon hire by the Director of Nursing or their designee. c. The Interact document is available at each nurses' station for reference. d. All corrections were completed on 11/1/23. e. The immediacy of the IJ was removed on 11/1/23. The scope was J at the time of the survey after ensuring the facility implemented education and their policy and procedures the scope was lowered to a D. The facility reported a census of 90 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #1 could not complete the Brief Interview of Mental Status becasue he is rarely/never understood and is severely impaired for cognitive skills. The MDS documented the resident had inattention but did not have an altered level of consciousness. The MDS also revealed a diagnosis of nondisplaced fracture of base of neck of right femur, and subsequent encounter for closed fracture with routine healing. The Medication Administration Record (MAR) dated October 2023 documented Resident #1 had an order for Oxycodone 5milligrams (mg) 1 tablet by mouth every 4 hours as needed. The MAR documented the resident received the Oxycodone on 10/19/23 at 12:30 PM and 2:25 PM and on 10/20/23 at 7:23 AM. The O2 Saturation Summary for Resident #1 documented the following: On 10/18/23 at 10:36 AM value of 98%. On 10/20/23 at 11:20 AM value of 90%. The Blood Pressure Summary for Resident #1 documented the following: On 10/18/23 at 10:36 AM 109/61. On 10/20/23 at 11:18 AM 96/63. The Pulse Summary for Resident #1 documented the following: On 10/18/23 at 10:36 AM 76 beats per minute. On 10/20/23 at 11:19 AM 58 beats per minute. The Progress Notes for Resident #1 documented the following: On 10/19/23 at 10:58 PM resident alert. Denies pain at this time. Good appetite. Compliant with medications. BP 121/78, and P 83. On 10/20/23 at 9:32 AM Resident #1 was up and in a wheelchair. Medication and PRN Oxycodone given per therapy request. Resident #1 worked well with therapy and returned to his room. Resident #1 was fed breakfast by his wife. Wife stated Resident #1 appears dopey at this time and stated he was awfully agitated when she left last night. Resident #1 had possible poor night sleep due to agitation. Resident #1 has a doctor's appointment at 11:00 AM. On 10/20/23 at 12:06 PM a nurse from clinic appointment called and stated Resident #1 was unresponsive in the waiting room at the clinic, A sternal rub was not effective, VS: BP 68/32 HR 36, narcan was administered at 11:13 AM, Resident #1 observed to still be unresponsive, squad called and Resident #1 was transported to the hospital for evaluation/treatment. Staff B called Resident #1's wife who answered and stated yes she was with Resident #1 at the hospital. Staff B documented Staff A stated Resident #1 received Oxycodone 5mg at 7:23 AM prior to Resident #1's morning therapy session, Resident #1's vital signs were last collected at 9:00 AM prior to Resident #1 leaving for appointment, and at that time Resident #1's blood pressure was 96/63 and pulse was 58. The Occupational Therapy Treatment Notes dated 10/20/23 at 10:27 AM documented the resident was wide awake and alert, willing to participate with therapy. The resident performed self cares including self feeding task utilizing regular utensils, double handed cups with lid and spout. Resident able to start self feeding with mod assist of therapist placing utensils in resident hand with food on end of fork then reaching up to mouth. Review of the document titled Appointment Details dated 10/20/23 revealed a primary diagnosis of unresponsiveness. The reason for the visit detailed the clinic reached out to Resident #1's facility to discuss patient arrival status. The DON was not available so clinic staff spoke with the ADON. The document detailed that Resident #1 should never have been brought to the clinic due to his vitals. The ADON was going to follow up with the clinical team at the facility and will reach out if has any additional questions. During an interview on 11/1/23 at 8:00 AM Resident #1's wife stated she arrived at the facility shortly after 10:00 AM on 10/20/23. She stated Resident #1 was unconscious in the wheelchair when she arrived, and she picked up his head to see if he would respond. The wife stated she let go of his head and it immediately dropped down to his chest. Resident #1's wife stated he did not respond to the stimulus. She stated Staff A, nurse, was sitting at the nurses station outside of Resident #1's room so she told Staff A that Resident #1 was out. The wife stated she asked Staff A what was going on with Resident #1. The wife stated Staff A never got up and never did anything with Resident #1. The wife stated Staff A told her she just gave him an Oxycodone. She stated Staff A told her Resident #1 was restless the night before. The wife stated during the van ride to the clinic appointment Resident #1 did not wake up at all and that worried her a lot. The wife stated when she and Resident #1 got to the clinic she was really worried because Resident #1's blood pressure and pulse were low. The wife stated that the staff at the clinic administered Narcan. Resident #1's wife stated Resident #1 was going to see a PA at the clinic. The wife stated that Resident #1 spent 5 days in the hospital and then moved to another facility on October 24, 2023. The wife stated Resident #1 had never been on Oxycodone prior to his admission to the facility. She stated her husband was treated at the emergency room initially for a drug overdose. The wife stated the ER doctor told her that Resident #1 had suffered from what the doctor called poly-drug use, a combination of different drugs that can result in overdoses. On 11/1/23 at 11:41AM Staff D, aide, stated she remembered Resident #1. Staff D stated she got Resident #1 up on the morning of 10/20/23. Staff D stated that day was the first time she had ever worked with Resident #1. Staff D stated Resident #1 was not out of it or unresponsive when getting him up in the morning. Staff D stated Staff A helped to transfer Resident #1 into the wheelchair. Staff D stated the therapist fed him breakfast after she got Resident #1 up for the day. Staff D stated the therapist wanted to see how much he could do on his own during the meal. Staff D stated after breakfast she did not see Resident #1 until his wife came. Staff D stated Resident #1's wife spoke to Staff A about his medications because the wife stated Resident #1 seemed out of it. Staff D stated Staff A informed her that physical therapy wanted him to have Oxycodone. Staff D stated Resident #1's wife never spoke to her personally. Staff D stated she was sitting at the nurses station during the conversation between Staff A and Resident #1's wife. Staff D stated Resident #1 looked like he was sleeping when he was leaving to go to the clinic appointment. Staff D stated she did not take Resident #1's vitals and never saw Staff A take his vitals. Staff D stated she did not remember the nurse following the wife to the room for an assessment. Staff D stated when she saw Resident #1 leave he was sleeping and was not responding as he was earlier in the day. Staff D stated Resident #1's wife was at the nurses station talking to Staff A. Staff D stated Resident #1's wife informed Staff A that her husband seemed out of it and unresponsive and asked if he had too much pain medication. On 11/1/23 at 12:07 pm Staff A, nurse, stated she remembered Resident #1 and believed he had been admitted that week. Staff A stated 10/20/23 was the first time she had laid eyes on resident #1. Staff A stated Resident #1's wife was at the facility and fed him breakfast. Staff A stated the wife informed her the resident was groggy and she stated it was possible he had a poor night sleep. Staff A stated after the wife mentioned he was groggy, the wife did not appear to be that concerned so Staff A did not assess Resident #1. Staff A stated earlier in the week, therapy informed Staff B that the Oxycodone had snowed Resident #1. Staff A stated Resident #1 did not appear in pain at the time of the Oxycodone administration and that she only gave the medication per therapy request. Staff A stated she would give medication for pain per recommendation from therapy. Staff A stated she obtained a blood pressure on Resident #1 prior to medication administration but did not complete the rest of the vitals until after therapy saw Resident #1. Staff A stated sedation is a normal side effect of pain medication administration. Staff A stated she never looked at Resident #1 prior to him leaving for his appointment. Staff A stated she never completed vitals or an assessment when his wife stated Resident #1 was groggy. Staff A stated the wife never expressed a serious concern about Resident #1 prior to leaving just that he was groggy. Staff A stated she did not remember if Resident #1 had parameters for blood pressures or his pulse. Staff A stated she only took care of Resident #1 a total of 4 or 5 hours. Staff A stated the facility did not have baseline parameters for vitals. On 11/1/23 at 1:37 pm the Physician Assistant (PA) stated she had never seen the patient prior to his appointment on 10/20/23. She stated the clinic nurse went to the waiting room for Resident #1 and noticed Resident #1 was unresponsive. The PA stated the resident's blood pressure was 62/38 and his pulse was 36 and faint. The PA stated the wife stated Resident #1 was given pain medication at the facility prior to therapy. The PA stated at that time Narcan was given. The PA stated the clinic called 911 because Resident #1's vials never recovered. The PA stated initially after the Narcan was given there was a slight increase in pulse but never recovered to baseline. The PA stated Resident #1 required a transfer to the emergency room to prevent further decrease in vital signs or a continued crash further leading to possible death. On 11/1/23 at 3:20 PM the DON stated the facility's expectation was that if there is a change in condition or unresponsiveness in a resident that an assessment would be completed immediately. The DON stated with the change in condition the physician would be notified. The DON stated the nurse should complete an assessment with 3 interventions prior to the medication intervention and the rating of the pain will be documented. The DON stated the 3 interventions are not documented on the computer. The DON stated the use of non narcotic pain medication would be administered prior to any narcotic. The DON stated any none medication option would be tried prior to administering any medication. The DON stated the facility's expectation is that vitals such as a blood pressure of 88/60, a pulse over 100, or a pulse in low 60's or any 50's would warrant an assessment. The DON stated if unusual vitals were obtained the nurse should complete an assessment. On 11/2/23 at 1:35 PM Resident #1's wife stated she did not feed Resident #1 breakfast on 10/20/23. She stated she did not get to the facility until 10:00 AM on 10/20/23. The wife stated she asked Staff A what was going on with Resident #1 because he was not responding as himself. The wife stated she told Staff A that Resident #1 was out of it and Staff A responded by saying she gave him Oxycodone and that would be the reason he was acting that way. The wife stated Staff A did not get up and did not assess Resident #1 or to take his vitals. The resident's wife stated Staff A did nothing at all. The wife stated her and Resident #1 left for the appointment shortly after with medivac. The wife stated that she rode in the medivac van to the appointment with Resident #1 and stated she also rode in the ambulance from the appointment at the clinic to the emergency room after 911 was called. The wife stated she called her daughter and son and their children came to the emergency room and took her to her car at the facility. On 11/2/23 at 1:40 pm the Police Detective (PO) stated Resident #1's wife went to the facility prior to an appointment on 10/20/23 and found Resident #1 slumped over in his wheelchair. The PO stated Staff A, nurse, stated she had given Resident #1 Oxycodone. He stated Resident #1's wife stated that both of them rode to the appointment in a transport van. He stated Resident #1's wife stated from there Resident #1 was transported via 911 ambulance to the ER. The PO stated that the documents that he had from Resident #1's wife stated that he had a possible overdose. The PO stated he had not made it to the facility as of 11/2/23. On 11/2/23 at 2:15 PM Staff F, the van driver, stated he vaguely recalled transporting Resident #1 to the appointment at the clinic on 10/20/23. Staff F stated he spoke to another driver and stated the resident was talking like he may have been confused. Staff F stated he did not remember if the wife rode with him or not. Staff F stated the resident seemed very confused and thought that he may have needed an escort from the facility as well because of the way Resident #1 was acting. Staff F stated that Resident #1 seemed very tired and his responses were weird and the words were not matching up. Staff F said he was driving and did not know if that was part of his diagnosis or not. Staff F stated more than likely he pushed the resident to the van very rarely do they allow anyone else push the resident out but he does not remember for sure. The facility Interact form for Change in Condition updated June 2018 documented to report to the doctor with an immediate notification any symptom, sign or apparent discomfort that is acute or sudden in onset, and a marked change or unrelieved. Review of undated document effective 5/10/17 titled, Comprehensive Assessment and Reassessment revealed that the assessment of the care or treatment required to meet the needs of the resident shall be ongoing throughout the resident's facility stay, with the assessment process individualized to meet the needs of the resident population.

Based on clinical record review, facility policy review, physician interviews and staff interviews the facility failed to provide respiratory care and services by sending a resident to an appointment without oxygen when oxygen was required to 1 of 1 residents reviewed (Resident #192). The facility reported a census of 87 residents. Finding include: The Minimum Data Set (MDS) dated [DATE] for Resident #192 documented a Brief Interview of Mental Status (BIMS) of 9 out of 15 indicating moderate cognitive impairment. The MDS documented the resident required extensive assist of one person for bed mobility, transfers, dressing, toileting and hygiene, and was not ambulatory in the last 7 day look back period. The MDS documented diagnosis of acute and chronic respiratory failure with hypoxia aneurysm of the heart, paroxysmal atrial fibrillation and pulmonary hypertension. The MDS documented the resident had shortness of breath with exertion and received oxygen therapy. The Care Plan for Resident #192 dated 3/9/23 documented she is at risk for complications related to respiratory failure. The care plan directed staff to monitor for signs and symptoms of shortness of breath and to administer oxygen as ordered. The Medication Administration Record for the resident dated June 2023 revealed an order for oxygen 1-4 liters (L) as needed to keep oxygen saturation above 90%. The Progress Notes for Resident #192 documented the following: On 6/19/23 at 2:56 PM the resident has been exhibiting hypoxic signs and symptoms throughout the shift. Resident has been refusing transfer to the emergency room (ER) until 1:15 PM when spoke to family and requested transfer. Vitals 122/68, 124, 24, O2 fluctuating between 56-75 percent on 5 liters. Squad arrived and transferred resident out at 1:49 PM. On 6/19/23 at 5:50 PM the resident came back from the ER at 4:00 PM. They did not find anything wrong and the daughter said the ER doctor told her they needed to quit sending her for unnecessary reasons. On 6/20/23 at 11:24 AM the resident was directly admitted to the hospital from her pulmonology appointment with a diagnosis of hypoxia. On 8/15/23 at 5:13 PM The hospital Pulmonologist, stated on 6/20/23 Resident #192 was seen at the pulmonary office with decreased 02 saturation and at that point the resident was sent to the hospital emergency room for admissions. The Pulmonologist stated Resident #192 was seen by a Nurse Practitioner (NP) in the clinic. The Pulmonologist stated when the resident was seen in the clinic her oxygen tank was empty and her oxygen saturation was 60%. He stated the oxygen tank was changed and Resident #192's oxygen saturation improved to 80% on 5 L. The Pulmonologist stated oxygen was then increased to 8 L and oxygen saturations improved to 84% - 85%. On 8/16/23 at 9:50 AM the Nurse Practitioner (NP), stated on 6/20/23 Resident #192 was seen at the pulmonary office with decreased 02 saturation. The NP stated at that point the resident was sent to the hospital emergency room for admissions. The NP stated Resident #192's oxygen saturation was 60%, they changed the tank and the resident's oxygen saturation improved to 80% on 5 L. The NP stated oxygen was then increased to 8 L and oxygen saturations improved to 84% - 85%. The NP stated Resident #192 was gray, dusty, and slumped over. The NP stated the oxygen tank was empty and Resident #192 was supposed to be on 2 L. On 8/17/23 at 11:30 AM the Director of Nursing (DON) stated oxygen should be turned on by anyone who can administer it, either a medication nurse or CMA. The DON stated if the facility knows the resident is going to be out for a while or to a doctor's appointment the facility will send another tank with the family or staff. The DON stated staff attend doctors appointments only when a resident requires escort. The DON stated residents that require escorts have low BIMS or no family members living in the area. The DON stated it is the facility's responsibility to ensure enough 02 is sent with the resident. On 8/17/23 at 12:22 PM Staff Z, Registered Nurse, stated Resident #192 was unresponsive on 6/19/23 and was sent to the hospital emergency room (ER). She stated the hospital sent her back to the facility saying there was nothing they could do. Staff Z stated on 6/20/23 when the resident went to the Pulmonology appointment the Certified Medication Aide (CMA) applied the oxygen prior to leaving. Staff Z stated she did not look at the oxygen tank prior to being sent off campus. Staff Z stated that CMA got a new oxygen tank prior to leaving for appointment. Staff Z stated oxygen tanks are kept on the sunrise wing. Staff Z stated frequently empty tanks are found in the full tanks with black tank nozzle cover in place at this facility. On 8/17/23 at 4:53 PM Staff CC stated she had worked at the facility almost 2 years. Staff CC stated she had picked up an empty oxygen tank from the oxygen tank holder on the full tank side. Staff CC stated the empty oxygen tank had a black cap in place just like when an oxygen tank is unused. Staff CC stated this has occurred in the last month and several times throughout time at the facility. Review of policy titled Oxygen Administration By Cylinder dated 10/10/19 provided by the Administrator revealed that oxygen shall be administered per physicians order for treatment of hypoxemia or hypoxia. Staff must firmly attach a pressure regulator (gauge) to the cylinder. Attach the flowmeter to the regulator. Using the wrench, open the tank by turning the gas outlet net counterclockwise. Open all the way with slow, even pressure. Attach tubing to the flowmeter/humidifier. Turn on oxygen to assure proper liters/minute supply. Turn off oxygen after a satisfactory test. Review of map revealed distance between facility and hospital to be 0.9 miles that is estimated to take about 3 minutes to drive distance.

