Every finding on record at Careage Hills Rehabilitation and Healthcare

Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was prepared under sanitary conditions. The facility identified a census of 38 residents. Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was prepared under sanitary conditions. The facility identified a census of 38 residents. Findings include: Observation on 3/4/26 at 12:00 p.m. Staff B, Cook, applied gloves after performing hand hygiene. Staff B with gloved hands grabbed the bread sack and opened the bread sack and poured out about 6 pieces of bread on top of small bowls. Then proceeded to tear up the bread with her soiled gloves and grab the milk jug and pour milk over the bread, then took off the gloves and applied new gloves. Observation on 3/4/25 at 12:30 p.m. Staff B had gloves on and opened the hamburger bun bag and took out the bun with her gloved hand, placed it on the plate, then grabbed the potato chip bag and used her soiled glove hand and grabbed the chips and placed them on the plate. Per the facility Policy named Food Handling dated 6/2015 revealed It is the practice of this facility to ensure all food is handled safely and as allowable under stateRegulations. Upon Ready to eat foods will not be touched with bare hands. Proper utensils such as tissue, spatula, tongs or single use gloves will be used for food handling. There will be minimal bare hand contact with food during preparation.If gloves are used proper use needs to be followed:A) Wash hands before and after wearing or changing gloves;B) Use gloves that fit properly and that are designed for the task at hand;C) Change gloves whenever you change an activity, the type of food being worked with or whenever you leave your workstation;D) Change gloves after sneezing, coughing or touching hair or face with gloved hands;E) Avoid wearing gloves whenever their use presents a potential safety hazard (near hot equipment where melting may occur.F) Vinyl gloves are recommended - use of latex or powdered gloves should be minimalInterview on 03/4/26 1:02 p.m. with Administrator revealed the expectation would be to utilize tongs when trying to get the bread out of the bread sack and putting on new gloves when touching food and changing gloves after touching the outside of food packages.

Based on clinical record review, staff interview, and facility policy review the facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital and a discharge to home for 2 of 3 residents (Resident #38 and Resident #43) reviewed. The facility reported a census of 38 residents.Findings include: Review of Resident #38's Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was discharged with anticipation to return to the facility. The MDS further revealed a Brief Interview for Mental Status (BIMS) was not completed for this MDS. Review of Resident #38's Electronic Healthcare Record (EHR) revealed an entry dated 11/22/25 at 9:29 a.m. that Resident #38 was sent to the emergency room for evaluation. The hospital later notified the facility, Resident #38 was admitted to the hospital. Review of Resident #43's Minimum Data Set (MDS) dated [DATE] revealed Resident #43 was discharged , return not anticipated. The MDS further revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive functioning. Review of a facility provided document titled, Notice of Transfer Form to Long Term Care Ombudsman dated November 2025 revealed that Resident #38 was not on the form. Review of a facility provided document titled, Notice of Transfer Form to Long Term Care Ombudsman dated January 2026 revealed that Resident #43 was not on the form. Interview 3/5/26 at 9:00 a.m. with the Staff A, Activities stated she completed the notifications to the Ombudsman monthly. Staff A stated that she pulled a report from the facility's electronic health record and used this report to send notification to the Ombudsman. Staff A, acknowledged that Resident #38 was not on the notification for November 2025 and was unaware of why. Interview 3/5/26 at 9:15 a.m. with Staff A, stated that she spoke with the Administrator, and revealed that she was pulling the wrong report. The report she was pulling did not have the transfer to on the report. Staff A stated that she pulled the correct report and notified the Ombudsman of the residents who were missed. The facility provided a policy named Admission, Transfer and discharge date d 10/2022 revealed when the facility transfers or discharges a resident, the facility shall ensure that the transfer is reported to the ombudsman per monthly report.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 residents (Resident #7) reviewed for PASRR requirements. The facility reported a census of 38 residents. Findings include: 1. The The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented diagnoses of psychotic disorder, neurocognitive disorder and depression. The MDS included a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. The Medical Diagnosis list for Resident #7 revealed the following diagnoses:Delusions, dated 6/6/25,Mild neurocognitive disorder, dated 6/6/25,Major depressive disorder, dated 7/7/25. The Clinical Orders for Resident #7 revealed the following medications:Duloxetine 20 mg daily for depression, dated 7/19/25The clinical record for Resident #7 lacked an updated PASRR to include the diagnosis of depression and the new medication, duloxetine.The Resident Assessment PASRR policy last revised May 2022 identified it is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State. Purpose: Mental disorder as defined in paragraph (k)(3)(1), of the SOM unless the State mental health authority has determined , based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority prior to admission: That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility and; If the individual requires such level of services, whether the individual requires specialized services; or Intellectual disability, as defined in paragraph (k) (3) (2) of the SOM, unless the State intellectual disability or developmental disability authority has determined prior to admission - That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and If the individual requires such a level of services, whether the individual requires specialized services for the intellectual disability. In an interview on 3/5/26 at 8:58 PM with the Administrator and Director of Nursing (DON), the Administrator stated the facility failed to update Resident #7's PASRR after the resident received a diagnosis of depression and a new medication order for duloxetine. The Administrator reported that at the time the facility's social worker changed jobs and the facility entered the process of hiring a social worker. The Administrator further reported the facility later hired a new social worker; however, that individual no longer works at the facility, and the facility remains in the process of hiring.

Based on clinical record review, facility record review and staff interviews the facility failed to document blood sugars and insulin on the medication administration record (MAR) for 1 out of 1 residents reviewed (Resident #4). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of diabetes mellitus, renal insufficiency and hypertension. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Interview with Resident #4 stated that he checks his blood sugar through his glucose monitoring device and notifies the nurse. Resident #4 stated the nurses will dial up the insulin pen and then he self administers it. Review of the Physician Orders revealed Resident #4's orders are as followed:Humulin, inject 3 units subcutaneous (insertion of medications beneath the skin ) (SQ) 3 times a day.Humulin, inject 3 units SQ per sliding scale 3 times a day: 151-200=2U; 201-250=4U; 251-300=6U; 301-350=8U; 351-400=10U; >400=12U Lantus Pen, Inject 10 units SQ at bedtime. Review of the Physician Fax form dated 10/2/25 revealed the physician gave orders for Resident #4 to check his own blood sugars and administer insulin independently. Review of January 2026 Medication Administration Sheet revealed the nursing facility failed to document the blood sugar and the amount of insulin given four times, on the 5th, 9th, 18th, 21st, 23rd, 28th, 29th and 30th. Review of February 2026 Medication Administration Sheet revealed the nursing facility failed to document the blood sugar and the amount of inulin given eight times, on the 1st, 4th, 6th, 13th, 16th, 21st, 25th, and 26th. The facility policy named Self Administration of Medications revised 2/2026 revealed Nursing will be responsible for recording self-administered doses in the resident'smedication administration record (MAR). Interview on 3/4/26 at 2:30 p.m. with Director of Nursing (DON) stated the expectation of the nurses are to get the blood sugar information from Resident #4, administer the insulin and document the blood sugar and insulin units on the medication administration records.

Based on observation, clinical record review, and staff interviews, the facility failed to ensure a safe transfer using a mechanical lift for 1 of 2 residents (Resident #11) according to facility policy and manufacturer guidelines. The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 documented diagnoses of dementia, muscle weakness, and abnormalities of gait and mobility. The MDS showed a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident could not complete the BIMS interview. The Care Plan, initiated 7/28/22, for Resident #11 indicated transfers require total dependence with assistance from two staff members using a mechanical lift. Observation on 3/3/26 at 11:55 AM revealed Staff C, Certified Nurse Aide (CNA), and Staff D, CNA, transferred Resident #11 from the bed to the wheelchair using a mechanical lift. During the transfer, Staff C raised the resident from the bed with the mechanical lift while the wheels remained braked. Staff C then lowered the resident into the wheelchair with the mechanical lift while the wheels remained braked. The User Instruction Manual dated 2024 for the mechanical lift indicated the lift has two braked casters which can be applied for parking. When lifting, the casters should be left free and un-braked (the only exception is when lifting a patient from the floor). The lift will then be able to move to the center of gravity of the lift. If the brakes are applied it is the patient that will swing to the center of gravity and this may prove disconcerting and uncomfortable. The undated Mechanical Lift Use Policy identified resident care will be provided in a safe, appropriate and timely manner in accordance with each resident's individual care plan and to protect Caregivers from potential injury. Residents will be assessed regarding need for assistance with transfer activities, mobility and repositioning through interdisciplinary assessment to determine which type of mechanical lift is most appropriate and effective for each resident. PROCEDURE:A. General: 1. Complete assessment to determine resident's need for mechanical lift support for transfers, mobility and/or repositioning. 2. Determine type of lift, if appropriate. 3. Document lift and transfer plan on resident's care plan and corresponding care directives (eg, Care Guide, Kardex, etc). 4. Do not use it when a resident is confused, agitated or otherwise unable to follow visual or verbal instructions/cues. 5. Follow lift manufacturer's guidelines in the use of the lift (eg, do not use a lift for residents whose weight exceeds the manufacturer's stated weight limit). B. Lift Use 1. Verify the type of lift to use, per Care Plan/Directive.2. Place the sling under the resident making sure it is square at the shoulders. 3. The sling will be attached to support straps. 4. One Caregiver will stabilize the resident while a second Caregiver (when applicable) guides the resident to the transfer destination, gently lowering the resident into a resting position. 5. Make sure the wheelbase is spread to ensure lift stability through the entire transfer and follow manufacturing guidelines. In an interview on 3/4/26 at 1:31 PM, Staff F, Registered Nurse (RN), when asked if the mechanical lift brakes needed to be on or off during a transfer, stated, I think unlocked, but I would have to check to be sure. In an interview on 3/5/26 at 8:58 PM with the Administrator and Director of Nursing (DON), the Administrator stated the facility recently provided lift training to staff as part of a survey result. The Administrator reported mechanical lift brakes should remain unlocked when lifting and lowering a resident so the lift can self-correct if needed. The Administrator reported the facility plans to provide additional education to staff.

Based on observation, clinical record review, staff interview, and per the current Centers for Disease Control and Prevention (CDC) guidelines the facility failed to use Enhanced Barrier Precautions (EBP) to prevent the spread of multidrug-resistant organisms (MDROs) and failed to provide proper hand hygiene after catheter care for 1 out 1 resident reviewed (Resident #2). The facility reported a census of 38 residents. Findings include: Observation on 1/21/26 at 10:19 AM revealed Staff E, Certified Nurse Aide (CNA), performed catheter care and emptied the catheter bag for Resident #2 without donning a gown as part of personal protective equipment (PPE) for EBP. After completing care with soiled gloves, Staff E wiped the urine bag spout with an alcohol wipe, pulled the resident's pants down, and collected the urine colander, barrier, and used alcohol wipe. Staff E opened the bathroom door, discarded the barrier and soiled wipe, turned on water, rinsed the colander, and flushed the toilet. Staff E then wrapped the colander in a clean garbage bag, removed the bag from the receptacle, tied it, and placed a new bag in the receptacle. Staff E doffed gloves, failed to perform hand hygiene, exited the bathroom, moved the bedside table, touched the call light box, exited the room, entered the keypad to the dirty utility, discarded the garbage bag, and entered another resident's room to answer a call light. The resident's room did not display signage or PPE required for EBP. In an interview on 3/4/26 at 1:31 PM, Staff F, Registered Nurse (RN), hesitated and failed to answer when asked if staff used EBP. When asked if a gown should be used when emptying a catheter, the nurse replied yes. When asked which residents required EBP, the nurse stated that an EBP sign and PPE outside a resident's room would indicate the need for EBP. Upon observing each hall, the nurse indicated that none of the residents' rooms had EBP signage or PPE and subsequently reported the findings to the Administrator. The Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Ref: QSO-24-08-NH GUIDANCE Enhanced Barrier Precautions (EBP) refer to 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. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do nototherwise apply; or Wounds and/or indwelling medical devices even if the resident is not known to beinfected or colonized with a MDRO.Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks orskin tears covered with an adhesive bandage (e.g., Band-Aid(R)) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealedsurgical wounds, and venous stasis ulcers. The Centers for Disease Control and Prevention website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), visited 4/9/25, updated 7/12/22, and dated 4/2/24 revealed Enhanced barrier precautions expand the use of PPE and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff and clothing. MDROs may be indirectly transferred from resident to resident during these high contact care activities. Nursing home residents with wound and indwelling medical devices are at especially high risk for both acquisition of and colonization with MDROs. The use of gown and gloves for high contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. The Centers for Disease Control and Prevention website titled, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes dated June 28, 2024 identified question: May nursing homes stop using Enhanced Barrier Precautions if we screen the infected or colonized resident and they test negative for the novel or targeted MDRO? Residents colonized with a novel or targeted MDRO are intended to remain on Enhanced Barrier Precautions for the duration of their stay in a facility. Because MDRO colonization is typically prolonged and follow-up testing to determine clearance may yield false negatives, CDC does not recommend routine retesting of residents with a history of colonization or infection with a MDRO or discontinuation of Enhanced Barrier Precautions after a subsequent negative test. The Standard and Transmission-Based Precautions last revised March 2024 included the following:Standard Precautions are infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Standard Precautions include: a. Proper selection and use of PPE, such as gowns, gloves, facemasks, respirators, and eye protection i. Use and type of PPE is based on the predicted staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens (e.g., gloves are worn when contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment are anticipated). b. Hand hygiene; c. Safe injection practices; d. Respiratory hygiene and cough etiquette; e. Environmental cleaning and disinfection; and f. Reprocessing of reusable medical equipment. Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs). In an interview on 3/4/26 at 1:37 PM with the Administrator and Director of Nursing (DON), the Administrator reported instructing staff to initiate EBP, hang signage, and place PPE where needed. When asked if the facility was following EBP requirements, the Administrator stated they had been; however, the Infection Preventionist recently parted ways with the facility, and the facility needed to readdress EBP with staff. The DON verified she instructed staff to initiate PPE at that time. The Administrator reported she would follow up with staff regarding hand hygiene practices.

