Every finding on record at Brooklyn Community Estates

Based on observation, staff interview, clinical record review, and facility policy review, the facility failed to obtain informed consent prior to the installation of bed rails for 2 of 2 residents (Resident #4 and Resident #25) and failed to attempt bed rail alternatives prior to installation for 1 of 2 residents (Resident #25) reviewed for bed rails. The facility reported a census of 42. Findings include:1. Review of the Minimum Data Set (MDS) assessment, dated 5/13/26, revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment. The list of diagnoses included non-Alzhemier's dementia, stroke with hemiplegia (impaired mobility) affecting right dominant side, malnutrition, and anxiety disorder. Resident #4 required substantial to maximal amount of staff assistance with bed mobility and dependent on staff assistance to transfer. The MDS revealed that a bed rail was used daily as a physical restraint. Review of the Care Plan, initiated 3/27/24, revealed the Focus area: Resident #4 uses full bed side rail for safety and to promote independence with bed mobility and assist with personal cares; Per staff assessment, considered restraints. The Care Plan identified a goal that Resident #4 would remain free from injury related to bed rail use. Interventions instructed the following, in part: Discuss and record with the resident/family/caregivers, the risks and benefits of the restraint, when the restraints should be used/applied, routines while restrained, and any concerns or issues regarding restraint use. Date initiated: 3/27/24. Ensure provider order is received for use of bed rails when assessed as a restraint. Date initiated: 3/27/24. Evaluate Resident #4's bed rails/restraint use at least quarterly: Evaluate/record continuing risk/benefits of restraint, alternatives to restraint, need for ongoing use, reason for restraint use. Date initiated: 3/27/24.Monitor/document/report as needed, any changes regarding effectiveness of restraint, less restrictive device, if appropriate, any negative or adverse effects noted. Date initiated: 3/27/24. Staff will provide frequent monitoring of Resident #4 when bed rails are used to ensure Resident #4 remains free of injury related to use. Date initiated: 3/27/24. Review of the Order Summary, dated 5/28/26, listed an order for restraints type 2 for full rail on one side of bed and 2 half rails on the right side of bed for safety and fall prevention, boundary. Review of the Restraint/Device/Enabler Assessment, dated 4/01/26, identified the use of one full side rail and one half side rail on Resident #4's bed that prevented independent exit/entry from the bed when in use. The assessment revealed that no other alternative measures were attempted or also used, besides the full bed rail and half bed rail, with an entry explaining: One day Resident #4 is lethargic, the next day up and talking, can not trust her. The Assessment identified risk of the device included loss of dignity, and listed benefits of the device included: Increases sense of safety/security per resident request.Mitigates risk of resident rolling out of bed.Mitigates the resident from self injury. The Assessment indicated with a checkmark that the following had been completed for restraint use: Consent obtained from the resident/family. Provider order obtained. Care Planned.Reassess monthly and with significant changes until discontinued. During an observation on 5/26/26 at 10:31 AM, Resident #4 laid in bed, a half bed rail at the top right of bed was in an upright position and the entire right side of the bed was placed alongside the wall. The left side of the bed had a full bed rail in an upright position with padding fixed along the inside of the full bed rail. During an interview on 5/28/26 at 11:24 AM, the Director of Nursing (DON) reported that Resident #4 had utilized a low bed and a fall mat prior to implementation of the full bed rail. The DON was unable to provide documentation of informed consent for use of bed rails prior to installation. 2. Review of the MDS Assessment, dated 3/18/26, revealed Resident #25 had a BIMS score of 8 out of 15, which indicated moderate cognitive impairment. The list of diagnoses included non-Alzheimer's dementia, heart failure, respiratory failure, and adjustment disorder with mixed anxiety and depressed mood. Resident #25 was dependent upon staff assistance for bed mobility and transfers. The MDS indicated that Resident #25 had not used restraints or alarms.Review of the Care Plan revealed an intervention, initiated on 3/17/25, for bed side rails as follows: Top half rails and lower half rails used to move self in bed, considered an enabling device per staff assessment, as it helps with functionality to promote independence, provides boundary and does not meet restraint criteria. Position assessment for use and safety completed by staff at least quarterly or with change in condition. Review of the Care Plan, initiated 9/18/24, revealed a Focus area for Resident #25 moderate risk for falls related to history of falls prior to admission, gait/balance problems, incontinence, side effects of antidepressants, and hearing problems. Interventions included the following, in part: Rail attempted with pool noodle to block the arm going down between the bed mattress and rail, which extreme force was not effective, so tried a padded overlay. Grab bar would be less boundary and she might roll out quicker but low bed for now. Grab bars are not considered safe or effective as assistive devices like the half rail. Date initiated: 4/23/26. Low bed. Date initiated 4/21/26. Housekeeping and maintenance look at spacing with mattress and rail. Date initiated: 4/21/26. Review of the Restraint/Device/Enabler Assessment, dated 3/12/26, identified the use of four half bed side rails on Resident #25's bed that did not restrict or prevent normal/independent movement due to physical limitations as resident cannot voluntarily exit the bed. The Section #5: Device/Enabler Assessment with Subcategory: Safety Assessment, revealed the following, in part: #2e: Has the risk of injury when enabler or device(s) are in use been addressed? Assessment response left blank. #2f: Select additional safety measures used. Assessment response left blank. During an observation, on 5/27/26 at 9:45 AM, Resident #25 laid in bed with four half bed rails in upright position. A half bed side rail on both top left and top right of the bed were in the upright position. A half bed side rail on both bottom left and bottom right of the bed were also in the upright position. During an interview on 5/28/26 ay 10:05 AM, the DON stated that an informed consent had not been obtained on Resident #25's four half side rails prior to implementation and explained this was because the side rails were not used as a restraint. The DON was unable to provide documentation of alternative interventions attempted prior to installation of the four half side rails on Resident #25's bed. Review of the facility policy titled, Side Rails Use Policy, not dated, revealed the purpose of policy was to prevent injury to a resident and allow for independent bed mobility. The Section titled Procedure, instructed the following, in part: Explain the purpose of side rails to the resident.Elevate side rails on those residents determined in need by the Care Plan process.Check the resident frequently for safety and security of side rails.

