Every finding on record at Davenport Lutheran Home

Based on observations, facility policy review and staff interviews, the facility failed to ensure a sanitary dining experience due to not all dietary staff wearing hair nets while plating and serving resident meals. The facility reported a census of 66 residents. Findings include: During an observation on 12/9/2025 at 12:00 pm, three male staff with beards and moustaches wore a covering for their chin but the upper part of the beards and moustaches were uncovered during the noon meal service. During an observation on 12/10/25 at 12:00 pm Staff B, Dietary Aid plated the food for residents in the Memory Care Unit, front and back dining rooms. Staff B wore a hair net which covered the top of her hair, however long curly hair hung down past the hair net which over the plates being prepped for the residents meal. During an interview on 12/10/25 at 1:28 pm, the Dietary Manager stated he discussed the policy for hair coverage with Staff B in the past and he will discuss the coverage of facial hair with his male staff. Review of the facility policy, titled Dining Services review date 3/5/25 revealed: a. All foods will be prepared under strict sanitary conditions meeting local and state and federal public health regulations. b. This department will plan, organize, and direct all phases of the dining services operation which includes departmental record keeping, safety and sanitation programs. c. The Dining Services Director was delegated full authority for implementing the dining services program. d. All employees must wear a hair restraint when handling and preparing foods unless the employee has shaved their head.

Based on observation, dining services record review, facility policy review, and staff interviews, the facility failed to document food temperatures before and after service for multiple meals in the memory care unit of the facility. The facility reported a census of 66 residents, with 24 residents on the memory care unit.Findings include: During an observation on 12/10/25, a review of the December 2025 Temperature Log for the memory care unit revealed a entries made before and after meal service during the evening meals on December 2, 3, 4, 7, and 8th, 2025; and for all meals on December 6, 2025. During an interview on 12/10/25 at 1:28 pm, the Dietary Manager stated he reviewed the temperature logs once a week as an audit and identified the missing logs of temperature testing before and after service in the memory care unit. On 12/6/25, there were no temperatures logged all day and the Dietary Manager stated he called the staff whom worked on 12/6/25 and he documented the temperatures for them on 12/9/25. The Dietary Manager stated that probably was not the right thing to do. Review of the facility policy, Dining Services review date of 3/5/25 revealed, in part:a. All foods will be prepared under strict sanitary conditions meeting local and state and federal public health regulations. b. This department will plan, organize, and direct all phases of the dining services operation which includes departmental record keeping, safety and sanitation programs. c. The Dining Services Director was delegated full authority for implementing the dining services program.

Based on Summary of Deficiency review, facility policy review and staff interviews the facility failed to conduct ongoing quality assessment (QA) and assurance activities, develop and implement appropriate plans of action to prevent repeated deficiencies in the area of infection control during the current and previous recertification surveys. The facility reported a census of 66 residents. Findings include: Review of the Summary of Deficiencies dated 10/31/2024, listed a citation at F0880 infection control. The current survey resulted in a deficiency at F0880. During an interview on 12/11/2025 at 10:17 AM, the Administrator reported she expected the staff to know about the use of EBP after the training done in the past year. Review of the Quality Assurance and Performance Improvement (QAPI) dated 11/12/25, reflected the facility developed, implemented, and maintains an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. The QAPI program is designed to ensure a process of providing high quality care, essential services, and programs that enhance and support the residents/patients physical and mental abilities as well as provides social and spiritual support.The LHAA-(Lutheran Home for the Aged Association) - E QAPI Steering Committee developed a QAPI Plan based on Federal guidelines. The QAPI Plan, approved by the LHAA- E Board of Directors, contains those processes which guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved.The facility Quality Assessment and Assurance (QAA) committee will be responsible to identify and respond to quality deficiencies throughout the facility, and for oversight of the QAPI program.The QAA committee:a. Must develop and implement corrective action;b. Monitor to ensure performance goals or targets are achieved;c. Revise corrective action(s) when necessary; andd. Consists of staff members who understand the characteristics and complexities of the care and services delivered by each unit, and/or department

Based on observation, clinical record review and staff interview, the facility failed to implement infection control practices during wound care for 2 of 3 residents reviewed. Enhanced Barrier Precaution (EBP) not utilized during care of a chronic wound (Resident #8), and hand hygiene not completed and equipment not disinfected during the care of pressure wound (Resident #7). The facility reported a census of 66 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] identified Resident #7 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Coronary Artery Disease, Neurogenic Bladder and Diabetes Mellitus. The MDS also identified Resident #7 required substantial/maximal assistance with toileting, upper and lower body dressing, personal hygiene, transfers in and out of bed and repositioning in bed and totally dependent on staff for assistance with putting on and removing footwear. The MDS identified Resident #7 with an indwelling urinary catheter. The MDS identified Resident #7 with an unstageable pressure ulcer which was not present upon admission. During an observation of wound care on 12/10/25 at 7:15 AM, Staff A, Licensed Practical Nurse (LPN) and Staff C, Certified Nursing Assistant (CNA) both donned isolation gowns and gloves prior to entering the room. Staff A did not change her gloves after she removed the soiled dressing and before she cleansed the wound to right heel. After Staff A cut through the soiled dressing, she did not disinfect her scissors before she cut through the new Xeroform dressing and the new Kerlix dressing. Staff A did not change her gloves after she cleansed the wound and before she applied the new dressing on the wound. During an interview on 12/10/25 at 2:47 PM, Staff A, LPN reported the following: when performing wound care, she would disinfect her scissors between different wounds and after removing a soiled dressing and before using it on a new dressing. Staff A also reported she would change her gloves during wound care if they became soiled and between different wounds. During an interview on 12/11/25 at 7:55 AM, the ADON (Assistant Director of Nursing)/Infection Preventionist reported during wound care, she expected nurses to disinfect the scissors before cares and after it touched any soiled dressings. The ADON also reported she would expect the nurses to change gloves after touching soiled dressings, cleansing wounds and before applying new dressings to the wound, and to use EBP. She reported she has done audits of the nurses doing wound care, but admitted she has not been able to during the past few months. 2. The MDS for Resident #8 dated 10/26/25 listed diagnoses of atrial fibrillation (irregular heart rhythm), rheumatoid arthritis, coronary artery disease, and malnutrition. The BIMS assessment reflected a score of 11 out of 15, moderate problems with memory and orientation. Review of the December 2025 Treatment Administration Record revealed the following wound care orders, started on 9/30/25: a. Betadine to Left Achilles daily and PRN-OTA one time a day. b. Betadine to Right Achilles daily and PRN-OTA one time a day. During an observation on 12/09/2025 at 10:57 AM, Resident #8's room door lacked a sign to direct the use of EBP. During on observation on 12/10/25 at 2:02 PM, Staff A, LPN entered Resident #8's room to complete the wound care. Staff A failed to utilize EBP during wound care. The ADON/IP reported she expected EBP in place for Resident #8 because of the pressure wounds. On 12/11/2025 at 10:17 AM, the Administrator stated she expected EBP used for residents with the chronic wounds. The facility provided the EBP policy dated 4/5/25 directed targeted gown and glove use during high contact resident care activities known as Enhanced Barrier Precautions (EBP) are infection control intervention designed to reduce transmission of MDROs. EBP must be used in conjunction with standard precautions to reduce the potential for transfer of MDROs to staff hands and clothing. Effective implementation of EBP requires staff training, adequate and readily available PPE for staff use with ongoing evaluation of compliance with EBP. Wounds (generally include chronic wounds, not shorter lasting wounds) and' or indwelling medical devices even if the resident is not known to be infected or colonized with a multi drug resistant organism (MDRO).Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.

Based on observation, resident interview, and staff interview the facility failed to maintain a sanitary, orderly, and comfortable interior in the facility dining room during 4 of 4 dining observations. The facility reported a census of 71 residents. Findings include: An observation in the main dining room on 10/28/24 at 12:14 PM, revealed, on the east side of the room, approximately 12-foot section of the bottom of a ceiling beam wrapped in plastic. The beam had approximately seven pieces of tan tape, on each side, to secure the plastic. The plastic contained clumps of a white, dark brown and black material. On the east side of the beam, the paint area above the taped section bubbled off the wall. The tape on west side pulled away from the beam, leaving approximately six feet of the plastic detached. This area of the beam hung above the floor, wall and door connecting the kitchen to the dining area. A white and tan stain measuring approximately 1 foot by 1-foot, and up seven bricks from the floor covered a portion of the wall and kitchen door. Staff used the door to set up the dining area, and service residents' meals. A beverage cart, with milk, juice, pop, water, and thickened liquids sat underneath the plastic covered beam, outside the kitchen door. During the observation at 12:31 PM, one resident stood under the plastic to get drinks for himself, with four other residents seated at a table three to four feet away. During an observation on 10/29/24 at 07:42 AM, staff in the dining room prepared drinks under the plastic to serve to residents. The tape and plastic on the beam remained as observed before. Visible chunks of material were missing along the bottom of the beam, and exposed unfinished ceiling area. Two residents were seated at a table 3-4 feet away. During an interview on 10/29/24 at 11:48 AM, the Dining Services Director stated he thought the ceiling damage was due to a roof leak that caused water damage. He was not aware when it would be repaired. During an observation on 10/29/24 at 12:35 PM, the plastic continued to sag at the lunch meal with 3 residents 3-4 feet away. A resident observed going to a cart sitting under the exposed area to get pop. During on observation on 10/29/24 at 3:22 PM, four food service carts sat under covered beam. One cart contained empty storage containers used to wash dishes in the dishwasher. The second held straws, hand wipes, and tissues. A third had a cut birthday cake exposed to air and a piece on a plate with a fork in it. The last one held napkins, cups, silverware, a plate, and a pitcher with a couple of inches of liquid in the bottom. During an observation on 10/29/24 at 3:46 PM, the Administrator stated the area was damaged from a [NAME] storm last year and they were appealing an insurance denial. The plastic was their fix while they waited. She recognized the plastic was hanging down and carts were under them.

Based on observation, facility policy review and staff interview, the facility failed to maintain a proper safe and appetizing food temperatures during a noon meal. The facility reported a census of 71 residents. Findings include: During an observation on 10/29/24 at 11:53 AM, Staff G, Dietary took food temperatures, with the following results: Turkey tetrazzini 177 F (degrees Fahrenheit) Peas 200 F Mashed potatoes 190 F Mixed vegetables 190 F Swedish meatballs 180 F Green beans 195 F Turkey tetrazzini pureed 200 F Peas pureed 200 F Gravy 200 F At 12:10 PM kitchen staff started the noon meal service to the residents in the dining room. The Dining Services Director stated room meals went out after dining room services was completed. He reported they use Styrofoam containers due to the increased number of room trays because it help temperatures longer. The last room tray was completed at 12:42 PM and sent out for delivery. Seven trays were delivered to resident rooms, and an additional one set aside for a resident who was sleeping. The last room tray was delivered at 12:59 PM and the test tray temperatures taken by the Dining Services Director. The turkey tetrazzini registered at 130 degrees and the peas at 148.9 degrees. After multiple attempts, he stated the tetrazzini was not going to meet the required temperature. He expected the turkey tetrazzini temperature at 140 or higher and said that was something they had to work on. The facility policy, reviewed on 3/3/24, titled Food Temperatures Procedures included, in part: 1. Hot foods shall be kept at 140 degrees. 4. If at any time the food temperature is below 140 degrees for hot food .the food shall be reheated in the microwave oven to 165 degrees. 5. A monitor shall be kept monitoring the food temperatures . 6. The food temperature monitor shall be reviewed by the Dining Services Director to assure the monitor is being completed.

Based on observation, record review and staff interview the facility failed to utilize Enhanced Barrier Precautions while providing high contact care for 1 of 3 residents with a indwelling medical device (Resident #52), and maintain a foley catheter collection bag and tubing off the floor for 1 of 2 residents (Resident #125). The facility reported a census of 71 residents. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], identified Resident #2 as cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 01 out of 15. The MDS listed diagnoses included: osteoporosis, seizure disorder and chronic obstructive pulmonary disease. The MDS assessed the resident required substantial/maximal assistance with most activities of daily living (dressing, bathing, using the toilet, etc). The MDS identified Resident #2 used the nutritional approach of a feeding a tube while a resident. A review of the Physician Order Summary with active orders as of 10/29/24, revealed an order for Enhanced Barrier Precautions (EBP, the infection control intervention designed to reduce transmission of multidrug-resident organisms that employs targeted gown and glove use during high contact resident care) - Staff to don gown and gloves prior to high-contact resident care activities, such as; Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, urinary catheter care, feeding tube care, Wound care including any skin opening requiring a dressing Face protection may also be needed if performing activity with risk of splash or spray. Order date: 4/1/24. The Care Plan, Date Initiated: 4/1/24, included a Focus area to address Resident requires enhanced barrier precautions due to G-tube. Interventions included, in part; Staff to don gown and gloves prior to high-contact resident care activities, such as: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, urinary catheter care, feeding tub cares, Wound care including any skin opening requiring a dressing During an observation on 10/29/24 at 9:57 AM, the door to Resident #52's room noted to have a Enhanced Barrier Precautions sign posted in a visible area. Staff A, Licensed Practical Nurse (LPN) entered the room to administer a morning GT feed. Staff A washed her hands, removed a carton of Jevity 1.5 cal formula and placed it on top of the over the bed table. Staff A then donned gloves and proceeded with preparing and administering the formula. Staff A did not wear a gown during this task. During an interview on 10/29/24 at 2:13 PM, Staff A LPN stated prior to a nurse providing any cares on a GT they should don gloves and check the GT site. She stated Resident #52 has EBP and she should have put on a gown and gloves before she administered the formula. During an interview on 10/30/24 at 12:47 PM, the Assistant Director of Nursing (ADON, and facility Infection Preventionist stated residents with GTs should be placed on EBP and nurses should don gloves and a gown prior to providing any cares with the GT. The facility policy, Reviewed: 4/19/24, titled Enhanced Barrier Precautions directed targeted gown and glove use during high contact resident care activities known as Enhanced Barrier Precautions (EBP) are infection control intervention designed to reduce transmission of MDRO's (mulidrug-resident organisms). EBP must be used in conjunction with standard precautions to reduce the potential for transfer to MDRO's to staff hands and clothing. The policy listed examples of indwelling medical devices included feeding tubes, and declared high-contact resident care activities included device care or use. The Procedure section #2 directed Perform hand hygiene and don PPE (personal protective equipment) prior to high contact cares, Do NOT wear the same gown and gloves for care of more than one resident. 2. The MDS, dated [DATE], identified Resident #125 as cognitively intact with a BIMS score of 13 out of 15. The MDS listed diagnoses included: atrial fibrillation (an abnormal heart rhythm), coronary artery disease and urinary tract infection. The MDS assessed the resident required substantial/maximal assistance with most activities of daily living and had an indwelling urinary catheter. A review of the Physician Order Summary with active orders as of 10/29/24, revealed the following orders: a. Change catheter bag/tubing twice monthly per facility protocol .Order Date: 8/22/24 b. Foley Catheter (per Dr.'s order). 16 FR (catheter size) with 10 ml (milliliters) bulb filled with 10 ml sterile water and connected to straight drainage, Change Once Monthly and PRN (as needed) .Order Date: 9/3/24 The Care Plan, Date Initiated: 9/3/24 included a Focus area to address Resident requires an indwelling catheter related to urinary retention. Interventions included, in part; Position bag below level of bladder. Assure the catheter bag does not touch the floor. Store collection bag inside a protective dignity pouch. During an observation on 10/29/24 at 11:50 AM, Resident #125 sat in his wheelchair while in the main dining room. The urine collection bag was out of the dignity cover and drug on the floor while he self propelled himself approximately 50 feet out of the dining area. At 11:56 AM, Staff B, Certified Nursing Assistant (CNA) assisted another resident to dining room table near Resident #125. Staff B did not change the position of Resident #125's collection bag. The collection bag remained out of the dignity cover on the floor. At 12:06 PM, Staff A, LPN administered medications to Resident #125 Staff A did not change the position of the collection bag. At 12:21 PM, Staff D, CNA adjusted the clothing protector of a resident at the same table with Resident #125. Staff D did not change the position of Resident #125 collection bag. At 12:26 PM, the Nurse Consultant walked past Resident #125 and did not change the position of Resident #125 collection bag. At 12:48 PM, Resident #125 continued to sit at the dining room table, the position of the catheter collection bag remained out of the dignity cover, on the floor. At 1:00 PM, Staff E, LPN pulled up Resident #125 collection bag and placed it in the dignity cover. A review of the Facility Policy titled: Catheter Care and dated as last reviewed 2/2/24 had documentation of the following: the tubing or the drainage bag should not touch the floor.

Based on record review, staff interview and facility policy review the facility failed to investigate an allegation of abuse for 1 out of 1 residents reviewed (Resident #75). The facility reported a census of 71 residents. Findings include: The Minimum Data Set(MDS) assessment tool, dated 7/25/24, listed diagnoses for Resident #75 included anemia, hypertension, renal insufficiency, osteoporosis, and Alzheimer's disease. The MDS stated the resident required moderate assistance from staff for toileting hygiene, showering, dressing, personal hygiene, and transferring. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 4 out of 15, indicating impaired cognition. Review of the medical record for Resident #75 failed to reveal any documentation regarding an incident between staff and resident. During an interview on 10/30/24 at 12:26 PM Staff H, Licensed Practical Nurse (LPN) stated Staff I, Certified Nursing Assistant informed her Resident #75 stated another CNA [Staff J, CNA] had given her a shower earlier and performed cares aggressively. Staff H called her managers the Director of Nursing and the Assistant Director of Nursing and informed both of them. During an interview on 10/31/24 at 10:14 AM the Director of Nursing stated she was aware of the incident with Resident #75 and Staff J. She stated she talked to Staff H, LPN about the incident when she reported it. She stated she did not talk to the resident or investigate it after she spoke with the nurse who reported it to her. During an interview on 10/31/24 at 11:27 AM the Administrator stated there was a situation between Resident #75 and a staff member. Staff notified me by phone when the incident occurred and the CNA involved was sent home. I thought an investigation was completed after the incident took place, it was determined it was a thorough washing and it was not well received. I would expect there to be an investigation. There should be documentation or an incident report if something happened. The facility policy, Reviewed: 3/15/24, titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property and Reporting Guidelines PROCEDURES section: D. INVESTIGATION declared It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, resident-to-resident abuse, exploitation and misappropriation of property) are promptly and thoroughly investigated. The Procedure for the section included: The investigation process is used to try to determine what happened and designated facility personnel will begin and investigation immediately. The information gathered is given to the Administrator/designee. 1. Abuse: When an incident or suspected incident of Abuse is reported, the Administrator/designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: a. A review of documentation to determine who was involved. b. Resident's statements: - Resident interviews will be conducted and documented by two members of the management as designated by the Administrator/designee two different times within 24 hours following the incident. - For non-verbal residents, cognitively impaired residents or resident who refuse to be interviewed, attempt to interview residents first. If unable, observe resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings. c. Resident's roommate statements (if applicable) d. Involved staff and witness statement of events e. A description of the resident's behavior and environment at the time of the incident. f. Injuries present including a resident assessment. The charge nurse on duty will immediately complete a body assessment for injuries and document finding on a body drawing g. Observation of resident and staff behaviors during the investigation h. Environmental considerations.

