Every finding on record at Deerfield Health Care Center

Based on clinical record review, hospital record review, internal incident investigation documentation, family and staff interviews, the facility failed to adapt safety interventions in response to cognitive changes for 1 of 3 residents reviewed for falls (Res #1). The facility reported a census of 23 residents. Findings include:The Minimum Data Set (MDS) of Res #1 dated 9/11/25 identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment (possible score of 0-15).The MDS of Res #1 dated 12/10/25 identified a BIMS score of 11/15.The MDS of Res #1 dated 3/10/26 identified a BIMS score of 10/15, a continued trend of lower scoring, indicating worsening cognitive impairment.The Comprehensive Care Plan of Res #1 identified a Focus Area of Impaired Cognitive Function or Impaired Thought Process, dated 10/13/25. The Care Plan directed staff to monitor/document/report any changes in cognitive function. The Care Plan identified a Focus Area of Activities of Daily Living (ADL) performance deficit, dated 9/5/25 with a revision date of 9/26/25. On 9/26/25 the Transfer assistance intervention was documented as using a Stand Aid (non mechanical lift) with one staff member assistance. On 4/23/26, the intervention changed to direct staff to use two staff member assistance using the EZ stand (stand up mechanical lift). On 6/11/26, the Care Plan was updated to two staff assistance with Hoyer (full body mechanical lift). And on 6/15/26, the Care Plan was updated to include 'Lift Recliner - Supervision/Assist'. Prior to the 6/15/26 notation, the Care Plan failed to address the fact that the resident had a lift recliner. A nursing note dated 5/31/26 documented a Certified Nurse Aide (CNA) had responded to Res #1's call light and the resident was found on the floor. After staff positioned the resident onto her back, a deep laceration on her forehead and a second laceration on the bridge of her nose were seen. Emergency services were called as well as the resident's daughter and the resident was sent to the Emergency Room. The note documented emergency services stabilized the resident placing a c-collar (cervical collar - a medical device worn around the neck to support the spinal cord, restrict head movement, and immobilize the cervical vertebrae) on her and used a backboard (a rigid, flat device used by emergency responders to immobilize a patient's spine during transport) to transfer her onto a gurney.The Investigation Summary provided by the facility documented a CNA entered the room of Res #1 approximately two minutes after the resident had pushed her call light. The CNA found the resident on the floor in front of her recliner and summoned the nurse for assistance. The nurse noted the resident was lying face down on her right side with her head against her nightstand. The Summary detailed the resident's lift chair/recliner was noted to be in an elevated position and that the resident was in control of her lift chair remote and able to operate it independently. The Summary stated it appeared as if the resident may have slid out of the elevated lift chair and hit her head on the nightstand as she fell to the ground.Resident #1 underwent a computed tomography (CT) scan at the hospital (a diagnostic scan to see detailed images of bones, organs, soft tissues). The CT scan of the cervical spine indicated an acute fracture was found of the C1 vertebra (the topmost bone in the spine located at the base of the skull). On 6/30/26 at 4:30 pm, the Director of Nursing (DON) stated no safety assessment for Res. #1's use of her lift recliner had been done as there had been no reason to. She stated there was no indication she was unsafe as she was able to control her chair remote, her tv remote and her phone. On 7/1/26 at 9:09 am, the Administrator stated quarterly nursing assessments are completed which include an education/notification subsection. She stated in this section, the nurse evaluates if there are any concerns which would warrant an Occupational Therapy/Physical Therapy referral and detailed this included transfers, mobility and device safety which would include chair safety. She indicated these assessments had been completed on Res #1 on 9/5/25, 12/10/25 and 3/10/26 and she was found to be safe at her current level of functioning in all areas. Her next assessment was scheduled for 6/10/26, but the fall happened prior to that being completed. She stated there were no indications prior to that time of a change in status or a need to implement additional safety measures.A nursing note dated 3/16/26 documented the resident having confusion in the evening at dinner time stating she did not know where she was at and that she didn't eat. A nursing note dated 3/17/26 documented the resident was having an episode of twitching of the face and upper body, denied pain but refused meals. A nursing note dated 3/18/26 documented Res #1's daughter requested transportation for a scheduled cardiac appointment be cancelled due to the resident experiencing tremors and delirium. A nursing note dated 3/19/26 documented the resident had been much more confused than normal, calling her son in Minnesota telling him to come to her house for a dinner party.A 3/20/26 encounter note by the facility Nurse Practitioner documented a mini cognitive exam was performed. The resident scored 0 on a 0-5 scale (indicating a positive screen for dementia).An encounter note authored by the Medical Director dated 3/24/26 documented the provider was seeing Res #1 for an acute visit due to cognitive and behavioral changes. The note described that over the past several weeks, the nursing staff had observed the resident was not acting like herself, with worsening sundowning (state of increased confusion, anxiety, agitation that affects people with dementia, typically begins in the late afternoons) in the afternoons. He noted on a visit from a week prior, she had experienced facial and upper body twitching, which had since improved (improvement following a medication change).A 3/24/26 note documented increased confusion and delusions/hallucinations over the past week. The note stated the medical provider had ordered the resident's oxygen levels to be checked at midnight and 4:00 am for three nights.An encounter note authored by the Medical Director dated 5/26/26 documented in the history of present illness the resident had diagnoses which included a cognitive decline. He noted the decline in her BIMS scoring. A nursing note dated 5/29/26 documented a CNA reported the resident was very confused in the morning upon arising for the day, was talking about her daughter's wedding ring, but was unsure how long she was wearing it or if she was wearing it at all. An additional nursing note dated 5/29/26 documented the resident's daughter was visiting and was updated in regards to her confusion that morning. On 7/1/26 at 10:30 am, a family member of Res #1 stated the resident had a lot of confusion. She stated for the past several months, she thought it had started in March, she continued to get very confused. She described one phone call the resident made to her son who lived out of state asking him to drive around the block to look for someone. She stated there was another time she could see staff in the hallway outside of her door and thought she was hosting a dinner party. She said she got upset because she thought people were in her house and would not leave. She said the confusion came and went and sometimes she would be back to normal self. She described that the resident had begun having multiple falls a couple of years earlier, prompting her move into the Health Center from higher levels of independence within the community where she previously resided. She stated she received physical therapy but could not walk well and the more she sat in her chair, the weaker she got. She stated that on the day of the Resident's fall, she obtained a broken neck and had 11 stitches. She said her lift chair had been found up as high as it could go. She assumed that the resident tried to stand up and walk. She said the resident was unable to recall what she was doing prior to the fall. She said the resident may have picked up the chair remote thinking it was the TV remote or she could have been sitting on the chair remote. She said there was no way of knowing what happened. She described the resident's confusion as being off and on. On 7/1/26 at 1:15 pm, Staff A, CNA, stated she had worked at the facility for approximately three years. She identified she had seen changes in Res #1 such as increasing confusion and some hallucinations. She stated the resident would describe seeing things that were not there but it was off and on, not continual confusion. She stated she would at times grab the wrong remote control between the TV remote and chair remote. She stated the resident was able to pick up her cell phone and make a call but occasionally she did need to ask for help with the phone or the TV remote. She stated she often witnessed the resident raising the lift chair and she would assist her in putting it back down or instruct her to do so. On 7/1/26 at 1:22 pm, Staff B, Licensed Practical Nurse (LPN) stated she had worked at the facility for four years and knew the resident well. She stated the resident was very confused, but also described it as coming and going. She stated she had never seen any concerns with using her remote controls and had no concerns regarding her lift chair.On 7/1/26 at 1:30 pm, Staff C, Medication Aide, reported working at the facility for three years. She stated she noticed no acute changes in Res #1 but said some days she was very confused and other days were better. She described sometimes seeing her get her things mixed up but generally knew which remote was for her TV and usually had no problems with it. She stated she usually kept it on the same channel. She also reported seeing the resident lift her recliner chair up in the air by herself but stated it was not frequent and stated she normally sat in the recliner with her feet up. She also stated the resident would occasionally raise the chair slightly in order to move her table in front of her if she was playing cards or things. She stated she did not have safety concerns regarding the chair. On 7/1/26 at 2:16 pm, Staff D, Registered Nurse (RN) stated she had worked at the facility for 12 years and worked regularly with Res #1. She stated she had become off and on increasingly confused, and stated she was sundowning. She stated urinalysis samples were run to test for urinary tract infections. She stated the resident's recliner had a pocket on the right side and she did have concerns of the resident using the remote. She stated she encouraged the resident to put the chair remote in the pocket and not have it on her lap. She felt she did at times mix up her remotes which is why she felt better if the chair remote was in the chair pocket. She stated this intervention was never care planned and there was no specific incident, but by word of mouth, it was encouraged for the chair remote to be in the chair pocket to avoid confusion. She stated that she never witnessed the resident ever lifting the chair up on her own and she did witness the resident using the chair remote appropriately to lift her feet or put them down. She stated Res #1 displayed symptoms of not knowing what day it was or the time. She stated if she had a UTI, her confusion got worse. She sometimes would not recognize her family or call them by the wrong names. She stated the resident always knew how to use her call light and she had never witnessed her attempting to transfer herself. A review of the Medication Administration Report (MAR) for March - May of 2026 was completed following the interview of Staff D. The resident was not on any antibiotic medications for treatment of a UTI during the reviewed time period. On 7/1/26 at 2:58 pm, Staff E, Physical Therapy Assistant stated he provided Physical Therapy services to Res #1 from March through May of 2026, discharging her from therapy prior to her fall. He stated she was very tired but was able to make conversations. He stated she had significant weakness and motor activity and her goals were not realistic as she really wanted to be able to walk. He stated when he would come get her or bring her back to room after therapy, he always ran the controls of the lift recliner and never witnessed her doing it herself. He stated PT does not do safety assessments for lift chairs and stated that Occupational Therapy normally will complete a safety evaluation. He voiced that Res #1 definitely was not safe to transfer herself. After reviewing Res #1's records in his computer, he reported that Occupational Therapy worked with the resident from September of 2025 through February of 2026. On 7/1/26 at 3:26 pm, Staff F, CNA stated she had worked at the facility for three years and primarily worked on the hall Res #1 resided on. She described when the resident would have episodes of shaking or twitches and then had moments of spacing out but described it did not happen frequently. She stated during her shifts (coming on at 6:00 am), she did not witness concerns with the resident using her lift chair. But she recalled she would hear about it from the afternoon/evening shift at times. She said when she transferred the resident into the chair, she would normally lay her back and place the remote to the lift chair in the pocket of the chair and give her the TV remote. She felt the resident did know the difference between the two remotes.On 7/1/26 at 3:46 pm, Staff G, Occupational Therapist, stated she would assist Res #1 in using the lift chair during transfers in and out of the chair to attend or return from therapy. She said no formal safety assessment of the resident using the lift chair had been completed. She voiced that OT primarily worked on wheelchair mobility, mobility related to completing her ADLs, sit to stand as it related to using the toilet and tolerance for standing for staff to be able to provide cares. She stated she did not note any large cognitive changes at the time she worked with the Resident (ending in February 2026). On 7/1/26 at 3:56 pm, Staff H, LPN stated he worked at the facility for the last 15 years and normally worked on the hall Res #1 resided on. He described he had noted some cognitive changes over the last few months, remembering specifically the day prior to her fall, she was very confused that day and he had reported it to her daughter but then the resident snapped out of it. He stated he did not witness the resident using her chair in an unsafe manner or have any safety concerns with the chair prior to her falling. On 7/1/26 at 4:10 pm, Staff I, CNA stated she worked the overnight shift several times a week for the last several years on the hall Res #1 resided on. She recalled the resident was initially able to use a stand aide and then declined to use the EZ stand. She reported the resident did have some confusion on her shifts and recalled when she was talking about having people over, describing a lot of people in her room, seeing things that were not there. She stated she would talk about needing to go upstairs, but then her confusion would clear up later and these episodes were on and off. She said if the resident was in the chair on her shift (she sometimes comes in at 6:00 pm rather than 10:00 pm) she would place the remote to the resident's chair in the pocket of the chair and give the resident the TV remote and her phone. She stated at times the remotes would confuse her but she was normally able to use the TV remote by herself. Staff I said the staff put the remote to the chair where the resident could not reach it. She stated at times when she would first come to work for the night shift, she would receive reports from off going staff of the resident raising her lift chair and staff putting it back down but stated the majority of the time she worked with her, the resident was already in bed when she arrived. On 7/2/26 at 8:00 am, the Medical Director recalled the episode in March of 2026 of when Res #1 had the twitching and she was not acting herself. He stated an antidepressant dosage had been raised and he lowered the dose back down and she appeared to improve after that. He felt when he saw her again in May of 2026, she was more at her baseline but did describe that her baseline was that she did have a cognitive deficit and recalled her BIMs scores declining. He said when he saw her in March, she was especially not her normal self. He was not aware of any issues with her lift chair and believed she had the chair for as long as she had resided at the facility. On 7/2/26 at 12:46 pm, Staff J, CNA stated she was a relatively new employee and had worked at the facility approximately 3 months. She said she did not know Res #1 well as she generally worked on the other side of the building. She confirmed she had cared for Res #1 on the day shift on 5/31/26. She stated she had no concerns that day and detailed that after lunch, Res #1 was assisted back to her recliner and she didn't notice anything out of the ordinary with her. She described that she had reclined the resident all the way back so she was comfortable and could rest and placed the remote to the chair in the chair pocket. She stated Staff K, CNA was the staff member who found the resident after her fall. On 7/2/26 at 12:57 pm Staff K, CNA said she had worked at the facility since October of 2025 and floated back and forth between the two halls. She felt she knew Res #1 pretty well. On the day of the fall, she stated she had just gotten onto the floor, clocking in at 2:00 pm. She stated Res #1's call light went off which was odd as the resident rarely rang for help that time of day. She said as she began to enter her room, she spoke Res #1's name to ask her what she needed but as she entered further she saw her on the floor. She described as she approached the resident, she saw blood on the carpet and then ran to get the nurse. She voiced that the normal routine of Res #1 was to be napping at that time of day. She stated staff normally placed the chair remote in the pocket of the recliner for the resident to reach for if needed. She said when she found the resident on the floor, the remote was dangling to the floor from the chair. On 7/2/26 1:13 pm, the MDS Coordinator stated lift chairs are not normally care planned unless there is a communication form regarding the chair from therapy. He stated after the fall, the lift chair was added to the care plan at that time. He was not aware of therapy placing any communication regarding the chair prior to her fall. On 7/2/26 at 1:19 pm, the Administrator stated for new admissions to the facility, on the admission sheet for a resident who would be receiving physical or occupational therapy, there is a subsection which includes chair safety. However, because Res #1 was transferred to the health care center from another part of the campus, she was not considered a new admission. Therapy had worked with her in the past and knew her so a safety assessment of the lift chair was never completed on her.