Based on observation, record review, and staff interviews, the facility failed to ensure residents did not experience significant medication errors for 1 of 4 residents reviewed (Resident #2). On 11/1/22, a recently admitted (10/24/22) Resident #2 went to a doctor's appointment at a clinic where labs were drawn. The physician identified the facility failed to administer the resident's insulin and 2 oral diabetic medications (meds) that the physician written upon the resident's admission to the facility. The physician notified the facility of their oversight, and they gave Resident #2 one of the ordered medications from the Emergency Box. But, they ultimately did not administer all 3 of Resident #2's omitted meds until 11/3/22. To keep this from occurring again, the facility educated staff and decided the Director of Nursing (DON) would audit all new admission orders going forward. On 11/19/22, the facility found they had failed to obtain Resident #2's laboratory (lab) test for PT/INR (to check the resident's bloody clotting time and ability after taking routine, scheduled blood thinning medication) as ordered for 11/7/22. When they drew the lab on 11/19/22, they found the resident's reading elevated, informed the physician, and obtained new orders. The facility implemented a new system at that time that educated and directed staff to enter lab orders on the treatment sheet so they would be seen more easily. However, after the Iowa Department of Inspections and Appeals' representative surveyor entered the facility for an investigation of 3 complaints, she identified that the facility had also failed to administer 3 additional scheduled admission medications to Resident #2 (which included a glaucoma eye drop) as ordered by the physician on 10/24/22. The surveyor informed the Director of Nursing of this on 11/30/22. These findings constitute an Immediate Jeopardy to resident health and safety. The facility identified a census of 92 current residents. Findings include: According to the Minimum Data Set assessment tool dated 10/30/22, Resident #2 had diagnoses that included urinary tract infection, diabetes mellitus, multiple myeloma, heart failure, and celiac disease. The MDS identified the resident had a Brief Interview for Mental Status exam score of 14, which indicated the resident experienced intact cognition. The MDS documented the resident required extensive staff assistance with bed mobility, transfers, dressing and toilet use. The care plan dated 11/7/22 directed staff to administer medications as ordered, monitor for adverse side effects, and obtain blood sugar checks as needed for symptoms. Review of the Hospital Discharge Orders dated 10/24/22 revealed staff did not note the orders as required and included the following orders: a. Glimepiride 4 mg (milligrams) 2 times a day (diabetic medication) b. Guaifenesin 400 mg 2 times a day c. Insulin degludec (tresiba flextouch 200 units/ml (milliliter) 34 units at bedtime subcutaneous injection (diabetic medication) d. latanoprost ophthalmic 0.005% solution 1 drop both eyes at bedtime (glaucoma) e. loperamide 2 mg as needed for loose stools not to exceed 4 tablet per day (diarrhea medication) f. losartan 50 mg daily (antihypertensive) g. Melatonin 3 mg at bedtime (sleep aide) h. metformin 500 mg 2 times a day (diabetic medication) i. ocular lubricant 1 drop 2 times a day as needed for dry eyes (eye lubricant) j. omega-3 1000 mg daily (supplement) k. polyethylene glycol 17 grams daily as needed for constipation (laxative) Review of the Medication Administration Record (MAR), dated October 2022, revealed staff failed to administer the medications listed above to Resident #2 at the beginning of her stay (specifics documented below). Review of the Physician's order dated 11/1/22, revealed a clarification order to restart Glimeperide 4 mg BID, Losartan 50 mg daily, Tresiba 34 units daily and metformin 500 mg 2 times a day. The order directed staff that Resident #2 required all medications listed on the hospital discharge orders (from admission on 10/24/22), which also included a diabetic diet with a fluid restriction of 1.25 liters daily. The order also directed staff to administer low dose sliding scale insulin with meals, change warfarin to 4 mg daily, and recheck PT/INR (prothrombin time test to measure how long it takes for a clot to form in a blood sample) on Monday (11/7/22); call with results. The order contained another lab request for a BMP (basil metabolic panel) and directed staff to obtain it on Thursday (11/3/22) and call with results. Facility staff did not note the order until 11/6/22. A Progress Note dated 11/1/22 at 1:40 AM, documented the notified the facility by phone that a BMP drawn by staff at the doctor's office during an appointment identified Resident #1 had a critical glucose of 457. A Progress Note, dated 11/3/22 at 12:34 PM, documented Resident #2's blood sugar measured over 500 and staff reported the elevated blood sugar result to the physician's office. The physician's office staff questioned why the facility had not started the resident's insulin or began to obtain blood sugar readings when the resident admitted to the facility on [DATE]. Review of the medication administration record, dated November 2022, revealed staff administered the following medications on the following dates: a. Glimepiride 4 mg twice daily starting 11/2/22. b. Losartan 50 mg starting 11/3/22. Staff had documented medication not available on 11/2/22. c. Metformin 500 mg starting 11/3/22. Staff had documented medication not available on 11/2/22. d. Tresiba (an insulin product) flex injection 100 units, inject 34 unit subcutaneous daily starting 11/3/22. e. Coumadin 2.5 mg daily NOT administered on 11/30/22. The MAR failed to include documentation regarding the following medications: Guaifenesin, latanoprost ophthalmic, loperamide, Melatonin, ocular lubricant, omega-3, polyethylene glycol. The BMP lab dated 11/3/22 revealed the resident had a blood glucose level of 451. Review of Physician's orders from 11/19/22 to 12/1/22 revealed: - An order dated 11/19/22, documented staff notified the physician of PT/INR results of 56/4.7 and identified Resident #2's current Coumadin dose as 4 mg daily. New orders directed staff to hold Coumadin on 11/19 and 11/20/22, recheck PT/INR on 11/21/22, and call the results to the physician. - An order dated 11/23/22, documented Resident #2's PT as 25.3 with an INR of 2.1. New orders directed staff to administer 3 mg Coumadin daily and recheck PT/INR in 1 week. - An order dated 11/25/22, identified Resident #2's PT measured 15.7, INR 1.3. New orders included administer Coumadin 5 mg daily and recheck PT/INR on 11/27/22. - An order dated 11/29/22, revealed the resident's INR measured 1.5 and directed staff to give Coumadin 5 mg daily and recheck PT/INR on 11/29/22. - An order dated 11/30/22, revealed Resident #2's PT measured 36 with INR of 3. New orders included give Coumadin 2.5 mg today, then return to Coumadin 5 mg daily and recheck the INR on Monday (12/5/22). - An order dated 12/1/22, revealed staff failed to administer the Coumadin 2.5. mg ordered on 11/30/22 - Resident #2's INR at 2.5. - An order dated 12/1/22, revealed facility staff had requested a clarification order for the following medications: Guaifenesin, latanoprost ophthalmic, loperamide, Melatonin, ocular lubricant, omega-3, and polyethylene glycol. During an interview on 11/30/22 at 11:38 AM the Director of Nursing stated when residents are admitted from the hospital, nurses are to fax the physician orders from the hospital to the pharmacy. Pharmacy then enters the orders into the MAR. Nurses can utilize the hospital orders until the doctor looks at the written list sent from the facility and signs the orders. The Nurse has to go over the flagged medications and also have to put in a diagnoses for each medication. They should be using the hospital orders to look at the medications on the MAR and if they don't match, they should reach out to the pharmacy to ensure they are received and also reach out to Primary Care Provider. Ideally, staff should write noted on the hospital order and the date reviewed. The DON verified Resident #2 did not have the ordered PT/INR lab draw on 11/7/22, but they did draw the lab on 11/19/22. She stated she was not sure why that occurred or how it was identified, but the facility implemented new order sheets for Coumadin and PT/INR for staff to use to ensure accuracy. She commented the facility utilized a lot of agency staff and they may not complete the process as instructed. She stated the PT/INR testing orders are now placed on the treatment administration record for staff to utilize. During an interview on 12/1/22 at 8:02 AM, the Physician stated he looked at Resident #2's medication orders during her visit as she had a high glucose level: she had not been getting her insulin. He continued that the hospital discharge orders had included insulin, so he wrote orders on 11/1/22 when the resident visited that directed facility staff to give all the medications ordered on the discharge form from the hospital, which included insulin orders. He verified he had written the orders again and the resident still didn't get the insulin. He recalled the facility subsequently called to notify him that Resident #2's blood sugar was over 500 on 11/3/22 and she still had not been receiving the insulin. The Physician reported that Resident #2 did not feel well, but he believed she did not have an outcome of harm due to the lack of insulin, although there was certainly a potential for harm. The Physician said he expected all medications to be administered by facility staff as ordered on discharge from the hospital, including the glaucoma eye drops. Review of the facility policy titled Transcribing Physician Orders, dated 5/6/16, directed staff to do the following: a. Obtain order, verbal, transfer form written for Fax, transcribe order onto a telephone order. If order is signed please put in the signature of physician box, order already signed via fax or transfer sheet, Notify pharmacy of new orders by faxing all orders over to them, all orders that are put in the E-MAR by the pharmacy will have a flag by them, this order needs to then be checked to be correct and then if correct, click on approve. Nurse is to check if medication is in for the right patient, right dose, right time, right route and right medication. Review of the undated facility policy titled Admission/Readmission, directed staff to call the Medical Doctor as soon as possible for the following: OK to follow hospital discharge orders, clarifications for blood glucose/insulin checks, Coumadin clarifications. A second nurse will need to review the admission paperwork and sign on the last page. A copy of the admission orders needs to be made and placed under physician's orders tab in the chart, original goes to the front office for Physician signature. If a resident is on Coumadin, make sure a red Coumadin flow sheet is made. Resident must have a next PT/INR check date specified, If none call the Medical Doctor. The facility was notified of the Immediate Jeopardy on 12/1/22. The IJ was removed on 12/1/22 and lowered from a scope and severity of level J to a D level when the facility took the following actions: 1. The facility re-educated staff regarding following physician orders and the systems in place including agency staff. Going forward agency will also receive information regarding the facility expectations regarding following physician orders. 2. The DON or ADON will audit all new admission orders going forward within 24 hours of admission for the next 12 weeks and will report results weekly to the QA committee who will review and make adjustments as needed and this will also be reviewed in our monthly QAPI meeting. The report will be sent to the facility medical director weekly for the next 12 weeks. 3. The facility implemented a new system that directed staff to put lab orders on the treatment sheet and educated staff regarding the same. 4. A copy of all physician orders will be placed in the DON and ADON box for their review. 5. INR lab draws entered into QMAR for date required and will include a results tab. 6. Nurse management will audit INR and Warfarin orders for the next 12 weeks and will report findings to the QA committee weekly who will then review and make adjustments as needed and this will also be reviewed in our monthly QAPI meeting. The results will be sent weekly to the facility medical director for the next 12 weeks.

Based on observations, clinical record review, family and staff interviews, facility investigative file review, and facility policy review, the facility failed to provide adequate nursing supervision and assistance devices to prevent hazards for 2 of 9 residents reviewed. (Resident #2 and #25). On 5/24/21 Resident #2 admitted to the facility from an Assisted Living because she had eloped (when a resident leaves the facility without staff knowledge or permission) twice and the facility was unable to keep her safe. In addition, the family reported the resident had eloped from their home prior to her stay at the Assisted Living Facility and indicated they informed the nursing facility of her past history of eloping from their home and from Assisted Living. The facility failed to accurately complete a wandering risk assessment for Resident #2 upon her admission, and staff reported the resident ambulated (walked) around the hallways for exercise on a routine basis. On Sunday, 10/17/2021 at approximately 1:30 PM, the facility learned the resident left the nursing home and went into the basement of the facility's Assisted Living located across the parking lot when they received a phone call from Assisted Living staff. The facility reported on Saturdays and Sundays the main entrance doors were left unlocked and unsupervised so family members could enter the building to visit. These findings constituted an Immediate Jeopardy to resident health and safety. The facility also failed to assist Resident #25 from the living room of the unit to his room by pushing him in his wheelchair without his wheelchair pedals present. The facility reported a census of 89 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 identified a Brief Interview of Mental Status (BIMS) score of 9. A score of 9 indicated moderate cognitive impairment. The MDS revealed she did not exhibit wandering behavior during the 7 day review period. The MDS documented she required supervision for bed mobility, locomotion on and off the unit, dressing toilet use, and personal hygiene. The MDS documented diagnoses that included: [CONDITION(S)], [CONDITION(S)], dementia, and restless leg syndrome. The baseline Care Plan completed on 5/26/21 provided the resident's daughter was the resident representative. The baseline Care Plan documented she required assistance of 1 staff for transfers and utilized a walker. The baseline Care Plan asked if the resident was an elopement/wander risk with the option to check yes or no; neither answers were checked. The Wandering Risk Assessment completed on 5/24/21 indicated she was at low risk for wandering. Under the history of wandering section it was not checked when ask if the resident was a known wanderer/history of wandering. The Progress Noted dated 10/17/21 at 1:46 PM documented at 1:30 PM the resident noted to have left the nursing home and went into the Assisted Living basement. Staff called the nursing home regarding the resident being in their building. Staff went to Assisted Living facility and escorted resident back to the nursing facility. Nurse assessed the resident; no signs or symptoms of injury, denied pain and discomfort. Observation on 10/28/21 at 10:30 AM revealed the main entrance doors to be unlocked, no alarms sounded when surveyor entered the facility. After entering the facility through the main entrance doors there is a dining room located directly to the right of the enter way. Observation on 10/28/21 at 3:30 PM revealed once outside of the main entrance, the sidewalk leads to a busy side street that leads to a cement water channel then a busy highway. Review of the facility's investigative file revealed the following handwritten statements: -Staff C Certified Nursing Assistant (CNA) documented she had picked up lunch room trays and saw Resident #2 walking up to her about 12:45 PM. Staff C asked her if she had a mask with her, then helped her look for one and placed it on her face. The resident then proceeded to go on her normal walk down the hall. Staff C continued walking the opposite direction to finish collecting lunch room trays. It was 1:15 PM when the nurse came into another resident's room where Staff C was, to inform her the resident was found at the Assisted Living building. Staff C walked up and brought the resident back. The written statement was signed by Staff C and dated 10/17/2021. -Staff E Licensed Practical Nurse (LPN) documented at 12:45 PM she noted the resident walking towards the nurse's station with her walker. Staff E was passing the noon medications and that was the last time she saw the resident. The written statement was signed by Staff E and dated 10/17/21. -Staff F Restorative Aide/Certified Medication Aide (RA/CMA) documented she went to the dining room about 12:00 PM-12:30 PM. Resident #2 was in her room sitting on her bed the last time she saw her. The written statement was signed by Staff F and dated 10/17/21. -Staff D Assisted Living Aide documented Resident #2 set off the door alarm at the AL building basement. She went downstairs to check on the alarm and found the resident wandering around. Staff D asked if she was lost and she stated she was look for [NAME]. Staff D asked what her name was and she did not answer. Staff asked where she came from and she pointed at the basement door. Staff D then took her upstairs to the living room to ask staff if they knew who she was. Staff again asked what her name was and she told them. Staff D then called the nursing home, described the woman and staff stated she lived at the nursing home. They sent someone up to get her. The written statement was signed by Staff D and dated 10/17/21. On 10/28/21 at 12:43 PM the Administrative Assistant and Medical Records/Secretary staff members provided they both work at the front deck, which is across from the main entrance. When asked who covers their breaks they stated they take turns going to break so one person is always there but if they both have to leave their desks they ask another staff member to cover. They provided the front doors are locked from 4:30 PM-8:00 AM, Monday through Friday. They stated during the weekend the doors are locked, staff enter through the loading dock and visitors enter through the locked side door. When the doors are unlocked and someone walks too close with the wander guard they stated the door will alarm and the same when the door is locked. The staff members were asked if the doors were locked when Resident #2 walked out of the main entrance, they stated they were unlocked. When asked why they stated so visitors could come in; they were left unlocked from 8:00 AM to 8:00 PM. The Administrative Assistant stated the main entrance doors are now locked completely on the weekends. On 10/28/21 at 1:09 PM Staff E stated Resident #2 would get up for breakfast, go for a walk for exercise. When asked where she walks to, she stated she will walk down the hallway to the nurse's station then back to her room. She will nap until lunch then at times she will do the same walking routine after lunch. If she did not walk in the mornings it was because she was doing activities but would walk after lunch. Staff E stated the last time she saw the resident the day she eloped was about 12:45 PM when she was passing medications; she walked passed her to the nurse's station and turned left. She wore pants, a fuzzy coat and closed toed shoes. The weather was not very chilly and it was not raining; that's all she could remember. Staff E indicated she completed the assessment when the resident was brought back to the facility; her assessment was within normal limits and she did have her walker with her. Staff E indicated the resident had never expressed wanting to leave the facility. On 10/28/21 at 1:44 PM Resident #2's family member stated the resident did have elopement incidents while in Assisted Living. The family member reported they did not have the staff to take care of elopements. When asked if the family was asked about these elopements when the resident was admitted to the facility, the family member indicated they let the facility know of the resident trying to leave the home and had some successes. The family member also stated the facility was aware of the resident's elopements from Assisted Living. When asked which staff member(s) they spoke to about the resident's elopement history they stated the Social Worker/Compliance Officer and Staff G. The family provided Resident #2 now has a wander guard on. On 10/28/21 at 1:48 PM the Director of Nursing (DON) was asked what measures the facility took after Resident #2 eloped from the facility and she stated they immediately put a wander guard on her. They had talked about moving her to the memory care unit but wanted to watch her for more eloping attempts. She stated the resident did start to go back to the doors so they moved her to the memory care unit. She provided they changed some processes such as locking the main entrance doors after the desk staff leave at 4:30 PM, Monday through Friday. The main entrance doors will be locked from 4:30 PM on Friday until 8:00 AM on Monday. They educated all staff on the door lock changes. On 10/28/21 at 2:25 PM the Social Worker/Compliance Officer provided Resident #2 was admitted from an Assisted Living facility and she had met with the daughters prior to the admission to complete paperwork. When asked what paperwork was completed prior to the resident being admitted she provided an admission packet. Review of the packet revealed no questions related to wandering or eloping. She felt the resident did very well transitioning from an apartment to the nursing home. She stated the daughters did not mention the resident had a history of eloping from their home and from Assisted Living. When asked what the reason for the resident's admission, she stated the resident was needing more assistance. On 10/28/21 at 6:13 PM Staff F reported Resident #2 likes to walk the halls with her walker for exercise; this was typical for her. Staff F indicated she liked to do things on her own and was independent to walk around. Staff F stated the day she eloped she did not seem any different any normal. She provided the resident wore pants, fuzzy jacket and was not sure what footwear she had on when she left the facility. When asked how the resident got out of the facility, she stated the front doors were unlocked and no one sat up there during the weekend. Staff F was asked why the main entrance was left unlocked on the weekends, she provided this allowed family to come in to visit the residents. On 10/28/21 at 6:27 PM Staff D stated shortly after lunch she was taking her tenants back to their rooms, when the basement of the Assisted Living facility, alarm started to go off. She went downstairs to shut off the alarm when she noticed someone was walking down there; unsure who it was. The woman was walking around, looked lost with a walker and knew it was not one of their tenants. She stated the resident was wearing a fuzzy jacket, pants and shoes. When asked how one would get from then nursing home to the Assisted Living facility, she stated they would have to walk up a ramp to the back of the building. She provided a nursing home staff members came up and took the resident back to the facility. On 10/29/21 at 11:55 AM the State Climatologist reported on 10/17/21 at approximately 12:45 PM the outside temperature was 72 degrees, humidity was at 23%, winds were at 9 mile per hour (mph), no heat index, no windchill or precipitation. On 10/29/21 at 12:16 PM Staff H LPN stated when she completes the wandering questions on the assessments she will ask the family for help, if the resident has dementia, and look at the discharging entity's paperwork. When asked if Resident #2's family was involved with completing her wandering assessment she stated she does not remember but if it was during COVID, the family could be present during the assessment. If the family was not there she would have gone through paperwork and there was no indication that she was a wanderer and the family did not indicate she had a history. On 10/29/21 at 3:22 PM Staff G stated Resident #2 would walk to the dining room and back. When asked to talk about the day she eloped from the facility, she provided it was reported to her that the resident was missing. She reported the incident to the DON and placed a wanderguard on the resident when she returned to the facility. She then educated staff to keep an eye on her and obtained an order to place her on the memory care unit if she continued to exit seek. Staff G was asked what education was provided to the staff immediately, she stated about the resident's wanderguard placement, to keep an eye on her more frequently than 2 hours and for the nurse to complete a new wandering risk assessment. Staff G stated she sat at the front office right across from the main entrance and then locked the doors when she left. The visitors were then updated to go to the side door right off of the parking lot, for weekend visits. On 11/3/21 at 1:39 PM the Administrator when asked whose decision it was to unlock the main entrance doors on the weekends he stated it was a discussion between himself and the leadership team. That team consisted of the previous DON and Assistant Director of Nursing (ADON). He verified that since Resident #2 eloped from the facility the facility now locks the front doors on the weekends starting at 4:30 PM on Friday until 8:00 AM on Monday. The Administrator provided visitors are now asked to enter from a side door that is locked at all times and requires a code to be entered before the doors unlock. He shared that this information was communicated to family members via email and/or a phone call. He added staff were also educated on the changes as well. When asked how the front desk is covered during breaks, he provided the two staff members do not take their breaks at the same time; this allows one person to be present at all times. When asked what if there is a call light he stated they would have another staff member sit in such as an activity personnel or the Chaplain. On 11/9/21 at 11:01 AM Staff C stated she was passing out lunch trays the day Resident #2 eloped from the facility. She was on the hall passing out trays when the resident walked by her, which was her normal. She stopped her, asked where her mask was and assisted with putting one on and the resident continued to walk. She stated this was about 12:45 PM. Staff C continued with her tasks when a nurse came to tell her the resident have been found at the Assisted Living building. This was about 1:15 PM-1:30 PM. She went up to get her and walked her back with her walker. She stated she was surprised the resident did not have a wanderguard on because she likes to walk a lot and was not sure what she would do with the front doors being unlocked. She stated recently they unlocked the doors on the weekends so visitors could come in a visit. When asked how the resident was when she escorted her back to the facility, she stated she was happy as a clam. Once she was back Staff G put a wanderguard on the resident, she was not sure if they locked the front doors after that. The facility was notified of the Immediate Jeopardy (IJ) on 10/29/2021. The IJ was removed on 10/29/2021 when the facility took the following actions: a. The facility locked the main entrance doors immediately and also on the weekends when they did not have staff to supervise the entrance. b. Staff applied a wanderguard to Resident #2's person. c. Facility management educated all staff members with regard to the main entrance doors detailed in a., above. d. Facility management educated all staff members about where visitors would be entering the facility when the main doors were locked. These actions lowered the deficiency from a scope and severity of J to D, with the need for ongoing monitoring of hazards to maintain residents' safety. 2. The MDS assessment dated [DATE] for Resident #25 identified a BIMS score of 2. A score of 2 indicated severe cognitive impairment. The MDS revealed the resident required limited assistance of two staff for transfers and extensive assistance of two staff for bed mobility. The MDS indicated he used a walker and wheelchair for mobility assistance. The MDS documented diagnoses that included: non-traumatic [CONDITION(S)], Alzheimer's disease, diabetes mellitus, anxiety, depression, and COVID-19. The Care Plan focus area dated 4/29/2020 indicated the resident had an Activities of Daily Living (ADL) self-care deficit related to impaired mobility, pain, Alzheimer's disease. He needs assistance with his ADLs. The Care Plan interventions included: he required two person extensive assistance for transfers and staff are always to use the walker for transfer assist. Observation on 10/28/21 at 12:58 PM revealed Staff I Certified Medication Assistant (CMA) assisted the resident to his room while in his wheelchair. Staff I failed to put on his foot pedals before pushing on his wheelchair approximately 26 feet from the day room to his room. The resident had gripper socks on at that time and could be heard sliding on the floor as he was pushed him from the day room to his room. On 11/9/21 at 11:20 Staff J Certified Medication Aide (CMA)/Staffing Coordinator stated when staff assisted residents in their wheelchair they are to use the foot pedals. On 11/9/21 at 11:32 PM Staff K Agency CNA stated staff are to use foot pedals when residents are being transported in their wheelchairs. On 11/9/21 at 12:08 PM Staff M LPN provided staff should have the foot pedals on a resident's wheelchair when transporting them in it. On 12/1/21 at 7:41 AM the DON stated foot pedals on a resident's wheelchair are to be used when actively transporting a resident in their wheelchair. When informed of staff not utilizing Resident #25's foot pedals to assist him to his room via wheelchair, she stated that is not good. The facility policy titled Assisted Wheelchair Propelling revised 1/23/2020 indicated any resident being assisted by staff to propel their wheelchair will have the leg rests attached on their wheelchair and the resident's feet placed on the foot pedals.

