Every finding on record at Elkader Care Center

Based on observations, clinical record review, Nurse Practitioner/Providers interview, resident and staff interviews, and facility policy and procedure review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers from developing or worsening on residents with a history of pressure ulcers for one of three residents reviewed (Resident #3). The facility reported a census of 28 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The facilities Pressure Ulcer Prevention Program policy (not dated) directed the facility staff should have a system in place that assured assessments were completed timely and appropriate; interventions implemented, monitored and revises as appropriate; and changes in condition recognized, evaluated, reported to the resident's attending practitioner and other healthcare professionals, ie.wound nurse and etc as appropriate. The Procedure included the following; a. Assess, reassess and document the ulcer's characteristics weekly. 1. Date. 2. Location of ulcer and staging. 3. Size. 4. Depth 5. Presence, location and extent of undermining or tunneling/sinus tract. 6. Exudate (drainage) a. Type: purulent/serous b. Color. c. Odor d. Amount e. Pain f. Wound bed. 1. Color and type of tissue/character, including evidence of healing (granulation tissue) or necrosis (slough or eschar). g. Description of wound edges and surrounding tissue: 1. Rolled edges. 2. Redness. 3. Hardness/induration (thickening or hardening of the skin). 4. Maceration (excessive moisture or fluid accumulation in the skin, leading to softening, swelling, and skin integrity breakdown). 5. Description of the healing of the pressure ulcer. b. Observation for infection. 1. Purulent exudate (drainage). 2. Peri-wound warmth. 3. Swelling. 4. Induration. 5. Erythema (redness of the skin). 6. Increasing pain or tenderness around the site. 7. Delayed wound healing. A Minimum Data Set (MDS) assessment form dated 10.10.24 indicated Resident #3 had diagnoses that included Radiculopathy of the Lumbar region, Cardiomyopathy, urine retention, Heart Failure (HF), Renal Insufficiency, and Diabetes Mellitus (DM). The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 (cognitively intact), required substantial to maximum assistance with most activities of daily living (ADL's), as frequently incontinent of urine, at risk for pressure ulcers, with one (1) stage II pressure ulcer on admission and not on a turning and repositioning program. The resident's Initial Care Plan located in Point Click Care (PCC) initiated 10.8.24 failed to address her skin breakdown/pressure ulcers but directed the facility staff to have assisted the resident with morning and evening cares. The residents Initial Care Plan reported to have been located in the resident's paper chart initiated 10.4.24 indicated the resident as admitted to the facility on 10.4.24 with a stage II pressure area to her left buttock with a current order for a specified dressing and discontinued 10.17.24 due to the completion of the Comprehensive Care Plan. The Initial Care Plan failed to address a turning or repositioning program but rather indicated the resident as independent. A Function Abilities form dated 10.10.24 at 2:23 p.m. indicated the resident required substantial to maximum assistance of staff with toileting hygiene, personal hygiene, transfers, and ambulation. A Wound/Skin Healing Record form indicated the resident had a pressure ulcer on her left buttock with the onset dated 10.4.24. The assessments included the following: a. 10.4.24 (no time documented) - A stage II pressure ulcer that measured 0.7 centimeters (cm) by (x) 0.3 cm and less than 0.1 cm deep with purple and non-blanchable surrounding skin that measured 1.5 cm x 1.5 cm. The staff failed to assess the resident's ulcered areas exudate, odor, exudate amount, wound bed, surrounding skin color and surrounding tissue/wound edges. Staff indicated the resident's Care Plan as updated. b. 10.10.24 (not time documented: - A stage II pressure ulcer that measured 8.0 cm x 2.0 cm and 0.01 cm deep with no exudate, slight odor, wound bed with epithelial tissue, slough and purple, normal surrounding skin color and tissue and wound edges, no tunneling or pain. The wound deteriorated in status. During an interview 10.18.24 at 12:29 p.m. Staff A, Registered Nurse (RN) confirmed she should have completed a more thorough assessment of the resident's decubitus ulcer on 10.4.24 and that she should have reported to the resident's Primary Physician the increase in size and slight odor of the decubitus following her 10.10.24 assessment. The staff member indicated when the resident arrived with the decubitus ulcer and purple surrounding skin she felt like the area had been waiting to open up. A Physician Progress Note form dated 10.15.24 at 11:48 p.m. indicated the resident's Assessment and Plan included the following in relation to the decubitus ulcer: a. At that time with the resident's Neutropenia (low white cells which hindered the ability to fight infections), the decubitus ulcer located at a high risk area for infection and lethargy had been treated with antibiotics due to the high probability of infection. During an interview 10.18.24 at 12:42 p.m. the Nurse Practitioner (NP) indicated her concern incurred when the resident came to them from home and originally left the hospital with barely an ulcer and when they saw her back in such a short period of time the status of the decubitus appeared shocking. The NP indicated the report she received from the facility addressed the ulcered area as a sore on her bottom but the area appeared certainly more than a sore. The NP indicated the area could have been prevented and/or minimized however the resident ended up septic with the decubitus the likely source and/or the contributing factor to her death. During an interview 10.18.24 at 11:31 a.m. the resident's primary Physician indicated she had no knowledge of the increase in size of the decubitus ulcer during her visit on 10.10.24 as the facility had faxed the status to her office after she had left for the day so she never assessed the area during that visit. The Physician also addressed the following issues during this interview: a. The resident presented with risk factors for a decubitus such as chronic kidney disease, HF, and DM. b. Not sure if the decubitus could have been prevented without having observed the area but she felt the decubitus progressed substantially in a short period of time. c. She had been aware when the resident presented in the emergency roiagnom on 10.15.24 the staff informed her the area had been odorous which added to the significance of infection. During an interview 10.18.24 at 12:16 p.m. the primary Physician indicated she felt there had been something the facility could have done to minimize the fast progression of the ulcered area and that there should had been better communication with her as the primary Physician. The Physician reiterated the ulcered area worsened faster than it should have at the time. The Physician indicated the resident passed away at 11:36 a.m. that morning from concerns with sepsis from the ulcered area and worsening renal failure. A Clinically Unavoidable Pressure Ulcer form signed by a Physician 10.18.24 addressed the pressure ulcer as unavoidable. During an interview 10.18.24 at 1:44 p.m. the resident's Primary Physician (same as above) confirmed she signed the Unavoidable Pressure Ulcer form that morning but thought the form had been a checklist of symptoms that could have caused the decubitus ulcer but her intent had not been meant for the form to have been conclusive. Again, the Physician reiterated if the staff would have communicated to her better related to the decubitus ulcer it could have been avoided and/or minimized. The Physician confirmed when she rounded and assessed the resident on 10.10.24 facility staff accompanied her but failed to communicate the worsening decubitus ulcer at that time and she would have expected a full report on the resident's current condition and worsening decubitus.

Based on observations, clinical record review, Nurse Practitioner/Physician/Providers interviews, resident and staff interviews, and facility policy review, the facility failed to provide proper assessments and interventions in a timely manner for 2 of 3 residents following a change of condition (Residents #3 & #2). The facility reported a census of 28 residents. Findings include: 1. The facilities Pressure Ulcer Prevention Program policy (not dated) directed the facility staff should have a system in place that assured assessments were completed timely and appropriate; interventions implemented, monitored and revises as appropriate; and changes in condition recognized, evaluated, reported to the resident's attending practitioner and other healthcare professionals, ie.wound nurse and etc as appropriate. The Procedure included the following; a. Assess, reassess and document the ulcer's characteristics weekly. 1. Date. 2. Location of ulcer and staging. 3. Size. 4. Depth 5. Presence, location and extent of undermining or tunneling/sinus tract. 6. Exudate (drainage) a. Type: purulent/serous b. Color. c. Odor d. Amount e. Pain f. Wound bed. 1. Color and type of tissue/character, including evidence of healing (granulation tissue) or necrosis (slough or eschar). g. Description of wound edges and surrounding tissue: 1. Rolled edges. 2. Redness. 3. Hardness/induration (thickening or hardening of the skin). 4. Maceration (excessive moisture or fluid accumulation in the skin, leading to softening, swelling and skin integrity breakdown). 5. Description of the healing of the pressure ulcer. b. Observation for infection. 1. Purulent exudate (drainage). 2. Peri-wound warmth. 3. Swelling. 4. Induration. 5. Erythema (redness of the skin). 6. Increasing pain or tenderness around the site. 7. Delayed wound healing. A Minimum Data Set (MDS) assessment form dated 10.10.24 indicated Resident #3 had diagnoses that included Radiculopathy of the Lumbar region, Cardiomyopathy, urine retention, Heart Failure (HF), Renal Insufficiency, and Diabetes Mellitus (DM). The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 (cognitively intact), required substantial to maximum assistance with most activities of daily living (ADL's), as frequently incontinent of urine, at risk for pressure ulcers, with one (1) stage II pressure ulcer on admission and not on a turning and repositioning program. The resident's Initial Care Plan reportedly located in the resident's paper chart initiated 10.4.24 indicated the resident as admitted to the facility on 10.4.24 with a stage II pressure area to her left buttock with a current order for a specified dressing and discontinued 10.17.24 due to the completion of the Comprehensive Care Plan. The Initial Care Plan failed to address a turning or repositioning program but rather indicated the resident as independent. A Functional Abilities form dated 10.10.24 at 2:23 p.m. indicated the resident required substantial to maximum assistance of staff with toileting hygiene, personal hygiene, transfers, and ambulation. A Wound/Skin Healing Record form indicated the resident had a pressure ulcer on her left buttock with the onset dated 10.4.24. The assessments included the following: a. 10.4.24 (no time documented) - A stage II pressure ulcer that measured 0.7 centimeters (cm) by (x) 0.3 cm and less than 0.1 cm deep with purple and non-blanchable surrounding skin that measured 1.5 cm x 1.5 cm. The staff failed to assess the resident's ulcered areas exudate, odor, exudate amount, wound bed, surrounding skin color and surrounding tissue/wound edges. Staff indicated the resident's Care Plan as updated. During an interview 10.18.24 at 12:29 p.m. Staff A, Registered Nurse (RN) confirmed she should have completed a more thorough assessment of the resident's decubitus ulcer on 10.4.24 and that she should have reported to the resident's Primary Physician the increase in size and slight odor of the decubitus following her 10.10.24 assessment. The staff member indicated when the resident initially arrived with the decubitus ulcer and purple surrounding skin she felt like the area had been waiting to open up. 2. An MDS assessment form dated 8.6.24 indicated Resident #2 had diagnoses that included Seizure/Epilepsy disorder, Borderline Personality disorder, Mild Intellectual disabilities, Anxiety, Depression, Respiratory Failure with Hypercapnia, and morbid obesity. The assessment indicated the resident had a BIMS score of 15 (cognitively intact) and required staff assistance with ADL's. A Care Plan included the following Focus areas and Interventions/Tasks as dated: a. The resident required 24 hour care related to (r/t) a Seizure disorder. (initiated and revised 2.26.21) b. The resident had altered respiratory status r/t sleep apnea and hypoxia. (revised 1.5.23) 1. Monitor for and symptoms of respiratory distress and report to the Physician as needed (PRN) the following: a. Decreased pulse oximetry, increased heart rate, restlessness, diaphoresis (sweating), headaches, lethargy, confusion, Empty (cough up blood from lungs), cough, Pleuritic pain (sharp chest pain that worsens with a cough or movement), accessory muscle usage, skin color changes, anxiety, shortness of breath (SOB) at rest. (initiated 3.12.21) 2. Monitor/document/report abnormal breathing patterns to the Physician: increased or decreased rate, periods of Apnea (no breathing), prolonged inhalation or exhalation, shallow breathing, prolonged deep breathing, usage of accessory muscles, pursed lip breathing and nasal flaring. (initiated 3.12.21) c. Non-invasive ventilator as ordered. (initiated 3.22.24) Progress Note entries included the following as dated: a. 10.11.24 at 12:56 p.m. - The resident stated she felt unwell. Runny nose, sore throat, and felt more tired. Lung sounds clear in all quadrants. Covid negative. A NP had been notified and directed the staff to have monitored the resident for worsening symptoms. Vital signs (VS) consisted of a Temperature (T) of 98.0 degrees Fahrenheit, Blood Pressure (B/P) 118/72, Pulse (P) 76, Respirations (R) 15 and an Oxygen Saturation (O2) at 88%. b. 10.12. 24 at 1:11 a.m. - A full assessment completed with no complaints of having felt poorly. c. 10.12.24 at 2:01 p.m. - T 98.0 and O2 saturation of 88-90% at various times however the facility staff failed to complete a thorough assessment. d. 10.12.24 at 8:57 p.m. - T 97.8 with no further assessment completed. e. 10.13.24 at 8:17 a.m. - Called to resident's room by a certified nursing assistant (CNA). Resident appeared to lethargic and not her mental status baseline. Resident unable to answer questions other than grunts. Resident lips cyanotic. Vitals obtained. Inability to raise her O2 saturation level above 84% post interventions. Bilateral lung sounds with crackles in all lobes. Sent to the local emergency room (ER). A State of Iowa Certificate of Death indicated the resident passed away 10.16.24 at 7:54 p.m. from Acute on Chronic Hypoxemic and Hypercapnic Respirator Failure due to (D/T) or as a consequence of Viral Pneumonia. During an interview 10.22.24 at 2:33 p.m., the resident's NP (Nurse Practitioner) confirmed she would have expected the facility staff to have completed a more thorough assessment and intervention for the resident until stable per standard of practice of 48-72 hours however the outcome probably would not have been different d/t the resident's co-morbidities. During an interview 10.22.24 at 1:06 p.m. Staff A, Licensed Practical Nurse (LPN) indicated per nursing judgment staff should have assessed a full set of vitals, lung sounds and any issue that affected the resident's symptoms. During an interview 10.22.24 at 1:24 p.m., Staff B, Registered Nurse (RN) indicated she had not been sure a B/P would have made a difference however hindsight is 20/20 and she should have assessed the resident's B/P. During an interview 10.22.24 at 3:30 p.m., Staff C, RN confirmed she would have assessed the resident from head to toe, which included the resident's lung sounds and edema per nursing judgement.