Based on observations, staff interview and facility policy review, the facility failed to ensure staff covered all hair with a hairnet. The facility reported a census of 47 at the time of the survey. Findings include: Observation on 4/7/19 at 11:34 a.m. with the Certified Dietary Manager (CDM) had approximately 4 inches of exposed hair not covered by a hair net. Observation on 4/8/19 during the lunch meal service that started at 11:48 a.m. , Staff A, cook, had 1-2 inches of exposed hair hanging from outside of the hair net. Staff C, dietary aide had 2 inches of exposed hair hanging from outside of the hair net. Staff B, cook had 2 to 3 inches of exposed hair not covered by a hair net. CDM noted to have 4 inches of exposed hair not covered by a hair net. Interview on 4-8-19 at 12:55 p.m. with the facility dietician acknowledged all 4 staff had exposed hair. Dietician stated she noticed this during the lunch meal service and was in agreement all hair should be covered. Stated the current hair nets they are using are not good about covering all hair. Will be looking for different hair nets for the staff to start using. On 4/10/19 08:23 a.m. interview with the Administrator, expectations are for all staff in the kitchen to have their hair covered properly. Moving forward, the facility is ordering a different type of hairnet. Revised facility policy dated 10/17/17 documented the following rules will apply to dietary safety operations: Hair nets and/or caps should be worn, hair will be covered completely in a manner that prevents any loose hair.

Based on observation, record review, and interview, the facility failed to maintain privacy during transport to the whirlpool room for 1 of 12 residents in the sample(Resident #27). The facility reported a census of 47 residents. Findings: 1. The MDS(Minimum Data Set) assessment tool, dated 3/29/19, listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assistance of 1 staff for personal hygiene and bathing, extensive assistance of 2 staff for toilet use and dressing, and total dependence on 2 staff for transfers. The MDS revealed the resident had BIMS(Brief Interview for Mental Status) score as 15 out of 15, indicating intact cognition. During an observation on 4/8/19 at 7:14 a.m., Staff D CNA(Certified Nursing Assistant) pushed the resident in a whirlpool chair out of her room down the hallway to the whirlpool room. The drape covering her did not extend down far enough and the resident's buttocks were exposed as staff transported her down the hallway, other resident's, staff members and surveyor present in the hallway at the time of the transport. A care plan entry, revised 6/14/13, stated staff assisted the resident with bathing/showering twice per week. The undated Resident's Bill of Rights, included in the facility's admission packet, stated each resident had the right to privacy in treatment and personal care. During an interview on 4/9/19 at 1:54 p.m., the DON(Director of Nursing) stated staff needed to cover residents fully with the bath blanket when transporting in the hall.

Based on record review, and staff interview the facility failed to notify the state ombudsman's office 2 of 2 times that Resident#26 had been admitted to the hospital 2 of 2 times. The facility reported a resident census of 47. Findings include: The Nurses Notes dated 12/16/18 at 1:40 a.m., documented the resident complained of left side pain of 8 on the 0 to 10 pain scale. The resident requested to be sent to emergency room . The Nurses Notes dated 12/16/18 at 4:30 a.m. documented the emergency room called and reported the resident would be admitted for diverticulitis, and antibiotic therapy. The Nurses Note dated 3/5/19 at 8:00 a.m., documented the resident had been transferred to the emergency room . The Nurses Note dated 2/6/19 at 3:30 p.m., documented the resident had been readmitted to the facility, and admitted to Hospice care. Upon clinical record review the resident's record lacked documentation that the ombudsman had been notified. During an interview on 04/09/19 at 2:56 p.m. the Administrator reported they had not been reporting the transfer, discharges of the residents to the Ombudsman office. .

Based on record review and staff interviews the facility failed to notify the family of the bed hold policy for 2 of 2 times that Resident#26 had been admitted to the hospital . The facility reported a resident census of 47. Findings include: The Nurses Notes dated 12/16/18 at 1:40 a.m., documented the resident complained of left side pain of 8 on the 0 to 10 pain scale. The resident requested to be sent to emergency room . The Nurses Notes dated 12/16/18 at 4:30 a.m. documented the emergency room called and reported that the resident would be admitted for diverticulitis and antibiotic therapy. The Nurses Note dated 3/5/19 at 8:00 a.m., documented the resident had been transferred to the emergency room . The Nurses Note dated 2/6/19 at 3:30 p.m., documented the resident had been readmitted to the facility, and admitted to Hospice care. During an interview on 04/09/19 at 2:32 p.m., the Director of Nursing reported they did not go over the bed hold policy every time the resident would go to the hospital. During an interview on 04/09/19 at 2:56 p.m., the Administrator reported they had not been going over the bed hold policy with the residents, or with the resident's responsible person that were transferred out of the facility.