Based on clinical record review, policy review, and staff interview the facility failed to maintain accurate Advance Directive records based on resident preference for 1 of 18 residents reviewed (Resident #42). The facility reported a census of 71. Findings include: The Minimum Data Set (MDS) for Resident #42, dated [DATE], revealed diagnoses of renal disease, encephalopathy, and hypertension. The MDS documented the resident scored 15 out of 15 on a Brief Interview for Mental Status exam, indicating intact cognition. A review of Physician Orders revealed a Full Code, order date [DATE]. A review of Care Plan, Date Initiated: [DATE], Revision on: [DATE] included a Focus area to address Advanced Care Planning - Full Code. Interventions included, in part; Staff will attempt cardiac resuscitation in the event [name redacted] is found without a [NAME] or breathing. [Name redacted] and her family have decided they would like medical treatment cardiac monitors oral/IV fluids and/or medications but do NOT want intubation or mechanical ventilation or artificial nutrition by tube. Less invasive airway support such as BIPAP (bilevel positive airway pressure - a noninvasive breathing machine that helps people breathe with they're having trouble) or CPAP (continuous positive airway pressure - a machine that uses mild air pressure to keep breathing airways open while sleeping) may be considered. [Name redacted ] wants transferred to the hospital if indicated but she or her family should be consulted before deciding on critical care. During an interview on [DATE] at 11:12 AM, Resident #42 stated her code status was for CPR (cardiopulmonary resuscitation). A review Resident #42 electronic health record Admission Record on [DATE] at 2:44 PM, revealed a Code Status: (Advanced Directives) Full Code. During an interview on [DATE] at 03:26 PM, Staff H, LPN (Licensed Practical Nurse)stated if someone went into cardiac arrest they would look in the paper chart or the computer for code status. She was not aware there was a difference in this resident's record. During an interview on [DATE] at 03:37 PM the Assistant Director of Nursing stated they (staff) can look at the paper chart or on the computer. She was not aware there was a discrepancy in Resident #42's record and stated they would fix it right away. A facility policy, Reviewed: [DATE], titled CPR Emergency Treatment/Life Support Measures Procedures section included, in part; Upon admission, the facility's CPR Emergency Treatment/Life Support Measures policy will be explained to the resident/resident representative. The resident/resident representative's wishes regarding CPR will be verified and documented in the medical record.

Based on clinical record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the state agency for 1 out of 1 allegation of abuse reviewed (Resident #75). The facility reported a census of 71 residents. Findings include: The Minimum Data Set(MDS) assessment tool, dated 7/25/24, listed diagnoses for Resident #75 included anemia, hypertension, renal insufficiency, osteoporosis, and Alzheimer's disease. The MDS indicated the resident required moderate assistance from staff for toileting hygiene, showering, dressing, personal hygiene, and transferring. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 4 out of 15, indicating impaired cognition. Review of the clinical record for Resident #75 failed to reveal any documentation regarding an incident between staff and Resident #75. During an interview on 10/30/24 at 12:26 PM Staff H, Licensed Practical Nurse (LPN) stated Resident #75 reported to Staff I, Certified Nursing Assistant (CNA) another CNA [Staff J] had given her a shower earlier and performed cares aggressively. She spoke with Resident #75 and the resident told her she did not want her [Staff J] to give her a shower any more because she performed perineal and anal cares aggressively. Staff H called her managers the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) and informed both of them. The Director of Nursing directed her to send Staff J home. Staff H stated the reason I did not chart anything on the incident was because it was the end of my shift and I was in the middle of giving report when it all happened, and I did not even send Staff J home. The nurse who I reported off to sent her home. I would do an incident report I guess if the situation called for it. During an interview on 10/30/24 at 12:49 PM Staff I, CNA stated Resident # 75 and her were ambulating back from the dining room and she kept asking me about a girl and she kept saying she was the weird one. Resident #75 told me she got a shower from her and it was very aggressive. The resident specifically said her bottom area was a very aggressive wash up. It was in the back area of her buttocks. Staff I stated she went and reported it to the nurse right away. No one from management ever came and talked to me about it. The DON, ADON or administrator never talked to me about it. The main thing I was told to report to the charge nurse. I went straight to the nurse. We then wait for follow up from the administration. The staff member was sent home right after it happened and since it happened I have not seen her since. During an interview on 10/31/24 at 10:14 AM the Director of Nursing (DON) stated she was aware of the incident with Resident #75 and Staff J, CNA. The policy on abuse is that we would report it immediately. We would investigate the incident. The person responsible for reporting the abuse would be me and I would notify the administrator and Chief Executive Officer (CEO) immediately. Typically now I consult with the CEO and I would submit it to the state agency. I did call the CEO and we spoke about it because the nurse stated it wasn't intentional and she wasn't being harmed in any way we chose not to report it. During an interview on 10/31/24 at 11:27 AM the Administrator stated there was a situation between Resident #75 and a staff member. Staff notified me by phone when the incident occurred and the CNA [Staff J] involved was sent home. Regarding reporting abuse I have to go look into it, I would have to refer to our policy I am not sure when it should be reported. The facility policy, Reviewed: 3/15/24, titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property and Reporting Guidelines PROCEDURES section: G. REPORTING AND RESPONSE declared, in part; It is the policy of this facility that abuse allegations (abuse including resident-to-resident abuse, neglect, exploitations, or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Laws to the Department of Inspections and Appeals Health Facilities Division. The Procedure, External Reporting section declared Initial Report: All allegations of Resident Abuse shall be reported to Iowa DIA not later than two (2) hours after the allegation is made.

Based on clinical record review, facility policy review, staff, and hospice provider interviews, the facility failed to obtain routine laboratory orders for routine INR (International Normalized Ratio - a test to measure how it takes for blood to clot compared to normal) labs to monitor the use of the anticoagulant, warfarin for 2 of 4 residents (Resident #1 and Resident #4). Resident #1 admitted to the hospital on 8/23/24 with a critical INR result of greater than 9 (Normal range desired for resident on warfarin is between 2-3) and subdural hematomas with midline shift (occurs when the pressure exerted by the buildup of blood and swelling around the damaged brain tissues is powerful enough to push the entire brain off-center, and is considered a medical emergency). Resident #1 was admitted to hospice on 8/28/24 with a primary diagnosis of subdural hematoma with midline shift and six (6) months or less to live. The facility reported a census of 73 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/29/24 at 3:20 PM. The IJ began on 5/15/2024, the day after Resident #1 had her last INR checked. Facility staff removed the Immediate Jeopardy on 8/30/24 through the following actions: a. INR levels obtained on all current residents (3) receiving Warfarin. This was completed to ensure therapeutic INR ranges and appropriate Coumadin dosages. b. Obtained Collaborative Drug Therapy Management Protocol Warfarin and INR Management Draft for review from Main at [NAME] Pharmacy to manage the facility's Anticoagulation Program. c. Created Pro-Time/ INR Tracking Flow Sheet with of draw dates, results, dose adjustment/order, and next lab date. Flow Sheet binders were immediately placed. Immediately educated staff on floor. d. Educational material uploaded on online education and assigned to all facility Nurses/CMAs titled: Long-Term Care (LTC) Anticoagulation Regulation and Education Review. e. Initiated Point Click Care prompt for noting INR results prior to administering Coumadin medication. The scope lowered from J to G at the time of the survey after ensuring the facility implemented education and policy and procedure changes. Findings include: 1. The Minimum Data Set (MDS) for Resident #1, dated 4/16/24, documented a Brief Interview of Mental Status (BIMS) of 7 indicating a severe cognitive impairment. The MDS documented diagnoses of coronary artery disease, heart failure, hypertension, and orthostatic hypertension. The MDS revealed Resident #1 received anticoagulation medication every day during the look back period. A clinical record review of Resident #1 Medication Administration Record's (MAR) for May 2024, June 2024, July 2024, and August 2024 documented Resident #1 received: a. Warfarin 2 mg (milligrams) 1 tablet every other day, started 1/29/24 b. Warfarin 3 mg 1 table every other day, started 1/29/24 (received on opposite day of the 2 mg dose) A Health Status Note, dated 4/30/24 at 10:28 AM, Note Text: Received orders from Dr. [name redacted] to check INR on 5/1/24 r/t (related to) recent ATB (antibiotic) treatment of doxycycline. A Health Status Note, dated 5/3/24 at 3:30 PM, Note Text: Received verbal orders to hold Coumadin (brand name of warfarin) and recheck INR 5/7/24. A review of a Progress Note, dated 5/8/2024 at 10:51 AM, for Resident #1 documented Resume Coumadin in 1 week per Dr. [name redacted] - pharmacy and POA (Power of Attorney), lab entered 5-14-24. A review of the clinical record, dated 5/14/24 with a report time of 1341 (1:41 PM) revealed INR lab results of 2.8. The record included a FAXED stamp with a handwritten date of 5/14/24, and a notation current dose warfarin 3 mg alternating with 2 mg. D. [name redacted] Any new orders? The document lacked a reply to the question. A review of the clinical record revealed the following documentation: a. Nurse Practitioner Note: 5/23/24 at 1:22 PM Nurse Practitioner (NP) evaluation related to resident complaint of hand swelling. The note did not address the resident's warfarin order, or INR lab orders/results. b. Nurse Practitioner Note: 5/24/24 at 2:40 PM NP evaluation related to bilateral hand pain. ROS (review of systems) Genitourinary (related to urinary tract) Reports Hematuria (blood in urine). No follow up order related to hematuria. The note did not address the resident's warfarin order, or INR lab orders/results. c. Nurse Practitioner Note: 5/28/24 at 2:11 PM NP evaluation related to post fall, unwitnessed without injury. ROS Genitourinary Reports Hematuria. No follow up order related to hematuria. The note did not address the resident's warfarin order, or INR lab orders/results. d. Health Status Note: 5/31/24 at 3:45 AM Note Text: Dr. [name redacted] returned fax on resident's fall with order to observe. The note did address the resident's warfarin order or INR lab orders/results. e. Nurse Practitioner Note: 5/31/24 at 1:46 PM NP evaluation related to complaint of arm pain. ROS Genitourinary Reports Hematuria. No follow up order related to hematuria. The note did not address the resident's warfarin order, or INR lab orders/results. f. Nurse Practitioner Note: 6/4/24 at 12:30 PM NP evaluation related to pain in left arm/x-ray results. ROS Genitourinary Reports Hematuria. No follow up order related to hematuria. The note did not address the resident's warfarin order, or INR lab orders/results. g. Health Status Note: 6/13/24 at 2:51 PM Note Text: New orders per [name redacted] ARNP (Advanced Registered Nurse Practitioner) related to Biofreeze to left upper extremity. The note did not address the resident's warfarin order, or INR lab orders/results. h. Doctor Visit Note: 6/20/24 at 2:07 PM Note Text: Resident seen by house MD (medical doctor) in-house for general geriatric visit with no new orders rec'd (received). A review of a Pharmacist Note, dated 7/18/24 at 2:41 PM, revealed Pharmacist Review .Most recent INR I could locate was from 5/14, will clarify with DON (Director of Nursing), if not drawn in last 4 weeks, would recommend drawing at this time. Per the clinical record, Resident #1 had an evaluation by the NP on 7/24/24 at 12:34 PM related to arm and hand pain. The note did not address the resident's warfarin order, or INR lab orders/results. A Health Status Note, dated 7/25/24 at 12:43 PM, Note Text: Resident seen by house MD today. No notation made regarding concerns or orders. Per a Nurse Practitioner Note, dated 8/20/24 at 1:12 PM, the resident evaluated by the NP for UTI (urinary tract infection) protocol r/t (related to) weakness and lethargy. Plan: UA (urinalysis) with c/s (culture and sensitivity). The note did not address the resident's warfarin order, or INR lab orders/results. A Health Status Note, dated 8/22/24 at 8:50 PM, Note Text: Dr. [name redacted] replied that it was okay to have an INR scheduled. Order will be scheduled into lab. A Health Status Note, dated 8/23/24 at 11:37 AM, Note Text: Resident has multiple bruises on her back and arm. Origin unknown. Resident does take blood thinners and INR pending at this time, skin sheet completed, fax out to MD will continue to monitor. Per a Nurse Practitioner Note, dated 8/23/24 at 12:48 PM, the resident evaluated by the NP with Chief Complaint: Pt (patient) is not baseline mental status, not responding to commands, or sitting up I the shower for staff. She is unable to answer questions. LABS Reviewed or order clinical lab test Notes/Findings: INR 10.2. PLANS Staff to assist with transfers, send to ER (emergency room ) to eval and treat. A record review of Emergency Department (ED) Physician Notes documented on 8/23/24 Resident #1 came to the ED due to altered mental status and found to have a critical INR lab of greater than 9. A review of the hospital History and Physical, dated 8/23/24, documented [resident] has a past medical history significant for atrial fibrillation and is on anticoagulation medication warfarin. A scan was completed and revealed a significant brain injury involving a large collection of blood (hematoma) on the left side of the head, with characteristics indicating both recent bleeding (acute) mixed with older blood (chronic) causing a slight shift of the brain midline towards the right side, along with a smaller area of fresh bleeding on the right side, and further extending along the falx cerebri (a dividing structure in the brain) and the tentorial leaflets (structures supporting the brain) - essentially a complex, multi-layered bleed across multiple brain regions. A local neurosurgery center was consulted, after discussion with Resident #1 family they decided that the patient would not be an ideal surgical candidate and the patient's family agree that the patient would not want to have surgical intervention. It was decided that the patient would stay at the hospital would reverse her INR. A Health Status Note, dated 8/26/24 at 1:40 PM, Note Text: Spoke with resident's daughter reports resident will be going to Hospice. During an interview on 8/29/24 at 12:31 PM with Staff A, Registered Nurse (RN) for a local hospice provider stated Resident #1 was admitted to hospice services on 8/28/24 for the diagnosis of subdural hematoma with midline shift and is has six (6) months or less to live. During an interview on 8/29/24 at 2:43 PM, the DON stated unable to find INR orders for Resident #1. The DON stated we should have standing orders for INR draw, and pharmacy management. 2. The MDS for Resident #4 dated 5/21/24 documented a BIMS of 1 indicating he is severely cognitively impaired. The MDS also documented diagnoses of heart failure, hypertension, and hemiplegia and that he received anticoagulation medication every day during the look back period. A review of Resident #4 MAR for May 2024, June 2024, July 2024 and August 2024 revealed scheduled orders for: a. Warfarin 2 mg 1 tablet daily every other day, start date 4/21/24. b. Warfarin 3 mg 1 tablet every other day (opposite of day of warfarin 2 mg given), start date 4/21/24. A review of the May - August 2024 MAR's revealed Resident #4 received warfarin as scheduled. A facility fax sheet, dated 4/2/24 revealed a communication to the facility provider Resident last INR was 2/29/24, current dose Coumadin 3 mg daily. May we have an order for next INR draw? Hand written response Yes, please should be monthly. A Health Status Note, dated 4/5/24 at 3:49 PM, Note Text: N.O. (new order) INR on 4/8/24. Check monthly. A Health Status Note, dated 4/22/24 at 4:20 PM, Note Text: INR results faxed over from the draw this morning at 4/22/24, Unknown of current order to be drawn. Next observable order draw date is 5/8/24. Results faxed to Dr. [name redacted). The clinical record lacked documentation regarding the completion of the INR check from 5/8/24. Health Status Notes, dated 6/7/24 at 3:12 PM, and 8/15/24 at 2:53 PM documented Resident #4 seen in by house MD. No notations regarding concerns or orders made. A Health Status Note, dated 8/22/24 at 8:53 PM, Note Text: Dr. [name redacted] replied to fax that is was okay to have an INR drawn. Order for INR will be put into the lab schedule. An Order Note, dated 8/24/24 at 2:53 PM, Note Text: Recheck INR 9/23/24 and cont (continue) current dose of Coumadin. The facility policy titled, Lab Values last reviewed 2/2/24 instructed the following: a. Physicians will be notified of all lab values to ensure prompt medical treatment if indicated. b. If the Doctors office has not called back by the end of the shift: Pass information regarding abnormal values and the lab report to the oncoming nurse.

Based on clinical record review and staff interview the facility failed to include the use of the anticoagulant medication warfarin for 2 of 2 residents reviewed (Resident #1 and Resident #4). Warfarin requires regular monitoring, assessment, and routine labs due to an increased risk of bleeding. The facility reported a census of 73 residents. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], listed diagnoses for Resident #1 included: coronary artery disease, heart failure, hypertension, and orthostatic hypertension. The MDS informed the resident received anticoagulation medication everyday during the look back period. A review of the May 2024 Medication Administration Record (MAR) revealed scheduled: a. Warfarin 2 mg (milligrams) 1 tablet every other day, start date of 1/29/24. Per the May 2024 MAR the medication administered 14 times. b. Warfarin 3 mg 1 tablet every other day (indications for use: anticoagulant), start date 1/29/24. Per the MAR the medication administered 14 times. A review of the June 2024 MAR revealed scheduled: a. Warfarin 2 mg (milligrams) 1 tablet by mouth every other day, with a start date of 1/29/24. Per the June 2024 MAR the medication administered 15 times. b. Warfarin 3 mg 1 tablet every other day (indications for use: anticoagulant), start date 1/29/24. Per the MAR the medication administered A review of the July 2024 MAR revealed scheduled: a. Warfarin 2 mg 1 tablet by mouth every other day, with a start date of 1/29/24. Per the July 2024 MAR the medication administered 16 times. b. Warfarin 3 mg 1 tablet every other day (indications for use: anticoagulant), start date 1/29/24. Per the MAR the medication administered 16 times. A review of the August 2024 MAR revealed scheduled: a. Warfarin 2 mg 1 tablet by mouth every other day, with a start date of 1/29/24. Per the July 2024 MAR the medication administered 11 times. Discontinued on 8/27/24. b. Warfarin 3 mg 1 tablet every other day (indications for use: anticoagulant), start date 1/29/24. Per the MAR the medication administered 11 times. Discontinued on 8/27/24. A review Resident #1's Care Plan revealed an absence of a Focus Area and related interventions to for the monitoring and assessments of warfarin and the associated risk of bleeding. The Care Plan did include a Focus Area to address Potential for Falls related to confusion and poor safety awareness. Has history of falling. The Care Plan documented falls having occurred on: a. 5/24/24 Fall, small laceration to left eye, therapy referral. b. 5/29/24 Fall, no injury, resident educated to use call light. 2. The MDS for Resident #4, dated 5/21/24, listed diagnoses included: heart failure, hypertension, and hemiplegia and that he received anticoagulation medication everyday during the look back period. A review of the May 2024 MAR revealed scheduled: a. Warfarin 2 mg 1 tablet every other day, with a start date of 4/21/24. Per the May 2024 MAR the medication administered 15 times. b. Warfarin 3 mg 1 tablet every other day, with a start date of 4/21/14. Per the May 2024 MAR the medication administered 16 times. A review of the June 2024 MAR revealed scheduled: a. Warfarin 2 mg 1 tablet every other day, with a start date of 4/21/24. Per the May 2024 MAR the medication administered 14 times. b. Warfarin 3 mg 1 tablet every other day, with a start date of 4/21/14. Per the May 2024 MAR the medication administered 15 times. A review of the July 2024 MAR revealed scheduled: a. Warfarin 2 mg 1 tablet every other day, with a start date of 4/21/24. Per the May 2024 MAR the medication administered 16 times. b. Warfarin 3 mg 1 tablet every other day, with a start date of 4/21/14. Per the May 2024 MAR the medication administered 15 times. A review of the August 2024 MAR revealed scheduled: a. Warfarin 2 mg 1 tablet every other day, with a start date of 4/21/24. Per the May 2024 MAR the medication administered 14 times. b. Warfarin 3 mg 1 tablet every other day, with a start date of 4/21/14. Per the May 2024 MAR the medication administered 14 times. A review Resident #4's Care Plan revealed an absence of a Focus Area and related interventions to for the monitoring and assessments of warfarin and the associated risk of bleeding. The Care Plan did include a Focus Area to address the Potential for Falls related to decreased mobility and weakness d/t (due to) history of CVA (cerebravascular accident, or stroke) affecting left side. During an interview on 8/30/24 at 11:24 AM, the Director of Nursing (DON) stated the Care Plans do not have specifics related to warfarin, and are the same as other residents.