Based on record review, and physician and staff interviews, the facility failed to perform ongoing thorough assessments and timely intervention for a resident with a change in condition after a fall (Resident #21). The sample consisted of 20 residents and the facility reported a census of 115 residents. Findings included: 1. Resident #21 had an admission Minimum Data Set (MDS) assessment with a reference date of 3/29/17. The MDS identified the resident had [DIAGNOSES REDACTED]., [MEDICATION NAME] degeneration (incurable eye disease that causes [MEDICAL CONDITION]), dementia without behavioral disturbances, metabolic [MEDICAL CONDITION], generalized muscle weakness, dysphagia (difficulty swallowing) and lack of coordination. The MDS documented a Brief Mental Status (BIMS) score of 4. A score of 4 identified the resident had a severe cognitive impairment. The assessment documented the resident required extensive assistance of 2 or more people with bed mobility, walking in the room and corridor, toileting. The resident required limited assistance of 3 people with transferring between surfaces. The MDS also documented the resident as unsteady and able to stabilize only with staff assistance. Review of a Care Plan dated 4/10/17, identified a problem with pain affecting the activities of daily living (ADLs) due to impaired mobility and a compression fracture with pain usually in the back. The Care Plan instructed the staff to administer pain medication as ordered for pain relief. The same Care Plan identified a problem due to recent hospitalization for [MEDICAL CONDITION], weakness, GERD, HLD, [MEDICAL CONDITION] bladder, [MEDICAL CONDITION], dementia and compression fracture. The Care Plan instructed the staff to ambulate the resident in the room and to/from meals with a front wheeled walker (FWW) and wheelchair to follow (1 person to assist and 1 person to push the wheelchair. The Care Plan instructed to give the resident verbal cues to complete tasks, keep the foot plates on when in the wheelchair and always recline when in the recliner. The Care Plan also identified the resident with a history of falls due to impaired mobility and balance, weakness, poor vision and decreased safety. The Care Plan documented the resident had a fall 4/10/17 and sustained a skin tear from this fall. The Care Plan documented the resident fell out of bed trying to cough up something stuck in his/her mouth. Review of the a physical therapy (PT) Progress Notes identified the following: Review of a PT Daily Treatment Note dated 3/22/17 indicated the resident ambulated with a FWW and CGA with wheelchair to follow for safety to include shout bout in therapy room of 10 feet and then a longer walk of 300 feet. On 4/4/17 the resident was able to safely transfer from the bed to the wheelchair requiring caregiver assist (CGA) to stand-by assist (SBA) with moderate verbal cuing (VC) for coordination and safety. The PT Progress Note documented patient and caregiver education on safety recommendations of CGA-SBA for transfers and mobility informing the family that this means to have a staff member ambulating with the resident due to unsteadiness and need for VC for safety. On 4/7/17, revealed the resident performed 4 sit to stand transfers from the wheelchair with CGA and minimal assistance with verbal cues for hand placement prior to sit/stand. Review of the Resident Progress Notes indicated on 4/10/17 at 2:01 AM, when checking on residents, the staff reported the resident on the floor next to his/her bed. The note documented the staff assessed the resident and found to have full range of motion (ROM) without pain and then lifted the resident to bed with a Hoyer lift (mechanical full body lift). The resident obtained a 2 centimeter (cm) by 2 cm skin tear to the left elbow. The note documented the nurse cleansed the tear and placed Steri-Strips (tape to hold wound in place) to the wound, covered with [MEDICATION NAME] (non-stick wound covering) and gauze. The staff started cranial checks due to this being an unwitnessed fall. The note documented the resident was further assessed for any other injury and none was found (except neurological assessment). The staff facsimile (faxed) and notified the physician. The fax identified the physician replied on 4/10/177 at 1:34 p.m. Review of a PT Daily Treatment Note dated 4/10/17 at 12:14 PM, revealed the resident performed seated bilateral lower extremity exercises active range of motion (AROM) to improve strength and functional mobility. The resident required maximum VC and encouragement to perform. The resident performed long arc quad (LAQ), heel/toe raises and marched approximate 5-10 times each. The note documented the resident not agreeable to participation throughout the treatment. Staff reported the resident fell in the morning and complained of pain in the left ankle and bilateral groin area. A physician telephone order dated 4/10/17 at 2:45 PM indicated the physician ordered steri-strips to the left elbow, change as needed, cover with [MEDICATION NAME] and gauze, change every day and as needed until healed. The physician ordered a chest x-ray. The Resident Progress Note dated 4/11/17 at 3:31 AM indicated the resident continued on fall monitoring. The note documented the resident was restless and pain medication was administered because the resident reported being uncomfortable. The staff repositioned the resident as well. The Medication Administration Record [REDACTED]. Review of an Observation Detail List report dated 4/11/17 at 10:33 AM revealed the resident required assistance of 2 staff persons with transfer and did not ambulate in the room or corridor on that shift. The nursing assessment on this date also documented the resident complained of neck pain and required a pain medication. The note documented the resident required one person for transfer assistance in the morning but after breakfast, the resident required 2 person assistance. Review of an Observation Detail List report dated 4/11/17 at 5:15 PM, revealed a nursing assessment that the resident complained of neck, shoulder and hip pain. The nurse administered pain medication. The MAR indicated [REDACTED]. On 4/12/17 at 1:38 PM the physician ordered to have Hospice to talk with the family. The resident had bilateral ribs, right shoulder, left hip and left knee series of x-rays and ordered [MEDICATION NAME] (narcotic pain medication) 5/325 1 to 2 tablets orally every 4 hours as needed. The MAR indicated [REDACTED]. Review of a PT Daily Treatment Note dated 4/12/17 at 2:27 PM, identified the resident reported pain when PT lifted his/her legs to help don (put on) pants. The PT changed the patient to assist of 2 nursing staff for transfers and bed mobility with a Hoyer lift as needed for safety. A MAR indicated [REDACTED]. A Medication Administration Record [REDACTED]. Review of a Resident Progress Note dated 4/12/17 at 10:54 PM indicated at 9:00 PM the resident complained of pain. The staff administered pain medication (see note above). The notes documented the staff assessed the right and left legs. The note documented a large round swelling on the inside of the left knee with bruising noted to both knees. The left knee bruise measured 2.4 cm (centimeters) by 1.8 cm. The right knee bruise measured 2.1 cm by 1.4 cm. The left hip measured 4.3 cm by 3.5 cm. The note documented the resident had no ROM to the left leg. At 3 PM on 4/12/17, the resident was able to bend his/her knee during the x-ray but unable at this time. The staff took the resident's vital signs and oxygen saturation at this time was 80% on room air. The staff applied oxygen per nasal cannula at 2 liters per minute and called the physician who ordered the resident to the emergency room . The Resident Progress Note indicated the resident went to the hospital via ambulance at 10:30 p.m. Review of a fax dated 4/12/17 notified the physician of bruising to the left knee measuring 2.4 cm by 1.8 cm; right knee measuring 2.1 by .4 cm and left hip 4.3 cm by 3.5 cm. The fax included a request to monitor until healed. The fax did not identify the date and time of the fax and when received. Review of an Observation Detail List report dated 4/12/17 at 11:08 PM, identified a nursing assessment that by the end of the shift there was no ROM (range of motion) to the left lower extremity, the resident refused to move related to pain and discomfort. The nurse documented the resident did not transfer or ambulate during the shift. The staff transferred the resident via slide from the bed to the gurney. Review of a radiology report dated 4/12/17 identified an acute displaced intertrochanteric [MEDICAL CONDITION] hip. The Resident Progress Notes dated 4/13/17 at 8:30 AM indicated the facility placed a call to the hospital Intensive Care Unit nurse to inform the resident's x-ray results identified an acute displaced intertrochanteric [MEDICAL CONDITION] hip. On 8/23/17 at 12:30 PM Staff A (registered nurse) was interviewed and stated on 4/12/17, the resident held up his/her legs when the certified nursing assistants (CNAs) tried to transfer him. Staff A stated she saw a decline in the resident on 4/12/17 but did not remember faxing or calling the physician about it. Staff A recalled giving the resident pain medication for back or neck pain. Staff A stated the resident had been SBA (stand by assistance) and doing pretty well, and then had a decline. She stated she didn't recall if the resident walked to the dining room but was propelled by staff in a wheelchair. On 8/23/17 at 3:35 PM, Staff B (licensed practical nurse-LPN) was interviewed and stated she remembered on 4/12/17, she gave the resident pain medication for shoulder, hip and knee pain. She stated she was training; mostly was administering medication that day. She stated the resident wasn't walking on 4/12/17. Staff B stated before she was an LPN, she had worked with the resident as a CNA. She stated the resident was walking then. Staff B recalled she was working with Staff C, LPN and they assessed the resident's hip and knee. She stated the knee and hip looked dark and swollen so they asked for an x-ray. Staff B stated if a resident has a change of condition, the nurse should call the physician. On 8/23/17 at 3:47 PM, Staff C (licensed practical nurse-LPN) was interviewed and stated she remembered the resident had a [MEDICAL CONDITION]. Before he fractured his/her hip, he was able to ambulate in his/her room and used [MEDICATION NAME] for pain. Staff C stated when there is a change in condition; you notify the physician or therapy if it's minor. On 8/24/17 at 7:50 AM, Staff E (licensed practical nurse-LPN) was interviewed and stated the facility no longer used any body-alarms but did use one-three motion sensors she thinks. The resident usually used a walker or wheelchair to ambulate. On 8/24/17 at 8:15 AM, the physician was interviewed and stated he came to the facility 2 days after the resident's fall and suspected the resident had a fracture. He ordered x-rays and additional pain medication. The physician stated he would expect the facility to notify him if a resident had increased pain and decreased function after a fall.