Based on clinical record review, staff interview, guidance from the Centers for Disease Control (CDC) and facility policy review, the facility failed to offer the recommended pneumococcal vaccine to eligible residents for 2 of 5 residents reviewed for vaccines (Resident #11 and Resident #13). The facility reported a census of 22 residents. Findings include: 1. The vaccine record of Resident #11 failed to reflect the resident having had any history of receiving a pneumococcal vaccine. The Minimum Data Set (MDS) of Resident #11 dated 1/23/25 documented an admitted to the facility of 3/1/22 and a date of birth of 3/2/1941. The electronic health record of the resident failed to reflect a declination form of refusing the vaccine. 2. The vaccine record of Resident #13 documented he had received the Prevnar 13 pneumococcal vaccine in 2018 and no further pneumococcal vaccines since that time. The MDS of Resident #13 documented an admitted to the facility of 10/17/22 and a date of birth of 9/26/1927. The electronic health record of the resident failed to reflect a declination form of refusing the vaccine. On 3/25/25 at 2:58 pm, the Administrator stated the facility was unable to locate further vaccine information or declinations of choosing to not receive pneumonia vaccinations for either resident. On 3/25/25 at 3:59 pm, The Director of Nursing (DON) stated the process for monitoring vaccine status of the residents is to fill out a form at the time of the resident admission to the facility. If the resident is eligible for a vaccine, and they indicate they wish to receive it, the facility will obtain the vaccine from the pharmacy or it may be done during an upcoming vaccine clinic. If the resident declines receiving the vaccine, the resident or resident representative signs a declination form indicating refusal of the vaccine. She stated staff went through the paper charts of both Resident #11 and Resident #13 and were unable to locate information on either of the residents of having received further vaccines or declining the vaccines. The CDC document titled Adult Immunization Schedule Notes, dated 11/21/24 documented the following: Age [AGE] years or older who have: Not previously received a dose of PCV13, PCV15, PCV20, or PCV21 or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21. If PCV15 is used, administer 1 dose PPSV23 at least 1 year after the PCV15 dose. Previously received only PCV13: 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PCV13 dose. The facility policy titled Infection Prevention Immunization: Pneumococcal, review date 8/1/23, documented the following: Policy Statement: [Facility] will offer the recommended pneumococcal vaccine as per Center for Disease Control (CDC), and provider ' s orders to residents unless contraindicated. Procedure: A. Upon admission, history related to immunizations is obtained from the medical information furnished by the transferring facility and from the resident and/or resident's legal representative. B. Admission Routine Orders/Clarification includes an order for Pneumococcal Vaccine per protocol. C. On admission, education is provided using the CDC Vaccination Information Statements (VIS) as reference. D. At the time of the first quarterly MDS and care plan meeting, the resident and/or resident's legal representative: 1. Receives re-education, as needed, regarding the benefits and potential side effects of the immunizations. 2. Is informed what portion of the cost for the pneumococcal vaccine the resident might be held accountable for based on his/her insurance coverage. 3. Is provided the opportunity to accept or decline the immunizations. a. The Immunization Consent form is signed by resident or resident's legal representative if he/she agrees to the immunization(s). The facility policy failed to reveal a procedure in place for monitoring the vaccination status of residents beyond the first quarterly MDS and care plan meeting.

Based on observation, clinical record review, staff interview and facility policy review, the facility failed to follow the recommended infection control precautions during catheter care for one of two (Resident #13) residents reviewed. The facility reported a census of 22 residents. Findings include: The Quarterly Minimum Data Set (MDS) of Resident #13, dated 1/9/25, documented the presence of an indwelling catheter. The MDS documented diagnoses that included renal insufficiency and obstructive uropathy (a condition where urine flow is blocked, leading to a buildup of urine in the urinary tract). On 3/24/25 at 2:35 pm, an Enhanced Barrier Precautions sign was observed on the door of Resident #13's private room. On 3/26/25 at 11:15 am, Staff A, Certified Nurse Aide (CNA) was observed emptying the urinary bag of Resident's #13's supra pubic catheter (a medical device that drains urine from the bladder directly through an incision in the lower abdomen, above the pubic bone). Staff A, CNA performed hand hygiene and donned gloves as Resident #13 self propelled himself in his wheelchair from his bedroom into his bathroom. Resident #13 wheeled himself to the handicap bar near the toilet and Staff A placed a gait belt on the resident. She assisted the resident to a standing position, and assisted the resident to lower his pants and brief and sit on the toilet. Staff A placed a paper towel on the floor and placed a graduated cylinder on the towel. Using an alcohol swab, Staff A cleansed the drain of the urine leg bag. She opened the drain and emptied the leg bag of urine into the graduated cylinder. Staff A obtained a new alcohol swab and cleansed the drain again before locking the drain. Staff A lifted the graduated cylinder and the paper towel and moved it further away from the toilet. Staff A removed her gloves, performed hand hygiene and placed new gloves on then assisted the resident to stand again. The resident self propelled out of the restroom. Staff A then emptied the urine into the toilet, rinsed the graduated cylinder, dumped the water also in the toilet and placed the graduated cylinder behind the toilet. Staff A removed her gloves and washed her hands prior to exiting the room. An isolation cart containing Personal Protective Equipment was observed in the resident room near the entrance to the bathroom. On 3/26/25 at 11:23 am, Staff A was asked about the signage on the door for Enhanced Barrier Precautions. She stated the sign means she was supposed to wear an isolation gown and that she had forgotten about that. She further stated she thought the sign had been removed for Resident #13. The State Surveyor asked what Staff A was aware of regarding Enhanced Barrier Precautions. She stated for any resident in the building who has a catheter or a feeding tube or a wound or other things, staff are to wear a gown and gloves when performing resident care. On 3/27/25 at 11:39 am, the Director of Nursing (DON) stated her expectation is for an isolation gown and gloves to be worn for any resident with a catheter, a chronic wound, etc. She stated all staff had received education regarding enhanced barrier precautions. The undated facility policy Transmission-based precautions guidelines documented the following on Page 5 of the policy: Enhanced Barrier Precautions: All residents with any of the following: Infection or colonization with an MDRO when Contact Precautions do not otherwise apply. Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. Apply gloves prior to high-contact resident care activities such as but not limited to: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care: any skin opening requiring a dressing. Change PPE and perform hand hygiene. Apply gown prior to high-contact resident care activities such as but not limited to: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care: any skin opening requiring a dressing. Change PPE and perform hand hygiene.

Based on observation, staff interview, and policy review the facility failed to properly secure medications to minimize loss or access for 1 of 1 medication carts. The facility reported a census of 25 residents. Findings include: During a continuous observation 4/24/24 at 7:05 AM the med cart on the northeast hall of the facility was left unlocked and unattended for 6 minutes by Staff A, Licensed Practical Nurse. In this time several staff (Director of Nursing (DON), and Staff B, Certified Nursing Assistant) walked past the medication cart. During an interview 4/24/24 at 9:20 AM with the DON revealed her expectation is that the med cart be locked when not with the cart. Review of a facility provided policy titled, Medication Provision-Medication Carts, with a review date of 4/26/22 documented: The Cart is to be locked when not attended by staff.

Based on personal record review and staff interview the facility failed to assure a contracted staffing agency completed the entire screen process for criminal background checks for one (1) agency staff reviewed. Findings include: According to an Iowa Criminal History Misdemeanor convictions only form dated 2.2.23 at 11:39:27 a.m. Staff A, Certified Nursing Assistant (CNA) had been arrested three (3) times as follows: a. 1st time - 2nd degree theft b. 2nd time - 4th degree theft c. 3rd time - 4th degree theft and disorderly conduct - fighting or violent behavior. A staffing agency who employed Staff A failed to appropriately pre-screen a completed criminal background check which would have resulted in the staff members ability or lack of ability through the Department of Human Services (DHS) to have worked in a long-term care setting based on her criminal history. According to an email 5.22.23 at 11:51 a.m. the staffing agency searched for the paperwork from DHS. According to an email 6.7.23 at 4:18 p.m. the Associate Executive Director confirmed the staffing agency had not provided the required documentation from DHS for Staff A. A Time Slip indicated Staff A worked on unit 200 at the facility on 2.22.23 from 10 p.m. until 6:30 a.m.

Based on observation, clinical record review, hospital record review, facility record review, staff interview, the facility failed to respond appropriately to an INR level below the target range for treatment for one resident reviewed and failed to appropriately monitor another resident's PT/INR as directed by the physician as a means to assure individual therapeutic levels. (Resident #1 and Resident #4) The facility identified a census of 22 residents. Findings include: 1. A Significant Change Minimum Data Set (MDS) assessment form dated 10/10/22 for Resident #1 documented diagnoses that included: systolic and diastolic heart failure (HF), abnormal anti-coagulant profile, atrial fibrillation (AF), respiratory failure with hypoxia and a duodenal ulcer with perforation and hemorrhage. The assessment documented the resident received an anti-coagulant (blood thinner) 3 days out of the past 7 during the look back period. A Physician's Orders with current orders as of 8/3/22 documented that the Resident#1 had a history of acute duodenal ulcer with hemorrhage and perforation (bleeding in the belly), aortic valve stenosis (clogged heart valves), gastrointestinal hemorrhage (bleeding in the intestine, and stomach). A Care Plan with a focus area initiated on 2/9/22 identified the resident as on anticoagulation therapy related to AF. The interventions included the following as dated: a. Labs as ordered. Report abnormal lab results to the MD. (initiated 2/9/22) b. Monitor/document/report to the physician as needed (PRN) signs and symptoms of anti-coagulant complications: lethargy, sudden changes in mental status and/or a significant or sudden change in vital signs. (initiated 2/9/22) A Medication Administration Record (MAR) form dated November 2022 documented a physician's order for warfarin (Coumadin) 1 milligram (mg) by mouth (po) every day (qd). (originated 10/7/22 and discontinued 11/21/22) A Nurse's Note with effective date 11/18/22 at 2:00 p.m. and Created date of 11/25/22 at 10:08 a.m. included the following entry; Late entry: As a therapist worked with the resident, she noticed resident as [NAME] than usual and reported the observation to the resident's daughter who also had been present. The nurse placed a call to the Physician who ordered a lab draw which included an INR (which had been due on 11/21/22). A Lab Results Report form with collection date of 11/18/22 at 4 p.m., received at the lab at 7:10 p.m. and reported at 8:53 p.m. documented the resident's PT (Prothrombin Test Time which measured how long it took for a blood clot to form in the blood sample) level at 18.3 and INR (International Normalized Ratio which measured if a person sustained a blood clotting problem) level at 1.6. The therapeutic range for a patient routinely anticoagulant as 2.0-3.0 and residents with a mechanical prosthetic heart valve as 2.5-3.5. The staff faxed the form to the physician's office but failed to call and address the abnormal lab values to the resident's physician and/or the on call physician. A hospital History and Physical form completed 11/27/22 documented the resident as admitted to the facility on [DATE] at 10:51 p.m. with an intracranial hemorrhage, a cerebral vascular accident (CVA) and precerebral occlusion and with the presence of a prosthetic heart valve. The resident's Certificate of Death filed 12/1/22 documented the resident passed away on 11/23/22 at 5:30 p.m. with the immediate cause of death as a stroke secondary to AF. A Notification to Physician or Family of Change in Resident Health Status policy dated 10/20/21 directed the Care Communities staff to have notified the resident's physician or designee as follows: a. An acute illness or significant change in the resident's physical, mental or psychosocial status (i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications.) The facility described nursing judgement as an integral part of the skilled care provided in the Care Communities; therefore, staff must have applied such judgment in a case-by-case basis for maintenance of an acceptable nursing practice. Some definitions included the following: b. A need for alteration in a treatment significantly such as a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or a need for initiation of a new treatment to have dealt with a problem. 2. An Admission MDS assessment form dated 10/24/22 for Resident #4 documented the resident had diagnoses which included: AF and non-Alzheimer's dementia. The MDS documented the resident had been on anti-coagulants 7 of the last 7 days in the look back period. A Care Plan with a focus area initiated on 10/17/22 and revised 10/18/22 identified the resident as on anti-coagulant therapy related to AF. The interventions included the following; a. Labs as ordered. Report abnormal lab results to the physician. (initiated 10/17/22). b. Monitor/document/report to the physician as needed (PRN) signs and symptoms of anti-coagulant complications: lethargy, sudden changes in mental status and/or a significant or sudden change in vital signs. (initiated 10/17/22) A Lab Results Report form collected 11/18/22 at 3:55 p.m., received at the lab at 8:37 p.m. and reported at 8:54 documented the resident's PT at a 20.7 ( abnormal results as indicated by the Orange text on the report) and INR at a 1.8 (abnormal results as indicated by the Orange text on the report), with the therapeutic range for a patient routinely anticoagulated as 2.0-3.0. The Physician order included the following: If on Coumadin 5 mg increase to 5.5 mg and recheck the PT/INR in one (1) week. During an interview 12/13/22 at 1:50 p.m. the Director of Nursing (DON) services indicated when staff faxed information to the physician the facility policy directed the staff to have placed the faxed forms into a binder as a reminder to follow up with the physician accordingly. The nurse, in this case, inadvertently placed the faxed form in the resident's medical record so the lab draw had been missed. During this investigation the mistake had been identified to the facility, the facility staff informed the resident's physician and a new order received to re-check the resident's PT/INR on 12/2/22. An Immediate Jeopardy (IJ) was identified on 12/14/22 and the facility was notified of the IJ at 11:30 a.m. that day. The IJ was removed later that day when the facility developed and implemented the following corrective action plan: 1. PT/INR will no longer be drawn on Fridays, if possible. If an emergency lab needs to be drawn on a Friday, the results will be called in to the on-call provider, even if they are not at a critical level. 2. Anticoagulant book implemented in order to better manage Coumadin tracking. 3. Process implementation of PT/INR draw date changes and physician notification of non critical labs drawn on Fridays. 4. Process implementation of anticoagulant book and fax process. 5 Staff educated on change in PT/INR draw guidance. 6 Staff educated on fax process The scope and severity level of the IJ deficiency was lowered from an J to an D at the time of the survey due to the need for continued monitoring after the facility completed the above removal plan.

