Every finding on record at Ennoble Nursing and Rehab

Based on observation, resident, family, and staff interviews the facility staff failed to knock and be acknowledged before entering a resident's room for 5 of 5 residents (Residents #1, #5, #17, #33 and#39). Facility reported census of 61 residents. Findings include: Resident #17's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive response. The MDS documented Resident #17 as independent (Resident completes the activity by themselves with no assistance from a helper for self-care). The MDS listed diagnoses of anxiety disorder, depression, coronary artery disease, and hypertension. During an interview on 07/15/24 at 11:02 AM, Resident #17 reported she was getting dressed one time and the staff just walked in. Resident #17 voiced she would like them to knock before entering. On 07/16/24 at 7:23 AM, observed Staff C (housekeeper) enter room D1 without knocking. Resident #17 and Resident #39 were present in the room. On 07/16/24 at 7:39 AM, observed Staff C enter room R15 without knocking. Resident #5 was present in the room. On 7/17/24 at 9:00 AM, observed Staff C enter room R17 without knocking. Resident #33 was present in the room. On 7/17/24 at 9:02 AM, observed Staff C enter room R13 without knocking. Resident #1 was present in the room. During review of personnel records on 07/17/24 at 9:34 AM, page 3 of Staff C's position description indicated she should knock before entering a resident's room. Staff C signed the position description on 06/14/23. An updated position description was provided to Staff C documenting the resident rights functions and knock before entering a resident's room. Staff C signed the position description on 03/20/24. During an interview on 07/17/24 at 10:24 AM, the Director of Nursing (DON) reported staff were to knock on the door and identify themselves prior to entering a resident room. Training on resident rights was provided upon hire and annually. During an interview on 07/17/24 at 10:30 AM, the Administrator reported resident rights training was provided on 09/24/23. Staff C was in attendance for the training. Resident privacy and confidentiality were discussed in the facility policy. During an interview on 07/17/24 at 1:35 PM, Staff C reported staff were to knock and identify themselves before entering a resident room.

Based on observation, record review, and staff interview the facility failed to keep Foley catheter and tubing off the ground to maintain infection control for 1 out of 2 catheters reviewed (Resident #28). The facility also failed to wear appropriate personal protective equipment when handling dirty linens and failed to properly cover linens when transporting. The facility reported a census of 61 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #28 as mildly cognitively impaired with a BIMS (Brief Interview for Mental Status) of 12 out of 15. The MDS listed the following diagnoses Anemia, Renal Insufficiency, and Neurogenic Bladder. It also identified Resident #28 required total assist of staff with personal hygiene, bathing, and toileting. The MDS indicated the resident had an indwelling catheter. Review of the final urine culture dated 6/16/24 indicated Resident #28 had a urinary tract infection and was started on Keflex (antibiotic) 500 milligram three times a day for seven days. Review of the Care Plan with a date initiated 6/20/24 indicated Resident #28 had an indwelling Foley catheter. The interventions directed staff to check tubing for kinks, position catheter bag and tubing below the level of the bladder, monitor and report to medical doctor for signs and symptoms of urinary tract infection. The Care Plan failed to address placement of tubing or Foley bag from touching the ground/floor. On 07/15/24 at 11:57 AM observed Staff pushing Resident #28 down the center hall in her wheelchair. The Foley catheter tubing and bag were touching the ground. The catheter bag had a privacy cover on it. On 07/15/24 at 12:25 PM observed Resident #28 in her wheelchair in the assisted dining room her Foley catheter bag on the ground and tubing was touching the ground under her wheelchair. On 07/16/24 at 7:55 AM Resident #28 observed sitting in her wheelchair in the assisted dining room catheter bag under the wheelchair resting on the ground and tubing on the ground. On 07/16/24 at 9:44 AM Resident #28 observed sitting in wheelchair in her room the catheter bag with privacy bag resting on the ground with tubing touching the ground. On 07/17/24 at 12:25 PM Resident #28 sitting in her wheelchair at the table in the dining room. Catheter tubing was lying on the ground below the chair. On 07/18/24 at 07:55 AM Staff A, Certified Nursing Assistant (CNA) stated the Foley bag and tubing should all be kept down below the level of the bladder. The catheter bag should be in the dignity bag underneath the wheelchair and it should not be touching the ground. The tubing should be looped and in the bag clipped up under the wheelchair and when in the bed the tubing should be clipped and secured so it does not touch the ground. On 07/18/24 07:58 AM Staff E, Licensed Practical Nurse (LPN) stated for a Foley catheter the tubing should be twisted up and off the floor and the bag should be off the floor. The tubing should never be kinked and kept below the bladder with the dignity bag covering it and make sure the tubing is off the floor. On 07/18/24 at 8:02 AM the Director of Nursing stated she would expect the Foley catheter bag to be kept inside the dignity bag unless they are in bed. The tubing should be off the ground and the tubing should be coiled up and in the dignity bag. When they are in bed laying down it should be beside down them and off the ground. The facility provided a policy titled Emptying a Urinary Drainage Bag with a revised date October 2010 which directed staff to keep the drainage bag and tubing off the floor at all times to prevent contamination and damage. 49976 2. In an observation on 7/17/24 from 8:32-8:44 AM Staff D, Housekeeper wheeled laundry down the hall and began to distribute it. Only the top shelf of the cart was covered with a sheet. Personal items were exposed on the lower two shelves with resident names visible. This was observed again at 12:45 PM. In an observation on 7/17/24 at 9:42 AM Staff D wore gloves and failed to wear a gown when she took linens and Personal Protective Equipment (PPE) gowns from a bin and placed them in the washing machine. In an interview on 7/17/24 at 8:11 AM the Environmental Services Supervisor (ESS) explained laundry staff gown up just when washing items coming from isolation rooms. During an interview on 7/17/24 at 12:30 PM the ESS explained she was not aware gown and gloves must be worn for all dirty laundry. She was aware that the laundry cart needed to be completely covered when transporting clean linens. The policy titled Standard Precautions, revised September 2022 instructed staff: linen soiled with blood, body fluids, secretions, excretions are handled and processed in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to other residents and environments. The policy titled Laundry Management, dated 1/01/2021 instructed staff: clean linen must be transported from the laundry to the clinical area on a clean covered cart. The policy failed to indicate the need for a gown when handling all dirty linens.