Related to investigation of facility-reported incident # -I: Based on record review, facility policy and interviews, the facility failed to ensure one (1) of three (3) residents received adequate supervision to protect Resident #6 from resident to resident abuse by Resident #5. On March 30, 2017 Resident #6 and Resident #5 sat together in an unsupervised day room when Resident #5 inappropriately touched Resident #6. Record review revealed Resident #6 severely cognitively impaired. A reasonable person in these circumstances would feel assaulted and or violated if a person touched his/her body in the manner that Resident #5 did. The facility reported a census of 113 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] listed dementia, [MEDICAL CONDITIONS] disorder/[MEDICAL CONDITION], depression and [MEDICAL CONDITION] as [DIAGNOSES REDACTED]. According to the Brief Interview for Mental Status (BIMS) assessment, Resident #6 scored 6 out of 15, which indicated a severe cognitive impairment. The MDS noted Resident #6 sometimes understood others and made him/herself understood. Resident #6 depended completely on staff to propel his/her wheelchair and required extensive assistance of two staff for all activities of daily living. The Care Plan noted an onset date of 3/26/17 noted Resident #6 had poor safety awareness and cognition related to [DIAGNOSES REDACTED]. The Care Plan also noted Resident #6 sometimes had difficulty interacting with others at times due to it making him/her uneasy. The Care Plan also instructed staff to develop a trusting relationship with Resident #6 and provide 1 to 1 as needed. Due to the inability to express pain, staff should monitor Resident #6 for nonverbal signs of discomfort and ensure the respect of his/her personal space. A progress note dated 3/30/17 at 9:55 a.m. revealed Resident #6 approached Resident #5 as he/she sat in the Green Garden Lounge. According to the progress note, Resident #5 put his/her hands down Resident #6's shirt and fondled his/her right breast. The residents were separated immediately. Resident #6 voiced concerns of being scared of Resident #5. A housekeeper had seen the incident and removed the resident from the situation. A progress note dated 3/30/17 recorded as a late entry 4/3/17 at 10:50 a.m. by the Assistant Director of Nursing (ADON) documented: this nurse spoke with Resident #6 after breakfast. When asked if Resident #6 ever felt scared or threatened by anyone while living in Bethany, the resident smiled and stated sometime he/she felt scared. The resident was unable to elaborate. When asked if anyone had ever touched him/her inappropriately, Resident #6 stated, yes, a (man/woman) touched his/her breast today, and then he/she motioned to the top of her/his right breast. The ADON asked the resident if it hurt and when the resident said no, documented no apparent injuries noted. A progress note dated 3/30/17 at 11:55 a.m. by the SW (social worker) documented Resident #6 responded yes when the SW asked him/her if he/she felt scared following the incident. Staff made Resident #6 aware he/she would be moved and he/she smiled and said okay. 2. The Minimum Data Set (MDS) assessment dated [DATE] listed dementia and difficulty walking as [DIAGNOSES REDACTED]. According to the BIMS (brief interview for mental status) aspect of the assessment, Resident #5 scored 15 out of 15, which indicated no cognitive impairment. The MDS noted that Resident #5 depended on the supervision of one staff to walk with a walker, but needed no supervision to self-propel his/her wheelchair throughout the facility. The 2/2/17 Care Plan identified that Resident #5 had socially inappropriate behavioral symptoms as evidence by pleasuring him/herself in community areas and in his/her room with the door open. The Care Plan instructed staff to assess whether the behavior endangered the resident and/or others, and intervene whenever necessary. According to the Care Plan, the resident should be redirected to his/her room if he/she had been in the common area while pleasuring him/herself and the door should be shut for privacy. The Care Plan also noted Resident #5's room had been rearranged on 2/2/17 to make it easier for him/her to close the door when in need of privacy. A Progress note dated 3/30/17 at 6:25 a.m. indicated Resident #5 had been sitting in the Green Garden Lounge with Resident #6. According to the document, Resident #5 approached Resident #6 and went down the right side of Resident #6's shirt and fondled his/her breast. The note said that Resident #6 had been removed and Resident #5 had been taken to the dining room for breakfast. The progress note documented that a personal alarm had been placed on Resident #5's door. A fax sent to the physician by the ADON on 3/30/17 noted that Resident #5 had been exhibiting increased sexually inappropriate behaviors as evidence by masturbating in the doorway of his/her room or with the door of his/her open. The document also noted that staff continued to encourage the resident to do it in the privacy of his/her room with the door closed, but often without success. According to the document, the resident had a history of [REDACTED]. The ADON requested an order for [REDACTED]. A Progress Note dated 2/7/17 at 6:25 p.m. noted that Resident #5 tries to touch females in an inappropriate manner and him/herself with the door open. The progress note indicated that Resident #5 had remained out of the dayroom due to the behavior, and had been encouraged to close the door to his/her room while pleasuring self. A Progress Note dated 2/2/17 at 1:49 p.m. documented that the DON (director of nursing) spoke to Resident #5 to ensure closure of door when he/she pleasured him/herself. The progress note indicated the room had been rearranged to ensure the door could close easily. A Progress Note dated 1/30/17 at 10:50 a.m. documented that Resident #5 had been observed in the day room at 8:45 a.m. in his/her wheelchair next to peers. The author noted that Resident #5 had been redirected to his/her room at that time without difficulty. The author also noted that at 10:35 a.m. Resident #5 had been seen sitting in his/her recliner in his/her room playing with his/her genitals. The author stated the bedroom door had to be closed to ensure privacy. A Progress Note dated 10/7/16 at 5:06 p.m. noted that Resident #5 will touch female staff inappropriately at times and needed to be redirected to abstain from doing that. A Progress Note dated 9/7/16 at 6:39 p.m. noted that Resident #5 had been inappropriate with peers and female staff at times. A Progress Note dated 8/7/16 at 1:02 p.m. noted that Resident #5 needed to be reminded to change clothes when they are soiled and had inappropriate sexual actions within view of others. The staff indicated the resident needed reminds to go to a private area. A Progress Note dated 7/22/16 at 8:46 p.m. noted that another nurse reported that Resident #5 slapped the laundry lady on the butt. The author indicated she educated the resident about being appropriate. A Progress Note dated 6/4/16 noted that a CNA reported that Resident #5 had been seen shaving another resident, and that Resident kissed Resident #5 on the cheek. An interview on 4/20/17 at 9:45 a.m. Staff F, Housekeeper revealed she saw Resident #5 touching Resident #6's breast on 3/30/17 at about 7:30 a.m. Staff F said as she prepared to start cleaning a about ½ way down the hall where she noticed Resident #5 sitting in his/her wheelchair, she became suspicious when she noticed him/her looking around. According to Staff F, Resident #5 had a tendency to masturbate in his/her room with the door wide open. Staff F said he/she seemed to enjoy it when other people saw him/her masturbating. Staff F stated that Resident #5 leaned way over in his/her wheelchair and extended his/her arm outward. Because of the resident's history, Staff F said she walked up behind Resident #5 and observed his/her hand down through the neck of Resident #6's shirt rubbing the top of Resident #6's breast in a circular motion. They were both in wheelchairs. Staff F stated Resident #6 seemed scared to death with his/her head hung down and drool running out of his/her mouth. According to Staff F, Resident #6 did not respond well to people anyway. Staff F said she worked at the facility since 2004 and knew Resident #6 very well. Staff F explained she focused more on what Resident #5 had done. Staff F said she asked Resident #5, What do you think you're doing? Keep your hands to yourself. According to Staff F, Resident #5 promptly left. She said there are a lot of vulnerable residents down in that lounge that cannot defend themselves. She said those residents depend on staff to do almost everything for them. Staff F said she had seen Resident #5 touching other residents on their arms. Staff F said Resident #5 had not touched those other residents in the same way he/she touched Resident #6, but only because opportunity had not presented itself to him/her yet. Staff F said she reported the incident of Resident #5 touching Resident #6 to the nurse. According to Staff F, the ADON came to her and asked for a written statement, which she gladly submitted. Staff F said they moved Resident #5 upstairs and put an alarm on Resident #5's door to know when he/she left his/her room. Staff F said she had previously seen Resident #5 masturbating in his/her room with the door open. She told the facility and they just told her that the resident had rights and to shut the door. According to Staff F, Resident objects to people closing door and will reopen it and continue to masturbate. Staff F said Resident #5 had been masturbating with the door ever since being admitted to the facility. She said the facility finally hung a privacy curtain about the time of the 3/30/17 incident so people that walked by the room could not see him/her. An interview on 4/19/17 at 4:25 p.m. with Staff E, CNA (certified nurse's assistant) revealed that Resident #5 had been moved to the 2nd floor about a month ago because he touched Resident #6's breast. She stated Resident #5 had a history of [REDACTED]. The CNA said she worked both upstairs and downstairs. She stated she has been instructed to redirect Resident #5 to his/her room if she saw the resident masturbating in a common area, but had never been told to shut the door to his/her room. An interview on 4/20/17 at 10:50 a.m. with Staff D, LPN revealed that she had been warned about Resident #5 when she oriented as an LPN. According to Staff D, Resident #5 asked her very forward and asked very intimate and graphic questions. Staff D said the resident had never touched her, nor had she ever seen him/her touching any other resident. She said Resident #5 had been moved upstairs about a month before. According to the LPN, she heard Resident #5 had his/her hand in Resident #6's shirt touching his/her breast. The LPN said she did not know of any other incidents where Resident #5 had touched other residents. Staff D said at some point they hung a curtain in his/her room that so people that walked by wouldn't see him/her when he/she lived downstairs. According to Staff D, they moved him/her back upstairs after he/she touched Resident #6. The LPN said they alarmed door after the incident. An interview on 4/27/17 11:15 a.m. with Staff G, RA (Restorative Aide) revealed last October or November she saw Resident #5 in the Garden Lounge rubbing another resident's arm back and forth. According to the RA, they were the last 2 residents that waited unsupervised in the lounge to go back to their rooms after a meal. When the RA returned to the lounge and noticed Resident #5 rubbing another resident's arm, he/she stopped when he/she realized the RA had been watching. Staff G said the other resident slept through it without waking up, and then the RA took that resident to his/her room. Staff G said she mentioned what she saw to other aids who no longer worked at the facility (Staff J, CNA and Staff O, CNA). The RA said she could not remember to which nurse she reported what she saw. The RA said she never even knew Resident #5 touched Resident #6. According to the RA, she had only been told about an incident between them and not to leave Resident #5 and Resident #6 alone together. The RA denied ever having seen Resident #5 touching or talking inappropriately to staff or residents. Staff G said she had never been informed Resident #5 had talked or behaved inappropriately to staff or other residents. The RA said before this incident, she had never attended an in-service or been told that she needed to keep an eye on Resident #5 or to keep him/her away from vulnerable residents. Staff G said she had been told to close Resident #5's door if she saw the resident masturbating with the door open. An interview on 4/27/17 at 12:20 p.m. with the Activity Director revealed that she had worked for the facility for about 2 years. She could not remember exactly when, but she expressed concern to the DON sometime around last Christmas, give or take a couple months. The Director said Resident #5 frequently masturbated with the door of his/her room open. She expressed concern that children might see him/her because of how frequently they visited throughout the year. The Director said the one in back might reach up and touch the back of the other one's neck and smile. The Director said she heard that Resident #5 inappropriately touched another resident in the Garden Lounge. She stated she did not know who or where they had been touched. Since the incident she had been told Resident #5 should be accompanied to and from all activities, supervised during the activity and kept far enough away from vulnerable residents they cannot physically be touched by Resident #5. An interview on 4/24/17 at 1:10 p.m. with Staff I, LPN revealed that she knew that Resident #5 masturbated frequently while residing downstairs. The LPN said it happened for a quite a long time before they put a curtain up. An interview on 4/27/17 at 11:55 a.m. with the DON revealed the Activities Director expressed concern last February about the high probability of kids that visited the facility seeing Resident #5 masturbating. When asked, the DON explained about delays that hindered her efforts to provide a more discreet environment for Resident #5 to masturbate She said a curtain had finally been hung in his/her room right before Resident #5 had been moved upstairs on 3/31/17. An interview on 4/27/17 at 1:15 p.m. with Staff J, CNA (ex-employee) revealed that she worked at the facility for 7 years, and quit 4 months ago. Staff J said Resident #5 could be inappropriate at time. She recalled he/she grabbed at my privates. According to Staff J, Staff G told her Resident #5 grabbed her breasts before too. Staff J said her old boss, (Staff L, Restorative Supervisor) had told her to keep an eye on Resident #5 because he/she lifted another residents shirt up downstairs between Oakridge and Maplewood. According to Staff J, Staff L relayed that information for the resident's protection. Staff J could not remember exactly when she received the information, but thought about 6 months before she went on maternity leave in August 2016. Staff J believed the ADON, Staff P and another MDS Coordinator brought it up during a staff meeting. She said they explained what to watch for and how to prevent Resident #5 from doing it to other residents. She said they virtually said Resident #5 should be supervised at all times and should not be left unattended with vulnerable residents. As she recalled, Staff J said Resident #5 seemed to be focused on residents that could not fend for themselves or remove themselves from a situation. Staff J said Resident #5 tried touching other vulnerable residents too, but they intervened before anything happened. The CNA said she reported it to the nurse. An interview on 4/27/17 at 2:00 p.m. with Staff K, LPN revealed her explanation about a progress note she entered on 2/7/17 at 6:25 p.m. The entry documented only behaviors noted Resident #5 tried to touch females inappropriately and him/herself while his/her door is open. Staff K stated he/she had remained out of day room due to behaviors. Encouraged to close door to room while pleasuring him/her(self). Staff K said a lot of staff have seen Resident masturbating with his/her door open. Staff K denied ever making the same observations. She said they tried keeping the resident out of the Garden Lounge because he/she had been seen masturbating in front of peers, and it had been happening more frequently. Staff K said a curtain had been added to his/her room downstairs about a month before being moved upstairs. When this surveyor attempted to contact Staff K about other progress notes she authored on 10/7/16, 9/7/16 and 6/4/16, contact could not be made. An interview on 5/1/17 at 4:55 p.m. with the DON the only thing that had ever been reported to her about Resident #5 being sexually inappropriate towards female staff was when he/she slapped the laundry lady on the butt last July. The DON said she attempted to get a curtain in Resident #5's room about 6 months before it actually got hung. She said she talked to the Maintenance Director, who said it could not be done because of the location of the sprinklers. The DON said when the Activity Director expressed concern about kids seeing Resident #5, she pushed to have the curtain hung again. She stated the last time she brought it up she involved the Administrator. An interview on 5/2/17 at 8:00 a.m. with Staff L, Restorative Supervisor revealed what she knew about Resident #5's history. She stated that Staff G reported the resident had been seen masturbating in Garden Lounge. Staff L also recalled that Resident #5 had always been aggressive with Staff J. Staff L denied she had knowledge that Resident #5 had lifted another resident's shirt prior to the 3/30/17 incident between Resident #5 and Resident #6. An interview on 5/2/17 at 8:15 a.m. with Staff M, LPN revealed her explanation regarding a progress not she authored on 1/30/17 at 8:45 a.m. that read 8:45 a.m. after breakfast Resident #5 had been observed in day room in wheelchair next to female peers. Resident had been redirected back to room without difficulties. 10:35 a.m. Resident #5 observed sitting in recliner in room playing with genitals. Bedroom door closed for privacy. Staff M said she saw Resident #5 in the day room with his/her hand down his/her pants so I redirected him/her back to his/her room. The LPN explained because of Resident #5's history, she did not want him/her to start masturbating and create an uncomfortable environment for the other residents sitting in the day room. The LPN said she heard that Resident #5 had been seen masturbating in the day room, but she had never witnessed that. When asked, the LPN said she did not have any knowledge that Resident #5 had ever inappropriately touched another resident. Staff M said she knew about the door alarm and to walk to and from meals with Resident #5, but she had never been told to always supervise him/her and never leave him/her unattended with vulnerable residents. Staff M said she just does that because she knows to be safe rather than sorry. An interview on 5/2/17 at 1:45 p.m. with Staff O, CNA (ex-employee) revealed that she worked at the facility for about 4 years, but quit about 2 years ago. Staff O said she remembered Resident #5's name and remembered him/her making weird inappropriate comments to other residents that were sexual in nature. She stated she could not remember specifics. An interview on 5/2/17 at 9:00 a.m. with Staff P, RN/MDS Coordinator revealed she did not know of any other incidents where he/she had either touched or talked inappropriately to staff or other residents. Staff P said that since the incident with Resident #6, staff have been instructed to supervise Resident #5 anytime he/she left his/her room. Staff P said his/her door had since been equipped with an alarm too. Staff P said she knew Resident #5's Care Plan contained the information now too. She said certain things automatically pop up on the CNA's computers for them to read and sign off on every shift, so they do not have an excuse for not being informed. An interview on 5/2/17 at 11:10 a.m. with Staff R, RA revealed that she had never heard about Resident #5 masturbating in his/her room, nor had she ever seen him/her doing it. She said they recently said to watch him/her, and if he/she left the dining room staff should assist him/her back to his/her room. According to Staff R, they had never told her not to leave him/her unsupervised, nor did they make it clear that she should take responsibility to supervise him/her if she happened to see him/her outside of his/her room without supervision. An interview on 5/2/17 at 12:45 p.m. with the Administrator revealed what he knew about Resident #5's sexual behavior. According to the Administrator, Resident #5 masturbated in his room with the door open, but otherwise kept to him/herself. He said that the resident never showed much interest in anything else. When this surveyor informed the Administrator what many other interviews revealed, he said if he had information that indicated Resident #5 might inappropriately touch another resident, he would have expected staff to implement the necessary interventions to protect the residents. An interview on 5/3/17 at 8:00 a.m. with Staff U, LPN revealed that she worked at the facility for about 2 years. Staff U said she used to work all over the building until about a month ago, but now she primarily worked the hallway that Resident #5 lives on. She said she had never been told that Resident #5 had sexual tendencies and if she saw him/her exhibiting them, she should intervene in a particular way. Staff U said she knew Resident #5 had been moved upstairs because he/she touched another resident's breast. According to Staff U, the ADON said he/she needed to be supervised outside of his/her room. An interview on 5/3/17 12:45 a.m. with the ADON revealed that nobody ever told her that Resident #5 lifted another resident's shirt about a year before the 3/30/17 incident between Resident #5 and Resident #6. The ADON also said she had not conducted an in-service or staff meeting that informed staff about the incident in question or instructed staff on how to intervene to prevent Resident #5 from assaulting other residents. The January 12, 2017 Abuse Policy documented all residents had the right to be free from abuse (sexual &mental). The Policy identified that Abuse is defined differently under Federal and State laws and included the following key definitions that should be considered when determining whether an event constitutes abuse. Resident abuse under the Federal guidelines means the willful infliction of injury, and included intimidation or mental anguish. This policy revealed this presumes that instances of all Residents even those in a coma, cause physical harm, pain or mental anguish. Sexual Abuse includes but is not limited to sexual harassment or sexual assault. The policy identified resident to resident sexual harassment, or sexual assault is also considered abuse.

Bethany Lutheran Home F323/G 8/4/16 Based on observation, record review and staff interviews, the facility failed to ensure adequate supervision to prevent falls for 1 of 20 active residents reviewed (Resident # 1). The facility reported a census of 113 residents. Findings included: Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 6/1/16. The MDS identified Resident #1 had [DIAGNOSES REDACTED]. on feet and lack of coordination. The assessment documented a BIMS (Brief Interview for Mental Status) score of 8 indicating moderate cognitive impairment. The MDS documented the resident required extensive assistance of 2 or more with bed mobility, transfer, dressing and toilet use. Walking in the room or corridor did not occur during the assessment period. The MDS documented the resident as not steady and only able to stabilize with staff assistance as well as impairment on one side in both the upper and lower extremities. Review of the Care Plan dated 1/8/16, identified the resident had a problem with falls due to a history of falling related to a post cerebrovascular accident with weakness, impaired balance, loss of arm and leg movement to the right side. The Care Plan indicated an approach dated 2/24/16, which instructed staff to not leave the resident alone in the room unattended while in the wheelchair. Review of a progress note dated 7/8/2016 at 12:35 PM documented the resident fell at 11:50 AM. The resident had a skin tear to the left forearm 3 centimeters (cm) in length. Staff applied steri-strips and covered the wound with gauze. The resident stated he/she leaned forward and the chair came with him/her. Staffs initiated cranial checks and were negative at the time. The resident ' s range of motion was within normal limits and the resident had no pain or discomfort noted. The staff lifted the resident from the floor with a mechanical lift and placed the resident back into the wheelchair. The staff notified the physician, family and hospice. The progress note documented the fall intervention directed the staff to not leave the resident in the wheelchair unattended while in the room. Review of a progress note dated 7/9/16 at 10:00 AM documented the resident was alert and oriented to self as normal. The note documented the resident had purple bruising to the upper right arm around the shoulder and the resident had a small raised area. The resident moaned when repositioning the arm. The note documented the resident's right hand as weak and the facility called the physician. Review of a progress note dated 7/9/16 at 11:22 AM indicated the physician returned the facility's phone call and ordered an x-ray of the upper arm and shoulder. Review of a progress note dated 7/9/16 at 5:49 PM indicated the physician notified the facility of the x-ray results concluded that the resident sustained [REDACTED]. The physician ordered a sling and follow-up appointment on the following Monday (7/11/16). During an interview with Staff B, license practical nurse (LPN) on 8/2/16 at 3:30 PM, she stated the resident had been in bed when she had given her/him eye drops about 5-10 minutes earlier. She stated after the resident was assisted to the wheelchair, the staff would usually bring the resident to the dining room or up by the nurse's station because the resident was not to be in the room unattended in the wheelchair. She stated she believed the certified nursing assistants (CNA) got the resident up and left her/him alone in the wheelchair in the room. She stated there is a Care Plan inside the closet door and the staff should reference the Care Plan. The LPN stated she didn't remember who the CNAs were that day. During an interview with Staff C, registered nurse (RN) on 8/2/16 at 4:07 PM, she stated Staff B had never dealt with a fall. Staff B contacted her for assistance. Staff C stated the resident fell from the wheelchair in the room. Staff C stated the facility put a sign up in the room after the fall to not leave the resident alone. Staff C stated the staff should know how to care for residents by reading a care plan in the closet. Staff C stated she wasn't sure who transferred the resident into the wheelchair and left him/her alone. During an interview with Staff D, CNA on 8/3/16 at 11:05 AM, she stated she worked with the resident on the day of the fall. She stated the resident fell right before lunch from the wheelchair near the TV landing with the wheelchair on top of him/her. Staff D believed Staff E, CNA transferred the resident. Staff D stated she was in another resident's room and heard the alarm and the resident yelling. Staff D went to the room and found the resident on the floor. Staff D stated the resident was not to be left alone in the room in a wheelchair. Staff stated that staff could read the closet care plan, check the nurse's station care plan or ask a nurse. During an interview with Staff E, CNA on 8/3/16 at 11:13 AM, she stated she was working with the resident on the day of the fall. She stated the fall occurred right before lunch. She stated that she and another CNA placed the resident in the wheelchair, but Staff B came into the room, so they left the resident with Staff B. Review of a Fall Scene Investigation form dated 7/8/16 at 11:50 AM documented the resident was reaching to the floor and fell to the floor. Review of a Fall Report dated 7/8/16 documented the resident was not to be left unattended in the wheelchair while in the room. Review of a radiology report dated 7/9/16 identified an x-ray of the right shoulder concluded there was an acute fracture involving right distal clavicle with mild displacement.