Based on observation, clinical record review, hospital clinical record review, staff interview and facility policy review the facility failed to provide the necessary assessments for 1 of 4 residents reviewed with a condition change. (Resident #1) The facility identified a census of 22 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 10/10/22 documented Resident #1 with diagnosis the included systolic and diastolic heart failure (HF), abnormal anti-coagulant profile, atrial fibrillation (AF), respiratory failure with hypoxia and a duodenal ulcer with perforation and hemorrhage. The assessment documented the resident received an anti-coagulant 3 days out of the past 7 during the look back period. A Care Plan with a focus area initiated on 2/9/22 identified the resident as on anticoagulation therapy related to AF. The interventions included the following as dated: a. Labs as ordered. Report abnormal lab results to the MD. (initiated 2/9/22) b. Monitor/document/report to the physician as needed (PRN) signs and symptoms of anti-coagulant complications: lethargy, sudden changes in mental status and/or a significant or sudden change in vital signs. (initiated 2/9/22) A Medication Administration Record (MAR) form dated November 2022 documented a physician's order for warfarin (coumadin) 1 milligram (mg) by mouth (po) every day (qd). (originated 10/7/22 and discontinued 11/21/22) A Nurse's Note entry dated 11/18/22 at 10:08 a.m. included the following entry: Late entry: As a therapist worked with the resident, she identified resident as [NAME] than usual and reported the observation to the resident's daughter who also had been present. The nurse placed a call to the Physician who ordered a lab draw which included an INR. Review of the resident's entire clinical record failed to reveal any completed assessments from the above documented entry until staff transferred the resident to the hospital on 11/20/22 with a diagnosis of with an intracranial hemorrhage, a cerebral vascular accident (CVA) and precerebral occlusion and with the presence of a prosthetic heart valve.

Based on clinical record review, staff interview and facility policy review the facility failed to follow physician orders for 1 of 4 residents reviewed. (Resident #1) The facility identified a census of 22 residents. Findings include: A Discharge Medication Reconciliation/Orders form dated 10/4/22 at 9:52 a.m. documented Resident #1 with physician orders that included sertraline (zoloft) 25 milligram (mgs) three (3) pills by mouth (po) every day (qd). A Proof of Delivery form from the pharmacy dated 10/4/22 at 6:40 p.m. failed to address and/or validate delivery of the resident's sertraline. A Physician Fax Order Request form dated 10/7/22 included the following documentation signed by the Physician 10/7/22: Staff requested an order for a restart of the resident's sertraline 25 mg 3 tablets po qd due to a pharmacy error which had not been processed correctly. The Physician then ordered sertraline 25 mg po qd x 3 days then 50 mg po qd. A Medication Error form dated 10/4/22 at 1:44 p.m. included the following documentation: Upon re-admission to community, the facility staff sent physician orders to the pharmacy. The pharmacy staff omitted the medication sertraline during the transition. The facility staff failed to catch the omission during reconciliation of the medications. Several days passed before the resident's daughter questions the dose of sertraline. During a facility investigation staff discovered the medication as not entered despite the physician order sheet. No apparent injury noted.

Based on observations, record review, interviews and facility policy review the facility failed to complete a safety and skin assessments and failed to provide adequate supervision to prevent a burn for 1 of 3 residents reviewed for supervision (Resident #1). Resident #1 required assistance of one staff for eating. Staff left Resident #1 unsupervised with a hot cup of coffee and Resident #1 sustained second degree [CONDITION(S)] on her thighs. The facility reported a census of 25 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE] Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, indicating in intact cognitive ability. The resident required extensive assistance with the help of two staff for bed mobility, transfers and toilet use, and required extensive assistance with the help of one staff for eating. The Care Plan interventions dated 9/2/22 directed staff to encourage the use assistive devices, safety measures to reduce the risk of infection, falls, and injury, and perform a safety risk evaluation on admission, as needed and upon changes in condition. The Care Plan updated 1/11/22 directed staff to be informed of special dietary and safety needs, on a mechanical soft diet, watch for difficulty swallowing, prolonged swallowing time, repeated swallows per bite, coughing, clearing throat, drooling, and pocketing of food. A review of POC Response History printed 3/9/22 at 11:49 AM, revealed staff documented Resident #1 had a new skin issue described as a reddened area noted on 2/17/22. According to an Incident Report dated 2/19/22 at 12:03 PM, Resident #1 was found to have wounds on her inner thighs. The overnight nurse had reported to the morning shift that they discovered blisters on the thighs while checking for incontinence. Some staff suspected that the injuries had been caused by the Hoyer sling but the resident later told them that a couple of days previous, she had spilled hot coffee in her lap. The follow up action to the incident included an interventions to put 3-5 ice chips in the coffee before serving coffee and dietary staff were instructed to wait for a Certified Nursing Assistant (CNA) before delivering the residents meals. Observation and interview on 3/8/22 at 10:37 AM revealed, Resident #1 sitting in a recliner chair in her room watching television. The resident had a severe left hand contracture, her speech was soft and slurred and her bottom lip was slumped on the right side. When asked about the injury she sustained on her thighs, Resident #1 said she that she had been alone in her room with a meal on the bedside table next to her recliner and with her right hand, she picked up her coffee thermos to take a drink. When she went to put the cup back on the tray it tipped over and spilled into her lap. Resident #1 said that she had not told the staff about the spill because she didn't think that they were interested. She said that a staff person had been with her in the room when the meal had been served to her, but all of a sudden the staff person left the room. The resident did not remember the specific meal or date of the incident. A review of the Nursing Notes and Physician Notes revealed the following entries: a. A fax communication dated 2/19/22 at 4:15 AM was sent to the doctor and stated that Resident #1 was found to have blisters and redness on bilateral inner thighs. The left thigh injury measured 5 centimeters (cm) x 3 cm. with an area of redness that measure 10 cm. long. The right thigh injury measured 2 cm. x 2 cm. On 2/22/22 the doctor signed the fax with a treatment order. b. A doctor's note dated 2/22/22 showed that the resident had a fluid filled blister to the right inner thigh and the left inner thigh had a stage 2 ulcer (previous blister). The posterior left thigh had a stage 2 ulcer, previous blister. c. On 2/24/22 a doctor's note included measurements as follows: left inner thigh 3 cm x 10 cm x 0.1 and right posterior thigh 0.5 cm x 1.0 cm x 0.1 cm. d. On 3/1/22 a doctor's note indicated that the resident had 2nd degree [CONDITION(S)] (second-degree [CONDITION(S)] affect the outer layer of skin and the next layer, the dermis) Retrieved from Second-degree burn: Causes, symptoms, and treatment (medicalnewstoday.com) on 3/14/22. The posterior left thigh had a stage 2 ulcer and the left inner thigh had a stage two ulcer, initially a blister (stage 2 ulcer is shallow with a reddish base) Retrieve from Stage 2 Pressure Ulcers | Wound Source on 3/14/22. e. On 3/3/22 a doctor's note included; the left inner thigh injury measured 1 cm. x 0.5 cm. x 1 cm. The right posterior thigh injury measured 1.2 cm. x 2 cm. x 0.1 cm. A left posterior thigh injury measured 1.3 cm. x 2.0 cm. x 0.1cm. On 3/8/22 at 12:29 PM, Staff F, Registered Nurse, stated she first learned about the blisters on Resident #1 on the morning of 2/19/22 when the overnight nurse had passed on in report that they discovered the blisters during overnight rounds. Staff F said that the resident told her that she had spilled coffee on her lap but she hadn't told anyone about it at the time of the incident. On 3/8/22 at 2:26 PM, Staff B, Licensed Practicing Nurse, stated she worked the overnight shifts. She said that a Certified Nursing Assistant (CNA) came to her after doing rounds on the night of 2/18/22 and reported that Resident #1 had blisters on her thighs. Staff B said that no information about these wounds had been passed onto her at shift report. The next morning, she told the day nurse and she faxed the information to the doctor. Staff B said that she asked Resident #1 what happened but the resident hadn't responded because she was sleepy at the time. Staff B assumed that the injuries must have been from the Hoyer sling. On 3/8/22 at 2:10 PM, Staff C, Certified Nurse Aide, stated she saw the blisters on Resident #1 when she was doing rounds on the overnight shift of 2/18/22 and she passed on the information to the day shift. She said that when she told the staff about the blisters in the morning, a couple of people indicated that they knew about the injuries and that it had been caused by a coffee spill. On 3/8/22 at 2:40 PM, Staff D, Certified Nurse Aide, stated she discovered the blisters on the resident on a morning shift when she and another CNA were getting the resident up for the day. She said that they had not gotten any information about the injuries during the shift report that morning. She did not remember the date, and said that they reported the injuries to a nurse but did not remember the nurse's name. The Weekly Skin Check printed 3/8/22 at 12:55 PM, documented an assessment on 2/7/22 at 9:32 AM. The assessment documented no new skin issues at that time. The Clinical Record lacked a weekly assessment from 2/7/22 to 2/19/22. According to a policy dated 2/16/22 staff were to use the Hot Liquids Safety Assessment to determine a resident's risk of [CONDITION(S)] from hot liquids to be completed on admission/readmission, as needed and with quarterly and annual MDS assessments. Resident #1 did not have such an assessment completed until after it was discovered that she had spilled hot coffee in her lap. The assessment dated [DATE] indicated that Resident #1 was at high risk for [CONDITION(S)] and required extra precautions and interventions at meal times. On 3/14/22 at 8:27 AM, the Director of Nursing (DON), stated they did not have a Hot Liquids Safety Assessment completed for Resident #1 before the coffee spill and the expectation was that the assessment was completed upon admission, readmission, change of condition and quarterly. She said that the MDS nurse was expected to alert the nursing staff when these are due. The DON said that when they did their investigation of the burn incident they discovered that weekly skin assessments were not being completed weekly. She said that nursing staff were expected to complete these weekly and that she would oversee the process.

Based on observations, facility record review, review of guidance from the Center for Disease Control (CDC), and staff interviews, staff failed to follow CDC guidelines for appropriate personal protective equipment in a medical facility by not wearing goggles while performing resident cares when county is considered high risk. The facility also failed to screen visitors for COVID-19 immediately upon entrance to the facility. The facility reported a census of 23 residents. Findings Include: 1. On 10/4/21 at 10:27 AM, the survey team entered the facility by the skilled nursing entrance. Upon entrance, staff took the team through the skilled nursing unit, to a room to place belongings and then to the front entrance to complete screening for COVID-19. It took approximately five minutes to pass between entrance and COVID-19 screening. 2. Observations in the facility revealed a lack of eye protection or hand hygiene by facility staff to minimize the chance of COVID-19 transmission. Observation on 10/5/21 at 8:37 AM revealed Staff D, Dietary Aide, took meals to residents' rooms. Staff D failed to wear eye protection during the meal delivery. Staff D entered and exited four resident rooms during the observation: Resident #1, #2, #5, and #125. Observation on 10/5/21 at 8:50 AM revealed Staff B, Registered Nurse (RN), and Staff C, Certified Nurse Aide (CNA), entered Resident #1's and Resident #125's rooms without eye protection Observation on 10/5/21 at 9:23 AM revealed Staff B entered Resident #124's room to pass medication without wearing eye protection. Observation on 10/6/21 at 9:02 AM revealed Staff C and Staff E, CNA, failed to wear eye protection while doing incontinent cares for Resident #123. Review of CDC's Interim Infection Prevention and Control Recommendations, updated 9/10/21, revealed if a facility is located in a county with substantial or high transmission, staff should use personal protective equipment (PPE), including eye protection (goggles or a face shield that covers the front and sides of the face that should be worn during all patient care encounters. Review of the CDC's COVID-19 Data Tracker revealed that on 10/4 and 10/5/21, [NAME] County Iowa showed a high rate of COVID-19 transmission. Interview on 10/7/21 at 11:29 AM with the Director of Nursing (DON) revealed the facility followed CDC guidelines. The DON stated she did not see why face shields or goggles were needed when everyone was fully vaccinated and they had no cases of COVID-19 in the building. 3. According to the Minimum Data Set (MDS) assessment of 6/24/21, Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment recorded Resident #5 required the assistance of one staff during walking, transfers and toilet use. Observation on 10/6/21 at 11:40 AM revealed Resident #5 sitting on the toilet. The resident stated he had finished. Staff H, CNA and Staff I, CNA washed their hands and applied gloves. Staff H and Staff I completed perineal care for the resident using appropriate hand hygiene. Staff placed a new incontinence brief and assisted Resident #5 to wash his hands. The observation revealed Staff H and Staff I wore masks while providing the resident's care, but no eye protection.

