Every finding on record at Community Memorial Health Center

Based on resident and staff interviews, record review and facility policy review the facility failed to accommodate an appropriate bathing time to honor residents preference for 1 of 17 residents (Resident #6) reviewed. The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses of anxiety, depression and cancer. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Interview on 1/20/26 at 2:13 p.m., with Resident #6 revealed she likes to take her shower between 6:00 and 6:30 p.m., and has not been taking them because when the facility staff come and offer her a shower it is too early or too late. Resident #6 further revealed she likes to take it at this time as there are not as many people in the hallways during this time. Review of bathing documentation dated 12/25/25-1/19/26 revealed the resident had refused her bath on scheduled bathing days or was marked as not applicable. Review of resident's Progress Notes lacked documentation regarding reason for refusal of bathing during the reviewed timeframe. Interview on 1/21/26 at 11:20 a.m., with Resident #6 confirmed she has not taken a shower or bath in the facility for the last 30 days as she does not want to take them so late when the staff has been offering the shower. Resident #6 goes on to explain she takes her medications for bedtime earlier and by the time the staff ask she is sleepy. She explains she has been washing up in her room on her own so she does not have any foul odors but she would take it in the facility if they would offer her a bath between 6:00 and 6:30 p.m She understands they are busy with supper but this is when she would like her showers. Resident further explained sometimes the staff ask her before supper and she tells them when she would like to take and the staff has told her no as they are busy with supper and she doesn't want to take it then as the facility can be super busy as that affects her anxiety. Resident denies anyone from the facility coming to her room and talking to her about when she would like to take a shower or why she has not had an actual shower or bath in at least 30 days. Resident stated she had told the Social Worker during care conferences she did not want to take baths so late at night but nothing has changed. Resident explained she is a stubborn lady but she is not going to be told when she has to do something. She has the ability to make the choice when she would like to take her shower. Interview on 1/21/26 at 11:33 a.m., with the Director of Nursing (DON) revealed the resident does refuse her bath and appointments all the time. The DON revealed staff has offered her a shower before supper and after super and the resident has never expressed what time she would like to take it. The DON stated she has gone down and talked to the resident about her bathing and she has never been told a time she would be willing to take her bath. The DON would look and see if there was any information the resident brought up bathing preferences during care conferences as she does not attend those. At the time of exit no documentation from care conferences was presented to surveyors regarding Resident #6 expressing concerns. Review of facility provided policy titled Resident [NAME] of Rights undated revealed the following items:A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The right to participate in the development and implementation of his or her person-centered plan of care.The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, plan of care and other applicable provisions of this part. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. Interview on 1/22/2016 at 8:51 a.m., with the DON revealed the residents can pick times they want to do things.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 2 residents (Resident #4) reviewed for PASRR requirements. The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of anxiety disorder, depression and post traumatic stress disorder (PTSD). The MDS included a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the MDS dated [DATE] revealed the following diagnosis:Anxiety disorderDepressionPTSD The clinical record lacked an updated PASRR to include PTSD diagnosis. Review of the PASRR dated 3/19/24 lacked inclusion of PTSD diagnosis. Review of the facility provided policy titled [NAME] policy with a revised date of 9/2025 revealed change in status includes; Additionally, if new psychiatric diagnosis is present that was not included on the initial review. Interview on 1/22/25 at 8:45 a.m., with the Director of Nursing (DON) revealed the diagnosis of PTSD should be on the PASRR and it should be resubmitted.

Based on observation, record review, and staff interview, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infection for 1 of 2 residents reviewed (Resident #1). The facility reported a census of 47 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored scored 13 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had an indwelling urinary catheter. Diagnoses included renal insufficiency and retention of urine.The Care Plan revised 7/28/25 identified the resident had a urinary catheter. The interventions included changing the catheter monthly and for dislodgement, and keeping the urinary drainage bag covered at all times.The Progress Notes dated 1/19/26 at 11:43 a.m. documented the resident returned from the hospital after a stay for UTI.On 1/21/25 at 2:25 p.m. Resident #1 sat in the chair in his room. The catheter bag was in a dignity bag hanging from his walker. The catheter tubing (1-1/2 to 2 feet) laying on the floor. Staff B Certified Nursing Assistant (CNA) came in, washed her hands and donned a gown and gloves. She brought a barrier, graduate, and alcohol wipes to the chairside. She removed the catheter bag from the dignity bag, the drain from its port, and wiped with an alcohol wipe. The drain hit the inside of the graduate. After she finished draining the bag she wiped the drain with an alcohol wipe. She replaced the drain and put the catheter bag back in the dignity bag. She cleaned up the area and left the room, with the catheter tubing still laying on the floor.On 1/22/25 at 9:10 a.m. the Director of Nursing (DON) stated staff should keep the tubing off the floor. She also thought the drain should not touch the graduate.The facility policy for Foley Catheter Care reviewed 5/2025 documented measuring the drainage at the end of each 8 hours included disconnecting the tubing over a graduate and allowing the urine to drain completely (being sure not to contaminate the drain). The undated facility policy for Emptying a Urinary Drainage Bag included not allowing the drain spout to come into contact with the measuring container, hands, or any other object (if accidental contamination occurred, wipe the drain spout with an alcohol sponge or swab), and keeping the collection bag and tubing off the floor at all times to prevent contamination and damage.

Based on observations, clinical record review, and staff interviews, the facility failed to accurately transcribe physician orders for psychotropic medications, including documenting the correct medication end dates in the electronic medical record, for 2 of 2 residents reviewed (Resident #3 and #22). The facility reported a census of 47 residents Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of Parkinson's Disease, dementia and Anxiety Disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident unable to complete a cognitive interview. The Care Plan with an initiated date of 11/17/25 showed Resident #3 used anti-anxiety medications related to an anxiety diagnosis. Resident #3 became anxious, raised her voice, verbalized paranoia, and cried uncontrollably at times. The written Physician Order dated 12/25/25 for Resident #3 showed Lorazepam 0.5 milligram (mg) tablet every 6 hours as needed for 180 days. The electronic Clinical Physician Orders dated 12/11/25 for Resident #3 showed Lorazepam 0.5 mg tablet every 6 hours as needed with an end date of indefinite. 2. The MDS assessment dated [DATE] for Resident #22 documented diagnoses of dementia, Alzheimer's Disease and Anxiety Disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident unable to complete a cognitive interview. The Care Plan with an initiated date of 9/5/25 showed Resident #22 used anti-anxiety medications routinely for physical aggression, increased periods of restlessness, and agitation. The written Physician Order dated 1/10/25 for Resident #22 showed Lorazepam 0.5 milligram (mg) tablet every 6 hours as needed for 180 days. The electronic Clinical Physician Orders dated 1/10/25 for Resident #22 showed Lorazepam 0.5 mg tablet every 6 hours as needed with an end date of indefinite. The Medications Orders policy last updated September 2025 identified:OBJECTIVE:The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders.RECORDING ORDERS:Medication Orders - When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. In an interview on 1/21/26 at 11:36 AM, the Director of Nursing (DON) reported staff failed to enter the physician's order into the electronic medical record as written. The DON stated the stop date should have been entered as 180 days. The DON further indicated that the responsible staff member has been identified and one-on-one education will be provided. In addition, education will be provided to all nursing staff to prevent recurrence.

Based on observation, clinical record review, staff interview, and per the current Centers for Disease Control and Prevention (CDC) guidelines the facility failed to use Enhanced Barrier Precautions (EBP) to prevent the spread of multidrug-resistant organisms (MDROs) during catheter care for 1 out 2 resident reviewed (Resident #24). The facility reported a census of 47 residents. Findings include: Observation on 1/21/26 at 10:19 AM showed Staff A, Certified Nurses Assistant (CNA) performed catheter care for Resident #24 without donning personal protective equipment of a gown. A sign posted in the resident's room instructed staff to don Enhanced Barrier Precautions (EBP), which included a gown, when providing catheter care. In an interview on 1/21/26 at 11:36 AM, the Director of Nursing (DON) reported Staff A, CNA, should have worn a gown for personal protective equipment when performing catheter care. The DON reported that she is also the Infection Preventionist and would expect staff to follow the EBP guidelines posted in the resident's room. The Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Ref: QSO-24-08-NH GUIDANCE Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do nototherwise apply; or Wounds and/or indwelling medical devices even if the resident is not known to beinfected or colonized with a MDRO.Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks orskin tears covered with an adhesive bandage (e.g., Band-Aid(R)) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. The Centers for Disease Control and Prevention website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), visited 4/9/25, updated 7/12/22, and dated 4/2/24 revealed Enhanced barrier precautions expand the use of PPE and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff and clothing. MDROs may be indirectly transferred from resident to resident during these high contact care activities. Nursing home residents with wound and indwelling medical devices are at especially high risk for both acquisition of and colonization with MDROs. The use of gown and gloves for high contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. The Centers for Disease Control and Prevention website titled, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes dated June 28, 2024 identified question: May nursing homes stop using Enhanced Barrier Precautions if we screen the infected or colonized resident and they test negative for the novel or targeted MDRO? Residents colonized with a novel or targeted MDRO are intended to remain on Enhanced Barrier Precautions for the duration of their stay in a facility. Because MDRO colonization is typically prolonged and follow-up testing to determine clearance may yield false negatives, CDC does not recommend routine retesting of residents with a history of colonization or infection with a MDRO or discontinuation of Enhanced Barrier Precautions after a subsequent negative test.The Enhanced Barrier Precaution policy last review August 2023 identified:PURPOSE:To reduce the risk of transmission of multidrug-resistant organisms (MDROs) in the facility.DEFINITIONS:1. Enhanced Barrier Precautions are an infection control measure that involves gown and glove use during high-contact resident care activities for residents who have open woundsor indwelling devices or who have a known recent colonization or infection with a MDRO (when Contact Precautions do not apply).2. High Contact activity includes activities that place the resident and the person helping them in close physical contact that increases the risk of transmission of MDRO between theresident and health care provider. These activities include:f. Device Care: Central Line, Urinary Catheter, Feeding Tube, Tracheotomy/Ventilator4. Indwelling Devices include any devices that are inserted into the resident and have contact with the external air such as foley catheters, central lines (including PICC lines),tracheostomies, feeding tubes or drains. They do not apply to peripheral IVs, dialysis shunts, AV fistulas, PortaCaths, Pacemakers or vascular stents.5. Personal Protective Equipment (PPE) used to reduce the risk of exposure to and transmission of microorganisms. EBP includes the use of gowns and gloves. In instanceswhere splashes/sprays are anticipated, face protection (mask or respirator) and eye protection (goggles or face shield) should also be applied.

