Every finding on record at Cedar Falls Health Care Center

Based on document review, time card review and staff interviews, the facility failed to ensure a Registered Nurse (RN) was in the facility for eight consecutive hours seven days a week. The facility reported a census of 49 residents. Findings include:A review of the May 2026 and July 2026 Nursing Schedules and Employee Time Detail Reports (Timecards) revealed the following:5/24/26Staff D, Licensed Practical Nurse (LPN), scheduled to work from 5:00 AM to 5:00 PM, clocked in at 4:57 AM and out at 5:31 PM per a Time Detail Report.Staff E, LPN, scheduled to work 5:00 PM to 5:00 AM, worked 4:55 PM to 5:26 AM on 5/25/26 per an invoice.The schedule lacked an RN7/5/26Staff D scheduled to work 5:00 AM to 5:00 PM, clocked in at 5:02 AM and out at 5:20 PM per the Time Detail Report.Staff F, LPN, clocked in at 5:00 PM and out at 5:19 AM on 7/6/26 per the Time Detail Report.The schedule lacked an RN On 7/27/26 at 11:30 AM the Director of Nursing (DON) reported an inability to hire nurses. On 7/29/26 at 10:32 AM the Administrator reported a staffing agency doesn't send notification when an RN calls off shift. The Administrator reported taking available nursing coverage at the last minute. The Administrator reported lacking proof from the staffing agency showing the RN called off shifts, but noted attempting to ensure 8 hours of RN coverage. The Administrator verified the facility lacked RN coverage on 5/24/26 and 7/5/26. On 7/29/26 a record review of the Daily Census Report dated 5/24/26 showed a census of 49 residents. A review of the Daily Census Report dated 7/5/26 showed a census of 50 residents, with 3 residents receiving Medicare Skilled services (short-term rehabilitative or skilled nursing care).

Based on observation, record review, and interview, the facility failed to provide timely toileting assistance and incontinence care to prevent Resident #6 from remaining in a wet brief and sitting on a urine-soaked wheelchair cushion for 1 of 1 resident (Resident #6) reviewed for incontinence care. The facility reported a census of 49. Findings include:Resident #6's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #6 required maximum assistance for toileting hygiene and toileting transfers. Resident #6 experienced occasional urinary incontinence (loss of bladder control) and frequent bowel incontinence (loss of bowel control). Diagnoses included fracture of left femur (broken thigh bone), chronic obstructive pulmonary disease (COPD) (long-term lung disease), bipolar disorder (mood disorder), anxiety (excessive worry), and dementia (memory loss). Resident #6's Care Plan initiated 6/26/26 and revised 7/1/26 identified a focus area for bladder incontinence, placing Resident #6 at risk for impaired skin, urinary tract infections (UTIs) (bladder infections), and peri-area (skin surrounding private areas) irritation. Resident #6's Care Plan initiated 6/26/26 identified a focus area for a self-care deficit requiring staff assistance with activities of daily living (ADLs), impaired balance during transitions requiring staff assistance or walking, and incontinence. Interventions directed two staff members for transfers. On 7/27/26 at 12:44 PM an observation revealed Resident #6 sitting on the edge of the bed while Resident #6 Representative stood at the foot of the bed and Staff A, Certified Nursing Assistant (CNA), remained in the room. Resident #6 Representative asked if the wheelchair cushion felt wet, stating Resident #6 couldn't sit on it. Resident #6 Representative removed the wheelchair cushion, displaying urine wetness soaked through to the bottom of the cushion. Resident #6 Representative asked if the fluid represented urine, and Staff A responded it could be. Resident #6 Representative stated the wheelchair felt wet too, asking staff to clean the wheelchair before placing Resident #6 into it. On 7/27/26 at 12:55 PM Resident #6 stated staff left them in a wet brief for 5 hours. On 7/28/26 at 1:00 PM Staff A stated changing residents every 2 to 3 hours. Staff A reported around lunchtime on 7/27/26 at 11:30 AM Resident #6 activated the call light requesting to use the bathroom. Staff A reported informing Resident #6 about lunchtime, stating plans to return after assisting in the dining room, and Resident #6 agreed. Staff A confirmed Resident #6's clothes and wheelchair cushion becoming wet with urine represented a normal occurrence. On 7/29/26 at 9:42 AM Staff C, CNA, stated if a resident requested bathroom assistance during lunch, staff provided help if sufficient staffing existed. Staff C reported dining room supervision required three staff members during lunch service. Staff C stated without enough staff, workers informed the resident assistance would occur after completing dining room duties. On 7/29/26 at 11:54 AM the Director of Nursing (DON) stated expectations for basic standards of care require changing residents every 2 hours upon rising, before and after meals, at bedtime, and as needed (PRN). The DON stated if a resident requests bathroom assistance during a meal, staff must assist the resident before going to the dining room. The Urinary Incontinence-Clinical Protocol policy revised April 2018 directed staff under treatment and management to provide scheduled toileting, prompted voiding, or other interventions to try to improve an individual's continence status.

Based on record review and interview, the facility failed to ensure staff properly prepared and distributed medications for residents on leave from the facility when Staff G, Registered Nurse (RN), sent full medication cards belonging to another resident (Resident #16) home with Resident #1 during a leave of absence for 2 of 2 resident reviewed (Residents #1 and #16). The facility identified a census of 49 residents. Findings include: A Five-Minute Meeting Form dated 3/5/26 documented nurses could only send one dose or medication for leave of absence, or order bubble packs (blister cards containing individual doses) from the pharmacy, order medications for leave of absence, and mark on the medication card and narcotic (controlled substance) sheets. The Five-Minute Meeting Form showed Staff G signed in signature slot 9, verified by the Director of Nursing (DON), confirming attendance at the education. A Medication Error Report dated 3/19/26 at 8:30 PM documented the facility received a phone call from Resident #1's Family Member informing the staff the facility sent medications belonging to another resident (Resident #10) home with Resident #1, in addition to Resident #1's medications. A Corrective Action Form dated 3/23/26 documented Staff G received a written warning for sending another resident's medication packet out with a resident on leave from the facility with family. Staff G received education via text message on 3/20/26 regarding the six rights of medication administration. The Administrator spoke to Staff G immediately after the phone call from Resident #1 Family Member. The Corrective Action Form didn't contain documentation of education on setting up medications for leave of absence. On 7/28/26 at 9:50 AM Resident #1's Family Member stated they didn't let Resident #1 take the wrong medications on 3/19/26. Resident #1's Family Member reported another resident's medication cards accompanied Resident #1's medication cards, and the cards contained multiple medication doses. On 7/28/26 at 10:43 AM Staff G stated full responsibility for the incident, noting Staff G didn't triple check medication cards. Staff G reported another resident's medication cards sat in the wrong slot in the medication cart with Resident #1's medication cards, causing Staff G to pick up the wrong cards and send them with the family. On 7/29/26 at 8:35 AM Staff G stated the other affected resident was Resident #16. Staff G reported both residents maintained similar medications, requiring a better card review. Staff G reported Resident #16's cards sat in Resident #1's slot in the medication cart. Staff G reported the nurses send full resident medication cards out when residents leave the facility. Staff G reported Resident #1 left the faciity on 3/19/26 between 3:00 PM and 5:00 PM, and Staff G sent their supper medication cards with the family. On 7/29/26 at 1:38 PM the Administrator stated staff send medication cards out when a resident leaves the facility. On 7/29/26 at 1:42 PM the DON stated corporate policy recently changed, requiring nurses to call the pharmacy to set up resident medications in a bubble pack for extended or overnight leaves. The DON reported the facility maintained a different policy when Resident #1 left the faciity on 3/19/26. The DON reported providing education to nurses on 3/5/26 regarding medication dispensing for leaves of absence, noting Staff G received a written warning for sending full medication cards out with Resident #1. On 7/29/26 at 2:20 PM Staff G stated feeling upset about the incident, noting the facility changed procedures to prohibit dispensing full medication packs as previously practiced. On 7/29/26 at 2:55 PM the DON stated the pharmacy refilled resident medication cards as needed, resulting in varying numbers of medications in each card when sent out. On 7/29/26 at 3:05 PM the Administrator and the DON stated the Administrator expected nurses to place one medication in each envelope and label appropriately. The DON stated staff couldn't use envelopes any longer and expected nurses to set up one medication per bottle with appropriate labeling, noting plans to order plastic medication bottles from the pharmacy. The Dispensing Medications to Resident's on Leave/Pass Policy dated April 2007 directed staff to provide scheduled and essential as-needed medications to residents away from the facility during medication passes, limited to the amount and doses needed for the anticipated absence. The policy directed the Charge Nurse to provide verbal and written directions to the resident or person signing out the resident, and directed staff to document absences on the Medication Administration Record (MAR) (medication tracking log). The policy directed the pharmacy to prepare and dispense medications for overnight or consecutive absences exceeding three days. The policy didn't reflect current regulatory requirements.

Based on observation, record review, facility policy review, and interview, the facility failed to ensure staff administered medications safely as prescribed without crushing non-crushable medications for 1 of 5 residents (Resident #10) reviewed for medication administration. The facility identified a census of 49 residents. Findings include:Resident #10's Order Listing Report signed by the Provider on 6/30/26 listed the following orders: a. Medications may be crushed unless otherwise contraindicated. b. Potassium Chloride (mineral supplement) Extended Release (ER) 10 Milliequivalents (MEQ), give 10 MEQ by mouth in the morning. c. Aspirin (ASA) (clot prevention medication), give 81 Milligrams (MG) by mouth in the morning for clot prevention.On 7/29/26 at 7:41 AM Staff H, Certified Medication Aide (CMA), prepared medications for Resident #10. Staff H placed a 10 MEQ Potassium Chloride ER tablet from the medication cart into a medication cup. Staff H placed one stock ASA 81 MG enteric coated (special coating to prevent stomach breakdown) tablet into the medication cup. Staff H crushed Resident #10's medications, mixed them into applesauce, and administered them to Resident #10.On 7/28/26 at 2:07 PM the Pharmacy Vendor Licensed Pharmacist reported staff shouldn't crush and administer Potassium Chloride ER oral tablets in applesauce. The Pharmacy Vendor Licensed Pharmacist stated guiding documents direct staff to break extended-release tablets in half, dissolve them in 4 ounces (oz) of water for 2 minutes, and administer immediately. The Pharmacy Vendor Licensed Pharmacist reported lacking information indicating Resident #10 required crushed medication.On 7/28/26 the Pharmacy Vendor provided Potassium Chloride ER Highlights of Prescribing Information, directing under Dosage and Administration to swallow tablets whole without crushing, chewing, or sucking. In an email on 7/28/26 at 2:29 PM, the Pharmacy Vendor Licensed Pharmacist communicated staff could cut potassium in half or dissolve it in water, but couldn't crush it.On 7/29/26 at 7:25 AM Staff G, Registered Nurse (RN), reported staff shouldn't crush extended-release potassium and enteric-coated ASA medications. Staff G confirmed the yellow baby ASA represented stock enteric-coated aspirin and shouldn't be crushed. Staff G reported Resident #10 should've received chewable ASA, which staff can crush.On 7/29/26 at 7:30 AM Staff G reviewed Resident #10's Electronic Medication Administration Record (EMAR) and reported the EMAR didn't indicate Resident #10 received crushed medications. Staff G reported the EMAR didn't specify ER potassium shouldn't be crushed and noted the EMAR order for baby ASA didn't specify chewable form.On 7/29/26 at 7:33 AM the Director of Nursing (DON) questioned Staff G whether the EMAR listed crushed medications. The DON reported lacking knowledge whether the pharmacy received a list of residents requiring crushed medications.On 7/29/26 at 7:38 AM the DON reported the resident profile page lists crushed medications, but the information didn't flow to the medication administration record. The DON reported instructing Staff G to create a list of all residents requiring crushed medications to provide to the consulting pharmacist and supplying pharmacist.On 7/29/26 at 8:23 AM the DON reported completing Staff H's medication administration orientation and provided a copy of Staff H's Medication Administration Competency Checklist dated 4/23/26. The checklist documented Not Applicable/NA regarding medication crushing policies. The DON reported training Staff H on C/D Hallway, noting Resident #10 represented the only resident requiring crushed medications at time of training and resided on A/B Hallway, so training didn't cover medication crushing. The DON reported avoiding untrue statements, noting belief training didn't address crushing medications due to training location.On 7/30/26 at 10:45 PM the DON reported notifying the pharmacy of residents requiring crushed medications and placing medication reference sheets in nurse binders on each medication cart to prevent staff from crushing non-crushable medications.The Administering Medications policy dated December 2012 directed staff to administer medications safely as prescribed. The policy instructed the DON to supervise and direct all nursing personnel administering medications or performing related functions. The policy lacked specific direction regarding crushed medication administration.

Based on record review and interview, the facility failed to ensure staff scheduled and provided transportation for medical appointments for 1 of 3 resident (Resident #1) reviewed for medical services. This failure resulted in Resident #1 missing specialty medical appointments. The facility identified a census of 49 residents. Findings include:A Diabetes/Endocrinology Visit record dated 3/5/26 documented Resident #1's next appointment scheduled for 4/9/26 at 1:30 PM. Resident #1's April 2026 Progress Notes lacked documentation of a Diabetes/Endocrinology Visit on 4/9/26. A Diabetes/Endocrinology Visit Note dated 5/14/26 documented the next scheduled appointment set for 6/18/26 at 9:50 AM. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired vision, seeing only light, colors, or shapes. Resident #1's MDS documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #1's MDS documented diagnoses including gastroesophageal reflux disease (acid reflux), end stage renal disease (kidney failure), and diabetes mellitus (high blood sugar). Resident #1's MDS documented Resident #1 received renal dialysis (blood filtering treatment). A Progress Note dated 6/18/26 at 10:44 AM written by Staff G, Registered Nurse (RN), documented an endocrinology clinic calling to report Resident #1 missed a scheduled appointment on 6/18/26, scheduling a virtual visit for 7/16/26 at 2:50 PM. On 7/28/26 at 9:50 AM Resident #1 Family Member stated Resident #1 missed several endocrinology appointments, adding Resident #1 maintains diagnoses of diabetes and legal blindness and cannot miss appointments. On 7/28/26 at 12:53 PM Resident #1 stated missing several endocrine and other medical appointments while residing at the facility. On 7/29/26 at 11:20 AM the Administrator provided a Ride Request Form documenting a scheduled bus ride for Resident #1 on 4/9/26 for an endocrinologist appointment at 1:30 PM with a return pickup time at 2:30 PM. The bottom of the form documented, We cannot do this ride today. The form contained a facsimile date of 4/8/26 at 8:51 PM. On 7/29/26 at 11:40 AM Dispatch at the Transportation Vendor stated vendor policy required transport notification by 4:00 PM the day prior to appointments or by 4:00 PM Friday for Monday appointments. On 7/30/26 at 8:01 AM Staff G reviewed the Progress Note dated 6/18/26 and reported lacking specific recollection regarding why Resident #1 missed the appointment. Staff G reported recalling the Director of Nursing (DON) mentioning clinic double-booking practices and noted staff typically document virtual appointments in progress notes. On 7/30/26 at 8:03 AM Lead Dispatch at the Transportation Vendor reported checking ride logs and finding no rides scheduled for the facility on 4/9/26, noting unscheduled transport occurs only when requests arrive after 4:00 PM the prior day. On 7/30/26 at 8:20 AM the Administrator reviewed the fax timestamp sent to the transportation service and stated the timestamps contained inaccuracies. The Administrator checked computer records for Resident #1's transportation scheduling on 4/9/26, which showed a fax sent to the transportation vendor on 4/8/26 at 8:55 PM. The Administrator reported the DON sent transportation request forms and noted receiving additional education on transport scheduling since taking over scheduling duties. On 7/30/26 at 8:40 AM the DON reported Resident #1 missed a gastroenterology (stomach and intestine specialist) appointment on 4/23/26 without record documentation explaining the absence, adding staff rescheduled the appointment for October 2026. The DON reported Resident #1 missed the 4/9/26 endocrinology appointment due to late transit setup and confirmed Resident #1 missed the 6/18/26 endocrinology appointment as well. The DON reported the corporation eliminated the facility scheduler position. The previous scheduler was upset her position had been eliminated. They found she had thrown resident appointment papers in the shredder. They retrieved as much resident information as they could to reschedule appointments. Some appointments were missed because they had no idea the appointment had been scheduled. The previous scheduler did the scheduling on paper instead of in the computer, so when she left, they were left with nothing. They started from ground zero. The DON confirmed the missed appointments. She stated they did not have a policy on their scheduling process. The undated Facility admission Contract Resident Rights policy directed residents hold the right to receive information regarding total health status and medical conditions, participate in treatment planning, and see their physician.

Based on observation, clinical record review, Center for Disease Control and Prevention (CDC) Guidelines, Policy review and staff interviews, the facility failed to prevent the spread of infection for 2 of 2 residents who tested positive for influenza A (Residents #17 and #38). In addition, the facility failed to implement droplet precautions, sanitize the barrier used during a blood sugar check for 1 of 2 residents observed (Resident #23), and failed to adhere to infection control practices during medication administration when dirty gloves contacted oral medication for 3 of 7 resident observed (Residents #16, #19 and #34). On 1/2/26, the facility failed to follow infection control protocols after Resident #17 tested positive for influenza A. After Resident #17 tested positive for influenza A, the facility failed to initiate isolation or droplet precautions to prevent the spread of influenza A. On 1/6/26, Resident #38 (Resident #17's roommate) displayed signs and symptoms of an upper respiratory tract infection with wheezing (a whistling sound indicating difficulty of air moving through the lungs). Resident #38 required the use of prednisone (steroids used to reduce swelling), an antibiotic, and nebulizers to help them breathe. Resident #17's and #38's room didn't have a sign or supplies in or near their room to indicate influenza A present in the room. The facility failed to implement control measures to prevent the transmission of influenza A to other residents in the facility, causing Resident #38 physical harm. The facility identified a census of 43 residents. Findings include:1. Resident #17's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) Score of 6, indicating severe cognitive loss. The MDS listed diagnoses of altered mental state, acute respiratory (lung) failure, and adult failure to thrive. During entrance on 1/5/25 at approximately 9:30 AM the Administrator reported Resident #17 tested positive for influenza A. On 1/5/25 at 11:21 PM observed Resident #17 lying in bed on his right side, with his room door open. His room didn't have personal protective equipment (PPE) set up and/or no CDC sign regarding the use of isolation on their door. Resident #17's roommate sat in a recliner. They had the privacy curtain pulled approximately 3-4 feet out from the wall so each roommate could see each other. On 11/5/25 at approximately 11:30 PM watched Resident #17's roommate walk out of the room to the dining room without being offered a medical mask until approximately 70-75 feet to the dining room. He walked by 9 other resident room doors and by 3-4 tables of residents in the dining room. He sat at the back of the dining room with another male resident. Two nursing staff sat assisting other residents in the dining area. A certified medication aide (CMA) stood at the medication cart at the front of the dining room by the nurses' station and one dietary staff passed meal plates in the dining room. They had approximately 24 other residents in the dining room. The staff still didn't offer him a medical mask. On 1/6/26 at approximately 7:30 AM witnessed Resident #17 lying in bed with the room door open. The room didn't have an isolation sign noted and/or PPE available outside the room to go in and provide care to Resident #17. On 1/6/25 at 9:10 AM observed a plastic 3 drawer bin with gloves, gown, medical masks and face shields. Resident #17 door lacked and direction, documentation, and/or guidance regarding droplet precautions for Resident #17's room. During an interview on 1/6/26 at 9:12 AM Staff F, Certified Nursing Assistant (CNA), stated she had not worked since the previous Thursday and no one communicated Resident #17 had a respiratory illness. Staff F added none of the staff knew the day before of him being ill. Staff F voiced Resident #17 should be on precautions. He still didn't have a sign for precautions on his door and he should so staff know what to do. He needed to wear a mask if he came out of the room. In addition, he had a roommate. Staff F pulled the curtain that morning as his roommate has been exposed and went out of the room the day before. Resident #17 laid in bed at the time in his room approximately four feet from the open room door. Interview completed on 1/6/26 at approximately 11:42 AM Staff F reported she just placed a PPE bin outside of Resident #17's room door. He tested positive for influenza. She didn't work the weekend and he should have been put on precautions when he returned positive with the flu. If she did work the weekend, she would have put an isolation bin outside his door. She stated she worn a mask and gloves in his room on 1/6/26 when she went in but they didn't place on precautions until just then. On 1/6/26 at 11:43 observed a CDC Droplet Precaution sign on Resident #17's room door. The CDC sign directed everyone must clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry with illustrated pictures showing use of a medical mask and a face shield or medical mask and goggles. Remove face protection before room exit. On 1/6/26 at 11:44 AM watched Staff G, Dietary Aide (DA), roll a cart with lunch trays down the D hallway. Staff G wore a medical mask and delivered a room tray to Resident #3's room. Staff G came out of Resident #3's room and positioned the meal cart in front of Resident #17's room. She failed to remove her mask or perform hand hygiene prior to entering Resident #17's room. Staff G wore only a medical mask as she entered Resident #17 room and placed a plate of food on his bedside table within 6 feet of them. Without performing hand hygiene or changing their mask, Staff G delivered Resident #17's roommate's tray. At 11:48 AM Staff G came out of the room and without performing hand hygiene assisted a visitor to apply a medical mask. They didn't direct the visitor to perform hand hygiene prior to visiting Resident #17's roommate. Staff G failed to apply goggles or a face shield, remove her face mask before exiting the room and perform hand hygiene immediately upon exiting the room. Staff G placed her hands on the meal cart and moved it down the hallway a few feet, then asked Staff H, Certified Medication Aide (CMA), if she had some hand sanitizer. Staff G sanitized her hands and without sanitizing the meal cart, she touch it in the same place she just had her hands and continued to serve 4 more resident room trays. On 1/6/26 at 11:49 AM Staff H reported they are to wear a mask, gown, gloves, and make sure to wash their hands on way out of the room. She stated Resident #17 tested positive for influenza A. He went to the emergency department (ED) on Friday. She returned to work on Monday (1/5/26). He didn't have PPE outside the room, so she just wore a mask and gloves to go in his room on Monday. On 1/6/26 at 11:51 AM the Director of Nursing (DON) stated she would save everyone a lot of time and work. Resident #17 went Friday (1/2/26) to the ED and returned that same day positive for influenza A. The nurse didn't pass on the information through the report, so no one knew about it on the weekend. On Monday (1/5/26) she put signs on the front and back door of the facility regarding visitation. She just put the CDC Droplet Precaution Sign on Resident #17's room door and started to complete staff education regarding communication and isolation precautions. She printed off the policy for education and got a standing order for Tamiflu for the residents. She said the nurse should have notified the on-call nurse 1/2/26 which would have been her and then she would have alerted the Infection Preventionist. They would instruct to place Resident #17 on droplet precautions. The facility should have placed Resident #17 on precautions on 1/2/26 when he returned from the hospital, but it got missed. They just placed him on droplet precautions at that time. The General Progress Note dated 1/6/26 at 6:18 PM documented a Provider visit for Resident #38 (roommate of Resident #17) with a chief complaint of signs and symptoms of upper respiratory illness (URI) with chills and malaise (extreme tiredness) for 2 days. The Progress Note indicated the staff alerted the nurse that Resident #38 had signs and symptoms of a URI. The hospital diagnosed his roommate with influenza A on Friday (1/2/26). The Progress Note documented Resident #38 as alert and appeared sick with wheezing. The Provider ordered Resident #38 to start Z-pack antibiotics, a prednisone (steroid therapy used to treat swelling) taper, and nebulizer (breathing) treatments as needed. On 1/7/26 at 8:11 AM Staff I, CNA, reported she worked 1/5/25 and they didn't have residents placed on isolation precautions. No one reported Resident #17 had influenza A. Interview completed on 1/7/26 8:16 AM Staff F reported she didn't work the weekend (1/2/26 - 1/3/26). If she would have worked the weekend, she would have put Resident #17 on precautions. Resident #17's roommate was out of the room and all over the facility all weekend and Monday (1/5/16). Resident #17's roommate had symptoms of the flu that morning and he is really sick. He even had a visitor yesterday and they tried to turn away the visitor, but they refused. The visitor at least wore a mask when she visited Resident #17's roommate. Resident #17 should have started precautions right away. During an interview on 1/7/26 at 10:11 AM Staff B, Registered Nurse (RN), reported he worked the weekend of 1/3/26 and 1/4/26. He didn't put any residents on any type of isolation precautions. It was possible that staff could have gone in the room to provide care to Resident #17 without PPE, but he didn't go into Resident #17's room himself. Interviews completed on 1/7/26 at 10:25 AM Staff F and Staff H reported the instruction they received said they only had to wear masks and gloves to enter Resident #17's room. On 1/7/26 at 11:39 AM Staff E, Assistant Director of Nursing (ADON)/Infection Preventionist (IP), reported it happened late at night and it wasn't passed through report that Resident #17 tested positive for influenza A. The nurse should have notified the on-call nurse, passed it through report and placed the resident on isolation precautions. The resident should be kept in their room for 7 days or until no signs and symptoms. She reported being the on-call nurse on 1/2/26 and never received any calls regarding a resident with influenza. She worked on Saturday (1/3/26) and Sunday (1/4/26) night shift and still never received a report of a resident positive for influenza A. During an interview on 1/8/26 at 10:19 AM the DON explained she expected the nurses to place residents with influenza A on droplet precautions immediately. The nurses are to call the On Call nurse right away. The DON and ADON serve as the On-Call nurse contacts. They would instruct the nurses on what to do for precautions. Staff are to follow standard precautions, wear gloves, and masks to care for a resident with influenza A. When queried about the CDC Droplet Precaution sign on Resident #17's room door, the DON confirmed she placed the CDC sign on the door. She stated she didn't think their policy required the staff to use droplet precaution, specifically eye protection. The Influenza Exposure Control Policy dated 2025 directed procedures for prevention and controlling exposure to influenza. The Policy directed to implement droplet precautions for residents with suspected or confirmed influenza for seven days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer. Staff to follow the facility's transmission-based precaution procedures while the droplet precautions are in effect. The CDC Infection Prevention and Control Strategies for Seasonal Influenza in Healthcare Settings dated April 28, 2025 under Modes of Transmission documented the influenza viruses have been thought to spread from person to person primarily through large-particle respiratory droplets and small particles in the air (e.g. coughing/sneezing). Transmission via large-particle droplets occurs during close contact between source and recipient persons, because droplets generally travel only short distances (approximately 6 feet or less) through the air. All respiratory secretions and bodily fluids with influenza are considered to be potentially infectious. The CDC Guidance directs droplet precautions should be implemented for patients with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer. Healthcare Personnel should apply a facemask when entering the room of a patient with suspected or confirmed influenza and remove the facemask when leaving the room, dispose of the facemask in a waste container and perform hand hygiene. If a patient under droplet precautions requires movement outside of the room, have the patient wear a facemask and follow respiratory hygiene and cough etiquette and hand hygiene. 2. Resident #23 MDS dated [DATE] identified a BIMS Score of 6, indicating severe cognitive loss. The MDS included diagnosis of diabetes mellitus. The MDS indicated he received insulin injections 7 days a week. An Order Summary report signed by the provider on 11/17/25 listed an order to check blood sugars 4 times a day (AM, noon, evening and bedtime). During an observation on 1/5/26 at 4:02 PM Staff J, RN, unlocked the medication cart, removed a plastic container with Resident #23's blood sugar machine, and supplies. Staff J removed the lid of the plastic container and placed the lid with the inside portion of the lid facing down on top of the medication cart. Staff J placed the blood glucose meter with a strip, lancet, gauze, and alcohol prep pads on top of the lid and carried it into Resident #23's room placing the lid on the bedside table. Staff J informed Resident #23 she would check her blood sugar. Staff J picked up the plastic lid and placed it with the inside portion of the lid facing down on the resident's bed and proceeded to check her blood sugar. Once completed, Staff J brought the lid with the supplies out of the room and placed it on top of the medication cart. She disposed of the lancet in the sharp's container, cleaned the meter and placed inside the plastic container which also contained lancets, alcohol prep pads, bottle of testing strips and gauze. Staff J then placed the plastic lid back on the plastic container without sanitizing the lid and placed in the medication cart. On 1/8/26 at 8:15 AM Staff B reported they are to use a paper towel as a clean barrier if they have to set any supplies down in a resident's room. The resident bedside tables can be pretty dirty at times, so a paper towel barrier needed used. On 1/8/26 at 10:34 AM the Director of Nursing explained she expected the staff to place a paper towel barrier down prior sitting any blood glucose supplies down in a resident's room. The Obtaining a Fingerstick Glucose Level Policy revised October 2011 failed to address the use of a clean barrier when performing a blood glucose checks to prevent potential cross contamination. 3. On 1/6/26 at 7:39 AM observed Staff H do the Medication Task. Staff H prepared Resident #34's medications and reviewed the January 2026 Electronic Medication Administration Record (EMAR) which included the following medication orders:a. Aspirin Oral Tablet Chewable 81 Milligrams (MG), give 81 MG by mouth one time a day.b. Sertraline Hydrochloride (HCL) Oral Tablet 100 MG, give 1 tablet by mouth in the morning. c. Eliquis Oral Tablet 5 MG, give 5 MG by mouth two times a day. d. Metformin HCL Oral Tablet 500 MG, give 1 tablet by mouth two times a day. Staff H performed hand hygiene, placed gloves on both hands, opened the medication cart, and removed Resident #34's medication cards from the cart. Staff H punched the Sertraline out of the back of the medication card into her right gloved hand, then placed it in a medication cup. Staff H touched the (computer) tablet with her right gloved hand to move the EMAR screen to be able to see each medication order. The tablet had visible smudged fingerprints all over the front screen of the tablet. Staff H continued the technique of punching each oral medication out of the back of the card into her right gloved hand and touched the screen on the dirty tablet multiple times prior to administering the medication to Resident #34. 4. On 1/6/26 at 7:44 AM watched Staff H complete the Medication Task as they prepared Resident #19's medications. Staff H reviewed Resident #19's January 2026 EMAR which included the following medications:a. Amlodipine Besylate Oral Tablet 5 MG, give 5 MG by mouth in the morning.b. Aspirin Low Dose Tablet 81 MG, give 81 MG by mouth in the morning. c. Clopidogrel Bisulfate Oral Tablet 75 MG, give 75 MG by mouth one time day.d. Lasix Oral Tablet 20 MG, give 1 tablet by mouth in the morning. e. Losartan Potassium-Hydrochlorothiazide Oral Tablet 100-25 MG, give 1 tablet in the morning. f. Mirtazapine Oral Tablet 15 MG, give 15 MG one time a day.g. Carvedilol Oral Tablet 25 MG, give 1 tablet two times a day. h. Seroquel Oral Tablet 25 MG, give 25 MG two times a day. Staff H performed hand hygiene, removed Resident #19's medication cards from the medication cart, donned gloves and proceeded to punch each medication out of the back side of the card into the palm of her right gloved hand, then placed the pill into a medication cup. Staff H used the same right gloved hand to touch the dirty screen, covered with visible finger smudges on the front screen, of the computer tablet as she scrolled through Resident #19's physician orders. Staff H dropped the Carvedilol (blood pressure medication) pill onto the top of the medication cart and picked the pill up with her dirty right gloved hand and placed into the medication cup, the administered the medications to Resident #19. 5. On 1/6/26 at 7:51 AM observed Staff B do the Medication Task and prepare Resident #16's medications for administration. Staff B reviewed Resident #16's January 2026 EMAR which included the following orders:a. Calcium Oral Tablet 500 MG, give 500 MG by mouth three times a day.b. Vitamin D 5000 Units, give two tablets by mouth in the morning. Staff B applied gloves, removed a total of nine medication cards from the medication cart for Resident #16, placing the cards on top of the medication cart. Staff B opened a drawer and removed a stock bottle calcium, opened, and shook a calcium tablet into the lid of the bottle, then transferred the pill into the medication cup. Staff B placed the calcium bottle back in the medication cart. Staff B took a stock bottle of vitamin D from the medication cart, opened the bottle, stuck his left gloved forefinger into the bottle of vitamin D to dig two vitamin D tablets from the bottle, then placed the tablets in the medication cup with his left gloved hand which had touched multiple other surfaces. Staff B administered the medication to Resident #16. During an interview on 1/7/26 at 2:50 PM Staff J, RN, explained they received instruction if they have to touch medications, then they need to wear gloves. If they punch a pill right out of the card into the cup, then they do not need to wear gloves. If they punch the pill into their hand and then put in the cup, they have to wear a glove. She stated that gloved hand should not touch any other surfaces or items between punching the pills out of the card of it the glove would have to be changed. On 1/8/26 at 10:03 AM Staff B reported they never received a guideline but he occasionally sanitized his computer with a germicidal wipe, but hasn't received guidance from the facility. On 1/8/26 at 10:05 AM the DON voiced the nurses shouldn't touch oral medications with dirty hands or gloves. She didn't where or why the nursing staff wore gloves during medication pass. On 1/8/26 at 10:10 AM the Administrator reported the facility didn't have a policy for sanitizing the laptops or tablet screens used for medication pass. Both the Administrator and DON agreed the laptops/tablets can be very dirty. The Administering Medications Policy revised December 2011 directed the staff to follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications.