Based on personnel file reviews, facility record review and staff interview, the facility failed to ensure staff trained in cardiopulmonary resuscitation (CPR) on duty at all times for six of 23 residents who requested CPR in a life threatening emergency (Residents #16, #73, #74, #76, #77, and #125). The facility reported a census of 23. Findings include: The documents entitled Iowa Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nursing Schedules from [DATE] to [DATE] and staff CPR Certification records revealed the facility failed to have CPR certified staff on duty on the following dates and shifts: a. [DATE] - 10 PM to 6 AM shift; b. [DATE] - 10 PM to 6 AM shift; c. [DATE] - 6 AM to 2 PM shift; d. [DATE] - 10 PM to 6 AM shift; e. [DATE] - 10 PM to 6 AM shift; f. [DATE] - 6 AM to 2 PM shift; g. [DATE] - 10 PM to 6 AM shift; h. [DATE] - 10 PM to 6 AM shift; i. [DATE] - 10 PM to 6 AM shift; j. [DATE] - 10 PM to 6 AM shift; k. [DATE] - 2 PM to 10 PM shift; l. [DATE] - 10 PM to 6 AM shift. During interview on [DATE] at 12:12 PM, the Director of Nursing (DON) stated that is all the copies of CPR certificates they have at this time. The facility planned to have a class to recertify all staff who need training in CPR. The facility policy entitled Advance Directives - Cardiopulmonary Resuscitation (CPR), revised [DATE], directed in Section E that CPR certified staff are available at all times (including during facility outings and facility provided transports) to provide CPR as needed.

Based on clinical record review, observation and staff and resident interviews, the facility failed to follow the physician's orders for 1 of 12 residents sampled (Resident #125). The facility reported a census of 23. Findings include: According to the Hospital Discharge Summary dated 9/23/21, Resident #125 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During interview with Resident #125 on 10/4/21 at 2:00 PM, the resident stated that her left toe was amputated and it had infection prior to coming to the facility. Observation on 10/5/21 at 3:13 PM revealed Resident #125's dressing looked dry and intact. Observation on 10/6/21 at 8:28 AM revealed Resident #125's dressing remained dry and intact. The Hospital Discharge Summary dated 9/23/21 ordered to keep the resident's wound dressing clean, dry and intact until her clinic visit (10/7/21). The Skin/Wound Note dated 10/3/21 at 3:27 PM recorded the resident's left foot dressing bled through all the gauze and onto the outer dressing. Staff A, LPN (Licensed Practical Nurse) documented she applied a clean dressing to the left foot in the same way as when removed. Staff A placed an ABD (large dressing) pad with [MEDICATION(S)] to the wound and covered it with Kerlix and then wrapped it. Resident #125 kept her foot elevated and denied pain. Staff A noted no signs of infection. Review on 10/6/21 at 8:54 AM revealed no physician's orders to change the dressing. During interview on 10/6/21 at 2:49 PM, Staff A stated she changed the dressing since it soaked through. Staff A stated she wanted the morning staff to call the physician to let them know. During interview on 10/6/21 at 2:50 PM, the Director of Nursing stated she would expect a phone call to the doctor, even an on-call doctor, prior to changing the dressing to make sure that is what they would want since the physician might have addressed it in a different way.

Based on clinical record review and staff interviews, facility staff failed to develop baseline care plans and/or documented rationale for their lack for 3 of 3 residents reviewed (Residents #123, #125, and #73). The facility reported a census of 23. Findings include: 1. According to the Admission Record, Resident #73 admitted to the facility on [DATE]. On 10/06/21, review of the resident's clinical record revealed no development of a baseline care plan within 48 hours of admission. In an interview on 10/6/21 at 9:00 AM, the Director of Nursing (DON) acknowledged that baseline care plans were not being done on admissions since August 2021 when a new company took over the facility. 2. According to the Admission Record, Resident #123 entered the facility on 9/17/21. The resident's clinical record failed to contain a baseline resident care plan completed within 48 hours of her admission to the facility. 3. According to the Admission Record, Resident #125 entered the facility on 10/1/21. The resident's clinical record failed to contain a baseline resident care plan completed within 48 hours of her admission to the facility. During interview on 10/6/21 at 10:01 AM, the DON stated she identified the problem this morning and the facility does not have baseline care plans at this time for residents admitted after 8/1/21.

Based on observations, interviews, and record reviews, the staff failed to follow appropriate infection control techniques during incontinence care for 1of 1 sampled (Resident #2) and failed to follow Centers for Disease Control (CDC) guidelines related to the COVID-19 pandemic. The facility reported a census of 27. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. The resident required extensive assistance of one staff with toilet use and personal hygiene. The resident was occasionally incontinent of urine. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 5/10/21 at 12:03 PM, Staff D (Certified Nurse Aide) removed a wet brief from Resident #2. With the same gloved hands Staff D adjusted her mask. Staff C reentered Resident #2's room and sanitized her hands. Staff D handed Staff C a new brief and Staff C attempted to put the new brief on Resident #2. Staff D moved her hair off of her shoulder, then placed Resident #2's brief through the bottom of Resident #2's pants. Staff D removed her gloves for the first time and started to don new gloves. Staff C stopped Staff D before she put new gloves on and handed her hand sanitizer. Staff D applied hand sanitizer and donned new gloves. The Care Plan problem dated 1/19/21 showed the resident has an activities of daily living (ADL) self-care performance deficit related to Alzheimer's, Confusion, and Dementia. The problem included the following interventions dated 1/19/21: a. Personal hygiene and oral care: The resident requires extensive assistance by one staff with personal hygiene and oral care. b. Toilet use: The resident requires extensive assistance by one staff for toilet use. The Care Plan problem dated 1/19/21 explained the resident was at risk for COVID-19 infection related to a congregate living environment. The problem included the following intervention dated 1/19/21 to have staff complete meticulous hand hygiene before and after each encounter with resident and others. During an interview on 5/11/21 at 11:00 AM, the Director of Nursing (DON) stated the staff shouldn't touch anything with dirty gloves. During an interview on 5/11/21 at 12:00 PM, the DON said that staff should wear their masks over their face. She said that she is constantly working on this with them. The Infection Control Program policy dated 9/9/20 said the staff members will integrate infection prevention and control processes into direct care activities. The section labeled Prevention and Control said that staff members, clients, and caregivers will be informed of any infection prevention or control precautions to be taken. The prevention and/or control precautions include but are not limited to the following as appropriate: a. Personal hygiene including adequate adherence to universal blood and body fluid precautions b. Hand washing techniques and appropriate use of personal protective equipment (PPE) such as gloves, gowns, protective eyewear, and masks. c. Appropriate use of aseptic (clean) techniques. Centers for Disease Control and Prevention website titled, Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 2/23/21, revealed Healthcare Personnel (HCP) should wear well-fitting source control (use of well-fitting face masks to cover a person ' s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing) at all times while they are in the healthcare facility. The website further revealed, if worn properly a facemask helps block respiratory secretions produced by the wearer from contaminating other persons and surfaces. 2. During an observation on 5/11/21 at 7:27 a.m., revealed Staff D (Certified Nurse Aide) sitting in the Dining Room at a table about 2 feet from a resident assisting them with their breakfast. Staff D had her mask down below her chin exposing her nose and mouth while talking to another staff member that was standing about 3 feet from Staff D. After Staff D saw the surveyor in the dining room doorway, she pulled mask backup and continued to assist the resident with breakfast. Staff did not perform hand hygiene after pulling mask backup to cover her face. 3. During an observation on 5/11/21 at 12:47 p.m., revealed Staff F (Registered Nurse) walked from the medication cart to the Nurses Station with her mask below her chin. Staff F had her nose and mouth exposed. Staff F pulled her mask backup to cover her face. Staff F failed to perform hand hygiene after pulling her mask back up. During an observation on 5/11/21 at 1:06 p.m., Staff F (Registered Nurse) outside of the Dining Room by the medication cart with her mask down below her chin revealing her nose and mouth. Staff F walked from the Dining Room doors to the medication cart, over to the Nurses Station and back to the medication cart before pulling her mask back up. Staff F completed a task on the medication cart and then did not perform hand hygiene after pulling her mask back to cover her face.

Based on observation, clinical record review, and interviews the facility failed to follow physician orders [REDACTED].#19). The facility reported and census of 28. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had [DIAGNOSES REDACTED].#19 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition. The MDS indicated the resident required extensive assistance of 2 staff for transfers. The MDS documented the application of nonsurgical dressings and ointments. The Care Plan updated 1/6/2020 identified a hematoma on the left anterior shin and the wound nurse to follow until resolved. The Care Plan directed the staff to apply Santyl Ointment 250 unit/grams to wound bed on left shin topically every day shift. The Wound Treatment Plan sheet dated 1/6/2020 documented Resident #19 hit her shin on the sit to stand lift and sustained a hematoma that measured 6.0 centimeters (cm) by 6.5 cm by 0.1 cm. The sheet revealed an order to apply skin prep to the hematoma two times a day, allow to dry, and leave open to air. Notify the Physician if the hematoma ruptured. The Physician order [REDACTED]. During an observation on 2/11/20 at 9:47 a.m. revealed a dressing to Resident # 19's left shin dated 2/10/20 and initialed by Staff D (Licensed Practical Nurse). The dressing contained drainage. During an observation on 2/12/20 at 8:59 a.m. revealed a dressing to Resident # 19's left shin dated 2/10/20 and initialed by Staff D. The dressing contained drainage. During an observation and interview on 2/12/20 at 9:42 a.m. with the Administrator and the Assistant Director of Nursing (ADON) revealed Resident # 19 in her room. Resident #19 had a dressing on her left shin dated 2/10/20 with Staff D's initials. The dressing contained dried and fresh drainage. The Administrator and Assistant Director of Nurses confirmed the date and initials on the dressing. The ADON reported the dressing needed changed every day.

Based on clinical record review and staff interviews the facility failed to resubmit a Preadmission Screening and Resident Review (PASRR) after a change in [DIAGNOSES REDACTED].#19). The facility reported a census of 28. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had diagnoses of depression and [MEDICAL CONDITION]. Resident #19 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition. The MDS indicated Resident #19 had difficulty focusing and had disorganized thinking. Resident #19 utilized antipsychotic and antidepressant medication for 7 of 7 days of the assessment. Resident #19 readmitted to the facility on [DATE]. The Care Plan dated 12/18/18 identified Resident #19 at risk for adverse effects related to use of [MEDICATION NAME] for [MEDICAL CONDITION] disorder. The Care Plan directed staff to evaluate effectiveness of medication and evaluate for reduction or elimination of [MEDICAL CONDITION] drugs. The Care Plan identified Resident #19 had depression and received [MEDICATION NAME]. The Care Plan directed staff to monitor, report, and document signs and symptoms of depression, risk for harming others, increased anger, labile mood or agitation, and feeling threatened by others or thoughts of harming others. Review of the PASRR Notice dated 6/29/18 revealed Resident #19 had no diagnoses of major mental illness. The PASRR diagnoses included anxiety disorder and panic disorder. The PASRR failed to reflect Resident #19 utilized [MEDICATION NAME] for delusional behavior. The PASRR documented no further PASRR screening required unless a suspected major mental illness of intellectual or developmental disability or had a significant change in behaviors or treatment needs. The Clinical Record revealed an order dated 12/23/19 to decrease Resident #19's [MEDICATION NAME] 12/23/19 from 12.5 milligrams (mg) two times a day to 12.5 mg every day. The order revealed a start date of June 2019 and a [DIAGNOSES REDACTED]. During an interview on 2/13/20 at 2:30 p.m., the Administrator explained the social worker did not know or it had not been communicated with her the need to resubmit the PASRR if a change in mental status or new medication had been added for a Resident.

