Every finding on record at Eastern Star Masonic Home

Based on clinical record review, staff interviews, and review of the facility's policy the facility failed to document 3 non-pharmacological approaches to minimize the need for as needed (PRN) psychotropic medications for 1 out of 5 residents sampled (Resident #30). The facility also failed to limit use of PRN psychotropic medications to 14 days for 2 out of 5 residents sampled (Resident #7 and #9). The facility reported a census of 73 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #30 identified a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The MDS documented the resident exhibited physical and verbal behavioral symptoms directed toward others 4 out of 6 days of the 7-day look back period. The MDS also documented the resident rejected evaluation or care 1 out of 3 days of the 7-day look back period. The MDS documented diagnoses that included: diabetes, depression, and dementia without behaviors. The MDS also documented the resident was taking antianxiety medications during the last 7 days. The Facility Pocket Care Plan dated 5/20/26 documented Protocols (facility guidelines) for Antianxiety which included common side effects for those types of medications. There were no specific interventions included. The Physicians Telephone Orders sheet signed by the physician on 1/27/26 contained an active order for lorazepam (a fast-acting prescription medication that slows down your brain and nervous system) 2 milligrams per milliliters (mg/mL). Give 0.25 mL every 4 hours as needed. The Physician Recommendations form signed by the physician on 2/9/26 gave orders to continue as needed lorazepam order for 180 days for agitation. The January Medication Administration Record (MAR) documented lorazepam was given to Resident #30 on 1/28/26, 1/29/26, and given twice on 1/30/26. The MAR lacked documentation of any interventions attempted prior. The February Medication Administration Record (MAR) documentation revealed lorazepam was given 16 times between 1/1/26 through 1/9/26. The MAR lacked documentation of any interventions attempted prior. The Order Audit Report revealed Staff G, Co. Director of Nursing (Co-DON) revised the lorazepam on 2/19/26 at 1:23 PM to include supplementary documentation details to include 3 interventions, music therapy (MT), snack, and activity (Act). Several Progress Notes between 1/28/26 through 2/19/26 lacked documentation of 3 interventions prior to administering lorazepam. On 5/21/26 at 10:35 AM Staff G, Co-DON acknowledged and confirmed that no supplemental documentation details were found for the resident's as needed (PRN) lorazepam order dated 1/28/26 at 10:12 AM. Also confirmed the supplemental documentation details to include music therapy (MT), snack, and activity (Act) interventions were created on 2/19/26. Staff G, Co-DON indicated that the supplemental documentation details should have been placed before 2/19/26. She reported she did not know why they were not there and could not remember. On 5/21/26 at 3:00 PM the Director of Compliance indicated he would expect 3 non pharmacological interventions be tried before administration of lorazepam which should be given after non pharmacological interventions are not successful. The Algorithm for Treating Behavioral and Psychological Symptoms of Dementia instructed:Step 1: Identify, Assess, and Treat Contributing FactorsStep 2: Select And Apply Non-Drug Interventions Step 3: Monitor Outcomes And Adjust Course As Needed. 2. Resident #7's admission MDS assessment dated [DATE] identified an admission date of 2/13/26 and a BIMS score of 5 out of 15 for Resident #7, which indicated the resident was cognitively severely impaired. The MDS listed diagnoses included: non-traumatic brain dysfunction and dementia. The MDS documented Resident #7's psychotropic medications included antipsychotic and antidepressant medications. Review of Resident #7's EMR revealed a 3/29/26 physician's order for Ativan Oral Tablet 0.5 mg (Lorazepam) to be given every 12 hours as needed for anxiety, agitation related to the resident's dementia. The end date was Indefinite. Review of Resident #7's paper medical record revealed a Physician's Telephone Order dated 3/29/26 for Ativan 0.5 mg PO [by mouth] Q12H [every 12 hours] X 90 days. The physician's order had not documented the rationale for extending the PRN order beyond 14 days as required. Review of Resident #7's Care Plan, dated 5/21/26 revealed he lived in the facility's Chronic Confusion and Dementing Illness (CCDI) unit. Protocols (facility guidelines) for Antipsychotic, Antidepressant, and Antianxiety included common side effects for those types of medications. Specific interventions included offer exercise group, music, one-to-one, tabletop activities, and informed staff that the resident enjoyed reading, magazines, and talking about his wife. Review of the Consultant Pharmacist's monthly medication reviews revealed on 4/30/26 a request was made to the physician regarding Resident #7's prescribed PRN Ativan medication for the clinical rationale supporting the continued need for this PRN medication. Continued review of the request revealed the physician had signed the request on 5/19/26 extending the duration for this order to continue for another 180 days with no rationale documented as required. 3. Resident #9's MDS assessment dated [DATE] identified the resident was cognitively severely impaired. The MDS listed diagnoses included: non-traumatic brain dysfunction, Alzheimer's Disease, dementia, and anxiety disorder. The MDS documented Resident #9's psychotropic medications included antipsychotic, antianxiety, and antidepressant medications. Review of Resident #9's EMR revealed a 2/26/26 physician's order for Lorazepam Oral Concentrate 0.25 ml to be given every 4 hours as needed for anxiety agitation related to the resident's anxiety disorder. A 4/9/26 physician's order changed the frequency to be given every 2 hours as needed. Review of Resident #9's Care Plan, dated 5/21/26 revealed she lived in the facility's CCDI unit. Protocols (facility guidelines) for Antipsychotic, Antidepressant, and Antianxiety included common side effects for those types of medications. There were no specific interventions included. Review of the Consultant Pharmacist's monthly medication reviews revealed on 4/9/26 a request was made to the physician regarding Resident #9's prescribed PRN Ativan medication for the clinical rationale supporting the continued need for this PRN medication. Continued review of the request revealed the physician had extended the duration for this order to continue for another 180 days with no rationale documented as required. In an interview on 5/20/26 at 12:58 p.m. with the Administrator and Staff E, Co-DON regarding psychotropic medications that were prescribed PRN (as needed) revealed the facility reviewed those PRN orders every two weeks for continued use. Both Resident #7's and Resident #9's PRN psychotropic medication reviews were requested. No PRN psychotropic medication reviews were received for Resident #7 or Resident #9 by the end of the survey. In an interview on 5/21/26 at 3:24 p.m. with Staff E, Co-DON and Staff G, Co-DON regarding Resident #7's and Resident #9's PRN orders for psychotropic medications being extended to 180 days with the attending physician/prescribing practitioner not documenting a rationale to extend those medications, revealed the facility's preferred pharmacy had recently switched its software and they explained that software change had contributed to why those PRN orders had not been reviewed as required. They agreed that PRN orders for psychotropic medications which were not for antipsychotic medications should have been limited to 14 days, unless the attending physician/prescribing practitioner had documented a rationale to extend that medication. Review of the facility's policy Medication Regimen Review dated October 2019 revealed the consultant pharmacist performs a comprehensive review of each resident's medication regimen at least monthly and Psychotropic medications (anti-anxiety,. and any other drug that affects brain activity associated with mental behavior.) must be reviewed monthly to ensure that: a. Residents who use psychotropic drugs receive. behavioral interventions,. in an effort to discontinue these drugs. b. PRN [as needed] orders for psychotropic drugs are limited to 14 days and cannot be continued beyond that time unless the resident's physician or primary care provider documents the rationale for this continuation as well as an anticipated stop date in the resident's clinical record. The policy further revealed that the consultant pharmacist's evaluation includes When possible, non-pharmacologic interventions are considered before initiating a new medication.

Based on facility investigation review, clinical record review, staff interviews and policy review the facility failed to report an allegation of resident to resident abuse within 2 hours to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for 2 of 2 residents reviewed (Residents #74 and #80). The facility reported a census of 73 residents.Findings include:The Progress Note dated 2/18/26 documented Resident #74 came to the nurse to take her to his room. Resident's #74's roommate (Resident #80) was lying on the floor in a pool of blood above his head. Resident #74 reported he had a confrontation with Resident #80. Resident #74 was separated from Resident #80 and was brought to the west dining room. The Incident Report (IR) dated 2/18/26 at 8:10 PM documented Resident #80 was observed laying on the floor in a pool of blood. Resident #80 had a 13 centimeter laceration to the back of his head related to a fall and was sent to the emergency room. Review of the document titled Self Report revealed the facility contacted the state agency regarding the allegation of resident to resident abuse on 2/19/26 at 5:03 PM. On 5/19/26 at 2:46 PM, the Director of Compliance reported the self report was initially called in to DIAL around 9 or 10 PM and then the self report was filed online the next day after the facility was able to gather further information regarding the incident.On 5/19/26 at 3:30 PM, the Director of Compliance reported he did not have any documentation that the phone call was made to DIAL. On 5/20/26 at 1:21 PM, DIAL Intake Specialist reported there were no calls documented from the facility on the call logs around 9 or 10 PM on the evening of 2/18/26.The facility policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy updated 07/2025 documented if the incident prompting the investigation results in serious bodily injury to a resident and there was reasonable belief that it was result of a crime committed, the Elder Justice Act requires the matter to be reported to law enforcement and DIAL within two hours by all persons having knowledge of the matter.

Based on clinical record review, facility document review, staff interviews and policy review, the facility failed to provide care and services according to accepted standards of clinical practice by not following physician orders resulting in medication errors for 2 of 2 residents reviewed (Residents #65 and #6) for medication errors. The facility reported a census of 73 residents.Findings include: 1. The Clinical Census revealed Resident #65 was admitted on [DATE] for hospice services. Resident #65 did not have a Minimum Data Set (MDS) completed. The facility form title Medication Error dated 5/9/26 revealed Resident #65 was incorrectly administered Oxycodone (opioid narcotic) 5 milligrams (mg). The form documented Resident #65 was drowsy but alert and responsive to verbal stimuli following the medication error. The Progress Note dated 5/9/26 documented a medication error. Resident #65 was given Oxycodone 5 mg instead of the prescribed Tramadol (opioid narcotic) 50 mg. The May 2026 Medication Administration Record (MAR) for Resident #65 lacked a physician order for Oxycodone. The MAR directed to give Tramadol 50 mg two tablets every 6 hours as needed for low back pain. On 5/20/27 at 2:31 PM, Staff D, Certified Medication Aide (CMA) acknowledged the medication error with Resident #65. Staff D said she thought the medication error had to do with having two brand new residents in rooms 14E (Resident #65) and 16E (Resident #82) with their last name both starting with the letter S. She said both residents wanted pain medication at the same time. She said she saw the letter S on the medication card and grabbed the wrong one. She said when she went to do a narcotic count at 10 AM she realized there was more Oxycodone gone then there should have been. She said there were three Oxycodone tablets gone and there should only have been one tablet gone. She said she gave Resident #82 one Oxycodone tablet (5 mg) and she had given Resident #65 two Oxycodone tablets (10 mg total). She said Resident #65 had an order for Tramadol 50 mg 2 tablets. Staff D said she self identified the medication error and reported it to the nurse. She said the nurse completed the required notifications. Staff D said she received reeducation to make sure to identify the resident and to triple check the medication cards with the resident name. She said normally she would pull the medication card out of the drawer and put it on top of the cart to compare it to the MAR. She said she did not do that and had left the card in the drawer. She said she also signed off the medication before she gave the medication and she normally does not do that. She said usually she administers medication and then signs the medication out. The Controlled Medication Utilization Record for Resident #82 documented on 5/9/26 at 9:08 AM one tablet of Oxycodone 5 mg was deducted with the remaining amount of 13 tables. The document reflected the count was corrected on 5/9/26 with the amount remaining to be 11 tablets instead of 13 tablets. The Controlled Medication Utilization Record for Resident #65 documented on 5/9/26 at 8:33 AM two tablets of Tramadol were deducted with the remaining amount of 40 tablets. The entry was crossed off with a line through it and the word error was written on the side. On 5/20/26 at 4:14 PM, the Director of Compliance reported he would expect the staff to follow the 3 checks and 6 rights of medication administration. The Director of Compliance reported he had talked to Staff D, CMA and she had reported to him also that she gave Oxycodone 5 mg 2 tablets (10 mg total) to Resident #65 which was consistent with the documentation on the narcotic record. He acknowledged the Medication Error Report did not reflect that two tablets of Oxycodone were given. He said Resident #65's Physician would be updated with the correct information. The facility policy titled Medication Administration reviewed 07/2025 documented the facility staff member will prepare and administer the medications to the resident following the 3 Checks and 6 Rights of Medication Administration and/or current best practices for Medication Administration. The facility form titled Medication Administration Audit documented the 6 rights of Medication Administration include the following: a. Right Resident b. Right Medication c. Right Time d. Right Route e. Right Dose f. Right Documentation In addition, the 3 Check prior to pulling and administering the medication included the following: a. Before removing from drawer b. As the drug is removed from the card c. Before returning the medication card to the cart. 2. The Minimum Data Set (MDS) dated [DATE] triggered Care Areas included cognitive impairment and poor memory. The admission Record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of osteoarthritis and pain. The Clinical Physician Orders revealed tramadol (a strong prescription painkiller used to block moderate to severe pain) 50 mg 2 tablets 3 times daily was discontinued on 2/17/26. The progress note on 2/17/26 at 2:10 PM documented the signed order to discontinue tramadol and start oxycodone (a strong, semi-synthetic opioid pain medication prescribed to relieve moderate-to-severe pain) 20 mg one tablet twice daily. The February 2026 Medication Administration Record (MAR) for Resident #6 directed to give oxycodone 20 mg one tablet twice daily for osteoarthritis which was started on 2/17/26 at 7:00 PM. The MAR showed the order for tramadol 50 mg two tablets three times daily order was discontinued on 2/17/26 at 2:07 PM. The MAR revealed the resident received the scheduled night dose of oxycodone. The Situation Background Assessment Recommendations (SBAR) dated 2/18/26 at 7:57 AM, documented tramadol 50 mg 2 tablets every 8 hours as needed was discontinued and started orders for oxycodone 20 mg twice daily on 2/17/26. The medication card was still in the medication cart after the tramadol was discontinued. Staff, H Certified Medication Aide (CMA) gave the tramadol by mistake. The facility form titled Medication Error dated 2/18/26 revealed Staff H, CMA incorrectly administered 2 tablets of tramadol (opioid narcotic) 50 milligrams (mg) on 2/18/26 at 6:30 AM. The form documented Resident #6 was alert, responsive to verbal stimuli, and vital signs were stable following the medication error. On 5/21/26 at 3:00 PM, the Director of Compliance indicated he would expect the CMA to follow the 6 rights of medication administration. Also, informed he would expect medication be pulled from the medication cart after the medication was discontinued. The resident's pocket care plan dated 5/20/26 documented protocols for opiod use and comfort risk.