Based on record review, policy review, resident, and staff interviews, the facility failed to have a restorative program available for all residents at the facility. The facility failed to implement a restorative plan for 2 of 2 residents that reported if they had an option to do therapy, they would (Residents #36 and #43). The facility reported a census of 43 residents. Findings include: 1. Resident #36's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. The MDS listed Resident #36 as dependent on staff (requires 2 staff to complete the task and the staff do all the work) for toileting, dressing, transfers and personal hygiene. The MDS included diagnoses of stroke, anxiety, depression, and hemiplegia (the loss of muscle function, causing an inability to move voluntarily to one entire side of the body, affecting the face, arm, and leg, caused by brain damage to the opposite side of the brain). Resident #36 Care Plan on 1/8/26 documented he is participating in the Restorative Nursing Program and needs strengthening and stretches to prevent contractures and to perform restorative exercises as order. The review of Resident #36's December 2025 Documentation Survey Report (a facility computer generated report from the resident medical record about the residents' activities of daily living, restorative, and activity attendance) on 1/8/26 lacked a restorative program. The review of Resident #36's January 2026 Documentation Survey Report on 1/8/26 lacked a restorative program. In an interview on 1/8/26 at 12:12 PM Resident #36 reported it was nice in the past to attend the restorative program. He added he thought might have participated twice in the past 5 years of living at the facility. He explained he would like to try a restorative program and if he liked it, he would possibly do it every day. 2. Resident #43's MDS assessment dated [DATE] identified a BIMS score of 6, indicating severe cognitive impairment. Resident #43 needed moderate assistance (required 1 staff to assist but do less than half the effort) for standing, transfers, and walking up to 50 feet. The MDS included diagnoses of depression, hypotension (low blood pressure), and hemiplegia (inability to move part of the body). The review of Resident #43's December 2025 Documentation Survey Report for December 2025 lacked a restorative program. On 1/8/26 Resident #43 Documentation Survey Report for January 2026 on 1/8/26 lacked a restorative program. In an interview on 1/8/26 at 12:17 PM Resident #43 reported he didn't have a restorative program he attended and probably wouldn't exercise every day, but would do it when he wanted to. In an interview on 1/8/26 at 11:24 AM the Administrator confirmed the facility didn't currently have a restorative program in place for residents in the facility but are working on implementing one. She described Resident #36 as non-compliant with cares and didn't know if he would complete a restorative program if it was implemented, but he would probably benefit from one. She added he used Part B therapy a few times in the past year. The Administrator described Resident #43 as new to the facility but would probably benefit from a restorative program. Review of the facility's Nursing Restorative Program manual dated May 2022 instructed on the implementation and maintenance of a restorative program in the facility.

Based on observation, staff interviews, and policy review the facility failed to post daily nurse staffing on 3 of 4 days of the annual survey. The facility reported a census of 43 residents. Findings include: An observation on 1/5/26 at 10:17 AM revealed the facility had nurse staff posting for 1/3/26 posted. An observation on 1/6/26 at 1:41 PM revealed the facility had nurse staff posting for 1/5/25 posted.An observation on 1/7/26 at 3:47 PM revealed the facility had nurse staff posting for 1/5/25 posted.In an interview on 1/8/26 at 11:24 AM the Administrator reported she expected the night nurse to complete the nurse staff posting for the next day and post it on their shift, then have the staff update as changes occurred. She repotted it's never been identified as an issue that it has not been updated before, and unsure why it was not completed this week. Review of Nurse Staffing Posting Information policy revised in unknown month, 2025 informed it is the policy to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time and the facility will post the nurse staffing at the beginning of each shift.

Based on record review, staff interviews, and policy review the facility failed to obtain informed consent prior to starting psychotropic medications that have black box warnings (the most serious safety warning the Food and Drug Administration (FDA) uses and requires the healthcare provider to have a comprehensive discussion with the resident about the risks, benefits, and alternatives for use) for 3 for 5 residents reviewed for psychotropic medications. (Resident #36, #40, and #8). The facility reported a census of 43 residents. Findings include: 1. Resident #36's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. It informed he received antipsychotic, antianxiety and antidepressant (3 types of psychotropic drug classes that are used to manage various mental health conditions by balancing chemical neurotransmitters in the brain, which are then released by nerve cells to transmit signals across tiny gaps to other neurons, muscles, or glands, allowing communication for all functions like thought, movement, mood, and sensation in the brain) medication in the past 7 days. The MDS also documented he has diagnoses of stroke, hemiplegia, anxiety, and depression. Resident #36's Order Summary Report signed on 11/17/25 included orders for antianxiety, antipsychotic, and antidepressant medications. Resident #36's December 2025 Medication Administration Record (MAR) documented he received antipsychotic and antidepressant medications daily Resident #36's MAR from 1/1/26 to 1/7/26 documented he received antipsychotic and antidepressant medications. Resident #36's Assessments in his medical record on 1/8/26 lacked the completion of an assessment regarding consent for antianxiety and antidepressant medications since admission to the facility. 2. Resident #40's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 12/9/25. The MDS identified a BIMS score of 15, indicating no cognitive impairment. The MDS included diagnoses of anxiety, depression, and insomnia. The MDS indicated he received antipsychotic and antidepressant medications in the lookback period. Resident #40's After Visit Summary dated 12/9/25 included orders to take two (2) antidepressant medications daily. Resident #40's December 2025 MAR documented he received antianxiety and antidepressant medications while at the facility since his admission. Resident #40's Assessments in his medical record reviewed 1/7/26 lacked completion of an assessment regarding consent for antianxiety and antidepressant medications since his admission to the facility. In an interview on 1/7/26 at 4:14 PM the Director of Nursing (DON) reported they are working on getting informed consents for black box psychotropic medications for all residents at the behavior meetings they complete weekly. She added they should document the consents in the Assessments portion of the resident's medical record. In an interview on 1/8/26 at 11:24 AM the Administrator reported she didn't have documentation of informed consents for psychotropic drug use for Residents #36 and #40. She explained the facility started having weekly behavior meetings in December and that is something they are working on a plan to be in compliance within the next quarter. Review of the facility's Antipsychotic Medication Use policy revised December 2016, lacked instruction of when to communicate and obtain informed consent of medications with black box warnings to the resident or resident representative. 3. Resident #8's MDS dated [DATE] showed a BIMS score of 15/15, indicating intact cognition. The MDS documented a Patient Health Questionnaire-9 (screening tool for monitoring the severity of depression) score of 6/29, indicating mild depression. The resident exhibited verbal behaviors 4-6 days per week and rejection of care 1-3 days per week. The MDS included diagnoses of stroke, depression, schizophrenia. The MDS reflected Resident #8 used antipsychotic and antidepressant medications during the lookback period. The General Progress Note dated 12/9/25 at 10:09 AM documented a new physician order for olanzapine (antipsychotic medication). A New Pharmacy Electronic Order dated 12/9/25 listed an order for olanzapine 5 milligrams (MG). Take one tablet by mouth daily every morning and olanzapine 10 MG take one tablet at bedtime. Resident #8's December 2025 Electronic Medication Administration Record (EMAR) included the following orders: Start date 10/31/24: Olanzapine 20 MG, give 0.5 tablet by mouth two times a day related to schizophrenia and schizoaffective disorder, depressive type. Discontinued 12/9/25. Start Date 12/9/25: Olanzapine 10 MG, give 10 MG by mouth at bedtime relate to schizophrenia. Documented as given every day following the start date in December. Start Date 12/10/25: Olanzapine 5 MG, give 5 MG by mouth in the morning related to drug induced subacute dyskinesia. Documented as given every day following the start date in December. Start date 3/8/24: Sertraline 100 MG by mouth one time a day Documented as given every day in December. Start date 1/31/25: Trazodone 100 MG one time a day (both antidepressant medications). Documented as given every day in December. Resident #8's January 2026 EMAR listed the following medications administered daily through review date of 1/7/26: Start Date 12/9/25: Olanzapine 10 MG, give 10 MG by mouth at bedtime relate to schizophrenia. Start Date 12/10/25: Olanzapine 5 MG, give 5 MG by mouth in the morning related to drug induced subacute dyskinesia. Start date 3/8/24: Sertraline 100 MG by mouth one time a day Start date 1/31/25: Trazodone 100 MG one time a day (both antidepressant medications). A 1/7/26 review of Resident #8's Electronic Health Record (EHR) Progress Notes, Assessments, and Miscellaneous documentation lacked documentation they facility informed them in advance of the risks and benefits of the medication, treatment alternative, or other options. During an interview on 1/7/26 at 12:33 PM the Administrator reported they didn't find any medication education or consent documentation for Resident #8 regarding his medications. They identified the issue of missing consent forms for psychotropic medications about a month ago and have tried to get any new medications orders addressed. On 1/8/26 at 10:20 AM the Administrator reported they identified the medication education consents as an issue. They worked on a quality assurance (QA) project and have added the consent education forms to the QA and will address it going forward.

Based on record review, staff interview, and policy review the facility failed to accurately code 1 of 2 residents with a Preadmission Screening and Resident Review (PASRR) (a federal assessment that is a requirement for Medicaid-certified nursing facilities to screen all applicants for serious mental illness, intellectual disabilities, or developmental disabilities to ensure they are placed in the most appropriate, least restrictive setting and receive needed services, preventing inappropriate institutionalization and promoting community-based care) (Resident #7) on the Minimum Data Set (MDS) assessment. The facility reported a census of 43 residents. Findings include: Resident #7 PASRR's dated 1/13/23 revealed she had a PASRR Level II outcome (a detailed evaluation confirmed an individual has a serious mental illness or intellectual disability related condition, that determined she needs specialized services, the result is not just a diagnosis but a decision about the necessary support, leading to recommendations for specialized care or community-based alternatives). Resident #7's MDS assessment dated [DATE] documented she didn't have a PASRR Level II outcome. In an interview on 1/8/26 at 10:17 AM the MDS Coordinator revealed she used a notebook to write down notes regarding the MDS's she completed. In the notebook she had Resident #7 as of 12/11/25 MDS, she had a PASRR Level I. She looked at Resident #7's PASRR dated 1/13/23 and confirmed she had a PASRR level II. The MDS Coordinator reported the MDS dated [DATE] was coded inaccurately. She explained her process normally worked but she must have looked at the PASRR too quickly. She reported she would modify the 12/11/25 MDS to fix the error. She added the facility didn't have a specific policy for completing MDS assessments and instead followed the Resident Assessment Instrument (RAI) manual (federal guidelines for completing the MDS in nursing facilities to assess long-term care residents) for instruction on how to complete the MDS.

Based on observation, clinical record review, policy review and staff interview, the facility failed to assess 1 of 1 residents positive for influenza A (Resident #17). The facility identified a census of 43 residents.Findings include:Resident #17 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) Score of 6, indicating severe cognitive loss. The MDS listed diagnoses of altered mental state, acute respiratory (lung) failure and adult failure to thrive. The Electronic Healthcare Record (EHR) Census documented Resident #17 resided in a room in the D hallway. A 1/2/26 Hospital After Visit Summary documented Resident #17 had a hospital emergency room (ER) visit for shortness of breath (SOB) with a diagnosis of influenza A and chronic obstructive pulmonary exacerbation (blockage in the lungs that makes it difficult to breathe). The After Visit Summary included to call the doctor or seek immediate medical care if they had any of the following:Trouble breathingFever with a stiff neck or severe headachePain or pressure in the chest or bellyFever or cough that returns after getting betterFeeling sleepy, dizzy, or confusedUnable to urinateExperience severe muscle pain, weakness or unsteadinessMedical condition worsensResident #17's Health Care Provider's Orders upon return from the hospital ER on [DATE] at 3:30 PM directed the following:Duo-nebulizer (breathing treatment) every 6 hours while awake for 7 days.Prednisone (steroid medication used to reduce swelling) 40 milligrams (MG) at 7 PM and then 1/3/26 every day for 4 additional days with their morning medications.Monitor pulse oximetry (blood oxygen level), if less than 90 percent (%) return to the emergency room. Start Tamiflu when arrives from pharmacy on 1/3/26. First dose given on 1/2/26 while at the ER. During entrance on 1/5/25 at approximately 9:30 AM the Administrator reported Resident #17 tested positive for influenza A. A 1/7/26 review of the Electronic Healthcare Record (E.H.R.) Assessments and Progress Notes lacked any physical assessment of Resident #17 since his return on 1/2/26 at 5:48 PM through 1/5/26. A 1/7/26 review of the EHR Vital Signs revealed the following:Temperature documented on 1/3/26 of 97.8 degrees Fahrenheit (F) at 12:15 PM onlyPulse documented 1/3/26 at 12:15 PM of 68 beats per minute (expected between 60-100).Respirations 1/2/26 at 8:15 PM and 1/3/26 at 12:15 PM of 16 breaths per minute (expected between 12-20).Blood pressure 1/3/26 at 12:15 PM of 116/69 (expected around 120/80). Oxygen oximetry1/3/26 at 2:22 AM of 91%1/3/26 at 8:34 AM 97%1/3/26 at 5:31 PM of 94%1/4/26 9:43 AM 94%1/5/26 7:36 AM 92%. The Daily Assignment Sheet for 1/3/26 and 1/4/26 documented the following staffing:6AM to 2 PM Staff B, Registered Nurse (RN), assigned to the A/B hallway and Staff C, Certified Medication Aide (CMA), assigned to the C/D hallway. 2 PM to 10 PM Staff D, Licensed Practical Nurse (LPN), assigned to the A/B hallway and Staff C assigned to the C/D hallway.10 PM to 6 AM Staff E, Assistant Director of Nursing (ADON) / Infection Preventionist, as the night nurse covering the facility. On 1/7/26 at approximately 11:00 AM, Staff B reported he worked the weekend of Saturday 1/3/26 and Sunday 1/4/26; but he didn't go into Resident #17 Room.On 1/7/26 at 11:39 AM Staff E reported everything with Resident #17 happened late at night and it didn't get passed through report that he tested positive for influenza A. She reported being the on-call nurse on 1/2/26 and never received any notification. She worked Saturday (1/3/26) and Sunday (1/4/26) on the overnight shifts and didn't know Resident #17 tested positive for influenza. During an interview on 1/7/26 at 1:17 PM the Director of Nursing (DON) reported she expected the nurse to assess a resident every shift when they have a change of condition. Specifically in regard to Resident #17 she expected the nurses to do a full set of vital signs, lung sounds, and a pulse oximetry every shift, then document it in the progress notes. The DON reviewed the January 2026 EMAR physician order for the pulse oximetry and reported she expected the nurses to actually document the oxygen level. She confirmed the facility's Infection Preventionist worked the night shift on 1/3/26 and 1/4/26, but said no one informed her a resident tested positive for influenza A. The Change in a Resident's Condition or Status Policy revised May 2017 under Policy Interpretation and Implementation defined a Significant Change of condition as a major decline in the resident's status that wouldn't normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. The Policy failed to address or direct when to complete a nursing assessment or what to include in the nursing assessment for a change of condition.

Based on record review, staff, resident and Nurse Practitioner interviews, and policy review the facility failed to complete pre and post dialysis (an external method to remove the wastes and toxins from the body with poor functioning kidneys) assessments (assessments involving checking the residents blood pressure, temperature, pulse, and weight; and inspection of the dialysis access site on the body) for 1 of 1 residents that received dialysis (Resident #40). The facility reported a census of 43 residents. Findings include: Resident #40's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 12/9/25. The MDS identified a BIMS score of 15, indicating no cognitive impairment. The MDS included diagnoses of anxiety, depression, and insomnia. The MDS documented he received dialysis treatment while at the facility. An interview on 1/7/26 at 9:40 AM the Social Worker at the local dialysis center reported Resident #40 received routine dialysis while living at the facility on 12/10/25, 12/12/25, 12/21/25, 12/23/25, 12/26/25, 12/29/25, 12/31/25, and 1/2/26. The Care Plan Problem revised 12/9/25 indicated Resident #40 required dialysis therapy. The Interventions directed to complete the dialysis flow sheet daily to observe shunt access site for complications and report abnormalities to the physician. Resident #40's December 2025 Medication Administration Record (MAR) lacked an a pre or post dialysis assessment directive except for 12/23/25, 12/29/25, and 12/31/25. The MAR didn't have anything to document an assessment for any other days in December 2025. On 1/8/26 review of Resident #40 MAR for January 2026 revealed he did not have a pre-dialysis assessment completed 1/2/26. In an interview on 1/7/26 at 2:42 PM the Director of Nursing (DON) reported the staff only document pre- and post-dialysis assessments on the MAR, and if they are not on there they didn't get done. In an interview on 1/8/26 at 10:14 AM Resident #40 said the staff at the facility did a good job monitoring him and denied issues related to dialysis. Review of the facilities Hemodialysis policy revised in 2025 instructed the facility to complete an assessment of the resident's condition and monitor for complications before and after dialysis treatments received at a certified dialysis facility. In addition, the policy directed the nurse to monitor and document the status of the resident's access site upon return from dialysis treatment to observe for bleeding or other complications.

Based on record review, policy review, staff, resident, and Nurse Practitioner interview, the facility failed to have set blood sugar parameters (a numerical range the blood sugar should remain in) in place for 1 of 3 residents reviewed (Resident #40). In addition, the facility failed to notify a resident's doctor after the completion of elevated blood sugar assessments to ask if additional medication or treatment is needed for 1 of 3 residents reviewed for insulin medication usage (Resident #40). The facility reported a census of 43 residents.Findings include:Resident #40's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 12/9/25. The MDS identified a BIMS score of 15, indicating no cognitive impairment. The MDS included diagnoses of anxiety, depression, and insomnia. The MDS documented he received dialysis treatment while at the facility. The MDS indicated Resident #40 received insulin medication during the lookback period.The Care Plan Problem revised 12/22/25 indicated Resident #40 had a diagnosis of diabetes mellitus and dependent on insulin.Resident #40's December 2025 and January 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked orders for blood sugar parameters. Review of Resident #40 Weights and Vitals Summary blood sugars from 12/9/25 to 1/7/26 documented the following blood sugars above 450 (milligrams per deciliter) mg/dL (typically expected between 70-150 mg/dL).a. 12/28/25 at 9:18 AM: 461 mg/dLb. 12/28/25 at 7:06 AM: 551 mg/dLc. 12/27/25 at 8:57 PM: 493 mg/dLd. 12/27/25 at 7:40 AM: 557 mg/dLReview of Resident #40 Progress Notes revealed the facility did not notify or call the Doctor for the following elevated blood sugars:a. 12/28/25 at 9:18 AM 461 mg/dLb. 12/28/25 at 7:06 AM 551 mg/dLc. 12/27/25 at 8:57 PM 493 mg/dLd. 12/27/25 at 7:40 AM 557 mg/dLReview of Resident #40 Progress Note dated 1/5/26 10:30 AM documented he vomited and refused to go to dialysis due to not feeling well. Instead he requested to go to the hospital.Resident #40 History and Physical from the local hospital dated 1/5/26 at 1:21 PM documented a blood sugar greater than 600 mg/dL. Documentation indicated he reported he feeling fairly well until the evening of 1/4/26 when his blood sugar started going up. At that time, he started experiencing abdominal discomfort with some nausea and vomiting. Review of Resident #40 Progress Note dated 1/5/26 at 5:31 PM documented the local hospital called to reported they admitted him for diabetic ketoacidosis (a life-threatening condition caused by a severe lack of insulin in the body, leading to high blood sugar, ketones, and blood acidity).In an interview on 1/7/26 at 4:14 PM the Director of Nursing (DON) explained she didn't know Resident #40's blood sugar parameters, but asked his doctor to get parameters orders in place for him. She explained she expected the nursing staff to call the Doctor if his blood sugar is below 70 or above 350 since they do not have sliding scale orders outside of that range (below 70 or above 350).In an interview on 1/8/26 at 10:14 AM Resident #40 reported the staff at the facility did a good job monitoring his blood sugars and said it always ran high, and the facility did nothing. He added that sometimes he refused medications or to go to the emergency room (ER) for evaluation and the facility did a good job monitoring him.In an interview on 1/8/26 at 11:24 AM the Administrator explained she expected staff to have parameters in place for Resident #40's blood sugars and to call his doctor outside of those parameters to seek guidance. In an interview on 1/8/26 at 11:44 AM Resident #40's Nurse Practitioner reported his blood sugars rapidly change, as he is very non-compliant with what he ate. She explained she expected the facility staff to notify her or his doctor of blood sugars below 40 mg/dL and above 450 mg/dL. She added she is at the facility on a rotating schedule, but usually came to the facility 3 times a week and the staff always let her know what his blood sugars are doing while she is onsite. She then informed his blood sugars can be at 350 mg/dL and then drop to 40 mg/dL in less than an hour and he can also go from 40 mg/dL to 350 mg/dL as well. Giving him extra insulin medication can be very hard to prescribe due to his diabetes being hard to manage.Review of the Hypoglycemia (elevated blood sugar) Management policy, copyright 2025 instructed residents with a diagnosis of diabetes or used medications that could lower the blood sugar should have orders for glucose monitoring and treatment for low blood sugars, unless otherwise ordered by their doctor.

Based on observation, clinical record review, policy review, manufacturer's guide for use and staff interview, the facility failed to properly prime an insulin pen and prevent expired insulin from being administered for 1 of 1 residents observed (Resident #39). The facility identified a census of 43 residents.Findings include:During the Medication Task observation on [DATE] at 11:55 AM Staff B, Registered Nurse (RN) reviewed Resident #39's Electronic Medication Administration Record (EMAR). Resident #39's EMAR documented a physician order for Lantus Solostar Insulin Pen 100 Units/Milliliter (ML). Inject 10 units subcutaneously. Staff B, without placing a needle on the insulin pen, set the insulin pen, dated [DATE], to 2 units, hit the plunger and primed the pen with no insulin expressed from the pen. Staff B then set the insulin pen to ten units and placed the needle on the pen to give the insulin to Resident #39. Staff B failed to check the insulin pen expiration until after the Surveyor asked for the date. Staff B first stated it was okay, then responded no it wasn't okay to give the insulin. At 11:57 AM Staff B obtained a new insulin pen for Resident #39. Staff B set the dial on the pen to 2 units without placing a needle on the pen. He again hit the plunger to prime the pen without any insulin visibly expressed from the pen. Staff B failed to prime the insulin pen per the manufacturer's directions a second time. On [DATE] at 12:30 PM the Director of Nursing (DON) explained she dialed the insulin pen to two units and hit the plunger to prime the insulin pen. The DON stated if she was being honest, she didn't think she placed a needle on the insulin pen prior to priming the pen either. Their pharmacist provided them with the procedure, and it is hanging in the medication room. On [DATE] at 11:25 PM the DON explained they have a guide the nurses use that has the insulin expiration dates. The list are in the nurses' stations.Interview on [DATE] at 11:30 AM Staff B verified they had an expiration list for the insulins at the nurses' station at one time. He looked for the insulin list but could not locate it in the nurses' station. On [DATE] at 11:37 AM the DON reported she called the pharmacy to get new copies of the insulin expiration list for the nurses to have in the nurses' stations.The How to Use An Insulin Pen (guide from pharmacy) dated 2014 directed to peel back the cover on the needle, screw the needle onto the pen, remove the cap from the needle, turn the dial to 2 units, hold the pen so the needle is up in the air, push the end of the pen in to clear the air, watch the tip of the needle for a drop of insulin. It may need done more than once to see the insulin drop on the needle. The Insulin Administration Policy revised [DATE] lacked step by step direction or guidance on the priming of an insulin pen or administration of insulin via pen. The Manufacturer's Step by Step guide to using a Lantus Solo Star Pen dated 2022 directed after 28 days to throw the opened Lantus pen away even if it still had insulin in it. The Guide instructed under Step 2 and 3 the following procedure to prime the insulin pen:Wipe the pen tip (rubber seal) with an alcohol swab.Remove the protective seal from the new needle.Line the needle up straight with the pen and screw the needle on.Dial a test dose of 2 Units.Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose.Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test.If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again.An Appendix of Resources Medications with Special Expiration Date Requirements dated 2007 (document from the facility pharmacy) documented a Lantus pen, in use and not refrigerated remained good for 28 days.

Based on policy review, document review and staff interviews, the facility failed to ensure an effective Quality Assurance Performance Program (QAPI) to address previously identified quality deficiencies, resulting in repeated identified concerns during the current survey. The facility reported a census of 43 residents.Findings include:A review of the facility's 12/12/24 Statement of Deficiencies and Plan of Correction showed citations for F760 ensuring residents are free of significant medication errors. The facility's Plan of Correction identified the following: Immediate education on correction administration per the manufacturer's guidelines for the staff involved.The facility identified all other residents using insulin pens to ensure staff were following correct administration.Education was provided on 12/18/24.The Director of Nursing (DON)/Designee performed audits daily x 5, weekly x 4, monthly x 2 with the results being forwarded to the QAPI committee. The Statement of Deficiencies also showed a citation for F880 Infection Control regarding staff touching medications with their bare hands during medication administration. The Plan of Correction documented the following: Staff involved were educated on proper infection control procedures.Staff washed hands and sanitized the medication cart per the facility infection control policy.Education was provided to staff on 12/23/24.The DON or Designee performed audits daily x 5, weekly x 4, monthly x 2 with the results being forwarded to the QAPI committee.The facility documented compliance on 1/9/25. During the facility's annual recertification from 1/5/26 to 1/8/26 observations, clinical record review, document review and policy review revealed repeated concerns for F760 insulin pen priming and administration and F880 Infection Control with dirty gloves touching oral medication prior to administration as evidenced on the 2026 Statement of Deficiencies. Interview completed on 1/8/26 at 10:05 AM the Administrator and DON acknowledged the facility didn't correct the issues from the last survey. The DON stated she observed medication passes since 1/9/25 but she didn't document any of the audits. She didn't know why the nurses started using gloves, or how that came to be. The nurses should not handle oral medications with dirty gloves. They can't touch the meds after touching the tablet screen. The consulting pharmacist comes in and completed medication inspection every month. The DON reported they planned a nursing skills fair and then they didn't get it done prior to survey. The QAPI Quality Assessment Assurance (QAA) Plan updated 12/18/23 outlined the DON or Designee would be responsible for the development and ongoing monitoring of care giver proficiency. Ongoing proficiency shall be determined through the evaluation process and all other processes deemed necessary through the QAPI process. The Policy further outlined the QAPI Committee would review all Performance Improvement Plans and outcomes to assure efficacy and sustainability.

Based on clinical record review, facility policy, and staff interviews, the facility failed to notify the physician when the facility failed to administer medications as prescribed for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 43. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score as 15, indicating intact cognition. The MDS included diagnoses of anxiety, depression, other psychoactive (mind altering) substance use, unspecified with mood disorder, and psychophysiologic insomnia (loss of sleep linked to the excessive worry about sleep).Resident #1's Medication Administration Record (MAR) for September 2025 and October 2025 documented Gabapentin (pain medication also used as an antianxiety medication) ordered for three times a day omitted (not documented) from 9/18/25 through 10/7/25.Resident #1's Progress Notes lacked documentation of the physician being notified of the omission of Gabapentin.On 10/22/25 at 3:25 PM The DON stated the CMA should have contacted the nurse when noted the medication was not available, then the nurse should have contacted the physician.On 10/22/25 at 3:30 PM The Administrator stated the nurse should have been notified by the CMA of medication not available and then the nurse should have notified the physician. The facility policy titled Acute Change in Condition Policy lacked direction for staff if medication was not available.

Based on clinical record review, facility policy, and staff interviews, the facility failed to administer medication as prescribed by the physician for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 43. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score as 15, indicating intact cognition. The MDS included diagnoses of anxiety, depression, other psychoactive substance use, unspecified with mood disorder, and psychophysiologic insomnia.Resident #1's Medication Administration Record (MAR) for September 2025 and October 2025 documented Gabapentin (pain medication also used as an antianxiety medication) ordered for three times a day omitted from evening dose 9/18/25 thru 10/7/25. On 10/21/25 at 12:35 PM the Director of Nursing (DON) provided the pharmacy delivery records for Gabapentin since admission 0n 8/1/25. She reported she would look further into the discrepancy with the medication.Resident #1's pharmacy delivery records noted they delivered 42 tablets on 8/1/25, 90 tablets on 8/14/25 and 90 tablets on late evening of 10/6/25. When compared to the MARs for August, September, and October of 2025 noted Resident #1 received their last dose of Gabapentin on 9/18/25 at noon, and they didn't receive any of the medication for the 3-times-a-day order after that. On 10/21/25 at 1:11 PM the DON reported she reviewed the number of Gabapentin available from the pharmacy to the MARs. Resident #1 last received their dose on 9/18/25 at noon. The facility didn't receive the new medication until 10/6/25.On 10/22/25 at 9:15 AM the DON reported they started having trouble with the Certified Medication Aides (CMA) not reporting to the nurses when medications are unavailable. On 10/22/25 at 1:30 PM the DON reported no staff reported concerns with pharmacy. They didn't know for sure what the staff did with faxes back from the pharmacy. On 10/22/25 at 3:25 PM the DON reported the CMAs should contact the nurse when they found the medication unavailable. then the nurse should have contacted the physician, pharmacy and the responsible party. She verbalized if the pharmacy didn't deliver the medication the next day, the nurse should have followed up with the pharmacy until they resolve the issue.On 10/22/25 at 3:30 PM the Administrator reported the staff should have notified the nurse of the unavailable medication, then the nurse should notify the physician and pharmacy as soon as possible. If the facility didn't receive the medication on the next delivery, the nurse should call the pharmacy again to resolve the situation.The facility policy titled Acute Change in Condition Policy lacked direction for staff if medication was not available.

Based on record review, policy review, and staff interviews the facility failed to report within the required time frame an allegation of abuse to Iowa Department of Inspection and Appeals and Licensing (DIAL) for 1 of 1 resident reviewed (Resident #1). The facility reported a census of 37 residents. Findings include: Review of the facility intake information reported to DIAL documented the facility reported Resident #1 had an allegation of missing money on 3/7/25 at 5:23 PM. The facility staff learned of the incident when Resident #1 reported it on 2/25/25. During an interview on 3/25/25 at 1:20 PM, the Social Service Designee reported Staff A, Certified Nurses' Aide (CNA), told her Resident #1 reported he had missing money on 2/25/25. The Social Services Designee reported it right away to the Director of Nursing (DON) during the morning meeting after they verified Resident #1 was missing $50. The Administrator instructed her to check Resident #1's room to make sure he didn't miss place it. The Social Services Designee reported back to the Administrator, they didn't find the money when they searched the room. During an interview on 3/26/25 at 9:30 AM, the Administrator reported she didn't feel Resident #1 had missing money because he had a history of misplacing things and she thought they would find the money. The Administrator acknowledged she should have reported it to DIAL within the required time frame. During an interview on 3/26/24 at 3:06 PM, the Director of Nursing reported the allegation of abuse should have been reported to DIAL within the required timeframe. The facility Abuse Prevention, Identification, Investigation, and Reporting policy revised 7/8/24 directed that staff must report allegations of abuse within 24 hours of the event that caused the allegation involving neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation, but did not result in serious bodily injury.