Based on observations, clinical record review, staff interviews, and facility policy review, the facility failed to provide adequate nursing supervision to prevent injuries with transfers using a mechanical lift for 1 of 3 residents reviewed (Residents #1). The facility reported a total census of 33 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of Alzheimer's Disease, seizures, cognitive communication deficit and need for assistance with personal care. The MDS showed the Brief Interview for Mental Status (BIMS) was not assessed. The MDS showed the Resident depends on staff for eating, oral care, toileting hygiene, bathing, dressing, personal hygiene, bed mobility and all transfers and the Resident depends on staff for wheelchair movement in and out of the facility. Review of Resident #1's Care Plan revealed the following:1. Resident was unable to ambulate initiated 11/1/23.2. Requires total dependence on staff with locomotion using wheelchair initiated 11/1/23,3. Requires total dependence on staff with transfers with hoyer lift and 2 person initiated 3/21/23.4. Requires total dependence on staff with bed mobility, bathing, toilet use, personal hygiene and oral care and dressing initiated 3/21/23. Review of Progress Notes revealed the following: 1. On 11/21/2025 at 7:29 p.m., by Staff E, Licensed Practical Nurse (LPN) at approximately 5:15 p.m., this nurse was called to the resident's room by Staff C, Certified Nursing Assistant (CNA). When inquiring about potential supplies needed (vitals, skin tear items) Staff C says everything! She fell out of the Hoyer sling! This nurse ran to the resident's room and noted resident laying on the floor on her left side, face down in a pool of blood. This nurse immediately called 911, rolled resident to her back and applied pressure to the resident's forehead. Staff D, Registered Nurse (RN) grabbed the resident's paper for the ambulance, and some gauze to cover skin tears noted to bilateral arms and left hand. When the ambulance arrived, this nurse noted indentation to the resident's forehead and a significant laceration. Family notified, bed hold was obtained. On-call staff were called and notified the Director of Nursing (DON) and Administrator. 2. On 11/24/25 at 8:53 a.m., The Administrator visited the resident in the hospital. The resident was stable and reacted to my words and touch. They are waiting on plastic surgery to consult for her broken nose to assist with her breathing in the future. 3. On 11/25/25 at 3:07 p.m., Resident returned to facility per ambulance and driver at 12:55 p.m 4. On 11/26/25 at 2:22 p.m., received new orders for treatment to bilateral elbows and left great toe. 5. On 12/1/25 at 3:26 p.m., received orders from the hospital to remove sutures now. Sutures were removed using the suture removal kit. Resident tolerated it well. 6. On 12/2/25 at 10:31 a.m., fall committee met. Fall on 11/21/25- Resident fell during transfer. Intervention is educated on facility policy of hoyer transfers. 7. On 12/2/25 at 11:01 a.m., the skin committee met. Resident returns from hospital on [DATE]. The resident has ecchymosis (discoloration under the skin, bruising) to face and arms from fall. Resident is showing improvement in discoloration and are in various stages of healing. The resident has 2 skin tears to the left and right elbow also from fall showing improvement. Forehead laceration sutures removed on 12/1/25. The resident was admitted from hospital with stage 2 pressure to the left great toe. Review of the local hospital Emergency Department (ED records revealed the following:1. Nursing home resident present to the emergency room via Emergency Medical Services (EMS) for a head injury sustained during a drop from a Hoyer lift. According to EMS the patient was being transported from chair to bed when she fell out of the Hoyer lift. EMS was called for a laceration with head injury. The patient is nonverbal.2. Under the physical exam head, significant signs of trauma. There is a 4 centimeter (cm) depression in the center of the forehead. There is a laceration in the center of this area that is T shaped. Approximate 3cm x 3cm x 3cm. There appears to be crepitus (crackling, popping, clicking, or grating sounds and sensations in joints or soft tissues during movement) in this area. The patient also has a significantly bloody nose. Her nose is slightly deformed. There is a significant amount of blood on the backside of the head but does not appear to be any crepitus in the posterior aspect (back side of head) of her head. There does not appear to be a laceration to the backside. 3. Patient Re-evaluation and Further Treatment, because of the serious nature of the head laceration and apparent head injury high level care involved. Spoke with a physician at a higher level of care who accepts patient for transfer. Arranged for air transport. Computed Tomography (CT) scan shows no traumatic brain injury at this time but given the patient's condition it is important to get trauma involved. Patient arrangement by air transportation has been facilitated. Family ok with the plan. 4. Assessment included fall, forehead laceration and nasal fracture. Review of hospital records revealed the following:1. Summary: female with past medical history significant for cognitive impairment, advanced dementia, seizure disorder who is bedbound and nonverbal at baseline, residing in a nursing home in Iowa who was flown in initially as a trauma transfer after she had a fall while using the lift. Initial CT head and CT spine done at the outside facility which showed closed nasal bone fracture but otherwise negative. She was found to have a laceration to her forehead, repair in the ED. She did receive a dose of Tylenol and morphine prior to transfer. She is being admitted to the hospital. 2. Assessment/Plan include: skin tear of the right elbow without complication, skin tear of the left elbow without complication, closed fracture nasal bone, complex laceration of the forehead, blunt head trauma, superficial laceration and fall. Review of facility document titled Five-Day Summary of Self-Reported Incident revealed the following:1. Overview of the incident- CNA notified nurse at 5:15 p.m., that resident fell while being transferred. Vital signs and neurological checks initiated. Resident family and primary care physician notified. Resident transported to local critical access hospital. The local hospital then transferred to a higher level hospital for further evaluation. 2. Self-Report Details- Staff C, CNA was transferring the resident using hoyer. CNA did not ask for a second person for assistance as is facility policy. The resident fell and suffered facial laceration and an injury to the nose. Review of the Major Injury Determination form revealed an X in front of the following statement, after reviewing the circumstances of the incident causing the injury, the previous functional ability of the patient and the patient;s prognosis, I believe the injury sustained is a major injury pursuant to 481 Iowa Administrative Code 50.7(1)(a)(3). The form was signed by the physician on 11/21/25 at 6:24 p.m Review of written statement by Staff C, CNA dated 11/21/25 revealed an incident time of 5:15 p.m Details included, went to get her up for supper. Had sling under her correctly, got hoyer raised up to transfer her to wheelchair. She started to lean forward and before I could do anything to stop her she fell face first onto floor. I called for nurse at that moment, nurse came and instantly called 911 for ambulance to take her to ER. Personal notes I would like to add: I should have had a second person for transfer but didn't and I understand that this could have ended differently. Interview on 12/3/25 at 2:07 p.m., with Staff C revealed she was transferring Resident #1 by herself and she knew she shouldn't have been. She was getting Resident #1 up for supper so the other CNA on shift was in the dining room feeding and couldn't leave the dining room to assist and the nurses were too busy to leave and help so she really didn't have any other choice. She had the sling hooked up and when she had her high enough that she didn't get caught on the bed she went to pull the lift back towards the wheelchair and went to swing Resident #1 and go into the chair the right way. That is when she started falling out of the sling, she started to lean forward and she went out the bottom and side of the sling. She pretty much fell face first onto the floor but did not hit the lift. She immediately called for a nurse and they came in and immediately called 911. Review of written statement of Staff E, LPN dated 11/21/25 at 6:06 p.m., revealed at approximately 5:15 p.m., this nurse was called to the resident's room by Staff C, CNA. When inquiring about potential supplies needed (vitals, skin tear items) Staff C says everything! She fell out of the Hoyer sling! This nurse ran to the resident's room and noted resident laying on the floor on her left side, face down in a pool of blood. This nurse immediately called 911, tolled resident to her back and applied pressure to the resident's forehead. Staff D, RN grabbed the resident's paper for the ambulance, and some gauze to cover skin tears noted to bilateral arms and left hand. When the ambulance arrived, this nurse noted indentation to the resident's forehead and a significant laceration. Family notified. Interview on 12/3/25 at 10:50 a.m., with Staff E, LPN revealed this nurse was passing medications in the dining room during the supper meal and something came across the walkie and she didn't quite hear what it was. Staff in the dining room told her it was Staff C asking her to come immediately to Resident #1's room. She asked over the walkie what she needed to bring and Staff C said everything she fell out of the hoyer. She immediately ran down to Resident 1's room. She revealed Staff C was standing by the bed and the resident was laying on the floor on her left side with her face in a pool of blood. She called Staff D to come and help right away and immediately applied pressure to Resident #1's head wound. Staff E revealed the call light was not on and Staff C had not asked for any help with the transfer. After the resident left with EMS she asked Staff C what had happened. Staff C said she did the transfer by herself and when she had the resident up high enough she went to move her and the resident went to sit up and before she could do anything she fell out of the mechanical lift sheet. Interview on 12/4/25 at 9:09 a.m., with Staff D, RN revealed he was surprised Staff C had transferred Resident #1 with no assistance. He was called to Resident #1's room by Staff E for assistance. Staff D revealed he called 911 and assisted with getting the paperwork done for EMS to take with for the hospital. Staff D revealed the resident was lying in a pool of blood and everyone was working to control and assisted in trying to cover her wounds. Staff D explained Staff C explained she was lifting Resident #1 with the hoyer to a certain level and went to move her and she went out of the sling. Interview on 12/4/25 at 1:46 p.m., with Staff G, Human Resources and Business Office Manager was the on-call person that weekend. Staff G revealed she had received a call from the facility Resident #1 had been transferred to the hospital after a fall out of the hoyer. Staff G explained she interviewed all staff working and Staff C never asked for help prior to the transfer of Resident #1. Staff G talked to Staff C and she stated that she did the lift by herself when the resident fell and she should have asked for help and it would have been a different outcome if she had asked for help. Staff C was removed from job duties immediately after incident. Review of facility policy titled Mechanical Lift with a reviewed date of 10/22 revealed it is the policy to help ensure the physical safety of our employees and our residents. This policy applies to all healthcare personnel involved in patient care and transfers within the facility. Always use a minimum of 2 healthcare personnel during patient transfers with a mechanical lift, with one operating the lift and one assisting. Interview on 12/9/25 at 1:37 p.m., with the Administrator revealed Staff C should have been using 2 staff to transfer Resident #1 with the mechanical lift.

Based on observations, resident and staff interviews and facility policy the facility failed to provide an adaptive call light for Resident #4 to call for assistance. The facility reported a census of 33 residents. Observation on 12/3/25 at 3:22 p.m., of Resident #4 transferring from her bed to her wheelchair with a mechanical lift. During the transfer Resident #4 revealed she did not have a call light she was able to operate. Resident #4 verbalized she had a button call light but was unable to operate that due to her multiple sclerosis. Resident #4 revealed the facility had given her a pad call light but sometime last week that broke. Resident #4 explained the facility came and took the call light pad and was going to fix the call light and it has not come back. Observation in the room revealed there was no call light or way for Resident #4 to call for assistance in the room. Interview on 12/3/24 at 3:22 p.m., with Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA, staff confirmed Resident #4 did not have a call light. Staff A showed Resident #4 was given a call light pendant with a small button to push and she was unable to push so last week Staff A had given her a bell to ring but when Staff A came to work today the bell was on the other side of the room and the roommate had it. Staff B confirmed Resident #4 was unable to use the pendant she was given and did not have a call light to use. Review of facility provided policy titled Call Light/Bell with a reviewed date of 8/2023 revealed it is the policy of this facility to provide the resident with a means of communication with nursing staff. Interview on 12/3/25 at 3:54 p.m., with the Administrator revealed Resident #4 had been given a pad call light that she was able to operate and it should be in her room. She will get that replaced immediately for the resident.