Based on clinical record review, staff interviews, and policy review, the facility failed to provide adequate nursing supervision to prevent an elopement for 1 of 1 resident reviewed (Resident #7). The facility reported a census of 73 residents. Findings include:The Clinical Census revealed Resident #7 was admitted on [DATE]. Resident #7 did not have a Minimum Data Set (MDS) completed. The facility assessment titled Wandering Risk Assessment completed on 2/13/26 at 1:26 PM identified a score of 11 indicating Resident #7 was a high risk to wander. The Baseline Care Plan signed by Resident #7's wife and dated 2/13/26 did not address high risk for wandering. The Incident Report dated 2/13/26 at 3:45 PM documented the incident category as an elopement. The form revealed a dietary staff member let Resident #7 out of the health center (supervised area) to a non-supervised area. Resident #7 went outside and a residential care facility (RCF) certified nursing assistant (CNA) saw Resident #7 walking by the RCF building and brought Resident #7 back to the health center.The facility form titled SBAR (Physician Notification) documented on 2/13/26 a dietary staff member let Resident #7 out of the health center. Resident #7 got outside. The RCF CNA noticed Resident #7 wandering near the RCF building. The RCF CNA brought him back to the health center. Resident #7 did not fall and there were no injuries. On 5/21/26 at 11:55 AM, Staff A, Registered Nurse (RN) reported Resident #7 had moved to the health center on 2/13/26. She said the dietary aide let Resident #7 out the door in the west hallway that goes to the RCF. She said Resident #7 then went out door #15 by the dumpsters. She said Resident #7 was found outside on the sidewalk by himself. She said she did not think he was outside very long as the dietary staff member had come up to her to ask if Resident #7 had moved to the health center. She said the dietary staff member told her that she had let Resident #7 out the health center door because she thought he still lived in RCF. She said she thought Resident #7 was outside for maybe 5-10 minutes. She said she went outside to look for Resident #7. She said an RCF aide was outside in her car taking a break and had seen Resident #7 by himself on the sidewalk. She said when she got outside she met the RCF aide and Resident #7. She said they had to get a wheelchair to bring him back to the health center. She said Resident #7 was wearing pants, a short sleeve t-shirt and shoes. She said he did not have a coat or winter clothes on. She said the weather was chilly but it was not snowing or raining at the time. When asked what interventions were put into place after the incident, she said, that's a good question. She said she thought she had left that up to the Co-Don's (Director of Nursing). She said she thought the intervention was about making sure all staff know the residents in the health center and making sure staff are informed so it does not happen again. She said she provided education to the dietary aide regarding double checking with the staff before letting a resident out and verifying if they should be let out or not. On 5/21/26 at 1:00 PM, observation revealed doors at the end of the west hallway in the health center are secured and required a code to leave. When exiting the health center through the west door, there's a door on the right side labeled #15 that leads to the loading dock/sidewalk, dumpsters and a residential street. Door #15 was not secured or alarmed. There was a sign on the door #15 stating video surveillance. On 5/21/26 at 2:49 PM, Staff B, Dietary Aide reported she was pulling a cart, entered the main health center door and Resident #7 exited out of the door into RCF. She said she thought Resident #7 still lived upstairs in the RCF. She said Resident #7 let himself out the back door where the dumpsters were located. She said she ran down the hallway in the health center and found the first staff member closest to the door which was Staff A, RN. She said she told Staff A that Resident #7 had gone out the door. She said Staff A panicked a little bit and then grabbed another CNA from a resident's room to help. Staff B said she went back outside and saw Resident #7 was walking down the sidewalk towards the elementary school. She said no one was with him. She said she called his name but he kept walking and did not turn around. She said at the end of the sidewalk there was a RCF CNA standing there and she grabbed Resident #7. She said Resident #7 was probably outside for a whole minute. She said everyone responded really quick. When asked if anyone in Administration had called her about the incident, she said not at that time but recently. When asked how recent, she said Staff E, Co-DON called her today (5/21/26) and she told her the same information. Staff B reported Resident #7 was outside by himself but she could not say where the RCF staff member had been the whole time. When asked if she had received any education after the incident, she said no. She said the situation was an accident. She said she was not paying attention and when she realized it was Resident #7, she went to the nurse and found out he had been moved. She said she has worked in the dietary department for 3 years, she said she knew she was not to let residents out the door. On 5/21/26 at 3:12 PM, the Co-DON's and the Director of Compliance reported the dietary aide was with Resident #7 and had eyes on him when he went outside. The Administrator reported the video surveillance was not available as the incident occurred more than 3 months ago. On 5/21/26 at 3:20 PM, Staff C, RCF CNA reported she was on break in her car and and she saw Resident #7 exit the door. She said she was parked along the road. She said when Resident #7 came out of the door, he was by himself. She said Resident #7 exit the door, he went left and started walking down the sidewalk towards the school. She said he did not have his walker with him. She said she jumped out of her car and headed to him. She said a dietary aide came outside and was walking behind him. She said she approached from the front and got to him first. She said she had him sit down on the ledge and then two other staff members came out with a wheelchair. She said the dietary staff member did not know Resident #7 had moved to the health center. She said she did talk to her the RCF Director of Nursing (DON) about what had happened and the RCF DON said the health center staff would take care of it. She said no one had reached out to her about the incident prior to today (5/21). She said the Director of Health Services reached out to her today to ask what had happened. On 5/21/26 at 4:05 PM, the Director of Compliance reported his expectation was for staff to stay with the resident if the resident exited the health center and required supervision. He said from what he knew the staff had eyes on Resident #7 the whole time. He said he did not consider the incident an elopement. He said the facility used a 5 minute form to provide education. The facility was not able to provide any documentation to show education was completed with the staff after the incident occurred. The facility policy titled Elopements and Wandering Residents reviewed 4/1/26 documented the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The policy directed the following when monitoring or managing resident at risk for elopement or unsafe wandering:a. Residents will be assessed for risk for elopement and unsafe wandering upon admission and throughout their stay by an interdisciplinary care plan team.b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person centered care plan.c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risk associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accident or elopementse. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions and document accordingly.f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff.

Based on personnel file reviews, facility policy review and staff interview, the facility failed to provide dependent adult abuse (DAA) training within 6 months of hire for 1 of 5 employees reviewed. The facility identified a census of 73 residents. Findings include:The personnel file for Staff F, Registered Nurse (RN) documented a hired date of 8/5/25. Review of the Dependent Adult Abuse Mandatory Reporter Training Certificates documented Staff F completed the 2 hour dependent adult abuse training on 3/24/26.The facility policy titled Abuse Prevention, Identification, Investigation and Reporting Policy reviewed 07/2025 revealed each employee shall be required to complete 2 hours of training related to identification and reporting dependent adult abuse within six months of initial employment. On 5/20/26 at 10:00 AM, the Director of Compliance acknowledged the DAA training was completed late. He reported the facility had recently changed their process where new hires would be enrolled in the DAA class right away and not wait the 4-6 months.

Based on observations, kitchen record review, and staff interview, the facility failed to ensure food safety was maintained by not obtaining food temperatures and not maintaining temperature logs. The facility also failed to ensure food was properly stored and labeled and all areas of the main kitchen were clean. The facility reported a census of 73. Findings include: 1. During a kitchen observation on 4/21/25 at 10:00 AM, food thermometers were identified in the food prep area. Review of the main kitchen food temperature logs from the past 4 months revealed the following: a. For the month of January 2024, a total of 9 out of 96 meals for the month had food temperatures documented b. For the months of February 2024, a total of 2 out of 84 meals for the month had food temperatures documented c. For the month of March 2024, a total of 12 out of 96 meals for the month had food temperatures documented d. For the month of April 2024, a total of 16 out of 60 meals for the month thus far had food temperature documented. During an interview on 4/23/25 at 2:15 PM, the Dietary Manager acknowledged the lack of food temperature documentation from the main kitchen staff. The Dietary Manager stated it is kitchen procedure to write down food temperature prior to being sent out to the satellite kitchenettes for meal service. The undated policy Food Temperatures noted food will be cooked and/or reheated to the correct temperature. Final temperature readings will be recorded into the book. 2. An observation of the main kitchen on 4/21/25 at 10:00 AM revealed the following: a. A bin full of serving utensils and squirt bottles had drops of dried brown food or liquid residue on several of the equipment. b. A large bowl of an unidentifiable food item was found the walk-in cooler. The item was uncovered and without a date/label. c. Two covered pans of food were found in the walk-in cooler without a date/label. d. Two round containers with an unidentifiable yellow liquid were found in the walk-in cooler. The containers were covered but without a date/label. e. An undated, non-labeled food item wrapped in foil was found in the walk-in cooler. f. An unsecured open bag of lettuce and an unsecured open bag of shredded cheese were found in a reach-in cooler without a date/label. g. Secured bags of frozen breakfast sausage crumbles and mozzarella sticks were found in the walk-in freezer without a date. h. The floor and the bottom portion of the stainless-steel backsplash, along the back wall with the large kitchen equipment, had visible debris, dust, and grime build-up. i. The floor in the dish machine room had visible dirt and grime build-up underneath the tables and dollies carrying the chemicals. Review of the April Kitchen Cleaning log showed staff initials daily signing off on the completion of the following tasks: a. Sweep/Mop cooking area b. Items Labeled/Dated/Covered c. Wipe down all equipment d. Sweep/Mop dish area During an interview on 4/23/25 at 2:15 PM, the Dietary Manager acknowledged the unlabeled/dated food items identified as well as the condition of the floor and lower portion of the backsplash in the main kitchen and dish room. The undated policy Kitchen and Food Storage Area stated the following a. Floors, walls, shelves, tables, utensils, and equipment shall be kept clean and in good repair b. Walls shall be easily cleanable c. All food after open will be covered, labeled, and dated appropriately.

Based on clinical record review and staff interview the facility failed to notify the Long Term Care (LTC) Ombudsman for 1 of 1 residents reviewed who transferred to the hospital (Resident #2). The facility reported a census of 73 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of hypertension, diabetes mellitus, and seizure disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. Review of Resident #2's Progress Notes revealed the following information: On 7/31/24 at 8:36 a.m. resident admitted to hospital. On 8/5/25 at 2:45 p.m. readmission from the hospital. On 1/12/25 at 11:57 p.m. resident transferred to emergency department. On 1/13/25 at 3:22 a.m. resident admitted to hospital. On 1/17/25 at 12.45 p.m. resident returned to facility via ambulance. Review of Resident #2's census tab revealed the following: On 7/31/24- hospital unpaid leave. On 8/5/24- active. On 1/13/25- hospital unpaid leave. On 1/17/25- active. Review of MDS listing revealed the following: On 7/31/24 - discharge return anticipated. On 8/5/24 - entry. On 1/13/25 - discharge return anticipated. On 1/17/25 - entry. Review of the facility document titled Notice of Transfer Form to Long Term Care Ombudsman dated July-August 2024 and December 2024-January 2025 lacked Resident #2's name. Interview on 4/23/25 at 2:18 p.m., with Staff A, Director of Compliance and Interim Infection Control, revealed that the Medical Records Department is in charge of the Ombudsman notification. Staff A revealed they were not reporting to the Ombudsman if the resident was discharged to the hospital on a bed hold. Staff A revealed they did not look at that as being discharged from the facility. Staff A revealed they are going to do an audit of all bed holds discharged to the hospital and report past discharges to the Ombudsman.