Based on record review, observations, and interviews the facility failed to follow infection control standards for 2 of 2 sampled (Residents #1 and Resident #19). The facility reported a census of 28. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Resident #1 had frequently bladder incontinence. Resident #1's Care Plan directed staff to provide perineal care after each incontinence episode. During an observation on 2/11/20 at 1:08 p.m. revealed Staff A (Nurse Aide) and Staff B (Nurse Aide) perform incontinence cares with gloved hands. Staff A and Staff B rolled Resident #1 side to side to remove the lift sling. Resident #1 raised their hips off the bed and Staff A pulled down Resident #1's pants. Staff A removed Resident #1's brief, soiled with stool and urine. Staff A placed the soiled brief in a trash bag. Staff A used disposable wipes and completed perineal care. Staff A and Staff B then assisted Resident #1 to roll to their left side. Staff A washed Resident #1's buttocks with disposable wipes. Without changing soiled gloves Staff A placed a clean cloth pad under Resident #1. Staff A next used the same gloved hands to placed a clean brief under Resident #1. Staff A placed gloved hands on Resident 1's sides and rolled Resident to the right and back onto their back to position brief. Staff A fastened the brief with the same gloved hands. Staff A pulled up Resident #1's pants with same gloved hands. Staff B collected soiled linens and trash and washed hands with soap and water. Staff A removed gloves and washed hands before leaving Resident #1's room. Staff A failed to change gloves or complete hand hygiene after completing Resident #1's perineal care, before touching clean linens and clothing. During an interview on 2/12/20 at 10:37 a.m. the Assistant Director of Nursing (ADON) reported an expectation of staff to change gloves after perineal care and before handling clean linen. The 2001 Med-Pass, Inc Perineal Care Policy directed staff to remove gloves and wash and dry their hands thoroughly after completing perineal care. 2. The MDS assessment dated [DATE] revealed Resident #19 had [DIAGNOSES REDACTED].#19 had a BIMS score of 12 indication moderately impaired cognition. Resident #19 required extensive assistance of 2 staff for transfers. The MDS reported the application of nonsurgical dressings and ointments. The Care Plan updated 1/6/20 identified a hematoma on Resident #19's left anterior shin and directed staff to apply Santyl Ointment 250 unit/grams to wound bed on left shin topically every day shift. During an observation on 2/12/20 at 10:05 a.m. Staff C (Licensed Practical Nurse) set up supplies for Resident #19's dressing change. Staff C washed her hands and placed a box of gloves on the over bed table. Staff C exited the room. At 10:11 a.m., Staff C knocked on door, entered, and washed her hands. Staff C donned gloves. Staff C grabbed the scissors and cut off the old dressing and placed the scissors in the basket, and grabbed the wound cleanser and wet the dressing to remove it the dressing was dry and stuck to the would removed kerlix then sprayed to remove the top 4 x 4 gauze and then sprayed the 2nd wound 4x 4 gauze with wound cleanser. Staff C removed her gloves donned new gloves took a damp 4x4's and patted the wound and repeated the process two more times. Staff C used a damp 4 x 4 and wiped drainage of the wound from the inside lower corner. Staff C removed gloves, donned new gloves, squeezed the santyl tube, and placed santyl on the end of her gloved index finger. Staff C used her gloved finger to apply santyl in a circular motion over the wound. Staff C removed her gloves and donned new gloves. Staff C opened the normal saline and applied it to a 4 x 4. Staff C placed the damp 4 x 4 on the open wound. Staff C removed her damp left glove and donned a new glove. Staff C grabbed the kerlix and wrapped the wound. Staff C grabbed the scissors out of the basket and cut the kerlix and placed the scissors back into the basket. Staff C taped the dressing and placed the dated and her initials on it. Staff C picked up items and walked to the bathroom. Staff C removed her gloves and washed her hands. During an interview on 2/13/20 at 2:36 p.m. the Administrator reported an expectation of the nurse to perform hand hygiene between glove use. The Hand Hygiene policy dated 10/15/2017 included the indications for hand hygiene anytime a team member removes protective gloves.

Based on clinical record review, observation, staff interview, and policy review, the facility failed to provide interventions to prevent a pressure sore from developing for one of one residents reviewed with impaired skin (Resident #3). The facility reported a census of 24 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 3 had [DIAGNOSES REDACTED]. The MDS documented the resident's brief interview for mental status (BIMS) score of 8, which indicated cognition moderately impaired. The MDS documented the resident had not ambulated (walked) and required extensive assistance of two staff for bed mobility and transfers. The MDS revealed the resident had a risk for pressure ulcers, and documented the resident had no pressure sores or arterial or venous ulcers. The treatments included a pressure reducing device in the bed and chair, and medication/ointment applied to other areas than the feet. The MDS assessment dated [DATE] indicated Resident #3 had a Stage 3 pressure ulcer (full thickness tissue loss) and a [MEDICAL CONDITION]. The skin/ulcer treatments included a pressure reducing device in the bed and pressure ulcer care. The MDS assessment dated [DATE] indicated Resident # 3 had a Stage 3 pressure ulcer. The treatments included pressure ulcer care, nutrition interventions, and the application of medication/ointment. The care plan revised on 9/14/18 revealed Resident #3 had a Stage 3 pressure ulcer to the right (R) heel related to immobility. The resident also had a diabetic ulcer to the (R) second toe. The staff directives and interventions included wound care treatments as ordered, Prevalon boots worn at all times, a pressure relieving device to the bed and chair, and to offload the heels. The Order Summary report dated 1/19/18 revealed orders for Prevalon boots at all times every shift for pressure ulcer on the (R) heel started on 9/12/18, and skin prep to all eschar areas on toes daily until the area healed started on 11/6/18. The Clinical physician's orders [REDACTED]. The Braden scale assessment completed on 10/5/18, indicated the resident had a moderate risk for development of pressure sores. The Pressure Injury Record documented the following skin assessments and measurements: (R) heel: a. 8/18/18 (onset date): 1.0 centimeter (cm) length (L) x 1.0 cm width (W) x 0 cm depth (D) The (R) heel felt boggy and had a dark purple area. The interventions included an air mattress and blue boots applied. b. 8/29/18: 3.4 cm (L) x 3.4 cm (W) x 0.1 cm (D). The heel wound had a scab over the area. The resident saw the wound nurse on 8/27/18 and had the wound debrided. c. 9/5/18: 4.0 cm (L) x 4.0 cm (W) x 0.1 cm (D) d. 9/17/18: 1.8 cm (L) x 1.8 cm (W) x 0.1 cm (D) e. 9/28/18: 3.0 cm (L) x 2.8 (W) and had black eschar present. Skin prep treatment applied. Resident #3 seen by the wound nurse weekly. f. 10/17/18: 3.8 cm (L) x 3.5 cm (W) x 1.6 cm (D) and had slough and eschar present g. 11/19/18: 1.6 cm (L) x 1.0 cm (W) x 0.1cm (D) h. 11/26/18: 1 cm (L) x 0.7 cm (W) x 0.1 cm (D) i. 12/3/18: 0.6 cm (L) x 0.5 cm (W) x 0.1 (D) j. 12/10/18: 1.1 cm (L) x 0.8 cm (W) x 0.1 cm (D) k.12/17/18: 0.6 cm (L) x 0.6 cm (W) x 0.1 cm (D) l. 12/24/18: 0.6 cm (L) x 0.6 cm (W) x 0.1 cm (D) m. 12/31/18: 1.6 cm (L) x 2.1 cm (W). Interventions included supplements as ordered and monitor the skin injury. n.1/3/19: 1.0 cm (L) x 1.0 cm (W). A scab covered the heel. o.1/14/19: 1.2cm (L) x 1.5 cm (W) x 0.1cm (D). A wound debridement performed on 1/7/19. The Physician's Encounter Note/Wound Treatment Plan documented the following: a. On 8/27/18: Resident #3 had a suspected deep tissue injury of the (R) heel and seen for re-assessment. No prevalon boots had been initiated. The facility found a pair of boots no longer in use and planned to wash and apply the boots on Resident #3's feet. The resident had an air mattress in place. Resident #3 had limited mobility and used a wheelchair for mobility. The resident had impaired cognition, on diuretics, and had diabetes. The wound measurements revealed an area 3.4 cm (L) x 3.4 cm (W) x 0.1 cm (D), and a fluid filled blister present. The wound treatment plan included skin prep twice a day and Prevalon boot at all times. b. On 9/17/18: A Stage 3 pressure ulcer on the (R) heel measured 1.8 cm (L) x 1.8 cm (W) x 0.1 cm (D) and a [MEDICAL CONDITION] on the (R) second toe. c. On 11/12/18: Prevalon boot to bilateral lower extremities not on initially. The (R) heel wound measured 2.0 cm (L) x 1.0 cm (W) x 0.1 cm (D) d. On 12/10/18: Prevalon boot to bilateral lower extremities not on. Boots placed after assessment. e. On 12/17/18: The (R) heel measured 0.6 cm (L) x 0.6 cm (W) x 0.1 cm (D). The wound had no drainage or signs of infection. The Prevalon boots ordered for the bilateral lower extremities are not on again today. Boots applied after the wound area assessed. f. On 1/7/19: Prevalon boot to bilateral lower extremities had not been in place the past several visits. Resident #3 had limited mobility and used the wheelchair for mobility. Resident #3 reported her feet had minimal feeling. The (R)heel wound measured 2.0 cm (L) x 1.7 cm (W) x 0.1 cm (D). The wound area measured 2.3 cm (L) x 1.7 cm (W) x 0.1 cm (D) after debrided. Orders included Prevalon boots to the bilateral lower extremities at all times as tolerated. The Treatment Administration Record (TAR) dated 1/1 - 1/17/19 revealed the following: a. Head to toe skin assessment weekly started on 11/05/2018 b. Prevalon boot on at all times as tolerated for preventative measures and had a start date of 1/18/19. The TAR lacked documentation of Prevalon boot 12/1/18 - 1/17/19. Observations revealed the following: a. On 1/17/19 at 9:31 AM, Resident #3 lying in bed on her back and had an air mattress on the bed. b. On 1/17/19 at 11:40 AM, Resident #3 sat in a wheelchair in her room. The resident had socks on her feet, and her feet sat on the unpadded wheelchair pedals. The resident reported she had dry peeling skin on her feet and staff watched her feet. c. On 1/17/19 at 2:20 PM, Resident #3 sat in her recliner in her room and had her feet elevated on the footrest. No Prevalon boots on. d. On 1/18/19 at 8:05 AM, Resident #3 sat in her wheelchair with her feet on the wheelchair pedals. The resident had tan colored socks on her feet. e. On 1/18/19 at 9:40 AM, Resident #3 sat in a wheelchair with her feet on the wheelchair pedals. Prevalon boot sat on top of a chair in her room. f. On 1/18/19 at 10:40 AM, Resident #3 lying in bed and had prevalon boots on her feet. During an interview 1/18/19 at 10:30 AM, Staff C, Licensed Practical Nurse (LPN), stated Resident #3 had a sore on her (R) heel for several months, and she had developed the sore while a resident at the facility. Staff C reported skin prep applied to the area for treatment. Staff C reported when residents' admitted to the facility, an assessment performed which determined if a resident had a risk for skin issues or pressure sore development. Staff C reported interventions then put in place such as repositioning residents every two hours, an air mattress placed on the bed, a referral made to Occupational Therapy to determine the type of devices needed, and a cushion placed in the wheelchair. Staff C confirmed Resident #3 had a risk for pressure ulcers and seen by a wound nurse weekly. Staff C confirmed he had changed the order for prevalon boots in the computer on 1/17/19 when the prevalon boots had not shown up on the MAR (medication administration record) or TAR. Staff C determined another staff person had entered the order and placed it under the wrong category so the entry had not shown up on the MAR indicated [REDACTED]. During an interview 1/18/19 at 10:45 AM, Resident #3 reported she had no feeling in her feet due to [MEDICAL CONDITION] and diabetes. Resident #3 reported she developed a sore on her heel shortly after being admitted to facility and when she started walking, the skin broke open. During an interview 1/18/19 at 10:50 AM, Staff D, Certified Nursing Assistant (CNA), reported interventions to prevent pressure areas included changing the resident's brief, applying a barrier ointment, repositioning residents, placing the foot of the bed up when a resident in bed, and placed a pillow under the leg if a resident had a sore on their feet. Staff D reported they had two residents wore special boots (Resident # 3 and Resident # 6). Staff D reported they donned Resident #3's boot only she was lying in bed. During an interview 1/18/19 at 2:30 PM, Staff E, CNA reported they repositioned residents every two hours, provided good pericare, and gave a shower to residents to prevent pressure sores. Staff E reported Resident #3 used special boots on her feet when in bed. Staff stated the resident used to wear the boots all of the time when the sore of her foot was more open, but when the wound started healing, the Resident had worn the boots less often. During an interview 1/18/19 at 2:45 PM, the Director of Nursing (DON) reported she had worked at the facility since 7/2018. Resident #3 developed a pressure sore on her (R) heel in 9/2018. The DON reported Resident #3 had an air mattress on the bed and a cushion in her wheelchair when the sore developed, but didn't have the boots. Resident # 3 now had boots, on a protein supplement, and had the wound nurse assessment weekly. The DON reported the Resident's provider had done a wound debridement a couple of weeks ago and after that, the wound size increased. In an undated facility policy titled Pressure Ulcer Prevention and Management revealed pressure ulcers usually formed when a resident remained in the same position for an extended period of time and caused increased pressure or a decreased blood flow to the area which then destroyed the tissues. The most common site for a pressure ulcer is near the surface of the body and bony area such as the heels, ankles, and toes. The policy indicated a Braden scale risk assessment completed upon admission, quarterly, and annually which determined the resident's level of risk for a pressure ulcer. When an at-risk resident identified, interventions implemented promptly in attempt to prevent pressure ulcers. The admission evaluation helped define the initial care approaches or interventions. The policy lacked initial care approaches or preventative interventions. The policy indicated a [DIAGNOSES REDACTED].