Based on observation, clinical record review, and staff and resident responsible party interviews, the facility failed to complete appropriate assessments of urinary catheter function in a timely manner, and have needed catheter replacement supplies in the facility, resulting in a residents discomfort and transfer to a local hospital for 1 of 2 residents reviewed for urinary catheter (Resident #3). The facility reported a census of 73 residents. Findings reveal: The 3/7/24 Minimum Data Set (MDS) Assessment tool revealed Resident #3 had diagnoses that included benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptom, cerebrovascular accident (a stroke) with hemiplegia (paralysis on 1 side of the body). The assessment identified Resident #3 required the assistance of at least one staff for transfers to and from bed or chair, dressing and toileting, and a urinary catheter used for elimination. An Indwelling Catheter related to Urinary Retention problem initiated 3/7/24 on the Nursing Care Plan directed nursing staff: 1. Use a leg bag with a tubing extender during the day and a large drainage bag overnight. 2. Change Foley catheter monthly and catheter bag and tubing twice monthly to decrease risk for infection. 3. Monitor urinary output every shift. Record the amount, type, color, and odor. Observe for leakage. 4. Provide catheter care every shift and as needed. A review of Physician Orders revealed a lack direction for staff to replace the urinary catheter routinely, or to flush the catheter for obstruction or signs of obstruction such as no urine output. A Nursing Progress Note transcribed by Staff B, Registered Nurse (RN) on 3/13/24 at 3:47 a.m. stated: Report given to this nurse at 10:00 p.m. that resident's catheter was not draining. This nurse assisted another nurse (Staff A, Licensed Practical Nurse, LPN) in flushing Foley catheter. Foley catheter blocked. This nurse attempted to reposition resident, resident was obviously in discomfort as he was grimacing with facial flushing. It was determined to replace Foley catheter with a new catheter. When deflating balloon less than 5 milliliters (ml) was released. Foley catheter came out very easy with a large blood clot. Bloody thick mucus urine was dripping from the penis, resident's responsible party stated the resident was injured sometime earlier. This nurse gathered all items to reinsert catheter, resident's responsible party continued to state the resident was injured and this nurse determined the best practice at this time was to send the resident to the hospital emergency room to evaluate further and reinsert catheter. A hospital emergency room physician progress note dated 3/12/24 described the resident presented from the nursing home related to urinary catheter problems/obstruction, and over 1000 ml of urine drained from the bladder when the physician inserted a urinary catheter. The facility's Urethral Foley Catheter Care policy dated as last reviewed 2/2/24 directed staff: 1. Catheters are replaced by nurses as prescribed by the physician. 2. Catheter bags should be emptied at least once a shift and the amount recorded on the CNA care sheets. Staff interviews revealed: On 7/9/24 at 2:05 p.m. Staff B, RN, stated she worked in the facility's locked dementia unit on the 10 p.m. to 6 a.m. night shift that began on 3/12/24, and was summoned to the long-term care facility that night by Staff A, LPN, who reported the resident had no urine in his drainage bag, and the resident had 100 cc urine output on the day shift that day (at 2:00 p.m.). When she assessed the resident there was no urine in the drainage bag, his abdomen was firm and distended, he had grimacing and non-verbal symptoms of pain, she attempted to flush the catheter but was unable to as there was an obstruction in the catheter, she repositioned the resident and did not observe urine output in the catheter after the resident was repositioned. When she deflated the balloon to remove the catheter there was only a small amount of fluid in the balloon, and there was bloody drainage as she removed the catheter with ease. The resident had a Coude type of catheter (specialty catheter for prostatic hypertrophy), the facility didn't have Coude catheters in stock, the resident's responsible party stated they had one at their home and left to retrieve it. The resident continued to have pain and bloody drainage from his penis, she determined it would be best to send him to the hospital for assessment and further care, and the resident was transferred at that time. On 7/10/24 at 3:18 p.m., Staff A, LPN, stated she worked the evening shift (2 p.m. to 10 p.m.) on 3/12/24, the resident's responsible party questioned her about the resident's urine output when they visited after 9 p.m., there was no urine in his drainage bag and she went to get Staff B, RN, because she thought she would know more about what to do with the resident's catheter. Staff A denied that she had assessed the resident's urine output, or for symptoms of catheter complications prior to the resident's responsible party visit that evening. On 7/11/24 at 8:02 a.m., the Director of Nursing (DON) stated if a resident had a urine output of 100 ml for a shift, the CNA should report that to the nurse, and the nurse should check the catheter for placement, function, problems, and notify the physician for directives for care if the issue isn't resolved with routine care/problem-solving techniques such as unkinking the tubing. The DON stated the facility should have had a replacement catheter at the facility for the resident. During an interview 7/8/24 at 4:08 p.m., the resident's responsible party stated the resident had a urinary catheter and they had cared for the resident at his home for several years. When they visited the resident around 9:30 p.m. on 3/12/24, there was no urine in his drainage bag, asked staff and they had not emptied the catheter, could tell the resident was uncomfortable and asked the nurse about it. The responsible party thought the resident had experienced some kind of trauma related to the catheter that day, such as having it pulled on, the catheter tip was pulled into the shaft of the penis and why it wasn't working that evening, the facility didn't have a catheter to replace it and why he was sent to the hospital that night.

Based on clinical record review, family and staff interviews, the facility failed to prevent the development of two Stage III (3) pressure ulcers for one of two residents reviewed. (Resident #120). The facility reported a census of 68 residents. Findings Include: The MDS (Minimum Data Set) Assessment identifies the definition of Pressure Ulcers: Stage I - An intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II - A Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. A review of the Admit Screener Form (Nurse's Admission Assessment) dated 10/28/22 at 5:20 PM revealed Resident #120 did not have any skin concerns. The MDS Admission assessment dated [DATE] identified Resident #120 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3 out of 15 points and had the following diagnoses: Coronary Artery Disease, Heart Failure, Diabetes Mellitus and Cerebrovascular Accident (stroke). The MDS also identified the resident required extensive staff assistance with most activities of daily living and totally dependent on staff for locomotion off the unit. It also identified the resident did not have any pressure ulcers. A review of the Nurse's Notes dated 11/8/22 at 12:39 PM revealed the following documentation: a. Open lesion to the left heel which measured 4 centimeters (cm) long and 3 cm wide with sanguineous (bloody) drainage. b. Right plantar foot identified with skin condition identified as other open lesion which measured 4 cm long and 3 cm wide and no drainage. A review of the November 2022 Treatment Administration Records (TAR's) revealed an order was not obtained until 11/10/22 (2 days after the wounds were identified and the order was requested by the facility). The TAR had the following orders dated 11/10/22: a. Cleanse right heel with normal saline and apply Hydrogel dressing daily until healed. b. Sure Prep to the left heel twice daily until healed, if opens, call doctor for new orders. A review of the Wound Care Physician Note dated 11/15/22 had documentation of the following: a. On 11/15/22 - Stage 3 pressure wound on the left heel for 7 days (date of onset 11/8/22) with Measurements: Length (L) =6 centimeters (cm), Width (W) = 6 cm and Depth (D) =not measurable. b. The right heel (no date of onset) had an Unstageable Deep Tissue Injury (DTI) with Measurements: L =6 cm W=6 cm D= 0.5 cm 80% necrotic tissue, no exudate. c. Recommendations: Float heels in bed, offload wound, reposition per facility protocol, turn side to side and front to back every 1-2 hours if able, sponge boot, may take off sponge boot for ambulation, therapy, otherwise should be on 100% of the time. A review of the November 2023 TARS revealed the following orders dated 11/15/22 (after the resident was admitted [DATE]): a. Prafo Boots on at all times except when working with therapies twice a day. b. Right heel wet to dry with 1/4 strength Dakin's Solution, cover with ABD pad and secure with Kerlix twice daily On 11/15/22, the Care Plan identified Resident #120 with the problem of skin breakdown related to decreased mobility, need for repositioning assistance. Has Stage 4 to the right heel and stage 3 to left heel and did not include the recommendations by the wound physician dated 11/15/22. A review of the Wound Care Physician's Note dated 11/29/22 documented the right heel was now open and identified as a Stage III pressure ulcer which measured 5 cm long, 5 cm wide and 0.5 cm deep with 50% necrotic tissue. The MDS dated [DATE] identified Resident #120 with a facility acquired Stage III pressure ulcer and a stage IV pressure ulcer. In an interview on 7/17/23 at 3:43 PM, Resident #120's spouse reported the footboard on the bed had metal brackets facing the mattresses. On 11/1/22, the resident ripped his feet on the footboard from rubbing his heels on the footboard. He had to have a Peripherally Inserted Central Catheter (PICC) line and Intravenous (IV) antibiotics for a month which she had to give Resident #120. In an interview on 7/25/23 at 8:17 AM, Staff O, Licensed Practical Nurse (LPN) reported Resident #120 did not have pressure ulcers when he was first admitted . He was considered high risk for developing pressure ulcers as he was diabetic and had limited mobility from a previous stroke. Resident #120 was very tall and would slide down in the bed and rub his feet on the footboard. He had one ulcer on his left foot and that is when they put the Prevalon boots on both feet. The bed extender was not placed on his bed until after the ulcers developed. She also reported when a wound is first identified, orders to treat it should be obtained within 24 hours. When treated at the Wound Clinic, if the Physician documents recommendations, these should be considered as new orders and should be addressed on the Care Plan. The nurse taking care of the resident had the responsibility to review Wound Clinic Notes for new orders and follow-up with orders to treat the wounds. The Care Coordinator had the responsibility to update the Care Plans. In an interview on 7/25/23 at 7:54 AM, Staff P, LPN reported the following: Resident #120 was considered high risk to develop pressure ulcers as he was diabetic and not as mobile as he used to be. She could not recall if the Prevalon boots had been placed on him before or after he developed the ulcers. There were two metal bars on the footboard where he rubbed his feet. His wife had pictures of the footboard and his feet where the sores matched the metal parts of the bed. The right heel opened first then the left one developed a blister. Resident #120 would frequently slide down the bed and his feet would hit the footboard as he was tall. The facility had a couple of extra-long beds in the building but all were in use, however, she reported the facility could have rented one. After Resident #120's wife said something about the footboard, they removed it. When a wound is first identified, the nurse should check the protocol on wounds as there are standing orders for treatments. When treated at the Wound Clinic and if the Physician documents recommendations, these should be considered as new orders and should be addressed on the Care Plan. The nurse taking care of the resident had the responsibility to review Wound Clinic Notes for new orders and follow-up with orders to treat the wounds. The Care Coordinator had the responsibility to update the care plans. In an interview on 7/24/23 at 10:54 AM, Staff L, Registered Nurse (RN) reported Resident #120 was so tall and witnessed him rubbing his heels against the footboard which caused the pressure ulcers. The staff should have placed an extender on his bed to prevent it. When a wound is first identified, orders to treat it should be obtained within 24 hours. When treated at the Wound Clinic and, if the Physician documents recommendations, these should be considered as new orders and should be addressed on the Care Plan. The nurse taking care of the resident had the responsibility to review Wound Clinic Notes for new orders and follow-up with orders to treat the wounds. The MDS Coordinator had the responsibility to update the care plans. In an interview on 7/24/23 at 11:23 AM, Staff G, Certified Nursing Assistant (CNA) reported if a resident was very tall and rubbed his heels against the foot board, she would report it to the nurse, reposition him and if still continues to be a problem, look into getting a different bed. In an interview on 7/25/23 at 12:04 PM, Staff D, CNA reported if a resident was very tall and rubbed his heels against the footboard, he would place an extension on the bed. He remembered putting an extension on Resident #120's bed but could not recall the date when he did. In an interview on 7/24/23 at 12:53 PM, the Director of Nursing (DON) reported the following: Resident #120 did not have pressure ulcers when he was first admitted . He was tall and would slide down in bed and his heels would touch the footboard which had two metal pieces attached to the bed. His feet touched those metal areas and the pressure would have caused the wound. At that point, the staff placed an air mattress on the bed and elevated his heels. The Wound Doctor removed the footboard when he first saw him here. The staff should have put an extender on the bed and put boots on him to prevent the ulcers from developing. She expected orders to be obtained to treat the wounds within 24 hours and would expect any new recommendations made by the Wound Care Physician to be treated as new orders and address this on the TAR and Care Plan. The nurse caring for the resident is responsible for follow-up on obtaining orders. The MDS Coordinator is responsible for updating the care plan. A review of the facility policy titled: Wound Management and Documentation which was last revised 2/1/23 documented the following: a. For all areas, the nurse shall implement a preventive intervention. b. Notify the Physician of the wound, communicate the assessment to the Physician and request a treatment.