Based on observations, clinical record review, Nurse Practitioner/Providers interviews, resident and staff interviews and facility policy review, the facility staff failed to follow their own policy and procedures as a means to prevent and or minimize pressure ulcers from developing on residents with history of pressure ulcers for one of three residents reviewed (Resident #3). The facility reported a census of 28 residents. Findings include: The facilities Pressure Ulcer Prevention Program policy (not dated) directed the facility staff the facility should of had a system in place that assured assessments were completed timely and appropriate; interventions implemented, monitored and revises as appropriate; and changes in condition recognized, evaluated, reported to the resident's attending practitioner and other healthcare professionals, ie.wound nurse and etc as appropriate. The Procedure included the following; a. Assess, reassess and document the ulcer's characteristics weekly. 1. Date. 2. Location of ulcer and staging. 3. Size. 4. Depth 5. Presence, location and extent of undermining or tunneling/sinus tract. 6. Exudate (drainage) a. Type: purulent/serous b. Color. c. Odor d. Amount e. Pain f. Wound bed. 1. Color and type of tissue/character, including evidence of healing (granulation tissue) or necrosis (slough or eschar). g. Description of wound edges and surrounding tissue: 1. Rolled edges. 2. Redness. 3. Hardness/induration (thickening or hardening of the skin). 4. Maceration (excessive moisture or fluid accumulation in the skin, leading to softening, swelling and skin integrity breakdown). 5. Description of the healing of the pressure ulcer. b. Observation for infection. 1. Purulent exudate (drainage). 2. Peri-wound warmth. 3. Swelling. 4. Induration. 5. Erythema (redness of the skin). 6. Increasing pain or tenderness around the site. 7. Delayed wound healing. A Minimum Data Set (MDS) assessment form dated 10.10.24 indicated Resident #3 had diagnoses that included Radiculopathy of the Lumbar region, Cardiomyopathy, urine retention, Heart Failure (HF), Renal Insufficiency, and Diabetes Mellitus (DM). The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 (cognitively intact), required substantial to maximum assistance with most activities of daily living (ADL's), as frequently incontinent of urine, at risk for pressure ulcers, with one (1) stage II pressure ulcer on admission and not on a turning and repositioning program. The resident's Initial Care Plan located in Point Click Care (PCC) initiated 10.8.24 failed to address her skin breakdown/pressure ulcers but directed the facility staff to have assisted the resident with morning and evening cares. The resident's Initial Care Plan reported to have been located in the resident's paper chart by the Administrator and initiated 10.4.24 indicated the resident as admitted to the facility on 10.4.24 with a stage II pressure area to her left buttock with a current order for a specified dressing and discontinued 10.17.24 due to the completion of the Comprehensive Care Plan. The Initial Care Plan failed to address a turning or repositioning program but rather indicated the resident as independent. A Function Abilities form dated 10.10.24 at 2:23 p.m. indicated the resident required substantial to maximum assistance of staff with toileting hygiene, personal hygiene, transfers and ambulation. A Wound/Skin Healing Record form indicated the resident had a pressure ulcer on her left buttock with the onset dated 10.4.24. The assessments included the following: a. 10.4.24 (no time documented) - A stage II pressure ulcer that measured 0.7 centimeters (cm) by (x) 0.3 cm and less than 0.1 cm deep with purple and non-blanchable surrounding skin that measured 1.5 cm x 1.5 cm. The staff failed to assess the resident's ulcered area's exudate, odor, exudate amount, wound bed, surrounding skin color and surrounding tissue/wound edges. During an interview 10.18.24 at 12:29 p.m. Staff A, Registered Nurse (RN) confirmed she should have completed a more thorough assessment of the resident's decubitus ulcer on 10.4.24 and that she should have reported to the resident's Primary Physician the increase in size and slight odor of the decubitus following her 10.10.24 assessment. The staff member indicated when the resident arrived with the decubitus ulcer and purple surrounding skin she felt like the area had been waiting to open up. During an interview 10.18.24 at 12:16 p.m. the primary Physician indicated she felt there had been something the facility could have done to minimize the fast progression of the ulcered area and that there should have been better communication with her as the primary Physician. The Physician reiterated the ulcered area worsened faster than it should have at the time. The Physician indicated the resident passed away at 11:36 a.m. that morning from concerns with sepsis from the ulcered area and worsening renal failure.

Based on facility record review, employee file review, staff interview, and policy review the facility failed to ensure 1 of 5 staff members (Staff A) completed the two hour Dependent Adult Abuse training within 6 months of their hire date. The facility further failed to complete the Single Contact Repository (SING) background checks prior to hire on 2 of 5 staff members (Staff B & Staff C). The facility reported a census of 29 residents. Findings include: 1. Review of an employee hire list provided by the facility during the survey week, revealed Staff A, certified nursing assistant (CNA), had a documented hire date of 8/2/22. The employee file lacked documentation of Iowa Department of Public Health (IDPH) approved Dependent Adult Abuse Mandatory Reporter training completed. In an interview 8/29/23 at 8:40 AM, the Administrator reported no record of dependent adult abuse mandatory reporter training was found for Staff A. 2. Staff B's, CNA, employee file contained a SING criminal background and abuse registry checks completed on 8/28/23. The employee filed had a documented hire date of 1/30/23. Staff B's timecard dated 8/1/23 - 8/29/23 revealed Staff B worked at the facility on the following dates: 8/1, 8/7, 8/8, 8/9, 8/10, 8/11, 8/14, 8/15, 8/16, 8/17, 8/20, 8/22, 8/23, 8/24, 8/25, 8/26, 8/29. In an interview on 8/29/23 at 8:40 AM, the Administrator verified Staff B's criminal history background check and abuse registry checks completed on 8/28/23, and that no prior background check completed prior to Staff B's hire date. The Administrator reported she expected background checks completed before an employee hired. The Administrator reported they had identified employee background checks not completed on some employees as they were going through employee files a couple of months ago. The Administrator reported they started a QAPI (Quality Assurance Performance Improvement) to ensure background checks were completed prior to an employee hired. 3. Staff C's, CNA, employee file contained a SING criminal background and abuse registry check completed 8/28/23. The employee filed had a documented hire date of 1/17/23. Staff C's timecard dated 8/1/23 - 8/29/23 revealed Staff C worked at the facility on 8/2/23 and 8/4/23. In an interview on 8/29/23 at 8:40 AM, the Administrator verified Staff C's criminal history background check and abuse registry checks completed on 8/28/23, and no prior background check completed prior to Staff C's hire date. The facility's Abuse Prevention, Identification, Investigation, and Reporting Policy updated 7/2019, revealed the facility screened all potential employees for abuse, and conducted an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to residents, prior to hire. The policy also revealed each employee required to complete an initial 2-hour training course provided by the Iowa Department of Human Services related to the identification and reporting of dependent adult abuse. The mandatory reported training needed completed within six months of hire, and every three years thereafter.

Based on observations, record review, and staff interview the facility failed to provide the correct serving amount as planned on the menu. The facility census was 37 residents. Findings include: During observation of the noon meal preparation on 6/14/22 at 11:00 a.m. the Dietary Supervisor placed 4 servings of the roast beef in the Robot Coupe to puree for the 3 residents with orders for a pureed diet, the Dietary Supervisor then added 3 slices of bread and about 1/2 cup of beef gravy to achieve the proper consistency for residents on a pureed diet, she then placed the mixture into a steam table pan, covered, and put in the oven without measuring the final product volume. During observation on 6/14/22 at 12:03 p.m. the noon meal service started for the main dining room, the surveyor observed blue handled scoops being used to serve the pureed roast beef and the blended vegetables, the Dietary Supervisor was asked about the color coded chart above the steam table that showed blue handled scoops hold a volume of 2 oz. or 1/4 cup, and she verified that was correct, meal service completed at 12:19 p.m. using those same blue handled scoops for the pureed roast beef and the blended vegetables. During an interview 6/14/22 at 12:28 p.m. the surveyor pointed out to the Dietary Manager that after serving 3 residents the pureed roast beef that about half of the original amount remained in the pan and asked her why that might be, the Dietary Manager replied she had not measured the finished product volume and the serving sizes should have been larger and there should not have been that much left over when the serving was complete. The surveyor also pointed out according to the menu the serving size for the blended vegetables was to be 1/3 cup but a blue handled 1/4 cup scoop had been used, the Dietary Supervisor responded she had overlooked the serving size and used the wrong scoop.

Based on clinical record review, document review, and staff interview, the facility failed to attempt and document non-pharmacological and behavioral interventions prior to the administration of as needed anxiolytic medication for 1 of 5 resident (Resident #10) reviewed for [CONDITION(S)] medications. The facility identified a census of 37 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #10 with short/long-term memory impairment as well as the presence of verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others), disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject), rejection of care and wandering 1-3 days per week. The MDS listed a diagnosis of non-specified dementia without behavioral disturbance, Non-Alzheimer's Dementia and identified the resident utilized antipsychotic, anti-depressant and anti-anxiety medication 7 of 7 days of the assessment reference period. An Order Summary Report signed by the Provider on 5/16/22 documented an order for AlprazolamTablet 0.5 Milligrams (mg). Give 1 tablet by mouth every 8 hours as needed for anxiety. Start Date 1/19/2022 The Care Plan dated 5/12/21 identified the Resident needed 24 hour care related to the diagnosis of dementia and cognitive impairment, experienced wandering, and had occasional verbal behavioral symptoms directed toward others. The Care Plan identified the following interventions: 1. Assess whether the behavior endangers the resident and/or others. Intervene if necessary. 2. Avoid overstimulation (e.g. noise, crowding, other physically aggressive residents). 3. Avoid power struggles with the resident. 4. Convey an attitude of acceptance toward the resident. 5. Explore with the resident, previous effective and ineffective coping mechanisms. Effective interventions include talking with resident and husband, if safe to do so leave resident and reproach a short time later. 6. Maintain a calm environment and approach to the resident. 7. Praise resident when behavior is appropriate. 8. Refocus conversation when resident becomes verbally abusive. Resident likes to talk about her family (include her husband in conversation). 9. If resident resists with activities of daily living, reassure resident, leave and return 5-10 minutes later and try again. 10. The resident's triggers for resisting care are being anxious, moving too quickly to perform task. The residents behavior is de-escalated by sitting with resident and explaining what task will be performed step by step, re- approach 10-15 minutes later, re-approach with different care giver if needed. 11. Approach from the front. Walk in step with resident first before redirecting. 12. Redirect resident from exit doors as needed. 13. Remove resident from other resident's rooms and unsafe situations. 14. When the resident begins to wander, encourage her to sit and hold a baby doll, offer to turn on the movie The Sound of Music for her, ask her about her husband and children. The April 2022 Medication Administration Record (MAR) revealed the resident received the as needed [MEDICATION(S)] medication on 4/24/22 at 7:38 p.m. and 4/29/22 at 9:55 a.m. A review of the MAR and the Nursing Progress Notes for April 2022 lacked documentation of resident trigger behaviors or interventions implemented prior to the administration of the antianxiety medication. The May 2022 MAR revealed the Resident received the as needed [MEDICATION(S)] medication on 5/1/22 at 7:35 p.m. A review of the MAR and the Nursing Progress Notes for May 2022 lacked documentation of trigger behaviors or interventions implemented prior to administration of the antianxiety medication. A review of the Progress Notes from 4/1/22 - 5/31/22 revealed no documentation of Resident #10 had any trigger behaviors or interventions documented for 4/24/22, 4/29/22 or 5/1/22. During an interview on 6/15/22 at 9:10 a.m. the Director of Nursing stated the order for the [MEDICATION(S)] did not get entered into the computer correctly. The computer order is to have an area where interventions must be entered for the administration of the as needed anti-anxiety medication. She stated there is a sheet of interventions hanging in the medication room that staff are to try and document. She reported her expectation is nursing interventions will be tried prior to giving the antianxiety medication. On 6/15/22 at 9:18 a.m. the DON reported the facility does not have a [CONDITION(S)] medication policy. The PRN (as needed) [CONDITION(S)] Intervention Sheet, undated, provided by the facility documented every PRN medication requires a Progress Note and electronic Medication Administration Record (eMAR) will open to the Progress Note tab when medication is being signed out. The note auto populates with the medication details, but there must be documentation why the medication is being administered. The [CONDITION(S)] Intervention Sheet listed the following interventions to try prior to giving a PRN [CONDITION(S)] medication: 1. Assess pain 2. Offer toileting 3. Offer food/drink 4. Reposition/offer rest/ambulation. 5. Massage/warm washcloth 6. Music/Television/Reading 7. One to One (time) 8. Remove to a quiet area 9. Family call/pictures 10. Favorite blanket/stuffed animal/doll or personal item 11. Monitor vital signs, assess if disease related 12. Alcoholic beverage if permitted 13. Physician notification and ideas 14. Other (specify) The PRN [CONDITION(S)] Intervention sheet further showed field for interventions to be entered into the electronic health record with the medication administration.

Based on record review and staff interview the facility failed to meet the requirements for QAPI committee meeting frequency and member attendance since January 2022. The facility census was 37 residents. Findings include: Review of the QAPI meeting attendance sign-in sheets for the past year provided by the facility 6/15/22 revealed an attendance sign-in sheet for every month except March, April, May, & June 2022, and review of the attendance sign-in sheet for February 2022 had only 4 signatures none of which were the Administrator or a Medical Director. The CMS (Centers for Medicare and Medicaid) regulations a QAPI meeting must have at least 5 members in attendance and 1 must be the facility Administrator or a Board Member. During an interview on 6/15/22 at 9:00 a.m. the facility Nurse Consultant stated there were no attendance sign-in sheets for March, April, & May of 2022 because no QAPI meeting had occurred for those past 3 months but said they are aware and are working on a PIP (Performance Improvement Plan) to ensure a QAPI meeting is held at least monthly from now on and the Nurse Consultant acknowledged the February QAPI meeting did not meet the member attendance requirement set by CMS.