Based on record review, law enforcement and staff interview the facility failed to provide transport to a higher level of care in a timely manner when resident assessment revealed a change in condition for 1 out of 3 residents reviewed (Resident #2). The facility reported a census of 57 residents. Findings include: The MDS (Minimum Data Set) dated 2/22/21 indicated that Resident # 2 had moderately impaired cognition with a BIMS (Brief Interview for Mental Status) score of 12. The MDS listed resident active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also indicated that Resident #2 needed extensive assist of one with bed mobility, transfers, bathing and dressing. Review of Resident # 2's progress notes from 2/22/21 at 3:45 p.m. revealed Resident #2 not responding to verbal or tactile stimuli. Unable to obtain manual blood pressure, electronic 143/38, heart rate 80, respirations 28, oxygen saturation 85% on room air, oxygen started at 2 liters per nasal cannula. Skin warm and dry, color pale. Lung sounds clear. Attempted to call condition report to physician, message left to return the call. A condition report called to son wants sent to emergency room for evaluation. A condition report to medical director new order noted. Review of the nursing home to hospital transfer form revealed resident sent to the hospital on 2/22/21 at 4:31 p.m. During an interview on 8/11/21 at 9:05 a.m., a local law enforcement officer revealed the facility initiated the call to 911 emergency services at 4:29 p.m. on 2/22/21 for transport of unconscious female to the hospital. During an interview on 8/11/21 at 10:04 a.m. with transport services human resource stated they have no record of call received from the facility for transport services on 2/22/21. Review of the emergency department physician note revealed Resident # 2 was seen 2/22/21 at 5:20 p.m. and revealed at the time emergency medical services picked her up the resident was unresponsive and hypoxic. They placed a nasal cannula and nonbreather mask at 15 liters with resultant oxygen saturations of 85%. Patient is unresponsive at the time of arrival. Her blood pressure was in the 70's systolic. No other history is available. No report showing called from the nursing home. During an interview on 8/11/21 at 10:10 a.m. with Staff A, Licensed Practical Nurse (LPN) stated for Resident #2 discharge to hospital on 2/22/21 we notified the Power of Attorney (POA) of condition change and he wanted her sent to the emergency room . I contacted the physician office and he did not respond and decided to call our Medical Director. A transport service notified of need for services but unable to transport so 911 activated. We call for transport as soon as we possibly can when someone is declining. During an interview on 8/11/21 at 10:55 a.m., the Director of Nursing (DON) stated she would expect staff to complete an assessment and notify family if there is a change of condition in a resident. The staff should work as a team to notify hospital, call transport services and if they cannot come in a timely manner notify emergency medical services. During an interview on 8/11/21 at 2:30 p.m. with Staff B, Registered Nurse (RN) stated she would immediately activate 911 after contacting the physician for order and talking to the family when a resident has a change in condition. During an interview on 8/11/21 at 2:40 p.m. with Staff C, LPN she stated if residents change in condition is an emergency would call 911 and fax the hospital and this would take minutes to send resident to the hospital. If the transfer is non-emergent then it takes about 15 minutes to get everything ready and send the resident out. Review of facility policy titled, Discharging the Resident, with a last revision date of February 2016 revealed the following directions to staff under discharging/transferring to the hospital number 6. Directions stated that should it become necessary to make an emergency transfer or discharge to a hospital or other related institution; our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made c. Prepare the resident for the transfer d. Prepare a transfer form to send with the resident e. Notify the representative or other family member f. Assist in obtaining transportation g. Others as appropriate or as necessary -

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure staff promoted resident dignity during the dining experience for two residents observed. (Resident #8 & #123) The facility census was 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 required extensive assistance with dining. During observation on 1/7/20 at 8:21 a.m., Staff B, Certified Nurse Aide, CNA was standing next to the resident who was seated for breakfast, assisting them to eat. Staff B left the resident and Staff J, CNA approached the resident and began assisting the resident while standing next to him. During observation on 1/8/20 at 8:18 a.m., Staff F, CNA was standing next to the resident assisted him to eat breakfast. Staff failed to sit down and be at eye level with the resident during the entire meal. 2. The plan of care dated 12/31/19, documented Resident #213 was to be assisted with dining (set up and/or assistance to eat). During observation on 1/7/20 at 12:27 p.m., Staff K, CNA stood next to the resident who was seated for lunch, assisting them to eat. Staff K did squat down when the resident started coughing but then stood up to finish assisting the resident to complete her meal. Staff failed to be at eye level with the resident. During interview on 1/9/20 at 7:16 a.m., Staff K, CNA stated if we are assisting a resident with eating we should be sitting down next to the resident and facing toward the resident. During interview on 1/9/20 at 7:29 a.m., Staff L, CNA stated when assisting a resident with eating, staff should be at eye level and should be visible and able to talk to the resident. During interview on 1/9/20 at 7:31 a.m., the Nurse manager expected staff to be on the side of the resident and should be sitting in a chair in between residents. Staff should be at eye level with residents. During interview on 1/9/20 at 7:34 a.m., the Administrator expected staff to sit in a chair and assist residents to eat. The facility provided an assistance with meals policy revised (MONTH) (YEAR) which encouraged staff to sit and not stand over patients while assisting them with meals.