Based on clinical record review, facility medical record, family, volunteer, resident, and staff interviews the facility failed to revise and implement interventions on the comprehensive Care Plan to include redirection for a resident with a known behavior of packing food into her mouth for 1 of 5 residents reviewed (Resident #2). The facility reported a census of 39. Findings Include: Resident #2 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 6, indicating severe cognitive impairment. The MDS included diagnoses of traumatic brain dysfunction (brain damage caused by an outside force), heart failure, hypertension (high blood pressure) and type 2 diabetes mellitus (a chronic condition where the body does not produce enough insulin). The MDS documented no swallowing disorders. The Care Plan Focus initiated [DATE] reflected Resident #2 had activities of daily living (ADL) self-care performance deficit related to confusion and impaired balance. The Intervention directed the staff Resident #2 had the ability to feed herself, but she could need cueing and set up assistance with her meals. The Care Plan Focus initiated [DATE] identified Resident #2 had the potential for nutritional problems related to her medical condition. The Care Plan directed staff to monitor, document and report to the primary physician as needed for signs and symptoms of dysphagia (pocketing food, choking, coughing, holding food in mouth, several attempts at swallowing). The Care Plan lacked information about Resident #2 packing food into her mouth. The Clinical Physician Orders printed [DATE] at 1:10 PM included a diet order dated [DATE] of a regular diet, regular texture, regular fluid, thin consistency (there was no change in texture or consistency of the food she was served). The Nutrition Progress Note completed [DATE] documented Resident #2 ate ,d+[DATE]% of her regular diet independently after set-up assistance. She accepted fluids and snacks at times. The note listed Resident #2 as edentulous (without teeth) with no reported issues chewing or swallowing. The Health Status Note dated [DATE] at 12:04 PM reflected Resident #2's tablemate alerted the staff of her possibly choking at 8:00 AM. The Certified Medication Aide (CMA) started the Heimlich maneuver, when the writer arrived, they took over. Resident #2 slumped to the floor, staff verified her code status and initiated cardiopulmonary resuscitation (CPR). The staff called 911 and the emergency responders arrived in around 2 minutes. They took over CPR and transferred her to the hospital. The writer notified Resident #2's sister of her condition. During an interview on [DATE] at 9:49 AM Staff A, Social Services, reported they observed Staff B, CMA, providing the Heimlich maneuver on Resident #2 on [DATE]. Staff A stood at the end of the hall approximately 60 feet away. Staff A proceeded down the hall and took over the Heimlich maneuver. Resident #2 became unresponsive and Staff B lowered her to the floor. Staff A verified they knew Resident #2 stuffed her mouth with food. During an interview on [DATE] at 11:17 AM, Staff B, revealed she saw Resident #2 walk away from the table on [DATE]. The tablemates alerted Staff B that Resident #2 stuffed 3 donut holes into her mouth. Staff B, approached Resident #2 and attempted to speak with her. Staff B revealed she observed a change in facial coloration in Resident #2. Staff B, CMA implemented the Heimlich maneuver. Staff B acknowledged they knew Resident #2 could pack her mouth while eating, but never observed her choke before the incident. On [DATE] at 1:49 PM Staff C, Certified Nurse Aide (CNA), acknowledged they knew Resident #2 could pack food in her mouth. Staff C stated she took handfuls of food at a time. Staff C reported they sometimes sat with Resident #2 while she ate. Staff C reminded Resident #2 to chew the food and take smaller bites. On [DATE] at1:54 PM Staff D, CNA, reported Resident #2 packed her mouth with food. At times Staff D sat with her as she ate. During an interview on [DATE] Staff E, CNA, reported they knew Resident #2 would place large amounts of food in her mouth. Staff E cut Resident #2's food into smaller bites. During an interview on [DATE], Staff F, Registered Nurse (RN), revealed she initiated Cardio Pulmonary Resuscitation (CPR) when they lowered Resident #2 to the floor on [DATE]. She didn't notice food in Resident #2's mouth. During an interview on [DATE] at 12:47 PM Staff G, Assistant Director of Nursing (ADON), acknowledged she updated the Care Plans on a day to day basis. Staff G explained didn't know Resident #2 stuffed her mouth with food while eating. During an interview with the Director of Nursing (DON), on [DATE] at 1:04 PM she indicated the CNA's reported their concerns directly to the nurses, ADON, and DON. Review of the Facility Care Plan, Comprehensive Person-Centered Care policy revised [DATE] instructed the following: a. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered Care Plan for each resident. i. The IDT includes: 1. The attending physician 2. A registered nurse who has responsibility for the resident 3. A nurse aide who has responsibility for the resident 4. A member of the food and nutrition services staff 5. The resident and the resident's legal representative (to the extent practicable) 6. Other appropriate staff or professionals as determined by the resident's needs or as requested by the resident b. The Care Plan Interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 1. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. 2. Assessments of residents are ongoing and Care Plans are revised as information about the residents and the residents' conditions change.

Based on observation, policy review, and staff interview the facility failed to serve hot food at a temperature of at least 135 degrees Fahrenheit (F) for 1 of 1 test tray requested. The facility reported a census of 38 residents. Findings include: The facility provided a test tray on 12/10/24 at 12:06 PM. The food temperatures measured the following: a. The casserole temperature - 55 degrees Celsius (C) or 131 degrees F. b. The beans temperature - 47 degrees C or 116.6 degrees F. Staff C, Dietary, confirmed she took the temperatures in Celsius. She reported she didn't know what the expected temperature of the food should measure. During an interview on 12/10/24 at 1:01 PM, the Dietary Manager explained they should serve the hot food at a temperature of at least 154 degrees F. The facility policy titled Food Preparation and Service, last revised October 2017, directed the staff to maintain hot food temperatures above 135 degrees F.

Based on clinical record review, staff and resident interviews, and observations the facility failed to provide appropriate supervision in accordance to a resident's Care Plan to ensure the safety of fell ow residents for 2 of 4 residents reviewed (Resident #3, #18). The facility reported a census of 45 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE] Resident #3 had diagnoses which included Alzheimer's, Dementia, anxiety, and depression. The resident had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. The resident exhibited behaviors of physical and verbal aggression towards others, putting others at risk. Resident #3 required supervision with transfers, ambulation, dressing, and eating. Review of the resident's Care Plan revised on 4/24/2023 informed staff Resident #3 had potential to demonstrate verbal and physically abusive behaviors. The Care Plan directs staff to provide 1:1 supervision until cleared by the psychiatric provider, administrator/director of nurses, and the primary care physician due to physically aggressive episodes on 4/13/23 and 4/20/23. The Care Plan directed the staff to call the police to assist in calming down the resident if needed and to send to the emergency room for evaluation and possible treatment. The Care Plan indicated the resident had physical aggression on 4/13/23 which resulted in a transfer to a local emergency room for medication review and to be placed on 1:1 with staff. The Care Plan revealed the resident had another physically aggressive episode on 4/20/23 which resulted in another transfer to a local emergency room , staff were directed to continue 1:1 supervision. Further review of the Care Plan revealed the staff failed to update the resident's Care Plan after he assaulted a female peer on 7/9/23. Review of the Progress Notes revealed: a. A note dated 4/13/2023 revealed Resident #3 punched a peer twice in the face. The staff transferred the resident to a local hospital for evaluation and placed Resident #3 on 1:1 supervision after the incident to protect other residents. The resident returned to the facility after the emergency room visit. b. A note dated 4/20/2023 revealed Resident #3 struck a peer in the chest with a closed fist. The staff transferred the resident to a local hospital for evaluation. The resident returned to the facility after the emergency room visit. The staff were directed to maintain the resident on 1:1 supervision. Review of the Progress Notes revealed the staff failed to document the Resident's assaultive behavior on 7/9/2023 which resulted in Resident #18 being transferred and evaluated in a local emergency room . Review of a Psychiatry Progress Noted dated 6/14/2023, the notes revealed diagnoses which included anxiety and dementia likely due to Alzheimer's disease, with behavior and mood disturbances, physical aggression, and irritability. The note stated on 2/22/23 the resident struck another resident twice in a 72 hour time frame, he had low tolerance for frustration and had been impulsive, putting himself and others at risk. A note labeled 5/16/2023 reveals the resident had been aggressive again with multiple altercations and a visit to a local emergency room . Review of the Point Click Care Behavior monitoring documentation form revealed the staff are required to document if the resident showed any signs of physical behavioral symptoms directed at others such as hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. Review of the form revealed the staff checked yes (indicating behaviors were present) on 7/9/23. Observations on 7/19/2023 from 10:40 am to 2:50 pm revealed Resident #3 in his room with the door closed without staff outside his room. It was noted on the left side of his door frame there was a non-functioning motion alarm. Observations on 7/19/23 at 11:05 am, 11:35 am, 11:50 am, 12:05 pm, 12:25 pm, and 2:50 pm, no staff present in the hall or at either end of the resident's hall watching the resident on 1:1 as directed per the Care Plan. During an interview with Staff A, Administrator, on 7/19/23 at 1:05 pm, the Administrator stated the 1:1 supervision on Resident #3 is open ended. Staff A reported the incident to DIA, informing DIA they placed the resident on 1:1 for 24 - 48 hours after the 7/9 incident and would then re-evaluate him. During this interview the Administrator was questioned why the resident does not currently have staff with him on 1:1 as directed in the Care Plan, the Administrator said the resident is off 1:1, he then informed the staff they don't have enough staff to watch him on 1:1. Surveyor informed Staff A that other staff in the building thought the resident was still on 1:1 and upon reviewing the assignment sheet there is a person assigned to do the 1:1 on the day shift today but that staff is not working today. The Administrator stated he hasn't told the staff yet the resident is off 1:1 supervision. During an interview with Staff B, Director of Nurses (DON) on 7/19/23 at 1:00 pm, Staff B stated on 7/9/2023 Resident #3 should have been observed on 1:1 supervision but was not being observed. The resident assaulted a female peer (resident #18) after the peer told Resident #3 he could not have a piece of her pizza. Resident #18 yelled No and he struck her. Staff B stated she was in the building painting her office but was not working. Staff C, LPN came to her office and reported the incident to her. Staff B asked Staff C who was 1:1 with the resident at the time of the assault, Staff C responded she did not know he was to be watched on 1:1. Staff B gave directive to keep Resident #3 away from the Resident #18 and to complete the appropriate paper work. Staff C failed to complete any paper work and when her shift was over she failed to return to work on her next assigned shift. Staff B stated no reports or paperwork were completed after the incident. Staff B stated she has reached out to Staff C, LPN several times without a response. Resident #18 (female peer who was assaulted) went to a local emergency room after the incident for an evaluation due to the assault. During review of assignment sheets dated 5/24 - 5/27/23, the sheets revealed a specific place to write each staff's name assigned to do 1:1 observations with 5 out of 12 shifts not assigned. During review of assignment sheets dated 7/1-7/11 the sheets revealed the following information: a. The assignment sheets revealed a designated place for each shift to write staff's name assigned to do 1:1 observations with blanks noted on 7/1 and 7/2 night shift and only 2 hours assigned for the evening shift. b. On 7/3 and 7/4 no staff assigned on evening and night shift. c. On 7/5 only 4 hours assigned on the evening shift and no staff assigned on night shift. d. On 7/6 and 7/7 the facility failed to assign staff to do 1:1 for all 3 shifts. e. On 7/8 no staff assigned to do the night shift observations. f. On 7/9 no staff assigned to complete 1:1 observations on evening and night shift (the evening Resident #3 assaulted Resident #18). g. On 7/10 no staff assigned to complete 1:1. h. On 7/11 no one assigned to observe on the resident on the night shift. On the bottom of all assignment sheets dated 7/1-7/11/23 there was a note informing staff - If there is no one scheduled to do one to one the staff will need to take turns spending time with him, the initials of the Director of Nurses followed the directive. Interview with the Director of Nurses on 7/19/23 indicated she placed this directive on the bottom of all assignment sheets. The 1:1 assignment is for Resident #3 due to assaultive behaviors. She stated all of the staff knew Resident #3 required 1:1 supervision at all times. During an interview with Staff D, Certified Nurses Aide on 7/19/23 at 3:00 pm, the CNA stated she worked the evening of 7/9 when Resident #3 assaulted Resident #18, she stated the incident occurred around 4 pm. Staff D stated all the staff knew Resident #3 required 1:1 supervision but they did not have enough staff to do this. Upon reviewing the staffing sheet for 7/9/23, she acknowledge no staff were assigned to provide 1:1 supervision for the resident and indicated in that case if no one is assigned the staff are to take turns but she stated they couldn't do that either due to not enough staff. She revealed we needed more staff, you cannot have only 3 aides for the entire building. The building has 4 separate halls and we only had 1 nurse, 1 certified medication aide and 3 certified nurses aides working. Staff D stated Resident #3 has been on 1:1 supervision for at least the past 2 months that she knows of for assaultive behaviors. During an interview with Resident #3's Medical Provider on 7/24/23 at 3:30 pm revealed she last saw the resident on 7/10/23 after he assaulted a female peer. She indicated the staff were to monitor him 1:1 due to his aggressive behaviors. During an interview with Staff E, RN/Nurse Consultant on 7/19/23 at 2:30 pm, Staff E indicated Resident #3 was to be observed on 1:1 due to assaultive behaviors on the day he assaulted Resident #18 on 7/9/23. Staff E revealed that possibly the staff did not know or was not aware the resident required 1:1 supervision in accordance to his Care Plan. The facility does not have a policy for 1:1 resident monitoring. Review of an Incident Report dated 7/9/23 completed by the Director of Nurses, provided to the surveyor on 7/19, revealed the nurse responsible for the care of Resident #3 on 7/9/23 received a report that Resident #3 struck Resident #18 in the face. The Incident Report indicated the incident was witnessed by another resident. The DON directed the nurse to separate the two residents and place Resident #3 on 1:1 supervision. Review of a second copy of the 7/9/23 incident report completed by the Director of Nurses and received on 7/26/23, the DON indicated the responsible nurse received re-education regarding previous directives that Resident #3 was on 1:1 supervision at the time of incident. During an interview with Resident #13 on 7/24/23 at 8:40 am, the resident stated she witness Resident #3 strike Resident #18 in the face while they sat in the dining room. She stated she could not remember the exact date but it was several weeks ago. The resident indicated Resident #3 walked up to Resident #18, told her to shut up and then hit her in the face. Resident #3 turned around sat down, then stood again heading back to Resident #18, yelling at her again. Resident #3 stated at the time of the incident no staff were in the dining room but after the incident they had a staff follow him around. Resident #3 stated it was frightening to watch that. Review of Resident #3's clinical record revealed an Interdisciplinary Note dated 7/21/23: After meeting with the team it was decided the resident could be taken off 1:1 observation with continued monitoring of behaviors. During an interview with Staff B, DON on 7/25/23 at 1:00 pm, the DON stated the staff did not document when they watched him on 1:1 or signed off they completed the monitoring. 2. According to a Minimum Data Set (MDS) dated [DATE] Resident #18 had diagnoses which included dementia, diabetes, heart disease, and anxiety. The resident had a Brief Mental Status Score of 15 which indicated she had intact cognitive ability. The resident independently moved about the facility with the assistance of her walker. Review of the Care Plan last revised on 10/25/22 indicated Resident #18 is dependent on staff for cognitive stimulation and social interaction due to anxiety. The resident moves about the facility independently with the use of a wheel walker. During an interview with the resident on 7/24/23 at 11:00 am, the resident stated some man hit her in the face while she sat in the dining room. The resident does not know his name but became tearful stating how much it hurt. She indicated he struck her in the jaw. She stated she does see the person who struck her in the hall and voiced she is afraid of him. Review of an Incident Report dated 7/9/23 at 10:05 pm revealed the following information: The Resident passed the medication cart at 4:00 pm and was crying and upset that Resident #3 hit her in the face. Staff C, LPN assessed the resident and asked what happened. She reported Resident #3 walked up to her and struck her in the face. There was no noted redness but had a slight bump on the occipital portion of head which is raised slightly and the front area above right temporal was red. Staff C alerted the family who wanted their loved one assessed at the hospital. The resident then went to a local emergency room for an evaluation. Ice applied and neurological checks initiated. The police were notified.

Based on observation, clinical record review, interviews, and facility policy review the facility failed to ensure a safe transfer for 1 of 5 residents reviewed, Resident #11 . Resident #11 required assistance of two staff with a full mechanical lift for transfer. On 5/20/23 two nursing staff transferred with a full mechanical lift when the lift tipped and the resident fell to the floor. Resident had previously fallen from the same type of lift when the lift tipped during a transfer on 1/29/23. The facility failed to identify the cause of the lift tipping and implement any measures to provide a safe transfer. A Root Cause Analysis (RCA) completed following the second fall determined that a new wheelchair had been provided that because of its size wasn't being positioned between the legs of the lift to properly approach and lift resident from the front. The resident sustained a fall that caused her back pain and fear of transfer. The facility reported a census of 46 residents. Findings include: The Minimum Data Set (MDS) assessment with a reference date of 4/11/23 for Resident #11 documented a score of 8 of 15 on Brief Interview for Mental Status (BIMS) test which indicated moderately impaired cognition. The resident had diagnoses that included Type 2 Diabetes Mellitus, morbid obesity, Schizophrenia, respiratory failure, anxiety, and depression and required extensive assistance of two staff for bed mobility and transfer. The resident had no falls since reentry. A Nursing Care Plan with a target date of 7/26/23 identified a focus area: ADL (Activities of Daily Living) performance deficit related to obesity, pain, and schizoaffective disorder with a goal to maintain current level of functioning, and directed the following interventions: Transfer with assist of 2 to get in and out of bed with hoyer (brand of full mechanical lift). A facility incident report documented a witnessed fall on 5/20/23 at 4:15 p.m. The report documented Resident #11 was being transferred with a hoyer with 2 Certified Nursing Assistant's (CNA), legs spread on lift. Resident was lying on back. The report failed to identify any factors that caused the lift to tip. The report documented no injuries from the fall. Review of a facility document titled Root Cause Analysis 5 Whys Worksheet dated 5/24/23 identified the problem as: Facility failed to safely complete hoyer transfer. Identified wide wheelchair provided by hospice had not worked with the current lift to have the legs of the lift spread when approaching the wheelchair from the front. Identified that the new wider wheelchair would not fit between the legs of the lift when approached from the front. Staff failed to communicate that new wheelchair required a change in how the transfer was completed. Solution identified included: Hoyer device removed from service as a precaution, one time therapy evaluation of transfer, lift with wider base on order, re-education with CNA's via observation/return demonstration, review with hospice regarding communication regarding resident equipment. A nursing progress note dated 5/20/23 at 5:08 p.m. documented Resident #11 was being transferred per hoyer, 2 CNA present, hoyer tipped over, legs spread apart per protocol. CNA grabbed hoyer pad before resident landed on floor to protect the head. Observation on 5/23/23 at 11:00 a.m. full mechanical lift labeled as a Invacare Reliant 600 in hallway marked with a handwritten sign attached with tape that instructed not to use lift. Observation and interview on 5/23/23 at 3:50 p.m. three CNA's entered Resident #11's room (Staff A, B, and C), transfer completed with an Invacare Reliant 600 full mechanical lift and full body sling. Legs of the lift not spread when lifted from the bed and were not opened when approached the bariatric wheelchair (wider and heavier chair designed for obese care) from its side. The legs of the lift were positioned with one leg under the wheelchair and one leg behind the back of the wheelchair. Sling was observed to not be positioned directly above the center of the wheelchair seat. Staff pulled on the side of the sling to center and align. In an interview following the transfer Resident #11 stated that she was afraid staff were going to drop her when she is transferred with the lift, but she doesn't want to just stay in bed. She additionally mentioned that she has been experiencing increased back pain following the fall from the lift however was non-specific and stated that she does take medications for pain already. In an interview on 5/23/23 at 4:15 p.m. Staff D, Licensed Practical Nurse (LPN) confirmed that when he entered the room after the fall the legs on the lift were spread apart and the CNA had reported that she had prevented the resident's head from striking the floor. Staff D stated that he was not sure what had happened, was unable to identify at what point during the transfer the mechanical lift had tipped and wondered if it was weight distribution. Pulled the lift involved out of service but confirmed that the lift that was used to return her to bed was the same type of lift. Staff D was unable to identify any new interventions or education targeted at preventing the lift from tipping that had been implemented. In an interview on 5/24/23 at 1:51 p.m. Staff E, CNA confirmed that she was one of the CNA's involved in the transfer on 5/20/23. She described that they were getting Resident #11 out of bed, had hooked up the sling and pulled the lift back to line up with the chair. Explained that Resident #11's wheelchair is so wide that you have to approach from the side. Further described that it happened so quick, the lift tipped in the direction of the residents feet when they moved the lift. Confirmed that they had spread the legs of the lift when position resident above the wheelchair. One of the lift legs was under the chair and the other leg was not. She replied that the lift had fallen completely to the floor, stated the lift is just so light on the bottom. Staff E stated that she had noticed in the past that the mechanical lifts can get a little unsteady, described as [NAME] and jerky. She had heard about the lift tipping the last time with this resident but was not here for that. Confirmed that she had not had any recent training, but after the last incident had received training on how to do a safe mechanical lift transfer. Denied that approaching from the side of the wheelchair was a method that had been instructed on as being safe, instructed to approach the wheelchair from the front. In an interview on 5/24/23 at 3:48 p.m. Staff F, Agency CNA described that she and Staff E had prepared the resident for transfer, had lifted her off the bed and when they were turning her the lift just tipped, it happened so fast. Not sure why it tipped, described the lift as old and not in good shape. In an interview on 5/23/23 at 3:20 p.m. the Nurse Consultant confirmed that Resident #11 had fallen from a hoyer on a previous occasion. This incident resulted in a fall after the lift tipped in January. Following the January incident the facility had completed education with return demonstration with a nurse observing. Informed that the Administrator has a representative from their medical supply company coming to look at all the lifts and determine why this is happening. Further interview on 5/24/23 at 10:15 a.m. the Nurse Consultant replied that she had just started working on a RCA of the fall, and had not determined the cause of the lift tipping that caused the resident to fall to the ground twice. The consultant stated that she had now been made aware that a new bariatric wheelchair had been provided by hospice. Described that the new bariatric wheelchairs are twice the width of a regular wheelchair, and she had been informed that staff were unable to approach from the front and were approaching the bariatric wheelchair from the side. The consultant stated that the facility should have been informed so that they could determine how to provide a safe transfer with the new equipment. The consultant additionally responded that an investigation should have been completed that would have included: staff involved, location of the lift, at what point in the transfer, and any other pertinent information so that analysis could take place to prevent further incidents. Consultant informed that further training had taken place today regarding correct mechanical lift procedure which she described and included: would expect staff to spread the legs on the lift during transfer and would expect to approach the resident's wheelchair from the front not the side. An observation on 5/24/23 at 4:10 p.m. Resident #11 was transferred with instruction during the transfer from the Nurse Consultant. The legs on the lift were spread apart for the transfer, and the staff were able to approach the wheelchair from the front using the Invacare Reliant 600 lift. Review of a Nursing Procedure: Lifting devices last reviewed 3/17 stated the purpose was to provide safe and proper use of lifting devices. Procedures included: Refer to the manufacturer's instruction on operation of lift, 2 persons required for all mechanical lifts, electric lifts do not required the base to be opened wide and hydraulic lifts do, move the lifter to the front of the wheelchair/chair. Never approach from the back or the side.

Based on observations, clinical record reviews, facility policy review, resident, and staff interviews, the facility failed to ensure 1 of 9 residents reviewed (Resident #41) was free from physical abuse resulting in injury. The facility failed to put interventions in place for a resident with a known history of violent behavior (Resident #22) to protect residents. This incident constituted immediate jeopardy (IJ) to the resident's health and safety. The Iowa Department of Inspections and Appeals notified the facility of the IJ on 12/8/22 at 1:20 PM. The facility reported a census of 55 residents. Findings include: 1. The admission Minimum Data Set (MDS) dated [DATE] for Resident #22 documented an admitted [DATE] from a psychiatric hospital. Resident #22 had Level II Preadmission Screening Resident Review (PASRR) in place. The MDS identified a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS included diagnoses of anxiety, depression, schizophrenia, and dementia with other behavioral disturbances. Resident #22 could independently complete most activities of daily living including ambulation. The Preadmission Screening and Resident Review (PASRR) form completed 9/20/22 by a local hospital behavioral health center revealed Resident #22 had a known behavior of physical aggression. The PASRR documented the admitting nursing facility must incorporate PASRR findings as part of the individual's plan of care. The PASRR further documented that Resident #22 went to the emergency department (ED) at a local hospital behavioral health center the day after he hit a resident at another nursing facility. This had been the third time of being seen in the ED in the previous several days because Resident #22 chose not to take his medications and had been physically forceful with others. The resident admitted to the hospital under an emergency detention order by the State District Court of the local county after a petition had been filed by the hospital alleging the resident to be seriously mentally impaired and a harm to himself and others. A copy of the court order had been provided with the PASRR assessment. Staff at the prior nursing home documented that they did not feel Resident #22 was safe to be around others due to his physical behaviors. The PASRR included that he told his doctor that he believed that someone poisoned his food, that he heard noises that other people did not hear and voices in his head. Resident #22 had a history of talking to himself, quickly changing moods, irritability, being rude, screaming, yelling, threatening, physically forceful with others, slamming doors, restlessness, demanding of others, and seeking attention from others. Resident #22's Care Plan revised 10/27/22 revealed the resident had the potential to demonstrate verbally abusive behaviors such as yelling and having loud outbursts related to dementia. Resident #22 had ineffective coping skills and a mental/emotional illness such as schizophrenia. Resident #22 could sometimes have behaviors or hallucinations where he might yell rambled words. In addition he can also yell and be verbally abusive toward staff and or residents at times. The Care Plan included the following interventions: a. Staff to intervene when he became agitated before the agitation escalated, guide away from the source of distress, and engage calmly in conversation. If Resident #22 responded aggressively, the staff should calmly walk away and approach later. The Care Plan dated 10/27/22 identified Resident #22 had a psychosocial well-being problem (actual or potential) related to the disease process of schizophrenia, dementia, intellectual disability, anxiety, and ineffective coping. The Care Plan included the following interventions dated 10/27/22: a. When conflict arises, remove the Resident to a calm safe environment and allow him to vent/share feelings. b. The Resident needs assistance, encouragement, and support to identify problems that cannot be controlled. c. Allow the Resident time to answer questions, verbalize feelings, perceptions, and fears frequently. The Care Plan lacked direction in regards to potential violent behavior towards others, incorporation of the PASRR recommendations, and how to provide safety for the staff and other residents. 2. The quarterly MDS for Resident #41 identified a BIMS score of 15, indicating intact cognition. The MDS documented included diagnoses of anxiety, depression and cancer. Resident #41 was independent with activities of daily living (ADLs). Resident #41's Care Plan revised 11/15/22 documented that Resident #41 had a psychosocial well-being problem (actual or potential) related to diagnoses of anxiety disorder and depression disorder. The Care Plan included an intervention of when conflict arises, remove to a calm, safe environment, and allow him to vent/share his feelings. During an interview 12/5/22 at 12:52 PM, Resident #41 revealed that Resident #22 came up to him recently and said he was mad at him for something. Resident #41 stated two days later Resident #22 came up to him, punched him in the left eye, and said there you go. Resident #41 stated after Resident #22 hit him, he held his face and walked away from him. Resident #41 further stated that he never did anything to Resident #22 and that he shouldn't be doing that to people. Resident #41 stated he had to have an eye procedure rescheduled due to the swelling from being punched in the eye by Resident #22 and stated the area hurt when he touched it. The Facility Incident Report dated 11/26/22 at 12:00 PM completed by Staff L, Licensed Practical Nurse (LPN), indicated that a Certified Medication Aide (CMA) called the nurses to the front nurses' station and informed them that Resident #22 hit Resident #41. The Incident Report further documented when the nurses went to Resident #22's room they observed him with a bruise and a big lump under his left eye. Resident #41 informed them that Resident #22 hit him. During an interview on 12/7/22 at 10:14 AM, Staff E, CMA, reported that on Thanksgiving Day she worked the C/D hall when she heard Resident #41 yelling. She stated that she saw Resident #22 in front of Resident #41 punching into the air in front of him screaming, I'm going to kill you! I'm going to kill you! Staff E explained that she left the medication cart to separate the two residents and directed Resident #41 to sit back down in the chair, in which he did. Staff E stated that she went back to the medication cart to complete the narcotic count. Staff E stated she then heard Resident #22 holler out again and as she turned around from the medication cart she saw Resident #22 hit Resident #41 in the eye. Staff E stated that she couldn't remember which eye was hit or which hand Resident #22 used but Resident #41's eye was black the Saturday after Thanksgiving. The facility policy titled, Abuse Prevention and Reporting, revised August 2019 revealed residents must not be subjected to abuse by anyone including other residents. The policy directed staff to identify, correct, and intervene in situations where resident to resident abuse is most likely to occur and provide protection by immediately separating the residents involved, moving the resident to another room or unit, providing 1:1 monitoring as appropriate, implementing discharge process immediately if the resident is a danger to themselves or others and initiating behavior crisis management interventions as applicable. During an interview on 12/13/22 at 9:35 AM, the Director of Nursing (DON) reported that if Resident #22 was being that aggressive toward Resident #41, she would have separated the two completely to a different room and contacted the provider in regards to the behavior including directing the use of as needed medication, contacting psychiatry and most likely starting a one on one (1:1). The DON further revealed that she expected the staff to intervene in order to prevent abuse, to give Resident #22 space, then ensure residents and staff stay away from him. The DON added Staff G, Registered Nurse (RN), remained sore after being hit by Resident #22. During an interview on 12/19/22 at 11:24 AM, the Administrator revealed it is an expectation that staff keep residents safe from abuse by intervening when needed, following policy, reporting to the Director of Nursing and/or Administrator as needed. The Abuse Prevention and Reporting Policy, dated August 2019, provided by the facility stated the facility prohibited the mistreatment, neglect, and abuse of resident, and misappropriation of resident property by anyone including but not limited to staff, family, or friends. Residents have the right to be free from verbal, sexual, and mental abuse, neglect, misappropriation of resident property, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The Policy defined Resident to Resident abuse as resident to resident physical contact that occurs, which includes but is not limited to where residents are hit, slapped, pinched or kicked and results in physical harm, pain or mental anguish. The Policy directed the staff to provide for the immediate safety of the resident upon identification of suspected abuse, neglect or mistreatment by immediately separating the resident from the alleged perpetrator, moving resident to another room, providing 1:1 monitoring as appropriate and implementing discharge processes immediately if the resident is a danger to self or to others. 42133 During an interview on 12/5/22 at 11:04 AM Resident #25 reported that Resident #22 at the end of her hallway is dangerous. He is hitting everyone. He punched a guy that lives on the A hallway. We should not have to live in danger every day. The staff lets him do whatever he wants to do because they are all afraid of him. During an interview on 12/5/22 at 11:05 AM Resident #16 reported she is tired of living in fear and shouldn't have to live in fear every day. On 12/12/22 at 3:48 PM the Administrator provided additional documentation of staff education for 1:1 supervision to all staff and updated the education on handling agitated/aggressive behaviors to ensure staff had received the required information. The Administrator or her Designees provided staff education on-site and via telephone to employees regarding the requirements of 1:1 supervision. The facility implemented the use of walkie talkies to communicate if someone needed to come takeover 1:1 supervision for Resident #22. They revised the daily wing schedules to assign the employee responsible for providing the 1:1 supervision and implemented the use of a sign in/out sheet for those staff providing the 1:1 supervision. The 1:1 supervision education specified Resident #22 to be under supervision at all times. When the Resident is in his room staff may remain outside of the room door. If the Resident is in the hallway, they must be within arms-length of the Resident. The Plan was submitted to the Surveyor via email at 3:48 PM. During an interview on 12/13/22 at 6:03 AM Staff Z, CNA, reported that she had been assigned to do one to one supervision for Resident #22. She reported she had been with him from 11:00 PM until 6:00 AM that morning. He had been in the front lounge until around midnight, then he went back to his room, and went to bed. Resident #22 slept from midnight to 5 AM, when she reported at 5 AM she got him up and brought him out to the dining room for coffee and cookies. Resident #22 observed at this time sitting at the dining room table drinking coffee and eating cookies, under 1:1 supervision. During an interview on 12/13/22 at 6:13 AM Staff X reported they were able to monitor Resident #22 with 1:1 for supervision during the night. He reported the resident had a good night sleeping from midnight to 5 AM which is his normal routine. He reported he planned to talk with the Director of Nursing (DON) and Administrator about covering the resident's mirror or taking the mirrors out of the room since the mirror seems to trigger his screaming and yelling. During an interview on 12/13/22 at 9:35 AM the Director of Nursing (DON) reported if a resident is aggressive the resident should be separated back to a different room. The physician should be contacted to give direction on what to do. She would probably put the resident on one to one supervision. When Resident #22 was at the hospital. They had done medication management on him and he didn't have behaviors and had been pleasant. He had bouts in front of the mirror but did not have physical aggression with anyone. She said there were no changes in the Care Plan after the staff observed him air punching, punching the back of the couches, and the door. She told the staff that his sister-in-law was very adamant that he has to get his medications to stay stable for his mental condition. If he didn't take his medications, they would re-approach him, and find a different staff member to try to get his medication administered. If that was unsuccessful, the staff were to try to call the sister-in-law to see if she could convince him to take his medications. The last resort is to call the DON to come give his medication. He has a delusional thought process. Some employees state they will not intervene as they do not want to get hit, but she has educated if any other residents come within the vicinity of Resident #22 they need to try to keep the other resident out of Resident #22's space. The Behavioral Management, Care Management Reference Anger and Aggression Policy dated 5/15 provided by the facility as a policy for accident/supervision documented the following approaches to be utilized: Dementia and/or related disorders: 1. Rule out potential causes of delirium or infection 2. Respond to cues of stress 3. Evaluate for pain, hunger and need to toilet 4. Reduce potential for injury 5. Plan for regular exercise 6. Be consistent Psychiatric Disorder: 1. Maintain a safe distance for caregivers and other resident/patients and visitors 2. Remove dangerous objects as able 3. Evaluate for depression and/or psychosis 4. Utilize behavior tracking records to determine time, place, possible triggers and meanings of behavior 5. Listen and validate feelings related to loss and grief 6. Acknowledge anger 7. Avoid rationalization and arguments 8. Include resident/patient and family/responsible party in planning the day and associated cares as much as possible; allow the resident/patient to have control over decisions as much as possible The Facility abated the immediate jeopardy on 12/12/22, decreasing the scope and severity to a D level deficiency.