Based on electronic medical record review and staff interview, the facility failed to document the use of non-pharmacological interventions prior to the administration of an as-needed psychotropic drug for 1 of 5 residents reviewed for unnecessary medications (Resident #65). The facility reported a census of 73. Findings include: The Minimum Data Set (MDS) Assessment, completed on 2/18/25, revealed Resident #65 with a Brief Interview for Mental Status score of 4, which indicates severe cognitive deficit. Diagnoses on the MDS include Alzheimer's Disease, depression, and neurocognitive disorder with Lewy Bodies Dementia. The MDS indicated Resident #65 with disorganized thinking and inattention, which are continuously present and does not fluctuate. Physical and verbal behaviors directed towards others are displayed daily. Resident #65 frequently rejects staff-assisted cares. The Care Plan, obtained on 4/23/25, revealed Resident #65 has a history of refusing cares with increased behaviors at meal times. Physician Orders, obtained on 4/24/25, documented Resident #65 prescribed Lorazepam 0.5mg every 12 hours as needed (PRN) for anxiety and agitation. Review of April 2025's Medication Administration Review sheet revealed PRN Lorazepam was administered to Resident #65 a total 12 times (4/1, 4/3, 4/6, 4/7, 4/8, 4/9, 4/15, 4/16, 4/17, 4/22, 4/23, 4/24). Review of Progress Notes failed to document the use of non-pharmacological interventions (food, drink, repositioning, etc) prior to the use of PRN Lorazepam for 8 of the 12 times the medication was provided (4/1, 4/3, 4/7, 4/8, 4/9, 4/15, 4/16, and 4/17). During an interview on 4/24/25 at 2:00 PM, Staff B, Co-Director of Nursing, reported nursing staff should provide 2-3 non-pharmacological interventions prior to the use of PRN psychotropic medications. Staff should document these attempts in the electronic medical record to ensure the medication was administered appropriately. The facility does not have a policy which outlines the use of PRN psychotropic medications.

Based on observations and staff interview, the facility failed to adequately prepare pureed foods to ensure the appropriate amount of nutrients were provided to residents receiving a pureed diet. The facility reported a census of 73. Findings include: The lunch menu on 4/23/25 for the pureed diet consisted of a pureed turkey burger on a bun, mashed sweet potatoes, pureed wax beans, and strawberry Thrive ice cream. During an observation on 4/23/25 at 9:35 AM, Staff E, Cook, prepared 3 servings of pureed turkey burgers. Three turkey burger patties and beef broth were pureed until the desired consistency was obtained. In a separate blender, Staff E pureed three servings of wax beans until the desired consistency was obtained. At no time during the observation did Staff E add hamburger buns to either the pureed turkey burger patties or the wax beans, which is a standard industry practice for pureed foods. During an interview on 4/23/25 at 2:15 PM, the Dietary Manager explained a total of 3 hamburger buns should have been added to the turkey burger patty and/or the wax beans. This would ensure the diet spreadsheet menu was followed as written and the nutritional content of the pureed meal was met. No policy available to outline the process of pureeing resident food.

Based on observation, record review, document review and staff interviews the facility failed to provide appropriate infection prevention practices by not following guidelines for enhanced barrier precautions (EBP) for 2 out of 2 residents reviewed (Resident #1 and #21). The facility reported a census of 73 residents. Finding include: 1. The Minimum Data Set (MDS) assessment for Resident #1 dated 1/20/25 identified a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS included diagnoses of pressure ulcer of left heel, seizure disorder, and osteoporosis. The MDS documented an unstageable pressure ulcer. Review of Resident #1's Care Plan with a date of 4/22/25 failed to mention the EBP's. Observation on 4/23/25 at 10:05 AM with Staff A, Registered Nurse (RN) completed treatment to the left heel pressure ulcer. Staff A did not apply the EBP prior to completing the treatment. Interview on 4/23/25 at 10:25 AM with Resident #1 stated staff just started applying the gloves and the gowns this week, but prior to that, it wasn't happening. Interview on 4/23/25 at 1:30 PM with Staff A stated he forgot to wear the EBP when doing the treatment, he stated that he usually puts it on prior, but today he forgot. Interview on 4/23/25 at 3:05 PM with Staff B, Co-Director of Nursing (DON) stated the expectation is that staff are to wear the EBP's when providing care or doing treatments. 40905 2. An MDS for Resident #21 dated 2/25/25, included diagnoses of stroke and hemiplegia (paralysis of 1 side of the body). The MDS identified the resident had a G-tube (abdominal gastric feeding tube). A Brief Interview for Mental Status score of 14 indicated mild cognitive impairment for decision-making. The Care Plan for Resident #21 documented resident on enhanced barrier precautions. Observation on 4/23/25 at 10:12 AM, Staff C, Licensed Practical Nurse and Staff D, RN entered Resident #21's room, sanitized their hands and applied gloves, did not apply gowns. Staff D proceeded to check placement of the G-tube and held the G-tube while Staff C administered medication into the G-tube. Interview on 4/23/25 at 2:30 PM, Staff C stated she knew it was protocol to wear a gown when administering medications per G-tube, she just forgot. Interview on 4/23/25 at 4:00 PM, Staff A, Director of Compliance stated the expectation is to wear a gown and gloves for enhanced barrier precautions while administering medication via G-tube to a resident.

Based on observations, staff interview, resident interview and family interview the facility failed to maintain a comfortable environment and safe functional equipment in the facility and resident rooms (Resident #4 , and #74) . The facility reported a census of 74. Findings include: 1. During an observation on 07/15/24 at 12:48 PM the thermostat in the conference room that leads into the memory care unit was 83.2 Fahrenheit. During an observation on 07/15/24 at 12:55 PM the thermostat in the hallways outside of room [ROOM NUMBER] E revealed the temperature of 82.1 Fahrenheit. In an interview on 07/15/24 at 12:50 PM Staff B, the Assistant Director of Nursing (ADON) relayed a company is returning to work on the air conditioner today, relayed it had just went down and a part had been ordered. In an Interview on 07/16/24 at 2:30 PM with family members, relayed had complained about the air conditioners not working in the memory care unit, referred to a phone text message to another family member alerted residents' room in memory care unit was 79 degrees and something must be done. Relayed a text in her phone on 07/5/2024 to a family member alerted the temperature was 76 degrees in resident family member room and felt this was not comfortable. Relayed staff had been running a hose to get water onto an outside air conditioning unit perhaps to get it to work better. In an Interview on 07/18/24 at 9:02 AM with Staff A relayed the memory care air conditioning had been out all summer and temperatures got up to 85 at the beginning of the summer, had heard they are working on bids. Relayed different companies looked at the system, fans were brought in along with the styrofoam coolers, and it helped some. Staff A relayed the start of the air conditioner issues began last summer in the unit and believed it was fixed then broke again. Residents are overall comfortable during the day, are out in the common area with the portable devices. Observation revealed temperatures in the common area at 77 degrees Fahrenheit. In an interview on 07/17/24 at 5:45 PM the Director of Compliance relayed had been working with different vendors on quotes for a new air conditioning units and parts were on order for the main unit. Relayed is aware of the issue and had brought in fans, portable units throughout and is hopeful with the new bids to correct the issue. Was relayed no actual policy on temperature, followed the Iowa code. In an interview on 07/18/24 at 2:00 PM the Administrator relayed the memory care section had two air conditioning units, one is working at half capacity and one is down. Relayed the general population unit had been fixed this week when a part arrived and was only down a few days. Relayed bids were received to replace the memory care units. 48886 2. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #75 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS further documented an admitted to the facility 7/2/24. During an observation on 7/15/24 at 1:18 PM, Resident #75's room temperature was 87.3 degrees Fahrenheit. During an interview on 7/15/24 at 1:20 PM, Resident #75 advised her room temperature is warm, stating it was at 91 degrees Fahrenheit earlier on this date. Resident #75 stated her room temperature has been warm since she admitted to the facility on [DATE], stating she would like for her room temperature to be around 72 degrees Fahrenheit and the room is uncomfortable. 3. The MDS assessment for Resident #4, dated 4/30/24, documented a BIMS score of 15, indicating intact cognition. The MDS further documented an admitted to the facility 9/28/23. During an observation on 7/15/24 at 1:42 PM, Resident #4's room temperature was 86.2 degrees Fahrenheit. During an interview on 7/15/24 at 1:45 PM, Resident #4 advised it has been this warm in her room all day today and last night. Resident #4 stated her room is always warm, but today is exceptionally warm. Resident advised her room is usually around 80 degrees, stating it is uncomfortable in her room. During an interview on 7/16/24 at 12:52 PM, Resident #75 stated her room is still a little too warm, she would like for it to be cooler, especially when she is trying to sleep. Resident #75 stated it is hard for her to sleep when the room is this warm. Resident stated the room is a little cooler today than yesterday, but it has not gone below 80 degrees yet. Observation of the thermostat in the resident's room revealed the room temperature to be 80 degrees Fahrenheit. During an observation on 7/17/24 at 10:57 AM, Resident #75's room temperature was 83.1 degrees Fahrenheit. During an interview on 7/17/24 at 10:57 AM, Resident #75 stated it is uncomfortable in her room, stating it has been uncomfortably warm in her room since she admitted on the 2nd of June. It makes it difficult to sleep. During an interview on 7/17/24 at10:59 AM, Resident #4 stated her room is never really cool, she always has a fan going. Resident #4 stated her room is usually in the 80's, today it is 77.7 degrees Fahrenheit. The resident said her room got into the 90's on 7/15/24.

Based on clinical record review and staff interviews, the facility failed to follow a physician's order for 1 of 1 residents reviewed to notify the physician or complete further assessments of daily weight changes within the established parameters (Resident #37). The facility reported a census of 74 residents. Findings Include: The MDS (Minimal Data Set) assessment dated [DATE] documented Resident #37 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS further documented the resident had diagnoses to include coronary artery disease, hypertension, diabetes, arthritis, and chronic ischemic heart disease. Review of the Electronic Health Record (EHR) for Resident #37 showed a physician order with a start date 8/16/23 with an order for daily weights. If weight changes more than 3 pounds in one day or 5 pounds in one week, staff is to assess and re-weigh; notify the provider, family, and document in the nurse's notes. Review of the EHR for Resident #37 revealed the following weight discrepancies: Weight gain of 6.6 pounds on 7/9/24; Weight gain of 4.5 pounds on 6/15/24; Weight gain of 4.2 pounds on 6/7/24; Weight gain of 4.3 pounds on 5/27/24; Weight gain of 5.9 pounds on 5/8/24; Weight gain of 5 pounds on 5/2/24 (resident refused to be weighed on 5/1/24; Weight gain noted between 4/30/24 and 5/2/24); Weight gain of 4.7 pounds on 3/19/24 (resident refused to be weighed on 3/18/24; Gain noted between 3/17/24 and 3/19/24); Weight gain of 11.1 pounds on 3/10/24. In each of the above cases, staff failed to obtain a reweigh, document acknowledgement of the weight change, further assess the resident, or notify the physician. Review of the monthly Treatment Administration Record (TAR), acknowledged the presence of bilateral lower extremity (BLE) edema. EHR progress note review between February 2024 thru July 2024 indicated an increase in BLE edema from a 2+ on 2/1/24 to 4+ pitting on 7/18/24. Staff E, Registered Nurse (RN), interviewed on 7/17/24. Staff E, RN, acknowledged Resident #37's daily weight order. Staff E, RN, explained certified nursing assistants (CNA) will obtain the daily weight and nursing staff on duty will enter the weight in the EHR. At this time, nursing has the ability to assess the weight for any changes. During an interview on 7/18/24, the Director of Nursing (DON) acknowledged Resident's #37 order for daily weights and the process staff should follow if a gain of 3 pounds in a day documented. The DON recognized the lack of assessments or acknowledgment from nursing staff regarding the weight discrepancies, regardless if the weight documentation was in error or correct. The DON unable to provide an explanation as to the lack of follow-up.