Based on observation, clinical record review and staff interview, the facility failed to ensure staff provided complete perineal care for one of three residents observed during personal care. (Resident #29) The facility census was 66 residents. Finding include: 1. The Minimum Data Set (MDS) assessment dated [DATE], showed Resident #29 required extensive staff assistance for transfer and toilet use and was frequently incontinence. The Care Plan dated 8/10/18, identified the resident as incontinent of bowel and bladder and had interventions so assist with toileting by staff and clean peri-area with each incontinence episode. During observation on 1/6/20 at 12:12 p.m., Staff B, Certified Nurse Aide, CNA toileted the resident who had a soiled brief. Staff B wiped the resident from front to back with one swipe of toilet paper and put on a new brief. Staff B failed to provide complete peri care when a resident was incontinent. During interview on 1/8/20 at 9:07 at 8:25 a.m., Staff C reported if a resident's brief was soiled, staff should do full peri cares and not just wipe the resident with paper tissue. During interview on 1/8/19 at 8:29 a.m., Staff D, Licensed Practical Nurse (LPN), reported staff should always do peri cares when a resident was incontinent. During interview on 1/8/20 at 1:55 p.m., the Nurse Manger reported observing the peri care and complete peri care was not done.

Based on observation, clinical record review and staff interview, the facility failed to ensure staff completed resident transfer in a safe manner in order to prevent accidents for two of two residents reviewed. (Resident #23 & #29 ) The facility census was 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #23 required extensive staff assistance for transfers, ambulation and other daily cares and had [DIAGNOSES REDACTED]. The Care Plan revised on 12/24/19, documented the resident had a risk for falls and injuries related to forgetfulness and de-conditioning, dementia, Alzheimer's, and won't use call light for assistance when feeling weak or unsteady. The Care Plan Interventions included : - toileting with an assist of 1 staff person (initiated on 07/31/2019). - transfer with an assist of 1 with a walker (initiated on 07/31/2019). Observation on 1/6/20 at 11:26 a.m., revealed the resident was toileted by Staff B, Certified Nurse Aide, CNA and remarked the resident had been weak today and wanted to assist the resident to bathroom. The Nurse Manager (also observing) reported they just assist the resident. Staff B transferred the resident from the toilet with the walker and walked the resident over to the wheelchair (approximately 6 feet) without using a gait belt. Observation 1/6/20 at 1:29 p.m., revealed a staff person transferring the resident from the dining room chair to the wheelchair, using a gait belt. During interview on 1/8/20 at 9:50 a.m., Staff E, Licensed Practical Nurse, LPN reported if the care plan stated 'assist with a walker' indicates staff assist using a gait belt, otherwise the care plan would state 'SBA' for Stand-By-Assist, or ambulate the resident with 'hand in hand' assist. She noted this was just standard practice. During interview on 1/8/20 at 2:00 p.m., the Nurse Manager reported it was in facility policy for staff to use the gait belt with transfers unless directed otherwise. The facility's Policy for Safe Lifting and Movement of Residents dated 7/2017 showed the Statement as: in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The Policy Interpretation and Implementation included: - staff are responsible for direct resident care will be trained in the use of manual (gait/ gait belts, and lateral boards) and mechanical lifting devices. - when ambulating residents, staff members should use a gait belt unless the resident's plan of care states otherwise. 2. The MDS assessment dated [DATE], documented Resident #29 required extensive staff assistance for transfer and toilet use and was frequently incontinence. The MDS showed the resident had [DIAGNOSES REDACTED]. The Care Plan revised on 11/19/19, identified the resident at risk for falls and injuries related to medication, blood pressure medication and required staff assist for transfers, impaired balance. The goal showed to decrease the risk of falls and/or minimize injuries from falls for 90 days. The Care Plan dated 8/10/18 also identified the resident had a self-care deficit and the need for staff assistance for daily living activities with interventions included the following: - toilet use: one person physical assist required. - transfer: one person physical assistance required. Observation on 1/7/20 at 8:10 a.m., Staff C,CNA walked the resident from the bed to the bathroom, approximately 10 feet without a gait belt. Observation revealed Staff C had a gait belt around her waist.