Based on clinical record review and interview, the facility failed to complete activity assessments for 7 of 9 residents reviewed (Residents #2,3,4,5,6,7,and 8). The facility reported a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) quarterly assessment dated [DATE], documented for Resident #2 revealed [DIAGNOSES REDACTED]. The chart lacked quarterly activity assessments. 2. The MDS annual assessment dated [DATE], documented Resident #3 with [DIAGNOSES REDACTED]. The chart lacked quarterly activity assessments. 3. The MDS quarterly assessment dated [DATE], documented Resident #7 with [DIAGNOSES REDACTED]. The chart lacked quarterly activity assessments. 4. The MDS dated [DATE], identified [DIAGNOSES REDACTED]. The chart lacked quarterly activity assessments. 5. The MDS dated [DATE], identified [DIAGNOSES REDACTED]. The chart lacked quarterly activity assessments. 6. The MDS dated [DATE], identified [DIAGNOSES REDACTED]., anxiety, and depression. The chart lacked quarterly activity assessments. 7. The MDS dated [DATE], identified [DIAGNOSES REDACTED]. The chart lacked quarterly activity assessments. In an interview on 11/22/16 at 1:50 p.m. the Activity Director verified quarterly activity assessments not being done. An interview on 11/22/16 at 2:45 p.m., the Administrator stated he thought they were being done by the Activity Director. Moving forward, his expectations are to have them done timely.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure staff completed thorough incontinence cares for one of three residents observed during personal cares. (Resident #1) The facility census was 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The care plan updated 12/16/13, included a problem completing activities of daily living The problem included an approach to provide peri care. During observation on 12/8/14 at 1:45 p.m., Staff C, Certified Nurse Aide, CNA completed incontinence cares as the resident laid in bed. Staff C removed the resident's incontinent brief that was soiled with urine. Staff C turned the resident to the right side and used disposable wipes to cleanse the residents left buttock and coccyx area. During the observation the resident was incontinent of urine while on their right side. Observation revealed the urine ran down the residents buttock on to the right hip. Staff C turned the resident and used disposable wipes to cleanse the residents anterior perineal area. Staff C turned the resident to the right side and used disposable wipes to cleanse the left buttock and coccyx area. Staff C placed a new brief on the resident without cleansing the residents outer right buttock or hip. During observation on 12/9/14 at 7:25 a.m., Staff D, CNA and Staff E, CNA completed incontinence cares for the resident. Staff E used disposable wipes to cleanse the residents anterior perineal area while the resident sat on the commode. Staff D assisted resident to stand. As the resident stood, the resident was incontinent of urine. Observation revealed urine ran down the resident's leg as they stood. Staff E directed Staff D to set the resident back on the commode. Staff D noticed the residents pants were wet with urine and changed them. Staff D again assisted the resident to stand as Staff E used a disposable wipe to cleanse the residents perineum to coccyx and pulled the brief and new pants up failing to cleanse the resident's legs of the urine residue. During interview on 12/10/14 at 10:45 a.m., the Director of Nursing (DON) explained she would expect staff to follow the proper procedure for incontinence care. The facility procedure for incontinence care directs staff to wash from front to back and turn the resident to the side to wash the buttocks and upper thighs.

Based on employee record review, facility policy review and staff interview, the facility failed to ensure one of five employees (Staff A) reviewed for dependent adult abuse education was completed within six months of hire. The facility census was 44 residents. Findings include: 1. The employee record for Staff A, dietary staff revealed a hire date of 5/16/14. The employee record lacked documentation of a two hour dependent adult abuse education class. During interview on 12/9/14 at 9:40 a.m., the Administrator reported the facility was waiting for approval for the new dependent adult abuse curriculum and should have sent Staff A somewhere else to complete the class. The facility's Dependent Adult Abuse Policy (undated) documented all mandatory reporters must complete the educational requirement for dependent adult abuse within six months of initial employment.

Based on clinical record review and interviews, the facility failed to take into consideration residents' choices and preference for two (2) of two (2) cognitively impaired residents (Resident #3 and Resident #1). Record review and staff interviews identified the facility completed routine catheter cares between 10 p.m., to 6 a.m., during the time residents would be sleeping. The facility identified a census of 41 residents. Findings include: 1.The Minimum Data Set (MDS) for Resident #3 completed 4/17/14, included [DIAGNOSES REDACTED]. The MDS reported the resident required two staff assistance for activities of daily living (ADL's) which included transfers, bathing, and dressing. Resident #3 used an indwelling catheter and required two staff to assist with toileting. According to the Brief Interview for Mental Status (BIMS) cognitive test, Resident #3 scored 6 out of 15 which revealed the resident had severe cognitive impairments. Resident #3 utilized a wheelchair with staff assistance for mobility. A care plan dated 7/22/13 identified Resident #3 used a catheter; and directed staff to monitor the resident for signs and symptoms of discomfort or a urinary tract infection. A Physician's Telephone Order dated 4/16/13 directed staff to change the resident's catheter monthly and as needed (PRN). An updated physician's orders [REDACTED]. The Nurse's Notes dated 10/28/13 documented the resident's monthly catheter change completed at 4:00 a.m. The Nurse's Notes entry dated 11/28/13 documented the resident's monthly catheter change completed at 3:00 a.m. The Nurse's Notes entry dated 2/28/14 documented the resident's monthly catheter change completed at 2:15 a.m. and a urine specimen obtained from the resident's catheter at 3:45 a.m. The Nurse's Notes entry dated 3/29/14 documented the resident's monthly catheter change completed at 10:30 a.m. The Nurse's Notes entry dated 4/28/14 documented the resident's monthly catheter change completed at 11:00 a.m. Review of the Treatment Administration Record (TAR) for Resident #3 dated 11/13 through 4/14 direct staff to routinely change the resident's catheter on the night shift. 2. The Minimum Data Set (MDS) for Resident #1 completed 3/6/14, included [DIAGNOSES REDACTED]. The MDS reported the resident required two staff assistance for activities of daily living (ADL's) which included transfers, bed mobility and dressing. Resident #1 used an indwelling catheter and required two staff to assist with toileting. According to the Brief Interview for Mental Status (BIMS) cognitive test, Resident #1 scored 0 out of 15 which revealed the resident had severe cognitive impairments. Resident #1 utilized a wheelchair as the primary mode of locomotion. A care plan dated initiated on 9/15/13 identified the resident with a [DIAGNOSES REDACTED]. The care plan directed staff to record the resident's urine outputs on the ADL flow sheet. A telephone order dated 8/27 (no year documented) and signed by the physician directed staff change the resident's catheter every 4 weeks. A Nurse's Notes entry dated 10/24/13 documented the resident's monthly catheter change completed at 2:30 a.m. A Nurses' Notes entry dated 2/26/14 at 7:24 a.m. documented the resident's monthly catheter change done on the 10:00 PM-6:00 AM shift which started on 2/25/14. The Treatment Administration Records (TAR's) for the months of 12/13 through 3/14 direct staff to routinely change the resident's catheter on the night shift. During interview on 5/14/14 at 1:45 p.m. Staff A, registered nurse (RN) stated routine monthly catheter changes for residents are done by the night shift nurse. Staff A reported it was easier for the night shift nurses to do them as the residents are already in bed. Staff A reported the facility had always completed catheter changes that way. During interview on 5/14/14 at 2:40 PM the Director of Nursing stated she was not sure when staff could change either resident's catheter without disrupting activities, meals, etc. She further stated that neither Resident #3 or Resident #1 probably cared about having their catheter's changed routinely between the hours of 10:00 PM-6:00 AM but had no documentation the issue had been discussed with either resident.