Based on clinical record review, resident and staff interviews and policy review, the facility failed to complete a wound treatment for 1 of 3 residents reviewed (Resident #1) and failed to complete an assessment for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 34 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 revealed a Brief Interview Mental Status (BIMS) of 15 indicating intact cognition. The MDS revealed diagnoses including type 1 diabetes, pressure ulcer of the right buttock and sacral region. The MDS further revealed the resident was dependent on staff for toileting assistance and personal hygiene. The Care Plan for Resident #1 initiated [DATE] revealed the resident had actual pressure ulcer development and directed staff to administer treatments as ordered. Review of Physician Orders for Resident #1 revealed an order effective [DATE] to treat left ischium (lower and back of the hip bone) with 1/2 strength peroxide and 1/2 strength normal saline (NS) then rinse with NS, apply 1/4 strength Dakins solution, cover secure with abdominal (ABD) pad and secure with Medipore tape two times a day and as needed if soiled. During an interview [DATE] at 2:30 PM, Resident #1 revealed on [DATE] around 4:30 AM, Staff A, Certified Nurse Aide (CNA) had removed the dressing to the wound on his ischium after he had a bowel movement. The resident further revealed the wound treatment did not get completed until 9:30 AM that morning. During an interview [DATE] at 8:30 AM, the Director of Nursing (DON) revealed she received a call from Staff A, CNA around 5:00 AM on [DATE] reporting the dressing change for Resident #1 needed to be completed as Staff B, Registered Nurse (RN) did not know how to complete it. The DON stated Staff B had completed the dressing change in the past. The DON further revealed she spoke to Staff B on the phone and walked her through the treatment process and directed Staff B to review the physician orders as well and Staff B had replied, I can do that. The DON stated that was the end of the conversation and she didn't hear anything else and when she arrived at work that day around 6:30 AM-6:45 AM, Staff B was still working and was not showing signs of not feeling well. During an interview on [DATE] at 11:36 AM, Staff B, RN revealed she was not able to complete the treatment to Resident #1's ischium on [DATE] as she didn't feel like she could stand long enough to complete the treatment. Stated she talked to the DON on the phone the morning of [DATE] and the DON had said, That is your problem and you need to figure it out in regard to Resident #1's treatment being completed. Staff B reported she told the staff she would wait until the next shift came in and she would help turn the resident. During an interview on [DATE] at 11:15 AM Staff C, CNA revealed she went to clean Resident #1 up the morning of [DATE] around 7:30 AM and one of the dressings for one of his wounds to his bottom was missing. Staff C reported she could tell he had had a bowel movement and wished someone would have alerted the nurse so that the treatment could have been completed sooner as it was obvious the treatment was missing. Clinical record review revealed the treatment to Resident #1's ischium was completed [DATE] at 9:30 AM by Staff D, RN. 2. The MDS dated [DATE] for Resident #2 revealed a BIMS had not been completed as the resident was rarely/never understood. The MDS revealed the resident's diagnoses included Alzheimer's disease and a seizure disorder and the resident was dependent on staff for all activities of daily living. The Care Plan initiated [DATE] revealed Resident #2 had seizure-like activity and directed staff to assess the resident as soon as possible if seizure activity occurred. During an interview on [DATE] at 11:36 AM, Staff B, RN reported on [DATE] the CNA's had reported Resident #2 was having seizures. Staff B reported she had gone down to look at the resident and the resident looked like her normal baseline and her eyes were open. Staff B reported that based on her assessment she was going to administer intramuscular (IM) Ativan but it had expired so she did not administer it. Staff B reported she did not go back and assess the resident as she wasn't feeling well and could not walk. Review of Progress Notes for Resident #2 revealed on [DATE] at 3:22 AM, Staff B, RN documented the CNA had reported the resident was having pre-seizure behavior. The Progress Notes lacked assessments related to the pre-seizure activity. Review of facility policy revised [DATE] and titled, Resident Assessment and Associated Processes, revealed it is the policy of this facility that residents will be assessed and the findings documented in their clinical health record. Review of facility policy revised [DATE] and titled, Physician Orders, revealed all physician orders will be followed through with upon the written order by personnel licensed to write orders and/or take verbal orders from the provider. During an interview on [DATE] at 11:45 AM, the DON revealed she would expect an assessment to be completed when a resident had seizure-like activity and treatments to be completed as ordered.

Based on observation and staff interview the facility failed to prepare food in accordance with professional standards for food service safety for 1 meal. The facility reported a census of 35 residents. Findings include: During observation on 2/5/25 at 11:07 a.m. the Dietary Supervisor (DS) removed his gloves, washed his hands and applied new gloves. The DS and started serving the noon meal, touching plates, utensils, covers on the steam table, diet cards and menus. During the service the DS retrieved a bun out of it's bag wearing the same gloves. He used tongs to put a hamburger on the bun. After sending the hamburger out, he changed his gloves without washing his hands. The DS continued to serve, touching multiple surfaces. He paused to make a peanut butter sandwich wearing the same gloves. He retrieved a package of cheese from the refrigerator and removed a slice wearing the same gloves. He served additional hamburgers handling the buns with gloves on that he had touched other surfaces with. On 2/6/25 at 2:14 p.m. the Dietician confirmed gloves that touched other surfaces could not be used to handle ready to eat food, and when changing gloves staff needed to wash their hands. The undated Guidelines for Food Handling policy documented food would be handled in a manner that minimized the risk of contamination. The procedure included ready to eat foods would not be touched with bare hands. Proper utensils such as single use gloves. tissue, spatula, or tongs would be used for food handling. If gloves were used, proper use needed to be followed including washing hands before and after wearing or changing gloves. The 2022 Food Code 3-304.15 documented the use limitation of gloves. If used, single-use gloves should be used for only one task such as working with ready-to-eat food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occurred in the operation.

Based on clinical record review, staff interview and policy review the facility failed to obtain bed hold notifications for 1 of 1 resident reviewed (Resident #6). The facility reported a census of 35. Findings include: Review of Resident #6's Electronic Healthcare Record (EHR) revealed Resident #6 was in the hospital from 5/13/24 to 5/16/24 and 5/17/24 to 5/18/24. Further review of the EHR page titled, Clinical Census confirmed the Resident was in the hospital on these dates. Review for bed hold notification for Resident #6 revealed there was no bed hold form to review for the dates of hospitalization . During an interview on 2/6/25 at 12:49 PM the Administrator stated these two bed holds were missed. The Administrator stated we had started a Performance Improvement Program (PIP) after our last annual survey. The Administrator stated that she was the person auditing the bedholds at that time and that they were missed and weren't followed back up on. She stated that the process is anyone that goes out needs to have a bed hold completed. She stated that if the resident is unable to sign, the staff will get a verbal over the phone and the bed hold form needs to be filled out. The Administrator stated these are also brought up in the morning meeting to go over. Review of a facility provided policy titled, Bed Hold with a revision date of 11/2016 revealed: it is the policy of this facility to inform the resident or the resident's representative, in writing, of the right to exercise the bed hold provision upon admission and before transfer to a general acute care hospital. A copy of this notification shall become a part of the resident's health record at the time of the transfer.

Based on clinical record review, staff interviews, and the facility policy, the facility failed to follow the facility policy regarding significant weight loss in 1 out of 1 residents reviewed for nutrition needs (Resident #33). The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #33 documented diagnoses of diabetes mellitus, cerebrovascular accident, and Non-Alzheime's dementia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Review of Resident #33's clinical record reviewed the following information: On 12/9/2024, the resident weighed 149.4 pounds (lbs). On 1/8/2025, the resident weighed 128.0 pounds which is a -14.3% Loss. Review of Resident #33's weights showed the last weight taken on 1/8/2 5was 128 lbs. There were no weights taken after this date. Review of facility Weight Committee Progress Notes dated 1/8/25 at 8:56 PM revealed the Resident had a weight loss of 5% in the past 30 days. Her Body Mass Index (BMI)-22, Covid positive, and poor appetite. A fax sent to increase supplement to twice a day. Resident #33's family and primary care physician were notified. Review of Resident #33's Registered Dietitian Progress Note on 2/5/2025 at 11:55 AM lacked information regarding her weight loss. Review of facility fax form dated 1/8/2025 revealed that Resident #33 had a weight loss of 5% in the past 30 days, 7.5% in 60 days and 10% in the past 5 months. The Physician Fax form revealed that Resident #33 was Covid positive and had a poor appetite. Resident #33 currently has an order for four ounces of boost, may we increase four ounces to twice a day. The physician signed the fax form. This fax form lacked information regarding the resident's actual weights. Review of Resident #33's Medication Administration Record for January 2025 revealed the facility failed to start the Boost twice a day. During interview on 2/6/25 at 12:46 PM the Director of Nursing (DON) stated that their policy is to do weights once a month, and have weekly weight meetings. The DON stated if a resident had a weight loss they will do weekly weights until it isn't recommended anymore. The DON stated they have weights being reported on the bath/skin sheets, and as of 2/6/25 she has added the ones that are needed to the medication administration record so staff can accurately report weight changes. The DON stated if Residents have a weight loss they will report it to the physician and look at getting a supplement, look at if they need more assistance with meals and move them to the assist table. DON stated that she has started a performance improvement program for weights. Review of facility provided policy titled Nutrition reviewed 7/2021 revealed the following: It is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident ' s clinical condition demonstrates that this is not possible. Each resident's nutritional status is assessed on admission and at least quarterly thereafter. Each resident is to be weighed upon admission, weekly weights for four (4) weeks and monthly weight thereafter unless otherwise specified by the attending physician. The weight will be entered into the resident's clinical record. Monthly weights are to be completed and reviewed by the Registered Dietitian, Dietary Technician and/or designee. Evaluations may include determining ideal body weight range, usual body weight, current diet order, % of food eaten, possible dental problems, and current illness, resident likes and dislikes, psychosocial needs, and any other change in medical condition that may impact weight gain or loss. Once the resident has been evaluated for nutrition status, the Registered Dietitian, Dietary Technician and/or designee will determine if there is a significant change in the resident ' s condition. If so, additional nutritional interventions will be offered to those residents. Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the Interdisciplinary Team to determine the cause of weight loss/gain, intervention required and need for further recommendations and/or referral. Family member/responsible party and attending physician will be notified. Care plan will be updated or revised as appropriate

Based on observation, interview and record review the facility failed to ensure that residents were free from abuse for 1 of 4 residents. Resident #1 fell to the floor and sustained a hematoma on the back of his head after another resident pushed him down. The facility reported a census of 33 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive deficit). The resident required set up assistance with eating, and was independent with walking, transfers and toileting. His diagnosis included benign prostatic hyperplasia (BPH), Diabetes Mellitus, and non-Alzheimer's dementia. During observation on 11/4/24 at 12:40 PM, Resident #1 had just finished his lunch. He was pacing the hallway near his room and the door to the outside where the residents took their smoke breaks. He went back into the dining room and in and out of his room several times. At 12:58 PM he was sitting in chair near a large fish tank, when a staff member came and escorted the group out to the patio for their cigarette break. The Care Plan updated on 7/1/24, showed that Resident #1 was allowed to smoke during designated smoking times that were offered 4 times a day. He participated with psychiatric services for evaluation and response to psychotropic medications. Resident #1 had impaired cognitive function with short term memory loss and had periods of agitation. According to Incident Report dated 8/5/24 at 7:30 PM, the nurse on duty that evening heard a loud bang. When she went to investigate, she found Resident #1 was flat on his back on the floor in front of the fish tank. The resident said he pushed me and pointed at another resident (Resident #2). Staff called for the police and an ambulance. A Nursing Note dated 8/5/24 at 11:50 PM, showed that the two residents were immediately separated. Resident #1 was taken to the emergency room and returned soon after with diagnosis of post traumatic subdural hematoma. An emergency room (ER) report dated 8/5/24 at 7:37 PM, showed that Resident #1 presented to the ER with a contusion to the back of the head and he complained of neck pain. The patient demonstrated the ability to move from the ambulance cot, stand, walk and transfer himself to the ER cot. A head scan showed the resident had sustained a small 4 millimeter (mm) subdural hematoma. The ER doctor consulted with the neurosurgeon at 8:35 PM, and they decided to send him back to the nursing home with increased monitoring. The MDS for Resident #2, dated 7/31/24, showed that he was admitted to the facility on [DATE] from the community. He had a BIMS score of 4 (severe cognitive deficit). He required set up assistance only for eating and dressing, and was totally independent with walking, transferring and toileting. His diagnosis included heart failure, peripheral vascular disease, diabetes mellitus and non-Alzheimer's dementia and adjustment disorder with mixed anxiety and depressed mood. An Incident Report dated 8/5/24 at 7:30 PM, showed that Resident #2 didn't say anything when Resident #1 accused him of pushing him down, but other residents saw the incident and said that Resident #2 did indeed push Resident #1. During interview on 11/4/24 at 3:00 PM Staff A, Certified Nurse Aide (CNA), said that she was working on 8/5/24 when Resident #1 fell . She said that it was after supper and she did not witness the event, but was in the area shortly after. Resident #2 was sitting in chair by the outside door and said I didn't do nothing. He then told her that Resident #1 threw water on him. Staff A said that most of the other resident's present said they didn't see anything but one said I'm not snitching. Staff A said that when it got close to 7:00 PM, Resident #1 tended to get more agitated as he waited for cigarette breaks. During interview on 11/4/24 at 2:09 PM Staff C, Certified Medication Aide (CMA) said that she did not know what was going on but saw Resident #1 on the ground. She said that Resident #1 tended to antagonize other residents and he gets naughty. She said that she knew of incidences where he had raised his hand to a CNA and threatened to hit her. During interview on 11/4/24 at 2:01 PM Staff D, CNA said that she was working the night of 8/5/24 but did not see the incident. She asked the other residents that were present but they said they hadn't seen anything. She said that Resident #1 told her that Resident #2 had pushed him, and that she had seen them get upset before and yell at each other. Staff D said that Resident #1 had threatened many people and if he didn't get out for a cigarette break, he would get especially agitated. She said that he had run toward her once with his hand in the air when another employee stepped in. On 11/5/24 at 4:15 PM, the Director of Nursing (DON) said that none of the staff witnessed the incident between Resident #1 and #2. She said that she had completed phone interviews with the staff that worked that night. She was not aware of any other altercations between the two residents. On 11/5/24 at 4:15 PM, the Administrator said that they did not know that Resident #2 had a history of aggressive behavior before he was admitted to the facility. She said that they gave the family a 30 day notice after the incident. She said that Resident #2 would antagonize other residents, for example, he would take a drink out of other resident's cups and that caused the increase in agitation the night of the fall. Apparently, he took a drink out of the cup that Resident #1 had, there were words back and forth, which led to the aggression. According to a facility policy titled: Resident Rights, Abuse Prevention and Reporting last revised on 05/2007, residents must not be subjected to abuse by anyone, including .other residents. The Administration would maintain evidence that all alleged violations were thoroughly investigated.