Based on observation, record review, staff and resident interviews, the facility failed to provide adequate supervision to ensure against hazards from self and assistive devices to prevent accident for 4 of 4 residents reviewed. Resident #1 fell and received a fracture when left unattended on the toilet. Staff that left the resident was supposed to be orientating on the day the incident occurred. Instead she was left alone to care for the resident. The resident also had other falls prior to the fracture without injury or with minor injury when care plan interventions were not in place. Resident #2 fell when staff could not respond to the alarm in a timely manner. Resident #4 had multiple falls and a fall with major injury when care plan interventions were not in place. During the investigation, Resident #5 (who recently sustained 2 major injury fractures and remained at high risk for falls, did not have care plan interventions in place. The facility identified a census of 115 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of [DATE]. The MDS reflected the resident had a BIMS (Brief Interview for Mental Status) score of 11. A score of 11 identified the resident had moderate cognitive impairment. The resident required extensive staff assistance of two staff members with bed mobility, transfers, dressing and toileting. The resident did not ambulate. A balance during transitions and walking test identified the resident as not steady and only able to stabilize with staff assistance when moving on and off the toilet, surface to surface transfer and moving from a seated to standing position. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident had experienced 2 falls with injury since the previous assessment. A Care Plan identified a problem on [DATE] for Activities of Daily Living functional/rehabilitation potential. An intervention dated [DATE] revealed the resident changed and required 2 person assistance with sit to stand transfers. Fall History: The resident's record identified an occupational therapy (OT) progress note dated [DATE] at 2:15 p.m. The note reflected the resident fell when left in the bathroom by self and after instruction to use the call light when finished. When found, the resident was on his/her knees, facing the toilet and saying his/her legs gave out (became weak). The resident received a small abrasion to the right knee/shin. The resident received education to use the call light for transfers. The OT identified the resident with poor insight and safety awareness and needed constant cues for safe transfers and to use assistance with transfers. The note identified the resident at risk for falls. An event report dated [DATE] at 10:43 p.m. identified an unwitnessed fall in the resident's room. Staff noted the resident sitting on the floor on his/her buttocks with legs extended out. The resident stated the legs gave out so the resident lowered self to the floor. The resident did not sustain an injury. The intervention listed on the event report following the incident, was a sign to use the call light for assistance with transfers and ambulation. The Care Plan contained the intervention dated [DATE]. An event report dated [DATE] at 1:20 p.m. identified an unwitnessed fall in the resident's room. Staff noted the resident sitting on his/her buttocks in front of the recliner. The resident stated he/she attempted to self- transfer from the recliner to the wheelchair and fell without injury. The intervention listed on the event report following the incident was a sign in room to wait for staff for all transfers. (Same intervention as after [DATE] incident) The Care Plan contained the intervention dated [DATE]. Event report progress notes, dated [DATE] at 3:03 p.m. identified the resident received from the fall a 3 centimeter (cm.) by 2.5 cm. abrasion to the right knee. An occupational therapist (OT) progress note, dated [DATE] identified the OT spoke with the nurses at the facility and found out staff did not park the power wheelchair out of the resident's reach. Staff stated they would pass the information on. A Care Plan addendum dated [DATE]; reflected staff should keep the wheelchair out of sight of the resident when in bed and recliner. An event report dated [DATE] at 10 a.m. identified an unwitnessed fall in the resident's room. The resident used the hand control to raise the recliner and slid out onto the floor. The resident did not sustain injury. The intervention listed on the event report following the incident is to place Dycem (nonskid material) in the recliner to prevent sliding. The Care Plan contained an addendum dated [DATE], that identified the Dycem intervention. An event report dated [DATE] at 7:40 a.m. identified a witnessed fall in the resident's room. The progress note for the incident identified the resident experienced an unwitnessed fall at 2:45 a.m. Staff found the resident lying on his/her back in front of the recliner. The resident stated he/she attempted to self- transfer from the recliner to the wheelchair without assistance. The call light was in reach. The resident did not sustain injury. The intervention listed on the event report following the incident to keep the wheelchair out of reach of the resident (already on the care plan on [DATE]). An event progress note dated [DATE] at 1:15 a.m. revealed the resident attempted to self- transfer to the toilet. An event report dated [DATE] at 9:10 a.m. identified an unwitnessed fall in the resident room. Staff observed the resident on the floor in his/her room in front of the recliner. Prior to the fall, the resident sat in his/her electric wheelchair. The resident stated he/she almost made it to the recliner. The resident received a small abrasion to the right knee. The intervention listed on the event report following the incident to offer to transfer the resident to the recliner after breakfast. Review of the Care Plan did not reflect this intervention to transfer the resident to the recliner after breakfast. An event progress note entry dated [DATE] at 7:30 p.m. identified that after supper, staff observed the resident attempt to self- transfer from the wheelchair to the bed. Staff educated the resident to use the call light for transfers. An event report dated [DATE] at 1:29 p.m. identified the resident with an unwitnessed fall in the resident's room. The resident stated he/she attempted to self- transfer from the electric wheelchair to the recliner. The resident stated the recliner moved back causing the resident to fall. The resident stated he/she did not like to ask for help. The intervention listed on the event report following the incident to ask the resident of he/she wanted to sit in the recliner after every meal. The care plan contained an addendum dated [DATE] that identified this intervention in place (before the [DATE]) incident An event report dated [DATE] at 8:32 p.m. identified an unwitnessed fall in the resident's room. Staff found the resident on the floor lying on the left side between the recliner and electric wheelchair. The resident stated he/she thought he/she could make it to the recliner. The resident denied injury. The intervention listed on the event report following the incident was for the resident to wear hipsters when up. An addendum to the care plan dated [DATE] identified an intervention for hipsters. An event progress note dated [DATE] at 1:48 a.m. revealed the resident attempted to self-transfer. Staff then assisted the resident to bed. Staff educated the resident to use the call light. An event report dated [DATE] at 6:07 p.m. identified an unwitnessed fall in the resident's bathroom. Review of computer progress notes identified the actual date and time of the incident as [DATE] at 10:11 a.m. The resident toileted self. The report identified that the resident transferred onto the toilet. While transferring back to the wheelchair, the resident got weak and went to the floor. The resident did not sustain injury. The intervention listed on the event report following the incident to place a stop sign on the bathroom doorway. A Care Plan addendum dated [DATE] identified an intervention for a magnetic stop sign in the bathroom door as a preventative due to self- transfers from electric wheelchair to toilet. An event progress note dated [DATE] at 9:06 p.m. identified the resident's ARNP (Advanced Registered Nurse Practitioner) called and asked about placing a personal chair alarm on the resident. Staff placed the alarm in the resident's wheelchair. The Care Plan reflected the intervention for a pressure sensitive alarm on at all times as of [DATE]. Major Injury Incident: An event report dated [DATE] at 10:30 p.m. identified an unwitnessed fall in the resident's bathroom. The fall progress note identified the resident sat on the toilet at 8:30 p.m. The resident attempted to reposition self while seated on the toilet and fell off the toilet. The resident landed on both knees and hands. Staff found the resident with his/her head in the doorway and laying anteriorly on the floor with feet towards the toilet. The resident denied pain. Observation identified abrasions to the left forehead and side of the face and bruising to both knees. Once staff lifted the resident from the floor with the Hoyer (mechanical) lift the resident complained of pain to the lower femur and knee cap. The nurse notified PACE (program of all-inclusive care service) who directed staff to apply ice and administer Ibuprofen (analgesic/anti-inflammatory) to the resident. Notify PACE if the resident's pain increased. On [DATE] at 8:20 a.m. the resident left for PACE. A root cause analysis and action plan after the incident identified the resident as short in stature due to [DIAGNOSES REDACTED] and with minimal lower extremity sensation and strength. A new nurse aide worked and the new nurse aide required more oversight. Due to dementia, the resident could not retain any education regarding safety to reduce the risk for falls. The resident lacked insight and had denial regarding limitations. A hospital diagnostic radiology report dated [DATE] at 12:11 p.m. identified the resident had a left subtrochanteric fracture of the proximal left femur with mild comminution and valgus angulation (left hip fracture). Nursing progress notes dated [DATE] at 3:27 p.m. and written by the Social Worker revealed the resident was unexpectedly admitted to the hospital. A hospital History and Physical report dated [DATE] reflected; on [DATE] the resident used the restroom and fell off the toilet trying to situate self. The fall resulted in severe left hip pain and the resident felt several pops. The resident laid on the ground (floor) for 2 minutes and staff assisted him/her to the scooter and then to bed despite reports of pain. On [DATE], the resident again told staff about the hip pain and x-rays identified a left subtrochanteric hip fracture. The resident underwent [REDACTED]. The Nursing Progress Notes dated [DATE] at 2 p.m. identified the resident readmitted to the facility following hospitalization . Staff Interviews: On [DATE] at 9:10 a.m. Staff A (licensed practical nurse- charge nurse) was interviewed and stated she worked when the incident occurred. Staff A stated the resident needed the bathroom so she and a new nurse aide (Staff B) transferred the resident to the toilet with the lift. The resident was incontinent of bowel. The charge nurse then left the resident with the new nurse aide. She stated it was a busy night. The nurse aide later came out of the room and asked the charge nurse to check on the resident because she needed to retrieve new hipsters for the resident. At that time, the charge nurse did not know the nurse aide removed the sit/stand lift. Normal procedure was to keep the sit/stand lift in place but since the resident had soiled clothing, staff took it away and didn't put it back, leaving the resident sitting on the toilet unsupported. Two minutes later, the charge nurse went in the room. The curtain was pulled so she did not make visual contact with the resident. Through the curtain, she asked the resident if he/she was OK and the resident said yes so the charge nurse left the room. A few minutes later the charge nurse heard a big thud. The resident stated he/she fell when he/she attempted to reposition self on the toilet. The charge nurse stated at the time of the incident, it was alright to leave an alarmed resident on the toilet if they kept the lift in place. After the incident, the staff have to stay with the resident. The charge nurse stated the nurse aide was new. Since the incident, Staff A stated she thinks the nurse aide had training but didn't know about the sit stand lift needing to stay in place. The charge nurse educated the nurse aide after the incident. The charge nurse stated the resident was not safe to leave without the lift and the resident made a lot of self- transfer attempts. Staff A stated she reported the incident and symptoms to the nurse at PACE. The nurse spoke with a nurse practitioner who directed Staff A to apply ice and administer Ibuprofen (analgesic) and they would assess the resident at PACE in the morning. The personnel file and schedule for Staff B, identified she had one day of orientation on [DATE]. The schedule reflected she should orientate on [DATE] but she did not receive orientation. On the night of the incident ([DATE]) the schedule reflected Staff B should receive orientation. Instead she worked alone with Resident #1. Review of her personnel file identified she signed orientation training on [DATE] (20 days after the incident). On [DATE] at 12:41 p.m. Staff C (unit manager) confirmed the nurse aide received one day of orientation prior to the incident and that on [DATE] Staff B worked as the third nurse aide and did not orientate. Staff B no longer worked at the facility and could not be contacted by phone. Other staff: On [DATE] at 3:55 p.m. Staff E (nurse aide) stated it was not OK (alright) to leave an alarmed resident in the bathroom unattended even if the lift was in place. She stated worked at the facility for 2 years and she knew that since she began employment. She stated regarding Resident #1, staff should not take the stand lift away if the resident sat on the toilet. If the resident soiled self, staff could unhook the lift, remove/change clothing and then hook the lift back up. On [DATE] at 7:20 p.m. Staff D (nurse aide) stated normal procedure was to stay with the resident in the bathroom. Staff D stated he found this out in a meeting 2 to 3 weeks before the incident. On [DATE] at 4:30 p.m. the Director of Nursing stated that during the investigation of the incident, they (the facility) discovered the nurse aide did not have orientation. They now have a new staffing co-coordinator. Observation: On [DATE] at 4:18 p.m. observation identified two nurse aides transferring the resident into the wheelchair via the EZ lift. The resident stated he/she recalled falling from the toilet. The resident fell and landed on his/her bottom. The resident stated he/she fell before. When asked if anything could have prevented the fall, the resident stated when he/she needs to go he/she needs to go. 2. Resident #2 had a Minimum Data Set (MDS) assessment, with a reference date of [DATE]. The MDS identified a BIMS (brief interview for mental status) test scored a 4. A score of 4 represented the resident had a severe cognitive impairment. The resident required extensive assistance from staff with bed mobility, transfers, dressing, toileting and personal hygiene. The resident ambulated with one person physical assistance. A balance during transitions and walking test identified the resident as not steady and only able to stabilize with staff assistance with all areas of testing other than when moving from seated to standing. When moving from seated to standing, the resident was not steady but could stabilize without staff assistance. The resident used a walker and wheelchair for mobility. The resident was incontinent of bowel and bladder. The resident had [DIAGNOSES REDACTED]. A Care Plan with a problem date of [DATE] identified the resident with a history of falling related to [DIAGNOSES REDACTED]. The resident continued to self- transfer unassisted even with multiple interventions in place for safety. The Care Plan contained an intervention dated [DATE], that directed staff to apply a pressure sensitive alarm on the resident at all times for self- notification. An intervention with an approach date of [DATE] directed staff to place an alarm above the bathroom door and offer to take the resident to the restroom around an hour after meals. An approach dated [DATE] directed staff to place a sign in the resident ' s bathroom reminding the resident to call for assistance before transferring. An intervention dated [DATE] directed staff to offer and encourage 2 hour toileting. The [DATE] activity of daily living Care Plan, directed the staff that one staff person needed to assist the resident with transfers and ambulation. Falls: An event report dated [DATE] at 3:55 a.m. identified an unwitnessed fall in the resident's room. Event progress notes on [DATE] at 12:08 a.m. identified staff observed the resident sitting on the floor next to his/her bed at 9:45 p.m. The resident stated he/she put pants on and slid to the floor. The intervention was to remove clothing from view of resident when he/she was in bed. An event report dated [DATE] at 2:31 p.m. identified an unwitnessed fall in the doorway of the resident's bathroom. The resident used the toilet alone. The intervention was to offer the restroom after lunch (already in place). An event progress note dated [DATE] at 2:37 p.m. identified the resident slipped from the wheelchair. Staff got the resident up from the floor with the Hoyer lift and placed the resident in bed with a call light and alarm in place. The event report did not identify whether the resident's alarms activated when the fall occurred. Staff F (nurse working when the incident occurred), stated on [DATE] at 11:45 a.m. she did not recall if the resident's alarms activated when the fall occurred. An event report dated [DATE] at 5:55 p.m. identified an unwitnessed fall in the resident's bathroom. An event progress note dated [DATE] at 6:15 p.m. revealed the resident's spouse came and notified a nurse aide that the resident fell . Staff found the resident sitting in front of the toilet. The resident did not sustain an injury. A tracking record dated [DATE] identified Staff E (nurse aide) stated the resident's alarms sounded when the fall occurred. On [DATE] at 10:17 a.m. Staff E stated she was the only one on the unit when the incident occurred. She heard the alarm sound when she worked with a resident that she could not leave. By the time she finished that resident and got to Resident #2's room, she found Resident #2 already on the floor. Observation showed, on [DATE] at 7:35 p.m., the resident attempting to get from bed to wheelchair per self with alarm sounding. A nurse aide responded to the alarm and assisted the resident into the wheelchair. 3. A Minimum Data Set (MDS) assessment with a reference date of [DATE] reflected Resident #4 had an impaired ability to understand others. The resident missed some part/intent of the message but comprehended most conversation. The resident had verbal behaviors directed towards others and rejected care 1 to 3 days out of the 7 days. The resident required limited staff assistance with bed mobility and eating. The resident required extensive staff assistance with transfers and ambulation in the room, toileting and personal hygiene. A balance during transitions and walking test identified the resident as not steady and only able to stabilize with staff assistance in all areas of testing. The resident used a walker and wheelchair for mobility. The resident occasionally experienced bladder incontinence. The resident had [DIAGNOSES REDACTED]. The resident had 2 falls since the previous assessment and one with injury. A Care Plan with problem start date of [DATE] identified the resident at risk for falls due to poor safety awareness and impaired mobility. The Care Plan directed staff to apply a personal alarm to the resident's bed and chair. A Care Plan approach revealed the resident did not remember to use the call light so the resident would call out for assistance. The activity of daily living care plan, dated [DATE] directed staff to toilet the resident before and after meals and at bedtime. Falls: An event report dated [DATE] at 11:41 p.m., revealed an unwitnessed fall in the hallway. An event progress note dated [DATE] at 12:13 a.m., identified the resident slid out of the wheelchair and sat on the pedals of the chair. The resident did not sustain an injury. The event report identified the intervention following the incident as Dycem (nonskid mat) to the wheelchair. The fall scene investigation, dated [DATE] at 7:45 p.m. identified the alarm sounded and staff found the resident. An event report dated [DATE] at 10:34 a.m. identified a witnessed fall in the resident room. An event progress note dated [DATE] at 10:50 a.m. revealed the resident's alarm sounded and staff arrived to see the resident walking and fall backwards against the bedside table. An assessment showed a 2 centimeter (cm.) long skin tear to the left elbow with 2 cm. by 2 cm. dark purple bruising around it. The resident also had a 1 cm. by 4 cm. red scrape to the left lower back. The resident stated he/she needed the bathroom. Staff last toileted the resident at 5 a.m. The resident experienced bowel and bladder incontinence at the time of the fall. A tracking record for improving patient safety (TRIPS) form revealed the date and time of the fall as [DATE] at 6:45 a.m. The event report identified the intervention following the incident was to offer to get the resident up first in the morning due to frequent attempts to get up by self. An event report dated [DATE] at 9:28 p.m. identified an unwitnessed fall in the hallway. The event report progress notes dated [DATE] at 9:31 p.m. identified the staff found the resident sitting on the floor in front of the wheelchair. The resident complained of mild pain in his/her bottom but did not want pain medication. The event report form identified the new intervention following the incident as to not leave the resident unsupervised in the hallway. Review of the Care Plan did not identify this intervention, instead the new intervention listed on the