Based on observation and staff interview, the facility failed to follow State Fire Marshal's guidelines for plugging electrical equipment into surge protectors in 1 resident room observed (room #31). The facility reported a census of 46 at the time of the survey. Findings include: On the Department of Inspection and Appeals Website in the February 2004, Insight, the Iowa State Fire Marshal documented clarification on the use of surge protectors. The article reported examples of devices prohibited from use with a metal surge protector were clocks, lamps, personal grooming and care devices, battery chargers, motor driven appliances such as air conditioners, refrigerators, pop-machines, compressors, and microwave ovens. The article reported the key idea to remember was devices plugged into a surge protector are voltage sensitive and lightening or electrical surges can permanent damage. 1. Observation on 10/29/13 at 3:10 p.m., revealed an air mattress, cell phone, and radio plugged into a metal surge protector in resident room #31. During the Environmental Tour on 10/30/13 at 10:45 a.m., the Maintenance Director acknowledged the air mattress and other two devices plugged into the surge protector.

Based on clinical record review and staff interview, the facility failed to document non-pharmacological interventions attempted prior to the administration of psychoactive medications for for 2 of 5 residents reviewed (Resident #1 and #9). The facility reported a census of 46 residents at the time of the survey. Findings include: 1. Resident #1's Minimum Data Set ((MDS) dated [DATE],documented [DIAGNOSES REDACTED]. The MDS reported the resident experienced physical and verbal behavioral symptoms toward others, and other behavioral symptoms not directed at others that included screaming and disruptive sounds. The residents Plan of Care dated 12/26/13, directed staff to allow the resident to vent concerns and feelings. Review of the resident's Medication Review Report for the period from 9/1/13 to 11/1/13, signed by the physician, included a physician's orders [REDACTED]. Review of the September 2013, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident's clinical record lacked evidence of nursing staff attempting or documenting non-pharmacological interventions attempted prior to administering the PRN [MEDICATION NAME] for anxiety on the dates identified in September. 2. Resident #9's MDS dated [DATE] documented [DIAGNOSES REDACTED]. The resident's Plan of Care dated of 1/16/14, directed staff to attempt the following interventions for the resident. -Do not respond with anger to resident's anger. Remove resident from others when aggressive outburst occurs. Meet with resident as needed to discuss concerns. -Encourage positive/acceptable ways to express anger. Encourage participation in activities of choosing. Visits with peers and watches television. -Contact family if behavior unmanageable and request they come and talk to resident. -Use calm, non threatening voice. -Assist resident to telephone and assist with dialing as needed. -Provide resident opportunity to express spiritual needs. Documentation on the resident's MAR for the period of 9/1/13 to 11/1/13, signed and dated by the physician on 8/30/13, included a physician's for [MEDICATION NAME] .5 mg 1 tablet by mouth every 6 hours PRN for increased emotional anxiety. A review of the September and October, 2013 MAR indicated [REDACTED]. The resident's clinical record lacked evidence of nursing staff attempting or documenting non-pharmacological interventions attempted prior to administering the PRN [MEDICATION NAME] for anxiety on the dates identified in September and October. During an interview on 10/30/13 at 12:10 a.m., the Director of Nursing stated she could not find documentation that showed staff had attempted non-pharmacological interventions prior to administering PRN [MEDICATION NAME], in the clinical record.

Based on clinical record review and staff interview, the facility failed to follow physician's orders when administering medications for 1 of 11 residents reviewed. (Resident # 3) At the time of the survey the facility reported a census of 46 residents. Findings include: Resident #3's Minimum Data Set ((MDS) dated [DATE], documented [DIAGNOSES REDACTED]. Resident #3's Medication Review Report for the period from 9/1/13 to 11/1/13, signed and dated by the physician on 8/30/13, directed nursing staff to administer [MEDICATION NAME] 0.125 milligrams (mg) 1 tablet by mouth 1 time a day every Sunday, Tuesday, Wednesday, Thursday, and Saturday related to [MEDICAL CONDITION]. The order directed staff to hold the [MEDICATION NAME] if the resident's pulse was below 60 beats per minute. The resident's August, September, and October 2013, Medication Administration Records (MAR), revealed nursing staff failed to consistently document the resident ' s pulse prior to administering [MEDICATION NAME], in accordance with the physician ' s order. The August MAR indicated [REDACTED]. 9/17, 9/22, 9/26, 9/28; and 20 of 27 days reviewed in October 10/6, 10/13, 10/15, 10/19, 10/20, 10/22, and 10/26. During an interview on 10/29/13 at 3:20 p.m., the Assistant Director of Nursing stated she believed nursing staff checked pulses prior to administering the [MEDICATION NAME] but had failed to complete the documentation on the new electronic medication administration record.