Based on observation, record review and staff interview the facility failed to complete nursing assessments and monitoring of residents after they returned from outpatient [CONDITION(S)] for 1 of 1 resident that received [CONDITION(S)] services. (Resident # 1). The facility reported a census of 32 residents. Findings include: The Resident's Minimum Data Set (MDS) dated [DATE] documented diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented a Brief Interview for Mental Status (BIMS) of 15, indicating the resident is cognitively intact. The face sheet for Resident # 1 documented an admitted [DATE]. Review of the physician signed Order Summary Report, physician ordered [CONDITION(S)] on Monday, Wednesday and Friday for the resident on 9/22/20. Review of resident's Hemodialysis Communication record revealed no documentation of a post [CONDITION(S)] assessment when the resident had attended [CONDITION(S)] on the following days reviewed: March 29 and 31, 2021; April 5, 7, 12, 14, 16, 23, 26, and 28, 2021; May 3, 5, 10, 12, 24, 26, and 31, 2021; June 2, 7, 9 11, 13, 14, 16, 21, and 23, 2021 During an interview on 6/29/21 at 10:16 AM, Resident #1 stated she goes to [CONDITION(S)] on Monday, Wednesday, and Friday. She stated the nurse does a pre [CONDITION(S)] assessment but not a post [CONDITION(S)] assessment. During an interview on 6/30/21 at 3:07 PM, the Director of Nursing (DON) stated she would expect vital signs (assessment) to be done before the resident goes to [CONDITION(S)]. She stated vital signs should be checked after [CONDITION(S)] but that is done at the [CONDITION(S)] center. She stated the vital signs taken at the [CONDITION(S)] center count as post [CONDITION(S)] assessment. -

Based on observation, clinical record review, and staff interview, the facility failed to develop and implement a behavior related care plan for 1 of 3 residents reviewed (Resident #20). The facility reported a census of 32. Findings include: The Minimum Data Set (MDS) with a date of 5/25/21 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section E of the MDS documented physical behavioral symptoms directed toward others 1-3 days of the 7 day lookback period. Review of the face sheet for Resident #20 showed it documented an admitted [DATE]. Review of Progress Notes dated 5/16/21 at 12:57 PM documented resident became aggressive with a staff member that was trying to assist her. Resident #20 was pulling on the gait belt, grabbing, pinching, and digging her nails into the staff member's arm. The resident grabbed the glasses and pulled off the staff member's face. Review of Progress Note dated 5/22/21 at 3:44 PM documented Resident #20 had been nonstop restless. She had crashed her wheelchair into people as well as other wheelchairs and tried to open the front door. Multiple interventions attempted. When staff tried to redirect resident, she would shout and try to hit. Review of Progress Note dated 6/28/21 at 2:55 PM documented Resident #20 hit another resident with a closed fist. Surveyors in the area alerted staff in the area and residents were separated. Review of the care plan for Resident #20 showed no care plan addressing the resident's behaviors. During an interview on 6/30/21 at 9:16 AM, the MDS Coordinator confirmed the MDS dated [DATE] had behaviors coded for the resident. She stated all care plans are in the computer and the care plans get updated quarterly and as needed. She acknowledged there was no care plan to address the resident's behaviors. During an interview on 6/30/21 at 9:21 AM, the Director of Nursing stated the resident did not have any behaviors. During an interview on 6/30/21 at 9:24 AM, Staff A stated Resident #20 could be short tempered with attitude and would swat at staff. She stated sometimes the behavior is directed towards other resident's. She stated when that happened; she would separate the resident from situation and notify the nurse. During an interview on 6/30/21 at 9:44 AM, the Nurse Consultant acknowledged that no care plan in place for the resident's behaviors. She stated she would expect a behaviors care plan to be in place. -

Based on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to ensure each resident had the right to make choices about aspects of life that were significant to them for one of 20 residents reviewed. (Resident 25) The facility census was 28 residents. Findings include: 1. The Face Sheet undated documented Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition and was on a mechanically altered diet (a diet that consists of foods that are moist and soft-textured). A Physician order [REDACTED]. Observation on 8/26/19 at 12:10 p.m., revealed the resident was sitting at the dining room independently eating lunch. The resident received ground hamburger, soft vegetables and a small side salad. When asked how his lunch was the resident stated it was not a fried burger and he did not like or want it ground up. The resident stated he had told the aides he did not want it ground up. During interview on 8/27/19 at 12:56 p.m., the resident revealed his only concern was not being able to choose how he gets his food. The resident stated yesterday his hamburger came ground up and that was not a goddamn hamburger and stated today he had a chopped-up hotdog and that was not a hotdog. The resident stated looking around and seeing others getting a real hamburger or a real hotdog upset him, because he wants normal food like the other residents. The resident revealed he was the person who was responsible for making his healthcare decisions, with his wife being involved as well. The resident stated he had asked aides and nurses if he could have a whole hotdog or whole hamburger that was not ground up, but they would not give it to him because a doctor had ordered the diet. The resident stated he had not mentioned it to his doctor because he did not think it would do any good. During interview on 8/27/19 at 1:46 p.m., Staff 3, Certified Nurse Aide, CNA revealed the resident was on a ground meat diet; however, she stated the resident gets upset about his meat being ground up, especially his hotdog's. Staff 3 stated the resident was not allowed to have a whole hotdog possibly for swallowing issue and she tells the resident he could not have a whole hotdog because he may choke. Staff 3 stated she has told nurses the resident wanted whole meats, but she has always been told the resident could not have his meat whole. During interview on 8/27/19 at 1:52 p.m., Staff 4, CNA revealed the resident always asked for whole hotdog's or whole meats; however, she did not think he could have whole meats because he would choke. Staff 4 stated she had reported the resident's request to the nurse, but she could not remember exactly who she had reported it to. During interview on 8/27/19 at 1:55 p.m., Staff 5, Licensed Practical Nurse,LPN stated she had not known of the resident requesting whole meats; however, if the resident was to request whole meats, she could not give it to him because of swallowing and aspiration concerns. During interview on 8/27/19 at 2:00 p.m., the Director of Nursing (DON) revealed the resident was on a mechanical soft diet with ground meats and the resident did question his diet sometimes, but if it was explained to him why he is on that diet, he is usually ok with it. The DON stated if he was not ok with it, they offer him a substitute, but sometimes he will not want the substitute and eat everything on his plate but the ground meat. The DON also stated the resident was the decision maker of his care, but his wife was very involved. The DON further stated the staff should never give him a whole hotdog or a whole hamburger. During interview on 8/27/19 at 2:11 p.m., the Assistant Administrator revealed it was her expectation the facility would have honored the resident's rights. During interview on 8/28/19 at 12:45 p.m., the DON revealed it was her expectation would have reported any concerns the resident had about his diet to her, specifically the resident requesting whole hamburgers or whole hotdog's, so she could have addressed it. During interview on 8/28/19 at 1:25 p.m., the Medical Director revealed it was his expectation the CNA's would have reported the resident wanting whole foods to the nurses so he would have been made aware of that preference. The Medical Director stated the resident had the right to refuse his ordered diet. Review of the facility's policy titled, Residents' Bill of Rights, revised 01/2018, revealed the resident had a right to a dignified existence and self-determination. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life. The policy revealed the facility must protect and promote the rights of the resident, including their rights to make choices about aspects of his or her life in the facility that were significant to the resident.

Based on observation and staff interview, the facility failed to store, and prepare food in a sanitary manner to prevent the possible spread of food borne illness. The facility census was 24 residents. Findings include: 1. Observation on 6/20/18 at 11:11 a.m., revealed Staff C, Cook took a loaf of bread off the shelf and placed it on the counter top. Staff C without sanitizing their hands removed three slices of bread from the bread wrapper, tore them apart and placed them directly into the blender At 12:04 p.m., Staff C cleaned a soiled thermometer and without sanitizing touched the chicken on the steam table with their bare hands. Observation on 6/20/18, during the noon meal service revealed five residents received the chicken. During an interview on 6/20/18 at 12:43 p.m. Staff C reported she knew she should not have touched the bread with her bare hands during the pureed process. During interview on 6/20/18 at 12:45 p.m., the Dietary Manager reported she would have expected Staff C to use tongs or gloves to handle the bread, and not her bare hands. 2. During initial tour of the kitchen on 6/18/18 at 9:50 a.m., with the Certified Dietary Manager (CDM) the following food storage concerns were identified in the dry storage room: a. An opened, undated instant whipped topping powder mix-resealed. b. An opened, undated packet instant lemon pudding powder-resealed. c. An open, dated but not resealed box of Malt O Meal and a box of Cream of Farina hot cereal. d. An opened, dated, but not resealed box of brownie mix, a box of white cake mix, and a box of pancake mix. e. Five open, undated packages of Jell-O powder-resealed. Items of concern found in the Turbo Air upright freezer included a bag of open, undated frozen raspberries-not resealed, a bag of open, undated sausage-not resealed, a cardboard tray of open, undated pastries-not resealed, a bag of open, undated dinner rolls-resealed and a bag of open, undated Tater Tots-not resealed. During interview on 6/20/18 at 2:22 p.m., the Dietary Manager reported they do not have a policy for food handling and storage they follow the 2013 Food Code. The Dietary Manager reported the food items in storage should be dated and sealed when opened.

Based on clinical record review and staff interview, the facility failed to ensure an as needed (PRN) order for an anti-anxiety medication was limited to 14 days or reviewed with rationale to continue and failed to ensure staff attempted non-pharmacological interventions prior to administration of the medication for one of five residents reviewed for unnecessary medications. (Resident #17) Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #17 had [DIAGNOSES REDACTED]. The care plan revised 5/11/18, included a problem of [MEDICAL CONDITION] medications: [REDACTED]. The problem included an intervention to review continued need for medication with prescriber an attempt dose reduction as warranted. Clinical record review revealed a physician order [REDACTED]. Clinical record revealed no physician review, rational or duration of continuation of the order after the order had been in place 14 days. The Medication Administration Record [REDACTED]. On seven of the occasions there were no documented attempts of non-pharmacological interventions. The MAR for the month of (MONTH) (YEAR), revealed the resident had received the medication one time, with no attempt of non-pharmacological intervention. On 6/20/18 at 2:40 p.m., Staff B, Nurse Consultant stated they had been unable to find any physician review or rationale for continuation for the order after 14 days in the chart, but a nurse had reviewed it. The nurse consultant stated the facility had been working to improve staff compliance with attempting non-pharmacological interventions before administering as needed [MEDICAL CONDITION]'s.

Based on clinical record review, facility policy review and staff interview, the facility failed to ensure the clinical record accurately reflected a resident choice for advanced directives for one of sixteen residents reviewed. (Resident #11) The facility census was 24 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #11 had [DIAGNOSES REDACTED]. Clinical record review revealed a Policy for Resuscitative Services/Cardiopulmonary Resuscitation (CPR) signed by the resident on [DATE], which indicated the resident wanted cardiopulmonary resuscitation (CPR) for the treatment of [REDACTED]. A progress note dated [DATE] at 12:59 p.m., documented the nurse spoke with the resident regarding their code status and the resident chose to change code their status to Do Not Resuscitate. On [DATE] at 11:30 a.m., the surveyor asked Staff A, Licensed Practical Nurse where to find the advanced directives for the resident. At that time Staff A opened the residents hard chart that revealed the form signed [DATE], indicating the resident wanted CPR. On [DATE] at 11:50 a.m., the Administrator stated the expectation would be for code status to be changed in the record right away if a resident decided they did not want CPR. At 12:19 p.m., Staff B, Nurse Consultant stated staff would follow resident wishes as documented in the chart, unless the resident made recent changes and then the floor nurse would use an updated list on the medication cart. At 12:20 p.m., Staff A stated if they found Resident #11 with no vital signs they would follow the form in the clinical record until an updated signed form received from the physician got placed in the chart. Staff A stated they did not have a list on the medication cart they followed. A facility policy for Cardiopulmonary Resuscitation dated [DATE], stated each residents resuscitation status will be maintained in the clinical record as follows: A signed CPR policy indicating the residents choice of CPR or don not perform CPR will be placed directly under the front cover of the residents chart.