Based on observations, clinical record reviews, resident, family, and staff interviews, the facility failed to assess and intervene for the necessary care and services, to maintain a resident's highest practical physical well-being. The clinical record review revealed the nursing staff failed to provide a timely thorough assessment for 1 of 13 residents reviewed (Resident #5). The facility's failure to provide a timely assessment and intervention resulted in an immediate jeopardy (IJ) to the residents of the facility. The Iowa Department of Inspections and Appeals notified the facility of the IJ on 12/8/22 at 9:53 AM. The facility decreased the citation to a D level prior to exit of the survey. The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of coronary artery disease (CAD), heart disease, diabetes, and seizures. The MDS indicated that Resident #5 had an inability to walk and needed two persons to assist with transfers from their bed to their wheelchair using a sit to stand lift. The Care Plan dated 10/21/22 for Resident #5 directed staff to monitor his blood pressure, notify the physician of any abnormal readings, and monitor/document/report to the physician any symptoms of coronary artery disease (CAD) to include chest pain or shortness of breath. During an interview on 12/7/22 at 12:46 PM Resident #5 stated about two weeks before, he had trouble breathing for four days, he didn't feel well, he slurred his words and the nurse did not check on him. Resident #5 stated Staff F, Certified Nursing Assistant (CNA), took him to the front office as he couldn't breath and he wanted to call for help. Resident #5 stated Staff G, Registered Nurse (RN), took his blood pressure then left. Resident #5 stated after that Staff F told the 2 PM - 10 PM nurse, Staff I, Licensed Practical Nurse (LPN), who assessed him and called the physician. During an interview on 12/6/22 at 10:15 AM Staff F explained that she notified Staff G that Resident #5's leg was very swollen, And they blew it off. Staff F stated a week later (12/1/22) Resident #5 was having difficulty breathing with a blood pressure of 243/101 (average blood pressure is 120/80), extremely high. Staff F reported that she told Staff G who took a manual blood pressure and stated it was 143/92. Staff F stated she lied. Staff DD, Director of Physical Therapy (DPT) took Resident #5's blood pressure and reported it was over 200. Staff F stated she reported the elevated blood pressure to Staff G again who replied that the nurses were going into report. Staff F stated Staff I was the next nurse on duty, who assessed Resident #5 and sent him to the hospital. During an interview on 12/7/22 at 2 PM Staff I explained that Resident #5 stayed in the hospital for two weeks. Staff I reported that when she came to work on 12/1/22, she saw Resident #5 with Staff F in front of the Director of Nursing's office, they were checking his blood pressure. Staff I stated Staff G reported Resident #5 blood pressure as 140/unsure. Staff I said she went and assessed Resident #5's blood pressure. She got a reading of 200/105, Resident #5 complained about shortness of breath, and had diminished lung sounds. Staff I added that she offered Resident #5 to go to the emergency department (ED), If he wants to go to the hospital, that's serious, because he never wants to go. Staff I stated the Emergency Medical Staff (EMS) were in the facility for another resident but took Resident #5 first as he was more serious. During an interview on 12/7/22 at 1:19 PM Resident #5's Representative said that she visited on 11/25/22. She explained that he looked like the Hulk, as his right arm appeared swollen three times its normal size. Resident #5's Representative stated the nurse was not worried about him. Resident #5's Representative stated Resident #5 called on 12/1/22, claiming that he couldn't breath and that he was on his way to the hospital. Resident #5's Representative stated Resident #5 legs were very swollen, they removed 18 pounds of fluid off of him. Resident #5's Representative stated the hospital doctor told her to keep on at the nursing home to weigh him daily. Resident #5's Representative stated the facility had not weighed the resident yet as of the time of the interview. During an interview on 12/7/22 at 3:04 PM Staff H, LPN, stated he worked before 11/25/22 and didn't assess Resident #5, He follows cardiology and his legs are always swollen. The Physician's Order dated 9/26/22 directed to weigh Resident #5 daily. During an interview on 12/8/22 at 12:15 PM Staff F said the could not weigh Resident #5 due to the mechanical lift scale being broken. The Nurses' Notes dated 11/23/22 at 12:51 PM, the Physical Therapist (PT) notified the nurse of 2-3 pitting swelling in both of Resident #5's legs. The nurse notified the physician and requested an order for compression socks if approved by the wound clinic. The Health Status Note dated 11/23/22 at 6:58 PM indicated that Resident #5's primary care provider (PCP) called regarding the request for compression stockings. The PCP directed to let the Wound Clinic decide the course of action. The Health Status Note dated 11/25/22 at 10:55 AM documented a call placed to the Wound Clinic. The Wound Clinic reported that had no provider that day and they planned to assess him on his next appointment on 12/2/22. The nurse notified the physician office who would not give an order for an antibiotic therapy at that time. The physician's office directed to monitor his site and if necessary he could be seen in the Wound Clinic earlier in the week. The Nurses' Notes dated 12/1/22 at 3:15 PM indicated that Resident #5 had shortness of breath, a pale face, an elevated blood pressure of 200/105, a pulse of 89, respirations of 28, diminished lung sounds throughout and a negative COVID-19 test. The nurse notified the physician, who provided an order to transfer Resident #5 to the hospital. At the time of the order an ambulance was at the facility, and the nurse notified the daughter of transport to the hospital. Resident #5's clinical record lacked additional assessments prior to his admission to the hospital on 12/1/22. Resident #5's Hospitalist History and Physical dated 12/1/22 at 6:33 PM indicated that he presented to the ED for high blood pressure and shortness of breath. He had a past medical history significant for CAD, heart failure with preserved ejection fraction (EF, a measurement used to determine the amount of blood that leaves your heart each time it contracts), type 2 diabetes insulin dependent, essential hypertension, and epilepsy. Resident #5 reported that he had high blood pressure that day and went to the ED. He reported having shortness of breath for at least a few days, worse with activity, but improved with rest. His shortness of breath improved after receiving Lasix (diuretic, releasing excess fluid from the body) in the ED. The ED course indicated he had no fever with a blood pressure on admission in the hypertensive urgency/emergency ranges (dangerous blood pressures), hypoxic (decreased oxygen) down to 88% that improved to 100% on 3 Liters (L). A chest x-ray revealed vascular congestion (fluid around his heart). The assessment determined a blood pressure of 186/92 and a weight of 291. The Impression indicated Resident #5's principle problem as a hypertensive emergency (high blood pressure) with active problems of acute decompensated heart failure, elevated troponin, benign hypertension, CAD, hyperkalemia (elevated potassium), type 2 diabetes, and anemia. Resident #5 denied chest pain but did have nitroglycerin in the ambulance. Resident #5's Hospital Notes dated 12/4/22 at 3:32 PM revealed he had a stroke due to being severely hypertensive (high blood pressure) on admission to hospital. The diuretic medication removed 18 pounds of fluid, with a weight of 273 pounds, and blood pressure stable at 120/56. On 12/8/22 at 10:41 AM the Director of Nursing (DON) stated she did not assess Resident #5 when he was brought up to her office. During a follow-up interview on 12/8/22 at 1:20 PM the DON stated she would expect the nurse to do treatments as ordered. The DON stated they are working on more specialized training and will have a new ADON next week. The facility removed the IJ and decreased the severity to a D level deficiency on 12/8/22 by doing the following: a. On 12/8/22 the nurses assessed the residents for signs and symptoms of a change in condition. The nurses notified the physician as necessary. b. The DON/Designee educated the licensed nurses on 12/8/22 related to completing timely assessments when a resident presents with a change of condition. Any licensed nurse who did not receive their education on 12/8/22 will complete their education prior to their next scheduled shift.

Based on observation, resident and staff interviews, record review and policy review, the facility failed to provide appropriate supervision in order to prevent physical abuse of 1 of 9 residents reviewed (Resident #41) resulting in injury and one staff member, Staff G, Registered Nurse (RN). The facility failed to put interventions in place for a resident with a known history of violent behavior (Resident #22) to protect residents and staff from abuse. Resident #22's admitted to the facility from a psychiatric hospital after assaulting another resident at a different facility. These incidents constituted Immediate Jeopardy to the resident's and staff's health and safety. The facility reported a census of 55 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] for Resident #22 documented an admitted [DATE] from a psychiatric hospital. Resident #22 had Level II Preadmission Screening Resident Review (PASRR) in place. The MDS identified a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS included diagnoses of anxiety, depression, schizophrenia, and dementia with other behavioral disturbances. Resident #22 could independently complete most activities of daily living including ambulation. The Preadmission Screening and Resident Review (PASRR) form completed 9/20/22 by a local hospital behavioral health center revealed Resident #22 had a known behavior of physical aggression. The PASRR documented the admitting nursing facility must incorporate PASRR findings as part of the individual's plan of care. The PASRR further documented that Resident #22 went to the emergency department (ED) at a local hospital behavioral health center the day after he hit a resident at another nursing facility. This had been the third time of being seen in the ED in the previous several days because Resident #22 chose not to take his medications and had been physically forceful with others. The resident admitted to the hospital under an emergency detention order by the State District Court of the local county after a petition had been filed by the hospital alleging the resident to be seriously mentally impaired and a harm to himself and others. A copy of the court order had been provided with the PASRR assessment. Staff at the prior nursing home documented that they did not feel Resident #22 was safe to be around others due to his physical behaviors. The PASRR included that he told his doctor that he believed that someone poisoned his food, that he heard noises that other people did not hear and voices in his head. Resident #22 had a history of talking to himself, quickly changing moods, irritability, being rude, screaming, yelling, threatening, physically forceful with others, slamming doors, restlessness, demanding of others, and seeking attention from others. Resident #22's Care Plan revised 10/27/22 revealed the resident had the potential to demonstrate verbally abusive behaviors such as yelling and having loud outbursts related to dementia. Resident #22 had ineffective coping skills and a mental/emotional illness such as schizophrenia. Resident #22 could sometimes have behaviors or hallucinations where he might yell rambled words. In addition he can also yell and be verbally abusive toward staff and or residents at times. The Care Plan included the following interventions: a. Staff to intervene when he became agitated before the agitation escalated, guide away from the source of distress, and engage calmly in conversation. If Resident #22 responded aggressively, the staff should calmly walk away and approach later. The Care Plan dated 10/27/22 identified Resident #22 had a psychosocial well-being problem (actual or potential) related to the disease process of schizophrenia, dementia, intellectual disability, anxiety, and ineffective coping. The Care Plan included the following interventions dated 10/27/22: a. When conflict arises, remove the Resident to a calm safe environment and allow him to vent/share feelings. b. The Resident needs assistance, encouragement, and support to identify problems that cannot be controlled. c. Allow the Resident time to answer questions, verbalize feelings, perceptions, and fears frequently. The Care Plan lacked direction in regards to potential violent behavior towards others, incorporation of the PASRR recommendations, and how to provide safety for the staff and other residents. 2. The quarterly MDS for Resident #41 documented a BIMS of 15 out of 15 indicating intact cognition. The MDS documented the resident had diagnoses of anxiety, depression and cancer and was independent with activities of daily living. The Care Plan for Resident #41 initiated 11/13/22 documented Resident #41 had a psychosocial well-being (actual or potential) related to diagnoses of anxiety disorder and depression disorder with the intervention when conflict arises, remove to a calm, safe environment. During an interview 12/5/22 at 12:52 PM, Resident #41 revealed Resident #22 came up to him recently and said he was mad at him for something. Resident #41 stated two days later Resident #22 came up to him and punched him in the left eye and said there you go. Resident #41 stated after Resident #22 hit him he held his face and walked away from Resident #22. Resident #41 further stated that he had never done anything to Resident #22 and he shouldn't be doing that to people. Resident #41 stated he had to have an eye procedure rescheduled due to the swelling that was a result of being punched in the eye by Resident #22 and stated the area hurt when he touched it. Review of facility incident report dated 11/26/22 at 12:00 PM completed by Staff L, Licensed Practical Nurse (LPN) revealed nurses were called to the front nurse's station and informed Resident #41 had been hit by Resident #22. The incident report further documented when the nurse's went to Resident #22's room they observed him to have a bruise and a big lump under his left eye and the resident informed them he had been hit by Resident #22. During an interview 12/7/22 at 10:14 AM, Staff E, Certified Medication Aide (CMA) revealed on Thanksgiving day she was working the C/D hall when she heard Resident #41 yelling. She stated Resident #22 in front of Resident #41 punching into the air in front of him screaming, I'm going to kill you! I'm going to kill you! Staff E stated she left the medication cart to separate the two residents and directed Resident #41 to sit back down in the chair in which he did. Staff E stated she then went back to the medication cart to complete the narcotic count. Staff E stated she then heard Resident #22 holler out again and as she turned around from the medication cart she saw Resident #22 hit Resident #41 in the eye. Staff E stated she couldn't remember which eye was hit or which hand Resident #22 used but Resident #41's eye was black the Saturday after Thanksgiving. Review of facility policy titled, Abuse Prevention and Reporting, revised August 2019 revealed residents must not be subjected to abuse by anyone including other residents. The policy directed staff to identify, correct and intervene in situations where resident to resident abuse is most likely to occur and provide protection by immediately separating the residents involved, moving the resident to another room or unit, providing 1:1 monitoring as appropriate, implementing discharge process immediately if the resident is a danger to self or others and initiating behavior crisis management interventions as applicable. During an interview 12/13/22 at 9:35 AM, the Director of Nursing (DON) revealed if Resident #22 was being that aggressive toward Resident #41 she would have separated the two completely to a different room and contacted the provider in regards to the behavior including directing the use of as needed medication, contacting psychiatry and most likely starting a 1:1. The DON further revealed the expectation would be for staff to intervene in order to prevent abuse, to give Resident #22 space and ensure residents and staff stay away from him. The DON then revealed Staff G that was hit by Resident #22 was still sore. During an interview 12/19/22 at 11:24 AM, the Administrator revealed it is an expectation staff keep residents safe from abuse by intervening when needed, following policy, reporting to the Director of Nursing and/or Administrator as needed. 42133 During an interview on 12/5/22 at 11:04 AM Resident #25 reported that Resident #22 at the end of her hallway is dangerous. He is hitting everyone. He punched a guy that lives on the A hallway. We should not have to live in danger every day. The staff lets him do whatever he wants to do because they are all afraid of him. During an interview on 12/5/22 at 11:05 AM Resident #16 reported she is tired of living in fear and shouldn't have to live in fear every day. During an observation on 12/5/22 at 11:49 AM Resident #22 ambulated with a four wheeled walker through the D hallway back to his room. The staff passed room trays saying hello to Resident #22's by his first name. As Resident #22 entered his room doorway, he hit the left side of his door frame with his left hand closed into a fist. He yelled that his name was not his first name, but his middle name. He proceeded to yell if you don't know English, then don't talk to me, then repeatedly yelled his name (referring to his middle name). During an observation on 12/5/22 at 11:58 AM Resident #22 sat in the room yelling loudly damn you all to hell. I told her before that I want to be left alone! Just leave me alone! God damn it! No staff or other residents were present in the room with Resident #22. Resident #22's yelling could be clearly heard up to the double doors at the entrance of the D hallway. During an interview on 12/5/22 at 12:00 PM Staff F, Certified Nursing Assistant (CNA), said that management did not give any direction. Resident #22 punched Resident #41 last week. Resident #22 is petrifying. She can usually get him calmed down but if he goes out on a rampage they just let him go because they don't want to get in his way. It's been going on for over a month. The nurses know about it. She said lately he has been punching the walls and screaming into the mirror. Staff F reported that Resident #22 came from a locked unit. During an interview on 12/5/22 at 12:50 PM Staff K, CNA, reported that Resident #22 mostly has been in his room yelling at himself. If other residents say something to him, he may yell back at the other residents. He does raise his voice at other residents, but then he will get really quiet. Staff K reported she is not afraid of him, but she does stay back because he may try to hit. She tries to keep her distance. When Resident #22 starts to scream he is ready to go at you, so you have to be careful. During an interview on 12/5/22 at 12:56 PM Staff F reported that Resident #22 has had behaviors of screaming/yelling, hitting the walls since his admission. He will say things like, No God damn it. Don't shit in my mouth. He sounds like he has another resident inside of him. He hits the wall so hard his knuckles bleed and he has had to go get band aids. He hit another resident about a week ago. He has been in the lounge punching the back of the couch. She is not sure if other residents are afraid of him. She feels he could hit another resident. You can hear other residents yelling at him. She doesn't feel like they get any direction from management on how to intervene with the resident. During an observation on 12/5/22 at 1:02 PM Resident #22 walked behind a male resident in a wheelchair stating, I'm going to kill him. I'm going to kill him. He did not make any movements toward the male in the wheelchair in front of him, Staff F intervened. He walked using a wheeled walker behind the resident through the double doors of the D hallway, through the dining room, and into the C hallway. He did not make any physical gestures and did not make any more verbal remarks. Staff F stated it has crossed her mind that Resident #22 could hurt her, but it hasn't happened, but it has crossed her mind that he could physically hurt her. During an interview on 12/5/22 at 1:11 PM Staff O, Registered Nurse (RN), reported that Resident #22 has exhibited yelling and punching with his fist into the air, like he is hitting an imaginary person. She does believe that he could hit another resident. She has not had any reports of him hitting staff and has not heard any staff state they are afraid of him. When Resident #22 is yelling and air punching, they just stay away from him. Staff O is not sure what they have instructed the staff to do in situations like that. She has not had any residents state they are afraid of him, but they do state this is not the place for him. A handwritten statement dated 12/6/22 by Staff G documented that Resident #22 sat in the dining room at 9:45 AM demanding to be called by his middle name. He screamed that he wanted to go have a cigarette and demanded Staff G let him go right now. Resident #22 then stood up and struck Staff G in the left neck/jawline. Staff N, LPN, witnessed the incident and called 911. Resident #22 sat back down in the chair and stated, don't let them take me. An undated handwritten statement written by Staff N revealed that she sat at the nurses' desk charting, while Resident #22 sat in a chair in the dining room screaming he wanted a cigarette. The CNA's were running behind for smoke breaks. Resident #22 got up and walked over to Staff G and with a closed fist hit her on the left side of her jaw and neckline. During an interview on 12/6/22 at 9:55 AM Staff G reported that Resident #22 struck her in the jaw and neck. On 12/6/22 at 10:00 AM observed the local police department on site at the facility assessing the situation for Resident #22. During an interview on 12/6/22 at 10:04 AM Staff F stated she saw Resident #22 punched the wall yesterday. During an observation on 12/6/22 at 10:05 AM Resident #22 told the police officer that he had hit Staff G because he needed a cigarette. The Emergency Medical Service (EMS) personnel arrived and started to assess the Resident. Resident #22 cooperated with the Police and EMS personnel. During an interview on 12/6/22 at 10:05 AM Staff G stated she needed to go stand outside until Resident #22 went out, then she left the area. On 12/6/22 at 10:11 AM observed EMS personnel taking Resident #22 out of the facility to the local emergency department (ED). During an interview on 12/6/22 at 11:38 AM Staff K, CNA, said that Resident #22 wanted to be called by his middle name for the last two days. He always called her by a shortened version of her name, but right before he hit her, he used her full first name stating he wanted a cigarette then he hit her so hard it knocked her dentures to the other side of her mouth. She then reported she went behind the nurses' station behind the other staff. She had been scared and reported she is now scared of Resident #22. She hadn't always been afraid of him but she verbalized she is now afraid of Resident #22. She stated Resident #22 has hit other residents. Staff K verbalized fear that Resident #22 will come back to the facility. During an interview on 12/6/22 at approximately 2:30 PM the Administrator reported if Resident #22 returns, he will be put on one to one observation by the staff. The Health Status Note dated 12/7/22 at 3:05 PM labeled as Late Entry indicated that Resident #22 returned to the facility after an overnight observation stay at the ED. While at the ED, Resident #22 received a new order of Seroquel 12.5 milligrams (MG). During an observation on 12/8/22 at 7:02 AM Resident #22 ambulated from his room at the end of D wing, all the way through the hallway, through the dining room, through the C wing, and up to the front nurses' station with no staff present. The Administrator saw him at the front double doors and asked him how his night was. He responded that it had been all right. The Administrator walked away from Resident #22 back into her office. Resident #22 then walked back through the double doors into the C wing out of the supervision of the Administrator or other staff and back to the D hallway. No staff were present in the D hallway. An empty chair sat outside Resident #22's room. During an observation on 12/8/22 at 7:53 AM Resident #22 sat on the seat of his walker eating breakfast in his room. Staff P, CNA, observed going in and out of room D 34. Staff P went out and performed hand hygiene, then entered Resident #22's room to check on him. Staff P then exited Resident #22's room and went into room D 35. Staff L, LPN, stood at the medication cart at the front of the D hallway going in and out of rooms passing medications. Staff L never looked down the hall towards the direction of Resident #22's room. At 7:55 PM Staff P came out of room D 35 and exited out of the D hallway through the double doors to the dining room. At this time Resident #22 observed yelling from his room, God damn it, stay out. During an observation on 12/8/22 at 7:57 AM the Housekeeping Supervisor came into the D hallway walking down to the shower room to obtain supplies, then left the D hallway. Staff L continued to go into random resident rooms to pass medications leaving no staff present in the D hallway. Staff L did not look down towards Resident #22's room when she returned to the hallway. On 12/8/22 at 7:59 AM observed Staff P reenter the D hallway then enter room D 35. Resident #22 started to yell loudly random words. At 8:00 AM Staff P donned personal protective equipment (PPE) to enter room D 39. Staff P entered Room D 39. Resident #22 started to yell even louder, I get no respect, repeatedly. Staff P came out of Room D 39 removing her PPE and peaked in on Resident #22. Staff P informed the surveyor that she didn't think that Resident #22 could have a roommate. Staff P then left to go into another Resident's room. Staff L not observed in the hallway at this time. On 12/8/22 at 8:02 AM witnessed Resident #22 yelling, I get no respect. You make me so nervous. I am fucking pissed at you, you fucking bitch. Fuck you. Last time God damn nuts. On 12/8/22 at 8:04 AM watched Staff P exit the D hallway through the double doors out to the dining room with the double doors closed behind her. Staff L not observed in the hallway. At 8:05 AM Resident #22 continued to ramp up screaming and yelling. At 8:05 AM Staff L came back to the hallway. Resident #22 observed walking in the room, no supervision outside of the doorway. At 8:06 AM Staff L left the hallway to enter room D 31 leaving no supervision in the hallway for Resident #22. Resident #22 continued to scream and yell from his room. At 8:09 AM Resident #22 observed sitting in front of the mirror in his room yelling into the mirror. On 12/8/22 at 8:10 AM observed Staff L return to the hallway to the medication cart to prepare medication. At 8:11 AM the Housekeeping Supervisor entered the D hallway going to the shower room to obtain supplies as Staff L went into another resident's room to pass medications. At 8:12 AM Staff P came back to the D hallway and walked to the shower room, then exited the D hallway. At 8:13 AM witnessed Staff F, CNA, entered the D hallway. During an interview on 12/8/22 at 8:14 AM Staff F stated they are to provide Resident #22 with one to one supervision. She stated she did not know who had been assigned to provide one to one supervision to Resident #22 from 6:00 AM to 8:00 AM On 12/8/22 at 8:15 AM observed Staff A, nurse aide (NA), enter the hallway carrying her purse and coat which she sat down on the chair outside of Resident #22's room. She stated she had to sit with Resident #22 to make sure that he didn't have any physical contact with anyone. During an interview on 12/8/22 at 11:26 AM Staff X, LPN, reported that Resident #22 assaulted a 100-pound lady at another nursing facility, really badly. They couldn't get him off of her. They had put the female resident in the same hallway as him and he assaulted her again. That facility sent him to the hospital and then he was admitted to Cedar Falls Health Care Center. Staff X reported being pretty upset when Resident #22 admitted to the facility. They were not given much history on Resident #22 with his admission. Staff X stated to be honest, they gave us zero guidance. He read the paperwork and he tried to give the staff guidance. He told the staff to keep an eye on him and if he got worked up to not push him, not escalate the situation, and to come get him if they needed him. Typically, they do not have issues until 5 AM then Resident #22 will get up and start hearing voices. In an email from the Administrator on 12/19/22 at 11:24 AM, the Administrator responded the expectation is that the staff keep residents safe from abuse by intervening when needed, following policy, reporting to the charge nurse, DON, and/or Administrator as needed. The Facility abated the Immediate Jeopardy on 12/12/22, decreasing the citation to a D level by ensuring the staff received education and provide a plan for one to one supervision for Resident #22. On 12/8/22 the Iowa Department of Inspection and Appeals determined an immediate jeopardy for the facility failing to provide supervision to prevent potential abuse for all other residents and staff. A Plan of Correction for removal of immediate jeopardy submitted by the facility on 12/8/22 detailed the following information: 1. Resident #22 Care Plan has been reviewed and updated by the DON/Designee on 12/8/22 with interventions regarding his history of physically aggressive behavior to ensure protection of residents and staff from physical abuse. 2. An audit was completed by the DON/Designee on 12/8/22 to identify residents with known violent behaviors to ensure their Care Plan has interventions regarding aggressive behavior to ensure protection of residents and staff from physical abuse. 3. The Regional Director of Clinical Services educated the Social Service Designee and Director of Nursing on 12/8/22 related to the requirements of implementing a plan of care that includes interventions for residents with aggressive behavior. 4. DON/Designee will complete audits of 24-hour reports including progress notes daily for 4 weeks then 5 times weekly for 8 weeks to ensure residents that present with aggressive behaviors continue to have Care Plan interventions implemented to address the aggressive behaviors. Results of these audits will be presented to the QAPI meeting monthly for 3 months for review and recommendations as needed. The DON is responsible for monitoring and following up as needed. An undated Staff Roster with the Administrator's initials handwritten by each employee's name titled Staff Education on how to handle agitated/aggressive behaviors was submitted to the Iowa Department of Inspection and Appeals on 12/8/22 at 9:56 PM. The document included Guidance for increased supervision during periods of aggression. a. Talk in a calm voice b. Make slow transitions or movements c. Do not engage in arguments d. Allow resident to have false allusions - do not tell them they do not exist e. Do not leave the resident unattended f. Provide a barrier between the upset resident and other residents (ex. Placing yourself between the upset resident and another resident that may be passing by. g. Try to redirect the resident to a quiet area with less people h. If warranted, use a personal device to call the facility for assistance (reminder you are not to leave the resident unattended). The Administrator notified the State Bureau Chief on 12/8/22 at 9:08 PM that Resident #22 went out to the emergency department per his request as he felt an increase in agitation. Resident #22 had a psychiatric appointment set up for the next week and the Administrator communicated that he would be one-on-one till further medical assistance is provided and he feels balanced out or the facility finds other placement. All staff were educated on how to handle behaviors of aggression on 12/8/22. During an interview on 12/12/22 at 10:12 AM Staff CC, Housekeeping/Laundry, reported that she did not get the behavioral training from the previous week. She thought they didn't have her correct phone number so they weren't able to get in touch with her, but she assumed she would get the training that day at some point. During an interview on 12/12/22 at 10:18 AM Staff R, CNA, reported that she did not receive any behavioral training from the previous week by the facility. During an interview on 12/12/22 at approximately 11:00 PM the Administrator reported she had educated all the employees on the Staff Roster or she had texted out the education on handling agitated/aggressive behaviors to the employees. She had not followed up with the employee to see if they actually received the education or understood the education that she sent out. The Nurse consultant stated to the Administrator that it is not enough to text the education out. She needs to provide follow-up to ensure the education was received and the staff understood the information. The Administrator reported she would provide further follow-up. During an interview on 12/12/22 at 12:30 PM Staff T, CNA, reported they worked 10 PM to 6 AM the past weekend Friday (12/9/22) and Saturday (12/10/22). She reported that she did not do 1:1 supervision for Resident #22 during those shifts, as the schedule indicated she worked as a regular CNA/Certified Medication Aide (CMA). She had been assigned to the D wing but technically they work everywhere in the facility. Friday night Resident #22 roamed around the first hour out to the front lounge, then to the dining room for about an hour. She reported they had four staff Friday night and only 2 sides on Saturday night. During an interview on 12/12/22 at 2:08 PM Staff U, CNA, reported they had not been able to do one to one supervision for Resident #22 on Friday (12/9/22) and Saturday (12/10/22) night. They checked on Resident #22 every 15 - 20 minutes. Staff T, CNA, went back to check the D wing. She stayed up front and watched the A and B hallways. The nurse did their regular job. They have residents that require two staff for their cares so they (Staff U and Staff T) worked together to complete rounds. Staff W, RN, watched the call lights to make sure that no one got up out of bed. Resident #22 sat up in the front lounge area for a few hours, then he got up, walked back to his room, and went to bed around midnight. Staff U explained that they did the best they could. On 12/12/22 at 2:14 PM Staff W reported they had someone call in that Sunday night at 9:10 PM. She explained that she reached out to several staffing agencies trying to get that staff replaced. She talked to the DON who gave her a list of staff to call. She talked to numerous people and could not get anyone to come in. She stated Resident #22 had been in the front lobby. They gave him food and fluids. Then he wanted to go back to the bathroom. They took him to the bathroom and they stayed with him until he went to sleep. They alternated checking on him but could not stay at his bedside 24/7. She reported she did not have a checklist to sign off, but they checked on him frequently. She reported that when the aides did rounds, she would go back, and check on him but she also had a mountain of orders to get through so she did sit at the desk to do orders. He slept the rest of the night. It wasn't easy but they worked as a team to watch him. On 12/12/22 at 3:48 PM the Administrator provided additional documentation of staff education for 1:1 supervision to all staff and updated the education on handling agitated/aggressive behaviors to ensure staff had received the required information. The Administrator or her Designees provided staff education on-site and via telephone to employees regarding the requirements of 1:1 supervision. The facility implemented the use of walkie talkies to communicate if someone needed to come takeover 1:1 supervision for Resident #22. They revised the daily wing schedules to assign the employee responsible for providing the 1:1 supervision and implemented the use of a sign in/out sheet for those staff providing the 1:1 supervision. The 1:1 supervision education specified Resident #22 to be under supervision at all times. When the Resident is in his room staff may remain outside of the room door. If the Resident is in the hallway, they must be within arms-length of the Resident. The Plan was submitted to the Surveyor via email at 3:48 PM. During an interview on 12/13/22 at 6:03 AM Staff Z, CNA, reported that she had been assigned to do one to one supervision for Resident #22. She reported she had been with him from 11:00 PM until 6:00 AM that morning. He had been in the front lounge until around midnight, then he went back to his room, and went to bed. Resident #22 slept from midnight to 5 AM, when she reported at 5 AM she got him up and brought him out to the dining room for coffee and cookies. Resident #22 observed at this time sitting at the dining room table drinking coffee and eating cookies, under 1:1 supervision. During an interview on 12/13/22 at 6:13 AM Staff X reported they were able to monitor Resident #22 with 1:1 for supervision during the night. He reported the resident had a good night sleeping from midnight to 5 AM which is his normal routine. He reported he planned to talk with the Director of Nursing (DON) and Administrator about covering the resident's mirror or taking the mirrors out of the room since the mirror seems to trigger his screaming and yelling. During an interview on 12/13/22 at 9:35 AM the Director of Nursing (DON) reported if a resident is aggressive the resident should be separated back to a different room. The physician should be contacted to give direction on what to do. She would probably put the resident on one to one supervision. When Resident #22 was at the hospital. They had done medication management on him and he didn't have behaviors and had been pleasant. He had bouts in front of the mirror but did not have physical aggression with anyone. She said there were no changes in the Care Plan after the staff observed him air punching, punching the back of the couches, and the door. She told the staff that his sister-in-law was very adamant that he has to get his medications to stay stable for his mental condition. If he didn't take his medications, they would re-approach him, and find a different staff member to try to get his medication administered. If that was unsuccessful, the staff were to try to call the sister-in-law to see if she could convince him to take his medications. The last resort is to call the DON to come give his medication. He has a delusional thought process. Some employees state they will not intervene as they do not want to get hit, but she has educated if any other residents come within the vicinity of Resident #22 they need to try to keep the other resident out of Resident #22's space. The Behavioral Management, Care Management Reference Anger and Aggression Policy dated 5/15 provided by the facility as a policy for accident/supervision documented the following approaches to be utilized: Dementia and/or related disorders: 1. Rule out potential causes of delirium or infection 2. Respond to cues of stress 3. Evaluate for pain, hunger and need to toilet 4. Reduce potential for injury 5. Plan for regular exercise 6. Be consistent Psychiatric Disorder: 1. Maintain a safe distance for caregivers and other resident/patients and visitors 2. Remove dangerous objects as able 3. Evaluate for depression and/or psychosis 4. Utilize behavior tracking records to determine time, place, possible triggers and meanings of behavior 5. Listen and validate feelings related to loss and grief 6. Acknowledge anger 7. Avoid rationalization and arguments 8. Include resident/patient and family/responsible party in planning the day and associated cares as much as possible; allow the resident/patient to have control over decisions as much as[TRUNCATED]