Based on clinical record review, facility policy review, staff and family interviews, the facility failed to provide CPR (Cardio [MEDICAL CONDITION] Resuscitation) to one of four residents reviewed during the investigation. Resident #1 was found pulseless and without respirations and CPR was not initiated. The facility census was 63 residents and 21 of those residents had designated for full resuscitation. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had moderately impaired cognitive skills and required extensive assistance to transfer and ambulate. A facility Expression of Wishes form dated [DATE], documented the resident requested Full Code Status. The Power of Attorney form revealed the resident designated his/her spouse as his/her agent. The plan of care included Admission Baseline- Full CPR, monitor breathing pattern, oxygen saturation and respiratory rate. The Admission Nursing Assessment effective [DATE] included an intervention for full CPR. A Physician order [REDACTED]. Progress Notes dated [DATE] at 9:17 p.m., documented Staff C, registered nurse, RN documented the resident experienced a possible change of condition and noted shortness of breath and other change in condition. Staff C notified the physician at 9:45 p.m. See SBAR for further information. At 9:55 p.m., Staff C documented the physician ordered 20 milligrams (mg) of [MEDICATION NAME] now and increase oxygen to 3 liters per mask, monitor condition and if worsens, will need to evaluate at emergency room . Contact physician in morning with condition report. Staff C notified the resident's spouse and the spouse stated she noticed a decline today while visiting and would not be surprised if he ended up in the hospital, she thought he was giving up. Progress Notes dated [DATE] at 12:17 a.m., documented Staff C noted the resident had a large amount of incontinent urine and oxygen saturation level was at 80% with oxygen at 3 liters. The resident continued with productive cough of clear frothy phlegm and refused times two to offer to send to emergency room and stated what would they do anyway. Discussed at length and continued to refuse to go and stated he was not having trouble breathing. At 1:03 a.m., Staff C documented the resident was awake and alert with oxygen saturation at 80% and continued with productive cough with clear phlegm and denied shortness of breath. Staff C noted the resident had difficulty with conversation and refused to go to the emergency room and said they would just keep him. At 2:00 a.m., notes revealed Staff C checked the resident on rounds and had saturation at 80% with oxygen at 3 liters, head of bed elevated, no distress and sleeping. At 2:45 a.m., Staff C documented the resident had no pulse, blood pressure or apical. The resident had cyanotic and cool skin. Call placed to spouse who stated no CPR, the resident would not want it and it should have been changed. At 3:00 a.m., Staff C reported the resident's spouse arrived and said she knew the resident worsened the last few days and would not have wanted to go back to the hospital. The spouse again said the resident did not want CPR. At 4:45 a.m., the funeral home left with the resident's body. At 8:17 a.m., the DON notified the physician of the resident's passing. The SBAR (Situation, Background, Appearance, Review) Communication Form dated [DATE], documented Staff C documented the resident had a change in condition with symptoms of shortness of breath and other change in condition. Oxygen saturation at 76% at 2 liters, congested, clear frothy phlegm and cyanotic. Condition worse and nebulizer treatment given without improvement and movement and talking made symptoms worse. Vital signs: Blood pressure ,[DATE], pulse 63, respiratory rate 20, temperature 98.4, weight 259 pounds. Respiratory Evaluation: abnormal lung sounds, cough, labored or rapid breathing, shortness of breath and large amounts of clear frothy phlegm. Appearance: Worsening of [MEDICAL CONDITION]. Resident's Weights and Vital Summary included: Oxygen Saturations: [DATE] at 9:21 p.m. -79% via nasal cannula [DATE] at 10:18 a.m.- 90% [DATE] at 7:46 a.m. - 90% Respiration Summary: [DATE] at 1:44 p.m. - 20 breaths per minute [DATE] at 9:54 p.m. - 19 breaths per minute [DATE] at 10:17 a.m. - 20 breaths per minute Pulse Summary: [DATE] at 1:44 p.m. - 63 beats per minute [DATE] at 9:54 p.m. - 50 beats per minute [DATE] at 10:17 a.m. - 58 beats per minute Temperature Summary: [DATE] at 1:44 p.m. - 98.4 degrees Fahrenheit [DATE] at 9:54 p.m. - 94.3 degrees [DATE] at 10:17 a.m. - 97.3 degrees Blood Pressure Summary: [DATE] at 1:44 p.m. - ,[DATE] [DATE] at 9:54 p.m. - ,[DATE] [DATE] at 10:17 a.m. - ,[DATE] A physician progress notes [REDACTED]. The resident's head hung forward and he failed to lift his head up to look at the physician. The resident had decreased lung sounds without rales or rhonchi, irregular but controlled heart rate, bilateral pedal [MEDICAL CONDITION] and a small sore on the right lower shin that appeared to be healing. The resident had evidence of fluid overload and ordered [MEDICATION NAME] (diuretic) daily, and no signs of pneumonia. The resident had an appointment to see the cardiologist the following week. Timeline of Events included: On [DATE] at 1:25 p.m., the resident returned from the physicians office with new orders for [MEDICATION NAME] 40 mg (milligrams) and Potassium 20 mg daily. Laboratory tests done at office. At 2:03 p.m., laboratory tests received with new orders for [MEDICATION NAME] 15 grams times two doses; clarification with physician returning call at 6:07 p.m., physician changed orders to discontinue potassium and give one dose of [MEDICATION NAME] today and one dose tomorrow. At 9:17 p.m., noted change of condition by charge nurse (shortness of breath). Physician notified. At 9:55 p.m., on call physician notified, new orders received, call placed to spouse (POA) with notification of change of condition. At 11:00 p.m., Charge nurse did vital signs and stated resident resting in bed with no distress. On [DATE] at 12:27 a.m., charge nurse assessed resident again, resident refused to go to the emergency room and had no complaints of difficulty breathing. Charge nurse again asked resident to go to the