Based on clinical record review, observations, family and staff interviews, and facility policy review, the facility failed to prevent falls resulting in hip fractures for two of nine residents reviewed (Residents #9 and #122) and failed to secure a safety strap around the resident's calves for one of three residents observed during transfers with a SPAN mechanical lift (Resident #31). The facility reported a census of 68 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #122 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 out of 15 points. The MDS also identified the resident with the following diagnoses: Diabetes Mellitus, pain in the right hip and pain in the left hip. The MDS documented the resident required limited staff assistance with bed mobility, dressing, toileting and personal hygiene and required extensive staff assistance with bathing. On [DATE], the Care Plan identified the resident with the problem of potential for falls related to weakness and on [DATE] directed staff to transfer with the assist of one using a gait belt and wheeled walker. A review of a Facility Incident Report dated [DATE] at 1:25 PM, documented the resident lost her balance in the hallway, the Report identified she was Care Planned to be allowed to be unattended in fall location. Resident found lying on left side with arms and legs extended, complaining of severe pain to left lower extremity (LLE), sent to ER (emergency room ). Resident #122 was ambulating independently in hallway to her room. A review of the Fall Scene Investigation Report dated [DATE] revealed the following contributing factors: a. Medications given prior to fall: cardiovascular, narcotic, diuretic, hyperglycemic, antidepressant. b. The resident was toileted last at 12:30 PM. c. The Care Plan stated the resident was one to one with transfers and ambulation with walker. The resident was walking by herself with walker and staff thought she was independent. d. Education provided on [DATE] by Director of Nursing (DON). e. Resident's Plan of Care indicated she required assist of one with transfers and ambulation. Staff are required to review Activities of Daily Living (ADL's) Card before providing cares and review while on walking rounds at shift change. Nurses are to remind Certified Nurse Aides (CNA's) to tell CNAs to give report and walk the unit for rounds and check ADL Cards every shift. A review of the Major Injury Determination form dated [DATE] at 1:25 PM, documented the following: Comminuted intertrochanteric fracture to the left hip, staff observed left lower extremity shortening and rotation and sent to the Emergency Department (ED) for evaluation. The Physician determined the resident sustained a major injury. A review of the nurse's notes revealed the following: a. On [DATE] 1:58 PM, the resident got up from the dining room table and began to walk towards her room when a peer came walking by quickly. Resident and peer's feet got tangled together and Resident fell on to her left side. Resident was on her left side and complaining of LLE pain. Resident's left foot was externally rotated. Call placed to medic for transport to ER. b. On [DATE] 1:09 PM, resident returned from the hospital by ambulance. c. On [DATE] 5:16 AM, this nurse was called to the resident's room by CNA. The resident was assessed at 5:10 AM and found to have expired. Hospice called. A review of the Hospital Discharge Summary dated [DATE] revealed documentation that the resident presented after a fall, LLE externally rotated and shortened upon presentation. Initial workup showing intertrochanteric comminuted fracture. Discussed with resident's family who confirmed patient should be Comfort Care. In an interview on [DATE] at 2:32 PM, Staff N, CNA reported she thought that Resident #122 was independent and she was in the dining room when she saw Resident #36 run into Resident #122. She also reported the CNA's carry Pocket Care Plans which shows how residents are supposed to be transferred. In an interview on [DATE] at 12:23 PM, the Assistant Director of Nursing (ADON) reported at the time Resident #122 fell , she thought she was independent, that she fell and sustained a hip fracture and sent to the hospital. In an interview on [DATE] at 12:53 PM, the DON reported on [DATE], Resident #122 got up from the dining room table with her wheeled walker and walked down the hall. Resident #36 was pacing in the hallway and walked in front of Resident #122, however did not have contact with Resident #122. Resident #122 had to stop suddenly and this caused her to fall. The staff should have assisted the resident as she was Care Planned to be assist of one. Resident #122 sustained a fractured femur. The fall could have been prevented if the staff had assisted her and could have stopped Resident #36 from running in front of Resident #122. 2. The MDS dated [DATE] identified Resident #31 as severely cognitively impaired with a BIMS score of 99 and had the following diagnoses: Epilepsy, Non-Alzheimer's Dementia and Osteoarthritis. The MDS also identified the resident required extensive staff assistance with transfers, toileting and bathing. The MDS documented the resident as totally dependent on staff for locomotion on and off the unit, dressing and personal hygiene. On [DATE], the Care Plan identified Resident #31 with the problem of self-care deficit and on [DATE] it directed staff to transfer the resident utilizing a SPAN lift (A lift that assists a resident to a standing position) with a medium sling. The Care Plan failed to direct staff to apply the straps around the calves of the resident. During an observation on [DATE] at 9:13 AM, Staff G, CNA and Staff H, CNA assisted Resident #31 to sit at the edge of the bed. Staff G pushed the SPAN mechanical lift in front of the resident as both aides secured the sling around the Resident #31's waist and secured to the lift and placed her feet on the platform. Resident #31 appeared to have difficulty standing up, Staff H had to hold her behind her back. Neither aide placed a strap around Resident #31's calves before they transferred her to the Geri chair. In an interview on [DATE] at 8:17 AM, Staff O, LPN reported when residents are transferred using the SPAN lift, the staff should secure a sling around the resident's waist and a strap around the resident's calves which then are secured to the lift. In an interview on [DATE] at 7:54 AM, Staff P, LPN reported when residents are transferred using the SPAN lift, the staff should secure a sling around the resident's waist and a strap around the resident's calves which then are secured to the lift. In an interview on [DATE] at 10:54 AM, Staff L, Registered Nurse (RN) reported when residents are transferred using the SPAN lift, the staff should secure a sling around the resident's waist and a strap around the resident's legs which then are secured to the lift. There should not be any reason why they would not be placed on the resident. In an interview on [DATE] at 11:23 AM, Staff G, CNA reported when residents are transferred using the SPAN lift, the staff should secure a sling around the resident's waist and a strap around the resident's legs which then are secured to the lift. In an interview on [DATE] at 12:04 PM, Staff D, CNA reported when residents are transferred using the SPAN lift, the staff should secure a sling around the resident's waist and a strap around the resident's calves which then are secured to the lift. In an interview on [DATE] at 12:23 PM, the ADON reported when residents are transferred using the SPAN lift, the staff should secure a sling around the resident's waist and a strap around the resident's calves which then are secured to the lift. In an interview on [DATE] at 12:53 PM, the DON reported when residents are transferred using the SPAN lift, the staff should secure a sling around the resident's waist and a strap around the resident's calves which then are secured to the lift. She thought Resident #31 only required the sling and would have to check the Care Plan to verify if she needed the strap around her calves. A review of the facility policy titled: Manual Lifts which was last revised [DATE] had documentation for use of the stand lift as follows: a. The Stand Lift is to be wheeled up to the resident with the resident's legs flush with the shin pads on the lift. b. Have the resident lean slightly forward, grasping the hand grips and place the support strap behind the resident, put the straps into locking cleats to fit the strap snugly and lock in place. c. Always buckle the shin straps around the shin pad. 45775 3. The MDS Assessment, dated [DATE], listed diagnoses for Resident #9 included: Non-Alzheimer's Dementia, stroke, and anxiety disorder. The MDS assessed the resident independent with transfers, walking in room, and required supervision walking on the unit. The MDS listed the BIMS score as a 3 out of 15, indicating severely impaired cognition. The Care Plan directed staff to monitor the residents' interaction with peers, as she does not like to be touched or have her belongings touched by peers. The Care Plan directed staff to be aware of the need to intervene as needed. An Incident Report, dated [DATE], reported during a disagreement Resident #33 pushed Resident #9 down, causing a fracture of her right femur. A Major Injury Determination Form, signed on [DATE] by the Medical Director, revealed the Resident #9's right hip fracture qualified as a major injury. During an observation on [DATE] at 11:00 AM of the video surveillance of the Memory Care Unit (MCU), revealed Resident #33 and Resident #9 in the dining room. No staff were noted to be in the dining area. Resident #33 pushed a trash can out of his way into the path of Resident #9. Resident #9 started a inaudible conversation with Resident #33. Resident #33 put his right hand on Resident #9 right wrist. Resident #9 pushed her right hand towards Resident #33, while he continued to hold on to her wrist. Resident #9 then her raised left hand and attempted to swing down near Resident #33's head. Resident #33 used his right hand to deflect Resident #9 left hand from hitting his head. Then Resident #9 fell to the ground. During an interview on [DATE] at 10:58 AM, Staff T, CNA stated she witnessed the altercation between Resident #9 and Resident #33. Staff T stated she was in the back-dining area, in the doorway of another resident. She explained she could not leave the doorway as the resident is a high fall risk and forgets to use her walker or ask for assistance. Staff T stated she heard Resident #9 and Resident #33 arguing, and attempted to verbally redirect them to walk away from each other. She stated the resident she assisted got up from the toilet and started to walk with her pants down, without her walker. Staff T stated she left the doorway to assist the resident, and when she returned to the doorway saw Resident #9 fall to the floor. Staff T stated from her view, it appeared Resident #33 pushed Resident #9 to the floor. Staff T stated the other staff assigned to work in the area, Staff U, CNA was helping another resident in their room. Staff T stated the Unit Nurse had gone to the front of the unit prior to the residents arguing. When queried about the after-meal process, Staff T stated after the residents are done eating, the staff clean up the tables so residents cannot eat leftover food from other residents' plates. She stated there are two garbage cans that staff use for this task. When done with cleaning up one garage can is returned to the area under the coffee maker, and the other is put into the locked kitchen area. Staff T stated the garbage can pushed away by Resident #33 should not have been left in the dining area. During an interview on [DATE] at 3:33 PM, Staff U stated she did not witness Resident #9 fall, as she was in another resident's room providing cares at the time. During an interview on [DATE] at 2:33 PM, Staff V, RN stated she did not witness the incident. Staff V stated she had watched the video surveillance and could not tell if Resident #33 pushed Resident #9. Staff V stated both Resident #33 and Resident #9 become argumentative and neither one will back down. During an interview on [DATE] at 10:40 AM, the DON stated staff had been cleaning up the dining room tables to stop residents from eating leftovers off plates. She stated after this is done the staff are then to assist non-ambulatory residents to their rooms to go to the bathroom and get cleaned up. The residents who are independent with ambulation are not assisted to their rooms, unless they make a request. The DON stated the trash can should not have been left in the dining area. She stated since the incident on [DATE] she talked to the Dietary Manager and requested Kitchen Staff clean off the tables after a meal. The DON stated this has helped the time after meals become smoother. The facility policy, dated [DATE], titled CCDI (Memory Care Unit) - Policy Statement read the Memory Care Unit will have a homelike atmosphere, yet safe, clean and attractive, the policy did not address dining room safety.

Based on clinical record review, observations, staff interviews, and facility policy review, the facility staff failed to perform complete perineal care (washing the resident's genital and anal area) on three of six residents reviewed (Residents #16, #55 and #57) and failed to ensure infection control practices for one of two residents reviewed with indwelling catheters (Resident #59). The facility reported a census of 68 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE], listed diagnoses of: non-traumatic brain dysfunction, Non-Alzheimer's Dementia, and muscle weakness. The MDS revealed Resident #57 incontinent of bowel and bladder, required extensive assistance of 2 staff for toilet use and totally dependent on 1 staff for personal hygiene. The MDS identified short term and long term memory loss and severely impaired decision making ability. The Care Plan for Resident #57 dated 5/11/23 listed a Focus Area of potential for skin breakdown related to decreased mobility and incontinence. The Care Plan identified interventions as follows: Extensive assistance with toileting, keep skin as dry as possible and minimize skin exposure to moisture, monitor for episodes of incontinence, provide incontinent cares as needed, and provide perineal cares twice per day and as needed. On 7/18/23 at 9:38 AM, Staff F, Certified Nurses Aide (CNA) and Staff Q, CNA assisted Resident #57 to the toilet. Staff F and Staff Q applied gloves. Staff F reported Resident #57 incontinent of urine. Staff F and Staff Q removed the incontinent brief, and continued to wear the same gloves as they washed his buttocks. Staff F failed to perform perineal care on his genital area following an identified incontinent episode. On 7/24/23 at 2:40 PM, Staff F verbalized the procedure for perineal care after toileting. She stated in the following order: wash hands, apply gloves, remove soiled product or clothing, wash hands, apply new gloves, clean resident, remove gloves, wash hands and assist with dressing. The facility provided a policy titled Peri-Care, dated 2/01/2023, indicated that after removing soiled pads, gloves are to be removed, staff sanitize or wash hands and reapply new gloves. Staff are then directed to cleanse the remainder of area where soiled pad may have touched. After cleansing, the Policy indicate staff to change gloves, wash and/or sanitize hands again before applying new incontinence product and repositioning resident. 25855 2. The MDS dated [DATE] identified Resident #16 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 0 out of 15 points and had the following diagnoses: Non-traumatic Brain Dysfunction, Alzheimer's Disease and Atrial Fibrillation (an abnormal heart rhythm). The MDS also identified the resident required extensive staff assistance with bed mobility, transfers, dressing, toileting and bathing. The MDS documented the resident to be totally dependent on staff for locomotion on and off the unit and personal hygiene. On 4/16/22, the Care Plan identified the resident with the problem of Self Care Deficit related to Confusion, impaired mobility, weakness and directed staff to: provide Activities of Daily Living (ADL) assistance for bathing, dressing, grooming, and hygiene as indicated. He required extensive to dependent assist for ADLs. An observation of incontinence care on 7/19/23 at 8:16 AM, revealed Staff D, CNA and Staff E, CNA entered the room to provide the care. Then both aides turned the resident to his right side after they removed the incontinent brief and provided peri care and noted a small amount of soft brown stool in the brief. Staff D used the correct procedure to cleanse the rectal crease, however, did not change gloves before she placed a new incontinent brief under Resident #16 and before she touched his shoulder and right outer thigh with the same gloves she used to clean the stool off with. 3. The MDS dated [DATE] identified Resident #55 as cognitively intact with a BIMS score of 15 out of 15 points and had the following diagnoses: Cancer, Coronary Artery Disease and Heart Failure. The MDS also identified the resident required extensive staff assistance with bed mobility, toileting and bathing. On 1/11/21 the Care Plan identified Resident #55 with the problem of Self Care Deficit related to impaired mobility, weakness and directed staff to provide ADL assistance for bathing, dressing, grooming, and hygiene as indicated. She requires limited to extensive assist with ADLs. In an observation on 7/18/22 at 11:05 AM, Staff A, CNA and Staff B, CNA both entered room, closed the door and assisted the resident to stand. Staff A used the correct technique to cleanse Resident #55's peri-rectal area front to back. She did not change gloves before she applied Peri Guard barrier ointment to the peri-rectal area and before she put on the incontinent brief and assisted the resident to sit in the wheelchair. 4. The MDS dated [DATE] identified Resident #59 as severely cognitively impaired with a BIMS of 0 out of 15 points and had the following diagnoses: Non-Alzheimer's Dementia, Urinary Tract Infection (UTI)) and Chronic Atrial Fibrillation (an abnormal heart rhythm). The MDS also identified the resident required extensive staff assistance with bed mobility, transfers, dressing, toileting, bathing and totally dependent on staff for locomotion on and off the unit and personal hygiene. The MDS documented the resident with an indwelling catheter. On 8/22/22 the Care Plan identified Resident #59 with the problem of requires a suprapubic catheter related to a diagnosis of Benign Prostatic Hyperplasia (BPH or enlargement of the prostate) and directed staff to position the bag below level of bladder. Assure catheter bag does not touch the floor. Store collection bag inside a protective dignity pouch. Observations of Resident #59's suprapubic catheter drainage bag on the floor on the following dates and times: a. On 7/17/23 at 12:15 PM as he sat in his wheelchair in the main dining room. b. On 7/17/23 at 12:45 PM assessment unchanged. In an observation of incontinence care on 7/18/23 at 7:49 AM, Staff C, CNA and Staff D, CNA donned isolation gown and gloves appropriately. After they provided incontinence care correctly, they did not change gloves before placing a new incontinent brief underneath Resident #59. In an interview on 7/25/23 at 8:17 AM, Staff O, LPN reported when providing incontinence care, aides would be expected to change gloves whenever they change different areas. She also reported any indwelling catheter bags should never be placed on the floor. In an interview on 7/25/23 at 7:54 AM, Staff P, LPN reported when providing incontinence care, aides would be expected to change gloves when they enter the room and touch anything. She also reported any indwelling catheter bags should never be placed on the floor. In an interview on 7/24/23 at 10:54 AM, Staff L, RN reported when providing incontinence care, aides should change their gloves whenever they become soiled. She also reported any indwelling catheter bags should never be placed on the floor. In an interview on 7/24/23 at 11:23 AM, Staff G, CNA reported when providing incontinence care, aides should change their gloves whenever they touch a new area. She also reported any indwelling catheter bags should never be placed on the floor. In an interview on 7/25/23 at 12:04 PM, Staff D, CNA reported when providing incontinence care, aides should change their gloves whenever the gloves get dirty. He also reported any indwelling catheter bags should never be placed on the floor. In an interview on 7/24/23 at 12:23 PM, the Assistant Director of Nursing (ADON) reported when providing incontinence care, aides should change their gloves whenever the gloves get soiled. She also reported any indwelling catheter bags should never be placed on the floor. In an interview on 7/24/23 at 12:53 PM, the Director of Nursing (DON) reported when providing incontinence care, aides should change their gloves whenever the gloves are soiled. She also reported any indwelling catheter bags should never be placed on the floor. A review of the facility policy titled: Catheter Care and last updated 2/1/23 revealed documentation of the following: Do not place the drainage bag on the floor.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure residents remained free from physical resident to resident altercations when one resident (Resident #36) hit two other residents (Resident #17, and #25) in a 24 hour time frame. The facility reported a census of 68 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated 4/11/23, listed the diagnosis of Resident #36 included: Non-Alzheimer's dementia, depression, and hypertension (high blood pressure). The MDS revealed the resident exhibited difficulty concentrating 12-14 days, short tempered and/or easily annoyed 2-6 days in the 14 days prior to the assessment date. The MDS listed no score for the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The Care Plan revealed the following Focus Areas: 1. A Focus area on Behavior Management related to sundown's (increase in confusion and undesirable physical/verbal behavior later in the day) in the afternoon with behaviors of yelling, crying and pacing the unit. Interventions for this area included: a. Ensure the safety of Residents and others. Initiated on 2/17/22. No revision date. b. Provide emotional support regarding new onset of repetitive behavior. Initiated on 2/17/22. No revision date c. Utilize diversion techniques as needed. Initiated on 2/17/22. No revision date 2. A Focus area on Cognitive loss with Communication, Mood and Behavior related to a diagnosis of Dementia with Behavioral Disturbance. Interventions for this area included: a. Assess if the mood/behavior endangers [the] resident and/or others. Intervene if necessary. The resident tends to be much calmer in the morning times. She still can be resistive/combative with cares in the am, but typically is calmer. The resident tends to become anxious and agitated, sundowns in the afternoon time- often beginning in early afternoon. She tends to pace about unit most of the time she is awake and does so until she is very tired. When she becomes anxious/agitated she tends to be looking for a way home and will exit seek by looking for and pushing on exit doors. She is often not easily redirected and has had periods of trying to open windows or using items in an attempt to break windows in effort to leave. b. Approach the resident calmly and gently and attempt to provide redirection. The resident is on 15 minute checks for safety/location. Know that the resident can become verbally and physically abusive with staff and peers at times. If unable to redirect the resident, leave her in a safe place/situation and reapproach her at a later time or with a different staff member. Monitor the residents' interactions with peers and be aware of the potential to strike out. Know that the resident can be quite resistive/combative with cares also. Again, approach the resident very gently and inform her of what you are going to be doing to assist with orientation to task at hand. Note the Resident can be/is very destructive with property and has broken the furniture in her room- doors are off of her wardrobe and will not be replaced while she is still exhibiting this type of behavior expression. She tends to remove chair cushions, items off the walls, etc. She often attempts to push peers in their wheelchair and/or tends to push tray tables around the unit. The resident is often noted asking questions and making demands when no-one is present in front of her. She also tends to yell out profanities. Monitor and attempt to redirect as able. Initiated on 2/17/22. Revision on 8/6/2022. A review of facility Incident Reports (IR) revealed Resident #36 involved in physical resident to resident altercations on the following dates: a. On 8/6/22, in the back dining/activity area, Resident #36 slapped another resident on the face two times. b. On 10/19/22, while walking down a hall on the unit, Resident #36 pulled the hood of a sweatshirt of the resident in front, causing that resident to fall. c. On 12/11/12, in an unspecified location, Resident #36 slapped Resident #17 on the face. d. On 1/29/23 at 6:00 PM, while in the back dining/activity area Resident #36 slapped Resident #17 on the face. e. On 1/29/23 at 10:05 PM, while at the Nurse's Station, Resident #36 slapped Resident #25 after she attempted to pull a piece of paper from his hand and he would not let go. f. On 1/31/23, after exiting a room, Resident #36 appeared agitated and slapped another resident who was in the hall. A Health Status Note dated 1/29/23 at 2:38 AM, documented the resident displayed anxiousness as evidenced by walking, pacing, and face grimacing. Staff assisted the resident to the bathroom, and she received as needed (PRN) medication. The resident then had periods of peaceful rest, and exciting room and wandering the halls. A Health Status Note dated 1/29/23 at 6:12 PM, documented Resident #17 crying and screaming she [Resident #36] slapped me in the face. During an interview on 7/24/23 at 10:30 AM, Staff K, Registered Nurse (RN) stated Resident #17 screamed and cried after Resident #36 slapped her face. Staff K reported Resident #17 had a red mark on her face. Staff K stated prior to the incident Resident #36 had been very restless, as evidenced by pacing and moving furniture. Staff K explained this is a sign the resident is experiencing a high stimulus and needed intervention. Staff K stated she did not have a staff start 1:1 until after Resident #36 slapped Resident #17. Staff K stated she should have had a staff start 1:1 when she recognized the triggers prior to the incident. A Health Status Note dated 1/29/23 at 10:41 PM, documented the resident attempt to grab something from Resident #25, and then slapped Resident #25. During an interview on 7/19/23 at 3:15 PM, Staff M, Licensed Practical Nurse (LPN) stated Resident #36 strikes out at people for unknown reasons. She explained the resident touches wheelchairs, tables, and picks up any item she sees on a table or the floor when walking around the unit. Staff M stated other residents yell at the resident when she touches their belongings then Resident #36 sometimes responds by striking out at the other resident. Staff M stated the resident is not willing to sit down and engage in an activity for more than several minutes at one time. She started Resident #36 does not like to go to her room, and typically will only stay in her room if she is sleeping for the night. Staff M stated staff need to ask Resident #36 to use the restroom every two hours, and if she is pacing, offer her a PRN as she may be anxious or physically uncomfortable. Staff M added it also helps when staff quietly walk with the resident. During an interview on 7/20/23 at 2:28 PM, Staff R, Certified Nursing Assistant (CNA) stated she worked the night Resident #36 slapped Resident #25. She stated she assisted when the incident occurred, and did not witness the event. During an interview on 7/25/23 at 9:01 AM, Staff S, RN stated she does not recall a time when Resident #36 slapped Resident #25. She added Resident #36 is always doing something. On 7/25/23 at 10:37 AM, the Director of Nursing (DON) stated she would expect staff to intervene if Resident #36 experiences increased anxiety or restlessness to prevent her striking out. The DON stated to intervene nursing staff should assess if a PRN is appropriate. Or ask another CNA or Environmental Aide to offer an activity or walk with the resident. The DON stated the resident should have 1:1 staff until she is calm. The facility policy, dated 11/15/22, titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property and Reporting Guidelines, Section Resident -Resident Altercation explained the facility will presume that instances of abuse cause physical harm, or pain or mental anguish in residents with cognitive and/or physical impairments which may result in a resident unable to communicate physical harm, pain or mental anguish in the absence of evidence to the contrary.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to complete and report to the ordering physician the Pharmacist Medication Regimen Review to consider recommendation for a gradual dose reduction of psychotropic medications for two of two residents reviewed, (Resident #27 and #47) . The facility reported a census of 68 residents. Findings Include: 1. Resident #27's Minimum Data Set (MDS) Assessment completed on 4/18/23 recorded the total score for the Brief Interview for Mental Status (BIMS) as 12 out of 15 indicating moderate impaired cognition. Medical diagnoses included major depressive disorder (MDD) and schizoaffective disorder. Antipsychotic and Antidepressant medications were listed along with no Gradual Dose Reduction (GDR) attempted or documented of why not attempted. Review of the July 2023 Medication Administration Record (MAR) and orders documented Resident #27 prescribed; Trihexyphenidyl HCl Tablet 2 milligrams (mg), (also known as artane; an antispasmodic drug used to treat involuntary movements from psychotropic drugs). Antidepressant - Serataline 100 mg take one tablet daily (also known as Zoloft), Antipsychotic - Seroquel (also known as Quetiapine fumarate; a medication used to treat schizophrenia) increased 7/11/23 from 200 milligrams at bedtime to 250 milligrams at bedtime by Veteran Administration (VA) Psychiatrist. Resident #27's Care Plan dated 9/1/20 included interventions for Resident #27's diagnosis of schizoaffective disorder and the resident's need for ongoing mental health services and medication management provided by the VA Psychiatric services or a facility designated Psychiatric Nurse Practitioner to evaluate the resident response and the effectiveness of psychotropic medications and evaluate the ongoing needs. Review of Progress Notes documented: a. On 5/11/23, a Pharmacy recommendation received regarding a GDR had been faxed to Resident #27's Medical Provider and not faxed to Resident #27's VA Psychiatrist Clinic who prescribes the psychotropic medication. b. On 5/12/23, Fax received from the Medical Provider which documented denied any changes requested for a GDR of psychotropic medications. Review of the Electronic Health Record (EHR) Progress Notes from 1/1/23 to 7/20/23 contained no documentation of sending Pharmacy Consultant Requests to Resident #27's VA Psychiatric Provider. Review of the facility Consulting Pharmacy Policies and Procedures, last reviewed date of 2/01/23 directed under the Procedures Section for Medication Review: Point C - Consultant (Pharmacist) review reports will be given to the Director of Nursing (DON) or Assistant Director of Nursing (ADON) upon completion. Point D - Nursing will review these reports and add any other pertinent information before sending it on to the Primary Physician. Point E - The reports will be sent to the Primary Care Physician within 7 days of review and documentation needed to support a GDR or if denied then documentation to support the denial decision. On 7/20/23 at 1:15 PM, the DON stated the Pharmacist is forwarding the completed reports. When asked why the GDR reports were not being sent to the Prescribing VA Psychiatrist, the DON acknowledged that would be a good idea. When asked why the providers are not documenting the needed psychotropic review information, the DON and ADON gave no response. Resident #27's mental health care had been provided by the VA Clinic since admission to the facility, however the VA Clinic Psychiatrist had not been sent the Pharmacy GDR information or documented the need to deny a requested GDR. 2. Resident #47's MDS dated [DATE] recorded a BIMS score of 13 out of 15, indicating moderate impaired cognition. The MDS identified medical diagnoses of depression, and other sexual dysfunction not known to a substance or physiological condition, and insomnia. The Care Plan dated 11/17/22 for Resident #47 identified interventions to monitor for behavior of inappropriately touching of staff. Interventions include to administer medroprogesterone acetate for hormone therapy (a hormone medication also known as provera) related to sexual behaviors. Assess if Resident #47 mood or behavior endangers self or others and intervene if necessary. Resident #47 attempts to grab female staff in the upper chest area. Monitor Resident #47 for change in cognitive status, communication, mood, behavior and notify medical provider as indicated. The EHR Nursing Progress Notes dated 5/3/23 showed Resident #47's Power of Attorney (POA) attended the Interdisciplinary Care Conference. The POA questioned the recent increase of medroprogesterone acetate from 150 mg intramuscularly (IM) ( medication is an injection into muscle) to 600 mg IM weekly on 4/21/23. Resident #47 noted to receive mental health services through the VA clinic. A further review of the resident's EHR showed upon admission Resident #47's order for medroprogesterone acetate had been 150 mg IM and orders had been signed by the Medical Provider. A review of Resident #47's medication history shown this was a significant decrease in dosage as Resident #47 had been receiving 600 mg IM weekly as ordered by the VA Psychiatric Clinic. On 7/20/23 at 1:15 PM an interview completed with the DON and ADON about the process of Consulting Pharmacy Review Reports and the procedure of Monthly Reports being reviewed by the Prescribing Psychiatrist. The DON stated the Pharmacist is forwarding the completed reports. When asked why the GDR Reports were not being sent to the prescribing Psychiatrist, the DON acknowledged that would be a good idea. When asked why the providers are not documenting the needed psychotropic review information, the DON and ADON gave no response. Resident #47 also receives two psychotropic medications ordered by the VA Psychiatric Clinic. The Pharmacist Monthly GDR Reports have been signed by the Medical Provider and not forwarded to the prescribing Psychiatrist. The Monthly Report contains no documentation for a GDR denial or reason for a denial.