Based on clinical record review, observation, and interviews the facility failed to provide ongoing assessments for two of three residents with pressure ulcers, (Residents #3 and #20). One resident had 4 (four) pressure ulcers which worsened as a result, and eventually the resident required hospitalization . Findings include: According to documentation in the clinical record, Resident #3 entered the facility on 3-13-2021 and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation in the facility Minimum Data Set (MDS) assessment form indicated Resident # 3 was not able to complete the Brief Interview for Mental Status (BIMS) indicating severe impairment in cognition and decision making skills. The assessment also described Resident #3 as requiring limited staff assistance with eating, extensive staff assistance with toilet use, dressing and personal hygiene and total staff assistance with transferring and bathing. Resident # 3 did not ambulate. The facility developed individual plan of care initiated 01-06-22 (and revised on 05-12-22) with a focus area of pressure ulcers to hips, ankle, coccyx related to disease process, history of ulcers, immobility, incontinence and is at risk for additional skin impairment. The plan directed staff to implement the following interventions: * Administer medications as ordered. Monitor/document for side effects and effectiveness. * Administer treatments as ordered and monitor for effectiveness. * Assess/record wound healing (FREQ). Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. * Avoid positioning the resident on my left side as resident will allow. * Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] * If the resident refuses treatment, confer with the resident, IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. * Resident has low air loss mattress to assist with wound healing and prevention. * Ensure low air mattress is working properly and settings are appropriate . * The resident requires low air mattress, cushion in wheelchair. According to documentation in the May Treatment Administration Record (TAR) staff were directed to complete a skin assessment every day shift every Wednesday. Documentation to be completed on Weekly Skin Assessment form. If area found, place on appropriate skin sheet. Order date was identified as 4-8-2021. Staff documented a skin assessment was completed on 5-11-2022. There was no documentation that staff completed a skin assessment on 5-4-22, 5-18-22, and 5-25-22. Review of the June TAR revealed staff failed to document that a skin assessment was completed on 6-1-22. According to documentation provided by the facility a Pressure Injury Weekly Assessment was completed on 4-29-22. At that time staff recorded the following measurements: Left ankle: stage 3 pressure area ; length 1.3 centimeters (cm) by 1.4 cm wide by 0.2 cm deep Left hip: stage 2 pressure area; 1.0 cm long by 0.9 cm wide by 0.1 cm deep Right hip: stage 2 pressure area: 2.5 cm long by 3.0 cm wide by 0.1 cm deep. During an interview on 6-8-22 at 1:58 p.m. the facility Administrator confirmed that no additional pressure injury weekly assessments had been completed. According to documentation in the Nurse's Note dated 5-2-22 at 2: 31 p.m. RN (Registered Nurse) assessed 3 wounds on buttock and hip. During an interview on 6-20-22 at 2:44 p.m. the facility Director of Nursing confirmed that she only helped a nursing assistant with personal cares and redressed the wound following cares. She stated she did not complete an actual assessment of the wounds at that time. Documentation in the Nurse's Notes dated 6-1-22 at 9:40 p.m. indicated staff sent a facsimile to Resident #3's physician regarding condition change, also concerning the appearance of residents wounds. Review of the facsimile indicated Resident #3 is very weak, not eating or drinking much, wounds on coccyx, right hip, LE (lower extremity) seem to be infected. Blood pressure 89/55, temperature 97.4; pulse 109, respirations 22 oxygen saturation 94% on room air. The next set of vital signs were documented on 6-4-22 at 1855 (6:55 p.m.) at which time staff recorded a temperature of 100.2 degrees, pulse 135, respirations 22 and blood pressure 91/54. Oxygen saturation was documented to be 80 percent on room air. Staff applied oxygen at 3 liters/minute per nursing judgement and contacted Resident #3's physician. Orders were received to transfer Resident # 3 to the hospital. According to documentation in the Hospital Consultation Notes dated 6-5-22 Resident #3 presented to the hospital with respiratory failure requiring [CONDITION(S)] to maintain oxygen saturation levels, [CONDITION(S)], and multiple decubitus ulcers. The skin assessment findings include: Left knee: 1 cm in diameter with 0 depth is a skin tear. Right hip/ishium: Stage IV able to probe to bone, measures 6 by 7.5 cm, 2 cm for overall depth at 12 o'clock. It also has 2.1 cm undermining. Left hip/ishium: has unstageable pressure ulcer; it is 100% eschar, measures 3 by 2.5 cm with a depth of 0.5 c.m. undermining at 7-10 o'clock at 0/4 cm depth. Left lateral ankle/malleolus: 2.2 by 2.5 cm with a depth of 0.2 cm; this is a pressure injury stage II, 100% nongranular tissue. Sacral: 4 by 1-1/2 cm pressure ulcer stage IV, overall depth is 0.9 cm. Slough present. During an interview on 6-16-22 at 11:34 a.m. Resident #3's Physician stated the wounds were not Resident #3's only problem, but probably contributed to his decline. She added the lack of assessments/documentation prevented the implementation of new treatments and interventions which could have prevented the wounds from getting worse and ultimately the hospitalization of Resident #3. 2. The MDS assessment dated [DATE] revealed Resident #20 admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further documented the pressure ulcer as Stage 3 with pressure ulcer care provided. The Care Plan, dated 6/3/22, noted a pressure ulcer on the coccyx and directed staff to treat per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note dated 6/16/22 documented wound measurements and a description of the stage 3 coccyx ulcer, as measured and assessed on 5/18/22 at the hospital. The resident's record contained no assessment of the wound by the facility until 6/15/22, the day after the resident returned from a 6/5/22 to 6/14/22 hospital stay. An observation on 6/29/22 at 10:30 a.m. revealed Resident #20 with a pressure ulcer to the coccyx/sacrum area. Staff cleaned and re-packed the wound as ordered. On 6/29/22 at 5:15 p.m., the Regional Nurse Consultant acknowledged the facility lacked pressure ulcer assessments during the transition between Directors of Nursing.

Based on observation, clinical record review, staff, resident and Physician interview, the facility failed to protect residents against burn hazards from the baseboard heating elements in their rooms by placing resident beds parallel to the heaters in their rooms for 2 of 8 residents reviewed (Resident #1 and #22). On 4/2/21 Resident #1 rolled out of low bed and was found by staff with body on top of the heater with the skin of the lower left leg, knee, and upper thigh touching the heater. A Physicians note dated 4/12/21 revealed that resident sustained [CONDITION(S)] that involved 10-19 % of his body surface with 0% to 9% 3rd degree [CONDITION(S)]. On 4/21/21, Staff confirmed that Resident # 22, a known fall risk, was found on the floor parallel to the bed. Observation on 4/21/21 revealed Resident #22's bed ran parallel to inside wall of room to the right of the baseboard heater approximately 2 inches from the heating element. These findings constituted an Immediate Jeopardy (IJ) to residents' health and safety. The facility identified a census of 47 residents. Findings include: 1. According to [NAME] Health Care, (https://sanfordhealthcare.org) third (3rd) degree [CONDITION(S)] destroyed the epidermis and dermis. 3rd degree [CONDITION(S)] may have also damaged the underlying bones, muscles, and tendons. The burn site appeared white or charred. There had been no sensation in the area since the nerve ending had been destroyed. During an interview on 4/20/21 at approximately 1:45 p.m. the Director of Nursing (DON) stated the IMPACT (Integrated Management Patient Coordination Team) described and documented resident [CONDITION(S)] by the Rule of Nine outline/terminology and/or assessment tool! The Rule of Nines: Adult addresses the following percentage of areas burned as a baseline: a. Back and front = 18% b. Posterior arm and head = 4.5 % a piece c. Posterior and anterior leg = 9% d. Front and back chest area = 18% e. Genitalia = 1% 2. A Minimum Data Set (MDS) assessment form dated 3/19/21 indicated Resident #1 had diagnoses that included [CONDITION(S)], adult failure to thrive, aneurysm of the iliac artery, cannabis use, alcohol dependence and pain in the right hip. The assessment documented the resident with a Brief Interview for Mental Status (BIMS) score of 9 (moderately impaired), required extensive assistance of two (2) staff with bed mobility and transfers and as non-ambulatory. The assessment documented the resident with no other skin issues other than an unstageable pressure ulcer. The assessment identified the resident as not on a turning and repositioning program and with occasional moderate pain with no scheduled or as needed (PRN) pain medication. A Care Plan initiated 3/18/21 documented the resident had focus areas that included an actual fall related to [CONDITION(S)] (dated 3/18/21), potential for impaired cognitive function related to [CONDITION(S)] drug use, a history of [CONDITION(S)] and prior alcohol use (dated 3/26/21), a stage IV pressure ulcer to the left buttock (initiated 3/29/21 and revised 4/7/21), potential for pain related to a wound to the left buttock, and left side from later chest to mid-calf (initiated 3/29/21 and revised 4/7/21), wound infection (initiated 3/30/21), the resident with partial and full thickness thermal [CONDITION(S)] to the left side from the lateral chest to mid-calf (initiated 4/7/21), an activities of daily living (ADL's) self-care performance deficit related to a diagnosis of adult failure to thrive (initiated 3/29/21) and incontinence related to impaired mobility and adult failure to thrive (initiated 3/29/21) The approaches included the following: a. Bed in low position. (Initiated 3/30/21) b. Body pillows for positioning. (Initiated 4/2/21) c. Fall mat at bedside. (Initiated 3/30/21) d. Resident moved to the other side of the room. (Initiated) 4/2/21) e. Cushion in wheel chair and a waffle cushion in the shower chair. (Initiated 4/6/21) f. Resident wore a hospital gown and brief only due to ulcer. (Initiated 4/6/21) g. Low air loss mattress to bed. (Initiated 3/29/21) h. Monitor and report to nurse any signs and symptoms of non-verbal pain. (Initiated 3/29/21) i. Administer antibiotics per Physician orders. (Initiated 3/30/21) j. Treatments per Physician orders. (Initiated 4/7/21) k. Showered daily with all dressings off for wound cleansing. (Initiated 4/13/21) l. Monitor/document location, size, and treatment of the skin injury. (Initiated 4/7/21) m. The resident required assistance of 2 staff members for repositioning and turning in bed and transfers. Used wheel chair as mode of transportation. n. The resident required 1 staff member for bathing and personal hygiene. Bed baths to have been completed per physician's order until [CONDITION(S)] healed. (Initiated 3/29/21 and revised 4/7/21) A Fall Risk Assessment form dated 3/13/21 at 1:19 p.m. documented the resident as at a moderate risk for falls. An Incident Report form dated 3/29/21 at 10:30 p.m. documented the resident as found sitting on his butt on the floor at the side of the bed with his back against the bed frame. The staff documented that the resident sat at the side of the bed and slid to the floor however, the incident had been unwitnessed. An Incident Report form dated 3/16/21 at 10 p.m. documented the resident as found as laid on the left side on the floor in front of his wheel chair. The resident sat in front of a table in his wheel chair, which staff offered numerous times to have assisted the resident to bed however he refused. This fall had also been unwitnessed. An Incident Report form dated 4/2/21 at 5:45 a.m. included the following documentation: The certified nursing assistants (CNA's) came to get the nurse and reported the resident rolled between the bed, which was in the lowest position and the wall and laid next to the heater. The situation had been unwitnessed. The nurse entered the room. The resident noted to have laid on his right side on the floor as the CNA's moved him away from the heater. The nurse rolled the resident and assessed his skin and noted a superficial open area to the resident's left outer lower leg which measured 25 centimeters (cm's) in length and 8 cm wide and a superficial open area on his left outer buttocks that measured 18 cm's in length and 6 cm's in width. A superficial area of redness noted to the left side. The areas cleansed, applied [MEDICATION(S)] cream to the areas of concern, covered with [MEDICATION(S)] (a none-stick bandage), and wrapped with rolled gauze to have secured the [MEDICATION(S)] to the left lower leg. Secured [MEDICATION(S)] to the area with tape. The resident tolerated the procedure with minimal signs of discomfort. The resident had ben assisted to stand with 2 staff members and positioned in bed. The resident continued to show minimal signs of discomfort. A call was placed to IMPACT (Integrated Management Patient Coordination Team). Review of physician's Progress Notes dated 4/5/21 at 7:30 a.m. revealed the following wound measurements as dated, timed, and labeled: a. Left mid back and lateral chest with an etiology of a thermal burn with partial thickness - Mid back - 10.0 cm x 2.0 cm x 0.1 cm (depth) with the wound bed described as pink and scabbed. The left lateral chest - 1.8 cm x 15.5 cm x 0.1 cm with the wound bed described as pink and scabbed with an intact serious filled blister with no exudate and/or odor. b. Left hip with an etiology of a thermal burn with partial and full thickness - 20.0 cm x 9.0 cm x 0.2 cm with a wound bed with yell/brown slough and several diffuse intact serous filled blisters with serous exudate and no odor. c. Left lower extremity from the distal lateral thigh to the left inner knee with an etiology of a thermal burn with partial and full thickness - 23.0 cm x 11.5 cm of eschar with scattered surrounding serous blisters the wound bed described as yellow/brown slough with several intact serous filled blisters with serous exudate and no odor. Review of the facilities Progress Note dated 4/6/21 at 2:54 a.m. included the following documentation: The resident currently rested in bed with his eyes closed. Staff provided treatments to the resident's buttocks and areas on his left side. The resident tolerated without difficulties. Noted many intact blisters to the left side buttock, thigh and lower legs with yellow drainage from the open areas. A Physician's Progress Notes form dated 4/6/21 at 3:30 p.m. included the following documentation from the resident's doctor's visit: Patient denied that he experienced pain. However, she questioned his cognitive ability to have told them how much pain he may have been in. He experienced a history of chronic small vessel ischemia and likely dementia. A Physician's Progress Notes form dated 4/12/21 at 9:45 a.m. documented the resident sustained [CONDITION(S)] that involved 10-19 % of his body surface with 0% to 9% 3rd degree [CONDITION(S)]. During an interview on 4/20/21 at 1:04 p.m., the Physician of resident #1 confirmed she felt the resident's injuries/[CONDITION(S)] had been considered a major injury. During an interview 4/14/21 at 10:45 a.m. the resident stated he could not recall having received the [CONDITION(S)] and could not recall if it was painful at the time. During an interview 4/15/21 at 10 a.m. Staff H, CNA confirmed she had been the one who found the resident on the heating unit. At approximately 4:45 a.m., she went and talked to him and told him the staff would return. At that time, the resident had been positioned on his back with his leg in the air as he played with his covers. Staff H then went to the front of the building and assisted staff with rounds. Around 5:45 a.m., all 3 of the staff members returned to the back hall and she told Staff I, CNA she planned to have provided cares to the resident. She entered the resident's room and Staff I followed. Staff H observed the resident and said oh my gosh. Staff I stated let's move the bed. The resident had been positioned on his left side, between the bed and the outside wall to the room with a low bed and an airflow mattress. The resident's body was on top of the heater with his skin (left lower leg, knee, and upper thigh) on the heater. The staff unlocked the bed as a means to have removed the resident from the heater. The staff got him onto the floor and rolled him on his right side and as they moved him off the heater there was skin adhered to the heater further described as skin peels and the skin on his body had been all red with no blisters at that time. The staff indicated the resident showed no appearance of pain as he never screamed or said anything but she described the resident as a quiet man. The staff immediately reported the incident to the nurse who assessed the resident. Staff H confirmed they had told people they needed to position the residents away from heaters for years. The staff member confirmed they had gone into resident rooms, covers had fallen on the heaters, and they would walk in and ask what the smell was. Staff H confirmed the resident's heating unit as adjustable but she could not recall the setting on the unit at the time of the incident. Staff H stated that even Staff J, LPN advised that as she sat by the resident, not even close to the heating unit, that it had been hot. Staff H further described Staff J as probably a foot or a foot and 1/2 away from the heater. During an interview, 4/13/21 at 4:50 p.m. the Administrator confirmed staff failed to check the temperature of the heating unit in the resident's room following the incident of finding him positioned against the unit. An observation on 4/14/21 at 10:25 a.m. revealed the wound covering over the upper portion of the burn wound on the outer left thigh as adhered with tape to the actual wound. During an interview at the same time, the Assistant Director of Nursing (ADON) confirmed the tape was adhered to the wound. During an observation on 4/13/21 at 4:56 p.m. the Administrator checked the temperature of the heating unit with a non-contact infrared thermometer for humans, which felt hot to the touch (the surveyor could not keep her hand on the unit), at 100.9 degrees on the lower unit and the upper unit (lid) registered Hi. During an interview on 4/14/21 at 11:20 a.m., the Director of Nursing (DON) indicated she felt the above stated temperatures had been inaccurate as the thermometer used by the Administrator read human's body temperatures. During an observation on 4/14/21 at 10:10 a.m., the heating unit felt hot to the touch. (The surveyor could not keep her hand on the unit) During an interview on 4/20/21 at 2 p.m. Staff A, maintenance confirmed all of the resident's rooms in the facility contained the same heating baseboard units which placed residents at a burn risk. An observation on 4/14/21 at 2 p.m. included Staff A, maintenance as he checked the temperature of 2 different heating baseboard units as he utilized an infrared thermometer used for appropriate monitoring of such units as follows: a. Room D 31 (not occupied) - The top cover of the heating base board unit from left, middle to right - 120 degrees, 130 and 128. The outlet area (middle section of the unit) from left, middle to right - 168 degrees, 194, and 173. b. The resident's room - The top cover of the heating baseboard unit from left, middle to right - 160 degrees, 233, and 214. An observation and interview on 4/20/21 at 2:15 p.m. included Staff A as he checked the temperature of the outlet area of the resident's heating baseboard unit from left, middle to right he reported the following temperatures- 176.2 degrees, 214.5 degrees and 212.4 degree. 5. A MDS assessment form dated 2/11/21 indicated Resident #22 had diagnoses that included diabetes mellitus (DM), non-Alzheimer's dementia, depression, dementia without a behavioral disturbance and [CONDITION(S)]. The assessment documented the resident with a BIMS score of 5, required extensive assistance of 2 staff with bed mobility and transfers and as non-ambulatory. The assessment documented the resident had 2 falls without injury the past quarter and not on turning and repositioning program. A Care Plan initiated 7/10/19 documented the resident with a focus areas that included the resident had an actual fall with no injury due to an unsteady gait (initiated and revised 7/15/19), at risk for mental status changes due to a diagnosis of dementia without behaviors (initiated 2/13/21) and an ADL self-care performance deficit related to dementia (initiated and revised on 2/11/21) a. Dycem in the recliner. (Initiated 1/20/21) b. Dycem in the wheelchair. (Initiated 5/21/20 and revised 4/16/21) c. Encourage the resident to position self by the nurse's station. (Initiated and revised 10/26/20) d. Floor mat next to bed when in bed. (Initiated 2/10/21) e. Resident not to have been left in wheel chair unattended. (Initiated 4/15/21) f. Bed in low position when resident positioned in bed. (Initiated 10/30/19) g. Required 2 staff assistance with repositioning in bed. (Initiated 2/11/21 and revised 2/25/21) h. Required 2 staff assistance with transfers with the use of a wheeled walker and a gait belt. The resident had been non-ambulatory. (Initiated 2/11/21 and revised 2/25/21) Review of the Physical Therapy Treatment Encounter Note(s) included the following entries as dated: a. 2/2/21 - The patient presented with impairments which included significant cognitive deficits which limited her ability to problem solve and to have followed cues, lower extremity weakness, balance deficits, hearing deficits, visual deficits and limited activity intolerance which resulted in functional limitations with included safety with transfers and the ability to ambulate. A Fall Risk Assessment form dated 4/21/21 at 12:09 p.m. documented the resident as at high risk for falls. Review of the resident's Incident Report forms included the following information as dated: a. 12/7/20 at 4 p.m. - Resident found on the floor in front of her recliner in her room with no injuries. b. 12/13 at 3 p.m. - Resident found on the floor in front of her recliner in her room with no injuries. c. 12/23 at 2:03 p.m. - Resident found on the floor in front of her recliner in her room with no injuries. d. 12/27 at 12:14 p.m. - Resident found on the floor in front of her recliner in her room with no injuries. e. 12/29 at 5:15 a.m. - Resident found on floor rolled up in 2 blankets parallel to the bed with no injuries. f. 1/18/21 at 7:30 p.m. - The resident sustained a witnessed fall from her wheelchair after another resident went by her in an electric wheel chair with no injuries. g. 1/20/21 at 9:59 a.m. - Resident found on the floor in front of her recliner in her room with no injuries. h. 2/3/21 at 2:15 p.m. - The resident sustained a witnessed fall after she attempted to stand without assistance and took 2 steps with no injury. i. 2/9/20 at 5:40 p.m. - Resident found in her room as she sat on her buttocks with her legs in a criss crossed position near the sink facing the bathroom door with her back towards the bed with no injuries. j. 3/11 at 3:46 p.m. - Resident found as she sat on her foot pedals of her wheel chair in the dining area with no injuries. k. 4/7 at 5:57 p.m. - Resident found as she sat on her foot pedals of her wheel chair in the dining area with no injuries. l. 4/15 at 10:30 a.m. - Resident found lying face down on floor on stomach, legs stretched and underneath wheelchair, head resting on crossed hands. During an interview on 4/21/21 at 1:49 p.m. Staff K, Registered Nurse (RN) confirmed the resident had been found on the floor parallel to the bed with her head towards the window. The bed had been positioned along the wall with the head of the bed along the wall that contained the window and right next to the baseboard heater. During an interview on 4/21/21 at 2:01 p.m., Staff K confirmed the resident resided in the same room at the time of the 12/29/20 fall as currently. During an interview on 4/21/21 at 2:01 p.m., Staff K confirmed the resident as in the same room at the time of the fall as now. Review of the resident's Progress Notes included the following entries as dated: a. 4/20/21 at 4:38 a.m. - The resident had been out to the table for the evening meal as she attempted to move her wheel chair, which allowed her to stand up with dishes. The nurse assisted the resident to have cleared the table and the resident made no further attempts to self- transfer. An observation on 4/21/21 at 10 a.m. revealed the resident's bed in low position with a fall mat present in room. Bed runs parallel to inside wall of room to the right of the baseboard heater (as a person looked into room) at approximately 2 inches from the heating element. If the resident would have fallen from her bed, she would/could have hit her head and/or shoulder on the heating element unit as there had been no bedside table beside the bed and/or any other barrier. During an observation and interview 4/21/21 at 10 a.m., the position of the resident's bed in conjunction with the heating unit element had been pointed out to the DON who indicated she planned to inform the Maintenance Director to have arranged the room appropriately. During an interview on 4/21/21 at 11:03 a.m., the Maintenance Director confirmed the problem with the baseboard heaters had been addressed in the past and present with no actions or interventions placed. An observation on 4/23/21 at approximately 9:40 a.m. revealed while walking down a hallway it was found that the Director of Nursing (DON) and Staff J housekeeping were in the resident's room. When questioned what they planned to do the DON said she did not know she had been directed to go to the resident's room. Then to do a re-enactment of the resident as she fell out of bed with the HOB up against the outside wall approximately 6 inches from the baseboard-heating element. Staff M, RN/Corporate Nurse requested Staff J fall out of bed 3 times. Two of the 3 times the head of Staff J landed against the heating element. During an interview 4/23/21 at 12:23 p.m. Staff J confirmed her head would have hit the heating element and/or would have been close. During an observation and interview on 4/23/21 at approximately 10 a.m. the Regional Director of Operations and the surveyor measured the approximate distance from the side of the resident's bed to the heating element and both agreed the distance as approximately 6 ½ inches. 6. An observation and an interview 4/20/21 at 2:15 p.m. as Staff A and surveyor walked out of the resident's room revealed the resident's rotating air mattress not plugged in. The staff member agreed and said you know why that is, so they keep the mattress sunk in so the resident would not have rolled out of the bed. The staff member then plugged in the rotating air mattress and confirmed the pressure as set on 250 degrees. The facility was notified of the Immediate Jeopardy on 4/22/21 at 1:39 p.m. The IJ was removed on 4/21/21 when the facility was advised by investigator of the immediate risk of the unsafe bed placement. An acceptable plan of correction was submitted 4/26/21 acknowledging risk of bed placement and measures taken to ensure resident safety. The scope and severity of the deficiency was lowered to a D after the IJ removal. The Plan of Correction by facility provided the following: 1. Resident's bed was moved across the room away from the heater. Full skin sweep was completed on resident. Physician was notified and treatment orders were received and implemented. Resident was seen by dietitian and new orders were received for [MEDICATION(S)] and magic cup to increase resident's protein intake. Resident's (HR) bed was moved on 04/20/21. A bedside table was placed between the bed and the wall. 2. An audit was conducted of entire facility to ensure all beds were a safe distance from the heater. Skin sweeps were completed on all residents on or before 04/08/21. 3. Education was provided to Administrator and Director of Nursing on Incident and Accident Prevention by Regional Director of Operations and Regional Nurse Consultant. All other staff from Cedar Falls Healthcare was then educated by Administrator and/or DON. 4. Audits of bed placement will be completed once weekly for 4 weeks, then once monthly for 2 months. The Audits will be reviewed in facilities QAPI meeting. -