Based on observations, clinical record review, and staff interviews, the facility failed to ensure safe transport of a resident in a wheelchair for 1 of 1 residents reviewed. (Resident #17). The facility reported a census of 74. Findings include: The Minimum Data Set (MDS) assessment for Resident #17, dated 5/21/24, documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The MDS further documented diagnoses to include non-traumatic brain function, heart failure, renal insufficiency, arthritis, and non-Alzheimer's dementia. The Daily Pocket Care Plan for Resident #17, dated 7/15/24, under the section titled ambulate-transfer/chair, documented resident assist of 2 with Hoyer for transfer and wheelchair for distance. During an observation on 7/15/24 at 2:12 PM, Resident #17 was in the hallway, propelling himself independently in his wheelchair with both feet, using both feet on the ground to propel forward. Staff C, CNA, redirected the resident when the resident began entering another resident's room. Staff C asked the resident if he wanted help to his room, then asked the resident to pick his feet up off the floor a little, and began to push him to his room. Staff C did not engage the foot pedals, the resident's feet were loose and hanging approximately one inch off the floor. Staff C pushed the resident to his room, which was located down the hallway and turning into another hallway. During an interview on 7/17/24 at 2:53 PM, Staff D, CNA, advised having knowledge of Resident #17's care plan and history of working on the unit where the resident resides. Staff D advised the resident is mostly independent with propelling himself in his wheelchair Only on occasion staff assist with pushing resident in his wheelchair. If they do assist the resident, staff should put the foot pedals down and have him put his feet on the pedals. Sometimes the resident takes the pedals off his wheelchair, he does not like having them on. Staff D stated staff should retrieve the foot pedals before pushing him for safety reasons, to prevent his feet from dragging and getting caught under the wheelchair. Staff D stated she has observed the resident being pushed in his wheelchair by staff without the pedals down and with just being told to hold his feet up off the floor. During an interview on 7/17/24 at 3:25 PM, the DON advised Resident #17 can propel himself in his wheelchair independently. If staff need to assist the resident, they should ensure the foot pedals are engaged and his feet are placed securely on the foot pedals before pushing him. The DON stated an expectation staff ensure the foot pedals are on the wheelchair and the resident's feet are placed on the foot pedals before pushing the resident in his wheelchair. The DON stated staff should not push the resident in his wheelchair without the foot pedals and should not ask the resident to hold his feet up on his own. The DON advised the cover sheet to the pocket care plan has an alert printed in red at the bottom which reads when pushing a resident in a wheelchair the foot pedals must be on. The DON advised the facility does not have a policy on wheelchair assistance, they follow state regulations and the Master Care Plan cover sheet. Review of the undated facility Master Pocket Care Plan cover sheet documented at the bottom of page 1; when pushing a resident in a wheelchair the foot pedals must be on.

Based on observation, clinical record review, facility menus and staff interview the facility failed to follow the menu for 18 of 18 residents in the unit. The facility reported a census of 72 residents. Finding include: Review of the January 2024 evening menu revealed on 1/25/24, residents to receive: *Open face hot turkey sandwich *Mashed potatoes *Turkey gravy *Brown sugar peaches *Cottage cheese *Milk Interview on 4/9/24 at 11:00 a.m., the facility assistant Dietary Manager confirmed and verified that the menu was not followed on 1/25/24 evening meal. Interview on 4/9/24 at 2:50 p.m., the facility Director of Quality Improvement confirmed and verified that the staff need to follow the menu as written and it is not acceptable to substitute unless you have approval from the dietician. Interview on 4/9/24 at 3:10 p.m., the facility Director of Nursing confirmed and verified that the evening nurse on 1/25/24, gave the resident a peanut butter and jelly sandwich rather than the meal that was on the menu. Record review documented on 1/26/24, Staff C (Licensed Practical Nurse) correction action level-Written Description of incident/behavior= Failure to provide evening meal as per regulations to residents.

Based on observation, and staff interviews, the facility failed to ensure open items were dated, and labeled in the coolers and walk-in freezer in the kitchen. The facility reported a census of 72 residents. Findings include: Observation on 4/8/24 at 11:35 a.m., in the main kitchen revealed the following: *Cooler #2, half opened clear bag of mild cheddar cheese, not dated *Cooler #1, clear pitcher with 3/4 full of brown liquid, not dated or labeled clear container of round brown items, not dated or labeled. *Walk in freezer- 1/2 bag of brown, round items, not dated or labeled *Cooks Cooler- 1 tin container with small, round brown/gray items, not dated or labeled, Interview on 4/8/24 at 11:40 a.m., Staff A, Dietary Aide (DA) confirmed and verified that those items in Cooler #1 were not dated and labeled and could not verify or identity those contents. Interview on 4/8/24 at 11:44 a.m., Staff B (cook) confirmed and verified that the items needed to be dated and labeled and was not able to state how long they were in the coolers or freezers. Interview on 4/9/24/23 at 11:00 a.m., the Assistant Dietary Manager revealed the items should have been dated when opened, and labeled.

Based on observation, menu review, and staff interview, the facility failed to follow the menu for 69 of 69 residents reviewed. The facility also failed to assure the menu was followed for 1 of 69 residents (Resident #29) requiring a mechanically altered diet. The facility reported a census of 69 residents. Findings include: The Minimum Data Set (MDS) for Resident #29, dated 6/20/23 identified the presence of short and long-term memory impairment. A review of Resident #29's orders revealed that she had a general diet order for mechanical soft texture. On 9/13/23 at 10:00 AM, a review of the lunch menu for Week 3 - Wednesday indicated that residents were to receive bread and margarine, and brown sugar margarine for their sweet potatoes. Observation on 9/13/23 during lunch service from 11:40 AM to 1:10 PM revealed that no resident received bread and margarine or brown sugar margarine for their sweet potatoes. Also observed during this lunch service, was a plate of ground pork with a sweet potato with the skin still attached to Resident #29 who required a mechanical soft diet. On 9/14/23 at 1:30 PM, an interview with the Dietary Manager, she stated that the residents should have received bread and margarine. She also stated that she didn't realize that brown sugar margarine was on the menu.

Based on observation, record review, and resident and staff interview the facility failed to update the resident's Care Plan for a urinary catheter removed for 1 resident and toileting assistance needed and newly acquired pressure ulcers and treatment for 3 of 18 residents reviewed (Residents #37, #48, and #56). The facility reported a census of 69 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #37 dated 8/23 /2023, included diagnoses of Diabetes Mellitus, fracture, and anxiety. The MDS documented the resident had an indwelling urinary catheter, was totally dependent on assistance of 2 staff for toileting, and had a Brief Interview for Mental Status (BIMS) score of 12, indicating mild cognitive impairment for decision-making. Interview on 9/12/23 at 8:23 AM, Resident #37 stated she no longer had a urinary catheter in place. Resident #37's Progress Notes dated 8/29/23 at 12:23 PM and 1:27 PM revealed a physician's order to remove the urinary catheter, toilet every 2 hours during the day, and the urinary catheter was removed with urine output to be monitored. Resident #37's Care Plan dated 9/11/23 documented Foley catheter and catheter cares per protocol. Interview on 9/14/23 at 1:48 PM, the Director of Nursing confirmed the Care Plan was not updated with the removal of the Foley catheter and toileting assistance needs /monitoring and expectation to update the Care Plan. 47261 2. The MDS dated [DATE] for Resident #56, documented the resident had a BIMS score of 13 indicating intact cognition. The MDS identified that the resident required limited assistance of one staff for all activities of daily living. The MDS also documented the resident used a walker or a wheelchair for mobility, and had a diagnosis of cellulitis (skin infection) to his left lower leg. The Care Plan, described as a Pocket Care Plan, which is updated daily, lacked documentation of the resident having pressure ulcers on his left toes or treatment for the wounds. The Treatment Administration Record (TAR) for September 2023 identified the resident to have twice daily treatments to the 2nd, 4th, and 5th toes of his left foot, and 4th toe of his right foot. Observation of wound care on 9/14/23 at 1:15 PM revealed that Resident #56 had wounds to his left toes only. 3. The MDS dated [DATE] for Resident #48, documented the resident had a BIMS score of 11 which indicated the resident had moderately impaired cognition. The MDS identified that the resident required extensive assistance of two or more staff for bed mobility and dressing, extensive assistance of one staff for wheelchair locomotion and toileting, and limited assistance of one staff for personal hygiene. The MDS also documented that the resident is unable to ambulate and is totally dependent on two staff for transfers. Diagnoses in the MDS documented the resident had diagnoses of peripheral vascular disease. The Care Plan lacked documentation of the resident having a Stage 3 pressure ulcer on his right lower leg or treatment for the wound.

Based on clinical record review and staff interview, the facility failed to document the type of enteral formula being used for 1 of 1 residents reviewed who received gastric tube/enteral nutrition (Resident #56). The facility reported a census of 69 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #56, documented the resident had a BIMS score of 13 indicating intact cognition. The MDS identified that the resident required limited assistance of one staff for all activities of daily living. The MDS also documented that the resident received nutrition through a gastric feeding tube that supplies 51% or more of the resident's total calories and averaged 501 cubic centimeters or more daily. The resident's Pocket Care Plan, which is updated daily, lacks documentation of what type or amount of enteral feeding the resident was to receive. Review of the resident's orders document that the resident received enteral feeding daily from 8:00 PM to 6:00 AM. The orders lack documentation of what type of enteral feeding he was to receive. In an interview with the Administrator on 9/14/23 at 2:35 PM, she stated that her expectation was that the orders state what type of enteral feeding the resident was receiving.

Based on observation and staff interview, the facility failed to ensure staff used proper food handling procedures to prevent possible contamination of food. The facility reported a census of 69 residents. Findings include: Observation on 9/12/23 at 8:03 AM revealed Staff F, Certified Medication Aide (CMA), carried a breakfast tray down the hallway with two glasses of juice that were not covered. Observation on 9/13/23 at 12:25 PM revealed Staff E, Dietary Aide, took a small plastic cup and dipped it into a container of brown sugar. Staff E had been serving meals and had not washed her hands or donned gloves prior to scooping the brown sugar out of the canister. Observation on 9/13/23 at 12:35 PM revealed Staff E hold a plastic mug with the handle and her index finger inside the mug and filled it with coffee for a resident. Observation on 9/13/23 at 12:40 PM revealed Staff C, Dietary Aide, who was dishing up plates, leave the serving kitchen to get more BBQ sauce for the lunch meal. Upon returning to the serving kitchen, Staff C immediately began dishing up plates without washing her hands. On 9/14/23 at 1:30 PM, an interview with the Dietary Manager, she stated that the expectation was for staff to follow infection control policies.

Based on observation and staff interview, the facility failed to ensure staff performed proper hand hygiene during patient care for 2 of 5 resident treatments reviewed (Residents #56 & #48). The facility reported a census of 69 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #56, documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS identified that the resident required limited assistance of one staff for all activities of daily living. The MDS also documented the resident had a Stage III pressure ulcer. The Treatment Administration Record (TAR) for September 2023 identified the resident to have twice daily treatments to the 2nd, 4th, and 5th toes of his left foot. Treatment included cleansing wounds with normal saline, applying mupirocin ointment, and cover with gauze and tape. On 9/14/23 at 1:15 PM the surveyor observed Staff B, Licensed Practical Nurse (LPN) and Staff A, Registered Nurse (RN) perform wound care to the residents' toes. No dressings were noted beneath residents' compression hose. Both nurses washed their hands and donned gloves. Staff B pulled the resident's right compression hose sock back, examined the foot and pulled the hose back down. She then pulled up the left sock to expose the toes, stood up, and pulled a plastic bin of dressing supplies out of a bag. She then took off her gloves and pulled the supplies out of the bin with her bare hands. After pulling out needed supplies, Staff B put clean gloves on without washing her hands. Staff A provided wound care with supplies handed to her by Staff B. Staff A cleansed the toes, applied ointment, and bandaged the toes without changing gloves or washing hands. Both Staff A and Staff B removed gloves and washed their hands after providing care. 2. The MDS dated [DATE] for Resident #48, documented the resident had a BIMS score of 11 which indicated the resident had moderately impaired cognition. The MDS identified that the resident required extensive assistance of two or more staff for bed mobility and dressing, extensive assistance of one staff for wheelchair locomotion and toileting, and limited assistance of one staff for personal hygiene. The MDS documented that the resident was unable to ambulate and was totally dependent on two staff for transfers. The MDS also documented the resident had a Stage III pressure ulcer. The Treatment Administration Record (TAR) for September 2023 identified the resident to have a wound to his right lower leg. Treatment included applying Vaseline gauze to the wound bed, cover with dry gauze, and wrap with roll gauze daily. On 9/14/23 at 10:50 AM the surveyor observed Staff B, LPN and Staff A, RN perform wound care to the resident's right lower calf. Both nurses washed their hands. Staff B then picked up a fall mat from beside the bed, folded it, and put it at the top of the bed. Staff B then put on gloves without sanitizing or washing her hands. Staff A, who had gloves on, held the residents' leg up while Staff B changed the dressing. Staff B cut the dressing off, squirted wound cleanser on the calf wound and wiped it clean. She then picked up a new package of Vaseline gauze, opened it, cut the gauze, and placed it over the wound. She then wrapped it with roll gauze. Staff B did not perform hand hygiene or change gloves after removing the old dressing and putting on the clean dressing. In an interview with the Administrator on 9/14/23 at 2:35 PM, she stated that her expectation was that staff would perform proper hand hygiene when caring for residents.