Based on clinical record review and staff interview, the facility failed to complete an adequate change in condition assessment for one of seven residents reviewed. The facility census was 43 residents. (Resident #7) Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #7 had [DIAGNOSES REDACTED]. The MDS documented the resident required oxygen therapy and assistance with bathing. A cardiologist report dated 3/25/13, documented the resident had severe leg [MEDICAL CONDITION] with a directive to increase the residents [MEDICATION NAME] (diuretic). A vitals report for March 2013, revealed the resident had a documented weight of 242 pounds on 3/25/13. On 3/26/13, the resident weighed 262 pounds, indicating the resident had a twenty pound weight gain in one day. Nurse notes revealed no assessment documented on 3/26/13. Nurse notes dated 3/27/13 at 10:55 a.m., documented the residents oxygen saturation was 53 percent on 2 liters of oxygen, lungs diminished to right base with crackles heard throughout. At that time the physician was notified with a new order received to increase the residents oxygen to 4 liters. Nurse notes at 12:45 p.m., documented the physician was updated on the residents oxygen saturation of 71 percent on 4 liters. At that time the physician ordered the resident to be transferred to the emergency room via ambulance. Nurse notes at 3:45 p.m., documented the resident was transferred from the Grinnell Regional Medical Center to the University of Iowa hospital via ambulance with [MEDICAL CONDITION], kidney failure, pneumonia and [MEDICAL CONDITION]. A hospital progress note dated 4/1/13, documented the resident was admitted to the cardiovascular critical care unit on 3/27/13, with [MEDICAL CONDITION] and shortness of breath. A discharge summary dated 4/4/13, included [DIAGNOSES REDACTED]. During interview on 4/25/13 at 1:30 p.m., the Director of Nursing (DON) verified the weights were documented as 242 pounds on 3/25/13 during a cardiologist visit and on 3/26/13 the resident weighed 262 pounds. The DON verified there was no documented assessment on 3/26/13 and stated the nurse who worked tended to be very particular about watching for weight gains and doing assessments. The DON stated it would be expected that an assessment be completed on a resident with a large weight gain.

Based on observation, clinical record review, facility policy and staff interview, staff failed to maintain infection control practices by not maintaining oxygen tubing in a clean sanitary manner for 1 (Resident #9) of 3 residents who utilized oxygen The facility reported a census of 40 residents. Findings included: 1. The quarterly Minimum Data Set (MDS) with a reference date of 08/30/12 documented Resident #9 with a BIMS (brief interview for mental status) score of 3 which indicated the resident demonstrated severely impaired cognition. The MDS indicated the resident required extensive assistance from staff for mobility and total assistance from staff for bathing, dressing, toilet use and personal hygiene. The MDS indicated the resident demonstrated shortness of breath when lying flat. The MDS documented the resident [DIAGNOSES REDACTED]. The Resident Care Plan with a goal date of 12/04/12 indicated the resident been on started on oxygen therapy on 08/08/08 for COPD and CHF. The physician order [REDACTED]. The oxygen administration policy (not dated) received from the facility on 09/20/12 directed staff to change nasal cannula each week and as needed. The policy did not address the need to maintain the nasal cannula and tubing in a sanitary manner. Observation on 09/19/12 at 8:50 a.m. revealed Staff A, CNA and Staff B, CNA (certified nursing assistants) propelled the resident to the bedroom to transfer into a recliner. The resident, sitting in a wheelchair, had a portable oxygen tank and oxygen infusing via a nasal cannula. After connecting the resident to a stand lift, Staff A removed the portable oxygen tank from the wheelchair and placed it over her shoulder as the staff transferred the resident. After settling the resident in the recliner, Staff A removed the nasal cannula attached to the portable tank; from the resident and placed the tank straps over the back of the wheelchair, wrapping the tubing around the wheelchair with the nasal cannula dropped down against the wheelchair. Staff A picked up a nasal cannula and tubing connected to an oxygen concentrator. The tubing that had been draped across the concentrator and fallen on the floor with the nasal cannula lying on the floor. Staff A turned the concentrator on and started toward the resident with the soiled nasal cannula until stopped by the surveyor. Staff A then turned off the concentrator, removed the cannula and tubing from the concentrator discarding them in to the garbage. Staff A exited the room after informing the resident she would go get a new tubing set. When Staff A returned to the room, she connected the new oxygen tubing set and cannula to the concentrator and placed the nasal cannula on the resident with the concentrator set at 2 liters. Staff A also placed a small black bag on the concentrator to place the tubing and cannula in when disconnecting the concentrator. At 9:50 a.m. the portable oxygen tank, tubing and nasal cannula remained draped around the wheelchair that had been stored in the resident's bathroom. The nasal cannula remained lying against the wheelchair back. At 11:55 a.m. Staff A, CNA and Staff B, CNA entered the resident's room to transfer to the wheelchair to take to the dining room for lunch. The staff used a stand lift to stand the resident up and provided personal hygiene. After obtaining the wheelchair from the resident's bathroom, the staff removed the concentrator from the resident, turned the portable oxygen tank on, placed the cannula that had been lying on the wheelchair back on the resident. The staff transferred the resident into the wheelchair and propelled the resident to the dining room for lunch. On 09/19/12 at 3:30 p.m. Staff C, the director of nursing and Staff D the assistant director of nursing, indicated they would look into the oxygen tubing not being placed in a bag and would correct the situation.