Based on observation (via video recording clips), clinical record and staff interview, the facility failed to ensure one (1) of seven (7) resident received assessment and interventions after a fall. The facility staff documented they completed comprehensive assessments and administered Resident #2's medications when in fact the video recording of events occurring in the resident's room after he/she sustained a fall on 3-10-17 to 3-13-17 at 2:32 p.m., showed care and treatment were inadequate and not been provided. The video clips from 3-11-2017 to 3-12-2017 revealed no nurses entered Resident #2's room for approximately 17 and 1/2 hours, however they documented completion of comprehensive assessments and medication administration. The findings resulted in an Immediate Jeopardy to resident's health and safety. The facility reported a census of 36 residents. Findings include: According to documentation in the clinical record, Resident #2 had [DIAGNOSES REDACTED]. The facility Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 scored 7 (of 15) points on the Brief Interview for Mental Status (BIMS) indicating severe cognitive decline. A BIMS assessment completed 04-20-2017 indicated a score of 2 (of 15) points, also indicative of severe cognitive decline. Both MDS assessments (with above dates) described Resident #2 as requiring extensive staff assistance with bed mobility, transferring and ambulation, dressing, hygiene and bathing and toilet use. Resident #2 required staff supervision for eating. The assessment indicated Resident #2 was frequently incontinent of bowel and bladder. The facility developed, individual plan of care for Resident #2 indicated the following focus areas and related interventions/tasks. * Resident at risk for falling related to unsteady gait and directed staff to: * transfer with assist of one, walker and gait belt * bed and chair alarms * bed in lowest position * scoop mattress to bed * sand strips on floor at side of bed * Ongoing evaluation of the effectiveness of current [MEDICAL CONDITION] medications and directed staff to: * Nurse will administer medications as ordered. * Nurse to notify MD of refusal of ordered medications During an interview on 06-19-2017 at 11:11 a.m. the facility Director of Nursing Services (DON) indicated the facility did not have a specific policy on neuro (neurological) checks. The Director of Nursing did provide a form dated 01-29-2014 titled Neuro check protocol. The form indicated the following: 15 min (minutes) X 4 30 min X 4 1 hour X 4 every hour X 2 every 4 hour X 2 every 8 hour X 72 * Neros (sic) must be checked with any head bump and unwitnessed falls on residents who are coded with short, or long term memory problems or have confusion. (hand written notation < 13 BIMS score). A Review of the facility Neurological Assessment Flow Sheet provided instructions for assessment to include the following areas: level of consciousness, pupil response, monitor functions-hand grasp, extremities, pain response and complete vitas (blood pressure, temperature and pulse. According to video recordings of events occurring in Resident #2's room starting on 3-10-17 at 5:48 p.m. and ending on 3-13-17 at 2:32 p.m. showed the lack of care and treatment as demonstrated by the examples listed below. The record video recording during the dates and times listed below showed approximately 59 seconds of activity in the room. The operating directions for the Nanny Camera indicated once supplied with power, the camera would automatically start motion detection recording. In motion recording mode, the camera will record video when the motion is detected. All videos are in one minute clips.) The time recordings of the video clips are approximately 2-3 minutes from real time and the weekend in question was the switch to daylights savings time. The video camera is program to adapt to daylight savings time change, however an individual also adjusted the time giving an hour off in some video clips. (Those specifics times and clips were shared with the Department). Each video recording is numbered, and includes the date & time in military time (for example 1400 means 2 p.m.). Review of video clip # 0122 dated 03-10-2017 at 1748 Resident #2 stands up from his/her chair and falls. At 1749 staff arrive to Resident #2's room. Video clips # 0123 at 1749:42 through clip # 0134 at 1804:49 show Staff G and Staff H attending to Resident #2. Not all actions of the staff are visible, however it is noted staff assist provide a pillow for Resident #2 while on the floor, and assist Resident #2 to a sitting position. Video clip # 0127 shows Staff G and Staff H assisting Resident #2 to stand, and a blood pressure reading to obtained while Resident #2 stands with assistance. Video clip # 0134 at 1804:49 shows Staff G leaving Resident #2's room with the blood pressure cuff. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 1745 and at 1800. Staff G documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clips # 0142 through # 0144 (1813:43 through 1815:52) shows Staff G in the room with Resident #2, with a blood pressure cuff and a white instrument ( i.e. tympanic thermometer). Nurse G remained in Resident #2's room approximately two minutes and nine seconds. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 1815. Staff G documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clips # 0151(1829:16 ) reveal an unidentified nursing assistant leaving Resident #2's room and Resident #2 attempting to eat and drink from the tray in front of him/her. The next video clip #0152 at 1848:16 shows a nursing assistant leaving Resident #2's room. The 19 minutes between the two video clips indicate no motion was detected by the camera. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 1830. Staff G documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clips # 0158 at 1907:11 shows Staff G enter Resident #2's room, and checks Resident #2's blood pressure and temperature. Video clip # 0159 at 1909:34 shows Staff G leaving Resident #2's room. Nurse G remained in Resident #2' room approximately two minutes and 23 seconds. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 1900. Staff G documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clip # 0162 shows Staff G (and an unidentified individual) enter Resident #2's room at 1931:32. Staff G has a blue object and a towel in her hand and then leaves the room. Video clip #0164 shows Staff G lowering the head of Resident #2's bed, placing a pillow on Resident #2's left side and leaving the room at approximately 1932:33. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 1930. Staff G documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clip # 0164 shows visitors in Resident #2's room at 1939:50. Review of video clip # 0165 shows Staff G enter Resident #2's room at approximately 1941:40 with a glass with a straw in it. Video clip # 0166 shows Staff G (and a visitor) examining Resident #2. Staff G appears to have a washcloth. In video clip # 0168 at 1944:47 an unidentified visitor to seen assisting Resident #2 in eating from the cup that Staff G brought in. From video clip # 0169 (at 1945:47) through video clip # 0177 (at 1955:22) Staff G is in Resident #2's room, talking with the visitor(s). Staff G leaves Resident #2' s room at that time. Video clip # 0178 at 1956:22 shows Staff G at the door to Resident #2's room, talking to the visitor and then leaving the doorway. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 2000. Staff G documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clip # 0188 (at 2029:48) shows Staff G in Resident #2's room talking with visitors. Video clip # 0190 (2032:30) shows Staff G talking to Resident #2's visitor. Video clip # 0191 (2033:32) and # 0192 (2034:38) shows Staff G in Resident #2's room with a blood pressure cuff in her hand. Video clip # 0193 (2036:03) shows Staff G leaving Resident #2's room. Staff G remained in Resident #2's room approximately seven minutes. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 1745 and at 2030. Staff G documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clip # 0016 (2132) revealed only Resident #2 in bed, in his/her room. The next video clip (# 0017) at 2141 also revealed only Resident #2 in the room. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 2130. Staff G documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clip # 0019 indicated Staff G walked into Resident #2's room at 2237:14. Staff G stood at the bedside and appeared to be looking at Resident #2. Staff G did not have any equipment with her, nor did she appear to use any equipment (i.e. blood pressure cuff or thermometer). Staff G exited the room (empty handed) at 2237:41. Staff G remained in Resident #2's room approximately 27 seconds. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 2230. Staff G documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clip # 0021 revealed Staff C to walk in and out of Resident #2's room. Video clip # 0022 at 2248 revealed Resident #2 in bed, with no staff entering, leaving or in Resident #2's room. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 2230. Staff G documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clip # 0023 at 0036 (on 03-11-2017) revealed Staff C to enter Resident #2's room and take out the water pitcher. Video clip # 0023 (0042) reveals Resident #2 in bed, with staff observed in the hallway. Video clip # 0025 (0043) reveals Staff C to bring a water pitcher back into Resident #2's room. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-11-2017 at 0030. Staff G documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clip # 0027 (at 0250) reveal Staff C and Staff I (certified nursing assistants) in Resident #2's room. Staff C and Staff I are again recorded in Resident #2's room at 0259. The video clip # 0028 at 0250 captures unidentified staff in the hallway walking past Resident #2's room. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-11-2017 at 0230. Staff G documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clip # 0031 reveals Staff G to enter Resident #2's room at 0410:54. Staff G appears to be checking Resident #2's blood pressure. Staff G leaves Resident #2's room at approximately 0412:51. (Staff G remained in Resident #2's room approximately one minute and 57 seconds.) Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-11-2017 at 0430. Staff G documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clip # 0055 (at 0830) reveals an unidentified nursing assistant enter and exit Resident #'2 room. The staff member does not have any contact with Resident #2. Review of the facility neurological assessment flow sheet indicated Staff F documented a neuro assessment on 03-11-2017 at 0830. Staff F documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clip # 0096 at 1223 revealed an unidentified individual to look into Resident #2's room. Resident #2 remains in bed. Video clip # 0097 at 1235 reveals Resident #2 in bed with no staff in the room. Video clip # 0098 at 1239 reveals Resident #2 in bed with no staff activity in the room. Review of the facility neurological assessment flow sheet indicated Staff F documented a neuro assessment on 03-11-2017 at 1230. Staff F documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clip # 103 reveals Staff F in walk into Resident #2's room at 1411:02 and looks at Resident #2, and touches his/her face. Staff F exits Resident #2's room at 1411: 14. Staff F remained in Resident #2's room for 12 seconds. Documentation in the nurse's notes dated 03-11-2017 at 14:04 are as follows: Resident resting quietly in bed with eyes closed through much of the day. Awakens easily to verbal and light tactile stimuli. Alert and responds to questions clearly and appropriately. PERRLA (pupils equal, round reactive to light and accommodation) Follows basic cues without difficulty. Bilateral hand grasp strong and equal. PAROM (passive, active range of motion) WNL (within normal limits) and without s/sx (signs/symptoms) pain or discomfort. Skin tear above L (left) eye scabbed over and without active bleeding noted. Some red bruising to surrounding area. T (temperature) 97.1 tympanic, BP (blood pressure) 123/60, P (pulse) 61, R (respirations) 18, O2 sat (oxygen saturation) 97% on RA (room air). Refuses to transfer from bed this shift. Staff assist with frequent repositioning and toileting needs. Pericare provided as needed. Refuses all scheduled medication with no s/sx adverse effects. Currently resting quietly in bed with eyes closed. Will continue to monitor. Review of video clips from # 104 (dated 1433 on 03-11-2017) through # 157 (dated 0758 on 03-12-2017) reveal no nurses entered Resident #2's room during those approximately 17 1/2 hours. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-11-2017 at 2030 and 03-12-2017 at 0430. Staff G documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clip # 0157 reveals Staff F to walk into Resident #2's room at 0758:09, (03-12-2017) look at Resident #2 and turn around and leave the room at 0758:12. Staff F remained in Resident #2's room approximately three seconds. A nurse does not enter Resident #2's room until video clip # 170. At 1014:47 Staff F enters Resident #2's room with a over the bed table with items included a blood pressure cuff, thermometer and pulse oximeter. Staff G [MEDICATION NAME] Resident #2 and appears to document her findings. Staff F exits Resident #2's room at 1016:32. Staff G remained in Resident #2's room approximately one minute and 45 seconds. Review of video clips # 0172 through # 0218 revealed another nurse did not enter Resident #2's room until 03-12-2017 at 1822: 33 when Staff G views Resident #2 from the doorway and then turns around and leaves. Documentation in the nurse's notes dated 03-12-2017 at 14:59 are as follows: Resident continues to rest in bed with eyes closed through shift today. Awakens easily and briefly to verbal and light tactile stimuli. Speech clear and appropriate. A & O (alert and oriented) per baseline. No change in mood, cognition or LOC (level of consciousness). PERRLA. Bilateral hand grasps equal. PROM and AROM baseline without s/sx pain or discomfort. Resident accepts all scheduled medication without difficulty. No s/sx pain or discomfort. Staff assist with frequent repositioning and toileting needs. Peri care provided as needed. Review of the facility neurological assessment flow sheet indicated Staff F documented a neuro assessment on 03-12-2017 at 1230. Review of video clips # 0219 (at 1829 on 03-12-2017) through #0238 (at 0525:11/actual time of 0725:11) reveal no nurse entered Resident #2's room. Video clip # 0236 shows Staff H stand at Resident #2's door for four seconds (actual time 0725:11 to 0725:15). Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-13-2017 at 0430. Staff G documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). (Review of the video clips indicated that neuro check documentation did not, 1. match the time the staff indicated the check was completed and/or 2. nursing staff was in Resident #2's room less than 3 minutes, and/or 3. equipment needed to complete the neuro check was not evident in the room.) Continued interview on 06-19-2017 at 11:11 a.m. the facility Director of Nursing Services (DON) indicated she stated nursing staff would follow the neurological assessment flowsheet which directed staff to assess the following areas: level of consciousness, pupil response, motor functions, pain response, vital signs and observations (i.e. [MEDICAL CONDITION], headaches, vomiting, paralysis). The Director of Nursing stated she would expect nurses would have been trained how to complete a neurological assessment while in nursing school. She also stated the nursing staff at the facility would utilize equipment including an automatic blood pressure cuff (which also assessed the resident's pulse), a tympanic thermometer, and a flash light (to check pupil response). The Director of Nursing estimated it would take a nurse from 7 to 10 minutes to complete a neurological assessment depending on their individual experience. According to documentation in Resident #2's Medication Administration Record [REDACTED]. Staff F signed that a medication due at 1300 (on 03-12-2017) was administered. Staff G signed that all medications due to be given at 1900 on 03-11-2017 were administered. Staff F and Staff G signed that all medications were administered as order on 03-12-2017. A review of the MAR for March 2017 documented the following pertinent medications were ordered: [MEDICATION NAME]- [MEDICATION NAME] ER tablet, give 1 tablet 50-200 millgrams (mg) by mouth daily at bedtime (10 p.m.) for [MEDICAL CONDITION]. [MEDICATION NAME]- [MEDICATION NAME] ER tablet, give1.5 tablet 25-100 mg by mouth daily at 1900 p.m. for [MEDICAL CONDITION]. [MEDICATION NAME]- [MEDICATION NAME] ER tablet, give 2 tabs 25-100 mg by mouth daily at 900 p.m. for [MEDICAL CONDITION]. [MEDICATION NAME]- [MEDICATION NAME] ER tablet, give 1 tablet 25-100 mg by mouth two time a day at 1200 and 1500 for [MEDICAL CONDITION]. [MEDICATION NAME] .5mg table, give 1 tab daily by mouth (at 1900) for anxiety Fentalnyl Patch (apply 1 patch every 3 days for chronic pain (was to be changed 3/12/17 at 1900) [MEDICATION NAME] HCT tablet, give 2.5 mg three time a day at 900, 1100, and 1800 for [MEDICAL CONDITION] Entacapone Tablet 200 mg give 0.5 mg five times a day at 900, 1200, 1500, 1800 and 2100 for [MEDICAL CONDITION]. [MEDICATION NAME] Sodium Tablet 50 mg give 1 tablet daily (9 a.m.) Arginald Packet Give 1 packet a day (at 9 a.m.) (nutritional supplements protein-Calorie ). [MEDICATION NAME] 1 capsule at bedtime (2000) for gastro-[MEDICAL CONDITION] Potassium Chloride 20 1 time by mouth at 900. Review of the video clips in their entirety reveal nurses' did not enter Resident #2's room on 03-11-17 or 03-12-17 with medications. The facility educated all nurses on completing neuro assessments which occurred on 6/15/17 and on 6/16/17 the charge nurses completed observation of medication pass and re-education for medication administration. The facility also in-service staff on providing incontinence care, meal assistance, offering fluids with the DON and charge nurses monitoring compliance. The facility abated the IJ on 6/16/17 when they completed these actions below and this lowered the severity to a D level.

Based on observation (via video recording clips), clinical record and policy review, the facility did not always ensured personal privacy for residents. According to video recordings of events occurring in Resident #2's room on 3-11-17 and 3-12-17, staff left the door open when providing personal cares to the resident exposing his/her naked body. A reasonable person would feel degraded, embarrassed and ashamed if exposed during cares. Concerns were noted for one resident (Resident #2) in a sample of seven (7) residents selected for review. The facility reported a census of 36 residents. Findings include: According to documentation in the clinical record, Resident #2 had [DIAGNOSES REDACTED]. The facility Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 scored 7 (of 15) points on the Brief Interview for Mental Status (BIMS) indicating severe cognitive decline. A BIMS assessment completed 04-20-2017 indicated a score of 2 (of 15) points, also indicative of severe cognitive decline. Both MDS assessments (with above dates) described Resident #2 as requiring extensive staff assistance with bed mobility, transferring and ambulation, dressing, hygiene and bathing and toilet use. Resident #2 required staff supervision for eating. The assessment indicated Resident #2 was frequently incontinent of bowel and bladder. The facility developed, individual plan of care for Resident #2 indicated the following focus areas and related interventions/tasks. * Risk of skin breakdown and directed staff to: * turn and reposition every two hours and as needed. * use incontinence products to maintain personal hygiene and dignity * Ability to complete ADL's (activities of daily living) have deteriorated and directed staff to: * do not rush resident; allow extra time to complete ADL's * provide assist with AM and PM cares * Resident experiences bladder incontinence and directed staff to: * provide incontinence care after each incontinent episode * use incontinence products to maintain hygiene and dignity * Resident had physical behaviors and is resistive to care at times and directed staff to : * encourage as much participation/interaction by the resident as possible during care activities * give clear explanation of all care activities prior to and as they occur during each contact * if resident resists with ADL's, reassure resident, leave and return 5-10 minutes later and try again * provide consistency in care to promote comfort with ADL's. Maintain consistency in timing of ADL's, caregivers and routine, as much as possible. According to video recordings of events occurring in Resident #2's room starting on 3-10-17 at 5:48 p.m. and ending on 3-13-17 at 2:32 p.m. showed the lack of personal privacy during personal care as demonstrated by the examples listed below. The record video recording during the dates and times listed below showed approximately 59 seconds of activity in the room. The operating directions for the Nanny Camera indicated once supplied with power, the camera would automatically start motion detection recording. In motion recording mode, the camera will record video when the motion is detected. All videos are in one minute clips.) The time recordings of the video clips are approximately 2-3 minutes from real time and the weekend in question was the switch to daylights savings time. The video camera is program to adapt to daylight savings time change, however an individual also adjusted the time giving an hour off in some video clips. (Those specifics times and clips were shared with the Department). Each video recording is numbered, and includes the date & time in military time (for example 1400 means 2 p.m.). Review of video clip # 0056 dated 03-11-2017 revealed two unidentified staff enter Resident #2's room at 0835. One staff removes the sheet/blanket from the resident's lower body, exposing Resident #2's unclothed perineum and legs. One staff exits the room, leaving Resident #2's unclothed body visible to anyone passing by in the hallway. Review of video clip #0181 dated 03-12-2017 revealed Staff J to enter Resident # 2's room at 1422:38. At that time Resident #2 was in bed, dressed only with a shirt and socks on. Resident #2's unclothed naked body was exposed from his/her waist to his/her feet. Staff J exited Resident #2's room at 1442:42 leaving the door open to the room showing Resident #2 exposed (showing his/her pubic hair and male/female genital area). Staff J returns to Resident #2's room at 1423:15 appears to talk to Resident #2 and exits the room at 1423:36, again leaving Resident #2's unclothed lower body completely exposed (showing his/her pubic hair and male/female genital area) and uncovered and the door to Resident #2's room open. Review of video clip # 0218 dated 03-12-2017 revealed Staff G to look in Resident #2's room (from the doorway) at 1822:33 and almost immediately leave. Resident #2 is observed wearing only a blouse, with the lower portion of his/her body completely exposed. Resident #2 has his/her feet out of bed and appears to be attempting to sit up. Staff G left Resident #2 exposed (showing his/her pubic hair and male/female genital area) and unattended, with the door to the room open to the hallway. The facility provided a written procedure form (not dated) titled Education for Incontinence Care. The form directed staff to explain the procedure to the resident, set up clean area and provide privacy. A reasonable person would feel degraded, embarrassed and ashamed if staff left the door open during cares exposing their naked body to anyone walking by. Record review revealed Resident #2 lacked the cognitive skills to express the psychological impact he/she would feel after staff left the door open during cares; or lack the physical ability to pull his/her blanket/cover up to cover his/her body. A reasonable person with a [DIAGNOSES REDACTED].