Based on observation, interview and record review the facility failed to thoroughly investigate alleged abuse for 1 of 3 residents, and failed to investigate an injury of unknown origin for 1 of 1 resident reviewed. The facility reported a census of 33 residents Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive deficit). The resident required set up assistance with eating, and was independent with walking, transfers and toileting. His diagnosis included benign prostatic hyperplasia (BPH), Diabetes Mellitus, and non-Alzheimer's dementia. The Care Plan updated on 7/1/24, showed that Resident #1 was allowed to smoke during designated smoking times that were offered 4 times a day. He participated with psychiatric services for evaluation and response to psychotropic medications. Resident #1 had impaired cognitive function with short term memory loss and had periods of agitation. According to an Incident Report dated 8/5/24 at 7:30 PM, the nurse on duty heard a loud bang down the hallway and found that Resident #1 was flat on his back on the floor in front of the fish tank. The resident said he pushed me and pointed at another resident (Resident #2). Staff called for the police and an ambulance. On 11/4/24 at 1:32 PM the Director of Nursing said that she did not have documentation of witness statements. She said that she called the staff, but none of them saw what happened. During interview on 11/4/24 at 3:00 PM Staff A, Certified Nurse Aide (CNA) said that she worked the evening of 8/5/24. It was after supper when another CNA told her that Resident #1 was on the floor. She said that Resident #2 was sitting in chair near the outside door and told her I didn't do nothing. Resident #2 told her that Resident #1 threw water on him and all the other residents sitting around said that they hadn't see anything. Staff A did not remember having been interviewed by the DON or having submitted a signed statement During interview on 11/4/24 at 2:17 PM Staff B, CNA, said that she was present the night of the incident but hadn't seen anything. Later that evening another resident that had been present told her; you should've seen that guy getting laid out. During interview on 11/4/24 at 2:01 PM Staff D, CNA, said that she worked the evening of 8/5/24. She did not see it happen but Resident #1 told her that Resident #2 pushed him down. She said that they would get upset with each other and say mean things to each other. She said that she hadn't completed a signed statement. 2) According to the MDS dated [DATE], Resident #4 was admitted to the facility on [DATE]. She had moderate difficulty with hearing and a BIMS score of 5 (severe cognitive deficit). Resident #4 was independent with dressing, hygiene, sit to stand, transfers and walking. Her diagnosis included non-Alzheimer's dementia, cerebrovascular accident (CVA), chronic pain and osteoporosis. The Care Plan updated on 4/3/24, showed Resident #4 had the potential for injury related to smoking. She had the potential for impairment to skin integrity and was at risk for falls. Staff were to use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. Resident #4 was on anti-platelet mediation, staff were directed to monitor for signs and symptoms of bleeding and to notify the doctor. A Nursing Note dated 6/28/24 at 10:33 PM, showed that Resident #4 had scattered dark bruising to the bilateral lower extremities and was reporting extreme pain to her lower back. A fax was sent to the doctor. Follow up Nursing Notes dated; 6/29/24 at 1:50 PM, 6/29 at 11:05 PM, 6/30 at 3:41 PM, and 6/30 at 11:46 PM, indicated that the resident had been up as usual and ambulated around the facility. Scattered bruising was present but no complaints of pain. The chart lacked description or measurements of the bruising. A Skin Evaluation /Weekly Evaluation (SEWE), dated 6/23/24 at 12:56 PM showed no new skin issues. A SEWE dated 6/30 at 1:38 PM, showed that the resident had scattered bruising of different sizes and stages of healing to the Bilateral Lower Extremities (BLE). The documentation lacked measurements. On 11/5/24 at 2:07 PM, Staff E, Licensed Practical Nurse (LPN), said that when she saw the bruising on the legs of Resident #4, on 6/28/24, she was surprised to find that there hadn't been any documentation of it. She said that when there was an unexplained, new skin issue the nurse would complete a risk management incident report. She tried to remember but thought that the resident denied pain, and the bruising was scattered, mostly on the front of the legs above the knees and near the hip. Staff E said that she would have passed it onto the next shift. On 11/5/24 at 10:25 AM, Staff F, Registered Nurse (RN) acknowledged that she had completed a skin evaluation for Resident #4 and saw that she had tiny bruises at various stages of healing. She said I probably should have measured and charted that. When asked what the process was for investigating unknown causes she said I've always been able to explain them and added that the resident must have bumped her leg on something. She did not know if there was an investigation on the cause of the bruising. On 11/5/24 at 2:12 PM when asked if there were any incident reports for Resident #4, the Administrator said that they did not have any. On 11/5/24 at 3:50 PM, Staff G, CNA brought Resident #4 into the whirlpool room for a bath. She asked the resident if we could look at her legs. The resident agreed and removed her pants on her own. She had a dark purple bruise on the inside of left thigh, a couple smaller bruises further down her left leg and one on the top of her right leg. The resident was unable to state how she got the bruising. On 11/5/24 at 4:15 PM, the DON said that she was not aware of new skin concerns for Resident #4. She said that she expected the nurses to initiate a risk assessment form with any change in skin condition, including bruises. She said that Resident #4 often put her hands in her pockets and pinched herself in those areas where there's bruising but she would have wanted to know so she could do an investigation. According to a facility policy titled: Resident Rights, Abuse Prevention and Reporting last revised 05/2007, residents must not be subjected to abuse by anyone, including .other residents. The Administration would maintain evidence that all alleged violations were thoroughly investigated. Any staff member who had reasonable cause to believe or reason to suspect any situation may be considered abuse or neglect along with injuries of unknown origin, including any bruises, skin tears or other injures would immediately report to the charge nurse. The charge nurse would complete an initial investigation to attempt to determine the cause of the injury through interviews of staff, resident and witnesses. Statements should include all details. Witnesses were encouraged to give a signed statement. The Administrator, Director of Nursing Services, Staff Development Coordinator and Social Service Director would review the incident. Any incident would be investigated by interviewing resident, staff and or other witnesses.

Based on observations, interviews, record and policy review the facility failed to ensure that residents were properly supervised, and interventions were utilized to prevent accidents for 5 of 5 residents reviewed, (Residents #1, #2, #3, #4 and #5), . Staff failed to use safe transfer practices for Residents #1, and #5. Resident #3 slid off of the [NAME] pool seat, and Resident #4 sustained a broken toe when a staff's dog tripped her. Staff failed to follow care plan interventions established to prevent further falls for Resident #2. The facility reported a census of 38 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #1 was admitted on [DATE] and did not have a Brief Interview for Mental Status (BIMS) assessment because she was rarely/never understood. She was totally dependent on staff for toileting, dressing, hygiene and transfers. Her diagnoses included Alzheimer's Disease, malnutrition, anxiety disorder, lack of coordination and parkinsonism. A Care Plan updated on 4/1/24, showed that she was on an antiplatelet and she had alterations in her neurological status related to tremors. She had the potential for mood problems related to Alzheimer's Disease, staff were to administer medication as ordered, and monitor for side effects and effectiveness. She was at risk for falls related to Alzheimer's tremors, and weakness. A Fall Incident report dated 3/30/24 at 4:30 PM, showed Staff A Licensed Practical Nurse (LPN) was called to the room of Resident #1 for a witnessed fall out of her recliner. The resident fell forward and hit her head on the floor and the side of her face hit the pedal of the wheelchair. Resident #1 sustained a skin tear to her right arm with scattered bruising, and a bump to the right side of her head. On 6/18/24 at 11:50 AM, Staff A, Licensed Practical Nurse (LPN) remembered the evening that Resident #1 fell from the recliner. She said Staff D and Staff G, Certified Nurse Aides (CNA), came and told her that the resident fell and had a hematoma and a couple of skin tears. When Staff A entered the room, the resident was in the recliner. She said the CNA's must've picked her up off the floor and put her in the chair before she had an opportunity to assess her. She asked them what happened, and they only said that she fell out of the chair and didn't know how it happened. Staff A then called the Director of Nursing (DON) and the Administrator. The resident was bleeding from the skin tear on her left arm, and from hematoma on her head. Staff A said that she had concerns with Staff D before this incident because she had observed that the CNA didn't know how to properly transfer residents. She also had concerns about Staff G and her job performance and reliability. She said that she had expressed those concerns to the DON previously. On 6/19/24 at 12:10 PM, Staff B, Registered Nurse (RN) said that it was unusual for Resident #1 to have a fall because she really wasn't moving around on her own or trying to get up without assistance. With a previous stay, the resident had been restless, and had many falls but with this stay (admit, 3/8/23) she wasn't able to move around much. She had a decrease in the Seroquel shortly before the fall, so they thought that may have been a factor. In a Counseling /Disciplinary Notice to Staff D, dated 4/1/24, it was documented that the CNA did not use a gait belt while transferring a resident and she did not notify the nurse immediately. Staff D was also counseled not to move a resident after a fall until the nurse could assess for injuries. The CNA was terminated from employment. On 6/20/24 at 7:40 AM, the DON said that Staff D told her she left the pedals on the wheelchair when she transferred Resident #1 from the wheel chair to the recliner. The resident was just on the edge of the seat of the recliner when she leaned forward and fell on her face on the floor. On 6/20/24 at 9:00 AM, the DON said that Staff D put the resident back into the chair by herself but did not report the fall to the nurse immediately. Staff G saw the scratch on the resident's face and she was the one that reported to the nurse. The DON acknowledged that the written warning for Staff D was related to the fall that Resident #1 had on 3/30/24. In a written statement by Staff D, the CNA indicated that Resident #1 was sitting half way in recliner, as she moved the wheel chair out of the way, the resident reached forward and fell , hitting her head on the floor and her cheek on the pedal of the wheel chair. 2) According to the MDS dated [DATE], Resident #4 had a BIMS score of 14 (intact cognitive ability). The resident was independent with toileting, dressing, transfers and walking. Her diagnosis included Cerebrovascular Accident (CVA), non-Alzheimer's Dementia, osteoporosis and chronic pain. A Care Plan updated on 3/1/24, showed the resident had acute confusion, staff were to monitor for signs and symptoms of delirium. She was at risk for communication problems related to a hearing deficit and wore a cochlear implant in her right ear. According to an Emergency Department (ED) report dated 3/24/24, Resident #4 presented to the ED on that date and was diagnosed with nondisplaced fracture of the fifth metatarsal bone in her right foot. Upon presentation, the resident reported that a large dog stepped on her foot and she was in severe pain. She was sent back to the facility with an orthopedic support shoe, and a follow up appointment with orthopedic doctor. A Nursing Note dated 3/24/24 at 2:59 PM, showed that Resident #4 had been walking through a doorway when a dog slid into her legs, causing her to twist her right foot and fall to the floor. She complained of pain to the right side of her foot. The doctor was called and she was sent to the ED. In an observation on 6/19/24 at 11:14 AM, Resident #4 was walking independently in the hallway and said hadn't had any falls. When asked about a dog, the resident said she loved to have dogs around the nursing home, makes it feel like home. On 6/19/24 at 11:15 AM, Staff H, Registered Nurse (RN) said that she witnessed the fall that Resident #4 had when she broke her toe. She said that a dog belonging to a staff person, had just come in from outside and his feet were probably a little wet. The dog slid into the resident as she was walking down the hallway. The dog was not on a leash and he hadn't been back to the facility since the incident. On 6/20/24 at 10:22 AM, Staff I, Certified Medication Aide (CMA) said that the dog that ran into Resident #4 was her German [NAME] and he would come to work with her the majority of her shifts. The dog was suspended after the incident. She said that it had been raining outside that day and, without her knowledge, a nurse let the dog out to be toileted while Staff I was in with a resident. When he came back inside, Resident #4 was in a doorway near the kitchen. He picked up speed coming around the corner, when he saw the resident in the doorway, he tried to slow down, but slid into her as she was in the middle of a step. She fell and rolled her foot. According to an undated facility policy titled: Pet Parent Responsibilities: staff or visitors were allowed to bring pets into the facility and must be responsible for pet's behavior the entire time. Staff were to keep pets with them and control them throughout the day. They would ensure that the pets behavior did not cause interference with daily activities. 3) The MDS dated [DATE], showed that Resident #3 had a BIMS score of 11 (moderate cognitive deficits). Sit to stand and toilet transfers were not attempted during the look-back period. The resident's diagnoses included Anemia, Renal insufficiency, anxiety, asthma and respiratory failure. The Care Plan updated on 1/16/24, showed Resident #3 had chronic bronchitis, staff were to monitor for difficulty breathing, and to remind the resident not to push beyond her endurance. Staff were to work with the Hospice team to keep the environment calm. Resident #3 had impaired cognitive function, dementia, impaired mobility, self-care performance deficit, weakness and she was totally dependent on staff for bathing /showering On 6/19/24 at 9:05 AM, Resident #3 was in bed with supplemental oxygen and noted to have a rattily cough, and an obvious skin tear on her elbow. She said that she had been at the end of her whirlpool bath one day, and as the water was draining, she slid off the seat. She had a seat belt on and there were 2 or 3 people in there trying to scoot her back up. She stated that she had pain in her knee and arm, with scratches on her knee and leg. She did not remember how she got out but she said that she loved to take a bath but hadn't used the whirlpool jets since that incident because she was afraid of it happening again. According to the Fall Incident Report dated 3/22/24 at 2:50 PM, Resident #3 slid almost all the way out of the whirlpool seat on that date. She had pain with movement and skin tears. The skin assessment showed a 2 centimeters (cm) x2 cm tear to her right forearm with bright red serosanguinous drainage. She had a 7 cm x 11.5 cm bruise on her left scapula, an abrasion to left ribs measured 1.5 cm x 11 cm, An abrasion to the left ribs 1.5 cm x 11 cm, and a bruise, 0.5 cm x 9 cm to the right ribs. On 6/19/24 at 4:30 PM, Staff J said that she gave Resident #3 a whirlpool bath the day that she slid from the chair. She said that the resident tended to slide down because she did not have much upper body strength. She said that she secured one plastic safety belt attached to the whirlpool chair, under the breast, like a gait belt but when the jets were turned on, the water shot up into the hole of the seat and the force of the water pushed the resident's bottom forward. When she drained the tub and opened the door, the resident slid down so far that Staff J could not pull her back up into the seat alone. By the time other staff could get there to help, the resident had half of her body on the floor. Her shoulders where on the seat and the belt was up into her arm pits. Staff J said that she was no longer the bath aide and chose to work the overnight shifts. On 6/19/24 at 4:40 PM, the DON demonstrated how the two straps were attached on the back of the seat in the whirlpool; one at the top and one at the bottom. When asked how the resident would be secured, she said that the straps were to be crossed over the residents to the opposite sides of the seat and attached to the back. A review of the orientation/training list, dated 2/24/22, for Staff J lacked specific training on giving whirlpool baths. On 6/20/24 at 7:21 AM, Staff K, Bath Aide, demonstrated that she secured the residents to the whirlpool seat with two straps, the bottom strap to go around the waist, and the top strap around the torso. When asked if she had training on the whirlpool and how to ensure the safety of the residents, she said that she had many years of experience and she knew how it worked. She did not know of a book or directions on proper use of the whirlpool or the straps. On 6/20/24 at 9:20 AM, the DON and the Administrator said that staff were taught how to use the safety straps in the whirlpool. She said that Resident #3 slid down the seat because she had a bowel movement while she was in the water and when the water was drained, the BM caused her to slide down. On 6/20/24 at 9:50 AM, the DON provided the training checklist for Staff K, and showed that she had been trained on the whirlpool bath. She said she that Staff K had been directed to watch the training video from the manufacturer. She pointed out that the video showed the straps crossed in front, but nowhere in the training did it say that the straps must be crossed. An Inservice Operation and Training Advantage Bath System video showed the straps attached to the whirlpool seat were crossed to the opposite side of the chair, under the resident's breast and attached on the back. 4) According to the MDS dated [DATE], Resident #5 had a BIMS score of 6 (severe cognitive deficit). She required substantial assistance with toileting hygiene, showers and dressing, and supervision with toilet transfer and sit to stand. Her diagnosis included non -Alzheimer's Dementia, Traumatic [NAME] Injury (TBI), anxiety, dysphagia, oral phase, and pain in left knee. The Care Plan updated on 1/7/24 showed that Resident #5 had alteration in neurological status, she was at risk for impaired thought processes related to depression and anxiety and staff were directed to give step by step instructions one at a time. The resident had self-care performance deficits, she had anxiety and was unsteadiness on her feet. Resident #5 ambulated independent with a walker and required maximum assistance to transfer on and off toilet. A Nursing Note dated 4/10/24 at 8:30 AM, showed the nurse was called to the resident's room and found her on the floor in front of toilet. Resident #5 did not have a gait belt on and was not wearing non-skid socks. The resident had been left unattended on the toilet and she stated that her back and legs were sore. On 6/19/24 at 3:16 pm, Staff E, LPN said that she was the nurse on duty when Resident #5 fell in the bathroom. She said that Staff G transferred Resident #5 to the toilet and the resident didn't have a gait belt on. Staff G left the resident on the toilet, which typically would have been okay, but she had left her there too long and the resident then tried to get up by herself, got weak, and fell . A Counseling/Disciplinary Notice dated 4/15/24 for Staff G showed that she had a written warning for leaving a resident unattended on toilet. The resident did not have proper footwear or gait belt on at the time. On 6/20/24 at 9:00 AM, the DON acknowledged that the fall from the toilet on 4/10/24 for Resident #5 was the reason for the written warning dated 4/15/24 for Staff G. The staff member had been terminated shortly thereafter. 5) According to the MDS dated [DATE], Resident #2 had a BIMS score of 10 (moderate cognitive deficits). She used a walker and wheelchair for mobility and required substantial assistance with lower body dressing and footwear. The resident required supervision/touch assistance with sit to stand, toilet transfer and sit to lying. She was frequently incontinent of urine, and occasionally incontinent of bowel. Her diagnosis included renal insufficiency, non-Alzheimer's dementia, unspecified fracture fifth lumbar vertebra and muscle weakness. The Care Plan showed Resident #2 had confusion/disorientation, weakness, and history of a vertebra and pelvic fractures. An addition to the Care Plan on 4/14/24 showed that staff were to have wheel chair behind resident when ambulating. On 5/31/24, staff were to place the walker further away from resident recliner out her sight so she doesn't try to reach for it. On 4/24/24 therapy directed to evaluate and treat, encourage the resident to use call light. The following was included on Incident Reports for Resident #2: a. On 4/14/25 at 11:15 AM the resident had a witnessed fall in the bathroom. b. On 4/24/24 at 9:56 AM The resident had an unwitnessed fall in her room and said that she was trying to get up on her own and hurt her wrist. c. On 5/31/24 at 4:15 PM Resident #2 was found on the floor stated that she was reaching for her walker and slid out of her chair onto the floor. On 6/18/24 at 3:59 PM Resident #2 was in the recliner with the walker in front of her within reach. The resident said that she did not need help with ambulating and she said that she hadn't had any falls. On 6/19/24 at 9:34 AM and unidentified Certified Nurse Aide (CNA) assisted Resident #2 to ambulate down the hallway toward her room. She did not have a wheel chair behind the resident and at 9:35 AM, the resident was in her recliner and her walker was out of reach by the television where the resident could see it. On 6/20/24 at 7:00 AM, Staff F, LPN said that Resident #2 has had many falls because she self-transfers and education really doesn't help with her because she thinks she can do it on her own. On 6/20/24 at 9:50 AM, the DON said that she thought the intervention to keep the walker out of sight went against the wishes of the family and didn't know if they were still implementing that. She thought the intervention to have wheel chair behind when ambulating had been discontinued. She said that they have struggled to find effective interventions for Resident #2 because the resident believed that she was able to ambulate and transfer on her own. An undated facility policy titled: Gait Belts, indicated that the gait belt must be used when transferring and ambulating resident who are not independent throughout the facility. An undated facility policy titled: Fall Management System showed that it was the policy of facility to provide each resident with appropriate assessment and intervention to prevent falls and to minimize complications if a fall occurs. An undated policy titled: Incidents and Accidents, showed that in the case of an accident, the resident would be provided immediate attention by a license nurse. Any staff witnessing an accident/incident render immediate assistance do not move the victim until he/she had been examined for possible injuries.