Based on clinical record review, staff and resident interviews and observations, the facility failed to notify the resident's physician of a change in condition, failed to complete timely and appropriate skin assessments, failed to assess a resident with complaints of hip pain post fall for 6 of 6 sampled residents (Residents #7, #9, #11, #16, #19, & #21). These findings constituted an Immediate Jeopardy to resident health and safety. The facility reported a census of 61 residents. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE] Resident #9 had [DIAGNOSES REDACTED]. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident showed intact cognitive ability and did not exhibit behaviors. The MDS identified Resident #9 required total assistance of 2 or more staff for bed mobility, toilet use, and personal hygiene. The MDS revealed the resident did not transfer, walk, or dress, experienced bowel incontinence, and utilized an indwelling catheter for urinary elimination. The MDS documented the resident weighed 571 pounds at the time of the assessment. The assessment revealed the resident had a risk for pressure sores, but did not identify any problems with impaired skin. Review of the care plan revised on [DATE] failed to identify Resident #9 had potential for or actual skin impairments and failed to identify the resident exhibited behaviors such as refusing cares, failed to identify the resident had pain related to her left shoulder from an unknown injury, and failed to indicate the resident utilized oxygen. The care plan failed to provide direction to staff on assisting the resident with Activities of Daily Living and did not identify resident needed ,[DATE] staff for bed mobility or transfers. Review of a re-entry Braden Skin assessment completed on [DATE] documented the resident as unresponsive to painful stimuli with constantly moist skin. The form revealed the resident was bedfast, had very limited mobility, and had a problem with friction/shearing because they required moderate to maximum assistance with moving. The assessment identified the resident as at a very high risk for skin impairments. Review of a Weekly Skin assessment dated [DATE] revealed staff had documented the resident had intact skin with [MEDICAL CONDITION] (swelling) noted to her left forearm related to a dislocation. Review of a Physician order [REDACTED]. a. X-ray to upper left arm to rule out acute/past injury, ordered on [DATE]. b. Ice pack/heat pack every 20 minutes as needed for swelling/pain 4 times daily to upper left arm, ordered on ,[DATE] and stopped [DATE]. c. [MEDICATION NAME] powder to affected areas topically to excoriation twice daily, ordered on [DATE]. Review of a local hospital emergency department record dated [DATE] revealed Resident #9 transferred to a local emergency room with complaint of shortness of breath, left arm swelling and pain, and left shoulder pain. The resident arrived via ambulance. The patient described her pain as sharp in the left arm and constant for the past 2 months. The physical exam in the emergency room revealed the resident exhibited decreased range of motion of the left shoulder and hand. The physician noted the resident's left arm is visibly distended and dusky looking. Her capillary refill is diminished and she reported tenderness with light palpations. X-rays completed on ,[DATE] revealed no fracture but did show [MEDICAL CONDITION]. The resident had [DIAGNOSES REDACTED]. Review of the Progress Notes dated [DATE] at 5:16 p.m. Staff S, RN contacted the resident's Primary Care Provider (PCP) to report a low blood pressure of ,[DATE] and low oxygen saturation level of 85% on 2 liters of oxygen. The staff received orders to send the resident to a local hospital and increase the oxygen to 5 liters. Review of a local hospital history and physical records dated [DATE] revealed the resident transferred to the emergency roiagnom on [DATE] for shortness of breath, left arm swelling and pain and pain to the left shoulder. The resident indicated the pain worsened when working with the therapist and she subsequently experienced shortness of breath. Upon further discussion with the patient, the patient states that her left arm might have been pulled in the nursing home during position change about 2 months ago. The physician noted the resident had diminished breath sounds due to body habitus, non-[MEDICAL CONDITION] in bilateral lower extremities, left hand swelling and skin changes noted on the left hand secondary to dependent [MEDICAL CONDITION]. The resident is alert and oriented x 3. The resident admitted to the hospital for a 23 hour observation period. Review of an Order Requisition (discharge orders) from a local hospital dated [DATE] Resident #9 had a new [DIAGNOSES REDACTED]. The resident discharged from the hospital with new orders for [MEDICATION NAME] powder topically twice daily as needed and a referral for physical and occupational therapy to evaluate and treat. The resident requested full code status. Review of a Progress Note dated [DATE] at 5:59 p.m., revealed Resident #9 returned to the facility via cot and transferred to her bed with the assistance of 6 staff. The staff positioned the resident with pillows under her left arm for comfort. Review of a telehealth visit progress note dated [DATE], revealed Resident #9 appeared groggy with a blank stare on her face. Review of a progress note dated [DATE] at 5:06 a.m. showed Staff T, LPN noted an increase in the resident's left hand [MEDICAL CONDITION], the aide reported the hand was in a dependent position, the aide propped up the resident's hand for comfort and Staff T indicated they will monitor the swelling. A note dated [DATE] at 5:58 a.m. documented the resident noted with more [MEDICAL CONDITION] to the left hand and complaints of pain. The staff attempted to prop up her left hand but resident reported the arm kept falling down. Staff T stated they will monitor the [MEDICAL CONDITION]. The staff failed to contact the PCP regarding the increase in [MEDICAL CONDITION] and pain. A progress note dated [DATE] at 9:31 p.m. revealed the resident complaining of right arm pain, they repositioned the right arm and will continue to monitor. A progress note dated [DATE] revealed the staff evaluated the resident's skin and found blisters on the resident's back. The facility failed to notify the PCP of the areas. Observation on [DATE] at 11:20 a.m. revealed 4 staff washed and put on gloves to prepare to provide cares for Resident #9. The resident lay on her back with oxygen on. The resident reported pain to the left arm and yelled out in pain with attempts to reposition. Staff U-C.N.A. cleansed the catheter, and the resident had redness to the left side of the abdomen with [MEDICAL CONDITION] noted to the area. The resident moaned loudly in pain, made gurgling sounds with respirations, and had a large amount of [MEDICAL CONDITION] to her left forearm and hand. Staff G-CNA/AD stood at the resident's left shoulder area. Staff G pulled a soiled bath towel out from under the resident. Observation revealed the towel contained a large amount of brownish brownish colored fluid and when asked where the towel came from, Staff G replied from under the resident's left arm pit. The staff rolled the resident onto her right side as she continued to moan loudly with pain. Observation showed the resident's bottom was a dark red color with BM present and contained an open area to the left buttock. Staff V-RN was present in the room to assist and when asked about the bath towel with drainage and the open areas, Staff V stated she had no idea where the drainage came from and did not know of any open areas. Observation on [DATE] at 1:15 p.m. revealed Staff V and the Director of Nurses (DON) in Resident #9's room completing a skin assessment. They reported they will contact the PCP when they complete the assessment. Review of a progress note dated [DATE] at 2:08 p.m. revealed the resident as very groggy, refusing all meals, lung sounds diminished, and mouth breathing with gurgling noises. The resident spoke incoherently and speech inaudible with shortness of breath with repositioning. The resident noted today with 2 open areas and excoriation to folds to abdomen, back, sides, and arms. Staff notified the PCP notified and gave orders for x-rays and medication to excoriated areas and treatment dressing orders for open areas noted during the assessment. A note on ,[DATE] at 2:45 p.m. revealed the social worker contacted the family to have the resident's code status changed to do not resuscitate after receiving an order from the PCP. Review of the resident's skin sheets revealed the staff failed to complete a weekly skin assessment due every Wednesday for the following months: a. The [DATE] Weekly Skin Assessment forms revealed the staff completed 1 skin assessment on [DATE]. b. The [DATE] Weekly Skin Assessment form revealed the staff completed 3 skin assessments during the month on ,[DATE], ,[DATE] and ,[DATE]. c. The [DATE] Weekly Skin Assessment form revealed the staff completed 2 assessments during the month, on ,[DATE] and [DATE]. Review of an Activities of Daily Living sign in sheet obtained [DATE] revealed staff provided Resident #9's last documented on [DATE]. Another sheet that accompanied the sign off sheet directed the staff to provide cares for the resident every shift. The sheet directed the facility now had suitable lift for the resident and we needed to start getting her up each day; perineal cares are not optional. There is a sign in sheet in her room for all to time, date and sign when they completed cares and D.O.N. to follow up. Observation on [DATE] at 10:30 a.m. revealed 6 staff in the resident's room preparing to provide care. The resident had a sling under her as staff prepared to weigh her with the Hoyer lift. The staff lifted the resident slightly off the bed, and the resident moaned loudly in pain. Observation revealed the [MEDICAL CONDITION] to the resident's left hand markedly increased from the observation on [DATE] and the resident non-responsive to staff. The resident made gurgling noises with respirations. During an interview with the PCP on [DATE] at 11:00 a.m., the PCP stated the resident had a dislocated left shoulder and [MEDICAL CONDITION] to her left hand, and neither the facility nor the resident had any idea how the injury occurred. The PCP reviewed her notes and stated the last time she saw the resident was on [DATE] via a telehealth visit and had not had any other communication with the facility until yesterday afternoon. At that time, staff reported blisters to the resident's back and also excoriated skin folds. The PCP stated the facility did not contact her with condition changes in her residents and when she gave an order they did not follow the orders given. The PCP stated the facility did not have enough staff to get Resident #9 out of bed for showers or to sit in her chair. The PCP stated she did not know the resident was non responsive with gurgling respirations or that she had an increase in left hand [MEDICAL CONDITION]. The PCP said she would contact the facility immediately and give an order for [REDACTED]. Review of a progress note dated [DATE] at 12:30 revealed the PCP called the facility and ordered staff to transfer the resident to a local emergency room due to critical labs and changes in medical status. Review of a local hospital emergency room report dated [DATE] revealed Resident #9 arrived to the emergency room at 12:57 p.m. and expired in the emergency room 4:10 p.m The emergency room physician noted the cause of death respiratory arrest. The notes indicated the facility transferred the resident to the emergency room as she had been less responsive since about 1:00 pm on [DATE]. The notes indicated the PCP reports the facility last called them on [DATE] that she was groggy after narcotic pain medications. The staff document upon arrival to the ED, the resident arrived in poor condition and unable to follow any commands, moaning loudly, with shallow respirations. Review of the physician exam revealed the resident's perineal areas is unclean, very malodorous and discharge noted throughout the area. The indwelling catheter present but without urine in the tubing. The resident is noted to have dried vomit throughout her back scalp and hair. During an interview with the Director of Nurse on [DATE] at 8:30 a.m. the DON stated the resident required assistance of multiple staff to complete her cares. She stated the nurses were responsible for the weekly skin checks, but obviously they were not getting the checks completed on a weekly basis. During an interview with Staff V-RN on [DATE] at 10:30 a.m., Staff V stated she did complete a skin assessment for the resident on ,[DATE] after everyone left the room. She stated she did not know the resident had open areas until then, she reported she noted 2 open areas on each of her breasts and all skin folds were reddened and excoriated. She placed a call to the PCP to receive orders for the excoriation. Staff V stated each nurse working on the unit is responsible for the skin assessments if it comes up on the treatment record, the days vary for each resident as the facility did not have a designated skin nurse. Staff V stated any nurse that measured wounds only completed the computer skin assessment form and did communicate the findings with other nurses. Staff V reported it took a minimum of 4 staff to roll Resident #9 for cares. During an interview with the Administrator on [DATE] at 12:45 pm., the Administrator verified staff had voiced concerns to her regarding the amount of assistance Resident #9 required to complete cares, that they need to find help when doing he cares. The Administrator reported being made aware of the skin issues noted on ,[DATE] and stated it concerned her greatly and added she would look into the situation. She stated the resident should have been getting a bed bath daily. During an interview with Staff R/RN/Corporate Nurse on [DATE] at 12:17 p.m., she stated she could not find physician notification for the increase in swelling noted on ,[DATE], the pain in right arm on ,[DATE], skin blisters noted to the resident's back on ,[DATE], the low oxygen saturation level of 87% on ,[DATE], or the low oxygen saturation level of 84% on [DATE]. Staff R stated they had no a physician notification policy but they had a policy regarding clinical change of conditions. During an interview on [DATE] at 12:30 p.m., Staff G-CNA/AD stated Resident #9 had a recent decline, although she had complained of pain to her left arm for a long time. Staff G identified that she was the person that had pulled the soiled bath towel out from under the resident during cares on ,[DATE]. She stated the drainage could have possibly been from the open area under her left breast and her yeasty folds. Staff G stated it required about 6 staff to provide cares for the resident. During an interview with Staff U-CNA on [DATE] at 2:00 p.m., Staff U stated they do not have the staff or the man power to provide care for Resident #9. She stated she had not seen the resident's skin condition for a time but reported it is much worse than before. She added the staff used to apply [MEDICATION NAME] powder to the folds and give her a daily bed bath, but stopped in June due to the lack of staff. Staff U stated she and others had asked for help with this resident but nothing was ever done to help. Staff U stated they could not get the Hoyer lift into the resident's room due to the extreme clutter. During an interview with Staff E-LPN on [DATE] at 11:22 a.m., Staff E stated it takes ,[DATE] people to provide care for Resident #9 and to turn her. She stated the Agency Nurses/CNAs do not provide the resident her cares as they should. She stated they have repeatedly asked the Administration and DON for assistance with this issue, but nothing was done. Staff E had been in the room for observation of cares on ,[DATE] and verified the resident had open areas, multiple reddened areas, and her left arm had a marked increase in [MEDICAL CONDITION]. Staff E also verified the resident was non responsive and that was a change of condition. Review of the change of Clinical Change in Condition Management Policy dated ,[DATE] directed staff to observe each resident's condition daily and communicate the changes that require further investigation which included: a. participation in daily routines b. physical assessment (i.e. cardiovascular, respiratory, mental status and neurological) c. behavior d. mobility e. comfort level f. response to medications. If abnormalities/changes noted, staff should contact the PCP and provide clinical data and information regarding the resident's condition and then document notification and physician response in the medical record. The policy directed staff are to initiate any new physician orders. The facility was notified of the IJ on [DATE]. On [DATE], the facility abated the Immediate Jeopardy and the Scope and Severity was lowered to an E level. The facility provided education to the nursing staff on Clinical Change in Condition Management Policy dated [DATE]. The policy instructed the Nursing Staff on notification and documentation requirements for all changes of residents condition to the PCP, family and facility staff. The facility formulated a new Shower Skin Check List and provided education to the Certified Nurse's Aides on the proper use of the form and expectations on reporting skin abnormalities. The ADON and MDS Coordinator performed skin checks on every resident in the facility and completed a Weekly Skin Assessment Form. 2. According to the MDS dated [DATE] Resident #11 had [DIAGNOSES REDACTED]. The MDS documented the resident had severely impaired cognitive ability and memory issues, and was totally dependent on 2 or more staff for transfers, dressing, toilet use, and eating. The resident had skin issues which included one Stage 1 pressure sore and two Stage 2 pressure ulcers. The facility failed to formulate a care plan to direct resident care with regard to wound care and Activities of Daily Living. Review of a Braden Score dated [DATE] revealed the resident had a high risk of pressure ulcer development. Review of a Weekly Skin Record dated [DATE] revealed the resident had wounds to his scrotum, left buttock, and right buttocks. Review of a Weekly Skin Record dated [DATE] revealed the resident had bruising to arms, an groin excoriated area, and also excoriation noted to left gluteal and right gluteal areas. Review of a Weekly Skin Record dated [DATE] revealed the resident had a ruptured blister to the upper back, left ear, and posterior of the neck. Review of a Weekly Skin Record dated [DATE] revealed the resident had open wounds to the right buttock, left ear, right knee, upper back, neck, scrotum, and inner left thigh. Review of the Treatment Record for [DATE] directed the staff to apply the following skin treatments: a. Mupirocin Ointment 2% topically three times daily to wounds, which started on ,[DATE] and was discontinued on [DATE]. The Treatment record showed staff failed to apply ointment 19 times out of 39 opportunities. b. [MEDICATION NAME] Zinc Ointment 500 unit/gram to the left ear and upper back blisters twice daily for 7 days beginning on [DATE]. The facility failed to apply the ointment on 3 occasions out of 14 opportunities. c. The physician ordered stoma adhesive powder followed by z-guard and then adhesive stoma powder again to the coccyx, perineal area, and scrotum on [DATE]. Staff failed to apply the treatment twice out of 10 opportunities. 3. According to the MDS dated [DATE], Resident #7 had [DIAGNOSES REDACTED]. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident demonstrated intact cognitive abilities. The MDS documented the resident required limited assistance of 1 staff for transfers and extensive assistance of 1 staff for dressing, toilet use and personal hygiene. The MDS also documented Resident #7 had a risk for developing pressure sores and had [MEDICAL CONDITION]. The care plan dated [DATE] documented Resident #7 as at risk for skin impairments, tears, and/or bruises. The care plan directed the staff to monitor skin with cares and inform the nurse of any concerns, to complete treatments as ordered, and to complete weekly skin and wound assessments by the licensed nurse and daily skin checks by the certified nursing staff for early identification of concerns. Review of a Weekly Pressure Injury Weekly Assessment forms revealed the following data: a. An assessment form dated [DATE] revealed the resident had a pressure sore on the left outer ankle which measured 0.5 centimeters by 1.0 centimeters (cm). The form documented the area was red with exudate noted, and identified the area as facility acquired, but did not identify when the area first appeared. b. The assessment form dated [DATE] revealed the left ankle pressure ulcer measured 0.5 cm by 0.5 cm, did not contain exudate, and the wound appeared black. c. An assessment form dated [DATE] revealed the pressure sore to the left outer ankle measured 1.6 cm x 0.4 cm and contained a scant amount of drainage. The form revealed staff last notified the physician on [DATE]. d. An assessment form dated [DATE] revealed the resident had a skin tear on the left outer ankle which measured 0.8 cm x 0.4 cm with a scant amount of drainage. Staff had last notified the physician on [DATE]. e. An assessment form dated [DATE] revealed the resident had a left ankle pressure ulcer which measured 2.2 cm x 2.5 cm, had wound drainage, and was identified as a Stage 2 pressure sore. f. An assessment form dated [DATE] revealed the resident had a left ankle pressure area which measured 1.5 cm x 2.2 cm and had drainage. Review of a physician's orders [REDACTED]. Review of the Pressure Injury Weekly Reports revealed the staff failed to assess the resident's pressure sore from ,[DATE] through [DATE]/20 (10 weeks). Observation on [DATE] at 9:35 p.m. revealed Staff O-RN providing Resident #7's wound treatment. Staff O cleansed the pressure area with wound cleaner and replaced the tubi grip socks to the left lower leg. The resident is had a black colored area to the left ankle. Review of the August and [DATE] Treatment Record failed to include a treatment for [REDACTED]. 4. According to the MDS dated [DATE], Resident #16 had [DIAGNOSES REDACTED]. The resident had a BIMS score of 15 which meant the resident demonstrated intact cognitive abilities. The resident required limited assistance of 1 staff for transfers and ambulation and extensive assistance of 1 staff for dressing, toilet use, and personal hygiene. The resident utilized a walker and wheelchair for mobility, was at risk for pressure sores, and had one Stage 2 pressure ulcer and one venous ulcer. Review of the care plan updated on [DATE] revealed the resident had impaired skin related to post amputation of toes to right foot, [MEDICAL CONDITION], and fragile skin. The care plan directed staff to monitor/document location, size and treatment of [REDACTED]. The care plan directed the staff to complete weekly skin assessment by a licensed nurse (initiated [DATE]). Review of a Braden Scale form last completed on [DATE] revealed the resident remained at low risk for pressure ulcers with a score of 17. Review of the Pressure Injury Weekly Assessment forms from ,[DATE] through [DATE] revealed the staff failed to complete weekly skin assessments for the pressure ulcer on Resident #16's right foot for 8 weeks throughout that time frame. Review of the August and [DATE] Treatment Administration Record directed the staff to apply ,[DATE] strength Dakins solution to the left foot wound topically twice daily, beginning [DATE]. Observation on [DATE] at 9:55 a.m. revealed Staff E-LPN removed the [MEDICATION NAME] from the resident's left lower leg, the dressing and packing from the left great toe area, and cleansed the wound with wound cleaner. Staff E re-applied a Dakins' dressing to the area and covered it with a 4 x 4 bandage. A facility Skin Care and Wound Management Policy dated ,[DATE] documented the staff strives to prevent resident skin impairments and to promote the healing of existing wounds. They are to complete the Braden Scale assessments on admission and then every 4 weeks, complete weekly skin assessments, communicate risk factors and interventions, and evaluate consistent implementation of interventions and evaluate effectiveness. 5. Review of the clinical record revealed Resident #19 admitted to the facility on [DATE]. According to the MDS dated [DATE], Resident #19 had [DIAGNOSES REDACTED]. The MDS documented the resident displayed intact cognitive abilities. The MDS also documented Resident #19 transferred with assistance of one staff, did not walk, and experienced incontinence of both bowel and bladder. The MDS revealed the resident had skin tear(s), moisture associated skin damage, and remained at risk for developing pressure ulcers. The MDS documented the resident did not have a pressure ulcer during the look back period, utilized a pressure reducing device for bed and chair, and received application of ointment/medications and nonsurgical dressings. The Care Plan documented the resident had impaired skin integrity due to admission to facility with an area on the right knee, initiated [DATE]. The Care Plan directed staff to administer treatments as ordered, measure area weekly and fill out appropriate skin sheet, and notify provider if area worsens. Monitor for signs of infection, refer to qualified professional as needed and provide pressure relief mattress on bed and cushion in wheel chair. The physician's orders [REDACTED].>a. [DATE] - Dress open right knee wound with silver alginate, cover with gauze, and secure with netting daily b. [DATE] - Venous cream (,[DATE] [MEDICATION NAME], ,[DATE] [MEDICATION NAME]) one time daily for area around right knee wound. c. [DATE] - [MEDICATION NAME] Border dressing daily. The [DATE] TAR (Treatment Administration Record) instructed staff to administer skin treatments as ordered, provide a skin assessment every Tuesday, and document weekly on the skin assessment form, dated [DATE]. The [DATE] TAR instructed staff to administer skin treatments to the right knees as ordered; silver alginate and venous cream. The [DATE] TAR instructed staff to administer [MEDICATION NAME] ointment to the right proximal upper leg wound, cover with gauze, and secure with band netting or paper tape. Weekly Skin Assessments included: a. [DATE] - skin intact b. [DATE] - skin intact c. [DATE] - skin intact d. [DATE] - skin intact Non Pressure Weekly Skin Record: a. [DATE] - Right knee surgical wound: 1.2 cm x 1.0 cm with serosanguineous exudate and surrounding skin excoriated. Improving. b. [DATE] - Open area right knee: First observed [DATE]. 1.5 cm x 1.5 cm x 0.1 cm depth with scant serosanguineous exudate and granulation. Stable progress. Resident #19's admission assessment on [DATE] included a right knee open area that measured 2.1 cm x 2.8 cm x 0.1 cm. Wound Clinic [DATE] - Impact virtual wound nurse visit: 1. Wound Assessment - right knee chronic infection 4.2 X 4.0 X 0.1 cm (centimeters) 2. Wound Bed - pink, small slough 3. Exudate - scant serosanguineous. No odor, peri wound is intact. 4. Assessment and Plan - Open wound right knee with complication. Dry wound base, discontinue alginate. [MEDICATION NAME] border dressing, change twice weekly on bath days. Not expected to heal due [MEDICAL CONDITION] chronic, post total knee replacement. 5. Goal - maintain wounds and prevent systemic infection. Impact visits dated ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE] contained no wound measurements. Observation on [DATE] at 11:00 a.m. revealed Staff O, RN provided wound treatment to the right knee. Staff O measured the right knee wound at 4 cm X 4 cm. and administered alginate and venous cream to the surrounding area. During an interview on [DATE] at 10:30 a.m., Staff Z, RN reported they knew about the resident's skin issues and added the resident had skin issues upon admission in July. Staff is to provide weekly skin assessments and notify the physician if the condition worsens. Staff Z stated the nurse assigned to the resident on the day the TAR instructed staff to provide the assessment responsible for making sure it gets completed. During an interview on [DATE] at 10:35 A.M., Staff Q, RN and Staff Z, RN reported they developed a new shower schedule with skin assessment sheets to be completed by CNA's and turned into them. They are to notify nurses if residents refuse. Staff Q and Staff Z will be auditing charts for skin assessments. Staff Z and Staff Q, RN reported they were aware of the lack of appropriate skin assessments and knew they needed to fix it. 6. According to the clinical record, Resident #21 admitted to the facility March, 2020. The MDS dated [DATE] documented the resident did not display cognitive impairment, transferred with extensive assistance of two staff, did not walk in the hall, and only walked once or twice in the room with two staff present. The MDS also revealed the resident required extensive assistance of two staff for dressing, toilet use, and personal hygiene. The resident had [DIAGNOSES REDACTED]. The MDS reported the resident had occasional pain, and no falls since admission/entry or re-entry, had a surgical wound and no other skin conditions. The MDS dated [DATE] revealed the resident transferred and ambulated independently. The Care Plan initiated [DATE] revealed the resident received [MEDICAL TREATMENT] Monday, Wednesday, and Friday due to [MEDICAL CONDITION]. The resident had a potential for falls related to end stage kidney disease and was on [MEDICAL TREATMENT]. The Care Plan instructed staff to keep the walker within reach of resident at all times, refer to qualified professional as needed. The Care Plan revealed the resident had chronic pain related to end stage kidney disease with [MEDICAL TREATMENT], depression and [MEDICAL CONDITION]. It instructed staff resident could request pain medication when needed, to administer [MEDICATION NAME] as ordered, anticipate need for pain relief and respond appropriately to any complaint of pain, monitor for signs of non-verbal pain, and refer to professional as needed. The Care Plan identified the resident had a risk for impaired skin integrity and directed staff to administer treatments as ordered, and apply pressure reduction mattress to bed and cushion in wheel chair. The Care Plan documented the resident as independent with bed mobility (no side rails), transfers, ambulation with a walker, and propelling their wheel chair. The resident required assistance of one staff for perineal care. The physician's orders [REDACTED].>a. Assess pain on a scale of ,[DATE] every shift tw (TRUNCATED)

Based on observation, record review, facility policy and staff interviews the facility failed to ensure that each resident receives adequate supervision to prevent elopement for 1 of 13 residents (Resident #48), identified by the facility at increased risk for elopement, who exited the facility unsupervised, which resulted in an immediate jeopardy to residents health and safety. The facility reported a census of 56 residents. 1. Resident #48 had a Minimum Data Set (MDS) assessment dated [DATE], that documented a [DIAGNOSES REDACTED]. The MDS documented no wandering and independent with ambulation in room and corridor. A care plan dated as initiated 4/29/19 identified a focus area titled resident is an elopement risk/wanderer as evidenced by disoriented to place, impaired safety awareness, resident wanders aimlessly with interventions that included attempt to distract from wandering by offering pleasant diversions, structured activities food, conversation, television, book of which resident prefers. A revision date of 6/4/19 established a goal that the resident will not leave facility unattended through the review date. Interventions include that included if resident expresses desire to leave facility due to missing friends/family, assist with calling family/friends. Intervene to assure safety and notify nurse if notice resident is attempting to remove Wander Guard device. Invite to scheduled activities. Resident my have staff or responsible party to go outside. Encourage to be properly dressed for inclement weather if resident insists on going outside. Elopement Risk form and/or face sheet with photo is placed in the Elopement Book at each nurses station. Repeat Wandering and at Risk for Elopement assessment routinely and with significant change in condition. Wander Alert- wander guard applied, check placement and function every shift. A Progress note dated 6/2/19 at 3:55 p.m., documented Staff B (licensed practical nurse) observed resident sitting on the couch in the lobby at 3:45 p.m. Staff A (certified nursing assistant) was in room A1 doing a 1-1 with a resident, Staff A asked if someone would sit with the resident while Staff A went to the kitchen for ice. Staff B sat in room A1 for less than 5 minutes. When Staff B and Staff A switched back Staff A observed out the window that resident was outside. Staff A and Staff B asked if resident was OK, and where they were going. Resident stated You cant touch me. Staff A and Staff B both stated We wont. Staff A using a calming speech and redirection to convince resident to follow staff back inside. Resident reassured by promising they could talk to the social worker on Monday. I want to go home. I want to go to my house on 22nd street. I don't want to be trapped here. Calming speech and redirection to get resident to come back in with Staff B and Staff A. Wander guard in place and functioning. Head to toe assessment complete. No abnormal findings. An incident summary with no date, documented on Sunday 6/2/19 between 3:45 p.m., and 3:50 p.m., resident was observed in the front facility parking lot by Staff A. The resident had a BIMS score of 4, for which indicated severely impaired for decision making abilities. Staff A saw the resident from the window of room A1 and upon arriving outside to redirect the resident with Staff B, the resident had opened a door to a van sitting in the parking lot belonging to another resident family member. Resident was dressed in pants and a light weight long sleeved shirt with tennis shoes on. Resident had 4 wheeled walker with as well. The outside temperature at the time the resident was noted to be outside was 75 degrees Fahrenheit. No rain or inclement weather noted. Staff A and Staff B immediately went outside to accompany the resident back into the facility. Resident was noted to be a bit upset but did not resist retuning to the building. Head to toe assessment of resident completed by Staff B, with no injuries noted. Proper placement and function of resident wander guard verified at this time. Wander guard system and door alarms checked for proper functioning as well. Staff re-education provided on elopement policy and procedures. A Wandering and at Risk for Elopement form dated 6/2/19, identified the resident with a score of 9 for which indicated resident is at moderate risk for wandering. A Wandering and at Risk for Elopement form dated 4/11/19, identified the resident with a score of 10, for which indicated resident is at moderate risk for wandering. Review of the Alarm Protocol with an issued date of 6/25/19, had a purpose to maintain residents safety by responding to door alarms and assessing the reason for the alarm. Guidelines include: *Staff are expected to respond to ALL door alarms at All times. *The following steps will be taken when a door alarm sounds. 1. The alarm panel will be checked by staff to identify which door is sounding. 2. Staff will respond to the door alarm, to assess the cause of the sounding alarm, including a visual assessment of the area outside of the door. 3. If the cause of the sounding alarm is not identified, staff will conduct a visualized resident count and document the resident count using the daily census sheet. 4. The Missing Resident Protocol will be implemented by staff in the event that a resident is observed outside the secured doors or if the resident count is inaccurate. During an interview on 6/24/19 at 3:42 p.m., Staff A (certified nursing assistant) stated that she was doing a 1-1 on a resident in room A1, for which is the east side of the south hallway, facing the parking lot, she stated that the resident wanted a glass of ice so she asked Staff B (licensed practical nurse) to take over the 1-1 while she ran to the kitchen to get some ice. Staff A stated as she was going by the smokers door (south door on the center hallway) alarms were sounding and she didn't think anything about the alarms sounding and proceeded to go by the A-B nurses station (on the east side of the facility) and passed right by the wander guard door alarm panel ( on the north wall of the A-B nurses station) and walked into the resident room when Staff A looked out the window facing the parking lot and saw a resident attempting to get into a van. Staff A ran out of the room and yelled at Staff B that a resident was in the parking lot outside. Staff A and Staff B went and pushed the codes on the left and right side of the front exit doors to silence the alarms and proceeded to go outside and persuade the resident back into the facility. Staff A admitted that she had failed to look at the wanderguard panel on the north wall behind the A-B nurses station and just felt it was the door that the smokers were coming in. During an interview on 6/24/19 at 3:45 p.m., Staff B stated that the resident was last seen sitting in A-B lobby area on a love seat. Staff B stated that Staff A asked if she would take over the 1-1 on the resident in room A1. Staff A came back to the room with in 1-2 minutes and Staff B walked out of the room, got to the front entrance of the facility and Staff A came running out of A1 room and stated that a resident was outside in the parking lot attempting to get in a van. Staff A and Staff B went out the front doors after punching in the codes to silence the alarms and proceeded to assist the resident back into the facility. During an environmental tour on 6/24/19 at 4:00 p.m., the Administrator demonstrated the actions the staff and resident had taken and the route the resident took on 6/2/19 after exiting the facility and assisted to measure the distances as described below: The distance from where the resident was last seen to the parked van in the parking lot was 73 surveyor steps, from the parked van, stepping over a 5 1/2 inch cement parking curb was 36 more surveyor steps to a 4 lane highway (Hudson Road) for which cars and delivery trucks were traveling by at 35 mile per hour. The Nation Weather Service Forecast Office for 6/2/19, documented the temperature at 77 degrees Fahrenheit. The immediate jeopardy was abated on 6/25/2019. The facility abated the IJ by reeducating staff on the process for elopement and establishing written process for staff when the alarm sounds. The facility also conducted elopement drills.