Based on observation, record review, and staff interview, the facility failed to ensure a residents right in self determining a time to get dressed/up for 5 of 5 residents reviewed with dementia (Resident #1, #2, #3, #4, and #5). The facility reported a census of 45 residents.1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 scored 3 on the Brief interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident depended on staff for toileting hygiene, upper and lower body dressing. The resident's diagnoses included Alzheimer's disease and insomnia.The Care Plan revised 8/4/25 identified the resident had a diagnosis of insomnia and she took scheduled Melatonin for it. Interventions included monitoring the resident for any change in sleep pattern, and staff would encourage a consistent routine each night. On 11/25/25 at 4:12 a.m. Staff A Certified Nursing Assistant (CNA) woke and checked Resident #1's (incontinent pad) and she was dry. Staff A then removed Resident #1's gown and dressed her with a top, and pants pulled up to the mid-thigh. Staff A covered Resident #1 and left the room.On 11/25/25 at 4:57 a.m. Staff A stated they had 6 people they were responsible for dressing on last rounds. Today they only had to do 3, because 3 of them got baths. The 6 people they dressed had dementia and could not say no. They dressed them and they stayed in, or went back to bed. She said 1 of the 3 people they needed to dress had already been done. 2) According to the MDS assessment dated [DATE] Resident #2 scored 0 on the BIMS indicating severe cognitive impairment. The resident required substantial/maximal assistance with toileting hygiene, and partial/moderate assistance with upper and lower body dressing. The resident's diagnoses included non-Alzheimer's dementia.The Readmit assessment dated [DATE] documented Resident #2 had trouble staying asleep, and waking in the night. Staff and family reported up more in the night recently, up 5-10 times.The Care Plan dated 4/23/25 identified Resident #2 had an Activity of Daily Living (ADL) deficit due to her cognitive loss and inability to initiate tasks. Interventions included Resident #2 required assist of 1 for all clothing tasks. Give her verbal prompts to move her extremities to assist in changing. The Care Plan Identified Resident #2 had dementia and took Memantine (medication to improve memory) as ordered daily. An attempt to discontinue Memantine caused increased confusion and was restarted. She did have some nights when awake more than others. Evaluate other factors that could cause insomnia such as excessive heat or cold, noise, lighting, facility routines, caffeine/medication and attempt to modify, if possible. On 11/25/25 at 4:35 a.m. Staff B CNA and Staff A assisted Resident #2 stand with some resistance. They were able to get the resident to the bathroom and sitting on the toilet. Staff removed the resident's pajama top and pants, and put on a (day) top and pants. They assisted the resident off the toilet, provided incontinent care, and walked her back to bed where she promptly started to lay down. Staff assisted her to get in the bed, covered her up, and left the room. 3) According to the MDS assessment dated [DATE] Resident #3 scored 3 on the BIMS indicating severe cognitive impairment. The resident required partial/moderate assistance with toileting hygiene, and upper/lower body dressing. The resident's diagnoses included Alzheimer's disease.The Care Plan dated 7/9/25 identified Resident #3 had an ADL self-care deficit related to cognitive loss and poor initiation of tasks. The resident required assist of 1 with toileting, toileting hygiene, and brief changes.On 11/25/25 at 5:05 a.m. Resident #3 laid back in a recliner covered with blanket, in the common area of the Special Care Unit (SCU). Staff C CNA said Resident #3 slept in the recliner and she had already gotten her up to toilet, got her dressed, then brought her back to the recliner. She said they were expected to get 6 people up before the day shift CNA's got there at 6 a.m. 4) According to the MDS assessment dated [DATE] Resident #4 scored 0 on the BIMS indicating severe cognitive impairment. The resident required substantial/maximal assist with toileting hygiene and lower body dressing, and partial/moderate assist with upper body dressing. The resident's diagnoses included Alzheimer's disease.The Care Plan dated revised 11/17/25 identified Resident #4 at risk for falls related to incontinence. Interventions included offering toileting 2 times nightly, approximately 1 and 4 a.m.On 11/25/25 at 5:07 a.m. Resident #4 laid back in a recliner in the common area of the SCU, covered with a blanket. Staff C CNA stated the resident slept in the recliner and she already got her up and dressed and brought her back to the common area. She said she had also already assisted another resident up and dressed, and he went back to bed. 5) According to the MDS assessment dated [DATE] Resident #5 scored 0 on the BIMS indicating severe cognitive impairment. The resident depended on staff for toileting hygiene and lower body dressing, and required substantial/maximal assist with upper body dressing. The resident's diagnoses included non-Alzheimer's dementia and insomnia.The Care Plan revised 11/24/25 identified Resident #5 had a diagnosis of insomnia for which he took Melatonin to sleep. Interventions included staff encouraged him to keep a consistent routine at night.On 11/25/25 5:20 a.m. Staff C and Staff B went to get Resident #5 up. He slept in his bed. Staff told him they were getting him up. Staff assisted the resident in sitting up and walking to the bathroom with some difficulty, the resident taking short choppy steps. Staff dressed the resident while on the toilet, provided incontinent care, then walked the resident to the common area and sat the resident in a recliner, reclined with his feet elevated. At 5:30 a.m. Resident #5 asleep in the recliner. Staff C stated if she did not get at least 6 people up before the day shift got there she would hear about it.During a meeting with the Administrator and the Director of Nursing (DON) on 11/25/25 at 10:50 a.m. the Administrator stated he didn't know they were getting residents up early. The DON stated they should start getting residents up at 6 a.m. unless residents were okay with getting up earlier or requested it.The facility [NAME] of Rights documented in the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative. The document included the resident had the right to and the facility must promote and facilitate resident self- determination through support of resident choice, including but not limited to right to choose schedules (including sleeping and waking times).

Based on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 1 of 1 residents reviewed for abuse (Resident #1). The facility reported a census of 46 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of Alzheimer's Disease, aphasia and cognitive communication deficit. The MDS showed the Brief Interview for Mental Status (BIMS) score was not assessed as the resident is rarely or never understood. Review of the facility Incident Report titled Alleged Abuse dated 3/8/25 at 6:02 p.m. revealed incident description received a phone call from staff regarding Staff A, Certified Nursing Assistant (CNA) and the approach she was using when she was providing total assistance with Resident #1 supper meal. Review of facility provided documentation titled Self Report of incident occurring on 3/8/25 at 6:05 p.m Review of written statement by Staff B, CNA, dated 3/8/25 at 6:10 p.m., I was feeding across from Staff A when she was feeding Resident #1. When Staff A offered Resident #1 a bite Staff A shoved the spoon into her mouth hitting her tooth and not paying any attention to where her mouth was. Staff A hit Resident #1's tooth hard enough to hear across the table. Staff A shoved another bite in Resident #1's mouth and when she didn't respond she forcefully shook her saying wake up, eat. After supper was over I called the Director of Nursing (DON) and let her know the situation. Interview on 10/6/25 at 3:44 p.m., with Staff B revealed she was feeding at the same table as Staff A and Staff A was roughly shaking Resident #1 saying wake up. Staff B explained Staff A was shaking Resident #1 that her body was shaking and she was not responding to her. Staff A attempted to give Resident #1 a bite of food and hit her tooth which she heard it across the table. Staff B explained she called the DON and told about the situation and Staff A was sent home immediately. Review of the facility intake information the facility submitted a self report on 3/10/25 at 2:24 p.m Review of the facility policy titled Abuse Policy and Procedure with a revision date of 7/2025 revealed all allegations of Resident abuse shall be reported to the Iowa Department of Inspections and Appeals not later than two (2) hours after the allegation is made. Interview on 10/7/25 at 11:34 a.m., with the Administrator revealed he thought the DON at the time had submitted the information to the state office.

Based on record review and staff interviews the facility failed to provide and maintain accurate resident records to reflect an incident occurring in the facility for 1 of 4 residents (Residents #1). The facility reported a census of 46 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of Alzheimer's Disease, aphasia and cognitive communication deficit. The MDS showed the Brief Interview for Mental Status (BIMS) score was not assessed as the resident is rarely or never understood. Review of the facility Incident Report titled Alleged Abuse dated 3/8/25 at 6:02 p.m. revealed incident description received a phone call from staff regarding Staff A, Certified Nursing Assistant (CNA) and the approach she was using when she was providing total assistance with Resident #1 supper meal. Review of facility provided documentation titled Self Report of incident occurring on 3/8/25 at 6:05 p.m. submitted to the state agency on 3/10/25 at 2:24 p.m Interview on 10/6/25 at 3:44 p.m., with Staff B revealed she was feeding at the same table as Staff A and Staff A was roughly shaking Resident #1 saying wake up. Staff B explained Staff A was shaking Resident #1 that her body was shaking and she was not responding to her. Staff A attempted to give Resident #1 a bite of food and hit her tooth which she heard it across the table. Staff B explained she called the DON and told about the situation and Staff A was sent home immediately. Review of Resident #1's Progress Notes lacked documentation of the incident from the incident occurring on 3/10/25. Interview on 10/7/25 at 11:24 a.m., with the Director of Nursing revealed she expects something to be in the chart about the incident.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility for 2 of 2 residents reviewed (Residents #8 and #9). The facility reported a census of 49 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 documented diagnoses of heart failure, diabetes mellitus and retention of urine. The MDS showed the Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of Resident #8's Census tab revealed the following information: On 7/8/24- hospital unpaid leave. On 7/11/24- active. Review of Progress Notes revealed the following: On 7/8/24 at 11:38 a.m., facility receives a phone call from Registered Nurse (RN) at the local hospital emergency room stated Resident #8 admitted to the hospital. On 7/11/24 at 10:15 a.m., Resident returned to facility from local hospital. Review of bed hold dated 7/8/24 revealed permission via phone for bed hold authorization but lacked a resident or representative signature. 2. The MDS dated [DATE] for Resident #9 documented diagnoses of hypertension, bradycardia (low pulse rate) and anemia. The MDS showed the BIMS score of 7 indicating severe cognitive impairment. Review of Resident #9's Census tab revealed the following information: On 5/31/24- hospital unpaid leave. On 6/11/24- active. On 7/26/24- hospital paid leave. On 7/30/24- active. On 8/9/24- hospital paid leave. On 8/13/24- active. Review of the Progress Notes revealed: On 5/31/24 at 9:06 p.m., received call from local hospital Resident was admitted to the hospital. On 6/11/24 at 10:45 a.m., resident arrived back at the facility in his wheelchair in stable condition. On 7/26/24 at 4:48 p.m., resident will be admitted to hospital for intravenous antibiotics. On 7/30/24 at 4:39 p.m., resident returned to facility from local hospital at 11:00 a.m On 8/9/24 at 11:14 p.m., phone call to local hospital for update on Resident #9. Nurse stated resident had been admitted . On 8/13/24 at 11:55 a.m., resident readmitted to the facility following hospitalization . Review of the bed hold dated 6/3/24 revealed verbal confirmation but lacked a resident or representative signature. Review of the bed hold dated 7/26/24 revealed verbal confirmation but lacked a resident or representative signature. Review of the bed hold dated 8/9/24 revealed verbal confirmation but lacked a resident or representative signature. Review of facility provided policy titled Bed Hold Notice updated 6/18 included: You are receiving this letter because you recently have been admitted to the hospital. According to Community Memorial Health Center's bed hold policy, verification of room reservation must be made within a 24-hour period from the time the resident is admitted to the hospital, or the bed will be relinquished. Interview on 11/6/24 at 9:54 a.m., with the Director of Nursing revealed the facility does not send the bed hold to obtain signatures if they have received verbal confirmation of a bed hold.