Based on observation, interview and record review the facility failed to follow interventions established in the care plan to prevent falls for 1 of 5 residents reviewed. Resident #2 had a history of falls and observations revealed that staff failed to implement two of those interventions. The facility reported a census of 38 residents Findings include. According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 10 (moderate cognitive deficits). She used a walker and wheelchair for mobility and required substantial assistance with lower body dressing and footwear. The resident required supervision/touch assistance with sit to stand, toilet transfer and sit to lying. She was frequently incontinent of urine, and occasionally incontinent of bowel. Her diagnoses included renal insufficiency, non-Alzheimer's dementia, unspecified fracture fifth lumbar vertebra and muscle weakness. The Care Plan showed Resident #2 had confusion/disorientation, weakness, and history of a vertebra and pelvic fractures. An addition to the Care Plan on 4/14/24 showed that staff were to have wheel chair behind resident when ambulating. On 5/31/24, staff were to place the walker further away from resident recliner out her sight so she doesn't try to reach for it. On 4/24/24 therapy directed to evaluate and treat, encourage the resident to use call light. The following was included in Incident Reports for Resident #2: a. On 4/14/24 at 11:15 AM the resident had a witnessed fall in the bathroom. b. On 4/24/24 at 9:56 AM The resident had an unwitnessed fall in her room and said that she was trying to get up on her own and hurt her wrist. c. On 5/31/24 at 4:15 PM Resident #2 was found on the floor stated that she was reaching for her walker and slid out of her chair onto the floor. On 6/18/24 at 3:59 PM Resident #2 was in the recliner with the walker in front of her within reach. The resident said that she did not need help with ambulating and she said that she hadn't had any falls. On 6/19/24 at 9:34 AM and unidentified Certified Nurse Aide (CNA) assisted Resident #2 to ambulate down the hallway toward her room. She did not have a wheel chair behind the resident and at 9:35 AM, the resident was in her recliner and her walker was out of reach by the television where the resident could see it. On 6/20/24 at 7:00 AM, Staff F, LPN said that Resident #2 has had many falls because she self-transfers and education really doesn't help with her because she thinks she can do it on her own. On 6/20/24 at 9:50 AM, the DON said that she thought the intervention to keep the walker out of sight went against the wishes of the family and didn't know if they were still implementing that. She thought the intervention to have wheel chair behind when ambulating had been discontinued. She said that they have struggled to find effective interventions for Resident #2 because the resident believed that she was able to ambulate and transfer on her own. According to the Job Description for a Certified Nurse Assistant, the primary purpose of the job was to provide each of resident with routine daily nursing care and services in accordance with the resident assessment and care plan and as directed by the supervisor.

Based on clinical record review, staff interview, and policy review the facility failed to provide proper transfer techniques while transferring a resident to prevent accidents for 1 of 3 residents (Resident #21) reviewed. The facility reported a census of 30 residents. Findings include: Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #21 to have a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. The MDS further revealed diagnosis of aphasia (loss of ability to understand or express speech), stroke, hemiplegia (paralysis of one side of the body), difficulty in walking, and need for assistance with personal care. Review of the Electronic Healthcare Record (EHR) tab titled, Progress Notes, revealed and entry from 11/1/23 at 1:44 PM by Staff A Licensed Practical Nurse (LPN) that she was summoned to Resident #21 ' s bathroom and found Resident #21 laying on her back on the floor, with the proper footwear on and no gait belt. Staff A further documented that Resident #21 did not have any visible injuries, but did show non-verbal cues of pain upon check of range of motion. This entry in the EHR then revealed that Resident #21 was transferred from the floor with a gait belt and two staff to her wheelchair. Resident #21 was then sent to the emergency room by ambulance for further evaluation and imaging. Review of Resident #21's Care Plan with a completion date of 10/26/23 revealed Resident #21 requires maximum assistance with transferring on and off of the toilet. During an interview on 3/26/24 at 11:19 AM with Staff A revealed this incident happened during a transfer with Staff B Certified Nurse Aide (CNA). Staff A revealed that Staff B had not utilized a gait belt during the transfer of Resident #21 who lost her footing and fell . Staff A then revealed that Staff B was working and this was her 1st or 2nd day on the job. Staff A stated when She went into Resident #21's bathroom she saw Resident #21 laying on her back with her feet facing the toilet. Staff A revealed she did complete an assessment, and did not witness any shortening of appendages, but could see with Resident #21's facial expressions she did have some pain as Resident # 21 is non-verbal. Staff A stated Resident #21 was transferred with a gait belt from the floor with two staff assisting Resident #21 to her wheelchair. Staff A then sent Resident #21 to the emergency room by ambulance for further evaluation and imaging. During an interview on 3/26/24 at 11:49 AM with Staff B revealed she had transferred Resident #21 to the toilet with a gait belt, and then removed the gait belt after Resident #21 had been positioned on the toilet. Staff B stated Resident #21 fell from the toilet to the floor. Staff B stated she paged over the pager for assistance with the Director of Nursing (DON), Staff A, and another CNA coming to assist. Staff B revealed an assessment was completed by Staff A, and Resident #21 was transferred from the floor with a gait belt to her wheelchair, and then sent to the ER for evaluation. Staff B stated that she did receive the gait belt policy. Staff B further revealed she was re-educated on gait belt use, and transfer techniques. Review of the emergency department notes dated 11/1/23 at 1:33 PM revealed a comment from the Advanced Registered Nurse Practitioner (ARNP) stating Resident #21 had right leg shortening with external rotation and pain with palpation. This document further showed x-ray results of the right hip and pelvis with findings read 11/1/23 at 3:09 PM by the Medical Doctor working at the outside emergency department revealing an acute fracture of the right femur neck with impaction with a plan for surgical repair. Review of Staff B's employee file revealed Staff B started working 10/19/23, and a skills checklist for CNA's skills were signed for Transfers from bed to chair, and Transfers to wheelchair completed 11/1/23. Staff B had signed proper use of gait belts skills 10/20/23. Another in-service training was completed 11/9/23 on gait belt use, and transfer techniques with Staff B signing this in-service. During an interview on 3/26/24 at 2:04 PM with the DON revealed her expectations would be for gait belts to be worn at all times when transferring, and to be kept on residents when toileting. During a follow up interview on 3/27/24 at 12:33 PM with Staff B revealed that after she took the gait belt off of Resident #21, she stepped just outside of the bathroom door to give Resident #21 privacy, and that is when Resident #21 fell off of the toilet. Staff B further stated she tried to catch Resident #21, but Resident #21 fell on her side on the floor. Review of an undated facility provided policy titled, Gait Belt Policy documented: a. Gait Belts must be used when transferring and ambulating residents who are not independent throughout the facility. The facility completed an inservice on 11/9/23 covering gait belt use and transfer techniques. The citation is considered a past non-compliance.