Based on observation, clinical record review, dietary menu review, resident, family and staff interviews, the facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service which resulted in an immediate jeopardy to residents health and safety. The facility failed to follow the signed dietician directed menus, to serve food timely, to provide additional supplemental foods, to have adequate foods available, to follow prescribed diets and to have sufficient staff to carry out dietary functions for 6 of 8 meals observed. The facility reported a census of 67. Findings include: Observations/interviews on Monday, (MONTH) 17, (YEAR) revealed the following: 1. Observation on 9/17/18 at 9:10 a.m. revealed many residents in the dining room eating their breakfast, the residents on regular diets were served scrambled eggs, toast, oatmeal and bacon. Observations revealed no pureed or ground sausage being served. Review of Week 1 menu revealed residents on regular diets were to be served bacon and residents on pureed, mechanical soft diets, ground or pureed sausage. At this time only 2 staff noted working in the kitchen, Staff A-Cook and Staff B-Dietary Aide (DA). Staff A indicted Staff C-Food Service Supervisor (FSS) has left for a while. During an interview with Staff A at 9:25 a.m., Staff A stated she did not have any butter or sausage for this morning's breakfast. She was aware she needed to serve ground and pureed sausage but none available. She worked over the weekend and they had to go to a local grocery store to get some butter but they used it over the weekend. She reported residents were frequently served the wrong diets. She indicated they have food in the facility but they do not have enough staff to prepare it. Staff A stated for example for lunch today they were to have spaghetti with meat sauce, garlic toast and fruit crisp. Staff A stated she does not have any ground beef in the building for the spaghetti meat sauce because she used it over the weekend to make soup and the residents will not get the fruit crisp they were supposed to get, they don't have enough staff to make it. Staff A stated she has worked alone in the kitchen as recent as last month. She stated she cooked, served and then cleaned up the kitchen because some staff didn't show up for work. Review of Week 1 menu directed staff to serve spaghetti/meat sauce, green beans, garlic toast, fruit crisp and milk for the noon meal and turkey/cheese on sliced roll, lettuce/tomato, tater tots, fresh melon cup and milk. During an interview and tour with the Administrator at 9:40 a.m. revealed no ground beef, butter, deli turkey meat, rolls, fresh fruit, lettuce or tomato for the evening meal. The Administrator sent a staff member to a local grocery store to pick up all food items needed for Monday's meals. Observations at 11:30 a.m. revealed Staff A standing at the stove cooking ground beef and the dessert was still baking in oven. There are 24 residents sitting in the dining room waiting for lunch to be served. A posted meal schedule in the main dining room indicated lunch was to be served at 11:30 a.m. Staff A said the noon meal probably won't be ready until about 12:30 p.m. At 12:31 p.m. Staff C-Certified Dietary Manager arrives to the facility from a sister facility to offer assistance. At 12:52 p.m. Staff C took cans of spaghetti sauce from a sack and began to open the cans of sauce, placing them in a cooking pot. At this time residents in the dining room were leaving the dining room without eating noon meal and shouting could be heard between residents in the dining room. At 1:05 p.m. food temperatures completed by Staff C some of the foods were not at correct temperature and had to be reheated. At 1:08 p.m. Staff C provided education to Staff A on the proper way to puree foods and asked where the recipes were located. Staff A didn't know where to locate recipes. At 1:13 p.m. Staff C takes over preparing the pureed foods and directed Staff A to the serving size chart on the wall. Staff C directed Staff A on the proper size of scoops to use for foods ready to be served. At 1:20 p.m. the first plate of food was served to the residents in the main dining room. The aides passing meal trays in the dining room informed Staff A many residents had left the dining room as they were tired of waiting. Staff A had to ask staff passing the food if a resident was in the dining room before she dished up their food. Staff A served a regular diet spaghetti with meat sauce, green beans and fruit crisp. Staff A failed to serve garlic toast to all regular and mechanical soft diets. Observation of Resident #7 at 1:40 p.m. revealed no cottage cheese given to the resident. The cook was informed to the lack of cottage cheese and served the resident a dish of cottage cheese, the resident ate approximately 1/2 of the cottage cheese. Review of the diet slip directed staff to provide cottage cheese for the noon meal. Observation of Resident #4 at 1:40 p.m. revealed the resident did not get their yogurt. Review of the diet slip directed staff to provide yogurt for the noon meal. At 2:01 p.m. Staff A served the last tray in the dining room but still had to serve the room trays. During an interview with Staff C at 2:16 p.m., surveyor made Staff C aware of the lack of bread served at the noon meal, she stated the staff were in need of extensive training and she will be returning to the building this whole week to provide supervision and training. Observation of the evening meal at 5:45 p.m. revealed approximately 1/3 of residents served their meal. The pureed deli meat, cheese and bun were located in the steam table and were served warm. Staff C informed the cook the sandwich needed to be served cold like the rest of the diets served , Staff A went ahead and served the sandwich warm. During an interview with the Staff D-Contracted Dietician at 2:45 p.m., Staff D stated tomorrow will be her last day in the facility and will no longer being provide dietary services to the facility. Staff D indicated she identified 6 weight losses from the previous week. Staff D stated she had an educational session with the dietary staff on 8/13/18. Staff D stated she will complete education again for the staff by Tuesday, (MONTH) 18. She stated frustration with the staff, she had made many attempts to educate them but they do not follow thru with the education. Staff D stated she was not aware the dietary staff were not following the menus she had approved and had not received any substitution logs to sign. During an interview with the Director of Nurses at 11:20 a.m. the D.O.N. stated they have a large turnover in dietary staffing, some of the staff just walked out during the shift and didn't return. They have a new FSS and the facility was working on getting her trained. The D.O.N. stated she goes into the kitchen to help out, last week she stated she cleaned the refrigerators and they were very dirty. Observations/interviews on Tuesday, (MONTH) 18, (YEAR) revealed the following: 2. On 9/18/18 at 10:26 a.m., the surveyor requested a copy of the substitution log from the previous day, Staff D could not locate the logs. Staff D stated she made the log out for yesterday but could not locate it nor any previous days. During an interview with Staff D at 9:57 a.m. Staff D stated she has told them almost weekly they need to have a diet book, this consists of the menu and the recipes but they do not follow thru with this. Staff D stated she does not think they make out substitution logs as she hasn't signed any, she indicated she provided them the forms. Staff D stated she would expect the staff to follow the menus as posted. Staff D aware of the weight loss for Resident #7 and that was why she added the cottage cheese, yogurt and additional eggs. Staff D stated the long term Food Service Supervisor resigned on 5/7/18 another manager hired but resigned on (MONTH) 9th and the current manager started her role on (MONTH) 23, (YEAR). Interview on Wednesday, (MONTH) 19, (YEAR) revealed the following: 3. During an interview with Resident #2's family member, the family member reported she was at the facility for at least 2 meals a day to provide eating assistance to her loved one. She reported the resident does not get the foods listed on the menu, he does not get his additional supplements ordered such as Magic Cup prescribed for 2 meals. She feels the dietary department has staff that were not properly trained. She voiced Resident #2's meals were frequently late and reported he had a weight loss. Observations/interviews on Saturday, (MONTH) 22, (YEAR) revealed the following: 4. Observation on 9/22/18 at 12:00 p.m. revealed the first food served in the main dining room, 30 minutes later than scheduled. Review of the noon meal menu directed staff to serve ice cream sundaes. Observation at this time revealed bowls of ice cream sundaes on the counter ready to serve, the ice cream had melted in the bowl. The Administrator directed the staff to discard the melted ice cream and to serve frozen ice cream to the residents. Observations/interviews on Monday, (MONTH) 25, (YEAR) revealed the following: 5. Observation on 9/25/18 at 8:30 a.m. revealed the Administrator in the kitchen serving breakfast from the steam table. The Administrator indicated 2 of the dietary staff failed to show up for work this am. The Administrator stated Staff D-CDM still was not here. During an interview with Staff E-Food Service Supervisor at 9:00 a.m. Staff E stated the cook didn't show up for work today, indicating they still have staffing issues in the dietary department. She stated she was often expected to perform duties as a Certified Nurse's Aide while working her job in the dietary department. She assists with feeding assistance, takes resident's back to their rooms from the dining room, provides incontinence cares and then returns to work in the dietary department. Observations at 11:05 a.m. revealed a housekeeper, wearing the same clothes she wore for cleaning, in the kitchen preparing food for the noon meal. During an interview with the Advanced Registered Nurse Practice at 10:10 a.m. she stated she comes every week to see residents. The A.R.N.P. was not aware that two of her residents had weight loss Residents #2 and #8 were not getting their prescribed meal supplements to prevent further weight loss and would have expected the staff to serve these foods to the residents. During an interview with Staff C-CDM at 4:05 p.m. stated she provided the dietary staff with education last week but this week they acted like they didn't know what to do. Staff C stated she left one evening last week, she forgot something so returned to the building, as she entered the kitchen she heard a dietary person say to another, She's gone, we don't have to do it that way anymore. Observations/interviews on Wednesday, (MONTH) 26, (YEAR): 6. An interview with the Medical Director at 10:34 a.m. revealed she was not aware of dietary issues, not aware the residents were not served their prescribed diets/interventions for those identified with weight losses. She stated it's a simple, basic thing that needs to be done and she would expect them to serve the correct diets. 7. During a group interview on 9/18/18 at 1:30 p.m. with 7 interviewable residents revealed they often do not get the food that was listed on the menu. The staff will offer an excuse that the food didn't get ordered and the meals were often about 1 hour late. During review of the (MONTH) (YEAR) Resident Council Minutes revealed the dietary does not serve the food correctly, they have missing menu items and the food was not prepared correctly. The resident group indicated the menus were not always passed out, they have food missing off the menu and they feel there was a lack of food. Review of the (MONTH) (YEAR) Resident Council Minutes revealed the residents spoke of not getting the food requested and the inconsistent meal times. The resident's feel supplies were low especially cream, sugar, coffee, butter and condiments. The meal times were changed and the residents were not aware of the changes. Review of the (MONTH) (YEAR) Resident Council Minutes revealed the residents made complaints about the meal time consistency and often late with no. 8. Review of a list provided by the Dietician on 9/24/18 revealed the following residents had orders for adaptive dietary equipment: Resident #6 had an order for [REDACTED].>Resident #9 had an order for [REDACTED]. Observations on 9/18 at 11:50 and 9/22/18 at 12:22 p.m. revealed Resident #6 at the dining table using regular silverware. During an interview with Resident #6 on 9/24/18 at 2:55 p.m., the resident stated it was much easier for her to eat when she used the adaptive silverware because of the arthritis in her hands. Observations on 9/19/18 at 10:40 a.m. and 12:02 p.m. revealed Resident #9 utilizing a two handled cup with a lid on it. During an interview with Resident #9 on 9/20/18 at 11:30 a.m. the resident stated she often gets her cups with lids on them. During an interview with Staff C-CDM on 9/18/18 at 12:00 p.m. revealed she was now aware of the lack of adaptive dining devices used in the dining room. She stated the dietary staff were responsible for the divided plates and the nursing staff were responsible to provide the adaptive silverware. Review of a dietary in-service dated 7/16/18 revealed the Dietician reviewed the use of adaptive equipment with the dietary staff. 9. Observation on 9/17/18 at 9:30 a.m., revealed temperature logs posted in the kitchen revealed the following: a. the white standing freezer had a (MONTH) (YEAR) log taped to the door. b. the refrigerator temperature log posted on the wall had a date of (MONTH) (YEAR). c. the three door refrigerator log posted on refrigerator had a date of (MONTH) (YEAR). d. the white ice cream freezer had an (MONTH) (YEAR) log attached. e. the milk cooler had a (MONTH) (YEAR) log posted. During interview on 9/17/18 at 10:08 a.m., Staff E, Food Service Supervisor, revealed she did not have any current temperature logs, what was posted was what she had. 10. Observation on 9/17/18 at 11:00 a.m., revealed the (MONTH) (YEAR) Dishwasher/Sanitizer log with no documented entries. Observation revealed Staff F, Dietary Aide washing dishes in the dishwasher. Staff F was asked to check the temperature of the dishwasher, she replied that she did not know how to do it. With assistance from Staff A, Cook, Staff F ran a temperature strip. The strip did not change color which indicated it did not reach the proper sanitizing temperature. Staff A called Staff G, maintenance supervisor to the kitchen to check the dishwasher. Staff G indicated the booster was reset and it should work now. Staff G ran another strip and the water temperature did not go to acceptable level. Staff G called a local contractor to fix the problem. During interview at the time Staff A indicated the water temperature had not been warm enough for a couple of days because she was able to take the dishes out of racks without burning her fingers, she failed to contact anyone regarding the issue. At 11:43 a.m. after repairs were completed, a strip was ran thru the dishwasher and turned an acceptable color indicating the hot water temperature reached an acceptable level. 11. Observation on 9/17/18 at 9:30 a.m., the dry storage room/dietary office had three opened boxes on the floor and a can of unopened fruit cocktail on the floor. Observation revealed the floor was litter with garbage such as used dietary hair nets, piece of chewed gum and unopened packets of artificial sweetener. The floor had black particles scattered throughout the room. On the second shelf of an open storage unit a gallon jar of mustard sat next to a spray bottle of the chemical strike force. 12. Observation on 9/17/18 at 9:25 a.m., revealed the food temperature logs were not up to date. Staff A, Cook, provided the daily food temperature logs dated (MONTH) (YEAR). Staff A stated she did not have any other logs and she did not do food temperatures this morning or the past weekend. During interview on 9/24/18 at 5:00 p.m., Staff A reviewed the log for 9/24 and noted only 2 foods (unidentified foods) had a temperature next to them, other than that the logs were empty. Staff failed to check temperatures of the resident food items prior to serving. During interview on 9/17/18 at 2:45 p.m., Staff D, Registered Dietician revealed she provided education to dietary staff on the importance of checking food temperatures and reported holding a dietary inservice about this on (MONTH) 16, (YEAR) and (MONTH) 17, (YEAR). Review of a Nutrition Services Manual policy dated 6/2015, directed staff to take food temperatures during preparation, cooking, meal service and storage of foods. The facility abated the IJ on (MONTH) 18, (YEAR), when dietary staff received education on following menus which include puree and scoop size, ensuring dishwasher safety and refrigerator monitoring and ensure sufficient food was present for planned menu. The IJ was lowered from L severity level to F with the need for continued monitoring of staff in following education provided.

Based on observation, clinical record review, staff and resident interviews, the facility failed to offer therapeutic diets as ordered and assistance with eating to prevent weight loss for 2 of 8 sampled residents (Resident #7 and #8). The facility reported a census of 67 residents. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE] Resident #7 had [DIAGNOSES REDACTED]. The resident had severe cognitive ability, required limited assistance of 1 staff for transfers, dressing and ate independently. Review of the resident's care plan dated 6/27/17 indicated the resident had potential risk for alter nutritional status and directed the staff to encourage high protein foods at each meal, to offer fried eggs with breakfast, cottage cheese with lunch and yogurt with supper. The care plan directed staff to serve diets as ordered and supplements as ordered. Review of the diet slip dated (MONTH) 17, (YEAR) indicated the resident chose cottage cheese, milk, mashed potatoes and gravy for her noon meal. Observation of the noon meal on (MONTH) 17 revealed the resident was served at 1:40 p.m. mashed potatoes with gravy only and did not receive the cottage cheese she requested as directed to be given to prevent weight loss. After the lack of cottage cheese was brought to staff's attention, the staff gave the resident a dish of cottage cheese which she consumed about 1/2. Review of the residents weight revealed the following: a. (MONTH) 5, weight of 130.0 pounds b. (MONTH) 4, weight of 130.2 pounds c. (MONTH) 10, weight of 128.4 pounds d. (MONTH) 5, weight 126.2 pounds e. (MONTH) 4, weight 123.6 pounds f. (MONTH) 7, weight of 121.0 pounds g. (MONTH) 4, weight of 119.2 pounds Resident #7 had a 10.8 pound weight loss in 6 months. (11% weight loss within 6 months) Review of a progress note to the Resident's physical dated 9/13/18, Resident #7 has had a significant weight loss, indicated her weight treading down since (MONTH) (YEAR) and requested an order for [REDACTED]. During an interview with the facility dietician on 9/18/18 at 9:57 a.m. the dietitian was not aware the staff failed to provide the resident with dietary supplements prescribed to avoid weight loss. 2. According to the MDS dated [DATE] Resident #8 had [DIAGNOSES REDACTED]. The resident had severe cognitive ability. Resident #8 required extensive assistance of 1 staff for transfers and limited assistance of 2 staff for dressing and eating. The MDS indicated the resident did not have issues with swallowing or chewing. Review of the Care plan dated 1/15/18 informed the staff the resident had increased nutrient needs related to low body weight and supplement use for weight maintenance. The care plan directed staff to have the resident sit at an assisted dining table and provide cues with eating, to encourage her to consume 50% or more of the meal offered, provide and serve the diet prescribed and serve supplements away from the meal time. Review of a physician order [REDACTED]. Observation of the noon meal on 9/17/18 revealed the resident received spaghetti with meat sauce, green beans, and fruit crisp but the staff failed to serve the garlic toast according to the menu. Observation on 9/19/18 at 8:35 a.m. revealed the resident sitting alone at the table without staff present. The resident observed taking sips of fruit juice only and not eating the breakfast offered. At the conclusion of the meal, no staff offered assistance and the resident did not eat breakfast offered. Review of the resident's weights reveal the following: a. (MONTH) 3, (YEAR) weight of 105.8 pounds b. (MONTH) 5 weight of 104.6 pounds c. (MONTH) 5 weight of 104.6 pounds d. (MONTH) 3 weight of 102.8 pounds e. (MONTH) 9 weight of 102.3 pounds f. (MONTH) 5 weight of 94.0 pounds and (MONTH) 31- 93.8 pounds g. (MONTH) 3 weight of 94.0 pounds and (MONTH) 5 -94.0 pounds The resident has had a 11.8 pound weight loss in the last 6 months. (11% weight loss) During an interview with the Dietician on 9/18/18 at 9:57 a.m. revealed Resident #8 had an increase in their 2 cal supplement, needs to sit at an assisted table. The dietitian stated she would expect the staff to offer the resident all foods according to the menu to give the maximum amount of food possible to the resident and offer eating assistance. Review of a progress noted dated 8/31/18. The note indicated the resident experienced a significant weight loss and recommendations were made to increase her supplement to promote weight maintained.

Based on clinical record review and interviews, the facility failed to timely assess and provide interventions for one (1) of four (4) residents reviewed. Record review revealed Resident #1 reported to staff she thought she had a stroke and her ability to speak worsened the next few hours. Staff interviews revealed the nurses did not promptly address Resident #1's significant change in condition. The facility reported a census of 64 residents. Findings include: 1. According to the Minimum Data Set assessment (MDS), dated [DATE], Resident #1 had no cognitive impairment and no difficulty being understood or understanding others. The MDS revealed Resident #1 had no signs or symptoms of [MEDICAL CONDITION]. The resident required the assistance of two staff to transfer and dress and had [DIAGNOSES REDACTED]. The Progress Notes dated 10/19/17 & 10/23/17 revealed Resident #1 had been admitted to the nursing home from the hospital after hip surgery. The resident demonstrated she was alert and oriented. The Progress Notes effective date 10/29/107 at 1:20 p.m., created at 2:18 p. m. by Staff C documented a CNA (Certified Nurse Aide) reported the resident states I feel like I had a stroke. The resident had slurred speech, delayed thought process, [MEDICAL CONDITION], hand grips equal and strong, and pupils dilated with assessment (vitals). CNA's reported yesterday the resident's talked normal. The resident wished to go to the hospital. Physician notified and order received if family agrees. The Progress Note effective date 10/29/2017 at 9:30 a.m., created by Staff B on 10/29/2017 at 4:07 p.m. reported the resident sat in the recliner in the room, requested medications be given whole in apple sauce and then without apple sauce, alert and oriented to self and pleasant. The resident had easy and unlabored respirations, grips strong and equal, regular heart rhythm; will continue to monitor. Hospital Records included: Discharge Documentation - admitted [DATE]. Reason for visit: Stroke. Final Diagnoses: [REDACTED]. The Emergency Documentation included: History of Present Illness: Presents with trouble speaking from the nursing home. Nursing home notified family at 1 o'clock p.m., but nursing home staff reported Resident #1's symptoms started early when the resident was unable to speak on examination or able to follow commands. Last seen normal around 8:00 a.m. Started with slurred speech and hard time finding words at 9:30 a.m. Stopped talking around 12:00 noon. Family notified at 1:10 p.m. Transported to emergency department for evaluation. The resident did not have history of stroke; however the resident had a right hip revision 2 weeks ago. During an interview on 1/31/2018 at 2:57 p.m. via phone, Resident #1's family member said the resident had a stroke that affected his/her speech. The resident returned home since December 2nd 2017. From the hospital, the resident went to a (different) nursing facility for therapy and speech continued working with the resident at home. During an interview on 2/2/18 at 11:30 a.m., the Physician reported checking the emergency room records and said staff should have notified the physician and followed up when the resident had a change in condition. The resident's speech was difficult at 9:30 a.m., and then stopped speaking later. The physician reported the resident is [AGE] years old and current on anticoagulant therapy, and he would not have recommended treatment with tPA (tissue plasminogen activator) as it's contraindicate. During an interview on 2/1/2018 at 5 o'clock p.m., Director of Nursing (DON) revealed the investigation showed the progress note dated Sunday, 10/29/2017 at 9:30 a.m. had actually been created at 4:07 p.m. by Staff B, RN. Staff B also entered the vitals for Resident #1 into the resident's record at 3:34 p.m. when he/she returned to the facility (later that day). The progress note dated 10/29/2017 had been created by Staff C, LPN (Licensed Practical Nurse) at 1:20 p.m Staff C came to the DON on Monday, 10/30/2017 and voiced a concern regarding Staff B. Resident #1's family member also came to the facility and voiced a concern. The DON checked the progress note at 9:30 a.m. and it failed to identify a concern at the time. Staff B said he/she told Staff C and Staff C said he/she had not been told about the resident. Staff C had checked the progress notes and saw no notes. The DON told Staff B that he/she should have called the physician when a resident reported feeling as if they had a stroke. The facility suspended Staff C for a delayed assessment. Staff D's written documentation dated 10/31/17 on the Risk Management Statement form revealed the following for the events on 10/29/17: Around 9:00 to 9:30 a.m. she answered Resident #1's call light and the resident reported she felt like she had a stroke. Staff D went to get Staff B who was nearby and she came right away. Staff D was asked to get the vitals cart and when she did, she watch Staff B complete vitals and then Staff B told her she was going to consult with Staff C who was in the dining room. Staff B told Staff D they were just going to watch Resident #1 for the time being. Staff D was not with Staff B when she spoke with Staff C. At 11:00-11:30 a.m. Staff D noticed Resident #1's speech was not the same as had been in the morning and she told Staff C who reported ok. Staff D did not see Staff C go in and assess Resident #1. At noon, Staff D told Staff E that her speech had gotten worse and no one seemed concerned or had looked in on Resident #1. Staff E and her tried to get Resident #1 to tell them what was wrong and they could barely make out what she was saying. They obtained vitals and gave them to Staff C. Staff D didn't see Staff C go into Resident #1's room. Around 1:30-1:45 p.m., Staff C asked them to get Resident #1 ready for ER (emergency room ) transport. During an interview on 1/31/2018 at 2:30 p.m., Staff D, CNA reported sometime after breakfast and before lunch between Resident #1 had the call light on and said I had a stroke. Staff D reported this to Staff B, RN and Staff B did an assessment with Staff D present. Staff D said Staff B talked to Staff C, LPN. Staff F, Medication Aide took over when Staff B left. The resident had the call light on again and Staff D reported it to Staff C. Staff C, in the dining room, had asked staff to check the resident's vitals. Staff D and Staff E checked the resident's vitals and reported to Staff C. The resident's speech had been affected. Staff D said Staff C should have responded quicker. Staff C called the ambulance to transfer the resident. During an interview on 1/31/2018 at 2:15 p.m. Staff B, RN reported working on 10/29/2017 from 6 a.m. until 10 a.m. and returned at 2 p.m. near the end of the 10 a.m. shift, Staff B went into Resident #1's room and administered his/her pills with no problem. About 15 minutes later, Staff D, CNA came to Staff B and said Resident #1 was not feeling well. Staff D and Staff B went into the resident's room. The resident had normal vital signs, denied pain and said he/she did not really know what was wrong. Staff B went into the medication room and told Staff C the vital signs were fine and hand grips were normal. The resident never mentioned feeling as though he/she had a stroke. When Staff B returned to the facility at 2 p.m., the ambulance had arrived and he/she heard Resident #1 went to the hospital. Staff E said the resident sat up for lunch and after that, stopped talking. The hospital called and asked when the resident's symptoms started. Staff B relayed the information that Staff E reported. During an interview at 2/1/2018 at 3:55 p.m., Staff C, LPN reported the facility terminated his/her employment. Staff C normally did MDS's at the facility but agreed to work on 10/29/2017 from 6 a.m. until 2 p.m. on B wing. Resident #1 resided on A wing. Staff C had not met the resident prior to that day. Staff B worked A wing, Staff C overheard Staff D tell Staff B that Resident #1 reported feeling like he/she had a stroke and did not feel well. Staff B reported to Staff C that the resident's vitals were normal. Staff C told Staff B to do what she thought needed to be done. Staff B walked away and Staff C continued with passing medications. Staff F, CMA (Medication Aide) replaced Staff B at 10 o'clock. When Staff C went to the dining room to monitor lunch after 12 o'clock, staff came and reported Resident #1 had an increase in symptoms. Around 12:50 p.m. Staff F gave Staff C Resident #1's vitals. That was the first Staff C knew of the concern. Staff C went to the resident's room and called the physician. Staff C checked the progress notes and Staff B failed to document earlier. The physician ordered the resident be sent to the emergency room . Staff B said the resident was fine when she left at 10 a.m. Staff C felt frustrated because Staff B failed to report the resident's assessment. Staff B documented late and incorrectly. Staff E, CNA never came to report a concern and Staff D never reported anything until closer to 1 o'clock p.m. Nobody told Staff C at 11:30 a.m. as reported. During an interview on 1/31/2018 at 1:40 p.m., Staff E, CNA said around 11:30 a.m., Staff D came and said something was wrong with Resident #1. Staff E went in and the resident mumbled stroke. The resident failed to speak clearly, a change in condition. Staff E reported the findings to Staff F, Med Aide. Staff F asked Staff E to get a set of vitals. The vitals appeared normal except for a slightly elevated temperature. Staff E reported to Staff F and observed Staff C in the dining room passing pills. Staff E told Staff F that the resident had a stroke and she needed to tend to the resident. Staff E never said anything to Staff C. Staff E went and held the resident's hand and tried to comfort the resident for about an hour. Lunch trays are served at 11:30 a .m. and Staff E never saw a lunch tray in the resident's room. At 12:30 p.m., Staff C entered the resident's room. Staff E told Staff C the resident had a stroke, failed to speak and had a droopy left face. The resident nodded Yes (up and down) when asked if she wanted to go to the hospital. Staff E heard the resident went to another facility. During an interview on 1/31/2018 at 3:15 p.m., Staff F, Medication Aide reported working on 10/29/2017 at 10 o'clock a.m. Staff F received a report from Staff B and failed to recall anything specific. Around 11:30 a.m., Staff E came and said Resident #1 had something going on and failed to talk. Staff F checked the resident who appeared distressed. Staff F reported to Staff C and Staff C said Staff B had taken care of it prior to leaving. At 12:05 p.m. Staff F checked the resident again and observed her shaky and not able to talk. Staff F asked Staff E to check vitals and reported to Staff C. Around 1 o'clock p.m., Staff C called the physician and sent the resident to the hospital.

Based on record review, physician and staff interviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 5 residents. Resident #2, with cognitive impairment, admitted to the facility from home with a history of falls prior to admission. Staff interviews revealed Resident #2 was known to not wait for staff assistance or reliably use the call light. The resident fell [DATE]. Staff documented the intervention to the fall as education and screen for therapy. The resident was cognitively not able to retain the education provided and the facility did not carry out the therapy screen. On [DATE] the resident fell sustaining intracranial hemorrhage (brain bleed) and fractured clavicle. The resident returned the facility on Hospice and expired [DATE]. Resident #3, with cognitive impairment, had a history of [REDACTED]. On [DATE] the resident fell unwitnessed and staff educated the resident to wait for assistance and to use the call light. The facility evaluated the resident room and the resident did not want to change any arrangement in the room. There was no intervention put in place following the incident. On [DATE] the resident fell unwitnessed during the night and sustained a fractured right hip. The facility implemented a night light and asked the resident's family to take some things from the room. The care plan did not reflect an increase in supervision for the resident. After the resident returned to the facility on [DATE], Resident #3 had an unwitnessed fall on [DATE] during the night and the facility staff did not conduct neurological checks. Later on [DATE] the resident's family requested Hospice and the resident expired [DATE]. The facility identified a census of sixty (60) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of [DATE], assessed Resident #2 with a Brief Interview for Mental Status (BIMS) score of 4 (severe cognitive impairment). The resident admitted to the facility on [DATE] from the community. The resident had hallucinations and physical behavior symptoms 1 to 3 days out of 7. The resident did not reject care or wander. The resident required extensive staff assistance with bed mobility, transfers, walking in room and corridor, dressing and toileting. The resident used a walker or wheelchair for mobility. A balance during transitions and walking test identified the resident as unsteady and only able to stabilize with staff assistance. The resident was occasionally incontinent of bowel and had a urinary indwelling catheter. The resident had [DIAGNOSES REDACTED]. The MDS did not identify falls since admission. The resident used an antidepressant daily. A falls CAA (care area worksheet) dated [DATE] revealed the resident had a history of [REDACTED]. The resident used a wheelchair for longer distances. The resident had dementia but had the ability to use the call light. The CAA identified that staff should assure the wheelchair and walker brakes were set prior to transfers. Staff should provide proper fitting and nonskid shoes while in the wheelchair and when ambulating. Provide safe, uncluttered, dry floors and good lighting in the room. An undated Kardex care plan identified the resident required staff assistance of one with mobility and transfers. A siderail screen assessment dated [DATE] identified the resident as a fall risk. A care plan dated [DATE] revealed the resident needed staff assistance for mobility and transfers and assist for toileting and transfers PRN. On [DATE] at 11:20 a.m. the care plan nurse stated she wrote it that way because the resident used a catheter. The care plan identified on [DATE] that staff educated the resident following the [DATE] fall. There was no other interventions on the care plan following the [DATE] fall. Progress notes dated [DATE] at 1:45 p.m. revealed the resident arrived at the facility via private vehicle. Progress notes dated [DATE] at 7:57 p.m. revealed one staff assisted the resident with gait belt and wheeled walker for ambulation. Progress notes dated [DATE] at 8:10 p.m. revealed one staff assisted the resident with transfers and ADLs. Progress notes dated [DATE] at 2:10 a.m. revealed staff found the resident laying on his/her back on the floor next to the dresser. The resident had no complaints of pain and assessment did not show abnormality. Two staff got the resident up from the floor and assisted the resident to the bathroom and then back to bed. On the same date at 11:32 p.m. staff transferred the resident with one staff and the walker as usual. A fall report dated [DATE] at 1:52 a.m. revealed staff found the resident laying on his/her back next to the dresser. The resident did not sustain injury and staff assisted the resident to the bathroom. The immediate action taken was assisted resident to the bathroom and then to bed. Will get orders for therapy to screen. The form revealed the precipitating factors were gait imbalance, and ambulating without assistance. Progress notes dated [DATE] at 9:38 p.m. revealed staff found the resident lying on the floor on his/her right side next to the bathroom door. The resident's glasses were off his/her face and the resident's head laid on top of the glasses. The resident complained of right hip pain. On the same date at 7:57 p.m. the emergency room (ER) called and stated the resident admitted to the hospital with [REDACTED]. A fall report dated [DATE] at 9:22 p.m. revealed the resident had increased confusion. Staff found the resident on the floor laying on the right side next to the bathroom door. The resident laid on top of his/her glasses and complained of right hip pain. Staff called the ambulance. The form identified the precipitating factors as confusion, gait imbalance, impaired memory and ambulating without assistance. An emergency department nursing assessment dated [DATE] with ER arrival time of 6:51 p.m. revealed the resident had pain and swelling over the right orbit (eye) with a large area of ecchymosis noted over the area. There was pain and swelling over the posterior occipital scalp. There was no active bleeding. The resident responded to verbal stimuli but speech was slurred and garbled. The resident had difficulty understanding and following verbal commands. The report identified the ER physician spoke with the facility nurse and who informed the physician that staff last saw the resident between 5:30 p.m. and 5:50 p.m. The resident fell in the room unwitnessed onto the right side. The resident complained of right hip pain and broke his/her glasses. This was the second fall in the last 30 days since resident arrived at the nursing home. The resident took baby aspirin as a blood thinner. The emergency department chart dated [DATE] at 7:05 p.m. identified the resident with a fractured clavicle and traumatic intracranial subarachnoid hemorrhage. A hospital history and physical, dated [DATE] identified the resident admitted to the intensive care unit (ICU). The consultation report dated [DATE] documented the CT scan (computer tomography) of the resident's head showed a small amount of acute subarachnoid hemorrhage with a small acute subdural hemorrhage overlying the anterior left frontal lobe measuring 2.5 centimeters (cm) and 3 millimeters (mm) in thickness. A transfer form dated [DATE] revealed the resident returned to the facility on with Hospice to follow and comfort measures. Nursing progress notes identified the resident continued to decline after readmission to the nursing home and expired on [DATE] at 3:50 a.m. A death certificate identified the time and date of death as [DATE] at 3:50 a.m. The manner of death was accident. The immediate cause of death was cardiac arrhythmia due to hypertension with other significant conditions of: subdural bleed due to recent fall, Parkinson's disease, diabetes mellitus and colon cancer remote. Staff Interviews: Staff that worked when the fall occurred: On [DATE] at 10:21 a.m. Staff A RN (registered nurse) stated she went down the hall and when she walked by the resident's room, she observed the resident on the floor laying on their right side. She called for help and stayed with the resident until help arrived. The resident complained of pain when touched so staff called 911. Staff A stated the resident was supposed to have assistance ambulating but the resident would get up and walk by self at times. The resident did not always use the call light. It was not activated at the time of the fall. Staff A stated the resident's responsible party informed the facility of the resident's falls at home when admitted to the facility. On [DATE] at 1:38 p.m. Staff B CNA (certified nurse aide) stated the resident needed assistance but he/she would try and do things on their own. The resident would get up per self a couple times a shift to use the bathroom for bowel movements. She stated staff was just in the resident's room with a food tray prior to the incident and the resident appeared confused. The resident was pretty good about using the call light and appeared steady on his/her feet when he/she paid attention. When the resident got distracted, then he/she would get unsteady. On [DATE] at 5:15 a.m. Staff D LPN (licensed practical nurse) stated she came on duty and had not taken over the shift yet when they found the resident on the floor. Staff A found the resident. Staff D stated the resident was noncompliant. The resident didn't wait or use the call light. In response to that, staff just counseled the resident and gave the resident reminders. On [DATE] the resident fell on the way to the bathroom so after staff got the resident up from the floor, they assisted the resident to the bathroom. Staff D stated staff isn't sure where the resident tried to go when he/she fell on [DATE]. They found the resident parallel to the wall in the same direction as the bathroom with the head to the hallway and feet by the bathroom. The resident's glasses were smashed and the resident had a black eye. They sent the resident to the hospital right away. On [DATE] at 2 p.m. Staff E CNA stated she was getting ready to leave on [DATE] when she heard Staff A yell. She grabbed the vitals cart and went to the resident's room and the resident was on the floor. The resident laid by the bathroom door. She stated the resident thought he/she needed the bathroom and would try to go by self a lot. Staff E would catch the resident going by self to the bathroom 3 to 4 times a shift. The resident needed help due to unsteadiness. The resident would not use the call light. She stated when she asked the resident if he/she needed anything, the resident would never request the bathroom and then shortly after that, the resident would go by self to the bathroom. On [DATE] at 1:05 p.m. Staff F RN stated she was giving report when Staff A found the resident on the floor. The bathroom door was wide open. Staff F stated she was in the resident's room at 5:15 p.m. to check the resident's blood sugar. Staff F stated she thought the resident was a 1 assist. The call light was not activated. After the incident, Staff F found out the resident still thought he/she needed to urinate and would keep trying to go the bathroom. The resident used a Foley catheter. The resident was not consistent with call light use or waiting for help. On [DATE] at 1:47 p.m. Staff G CNA stated she was in the front of the building when the resident fell . The resident required 1 to 2 staff to assist with ambulation. The resident would sometimes try to self transfer. The resident was good about using the call light. They always walked the resident with 2 staff because the resident leaned when walking. Other staff: On [DATE] at 6:25 a.m. Staff C CNA stated the resident would sometimes use the call light and sometimes would not use the call light. Sometimes when going down the hall, staff would catch the resident standing up by self. The resident was not always steady on feet. On [DATE] at 6:55 a.m. the Director of Nursing (DON) stated the resident required assistance of one staff for transfers and ambulation. The DON stated she educated the resident on falls and use of the call light. She stated the intervention following the [DATE] fall was to educate the resident. They planned to do a therapy screen on Monday [DATE] but they couldn't get insurance verification until Monday so the screen was not done. Some staff said the resident used the call light frequently and other staff said he/she did not but staff would sometimes catch the resident halfway to the bathroom. The DON stated staff just did the normal supervision on the resident by looking in when going by the room. They did not have the resident on a toileting plan since the resident used an indwelling urinary catheter. When the second fall occurred, the resident was off balance from the prior fall. On [DATE] at 5:50 a.m. Staff I (CNA) stated she was told in report (before the resident's falls) that the resident was independent. 2. A MDS with assessment reference date of [DATE], assessed Resident # 3 with a BIMS score of 11 (moderate cognitive impairment). The MDS identified the resident as independent with transfers and toileting and needed supervision with ambulation. A balance during transitions and walking test revealed the resident with a score of 1 in all areas of testing. A score of '1 identified the resident as not steady but able to stabilize without staff assistance. The resident used a wheelchair for mobility. The resident was continent of bowel and bladder. The resident had [DIAGNOSES REDACTED]. The resident had 2 falls without injury since the prior assessment. A self care deficit care problem with initiation date of [DATE] revealed the resident required assistance if one staff with transfers, ambulation, toileting, dressing and showers as resident allowed. An intervention dated [DATE] revealed the resident frequently took self to the bathroom, transferred and ambulated in room by self and refused to use the call light for assistance. A care plan with problem initiation date of [DATE] revealed the resident was at risk for falls. An intervention dated [DATE] identified the resident as noncompliant with using call light when needing assistance. History of falls and self transfers: An incident report dated [DATE] at 4:45 a.m. revealed staff responded to a call light and found the resident sitting on his/her buttocks at the bedside. The resident denied injury. The report and care plan did not identify an intervention after the incident. An incident report dated [DATE] at 11 p.m. revealed staff found the resident sitting on the floor onto his/her bottom. The resident claimed he/she slid off the bed. The resident did not sustain injury. The care plan identified staff initiated assist bars on the right side of the bed on [DATE]. An incident report dated [DATE] at 3 p.m. revealed the resident sat at the side of the bed and slid off to the floor. The resident did not sustain injury. The care plan identified staff initiated a scoop mattress on [DATE]. An incident report dated [DATE] at 9:45 p.m. revealed staff found the resident seated on the floor in front of the wheelchair. The resident tried to get something from his/her new fridge. The resident did not sustain injury. The care plan updated [DATE] identified staff asked the resident's family to provide a table for the fridge to sit on to elevate to a safer level for easier access. An incident report dated [DATE] at 10:30 a.m. revealed staff found the resident lying on his/her left side between the bed and TV stand. The resident's head was towards the foot of the bed and legs pointed toward the head board. The resident tried to walk to his/her wheelchair from the bathroom. The resident did not sustain injury. The incident report identified that staff educated the resident on the importance of using the call light. On [DATE] the physician ordered lactaid (for milk intolerance) for the resident's diarrhea to decrease bathroom urgency/need. An incident report dated [DATE] at 6:30 a.m. revealed staff observed the resident sitting by his/her bed. The resident stated he/she slid from the wheelchair. The report identified the resident as incontinent and ambulating without assistance. The resident did not sustain injury. The report identified staff educated the resident on using the call light and getting assistance before transferring. Staff assessed the resident's room and the resident declined to make any changes in room arrangement. The care plan did not reflect a new intervention in response to the incident. (The care plan contained an intervention, dated [DATE] to toilet the resident every two hours.) The incident report dated [DATE] did not identify when staff last toileted the resident. Progress notes identified the resident was hospitalized from [DATE] to [DATE] with [DIAGNOSES REDACTED]and congestive heart failure. After return to the facility the resident returned to ER (emergency room ) twice that day finally returning on [DATE] at 6:17 p.m. An incident report dated [DATE] at 1 a.m. revealed staff found the resident laying on his/her back next to the closet. The resident stated he/she hit the back of the head hard on the floor. The resident complained of back, neck, lower back and leg pain. The resident stated he/she tried to get to the bathroom. The resident transferred to the emergency room (ER). The report identified the facility would call the family and ask them to remove some items from the resident's room and provide a night light. The incident report did not identify when staff last toileted the resident. An ER note, dated [DATE] revealed history was obtained from the resident who had a history of [REDACTED]. The resident fell trying to get out of bed and no complains of right leg pain. The ER discharge identified the resident with a closed fracture of the hip. The resident admitted to medical/surgical. The ER non-portable report dated [DATE] identified Resident #3 had a right intertrochanteric hip fracture. A transfer form identified the date of transfer as [DATE] back to the facility for skilled services following ORIF for right hip fracture. A physician visit note dated [DATE] revealed the ARNP (advanced registered nurse practitioner) stated the resident was in a lot of pain following right hip fracture. The ARNP added additional pain medication for the resident's pain. The ARNP documented no concerns with the resident's respiratory status. On [DATE] at 5:15 a.m. Staff D LPN stated she worked when the resident fell on [DATE]. Staff D found the resident on the floor when she did rounds. Staff D stated staff checked the resident every 2 hours. If the resident got up by self, staff would counsel the resident on the need to use the call light and wait for help. Staff D asked the resident if anything hurt. They rolled the resident to his/her back and the resident screamed in pain. The call light was not activated. Staff D called the doctor and the resident went to ER. She didn't know when staff last checked the resident. She assumed it was at 10 p.m. or 10:30 p.m. The resident just went downhill after the hip fracture. An incident report dated [DATE] at 2:13 a.m. staff found the resident laying on the left side on the floor with head and shoulders under the bed and legs extended towards the sink. The resident did not sustain injury. The resident stated he/she was looking for red and denied hitting his/her head. The intervention was for staff to check on the resident at the end of first rounds. The progress notes dated [DATE] at 2:23 a.m., revealed Resident # 3 was found lying on his/her left side on the floor with his/her head and shoulders under the bed (by the foot of the bed); and his/her legs were extended out towards the sink. Staff documented the resident denied hitting his/her head and staff assessed the resident. The resident then tried to climb/pull curtains off the wall. Staff notified the nurse manager. At the time of the [DATE] fall the resident received Eliquis (anticoagulant) 5 milligrams (mg.) twice a day. Facility policy identified staff should conduct neurological (neuro) checks if there was suspected head injury. On [DATE] at 12:50 p.m. the DON stated staff did not conduct neuro checks following the [DATE] fall. She stated head injury was not suspected. On [DATE] at 11:13 a.m. the resident's family requested a Hospice consultation. On [DATE] at 5:04 p.m. the resident appeared very lethargic, restless and confused. The resident admitted to Hospice. The resident continued to decline and expired on [DATE] at 7:20 a.m. On [DATE] at 3:11 p.m. the resident's physician stated the facility should perform neuro checks after any falls especially an unwitnessed fall. She stated she completed the resident death certificate and thought she identified COPD as the cause of death. Additional Interviews: On [DATE] at 6:15 a.m. Staff J CNA stated she heard the resident yell for help and found the resident on the floor on his/her side by the closet. Staff J guessed the resident planned to go to the bathroom. The resident stated he/she tried to get up. Staff J stated she checked the resident on rounds at midnight and the resident didn't need anything. The resident is not supposed to transfer per self. The resident wasn't good about using the call light and would get up without help. On [DATE] at 10:21 a.m. Staff A RN stated the resident got up all the time by self to the toilet and did not use the call light. On [DATE] at 2 p.m. Staff E CNA stated the resident rarely ever waited for help or used the call light. Staff E stated she would catch the resident in the bathroom. The resident also self transferred from bed to wheelchair and wheelchair to bathroom. The resident would get unsteady. Staff would offer to help the resident but the resident declined help. On [DATE] at 2:50 p.m. Staff H CNA stated Resident #3 was independent with transfers. On [DATE] at 10:25 a.m. the care plan nurse stated the resident would not use the call light and did attempt to self transfer. The care plan reflected this. The resident was supposed to have assistance. On [DATE] at 5:50 a.m., Staff I CNA stated sometimes the resident was totally independent and other nights the resident was total care.