Based on clinical record review, facility investigation review, staff interviews, and facility policy review the facility failed to conduct a thorough investigation of an allegation of abuse. On 4/3/24, the nurse learned of a Certified Nurse Aide (CNA) slapping Resident #1 on the leg. After learning of this allegation of abuse, the facility allowed the CNA to finish working the scheduled night shift and to continue to work unattended behind closed doors with other residents. This failure resulted in residents living at the facility to be exposed to the potential of abuse therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of April 9, 2024 on June 30, 2024 at 3:32 p.m The facility staff removed the IJ on July 3, 2024 through the following actions: a. On 6/30/24 the facility suspended Staff F, CNA b. Provided education on 7/3/24 and ongoing until all staff currently working have been retrained to include the following: i. Separate the alleged abuser from the resident identified and send the individual home. ii. Immediately notify the charge nurse who will notify the Director of Nursing (DON) or Administrator. 1. You must speak directly with on of these 2 individuals. 2. Numbers for these 2 individuals are posted in the staffing book. iii. If it is a charge nurse responsible for the abuse, you must call the DON or Administrator immediately. iv. The DON or Administrator will begin the investigation and the employee will be contacted once a comprehensive investigation is completed. The scope lowered from a K to E at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE]/24 for Resident #1 documented diagnoses of Alzheimer ' s Disease, anxiety disorder and non-traumatic brain dysfunction. The MDS showed the Brief Interview for Mental Status (BIMS) score of 02, indicating severe cognitive impairment. Review of facility Incident Report dated 4/3/34 at 1:15 a.m., revealed incident description according to staff statements 2 Certified Nursing Assistants (CNA's) Staff E, CNA and Staff F, CNA entered the residents room to provide incontinence care, when they attempted to remove the incontinent brief Resident #1 became agitated and started swinging and kicking. According to the initial statement, Staff F slapped the resident on the thigh. Immediate action taken revealed a description reported to the charge nurse who instructed Staff E to report to the Director of Nursing. Call was placed to DON with no answer. When DON arrived on 4/3/24 at 6:30 a.m.,the incident was reported at that time. DON did not hear the phone and staff did not try another call. Review of Resident #1's Progress Notes lacked documentation of the incident occurring on 4/3/24. Review of facility investigation of self-report of incident occurring on 4/3/24 at approximately 1:15 a.m.-1:30a.m. revealed the following: a. Interview conducted with Staff E. According to her interview and written statement she went to assist with checking and changing 2 residents that require assistance of 2. Staff E and Staff F entered Resident #1's room and began the process of changing him. He did become combative. Staff E indicated Resident #1 swung out at her with his hands and made contact. During the final steps Staff D stated Staff F slapped Resident #1 with her hand and said stop it. Staff E stated when they were done, both CNA's entered the hallway and Staff F said sorry didn't mean to hit him but damn. After Staff E left the unit she informed the charge nurse that the act had occurred and the charge nurse stated yes to call the DON. b. Interview conducted with Staff F. According to her interview and written statement Staff F and Staff E entered Resident #1's room, Resident #1 was informed the CNA's were there to check and change him. Resident #1 was agreeable. When the CNA's attempted to remove the incontinent brief Resident #1 became agitated and started kicking and hitting. Staff F indicated when he first became agitated she held both his hands so he would not hit, he then began kicking with his feet and kicked staff E with his feet in her ribs. According to Staff F, they finished the process and left the room. c. Based on the information the facility is unable to confirm or deny that the incident occurred. d. A mandatory staff meeting will be held on March 18, 2024 for all nursing department staff on adult abuse. Staff F will complete Iowa Department of Health and Human Services mandatory adult abuse before her next scheduled shift. She will also not be scheduled in the dementia unit for 90 days at the end of that period if she has not had any further violations, she can be scheduled in the dementia unit. Review of written statement by Staff E, signed and undated revealed on April 3 at 1:15 a.m., went into help Staff F with the 2 gentlemen. Resident #1 was being combative. After the last time of Resident #1 hitting and kicking me Staff F slapped Resident #1 and told him to stop it. After we were done changing him Staff F said sorry didn't mean to hit him but damn. Review of written statement by Staff F signed and dated 4/4/24 revealed Staff E and Staff F went to change Resident #1, on the first check he was ok when we told him what we were going to do. Was ok until we went to change him. We opened the depend and that is when he started to hit and I grabbed his hands and Staff E went to change him and that was when he kicked her in her ribs and lost balance, went to the hall. Then we got finished, I told him that was not nice to kick her and he laughed about it. Cleaned up the room and left. Second check went a lot better. An electronic message (e-mail) to Staff G, Nurse Practitioner dated 4/5/24 at 11:32 a.m., revealed the facility had a self report of an aide slapping Resident #1 while providing care. Interview on 7/2/24 at 4:22 p.m., with Staff E, CNA revealed on 4/3/24 at approximately 1:15 a.m., she went to assist Staff F, CNA with Resident #1 with care. During cares Resident #1 was hitting and kicking at staff assisting him. Staff F slapped Resident #1 on the upper left leg between the hip and knee area. Staff E reported it to Charge Nurse on duty. Charge Nurse stated she needed to call the DON right away. At 1:45 a.m., placed a call to the DON. Staff E revealed she did not answer so she left a message. At 1:48 a.m., sent the DON a text message. Staff E revealed Staff F continued to work the rest of her shift and the other staff working assisted her as Staff E was busy with her residents. Review of Staff F's time sheet revealed the following information: a. On 4/2/24 punched in at 10:00 p.m. and punched out 4/3/24 at 6:00 a.m. b. Staff F did not have any time clock punches from 4/4/24-4/8/24 c. Staff F returned to work as of 4/9/24 punched in at 9:45 p.m. and punched out 4/10/24 at 6:15 a.m. Review of the facility provided policy titled Abuse Prevention, Identification, Investigation and Reporting Policy dated July 2019 revealed under initial or immediate protection during facility investigation; a. Upon receiving a report of an allegation of resident abuse the facility shall immediately implement measures to prevent further potential abuse of residents from occuring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating them employee accused of abuse from all residents through the following or a combination of the following, if practicable: i. Suspending the employee ii. Segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility iii. And in rare instances separating the employee accused of abuse from the resident alleged to have been abused, but allowing the employee to care for and have contact with other residents, only if there is a second employee who remains with and accompanies the employee accused of abuse at all times to supervise all contacts and interactions with the residents. b. Following the completion of the facility investigation, if the facility concludes that the allegations of resident abuse are unfounded, the employee may be allowed to return to job duties involving resident contact, but the employee must maintain a separation and have no contact with the resident alleged to have been abused, by reassigning the accused employee to an area of the facility where no contact will be made between the accused employee and the resident alleged to have been abused. This separation must be maintained until the Department concludes its investigation and issues the written results of its investigation. Note if the DIA determines there was abuse (even though the facility did not substantiate the abuse), there is risk that DIA could cite the facility with Immediate Jeopardy, for allowing an abuser to have access to other residents while the matter is being investigated. Interview on 7/3/24 at 10:32 a.m., with the DON revealed the staff member should have been separated immediately from the resident and should not have worked the rest of the night shift.

Based on record review, interview, and facility policy the facility failed to have the Infection Preventionist at quarterly meetings for their quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 50. Findings include: Review of the facility document titled Quality Assurance Process Improvement (QAPI) sign in sheet 2024: a. Document dated January lacked the signature of the Infection Preventionist. b. Document dated February lacked the signature of the Infection Preventionist. c. Document dated March lacked the signature of the Infection Preventionist. d. Document dated April lacked the signature of the Infection Preventionist. e. Document dated May lacked the signature of the Infection Preventionist. Review of the facility provided policy titled Quality Assurance Process Improvement dated July 1, 2024 revealed the Administrator is responsible for assuring that this facilitiy's QAPI program complies with federal, state, and local regulatory agency requirements. Interview on 7/3/24 at 10:32 a.m., with the Director of Nursing (DON) revealed Staff D, Registered Nurse is the Infection Preventionist (IP) and is usually working the floor as a nurse during QAPI meetings so she has not attended them. The DON further revealed she has been working on getting her IP certification but does not currently have it.

Based on clinical record review, facility record review, staff interviews and facility policy the facility failed to appropriately implement interventions to protect 1 out of 3 residents (Resident #1) reviewed from physical abuse. The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE]/24 for Resident #1 documented diagnoses of Alzheimer s Disease, anxiety disorder and non-traumatic brain dysfunction. The MDS showed the Brief Interview for Mental Status (BIMS) score of 02, indicating severe cognitive impairment. Review of facility Incident Report dated 4/3/34 at 1:15 a.m., revealed incident description according to staff statements 2 Certified Nursing Assistants (CNA's) Staff E, CNA and Staff F, CNA entered the residents room to provide incontinence care, when they attempted to remove the incontinent brief Resident #1 became agitated and started swinging and kicking. According to the initial statement, Staff F slapped the resident on the thigh. Review of facility investigation of self-report of incident occurring on 4/3/24 at approximately 1:15 a.m.-1:30a.m. revealed the following: a. Interview conducted with Staff E. According to her interview and written statement she went to assist with checking and changing 2 residents that require assistance of 2. Staff E and Staff F entered Resident #1's room and began the process of changing him. He did become combative. Staff E indicated Resident #1 swung out at her with his hands and made contact. During the final steps Staff D stated Staff F slapped Resident #1 with her hand and said stop it. Staff E stated when they were done, both CNA's entered the hallway and Staff F said sorry didn't mean to hit him but damn. After Staff E left the unit she informed the charge nurse that the act had occurred and the charge nurse stated yes to call the DON. b. Interview conducted with Staff F. According to her interview and written statement Staff F and Staff E entered Resident #1's room, Resident #1 was informed the CNA's were there to check and change him. Resident #1 was agreeable. When the CNA's attempted to remove the incontinent brief Resident #1 became agitated and started kicking and hitting. Staff F indicated when he first became agitated she held both his hands so he would not hit, he then began kicking with his feet and kicked Staff E with his feet in her ribs. According to Staff F, they finished the process and left the room. Review of written statement by Staff E, signed and undated revealed on April 3 at 1:15 a.m., went into help Staff F with the 2 gentlemen. Resident #1 was being combative. After the last time of Resident #1 hitting and kicking me Staff F slapped Resident #1 and told him to stop it. After we were done changing him Staff F said sorry didn't mean to hit him but damn. Review of written statement by Staff F signed and dated 4/4/24 revealed Staff E and Staff F went to change Resident #1, on the first check he was ok when we told him what we were going to do. Was ok until we went to change him. We opened the depend and that is when he started to hit and I grabbed his hands and Staff E went to change him and that was when he kicked her in her ribs and lost balance, went to the hall. Then we got finished, I told him that was not nice to kick her and he laughed about it. Cleaned up the room and left. Second check went a lot better. An electronic message (e-mail) to Staff G, Nurse Practitioner dated 4/5/24 at 11:32 a.m., revealed the facility had a self report of an aide slapping Resident #1 while providing care. Interview on 7/2/24 at 4:22 p.m., with Staff E, CNA revealed on 4/3/24 at approximately 1:15 a.m., she went to assist Staff F, CNA with Resident #1 with care. During cares Resident #1 was hitting and kicking at staff assisting him. Staff F slapped Resident #1 on the upper left leg between the hip and knee area. Staff E reported it to charge nurse on duty. Charge nurse stated she needed to call the DON right away. At 1:45 a.m., placed a call to the DON. Staff E revealed she did not answer so she left a message. At 1:48 a.m., sent the DON a text message. Staff E revealed Staff F continued to work the rest of her shift and the other staff working assisted her as Staff E was busy with her residents. Review of Resident #1's Progress Notes lacked documentation of the incident occurring on 4/3/24. Review of the facility provided policy titled Abuse Prevention, Identification, Investigation and Reporting Policy dated July 2019 revealed the following information: a. All residents have the right to be free from abuse. b. Physical abuse includes but is not limited to hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment, including but not limited to, pinching, spanking, slapping of hands, flicking or hitting with an object. The risk for abuse may increase when a resident exhibits a behavior that make provoke a reaction by staff, residents or others such as physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects and resistive to care and services. Interview on 7/3/24 at 3:30 p.m., with the Administrator revealed he could not confirm or deny the incident occurred after their investigation.