Based on clinical record review, facility policy review and staff and physician interviews, the facility failed to ensure a resident (#1) did not experience a significant medication error out of six total residents reviewed. Resident #1's physician ordered staff to administer a diuretic medication ([MEDICATION NAME]) and staff failed to implement the order until four days later resulting in a significant decline in the resident's condition and hospitalization . The facility identified a census of 67 current residents. Findings include: The Minimum Data Set assessment dated [DATE] documented Resident #1 had [DIAGNOSES REDACTED]. The assessment documented he had clear speech and the ability to express his ideas and wants. At the time of the assessment, he did not display shortness of breath of dehydration. The assessment also documented Resident #1 received a daily diuretic medication (to remove water from the body). The resident's care plan, initiated on 6/6/17, documented use of a diuretic under the focus area for elimination patterns. The resident's Electronic Medical Record (EMR) contained the following information: a. A Health Status Note dated 5/13/19 at 11:30 am recorded staff observed the resident sitting on a bench in the hall. He dry-heaved and coughed up some phlegm and was assisted to his room. Staff noted a five pound weight gain in one day and [MEDICAL CONDITION] to both lower extremities. The resident's vital signs showed a pulse rate (P) of 94, a respiratory (R) rate of 40 and pulse oximetry (POx, or how well the blood carries oxygen) read 97% on room air (normal is 90% or above). Staff faxed the physician with an update and called the resident's daughter. At 5:48 p.m., the resident's physician ordered the resident to receive [MEDICATION NAME] 2 milligrams (mg) by mouth every day for the next three days in addition to [MEDICATION NAME] (diuretic) 20 mg. every morning. Review of the Medication Administration Record (MAR) for 5/19 revealed the resident received the new order of [MEDICATION NAME] 2 mg on 5/14 and 5/15/19. b. A Health Status Note dated 5/15/19 at 10:15 am documented Resident #1 had an unsteady gait, pallor and swelling in his face, eyes and abdomen. The note documented he started to receive [MEDICATION NAME] on 5/14/19. His weight measured 187.9 pounds on 5/11/19 and his weight measured 192.0 that day. His P measured 60, his R were at 22 and his POx measured 96% on room air. The assessing nurse, the Director of Nursing, spoke with the resident's daughter and updated her on Resident #1's health status. The daughter agreed with obtaining laboratory tests and the resident's physician ordered a complete blood count (CBC) and basic metabolic panel (BMP) to be drawn. At 2 pm, staff faxed the physician the results of the laboratory testing. At 8:44 pm, the physician ordered staff to hold Resident 1's [MEDICATION NAME]. Review of the laboratory results dated [DATE] revealed the resident had a blood urea nitrogen level of 29 (a reference range runs 8 - 21) and a Creatanine level of 1.99 (a reference range runs 0.44 - 1.21). Both tests measure the health of one's kidneys in filtering and removing bodily waste products and toxins. c. An Order Note dated 5/17/19 at 5:11 pm revealed Staff A, RN (Registered Nurse) received and noted a physician's orders [REDACTED]. Review of the resident's MAR and physician's orders [REDACTED]. d. A Health Status Note dated 5/20/19 at 10:42 pm documented Resident #1 as unable to feed himself very well. At times, he would bring the spoon to his mouth but other times he would miss. He said a few words and did not smile per his usual. At 3 am, staff documented the resident got up to the bathroom but was unable to eliminate. His speech became unintelligible and he could not clearly state his name. The resident's P measured 87, his R measured 31 and his POx measured 95% on room air. e. A Health Status Note dated 5/21/19 at 11:37 am recorded Staff A called the resident's family and informed them his [MEDICATION NAME] had not been given for a few days. An assessment at 11:05 am revealed the resident as sleepy, restless and jerking in his sleep. He woke with verbal stimulations but his speech was garbled and unclear at times. The resident's skin appeared pale, warm and dry. He had [MEDICAL CONDITION] to both legs. His R measured 40 and heavy, his P at 80 and regular and POx measured 94% on room air. A note at 5:07 pm documented Resident #1 admitted to the hospital at that time. The Hospital Course Summary dated 5/24/19 documented Resident #1 entered the hospital with an increasing cough and shortness of breath. Further investigation revealed he was seen in the physician's office on 5/16/19 and started on [MEDICATION NAME] 2 mg daily. Unfortunately, this order was never carried out. Resident #1 started on intravenous [MEDICATION NAME] every 8 hours and in three days, his weight dropped 19 pounds. The resident's admitting and discharge [DIAGNOSES REDACTED]. The summary documented he discharged from the hospital on [DATE] back to the facility. During interview on 5/28/19 at 7:45 pm, Staff A remembered the [MEDICATION NAME] did not get ordered correctly. Staff A stated she really did not know how that happened or what got missed. She felt sure she put it in the EMR (electronic medical record), but maybe it didn't save. During interview on 5/29/19 at 5:30 pm, the resident's physician stated the lack of [MEDICATION NAME] implementation on 5/17/19 constituted a significant medication error for Resident #1. He talked with the facility's administration afterwards, telling them it was a major error and probably landed the patient in the hospital. He wanted to know how it happened and what was being done to prevent future occurrences. The physician stated he was satisfied with the facility's actions: they got back to him within 24 hours with the answer to the first question and called him back the next day with prevention of future occurrences. The facility's Receiving physician's orders [REDACTED]./24-hour report sheet/PCC (point click care) Dashboard. A Quality Assurance (QA) procedure dated 5/23/19 documented the orders would also be reviewed by the night charge nurse for accuracy and would be triple checked by the Director of Nursing (DON) or her designee. Interview on 5/30/19 at 10:30 with the DON revealed, that originally staff would copy a new order and put it in her folder for later review. The facility put this QA process in place after the annual health survey of 2/18/19. The DON looked at the copies of orders to make sure they were accurate. Since the error detailed above, the facility also had the night shift charge nurse check over new orders in addition to the DON. She stated she would not have known to look at health status notes for any new orders; the facility has used the EMR to record new orders since 2014. The deficient practice detailed above resulted in an immediate jeopardy situation for the facility. The facility abated the immediate jeopardy on 5/24/19 by re-training all nursing staff on the Receiving Physician order [REDACTED]. This abatement resulted in past noncompliance for the facility.