Based on observation, record review and staff and resident interviews, the facility failed to prevent the development, promote healing and prevent infection of pressure ulcers (Resident #3). The facility identified a census of 67 residents and the sample consisted of 3 residents. Resident #3 had a coccyx pressure ulcer upon admission and a blister on the abdominal fold. The resident developed additional open areas on the buttocks and the coccyx area increased in size due to lack of timely repositioning and thigh wound areas due to pressure from the tubing of the bladder indwelling catheter. Observation identified the resident not repositioned in order to promote healing and prevent further development of pressure ulcers. Observation during cares identified a staff member performing incontinency care and contaminated the wound by moving the soiled cloth over the open area. Findings include: Resident #3 had a 14 day assessment with a reference date of 12/5/16. The MDS identified Resident #3 had no cognitive problems and required extensive assistance from staff for bed mobility and transfers. The resident experienced incontinent episodes and had a Foley indwelling bladder catheter to drain urine into a bag. The MDS identified the resident at risk for the development of pressure ulcers and did not have any pressure ulcers present. The MDS indicated the resident had moisture associated skin damage (MASD) and had pressure reducing devices on the bed and in the chair. The MDS identified the resident had [DIAGNOSES REDACTED]. Resident #3 had a MDS (Minimum Data Set) assessment with a reference date of 12/26/16. The MDS documented the resident required extensive assistance of 1 staff person for bed mobility and dressing. The MDS identified the resident to be at risk for the development of pressure ulcers. The MDS identified a risk for developing pressure ulcers, had moisture associated skin damage and no unhealed pressure ulcers. The MDS documented the resident had no turning/repositioning program. The resident experienced bowel incontinence frequently and had a bladder indwelling catheter. A Nursing Admission Data Collection assessment dated [DATE], documented the resident had an open area, located on the coccyx which measured 4.0 cm x (by) 0.1 cm, and superficial. The form identified no other open areas on admission, and a blister on the abdominal fold. The care plan dated 12/1/16 included no problem related to alteration in skin integrity or interventions to identify prevent, promote healing, etc. A weekly skin report all other skin problems worksheet dated 1/3/17, documented the resident had a 0.8 centimeter (cm) x 0.2 cm open area on the coccyx (not facility acquired) and first identified on 11/28/16. The form also documented the resident had a 0.3 cm x 0.3 cm open area on the left buttock, first identified 11/27/16. During the initial facility tour on 1/9/17 at 10:15 a.m., the facility Director of Nursing (DON) identified the resident as being a reliable interview. During an observation on 1/10/17 at 8:40 a.m., the resident laid in bed on back (supine position). Staff A (Certified Nurse Aide, CNA) and Staff B CNA assisted the resident with morning cares. Staff A and Staff B (CNA) assisted the resident to turn to the left. Observation identified bright red blood on a soaker (thick incontinence pad) pad under the resident. The resident had stool incontinence. The resident had visible open areas on the coccyx and right and left inner buttock. Staff A used a cloth and wiped stool over the open areas, as well as over an open area on the resident ' s right inner thigh. At that time Staff B exited the room and returned with Staff C (Licensed Practical Nurse, LPN). Observation identified at that time, the resident had a deep red linear discolored area of skin which ran across the anterior upper thigh and visible when the catheter tube had been moved from the area. Staff A assisted the resident to turn to the right so Staff C could assess the open areas. Observation again identified open areas to the right inner thigh, coccyx and right and left buttock. At that time Staff C directed Staff B to make sure they cleaned the resident well and stated they would return to complete a treatment to the areas. Staff A and Staff B continued to assist the resident to complete morning cares and at 9:00 a.m., assisted the resident to transfer to a wheelchair. At that time the resident stated they normally got up at 7:30-8:00 a.m. Staff C returned to the room and the resident stated since they were already up and dressed, she/he wanted to eat breakfast before the treatment. At that time Staff A verified they and Staff B had been the aides assigned to the wing and this had been the first time they had been in the room to provide any care to the resident, which would have last been done prior to 6:00 a.m. by the night shift and they did not know what time. Observation at 11:00 a.m. (same day-1/10/17), the resident sat in their room in the wheel chair. At 1:00 p.m., the resident sat in their room in the wheelchair. At 1:30 p.m., the resident sat in their room in the wheelchair. At that time, Staff C verified they had not provided a treatment to the resident but would let the surveyor know when they completed it. Staff C stated they had asked the resident a few times already and the resident did not want to lie down so they could do the treatment. Staff C stated they had asked the resident at breakfast time and again when the resident had gotten their lunch. Staff C then entered the resident ' s room with the surveyor. Staff C asked the resident if they could do the treatment to their bottom and the resident stated they had been scheduled to go to therapy then. At that time the resident stated no staff had been in the room to reposition him/her since they had been transferred to the wheelchair that morning. The resident stated their bottom hurt but staff did not believe that. Staff C stated they would send someone in to reposition the resident. At 3:00 p.m., the resident sat in their room in the wheelchair. The resident verified a staff person had just been in to help him/her reposition in the wheel chair. At 3:05 p.m., the surveyor informed the facility DON the resident had been sitting in the wheel chair with open areas identified that morning which had not yet been treated. Staff C then stated the resident had been in the therapy room at that time. The surveyor informed Staff C the resident had been observed sitting in the wheelchair in their room. Staff C stated they could then do the treatment. Observation at 3:15 p.m. (same day-1/10/17), identified Staff D (CNA) and Staff E (CNA) transfer the resident from the wheelchair to the bed and removed the resident ' s pants. Staff C noticed the linear dark red line which remained on the resident ' s right anterior and inner thigh and stated Oh what is that. Staff C then stated it looked like the catheter tube on the leg to be tight. Staff C measured the area to be 10.0 cm x 0.4 cm. Staff C asked the resident to turn and the resident stated they needed help to roll in bed. Staff C assisted the resident to turn to the left. Observation identified a visible open area on the right inner thigh with a small amount of bleeding. The resident complained of pain to the bottom area. Staff C informed the resident their skin had broken down more. Staff C told the resident they needed to be repositioned more. Staff C then measured the following superficially open areas: a. coccyx, 2.3 cm x .3 cm b. left gluteal cleft, 1.0 cm x 1.0 cm c. left gluteal cleft, 0.6 cm x 0.2 cm d. right gluteal cleft, 1.5 cm x 0.4 cm e. right gluteal cleft, 0.7 cm x 0.4 cm f. right gluteal cleft, 1.5 cm x 1.0 cm g. right inner thigh, 1.2 cm x 0.5 cm h. right posterior thigh, 0.5 cm x 0.2 cm Staff C also measured a red area on the left inner thigh 1.0 cm x 0.3 cm. Staff C then applied [MEDICATION NAME] (anti-bacterial cream) cream to all areas with no cleansing of the areas prior to the application. A Progress Note dated 1/10/17 at 4:03 p.m., documented the measurements obtained and did not include the open area measured on the right inner thigh, 1.2 cm x 0.5 cm., or the red area on the left inner thigh 1.0 cm x 0.3 cm The note documented the Impact Team had been called. Review of skin grid for all other skin impairment forms revealed no sheet for the open area to the coccyx or the left gluteal cleft 0.6 x 0.2 cm or right inner thigh 1.2 cm x 0.5 cm A physician order [REDACTED]. A physician order [REDACTED]. On 1/11/17 at 8:00 a.m., the facility DON stated they had panicked the previous day when the discussed of the resident ' s open areas. The DON stated they had added a low-air loss mattress to the resident ' s bed and another cushion to the resident ' s wheelchair. The DON stated they now felt they had just panicked and should not have added the interventions because the areas were not pressure related. The DON stated they had also had the care plan nurse add a problem for skin to the care plan and it should have been on it already. At 9:15 a.m., the facility DON stated they were not sure how Staff C documented all of the wound measurements but they had been unable to find anything more than had been provided. The DON verified they had added a gel cushion to the resident ' s wheel chair because it would reduce pressure to the areas more than the one that had already been in the chair.

Based on observation, clinical record review, staff, resident and community member interviews and review of a police report revealed the facility failed to ensure one of four residents remained in a safe and secured environment (Resident #1). The facility identified a census of 65 residents. Findings include: During an interview 5/30/15 at 10:20 a.m., the Director of Nursing (DON) confirmed she spoke with the Administrator who indicated the Wander guard alarm system had been shut off on the courtyard door about 1 week prior to the elopement. Additionally, a Sentry alarm box was secured to the door but the facilities procedure was to shut the alarm off during the day and turn it on at night so residents could go outside to smoke. According to a typed statement dated 6/3/15, the Administrator documented he didn't want to lock the residents or staff in or out of the building so he gave the directive to the maintenance man to shut off the Wander guard device on or near the 15th of May. During an interview 6/9/15 at noon, Maintenance confirmed a directive by the Administrator to shut off the Wander guard system at the courtyard door 2 weeks if not 4 weeks prior to the elopement as the system had been malfunctioning. The system had been reactivated the day after the elopement with the parameters of the system turned down at that time. According to a typed statement 6/4/15 at 12:15 p.m., the Administrator confirmed the Wander guard alarm device had been re-activated the day after the elopement 5/25/15. According to a Police Department Call For Service Record formatted 5/24/15, a call had been received at 1:18:24 from a community member who indicated at 1:15 p.m. a male/female came into his/her house by mistake and did not look well at all. The identified person had gray hair and a blue shirt but had been stumbling around and it looked like something had been very wrong with him/her. The person then walked to the corner of 1st and Francis and had been walking towards McDonalds on 1st Street. At 1:35:17 the officer had been dispatched, arrived at 1:37:31 picked up the person and returned him/her to the facility at 1:57:55. During an interview 6/4/15 at 9:44 a.m., the community member confirmed Resident #1 walked into his/her house, stood there as he/she had been out of breath and said this is not my house (with deep breaths between words) and then took off. Resident #1wore blue pants and a dark short sleeved shirt with tennis shoes. Because he/she thought there had been something wrong he/she watched the person walk up a couple streets to 1st Street, crossed over the road (not on a cross walk and with no street lights present). The road contained cars traveling however he/she had not walked in front of any cars on the road. The person then walked East on the sidewalk along 1st Street. The community member then called the police as he/she had to go to work. The community member returned to his/her home, changed for work and traveled down 1st Street at which time he observed two police cars and an ambulance with the person/resident at a day care center across from McDonalds. During an interview 6/3/15 at 4:40 p.m., Resident #1 confirmed he/she went for a walk on Sunday and walked down Hudson to 1st street on the road and almost got to McDonalds as he/she had been trying to get home. According to a History and Physical Psych form dated 4/19/15 Resident #1 was admitted to the hospital on [DATE] with increased confusion a self-care deficit and wandering. The chief complaint included a history of alcohol dependence and cognitive disorder with reportedly wandering the neighborhood and knocking on people's doors. Additionally, he/she had been found on the streets only with his/her socks on. The Minimum Data Set (MDS) assessment form dated 5/5/15, identified Resident #1 was admitted to the facility on [DATE] from an acute care hospital with [DIAGNOSES REDACTED]. The assessment indicated Resident #1 ' s able to make self-understood and understand others, with a Brief Interview for Mental Status (BIMS) score of 5 out of 15, fluctuating inattention and disorganized thinking, required supervision with ambulation and locomotion, limited assistance with transfers and as not steady but able to stabilize without staff assistance when walking, turning around and any surface to surface transfer and with one fall without injury. According to a BIMS form dated 5/26/15, Resident #1 received a score of 12 that indicated intact cognition. According to a Care Plan with a problem initiated 4/28/15, Resident #1 had a focus area of altered thought related to dementia with behavior disturbances, psych medication use, anxiety and depression. The interventions included the following: a. Elopement profile in place. b. Wander guard in place, check every shift. According to facility progress notes dated 4/28/15 at 11:00 a.m. Resident #1admission to the facility included placement of a Wander guard to the left ankle area. According to a Treatment Administration Record (TAR) form dated 5/1/15 through 5/31/15, the facility staff failed to check the functionality of Resident#1 ' s Wander guard device until 5/27/15. A Wandering and at Risk for Elopement form dated 4/28/15 at 1:10 p.m., indicated Resident #1 as a moderate risk for wandering. A Wandering and at Risk for Elopement form dated 5/24/15 at 2:15 p.m., indicated Resident #1 as a high risk for wandering. A Fall Risk Assessment form dated 4/28/15 indicated Resident #1 a moderate risk for falls. A Fall form dated 4/30/15 at 4:00 p.m., indicated Resident #1 went to get up from a chair, lost his/her balance and ended up falling on the right side of a side table where he/she had been sitting with no injuries sustained. During an interview 5/30/15 at 8:50 a.m., the DON indicated the Wander guard system at the courtyard door had been malfunctioning at the time of the elopement. Additionally, Resident #1 told the DON he/she kicked the hell out of the gate in the courtyard which had a horseshoe clamp, bent the horseshoe clamp far enough to get out (with a lock connected to the other side of the clamp and still in place) left facility, crossed the highway and she thought she zig zagged through houses until he/she arrived at McDonalds on 1st Street. During an interview 6/3/15 at 1:20 p.m., Staff C, Licensed Practical Nurse (LPN) indicated on 5/24/15 she received a telephone call from a police officer who stated he believed to have one of the facility residents and proceeded to share the name of Resident #1. The staff member then asked Staff B, Registered Nurse (RN) if Resident #1 resided in Staff B ' s work area and that was confirmed. Staff C then spoke with the Certified Nursing Assistants (CNA'S) assigned to the B wing of the facility to find out when Resident #1 was last observed. Staff D, CNA had been the last person to observe the resident which had been thought to have been 45 minutes prior. According to an undated hand written note, Staff D identified she last observed Resident #1 around 12:45 p.m. to 1:00 p.m. on 5/24/15. During an interview 6/4/15 (time unknown), Staff C confirmed she had not been aware the Wander guard system to the courtyard had been unarmed on the date of the elopement and for approximately 10 days prior to the event as well. During an interview 6/4/15 at 1:09 p.m., Staff B, RN confirmed she had not been aware the Wander guard alarm system on the courtyard door had been unarmed on and before the elopement. The staff member indicated she checked the functionality of the alarm 5/24/15 at approximately 10:30 a.m. and found it had not been working so she left a note for the maintenance man related to her findings. Additionally the staff member confirmed the Sentry door alarm on the courtyard door had been shut off during the day per facility protocol. The staff member went onto say on 5/24/15 at approximately 11 a.m. to 11:30 a.m. she administered Resident #1's noon medications to him/her in the dining room area per usual. At around 1:45 p.m. Staff C, Licensed Practical Nurse (LPN) approached her and said the police had been on the telephone and questioned if Resident #1resided at the facility. The staff member then spoke with the police on the telephone that informed her Resident #1found wandering on 1st street and entered a person's house. After the staff member confirmed Resident #1 resided at the facility the police informed her they would return Resident #1to the facility. During an interview 6/4/15 at 1:01 p.m., Staff A, Certified Nursing Assistant (CNA) confirmed she was not aware the Wander guard alarm system on the courtyard door had been unarmed on and before the elopement. During an interview 5/30/15 at 1:04 p.m., the MDS Coordinator indicated she received a telephone call from Staff B on 5/24/15 at which time she had been informed of the elopement and planned to go to the facility to investigate the situation. Upon arrival she found the Wander guard alarm system on the courtyard door as not functional so she turned on the Sentry II door alarm which she confirmed as always shut off during the day and on at night. According to a 15 Minute Check form dated 5/26/15, the facility staff failed to document the checks from 12:45 p.m. through 2:15 p.m. An observation 6/3/15 at 4:05 p.m. with the Administrator present, revealed the Wander guard door alarm on and functional (at a close range) to the courtyard door with one staff responding however an alarm box placed on the top of the door on 5/29/15 sounded several times as residents were coming and going and no staff responded. During an interview 6/4/15 at 1:44 p.m., the Administrator confirmed the two Wander guard alarm devices placed in the facility are located at the front door and the courtyard door and he only shut off the courtyard Wander guard alarm device due to it malfunctioning. According to a written statement provided by the facility there had been 10 residents who wore Wander guard devices and identified as a wandering risk. According to a Pathway To Wandering And At Risk For Elopement form revised 5/25/06, one of the staff directives included to inspect the residents every shift to ensure the bracelet was in place and document on the treatment record. Note: At the time of the onsite investigation the deficiency was coded at a K level for immediate and serious jeopardy. By May 29, 2015 the facility had implemented measures that adequately addressed the jeopardy issue and the grid placement was lowered to an E level. The facility provided a plan for alarm use in the facility and monitoring resident safety.

Based on observation and interviews with residents, staff, and family, the facility failed to provide a safe environment for residents when they repeatedly used space heaters in Hallways and in a resident's bedroom. The onsite investigation revealed the space heaters tested at 150 -172 degrees Fahrenheit which were being left unattended. The staff interviews determined no provisions were in place to protect residents from hazards. The findings constitute an immediate jeopardy to residents health and safety. Concerns noted in 4 of 4 resident hall ways, 2 of 6 offices observed and 1 of 7 resident rooms observed. Findings include: Upon entrance to the nursing home on 1/6/14 at 8:30 a.m., observation showed two unsupervised space heaters (Stanley Utility Heaters) in use located on Hall A. Observation revealed the front of the space heaters hot to the touch. The warning labels on the tops of the space heaters read "Caution: High temperature." Continued observation revealed two unsupervised heaters in use in the B hallway, two unsupervised heaters in use in the D hallway and one Stanley heater in use in the C hallway. Observation revealed all heaters "On" and hot to the touch. Testing of the air directly in front of one of the heaters in the A hallway revealed a temperature of 172.5 degrees Fahrenheit, which was verified by Staff D (nurse). When interviewed at this time, the three nurses on duty, Staff B, Staff C and Staff D stated the facility first utilized these space heaters on the evening shift on 1/3/14. All three nurses reported they did not receive any directions or instructions regarding the use of the space heaters or supervision of the space heaters. The nurses stated residents had been complaining of the facility being too cold. The nurses reported noticing cold temperatures inside the facility including in the dining room and in resident bedrooms and bathrooms, especially in the bedrooms of Resident #1 and Resident #3. Observation on 1/6/14 at 9:15 p.m. revealed Resident #5 in bed, covered with 4 blankets. Resident and spouse reported the bedroom was too cold for comfort for the last week. The resident stated at home, he/she kept his/her home at 70 to 72 degrees Fahrenheit. The resident stated he/she had refused to get out of bed for showers due to the temperatures in the facility. The resident stated his/her bedroom and the shower room were too cold to take showers and it caused him/her to get chilled. The resident stated he/she had voiced concerns regarding the cold temperatures and staff had told him/her that he/she was fortunate due to other bedrooms were even colder than his/her bedroom. The resident's spouse stated he/she had inquired about bringing in a space heater and was informed they were not allowed to use a space heater. The spouse stated he/she had asked the Administrator why the facility was allowed to use space heaters and they could not use one in their room. The spouse stated the Administrator informed him/her if it got too cold in their bedroom, he/she could bring one of the space heaters into their room for a couple hours. The resident's bathroom tested 56.4. degrees Fahrenheit. When interviewed on 1/6/14 at 9:30 p.m. the Director of Nursing stated on 1/3/14 the facility Administrator bought and placed the space heaters due to extreme cold weather outside and cold conditions inside the facility. She stated they had given the residents extra blankets. They also checked all windows on 1/3/14 to ensure all windows were closed. They also turned up the heat and the Maintenance Supervisor was going to seal the cold air vent in the resident bedrooms and bathrooms last Friday due to cold air coming in through these vents. Observation at this time revealed cold air drafts at the bases of the exit doors and around the windows in the dining room. At this time the Director of Nursing verified the running space heaters was hot to touch and the air directly in front of one of the running heaters tested 153.9 degrees Fahrenheit at this time. On 1/7/14 at 10:30 a.m. the Administrator requested surveyor re-test the Stanley Utility Heater temperature. The Administrator brought a heater to the surveyor and then left the room to answer a phone call. At 11:34 a.m. the Administrator returned at which time surveyor plugged in the heater and turned it on. The heater soon became too hot to touch the front of the heater and the air directly in front of the heater tested 150.3 degrees. The Administrator verified the temperature of the air and the face of the heater hot to the touch. When interviewed on 1/7/14 at 8:30 a.m. the Administrator stated approximately a couple weeks ago, residents began to express concerns about being cold inside the building. The Administrator stated residents had complained about cold air coming in through the gaps in the windows and they had put blankets over the windows. He also stated he bought the space heaters last Friday in anticipation of the cold air snap. The Administrator stated some of the resident bedrooms tested 68 degrees. He denied receiving or requesting a waiver or permission to utilize space heaters in the facility. The Administrator stated he had called the fire Marshall who stated they could not use space heaters. The Administrator denied having a Policy or Procedure for the use of the space heaters and denied giving the staff any directions for the use or supervision of the heaters. He stated he just told them to use them in the hallways and they could move them or point them to cold areas. The Administrator stated last Sunday the staff called him to ask if they could hold the showers in the front of the building due to the shower room was too cold to give showers. Tour of the facility on 1/7/14 at 9:10 a.m. revealed Resident #6 in his/her room sitting in front of a Lasko portable room heater. The resident stated he/she felt chilled due to had just received a shower and had wet hair. The resident stated he/she had their space heater for a long time. When interviewed at 9:00 a.m. the Administrator stated the resident was informed to unplug his/her space heater when not in his/her bedroom. Resident #6 ' s MDS dated [DATE] documented the resident scored at 12 on the cognitive test (Brief Interview for Mental Status ) which indicates the resident had moderate cognitive impairments. A clinical note (prior to admission) dated 9/30/13 identified Resident #6 had [DIAGNOSES REDACTED]. On 1/8/14, the Administrator informed the Department in writing the space heaters were removed Monday night 1/6/14. Observation on 1/9/14 at 11:30 a.m. revealed a Patton milk house style utility heater in the closed Social Worker office, plugged in and running. Observation revealed no one in the Social Worker office at this time. When interviewed on 1/9/14 at 2:00 p.m. the social worker stated she brought a space heater in to the facility to use in her office last Monday. She stated the Administrator told her she had to be in her office when the heater was " On " . She stated she had failed to tell her assistant about turning the heater off when not in the office. The social worker stated it was cold in her office due to the cold air that came in through the front door. Tour of the facility on 1/9/14 at 11:30 a.m. revealed the cold air ducts in the shower rooms open and cold air blowing in the shower rooms. The air from one of the cold air vents in the shower room tested 65.3, one of the vents tested 50.9. One of the cold air vents in the second shower room tested 60.1 degrees. Observation revealed the exit door off the C hallway with cold air coming in under the exit door tested 48.0. The bathroom of Resident #5 tested 55.9. Observation in the C hall approximately eight feet from the exit door the air tested 63.0 degrees. Observation on 1/9/14 at 2:07 p.m. revealed a Patton milk house style utility heater on and running in the office of the Assistant Director of Nursing. Observation revealed the heater on the floor within inches of items including office supply items and a cloth bag. The Assistant Director of Nursing stated she obtained the heater last winter and was instructed she had to be in her office when it was on. The facility abated the IJ on 1/9/14 when they implemented the following: On 1/9/14 the Administrator informed the Department in writing that all space heaters had now been removed from the facility. In addition, on 1/8/14, the Administrator reported bathroom vents were sealed as on 1/7/14. The Administrator reported all windows had been checked for drafts and caulking had been completed on 1/8/14. The Administrator reported the concrete outside of the patio door had been cut down two weeks ago and the contractor had been called again with the intention to cut down the concrete again on 1/8/14. These actions lowered the deficiency from a scope and severity of K to E, with the need for provisions to monitor the residents environment from hazards. The Stanley Instruction Manual printed from the Internet revealed General Safety Information for these heaters. The Warnings included: Extreme caution is necessary when any Heater is used by or near children or (others) and whenever the Heater is left operating unattended. Another warning noted: This Heater is HOT when in use. To avoid burns, do not let bare skin touch hot surfaces. Keep combustible materials, such as clothes at least 3 feet from the front of the Heater and keep them at least one foot from the sides and rear. Another Warning read, "WARNING: SMALL PLASTIC GRILL IS HOT WHEN HEATER IS IN OPERATION." The Patton Owner's Guide printed from the Internet revealed General Safety Information for these heaters contained safety instructions. These instructions included: The heater is hot when in use, Keep combustible materials, such as furniture, pillows, bedding, papers, clothes, and curtains at least 3 feet from the front of the heater and keep them away from the sides and rear, Extreme caution is necessary when any heater is used by, or near children or invalids, and whenever the heater is left operating and unattended, and Always unplug the heater when not in use.