Based on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 1 of 1 residents reviewed for abuse (Resident #1). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE]/24 for Resident #1 documented diagnoses of Alzheimer's Disease, anxiety disorder and non-traumatic brain dysfunction. The MDS showed the Brief Interview for Mental Status (BIMS) score of 02, indicating severe cognitive impairment. Review of facility Incident Report dated 4/3/34 at 1:15 a.m., revealed incident description according to staff statements 2 Certified Nursing Assistants (CNA's) Staff E, CNA and Staff F, CNA entered the residents room to provide incontinence care, when they attempted to remove the incontinent brief Resident #1 became agitated and started swinging and kicking. According to the initial statement, Staff F slapped the resident on the thigh. Immediate action taken revealed a description reported to the charge nurse who instructed Staff E to report to the Director of Nursing. Call was placed to DON with no answer. When DON arrived on 4/3/24 at 6:30 a.m.,the incident was reported at that time. DON did not hear the phone and staff did not try another call. Review of facility provided documentation titled Investigation of Self-Report of incident occurring on 4/3/24 at approximately 1:15 a.m.-1:30 a.m Review of written statement by Staff E, undated revealed on April 3 at 1:15 a.m., I went into help Staff F with the 2 gentlemen. Resident #1 was being combative. After the last time of Resident #1 hitting and kicking me Staff F slapped Resident #1 and told him to stop it. After we were done changing him Staff F said sorry didn't mean to hit him but damn. Interview on 7/2/24 at 4:22 p.m., with Staff E, CNA revealed on 4/3/24 at approximately 1:15 a.m., she went to assist Staff F, CNA with Resident #1 with care. During cares Resident #1 was hitting and kicking at staff assisting him. Staff F slapped Resident #1 on the upper left leg between the hip and knee area. Staff E reported it to charge nurse on duty. Charge nurse stated she needed to call the DON right away. At 1:45 a.m., placed a call to the DON. Staff E revealed she did not answer so she left a message. At 1:48 a.m., sent the DON a text message. Staff E revealed Staff F continued to work the rest of her shift and the other staff working assisted her as Staff E was busy with her residents. Review of facility intake information the facility submitted a self report on 4/3/24 at 11:52 a.m Review of the facility provided policy titled Abuse Prevention, Identification, Investigation and Reporting Policy dated July 2019 revealed the following information: a. All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations to the Administrator or designated representative. b. All allegations of Resident abuse shall be reported to the Iowa Department of Inspections and Appeal not later than two (2) hours after the allegation is made. Interview on 7/3/24 at 10:32 a.m., with the DON revealed the report should have been reported before it was to DIAL.

Based on clinical record review, facility record review, staff interviews and facility policy review the facility failed to provide accurate resident records for 1 of 4 residents (Residents #1). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE]/24 for Resident #1 documented diagnoses of Alzheimer's Disease, anxiety disorder and non-traumatic brain dysfunction. The MDS showed the Brief Interview for Mental Status (BIMS) score of 02, indicating severe cognitive impairment. Review of facility Incident Report dated 4/3/34 at 1:15 a.m., revealed incident description according to staff statements 2 Certified Nursing Assistants (CNA's) Staff E, CNA and Staff F, CNA entered the residents room to provide incontinence care, when they attempted to remove the incontinent brief Resident #1 became agitated and started swinging and kicking. According to the initial statement, Staff F slapped the resident on the thigh. An electronic message (e-mail) to Staff G, Nurse Practitioner dated 4/5/24 at 11:32 a.m., revealed the facility had a self report of an aide slapping Resident #1 while providing care. Interview on 7/2/24 at 4:22 p.m., with Staff E, CNA revealed on 4/3/24 at approximately 1:15 a.m., she went to assist Staff F, CNA with Resident #1 with care. During cares Resident #1 was hitting and kicking at staff assisting him. Staff F slapped Resident #1 on the upper left leg between the hip and knee area. Staff E reported it to charge nurses on duty. Review of Resident #1's Progress Notes lacked documentation of the incident from the incident occurring on 4/3/24. Review of facility provided policy titled Charting and Documentation policy and procedure dated 6/1/24 revealed the following: a. All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, function or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's cognition and response to care. b. The following information is to be documented in the resident medical record i. Changes in the resident condition. ii. Events, incidents or accidents involving the resident. Interview on 7/3/24 at 10:32 a.m., with the Director of Nursing (DON) revealed the incident with Resident #1 should have been documented in his medical chart.

Based on observation, staff interview and record review, the facility failed to update the resident's care plan to accurately reflect the resident for 4 of 13 reviewed (Residents #2, #16 #20, #41). The facility reported a census of 50 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of diabetes mellitus and edema. The MDS showed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Review of the MDS dated [DATE] revealed diuretic medication was taken in the last 7 days in the look back period. Review of the October 2023 Medication Administration Record (MAR) revealed the following orders: a. Lasix tablet daily (diuretic medication) with an order date of 1/7/23. Review of the Order Summary Report signed by the physician on 11/2/23 revealed the following orders: a. Lasix tablet daily with an order date of 1/7/23 and a start date of 1/8/23. Review of the Care Plan with a revision date of 10/25/23 lacked information regarding the usage and side effects of diuretic medication. 2. The MDS assessment dated [DATE] for Resident #16 documented diagnoses of major depressive disorder, anxiety disorder and post-traumatic stress disorder. The MDS showed a BIMS score of 15, indicating no cognitive impairment. Review of Progress Notes revealed the following information: a. On 10/16/23 at 3:00 a.m., oxygen on at 2 liters per minute. b. On 10/18/23 at 9:26 a.m., request was also made for PRN oxygen. Resident did not require as needed oxygen yesterday or today during the day shift but the resident stated he wore oxygen overnight last night. c. On 10/24/23 at 2:59 p.m., resident was sent with oxygen at 2 liters via nasal cannula. d. On 10/27/23 at 12:35 p.m., nurse applied 2 liters of oxygen via nasal cannula. e. On 10/31/23 at 4:45 a.m., nurse applied 2 liters of oxygen via nasal cannula . Review of order dated 10/16/23 revealed an order for oxygen as needed to keep oxygen saturation above 90%. Review of the Care Plan with a revision date of 10/23/23 lacked any information regarding oxygen usage. 3. The MDS assessment dated [DATE] for Resident #20 documented diagnoses of heart failure, anxiety disorder and Alzheimer ' s Disease. The MDS showed a BIMS score of 3, indicating severe cognitive impairment. The MDS revealed diuretic medications were taken 7 out of the last 7 days in the look back period and opioid medication were taken 2 out of the last 7 days in the look back period. Review of the October 2023 MAR revealed the following orders: a. Lasix tablet daily (diuretic medication) with an order date of 2/15/22, b. Morphine Sulfate (opioid pain medication) with an order date of 5/12/23. Review of the Order Summary Report signed by the physician on 10/19/23 revealed the following orders: a. Lasix tablet daily with an order date of 2/15/22 with a start date of 2/16/23. b. Morphine Sulfate with an order date of 5/12/2 with a start date of 8/7/23. Review of the Care Plan with a revision date of 10/31/23 lacked information regarding the usage and side effects of diuretic and opioid pain medication. Interview on 11/02/23 at 8:41 a.m., with the Director of Nursing (DON) revealed the care plan should include all high risk medications and side effects and should be personalized to each resident's needs. 44420 4. The MDS dated [DATE] for Resident #41 identified the BIMS score of 0 which indicated severe cognitive impairment. The MDS indicated Resident #41 required an extensive assistance of 2 persons for transfers, bed mobility, and toileting. The MDS included a diagnosis of dementia, heart failure and anxiety. The hospital records dated 7/5/23 for Resident #41 showed a diagnosis of myocardial infarction (MI), congestive heart failure (CHF), pulmonary embolism (PE) and syncopal episodes related to the PE. The Progress Notes dated 10/25/23 for Resident #41 showed a urinary analysis indicated the presence of a urinary tract infection (UTI). The provider prescribed Keflex 500 milligrams (mg) to be administered twice a day. The Physician Order dated 7/11/23 showed Resident #41 prescribed the anticoagulant Eliquis 5 mg every 12 hours for treatment of the PE. The Care Plan reviewed on 11/1/23 showed the facility failed to include the following items on the care plan: CHF, Recent MI, PE, UTI and Anticoagulant. In an interview on 11/2/23 at 9:13 AM, the Director of Nursing (DON), reported that she expected the care plan to be updated to reflect the resident's current condition and care needs.

Based on record review and staff interview, the facility failed to have a facility assessment updated. The facility reported a census of 50 residents. Findings Include: Review of the facility assessment revealed an updated date of 6/2/22. The facility does not hvae a policy on facility assessment or revision. Interview on 11/02/23 at 8:54 a.m., with the Administrator revealed the facility did not have the facility assessment updated for 2023 and everyone was working on their parts to get it updated. He further revealed it should be completed yearly.

Based on clinical record review, staff interview and policy review the facility failed to incorporate specialized services into resident ' s care with a Level II PreAdmission Screening and Resident Review (PASRR) for 1 out of 2 residents (Resident #16). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #16 documented diagnoses of major depressive disorder, anxiety disorder and post-traumatic stress disorder The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the clinical record revealed a PASRR level II dated 4/7/23 approved with specialized services. The recommendations revealed the following specialized services and rehabilitative services for the resident to reside in a nursing facility. The Care Plan with a revision date of 10/23/23 lacked information regarding rehabilitative services from the PASRR level II and lacked a diagnosis of post-traumatic stress disorder. Interview on 11/02/23 at 8:43 a.m., with the Director of Nursing revealed all level II services should be listed on the resident ' s care plan and the facility does not have a policy for PASRR and they follow the federal regulations.

Based on clinical record review, policy and procedures, resident and staff interviews, the facility failed to implement measures to ensure the personal alarm sounded when a resident arose from the chair for 1 out 1 residents reviewed (Resident #41). The facility reported a census of 50. Finding included: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #41 identified the Brief Interview for Mental Status (BIMS) score of 0 which indicated severe cognitive impairment. The MDS indicated Resident #41 required an extensive assistance of 2 persons for transfers, bed mobility, and toileting. The MDS included a diagnosis of dementia and anxiety. The Care Plan last revised on 10/26/23 showed Resident #41 as a high fall risk related to impaired cognition due to Alzheimer's Dementia. The Care Plan also indicated a past fall resulted in a hip and pelvis fracture. The Care Plan instructed staff to use a chair alarm when the resident is in a wheelchair or recliner. The Incident Report dated 9/11/23 at 1:33 AM, created by Staff D, Licensed Practical Nurse (LPN), showed staff observed Resident #41 slide to the floor from the wheelchair. Staff D described the resident to be on the floor, in a seated position, with her back against the wall. Staff D indicated the wheelchair alarm did not sound at the time of fall. Upon further investigation Staff D noted the alarm was missing a battery. When Staff D questioned staff they reported not hearing the chair alarm when they assisted the resident from the bed to the chair approximately one hour prior to the incident. In an interview on 11/1/23 at 2:13 PM, Staff D reported the chair alarm needed three batteries to be operational. When Staff D checked the alarm, she found one battery to be removed from the alarm, which prevented the alarm from sounding at the time of the fall. Staff D explained the reset button needed to be pushed three times to stop the alarm but found that Resident #41 ' s reset button sometimes failed to function properly. When the reset button failed, staff removed the batteries to stop the alarm from sounding. Staff D reported issues with the reset button occurred since May 2023. In an interview on 11/2/23 at 9:13 AM, the Director of Nursing (DON) reported that she expected staff to make the facility aware of equipment that failed to function properly. The DON reported after this fall she educated staff to ensure alarms functioned properly and were engaged when in use. The DON reported the facility lacked a policy regarding personal alarms.