Based on record review and observation (via video clips from granny cam) the facility failed to accurately document assessments completed on residents. Concerns were noted for one resident (Resident #2) in a sample of 7 residents. The facility reported a census of 36 residents. Findings include: According to documentation in the clinical record, Resident #2 had [DIAGNOSES REDACTED]. The facility Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 scored 7 (of 15) points on the Brief Interview for Mental Status (BIMS) indicating severe cognitive decline. A BIMS assessment completed 04-20-2017 indicated a score of 2 (of 15) points, also indicative of severe cognitive decline. Both MDS assessments (with above dates) described Resident #2 as requiring extensive staff assistance with bed mobility, transferring and ambulation, dressing, hygiene and bathing and toilet use. Resident #2 required staff supervision for eating. The assessment indicated Resident #2 was frequently incontinent of bowel and bladder. The facility developed, individual plan of care for Resident #2 indicated the following focus goals and related interventions/tasks for : skin breakdown, ability to complete ADL's (activities of daily living), bladder incontinence, risk for falling related to unsteady gait, tranfer with the assist of one, walker and gait belt, ongoing evaluation of the effectiveness of current [MEDICAL CONDITION] medications, resident had physical behaviors and is resistive to care at times, potential for weight loss and fluid deficit. According to video recordings of events occurring in Resident #2's room starting on 3-10-17 at 5:48 p.m. and ending on 3-13-17 at 2:32 p.m. showed the following examples of inaccurately document assessments. The record video recording during the dates and times listed below showed approximately 59 seconds of activity in the room. The operating directions for the Nanny Camera indicated once supplied with power, the camera would automatically start motion detection recording. In motion recording mode, the camera will record video when the motion is detected. All videos are in one minute clips.) The time recordings of the video clips are approximately 2-3 minutes from real time and the weekend in question was the switch to daylights savings time. The video camera is program to adapt to daylight savings time change, however an individual also adjusted the time giving an hour off in some video clips. (Those specifics times and clips were shared with the Department). Each video recording is numbered, and includes the date & time in military time (for example 1400 means 2 p.m.). Review of video clip # 0122 dated 03-10-2017 at 1748 Resident #2 stands up from his/her chair and falls. At 1749 staff arrive to Resident #2's room. Video clips # 0123 at 1749:42 through clip # 0134 at 1804:49 show Staff G and Staff H attending to Resident #2. Not all actions of the staff are visible, however it is noted staff assist provide a pillow for Resident #2 while on the floor, and assist Resident #2 to a sitting position. Video clip # 0127 shows Staff G and Staff H assisting Resident #2 to stand, and a blood pressure reading to obtained while Resident #2 stands with assistance. Video clip # 0134 at 1804:49 shows Staff G leaving Resident #2's room with the blood pressure cuff. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 1745 and at 1800. Review of video clips # 0142 through # 0144 (1813:43 through 1815:52) shows Staff G in the room with Resident #1, with a blood pressure cuff and a white instrument ( i.e. tympanic thermometer). Nurse G remained in Resident #2's room approximately two minutes and nine seconds. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 1815. Review of video clips # 0151(1829:16 ) reveal an unidentified nursing assistant leaving Resident #2's room and Resident #2 attempting to eat and drink from the tray in front of him/her. The next video clip #0152 at 1848:16 shows a nursing assistant leaving Resident #2's room. The 19 minutes between the two video clips indicate no motion was detected by the camera. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 1830. Review of video clips # 0158 at 1907:11 shows Staff G enter Resident #2's room, and checks Resident #2's blood pressure and temperature. Video clip # 0159 at 1909:34 shows Staff G leaving Resident #2's room. Nurse G remained in Resident #2' room approximately two minutes and 23 seconds. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 1900. Review of video clip # 0162 shows Staff G (and an unidentified individual) enter Resident #2's room at 1931:32. Staff G has a blue object and a towel in her hand and then leaves the room. Video clip #0164 shows Staff G lowering the head of Resident #2's bed, placing a pillow on Resident #2's left side and leaving the room at approximately 1932:33. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 1930. Review of video clip # 0164 shows visitors in Resident #2's room at 1939:50. Review of video clip # 0165 shows Staff G enter Resident #2's room at approximately 1941:40 with a glass with a straw in it. Video clip # 0166 shows Staff G (and a visitor) examining Resident #2. Staff G appears to have a washcloth. In video clip # 0168 at 1944:47 an unidentified visitor to seen assisting Resident #2 in eating from the cup that Staff G brought in. From video clip # 0169 (at 1945:47) through video clip # 0177 (at 1955:22) Staff G is in Resident #2's room, talking with the visitor(s). Staff G leaves Resident #2' s room at that time. Video clip # 0178 at 1956:22 shows Staff G at the door to Resident #2's room, talking to the visitor and then leaving the doorway. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 2000. Review of video clip # 0188 (at 2029:48) shows Staff G in Resident #2's room talking with visitors. Video clip # 0190 (2032:30) shows Staff G talking to Resident #2's visitor. Video clip # 0191 (2033:32) and # 0192 (2034:38) shows Staff G in Resident #2's room with a blood pressure cuff in her hand. Video clip # 0193 (2036:03) shows Staff G leaving Resident #2's room. Staff G remained in Resident #2's room approximately seven minutes. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 1745 and at 2030. Review of video clip # 0016 (2132) revealed only Resident #2 in bed, in his/her room. The next video clip (# 0017) at 2141 also revealed only Resident #2 in the room. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 2130. Review of video clip # 0019 indicated Staff G walked into Resident #2's room at 2237:14. Staff G stood at the bedside and appeared to be looking at Resident #2. Staff G did not have any equipment with her, nor did she appear to use any equipment (i.e. blood pressure cuff or thermometer). Staff G exited the room (empty handed) at 2237:41. Staff G remained in Resident #2's room approximately 27 seconds. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 2230. Staff G documented she completed pupil response, hand grips, pain response, vitals, level of consciousness and observations ([MEDICAL CONDITION], headaches, vomiting or paralysis). Review of video clip # 0021 revealed Staff C to walk in and out of Resident #2's room. Video clip # 0022 at 2248 revealed Resident #2 in bed, with no staff entering, leaving or in Resident #2's room. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-10-2017 at 2230. Review of video clip # 0023 at 0036 (on 03-11-2017) revealed Staff C to enter Resident #2's room and take out the water pitcher. Video clip # 0023 (0042) reveals Resident #2 in bed, with staff observed in the hallway. Video clip # 0025 (0043) reveals Staff C to bring a water pitcher back into Resident #2's room. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-11-2017 at 0030. Review of video clip # 0027 (at 0250) reveal Staff C and Staff I (certified nursing assistants) in Resident #2's room. Staff C and Staff I are again recorded in Resident #2's room at 0259. The video clip # 0028 at 0250 captures unidentified staff in the hallway walking past Resident #2's room. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-11-2017 at 0230. Review of video clip # 0031 reveals Staff G to enter Resident #2's room at 0410:54. Staff G appears to be checking Resident #2's blood pressure. Staff G leaves Resident #2's room at approximately 0412:51 Staff G remained in Resident #2's room approximately one minute and 57 seconds. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-11-2017 at 0430. Review of video clip # 0055 (at 0830) reveals an unidentified nursing assistant enter and exit Resident #'2 room. The staff member does not have any contact with Resident #2. Review of the facility neurological assessment flow sheet indicated Staff F documented a neuro assessment on 03-11-2017 at 0830. Review of video clip # 0096 at 1223 revealed an unidentified individual to look into Resident #2's room. Resident #2 remains in bed. Video clip # 0097 at 1235 reveals Resident #2 in bed with no staff in the room. Video clip # 0098 at 1239 reveals Resident #2 in bed with no staff activity in the room. Review of the facility neurological assessment flow sheet indicated Staff F documented a neuro assessment on 03-11-2017 at 1230. Review of video clip # 103 reveals Staff F in walk into Resident #2's room at 1411:02 and looks at Resident #2, and touches his/her face. Staff F exits Resident #2's room at 1411: 14. Staff F remained in Resident #2's room for 12 seconds. Documentation in the nurse's notes dated 03-11-2017 at 14:04 are as follows: Resident resting quietly in bed with eyes closed through much of the day. Awakens easily to verbal and light tactile stimuli. Alert and responds to questions clearly and appropriately. PERRLA (pupils equal, round reactive to light and accommodation) Follows basic cues without difficulty. Bilateral hand grasp strong and equal. PAROM (passive, active range of motion) WNL (within normal limits) and without s/sx (signs/symptoms) pain or discomfort. Skin tear above L (left) eye scabbed over and without active bleeding noted. Some red bruising to surrounding area. T (temperature) 97.1 tympanic, BP (blood pressure) 123/60, P (pulse) 61, R (respirations) 18, O2 sat (oxygen saturation) 97% on RA (room air). Refuses to transfer from bed this shift. Staff assist with frequent repositioning and toileting needs. Pericare provided as needed. Refuses all scheduled medication with no s/sx adverse effects. Currently resting quietly in bed with eyes closed. Will continue to monitor. Review of video clips from # 104 (dated 1433 on 03-11-2017) through # 157 (dated 0758 on 03-12-2017) reveal no nurses entered Resident #2's room during those approximately 17 1/2 hours. Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-11-2017 at 2030 and 03-12-2017 at 0430. Review of video clip # 0157 reveals Staff F to walk into Resident #2's room at 0758:09, (03-12-2017) look at Resident #2 and turn around and leave the room at 0758:12. Staff F remained in Resident #2's room approximately three seconds. A nurse does not enter Resident #2's room until video clip # 170. At 1014:47 Staff F enters Resident #2's room with a over the bed table with items included a blood pressure cuff, thermometer and pulse oximeter. Staff G [MEDICATION NAME] Resident #2 and appears to document her findings. Staff F exits Resident #2's room at 1016:32. Staff G remained in Resident #2's room approximately one minute and 45 seconds. Review of video clips # 0172 through # 0218 reveals another nurse did not enter Resident #2's room until 03-12-2017 at 1822: 33 when Staff G views Resident #2 from the doorway and then turns around and leaves. Documentation in the nurse's notes dated 03-12-2017 at 14:59 are as follows: Resident continues to rest in bed with eyes closed through shift today. Awakens easily and briefly to verbal and light tactile stimuli. Speech clear and appropriate. A & O (alert and oriented) per baseline. No change in mood, cognition or LOC (level of consciousness). PERRLA. Bilateral hand grasps equal. PROM and AROM baseline without s/sx pain or discomfort. Resident accepts all scheduled medication without difficulty. No s/sx pain or discomfort. Staff assist with frequent repositioning and toileting needs. Peri care provided as needed. Review of the facility neurological assessment flow sheet indicated Staff F documented a neuro assessment on 03-12-2017 at 1230. Review of video clips # 0219 (at 1829 on 03-12-2017) through #0238 (at 0525:11/actual time of 0725:11) reveal no nurse entered Resident #2's room. Video clip # 0236 shows Staff H stand at Resident #2's door for four seconds (actual time 0725:11 to 0725:15). Review of the facility neurological assessment flow sheet indicated Staff G documented a neuro assessment on 03-13-2017 at 0430. During an interview on 06-19-2017 at 11:11 a.m. the facility Director of Nursing Services indicated the facility did not have a specific policy on neuro (neurological) checks. The Director of Nursing did provide a form dated 01-29-2014 titled Neuro check protocol. The form indicated the following: 15 min (minutes) X 4 30 min X 4 1 hour X 4 every hour X 2 every 4 hour X 2 every 8 hour X 72 * Neros (sic) must be checked with any head bump and unwitnessed falls on residents who are coded with short, or long term memory problems or have confusion. (hand written notation < 13 BIMS score) Review of the video clips indicated that neuro check documentation did not, 1. match the time the staff indicated the check was completed and/or 2. nursing staff was in Resident #2's room less than 3 minutes, and/or 3. equipment needed to complete the neuro check was not evident in the room. She stated nursing staff would follow the neurological assessment flowsheet which directed staff to assess the following areas: level of consciousness, pupil response, motor functions, pain response, vital signs and observations (i.e. [MEDICAL CONDITION], headaches, vomiting, paralysis). The Director of Nursing stated she would expect nurses would have been trained how to complete a neurological assessment while in nursing school. She also stated the nursing staff at the facility would utilize equipment including an automatic blood pressure cuff (which also assessed the resident's pulse), a tympanic thermometer, and a flash light (to check pupil response). The Director of Nursing estimated it would take a nurse from 7 to 10 minutes to complete a neurological assessment depending on their individual experience. Review of the video clips in their entirety reveal nurses' did not enter Resident #2's room on 03-11-17 or 03-12-17 with medications. According to documentation in Resident #2's Medication Administration Record [REDACTED]. Staff F signed that a medication due at 1300 (on 03-12-2017) was administered. Staff G signed that all medications due to be given at 1900 on 03-11-2017 were administered. Staff F and Staff G signed that all medications were administered as order on 03-12-2017.