Based on Observation, policy and clinical record review, the facility did not ensure oxygen therapy provided according to the individualized need of 1 of 1 resident (Resident # 11) in the sample reviewed for respiratory care. The facility reported a census of 24 residents at the time of the survey. Findings include: The annual Minimum Data Set ((MDS) dated [DATE], indicated Resident # 11 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 3. The MDS also indicated Resident # 11 needed extensive assistance for activities of daily living. The MDS listed Resident # 11's active [DIAGNOSES REDACTED]. The MDS documented Resident # 11 required Oxygen therapy. The physician's orders printed on 1/18/19, directed staff to provide Resident # 11 Oxygen treatment at 4 liters per minute (L/M) via nasal cannula at bedtime. Resident # 11's care plan showed cardiovascular problem related to [DIAGNOSES REDACTED]. The care plan interventions directed staff to assess heart rate, respiration and administer Oxygen as ordered: Oxygen 4 L/M via nasal cannula every night. Observations during the survey showed inconsistencies with regard to the resident's Oxygen therapy as follows: a. On 1/17/19 at 11:07 AM, Resident # 11 was in room, seated in recliner and with Oxygen at 2.5 L/M via nasal cannula. b. On 1/17/19 at 11:49 AM, Resident # 11 sat quietly in the dining room waiting for lunch with no Oxygen on. c. On 1/17/19 at 1:53 PM, Resident # 11 had her head bowed and eyes closed while sitting in her room recliner chair. The Oxygen concentrator was set at 2.5 L/M, and connected to tubing but the end of tubing or the cannula rested on Resident # 11's chest, instead of being in place in Resident # 11's nostrils. d. On 1/18/19 at 8:17 AM, Resident # was in the dining room for breakfast with no Oxygen on. e. On 1/18/19 at 8:52 AM, Resident #11 was at a newspaper reading activity with no Oxygen on. f. On 1/18/19 at 9:42 AM, Resident # 11 had ongoing Oxygen 2.5 L/M while asleep in room recliner. During interviews, there were inconsistent statements from staff members regarding Resident # 11's Oxygen therapy as follows: On 1/17/19, at 1:57 PM, Staff A Certified Nurse Aide (CNA) said Resident # 11 had to have her Oxygen on while in her room. Staff A verified the Oxygen cannula was out and on Resident # 11's chest area. Staff A also verified the Oxygen setting at 2.5 L/M. Staff A stated Resident # 11's capability of taking cannula out from her nostrils. On 1/18/19, at 10:38 AM, Staff B Licensed Practical Nurse (LPN) stated she believed Resident # 11's Oxygen therapy order to be PRN (as needed), and said Resident # 11 did not need to use it all the time, even in her room. Staff B reported Resident # 11's Oxygen was ongoing at 2.5 L/M. On 1/18/19, at 10:55 AM, Staff B stated she checked Resident # 11's Oxygen therapy orders and found it was supposed to be set at 4 L/M at bedtime. Staff B also stated she did a trial with the resident's Oxygen off but brought down Resident # 11's Oxygen saturation to 88%, and that it went back up to 92% with Oxygen therapy. Staff B said she was going to call the physician to report her assessment and clarify the Oxygen therapy orders, stating further that Resident # 11 obviously needed the Oxygen therapy at the time. The facility policy titled, Oxygen Administration with revision date of 10/10, directed staff to verify that there is a physician's order for the procedure, and to review the said orders and facility protocol for oxygen administration. The policy also directed staff to review resident's care plan to assess for any special needs of the resident.

Based on record review, facility policy, visitor and staff interviews, the facility failed to implement appropriate interventions to protect one resident (Resident #2) from another resident (Resident #1) that touched her in a sexually inappropriate manner four days before a second incident occurred. The facility reported a census of 28 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1's Brief Interview for Mental Status (BIMS) score as 10 out of 15, which indicated moderately impaired cognition. The MDS revealed Resident #1 ambulated (walked) independently in his room, but required supervision when he ambulated throughout the facility. The Care Plan dated 5/25/18 directed staff Resident #1 required supervision while ambulating in common areas and to assist as needed. The Care Plan also directed staff to monitor and check on the resident frequently when he was not in the common areas. The Care Plan also documented the resident had a history of [REDACTED]. A revision dated 7/26/18 directed staff to complete 15 minute checks for 72 hours. Prior to the revision, the Care Plan lacked any interventions to deter or prevent Resident #1 from acting in a sexually inappropriate manner toward female residents. Observation on 8/2/18 at 7:38 a.m. revealed approximately 15 residents sat in wheelchairs in the lobby area directly outside the entrance of the dining room with their eyes closed. Approximately ½ of the residents were female (including Resident #2). Further observation revealed Resident #1 sat inside the dining room at the first table to the left of the entrance; awake and apparently waiting for breakfast to be served. No staff or other persons other than the residents were present in the immediate area, which included the nurse's station, dining room, lobby area and therapy room from 7:38 a.m. to 7:41 a.m. At that time, a nurse approached the nurse's station. Resident #1's chart lacked any other documentation regarding investigations and interventions related to Resident #1 inappropriately touching Resident #2 on 7/22/18 and 7/26/18. The facility's Resident Abuse Policy revised on 2/23/17 documented its purpose was to prevent residents from being subjected to abuse by anyone, including other residents. According to the policy, abuse included verbal abuse, sexual abuse, sexual misconduct, physical abuse and mental abuse. The procedure directed staff to report abuse to their supervisor if they are uncomfortable reporting it to management personnel. The policy also directed staff to ensure the safety of residents at all times, and to remain with the resident, call for help if needed, and never leave a resident who is afraid alone. According to the document, the results of the abuse investigation must be reported to the Administrator or his/her designated representative and the state agency within 5 working days of the incident. A Progress Note dated 4/15/18 at 7:53 p.m. documented the Resident #1 acted in a sexually inappropriate manner with staff. A Progress Note dated 7/5/18 at 3:06 p.m. documented a male nurse responded to Resident #1's call light. The resident stated he did not want a male nurse, he wanted one of the female CNAs to help him. A Progress Note dated 7/26/18 at 1:40 p.m. documented a late entry from 7/23/18 at 1:45 p.m. The nurse wrote that morning, a CNA reported Resident #1 inappropriately touched and kissed a female resident on the evening of 7/22/18. A Progress Note dated 7/26/18 at 1:43 p.m. documented the social worker reported a resident from independent living told her Resident #1 kissed a female resident and looked down her shirt. An untitled handwritten document dated 7/23/18 and authored by Staff N, LPN documented a CNA reported Resident #1 kissed Resident #2 and grabbed her breast. A document titled Alleged Abuse Details Report - Occ # 0 documented Resident #1 allegedly committed sexual abuse on 7/22/18 at 7:00 p.m. per staff witness. According to the document, the Administrator was notified on 7/23/18 at 8:35 a.m. General information related to Occ # 0, documented the alleged abuse occurred in the common area. According to the nurse that documented the allegation on 7/26/18 at 10:04 a.m., a CNA reported she saw the alleged abuse the prior evening (7/22/18), but didn't report it until the next day on 7/23/18 when she reported it to him. A document titled Alleged Abuse Details Report - Occ # 6 noted that Resident #1 allegedly committed sexual abuse on 7/26/18 at 10:00 a.m. according to a visitor. According to the document, the Administrator was notified on 7/26/18 at 10:30 a.m. General information related to Occ # 6, documented that the alleged abuse had been witnessed by a resident visiting from independent living. The visitor reported they saw Resident #1 kissing Resident #2 and looking down her blouse. Recent Occurrences documented an incident of alleged abuse numbered 0 that occurred on 7/22/18 at 7:00 p.m. 2. The MDS assessment dated [DATE] identified Resident #2 had [DIAGNOSES REDACTED]. The MDS indicated Resident #2 depended on 1 to 2 staff for most activities of daily living, including wheelchair locomotion. The 8/13/12 Care Plan documented Resident #2 required assistance with daily cares due to memory loss and decreased mobility. The Care Plan also instructed staff to help the resident into her recliner after meals until she could rest in bed. The Care Plan lacked any interventions regarding how to monitor or protect Resident #2 from inappropriate touching such as the incident on 7/22/18. The Care Plan did include an entry dated 7/26/18, which noted the facility moved her to a room on another hall. Resident #2's chart lacked incident reports, progress notes, or any other documentation regarding investigations related to Resident #1 sexually assaulting her on 7/22/18 and 7/26/18 respectively. An interview on 7/30/18 at 9:45 a.m. with Staff I, CNA revealed on 7/22/18 she and 3 other CNAs helped transfer about 6 or 7 residents from the dining room to the lobby area right outside the dining room at about 6:15 p.m. Staff I said the other CNAs went about their business and she stayed to clean up the dining room. Staff I reported Resident #1 stood from his table as she cleaned it and left the dining room. According to the CNA, she looked saw Resident #1 stood next to Resident #2 with his hand down her shirt as she sat in her wheelchair. Staff I said she did not see him kissing Resident #2, but did see his hand moving around inside her shirt, so she approached Resident #1 immediately and said You're not supposed to do that. Staff I reported Resident #1 smiled and walked to his room and Resident #2 said she was fine. Staff I stated she thought Resident #2 remained in the lobby while she finished cleaning the dining room. Staff I said she did not tell anyone what she observed. Staff I said she told the nurse on Monday morning about 7:00 or 7:30 a.m. Staff I said she didn't know what she was thinking, because staff are to report anything that happens to our DON or Administrator when it happens. An interview on 7/30/18 at 11:55 a.m. with Resident #2's visitor revealed she saw Resident #2 in her recliner while Resident #1 leaned over her with his face next to hers. The visitor said she stepped back to listen to what he was doing. The visitor said Resident #2 usually has her blanket pulled up over her face, but the blanket covering her then was pulled down to her chest and his hand/arms were on her. The visitor said she did not know what or if Resident #1's hands were doing anything because she was so angry. The visitor said she heard Resident #1 say you're a beautiful, good woman. The visitor said Resident #1 did not see her. The visitor said she did not like what she saw, so she went to office to report it. According to the visitor, she has seen Resident #1 coming out of his bathroom wearing only a tee shirt. The visitor recalled another incident when she could not help but see Resident #1 exposed because he left the door to his room open, and another time when he sat on his bed unclothed. An interview on 7/30/18 at 12:15 p.m. with Staff G, CNA revealed the facility moved Resident #2 to the 100 hall because Resident #1 touched Resident #2 inappropriately. According to the CNA, the facility staff told her to watch Resident #1 the day they moved Resident #2, but not before then. Staff G also denied anyone told her to complete 15 minute checks on Resident #1 due to sexually inappropriate behavior. Staff G said she is supposed to intervene and tell her supervisor if she sees anyone mistreating a resident. An interview on 7/30/18 at 1:53 p.m. with Staff E, CNA revealed the facility told her room changes were done so Resident #1's wife could be closer to him. As a result of the room changes, Staff E said she realized Resident #2 resided on 100 hall. The CNA said nobody told her Resident #1 touched Resident #2 inappropriately or to complete frequent checks to know Resident #1's whereabouts related to sexually inappropriate behavior. Staff E said sometimes Resident #1 undresses in his room with the door open, and staff was supposed to make sure he did it privately. An interview on 7/30/18 at 3:25 p.m. with the DON revealed the facility did not implement 15 minute checks on Resident #1 after the first incident. The DON said the only sexual misconduct that Resident #1 exhibited before 7/22/18 was towards staff; which would be documented in nurse's notes. The DON also said the incident is kind of vague to us too. I would expect staff to document completely and accurately. When asked, the DON could not provide any documents to show their investigation. An interview on 7/31/18 8:24 a.m. with Staff A, LPN, revealed that she documented Resident #2 made inappropriate sexual comments to staff that walked by him. Staff A also said Resident #1 undressed and lay on his bed unclothed and naked with the door open about once a day since she started working here last April. When asked, Staff A said those types of behaviors should be charted, although they are not. The LPN said there was only one nurse on the floor when she started. Staff A said she thought lack of documentation could be attributed to that. The LPN explained that people get busy and they might forget and/or they might not get everything charted that they wanted to. When asked, Staff A stated she did not know anything happened between Resident #1 and Resident #2 until the overnight nurse said something about it at shift change that morning. Staff A said that nurse told her Resident #2 changed rooms because of an issue between the residents. The LPN said she read a fax to a Dr. notifying him about inappropriate sexual behavior between Residents #1 and #2. The LPN said she had not worked since 7/25/18, and nobody mentioned the sexual misconduct at that time either. An interview on 7/31/18 at 8:50 a.m. with Staff B, CNA revealed that he knows Resident #1 very well. Staff B said about a week or two ago he changed Resident #1 after an episode of incontinence. Staff B said Resident #1 put his call light on about 10 minutes later. The CNA said he responded and found Resident #1 on his bed with his brief down. Staff B asked the resident what he needed and Resident #1 said could you get a female in here. Staff B said he informed the nurse. Staff B recalled Resident #1 talking inappropriately about a female CNA. Staff B said the facility talked about changing Resident #2's room a couple days before they actually did it, but didn ' t ' ' tell him (Staff B) why they were changing rooms. Staff B said they told him to make sure Resident #1 was not going into female resident's rooms and to check on him as much as you can. Staff B said he was not aware that Resident #1 touched Resident #2 inappropriately another time before the move. Staff B said Resident #1 walks independently and it's hard to know where he's at all the time On 7/31/18 at 10:26 a.m., Staff H, CNA revealed Resident #1 undressed in his room with his door open and sometimes steps into the hall looking for help with nothing on. Staff H said she never knew about him acting sexually inappropriate, but she did know that he always wanted women to shower him. Staff H said she has never seen or heard of him being sexually inappropriate to female residents and denied ever being told to monitor him for being sexually inappropriate towards female residents. In an interview on 7/31/18 at 12:10 p.m., the Administrator revealed staff failed to inform her about Resident #1 inappropriately touching Resident #2 on 7/22/18 when it happened. The Administrator said she found out about it about on 7/23/18 at about 8:45 a.m. The Administrator said staff did not implement interventions appropriately. She said nurses know residents should be separated and 15 minute checks are supposed to be implemented. The Administrator denied having any documentation to confirm that 15 minute checks were being done or that a thorough investigation had been conducted. An interview on 8/1/18 at 8:15 a.m. with Staff M, LPN revealed that she has only worked at the facility for about a month. The LPN said she has never been told that Resident #1 touched another resident inappropriately. The LPN said they were doing 15 minute checks on Resident #1 for a couple days, but she thought it was because Resident #1 had been trying to find his wife's room on 100 hall. Staff M said nobody told her to monitor him closely. An interview on 8/2/18 at 7:45 a.m. with Staff N, LPN revealed that the social worker and the DON told him on 7/26/18 at 10:30 a.m. about a 2nd incident of Resident #1 inappropriately touching Resident #2. The LPN said he informed them he just got done notifying the Dr. and Resident #1's family about the 7/22/18 incident when they reported the 2nd incident to him. An interview on 7/31/18 at 12:10 p.m. with the Administrator revealed she had not been informed about Resident #1 inappropriately touching Resident #2 on 7/22/18 when it happened. The Administrator said the CNA that witnessed it did not report it to anyone until the morning of 7/23/18. When asked, the Administrator stated she expected staff to report abuse immediately.