Based on record review, and staff interview, the facility failed to provide adequate assessment and timely intervention for 1 of 4 residents reviewed (Resident #1). On 4/15/23 at 2:50 a.m. Resident #1's alarm sounded and as staff responded they heard a thud and found resident laying on the floor on his right side. Facility staff failed to complete a thorough assessment which included range of motion (ROM) and failed to initiate neurologic checks following the unwitnessed fall. Additionally, the staff failed to complete a follow up assessment following the fall when pain was noticed during transfer with weight bearing. At 6:38 a.m. resident was assessed for ongoing right leg pain. Resident noted to have external rotation of the right leg, resident was transferred to the local ER and was diagnosed with right femoral neck fracture (hip fracture) and admitted to the hospital for surgery to repair. The facility reported a census of 44. Findings include: The Minimum Data Set (MDS) assessment with a reference date of 3/6/23 for Resident #1 identified severely impaired cognitive skills for decision making. The MDS further revealed the resident required assistance of one for transfer, and walking. The resident had diagnosis that included Alzheimer's disease, and overactive bladder. An Un-witnessed Fall Report initiated on 4/15/23 at 2:50 a.m. by Staff A, Licensed Practical Nurse (LPN) documented that Resident #1 had been found lying on the floor near the entry door. Nurse assessed the resident, skin was intact. Bed was in lowest position. Certified Nursing Assistant (CNA) reported resident had been changed one hour prior. Resident confused, unable to report what was doing prior to the fall. No signs of discomfort, no signs of bone fracture noticed, all extremities working well. Resident helped with assist of two back to bed. Review of an Investigation Summary prepared by the Director of Nursing (DON) revealed Staff B, CNA responded to floor alarm sounding in Resident #1's room. Before entering the room, she heard a thud. Found resident lying on the floor approximately 15 feet from his bed on his right side. Resident had been checked at 2:00 a.m. In an interview with the DON, Staff B, CNA reported that the resident complained of right leg pain when assisted to bed. However, Staff A, LPN documented no pain with transfer with weight bearing. A Progress Note dated 4/15/23 at 3:33 a.m., Staff A, LPN documented CNA entered the resident room and found lying on the floor. No discomfort or pain reported, resident was transferred with two assist with gait belt to bed, able to bear weight. Recommendations included, resident to be checked every 30 minutes. The clinical record lacked documentation of ROM, further assessment or documentation, or neuro checks by Staff A, LPN. A Progress Note dated 4/15/23 at 6:38 a.m. initiated by Staff C, LPN documented she was summoned to Resident #1's room. CNA informed resident had yelled out in pain when she tried to touch right leg. LPN assessed right leg noted externally rotated. No bruising noted at that time. Resident would not allow staff to touch right leg. Family notified and requested transfer out to local hospital. 911 called for transfer to local emergency room for evaluation via ambulance. Staff C, LPN further documented at 6:54 a.m. that ambulance arrived and resident assisted to stretcher and left for local ER. During an interview on 8/17/23 at 9:51 a.m. Staff C, LPN stated she had arrived to work at 4:00 a.m. on 4/15/23 but Staff A, LPN was working Resident #1's unit until 6:00 a.m. so wasn't involved with the fall until she was summoned via the walkie at 6:38 a.m. Recalled the CNA reported she was going to lotion his legs, when she touched him he yelled in pain which prompted her to call for a nurse. When Staff C, arrived at the bedside she noticed that the right leg was externally rotated and initiated arrangements to transfer out. Staff C responded that she had not received a verbal report on the fall from Staff A, LPN prior to his shift ending and would have expected follow up and ongoing assessment for injuries and neuro checks to have been initiated with an unwitnessed fall. Confirmed this had not occurred. In an interview on 8/17/23 a.m. the DON stated that staff are expected to follow the protocols identified for fall response and neurologic checks. Additionally, would expect staff to monitor for changes as they provided care to the resident. The DON stated that that Staff A, LPN had failed to assess ROM to include observation of external and internal rotation, failed to complete neurologic checks as indicated in the fall policy, and failed to complete follow up assessments. Based on these identified issues associated with a fall with a negative outcome and resident not assessed in a timely manner Staff A was terminated immediately. Review of a hospital document titled History and Physical report dated 4/15/23 at 9:37 a.m. revealed the resident fell at the facility. Resident complained of severe pain at 6:00 a.m., was brought by ambulance where x-rays demonstrated a displaced femoral neck fracture. Orthopedic consultation has planned surgical repair this morning. Review of a facility Corrective Action Form signed on 4/26/23 documented Staff A was terminated for lack of assessment of fall and falsification of documentation. The issues identified in the document included: Lack of ROM assessment including external and internal rotation, failure to complete neuro checks as indicated by facility policy, and no follow up assessment was completed after the fall. The document noted Staff A, LPN refused to sign. Review of an undated facility policy titled Fall Prevention and Response Policy included, when a fall occurs: initiate neurologic checks if the fall was unwitnessed, post fall documentation includes intervention, response to interventions, effectiveness of interventions, and injuries noted, and documentation of post-fall status will occur in progress notes every shift for at least 72 hours and as needed. Review of an undated facility policy titled Neurological Assessment included: Neurological assessments are indicated following an unwitnessed fall. Perform neurological checks with the frequency as per the falls protocol.

Based on record review and staff interview, the facility failed to provide adequate assessment and timely intervention for a change in condition for 2 of 2 resident's reviewed (Resident #104, and #3). Resident #104 fell and sustained a head injury and fracture of the C1 vertebrae (neck) on [DATE]. On [DATE] the resident had pain documented on the Treatment Administration Record (TAR) with no documentation interventions were implemented to relieve the pain. The resident also had a change of condition with his oxygen (O2) saturation (sat) dropping to 52% (normal above 90%) and respirations 30 (normal ,d+[DATE]) and labored around 9:30 a.m. The facility failed to assess the resident's lung sounds related to the change. On [DATE] at 1:45 a.m. (approximately 16 hours after the drop in O2 sats) the resident left by ambulance to the emergency room with pain documented at a 6, respirations of 44, and crackles throughout his lungs. The resident went into respiratory arrest and died in the ambulance. Resident #3 had [CONDITION(S)] (swelling) in the lower extremities and a care plan intervention to weigh weekly. The facility failed to follow through with the intervention. The facility reported a census of 55 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #104 scored 2 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required extensive assistance with bed mobility, transfers, walking in the room, dressing, toilet use and personal hygiene. The resident required limited assistance with walking in the hallway. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Progress Notes dated [DATE] at 12:02 a.m. documented the resident had an unwitnessed fall at 10:55 p.m. in his room. The nurse aide heard a sound and found him on his right side next to his bed bleeding from his head. The nurse evaluated the resident, called the wife at 11 p.m. and asked for permission to send him to the emergency room (ER) to be evaluated and treated. The hospital called at 11:02 p.m. to get a telephone order to send the resident. At 11:08 p.m. 911 called and they had to try to find an ambulance since all those around were dispatched out with other calls. At 11:35 a.m. dispatch called back and said another ambulance would transfer the resident. At 11:55 p.m. the ambulance came and transported the resident onto the gurney, leaving the facility at 12 a.m. The resident was alert after the fall and only complained of his head hurting in the general area where his head bled from. They cleaned the resident up with sodium chloride (NaCl), and gauze placed on his head with pressure to help with the bleeding. His wife would be at the hospital waiting for his arrival. A hospital Emergency Department note dated [DATE] documented the resident had a laceration of the head and a C1 cervical fracture. The history of present illness (HPI) documented a resident with dementia in the memory care unit apparently sustained a fall earlier in the night and had a laceration on the right eyebrow. The resident had some neck pain, and also pain in the pelvis. He had a stellate (a tear in the skin caused by [MEDICATION(S)] trauma) laceration above the right eyebrow, and hematoma or swelling around that area, approximate 5 or 6 cm total length. Basically gouged into the center of the stellate laceration and it kind of stretched the tissue due to frailty and old age. It had continuous oozing without a pressure dressing. The laceration measured 5 cm to 2 cm. The resident had a very irregular wound. He had Computed Tamography (CT) of the cervical spine without contrast. The findings included fractures of both the anterior and posterior arches of C1. The anterior arch fracture was distracted (widened) by about 11 mm. The Progress Notes dated [DATE] at 9:48 a.m. documented the Resident returned via ambulance at 9:05 a.m. The ER Dr. consulted with a neuro-surgeon. The resident with C1 fracture and felt not a candidate for surgery. He received a soft collar to wear. Per the Dr. notes they were to do best they could to keep collar on but understood it may be difficult to do. The resident had multiple sutures on top of his forehead. They were to leave the pressure bandage on for 48 hours then apply an ointment. Sutures should be removed in ,d+[DATE] days at follow-up appointment. The resident also needed a neck x-ray to assess the break. Both orbital areas were very bruised and swollen. Told if became too anxious they were to call the ER for orders of a calming type medication. Also, if presented to be in excessive pain they could call. The Care Plan identified an actual post incident [DATE] when the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] sudden unexplained pain, or sudden loss of sensation. Contact the Physician promptly with any concerns. If medication needed for pain call the ER. The Progress Notes dated [DATE] at 9:30 a.m. documented the on duty nurse reported the resident's oxygen (O2) saturation (sat) had dropped and she put him on oxygen. The nurse stated she tried calling the Physician's office but she was not in. The nurse went into the resident's room to assess him. The resident noted to be laying in bed with eyes closed, oxygen on per nasal cannula. The resident's spouse present. The nurse asked the spouse if she could do anything for the resident or her. The nurse brought the spouse a cup of coffee. As leaving the unit, the spouse came out of resident's room and stated the resident wanted a drink of water and he had to poop. The nurse suggested staff use the potty chair on wheels and transfer the resident from the bed and let him use the bathroom. Staff agreed and the nurse left the unit. At 9:50 a.m. the nurse paged to the unit. Upon entering room, nurse (Staff N Registered Nurse) noted to be taking vitals on the resident laying in bed. Staff P Licensed Practical Nurse (LPN), stated the resident became unresponsive on the toilet so they laid him back down in bed. The nurse asked if he had a bowel movement and the other nurse stated yes. This nurse stated that he may have had a vagal response. The nurse asked the resident's spouse if she would like the resident to be sent to the hospital and the wife stated no, she wanted him to be comfortable and to stay at the facility. The nurse told the on duty nurse the spouse's wishes and reminded the on duty nurse to contact the doctor regarding the episode and need for O2 and to document. The [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident last received Tylenol for pain on [DATE] at 7:17 a.m. with pain documented at 6 (0 no pain, 10 worst pain) and indicated it was effective. The Treatment Administration Record (TAR) documented the resident's pain on [DATE]: a. 4 at 4 a.m. b. 4 at 8 a.m. c. 3 at 12 p.m. d. 0 at 6 p.m. e. not assigned a number at 8 p.m. f. and a 6 on [DATE] at 12 a.m. The clinical record lacked documentation the facility implemented interventions to help relieve the pain. The Progress Notes dated [DATE] at 2:09 p.m. documented the resident was unresponsive while using the bathroom for ,d+[DATE] minutes. The resident had been weak and sleepy during the a.m. shift. The resident's 02 was down to 52% (,d+[DATE] normal) started O2 at 2 liters. Fax sent to the doctor and family notified. Vitals temp 97.7, pulse 46 (normal ,d+[DATE]), B/P ,d+[DATE], respirations 30 (normal ,d+[DATE]) with labored breathing. He refused his meals and noon shakes. A fax dated [DATE] notified the Physician of the resident's condition. The resident fell [DATE] with sutures at the forehead and soft neck collar. The resident's O2 sat dropped down to 52 %, and the nurse started O2, and the resident had labored breathing. The resident complained of abdominal pain, and request to use the restroom. In the process he became unresponsive for ,d+[DATE] minutes while sitting on the bathroom. His oxygen started going up to 74 %. Would keep monitoring him. Asked if the Physician would recommend continuing the O2, and how long. The Advanced Registered Nurse Practitioner responded to continue O2 at ,d+[DATE] liters to maintain O2 sats greater than 90% until progress report on [DATE] to the Physician. On [DATE] at 9:17 p.m. the resident refused to cooperate and became more combative when obtaining vital signs and assessment. He refused to put the oxygen back on but agreed to be changed and repositioned in bed. The resident refused his medications and meals. The resident slept peacefully in his room at that time. The Progress Notes dated [DATE] at 9:50 p.m. documented the fax came back to continue O2 per nasal cannula ,d+[DATE] liters to maintain O2 sats greater than 90%. Continue O2 continuously until progress report on Thursday, [DATE] to the physician. The Progress Notes dated [DATE] at 1:15 a.m. documented a call placed to the ER to get in touch with the on-call regarding the resident. The resident's vital signs were (VS) 97.[DATE] O2 at 2 L NC. The resident's lung sounds had crackles throughout, and audible gurgling. The resident unable to verbalize the presence of pain, restless, moving his legs out of bed. A call placed to update the spouse. The on-call updated on the resident. Received an order to send resident to the ER for further evaluation. The spouse would follow the ambulance to the ER. The Progress Notes dated [DATE] at 1:55 a.m. documented the ambulance arrived 1:40 a.m. departed with the resident at 1:45 a.m. The ambulance personnel called at 1:52 a.m. and stated the resident quit breathing and asked if he had a do not resuscitate (DNR) and he did. The spouse followed behind the ambulance. The Progress Notes dated [DATE] at 2:49 a.m. documented the ER called and stated the resident passed away [DATE] at 2:15 a.m. with the spouse at the bedside. A hospital Discharge Plan dated [DATE] documented the resident dead on arrival to the hospital. The clinical impression: death due to respiratory arrest, C1 cervical fracture, and dementia. The history of present illness (HPI) documented the resident with a recent fall at the nursing home sustaining a laceration to his head and a C1 fracture. The Emergency Medical Service (EMS) was called today due to increasing respiratory difficulty. Upon arrival they said he had a pulse and breathing, however, shortly after coming out into the cold air he respiratory arrested. They did assist the the resident with bag mask ventilation although they did not find it to be that effective. He lost his pulse enroute. Because he had a DNR they did not do further intervention. On [DATE] at 1:20 p.m. the resident's spouse stated on [DATE] the resident was not doing well. She went and spent time with him and went home to eat. She came back and the SW told her he was resting and she didn't need to be there. She went home and that was her biggest regret. He died in the ambulance and she didn't get to be with him. On [DATE] at 11:15 a.m. the Physician's Assistant (PA) stated she would definitely expect the resident's lung sounds to be assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 12:30 p.m. Staff O Registered Nurse (RN) Director of Nursing (DON) at the time, stated she was called to the unit because the resident became unresponsive (the a.m. of [DATE]). They had oxygen on him but she did not know the O2 sat dropped down to 52. She would expect an assessment of the resident's lung sounds. That may have changed their response. She did talk to the resident's spouse (that morning) but maybe didn't know the full extent of his condition. On [DATE] at 4:50 p.m. Staff P Licensed Practical Nurse (LPN) stated she could not remember details. When looking at documentation she said she did neuro checks on the resident and his O2 sat was 52. He had labored breathing. She started oxygen. Then he became unresponsive on the commode. She called the other nurse (Staff N RN) to see what she thought of him. The other nurse called the DON. She said she did not check his lungs because others were assessing him. She didn't know who assessed what. On [DATE] at 11:44 a.m. Staff N RN remembered Staff P calling her back to the unit [DATE] to see what she thought. She was maybe in the unit 5 minutes and called the DON. She did not do any assessment of the resident. On [DATE] at 2:40 p.m. Staff M RN worked at the facility a few shifts for agency. She worked [DATE] overnight into [DATE]. She worked south hall. She didn't know why she went back to the unit but the resident clearly needed pain medication. When she asked the resident about pain he squeezed her hand. He had crackles throughout his lungs with labored breathing. He wasn't taking pills and he needed something in liquid form. She thought he needed [MEDICATION(S)]. She said something should have been done before this. She had the other nurse come to the unit, (Staff L RN). She helped with phone calls. She did not feel the resident just suddenly got this way. On [DATE] at 3:19 p.m. Staff L stated she worked the night the resident died . When she went to the unit he was in bad shape. She thought he should have had something done sooner. 2. The Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated mildly impaired cognition. The same MDS revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on [DATE] at 1:59 PM revealed the resident had swollen feet and legs, she was wearing [CONDITION(S)] wear during observation. The Progress Note dated [DATE] at 3:30 PM revealed the resident had increasing pitting [CONDITION(S)] to bilateral lower extremities, 2+ to right lower extremity, ,d+[DATE]+ to left lower extremity. Resident has had 7 lbs. weight gain in past month. Lungs with diminished bases. No dyspnea noted. Oxygen saturation 94% on room air. The Individual Care Plan, undated, revealed interventions directing staff the resident was to be weighed weekly or as specified by physician and to monitor weight as ordered and report ,d+[DATE] pound weight gain in 1 week. The Weight Summary dated [DATE] revealed the resident's weights from [DATE] to [DATE]. The resident's weight was documented 2 times in ,d+[DATE] and ,d+[DATE], the remaining weights were taken monthly. The Medication Review Report dated [DATE] signed by a physician lacked orders for frequency of weight measurements. In an interview on [DATE] at 9:21AM, the Director of Nursing (DON) reported she would expect a resident's weight be obtained as directed by their care plan.