Based on clinical record review, staff, family, physician interviews, and policy review, the facility failed to notify the physician and family in a timely manner after a resident ' s fall with head injury (Resident #9). The facility reported a census of 75 residents. Findings include: The Minimum Data Set ((MDS) dated [DATE] documented Resident #9 had [DIAGNOSES REDACTED]. The MDS documented the resident had short and long term memory as well as severe cognitive impairment. The MDS documented the resident required extensive assistance with one staff member for bed mobility, transfers, walking, and personal hygiene. The MDS documented the resident had no falls in the assessment period. The MDS documented the resident received a medication to thin the blood daily. The face sheet updated 9/21/16 and care plan dated 3/5/13 documented the resident as a FULL CODE. The September 2016 Medication Administration, Record showed the resident received [MEDICATION NAME] (medication to thin the blood for stroke prevention) from 9/1/16 to 9/17/16, but the [MEDICATION NAME] had been held on 9/18/16. The Fall Investigation dated 9/18/16 at 2:15 a.m. documented the resident had an unwitnessed fall. The resident wore slipper socks and the alarm sounded. The resident had range of motion normal for the resident. The resident sustained [REDACTED]. The Fall Investigation documented staff notified both the physician and family on 9/18/16 at 10:30 a.m. The Progress Notes dated 9/18/16 at 2:15 a.m. documented the resident fell and sustained 2 lacerations on the forehead, laceration on left wrist, both knees bruised, and abrasion on the right shin. Staff A, licensed practical nurse, documented she started neurological checks, competed vitals and sent a facsimile to the physician. The Progress Notes dated 9/19/16 at 5:04 a.m. Staff A administered [MEDICATION NAME] prn (as needed) medication for anxiety/agitation. The Progress Notes dated 9/18/16 at 9:18 a.m. Staff B, licensed practical nurse, documented the resident had been up all night following the fall, and now rested quietly. The Progress Notes dated 9/18/16 at 9:20 a.m. Staff B administered PRN (as needed) [MEDICATION NAME] and documented the medication had been effective. The Progress Notes dated 9/18/16 at 9:30 a.m. documented Staff B left a message for family member #1 regarding the fall. Staff documented resident had been resting well this morning and arouses easily during neurological checks. The resident became irritated when staff completed neurological (neuro) checks but usual behavior. The neurological checks remain normal. The resident did moan at times when staff moved his/her limbs. The Progress Notes dated 9/18/16 at 12:56 p.m. documented by Staff B indicated two (2) staff assisted the resident to the toilet but the resident became angry and combative. The resident refused to eat and spit out the medications. Staff B change the dressing on the left side of the resident's forehead and staff noticed an increase in bruising around the area and some swelling remained. The resident ' s left eyelid very purple and swollen and staff found documented it was difficult to check eye response (neuros). Staff B notified the on call physician that gave an order to send the resident to the emergency room if the resident's family agrees. Staff B contacted family member #1 who wanted to consult with family member #2. The Progress Notes dated 9/18/16 at 2:44 p.m. Staff C, licensed practical nurse, documented she called the on call physician to obtained an order for [REDACTED]. The laboratory test results dated 9/18/16 at 3:19 documented the laboratory called Staff C with the results of the PT/INR as the level registered critically high at 4.8. (A previous laboratory test revealed a PT/INR test done on 8/23/16 for Resident #9. The INR registered at 2.1 which remained in normal limits. ) The Progress notes date 9/18/16, documented at 4:13 p.m. the blood test returned and Staff C obtained an order to hold the [MEDICATION NAME] 9/18/16 and recheck the PT/INR on 9/19/16. The Progress Notes dated 9/18/16 documented the resident sleeping at 7:42 p.m. The Progress Notes dated 9/18/16 at 9:44 p.m. Staff C documented the resident rested in bed for most of the shift. The resident refused to eat or drink and refused an ice pack for forehead. The resident sat up on side of bed and stood with walker but sits right back down. The resident had no impairment in all four extremities, no bruising to the extremities, and did not show discomfort with movement. On 9/19/16 at 5:45 a.m. the Progress Notes documented the resident received a suppository. On 9/19/16 at 8:20 a.m. Staff D, licensed practical nurse, documented in the Progress Notes the resident had a fever, high blood pressure, and low oxygen levels. Staff D documented the resident as unresponsive and moaning with movement. Staff documented the resident ' s pupils sluggish. Staff D called family member #1 and informed her that the resident will be sent to the emergency room . At 8:45 a.m. the ambulance transported the resident to the hospital. The Fall Assessment and Documentation Policy revised 1/16/14 notify the physician immediately, call if emergence, fax if non-emergency. Review of the Neurological Checks documented the first check completed an hour after the resident sustained [REDACTED].#9 ' s Neurological Check List dated 9/18/16 at 3:15 a.m. documented vital signs, alert level of conscious and level of pain a 7 on a 1-10 scale. Review of the clinical record identified the last neurological check had been done on 9/18/16 at 3:07 p.m. and the resident ' s record did not included any further assessment until 9/19/16 at 8:20 a.m. The emergency room documentation on 9/19/16 documented Resident #9 arrived via ambulance from nursing home unresponsive. He/she fell late and hit his/her head and is on [MEDICATION NAME] with an INR of 4.8. He/she has been unresponsive this morning except to painful stimuli and had a large hematoma to the left orbital (eye) area . The resident had a fever and low blood oxygen level. The hospital completed a computed tomography (CT) scan of the brain on 9/19/16 at 9:09 a.m. which showed big left temporal lobe hemorrhage, right frontal hemorrhage, and subarachnoid bleeding (bleeding in the space between the brain and tissue covering the brain). The report documented the resident had been [DIAGNOSES REDACTED]. The resident had unspecified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes. The History and Present Illness document: Family decided to have resident to remain full code and transferred to another trauma center. The INR registered 5.1 and the resident received 2 units frozen plasma and Vitamin K which counteracts the [MEDICATION NAME] during the Life Flight. Physician Interview: During an interview on 10/6/16 at 9:45 a.m. the resident's attending physician stated he could not locate any facsimile from 9/18/16 regarding the fall and the information provided. The physician stated the resident had a stroke and took [MEDICATION NAME] daily. The physician reported he was not aware of the cause of death. The physician stated he would have given order ' s to send Resident #9 to the emergency room the morning when the resident fell with a head injury and on [MEDICATION NAME]. During an interview on 10/6/16 at 1:10 p.m. the on call physician stated he could not locate a facsimile from the facility regarding the resident's fall. He did not receive information regarding the fall until the afternoon of 9/18/16. The on call physician stated if the facility informed him the resident fell , had a head injury, took [MEDICATION NAME], and had a FULL CODE status. The physician stated if the resident was a FULL Code he/she needed to go to the emergency room (ER) and not wait for family (notification). The physician reported staff sending the resident earlier might have changed the resident's prognosis. During an interview on 10/6/16 at 9:02 a.m. family member #1 stated she received a voice mail on 9/18/16 at 9:30 a.m. that the resident fell at (approximately) 2 a.m. that morning. She felt she should been notified at change of shift or 6:00 a.m. The voice message from the facility indicated Resident #9 had sustained [MEDICAL CONDITION] but doing fine. Family member #1 provided a transcript to the surveyor on 10/7/16 at 12:12 p.m. regarding her conversation with the facility on 9/18/16 at 9:30 a.m The voice message indicated: Just wanted to let you know your family member took a tumble again last night. He/she got a pretty good goose egg on his/her (forehead) right above his/her left eye- uh got a little laceration there too. He/she seems ok we've been doing neuro checks on him/her every hour and she's/he's waking up and he/she is still just a feisty as ever .If you want to give me a call, I can go into little more detail. Otherwise, just know he/she is doing ok. During an interview on 10/6/16 at 1:24 p.m. family member #2 did not know the resident fell until 1:30 p.m. (on 9/18/16) She stated she spoke to Staff C who told her the resident had a black eye and a laceration on the head but stated the resident acted as usual. Family member #2 called the facility at 2:51 p.m. The facility had received an order to check the PT/INR and again told her the resident acted fine. At 3:56 p.m. family member #2 stated Staff C called her to tell her about the blood test results. At that time family member #2 discussed sending the resident to the emergency room . Staff C stated the facility provided monitoring and the emergency room would do nothing different. Staff C stated the facility would take better care of the resident and the resident could not get an ambulance because the resident did not have a critical condition. Staff C did not inform her of the resident's bleeding, swelling, or that Resident #9 refused to eat. Family member #2 felt the facility did not tell her accurate information so she could make a decision to the send the resident to the emergency room . Staff interviews: During an interview on 10/6/16 at 1:50 p.m. Staff C stated she spoke to family member #2 when she got the order for the PT/INR and then called her later with the blood test's results. Staff C stated she told family #1 that the nurses completed vital signs and assessments. Staff C thought going to the hospital would be to traumatic for the resident. Staff C stated the situation did not constitute an emergency and the hospital wound not do anything different than what the facility provided. During an interview on 10/4/16 at 2:36 p.m. Staff C licensed practical nurse (LPN), worked evening shift (2 p.m.) on 9/18/16 and stated she completed vitals and neurological checks. The resident could raise arms and legs and speaking was normal. Staff C did obtain an order from the on call physician for a PT/INR blood test since the resident took [MEDICATION NAME] and fell and hit his/her head. Staff C stated she would have called the physician after the fall because the resident hit the head and took [MEDICATION NAME]. During an interview on 10/6/16 at 8:06 a.m. Staff E stated she heard the resident's alarm and observed the resident face down on the floor with blood coming from the head and the resident ' s arm. Staff E stated she thought the resident needed stitches but Staff A stated she would put steri strips on the [MEDICAL CONDITION]. The resident would not remain in bed so placed the resident in the wheelchair and sat the resident in the lounge area where staff could monitor the resident. Staff E stated she had to wipe the resident's face several times because the [MEDICAL CONDITION] kept bleeding. During an interview on 10/5/16 at 3:07 p.m. Staff F, CNA worked the overnight shift 9/18/16. Staff F stated he heard the resident's alarm. Staff F observed the resident on the floor with blood coming from the head. Staff F, Staff A, and Staff E assisted the resident to bed but became restless. Staff F stated they sat the resident in a the wheelchair and placed the resident in area between the nurse's station so they could monitor the resident. During an interview on 10/5/16 at 9:37 a.m. Staff A, licensed practical nurse (LPN) stated at 2:15 a.m. she heard the resident's alarm sounding. Both Staff F, certified nurse aide, and Staff E, certified nurse aide, responded to the resident's alarm and observed the resident on the floor. The resident had sustained [MEDICAL CONDITION] with multiple abrasions and bruises. Staff A stated she sent a facsimile to the physician because she did not think the fall as an emergency situation. Staff A stated she started neurological checks right away and placed steri strips to the [MEDICAL CONDITION]. Staff A stated the resident became very restless and gave [MEDICATION NAME]. Staff A stated she did not call the family because of the time of night. During an interview on 10/5/16 at 10:01 a.m. Staff B worked day shift (6 to 2 shift) on 9/18/16 and stated she continued the neurological checks every 1/2 hour to 1 hour. Staff B described the resident as combative but stated usual behavior for the resident. Staff B stated she spoke to family member #1 at 9:30 a.m. to inform her of the fall. Staff B stated she told family member #1 that the resident fallen early am (morning) and had a bump on the head but acted as usual. Staff B stated later in the shift she wanted to send the resident to the emergency room because of the increase in swelling and bruising around the eye as well as the resident took [MEDICATION NAME]. Staff B called the on call physician who gave an order to send to the hospital if family agreed. Staff B left messages for family member #1 and family member #2. Staff B stated she spoke to family member #1 who wanted to consult family #2 before sending the resident to the emergency room . Staff B she did not hear from either family member before the shift ended. During an interview on 10/4/16 at 2:22 p.m. Staff D, licensed practical nurse (LPN) worked the day shift on 9/19/16 and stated that morning the resident became unresponsive, had a fever, high blood pressure, increase respirations, and low oxygen levels. Staff D sent to the resident to the emergency room and spoke to family member #1. Staff D stated she would have sent the resident to the emergency room when the resident fell . During an interview on 10/6/16 at 2:30 p.m. the Acting Director of Nursing could not locate the facsimile sent on 8/18/16 at 2:15 a.m.

Based on record review and staff interview the facility failed to assess Resident #14's vital signs (blood pressure, pulse, respirations, temperature) with a change in condition for 1 of 15 residents reviewed (Resident #14). The facility reported a census of 75 residents. Findings included: Resident #14's 7/5/16 Hospital Discharge Summary documented [DIAGNOSES REDACTED]. Staff documented in the nursing Progress Notes dated 7/22/16 at 6:10 p.m. the resident complained of heart pain. Staff measured the resident's oxygen saturation level low at 76%. Staff returned the resident to their room and applied oxygen at 4 liters/minute. Staff administered breathing treatments and then measured the resident's oxygen saturation still low at 82%. At 9:53 p.m. staff documented the oxygen saturation had still been in the upper 80's and found the resident hadn't completed the breathing treatment. After completing the breathing treatment staff measured the oxygen saturation at 93%. The record lacked any documentation indicating staff measured the resident's vital signs (pulse, respirations, blood pressure or temperature). During interview on 8/25/16 at 9:41 a.m. Staff A, Registered Nurse stated when a resident experienced such low oxygen saturation and chest pain she would expect the nurse to measure the resident's vital signs. Staff documented in the Nursing Progress Notes on 7/24/16 at 1:30 p.m. the resident had been fatigued through the day. Staff had encouraged the resident to come to meals and activities. The resident complained of feeling tired and nauseated. Staff returned the resident to their room to use the bathroom. The resident became pale and unable to bear weight. Staff eased the resident to the floor and got the nurse. Upon entering the room the nurse noted the resident pale, with shallow breathing, saliva coming from the mouth and unresponsive. They returned the resident to bed and noted the resident had apnea and a faint/weak pulse. The record lacked any measurement of the pulse, respirations or blood pressure. Staff documented they placed a call to a family member to inform of the resident's sudden decline. Staff documented the resident passed shortly after phone call was placed. The record lacked any measurement of vital signs through the day when the resident exhibited fatigue, complained of feeling tired and nauseated; when staff found the resident on the floor or when the resident had passed. During interview on 9/19/16 at 12:12 p.m. the LPN stated the resident had said earlier in the day he/she didn't feel well. The LPN stated she had gotten the resident's temperature, but didn't record it. It had been normal. She stated she didn't recall measuring other vital signs or calling the physician. During interview on 8/25/16 at 9:24 a.m. Staff A RN stated she would expect staff to assess the resident and measure vital signs with any change of condition or with the appearance of death.

Based on record review, staff interviews and review of facility policy/procedures, the facility failed to ensure Resident #1 received adequate assistance/supervision with transfers and ambulation and with the use of a gait belt to ensure transfers were accomplished in a safe manner. The facility failed to develop a Care Plan with directives and criteria for when the staff are to use one or two staff members when transferring the resident. The sample consisted of 4 residents and the facility reported a census of 71 residents. Findings include: Resident #1 had a quarterly Minimum Data Set (MDS) assessment with a reference date of 11/3/15. The MDS identified Resident #1 had a BIMS (Brief Interview for Mental Status) score of 13 (a score of 13 identified the resident as not cognitively impaired). Resident #1 required extensive physical assist of 2 staff members with bed mobility, transfers, and toileting. The MDS noted the resident was non-ambulatory and used a wheelchair for mobility. The [DIAGNOSES REDACTED]. The MDS revealed the resident had functional limitations in range of motion for the upper and lower extremities of one side of the body. The MDS reflected the resident had balance problems and not steady and only able to stabilize with staff assistance when moving from a seated to standing position and moving on and off toilet. The MDS indicated the resident had not had any falls in the three month period since the prior MDS assessment. The Care Plan for Resident #1 noted the resident required extensive assistance of 1-2 staff members for toilet use. The Care Plan noted the resident as non-ambulatory but could bear weight during transfers and could stand and pivot turn with the assist of 1-2 staff members. Interventions included the use of a PRN (as needed) large gait belt for mobility and a bedside commode for toileting. The Care Plan did not give criteria or direction to staff when to transfer with one or 2 persons and when or when not to use the gait belt. Review of the resident's Morse Fall Scale dated 11/8/15 identified the resident as a moderate risk for falling with a score of number 35 (moderate risk equals 25-44) due to impaired gait. The facility Fall Investigation report dated 11/15/2015 revealed the resident experienced a witnessed fall. Factors documented at the time of the fall reflected the resident lost strength and appeared to get weak as Staff C, Certified Nurse's Aide, attempted to transfer the resident from the bedside commode to the resident's wheelchair without assistance of a second staff member. The CNA was forced to lower the resident to the floor. The document revealed the resident was alert and oriented at the time of the fall and complained of right hip pain. A local hospital emergency room (ER) report reflected the resident was admitted to the hospital on [DATE]. Record review of a radiology report dated 11/15/15 revealed the resident had an intertrochanteric fracture of the right hip. Osteoporosis (progressive bone disease that weakens bones and makes them susceptible to bone fractures) was noted. The Progress Notes dated 11/21/15 at 1:59 P.M. reflected the resident returned to the facility from the hospital. The resident had a temperature of 100.2 (normal 98.6). The nurse administered Percocet (narcotic analgesic) at 1:55 p.m. The resident grimaces with movement but denies pain. On 11/22/15 at 2:52 a.m. the nurse gave the resident Percocet for right hip pain. On 11/29/15 at 7:20 p.m. the note reflected the nurse sent a fax to the physician and required an order for [REDACTED]. On 11/30/15 at 9:08 p.m. reflected the facility received Fentanyl patches 12 micrograms from the pharmacy and the nurse applied one to the left chest region. On 12/2/15 at 10:56 a.m., the resident voiced complaints of right hip pain. The nurse administered Percocet at 9:40 a.m. with relief obtained. On 12/8/15 at 2:00 PM, Staff C, Certified Nurse Aide, was interviewed and stated she was assigned to care for Resident #1 on the evening shift of 11/15/15. Staff C stated she was aware the resident's Care Plan directed the staff to use a gait belt for transfers PRN (as needed) basis and the resident was transferred with extensive assist of 1-2 staff members. Staff C stated she and another CNA assisted the resident into his/her nightgown and transferred the resident, using a gate belt and onto the resident's bedside commode. She stated after placing the resident on the commode, the resident complained the gait belt was too tight so Staff C removed the gait belt from the resident's waist. Staff C stated she and her co-worker left the room to give the resident some privacy. When the resident put on the call light (activated). Staff C returned to the resident's room. Staff C stated her co-worker was on break at the time so she decided to transfer the resident from the commode to her/his bed by herself. Staff C stated she stood the resident up and stood on the resident's weak right side as she performed hygiene cares for the resident. She stated as she bent down to pull up the resident's pants, the resident's weak right knee gave out and the resident slid to the ground. Staff C stated she did not put the gait belt on the resident before assisting him/her to stand and she was unable to keep the resident from sliding to the ground. Staff C stated she notified the nurse that the resident had fallen and assisted the nurse with assessing the resident and preparing the resident for transfer by ambulance to the ER. Staff A, B, and Staff C placed a gait belt on the resident and transferred the resident to bed. The resident voiced pain and winced when the right hip area was touched. Staff C stated when she was first hired and oriented, she was instructed to use the gait belt when assisting residents with transfers and she is unsure of why she did not use the gait belt when transferring Resident #1. Staff C stated since the resident's fall, the staff has been instructed to use the gait belt with all assisted transfers. She stated there was now a gait belt hanging on the wall in every resident room. On 12/8/15 at 1:00 PM, the Director of Nursing (DON), was interviewed and stated after the resident experienced the fall and fracture, she conducted an internal investigation to determine what had occurred. The DON stated she was aware the CNA had not used a gait belt to transfer the resident. She stated normally she would expect to see staff use the gait belt for any resident transfer when the resident has weakness on one side. The DON stated she is currently discussing a change in the policy wording (not having PRN) with the Assistant DON and the fall nurse. Record review of the facility Ambulation policy (reviewed on 3/2015) reflected the policy to have a subtitled Use of Gait belts are Care Plan as needed (PRN). The policy instructed staff to get help if needed, to place the gait belt properly around the resident's waist and make sure it was tight enough to be secure. If the resident becomes weak, falls, or loses balance; gently ease the resident to the floor, call the nurse who must then examine the resident for injury.