Care Plan for falls and after the incident and dated [DATE] was toilet after supper, which was already in place since [DATE]. A TRIPS form identified the date and time of the incident as [DATE] at 6:50 p.m. The report did not identify if the alarm activated or if Dycem was in place when the fall occurred. The resident did not receive injury. An event report dated [DATE] at 9:30 p.m. reflected a witnessed fall at the nurse ' s station. A TRIPS form identified staff saw the resident slide out of the wheelchair. The investigation form contained with the TRIPS information did not identify if the alarm sounded or if Dycem was in place. The Care Plan contained an addendum dated [DATE], that directed staff to replace Dycem to the wheelchair. The resident did not receive injury during the fall. An event report dated [DATE] at 7:31 p.m. reflected an unwitnessed fall in the hallway. An event progress note, dated [DATE] at 7:36 p.m. reflected the staff noted the resident sitting on his/her bottom in front of the wheelchair with legs extended. The resident did not sustain an injury. The Care Plan contained an addendum on [DATE] (after the incident) that directed staff to place Dycem on top of the alarm pad. The TRIPS form identified the fall occurred on [DATE] at 7 p.m. Staff responded to the alarm. The form did not identify if Dycem was in place when the fall occurred. Major Injury Incident: An event report dated [DATE] at 5:38 a.m., revealed an unwitnessed fall in the resident's room. An event progress note dated [DATE] at 5:54 a.m. identified the resident fell to the floor and landed on the right side while attempting a self- transfer. The resident complained of pain. The physician ordered an x-ray. After the facility could not get the x-ray at the facility, the resident transported to the emergency room (ER) for an evaluation. On the same date at 10:10 a.m. the facility received a call from the ER. The hospital staff reported the resident had a fractured pelvis and would return to the facility with orders for a Fentanyl (narcotic) pain patch. A TRIPS form identified the fall occurred on [DATE] at 4:45 a.m. The form did not identify if the resident's alarm sounded when the fall occurred. An x-ray report dated [DATE] identified the resident with a fracture of the right superior and inferior pubic ramus extending to the pubic symphysis with mild displacement. An emergency department (ED) note identified the fracture as a pelvic ring fracture. The ED discharge instructions on pelvic fracture identified that pelvic fractures were usually due to a fall or a car accident. Walking or changing positions may be painful. On [DATE] at 4:40 p.m. Staff G (nurse aide) stated she found the resident on the floor on [DATE]. She stated the resident hollered at 2:30 a.m. so she took the resident to the bathroom and got him/her back in bed. Staff G stated she finished rounds at 3 a.m. and then did some charting. She rechecked the resident at 4 a.m. then around 4:30 a.m. she heard he resident holler. Staff G stated she went to the resident's room and found the resident on the floor. The resident's alarm did not sound when the resident fell . Staff G got Staff H (licensed practical nurse) to come and assess the resident. Staff G stated the resident was supposed to walk with one person's assistance. Staff G stated the resident had too many blankets on the night of the fall and this may have caused the alarm not to activate. She stated the alarm sounded when she took the blankets off of the alarm pad. The resident would never use the call light and always got up on own. Staff checked the resident every 2 hours. On [DATE] at 6:20 a.m. Staff H stated Staff G called and said the resident fell so she came to the resident's room and found the resident laying on his/her right side. The resident had a skin tear to the right arm. She tried to get the resident to roll over but the resident screamed bloody murder. Staff H called the physician who asked Staff H to have mobile x-ray come. Mobile x-ray could not get the x-ray due to the resident having so much pain so Staff H sent the resident to the hospital. The resident had a broken pelvis. Staff H stated the resident was known to get up on his/her own a lot. She didn't know why the alarm didn't sound. The alarm was intact when Staff H saw it and the pad was positioned correctly. After the fall, the resident went downhill and expired. On [DATE] at 3:30 p.m. Staff I (staffing coordinator and supply order person) stated from [DATE] to [DATE] the facility figured out they were using incompatible (wrong) transmitters for the alarm boxes and pads. They were in circulation for 2 weeks. The alarm box would sound but it wouldn't come across on the call light board or pagers. Staff I stated there was no way to know if Resident #4 used the alarm. On [DATE] at 3:35 p.m. a service representative for the alarm company said blankets would not defeat the alarm from working. If the facility used the wrong transmitter, it may cause the system not to work correctly. Reenactment of incident: On [DATE] at 3:46 p.m. the Director of Nursing (DON) performed a reenactment of the incident and laid in bed with four bath blankets. The alarm sounded when she got out of bed, even when the blankets remained on the bed pad. On [DATE] at 5:38 a.m. Staff G stated the resident's alarm didn't always go over the pagers or call light system before the incident occurred. On [DATE] at 5:45 a.m. the surveyor informed the DON that Staff G said the alarm didn't always go across the pagers or call light system prior to the incident. The surveyor stated she wondered if the resident used one of the wrong incompatible transmitters. The DON stated she thought the resident probably did. On [DATE] at 6:08 a.m. the Director of Nursing (DON) and Staff G reenacted the incident with 5 double-folded bath blankets and one double folded quilt. The alarm still activated when the DON got up and placed the blankets to her side as Staff G directed and stated they were on the night of the incident. At that time, Staff G stated prior to the incident, the alarm did not go across the pagers or the call light board but the alarm itself would work. The night of the incident, the alarm did not work. She stated about a month before the incident, the alarm wasn't going across the pagers or board so she told a nurse who replaced the alarm. After the resident got a new alarm, it still wouldn't always go across the pager or board but she didn't report it again. A resident physician order/progress note transfer form identified the resident admitted to the hospital on [DATE] for pubic fracture, urinary tract infection and atrial fibrillation. The resident returned to the facility on comfort care, bedrest, oxygen and Dilaudid (narcotic) for facial grimacing. An authorization for ambulance services dated [DATE] contained a medical necessity questionnaire that identified the resident with severe dementia and pelvic fracture. The resident was recently in the hospital for atrial fibrillation. The family wanted comfort care. The admission orders [REDACTED]. Resident progress notes dated [DATE] at 2:20 a.m. identified staff found the resident expired at 2:15 a.m. 4. A Minimum Data Set (MDS) assessment with a reference date of [DATE] assessed Resident #5 with a brief interview for mental status (BIMS) score of 9. A score of 9 identified the resident had a moderate cognitive impairment. The resident required extensive staff assistance with bed mobility, transfers, dressing and toileting. A balance during transitions and walking test identified the resident as not steady and only able to stabilize with staff assistance in all areas of testing. The resident used a wheelchair for mobility. The resident was always incontinent of urine and occasionally incontinent of bowel. The resident had [DIAGNOSES REDACTED]. A resident admission record identified the resident had an admission date of [DATE]. A skilled admission form dated [DATE] at 4:30 p.m. identified the resident was admitted to the facility for weakness and heart failure. A Care Plan dated [DATE] identified the resident transferred and ambulated with the assistance of one staff and a walker. Following admission into the facility, the resident had the following falls: An event report dated [DATE] at 7:30 p.m., revealed an unwitnessed fall in the resident's room. The resident received a bump to his/her head. An event progress note dated [DATE] at 2:32 a.m., revealed the resident returned from the emergency room (ER) The resident received orders for Cipro (antibiotic) for a urinary tract infection. The entry identified the resident with a large bruise to the back of the head. The intervention following the incident was: toilet every two hours. An event report dated [DATE] at 12:09 a.m., revealed an unwitnessed fall in the resident room as the resident walked. An event progress note identified the resident fell . Staff found the resident flat on his/her back. The resident complained of right hip and shoulder pain. The resident transferred to the emergency room for an evaluation.

Based on observation, record review, staff interviews and review of facility policy/procedures, the facility failed to provide adequate supervision to ensure against hazards from self, failed to revise the Care Plan to promote resident safety and failed to meet the needs of the resident by an adequate working schedule (Residents #1 and #3). The sample consisted of 4 residents and the facility reported a census of 118 residents. Findings include: 1. The facility Fall Prevention policy dated 6/23/09 identified the facility that fall prevention will be implemented to decrease the number of falls. The procedure directed staff that if a fall occurs, interventions would be implemented in an attempt to prevent further falls. The Resident Admission Record identified Resident #1 had an admission date of [DATE] into the facility. The record revealed the resident had [DIAGNOSES REDACTED]. An online incident reporting form identified the resident had advanced dementia, hypertension, diabetes and an extensive history of falls. The right humerus fracture occurred from a fall at home. The resident had a history of [REDACTED]. The resident had a fall on 6/22/13 with no injury as well as a fall on 7/1/13 with no injury. On 6/23/2013, the resident scored a 3 out of 15 on a cognitive test. Resident limitations to right arm was non-weight bearing, no lifting, and wore an immobilizer to the right arm. The resident required assistance of two people for transfers, walking, toilet use and dressing. On 7/4/13 at 8:15 p.m. staff found the resident on the bathroom floor, complaining of left hip pain. The resident was admitted to the hospital with [REDACTED]. A hospital physician History and Physical report dated 6/5/13 assessed the resident with advanced dementia sustained a fall and fractured right humerus. The Nurse's Notes dated 6/10/13 at 10:00 p.m. noted resident admitted to the facility for skilled/therapy services due to a humerus fracture. Resident pleasant, very confused. The Nurse's Notes dated 6/11/13 at 4:06 a.m. reflected the resident had increased confusion, thinking she/he at home or other institution, increased restlessness and voiced complaints of pain . The resident received antianxiety and analgesic at 11:55 p.m. A Minimum Data Set (MDS) assessment, with a reference date of 6/17/13 identified the resident with impaired temporal orientation, impaired recall and impaired cognition scoring 4 out of a possible 15. The resident required extensive assistance of two persons for bed mobility, transfers, walking, dressing and toilet use. The resident experienced frequent episodes of bowel and bladder incontinence. The resident reported suffering from frequent pain. The facility computer notes indicated the following: On 6/12/13 at 10:09 p.m. resident very confused and upset when aides perform cares. On 6/13/13 at 2:22 a.m. difficulty making wants and needs known related to confusion. Requires total assistance for repositioning. Limited range in motion of right arm due to fracture. On 6/14/13 at 2:07 a.m. resident needs must be anticipated as resident had difficulty in making needs know. On 6/17/13 at 1:31 p.m. resident needs reminded often to not take arm out of sling. Resident incontinent of bowel and bladder. Resident required maximum assistance of two persons with bathroom duties and transfers. On 6/18/13 at 2:18 a.m. resident confused and resistant with cares. On 6/18/13 at 5:53 p.m. resident confused and continues to try to get up from wheelchair. On 6/20/13 at 10:11 p.m. resident was not always able to make needs known. Needs should be anticipated and resident asked to be helped. On 6/21/13 at 6:26 p.m. resident alert and confused at times, had hard time conveying needs. The Nurse's Notes dated 6/22/13 at 6:45 a.m. at 5:20 a.m. revealed the staff observed the resident sitting on the floor in front of the recliner. Staff assisted resident up from the floor with the assistance of three people and a Hoyer mechanical lift. Resident stated he/she walked from bed to recliner and slid to the floor. A TRIPS (Tracking Record for Improving Patient Safety) report dated 6/22/13 identified an intervention of 1 hour checks to be performed as a result of the fall. The facility computer notes titled Bethany Lutheran Home, Inc. identified the following: On 6/22/13 at 9:11 p.m. resident was very confused. Resident was easy to calm for first half of shift. When being put to bed, he/she felt very upset and screamed at the aides. 6/26/13 at 1:28 a.m. sitting in wheelchair at the desk, confused and disorientated to time and place, thinks another resident is his/her spouse. Ativan (anti-anxiety) given for agitation and restlessness. The Care Plan dated 6/26/13 included a problem with Activities of Daily Living/Rehabilitation deterioration regarding [DIAGNOSES REDACTED]. The approach identified the resident as more alert in the morning and to use 2 staff members to transfer the resident, use a gait belt and cue with encouragement. The resident displayed increased confusion in the evening and may require 2 staff member assistant with a Hoyer transfers due to unable to follow commands and track (mentally). The Care Plan reflected the resident at risk or falls due to dementia, a history of falls and a fractured arm. The only approach listed on the plan of care directed staff to give the resident verbal reminders not to ambulate/transfer without assistance and to see fall intervention form for interventions. The Bethany Lutheran Home Fall Safety Plan included: On 6/22/13 the resident slid out of (the) recliner. Interventions: one hour checks. On 6/26/13 preventative: sign placed on door, do not leave resident in room unattended in wheelchair. Bethany Lutheran Home, Inc. (computer notes) included: 6/26/13 at 5:11 p.m. resident gets more confused toward evening. 6/26/13 at 11:09 p.m. resident confused and not able to make needs known. 6/27/13 at 1:15 p.m. resident combative with cares this morning, had difficulty processing his/her environment and staff's motives for assisting him/her. 6/27/13 at 1:26 p.m. documented resident reported clear nasal drainage while eating which resident reported normal for him/her since his/her stroke. 6/29/13 at 1:19 p.m. resident alert with pleasant confusion noted. Resident complained of left wrist discomfort. Area noted slightly swollen, as day goes by, are had gotten red in color. Resident incontinent and wore disposable brief. Resident required maximum assistance of two persons with bathroom duties and transfers. Resident continued to wear immobilizer on at all times to right arm. Resident required several reminders to not use arm. 6/30/13 at 5:41 p.m. resident confused and could not say full name. Resident began to speak about unrelated subjects when asked yes/no questions. 7/1/13 at 1:34 a.m. resident confused and disoriented to time and place and Ativan given orally to promote rest. Nurse's notes included: 7/1/13 at 7:10 p.m. resident tried to stand up in/from wheelchair in presence of daughter and slid onto knees. Fall Safety Plan dated 7/1/13 read, "Resident being transferred by daughter and lowered to knees. Interventions: educate daughter to ask for assistance when resident transferred. On 7/29/13 at 3:45 p.m. a family member was interviewed and stated she feels she needs to stay with the resident throughout the day to provide the supervision the resident requires in order to prevent falls. The family member stated on 7/1/13 she and the resident was awaiting staff to come and assist the resident when suddenly the resident stood up from the wheelchair and slid to the floor. The family member stated she was not trying to assist the resident. The TRIPS dated 7/1/13 at 6:45 p.m. included exact position resident found. The resident found on knees in front of the recliner. Brief narrative of this incident identified the resident started to stand from the wheelchair. The resident's family member thought she could help. Resident slid to his/her knees and in that position facing the recliner. The cause of the incident was: family thought she could help. Bethany Lutheran Home, Inc. (computer notes) included: 7/3/13 at 1:34 a.m. resident sitting at the desk in wheelchair, very restless and agitated. Ativan given for rest and effective in one half hour. 7/3/13 at 7:00 p.m. resident confused and angry at times this shift. Multiple episodes of standing and trying to ambulate on his/her own this shift with re-direction necessary. The Nurse's Notes dated 7/4/13 at 8:20 p.m. noted resident found in bathroom laying on right side on floor, facing the wall. Resident stated, "I stumbled onto the ground." Resident lifted to bed by Hoyer and three people. Resident complained of right leg pain during assessment. This nurse was limited on assessment due to resident refusal due to hip pain. Right leg shorter than the left (leg). Resident had increased confusion this shift. Fall was unwitnessed. The Nurse's Notes dated 7/5/13 at 9:10 a.m. indicated the nurse placed a call to the hospital. Resident admitted for right hip fracture. On 7/30/13 at 8:30 a.m. the Director of Nursing (D.O.N.) was interviewed and stated the Unit Managers of each unit complete the assessments for residents on their units and the unit managers attend the Care Plan meetings for the residents on their units. The D.O.N. stated her goal was for the facility to be an alarm free facility by May 1, 2013. She stated she first began to remove the alarms last January or February and they began this transformation on the Sunrise Unit. When asked what types of interventions did they put into place when they removed residents' personal, bed or chair alarms, the D.O.N. stated if the resident fell or scored at a high fall risk, they would use non-skid socks, encourage the use of call lights, and instruct the family not to leave the resident in certain positions. The D.O.N. stated that alarms do not keep them (residents) off the floor. The D.O.N. stated at one point 33 residents utilized alarms. When asked how they convey Care Plan interventions, specifically fall risk interventions, to all staff, the D.O.N. stated through the resident's plan of care and fall interventions which were kept at the nurse's station. When asked how someone would know what interventions were in place at the time of a fall, the D.O.N. stated fall interventions would be identified in the computerized nurse's notes for residents receiving skills services and in the hand written nurse's notes for all non-skilled residents. The Director of Nursing stated when the resident fell and sustained a hip fracture they were working with fewer staff than planned. She stated on 7/4/13 for the afternoon shift, they had scheduled four Certified Nursing Assistants to work on the Sunrise Unit, however due to staff on other units calling in sick that day, one nursing assistant was pulled from the Sunrise Unit to work in the dementia unit. When interviewed on 7/29/13 at 9:00 a.m. the Unit Manager for the Sunrise Unit, Staff D stated she admitted this resident to the facility. The resident was admitted to the facility due to a fractured arm from a fall at home. The resident was confused and required staff assistance for transfers. The resident was fairly good in the mornings; however he/she had sun downing (symptoms of anxiety, restlessness, confusion, combativeness) in the afternoons. The resident was not able to remember to use the call light consistently. They tried to keep this resident at the nurses ' station for closer observation. The staff did not plan any one to one activities or supervision for this resident. At the time of admission, she identified this resident's risk for falls and implemented one intervention. The one intervention was to remind the resident to use the call light. After this resident's first fall in the facility she implemented a second intervention, for staff to check on this resident every hour. On 6/26/13 she also initiated for staff not to leave this resident alone in his/her room due to they were finding this resident getting out of his/her wheelchair alone. Staff D stated, "We were shying away from alarms." They were trying to be an "alarm free" facility. When in his/her bedroom, this resident was to be either in bed or in recliner. The resident was fascinated with the foot rests on the wheelchair and would lean over and fall. The resident tried to stand up frequently when in the wheelchair. The staff would then tell the resident to sit down, especially in the evening. Verbal reminders to use the call light or not to stand up unassisted were not effective due to this resident's memory loss. Staff D stated this resident was constantly getting up independently. Staff D stated basically this resident required one to one supervision to prevent him/her from getting up by him/her. Staff D stated they could not always keep this resident near them for supervision. Staff D stated they used to use personal alarms in the past that would instruct the resident by name to sit down; however they did not try any alarms with this resident. Staff D stated she was directed by the Director of Nursing to go alarm free. On 7/4/13 she first planned for staff not to leave this resident alone in his/her recliner due to the resident had a fall and then she thought she could not prevent this resident from sitting in his/her recliner so she disregarded her planned intervention. While