Based on clinical record review and staff interviews the facility failed to ensure administration times for medications occurred so the medications could be the most therapeutic for 1 of 5 residents reviewed (Resident #3). The facility census was 49 residents. Findings include: 1. Resident #3's Minimum Data Set ((MDS) dated [DATE] revealed [DIAGNOSES REDACTED]. Resident #3 had moderately impaired cognition and could understand others. Resident #3 required supervision with bed mobility and walking. The resident walked independently in his/her room with a walker, ate independently, used the toilet independently and transferred from the bed to chair independently. Review of the Resident Care Plan dated 1/18/12 directed the staff to administer medications as ordered, to have a pharmacy consultant review medications and for the nurses to monitor for potential side effects of medications. Review of the physician's orders [REDACTED]. a. [MEDICATION NAME] sodium ([MEDICAL CONDITION] hormone) 175 mcg (micrograms) orally every morning, start date 5/4/2011 b. [MEDICATION NAME] (anti ulcer) 1 tablet orally twice daily, start date 3/4/2011 c. [MEDICATION NAME] sulfate (iron supplement) 325 milligrams twice daily, start date 5/12/2011 Review of the signed Physician's Telephone Orders sheet dated 12/14/11 directed the staff to move the [MEDICATION NAME] to 11:00 a.m. and 8:00 P.M. as it should not be given with [MEDICAL CONDITION] medication, it could affect the effectiveness of the medication. Review of an order dated 12/15/11 directed to the staff to discontinue the [MEDICATION NAME] and to change [MEDICATION NAME] sulfate to 325 milligrams daily. Review of the December 2011 Medication Administration Sheet (MAR) revealed the following: a. [MEDICATION NAME] 175 mcg scheduled to be administered daily at 6:00 a.m. b. [MEDICATION NAME] 1 tablet scheduled to be administered at 6:00 a.m. and 8:00 p.m. c. [MEDICATION NAME] sulfate 325 milligram 1 tablet scheduled to be administered at 7:00 a.m. and 5:00 p.m. A review of the MAR indicated [REDACTED]. The medication box had a hand written note which indicated [MEDICATION NAME] interacted with [MEDICATION NAME]. The [MEDICATION NAME] sulfate had a discontinuation dated of 12/15/11 with a new order dated 12/15/11 directing the staff to administer [MEDICATION NAME] sulfate 325 milligrams daily at 5:00 p.m. Review of a Physician's Progress Note dated 12/15/11 indicated Resident #3's Physician had a conversation with the resident in regards to their [MEDICAL CONDITION] treatment. The Physician explained to the resident that their elevated [MEDICAL CONDITION] Stimulating Hormone (TSH) level could be due to the possible absorption problems with their [MEDICATION NAME] with [MEDICATION NAME] and iron interactions. Clinic notes dated June 9, 2011 indicated Resident #3 stated all her medications were given regularly and on time. Under Impression and Recommendations the physician noted it was likely the persistently elevated TSH was due to inadequate absorption of the [MEDICATION NAME] from the GI (gastrointestinal) tract. The note indicated the [MEDICATION NAME] may be the problem and the importance of administering the [MEDICATION NAME] at least 2 hours before food or medications. The note further indicated [MEDICATION NAME], and iron can lead to poor absorption of [MEDICATION NAME]. Review of the [MEDICAL CONDITION] Stimulating Tests (TSH) levels revealed the following: a. The TSH drawn on 4/27/11 revealed a result of 45.90 (the normal range for this test is 0.34-4.82) b. The TSH drawn on 5/23/11 had a result of 59.39. c. The TSH drawn on 12/21/11 had a result of 21.15 d. The TSH drawn on 2/13/12 had a result of 0.53 (normal range). The [MEDICATION NAME] and [MEDICATION NAME] sulfate dosages were changed on 12/15/11, after this date the TSH levels returned to a normal range. An interview with the Director of Nurses (DON) on 3/7/12 at 9:00 a.m. revealed a family member brought the possible drug interactions to the staff's attention in December 2011, changes were made to the medications after consulting the resident's physician. The DON stated the clinic notes from the consult did not get sent to the facility. The DON stated the Pharmacy monthly reviews failed to reveal a possible drug interaction between the [MEDICAL CONDITION], stomach and iron medications. According to the 2010 Mosby's Nursing Drug Reference book used by the facility indicated [MEDICATION NAME] should be given on an empty stomach. When given with [MEDICATION NAME] sulfate, absorption could be decreased, and antacids, or iron should be given separate from [MEDICATION NAME] by four hours. Nursing considerations from the same drug reference for [MEDICATION NAME] indicated the medication should be given on an empty stomach, one hour before meals or other medications and at bedtime.

Based on observation, staff interview, and facility policy, the facility failed to maintain 4 residents' personal refrigerators for sanitation and document the internal temperatures of the refrigerators to ensure the internal temperatures were maintained within in the parameters for cold food temperature safe storage, the facility also failed to maintain cleanliness to resident equipment (wheelchairs, tower fans, stand lifts, shower chair and heat register). The facility reported a census of 50 residents. Findings include: 1. Observations of the facility on August 29, 2011 through August 31, 2011, noted 4 residents rooms (#3, # 20, # 33, and # 44) had private refrigerators. With the Resident # 3's permission, the temperature check of Room # 44's refrigerator on 08/29/2011 at 11:20 A.M. revealed no internal thermometer and no documentation to indicate the staff monitored the internal temperature. The resident stored bananas, pop, crackers, and other fruit. Resident #3 stated no one checks the refrigerator except herself/himself. From 8/2011 through 08/30/2011, the refrigerator held no thermometer and no observations of staff checking the refrigerator. Resident # 3's BIMS (Brief Initial Mental Status) on the 6/15/2011 MDS (Minimum Data Set) equaled 14 good decision making skills. On 08/30/2011 at 8:40 A.M., an observation of Resident # 15's dorm size personal refrigerator revealed no internal thermometer and no documentation of internal temperatures monitored by staff for the refrigerator. The refrigerator held candy, cookies, and Yogurt with no dates. A paper cup with lite-colored liquid sat on a paper towel in the refrigerator. Resident # 15's BIMS (Brief Initial Mental Status) interview documented a 10 which indicated moderate mental impairments. Another observation of Resident # 15's refrigerator on 08/31/2011 at 12:20 P.M. revealed the internal temperature of the refrigerator was 62 degrees. On 08/31/2011 at 8:15 A.M., Staff A revealed the housekeeping staff did not document the internal temperatures of the resident's refrigerators or keep thermometers in the refrigerators. Staff A indicated the housekeeping staff did defrost the refrigerators periodically. The facility identified 4 residents with personal refrigerators in Room # 3, #20, # 33, and # 44. The facility policy for Resident Refrigerator Cleaning dated 11/2010 directed the housekeeping supervisor to keep a list of personal resident refrigerators. The policy directed housekeeping staff to check each personal resident refrigerator monthly for proper functioning and defrosting, maintain each refrigerator at 40 degrees, place a thermometer in each personal refrigerator and check monthly. 2. During the environmental tour on 08/31/11 at 1:30 p.m. several items were observed to be dusty or covered with debris. These included: a. tower fan located in the front lobby with dust covering the louvers. b. the heat register vent in the main dining room had debris covering the vent opening. c. a shower chair located in the middle hall shower room with brown substance on the bottom of the seat d. two mechanical stand lifts in the middle hallway had debris on the platforms. e. tower fan in the middle hallway with debris on the louvers f. a wheelchair located outside of Room 19 on the east hallway with dried food debris under the seat cushion and white substance on top of the seat cushion. g. a wheelchair located outside of Room 20 on the east hallway with dried food debris under the seat cushion h. two tower fans located in the east hallway covered with dust i. the chair rail in the east hallway covered with white dust particles On 08/31/11 at 2:00 p.m. Staff A noted that housekeeping is responsible for cleaning wheelchairs in the middle hallway and nursing responsible for cleaning the wheelchairs in the north and east hallways. On 08/31/11 at 3:00 p.m. Staff H stated cleaning logs were not maintained for the above mentioned items.