Based on observation, document review, and interviews, the facility failed to ensure systems were in place to prevent the development of avoidable pressure ulcers and failed to identify open areas on 2 of 3 residents reviewed (Residents #1 and #3) for skin integrity. The facility had a census of 28 residents. Findings include: 1. Resident #1 ' s Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had [DIAGNOSES REDACTED]. A score of zero identified the resident as severely cognitively impaired. Resident #1 required extensive assistance of 2 staff persons for transfers, bed mobility, walking, dressing, and toilet use & extensive assistance of 1 staff person for personal hygiene. A Braden Scale for Predicting Pressure Sore Risk completed on 10/12/15, documented Resident #1 was slightly limited in sensory perception, moist, walks frequently, slightly limited mobility, adequate nutrition, potential problem for friction & shear resulting in a score of 18. A score of 18 identified the resident at a low risk for the development of pressure ulcers. Resident #1 ' s Review of Indicators of Pressure Ulcers dated 9/8/15, documented the resident needed a special mattress or seat cushion to reduce or relieve pressure, required a regular schedule of turning, had risk factors including immobility, incontinence, and cognitive loss. Additional risk indicators included dementia, antipsychotic, antianxiety, and narcotic drugs. On 9/8/15 at 12:51 p.m., the MDS coordinator/Assistant DON (Director of Nursing) documented the following; Due to recent weight loss and lack of appetite as well as decreased mobility, the resident is at risk for skin breakdown. Resident has a pressure reliving mattress on (the resident) bed and a cushion in (the resident) chair. Resident is encouraged and assisted to change positions at least every 2 hours. Resident #1 ' s Care Plan dated 9/8/15, documented the resident was at risk for skin breakdown had a pressure relieving mattress on the residents bed and a cushion in the resident ' s chair. The Care Plan directed staff to implement the following interventions, monitor the resident ' s skin during daily cares and report any red or open areas to the nurse and doctor as needed, encourage the resident to change positions at least every 2 hours, encourage and assist with fluids and eating, and apply lotion to dry skin as needed. Resident #1 ' s Care Plan dated 10/26/15 documented the resident was receiving hospice care and directed staff to monitor the resident ' s skin and notify the hospice staff of any changes. Observation on 11/17/15 at 7:05 a.m., showed Staff O, CNA (Certified Nursing Assistant) and the Director of Nursing (DON) assisting Resident #1 in the bathroom. Observation identified the resident ' s reddened backbone. The resident complained of back pain in the area of the gait belt stating, it felt like a fingernail. Observation identified Staff O as not causing pressure from a fingernail. At 7:25 a.m., the resident said my backbone. At 7:28 a.m., the resident said oh, my backbone. The DON responded, I know you don ' t like the gait belt, I'll take it off. Without assessing the resident ' s back, staff assisted the resident to a wheelchair, without a pressure-relieving device on the back, and then wheeled the resident to the dining room. Observation on 11/17/15 at 8:55 a.m., revealed Resident #1 complaining of back pain, Staff G, CNA rubbed the resident ' s back. The back of the resident ' s wheelchair did not have a pressure-relieving device. Observation on 11/17/15 at approximately 9:15 a.m., showed Resident #1 sleeping in a recliner in the common area where the resident remained, without repositioning until lunch at approximately 11:45 a.m., when staff took the resident to the dining room. Observation on 11/18/15 at 2:05 p.m., showed Resident #1 attempting to get out of the reclined recliner chair in the common area, where the resident had been napping since after lunch. Staff assisted the resident to the wheelchair, without a pressure-reducing device on the back, and took the resident to the bathroom. Upon request, while in the bathroom, the DON exposed the resident ' s back for examination revealing an approximately 3-inch reddened area over the bony prominence of the resident ' s spine with 2 open areas and a small scratch that was scabbed. The DON reported she would measure the area, start a skin sheet, and notify the physician to get a treatment started. During an interview, at the time of the observation, the DON confirmed she was unaware of the reddened and open areas on the resident ' s back. On 11/18/15, the DON provided the following documentation and measurements dated 11/18/15 describing the open areas on Resident #1 ' s back. Present on the lower mid-spine ([MEDICATION NAME]) is a pressure ulcer. Stage I, length in centimeters (cm) equals 6.0, width in cm equals 1.0. Skin is blanchable. Present on the lower mid-spine ([MEDICATION NAME]) is a pressure ulcer. Stage II, length in cm equals 0.8, width in cm equals 0.8. Present on the lower spine (lumbar) is a pressure ulcer. Stage II, length in cm equals 1.0, width in cm equals 0.5. The DON also confirmed facility staff were aware of the resident ' s back pain and had provided pain medication for the pain. Additionally, the DON confirmed the resident had not had a pressure-relieving device on the back of their wheelchair prior to 11/18/15. 2. Resident #3's quarterly MDS assessment dated [DATE] documented the resident had [DIAGNOSES REDACTED]. Resident #3 required extensive assistance of 1 staff person for transfers, bed mobility, walking, dressing, toilet use, and personal hygiene. The resident was frequently incontinent of bowel and bladder, was not on a toileting program, and was at risk of developing pressure ulcers. According to the MDS, staff was to provide pressure-relieving devices for the resident's chair and bed and include the resident in a turning/repositioning program. A Braden Scale for Predicting Pressure Sore Risk completed on 10/12/15 documented Resident #3 was slightly limited in sensory perception, occasionally moist, walks occasionally, had very limited mobility, adequate nutrition, potential problem for friction & shear resulting in a score of 16. A score of 16 identified the resident at low risk for the development of pressure ulcers. Resident #3's Care Plan, prior to 11/16/15, did not address the resident's risk for skin breakdown or interventions. Resident #3's Care Plan dated 11/16/15 did address the resident's risk for skin break down; however, it did not address the 2 open areas identified on 11/16/15. Observation on 11/16/15 at 8:20 a.m., 9:19 a.m., 10:50 a.m., and 12:40 p.m., identified Resident #3 in the same reclined position in a recliner in the resident's room. Observation on 11/16/15 at 2:10 p.m. identified Resident #3 reclined in a recliner with their legs over the edge attempting to get up. Observation on 11/16/15 at 2:10 p.m., showed Staff O, Certified Nursing Assistant (CNA) toileting the resident and revealed Resident #3's left buttocks was red and the right buttocks was very reddened with 2 open areas. Staff O did not mention the open areas and continued with peri care. Upon request, Staff O opened the gluteal crease revealing 2 open areas. Staff O said she would report the areas to the nurse on duty and assisted the resident to their recliner chair (without a pressure-reducing device). Resident #3 complained of pain in the left foot. Staff O examined the resident's foot and found a reddened indented crease all the way around the resident's foot just above the arch, rubbed the area and readjusted the resident's knee high TED hose. At the time of this observation, neither the resident's recliner nor wheelchair had a pressure-reducing device. Staff O left the resident's room and reported the open areas and left foot pain to Staff P, LPN (Licensed Practical Nurse) at 2:25 p.m. Staff P stated she would look at the areas of concern. Observation on 11/16/16 at 2:35 p.m. showed Staff P conducting the resident's scheduled assessment. Staff P failed to examine the resident's skin on the gluteal crease. On 11/16/15 at 3:05 p.m., after conducting assessments on 2 other residents, when asked, Staff P stated she was done with assessments. Staff P did not return to Resident #3's room. Observation on 11/17/15 at 8:13 a.m. showed Staff M assisting the resident to the toilet, revealing the 2 open areas on the resident ' s right buttock remained. During an interview on 11/17/15 at 12:07 p.m., the DON stated she followed up with Staff P regarding her failure to assess Resident #3's bottom after Staff O reported the resident had open skin areas. The DON confirmed that Staff P did not assess the resident's bottom and she was unable to locate any documentation related to skin issues or skin an assessment identifying open areas prior to 11/16/15. On 11/17/15 the DON provided the following documentation and measurements dated 11/17/15 describing the 2 open areas on Resident #3's right buttock. The resident was noted with 2 areas to the right buttock. The first area measured 0.8 by 0.4 centimeter (cm) and the second area measured 0.5 cm in diameter.

Based on record review, observation, family, and staff interviews, the facility failed to provide adequate supervision for one of two residents reviewed with a fall and fracture (Resident #11) and failed to revise the written health care plan which are located in the resident ' s bathroom so the resident ' s specific needs are met for safety. The facility reported a census of 28 residents. Findings include: 1. The Minimum Data Set (MDS) assessment with a reference date of 8/8/11 indicated Resident #11 had [DIAGNOSES REDACTED]. The MDS documented the resident required moderate assistance for bed mobility, transfers, and ambulation. The MDS documented the resident had a history of [REDACTED]. A cognitively intact person would score 13-15. A score of 00-7 indicates severe impairment. The care plan directed staff to start the following interventions: On 5/13/11, the staff were to utilize a low bed and a floor mat when the resident ' s in bed. On 6/10/11 the staff are to observe for unusual obstacles when ambulating the resident. On 6/28/11, the staff are to remind the resident to use the call light. On 7/10/11 the staff are to toilet the resident between 1:30 - 2:00 p.m. On 7/23/11 the staff are to apply the pressure alarm to the dining room chair. On 8/16/11 the staff are to place the personal alarm out of the resident's reach because the resident will turn the alarm off. The incident report dated 6/10/11 indicated the staff lowered the resident to the floor. The fall intervention directed staff to remind the resident to accept help for personal cares. The incident report dated 6/28/11 at 1:15 p.m. indicated the resident on the floor in front of the recliner. The alarm sounded. The fall intervention directed staff to constantly remind the resident to not get up without help. The incident report dated 7/10/11 dated 2:00 p.m. documented staff observed the resident on the floor between the recliner and the wall. The alarms sounded. The fall intervention directed staff to toilet the resident in the afternoon. The incident report dated 8/16/11 at 8:25 p.m. documented the resident sat in the recliner with alarms in place. The resident disabled the alarms and fell . The fall intervention directed staff to place the alarms out of the resident's view. The clinical record documented the resident fell in the dining room (no incident report). The fall intervention directed staff to apply a pressure alarm on the dining room chair. The incident report dated 9/19/11 at 3:46 p.m. documented Staff P, Certified Nurse Aide, (CNA) assisted the resident to the toilet. Staff P assisted the resident to the recliner. Staff P placed the alarms within the resident's reach. The resident disabled the pressure alarm and the personal alarm. Staff N, Licensed Practical Nurse, observed the resident fall to the floor on the right side. Staff N completed an assessment including range of motion. The resident had no impairment but when staff assisted the resident to stand, the resident complained of pain in the right hip area and could not bear weight on the right leg. Staff N transferred the resident to the hospital. An x-ray report dated 9/11/11 documented the resident had a minimally displaced osseous fracture of the right leg. The staff referred to the plan of care dated 9/22/11 located in the resident's bathroom. The plan of care directed staff to utilize a personal alarm, pressure alarm for the recliner and wheelchair and a floor alarm. The plan of care did not direct staff to place alarms out of the resident's reach. During an interview on 10/3/11 at 8:15 a.m., Staff C, Director of Nursing, stated that Staff P worked for a temporary staffing service but not assigned to the resident that day. Staff C stated the temporary staff did not have access to the computer care plans. Staff C stated the nursing assistants use the care plans located in the resident's bathroom. During an interview on 10/3/11 at 8:32 a.m. Staff M, Activity Director, stated she heard the resident fall. Staff M stated Staff N, entered the room first then Staff M entered the room. Staff M stated she and Staff O, CNA, assisted the resident to bed. Staff M then exited the room. During an interview on 10/3/11 at 9:48 a.m. Staff P stated she helped the resident but did not have the resident in her assignment that evening. Staff P stated she assisted the resident to the bathroom then assisted the resident to the recliner. Staff P clipped the personal alarm to the resident's shirt and turned the pressure alarm on underneath the resident. Staff O, CNA, instructed Staff P on how the alarms worked but did not direct her as to the placement of the alarms. Staff P stated she looked at the plan of care in the bathroom which instructed what alarms the resident utilized. Staff P stated she had no knowledge the resident turned the alarms off. During an interview on 10/3/11 at 10:05 a.m. Staff L stated the temporary staff are provided with a list of residents and the alarms the residents utilized. Staff L stated the temporary staff are told about the plan of care in the bathroom to utilize when helping with unfamiliar residents. During an interview on 10/3/11 at 10:25 a.m., Staff Q, CNA, stated the resident frequently turned alarms off. Staff Q stated staff needed to keep the pressure alarm box and the clip for the personal alarm out of reach. Staff Q stated she referred to the plan of care located in the resident's bathroom for resident cares. During an interview on 10/3/11 at 10:30 a.m. Staff H, CNA, stated she has not seen the resident turn the alarms off. Staff H stated she referred to the plan of care located in the resident's bathroom for resident cares. During an interview on 10/3/11 at 10:34 a.m. Staff I, CNA, stated staff need to clip the personal alarm to the back of the resident's shirt out of reach. Staff I stated she has not seen the resident turn the alarms off. Staff I stated she referred to the resident's plan of care located in the resident's bathroom for cares. During an interview on 10/3/11 at 11:20 a.m., a family member of the resident, stated the resident frequently turned the alarms off and tried to get up without assistance. During an interview on 10/3/11 at 2:12 p.m. Staff O, CNA, stated she informed Staff P about alarms for the resident. Staff O thought she told Staff P about putting the alarms out of reach and referred Staff P to the plan of care located in the resident's bathroom. Staff O stated the resident frequently takes the alarms off. Staff O stated when she assisted after the fall, she observed the pressure alarm box on the telephone stand within the resident's reach. Staff O stated the facility utilizes temporary nursing aide staff frequently. During an interview on 10/3/11 at 2:00 p.m. Staff N (Licensed Practical Nurse) stated when the resident fell , no alarms sounded. Staff N stated the resident's personal alarm was unclipped and the pressure alarm box was in the off position. Staff N stated the resident had a history of [REDACTED]. During an interview on 10/3/11 at 2:25 p.m. Staff L (Registered Nurse) stated when the resident returned from the hospital, the nurse updated the number of staff needed to transfer the resident on the plan of care located in the resident's bathroom. Staff L stated the rest of the resident's plan of care remained the same. Staff L stated they did not keep a copy of the plan of care before the resident fell but verified the plan of care did not direct staff to put alarms out of reach. Staff L stated the temporary staff do not have access to the care plan on the computer.