this resident was in the hospital for the treatment of [REDACTED]. When asked what other interventions had they implemented on other residents that they had not attempted for this resident, Staff D stated with other residents, they had implemented other interventions including the use of alarms, provide increased activities, increase visual checks, the use of warm blankets, the use of hipsters to prevent hip fractures and to offer two hour toileting assistance. The resident had a history of [REDACTED]. The resident had decreased thought process and memory loss and decreased safety awareness since admission. He/she was not safe, such as he/she did not have the wisdom to not reach for his/her foot pedals on the wheelchair, and to lock the wheelchair brakes before standing up. The resident was non-compliant due to his/her memory impairment. Normally the facility would staff four aides on Sunrise unit, two aides per hall. The Unit Manager stated when a staff member calls in or does not report to work, they are to call in the on call staff member, or go through and call all staff to fill the vacant staff position. This Unit Manager stated Sunrise Unit housed 35 residents and was the busiest unit. Sunrise unit had eight skilled residents where the other units had only one or two. On 7/31/13 at noon, a Licensed Practical Nurse, Staff C was interviewed and stated she routinely worked on the Sunrise unit. She described this resident as a confused resident who would do well (less confusion) for a few hours and then would be more confused. This resident's confusion varied throughout the day. This resident would get up independently without staff assistance. The resident would also scoot to the front edge of the chair. When you would ask the resident what he/she was doing, the resident did not know due to he/she was so confused. For a while they did not allow the resident in his/her wheelchair alone, they had to keep the resident with them. Normally the resident was in his/her recliner. The resident would try to get out of the recliner. Sometimes the resident would say he/she needed to use the restroom but other times the resident was just too confused to say what he/she needed. The daughter is frequently here so the daughter would come and tell them what the resident needed. The staff on the Sunrise unit varied from three to four aides. Staff C stated Sunrise is a busy hall. She first learned there was a concern on 7/4/13 when she heard an aide yell for help. She ran to this resident's bedroom where she saw the resident on the floor in the bathroom. The resident stated they stumbled and fell to the floor. Due to the small space and the way the resident was lying, she could only do range of motion to the resident's left side, which was alright. They then got the Hoyer lift and lifted the resident up off the floor and onto the resident's bed. The resident would not allow full assessment of his/her range of motion. About five or ten minutes after getting the resident into bed, Staff C did range of motion of this resident's extremities and noted this resident's right leg was shorter than the left and was painful. She then called the other nurse in to assess this resident. Staff C stated for the most part staff are able to answer call lights in a timely manner, but they do have nights when it is tougher, like when there are only three aides working. The aides are always running and they are never resting. Prior to this resident's fall/fracture, she noticed Resident #1 had increased confusion and wore his/her right arm immobilizer. On 7/30/13 at 5:00 p.m. a Certified Nursing Assistant (CNA), Staff E was interviewed and stated normally the facility will staff four CNA ' s on the second shift on Sunrise unit. They had two CNAs per hall. Prior to this resident's fall they worked with only three CNAs on Sunrise unit two or three times a week. When they work with only three aides, they work together without any hall assignments due to one aide cannot work alone on a hall. On the Fourth of July it was definitely busier than usually with call lights going off, they were just pulled in different directions. The nurses try and help as time allows, however, that night the nurses were busy. This resident liked to do things him/herself. The resident was not used to people telling him/her that he/she could not get up without help. The resident would say, okay, but did not understand the call light. This resident was restless that night. They tried to keep the resident in his/her recliner as much as they could. The nurses told them the only safe place for this resident was in the recliner and not in bed or wheelchair due to this resident would climb out. They had taken this resident to the bathroom prior to the evening meal. After supper she was working a couple rooms down from this resident. When she stepped out into the hallway she heard moaning and groaning. She ran to this resident's bedroom where she found this resident on the floor, in the bathroom, by the toilet. The resident had been in the recliner. The resident had his/her immobilizer on the right arm. Since returning from his/her fractured him, they use a sensor alarm on this resident. The resident will still try and get up unassisted and the alarm will sound and they are able to reach the resident before the resident can try and stand up. This resident required a lot of one to one assistance. On 7/31/13 at 5:00 p.m. a Licensed Practical Nurse, Staff F was interviewed and stated on 7/4/13 he worked the afternoon shift. He was passing medications on Sunrise unit when suddenly an aide asked, "Is (he/she) supposed to be doing that?" He looked and saw this resident up out of the wheelchair and walking down the hall by him/herself by the nurses ' station. The resident's gait was very unsteady. He had seen this resident do this a couple of times. This was after supper and before the fall. The resident did not say where he/she was going or what he/she was doing. After supper the staff had taken the resident to the nurse's station. Staff F stated normally they had five or six aides on Sunrise. Staff F stated, "We were very short handed that night." Two residents fell in the Sunrise unit on the second shift. Later he heard an aide call out for help. He ran to the resident's bedroom where he saw the resident on the floor in the bathroom. The resident was in pain. He noticed the resident's right leg was shorter than the left. The resident cried out in pain when he touched the resident's hip. They used a Hoyer lift to get the resident off the bathroom floor and into bed. He then instructed the resident ' s charge nurse, Staff C to call the resident ' s physician. Staff F stated he does not believe it is humanly possible for three aides to provide all cares and supervision on the Sunrise unit. Staff F stated they had many residents at high risk for falls. On 7/31/13 at 3:30 p.m. Staff G, Certified Nursing Assistant was interviewed and stated she worked on Sunrise unit the afternoon shift on 7/4/13. She stated it was just more hectic that day. She stated the three aides worked together, they did not divide up the hallways. She also stated that day, there were a few call lights "out" meaning the call lights were on for longer than the allowed 15 minute time frame. This resident was not to be left alone in his/her room in the wheelchair due to he/she was a fall risk. After supper that night, the resident kept getting up out of the wheelchair. They transferred the resident from the wheelchair to the recliner. The resident did not transfer well that night. Staff G stated she did not believe 3 Certified Nursing Assistants were adequate to provide resident cares and supervision. When asked what they do different on another hall, Staff G stated they staffed 3 aides for 35 residents on Sunrise unit and they staff 2 aides for 15 residents on Ivy unit, plus they have a RA (resident assistant) on that unit as well, to assist with activities and non-nursing duties such as passing ice water. On 8/1/13 at 7:43 a.m. at the Sunrise nurse's station, observation revealed Staff H (Certified Nursing Assistant) seated at the nurses ' station. Observation also revealed multiple resident call lights sounding in the Sunrise Unit at this time. Staff H remained seated filing paper work into resident records. Continued observation revealed this Certified Nursing Assistant continued to sit even though the call lights continued to sound. Observations revealed no other staff in sight. Staff H reported four Certified Nursing Assistants were working the Sunrise unit at this time. Staff H then continued to sit and file papers in resident records. When interviewed at this time, Staff H stated she could not answer the call light due to she was on light duty. When interviewed on 8/6/13 at 10:11 a.m. Staff I, Certified Nursing Assistant, and described Resident #1 as a very confused resident who did not know what was going on (cognitively impaired). The resident was very fearful of falling. The resident was very skittish. The resident would not ask for assistance. The resident would just get up. Staff I worked on 7/4/13. She came on duty at 6:00 p.m. They had three aides to work the Sunrise unit. Staff I stated they worked all over the facility. Staff I stated three aides were not adequate to provide all cares and supervision. Staff I stated they required at least five aides on Sunrise unit to provide adequate care and supervision. On 7/4/13, prior to the fall, this resident had been up and down repeatedly from the recliner, which was unusual for this resident. Normally the resident was satisfied when seated in the recliner. Staff I was at the nurses ' station on Sunrise unit after supper when she looked up to see this resident walk from his/her bedroom up to the nurses ' station attempting to put on a sweeter. Staff I asked the nurse, Staff F if that was normal for this resident to walk independently down the hall. When Staff F informed her no, she got up and walked the resident back to his/her bedroom and assisted the resident back into the recliner, placed the resident's feet up and positioned the over bed table next to the resident. Staff I stated normally she would have assisted the resident to the bathroom, however since this resident was to have the assistance of two persons with toileting; she walked the resident back to his/her room and to the recliner instead of assisting him/her to the bathroom. She did not offer to assist this resident to the restroom. She then left the resident's room to go and care for another resident. Prior to the resident's fall that evening, the resident was much more restless than usual. The night was very hectic that night. It is always a busy unit, but that night it was hectic. She did not provide this resident with any cares, including any toileting needs that day. 2. The Resident Admission Record for Resident #3 noted an admission date of [DATE]. The admission [DIAGNOSES REDACTED]. An initial Care Plan, dated 10/31/12 noted Resident #3 required assistance of two persons for positioning, was dependent for mobility, required fall precautions and behaviors required 15 minute checks. This resident's Care Plan dated 2/21/12 noted Resident #3 at risk for falling due to severe senile dementia. The goal was the resident would remain free from major injury. The approach directed staff to place the resident in a fall prevention program and to see the fall interventions list. A hospice physician notification sheet dated 6/5/13 documented the staff notified the physician to the resident ' s increased behaviors consistently. The physician ordered Risperdal (antipsychotic) 0.25 milligram orally two times a day routinely. A Nurse's Note dated 6/10/13 at 3:20 p.m. noted staff found the resident on the floor mat. The resident was resting in bed prior to the fall out of bed. A TRIPS (Tracking Record for Improving Patient Safety) form dated 6/10/13 documented the resident fell out of bed. This document also reflected the fall mat effective and no further treatment. Unknown cause of incident. A hospice physician progress notes [REDACTED]. A Nurse's Note dated 6/17/13 at 8:45 p.m. reflected the resident was found by hearing a fall in the hallway next to the nurses ' station. The resident assessment identified left shin bruise/bump, scratch on spine, mid back, left forehead lump/bruise, left cheek bruise, and skin tear left index finger first knuckle. A communication (fax) sheet sent to the resident's physician dated 6/17/13 noted the resident as found on face/forehead in front of locked wheelchair by the nurses ' station. TRIPS dated 6/17/13 noted staff found the resident on the ground on right side and feet were tangled in the chair. The cause of the incident was identified as the resident trying to do something with (his/her) feet. Tipped wheelchair. The intervention put in place consisted of 15 minute checks and to keep the resident with medication aide/staff at all times while in the wheelchair. Nurse's note dated 7/4/13 at 3:10 p.m. indicated the resident was found on the floor pad beside the bed. A TRIPS dated 7/4/13 noted the resident sitting on buttocks with back against the back of the bed. The interventions put in place by the facility directed staff to toilet the resident prior to lying down after meals The MDS assessment, with a reference date of 7/17/13, identified Resident #3 with long and short-term memory impairment, severe cognitive impairment, behaviors included physical, verbal and resistance of care, required extensive assistance for bed mobility, transfers, dressing toilet use and hygiene, non-ambulatory, impaired balance, always incontinent of bowel and bladder. The MDS identified [DIAGNOSES REDACTED]. The plan of care dated 7/24/13 and the Fall Safety Plan revealed the staff did not update/include this last planned intervention to reduce the risk for falls such as toilet resident prior to lying down after meals. Review of the Fall Risk Assessment tool dated 7/4/13 noted this resident's risks of falls included: disoriented times three at all times, physical support required for ambulation, bed mobility, always incontinent of bowel and bladder. The nurse documented the resident sustained [REDACTED]. The resident had sustained falls on 6/10/13 and on 6/17/13. This resident's Fall Safety Plan identified the following falls and interventions: 9/18/12 Resident found on floor next to bed and the intervention to request floor mat 10/2/12 Slid out of bed. The intervention to evaluate for a low bed fall mat. 12/2/12 Found on fall mat. Continue current interventions as effective. 12/28/12 Getting out of bed, rolled onto fall mat. The intervention effective 1/10/13 Discontinue alarm on bed due to low bed fall mat. 1/24/13 Discontinue alarm in chair due to not attempting to transfer from chair. 3/25/13 fell out of bed. Low bed fall matt effective 6/10/13 Found on fall mat. Low bed fall mat effective. 6/17/13 Observed on floor by wheelchair. Intervention of 15 minute checks. Keep resident with med aide/staff at all times while in wheelchair. 6/27/13 Discontinue to keep resident with med aide/staff at all times, while in wheelchair, unable to provide one on one care. 6/27/13 If possible when resident in wheelchair and having heightened energy, keep with staff members. 7/4/13 Slid out of bed. Low bed fall mat effective On 7/31/13 at 5:40 p.m. the Director of Nursing stated the Fall Safety Plan Interventions of a low bed fall mat effective with no new interventions after each fall from bed, were appropriate due to their goal was for no major injury and not to reduce falls and/or the risk for falls, therefor no new interventions were necessary. 3. Based on observation and staff interviews, it was determined the facility failed to ensure the residents ' environment remained as free of accident hazards as possible when they failed to store/secure potentially hazardous chemicals and oxygen tanks when not in use and/or under direct supervision. Observation on 7/31/13 at 8:20 a.m. revealed an unlocked housekeeping cart left in a resident hallway/Sunrise hallway. Observation also revealed no staff in sight. Observation of this cart revealed the upper/unlocked compartment contained the following potentially hazardous chemicals: a. A spray bottle of Neutral Cleaner and Disinfectant with a warning label: Keep out of reach of children. DO NOT DRINK. b. Disinfectant Heavy Duty Acid Bathroom Cleanser with a warning on the label: Keep out of reach of children. DO NOT DRINK. Caution: May cause eye and skin irritation. c. Tilex Bathroom Cleaner with a Warning: Keep out of reach of children. Active ingredient: Ammonia Chloride d. Glass Force Professional Strength Glass Cleanser with a warning: DO NOT DRINK. May cause eye irritation. Wash thoroughly after handling. Observation of this cart also revealed an unlocked bottom compartment which contained two bottles of Oxivir TB General Virucide Bactericide Tubercalocide Fungicide Sanitizer with a warning: Keep out of reach of children. Active ingredient: Hydrogen Peroxide. At 8:30 a.m. on 7/31/13, a housekeeping staff member, Staff A exited a resident bedroom, two doors down from the unsupervised housekeeping cart. Staff A stated they had been cleaning the resident bedroom floor. Staff A returned a large floor dust mop to the housekeeping cart. When interviewed at this time, Staff A verified she left the housekeeping cart unlocked and unsupervised. She also stated she was taught to always lock this cart when not in use. When asked why she left the cart left unlocked, she replied it was difficult to get in one resident's bedroom to clean, and so she just went to the room to clean. At 7/31/13 at 8:32 a.m. the housekeeping supervisor, Staff B approached the unlocked housekeeping cart in the Sunrise hallway. At this time Staff B stated she teaches housekeeping staff to never leave their cart unlocked. At this time, Staff A stated, "We have a problem with carts, they come loose/unlocked." Continued observation of this unlocked housekeeping cart revealed t

Based on record review and interviews, the facility failed to adequate monitor anticoagulant medication according to physicians' orders for three (3) of (4) residents reviewed. On 11/15/12, Resident #8's physician directed staff to check his/her PT/INR ([MEDICATION NAME]/International Normalized Ratio) in one week. The nursing home staff did not complete the PT/INR test until 15 days later. On 11/30/12 the physician order [REDACTED]. In addition the nursing staff administered an antibiotic and [MEDICATION NAME]/[MEDICATION NAME] medication concurrently. Resident #8's PT/INR was elevated to critical level of 5 (with a therapeutic INR range between 2.0-3.0.). The facility did not follow physician's orders [REDACTED]. The facility identified a census of 115 residents. Findings include: 1. Record review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident # 8 revealed [DIAGNOSES REDACTED]. Record review of the Care Plan dated 11/7/12 revealed the resident a high risk for adverse effect of hematologic agents. The care plan directed staff to give Resident #8's [MEDICATION NAME] (an anti-coagulant medication used to thin blood) as ordered from the physician and to monitor for signs and symptoms of bleeding. The intervention directed staff to assess the resident for signs/ symptoms of bleeding: epistaxis, melera, gingival bleeding, painful joint effusions, hematemesis and bruising. The care plan informed staff of possible drug interactions with antacids, aspirin, history of antagonists and [MEDICAL CONDITION] medications. The care plan directed staff to complete PT ([MEDICATION NAME]) and INR as ordered; and to report Resident #8's lab (laboratory) results and signs and symptoms of bleeding to the physician. Record review of the Nursing FAX dated 11/15/12 revealed the resident had a PT of 19.4 and an INR of 1.6. The resident currently on 2 milligram on Monday, Wednesday, and Friday; and 1 milligram (mg) on Saturday, Sunday, Tuesday, and Thursday. The physician ordered the [MEDICATION NAME] medication be changed to 2 mg on Monday, Wednesday, Friday, Saturday, and Sunday and 1 mg on Tuesday and Thursday and to re-check the Resident's PT/INR in 1 week. Review of the [MEDICATION NAME] Flow Sheet for the Resident revealed on 11/15/12 the PT/INR of 19.4 and an INR of 1.6. The sheet indicated the PT/INR should be re-checked in one week. The next PT/ INR had been done on 11/30/13 (15 days later) with results of PT 22.7 and INR of 1.9. The physician ordered to continue the same dose of [MEDICATION NAME] and to re-check the PT/INR in 2 weeks. The next PT/INR had been done on 12/24/12 (24 days later) with a PT of 33.9 and INR 2.8. Staff were to recheck the PT/INR in 1 week. On 12/31/12 the results of the PT at 61.6 and INR of 5.1 (critical values). The physician ordered to hold [MEDICATION NAME] and to administer Vitamin K 5 milligrams; and to re-check the resident ' s PT/INR in the morning and call the physician on call. The facility rechecked the PT/INR as ordered on [DATE], and the physician ordered to continue to hold the [MEDICATION NAME] medication. Record review of the Nurses Notes dated 12/12/12 at 3:25 p.m. revealed the resident returned from the dental office. The resident had a dental restoration on the lower right side of the mouth. Record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the facility calendar reveal Resident #8 did not have a PT/INR done on 11/23/12 as the physician ordered or on 12/14/12. Review of the Nurses Notes dated 12/25/12 at 9:30 p.m. revealed the resident had an upset stomach at supper. Staff assisted Resident #8 to his/her bed without further emesis. The resident stated he/she just did not feel well. Staff interview with Staff D9 Registered Nurse (RN) on 3/26/13 at 11:15 a.m. revealed Resident #8's physician approved for the facility staff to complete the PT/INR lab in the facility. Staff D9 reported after the lab is complete, the charge nurse will normally fax the physician the results. The documentation on the fax would include the resident's current dose of [MEDICATION NAME], results of the PT/INR and requests for new orders. The physician faxes the facility back new orders. If new orders are not received by 4:00 p.m. the charge nurse is to call for new [MEDICATION NAME] orders. Staff D9 reviewed the physician orders [REDACTED]. On 3/26/13 at 1:00 p.m. she reported when she took the order for the resident's lab she documented the lab to be drawn on 11/30/12 rather than 11/23/12 as ordered. An interview with Staff E8 RN on 3/26/13 at 1:30 p.m. revealed she did not document the lab for Resident #8 on the calendar (should have been drawn on 12/14/12). Staff E8 reported the lab should have been completed on 12/14/12 as ordered, instead of 12/24/12. An interview with the Director of Nursing on 3/26/13 at 12:30 p.m. revealed the charge nurse should document the date on the facility calendar when a Resident's PT/INR's lab is due to be drawn for each resident. The charge nurse looks at the calendar each day and determines the PT/INR lab to be drawn. The DON stated according to the calendar, Resident #8's PT/INR labs did not get documented to be drawn on 11/23/212 and 12/14/12 as ordered. An interview with Resident #8's physician on 3/27/13 at 10:45 a.m. revealed the resident's PT/INR lab can go from normal to critical. The need to monitor the lab is necessary due to the resident fairly unstable. The physician stated Resident #8's is a difficult patient and needed to monitor the PT/INR lab every other week. He stated it was very important to perform Resident #8's labs as ordered as he/she is at risk for bleeding, although the resident has not showed symptoms of bleeding yet. The resident is at risk for [MEDICAL CONDITION]. The physician stated an antibiotic such as [MEDICATION NAME] may affect the [MEDICATION NAME] level. The physician stated the facility did not notify him the PT/INR labs were not done (on 11/23/12 and 12/14/12) as ordered. He concluded the resident had been sub-therapeutic before and had a stroke because of it. The resident's PT/INR labs need to be done as ordered. 