Based on observation, record review, staff interview, and facility policy, the facility failed to maintain sanitary conditions while emptying a catheter bag, providing wound cares, and toileting a resident in 2 out of 15 residents' sampled (Resident # 1 and Resident # 4). The facility reported a census of 50 residents. Findings include: 1. The Annual MDS (Minimum Data Set) for Resident #1 with an assessment reference date of 08/24/2011 revealed a BIMS (Brief Interview of Mental Status) score of 15 which indicated intact cognitive abilities. Facility staff provided total assistance for transfers, bed mobility, locomotion, dressing, and personal hygiene cares. An indwelling (goes into the bladder and has a bulb inflated with sterile water to hold it inside the bladder) Foley catheter released the urine from the bladder into a catheter bag. [DIAGNOSES REDACTED]. The plan of care with a problem onset date of 11/08/2000 directed facility staff to drain the catheter bag of output fluid (urine) every shift. During an observation on 08/30/2011 at 7:00 A.M., Staff B and Staff C entered the resident's room, washed their hands, and donned gloves. After placing the resident into a wheel chair, Staff C obtained a urinal from the bathroom and placed it directly on the floor without using a barrier. Staff C emptied urine from the catheter bag into the urinal and emptied the urine into the bathroom stool. After rinsing the urinal, Staff C discarded her gloves and washed her hands. During an interview on 08/31/2011 at 10:50 A.M., Staff D stated facility staff should lay a clean barrier on the floor prior to placing a urinal on the floor to empty the urine from a catheter bag. The facility's undated procedure from Mosby's textbook doe Nursing Assistants directed facility staff to place a paper towel under the graduate/urinal on the floor when emptying the catheter bag. A review of the physician's orders [REDACTED]. The plan of care did not include a problem for skin breakdown. During an observation on 08/30/2011 at 08:30 A.M., Staff B and Staff C entered Resident # 1's room, washed their hands, and donned gloves. The resident laid on the bed. Staff B placed a clean barrier on the head of the bed and placed a paper cup with saline soaked gauze, dry gauze, and [MEDICATION NAME] film dressings on it. Staff C rolled the resident to the right side. Staff B removed the [MEDICATION NAME] film dressing from the left ischial fold and placed it in a plastic bag. There was an open wound on the left ischial fold with a small amount of red fluid drainage. Staff B changed gloves after removing the old dressing, took a saline soaked gauze and rubbed the wound bed area over and over with the same gauze over the entire wound bed. Staff B repeated rubbing the wound bed with a second saline soaked gauze in the same manner. Staff B dried the wound with a dry gauze rubbing over and over the wound bed. Staff B changed gloves and applied the [MEDICATION NAME] film over the wound. Both Staff B and Staff C removed their gloves and washed their hands prior to leaving the room. During an interview on 08/31/2011 at 12:15 P.M., Staff D verbalized facility staff should cleanse a wound area once with saline spray or soaked gauze and not keep going over it. Staff H could not find a facility procedure for wound cleansing care.