Based on observation, record review and staff interview, the facility failed to assure a resident had the identified interventions in place to prevent a fall with a major injury for 1 of 6 residents reviewed (Resident #104). Resident #104 had an intervention for a bed alarm to alert staff to his getting up. On 12/31/21 the resident sustained a fall in his room with no alarm. The resident sustained a head injury requiring sutures and C1 (neck) fracture. The facility reported a census of 55 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #104 scored 2 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required extensive assistance with bed mobility, transfers, walking in the room, dressing, toilet use and personal hygiene. The resident required limited assistance with walking in the hallway The resident's diagnoses included non-traumatic [CONDITION(S)], dementia with lewy bodies, and a stroke. The resident had 2 falls without injury, and 2 falls with non-major injury since the prior assessment. The Care Pan identified the resident a high risk for injury and potential falls due to impaired balance, weakness, and need for assistance with mobility. Interventions included: A bed alarm would be used to alert staff to his getting up, initiated 12/8/21. A Tracking Record for Improved Patient Safety (TRIPS) form documented the resident fell on [DATE] at 7 p.m. The resident self transferred and walked with his walker. The root cause identified the resident stated he lost his balance. The immediate intervention was close monitoring. A TRIPS form documented the resident fell on [DATE] at 9 p.m. The root cause of the fall identified as decreased mental, cognitive and neuromuscular systems. The immediate intervention was a bed alarm. A TRIPS form documented the resident fell on [DATE] at 2:34 p.m. The resident fell trying to sit back on a chair. The immediate interventions included reminding the resident to check before sitting, and monitoring the resident closely in and out of his room. A TRIPS form by Staff J Licensed Practical Nurse (LPN) documented the resident fell on [DATE] at 10:55 p.m. The resident was alone and unattended. The alarm was not attached to the bed. The root cause of the fall was the alarm was not plugged in, in order for the resident to get help. The Progress Notes dated 1/1/22 at 12:02 a.m. documented the resident had an unwitnessed fall at 10:55 p.m. in his room. The nurse aide heard a sound and found the resident on his right side next to his bed bleeding from his head. He evaluated the resident, and called the wife at 11 p.m. and asked for permission to send him to the emergency (ER) to be evaluated and treated. The hospital called at 11:02 p.m. to get a telephone order to send the resident. At 11:08 p.m. 911 called and they had to try to find an ambulance since all around us were dispatched out with other calls. At 11:35 a.m. dispatch called back and said another ambulance would transfer the resident. At 11:55 p.m. the ambulance came and transported him onto the gurney, leaving the facility at 12 a.m The resident was alert after the fall and only complained of his head hurting in the general area where his head bled from. They cleaned the resident up with sodium chloride (NaCl), and gauze placed on his head with pressure to help with the bleeding. His wife would be at the hospital waiting for his arrival. A hospital Emergency Department note dated 1/1/22 documented the resident had a laceration of the head and a C1 cervical fracture. The history of present illness documented a resident with dementia in the memory care unit apparently sustained a fall earlier in the night and had a laceration on the right eyebrow. The resident had some neck pain, and also pain in the pelvis. He had a stellate (tear in the skin caused by [MEDICATION(S)] trauma) laceration above the right eyebrow, and hematoma or swelling around that area, approximate 5 or 6 cm total length. Basically a gouged into the center of the stellate laceration and it kind of stretched the tissue due to frailty and old age. It had continuous oozing without a pressure dressing. The laceration measured 5 cm to 2 cm. The resident had a very irregular wound. The resident had Computed Tamography (CT) of the cervical spine without contrast. The findings included fractures of both the anterior and posterior arches of C1. The anterior arch fracture was distracted (widened) by about 11 mm. The Progress Notes dated 1/1/22 9:48 a.m. documented the Resident returned via ambulance at 9:05 a.m. the ER Dr. consulted with a neuro-surgeon. The resident with C1 fracture and felt not a candidate for surgery. He received a soft collar to wear. Per the Dr. notes they were to do the best they could to keep the collar on but understood it may be difficult to do. The resident had multiple sutures on top of his forehead. They were to leave the pressure bandage on for 48 hours then apply an ointment. Sutures should be removed in 10-14 days at follow-up appointment. The resident also needed a neck x-ray to assess the break. Both orbital areas were very bruised and swollen. The were told if he became too anxious they were to call the ER for orders of a calming type medication. Also, if presented to be in excessive pain they could call. On 7/26/22 at 1:20 p.m. the resident's spouse stated she kept a diary of events. She said the night he fell they called her and she went to the hospital, getting there before he did. She could not understand why they didn't answer the alarm before he fell , they never explained that to her. She said he had a broken neck and had stitches on top of his head. She could not understand how that happened. He went back to the facility at 9:30 a.m. the next morning. On 7/26/22 at 3:02 p.m. Staff K Certified Nursing Assistant (CNA) worked 2-10 p.m. the night he fell . She didn't remember putting him to bed. He was supposed to have a bed alarm on. She gave report at 10 p.m. and didn't remember checking the alarm. She assumed it was on. On 7/27/22 at 9:51 a.m. Staff R CNA worked the night the resident fell and went to the hospital. He didn't recall report that night. He said he was sitting when he heard a bang and then found the resident on the floor and bleeding from the head. On 7/27/22 at 12:30 p.m. Staff O Registered Nurse (RN) stated she was the former Director of Nursing (DON) and was in that position when the resident fell and sustained the injuries 12/31/21. She said apparently the resident did not have the alarm on at the time. Action was taken immediately to correct the problem. During an observation on 7/28/22 at 11:35 a.m. the current DON and Office Manager (OM) demonstrated the bed alarm. The office manager sat up and stood. The alarm sounded as soon as she stood up off of it. The DON stated if the alarm were on the night he fell , it should have sounded alerting staff to check on him. On 7/28/22 at 3:19 p.m. Staff L RN stated she worked the night the resident fell and had a fracture. She said he did not have the alarm on.