Based on clinical record review, observations, staff interviews, and facility policy review, the facility staff failed to provide necessary respiratory care according to the Physician's orders for 1 out of 1 residents reviewed (Resident #2). The facility reported a census of 68 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], listed the active diagnoses: Heart Failure, chronic obstructive lung disease (COPD), and chronic respiratory failure with hypoxia. The MDS reflected shortness of breath or trouble breathing when lying flat. The MDS identified Resident #2 required extensive assist of two staff for bed mobility and dependent on two staff for transfers. The MDS documented the Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. The Care Plan for Resident #2 dated 5/01/23, listed a Focus Area of oxygen therapy due to COPD and chronic respiratory failure. The Care Plan identified interventions as follows: Administer Oxygen (02) at 1 liter (L) continuously per nasal cannula. The Physician's Order dated 4/14/2022, directed Oxygen @ 1 L continuous every shift. The following observations revealed the oxygen for Resident #2 at an incorrect level: a. On 7/17/23 at 10:23 AM, the oxygen concentrator next to Resident #2's bed revealed the liter flow at 3 liters. b. On 7/17/23 at 11:33 AM, the oxygen tank on Resident #2's wheelchair revealed the liter flow set at 1.5 liters. c. On 7/18/23 at 09:00 AM, the oxygen concentrator next to Resident #2's bed revealed the liter flow set at 3 liters. d. On 7/18/23 at 2:57 PM, the oxygen concentrator next to Resident #2's bed revealed the liter flow set at 3 liters. e. On 7/19/23 at 9:37 AM, Staff F and Staff G performed incontinent cares on Resident #2. Head of bed was kept in low position and oxygen nasal cannula was removed for entire procedure, 9:37-10:05 AM. Resident #2 using accessory abdominal muscles and performed shallow breathing during this timeframe, requested that staff hurry up. f. On 7/19/23 at 10:07 AM, the oxygen concentrator next to Resident #2's bed revealed the liter flow set at 3 liters. g. On 7/17/23 at 10:23 AM, Resident #2 stated her oxygen flow ran at 2 liters. On 7/19/23 at 9:37 AM, Staff I Licensed Practical Nurse (LPN) reported Resident #2 required oxygen all the time and lacked knowledge of the ordered flow rate. On 7/19/23 at 3:42 PM, the Director of Nursing (DON) reported the Floor Nurses are responsible for setting oxygen flow rate and stated Resident #2's oxygen order indicated 1 liter continuous flow of oxygen. The DON viewed Resident #2's oxygen concentrator, the liter flow sat at 3 liters, DON adjusted flow to 1 liter and proceeded to check Resident #2's oxygen saturation level. The Facility provided an undated policy titled Oxygen Guidelines for Nursing Department, revealed the requirement of a Physician's Order for use of oxygen and documentation of an order in the Medication Administration Record (MAR). The policy indicated oxygen is a medication in that Nurses or Certified Medication Aide (CMA) are the only staff who are to be adjusting flow rate or changing tanks. Facility policy and procedure for noting orders, last reviewed on 2/01/23, revealed the Nurse noting an order shall check that the order has been properly transcribed to ensure accuracy.

Based on clinical record review, observations, staff interviews, and review of the facility Gastric Feeding Tube Policy and Procedure, the facility staff failed to follow policy and procedure by not maintaining the residents' head of bed at 45 degrees or above during continuous infusion or stopping the continuous tube feeding infusion if the head of bed was below the 45 degrees for two of two residents reviewed with G-tubes (Resident #51, and #64). The facility reported a census of 68 residents. Findings Include: 1. Resident #64's Minimum Data Set (MDS) completed 6/16/23 listed the total score for the Brief Interview for Mental Status (BIMS) as 7 out of 15, indicating severe impairment. Medical diagnoses included cerebral infarction (stroke), dysphagia (difficulty in the ability to swallow), G-tube feeding, (Gastrostomy tube surgically placed device to give direct access to the stomach for nutritional feeding), and aphasia (the inability to speak or understand verbal language due to an injury to the brain). The Care Plan dated 3/10/23 included interventions for Resident #64 to receive continuous tube feeding to run 22 of 24 hours per day. The head of bed (HOB) to be 45 degrees at all times during infusion. Monitor, document, and report and signs or symptoms of aspiration that included: fever, shortness of breath (SOB), abnormal breath or lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation, fecal impaction, diarrhea, nausea, vomiting, dehydration; monitor for tube dislodgement or malfunction. On 7/19/23 at 7:05 AM, Staff J, Licensed Practical Nurse (LPN) was observed preparing Resident #64's tube feeding and initiating a new infusion system. Above the resident bed was observed a laminated sign including a protractor marked at 45 degree angle and reminding staff to always have the resident at 45 degrees during tube feeding infusion (22 of 24 hours per day). The head of bed for Resident #64 was approximately 20 degrees while Staff J, LPN prepared and initiated the tube feeding. Staff J, prepared a label for the nutrition bag that included the date, Resident #64's first initial and last name, room number and the rate per hour; 60 milliliters per hour. The labeled tag omitted the nutritional product; Jevity 1.5 liquid calories. On 7/19/23 at 7:28 AM, Staff J, LPN elevated the HOB to approximately 25 degrees and exited the room. On 7/19/23 at 8:33 AM, Staff G, Certified Nurse Aide (CNA) observed providing patient peri-care (washing the resident genitals and anal area). Upon entering the room Staff G, CNA picked up the electronic call light from the fall mat beside the bed, removed the fall mat, raised the bed horizontal height to waist high and then lowered the HOB from 25 degrees to approximately 15 degrees while continuous tube feeding remained running. Staff G, CNA assisted Resident #64 roll to right side which stretched the tube feeding line. At 8:56 AM, Staff G, placed a new brief on Resident #64, lowered the horizontal height of bed to lowest position and left HOB at approximately 15 degrees, and then left the room while tube feeding remained at continuous infusion. Review of the facility Gastric Feeding Tube Policy and Procedure directed the Nursing Staff on the following: a. At Point #11 of the Policy and Procedure states to record procedure, type of formula, and the amount of feeding used, the amount of water used, the amount of fluid aspirated prior to the feeding, and the intake and output. Include all pertinent observation such as how the resident tolerated the feeding. Review of Resident #64's Electronic Medical Administration Record (EMAR) and Treatment Administration Record (TAR) revealed only documentation of the nutrition; Jevity 1.5 liquid calories at 60 milliliters per hour with 45 milliliters water running over 22 of 24 hours per day. The MAR also included signing off the two hours from 5:00 AM to 7:00 AM the infusion is on hold. The TAR contained a sign out for changing the feeding bag and syringe daily however no further information as required per facility policy. A review of the Electronic Progress Notes since Resident #64's admission, no documentation of the feeding tube type of formula, amount of feeding used, the amount of water used, the amount of fluid aspirated prior to the feeding, and the intake and output or the residents toleration of the feeding charted. In an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) the question was asked about entering the orders on the MAR and TAR for the tube feeding. The DON stated the nutrition is received from the Pharmacy. The orders for tube feeding placed by the facility staff. When asked about the degree the HOB should be raised, the DON and ADON stated 45 degrees. The ADON further stated the HOB degree is placed on a sign posted above the residents bed. When asked about education for staff about tube feeding, the DON stated during orientation staff are signed off once competently completed the procedure. 25855 2. The MDS dated [DATE] identified Resident #51 as cognitively intact with a BIMS score of 14 out of 15 points and had the following diagnoses: Hemiplegia, Anxiety Disorder and Psychotic Disorder. The MDS also identified the resident as totally dependent on staff for all activities of daily living, had an indwelling catheter and always incontinent of bowel and had a stage 4 pressure ulcer. On 3/8/22 the physician ordered the tube feeding of Jevity 1.2 to run at 60 milliliters (ml) per hour continuously. On 3/10/22 , the Care Plan identified Resident #51 required a tube feeding, however, it did not direct CNA's to ask the nurse to hold the tube feeding while providing cares if the head of the bed needs to be flat. Observations of Resident #51 revealed the following: a. On 7/17/23 at 12:26 PM, the bag of tube feeding label only had 7/16 at 2123 (9:23 PM) written on it. It did not include documentation of the contents or the rate it should have been running at. b. On 7/19/23 at 6:48 AM, the bag of tube feeding label only had 7/18 at 2100 (9:00 PM) written on it. It did not include documentation of the contents or the rate it should have been running at. The tube feeding was not infusing as the Kangaroo pump had not been turned on. c. On 7/19/23 at 7:19 AM, the tube feeding was now running via Kangaroo pump at 60 ml per hour with the head of the bed elevated. Staff D, CNA entered the room and began to lower the head of the bed. The surveyor left the room immediately to inform the nurse. Staff I, LPN entered the room and put the tube feeding on hold and informed Staff D to call her when finished with cares so she could resume the tube feeding. In an interview on 7/25/23 at 8:17 AM, Staff O, LPN reported when hanging a new bag of tube feeding, the nurse should write on the label of the bag the resident's name, date, the name of the feeding and the flow rate. She also reported before aides provide cares on residents with continuous tube feedings, they should ask the nurse to stop the feeding. In an interview on 7/24/23 at 10:36 AM , Staff I, LPN reported when hanging a new bag of tube feeding, the nurse write on the label of the bag the resident's name, date, time, the type of feeding and rate. She also reported before aides provide cares on residents with continuous tube feedings, they should call the nurse to turn the feeding off during cares. In an interview on 7/24/23 at 10:54 AM, Staff L, Registered Nurse (RN) reported when hanging a new bag of tube feeding, the nurse should write on the label of the bag the resident's name, volume administered per hour, date, time and flush per hour. She also reported before aides provide cares on residents with continuous tube feedings, they should call the nurse to put the feeding on hold during cares. In an interview on 7/24/23 at 11:23 AM, Staff G, CNA reported when aides are getting ready to provide cares on a resident with continuous tube feedings, before aides provide cares on residents with continuous tube feedings, they should call the nurse to stop the feeding during cares. In an interview on 7/25/23 at 12:04 PM, Staff D, CNA reported when aides are getting ready to provide cares on a resident with continuous tube feedings, they should She also reported before aides provide cares on residents with continuous tube feedings, they should call the nurse to put the feeding on hold during cares. He admitted he forgot to do that because he was nervous to have the surveyor watching him provide cares. In an interview on 7/24/23 at 12:23 PM, the Assistant Director of Nursing (ADON) reported when hanging a new bag of tube feeding, the nurse should write on the label of the bag the date, time and name of the resident. She also reported before aides provide cares on residents with continuous tube feedings, they should call the nurse to put the feeding on hold during cares. In an interview on 7/24/23 at 12:53 PM, the Director of Nursing (DON) reported when hanging a new bag of tube feeding, the nurse should write on the label of the bag the date, time, type of feeding and the rate. She also reported before aides provide cares on residents with continuous tube feedings, they should call the nurse to stop the tube feeding and never lay the head of bed flat while the tube feeding is running.