emergency room and again refused. At 1:03 a.m., charge nurse checked oxygen saturation, again asked resident to go to the emergency room and he refused. At 2:00 a.m., charge nurse and Certified Nurse Aide, CNA assisted with incontinence care, checked vitals and no distress noted. At 2:45 a.m., CNA found resident unresponsive, paged for charge nurse and nurse responded. Resident was cold and cyanotic with no radial pulse or breaths noted. Nurse ran to telephone residents spouse to inform that CPR needed to be initiated. Wife stated definitely not, no CPR, resident would not want that, it should have been changed. The facility layout revealed the resident's room A-8 had three other resident rooms, two utility storage rooms and an activity storage room between it and the nurses station on A Hall. During interview on [DATE] at 9:15 a.m., the resident's spouse reported she last visited the resident on [DATE] at the facility and left at approximately 2:30 p.m. The facility contacted her early in the morning and reported they had called the physician and started the resident on [MEDICATION NAME], a diuretic. The nurse asked if they should send the resident to the hospital. The spouse indicated the resident made those decisions and apparently he did not want to go when the nurse asked. The resident told the spouse several times that he did not want to go to the hospital and did not want to go through all of that again. The resident had [MEDICAL CONDITION] for several years. Around 3 o'clock in the morning the facility called the spouse again and said the resident had just passed away and what did she want to do, did she want to go to the facility. The spouse went to the facility and staff assisted with funeral arrangements. The nurse had asked if the spouse wanted the resident to have CPR. The spouse indicated it was the resident's wishes not to have CPR if he could not survive. The spouse told the nurse the resident did not want to be saved, did not want to go to the hospital and to let him rest. When the resident told the spouse about CPR, he said only if he could survive, only if it would help him live longer. The resident did not want to be put on machines. The resident had a pacemaker and the spouse thought that could be an issue. The spouse said the resident was tired of fighting it, just gave up. The spouse said the facility never called after notifying her of the new order for [MEDICATION NAME] until they called when the resident passed away. The spouse revealed had she known of the resident's worsened condition, she may have told them to go ahead and send the resident. During interview on [DATE] at 12:30 p.m., Staff A, Administrator reported the resident passed away and his full code status had not changed since admission on [DATE]. Staff C, RN worked from 6 o'clock p.m. on [DATE] until 6 o'clock a.m. on [DATE]. During the night shift, Staff C noted the resident had a change in condition, assessed the resident and notified the physician and received a new physician order. Staff C notified the resident's spouse. Staff asked the resident to go to the emergency room , but the resident refused. The resident's spouse said she felt the resident was giving up. The resident's oxygen saturation level measured 80%. Staff C checked on the resident frequently. At approximately 2 o'clock a.m., Staff D, CNA and Staff C provided cares for the resident and at 2:45 a.m. Staff D observed the resident without respirations. Staff C knew the resident had a full code status, the resident appeared cold and cyanotic and called the spouse. The spouse said not to start CPR; the resident would not want it. Staff A and Staff B, DON (Director of Nursing) interviewed Staff C and suspended her and reported it to the Iowa Board of Nursing, Ombudsman and the physician. Staff B educated all nurses before they stepped onto the floor. They also did an audit on all residents and their code status. Staff C checked the resident's code status around midnight that night and knew he was a full code. During interview on [DATE] at 2:20 p.m., Staff B, DON revealed the facility suspended Staff C for not following the CPR policy and not notifying the physician of the residents worsened condition. The resident's oxygen saturation level read 80%. Staff C said she kept a close eye on the resident and asked the resident if he wanted to go to the emergency room but the resident refused. Staff D, CNA called Staff C immediately upon observation. Staff B educated all nurses on [DATE] regarding the CPR policy, assessment after a significant change and the completion of vital signs. The facility did an audit of all resident's code status. During interview on [DATE] at 2:43 p.m., Staff C, RN reported she worked at the facility for three years. On [DATE] staff assisted the resident to bed. The resident had his own machine for measuring oxygen saturation and it read 76%. Staff C assessed the resident and administered a breathing treatment without a change in condition and she notified the physician. The physician ordered [MEDICATION NAME] and to increase the resident's oxygen to 3 liters. The physician told Staff C if the resident's symptoms get worse, he suggested the resident go to the emergency room . Staff C explained to the resident what the physician wanted him to go to the emergency room if he did not improve. The resident said he did not want to go. At midnight Staff C and Staff D provided cares and the resident's oxygen saturation read 80% and he coughed up phlegm. The resident said he was fine. Staff C encouraged the resident to go to the emergency room , but the resident refused. Earlier when Staff C called the resident's spouse, she said the resident had not felt well. Staff C told the spouse the resident should go to the hospital and the spouse indicated she was not surprised. At approximately 2 o'clock a.m., Staff C and Staff D provided cares, the resident's oxygen saturation read 80% and the resident slept. The resident's fingernails did not appear bluish at that point and the resident woke up when they provided cares. At approximately 2:45 a.m., Staff D called Staff C to the residents room as she thought the resident had passed. Staff assessed the resident and found the resident stiff and no