Based on observation, record review, staff and family interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistive devices to prevent accidents for two of four residents reviewed with accidents. (Resident #1 and Resident #4) Facility census was thirty (30) residents. Findings include: 1. A Minimum Data Set (MDS) with an observation end date of 1/19/11 identified Resident #1 with impaired ability to understand others. A brief interview for mental status (BIMS) identified the resident with a score of 1 (severe cognitive impairment). The MDS identified the resident required supervision with ambulation. The resident required limited staff assistance with bed mobility, transfers and toileting. The MDS identified the resident as not steady, but able to stabilize without human assistance when: moving from seated to standing, walking with assistive device, turning around and facing the opposite direction while waling, moving on and off the toilet and transferring between bed and chair. The resident utilized a walker for ambulation (walking). The resident had [DIAGNOSES REDACTED]. According to a summary report, dated 2/25/11 and written by Staff K, the resident ambulated independently with a walker during the day. The resident used alarms on the bed and floor during the night because of the resident's tendency for weakness and confusion at night. The resident had 6 falls in the last 6 months which all occurred between 3 p.m. and 9:45 p.m.. One required stitches to the scalp and during a fall on 2/24/11, the resident sustained [REDACTED]. It was two years ago that the resident required sutures to the head. Falls according to incident reports: On, 6/21/10 at 5:50 p.m., staff found the resident in the dining room lying on his/her back with the walker to the side of the resident. The resident hit head and sustained a 2 centimeter (cm.) by 2 cm. hematoma to the back of the head and a skin tear on the right elbow measuring one centimeter (cm.) by 1 cm. After the fall, staff observed the resident's water cup on the floor. The intervention the facility provided: "to observe resident and remind resident to make sure walker is close and hands free of cups or glasses". 8/7/10 at 7 p.m., staff found the resident after hearing a "disturbance" in the common living room. Staff found the resident on the floor with a 1.5 cm. by 0.5 cm. laceration to his/her left parietal area of the head. The resident complained of head pain Observation showed a significant amount of blood. The report did not identify interventions after the incident. 9/12/10 at 6:40 p.m. the resident fell as (s)he rushed to the bathroom in the resident room. Another resident saw the resident on the floor and called for help. The resident did not sustain injury. At this time, the resident's daughter stated she did not want personal alarms on the resident while the resident is awake. Staff made 15 minute checks on the resident from 1845 to 2200 on 9/12/10. 10/17/10 at 7 p.m. staff found the resident in a sitting position on the bathroom floor and lost balance. The resident denied pain and staff did not observe injury. An investigation summary indicated the resident is independent and uses walker which was present. The resident becomes unsteady frequently. Staff told the resident to call for assistance. The intervention following this fall was: to reinforce with resident to call for assistance when feeling unsteady and "resident requires more supervision when in the bathroom". 1/13/11 at 9 p.m. Staff found the resident in a sitting position in the bathroom. No injury observed. The resident was in the bathroom with walker close by but lost balance. The intervention was: to check on resident more frequently when in the bathroom or on way and assist resident with cares. 1/17/11 at 1 p.m. resident standing in dining room and took a drink of coffee falling backwards. No apparent injury. The intervention was: Nothing will be changed according to daughter. A facsimile to the physician dated 1/17/11 indicated the facility spoke with the resident's daughter. The daughter stated she wanted no alarms or one to one assistance for the resident. "If the resident falls and breaks a hip, then they will deal with that at the time". 1/18/11 at 9:45 a.m. the resident got up from a chair in the activity room and fell backwards sustaining a 4 cm. diameter hematoma to the left posterior head. The intervention was: Daughter does not want a chair alarm on resident at this time. 2/24/11 at 9:45 p.m. staff found the resident in a sitting position on the bathroom floor. The resident could not move the right hand and observation showed a skin tear on the palm of the hand. The resident only had socks on and lost balance using the right hand to catch self when the resident fell . The intervention for this incident was: to observe resident closely when up and ambulating and that resident has proper footgear on. Staff notified the physician of the complaints of pain and the resident transported to the emergency room for examination. The resident returned that same night with a splint on the right wrist. An x-ray report dated 2/24/11 identified the resident with a nondisplaced vertical fracture of the distal radius. Staff Interviews: On 3/15/11 at 2:25 p.m. Staff B indicated she watches the resident "every minute and second". She stated she checks the resident when she goes down the hall or staff will have the resident come to the common area. On 3/15/11 at 12:42 p.m. Staff C identified herself as new at the facility. She stated she applies alarms to the resident when the resident is in the chair and when the resident is in bed. At that time, Staff C and the surveyor viewed the resident. Observation showed the resident seated in a chair in the resident's room with a seat alarm underneath the resident as the resident sat in the chair. On 3/15/11 at 12:20 p.m. Staff D stated there is no set time that staff checks on the resident. Staff C stated staff checks the resident at least every two hours but "I'm sure its more often than that". She stated she was the charge nurse when the resident fell on [DATE] and she instituted 15 minute checks until her shift ended that evening. On 3/15/11 at 11:45 a.m., Staff E stated she goes in and checks the resident as "many times as I need to". She stated when the resident is "in a mood to roam" then its necessary to check more often. On 3/14/11 at 2:35 p.m., Staff H stated it was close to 10 p.m. on 2/24/11 and she heard the resident when she was right outside the resident's door. She found the resident in a sitting position on the floor and the resident complained of wrist pain. Staff H stated they put an alarm on the resident's chair and bed after that but the resident can turn it off. Most of the time there is no alarm on the chair and at bedtime the resident "may have it" on the bed. When she found the resident on the floor on 2/24/11, Staff H stated she heard the resident yelling. She did not hear an alarm. Staff H identified herself as "the first one there". She was not sure where the resident was prior to the fall. Staff H stated that following the fall, the resident's daughter agreed to short term use of alarms. Staff H stated the resident got less steady over the last year. On 3/14/11 at 2:10 p.m., Staff J stated "we do our best" to keep an eye on the resident. She stated the resident uses an alarm when in bed and sometimes it sounds every 15 minutes. She stated the resident knows how to take the alarm off. Staff J stated on 2/24/11 the resident was in the recliner watching television prior to the fall. Staff J stated a chair alarm sounded but by the time she arrived the resident was on the floor. Staff J saw the resident's wrist was "not right" and the resident went to the emergency room right away. Care Plan: The care plan in place at the time of the 2/24/11 fall identified a problem start date of 8/4/10. The problem identified the resident at risk for falls related to poor balance, forgetfulness in senile dementia and history of increased confusion and falls. The care plan identified the following interventions: 1/8/10 Be sure walker is nearby 2/17/10 toilet resident more frequently when the resident shows increased confusion, 3/28/10 assist resident to apply gripper socks when goes to bed so they are on if the resident gets up at night 5/29/10 toilet at 1 a.m. nightly, 6/21/10 supervise resident while ambulating. Relieve the resident of any cups or glasses while ambulating 7/18/10 when resident is ill and until confusion improves keep a close eye on the resident (consistently for 3 hours) then ambulate with the resident for 3 days in the hall, answer call light in a timely manner, instruct resident to use call light for assistance when needed, keep bed lowered to floor, keep call light in reach, keep room free of clutter, monitor lying, sitting and standing blood pressure, physical therapy to evaluate as needed, personal alarm on while in bed during night, remind/assist to apply shoes or nonskid slippers or socks before attempting transfers or ambulation, 8/7/10 encourage resident to stay ion bed and keep reminding to use call light, 9/12/10 whenever resident shows signs or symptoms of urinary tract infection toilet every two hours, 10/17/10 staff to check on resident more often when in bathroom. encourage to call for help if feels unsteady, 1/13/11 check to see if resident is in bathroom each time going by room and if there, stay with her to steady her until resident fin finishes, 1/27/11 if resident stands up from the dining table ask resident and assist resident as needed to reseat self until staff gets walker to resident, 2/24/11 be sure resident has shoes on and not only socks. Observation: Observation showed, on 3/15/11 at 10:50 a.m., the resident on the toilet with the door slightly cracked making the resident's walker in bathroom visible. Observation showed staff walking by the resident's room several times on their way to other rooms. Staff did not look in on the resident. The surveyor constantly observed the resident's room/bathroom for staff to check on the resident. No staff checked on the resident until Staff E went in at 11:24 a.m. and peeked in on the resident. She then left the resident in the bathroom on the toilet. The resident did not leave the bathroom until 11:35 when staff then walked the resident to the common living area. Observation showed, on 3/14/11 at 12:55 p.m. the resident in the bathroom on the toilet. At that time, Staff L stated staff does not stay with the resident when the resident is on the toilet. The resident likes to sit on the toilet and staff comes back later. Observation showed, on 3/14/11 at 4:20 p.m., 3/15/11 at 12:42 p.m. and 4:25 p.m. the resident in the resident's room seated in an easy chair with a seat alarm on. (not care planned for a chair alarm) On 3/14/11 at 1:20 p.m., the resident denied having any falls. The resident could not answer when the surveyor questioned the resident about what happened to the resident's wrist. On 3/15/11 at 9:09 a.m., the resident's daughter confirmed she does not want alarms on the resident and that she fully understood the risks. Major Injury Form: On 3/15/11 Staff A sent a major injury determination form to the resident's physician. On 3/16/11, the physician returned the form identifying the right wrist fracture as a major injury. 2. A Minimum Data Set (MDS) with an observation end date of 12/15/10 assessed Resident #4 with a BIMS (brief interview for mental status) score of 10. A score of 10 identified the resident with moderate cognitive impairment. The MDS identified the resident to require supervision with transfers and ambulation. The resident was independent with toileting. The resident used the following mobility devices: walker and wheelchair. The resident had [DIAGNOSES REDACTED]. The resident had shortness of breath and utilized oxygen to breathe. The MDS identified the resident with a fall with unjury since the prior assessement. Progress notes identified the following information: 12/7/10 at 10:30 a.m. the resident fell on the way to the bathroom and received a 5 centimeter (cm.) by 5 cm. skin tear on the left elbow. The resident also received an abrasion on the nose. Observation showed a 2.5 cm. by 2.5 cm. bruised area around the abrasion with swelling. The resident refused to move the left leg. The facility notified the physician and the physician ordered an x-ray which was negative for fracture. The progress note stated today the resident would have fallen while walking to lunch had a nurse aide not caught the resident. The resident is also not using walker in room. The care plan contained an intervention dated 12/26/10 which directed staff to make sure the resident has his/her walker next to resident as a visual reminder. Summary of incident follow up reports identified the following information: 2/20/11 at 8 p.m. staff identified the resident as ambulating in room without walker. Staff found the resident on the floor in a sitting position next to bed. The resident did not sustain injury. A care plan addendum dated 2/20/11 stated "when up ambulating use the walker to help guidance and unsteadiness" and "remind to use walker and if you see resident without it, get it for him/her". 2/25/11 at 10:30 a.m. stated staff found the resident on the floor in the resident's room. Resident fell as resident ambulated to the bathroom without the walker. The resident lost balance. A care plan intervention dated 2/25/11 identified staff provided visual reminders for resident to use walker. Observation showed, on 3/14/11 at 1:30 p.m., the resident in bed. The resident stated (s)he does not recall falling. Observation showed, on 3/15/11 at 9 a.m., the resident in the bathroom without the walker. The resident remained in the bathroom without the walker until 9:20 a.m. when the surveyor got Staff F. Staff F checked on the resident in the abthroom and began to leave the room when the surveyor asked if the resident had his/her walker. Staff F stated "no" and got the walker. Staff F then stated, "I guess our signs (to remind to use walker) don't do much good". On the same date at 11 a.m. , observation showed the resident in the recliner with the walker a distance away at the foot of the resident's bed unavailable.