Based on observation, record review and staff interview the facility failed to provide adequate supervision and/or appropriate positioning to prevent injuries for 3 of 7 residents with falls reviewed (Residents #3, #6, and #10) and failed to ensure hazardous chemicals were securely stored out of reach of cognitively impaired residents. The facility reported a census of 76 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 5/20/14 documented Resident #6 with severely impaired cognition, required extensive staff assistance for bed mobility, transfers, toilet use, personal hygiene, and bathing, had not ambulated, bilateral lower extremity range of motion impairment, and used a wheel chair for mobility. The MDS documented the resident only able to balance with staff assistance when moved from a seated to standing position, moved on and off the toilet, and for surface to surface transfers, had not walked or turned around, and the resident without falls since the previous assessment period. The same MDS documented the resident's [DIAGNOSES REDACTED]. A facility Admission Record documented the resident admitted to the facility 2/14/14. A Morse Fall Scale completed 2/14/14 documented the resident score 65 and a score of 45 and higher indicated the resident had a high risk for falling. A Morse Fall Scale completed 5/20/14 documented the resident with a score of 75. A Care Plan/Approaches dated 2/25/14 identified Resident #6 had a problem with Mobility Patterns/Needs and Accidents/Falls. Care plan Approaches directed staff the resident able to bear weight during transfers, standing, and pivoting with the assistance of 1 or 2 staff, use an easy stand lift when needed (start date 3/31/14), had a wheel chair and required staff assistance when wheeled, and the resident without alarms. A nursing Progress Notes incident entry dated 5/23/14 at 1:36 p.m. documented the resident lying on the floor with 2 CNA's (Certified Nurse's Aide) present. The resident slid out of the wheel chair onto the floor when a CNA pulled the wheel chair back out of the bathroom and the resident grabbed the bar. The resident stated pain present in the left hip and groin area and the resident transferred to the hospital via ambulance at 2:20 p.m. An entry at 6:56 p.m. documented the resident had a left hip fracture. An entry dated 5/28/14 documented the resident returned to the facility at 3:25 p.m. and the resident had a 4 centimeter incision to the left hip. A facility Incident Report dated 5/23/14 at 1:10 p.m. documented the resident lying on left side with 2 CNA's present, the resident grabbed a bar in the bathroom when a CNA pulled the wheel chair backwards, and slid out of a wheel chair onto the floor. The report identified the resident with confusion and memory problems. A Fall Investigation dated 5/23/14 documented the resident's fall risk factors included osteoporosis, incontinence, decline in cognition, impaired cognition, and other dementia. A Radiology report dated 5/23/14 documented the resident with a subcapital fracture of the left proximal femur. An Operative Report dated 5/27/14 documented the resident had a left femoral neck fracture and percutaneous pinning of the left hip 5/24/14. During interview 7/22/14 at 9:36 a.m. Staff O stated she and Staff M, CNA's, present on 5/23/14 when the resident slid out of the wheel chair and sustained a hip fracture. Staff O present in the resident's room and stated the pressure relief currently in the resident's lift chair located in the resident's wheel chair at the time of the fall and the fabric of the cushion slightly slippery. Observation revealed the cushion felt slightly slippery. Staff O stated Dycem (no slip fabric) now placed on top and below the cushion in the resident's lift chair. Staff O stated after toileted the resident sat on the wheel chair with a pressure relief cushion in place and the resident's buttocks left approximately 5 inches, or possibly not that much, of gap at the back of the wheel chair. Staff O stated the resident had never reached out for the safety bar on the wall before when staff pulled the resident backwards out of the bathroom. Staff O stated she had completed pericare, removed gloves, and washed hands when fall happened. During further interview 7/22/14 at 10:02 a.m. Staff O stated prior to the fall in the bathroom, the resident stood with a gait belt on while she completed pericare, the resident stood well after assisted to a standing position, Staff M placed the wheel chair behind the resident while Staff O removed gloves. Staff M pulled the wheel chair backwards over a minimally raised area on threshold, and Staff M stated this possibly startled the resident. Staff O stated Staff M stopped pulling the wheel chair backwards immediately when saw the resident grab the safety rail, and Staff O unable to reach the resident in time to prevent sliding out of the wheel chair. Staff O stated the 2 staff planned to reposition the resident in the wheel chair. During interview 7/22/14 at 10:20 a.m. Staff M stated she and Staff O toileted the resident after lunch on 5/23/14 before the fall/fracture. Staff M stated Staff O completed pericare while the resident stood well and held the bathroom safety rail. Staff O stated she pushed the resident's wheel chair behind the resident, the resident sat on the wheel chair with approximately 4 to 5 inches of gap at the back of the wheelchair normal for the resident after toileted, and the resident usually leaned back in the chair. Staff M stated she placed the wheel chair completely in the bathroom behind the resident facing the safety bar while Staff O removed gloves. Staff M stated she began to pull the wheel chair backwards out of the bathroom for more room to position the resident better in the wheel chair with one staff in front of the resident to manage the resident's legs and the other staff member to use the gait belt to lift the resident back and up towards the back of the wheel chair. Staff M stated the resident leaned forward and grabbed the safety bar on the wall at the same time the wheel chair pulled backwards, staff M attempted to grab the resident's shoulders, unable to reach due to the resident's buttocks now positioned further towards the front of the wheel chair, and sliding off the wheel chair seat. Staff M stated Staff O turned around after gloves removed and unable to reach the resident in time. Staff M stated the resident had never grabbed the safety bar before and the incident happened too quickly. During observation 7/22/14 at 2:20 p.m. the ADON (Assistant Director of Nursing) measured the depth of the resident's wheel chair with the pressure relief cushion at the time of the 5/23/14 fall at 17 inches. Staff M and Staff O stated the resident's buttocks positioned approximately 4 to 5 inches from the back of the wheel chair prior to sliding out of the wheel chair 5/23/14. 2. An MDS assessment tool dated 2/11/14 documented Resident #10 with moderately impaired cognition, required extensive staff assistance for bed mobility, transfers, ambulation, toilet use, personal hygiene, and bathing, with upper and lower extremity one side range of motion impairment, and used a walker and wheel chair for mobility. The MDS documented the resident only able to balance with staff assistance when moved from a seated to standing position, walked, moved on and off the toilet, and for surface to surface transfers, had not turned around, and without falls during the previous assessment period. The MDS documented the resident's [DIAGNOSES REDACTED]. A Morse Fall Scale dated 11/13/13 documented the resident scored 90 and a score higher than 45 indicated the resident high risk for falling. A Morse Fall Scale dated 2/12/14 documented the resident with a score of 75. The resident's Care Plan/Approaches dated 2/21/13 documented the resident with Mobility Patterns/Needs and Accidents/Falls concerns and interventions included to ambulate and or transfer the resident with 1 to 2 staff and follow with a wheel chair. The resident can independently move the wheelchair for short distances at times. An intervention dated 9/6/12 directed CNA's to remain with the resident at all times when on toilet. An Incident Report dated 12/18/13 at 8:20 p.m. documented the resident fell off the toilet after his/her head felt heavy, the CNA by the resident's bed and unable to reach the resident in time to prevent a fall, the resident hit head, received a 3 centimeter (cm) long by 0.2 cm deep laceration on the left temple by the eye brow, and a bruise on a cheek bone. A Fall Investigation dated 12/19/13 documented the CNA educated and disciplined. During interview 7/24/14 at 8:50 a.m. the DON verified the new Care Plan intervention directed the CNA to face the resident at all times and a different toilet riser placed in the resident's bathroom. The DON stated the resident preferred privacy in the bathroom and a CNA of the opposite sex with the resident at the time of the fall. An Incident Report dated 4/19/14 at 4:45 a.m. documented the resident fell off the toilet and hit left temple and ear on doorway when reached over to wipe self. The report documented the CNA stood in the doorway and looked in shirt pocket to obtain resident list at the time of the fall. The nurse documented the CNA needed to stand closer to the resident during toileting and assist the resident with pericare. A nursing Progress Notes entry dated 4/19/14 at 5:12 a.m. documented the nurse directed the staff member to concentrate on the resident. 3. The Minimum Data Set (MDS) with a reference dated 3/25/14, documented for Resident #3 [DIAGNOSES REDACTED]. The MDS documented the resident with long and short term memory impairments and severely impaired decision making abilities, and required total dependence with transfer and locomotion on and off the unit. The Morse Fall Scale dated 1/1/14, documented a score of 75 and the resident at high risk for falling, has a history of falling and needs assist from the nurse for wheelchair mobility. The Incident Note dated 2/20/14, documented the resident being pushed by a certified nursing assistant in wheelchair out of the television lounge when feet curled under the wheelchair and caught on the carpet, causing resident #3 to fall forward out of chair. Resident #3 bumped his/her forehead on carpet, 4 centimeter (cm) reddened area, possible start of abrasion. Right hand 4th knuckle has 1 cm skin tear. Pinpoint open area on right index finger cleansed and left open to air. 4. Observation on 7/21/14 at 10:40 a.m., revealed an unlocked cabinet underneath the sink in the east kitchenette with a gallon of TMA-Quaternay sanitizer for which read Keep out of reach of children. The Material Safety Data Sheet: Emergency Response Procedures: a. First aid: eyes, flush with water for at least 15 minutes. Seek medical attention. b. Skin: Wash exposed skin with soap and water until gone. Remove affected clothes, rinse off product and wash clothes before reuse. c. Inhalation: If affected, remove individual to fresh air, get medical attention at once if there is any discomfort. d. Ingestion: Dilute by giving large amounts of egg whites or gelatin, or milk or water. Get medical attention immediately. Do not induce vomiting. Interview on 7/21/14 at 10:40 a.m., Staff A (dietary aide) confirmed and verified that the chemical needed to be kept locked at all times.