Based on observation and record review the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Concerns were noted for 3 residents in a sample of 7 residents. The facility reported a census of 36 residents. Findings include: 1. According to documentation in the clinical record, Resident #2 had [DIAGNOSES REDACTED]. The facility Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 scored 7 (of 15) points on the Brief Interview for Mental Status (BIMS) indicating severe cognitive decline. A BIMS assessment completed 04-20-2017 indicated a score of 2 (of 15) points, also indicative of severe cognitive decline. Both MDS assessments (with above dates) described Resident #2 as requiring extensive staff assistance with bed mobility, transferring and ambulation, dressing, hygiene and bathing and toilet use. Resident #2 required staff supervision for eating. The assessment indicated Resident #2 was frequently incontinent of bowel and bladder. The facility developed, individual plan of care for Resident #2 indicated the following focus areas and related interventions/tasks. * Risk of skin breakdown * turn and reposition every two hours and as needed. * use incontinence products to maintain personal hygiene and dignity * Ability to complete ADL's (activities of daily living) have deteriorated * do not rush resident; allow extra time to complete ADL's * provide assist with AM and PM cares * Resident experiences bladder incontinence * provide incontinence care after each incontinent episode * use incontinence products to maintain hygiene and dignity * Resident had physical behaviors and is resistive to care at times * encourage as much participation/interaction by the resident as possible during care activities * give clear explanation of all care activities prior to and as they occur during each contact * if resident resists with ADL's, reassure resident, leave and return 5-10 minutes later and try again * provide consistency in care to promote comfort with ADL's. Maintain consistency in timing of ADL's, caregivers and routine, as much as possible. * Resident has potential for weight loss and fluid deficit related to poor intake of fluids at times * allow resident to choose comfortable dining environment. Prefers to dine in room at times * encourage resident to drink fluids between meals * prefers room tray at breakfast and likes a light breakfast or is often refusing breakfast altogether. In the past would drink a malt at breakfast * encourage the resident to drink fluids of choice, prefers to use a shortened straw with beverages According to video recordings of events occurring in Resident #2's room starting on 3-10-17 at 5:48 p.m. and ending on 3-13-17 at 2:32 p.m. showed the lack of care and treatment as demonstrated by the examples listed below. The record video recording during the dates and times listed below showed approximately 59 seconds of activity in the room. The operating directions for the Nanny Camera indicated once supplied with power, the camera would automatically start motion detection recording. In motion recording mode, the camera will record video when the motion is detected. All videos are in one minute clips.) The time recordings of the video clips are approximately 2-3 minutes from real time and the weekend in question was the switch to daylights savings time. The video camera is program to adapt to daylight savings time change, however an individual also adjusted the time giving an hour off in some video clips. (Those specifics times and clips were shared with the Department). Each video recording is numbered, and includes the date & time in military time (for example 1400 means 2 p.m.). Review of video clips # 0057 and # 0058 on 03-11-17 beginning at approximately 0836 reveal two unidentified nursing assistants enter Resident #2's room to provide peri care. One staff takes on washcloth and makes two downward motions slightly across the top and through the center of the resident's anterior perineum. A second washcloth is used to make one (rinsing) motion and staff use a white cloth to make one drying motion. Staff remove Resident #2's upper clothing and drop the items on the floor. Staff assist Resident #2 to roll side to side as they remove the soiled soaker. Staff then drop the soaker with the used linens onto the floor. Staff complete a change of the bottom sheet and provide a clean soaker on the bed. The soiled linens are removed from the bed and heaved on the floor. The resident's pillow also falls onto the floor. Review of video clips # 0123 and #0124 reveal Staff J and Staff K to enter Resident #2's room. Staff J placed two blue washcloths on the side rail of Resident #2's bed. Both washcloths fall off the side rail to the floor. Staff J picks up the washcloths and then appears to smell one of the wash clothes prior to cleansing Resident #2's anterior perineum. Staff J did not have gloves on. Staff removed Resident #2's shirt/blouse (and dropped it on the floor) and while lying on his/her side Staff J used the same washcloths to cleanse his/her buttocks and then upward to the lower and middle of his/her back. Video clip # 0129 dated 03-11-2017 reveal staff picking up linens from off the floor and exiting Resident #2's room. Review of video clips #0147 through # 0149 dated 03-12-2017 at 0654, reveal Staff L and Staff M in Resident #2's room, to provide peri care. Staff L did not put on gloves, used up and down motions to cleanse and rinse both Resident #2's anterior and posterior perineum and did not use a clean area of the cloth for each washing and rinsing motion. When Staff L completes the peri care she tosses all the linens on the floor. While changing the bottom sheet of the bed the clean soaker falls off the bed and onto the floor. Staff M picks up the soaker from the floor and Staff L and Staff M use the soaker to finish making the bed. Review of video clips # 0167 dated 03-12-2017 at 0904, reveal two nursing assistants enter Resident #2's room. With an ungloved hand, Staff L feels the soaker under Resident #'2 buttocks, leaves the room and returns with a clean soaker. Together the nursing assistants change the soaker under Resident #2 and the unidentified nursing assistant tosses the used soaker on the floor. The nursing assistants do not provide any peri care for Resident #2. Review of video clips # 0183 and # 0184 dated 03-12-2017 at 1425 reveal Staff J and Staff A to enter Resident #2's room and bring in linen supplies. Staff J places 2 wash cloths in the side rail of the bed and begins cleansing the outer thigh and buttock of Resident #'2's left side. Staff A removes the soaker from under Resident #2 and drops it on the floor. Staff J removes the pillowcase from a pillow and flings it onto the floor. Staff J then uses the same wash and rinse cloth to cleanse Resident #2's anterior perineum. Staff J does not have gloves on, nor does she rotate the cloth, or use front to back motions. Review of the video clips revealed staff provided Resident #2 with fresh water on 03-11-2017 at 0043, 0954, and 1619; on 03-12-2017 at 0035, 0831 and at 1336 and on 03-13-2017 at 0839. Staff did not offer Resident #2 a drink at any of these times. The video clip ( #0091) on 03-11-2017 at 1135 reveals an unidentified staff set a glass of fluids and an unopened straw on Resident #2's bedside stand. The unidentified staff did not offer Resident #2 a drink. During the continuous video clip recordings on 03-11-2017 no meal trays were observed to be served to Resident #2. Resident #2 was not observed to be out of bed on that date. Documentation on the facility consumption record indicated Resident #2 refused breakfast and dinner on 03-11-2017 and the record lacked documentation for the supper meal. The consumption record indicated Resident #2 refused breakfast and dinner on 03-12-2017 and the record lacked documentation for the supper meal. Resident #2 was not observed to be out of bed on 03-12-2017. The consumption record indicated Resident #2 refused breakfast on 03-13-2017 and at noon had a poor intake of food, but an excellent intake of fluids. Continuous observation of the video clips also revealed that staff did not offer or assist Resident #2 with any personal cares including oral hygiene, personal hygiene (washing face and hands) or hair care. Continuous observation of the video clips also revealed no motion detected in Resident #2's room (signifying no staff in the room) from 1720 on 03-11-2017 until 0035 on -3-12-17, a span of 7 hours and 15 minutes in which Resident #2 was not repositioned. The last motion detected on 03-12-17 was at 1822 and no motion/no staff observed in Resident #2's room until 0349 on 03-13-2017, a span of over nine hours, with no staff assisting Resident #2 with repositioning are incontinent cares. 2. According to documentation in the clinical record, Resident # 3 had [DIAGNOSES REDACTED]. According to documentation in the facility Minimum Data Set (MDS) assessment dated [DATE] Resident #3 had long term and short term memory problems and was severely impaired in his/her decision making skills. The assessment also described Resident #3 as requiring extensive staff assistance with transferring, bed mobility, hygiene and bathing and toilet use. The assessment also indicated Resident # 3 was frequently incontinent of bowel and bladder. Resident #3's individual plan of care dated 05-16-2017 directed staff to assist to the toilet before and after meals, at bedtime and as needed; provide incontinent care after each incontinent episode; and to use incontinent products to maintain personal hygiene and dignity. Observation on 06-13-2017 at 9:56 p.m. revealed Staff A and Staff B to gather supplies to provide incontinence care for Resident #3. Staff A donned gloves and wet washcloths. Staff A applied soap to one washcloth. Staff B left Resident #3's room, stating she just needed thirty seconds. Staff A then removed the top sheet from over Resident #3 , and used one wash cloth to cleanse with a downward motion through the anterior perineum,. Staff A then cleansed each side of the anterior perineum with out rotating the washcloth, to use a clean portion for each cleansing motion. Staff A then proceeded to rinse Resident #3's anterior perineum in the same manner. Staff A held both the cleansing wash cloth and rinsing wash cloth in the same hand. When Staff B returned to Resident #3's room, Staff A held on to the side rail with her gloved hands, while assisting Resident #3 to roll to his/her left side. Staff A then used the same wash cloths to use three upward motions (with each wash cloth) to wash and rinse Resident #3's posterior perineum. Staff A did not rotate the wash or rinse cloth. Staff A placed the soiled items in a plastic bag with she then placed on the floor. 3. According to documentation in the clinical record, Resident # 6 had [DIAGNOSES REDACTED]. According to documentation in the facility Minimum Data Set (MDS) assessment dated [DATE], Resident # 6 scored 3 of 15 points on the Brief Interview for Mental Status (BIMS) indicating severe cognitive decline. The assessment also described Resident #6 as requiring extensive staff assistance with transferring, bed mobility, hygiene and bathing and toilet use. The assessment also indicated Resident #6 was frequently involuntary of bowel and always incontinent of bladder. Resident #6's individual plan of care dated 06-06-2017 directed staff to keep clean and dry as possible and to use incontinent products to maintain personal hygiene and dignity. Observation on 06-19-17 at 3:49 p.m. revealed Staff D and Staff E to enter Resident #6's room. Staff D gathered supplies to provide peri care for Resident #6 and indicated she would begin with cleansing the posterior area due to the resident being involuntary of bowel. Staff D donned gloves and initially cleansed the area with toilet tissue. After washing her hands and donning new gloves, Staff D used a soapy washcloth and cleansed the outer side of the buttocks in an upward motion, rotating the cloth between motions. Staff D used a second soapy cloth to wash the center of the buttocks. Staff B rinsed the area in the same manner, using upward motions and then patted the area dry. Staff then assisted Resident #6 to roll on his/her opposite side and Staff D used a soapy wash cloth to cleanse through the center for the anterior perineum, down each side, the inner thigh area and across the top of the perineal area. Staff D failed to change gloves after cleansing Resident #6's buttocks and before cleansing the anterior perineum. During an interview on the facility Director of Nursing indicated she would have expected staff to wash their hands and don clean gloves after cleansing the posterior perineum and prior to cleansing the anterior perineum. The facility provided a written form (not dated) titled Education for Incontinence Care. The form directed staff to do the following: 1. Explain procedure to resident, set up clean area, provide privacy. 2. Hand hygiene, put on gloves 3. Remove soled pad, clothing linen and put in appropriate place. Replace a clean pad under resident. 4. Female - one swipe down front of vaginal area, using front to back strokes always, then wash groin making sure to get all areas of the skin that have been soiled. Rinse and pat dry. 5. Roll resident onto side wash, rinse, pat dry. Remember to clean all areas that are soiled using front to back technique using a clean area of wash cloth with each swipe. 6. Roll dirty pad under resident and apply clean pad. 7. Roll resident onto other side, remove dirty pad, and pull clean pad through. 8. Wash, rinse, and pat dry the other hip. Remembering front to back swipes and using a clean area of washcloth with every swipe. 9. Return resident to supine position. Remove gloves and wash hands and apply new gloves if Vaseline barrier is needed. Hand hygiene and position resident for comfort with call light in reach.