Based on clinical record review, observations and staff interviews, the facility failed to provide an adequate door alarm system be in place to prevent the risk of elopement for one of one residents reviewed (Resident #35). The resident walked out of the locked Memory Care Unit (MCU) while following a visitor and proceeded to walk up a hallway and exit the building through unalarmed double doors. This failure resulted in an Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 68 residents Findings Include: 1. Resident #35's Minimum Data Set (MDS) Assessment completed 5/31/22 listed diagnoses that included: unspecified dementia without behavioral disturbance, [CONDITION(S)], and heart failure. The MDS listed Resident #35 required the limited assistance of one staff for walking in her room and on the unit, and extensive assistance of two to move off the unit and return from off unit locations. The MDS reflected the resident's Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating severely cognitively impaired. The Care Plan dated 3/18/22 identified the resident as at risk for wandering and elopement, and ambulates with wheeled walker independently, and used a wheelchair at times for longer distances as she tends to tire. The Wandering Risk assessment dated [DATE] indicated the assessment done monthly, and the resident can follow instructions, is ambulatory, can communicate, and has no history of wandering, The assessment scored the resident at a 9, indicating at risk to wander. Review of the Nurse's Progress Notes revealed the following: a. On 3/16/22 at 6:00 PM, the resident was up front and attempted to go outside b. On 3/25/22 at 10:40 AM, the provider noted the resident refused to wear a Wanderguard, and the resident wanders throughout the facility and the divide is needed to prevent her from exiting through the wrong doors. c. On 3/25/22 at 1:36 PM, the resident took the Wanderguard from the nurse after attempted to put it on and would not give the device back. The resident was placed on fifteen minute checks. d. On 3/28/22 at 2:30 AM, the resident noted to be without a Wanderguard, and a replacement not available. e. On 4/1/22 at 2:45 AM, the resident refused to wear Wanderguard, 15 minute checks put into place f. On 4/1/22 at 4:46 PM, two Certified Nursing Assistants (CNA's) were walking up the ramp of the MCU hallway entrance and noted the resident had walked out of the back exit door and turned around to come back inside but the automatic door had closed. The CNA's immediately opened the door and assisted the resident back inside without difficulty G. On 5/28/22 at 12:55 AM, noted the resident ambulates with walker and can exit seek at times The July 2022 Treatment Administration Record (TAR) documented the resident without the Wanderguard on 27 of 42 twice daily checks. The facility reported Resident #35 eloped from the building on 7/20/22 at 4:13 PM, and the event is recorded on video. An observation on 7/20/22 at 4:45 PM of the video surveillance of the interior exit door of the MCU, and of the south exterior double sliding doors showed on 7/20/22 a visitor, staff and several residents near the exit door. As the visitor left at approximately 2:56 PM, residents and staff dispersed, and at 2:57 PM Resident #35 walked out of the MCU unit door, behind a visitor. The resident turned to the left, walked up a hallway and exited the double doors at 2:58 PM. The video revealed Staff D, Licensed Practical Nurse (LPN), and Staff E CNA left the unit at 3:04 PM (six minutes lapsed) to look for the resident, and returned with her at 3:09 PM. During the observation of the video surveillance on 7/20/22 at 4:50 PM, Staff J, LPN stated earlier in the day the Wanderguard was removed from Resident #35's ankle as [CONDITION(S)] had caused tightness and discomfort. She added a fax had been sent to the provider to request an order to discontinue the device due to the tightness, and the resident residing on a locked unit. On 7/26/22 at 11:53 AM, the State Climatologist revealed the weather conditions on 7/20/22 at 2:57 PM to 3:09 PM at the location Resident #35 left the facility are recorded as: 87 degrees Fahrenheit (F), humidity at 53%, which resulted in a heat index of 90 degrees F. The wind was from the west northwest at 17 miles per hour (MPH), with gusts up to 25 mph. The sky was partly cloudy, with no precipitation recorded. During an interview on 7/21/22 at 11:27 AM, Staff I, LPN and MCU Unit Manager stated the code required alarm on the MCU Unit is for the interior door only. Staff I stated five staff were scheduled on the unit at the time of the elopement, for a MCU census of 24 residents. During an interview on 7/21/22 at 11:34 AM, Staff F, CNA stated she was in the back of the unit (part of unit furthest away from the exit door used in the elopement) when Staff G, CNA asked her to look out the window of room #314 to confirm Resident #35 stood across the street talking to an independent living resident. Staff F stated she immediately saw Resident #35 outside and ran to tell a Nurse and left the unit to help find the resident. During an interview on 7/21/22 at 12:11 PM, Staff G, CNA stated after she clocked in for her shift she always looked to say hi to Resident #35. When she was unable to locate the resident on the Unit, she went to the resident's room (#314) and that is when she observed Resident #35 outside, across the street talking to another lady she did not know. Staff G stated she immediately asked Staff F, CNA to confirm Resident #35 stood across the street from the facility. During an interview on 7/21/22 at 12:29 PM, Staff E, CNA stated she assisted with getting Resident #35 back to the facility after the elopement. Staff E stated the resident was across the street in front of one of the independent living cottages talking to women who lived in the home. Staff E stated the resident was tired when returning to the facility, so she had her rest on the walker seat. Staff E stated that Resident #35 did not have a Wanderguard. She added the Wanderguard sounds an alarm when a resident is near the MCU Unit exit door, and the alarm gets louder when a resident exits. Staff E stated there is not a security or Wanderguard alarm on the north exit door across from the Unit or on the double door exterior exit the resident used to leave. During an interview on 7/21/22 at 12:43 PM, Staff B, LPN stated she was on the Unit when Resident #35 eloped. Staff B stated the exit door to the Unit has a security and a Wanderguard alarm. However, the north exterior exit door across from the Unit, and the south exterior exit double doors are not equipped with alarms. An observation of the north exterior door on 7/21/22 at 12:57 PM revealed the door is unlocked, and not equipped with an alarm. The door is locked from the outside. An observation on 7/21/22 at 1:00 PM of the elopement path revealed the resident turned right when exited the facility, walked through the parking lot, down an access road to the facility's Independent Living Housing, crossed the road and walked along a sidewalk. The distance measured approximately one tenth of a mile. The surfaces walked were asphalt and concrete, with multiple uneven sections throughout. An observation on the south exterior double doors on 7/21/22 at 12:59 PM revealed the doors automatically opened when an object is within four and half feet four of the exit. The doors were not equipped with an alarm, and only locked from the outside. During an interview on 7/21/22 at 2:11 PM, Staff D, LPN stated Resident #35 continually asked for the Wanderguard to be removed as it becomes tight due to [CONDITION(S)]. The Wanderguard had to be cut off in the past due to becoming too tight. Staff D denied knowing if anyone had tried to put the Wanderguard in a location that would not cause discomfort. Staff D stated Resident #35 has attempted to elope in the past as she became anxious about her children and wanted to go home to check on them. During an interview on 7/26/22 at 1:19 PM, the Director of Nursing (DON) stated her expectation is staff would monitor a resident with a Wanderguard when they are near a door, and when a visitor is leaving to prevent a potential elopement. A facility policy, dated 2/16/22, titled Elopement Prevention and Response revealed fire doors are alarmed and not locked and will activate if there is an attempt to exit. The Wanderguard bracelet device when sensed at alarmed doors will sound both at the door and the Nurse's Desk to alert staff that the resident is attempting to exit. The State Agency informed the facility of the Immediate Jeopardy (IJ) on July 21, 2022 at 3:30 PM. Facility staff removed the Immediate Jeopardy on July 21, 2022 at 5:50 PM through the following actions: a. An additional sign placed at the Memory Care unit (MCU) door reminding guests to call for help if a resident is standing by the exit when they are preparing to leave the unit. b. Pull away alarms placed on interior MCU door to unit, south exterior sliding doors, and north exterior door. c. A Wanderguard placed on Resident #35 right shoe and walker basket d. Education for staff regarding wandering and elopement placed at time-clock. e. Specific education on wandering and elopement for nursing staff with the education regarding wandering and elopement placed in CE Solutions Education Portal (computer program utilized by the facility for trainings/inservices for staff). f. Local Security Company contacted and scheduled to install alarmed devices above the north and south exterior exits to the rear of the building. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures.

Based on record review, observations, and interviews the facility failed to transfer a resident as directed by the care plan of care that resulted in an injury for 1 of 5 sampled (Resident #3). The facility reported a census of 87 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had [DIAGNOSES REDACTED]. Resident #3 had severe cognitive impairments. The MDS dated [DATE] revealed Resident #3 required extensive assistance of 2 staff with reposition in bed, transfers, dressing, eating and toileting use. The Care Plan dated 7/27/18 directed the staff to provide a wheelchair for mobility, propelled by staff, non-ambulatory, dress and transfer using cautious movements and provide assistance of two staff for transfers with a gait belt. The Incident Report sheet dated 1/30/19 at 9:45 p.m. revealed Resident #3 sustained a laceration to her right lower extremity that measured 8 centimeters (cm) by 11 cm. The injury resulted when staff transferred Resident #3 from the bed. The sheet revealed the staff noticed a jagged area on the wheelchair foot pedal and repaired the foot pedal. The sheet revealed staff education provided due to Resident #3 transferred with assistance of one staff instead of two as per care plan. An Emergency Department Physician Notes dated 1/30/19 at 10:48 p.m. revealed Resident #3 being transferred when she slipped and hit her leg against her wheelchair. Resident #3 sustained 9 cm L-shaped laceration on the lateral aspect of the right lower leg. The skin tear required 15 stitches to repair. The note revealed the staff transferred Resident #3 with assistance of one staff when two staff required. Resident #3 prescribed [MEDICATION NAME] (antibiotic) 500 milligrams by mouth 3 times a day for 7 days. A written statement by Staff A dated 1/30/19 revealed Staff A transferred Resident #3 with a gait belt by herself, noticed the skin tear, summonsed the nurse, and discovered the wheel chair leg connection is what caused the injury. During an interview 4/3/19 at 2:54 p.m. Staff A (Nurse Aide) stated she worked the evening shift on 1/30/19, she normally removed the foot pedals from the wheel chair but didn't that night and that is what she hit the resident's leg when she transferred her by herself from the wheel chair to her bed, she noticed the skin tear on her leg, put the call light on, applied pressure to the area then went to get the nurse when no one answered the call light. She had been instructed to follow the resident's care card and staff should follow the care card. During a subsequent interview on 4/4/19 at 1:55 p.m., Staff A stated the resident was normally in bed before 8:00 p.m., it was late, between 9:30 p.m. and 10:00 p.m., she made a poor decision to transfer the resident by herself and knew the resident required 2 staff assist for transfer. A call light report provided by the administrator on 4/4/19 at 11:40 a.m. revealed there were no call light activations from the resident's room on 1/30/19. During an interview on 4/4/19 at 2:36 p.m. Staff C (Licensed Practical Nurse) stated she worked the evening shift on 1/30/19, between 9:45 p.m. and 10:00 p.m. Staff A summoned her to Resident #3's room. Staff C observed a large skin tear on the right lower leg with minimal drainage but required stitches. She stated Staff A could have asked her for help with the transfer but didn't, Staff A was upset and told her she transferred the resident by herself. A Progressive Discipline form dated 1/30/19 stated Staff A had not followed the plan of care when she transferred Resident #3 and resulted in a skin tear that required stitches, the employee educated at the time and additional education provided by management after the incident. During an interview on 4/7/19 at 3:20 p.m. Staff B (Nurse Aide) stated she worked the evening shift on 1/30/19 on the resident's hall. She was familiar with the resident and knew she was a transfer of 2 staff with a gaitbelt. During an interview on 4/4/19 at 11:30 a.m., the Assistant Director of Nursing (ADON) stated the resident closet contained care cards and she expected the staff to review the care card every shift. During an interview on 4/3/10 at 10:38 a.m., the Director of Nursing stated an expectation of staff to follow the care cards. The Director of Nursing reported Staff A failed to follow the care card directives and Staff A received discipline. During an interview on 4/4/19 at 11:30 a.m., the Assistant Director of Nursing (ADON) stated the resident closet contained care cards and she expected the staff to review the care card every shift. During an interview on 4/3/10 at 10:38 a.m., the Director of Nursing stated an expectation of staff to follow the care cards. The Director of Nursing reported Staff A failed to follow the care card directives and Staff A received discipline. On 3/1/19, staff were directed to apply [MEDICATION NAME] (a soft, sleeve-shaped garment that reduced swelling and provided some protection from minor skin injuries) applied to both lower legs in the morning, and removed at bedtime. On 3/27/19, staff were also directed to apply arm sleeves (a soft, loose-fitting sleeve applied to the arm for skin protection) at all times except bathing. The facility's Mini Card Plan (ADL card) policy and procedure, dated 5/16/18, directed that a mini version of the care plan, also referred to as an Activity of Daily Living (ADL) card, was established for each resident, maintained in the resident's closet and at the nurse's station, and staff were to review the mini care plan card to provide the care as directed by the care plan. The Wound Weekly Observation Tool forms revealed: a. On 1/30/19, skin tear that measured 8.0 cm long, 11.0 cm wide, with moderate amount of bloody drainage resulted when resident transferred from wheel chair to bed, sent to the ER for treatment b. On 2/17/19, the wound worsened, measured 6.0 cm by 3.0 cm with small bloody drainage, the skin around the wound red/irritated, physician order [REDACTED]. c. On 3/20/19, the wound worsened with granulation and slough tissue present, measured 3.7 cm by 1.2 cm by 0.3 cm deep and required mechanical debridement (removal of necrotic tissue) by a wound care specialty company nurse. d. On 4/3/19, the wound improving, measured 3.0 cm by 0.6 cm by 0.1 cm depth, with small serous drainage, cleansed daily with normal saline, [MEDICATION NAME] gel applied to wound, covered with [MEDICATION NAME] gauze, performed daily and as needed. During an interview on 4/3/19 at 11:01 a.m., Staff F (Licensed Practical Nurse/Wound Nurse) stated she didn't follow the resident's wound care until 3/20/19 when the right lower leg wound was debrided by the wound care company's nurse, and wound healing was slowed by infections that required treatment with antibiotics.

Based on record review and interviews the facility failed to provide adequate supervision to prevent accidents for 1 of 3 sampled. Concerns identified for Resident #3. The facility reported a census of 88. Findings include: According to the Admission Record dated 6/19/18 Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 required extensive assistance of two staff with bed mobility, transfers and toilet use. Resident #3 had frequent bowel and bladder incontinence. The Fall Assessment Tool dated 10/9/18 revealed Resident #3 had a moderate fall risk. The ADL Card (Care Card) dated 5/28/18 directed the staff to provide assistance of one staff with a gait belt and a wheeled walker for transfers, walk to and from the bathroom, assist to toilet every two hours and as needed during the day, prefers a urinal overnight, incontinent overnight and check and change every two hours overnight. The Progress Note dated 6/18/18 revealed the staff found Resident #3 at 5:30 a.m. lying on the left side on the floor. Resident #3 unable to extend left leg without pain, had a skin tear and swelling to the left elbow and reported I bumped my head for a minute. Resident #3 transported to the emergency room . The Fall Scene Investigation Report dated 6/18/18 at 5:30 a.m. revealed the staff found Resident #3 on the floor outside the bathroom door. The report revealed the staff last observed Resident #3 in bed at 5:15 a.m. and last toileted Resident #3 at 2:45 a.m. The immediate intervention revealed the facility provided staff education regarding toileting every two hours. The pelvis and left lateral hip final x-ray report dated 6/18/18 revealed Resident #3 sustained an acute intertrochanteric [MEDICAL CONDITION] femur. The Major Injury Determination form dated 6/18/18 revealed the physician determined Resident #3 sustained a major injury. An interview on 10/10/18 at 8:53 a.m. Staff A (Nurse Aide) reported he/she did not recall Resident #3. Staff A did not recall being asked about this incident by the Administration. Staff A reported he/she checks the care cards in the closets at the beginning of each shift because they change all the time. An interview on 10/10/18 at 2:47 p.m. Staff B (Charge Nurse) reported she did not recall Resident #3. Staff B reported on the overnight shift the staff follow the care cards. Staff B reported the care cards specify if the resident needs toileted or a check and change. An interview on 10/10/18 at 11:24 a.m. Staff C (Assistant Director of Nurse) reported she talked to Staff A and B after the fall and believed the Investigation Report to be accurate. Staff C did not know who saw Resident #3 at 5:15 a.m. Staff C reported the care plan was not followed and disciplinary action was taken and all staff received education on 6/19/18 and 6/21/18. Staff C reported had the staff followed the care plan, it's possible the fall could have been prevented. The facility correction date is 6/21/18 following a mandatory staff meeting reviewing resident care plans.

The following information relates to investigation of # -C, # -C and # -I. Based on record review and staff interviews the facility failed to provide adequate supervision for 3 of 4 sampled. Concerns identified for Residents #1, #2 and #4. The facility reported a census of 75 residents. Findings include: 1. The Admission Record dated 5/26/17 revealed Resident #2 had [DIAGNOSES REDACTED].#2 resided on the special care unit. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 had severe cognitive impairments. Resident #2 required extensive assistance of two staff with transfers. Resident #2's ability to focus fluctuated. Resident #2 had physical behaviors including hitting/kicking/pushing/scratching/grabbing and or abusing others which occurred 1 to 3 days a week. The ADL (activities of daily living) Card dated 4/28/17 directed the staff to transfer Resident #2 with assistance of one to two staff. The resident was able to propel self short distances in the wheelchair (with staff to assist as needed). Resident #2's plan directed staff to check for his/her location/safety (every) 15 minute. Resident #2 wears a wander-guard and when anxious or looking for spouse, staff are to provide comfort and reassurance as the resident had exit seeking behaviors. Staff were informed Resident #2 had a potential to strike out. The Care Plan updated 1/13/17 directed the staff to keep Resident #2 away from Resident #1 due to a history of altercation. A progress note dated 4/13/17 at 2:32 a.m., revealed Resident #2 had increase agitation and was hitting, kicking and trying to bite. A progress note dated 4/24/17 at 2:04 p.m. revealed Resident #2 attempted to wander into other residents rooms when up in wheelchair. 2. The Admission Record dated 5/26/17 revealed Resident #1 had [DIAGNOSES REDACTED]. Resident #1 resided on the special care unit. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had severe cognitive impairments. Resident #1 required extensive assistance of one staff with transfers. Resident #1 had physical behaviors including hitting, kicking, pushing, scratching, grabbing and or abusing others which occurred 1 to 3 days a week. The ADL (activities of daily living) Card dated 2/23/17 directed the staff to: allow Resident #1 to eat in hallway outside of the dining room with staff supervision, frequently calls out for spouse and 15 minute checks. The ADL plan informed staff Resident #1 was known to wander and can become agitated at times; if agitated and wandering, staff were to provide one on one supervision. A door alarm was used to alert staff when he/she left the room, staff to escort him/her when out of room to destination. Staff are to rotate supervision between nurse aides and nurse on unit and staff to supervise resident at all times when out of his/her room. The Incident Report dated 4/27/17 at 7:00 p.m. revealed Resident #1 placed his/her hand on Resident #2's shoulder. Resident #2 grabbed Resident #1's hand and bit through the skin of Resident #1's left thumb. The staff separated the residents and initiated one on one supervision. The staff received education on expectations. The Progress Notes dated 4/27/17 at 9:07 p.m. revealed Resident #1 had been in the common area walking towards the TV room. During the transit he/she placed his/her hand on Resident #2's shoulder and Resident #2 took Resident #1's hand and bit into his/her left thumb. The staff documented she was at the nursing station/medication room when she heard the aides separating the residents. The nurse documented Resident #1's hand was bleeding and had teeth indentions on them. The staff received education that Resident #1 needs to receive one on one escort and not distant supervision. The staff noted Resident #1's door alarm turned on. However, the alarm did not alarm when stimulated by motion. The staff contacted the physician and received an order to cleanse the skin tear (bite) with normal saline, apply triple antibiotic ointment and cover with medipore for five days. An interview on 5/26/17 at 3:25 p.m. Staff A (nurse aide) reported another staff escorted Resident #1 and then needed to go do something. Staff A had to supervise the residents in the lounge. Residents #1 and #2 were outside the lounge. Staff A observed Resident #1 walk into the back of Resident #2's wheelchair and reach out at Resident #2. Resident #2 grabbed Resident #1's left arm and bit Resident #1's left thumb. Staff A reported he/she ran over and separated the residents. An interview on 5/30/17 at 2:00 p.m. Staff B (nurse) reported he/she did not assign a specific staff to supervise Resident #1. Staff B reported as a general rule the staff person who responds to Resident #1's alarm is in charge of supervising Resident #1. Staff B reported he/she supervised Resident #1 in the hallway during the evening meal. Staff B reported the nurse stays in the dining room until the last resident leaves the dining room. Staff B did not recall who escorted Resident #1 from the evening meal. Staff B reported the staff distantly supervised Resident #1 when the incident occurred. Staff B reported the staff received education on 4/20/17 to increase supervision on the unit to prevent resident to resident altercations. 3. The Admission Record dated 5/30/17 revealed Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had severe cognitive impairments. The MDS revealed Resident #4 required extensive assistance of two staff with bed mobility, transfers and toilet use. The ADL (activities of daily living) card dated 5/3/17 directed staff provide 15 minute checks for safety, slipper socks or wear rubber soled shoes for the shower room. The care plan indicated Resident #1 needed a hi/low bed with fall mattress, body pillow on open side of the bed and soft touch call light, place call light on body pillow when in bed and encourage to remain in common area when up for supervision/safety. The Care Plan initiated on 6/22/15 also revealed Resident #4 frequently restless with many self -transfer attempts. Resident #4 required toileting assistance every 2 hours, as needed during the and overnight. The care plan directed staff to not leave Resident #4 unattended on the toilet for his/her safety. Progress Notes dated 3/4/17, 3/9/17, 3/11/17, revealed Resident #4 attempted to self transfer, and or increased restless or agitation. The Progress Note dated 3/21/17 at 8:58 p.m. revealed Staff C left the unit to make a phone call and asked the nurse in training to monitor the residents sitting around the nurse's station. When Staff C returned to the unit the nurse in training was nowhere to be found. Staff C observed Resident #4 face down on the floor with his/her legs caught in the wheelchair foot pedals. Staff C observed another resident assisting Resident #4 by holding Resident #4's arm. The nurse freed Resident #4's legs and assessed Resident #4. Resident #4 yelled he/she needed to go to the hospital. Resident #4 had constricted and fixed pupils. Staff C called 911. The Progress Note dated 3/22/17 at 1:11 a.m. revealed Resident #4 returned to the facility with no new orders. The Progress Notes dated 3/22/17 at 10:42 a.m. revealed Resident #4 bruises to the left side of the face (from the hairline to the left eye), the left shoulder, the left elbow, the left hand and the left knee. The staff administered as needed Tylenol with the morning medication pass. During an interview with Staff C, (nurse) on 5/30/17 at 3:29 a.m. revealed Resident #4 attempts to self transfer. Regarding the fall, Staff C was training a new nurse (only met her one day). Staff C asked the nurse in training to keep an eye on Resident #4. Staff C stated someone had to supervise residents sitting in the common area, that's why they are sitting there. Staff C went to main unit and when she returned Resident #4 was on the ground. Resident #4 was bleeding from the head, and wasn't making sense and her/his eyes were fixed. Staff C had Resident #4 sent to the ER (emergency room ). Staff C reported she only left the area for 5 minutes and assumed Resident #4 attempted to self transfer or bend down as he/she will do this often. Staff C stated if someone would have been there, they could have intervened. Staff C asked the nurse in training why she left Resident #4 unattended and she responded it wasn't her job (to watch residents) and this was for the aides (CNAs) to do. Staff C told everyone to work together. During an interview with Staff D, Certified Nurse Aide (CNA) on 5/30/17 at 4:14 p.m., she reported Resident #4 needed staff to watch him/her closely. Staff D reported Resident # 4 needed increased supervision and the resident will attempt to self transfer. Staff D reported at night, staff communicates with nurse and other aides so someone is supervising in the common area. An interview on 5/30/17 at 4:42 p.m. the Assistant Director of Nurses (ADON) reported she reviewed the surveillance footage and saw the nurse in training passing medications. The ADON reported she observed Resident #4 bent over in the wheelchair. The ADON reported the nurse in training walked by Resident #4 bent over and did not stop and interact with Resident #4. The ADON reported had the nurse in training stopped and helped Resident #4 probably wouldn't have fell forward.