pulse. Staff C ran to the desk and called the spouse. Staff C reported she knew the resident was a full code but he was cold and stiff. Staff C told the spouse they could start CPR and call 911 and the spouse told Staff C no, he would not want that. Staff C revealed the CPR policy required staff to start CPR on a resident with a full code status. Staff C felt since the spouse said not to do CPR, she did not do it. Staff C indicated if she knew the resident was near death, she would have sent the resident. But, the resident seemed alert ,did not show signs such as blue fingernails and appeared to be doing better. If Staff C had known, she would have called the spouse and said they needed to send the resident and the spouse probably would have gone along with it. When the spouse came to the facility after the resident passed, Staff assisted her with funeral home arrangements. Staff C received a write up and education, she knew the policy but thought the spouse made the call. The facility suspended Staff C from work. Staff C reported she felt bad and realized she should have done CPR. Upon hire, she reviewed the CPR policy. During interview on [DATE] at 3:35 p.m., Staff C revealed when she assessed the resident on [DATE] the resident sat upright with the head of bed elevated. Staff C observed the resident felt cool and had cyanotic fingernails and mouth. Staff C grabbed the resident's right and left wrists and found no pulse. Staff C put her head and hand on the resident's chest and failed to feel respirations or hear a heart beat. Staff C had no stethoscope with him/her at the time. The resident's eyes were half open and glassy. Staff C reported she just checked radial pulse and respirations. The bed sheet covered the lower extremities. The resident sat up just like they left him approximately 30 minutes prior. Staff B could tell when she picked up the resident's wrists that the resident was abnormally and moderately stiff, and limp with no physical response at all. The hands, fingernails and mouth were bluish/purple and all over pale and cold. Staff C knew the CPR policy and knew the resident had a full code status. If the spouse had requested CPR, Staff C would have provided it. During interview on [DATE] at 11:40 a.m., Staff D, CNA reported working on [DATE] at 10 o'clock p.m. until [DATE] at 6 o'clock a.m. When Staff D arrived at the facility she heard in report the residents oxygen saturation levels fluctuated and he needed to frequent checks. Staff D reported the resident appeared lethargic and complained of being hot and reported it to Staff C. Staff D opened the resident's window and covered him/her with a sheet. Staff C frequently asked the resident if he wanted to go to the hospital and the resident refused. At approximately 2 o'clock a.m. Staff D and Staff C provided cares and repositioned the resident. A half hour later, Staff D entered the resident's room and the resident had passed away. Staff D observed the resident lifeless, cold to the touch and when Staff D placed her hand on the resident's stomach, she felt no movement. Staff D called Staff C to the room. Staff D observed Staff C look at the resident, feel the residents wrists and said yes, he was dead. Staff C called the resident's wife. Staff D reported she had no knowledge the resident had a full code status. Staff C never revealed the resident's code status or what the spouse said. Staff C and Staff D prepared the body, the resident's spouse arrived and they assisted with finding a funeral home. During interview on [DATE] at 12:48 p.m., Staff D revealed at 2:30 a.m., the resident's head drooped down and Staff D felt no respirations. After Staff C called the resident's spouse, Staff D and Staff C pulled the bed sheet back and moved the resident. The limbs were stiff and the residents face and legs appeared purple. They placed the resident's arms up on his/her chest, they had to bend them at the elbow, not horribly difficult but stiff. During interview on [DATE] at 11:10 a.m., Staff F, RN reported working from 6 o'clock p.m. on [DATE] until 6 o'clock a.m. in [DATE] in the back section of the building. Staff C worked the front section and never called a code, and never informed Staff F of the residents passing. Staff C told Staff F the resident had passed and the spouse was on the way. Staff F reported the CPR policy required staff to initiate CPR of full code residents no matter what, even if the resident had clearly passed away, until Emergency Medical Services (EMS) arrived and took over, or the power of attorney tells them to stop. All staff were re-educated regarding the policy. During interview on [DATE] at 2 o'clock p.m., Staff G, Licensed Practical Nurse, LPN reported working on [DATE] during the day shift. The resident went to the physician during the day and appeared normal. The resident's profile documented the code status. All staff knew where to look for code status and knew to initiate CPR on a resident with full code status, direct someone to call 911 and do not stop until paramedics arrive. The DON provided re-education for all staff regarding CPR and code status. During interview on [DATE] at 1:50 p.m. Staff H, LPN reported staff was to initiate CPR after checking if you are not sure, even if the resident obviously passed away until EMS arrives. The DON re-educated all nurses regarding initiating CPR. When the resident was admitted , Staff H asked the resident and his spouse about the full code status. The spouse said the resident had a full code status and they were working on it. Staff H directed them to discuss it with the social worker if needed. During interview on [DATE] at 9:05 a.m., Staff I, Social Worker reported she reviewed admission paper work with the resident and read the facility Expression of Wishes form and repeated it again to ensure the resident understood the question. The resident electronically signed the form and requested full code status. The spouse did not say anything. The resident was alert and oriented. The Immediate Jeopardy was corrected on [DATE] after the following actions were taken: The facility Education Campus, nursing - licensed only form revealed on [DATE] nurses received the following education: Recognizing and Responding to CPR - Full Code, instructed by the DON. Subject: Cardiopulmonary Resuscitation (CPR), approved by(NAME)Lin, MD, effective date [DATE]. Policy: Facility clinical staff shall respond immediately to all notifications of patient arrest and need for resuscitative interventions. All licensed Respiratory Care Practitioners (RCP's)and Nursing of facility may perform CPR services under the general supervision of the physician. All RCP's, RN's and LVN's must be certified as Providers of Basic Life Support, either by the American Heart Association or the American Red Cross. To Call Code Blue in the facility: When a patient shows signs of cardiac or respiratory arrest, Code Blue must be called, unless a specific written order by the physician states that a code shall not be called. Clinical staff shall perform the following when calling a Code Blue: If the patient shows no pulse or sign of respiration, Code Blue must be called. CPR must be initiated immediately when the Code Blue has been called. The Code Blue Team shall respond once the call has been made. Regardless of how long the patient may have been in this condition, CPR must be initiated at once after the condition has been discovered. Note; The attending physician must be notified that CPR has been performed. This is the RN's responsibility. Effective immediately, [DATE] included: a. Nurses will not copy and paste assessments b. Nurses will do your own vital signs on every assessment you need to complete skilled, etc. c. Vital signs on your assessment will be current (day of the assessment) d. Nurses will have stethoscope on them at all times. e. Change in condition - need to re-evaluate condition and document findings until patient is stable, include vital signs, notify MD again if condition not improving and document it, notify DPOA (Durable Power of Attorney) again if condition not improving and document it and if full code may want to contact DPOA and have them change it. f. Full code - you start CPR immediately, you can have another staff member call 911 and then the DPOA to see if they still want CPR even after the patient is found deceased g. Braden and Skin Assessments - signing them off on the eMAR (medication administration record) and not completing them in PCC (Point Click Care). The facility Quality Improvement Action Plan included: a. Quality Deficiency - Not performing CPR on a full code status patient Interventions/Action Steps - MD notified, DIA (Department of Inspections and Appeals) notified, Ombudsmen notified, Iowa Board of Nursing notified, Investigation initiated, Licensed nurse suspended, Licensed nursing employees re-educated on policy of CPR full code patients will have CPR initiated immediately if patient found without a pulse and audits to be completed for 8 weeks. Responsible persons - DON and Administrator Target Date - [DATE] b. Quality Deficiency - Not completing comprehensive assessment or documentation after significant change with no improvement, not taking complete vital signs. Not notifying MD or DPOA after significant change with no improvements and copy and pasting assessments and vital signs, not day of assessment. Interventions/Action Steps - Patients with current condition changes have been reviewed, licensed nursing employee's re-educated on Interact 3.0 and Promoting Effective Communication and Coordination of Care, and audits completed for 8 weeks by the DON. Target Date - [DATE]

Based on observation, interviews, and record review the facility failed to handle food in a sanitary manner for 2 out of 2 meals observed in 2 out of 2 dining rooms. The facility; reported a census of 61 residents. Findings included: During an observation on 8/1/17 at 7:46-7:58 a.m., Staff J-Cook with gloved hands, pushed the steam table from the independent dining room to the assisted dining room and plugged the power cord into the outlet. After transporting the steam table Staff J did not change their gloves, wash hands or use hand sanitizer before serving the residents breakfast. Staff J proceeded to serve 3 residents breakfast without changing gloves. At 7:49 Staff J with the same gloved hands opened the bread bag, removed 4 slices of bread and placed them in the toaster. With the same gloved hands Staff J took bread from the bread bag, placed it in the toaster 12 more times during the meal, while handling the egg scoop, tongues, cereal container, butter, and jelly packets. At 7:58 a.m., Staff J sneezed into the gloved hand and served 1 more resident breakfast. During an observation on 8/1/17 at 11:45-11:54 a.m., Staff K-Cook with bare hands pushed the steam table from the independent dining room to the assisted dining room prior to Staff K picking up a hot dog bun and placing it on a resident's plate, the staff failed to wash hands or use hand sanitizer. Staff K picked up plates and scooped up beans with the bare hands. Staff J with a gloved hand picked up a hand full of potato chips from a large bowl and placed the chips on the resident's plates. Staff K handled serving utensils, plates and hot dog buns with bare hands for a total of 16 resident. Staff J used the same gloved hands to serve potato chips to a total of 13 residents. During an interview on 8/1/17 at 12:01 p.m., Staff J reported handling bread and chips with gloved hands after handling plates, serving utensils, butter, jelly packets and the plug in cord was an appropriate practice. During an interview on 8/1/17 at 12:03 p.m., Staff K reported using hand sanitizer before lunch service. Staff K reported the normal standard is to use tongs when handling bread not bare hands. During an interview on 8/2/17 at 10:10 a.m., the Dietary Manager reported staff are expected to use tongs when serving bread and chips. The Dietary Manager stated further training is needed for Staff J and Staff K. The facility provided a policy titled Safe Food Handling dated 2/09, the policy indicated resident food should be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods with hands. The facility provided an undated policy titled Dish Handling, directing gloves are to be worn when handling food items only. Wash hands before putting on gloves and removing them. Remember once a glove has touched anything other then food, it must be changed.