Based on observation and record review the facility did not always follow basic infection control practices including hand hygiene procedures involved in direct resident contact and practices in which staff handled and transported linens as to prevent the spread of infection. Concerns were noted for 3 residents in a sample of 7 residents. The facility reported a census of 36 residents. Findings include: 1. According to documentation in the clinical record, Resident #2 had [DIAGNOSES REDACTED]. The facility Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 scored 7 (of 15) points on the Brief Interview for Mental Status (BIMS) indicating severe cognitive decline. A BIMS assessment completed 04-20-2017 indicated a score of 2 (of 15) points, also indicative of severe cognitive decline. Both MDS assessments (with above dates) described Resident #2 as requiring extensive staff assistance with bed mobility, transferring and ambulation, dressing, hygiene and bathing and toilet use. Resident #2 required staff supervision for eating. The assessment indicated Resident #2 was frequently incontinent of bowel and bladder. The facility developed, individual plan of care for Resident #2 indicated the following focus areas and related interventions/tasks. * Risk of skin breakdown * turn and reposition every two hours and as needed. * use incontinence products to maintain personal hygiene and dignity * Ability to complete ADL's (activities of daily living) have deteriorated * do not rush resident; allow extra time to complete ADL's * provide assist with AM and PM cares * Resident experiences bladder incontinence * provide incontinence care after each incontinent episode * use incontinence products to maintain hygiene and dignity * Resident had physical behaviors and is resistive to care at times * encourage as much participation/interaction by the resident as possible during care activities * give clear explanation of all care activities prior to and as they occur during each contact * if resident resists with ADL's, reassure resident, leave and return 5-10 minutes later and try again * provide consistency in care to promote comfort with ADL's. Maintain consistency in timing of ADL's, caregivers and routine, as much as possible. According to video recordings of events occurring in Resident #2's room starting on 3-10-17 at 5:48 p.m. and ending on 3-13-17 at 2:32 p.m. showed the lack of care and treatment as demonstrated by the examples listed below. The record video recording during the dates and times listed below showed approximately 59 seconds of activity in the room. The operating directions for the Nanny Camera indicated once supplied with power, the camera would automatically start motion detection recording. In motion recording mode, the camera will record video when the motion is detected. All videos are in one minute clips.) The time recordings of the video clips are approximately 2-3 minutes from real time and the weekend in question was the switch to daylights savings time. The video camera is program to adapt to daylight savings time change, however an individual also adjusted the time giving an hour off in some video clips. (Those specifics times and clips were shared with the Department). Each video recording is numbered, and includes the date & time in military time (for example 1400 means 2 p.m.). Review of video clips # 0057 and # 0058 on 03-11-17 beginning at approximately 0836 reveal two unidentified nursing assistants enter Resident #2's room to provide peri care. One staff takes on washcloth and makes two downward motions slightly across the top and through the center of the resident's anterior perineum. A second washcloth is used to make one (rinsing) motion and staff use a white cloth to make one drying motion. Staff remove Resident #2's upper clothing and drop the items on the floor. Staff assist Resident #2 to roll side to side as they remove the soiled soaker. Staff then drop the soaker with the used linens onto the floor. Staff complete a change of the bottom sheet and provide a clean soaker on the bed without sanitizing the mattress. The soiled linens are removed from the bed and heaved on the floor. The resident's pillow also falls onto the floor. Review of video clips # 0123 and #0124 reveal Staff J and Staff K to enter Resident #2's room. Staff J placed two blue washcloths on the side rail of Resident #2's bed. Both washcloths fall off the side rail to the floor. Staff J picks up the washcloths and then appears to smell one of the wash clothes prior to cleansing Resident #2's anterior perineum. Staff J did not have gloves on. Staff removed Resident #2's shirt/blouse (and dropped it on the floor) and while lying on his/her side Staff J used the same washcloths to cleanse his/her buttocks and then upward to the lower and middle of his/her back. Video clip # 0129 dated 03-11-2017 reveal staff picking up linens from off the floor and exiting Resident #2's room. Review of video clips #0147 through # 0149 dated 03-12-2017 at 0654, reveal Staff L and Staff M in Resident #2's room, to provide peri care. Staff L did not put on gloves, used up and down motions to cleanse and rinse both Resident #2's anterior and posterior perineum and did not use a clean area of the cloth for each washing and rinsing motion. When Staff L completes the peri care she tosses all the linens on the floor. While changing the bottom sheet of the bed (staff did not sanitize the mattress) and the clean soaker falls off the bed and onto the floor. Staff M picks up the soaker from the floor and Staff L and Staff M use the soaker to finish making the bed. Review of video clips # 0167 dated 03-12-2017 at 0904, reveal two nursing assistants enter Resident #2's room. With an ungloved hand, Staff L feels the soaker under Resident #'2 buttocks, leaves the room and returns with a clean soaker. Together the nursing assistants change the soaker under Resident #2 and the unidentified nursing assistant tosses the used soaker on the floor. The nursing assistants do not provide any peri care for Resident #2. Review of video clips # 0183 and # 0184 dated 03-12-2017 at 1425 reveal Staff J and Staff A to enter Resident #2's room and bring in linen supplies. Staff J places 2 wash cloths in the side rail of the bed and begins cleansing the outer thigh and buttock of Resident #'2's left side. Staff A removes the soaker from under Resident #2 and drops it on the floor. Staff J removes the pillowcase from a pillow and flings it onto the floor. Staff J then uses the same wash and rinse cloth to cleanse Resident #2's anterior perineum. Staff J does not have gloves on, nor does she rotate the cloth, or use front to back motions. 2. According to documentation in the clinical record, Resident #7 had [DIAGNOSES REDACTED]. Review of the facility Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 scored 2 of 15 points on the Brief Interview for Mental Status (BIMS) indicating severe cognitive decline. The assessment also described Resident #2 as requiring extensive staff assistance with bed mobility, transferring ambulation , hygiene and bathing and toilet use. The assessment also indicated Resident #7 was frequently involuntary of bowel and always incontinent of bladder. The individual plan of care dated 05-03-17 directed staff to do the following: * assist Resident #7 to the toilet before and after meals and as needed * provide incontinent cares after each incontinent episode * use personal incontinent products to promote hygiene and dignity * keep clean and dry as possible Observation on 06-13-2017 at 9:45 p.m. revealed Staff A and Staff B to enter an unidentified residents room while doing evening shift rounds. At that time Staff A used her bare hand to check the resident's unclothed perineal area for incontinence. Staff A indicated the resident was not incontinent and proceeded to leave the room (without washing her hands) and proceeded to the next room. At 9:46 p.m. Staff A and Staff B entered Resident #7's room. Without washing her hands, Staff A unsnapped the brief on Resident #7 and reached in feeling the brief and stated it was wet. Staff A then removed her hand, and appeared to smell her hand, and stated Resident #7 was just sweaty. Staff A then re-snapped Resident #7's brief, replaced a blanket, and removed one blanket, turned off the light and exited the Resident #7's room. At that time Staff A stated to Staff B that she (Staff B) could do the (rounds) on the next hall. At 9:52 p.m. Staff A and Staff B entered Resident #6's room. At that time Staff B washed her hands, and Staff B then, also washed her hands. 3. Observation on night shift rounds on 06-14-2017 revealed Staff C to enter a residents room at 12:16 a.m. Staff C washed her hands and donned gloves. Staff C then felt the residents uncloths perineum, and indicated the resident was not incontinent. However, Staff C handled the resident's pillow prior to removing her gloves and washing her hands.

Based on record review and interviews, the facility failed to complete nursing assessment for one of four residents (Resident #4) who had an onset of adverse symptoms which represented a change in physical condition. Record review established Resident #4 with a prior surgery due to a twisted bowel movement. On [DATE], Resident #4 had complaints of pain, and a distended abdomen. The aides informed the only nurse working of the resident ' s adverse changes and the nurse did not assess the resident ' s abdomen discomfort, complains of pain or complete vitals signs and instead treated the resident with Tylenol. The oncoming nurse assessed the resident ' s condition and transferred the resident to the emergency room where he/she passed away approximately ? hour after arrival of a cardiorespiratory arrest caused by bowel obstruction. The facility identified a census of 35 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment tool dated [DATE] showed the resident had [DIAGNOSES REDACTED]. The resident had a score of 15 out of 15 for the BIMS (Brief Interview for Mental Status), showing no memory loss. The resident required assistance of 2 staff persons for bed mobility, transfers, and toilet use. (Gastroparesis is a disease of the muscles of the stomach or the nerves controlling the muscles that causes the muscles to stop working.) A physician's order [REDACTED].#4. The Plan of Care revised on [DATE] showed the resident had complaints of pain related to a history of gastroparesis and abdominal pain. Interventions for this concern included the following: - administer medications as ordered, monitor effectiveness and any adverse side effects. - assess effects of pain on the resident. - evaluate effectiveness of pain management interventions and adjust if ineffective or adverse side effects emerge. - monitor for any complaints of pain, location, duration, quantity, quality, alleviating factors, and aggravating factors. - monitor for any non-verbal signs of pain. The resident had a plan of care revision on [DATE] for being at risk for weight loss/ nutritional issues (with his/her weight at ,[DATE] pounds); and a history of gastroparesis and recent surgery for [REDACTED]. Clinical history: Progress Notes (Nurse's Notes) revealed the following for the month of June, 2014: -[DATE] at 9:35 p.m.: The resident had been assessed by the nurse with his/her temperature at 98.0 degrees, pulse rate at 84 beats, respirations at 20 breathes per minute, blood pressure (B/P) at ,[DATE] and the oxygen saturation (O2 Sat.) level at 98 % (percent). The resident had a history of [REDACTED]. The resident had a large bowel movement this morning and had no emesis this shift. Bowel sounds remain active in 4 quadrants, abdomen is 'tight', non-tender to light palpitation with no distention noted. The nurse called the hospital with the assessment reported and they agreed the resident does not currently have an emergent situation and to continue to monitor throughout the night. If the symptoms persisted, the resident may be seen at the clinic tomorrow. They agreed to administer an anti-emetic medication (controls nausea and vomiting) to see if it would help relieve symptoms). At [DATE] at 12:10 a.m. the resident moaned in pain and rated the pain as "10" on a 1 to 10 scale and described his/her pain as "excruciating". The nurse completed an assessment and documented the following: temperature at 97.9 degrees, pulse at 98, and respirations at 24, B/P at ,[DATE], and O2 Sat. at 98 %. Some dry heaving noted. Abdomen firmer than previous assessment and slightly tender to light palpitation, bowel sounds present to all quadrants, but hypoactive in the left lower quadrant. At 12:20 a.m., called the resident's spouse, who wanted the resident seen in the emergency room . At 1:00 a.m.: the resident exited the facility in the ambulance. The Progress Notes revealed on [DATE] at 1:38 p.m.: the resident had been readmitted to the nursing home after hospitalization and surgery due to twisted bowel. The Progress Notes revealed the following for the month of September, 2014: On [DATE]: Seen by the foot Physician with toenails trimmed. Progress Notes revealed the following for the month of September, 2014: On [DATE] at 7:07 a.m., Staff D, Registered Nurse (RN) documented she had been called to Resident #4 ' s room by Resident Care Technician (RCT) who reported, the resident did not look right. Staff D documented the resident was drowsy, but able to arouse and verbally respond. Resident stated," please, I need some '[MEDICATION NAME]', did not open his/her eyes. Staff D assessed the resident as follows: temperature at 100.0 degrees, Apical heart rate at 56, respirations at 40, grunting and unable to hear the blood pressure. O2 Sat. not registering. The resident ' s abdomen distended, firm and the resident complained of pain in the abdominal area. Staff D identified no bowel sounds heard, no audible congestion or wheezing, and she was not able to hear lung sounds due to the resident's grunting and not following directions to take deep breathes. Staff D documented the resident ' s skin was cool, clammy, and pale. The resident ' s right amputation mottled along with abdomen. Staff D documented night shift Aide (RCT) reported the resident had 2 bowel movements in the night, large and small with the stool was soft, unformed, and brown in color. The resident voided one time in the night, small amount dark, concentrated urine, brownish in color according to the Aide. Charge Nurse had been informed of the assessment. At 6:20 a.m., (same date) another nurse (Staff A) documented she called for a transfer order and 911 had been called requesting an ambulance. At 6:35 a.m., the ambulance arrived and transported the resident out of the building. At 7:30 a.m., the physician reported to the nursing home of the resident ' s death. The progress notes discharge summary dated [DATE] documented Resident #4 had been admitted to the care facility on [DATE] from a skilled care center due to Stage III pressure area to his/her right leg stump [MEDICAL CONDITION] infection ([MEDICAL CONDITION]-resistant Staphylococcus aureus). The summary noted the resident continued to improve and progress in health. On [DATE] (two days prior to the resident ' s death) the resident went to the doctor and returned with a new prosthetic and orders for PT (physical therapy) services to evaluate and treat so that the resident could regain strength and transfer independently to return home. The radiology report dated [DATE] postmortem (at 7:59 a.m.) identified there was [MEDICATION NAME] distention of portions of the color, and air-filled mildly distended loops of small bowel. The report noted cecum may reside in the left upper quadrant. The report noted it was unclear if this represents an obstructive pattern, or ileus (a painful obstruction of the ileum or part of the intestine). The hospital report noted the [AGE] year old resident brought in to theER on [DATE]. The clinical history/[DIAGNOSES REDACTED]. In June (2014) the resident developed volvulus (a loop of bowel is twisted) which resulted in operative intervention. The resident also had an idiopathic intermittent gastroparesis which would present suddenly with hugely dilated stomach, would be treated with NG suction and would resolve and go away. The resident got re-fitted for knee prosthesis last week in hopes of getting back home to care for his/her spouse. When presented at the ER, the resident was cool, clammy, no detectable pulse or blood pressure. The hospital report noted obvious huge, tense, distended abdomen. The NG tube was immediately placed and intravenous access very, very difficult and nonexistent. The resident did not respond to measures and not quite half an hour (,[DATE]) post arrival resuscitative efforts were halted at 7:16 a.m. The resident had a huge dilated colon, proximal ileum. The resident expired as result of cardiorespiratory arrest caused by bowel obstruction, probably due to an acute colonic obstruction/torsion (twisted or rotated). The Follow Up Question Report dated [DATE] to [DATE], showed no bowel movement for Resident #4 between [DATE] to [DATE] at 5 a.m. An interview on [DATE] at 1:55 p.m., Staff C, Resident Care Technician (RCT), reported the resident complained of a bad stomach cramps around 12:48 a.m., during first rounds. She noted the resident had appeared sweaty and clammy, and reported this to the nurse (Staff B). The resident had a large bowel movement and few moments later had a small bowel movement. The resident asked for a pain medication around 4:00 a.m., unsure of where the pain was, but reported it to the nurse (Staff B). She saw the nurse go to the medication cart and go to the resident's room. On last rounds, she noted the resident was sleeping. After the resident was sent to the emergency room , Staff C reported to Staff D (morning nurse), the resident did not have a good night and had reported this concern to the night nurse (Staff B), during their shift. An interview on [DATE] at 6:50 a.m., Staff G, RCT, reported the resident complained of stomach cramps around midnight. Staff G stated she told Staff B, about the stomach cramps, who replied, let's see what the bowel movement produces. Around 4:00 a.m., she noticed the resident had a firm stomach and told Staff B. She also reported this seemed similar to the last time the resident had to go to the hospital. Staff G, noted the nurse took equipment and went down to the resident's room. Staff G reported during shift report to Staff E (RCT) that Resident #4 " was acting funny', when the morning nurse Staff D overheard this. Staff D proceeded to go assess Resident #4 and ordered an ambulance be called. Staff G reported of looking in on the resident around 5:15 or 5:30 a.m., who had been moaning, as if sleeping. Staff G stated it was like the last episode, except the resident did not ask for the NG tube, ask to go to the hospital, or complain of pain as much as last time. An interview on [DATE] at 7:25 a.m., Staff E, RCT, reported of going into the resident's room (no call light had been on) to check Resident #4's roommate. Resident #4 called out Staff B's name, in a weak voice. Staff E informed the resident who she was and asked the resident what he/she wanted. The resident replied of not being able to take this pain anymore. Staff E put a hand on the resident's stomach, noting it was bloated. She told the resident she would get a nurse. Staff D was already coming down the hall, so Staff E told Staff D, the resident needed a nurse. Staff D promptly went into the room. As Staff E headed down the hall and Staff D called out at her to go get the Charge Nurse. An interview on [DATE] at 8:18 a.m., Staff D, Registered Nurse (RN), reported of coming in [DATE] at 6:00 a.m., when asked by the night aides to check out Resident #4 because something was not right. Staff D assessed the resident, informed the Charge Nurse and had an ambulance called for Resident #4. Staff D reported the night Aides (RCT'S) had informed her Resident #4 was not right all night and the night nurse (Staff B) did not do anything. An interview on [DATE] at 4:15 p.m., Staff B reported of giving the resident a pain medication for abdominal pain. She noted it is okay to give a onetime order of Tylenol as a standing order, and get an affirmative order from the physician later. Staff B reported the resident's temperature was okay, but did not assess any other vitals signs as, the pulse, B/P, and O2 Sat. Staff B acknowledged of not assessing the resident's bowel sounds, or assessing for abdominal distention. Staff B noted the resident did not put on the call light the rest of the night, so felt the resident was contented with the pain medication. Staff B did not recall Staff G reporting to her during the night of this complaint resembling the last episode, where the resident went to the hospital. Staff B acknowledged the failure to document the night's events, and stated she should have. The Medication Administration Record [REDACTED]. The employee counseling form identified Staff B had reported to the DON and Administrator that she was aware that Resident #4 had been in pain. Staff B reported she gave the resident Tylenol for abdomen pain and she had seen the resident ' s stomach distended. Staff B reported she did not complete a full assessment and Resident #4 had been sent to the emergency room soon after 6:00 a.m. when the day nurse arrived and completed an assessment. The facility terminated Staff B because she did not complete an assessment and noted the staff had a prior final warning and suspension for not complementing assessments prior to this incident that occurred on [DATE]. The prior employee counseling from [DATE] documented Staff B received a suspension for the seriousness and possible life threatening consequence from not completing a thorough assessment when a resident ' s condition changed. An interview on [DATE] at 8:41 a.m., the Director of Nursing (DON) reported of being called about the resident's situation. When she came in she questioned how this happened so fast, thus conducted interviews. The 2 night aides had written statements and verbally maintained the same story. The resident complained of abdominal pain, had 1 large stool and 1 small stool. They did report this concern to the night nurse, Staff B (Licensed Practical Nurse). One of the RCT'S reported telling the night nurse, this problem resembled the last time the resident had pain and had to go to the hospital. The DON interviewed Staff B, who reported of giving the resident a pain medication (Tylenol) for abdominal pain. When noted there was no documentation of the Tylenol given on the resident MAR'S. The DON reported Staff B's interview revealed the nurse did not assess the resident ' s pain, or did not assess for bowel sounds or abdominal distention. The DON reported the RCTs were worried about the resident so as soon as Staff D (RN) came into the facility that morning, they both asked her to assess the resident which was done and the resident had been sent to the emergency room . The DON stated they terminated Staff B for not following nursing procedure. The DON reported she would expect an assessment would be completed when the resident complained of abdominal pain, especially knowing the resident's history and to call the physician. During an interview with the Administrator on [DATE] at 9:00 a.m. she reported she did not know that the resident ' s death was related to the bowel obstruction. The DON was also present at this time and stated the physician reported this to the nursing home. The Department requested the death record for Resident #4. The immediate cause of death identified cardiorespiratory arrest due to or as a consequence of acute colonic obstruction with the time of death at 7:16 a.m., on [DATE]. During an interview with the Nurse Consultant on [DATE], at 10:45 a.m. she stated she had issues with Staff B and wrote her up and cut her hours and hoped it would be less stress (for Staff B). The consultant reported she did not agree with the death certificate, feels it was not a bowel obstruction since the resident had two bowel movements that night. An interview with the physician(their medical director) on [DATE] at 12:14 p.m., he stated he called the nursing home and talked with someone to ask if there was anything unusual for the resident as the resident was almost gone by the time he saw the resident in the emergency room .The postmortem x-ray showed bowels with gas so it was not the grastroparesis. The resident had a gastroparesis ,[DATE] times in the past maybe the last time had been in ,[DATE]. The resident would just get huge in a fast time, very suddenly. The physician was asked if the resident had come in earlier to the emergency room , could there have been a different result or could the resident have been saved. The physician shook his head and said, " I don ' t know, but I don ' t think so " . The physician reported this hospital wasn ' t well acquainted with Resident #4. The physician reported he did not know if the hospital would have known what to do as before when they (the hospital) sent the resident to Dubuque in [DATE].