Based on resident and staff interviews and policy review the facility failed to have ready and reasonable access to personal funds upon request for 2 of 12 residents reviewed (Resident #25 and #30). The facility reported a census of 30. Findings Included: In an interview on 3/25/24 at 1:32 PM, Resident #30 stated, We can't get money when we want it because the person isn't here. We can plan for the weekend and they will leave money but only if we make plans. In an interview on 3/25/24 at 1:59 PM, Resident #25 stated, I haven't asked for money because that staff isn't here on the weekend. If I need money I would have to call my son. In an interview on 3/26/24 at 1:13 PM, the Operations Manager (OM) reported personal funds were available to residents after business hours and weekends by making predetermined arrangements with the social worker. In an interview on 3/26/24 at 2:47 PM, the Social Worker (SW) reported residents with the proper cognitive ability could use funds from their envelope located at the nurse ' s station. The SW explained residents could get up to $10 of their funds after business hours and on weekends. When asked if staff had the ability to obtain more than $10 upon a resident's request, the SW replied, Residents can ask for more ahead of time if needed. In an interview on 3/26/24 at 3:12 PM, when asked what happened if a resident requested more than $10 from personal funds after business hours or on the weekend, Staff C, Certified Nurses Assistant (CNA) replied, I guess they just wouldn't have any. After counting the funds in Resident #25 ' s envelope, Staff C reported a total of 29 cents. After counting the funds in Resident #30's envelope, Staff C reported a total of $7.75. In an interview on 3/26/24 at 3:01 PM, the Operations Manager (OM) reported the facility discussed different strategies to accommodate resident access to personal funds and efforts were still ongoing. In an interview on 3/27/24 at 8:35 AM, Staff D, Licensed Practical Nurse (LPN), reported some of the resident's had funds in an envelope at the nurses station. When asked what happened if a resident asked for more funds than available in their envelope, after business hours or on the weekend, Staff D replied, They could get it on Monday or ask ahead of time. After counting the funds in Resident #29's envelope, Staff D reported a total of 29 cents. After counting the funds in Resident #30's envelope, Staff D reported a total of $7.75 dollars. The Resident Funds policy dated June 2016 identified it is the policy of this facility to ensure resident funds maintained or managed by the facility are protected. PROCEDURE: Our Resident fund policies and procedures are uniformly applied to residents without regard to race, color, creed, national origin, age, sex, religion, handicap, or payment source. 1. The objectives of our resident fund policies are to: a. Provide a means for protecting resident funds managed by the facility b. Provide for an individual accounting of funds received and disbursed on the resident ' s behalf c. Provide a means for the resident to manage his/her funds or to have a guardian appointed to do so. d. Establish uniform guidelines to follow in implementing policies and procedures to protect the residents funds. 2. It shall be the responsibility of the Administrator to inform all residents, prior to or upon admission, of the facility ' s policy and procedure governing the management of resident funds. 3. Resident personal funds account does not exceed $2,000.00. 4. A separate record is maintained for each resident ' s personal funds account, including receipts and expenditure. 5. The resident ' s personal funds account is maintained separately from any account of the assisted living facility. 6. This community will provide a copy of the record of the resident ' s personal funds account to the resident or resident ' s representative at least once every three months. 7. This community will notify a resident ' s representative, family member, public fiduciary, or a trust officer if the manager determines the resident is incapable of handling financial affairs. 8. The community will ensure a resident receives at least 30 calendar days written notice before any increase in a fee or charge, except when a resident ' s need for assisted living services change, as documented in the resident ' s service plan.

Based on personnel file reviews, staff interviews, and policy reviews the facility failed to complete the Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry and Professional License information prior to employment for 2 of 5 employees reviewed (Staff E and Staff F). The facility census was 30. Findings include: On 3/26/24 Staff E, LPN's personnel file did not contain the Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry and Professional License information. Staff E was rehired on 7/18/22. On 3/26/24 Staff F, CNA ' s personnel file did not contain the Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry and Professional License information. Staff F was rehired on 10/11/22. On 3/26/24 at 2:19 PM the Business Office Manager completed an online verification via the facility ' s SING account for Staff E and F ' s background checks. The Business Office Manager stated the facility failed to complete background checks for both Staff E and Staff F prior to rehire. On 3/26/24 at 1:04 PM the Executive Director confirmed that Staff E and Staff F did not have background checks prior to rehire. The facility ' s Pre-Employment Investigations Iowa Policy revised January 2022 revealed the employee may not begin employment until the Accurate Background Check is passed and the SING Background Check is completed and approval for work is given. The facility ' s Abuse Prevention and Reporting Policy/Procedure revised 5/2007 revealed that pre-employment screening must be completed to ensure that potential employees do not have a disqualifying event and have the appropriate certification. The Executive Director on 03/28/24 at 8:31 AM stated the expectation was that the SING and background checks were to be completed before the staff work the floor.

Based on clinical record review, staff interview, and policy review the facility failed to obtain bed hold notifications for 1 of 3 residents (Residents #21) reviewed. The facility reported a census of 30. Findings include: Review of Resident #21 ' s Electronic Healthcare Record (EHR) revealed Resident #23 was in the hospital from 11/1/23 through 11/4/23. Further review of the EHR page titled, Clinical Census, confirmed the Resident was in the hospital on this date. Review for bed hold notification for Resident #21 revealed there was no bed hold form to review for the dates of hospitalization . During an interview 3/26/24 at 2:30 PM the Administrator revealed there was no bed hold for Resident #21 going to the hospital 11/1/23. During a follow up interview 3/26/24 at 2:47 PM with the Director of Nursing (DON) and the Administrator revealed their expectation would be to get a bed hold every time a resident is transferred or discharged from the facility. Review of a facility provided policy titled, Bed Hold, with a revision date of 11/2016 revealed: a. The resident, or the resident ' s representative, shall be informed, in writing, of their right to exercise the bed hold provision in the event of a transfer from the facility to a general acute care hospital.

Based on record review and interviews, the facility failed to utilize a safety belt in the whirlpool tub chair resulting in a fall causing a fractured neck for 1 out of 1 residents reviewed, (Resident #135). The resident later passed away the same day of the incident. The facility reported a census of 30 residents. A determination was made that the facility's noncompliance with one or more requirements of participation placed all residents in the facility in immediate jeopardy, beginning 2/20/21. On 9/23/21 at 12:15 PM, the Administrator was notified of the immediate jeopardy at F689 per phone call and given the IJ template at 12:25 PM. The immediate jeopardy was removed on 9/23/21 after the surveyor verified implementation of a removal plan.The scope and severity was lowered to an E. Findings include: A Minimum Data Set (MDS) assessment dated [DATE] for Resident #135 showed a Brief Interview for Mental Status score of 4 indicating severe cognitive impairment. The MDS showed the resident had diagnoses of dementia, lack of coordination, weakness, pneumonia, and [CONDITION(S)]. The MDS showed the resident required extensive assistance with two staff for transfers and extensive assistance with one staff for locomotion and bathing. Review of the Progress Note dated 2/20/21 at 10:57 AM stated Staff A Registered Nurse (RN) was called down to the shower room by Staff B Certified Nurse Aide ( CNA ) and observed the resident lying on the floor on his right side. The resident stated I am Okay. The facility called 911, and assessed the resident and completed a set a vitals. A skin tear was observed, covered and pressure applied. The Progress Note stated the resident was assisted into a wheelchair by 3 staff members and waited for the emergency medical technician (EMT) to arrive. Review of the Incident Report dated 2/20/21 stated Staff A RN was called down to the shower room by Staff B CNA where the resident was observed lying on the floor on his right side. Resident #135 received a bruise to the face and had a laceration to the top of the scalp. During interview on 9/22/21 at 12:33 PM Staff B CNA stated she was the bath aid on 2/20/21 and was to give Resident #135 a bath in the whirlpool. She stated the bath went fine and in the end the resident was sitting in the whirlpool chair that was swung out of the tub and was in low position. Staff B CNA stated the residents wheelchair was in the bath room located to the left of the resident. Staff B CNA stated she turned around and faced the sink to grab something and was within 2.5 to 3 feet of the resident with her back towards him. The sink had a mirror on the wall above it and stated she saw the resident fall forward in the mirror. Staff B CNA stated she immediately turned the call light on and then started to yell for help. Staff B CNA stated the resident was talking to her the entire time. Staff B CNA stated several staff members came along with the nurse and the resident was assessed for injury and then transferred to a wheelchair. Staff B CNA stated the ambulance crew came and resident was placed on a gurney and taken to the ER. Staff B CNA stated she was not using a bath chair safety belt at the time of the incident. During interview on 9/22/21 at 2:17 PM Staff A RN stated she was the nurse on duty and ran to help the resident in the shower room. Staff A RN stated that there was no whirlpool chair safety belt in the room at the time of the incident. During interview on 9/22/21 at 2:33 PM Staff C Interim Administrator stated she investigated the bath area the following morning after the incident and found a yellow and black whirlpool chair safety belt located in the bottom cabinet in the bathroom . Interview on 9/23/21 at 7:57 AM with Staff B CNA revealed she had worked at the facility for 4 years and was never trained on using a belt for the whirlpool chair. Staff B CNA stated she has never seen her co-workers use a belt when she has assisted with transfers in the whirlpool. Stated she looked for belts but could not find any and then two belts appeared after the incident. Interview on 9/23/21 at 8:27 AM with Staff D CNA revealed she has worked at the facility for about a year. She stated that she was never trained on using a belt with the whirlpool and that she has given several baths in that time and never used a whirlpool chair safety belt. Staff D CNA stated she looked through all the cabinets in the bathroom for items and never saw a belt. She stated two belts a yellow and a black one appeared after the incident. Interview on 9/23/21 at 8:40 AM with Staff E CNA revealed she was only trained on using belts with the whirlpool tub after the fall incident. She stated she had to ask a lot of questions as she learned how to give a whirlpool bath to the residents. Staff E CNA stated the safety belts were located in the cabinet in the whirlpool room. Interview on 9/23/21 at 8:31 AM with Resident #30 with a BIMS of 14 which indicates intact cognition, stated she does not ever remember a belt being used while in the whirlpool tub. Interview on 9/23/21at 12:54 PM with Staff A RN and Staff B CNA stated that normally around 15 out of the 30 residents prefer the use of the whirlpool tub over a shower. Review of the [NAME] Bathing Safe Operation and Maintenance manual for whirlpool model number 0-1L stated on page 4 that only personnel who have been thoroughly trained in the operation of the [NAME] Transfer Lift System should operate this equipment. Operation of this equipment by untrained personnel could result in injury to the operator or patient. On page 6 under Transferring from Bed to Bath, and/or lifting with Standard [NAME] Transfer System, step 7 stated, route the safety belt through the safety belt loops of the chair frame prior to placing the resident into the chair. Step 8 Transfer the resident into the [NAME] Transfer using the proper nursing transfer techniques. Bring the safety belt around the resident to the buckle connector. Step 9. All residents must always be securely safety belted at the waist when using any of the [NAME] Lift Systems. Ensure that the safety belt is routed through the loose buckle end as shown in the picture to the left. Pay close attention to the placement of the serrations of the buckle. If routed the opposite way, the safety belt will slip. Tighten safety belt by pulling on the loose end of the safety belt. Review of the Progress Note dated 2/20/21 at 1:41 PM stated the facility was notified by the hospital Resident #135 had sustained a fracture to his C1 and C2 which are the first two vertebrae at the top of the cervical spine and a fracture to his nose. Hospital staff stated they were transferring the resident to another hospital to have a surgeon evaluate. Review of the facilities investigation report showed the facility was notified Resident #135 passed away on 2/20/21 at 10:22 PM. Review of the Counseling/Disciplinary Notice dated 2/20/21 for Staff B CNA lacked any documentation Staff B CNA was counseled on ensuring residents were properly placed in the whirlpool tub chair with the safety belt securely belted around the resident while whirlpool chair was being used. Review of the documented showed Staff B CNA did not sign the Counseling/Disciplinary Notice until 3/3/21. Abatement Plan: 1. On 9/23/21 the whirlpool tub was immediately placed out of service. 2. On 9/23/21 the whirlpool room door lock code was changed to a new pin, with only the Administrator knowing the new pin. 3. On 9/23/21 the facility updated their policy and procedures related to the use of the whirlpool to include the use of the safety belt. 4. A new whirlpool tub has been purchased. 5. All nursing staff will be provided training prior to use of the new whirlpool once installed. 6. CNA orientation skills checklist updated to include proper use of safety belt with whirlpool baths. The immediate jeopardy was removed on 9/23/21 after the surveyor verified implementation of the removal plan.The scope and severity was lowered to an E.