Based on observation, record review, interviews with resident, staff and resident family, the facility failed to ensure residents received adequate supervision against hazards and failed to implement and or revise care plan interventions intended to prevent falls for two (2) of six (6) (Resident #6 and Resident #5). Resident #6 stood up and fell backwards and hitting his/her head on the table behind where he/she had been sitting. Resident #6 sustained a head injury which required 5 staples to close the wound. The resident's care plan directed staff to apply an alarm in all chairs and staff failed to implement the care plan intervention. In addition, both Resident #6 and Resident #5's had repeated falls in which their care plans failed to address their ability to remove alarms and or where staff should place alarms. The surveyor's observation during the investigation identified care plan intervention not in place as the care plan directed. The facility identified a census of seventy-seven (77) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 7/26/11 assessed Resident #6 with a brief interview for mental status (BIMS) score of "8" (moderate cognitive impairment) . The MDS documented that the resident required extensive staff assistance with bed mobility, transfers, ambulation, dressing, toileting, personal hygiene and bathing. A "balance during transitions and walking" test documented the resident as not steady and only able to stabilize with human assistance with moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfers. The resident had functional range of motion limitations of both upper and lower extremities. The resident had [DIAGNOSES REDACTED]. The MDS identified fall since the prior assessment 2 without injury and one with injury. A MDS dated [DATE], documented the resident scored "10" on his/her BIMS. The assessment determined no change (or improvements) from the prior MDS regarding the resident's balance during transition and walking. A 10/25/11 fall risk assessment identified the resident with a score of "21". A score of 10 or above indicates high risk for falls. Eastern Star Masonic Home Incident Report identified the following: 6/29/11 at 2:30 a.m., staff found the resident on the floor between night stand and bed. The resident stated he/she got up to get robe and fell . The resident complained of right mid back discomfort. Assessment showed a 5 centimeter (cm.) by 5 cm. red area to the mid back. The alarm did not sound and the resident admitted to turning the alarm off because its "too noisy". The resident then demonstrated how he/she got to foot of bed and turned off alarm. The new intervention to prevent reoccurrence was "low bed and mat beside bed". 7/8/11 at 5 a.m., the resident attempted to walk to the sink from the recliner. The resident pulled all wires from behind recliner to get to alarm and then shut it off. The new intervention to prevent recurrence was: Will have 2 alarms while in chair and bed. Reeducated on dangers of self ambulation. 7/10/11 at 8:10 a.m., the report stated the resident left facility with spouse and while spouse turned back the resident attempted to self transfer and slipped on flip flop shoe. The intervention to prevent recurrence as "Don't wear flip flops". 8/16/11 at 4:30 p.m. the resident lost balance when coming in east door after spouse took outside. The resident sustained [REDACTED]. abrasion to the right elbow and 3.5 cm. by 2.8 cm. bruise to right forearm. The intervention to prevent recurrence was "Remind spouse not to drop off resident at door and resident needs gait belt when ambulated". 8/25/11 at 4:30 a.m., the report stated the resident's alarm sounded and staff found the resident seated on the floor in room by vanity. The resident attempted to get to the bathroom by self resulting in a fall. The intervention to prevent recurrence was "Remind to wait for help and must use call light. Discussed what can happen when you fall". 9/18/11 at 4 p.m. Resident returned to facility by family. Staff walked by room and observed resident sitting on floor between foot of bed and closet. Resident leaning against closet. Resident stated he/she got up to plug in phone. Alarms did not sound. Staff identified after the resident returned to the facility, no one turned the alarm on when resident returned to facility. The resident did not sustain injury. The intervention to prevent recurrence as "Reminder placed in room to remind staff and family to make sure alarm is turned on after transfer in and out of wheelchair. Staff reeducated to check alarms when resident returned to building". 9/27/11 at 10:45 p.m., staff found the resident on the floor by bed. Resident shut alarm on recliner off and ambulated to the bed per self. The resident did not use call light. No injury sustained. The intervention to prevent recurrence was "Place chair alarm box in center of back of recliner". 9/29/11 at 12:35 p.m. alarms sounded and staff observed the resident in seated position on floor with back against neighbor's bathroom door. The resident tried to pull slacks down and fell . Resident did not use call light. The resident sustained [REDACTED]. bruise with a 1.5 cm. firm area within. The intervention to prevent recurrence as "Placed in recliner with alarm on because resident wanted nap". 11/9/11 at 9 a.m. staff found resident on floor with television (TV) in lap. Resident identified self as putting a blanket away became unsteady grabbing the TV and fell . The resident complained of knee soreness. Staff observed a 1.5 cm. by 1 cm. abrasion to the left knee. The alarm did not sound when the resident fell . The intervention to prevent recurrence as "nurse aide education". 11/13/11 at 5:30 p.m. while in dining room resident got up on own and attempted to ambulate out of dining room and lost balance and fell backwards hitting head on table behind his/her chair. Staff observed bloody drainage from the back of the head. Assessment showed a 0.2 cm. by 4 cm. to back of head. Pressure and ice pack applied. At 7:30 p.m., of the same date the facility informed the physician of the incident. The resident transported to the emergency room (ER) for evaluation. Hospital patient progress notes and physician orders [REDACTED]. A late entry for 11/13/11 written on 11/15/11 at 3:30 p.m. stated nurse (Staff A) spoke with nurse aide (Staff B)who failed to apply alarm in dining room chair. Staff B stated she did not know how to get alarm out of wheelchair and forgot to place another alarm under resident after transfer into dining room chair. Staff A educated Staff B to place alarm under resident in dining room chair. An entry dated 11/15/11 at 8 p.m. identified the resident with five staples to the back of the head. On 11/15/11 at 3:15 p.m. the resident and spouse stated the resident got 5 stitches to the back of the head Sunday because the resident did not have alarm on and got up and fell . The resident stated he/she stood up and got his/her feet tangled up and fell down. On 11/16/11 at 2:40 p.m. Staff A stated the resident's alarm on the wheelchair is permanently attached to the wheelchair. Staff B did not realize it was permanent and then forgot to put one in the dining room chair. On 11/16/11 at 2:45 p.m. Staff B confirmed what Staff A reported regarding the incident. Observation showed, on 11/16/11 at 2 p.m. the resident seated in a recliner in room with alarm in pocket at side of recliner easily in reach of resident. At 2:05 p.m., the surveyor summoned the Director of Nursing who confirmed the alarm was in pocket at side of chair. At that time the Director of Nursing identified the recliner as a new recliner. The resident's other recliners did not have a pocket at the side. Observation earlier (the same date at 11:30 a.m.) the resident seated at the dining room table in wheelchair with alarm on and his/her spouse present. A care plan dated 11/4/10 identified the resident with a high fall risk, intermittent unsteady gait and unaware of risk for falls and injury. Reminders to use call light not effective/appropriate. An addendum, dated 2/3/11 directed staff to use alarms on all chairs. An addendum dated 9/22/11 directed staff to place alarm at center back of recliner. 2. A Minimum Data Set (MDS) with observation end date of 9/19/11 assessed Resident #5 with a brief interview for mental status score of "8". The MDS documented the resident required extensive staff assistance with bed mobility, transfer, ambulation, dressing, toileting, personal hygiene, bathing and supervision. A "balance during transitions and walking" documented the resident as not steady and only able to stabilize with human assistance with moving from seated to standing, walking, turning around and facing the opposite direction while walking, moving on and off toilet, surface to surface transfers. The resident utilized walker and wheelchair. The resident had [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. A history and physical dated 9/4/11 identified the resident the resident with [DIAGNOSES REDACTED]. The resident admitted to the facility on [DATE] following hospitalization . Falls: An Eastern Star Masonic Resident Incident Report dated 9/13/11 at 12:45 a.m. documented staff found the resident on the floor lying on the left side. The resident stated he/she tried to get walker and went down easy. Resident shut alarm off and it did not sound. The new intervention to prevent recurrence stated "Moved bed alarm to head of bed and next to wall" and "put slipper socks on". An Eastern Star Masonic Resident Incident Report dated 9/21/11 at 6:50 p.m., documented the facility received a call from the resident's family member to report the resident called her to say the resident was on the floor. When the charge nurse (Staff A) went to the room, she heard the alarm sound. The resident stated he/she slid off the foot of the bed trying to reach for the phone. The resident denied pain. The new intervention to prevent recurrence was "landing strip placed beside bed". On 11/16/11 at 1:38 p.m. Staff A confirmed the alarm was not audible until she got to the room. Staff A couldn't think of any other times the alarm was not heard. Staff A also stated the resident was a quick mover. An Eastern Star Masonic Resident Incident Report dated 9/23/11 at 2:30 a.m., documented staff found the resident on the floor by the bathroom door. The resident denied injury. The alarm did not sound when the fall occurred. The new intervention to prevent recurrence stated, "Continue to check alarms frequently. Alarm box moved out of reach to head of bed where resident cannot reach it". An Eastern Star Masonic Resident Incident Report dated 10/18/11 at 2:40 a.m. documented a nurse aide walked by the resident's room and did not see the resident in bed, no alarm sounding and no call light on. Staff found the resident sitting on floor in bathroom facing the toilet. The resident stated he/she lost balance and slid down the wall. The nursing progress notes dated 10/18/11 at 3 a.m., identified a 4.5 centimeter (cm.) skin tear on the right arm just below elbow. Directly below that area was a 2 cm. skin tear. Observation showed, on 11/15/11 at 3:05 p.m. 2 staff transfer the resident from the wheelchair to the toilet. The alarm sounded when staff stood the resident for the transfer. At that time, staff stated the resident does unplug the alarm and most of the time, unplugs it when in bed. The care plan dated 9/23/11 identified the resident as a high fall risk with intermittent unsteady gait. The care plan did not identify that the resident removed alarms and that staff should place alarm out of reach or where to place the alarm.

Based on clinical record review, observation and staff interviews, the facility failed to maintain an environment free of accident hazards and provide adequate supervision to ensure against hazards from self, others, or elements in the environment for 1 of 5 residents (Resident #1). The facility reported a census of 75. Findings include: Record review of the Minimum Data Set (MDS), dated [DATE], for Resident #1 revealed [DIAGNOSES REDACTED]. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 5 which signified the resident had severe cognitive skills for decision making. The MDS documented the resident required extensive assistance of 1 person for transfers and ambulation and under balance during transitions and walking indicated the resident was not steady, only able to stabilize with human assistance.. Record review of the Facility Resident Care Plan/Approaches, dated 9/22/11, revealed the resident had a concern of accidents and a high risk for falls. The care plan documented the resident unaware of risk for falls and injury and reminders to use the call light were not effective and or appropriate. Staffs were to provide and maintain a safe environment to include adequate lightening and clean, dry floors for the resident. Interventions of a bed alarm and chair alarm were implemented on 11/3/11. Although the resident did trigger for high fall risk, the care plan did not address the need for staff to remain with the resident during toileting. Record review of the Nurse's Progress Notes, dated 1/10/11 at 3:15 P.M., revealed staff found the resident sitting on the bathroom floor. The resident received no injuries. The resident told the staff member he/she sat down on the floor from the toilet. Record review of the facility Resident Incident Report, dated 1/10/12 at 3:15 P.M., revealed the resident was found sitting on the bathroom floor with no injuries noted. The resident stated I sat down on the floor from the toilet. The Incident Report documented the resident had alarms but these were not in place due to the resident sitting on the toilet. Staff interview on 1/11/12 at 1:00 P.M., with Staff A Certified Nursing Assistant (CNA) revealed she toileted Resident #1 10 minutes prior to the incident. When Staff A next checked on the resident after toileting him/her the resident was messing with the alarm box and voiced the need to use the toilet again. Staff A placed the resident on the toilet and walked out in to the room area. She then heard an alarm from another resident's room. She left the resident sitting on the toilet and left the resident's room to help the other resident. She said she entered the second resident's room and found the resident standing up. She sat the resident back down into the recliner and after approximately 3-5 minutes she returned to Resident #1's room and found the resident sitting on the bathroom floor. She said she asked the resident what happened and the resident told her he/she sat on the floor from the toilet. She said she did not place an alarm on the resident prior to leaving the resident on the toilet. She said she knew the facility policy directed not to leave resident's who required alarms for fall interventions alone on the toilet. She said the resident had not fallen off the toilet before. The incident occurred approximately 3:00-3:15 P.M. and she had been the only staff member in the hall. The second CNA took her break at that time. Interview with Staff B Licensed Practical Nurse (LPN), on 1/11/12 at 1:40 P.M., revealed Staff A told her Resident # 1 was on the bathroom floor. When she entered the resident's room, the treatment nurse finished taking the resident's blood pressure. She said she asked the resident to tell her what happened. The resident told her he/she slipped off the toilet and sat on the floor. She said staff A had been the only staff member in the hall at the time of the incident. She said Staff A told Staff B she responded to an alarm on a second resident and left Resident #1 on the toilet unattended. She said Staff A told her she had only been away approximately 3-5 minutes. She also said the facility policy stated no alarmed residents were to be left unattended while on the toilet. Staff interview with Staff C CNA, on 1/11/12 at 1:38 P.M., revealed she had been on break at the time of the incident. She said Staff A told her Resident #1 slipped/fell on the bathroom floor. She said she and the charge nurse assisted the resident up off the floor. She said the facility policy required staff to stay with alarmed residents while sitting on the toilet. Staff interview with the Director of Nursing on 1/11/12 at 1:00 P.M., revealed she would expect staff to stay with high fall risk residents which required alarms for safety prevention for falls.