Based on record review and staff interviews, the facility failed to implement the physician's order [REDACTED].#3) who had fallen out of bed and sustained a fractured humerus (upper arm). This resident fell out of bed a second time the same day and fractured his/her other humerus. Three residents were reviewed and the facility reported a census of 47 residents. Findings include: 1. A Minimum Data Set (MDS) assessment tool, with a reference date of 4/27/11, identified Resident #3 as moderately cognitively impaired. The assessment further indicated the resident needed staff supervision for bed mobility, ambulation, and personal hygiene. The assessment documented the resident's [DIAGNOSES REDACTED]. The resident's care plan dated 5/4/11 identified the resident as at risk for falls related to a history of falls in the facility, incontinent of urine, medications and short term memory loss. The Plan of Care instructed staff to quickly respond to the resident if in need of assistance, evaluate the environment (for hazards) of resident's room and other areas frequented by the resident, the Nurse/CRA (Certified Rehab Aide) to evaluate effectiveness of safety/assistive devices and need for other interventions, and to observe for changes in memory or decision making that might affect fall risk. A handwritten note dated 6/30/11 stated the resident had had an early a.m. fall with a new intervention-bed alarm. A nurses' notes entry dated 6/28/11 at 6:50 a.m. documented the resident complained of a severe headache and had a high blood glucose level (305). The nurse called the resident's physician and obtained an order to transfer the resident to the hospital emergency room (ER) for evaluation and treatment. A history and physical report dated 6/28/11 documented the hospital admitted the resident for treatment of [REDACTED]. According to a nurses' note dated 6/29/11 at 12:00 p.m., the facility readmitted the resident from the hospital. A nurses' note dated 6/30/11 at 4:25 a.m. stated staff found the resident on the floor under the bed frame lying on his/her back. The resident told the nurse the building was on fire and he/she had been trying to get out. Staff noted the resident had a laceration to the right side of his/her forehead which bled profusely, and complained of extreme pain in the right shoulder/arm, and was unable to move right arm. The nurse notified the resident's physician of the resident's condition and made arrangements to transfer the resident to the ER. According to a nurses' note dated 6/30/11 at 10:15 a.m., the resident returned to the facility with the following physician orders: Bed Alarm related to risks for falls, Tramadol for pain, ice to shoulder, follow up with orthopedic appointment, arm sling and wound care-sutures out in 10 days, keep in bulky pressure dressing for 3 days. An x-ray report dated 7/1/11 noted the resident had a right comminuted proximal humeral fracture (upper arm fracture). A Safety Fall Investigation for the fall on 6/30/11 at 4:25 a.m. noted the resident had cognitive delirium and made poor decisions. The resident was found under the bed stating the building was on fire. The resident sustained [REDACTED]. Plan was to add an alarm and the use of a quad cane. Nurses' notes documented the following information: On 6/30/11 at 2:30 p.m., the resident complained of pain in the forehead, eyes, mouth and right arm. On 6/30/11 at 7:50 p.m. staff received a new order to administer Vicodin to the resident for pain control. On 6/30/11 at 8:05 p.m., staff administered Vicodin to the resident for complaints of extreme pain which he/she rated a "10" on a scale of 1 to 10. On 6/30/11 at 8:20 p.m., staff found the resident on the floor of his/her room, face down with both arms folded under him/her. The resident complained of extreme pain in arms, legs and both hips. Staff received an order to transfer the resident via ambulance to the ER. On 7/2/11 at 3:35 p.m., the facility readmitted the resident to the facility with [DIAGNOSES REDACTED]. The resident had both arms in sling due to the fractures. The resident exhibited pain on admission; cried when transferred. Resident had a laceration to the right forehead, purple bruising around eyes down into jaw and between his/her eyes and nose. Both arms were bruised and swollen as was the right knee cap. The resident was seated on a chair pad alarm; a bed alarm, hi-low bed, and floor pad were all in place. The Safety Fall Investigation report for 6/30/11 at 8:20 p.m. noted the resident had a second fall in 24 hours. The resident suffered from delirium and was off balance with a fracture of the right humeral neck. The report indicated the facility had added the use of a quad cane prior to the resident's second fall. During an interview on 7/21/11 at 9:40 a.m., the Director of Nursing (DON) stated Resident #3 was a very pleasant, disoriented person who became delusional when he/she had a urinary tract infection. The DON further stated the nurse, Staff A, failed to follow up on the order to implement a bed alarm intervention. Staff A had apparently instructed Staff B, Certified Nursing Assistant (CNA) to put an alarm on the resident's bed, but the nurse failed to ensure it had been done. Staff A also failed to document the new intervention in the communication book and on the communication board so that all staff were aware of this new order. When Staff E, the second shift nurse, found the bed alarm order she instructed a nursing assistant, Staff C, to check and make certain an alarm was on the resident's bed. However, at that time, Staff C was asked to assist another resident. The DON stated Staff A failed to report the new order to the next shift nurse, failed to write this update in the communication book, failed to document this new order on the board, failed to follow up to ensure Staff B placed the alarm on the bed, and failed to place the alarm when she assisted the resident to the bed. Staff B also failed to place the alarm on the bed as directed. Review of Staff A's and Staff B's personnel files revealed the DON counseled both employees regarding these failures. When interviewed on 7/18/11 at 4:10 p.m., Staff A, a Registered Nurse, stated prior to 6/30/11 Resident #3 had short-term memory loss and walked with a walker. Staff A stated the resident fell in the early morning on 6/30/11 and sustained an injury to the right shoulder. The resident then required assistance and had to use a cane in his/her left hand due to the inability to use the walker. Staff A readmitted this resident back into the facility after he/she returned from the first fall. Staff A assisted the resident to the bathroom and then to the resident's bed. The nurse admitted knowing the resident needed a bed alarm; however, the nurse assisted the resident to bed and left him/her alone in bed without an alarm in place. Staff A stated she had asked Staff B to place an alarm on the resident's bed. The nurse stated when she assisted this resident to bed; the resident was in his/her normal state of confusion and in a lot of pain. The resident verbalized his/her understanding of his/her need for assistance prior to exiting the bed, however, Staff A acknowledged this resident had memory loss and his/her cognitive skills fluctuated. When interviewed on 7/25/11 at 2:52 p.m., Staff B stated she was on lunch break on 6/30/11 when Staff A pulled her into the nurse's station and told her to put an alarm on Resident #3's bed because she was coming back from the hospital and needed an alarm. Staff B stated she then went outside for a 15 minute break. When she returned to work, she assisted other staff with getting other residents up for the noon meal. She then assisted a resident with eating the meal and assisted residents with their exercises. Staff B stated she left work that day sometime between 2:00 p.m. and 3:00 p.m. Staff B reported her mother called her from the facility between 7:30-8:00 p.m. and while they were talking, Staff B remembered she hadn't placed an alarm on the resident's bed. Staff B asked her mother if she would put an alarm on the resident's bed, but it was too late, the resident had already fallen. When interviewed on 7/25/11 at 2:25 p.m., Staff C, CNA, stated on 6/30/11 the nurse, Staff E came to her and asked her to check to see if there was an alarm on this resident's bed. Staff C stated she felt this was odd because it should have been an automatic response to place a safety alarm on the bed of a resident who had fallen and sustained a fracture. Staff C proceeded to check on the alarm situation, however, she was asked to assist with changing another resident out of his/her soiled clothing. Staff C heard that Resident #3 had fallen again when exiting the other resident's room. She went to the resident's room. The resident was lying face down on the floor. She noted no bed alarm on this resident's bed. Staff C stated when they come to work, they are expected to read the communication book and communication board for any changes in residents' care plans. They do not receive a verbal report. When interviewed on 8/9/11 at 9:00 a.m., Staff E, a nurse, stated when she came to work on 6/30/11, the day nurse was busy so she read through Resident #3's admission orders [REDACTED]'s orders. That evening, after staff seated the resident in the living room, the resident continued to stand up unassisted, so they placed a chair alarm on the resident to prevent unassisted transfers from the chair. She then asked a nursing assistant to make sure there was an alarm on this resident's bed. She did not follow up on this as she assumed the nursing assistant followed her instructions. Staff E later administered the resident a narcotic pain medication. The resident laid in bed and rated his/her pain as a ten on a scale of one to ten, with ten being the most severe. She reminded the resident to use the call light for assistance; however, she had never known this resident to use the call light because he/she had been totally independent prior to the fall/fracture. A short time later she was paged to the resident's room and found the resident lying face down on the floor with an immobilizer still on one shoulder/arm and both arms underneath the resident. The resident complained of pain all over his/her body. The nurse was afraid to move the resident due to the complaints of pain and the resident's position on the floor. The nurse then called the physician and made arrangements to transfer the resident to the hospital.