Based on record review and interviews the facility failed to provide adequate nursing supervision to protect against hazards from self or others when a resident fell from a lift recliner during a power outage and sustained a fracture for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 72. Findings include: According to the Admission Record dated 3/24/17, Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had highly impaired hearing, unclear speech and sometimes understood by others. Resident #1 had severe cognitive impairments. Resident #1 required extensive assistance of two staff with transfers. The ADL (Activities of Daily Living) Card dated 2/23/17 directed the staff to provide assist of one with transfers; staff assist with locomotion and toilet every two hours. The Fall Scene Investigation Report dated 3/7/16 at 12:01 a.m. revealed the staff found Resident #1 on the floor in the supine position. Resident #1 complained of pain in the neck, back of the head and right leg with movement and unable to move the left leg. The report revealed the lights off due to a power outage. The recliner chair controls not working and the chair in a slightly forward position. The call lights were not working due to the power outage. Resident #1 sitting in the recliner chair prior to the fall. Resident #1 stated via gestures and mouthing that he/she slid out of the chair. The nurse aide reported the resident insisted on sitting in the recliner chair. Resident #1 transferred to the emergency room for evaluation. The Fall Progress Notes dated 3/7/17 revealed it appeared Resident #1 fell forward out of the chair. The recliner was in the up position. The power was out at the time due to severe weather. The facility provided education to staff. The hospital note dated 3/7/17 revealed Magnetic Resonance Imaging showed Resident #1 had a fracture of the second vertebra in the thoracic spine. An interview on 3/24/17 at 9:00 a.m. the Assistant Director of Nurses (ADON) reported a tornado warning started around 10:00 p.m. and the power went out at 10:30 p.m. The charge nurses cleared the warning at 11:00 p.m. However, the power remained off until 1:50 a.m. The ADON reported the staff returned Resident #1 to his/her room at 11:20 p.m. Resident #1 went to the bathroom and wanted to return to the recliner chair. Staff A showed Resident #1 the remote to the chair and that the chair would not go down. The chair was stuck in the up position. Resident #1 insisted on sitting in the chair. Staff A left Resident #1 in the recliner chair with the seat up. The ADON reported Resident #1 couldn't call for help. Resident #1 can only whisper. The ADON reported Staff A reported placing a locked wheelchair in front of Resident #1. Staff a did not check on Resident #1 from 11:30 a.m. until he/she was found on the floor at 12:01 a.m. An interview on 3/24/17 at 1:25 p.m. Staff A (nurse aide) reported the nurse called a tornado warning and instructed the aides move the residents into the hallway. Later, the power went out and the nurse instructed the aides to use flash lights to check the residents. Once the tornado warning was clear, Staff A assisted Resident #1 to the bathroom. Resident #1 normally sleeps in a recliner chair. The recliner was in the up position. Staff A showed Resident #1 the remote for the recliner would not light up. Staff A wrote on the dry erase board to tell Resident #1 the power was out. Resident #1 kept pointing to the recliner chair. Staff A put Resident #1 in the recliner chair and left the room. Staff A reported he/she locked the wheelchair in front of Resident #1. Staff A reported the recliner was not in the highest position but it was up. Staff A reported the nurse did not instruct the staff to complete frequent checks while the power was out. Staff A reported Resident #1 uses the call light up to 5 times a night to get help to the bathroom. Staff A reported he/she did not check on Resident #1 again. An interview on 3/24/17 at 3:08 p.m. Staff B (charge nurse) reported she told the staff to complete 15 minute checks on the residents during the power outage. Staff B reported the auxiliary power was running. However, the call lights did not work. Staff B reported staff from the prior shift stayed over to help during the tornado warning. Staff B reported he/she went to the room after the fall. Resident #1 gestured that he/she slid from the recliner onto the floor. Staff A reported she helped Resident #1 to the toilet at 11:20 p.m. Staff B had no knowledge of the staff checking on Resident #1 after going to the bathroom. Staff B reported Resident #1 could not summon help without using the call light. The Safety - Emergency Lights policy revised April 8, 2016 failed to direct the staff what to do in the event the call lights are nonfunctional due to a power outage.

Based on observation, record review and staff interviews, the facility failed to maintain and protect Resident #1 from hazardous personal equipment. Four residents were reviewed and the facility reported a census of 83 residents. Staff assisted Resident #1 onto a riser located on the toilet. For safety, the riser needed to be secured to the toilet. The resident reached towards the sink and the riser lifted and slid. The resident's hip fractured. Findings include: 1. Resident #1 had a quarterly MDS with a reference date of 7/23/2013 which identified the resident required one staff person to assist with toileting. The fall investigation dated 9/4/2013 at 8:30 a.m. revealed the nurse approached the resident ' s room and found the resident sitting on the toilet. The resident voiced she/he thought her/his hip was fractured. The resident voiced complaints of pain and yelled out the riser felt like it was putting pressure under the hip. The staff transferred the resident to bed with the use of a Hoyer (mechanical lift) and supported the hip with their hands. The resident described the pain as 8 on a scale of 1-10 with 10 as the worst pain. The Nurse ' s Notes dated 9/4/2013 at 8:30 a.m. reflected the resident had slipped on the toilet. The nurse contacted the physician and received orders to send the resident to the hospital for an evaluation and treatment. The hospital discharge records revealed the resident had an admission date of [DATE] for a fracture of the right femur (thigh/hip). The resident required surgery for [REDACTED]. Staff A (Certified Nursing Assistant) was interviewed on 9/25/2013 at 1:00 p.m. Staff A demonstrated what had occurred in the bathroom (on 9/4/13). The resident sat on the toilet and wanted a paper towel. Staff A handed the resident the paper towel. The resident then reached with her/his right hand over to the sink. The resident had her/his left hand on the grab bar. When the resident reached to the right, the toilet riser slid with the resident to the right. Staff A stood facing the resident on the resident ' s right side. Staff A stated when she saw the resident start to fall, she grabbed the gait belt and kept the resident from falling to the floor. The riser moved with the resident and Staff A described the riser as not secured. Staff A stated she did not check the riser each time prior to transferring the resident onto the toilet. Staff A stated the resident ' leg was in an awkward position and externally rotated. Observation on 9/24/13 at 1:50 p.m. revealed the toilet riser in Room 23 not secured to the toilet. The Administrator present during the observation reported the staff check the risers before placing the residents on the toilet and tighten the riser if it is loose. Observation on 9/24/13 3:31 p.m. revealed the toilet riser in Room 23 not secured to the toilet. Observation on 9/25/13 at 9:41 a.m. revealed the toilet seat riser in Room 23 not secured to the toilet. The surveyor moved the seat riser side to side and lifted it up off the toilet. On 9/25/13 at 12:03 p.m. the Administrator was interviewed and reported she had the maintenance staff check the toilet seat riser in Room 23 after the observation on 9/24/13. The maintenance staff checked the seat riser and had to change it because it was not secure. On 9/25/13 at 1:40 p.m. the Administrator reported the facility educated the staff to check the toilet seat risers prior to placing the residents on the toilet on 9/19/13 at an in-service. The CNA MEETING agenda for 9/19/13 revealed a directive to make sure to tighten the toilet seat riser before sitting the resident on the toilet. The sign in sheet revealed Staff A attended the meeting.

The following information relates to investigation of # -I. Based on clinical record review and interviews, the facility failed to implement interventions and provide adequate supervision designed to prevent accidents for 1 of 6 residents reviewed. Resident #6 fell and sustained a fractured left hip, subdural and subarachnoid hemorrhage; and subsequent death when staff failed ensure care plan interventions were in place at the time of the fall. The facility reported a census of 79 residents. Findings include According to the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had [DIAGNOSES REDACTED]. The MDS with the assessment reference date of [DATE] revealed Resident #6 required extensive assistance of one staff with bed mobility, transfers, dressing, toilet use and personal hygiene. The assessment determined Resident #6 unsteady and only able to stabilize with staff assistance when moving from seated to standing position, when walking, when moving from surface to surface transfer (transfer between bed and chair or wheelchair). Resident #6 used a walker and wheelchair for mobility. The ADL Care Card sheet updated [DATE] directed the staff to use a hi/low bed, a floor mat and non skid slippers at all times. The sheet updated on [DATE] directed staff to use a body pillow with a soft touch call light on the edge of the bed. The Care Plan with a start date of [DATE] directed staff to transfer with assist of one and a wheeled walker for safety. The care plan identified the resident had a potential for falls related to weakness and periods of confusion and directed the staff to implement the following interventions: a. see ADL care plan for transfers and ambulation status. Non skid footwear for all transfers. bXXX[DATE] -non skid slippers on at all times in bed c. Keep bed in lowest position with wheels locked. dXXX[DATE] - hi-low bed with floor mat. e. [DATE]- body pillow with soft touch call light on edge of bed. Nurse's notes dated [DATE] at 11:30 a.m., documented Resident #6 had been alert and had no complaints of pain or discomfort. The resident ' s speech was clear and he/she was able to make his/her needs known. The notes documented resident requires 1 to 1 ext (extensive) assistance with transfers, toileting and dressing and used a wheelchair for mobility propelled by staff. Nurse's notes dated [DATE] (no time) (written by Staff F) identified a CNA approached the nurse and informed her Resident#6 was on the floor in his/her room. The note documented Resident #6 was not responsive when initially assessed, blood surrounded the left side of his/her face and his/her left eye was swollen shut. The nurse was unable to assess the lower or upper extremities due to possible neck concerns and 911 was immediately called. The nurse asked for assistance from the other nurse who applied pressure to the resident ' s eye area. The resident was not able to respond to the nurses for several minutes, and after several minutes followed with only small commands but not verbal (responses) compared to his/her normal. The Incident Report dated [DATE] at 9:10 p.m. revealed the staff found Resident #6 lying on his/her left side on the floor. Resident #6 did not respond to verbal stimuli. The staff noted blood around his/her head and the left eye swollen shut. The Incident Report revealed the bed not in the lowest position and the mat not in place. The emergency Medic report dated [DATE] documented the following: on [DATE] at 9:13 they received a call from the nursing home and responded to Resident #6's fall. The medics documented the roommate stated he/she heard a thump. The medics documented the nursing home staff reported they witnessed the resident lying on the hard ground not responding and had a golf ball size hematoma with a laceration on the left side of his/her head and his/her left eye swollen. The medics reported the resident had been transported to the hospital with little to no change in his/her condition. The hospital history and physical dated [DATE] documented Resident #6 had been found on the ground with caked blood over his/her scalp and had been brought into the emergency room . The impressions identified a small subdural and subarachnoid hemorrhage, avulsion fracture of left greater trochanter, laceration of left temporal area, and hematoma over the left eye. The hospital determined the resident would be admitted although the physician did not think he/she would be a surgical candidate for the hip issues. The hospital would be transferring the resident back to the nursing home once his/her pain was under control. The hospital discharge summary dated [DATE] identified after his/her admission; he she remained stable and had suddenly ceased his/her respiration. Since the resident had a DNR (Do Not Resuscitative) preference per his/her family ' s request, no resuscitative measures were initiated and he/she expired at 12:28 p.m. on [DATE]. An interview on [DATE] at 10:40 a.m. the physician was interviewed and was aware Resident #6 had a fall and some interventions were not in place. The physician called the hospital and the nurse at the hospital informed him/her that Resident #6's cardiac enzymes were elevated. The Physician reported it was questionable if Resident #6 had a heart attack or not. The Physician indicated that Resident #6 may have had stress on the heart after the fall that elevated the cardiac enzymes. The Certificate of Death revealed Resident #6 immediate cause of death from acute cardiac arrhythmia. The underlying cause of death was acute fall with left hip fracture and subdural hemorrhage. Interviews: An interview on [DATE] at 12:16 p.m. Staff A, licensed practical nurse (LPN) reported assisting Resident #6 to his/her room after supper and left him/her on the edge of the bed. Staff A told Staff G that he/she left Resident #6 on the edge of the bed with the bed in the high position. After the incident, Staff A stated she had been called to assist in the resident's room around 8:30 p.m. to 9 p.m. Staff A reported she noticed blood on the floor when she entered the room and the resident remained on the floor until the medics arrived. During an interview with Staff G (LPN) on [DATE] at 3:15 p.m., she reported Staff A (LPN) informed her she had left Resident #6 on the edge of the bed. Staff G stated she did not know why Staff A had left Resident #6 like that so she went to the resident ' s room right away. Staff G stated she helped Resident #6 to his/her bed and elevated the head of the resident ' s bed and handed him/her the call light. Staff G reported she was unaware Resident #6 needed the body pillow or the fall mat. Staff G stated she remember the bed was at knee level as she had bent down to give Resident #6 the call light. Staff G stated she did not put the mat and pillow in place and left the room. Approximately 15 minutes later she answered the call light in bathroom and Resident #6 had been on the toilet. Staff G stated Staff B came in and took over. Staff G told Staff B to not leave Resident #6 unattended on the toilet, and Staff B responded the resident was fine. Staff G asserted it was not fine and Resident #6 asked her not to be so hard (tough) on Staff B. Staff G left to answer another resident ' s call light. Staff G reported before she left that night Staff B told her everyone was in bed except for one resident. Staff G stated at the time of the incident she was unaware of the fall interventions because she was a new staff. Staff G had been hired on [DATE]. An interview on [DATE] at 2:13 p.m. Staff F, licensed practical nurse (LPN) reported responding to Resident #6 on the floor. Staff F stated she had been told by Staff E that Resident #6 was on the floor. Staff F found Resident #6 on his/her left side and was uncertain of the resident's injuries so she did not move Resident #6 until the medics arrived. Staff F reported the bed was not in the lowest position; the mat was folded in half under the bed; and the body pillow was sitting on the chair in the corner. During an interview with Resident #7 (Resident #6's roommate) on [DATE] at 2:49 p.m. he/she reported hearing a thump sound and looked down towards to floor and noticed Resident #6 on the floor at the foot of his/her bed. Resident #7 stated he/she heard Resident #6 get out of bed and fall, and reported it was loud. A written statement by Staff B dated [DATE] documented after supper Staff A informed him Resident #6 needed to use the bathroom. Staff B documented he went to the resident's room and assisted him/her from the bed to wheelchair using a gait belt. Staff B documented he helped the resident sit on the toilet and handed him/her the call light and left. Staff B documented he asked the resident to pull the call light cord when he/she was ready. Staff B documented within 10 minutes Staff G informed him not to leave resident's unattended as he/she may attempt to self transfer. Staff B documented he was unaware of this and within 5 minutes he had returned to assist Resident #6. As Staff B was assisting Resident #6 in getting ready for bed the nurse (Staff G) entered Resident #6's room and handed Staff B cream to be applied during peri-care. Staff G left the room and after Staff B assisted the resident's clothing, he asked the resident to return to bed and helped him/her back into bed in the same position he had found him/her before he had taken the resident to the toilet. An interview on [DATE] at 10:20 a.m. the Administrator reported that he/she conducted an investigation of the incident. It was determined that Staff A left Resident #6 unattended on the edge of the bed. This happened earlier in the shift. Staff A did not put the bed in the lowest position. Staff A told Staff G he/she left Resident #6 on the edge of the bed. Staff G immediately went to the room and elevated the head of the bed and put Resident #6's legs in the bed. Staff G left the room without putting the bed in the lowest position and putting the mat in place. Later in the shift, Staff B assisted Resident #6 to the bathroom and left him/her unattended on the toilet. Staff G answered the call light and found Resident #6 unattended. Staff G told Staff B not to leave Resident #6 unattended on the toilet. Staff B assisted Resident #6 back to bed in the same way he found him/her. The Administrator stated that Staff B did not put the bed in the lowest position, no body pillow in place and he did not put the floor mat in place. The Administrator reported 3 staff had not followed the resident's care plan. An undated document titled Addendum to Resident #6's fall documented Staff B had failed to put the floor mat in place as well as lower the bed upon putting Resident #6 to bed that night. The document identified the facility as ADL Care Cards that are derived from the care plan and Staff B reported to the Administrator that he knew where the ADL cards were, but did not look at the care cards. An interview on [DATE] at 9:42 a.m. Staff C reported she look at the care plan if she need to know how to care for the residents. Staff C indicated when a new intervention is implemented the nurse informs them in report. An interview on [DATE] at 10:05 a.m. Staff D reported the nurse tells them in report when there is a new intervention. Staff D indicated the staff was directed to check the care plans at the beginning of each shift.