Based on record review, staff and resident interviews the facility failed to report an allegation of neglect to the Department for Resident #4. The facility reported a census of 35 residents. Findings Include: 1. Resident #4's Minimum Data Set (MDS) assessment tool dated [DATE] showed the resident had [DIAGNOSES REDACTED]. The resident had a score of 15 out of 15 for the BIMS (Brief Interview for Mental Status), showing no memory loss. The resident required assistance of 2 staff persons for bed mobility, transfers, and toilet use. The Plan of Care revised on [DATE] showed the resident had complaints of pain related to a history of gastroparesis and abdominal pain. Interventions for this concern included the following: - administer medications as ordered, monitor effectiveness and any adverse side effects. - assess effects of pain on the resident. - evaluate effectiveness of pain management interventions and adjust if ineffective or adverse side effects emerge. - monitor for any complaints of pain, location, duration, quantity, quality, alleviating factors, and aggravating factors. - monitor for any non-verbal signs of pain. The resident had a plan of care revision on [DATE] for being at risk for weight loss/ nutritional issues (with his/her weight at ,[DATE] pounds); and a history of gastroparesis and recent surgery for [REDACTED]. The Progress Notes revealed the following on [DATE] at 1:38 p.m.: the resident had been readmitted to the nursing home after hospitalization and surgery due to twisted bowel. Progress Notes revealed the following for the month of September, 2014: On [DATE] at 7:07 a.m., Staff D, Registered Nurse (RN) documented she had been called to Resident #4 ' s room by Resident Care Technician (RCT) who reported, the resident did not look right. Staff D documented the resident was drowsy, but able to arouse and verbally respond. Resident stated," please, I need some '[MEDICATION NAME] " and did not open his/her eyes. Staff D assessed the resident as follows: temperature at 100.0 degrees, Apical heart rate at 56, respirations at 40, grunting and unable to hear the blood pressure. O2 Sat. not registering. The resident ' s abdomen distended, firm and the resident complained of pain in the abdominal area. Staff D identified no bowel sounds heard, no audible congestion or wheezing, and she was not able to hear lung sounds due to the resident's grunting and not following directions to take deep breathes. Staff D documented the resident ' s skin was cool, clammy, and pale. The resident ' s right amputation mottled along with abdomen. Staff D documented night shift Aide (RCT) reported the resident had 2 bowel movements in the night, large and small with the stool was soft, unformed, and brown in color. The resident voided one time in the night, small amount dark, concentrated urine, brownish in color according to the Aide. Charge Nurse informed of the assessment. At 6:20 a.m., (same date) another nurse (Staff A) documented she called for a transfer order and 911 had been called requesting an ambulance. At 6:35 a.m., the ambulance arrived and transported the resident out of the building. At 7:30 a.m., the physician reported to the nursing home of the resident ' s death. The radiology report dated [DATE] postmortem (at 7:59 a.m.) identified there was [MEDICATION NAME] distention of portions of the color, and air-filled mildly distended loops of small bowel. The report noted cecum may reside in the left upper quadrant. The report noted it was unclear if this represents an obstructive pattern, or ileus (a painful obstruction of the ileum or part of the intestine). The hospital report noted the [AGE] year old resident brought in to theER on [DATE]. The clinical history/[DIAGNOSES REDACTED]. In June (2014) the resident developed volvulus (a loop of bowel is twisted) which resulted in operative intervention. The resident also had an idiopathic intermittent gastroparesis which would present suddenly with hugely dilated stomach, would be treated with NG suction and would resolve and go away. The resident got re-fitted for knee prosthesis last week in hopes of getting back home to care for his/her spouse. When presented at the ER, the resident was cool, clammy, no detectable pulse or blood pressure. The hospital report noted obvious huge, tense, distended abdomen. The NG tube was immediately placed and intravenous access very, very difficult and nonexistent. The resident did not respond to measures and not quite half an hour (,[DATE]) post arrival resuscitative efforts were halted at 7:16 a.m. The resident had a huge dilated colon, proximal ileum. The resident expired as result of cardiorespiratory arrest caused by bowel obstruction, probably due to an acute colonic obstruction/torsion (twisted or rotated). The Department requested the death record for Resident #4. The immediate cause of death identified cardiorespiratory arrest due to or as a consequence of acute colonic obstruction with the time of death at 7:16 a.m., on [DATE]. The employee counseling form identified Staff B had reported to the DON and Administrator that she was aware that Resident #4 had been in pain. Staff B reported she gave the resident Tylenol for abdomen pain and she had seen the resident ' s stomach distended. Staff B reported she did not complete a full assessment and Resident #4 had been sent to the emergency room soon after 6:00 a.m. when the day nurse arrived and completed an assessment. The facility terminated Staff B because she did not complete an assessment and noted the staff had a prior final warning and suspension for not complementing assessments prior to this incident that occurred on [DATE]. The prior employee counseling from [DATE] documented Staff B received a suspension for the seriousness and possible life threatening consequence from not completing a thorough assessment when a resident ' s condition changed. An interview on [DATE] at 8:18 a.m., Staff D, Registered Nurse, reported of coming in [DATE] at 6:00 a.m., when asked by the night aides to check out Resident #4 because something was not right. Staff D assessed the resident, informed the Charge Nurse and had an ambulance called for Resident #4. Staff D reported the night Aides (RCT'S) had informed her, the resident was not right all night and the night nurse (Staff B) did not do anything. Staff D reported Staff B had been suspended (prior) and then put to work on night shift. An interview on [DATE] at 1:55 p.m., Staff C, Resident Care Technician, reported of the resident complaining of 'bad stomach cramps' around 12:48 a.m., during first rounds. She noted the resident had appeared sweaty and clammy, and reported this to the nurse (Staff B). The resident had a large bowel movement and few moments later had a small bowel movement. The resident asked for a pain medication around 4:00 a.m., unsure of where the pain was, but reported it to the nurse (Staff B). After the resident had been sent to the emergency room , Staff C reported to Staff D (morning nurse), the resident did not have a good night and had reported this concern to the night nurse (Staff B) during their shift. An interview on [DATE] at 6:50 a.m., Staff G, RCT, reported the resident complained of stomach cramps around midnight. Staff G stated she told Staff B, about the stomach cramps, who replied, let's see what the bowel movement produces. Around 4:00 a.m., she noticed the resident had a firm stomach and told Staff B. She also reported this seemed similar to the last time the resident had to go to the hospital. Staff G, noted the nurse took equipment and went down to the resident's room. Staff G reported to the morning shift RCT, Staff E the resident " was acting funny " , and when the morning Nurse, Staff D, overheard this she proceed to assess Resident #4 and ordered an ambulance be called. Staff G, reported of looking in on the resident around 5:15 or 5:30 a.m., who was moaning as if sleeping. Staff G said it was like the last episode except the resident did not ask for the NG tube, ask to go to the hospital, or complain of pain as much as last time. An interview on [DATE] at 7:25 a.m., Staff E, RCT, reported of going into the resident's room (no call light had been on) to check Resident #4's roommate. Resident #4 called out Staff B's name in a weak voice. Staff E informed the resident who she was and asked the resident what he/she wanted. The resident replied of not being able to take this pain anymore. Staff E put a hand on the resident's stomach, noting it was 'bloated'. She told the resident she would get a nurse. Staff D was already coming down the hall, so Staff E told Staff D the resident needed a nurse. Staff D promptly went into the room. As Staff E headed down the hall and Staff D called out for her to go get the Charge Nurse. An interview on [DATE] at 4:15 p.m., Staff B reported of giving the resident a pain medication for abdominal pain. She noted it is okay to give a onetime order of Tylenol, as a standing order, and get an affirmative order from the physician later. Staff B reported the resident's temperature was okay, but did not assess any other vitals signs. Staff B reported she did not assess the resident ' s pulse, B/P, or O2 Sat. Staff B acknowledged she did not assess the resident's bowel sounds, or assess the resident for abdominal distention. Staff B noted the resident did not put the call light on the rest of the night so felt the resident was contented with the pain medication. Staff B did not recall Staff G reporting to her during the night of this complaint resembling the last episode where the resident went to the hospital. Staff B acknowledged the failure to document the night's events, and stated she should have. The Medication Administration Record [REDACTED]. An interview on [DATE] at 8:41 a.m., the Director of Nursing (DON) reported of being called about the resident's situation. When she came in, she questioned how this happened so fast, thus conducted interviews. The 2 night aides had written statements and verbally maintained the same story. The resident complained of abdominal pain, had 1 large stool and 1 small stool. They did report this concern to the night nurse, Staff B (Licensed Practical Nurse). One of the RCT'S reported telling the night nurse, this problem resembled the last time the resident had pain and had to go to the hospital. The DON interviewed Staff B, who reported of giving the resident a pain medication (Tylenol) for abdominal pain. When noted there was no documentation of the Tylenol given on the resident MAR'S. The DON reported Staff B's interview revealed the nurse not assess the resident ' s pain, not assessing for bowel sounds or abdominal distention. The DON reported the RCTs were worried about the resident so as soon as Staff D (RN) came into the facility that morning, they both asked her to assess the resident which was done and the resident had been sent to the emergency room . The DON terminated Staff B for not following nursing procedure. The DON reported she would expect an assessment would be completed when the resident complained of abdominal pain, especially knowing the resident's history and to call the physician. The surveyor asked if this should be reported and the DON stated she did not know, but had reported this to the Administrator and the Facility's RN (Registered Nurse) Consultant. During an interview with the Administrator on [DATE] at 9:00 a.m. she reported she did not know that the resident ' s death was related to the bowel obstruction. The DON was also present at this time and stated the physician reported this to the nursing home. During an interview with the Nurse Consultant on [DATE], at 10:45 a.m. she stated, " did not feel it was neglect, just poor nursing " . The Nurse Consultant reported she had issues with Staff B and wrote her up and cut her hours and hoped it would be less stress. The consultant reported she did not agree with the death certificate, feels it was not a bowel obstruction since the resident had two bowel movements that night. The facility ' s Dependent Adult Abuse Policy for prevention, identification, investigation and reporting policy included the following information: Identification, Investigation and Reporting of Abuse: Dependent adult abuse is defined under Iowa law, pursuant to Iowa Code Chapter 235E as: Neglect of a dependent adult abuse, " Neglect of a dependent adult means the deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care or other care necessary to maintain a dependent adult ' s life of physical or mental health. The Reporting section included the following: if an employee is required to make a report pursuant to this section, the person in charge shall notify the Iowa Department of Inspection and Appels within 24 hours of such notification. The department did not receive a report of alleged neglect/abuse.