Based on observation, record review, facility policy and staff interviews the facility failed to ensure each resident received adequate supervision to prevent elopement for 1 of 10 residents identified by the facility with wanderguards, (Resident #1). Resident#1 exited the facility unsupervised and the facility failed to properly respond to an activated door alarm which resulted in immediate jeopardy to resident health and safety. The facility reported a census of 67 residents. Findings include: Resident #1 had a Quarterly Minimum Data Set (MDS) assessment dated [DATE], that documented a [DIAGNOSES REDACTED]. Resident #1 scored 5 of 15 on a BIMS (brief interview for mental status) test which indicated severely impaired cognition. The MDS documented the resident had signs of symptoms of [MEDICAL CONDITION], inattention and disorganized thinking. The MDS documented no wandering and Resident #1 required supervision with locomotion off the unit and a walker for mobility device. A Potential Elopement assessment dated [DATE], documented: *Prior elopement attempts at home-no *One or more elopements attempts at facility-no *Alzheimer/dementia diagnosis-yes *Resident is very mobile with or without assistive devices-N/A, has wandergaurd Resident #1's Care Plan, dated as initiated [DATE], identified a focus area for injury, high risk for, potential for injury related to impaired thought processes, use of [MEDICAL CONDITION] medications, history of falls, occasional incontinence of bowel and bladder, interventions include: Wanderguard bracelet in use, check daily to ensure functioning properly, Change as need (PRN), see Electronic Treatment Administration Record (ETAR). Provide 1 assist for supervision with transfers/ambulation as allows. Transfer/ambulate with 4 wheeled walker. A Progress Note dated [DATE] at 8:47 p.m., documented Resident #1 found in the Assisted Living. Staff accompanied resident back to the building safely. Wanderguard found not to be working. Wanderguard replaced. A Missing Resident Procedure/Drill dated [DATE] at 7:30 p.m., documented the following: 5. e. alarm on/off - wanderguard changed. Resident walked with walker to adjoining assisted living. Assisted Living staff brought resident back. Made no attempt to exit doors to outside. 2. a. Time resident last seen: 7:20 p.m., at the nurses station c. Were alarms on: Door alarm-yes, wanderguard not working d. Time and place when resident was found- Assisted Living at 7:30 p.m. e. Who found the resident-Assisted Living Personal Staff Assistant f. Physical assessment done to determine injuries- no injuries noted A summary written by the facility: Time line of events on [DATE] and when last time seen/cared for by staff: Certified Nursing Assistant (CNA) for Nursing home; last saw Resident #1 seated in dining room at approximately 7:00 p.m.-7:15 p.m. Dietary Cook, saw resident at south nurses station talking with another CNA at 7:20 ish p.m. CNA from Assisted Living, noticed resident walking in Living Room of Assisted Living at 7:30 p.m., and promptly took resident back through the door to the nursing home. CNA saw resident again at approximately 7:20 p.m.- 7:25 p.m. walking down East Hall with Assisted Living staff, CNA escorted resident back to resident room and assisted resident into a recliner. Staff informed another CNA of the incident: Staff notified the Registered Nurse and they together checked the Wanderguard at the exit door between the nursing facility and the assisted living and discovered it was not working. The RN instructed the CNA to retrieve another wanderguard from the store room. Careplan: Note: admitted on [DATE] from Community Memorial Assisted Living (attached to the nursing home) due to Alzheimer Diagnosis. History of Elopement attempts or wandering behavior: Wanderguard was included on care plan upon admission due to increased confusion. While resident never eloped from this door or any exit door, there was a threat of seeking out resident apartment because often traveled between the nursing home and the assisted living prior to moving to the care center. Diagram of floor plan: The distance from the door between the nursing facility and the assisted living to the assisted living room is approximately 100 feet. Staff Response to door alarm: RN heard door alarm and went to panel to read which door was sounding. RN discovered it was the door going into the Assisted Living. RN proceeded to the door and glanced into residents room on way. Not seeing anyone, RN returned to panel and shut off alarm. RN responded to CNA's when they told RN what had occurred by participating in the wanderguard test and replacement, but this was approximately 30 minutes following the alarm. Approximately how long was the resident gone before assisted living staff returned resident: Approximately ,[DATE] minutes Process prior to addition the expiration dated to the Treatment Administration Record: Old process was to write in a notebook the residents name, date of activation, and date of expiration according to the back of the device. How did you know when to change the wanderguards? Wanderguards were tested daily (see attachment) by charge nurse and recorded on the Treatment Administration Record. The test light will blink GREEN four times to indicate the bracelet is transmitting a radio signal that can be detected by a monitored door. At 5:01 a.m. on [DATE], the Resident #1's device blinked GREEN. Plan of Correction: 1. RN (hire date of [DATE]) was re-educated on [DATE]; *Door alarms/procedures. *Resident alarm systems. *Elopement/missing person policy and procedure. 2. All staff education posted for Door Alarm procedure. Deadline; [DATE] 3. NEVER SHUT OFF DOOR ALARM WITHOUT being 100% sure as to why it sounded was posted at the two door alarm panels yet to be reprogrammed on [DATE]. Prior to COVID-19 we had a technician come to the facility and reprogram old door alarm system on the North side of the building so that it couldn't be shut off without having to be at the door which triggered the alarm. Our plan is to reprogram the other two panels. On [DATE], technician was contacted to schedule when could come back in, he thought Monday [DATE]. 4. QAPI for door alarms audits will be conducted on all doors, all shifts and continues until all responses are correct for 3 months. Beginning [DATE]. 5. Wandering resident policy reviewed by the Director of Nursing on [DATE]. 6. Wanderguard activation, documentation, and testing policy was reviewed and updated by the Director of Nursing on [DATE]. Education for all licensed nurses will be done by [DATE]. Orientation materials for new hires includes updated policy and new policy included in nursing policy binders for reference on [DATE]. 7. All residents with wanderguards were reviewed on [DATE] for expiration dates on device and 90 day activation dates to be sure noon have expired on either date. None were found. 8. Two new universal testers for wanderguards ordered to have as backups for current devices on [DATE]. 9. New system for tracking wanderguards implemented on [DATE]. a. On tote with Wanderguards are instructions for wanderguard activation and documentation. 1. Activate Wanderguard system. 2. Record date of activation on TAR 3. Set replacement alert for 90 days from activation or expiration date of device (located on back) whichever comes first. b. Educated licensed nursing staff to new procedure and policy updates. Deadline [DATE]. 10. All exit doors in the Assisted Living will have alarms on them. Technician will place exit door alarms that send signals to personnel pager when triggered. Each exit door will have key pad code. Contact was made on [DATE] to schedule work. During an interview on [DATE] at 2:15 p.m., Staff A (CNA), stated she down the long hall in the Assisted Living on [DATE] and heard someone talking out by the living room, so Staff A went to the living room, looked at the hall clock, which read 7:30 p.m., and found Resident #1 with a 4 wheeled walker, saying I just don't know, I just don't know. Staff A was able to identify the resident as the resident used to live in the Assisted Living. Staff A took Resident #1 back to the nursing facility through the south east door of the facility. Resident #1 had told Staff A she was tired and could not walk any further so Staff A had the resident sit down on the seat of her walker and pushed her back to the nursing home side. Staff A stated the wanderguard on the resident walker failed to sound as the resident went through the doors. Staff A stated she was met by another CNA in the hallway by the residents room who took over and then Staff A went back to the Assisted Living. During an interview on [DATE] at 5:15 p.m., Staff B, CNA, stated that around 7:30 p.m., on [DATE], Staff B saw Staff A pushing Resident 1# through the southeast door of the facility. Resident #1 was sitting on the seat of the 4 wheeled walker. Staff B stated she assisted the resident into the recliner in her room and then proceeded to notify the RN on duty that Resident #1 had left the facility unattended. Staff B stated she last saw the resident in the dining room around 7:00 p.m., then left the dining room to attend a call light that was on. Staff B stated she didn't hear a door alarm or the wanderguard alarm sound as the resident left the hallway. During an interview on [DATE] at 12:15 p.m., Staff C, CNA, stated she had worked the evening shift on [DATE] and she had last seen Resident #1 ambulating down the hallway with a 4 wheeled walker between 7:00 p.m.-7:10 p.m. Staff C stated she thought the resident was going to her room so Staff C proceeded to do her job duties on the south west end of the facility. Staff C stated around 8:00 p.m., staff were at the nurses station visiting about Resident #1 leaving the facility and the resident wanderguard failed to sound. Staff C stated she went into Resident #1's room and grabbed the walker and proceeded to go to the southeast door and the alarm failed to activate, so Staff C then took the walker with the wanderguard on it and went to the east door in the dining room and the wandergaurd failed to sound at that door also. Staff C stated she told the RN on duty to go and get a new wanderguard, activate the wanderguard and then Staff C went into Resident #1's room and placed the new activated wanderguard on the residents left wrist and removed the wanderguard that failed to alarm from the 4 wheeled walker. During an interview on [DATE] at 4:10 p.m., Staff D (Register Nurse) stated he had worked the evening shift on [DATE]. Staff D stated he heard the southeast door alarm sound, not sure of the time, proceeded to walk over to the panel on the north side of the hall, across from the nurses station and noticed that the alarm was red and said south east door. Staff D stated he proceeded to walk down the southeast hallway and look into the resident rooms. Staff D said he looked through the window on the south east door, didn't see anything, proceeded to shut the door alarm off, walked back to the alarm on the panel that was sounding and flipped the switch to re-activate the southeast door alarm. Staff D stated he didn't go through the southeast door to verify that it was a resident or staff member. Staff D said he was notified by Staff B about 7:30 p.m., that Resident #1 had left the facility unattended and was found in the Assisted Living area. Staff D then proceeded to do an assessment on the resident, found no injuries and went back to passing medications. During an interview on [DATE] at 4:00 p.m., the facility Director of Nursing (DON) stated it is an expectation of the charge nurse to verify that when a door alarm is sounding to physically go out the door and check to see if it was a resident or staff member and if they fail to see anything they need to put into place the Missing Resident policy and procedure and follow the guidelines before re-activating the door alarm. During an interview on [DATE] at 9:15 a.m., the facility Administrator confirmed and verified the wandergaurd system failed by not sounding as Resident #1 went through the southeast door of the facility. Upon the facilities investigation, the wandergaurd was activated on [DATE] and reading the manufacturers guidelines after 90 days the wanderguard needs to be removed from the resident and a new wanderguard placed on, that would mean on [DATE] Resident #1 should of had a new wanderguard placed on their person. The other system that failed was the RN on duty that evening failed to physically go through the southeast door to verify if the door alarm sounded due to a resident leaving the facility or a staff member that was leaving. The Administrator stated the expectation of the nursing staff is to verify if it was a resident or staff leaving prior to shutting off the alarm and re-activating the alarm again on the control panel. During an environmental tour on [DATE] at 3:20 a.m., the facility Assistant Director of Nursing and surveyor went around to all the door alarms and they all sounded and staff responded quickly to the door and wanderguard alarms. The distance from where the resident was last seen in the facility to the Assisted Living area was 120 surveyor steps for which there was a door leading out into the parking lot of the facility and a brown door leading into the Assisted Living area that Resident #1 went through. The Weather Underground for [DATE], documented the temperature at 6:56 p.m., -2 degrees Fahrenheit, with the wind out of the southeast at 10 miles per hour and the low of -27 degrees. Review of the Wandering Resident policy dated 2021 documented: Policy: It is the policy of the Community Memorial Health Center to identify and protect the wandering resident. Purpose: To maintain a safe environment for the wandering resident. Procedure: Families will be informed on admission and sign a statement that residents will receive the least restrictive physical and chemical restraints possible to assure safety, however, the facility is unable to guarantee the resident will not elope. A. An alarm system is connected to all exit door. B. All residents will have a photograph in their medical record for identification purpose. C. Wandering residents will be identified on their care plan with appropriate goal and approaches. D. Staff members will be inserviced yearly in accordance with State and Federal regulations. The agenda of the inservice will include: 1. The identification of wandering residents. 2. The identification of potential environmental hazard: parking lots, street, parks. etc. 3. How to prevent and deal with the wandering resident. 4. The procedure for missing residents. 5. How to relocate wandering residents who cannot be protected. 6. The procedure for contacting the police and/or family. Review of the Stanley (First Q) Wanderguard departure alert system, user instructions with no date documented: Warning- Do not place the signaling device on or next to metal, such as wheelchair frames, jewelry, watches, etc, or allow it to come in contact with a door or associated hardware such as crash-bars, push-bars, etc, metal could interfere with the signal sent to the door modules. Signaling device activation: 1. Note the date on the back of the device. This is the last day the device can be activated to provide approximately 90 days of useful life. Record the date in the residents record. The facility was notified of the immediate jeopardy and given the IJ template on [DATE] at 12:00 p.m. The immediate jeopardy was removed on [DATE] as the facility provided education to all staff on Elopement Risk/Elopement (Missing Resident) Process and that all staff will check any door alarm that sounds for a resident that went through or a staff and never shut off door alarm without being 100% sure as to why it sounded. Wandering Resident policy reviewed with all staff and Wanderguard Activation, Documentation and Testing policy reviewed by all staff. At the time of exit, the scope and severity was lowered to an D.