2. Review of the MDS dated [DATE] for Resident #6 documented a BIMS (Brief Interview for Mental Status) score of 14 which indicated intact cognitive status. The MDS documented that Resident #6 required limited assist of 1 person for bed mobility, transfer, locomotion, dressing, and personal hygiene. The MDS documented the resident to be occasional incontinent of bladder. The MDS identified Resident #6 received an anti-coagulant 7 days per week. a. Review of a document titled Community Pharmacy Request for Additional INR dated 2/6/13 and signed by the physician listed as Resident #6 had been placed on [MEDICATION NAME] and the pharmacy recommended a PT/INR lab be drawn 72 hours after initial dose of the antibiotic. The Physician responded yes to the test and listed 2/7/13 as the date the PT/INR should be drawn. Review of the [MEDICATION NAME] Flow Sheet for Resident #6 did not record a PT/INR done on 2/7/13. The next PT/INR was dated 2/22/13. Review of the 24 hour nursing report for Resident #6 dated the evening of 2/6/13 documented need notified on PT/INR for 2/7/13 due to [MEDICATION NAME] interaction with [MEDICATION NAME]. Review of the 24 hour nursing report for the morning of 2/7/13 listed a PT/INR to be done. Review of the 24 hour nursing report for the evening of 2/7/13 documented the PT/INR not done, no order. An interview with Staff J8, RN on 3/26/13 at 4:30 p.m. as to why the PT/INR had not been drawn and she stated that the PT/INR had not been on the [MEDICATION NAME] flowsheet and protocol had not be followed. She also reviewed the calendar and stated that the PT/INR was on the calendar but not crossed off which would have indicated that it had been completed. b. Review of the Doctor's Orders and Progress Notes dated 3/2/13 at 6:55 p.m. documented that a dose of [MEDICATION NAME] 2 mg had not been given. The physician responded to continue 2 mg every day and to recheck the PT/INR on 3/14/13. Review of the MAR (Medication Administration Record) date March 2013 showed that Resident #6 [MEDICATION NAME] had not been signed off as given. 3. The Nurse's Notes dated 3/15/13 at 1:05 p.m. for Resident #16 revealed he/she had been admitted to the nursing home after hip surgery. Nursing assessment dated [DATE] identified the resident required 2 person assist for bed mobility and transfers. Review of the Physician's Telephone Orders dated 3/21/13 revealed the order for [MEDICATION NAME] (blood thinner)1.5 mg (milligrams) every day through Sunday 3/24/13 and to recheck a PT/INR (determine clotting tendency of blood) on 3/25/13 and call the Pharmacy with the results. Review of the MAR indicated [REDACTED]. Review of the Nurse's Notes dated 3/25/13 at 10:30 a.m. revealed the resident's PT 25.4 and INR 2.1. The note also revealed the order to continue the same dose of [MEDICATION NAME] 1.5 mg daily and recheck the PT/INR on Thursday 3/28/13. Review of the Physician's Telephone Orders dated 3/25/13 revealed the order for [MEDICATION NAME] to continue the same dose and check the INR on Thursday. During an interview with Staff C13, RN, (Registered Nurse) on 3/27/13 at 3:15 p.m. she stated that she checked with the Pharmacy and they did not receive a physician's orders [REDACTED]. Based on clinical record review, the facility failed to ensure that Resident #9's medication regimen was free of unnecessary medications. 4. Accordingly to the MDS assessment dated [DATE] Resident #9 had [DIAGNOSES REDACTED]. Review of the care plan date 1/28/13 revealed that Resident #9 could become physically and verbally abusive toward staff when assisting her/him with his/her care. The resident often became agitated with increased environmental stimuli. The care plan instructed the staff to give medications as ordered for agitations and review as necessary for effectiveness. The care plan also documented that Resident #9 had the risk for decreased cognition due to [MEDICATION NAME] (an antianxiety medication) and as-need antipsychotic (medications). The review of the MAR indicated [REDACTED] a. [MEDICATION NAME] Concentrate 2 milligram/ml (milliliter) the staff could administer .5 milligrams (mg) to 2 mg q (every) 4-6 hr prn as needed for mild agitation b. [MEDICATION NAME] Concentrate 2 mg/ml the staff could administer .5 mg-2 mg q 4-6 hr as needed for mild agitation c. [MEDICATION NAME] 5.5 mg/ml Plo Gel apply .5 mg(1 ml) topically every 4 hr prn for agitation/anxiety (equal to [MEDICATION NAME] 1 mg) d. [MEDICATION NAME] 5.5 mg/ml Plo Gel apply .5 mg(1 ml) topically every 4 hr prn for agitation/anxiety (equal to [MEDICATION NAME] 1 mg) e. [MEDICATION NAME] 2 mg tablets give 0.5 mg/ml Plo Gel apply 1 ml (.5 mg) topically twice a day f. [MEDICATION NAME] 2 mg tablets give .5 mg(1 mg) topically every 4 hours as needed for agitation/anxiety g. [MEDICATION NAME] Con 2 mg/ml give .25 ml (0.5 mg) sublingually every 4-6 hours as needed for agitation h. [MEDICATION NAME] Con 2 mg/m give .75 ml (1.5 mg) sublingually every 4-6 hours as needed for agitation i. [MEDICATION NAME] Con 2 mg/ml give 0.5 ml (1 mg) sublingually every 4-6 hours as needed for agitation j. [MEDICATION NAME] Con 2 mg/ml give 1 ml (2 mg) sublingually every 4-6 hours as needed for agitation The review of the MAR indicated [REDACTED] a. [MEDICATION NAME] Con 2 mg/ml the staff needed to administrate the medication [MEDICATION NAME] .25 ml-1 ml (0.5-2 mg )sublingually every 4-6 hours as needed for moderate to severe agitation b. [MEDICATION NAME] Con 2 mg/2 ml give .75 ml (1.5 mg) sublingually every 4-6 hours as needed c. [MEDICATION NAME] Con 2 mg/ml give 0.5 ml (1 mg) sublingually every 4-6 hours as needed d. [MEDICATION NAME] Con 2 mg/ml give 1 ml(2 mg) sublingually every 4-6 hours as needed e. [MEDICATION NAME] Con 2 mg/ml give .25 ml(0.5 mg) sublingually every 4-6 hours as needed The continued review of the March 2013 MAR indicated [REDACTED] a. [MEDICATION NAME] ([MEDICATION NAME]) .5 mg/[MEDICATION NAME] 12.5 mg/ [MEDICATION NAME] 0.5 mg (2 mg tables) and to insert 1 suppository per rectum every 6 hours as needed for severe agitation b. [MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME](1 mg tablets) apply 1 ml topically as directed every 6 hours as needed

Based on record review and staff interview the facility failed to adequately assess and provide timely interventions for 2 of 9 residents reviewed who had significant changes in conditions (Residents #2 & #6) The facility identified a census of 114 current residents. Findings include: 1. According to the MDS (minimum data set) assessment with an assessment reference date of 9/7/11, Resident #2 had [DIAGNOSES REDACTED]. The MDS identified the resident had severely impaired cognition, required limited assistance with bed mobility and transferring, and extensive assistance with toileting. According to the MDS the resident had occasional urinary incontinence. Review of a history and physical report dated 9/8/11 revealed the resident presented to the emergency room with severe agitation and severe abdominal pain. The report stated the resident's spouse had called the physician to report he/she could not keep the resident in bed and was afraid he/she would fall. Hospital staff inserted a foley catheter into the resident's bladder, and the resident's agitation and abdominal pain decreased as a result. The report indicated the resident had presented with acute [MEDICAL CONDITION], but no urinary tract infection. The Nurse's Notes dated 9/8/11 at 3:00 p.m. revealed the resident had exhibited urinary frequency and staff had called the physician to request a urinalysis order. At 3:30 p.m. the resident asked staff to get an order for [REDACTED]. The resident continued to try and get up out of bed, and the spouse asked if staff could give him/her something to calm the resident down. Staff documented giving the resident Tylenol. The resident continued to try and get out of bed and the spouse did not allow the resident to get up. Staff documented noting an increase in the resident's anxiety. Staff then documented receiving a call from the physician with an order to transfer the resident to the emergency room for evaluation. At 5:30 p.m. the ambulance arrived at the facility to transfer the resident. A note at 9:00 p.m revealed the hospital had drained 2200 cubic centimeters of urine from the resident's bladder and that he/she would be staying overnight in the hospital. A note dated 9/9/11 at 4:00 p.m. indicated the resident had returned from the hospital with a foley catheter in place. During an interview on 9/22/11 at 3:10 p.m., the resident's spouse indicated the resident had attempted to urinate without success on the day he/she went to the hospital. The spouse stated the facility could not get a urine specimen because he/she could not urinate. The spouse further indicated the resident rolled back and forth in bed and that his/her eyes were crazy and the spouse was afraid the resident would fall. The spouse stated he/she asked the nurse to give the resident something to calm him/her down and for an antibiotic. The spouse stated that he/she had called the physician at 5:05 p.m. regarding her spouse's condition and the physician made arrangements for the resident to be transferred to the emergency room . During an interview on 9/22/11 at 3:10 p.m., Staff B, LPN (licensed practical nurse), stated that when she came on duty at 2:00 p.m., the nurse reported to her that the resident had exhibited frequency of urination that day, but that she had not called the doctor to report this to him/her. Staff B stated that she thought that something had to be wrong (with the resident) because he/she was so agitated, so she called the doctor to request a urinalysis order (to rule out a urinary tract infection). Staff B stated the resident's spouse had asked her to "please give him/her something" so she had given the resident some Tylenol; the spouse had also asked her to get an antibiotic order for the resident. She stated she did not assess/palpate the resident's bladder and did not remember conducting an assessment on the resident because it was a very busy shift. Staff B further stated the resident's spouse had called the doctor and he/she had ordered the resident transferred to the hospital. During an interview on 10/10/11 at 8:46 a.m., Staff C, LPN, stated that staff had informed her on 9/8/11 that the resident had been acting strangely and had made frequent trips to the bathroom that day. Staff C indicated she had assisted the resident to the bathroom, hadn't heard him/her void, but had noted his/her brief was wet. Staff C verbalized she had checked the resident's blood sugar and vital signs that were within normal limits and asked the resident if he/she was in pain or had difficulty urinating to which the resident did not respond. According to Mosby's Manual of Clinical Nursing (second addition, 1989), acute [MEDICAL CONDITION] may cause the patient/resident severe suprapubic pain and pressure sensations due to overdistention of the bladder. Overflow incontinence is also a symptom of [MEDICAL CONDITION]. 2. According to the MDS assessment dated [DATE], Resident #6 had [DIAGNOSES REDACTED]. The MDS identified the resident with severely impaired cognition, and required extensive assistance with bed mobility, transfers, and toileting. Review of the resident's care plan dated 1/26/11 directed staff to assess the resident for signs and symptoms of urinary tract infection including: dark, cloudy, bloody or foul smelling urine, and/or complaints of low back pain and increased confusion. Nurses' notes dated 8/28/11 for the 10:00 p.m. to 6:00 a.m. shift indicated the resident's urine appeared dark amber in color with a large amount of sediment noted. The note further indicated the resident complaint of burning and back pain for which a pain pill was ineffective at that time. No further assessment was documented for the resident concerning back pain or urinary status until 9/2/11. Review of the physician facsimile dated 8/28/11 revealed an order for [REDACTED]. Review of the laboratory report dated 8/30/11 revealed the urinalysis contained white blood cells 50-100 and bacteria 10-100. The microbiology report dated 8/30/11 indicated the UA was contaminated so no sensitivity testing had been conducted. A handwritten query, undated, asked if the resident had any symptoms or was currently on antibiotics. A handwritten statement dated 9/2/11 indicated the resident had cloudy urine containing sediment with no complaints, no signs/symptoms, and currently on no antibiotics. A third handwritten statement indicated, "watch and no therapy." Review of the Nurse's Notes dated 9/2/11 revealed the resident's family member expressed concerns that the resident had not been placed on an antibiotic due to the resident's increased confusion, complaints of back pain and sleeping. The family requested the nurse call the physician for suggestions. The physician subsequently gave an order for [REDACTED]. A nurses' note dated 9/2/11 for the 2:00 p.m. to 10:00 p.m. shift indicated the first dose of an antibiotic had been administered to the resident who complained of back pain. The nurse documented offering a pain pill to the resident which he/she refused. The nurse indicated the resident had been increasingly falling asleep in the wheelchair and that the resident hadn't recognized his/her granddaughter which indicated the resident as more confused than usual. The nurse documented the resident's urine as foul smelling.

Based on record review, observations and physician and staff interviews, the facility failed to provide adequate supervision to ensure against hazards while transferring Resident #1 with a mechanical lift. The sample consisted of 4 residents. The facility reported a current census of 115 residents. Findings include: 1. The MDS (minimum data set) dated 2/14/11 for Resident #1 revealed pertinent [DIAGNOSES REDACTED]. The assessment revealed the resident required total dependence with 2+ persons for transfers, bed mobility, toilet use and total dependence with 1 person for personal hygiene. The MDS further documented Resident #1 with impairment on both sides of upper and lower extremities, weight of 234 pounds and 6 foot 2 inches tall. The physician's orders [REDACTED]. The Care Plan (located in a binder on the residents' chart rack) that includes a Fall Safety Plan with a review date of 2/1/11 for Resident #1 revealed the resident at risk for falls due to weakness. The Care Plan indicated the following interventions for staff to follow: a. Explain call bell/light and assess ability to use. b. Ensure use of safe adequate footwear. c. 2/14/11 DC (discontinue) sit/stand lift, Hoyer lift at all times. d. Monitor and document perceptual changes. e. Observe for decrease of functional status... f. Observe for gait unsteadiness. g. Physical therapy as ordered. h. Non-skid socks on at HS (hour of sleep). i. Use wheelchair for mobility and assist of one. Review of the Tracking Record for Improving Patient Safety (T.R.I.P.S.) form dated 2/14/11 revealed the resident had been in the sit/stand lift when he/she became limp falling from the lift sling onto the bathroom floor. Resident #1 sent to the emergency room for injury. Review of the Fall Risk Assessment for Resident #1 dated 11/17/10 documented a score of 16. The same assessment dated on 2/14/11 documented a score of 17. A score of 10 or above represents that the resident is at a high risk for falling. The History and Physical dated 2/14/11 by the resident's primary care physician revealed Resident #1 sustained a scalp laceration with a subdural hematoma (bleeding on the brain). The Nursing Summary dated 2/27/11 revealed Resident #1 transfers with mechanical sit to stand lift for all transfers and the intervention following fall of 2/14/11 revealed to use the Hoyer lift only. The staff completing the summary failed to know the correct transfer procedure to follow for Resident #1. The nurse ' s notes dated 1/11/2011 at 8:45 a.m. indicated the staff assisted the resident to the toilet after breakfast and used the E-Z stand lift. While the nursing assistants lowered the resident onto the toilet with the lift, the resident went unresponsive for approximately 30 seconds. After 30 seconds, the resident quickly became responsive. On 3/3/11 at 11:57 A.M. the resident's primary care physician was interviewed and stated the resident would be soon seeing a cardiologist. The physician stated he/she had referred the resident to a cardiologist. The physician stated the facility had reported the resident had become unresponsive for seconds when taken to the restroom. The physician continued to state the nursing staffs have assessed the kept her/him well informed. The physician stated [DIAGNOSES REDACTED]is the [DIAGNOSES REDACTED]. There is no warning when an episode can happen and she/he hoped the cardiologist can change his/her medications to help the heart function better. The physician stated the resident wore a halter monitor for a few days for further data regarding the heart condition. During an interview on 3/2/11 at 2:10 P.M. Staff C, C.N.A. (Certified Nursing Assistant), stated the resident turned on his/her light and needed to use the restroom. Staff C stated Staff D, C.N.A. went to get the sit/stand lift. Staff C stated she/he positioned the resident in his/her room so the lift could be placed in front of the resident. Staff C positioned the resident and assisted with placing his/her feet on the base of the lift. Staff C stated she/he took the sling and positioned it around his/her back, from the resident's right side and Staff D, hooked up the loops over the knobs on the left side. Staff C stated Staff D fastened the waist strap and also stated could not remember if the belt clip snapped into locked position or not, stating they just go in and do it, just like any other day without thinking about it. Staff C stated as she watched the legs of the lift and the resident's legs, she/he looked up and saw the resident was bright red and going limp leaning back and to the left. Stated C stated as he/she began leaning, he/she saw the loop of the sling slip up off the knob of the lift arm and he/she was falling so fast, before she/he knew it and she/he stated was behind the lift and not able to reach the resident. Staff C yelled out the resident ' s name. Staff C stated Staff D appeared in shock and didn't grab him/her; she just stood there with no expression on her/his face. During interview on 3/2/11 at 11:00 A.M. Staff D, C.N.A. stated she helped Staff C to take Resident #1 to the restroom, she stated she hooked up one side of the sling and fastened the waist strap and buckling it. She stated she couldn't remember if the buckle clicked or not and stated so she could not say if the buckle locked in place or not. She stated she felt awful and thinks about this all the time and wonders what she/he could have done different. Following this interview the DON (Director of Nursing) and Staff D took this writer to the facility garage to see the lift used in the transfer on 2/14/11. Staff D hooked the DON up in the sit/stand lift. When hooking up the waist strap and fastening the buckle, the buckle did snap shut and it made a loud noise when it locked into place. This writer attempted to pull it apart and was not able to do so. The buckle was intact and functional, made of a heavy plastic material with no broken parts found. During an interview on 3/2/11 at 3:15 P.M. Staff B, LPN (Licensed Practical Nurse) stated she/he entered Resident #1's room to find him/her on the floor with his/her head on the wall, with head bent and a pool of blood under head. Staff B stated the resident's feet found on the foot platform of the lift, the lift found in the bathroom doorway and the resident had a cold washcloth on his/her forehead and stretched out on the floor. Staff B stated Staff C kept telling her/him they made sure everything had been fastened, so much that it made her think maybe they didn't have everything fastened. Staff B stated both Staff C, and Staff D had said that day, they did not hear the waist belt lock into place. Staff B stated she/he went over it with them and felt they were sorry for what happened. Staff B stated Staff D ' s fairly new and continues to require some instruction at times. She stated all new staff are checked off on their skills before they go onto the floor to work and stated they know this stuff. During an interview on 3/3/11 at approximately 9:15 A.M. the DON stated they (referring to Staff C, and Staff D) failed to follow their policy and procedure. The Administrator stated both of the staff members had received training with the sit/stand lift prior to the fall and again after the fall. The Administrator stated the staffs know how to do it correctly.