Based on observations, record review, policy and interviews, the facility failed to provide adequate supervision to protect 2 of 2 residents at risk for elopement. On [DATE] Resident #1 eloped from the facility without staff's knowledge and walked a few blocks away. An off duty employee identified Resident #1 and alerted the facility staff. The facility placed a Wander Guard bracelet on the resident approximately a ½ (half) hour before Resident #1 eloped, however the alarm did not activate/sound. Record review and observation revealed Resident #2's Wander Guard bracelet not consistently activating when tested . The findings constitute an immediate jeopardy to residents health and safety. The facility reported a census of 29 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] noted Resident #1 had been admitted on [DATE] from another nursing home. The MDS listed anxiety, schizophrenia, and amnesia as [DIAGNOSES REDACTED]. The BIMS (brief interview for mental status) assessment indicated Resident #1 had severe cognitive impairment indicated by the score of 4 out of 15. The MDS also noted that Resident #1 walked independently without the use of assistive devices. The Care Plan identified Resident #1 at risk for falls due to psychoactive drug use on [DATE], and staff should anticipate and meet his/her needs. The Care Plan revealed Resident #1 at risk for impaired cognitive functioning, dementia or thought processes related to psychoactive drug use and a [DIAGNOSES REDACTED]. On [DATE] Resident #1's care plan identified he/she at risk for elopement and attempts to go out the door. Staff completed an elopement risk assessment and placed a Wander Guard bracelet to the resident's right wrist. The initial Elopement/Wandering Evaluation dated [DATE] identified Resident #1 as high risk indicated by the score of 11. A progress note dated [DATE] at 1:41 p.m. noted Resident #1 continually talked about the need to go see a friend that lived 3 blocks from Fareway. According to the document, Resident #1 attempted to go out the east door, but staff intervened. An elopement assessment had been completed and a Wander Guard applied to his/her right wrist. A progress note dated [DATE] at 1:45 p.m. noted the frigid temperatures had been discussed with Resident #1 and the facility could assist in trying to arrange a meeting with his/her friend. The Elopement/Wandering Evaluation dated [DATE] identified Resident #1 as high risk indicated by the score of 14. A progress note dated [DATE] at 2:08 p.m. noted as the DON (Director of Nursing) was about to leave the parking lot, an off duty employee was pulling into the parking lot saying Resident #1 had been seen walking down the sidewalk. The DON drove to the location of Resident #1 and the resident got into her vehicle. The note identified the Resident stated he/she intended to walk to a friend's house that lived up the street. The DON reminded the resident how they just discussed arranging a meeting to see the friend when Resident #1 said I know, but I want to see them. The noted revealed the resident wore sweatpants, a sweatshirt, winter coat, shoes, socks and a cap on his/her head. When asked, the resident said he/she exited the facility through the door they use when they go out to smoke. A progress note dated [DATE] at 2:15 p.m. noted the Administrator walked with Resident #1 to the doors; and the Wander Guard alarm sounded each time. A progress note dated [DATE] at 2:26 p.m. noted the outside temperature had been sunny, 31 degrees with 5 miles per hour (mph) winds at the time of elopement. A progress note dated [DATE] at 8:08 p.m. noted Resident #1 attempted to exit the facility (independently) once during the shift and staff intervened. A progress note dated [DATE] at 5:04 a.m. noted Resident #1 had been checked on frequently. The resident had been sleeping on the couch by the birds and (previously) sitting at the table in the south hallway. A progress note dated [DATE] at 11:42 a.m. noted Resident #1 had been pacing the halls. A progress note dated [DATE] at 7:56 p.m. noted Resident #1 attempted to exit the facility twice during the shift. The Wander Guard sounded and staff intervened. A progress note dated [DATE] at 7:16 a.m. noted Resident #1 went outside last evening. Alarm sounded. Returned inside with staff without incident. An interview on [DATE] at 8:15 a.m. with Staff C, RN, revealed she made the entry on [DATE] at 7:16 a.m. that read Resident #1 went outside last evening; alarm sounded. Returned inside with staff without incident. The RN said the alarm went off so she radioed for everyone to do a head count. She stated that she thought both the Wander Guard alarm and the door alarm sounded, but could not be sure. Staff C said a CNA in the break room radioed back that she saw Resident #1 in the front parking lot. Staff C reported because of his/her location, the RN said she believed the resident exited the front door. The RN said they brought the resident in without incident. Staff C said the resident frequently asked to go out and smoke, but he/she had never attempted to exit. Besides the recent elopement, the RN said she did not know any other elopements. A progress note dated [DATE] at 3:47 p.m. noted Resident #1wandered into another resident's room and urinated on the floor. Resident #1 attempted to exit the facility twice at that point in the shift. A progress note dated [DATE] at 5:47 p.m. noted the nurse had been in another resident's room when she heard the door alarm and the Wander Guard alarm activate. She looked out the window and saw Resident #1 outside the front door. The nurse ran outside. She told the resident he/she had to let someone know before going outside and The resident replied Why, the alarm went off like it was supposed to. A progress note dated [DATE] at 7:00 p.m. noted that Resident #1 went outside when he/she saw another staff member out there. Easily redirected back into the facility. An interview on [DATE] at 10:40 a.m. with Resident #1 revealed he/she exited the facility through the alarmed door at the end of the east hall, not the smoking door the facility thought he/she used. The resident stated it happened about 10:00 a.m. 2. The MDS assessment dated [DATE] noted Resident #2 had been admitted on [DATE] from another nursing home. The MDS listed dementia, depression, psychotic disorder and tobacco use as [DIAGNOSES REDACTED]. The BIMS assessment indicated Resident #2 had severe cognitive impairment indicated by the score of 8 out of 15. The MDS also noted that Resident #2 walked independently without the use of assistive devices. The initial Elopement/Wandering Evaluation dated [DATE] identified Resident #2 as low risk indicated by the score of 9. The Care Plan identified Resident #2 as being at risk for falls due to psychoactive drug use on [DATE], and staff should anticipate and meet his/her needs. A revision dated [DATE] identified Resident #2 as a wanderer at risk for elopement related to impaired safety awareness. A Wander Guard bracelet had been applied to the resident. A progress note dated [DATE] at 4:41 p.m. noted that Resident #2 had a Wander Guard bracelet applied to the right wrist due to continued wandering in the hallways and consistently looking for a cigarette or wanting to go smoke. A progress note dated [DATE] at 7:55 p.m. noted that Resident #2 attempted to exit the facility once during the shift. A progress note dated [DATE] at 11:03 p.m. and authored by Staff C noted Wander Guard to right wrist. Check every shift for wandering. Alarm does not go off. On [DATE] at 8:15 a.m. Staff C, Registered Nurse was asked about the entry made on [DATE] at 11:03 p.m. for Resident #2, which read Check every shift for wandering, WG (Wander Guard) to right wrist, alarm does not go off, she said when the resident walked by the door, the bracelet usually activated the alarm, but this time it did not. The RN said she did not report it. 3. While testing alarms on [DATE] at 8:10 a.m. at the end of the east hall where Residents #1 and Resident #2 reside, Staff A, Housekeeper stated the alarm on the door leading outside had been mounted temporarily about a month before because the other one had broken. The alarm sounded only at that location whenever the door opened, unless someone intentionally used the key to disable it. The same key was used to silence the alarm if it had been activated. The key had been kept above a frame mounted on the wall. The alarm had been mounted right above the door, and the switch was accessible to anyone that wanted to use it. A switch on the alarm could be manually changed to delay the activation for 15 seconds after the door opened. Observation showed a door leading into the break room at the opposite end of the east hall had been equipped with a door alarm. The alarm could be disabled by pushing a button (located about 3 feet from the floor) so the alarm would not sound once the door opened. Observation inside the break room, showed a door that led outside had been equipped with an alarm mounted at the top of the door. The alarm sounded only at that location anytime the door opened, and shut off as soon as the door closed with the automatic closer. At a later time, the surveyor asked Staff F, CNA to activate the alarm inside the break room as the surveyor stood in the nearby hallway to listen for the alarm. The door alarm could barely be heard when standing next to the door that led into the break room from the hallway. A South Hall exit door that led outside had been equipped with an alarm that sounded at that location only. While testing alarms with Staff A present during an observation on [DATE] at 10:22 a.m., the Wander Guard alarm failed to activate when Resident #2 walked through the door. Resident #2 had been wearing a winter coat and had on a Wander Guard bracelet. As a follow up, Resident #2 walked through the door again wearing the same coat and this time the alarm activated. Staff A said she did not understand why it failed the first time. Interviews: An interview on [DATE] at 12:00 p.m. with Staff D, Laundry, revealed she had gotten off work about 10:00 a.m. on [DATE]. She said she had driven by the facility about 1:00 p.m. or 1:30 p.m. that afternoon and saw Resident #1 about ½ block west of Fareway on Bluff Street. She said the resident had on a brown corduroy coat, sweat pants, stocking cap and shoes. To ensure the resident's identity, she turned around and drove past him/her again. According to Staff D, she drove to the facility and told the DON. Staff D said they each drove separate vehicles, and she left when she saw the resident get into the DON's van. According to Staff D, whenever she had a problem with a Wander Guard not being activated by a bracelet, she told the DON or the Administrator. Staff D said that sometimes she takes residents out to smoke at 8:00 a.m. to help the CNAs (certified nursing assistant). She said the alarms have not always gone off. Staff D said she believed one of two things caused the alarm to fail. According to her, either heavy winter coats or another person walking between a resident's bracelet and the alarm acted as a barrier. Staff D said now nurses roll up the resident's coat sleeves to prevent the coat from obstructing the signal. Staff D said she did not trust the alarm system as 100% reliable. She said she always made sure to keep her eyes on the residents. An interview on [DATE] at 2:20 p.m. with Staff B, LPN (Licensed Practical Nurse) revealed the facility put the Wander Guard bracelet on Resident #1 the morning he/she eloped. According to the LPN, Resident #1 talked about wanting to visit a friend in Cherokee since he/she had been admitted to the facility. Staff B said they tried to appease him/her by saying they would arrange that sometime. After telling him/her the prior, he/she went about his/her routine of walking around the facility. Staff B said the resident continued to talk about visiting his/her friend. The LPN said at some point that afternoon before he/she eloped, he/she came to the nurse's station and asked her a couple of questions. She referred him/her to the DON's office because of the nature of the question. Staff B said Resident #1 left the nurse's station and headed towards the DON's office and then did not see him/her again until the resident returned to the facility with the DON after the elopement. Staff B said she saw the resident headed toward the DON's office, so she assumed he/she went there. The LPN said shortly after she saw him/her, the DON approached her and said she was leaving for the day. Staff B stated she called the DON a few minutes after she left because she had a question. Once Staff B asked the question, the DON told her that should be the least of her worries. The DON asked Staff B if she knew the location of Resident #1. Staff B said she told the DON she had just seen the resident and sent him/her to her office before she left the building. The DON informed Staff B Resident #1 was down by the school and she would be bringing him/her back. Staff B said they returned minutes later. Staff B said this was the first time she heard of problems with alarms not being activated by resident's that wore bracelets. An interview on [DATE] at 8:30 a.m. with Staff E (Registered Nurse), RN revealed she worked as an aide from 6 a.m. to 2 p.m. the day Resident #1 eloped ([DATE]). According to Staff E, the resident had been asking to walk downtown between 10:00 a.m. and 1:00 p.m. Staff E said she told him/her it was cold outside and suggested calling his/her friend instead. Staff E said she tried to utilize interventions in an effort to redirect him/her. She said she tried an activity, having him/her up by the nurses' station to watch a movie. She said he/she constantly paced the halls looking for his/her room. Staff E said she believed Resident #1 actually forgot where his/her room was located. She said she assessed him/her every day since the elopement. She said they use a box (a small electronic device) to check his/her Wander Guard bracelet every shift. The RN said a green light comes on when it functions properly and a red light comes on if not. The nurse said they replace it if the red light comes on or when it reaches its expiration date. The housekeeper uses the same box to check the alarms at the doors. According to the RN, Resident #1 pushed the button to disable the door alarm at the smoking door and walked out the 1st glass door, but not through the 2nd door to the outside. He/She was easily redirected back inside. Since he/she demonstrated the ability to disable the door alarm and expressed an interest in walking somewhere, the RN told the DON they needed to apply a bracelet. The RN said she took him/her into the DON's office and assessed whether or not the bracelet should be applied. The results indicated he/she needed a bracelet. The RN said she informed Staff B, the on duty nurse. The RN said Staff B was busy, so she did it herself. Staff E activated the bracelet, and used the box to verify that it worked properly. Staff E said she did not check the bracelet against the Wander Guard alarm. The RN said that shortly after Resident #1 had been admitted ; he/she tried to push the door open to go out. She said he/she had been used to going out to smoke anytime he/she wanted at the facility he/she came from. She said it has been difficult for Resident #1 and #2 to adjust to smoking at specified times only. According to the RN, the resident's bracelet activated the alarm to sound when he/she returned after eloping. The RN said she checked it with the box again, and it tested OK. The RN said Resident #1 had a big dark green or brown heavy coat on when he/she walked in. She stated he/she also had on long pants, a shirt, socks, shoes and a baseball hat. She said the cap did not cover his/her ears. The RN said the admitting nurse does the initial elopement evaluation. According to the RN, every new admission should be evaluated. She stated that a good nurse should apply a bracelet when a newly admitted resident fails the elopement assessment. An interview on [DATE] at 1:10 p.m. with the Maintenance Supervisor revealed he found a broken wire on the far east door so he replaced it with a temporary alarm a couple weeks ago. He stated the alarm sounded just at that location, nowhere else in the building. He worked at the facility for about a year and the break room alarm system was configured the way it currently is. The Maintenance Supervisor reported he checked the schematic and figured out whoever wired the Wander Guard alarm at the smoking door had 3 wires in the wrong place. He believed that explained why the alarm failed on occasion An interview on [DATE] at 8:05 a.m. and subsequent interviews with the DON revealed what she knew about Resident #1's elopement and the facility's alarm system. The DON said Resident #1 had been seen pushing the button to silence door alarms. The DON reported they made the decision to put a Wander Guard bracelet on him/her shortly before he/she eloped (on [DATE]). According to the DON, the resident exited the smoking door on the east hall where Residents #1 and #2 reside. The DON stated apparently Resident #1 had pushed the button to silence the door alarm, and the Wander Guard bracelet he/she wore had not activated the Wander Guard alarm when he/she exited because the resident had been wearing a corduroy coat that apparently acted as a barrier that caused the alarm to fail. The DON said she had not known Resident #1 eloped until an off duty employee pulled into the parking lot as she was about to leave for the day. She said Staff D, Laundry Aide informed her she had seen the resident walking on the sidewalk, about 1 ½ blocks near the Fareway. The DON said she drove to Resident #1 and he/she got into her vehicle. She said once she returned Resident #1 to the facility, they checked the Wander Guard alarm and bracelet he/she had on and it did not sound while he/she had his/her coat on. The DON stated but the alarm did sound when the resident was not wearing his/her coat. The DON said they had maintenance change the sensitivity on the alarm to compensate for the heavy coat. She said they did an initial elopement assessment when the resident was admitted from another facility. The DON said he/she scored an 11, which indicated a medium to high risk of elopement. When asked why Resident #1 did not wear a Wander Guard bracelet with a score of 11 and Resident #2 did with a score of 9, she stated up until that point, they used discretion on an individual basis according to their observations and not necessarily based on scores. She said Resident #2 demonstrated behaviors that warranted a more immediate need for a bracelet. During another interview, the DON stated the records that followed Resident #1 from the facility where he/she previously resided were incomplete and she did not know if the resident had a history of [REDACTED]. The DON stated she did not have any observations or knowledge that warranted the decision to apply a Wander Guard (WG) bracelet to the resident. This surveyor also informed the DON that interviews also confirmed that the Wander Guard alarm on the smoking door had failed on other occasions before Resident #1 eloped. The DON said nobody shared that information with her before the day he/she eloped. She said she expected staff to relay that type of information. A document titled Code Alert System Quote for a new alarm system had been written for the facility on [DATE] and expired on [DATE]. A document titled Code Alert System Quote for a new alarm system had been written for the facility on [DATE] and will expire on [DATE]. An interview on [DATE] at 10:45 a.m. with the Administrator revealed she expected the Wander Guard alarm system to work 100% of the time. She said she had consulted the appropriate people to inquire about updating the whole alarm system. She said Wander Guard had been contacted about a replacement part last October or November, at which time they had been informed the facility's system would become obsolete. According to the Administrator, they asked for a quote at that time. She stated after Resident #1 eloped on [DATE], the system's sensitivity had been adjusted when they realized the alarm failed to activate. The Administrator said she thought they resolved the problem by making that adjustment, and did not need to upgrade the system yet. On [DATE] the Administrator said they ordered a new alarm system that will be installed within 5 business days. The facility revised their Elopement Policy on ,[DATE]/ and instructed staff to complete an assessment of wandering residents. The policy indicated residents with a history of behaviors, including wandering, will be obtained prior to admission. The policy noted that an alarm bracelet may be placed on the resident to audibly alert staff of attempts by the resident to exit (the building). The protocol indicated an alarm bracelet may be used for residents that had been considered at higher risk based on previous elopements. The policy indicated staff would implement frequent checks/monitoring as appropriate. The policy indicated residents with an exacerbation of wandering or exit seeking behaviors that continue, staff will provide 1:1 supervision until the physician can assess the resident for causes and or alternative placement is determined. The policy indicated when a door alarms are de-activated or turned off, staff will perform immediate head count to ensure all residents are accounted for and (notify) the unit nurse will/DON/Administrator will investigate how the door alarm de-activated. The facility abated the IJ on February 28, 2017 when they completed the following: a). Replaced Wander Guard bracelets for all residents (two). b). The Wander Guard system will be tested daily per shift by the charge nurse (or designee) to validate the equipment is consistently functioning as intended. c). Secondary alarms were purchased and placed on all (exit) doors. d). Doors with codes to disable were replacement with alarm has been purchased and installed with the key maintained at the nurse's station. e). All residents identified at risk for elopement continue to be checked every 30 minutes and document on the observation flow sheet. f). The Wander Guard equipment, including bracket and detections units at the door will be checked every shift by the Charge Nurse with bracelet documentation complete on the TAR (Treatment Administration Record) and door checks documented on the flow sheet. g). All residents at risk for wandering or elopement will be frequently checked with documentation noted on the flow sheet. h). The facility re-assess residents' at risk for elopement/wandering for implementation of Wander Guards as needed. All staff were educated on the use and management of the Wander Guard equipment to minimize the elopement risk and maximize resident safety (all information listed above). The training consisted of new door alarms, frequent checks, door checks and the Wander Guard policy. Staff were trained on [DATE], and continued training on [DATE]. These actions lowered the scope and severity of the IJ to a D level with the need for ongoing monitoring to maintain residents safety. The facility purchased a wandering management system to replace the current system entirely. On [DATE] the facility informed DIA the new system was now in place.