Based on clinical record review and staff interviews, the facility failed document urine output from a Foley catheter for one resident reviewed. The facility census was 80 residents. (Resident #4) Findings include: 1. According to physician orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified the resident with a urinary tract infection and symptoms of [MEDICAL CONDITION] and required staff assistance with most activities of daily living. The care plan dated as last reviewed on 3/28/12 identified the resident required an indwelling catheter related to [MEDICAL CONDITION] and directed staff to monitor urinary output every shift. Record the amount, type, color and odor and observe for leakage. Nurse notes dated 5/14/12 at 2:00 p.m., revealed the nurse aide reported the resident without urinary output that shift. The brief was wet and the resident complained of lower abdominal pain. Staff noted an attempt to reposition the resident to check the catheter tubing for any kinks. The 24 hour report sheet (a communication tool from one shift to another) dated 5/14/12 revealed day shift documented the same information as in the nurse notes. The evening shift documented little output in the catheter bag and witnessed urinating into the toilet. The night shift document an output of 950 milliliters (ml). The resident's intake/output record dated May 2012 revealed zero output for day shift, "went in toilet" for evening shift and 800 ml for night shift. During interview on 5/17/12 at 10:15 a.m., the DON reported the nurses on second and third shifts should have documented an assessment in the nurse notes regarding the urine output on 5/14/12. During interview on 5/17/12 at 11:20 a.m., Staff A, LPN reported when he/she cared for the resident on 5/14/12, they did not recall first shift reporting the problem with the lack of urine output and did not monitor it, that if it had been reported, would have checked the amount and charted in the nurse's notes, the 24 hour sheet and the intake/output sheets.

The following information relates to the investigation of # -C. Based on clinical record reviews and interviews, the facility failed to provide nursing provisions with assessment for one (1) of six (6) residents reviewed (Resident #3). The facility staff failed to adequately assess Resident #3's diabetic condition and intervene in response to the resident's symptoms which resulted in hospitalization for critical glucose level. The facility reported a census of 79 residents. Findings include: According to the admission physician's orders [REDACTED]. The physician's orders [REDACTED].= none, 151 - 200 = 2 units, 201 - 250 = 3 units, 251 - 300 = 4 units, 301 - 350 = 5 units and 351 - 400 = 7 units). The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Nurses Notes dated 2/12/12 at 1:00 a.m. revealed Resident #3's vital signs: 93.6 degrees Fahrenheit, pulse 70, respirations 20, blood pressure 130/70 and pulse oximetry reading of 94%. Resident #3 had confusion, unable to answer questions and occasionally responded when name called out. Resident #3 hollering out in pain in two minute intervals. Skin tear noted on the left wrist. The resident had body spasms. Staff notified the physician of the change in condition. The staff received an order to administer Tylenol 650 milligrams (mg) as needed and if not effective administer [MEDICATION NAME] 5/500 mg every six hours as needed. If no change, notify the physician again. The staff placed another body pillow in the bed to prevent further harm. The Nurse's Notes dated 2/12/12 at 2:20 a.m. revealed Resident #3 fell out of bed. The staff notified the physician and sent Resident #3 to the emergency room for evaluation. The emergency medical service transported arrived at 2:00 a.m., to transport Resident #3 to hospital. The Nurse's Notes dated 2/12/12 at 5:10 a.m. revealed Resident #3 admitted to the hospital with [REDACTED]. The hospital admission record documented on 2/12/12 Resident #3 had episode of unresponsiveness and [DIAGNOSES REDACTED]. The report documented today the resident was found on the floor unresponsive and blood sugar was checked and it was low. The resident was transferred to hospital for further evaluation. In the emergency room , the resident was unresponsive and unable to follow commands and found to have blood sugar of 28 and hypothermic. The resident received [MEDICATION NAME] in the emergency room . The Emergency Department Physician Notes dated 2/12/12 at 2:35 a.m. revealed Resident #3 had a low temperature of 94.7 degrees Fahrenheit. At 3:10 a.m. a lab draw showed Resident #3 had a critical glucose level of "28". The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The staff did not administer the sliding scale insulin. At bedtime the staff administered the [MEDICATION NAME] N 10 units SQ as ordered. During an interview with Staff I, CNA on 2/29/12 at 6:36 a.m., she reported being assigned to work with Resident #3 and he/she was yelling the night of the incident. Staff I reported Resident #3 started yelling around 12:30 to 1:00 a.m., and she described Resident #3 ' s body as twitching with his/her muscles were spasms and reported the resident was restless in bed. Staff I reported she thought the resident was going to have a [MEDICAL CONDITION], based on the way he/she was jerking and moving non-stop. Staff I reported Staff G and Staff A came into Resident #3 ' s room and Staff A brought Resident #3 ' s chart into the room. Staff I reported no one knew anything about Resident #3. During an interview with Staff A,( LPN) on 2/29/12 at 6:44 p.m., she reported she had never cared for Resident #3 prior to this incident. Staff A reported she asked the CNA (Staff I) to alert Staff G (LPN). Staff A reported Staff G did not know Resident #3 either. Staff A reported Staff G completed an assessment and she got the resident's chart and informed Staff G of Resident #3's diagnoses, diabetes mellitus, dementia, failure to thrive. Staff A reported Resident #3 had been flailing (thrashing) around in bed. Staff A reported the treatment cart was obtained and the doctor was notified, the CNA stayed with the resident and she went back to her hall. An interview on 2/28/12 at 3:27 p.m. Staff G, LPN reported he/she did not know Resident #3 had a [DIAGNOSES REDACTED]. Staff G verified he/she did not check Resident #3's blood glucose level. Staff G reported this was her first encounter with Resident #3. Staff G reported she asked whether Resident #3 had come back from the hospital and was told no, and the resident had received 10 units of insulin at the hospital.

Based on clinical record review and staff interviews, the facility failed to ensure Resident #1 received adequate nursing supervision. The facility failed to provide interventions to keep Resident #1 safe and free from injury. The facility reported a census of eight four (84) residents. Findings include: Record review identified Resident #1 admitted to the nursing home on 08/05/2010. The Resident Care Sheet informed staff Resident #1 had a risk for falls and directed staff to not leave unattended. According to the admission Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had [DIAGNOSES REDACTED]. The assessment identified Resident #1 had impaired cognitive skills for daily decision making. The resident's impaired cognitive skills revealed his/her decisions were poor and s(he) required reminders, cues, and supervision in planning, organizing and correcting daily routines. The assessment established Resident #1 had both short and long term memory deficits yet had the ability to make him/her(self) understood and usually understood others. The MDS documented s(he) required extensive assistance of two staff for transfers and toilet use, and had frequent bowel and bladder incontinence. During a test for balance the resident could not stand without physical assistance and demonstrated s(he) was unstable, but could rebalance him/her(self) as required for balance while sitting. The MDS documented Resident #1 fell within the previous 30 days. The RAP (resident assessment protocol) date 08/16/2010 documented Resident #1 had significant cognitive impairment due to dementia, continues to try to get up independently and had multiple falls. The resident wandered, fell in the past 30 days and used psychotropic medication. The resident needed close monitoring while awake as resident tended to get up independently. The resident had multiple falls since admission, used a lap buddy that he/she could remove, and also had a hi-low bed and a floor mat for safety. The resident moved to the special care unit on 08/17/2010. The Fall Risk assessment dated [DATE] documented Resident #1 scored 17 points representing a high risk for falls. Resident #1's Care Plan with the goal date of 11/24/10 documented a concern related his/her cognitive loss, and this affected his/her ability to communicate. The care plan identified the resident with Dementia and directed staff to provide 24 hour supervision, assistance with activities of daily living (ADL) in the special care unit, and a wander-guard due to history of wandering. Resident #1 had another care plan to address his/her potential for falls as s(he) had multiple falls recently. The goal addressed the resident's poor decision making skills and safety awareness and that the resident used psychotropic medications. The goal directed staff to frequently monitor the resident while s(he) was awake, and provide assistance as needed. The goal directed staff to ensure that when the resident was in common areas, to provide increase supervision. The care plan documented the following: 8/8/10, Resident #1 uses a lap buddy when up in the wheelchair and the resident could remove the lap buddy independently. The care plan reported Resident #1 had falls on 08/19/10 and 08/22/10. Fall/Incident Reports documented Resident #1 had a fall on 8/22/10 at 2:40 p.m. as staff observed resident lying on floor on his/her back flat in the middle of the room. Another resident reported the resident stood and fainted. Resident #1 had been sitting in a chair, no wheel chair, and aide was outside of the room, did not see the fall but came in immediately after the fall. The RN completed the first neurological assessment and it showed the resident ' s condition within normal limits, however the second neurological assessment revealed inappropriate response. Staff notified family, emergency services and physician and the resident transferred to the emergency room . The report identified condition that could have contributed to the fall, and documented the resident had a fainting spell earlier (that morning) while another aide helped resident use the restroom. The Nurse's Notes dated 08/22/2010 at 2:40 p.m., Staff C, RN (registered nurse) documented Resident #1 stood and fell to the ground. Another resident observed that the resident fainted. The resident stated he/she hit head but without other injuries. Neurological checks done, notified family, and physician ordered frequent neurological checks. At 3:10 p.m. Staff C documented the resident did not respond to questions, and family and physician called. The POA (power of attorney) requested a scan. At 3:20 p.m. Staff C documented the resident began seizure activity and EMS transferred the resident to the emergency room . Staff A told Staff C the resident had a fainting spell that morning, and he/she reported the incident to nurse (Staff G). The History and Physical final report dated 08/22/2010 documented Resident #1 had a fall at the nursing home and brought for what was a subdural hematoma. The report documented the resident had an unwitnessed fall and not speaking briefly post fall. The CT scan of the head showed a small subdural hematoma on the left parietal lobe. The resident was then admitted for observation until aphasia resolved and s(he) was able to communicate very well, moving both extremities, and not lethargic or drowsy. The resident had an underlying history of congestive heart failure with a poor ejection fraction, dementia, and hypertension. The Discharge Summary documented the resident left the hospital on [DATE] and returned to the nursing home with a stable subdural hematoma. The physician and family determined the resident was not a surgical candidate. The nurse's note identified on 8/27/10, the resident passed away. Clinical Record review identified the prior falls for Resident #1: a. 08/05/2010 at 7:50 p.m. the Fall/Incident Report documented staff caught the resident as he/she stood up from the recliner, leaned over and started to fall forward. Staff lowered the resident to the floor. The intervention put in place after management review documented staff would monitor the resident for adjustment, as s(he) had just been admitted . The nurse's note dated 8/5/10 described the incident as follows: the resident had been sitting in a recliner in the TV room and had attempted multiple times to get up by him/her(self) and staff redirected him/her back to his/her chair. The nurse documented the resident stood up by him/her(self) and as s(he) started to fall, the nurse lowered the resident to the floor. b. 08/08/2010 at 4:45 p.m. the Fall/Incident Report documented staff found resident lying on the floor in front of the nurse ' s station with no apparent injury. The resident stated s(he) tried to get up and fell . The nurse's note dated 8/8/10 from 6 a.m. to 2 p.m. documented resident in the recliner, and constantly attempting to stand up. The staff documented the only successful method was 1:1, and Resident #1 enjoyed talking with staff. The staff documented the resident required little redirection when 1:1 had been provided. Another entry in the nurse ' s note documented an intervention of a lap buddy. c. 08/09/2010 at 7:30 p.m. the Fall/Incident Report documented staff found the resident laying on the floor on his/he left side in day area with head against walker. Resident had been sitting in the wheelchair. The resident sustained [REDACTED]. The resident stated he/she wanted to go his/her room and tripped. The intervention put in place after management review documented a lap buddy should be used to keep the resident safe. d. 08/12/2010 at 11:45 a.m. the Fall/Incident Report documented the resident attempted to self transfer from the wheelchair to the recliner and fell on his/her knees. The intervention put in place after management review documented needs order for lap buddy Hospice working on it (already has lap buddy) and s(he) can removed it. The other intervention suggested PT/OT evaluation e. 08/14/2010 at 5:50 p.m. the Fall/Incident Report documented staff found the resident on knees in front of bench outside the front doors. Resident stated he/she wanted fresh air. The intervention put in place after management review documented a wander guard placed and moved the resident to a secure unit on 8/17/10. The nurse ' s notes identified Resident #1 receiving 1:1 and on 15 minute checks on 8/16/10. The nurse ' s notes identified the resident learned how to removed the lap buddy. The nursing notes documented arrangements had been made to transfer the resident to a locked unit, with smaller group activity that may keep the resident busy. f. 08/19/2010 at 6:30 p.m. the Fall/Incident Report documented staff witnessed resident removed the lap buddy, reach to touch another resident, and slide down off the wheelchair. The nurse's notes dated 8/20/10 at identified Resident #1 on 15 minutes checks and had attempted several times to get up on his/her and knew how to take off the lap buddy. Interviews: During an interview on 09/21/2010 at 10:45 a.m., the Administrator reported staff should observe the TV (television) room and the alcove right outside the TV room whenever residents sit in the room. Another resident said Resident #1 stood and fainted. Staff D could not view the entire TV room from where he/she stood. Staff C, a new employee failed to post assignments for TV room supervision at the beginning of the shift. Staff should have known to supervise the TV room. After interviewing staff, no disciplinary actions were issued. The DON provided staff education. Resident #1 had a lap buddy when in wheel chair, and could sit in a regular chair without a lap buddy in supervised areas. During an interview on 09/15/2010 at 2:50 p.m., Staff C, RN reported on 08/22/2010 nothing had been reported by the previous shift regarding Resident #1's condition. Early in the shift, he/she heard a scream and found Resident #1 on the floor in the TV room and reported hitting his/her head. Another resident in the room said Resident #1 got up and fainted. While doing the second neurological assessment, the resident had a change in condition and Staff C called the family, physician and EMS. The resident began seizing and the ambulance arrived. Staff A told Staff C the resident had a fainting spell earlier in the day. Resident #1 had not been in the unit very long, had a lap buddy that he/she could remove, however it deterred him/her. One staff monitors the TV room and hall. On 09/21/2010 at 7:45 a.m., Staff C recalled Resident #1 sat in a regular chair in the TV room, not in a wheelchair. That day Staff C did not post TV room monitoring assignments, one of the staff said they had worked it out amongst themselves. Now Staff C posts the assignments. Typically, Resident #1 sat in the TV room in the wheel chair with a lap buddy on at the change of shift. During an interview on 09/20/2010 at 2:10 p.m., Staff D, CNA (Certified Nurse's Aide) reported on 08/22/2010 at around 2:35 p.m., he/she stood in the hall not far from the TV room. First shift had left and Staff D planned on passing linens. Staff D heard a resident yell that someone fell . Staff C and Staff D entered the TV room and found Resident #1 on the floor on his/her back. Staff D stated typically when second shift staff arrived, they observe the posted assignments. Staff D stated Staff C, a new nurse, had not posted assignments for that day. Staff D stated no one told her to monitor the TV room that day. Staff D stated someone monitored the TV room at all times. Staff D stated Resident #1 had a lap buddy that he/she removed easily, and no alarms. Staff D could not recall if the resident had a lap buddy or sat in a chair or the wheelchair the day of the fall (8/22/10). Staff D stated Staff A had told her that Resident #1 had a fainting spell earlier and that he/she reported it to Staff G. Staff D stated she had been told by Staff A that Resident #1 sat in the TV room alert and appeared okay prior to the fall. Staff D demonstrated to the surveyor where she had been standing in the hall at the time of the fall. The demonstration showed Staff D was unable to see the area along the wall where Resident #1 had been seated prior to the fall. During an interview on 09/15/2010 at 5:30 p.m., the DON (director of nursing) reported staff ambulated and offered snacks to Resident #1 when anxious. The DON stated Staff G failed to recall Staff A reporting the resident's fainting spell earlier in the day. The DON stated residents with a fall risk sit in the TV room and staff provide supervision to them. Staff C told the DON on 08/22/2010 at the change of shift, he/she sat at the nurse's station and Staff D stood in the hall. Neither Staff C nor Staff D witnessed the fall. Staff C had not posted TV room supervision assignments yet. Staff A said he/she told Staff G that Resident #1 had a fainting spell earlier in the day. The resident did not have a history of fainting spells. The physician recently prescribed Remeron, an antidepressant. The DON did not give Staff D a verbal counseling since the nurse had not yet issued assignments. During an interview on 09/15/2010 at 2:05 p.m., Staff A, CNA reported on 08/22/2010 he/she assisted Resident #1 to get up around 6:30 a.m. The resident did not go to the dining room for breakfast, but did go to lunch. The resident reported not feeling well, but when asked what was wrong, he/she did not know. Staff A assisted the resident to use the toilet with a walker and during the fourth trip, the resident appeared to faint. Staff A assisted the resident to sit on the bed. The resident held his/her hand to his/her head and said he/she did not feel well. At approximately 12 o'clock Staff A reported Resident #1's condition to Staff G, and Staff G replied it "was probably his/her blood pressure going up or down. " Staff A failed to recall who assisted the resident to the TV room after lunch. Staff A worked second shift as well, but switched sections. After the change of shift, Staff D monitored the TV room. As Staff A walked out of a resident's room he/she heard a loud bang and a resident yell help, and he/she observed Resident #1 on the TV room floor. Staff A stated Resident #1 had no alarms, and that no residents do in the unit, and instead someone monitors the TV room in two hour intervals. During an interview on 09/16/2010 at 9:15 a.m., Staff G, LPN (licensed practical nurse) reported Resident #1 made frequent attempts at rising from the chair and had a lap buddy that he/she removed easily. Staff constantly observed the resident. On 08/22/2010 the resident tried to get up from the chair 2-3 three times during breakfast and lunch. Staff G had to remind the resident to sit. Staff G said Resident #1 appeared fine all day, never heard anything reported, and Resident #1 never complained of dizziness or not feeling well. During an interview on 09/16/2010 at 11:10 a.m., Staff F, CNA reported working the day shift on the unit on 08/22/2010. Staff F observed Staff A assist Resident #1 in the wheel chair before lunch. Staff F heard Staff A tell Staff G something about Resident #1 having dizziness. Staff F did not know if Staff G heard Staff A. Staff F observed Resident #1 after lunch in the wheel chair with a lap buddy on. Staff F assisted the resident to use the toilet after lunch when the resident asked. During an interview on 09/21/2010 at 8:45 a.m., Staff H, CNA reported on 08/22/2010 he/she observed Resident #1 before lunch when Staff G asked Staff H to lay Resident #1 down. Resident #1 always had a lap buddy on when up in the wheel chair, and staff always supervise the TV room. During an interview on 09/21/2010 at 10:30 a.m., Staff B, CNA reported on 08/22/2010 he she worked second shift. TV monitoring assignments had not been posted yet. As Staff B passed linens and assisted residents use the toilet, he/she heard a resident yell for help. When Staff B responded to the call for help, Staff D had already entered the TV room. Since the incident, TV room monitoring times are posted. During an interview on 09/20/2010 at 2:30 p.m. Staff E, CNA reported working days on the unit on August 22, and did activities with the residents. In the afternoon, Resident #1 sat in the wheel chair along the wall next to Staff E. Staff E indicated the resident appeared alert and talked about going to Pleasant Valley and needed to gas up the truck. Staff E always let's staff know when he/she left the TV room, but failed to recall who he/she told on 08/22/2010. Staff E failed to recall if the resident had a lap buddy on. The care plan directed staff to provide supervision when in common areas. The facility had no staff member assigned to provide the necessary supervision. The nurse failed to post the staff responsible for ensuring Resident #1 received the safety interventions necessary. The facility failed to provide reassessment to keep the resident safe and free from injury.