Based on observation, record review, staff interviews, and review of the gait belt policy/procedure, the facility failed to provide adequate supervision to protect against hazards and failed to use a gait belt when transferring Resident #6. The sample consisted of 5 residents and the facility identified a census of 69 residents. Findings included: 1. Resident #6 had a Minimum Data Set (MDS) assessment with a reference date of 2/11/15. The MDS identified Resident #6 with severely impaired cognition, required supervision by 1 staff member for bed mobility, limited assistance from 1 staff member for transfers, ambulation in the room, toilet use, and personal hygiene. The resident had a lower extremity range of motion impairment on 1 side, used a walker and wheel chair for mobility, and had not experienced falls during the previous assessment period. The MDS documented the resident as only able to balance with staff assistance when moved from a seated to standing position, to walk, turn around and face the opposite direction when walked, move on and off the toilet, and for surface to surface transfers. The same MDS documented the resident's [DIAGNOSES REDACTED]. A Fall Risk Assessment sheet documented the resident scored12 on 5/25/14 and scored 11 on 11/15/14 and 2/13/15. A score of 10 or higher identified the resident as a high risk for falls. A Resident Care Plan documented the resident had an admitted into the facility on [DATE]. A focus area with an initiated date of 11/27/13, documented the resident had limited physical mobility related to a right hip fracture with repair secondary to a fall. Interventions dated 11/27/13 directed staff the resident required a raised chair cushion to wheel chair and recliner and the resident was allowed to bear weight. An intervention dated 2/14/14 documented the Dycem (nonskid material) placed on the recliner to prevent sliding and an intervention dated 2/23/14 documented a bed alarm was placed. On 5/7/14, the Care Plan directed staff to assist the resident with pivot transfers and ambulation with 1 or 2 staff as the resident able to tolerate and to use a stand lift when needed. The Care Plan had a focus area dated 11/27/13 related to poor balance and had a fall resulting in a right hip fracture. An intervention dated 6/29/14, directed staff to remind the resident to plant his/her feet on the floor and focus on the task when standing. A Care Plan entry dated 9/18/14 identified the resident with pain related to osteoporosis and a hip joint replacement. The Care Plan directed staff to administer analgesics and assess the resident's pain. A Physician Facility Visit Progress Note dated 5/21/14 documented the resident continued to experience right hip and upper thigh pain following the November 2013 right hip replacement, painful to bear weight, balance not the best, and the family and resident declined right hip revision surgery. A Physician Facility Visit Progress Note dated 11/19/14 documented the resident doing fairly well; pain is fairly under control and the resident received analgesics for pain and medication for osteoporosis. A Tracking Record For Improved Patient Safety (TRIPS) sheet dated 6/17/14 at 5:00 p.m. documented the resident's chair alarm sounded, the resident stated he/she reached for the telephone, staff found the resident on the floor in front of the recliner, resident confused, had a 3.0 cm (centimeter) by 0.1 cm skin tear to the left hand. Staff documented the chair as in an upright position and the chair control within reach. New interventions directed staff to keep the chair control out of the resident's reach and to use nonskid material in the chair. During an interview 3/4/15 at 8:00 p.m. Staff C, LPN (Licensed Practical Nurse), stated she remembered the fall very well. The recliner had no nonskid material at the time of the fall, and she placed nonskid material in the chair immediately. Additional TRIPS reports documented the resident had falls 1/8/14, 2/3/14, 2/14/14, 6/26/14, and 6/29/14. A TRIPS report documented by Staff A, RN (Registered Nurse) dated 2/14/15 at 8:00 a.m. revealed staff called Staff A to the resident's room. Staff B (RN) had gone to get the resident for breakfast. The resident laid on right side on the floor, had a skin tear to the right elbow, resident stated had right hip/leg pain, and grimaced with movement. Staff A documented the cause of the incident possibly due to the resident's right leg gave out and she/he lost their balance. Staff B documented a note written on 2/14/15 that she had gone to the resident's room to take the resident to the bathroom and then to the dining room for breakfast. Staff B documented the resident stood with the walker and her help. The resident stood well and stable on feet. Staff B reached to shut off the alarm and grab the gait belt, and the resident took a step, lost his/her balance, and fell to the floor landing on the right side. Staff B stated she had not bumped the resident and the floor was free from clutter. Staff B called for assistance. Staff A came and assessed the resident and both staff assisted the resident back to the recliner. The Nurse's Notes dated 2/24/15 at 8:00 a.m. reflected the resident was sent to the emergency room at 9:00 a.m. due to pain in the right hip/leg. An entry at 1:00 p.m. documented the resident was required to stay at the hospital for pain management. An entry dated 2/15/15 at 11:40 a.m. documented the resident with a pelvic fracture. An entry dated 2/16/15 at 2:00 p.m. documented the resident returned to the facility. An Attending Physician report documented the resident with a hospital admission date of [DATE]. The report reflected the resident had a pelvic fracture involving the superior pubic rami and possibly the inferior (pelvis). The physician admitted the resident for pain control, and orthopedic consult ordered. An orthopedic consultation dated 2/15/15 confirmed the resident's x-rays identified a minimally displaced right ischial and pubic ramus fractures and a past hemiarthroplasty of the right hip. The physician identified a plan to have physical therapy and occupational therapy see the resident tomorrow (2/16/15) and for the resident to return to the facility when pain control is managed better. A physician signed the Major Injury Determination Form on 2/17/15 and documented the resident's prognosis as good. The physician identified the resident had not sustained a major injury. A February 2015 Medication Administration Record (MAR) had an entry for staff to assess the resident's pain 4 times daily. The MAR documented a physician order, dated 10/23/14, for staff to administer Acetaminophen (same as Tylenol) 1000 mg. (milligrams) when needed for pain, up to 3000 mg. daily. Staff documented the resident without pain, and had not received any Acetaminophen, from 2/1/15 until the resident returned from the hospital 2/16/15. In addition, the same MAR documented the resident received Tramadol (used to treat pain) 50 mg. 3 times daily (order date 11/15/14). A February 2015 MAR entry dated 2/16/15 directed staff to administer Acetaminophen 500 mg. every 6 hours PRN (as needed) for pain. Staff documented Acetaminophen 500 mg. given 2/18/15 at 3:30 a.m. for back and pelvic pain. The resident rated the pain as a 6 out of a 1-10 pain scale. Staff administered Acetaminophen 1000 mg. 2/19/15 at 2:30 a.m. for pelvic and back pain again rated the pain as 6 by the resident, Acetaminophen 1000 mg. 2/20/15 for pelvic pain (pain level not documented), and Acetaminophen 500 mg. 2/11/15 at 11:50 a.m. for pelvic pain rated 5 by the resident. Review of the February 2015 MAR revealed staff documented the resident experienced pain rated as follows after returning from the hospital on 2/16/15: a. Pain rated 3 on 2/16 and 2/28. b. Pain rated 3 to 5 on 2/17, and 2/18. c. Pain rated 2 to 5 on 2/19. d. Pain rated 2 to 3 on 2/20 and 2/24. e. Pain rated 2 to 4 on 2/21, 2/22, and 2/23. f. Pain rated 2 on 2/24, 2/25, and 2/27. g. Pain rated 1 to 4 on 2/26. The facility policy/procedure titled Gait Belts For Transfer, updated on 11/96, reflected that gait belts are provided to assist staff to safely transfer or ambulate residents. The policy directed staff to transfer a resident by assisting the resident to a standing position by grasping the belt at the waist from underneath and pivot the resident into a chair or bed. The policy directed staff when ambulating a resident, to assist the resident to a standing position by grasping the belt from underneath. After the transfer is completed, remove the belt and return to the hook by the bathroom door. During an interview on 3/3/15 at 1:40 p.m., Staff I, CNA (Certified Nurse Aide), stated she worked 2/13/15, used a gait belt, and walked with the resident that day. Staff I stated the resident required 1 staff assistance at the time of the 2/14/15 fall. Staff I stated she always placed a gait belt on the resident before assisting to a standing position and the resident never attempted to stand alone. During an interview on 3/3/15 at 1:45 p.m., Staff A, RN (Registered Nurse), worked the day shift on 2/14/15 when the resident fell . Staff A stated she sometimes would put the gait belt on the resident before standing. The resident required assistance to stand. Sometimes the resident stood with placement of the CNA ' s hand on his/her back. Staff A stated the resident's right leg is weaker and sometimes would give out. Staff A stated she always put the gait belt on before the resident ambulated. During an interview on 3/3/15 at 1:53 p.m., Staff E, CNA, stated she had occasionally transferred the resident prior to the 2/14/15 fall and had not always used a gait belt to transfer and ambulate the resident. Staff E stated the resident waited for staff assistance to stand, walked well, and Staff A sometimes held onto the waist of the resident's pants to ambulate the resident to the toilet. During an interview on 3/3/15 at 2:05 p.m., Staff F, CNA, stated she seldom took care of the resident prior to the 2/14/15 fall. Staff F stated she preferred to transfer the resident with 2 staff. Staff F stated she had transferred the resident alone, used a gait belt and held the resident under the arm and assisted to a standing position. Staff F stated not all residents required a gait belt to assist with transfers but she used a gait belt for this resident (Resident #6). During an interview on 3/3/15 at 2:45 p.m., Staff G, CNA, stated the resident walked well with 1 staff assistance prior to the 2/14/15 fall. Staff G stated the resident required assistance to stand the majority of the time and she always used a gait belt. Staff G stated she would place the gait belt on the resident while seated, assist with standing the resident and then wait a couple of seconds for the resident to have balance. During an interview on 3/3/15 at 3:12 p.m., Staff H, Restorative Aide, stated the resident had difficulty with flexion of the right hip since hip replaced (November 2013). Staff H stated before the 2/14/15 fall, the resident required 1 staff with minimal to moderate assistance to transfer out of a chair. Staff H stated she always applied the gait belt before the resident stood, and the resident walked well once he/she stood and balanced. Staff H stated any time resident required 1 staff assistance for transfers and ambulation, she used a gait belt and when a resident required stand by assistance she had not used a gait belt. During an interview on 3/4/15 at 7:25 a.m., the DON (Director of Nursing) stated nothing said the resident needed a gait belt to help the resident stand. The DON stated Staff B (RN) stood the resident without a gait belt prior to the fall of 2/14/15. Staff B reached for the gait belt and the resident lost her/his balance and fell . During an interview on 3/4/15 at 9:40 a.m., Staff B stated she worked as a (CNA) the day of the fall on 2/24/15 at 8:00 a.m. Staff B stated she offered toileting to the resident prior to the fall and assisted the resident to the dining room for breakfast. The resident sat in a non-electric lift recliner with feet elevated. Staff B stated she stood on the resident's right side and lowered the resident's feet to the floor, placed her arm under the resident's right arm and assisted the resident to a standing position. Staff B stated the pressure pad alarm sounded. Staff B stated the resident took a step at the same time Staff B turned, without moving her feet, in order to turn the alarm off and get a gait belt off the bedside table (within reach). Staff B stated the resident had never taken a step like that before and normally she would let the alarm continue to sound. Staff B stated she realized she had not put the gait belt on the resident due to conversing with the resident. During an interview on 3/4/15 at 12:40 p.m., the DON read the Gait Belts For Transfer policy/procedure. The policy directed the staff to use a gait belt to assist the resident to a standing position prior to transfers and ambulation, but stated the resident had been doing so well. During an observation 3/4/15 at 7:50 a.m., the resident sat in an electric lift chair/recliner in his/her own room. During an observation at 8:15 a.m. the same recliner lacked Dycem (to prevent sliding) anywhere on the seat. During an observation 3/4/15 at 9:22 a.m., Staff I and Staff D (RN) used a stand lift and transferred the resident to and from the toilet. Observation revealed a red piece of nonskid (Dycem) material underneath the water proof pad and above the pressure pad alarm. Staff I and Staff D denied placement of the Dycem. During an interview on 3/4/15 at 4:00 p.m., the DON stated she had placed the Dycem on the resident's recliner seat after the staff informed her the chair did not have any Dycem.