Based on observation, record review, and staff interview the facility failed to provide adequate supervision and implement care plan interventions to prevent injuries for one of (1) of ten (10) residents reviewed. Staff A left Resident #11 turned to the side holding the grab bar while lying on an air mattress. While Staff A was in the bathroom, the resident slid from the bed suffering a tibial fracture. Staff A did not use a second staff person to assist with providing care to Resident #11 as the kardex care plan directed staff to. The resident also sustained repeated scrapes to the torso due to sheepskin not in place on the wheelchair. The facility reported a census of 31 residents. The facility further failed to secure hazardous chemicals from 9 cognitively impaired, independently mobile residents. The facility reported a census of 31 residents. Findings include: 1. A Minimum Data Set (MDS) with an assessment reference date of 6/5/13 assessed Resident #11 with a brief interview for mental status (BIMS) score of 11 ( a score of 11 conveys moderate cognitive impairments). The resident required the assistance of two staff with bed mobility, toileting and personal hygiene. The assessment identified Resident #11 did not walk (non-ambulatory). The resident had functional range of motion limitations of one side of the upper extremities and both lower extremities. The assessment identified the resident frequently incontinent of bowel and bladder. The resident had [DIAGNOSES REDACTED]. The resident did not have falls identified since the previous assessment. Progress notes, dated 7/6/13 at 5:51 a.m. revealed a nurse aide summoned the nurse to the room. The resident was on his/her right side on the floor in front of the bed. Staff did not observe injury and the resident denied pain. Progress notes dated 7/6/13 at 1:39 p.m. revealed staff assessed a red scraped area to the left knee measuring 3 centimeters (cm.) by 1.3 cm. The resident complained of pain in the right shoulder. Staff sent the resident to the emergency room (ER). On the same date at 4:29 p.m., the resident returned to the facility. Progress notes identified the resident with a right tibia fracture. The resident returned with wearing a splint with ace wrap. Staff administered Tylenol (analgesic) for pain. An emergency physician record undated identified the resident's chief complaint as fall injury to right lower leg and right shoulder. The resident fell last night and the resident fell from bed. The resident had mild pain in the right leg and shoulder. The impression was "spiral fracture of right lower leg". A major injury form dated 7/6/13 at 6:40 p.m. identified the injury as NOT a major injury. The resident's previous functional ability listed on the major injury form was two staff assist with transfers and ADLs (activities of daily living). An x-ray dated 7/6/13 identified the clinical indication for the x-ray as "history of pain post fall." The x-ray identified an oblique fracture of the distal tibia with 15 degrees of posterior angulation and 2 millimeters (mm) of separation. On 7/8/13 the resident saw the orthopedic physician, who diagnosed the injury as "tibial fracture". On 8/5/14 an x-ray showed a healing distal tibial comminuted oblique spiral fracture. A narrative summary regarding the incident, undated identified Staff A (nurse aide) changed the resident's brief while the resident laid in bed. Staff A placed the new brief under the resident's right side first, then turned the resident on the right side to get the new brief fully under the resident. The resident then began having an involuntary bowel movement. Staff A stated the resident held onto the grab bar with his/her right hand and while the resident held his/her(self) in that position, Staff A went into the resident's bathroom to get a washcloth and heard a noise. Staff then observed the resident lying on the right side on the floor beside his/her bed. Staff A notified the charge nurse (Staff B licensed practical nurse) who arrived and assessed the resident. Staff B did not identify injury. Staff returned the resident to bed via Hoyer lift sling. The resident used a low air mattress on the bed. On 7/6/13 at 1:39 p.m. Staff C (registered nurse) assessed swelling and bruising to the right ankle which measured 3.6 centimeters (cm.) by 3.2 cm. The resident also complained of right shoulder pain. The resident transferred to the ER for examination and x-rays. On 7/8/13 at 10:45 a.m. the resident saw the orthopedic surgeon regarding the tibial fracture. At 1:30 p.m., the physician performed a closed reduction of the fracture and the resident returned to the facility with a cast on the right lower leg. Staff Interviews: Staff Working 7/6/13 when the incident occurred: On 4/2/14 at 2:03 p.m. Staff A (nurse aide) stated she was the only nurse aide working and she informed the nurse she planned to get Resident #11 up. Staff A stated that was one of her first nights working alone. The resident told Staff A he/she could hold themselves over by holding the grab bar and Staff A stated she believed the resident. Staff A then left the resident unattended lying on his/her side holding the grab bar on the low air mattress and went into the resident's bathroom to get a washcloth. Staff A stated the bed was in high because she was working with the resident. While in the bathroom, Staff A heard a noise and when she looked she saw Staff A on the floor. Staff A stated no one told her the resident was a two person assist. The nurse aide that trained Staff A performed cares on the resident alone. Staff A stated she was performing peri care when the incident occurred and just left to get wash cloths. The surveyor attempted to contact Staff B (licensed practical nurse) during the investigation and was not able to contact her. Other Staff: On 4/2/14 at 2:50 p.m. the former Administrator stated she investigated the incident. The conclusion was that the resident used a special air mattress. The resident had a spasm which was a common occurrence due to his/her [DIAGNOSES REDACTED]. The former Administrator stated she laid on the bed and a wrong shift made her fall out because of the air mattress. She stated the level of air was not correct, causing the fall out of bed. She stated the resident told Staff A that he/she would be fine but he/she had a spasm and rolled out. She stated the resident was a two person assist for transfers and one staff when in bed. When the surveyor informed her the kardex care plan indicated staff should use two for peri care and activities of daily living, the former Administrator stated "OK". On 3/31/14 at 12:20 p.m. Staff C (registered nurse) stated she heard the resident fell in report the morning of 7/6/13. Staff C sent the resident to the ER because something didn't look right. She observed swelling of the lower leg. She stated when the fall occurred the resident was leaned on the side of the bed and fell out. The facility did an internal investigation. She stated Staff A was a brand new nurse aide. Staff B (charge nurse when incident occurred) quit right after the incident occurred. Staff C stated the resident can ' t hold him/her(self) over due to his/her [DIAGNOSES REDACTED]. The resident ended up going to a specialist and got a splint. On 4/1/14 at 4:10 p.m. Staff A17 (nurse aide) stated the resident was and still is a two person assist at all times. Staff A17 knew this because that is what the care plan said. Staff A17 stated she would never leave the resident alone laying on his/her side on her air mattress bed. She stated she knew that by using her common sense. The resident could fall. On 4/1/14 at 3:48 p.m., Staff A12 (nurse aide) stated staff always used two when caring for the resident. It is in the care plan in the Kiosk. Staff A12 stated she did not know of any staff that left the resident unattended lying on his/her side on the air mattress bed. She stated the resident needs someone with him/her. On 4/1/14 at 3:15 p.m. Staff A13 (nurse aide) stated at the time of the incident and now, two staff are required to provide activities of daily living (ADLs) for the resident. She stated it is hard to roll the resident with one person and two staff are needed to clean the resident properly. She knew how many staff to use by asking the charge nurse. She stated it was not Ok to leave the resident on his/her side unattended in bed for safety reasons. She did not know if that information was written anywhere. Care Plan: The Kardex care plan in place when the incident occurred dated 6/12/13 directed staff to use two staff with peri care and needed monitoring/reminding/assistance with turning and repositioning. Care Guide: The care guide in place on 7/6/13 identified the resident required assistance with bed mobility, dressing, bathing and toileting. The care guide did not identify how many staff should provide assistance. On 4/1/14 the interim Director of Nursing (DON) stated staff used care guides when the 7/6/13 incident occurred. They switched to using the Kiosk computer care plan for nurse aides in August or September 2013. When staff are hired, the interim DON takes staff through the steps of how to use the Kiosk care plan guide. Observation showed, on 4/1/14 at 7:10 a.m. and 7:25 a.m., Staff J (nurse aide) provide morning care and dress the resident. Staff J provided the cares alone. Staff J also provided range of motion to the resident. When Staff J stretched the extremities, the resident grimaced with pain. Scrape on Torso Incidents: Progress notes dated 1/23/14 at 4:27 p.m. revealed staff noted an open area on Resident #11's right side where the resident leans up against the wheelchair. The uppermost area measured 4.2 centimeters (cm.) by 2 cm. red in color and the lower area measured 3.9 cm. by 2.2 cm. and also looked red in color. The resident stated he/she did not know the area was there. Staff applied sheepskin to the side where resident leans up against the wheelchair. A facsimile (fax) to the physician, dated 1/29/14 identified staff placed a Tegaderm (transparent dressing) to the resident's right torso abrasions. The fax identified staff would place an ABD pad and wool on the wheel chair for protection. On 3/28/14 at 8:51 a.m. progress notes documented by Staff C (registered nurse) revealed the right torso abrasion reopened. Staff noted the resident leaned up against the right lateral glide of the wheelchair. A skin alteration form dated 3/28/14 identified the abrasion area measured 4.9 cm. by 1.1 cm. It did not identify whether the sheepskin wool was in place when the area reopened. On 4/2/14 at 12:25 p.m. Staff C (registered nurse) stated the sheepskin wool was not in place when the right torso abrasion reopened. Review of the care plan dated 3/12/14 did not identify an intervention for sheepskin wool to the wheelchair. Observation showed, on 3/31/14 at 1:30 p.m. sheepskin padding in place on the right side of the resident's wheelchair. 2. During Environmental Tour of the facility open therapy room on 4/2/14 at 1:06 p.m. observation revealed the lower shelf of an unlocked cabinet contained a canister of Betco Disinfectant Quat-Stat. The Material Safety Data Sheet for the disinfectant identified the substance as combustible, corrosive and may cause burns. The facility reported 9 residents with cognitive impairment that remained independent in mobility either by ambulation or in a wheelchair.