Based on observation, interview, and record review the facility failed to provide complete peri-care for 1 out of 5 resident reviewed (Resident # 3.) The facility reported a census of 61 residents. Findings included: The Minimum Date Set (MDS) for Resident # 3 dated 6/1/17, listed a [DIAGNOSES REDACTED]. The MDS continued to reflect the resident is totally dependent on 2 staff for transfers/toileting and is always incontinent of bowel and bladder. The Care Plan for Resident # 3 dated 6/2/17, directed staff to provide 2 person physical assist to toilet, 1 person physical assist with personal hygiene and staff are directed to clean peri-area after each incontinent episode. Review of the Resident's Urinalysis and culture dated 6/9/17, the results indicated the resident had greater than 100,000 cfu per milliliter (ml) of Escherichia coil (E.coli) (a bacteria found in the intestine). During an observation on 7/31/17 at 1:44 p.m., Staff L Certified Nursing Assistant (CNA) and Staff F CNA placed Resident # 3 on the toilet. Staff L reported the brief removed contained bowel movement and urine. At 1:52 p.m., Staff F failed to wash the front peri-area. Staff F wiped the rectal area with 3 swipes without changing the surface of the wash cloth, bowel movement visible on the wash cloth. Staff F changed the surface and again wiped the rectal area 3 times without changing the surface of the cloth with each swipe. During an interview on 8/2/17 at 11:00 a.m., Staff E CNA reported when a resident is incontinent of bowel and bladder staff need to complete full peri-care washing the front to back and changing the surface with each swipe of the cloth. During an interview on 8/2/17 at 11:05 a.m., Staff I CNA stated after a resident is incontinent of bowel and bladder staff should wash the resident front to back, changing surfaces after each swipe, and wash all areas that came in contact with bowel and urine. During an interview 8/2/17 at 11:13 a.m., the Director of Nursing reported the expectation of staff is to provide complete peri-care after each incontinent episode. Washing the resident front to back, changing the surface with each swipe and washing all areas that were contaminated with bowel and urine. The facility provided a policy titled Incontinent Care dated 2006, the policy directed staff to wash all soiled skin areas from front to back.

Based on record review, staff interviews and review of policy and procedures, the facility failed to ensure the staff treated residents with dignity and respect and free from abuse when caring for or talking about them by telephone social media live streaming (Resident #1, #2). The sample consisted of 4 residents and the facility reported a census of 68 residents. According to the facility investigation, on March 29, 2017 they (the facility) received a report that Staff A, CNA (Certified Nurse's Aide), an employee of the facility, posted live video feed on Instagram, a social media account, and delivered this live streaming to 7 friends/people without knowledge or consent of the residents. The live video consisted of a conversation with Resident #2. Staff A stated she was going to a co-worker's grandma/grandpa room. The conversation included the staff took the resident to the toilet. The resident voiced she had soiled her sock and needed it changed. The resident's face was shown while in bed. The facility investigation indicated Staff B, Dietary Aide, observed the live video on Instagram on 3/28/2017, at approximately 9:30 p.m. and reported it to the facility the following day. Staff A took an Instagram of Resident #1's name plate outside of the door and shared with social media. On 3/30/17, the facility provided training to staff regarding the Social Media policy. Findings Include: 1. Resident #2 had a MDS (Minimum Data Set) assessment with a reference date of 3/30/2017. The MDS indicated Resident #2 had no cognitive impairment and required assistance of staff to transfer and did not ambulate. The resident had [DIAGNOSES REDACTED]. The Incident Tracking System reported on 3/28/2017 at approximately 9:45 p.m., the CNA (Certified Nurse's Aide) had activated a cell phone live streaming Instagram to 7 people when taking care of a resident. The people had access to hear or see live streaming. The Instagram enabled them to hear a resident in the background talking and a picture of the resident's face. The facility notified the resident's family and physician on 3/30/2017. During an interview on 4/13/2017 at 8:30 a.m., Staff E, Administrator, reported Staff B, dietary personnel, observed Staff A, CNA live stream on Instagram while at work on 3/2/2017. Staff B reported viewing video of the nurse's station, Resident #1's room name plate, and mentioned Resident #2 name and viewed his/her face. While Staff A assisted Resident #2 to the bathroom, the phone faced the ceiling during cares, however viewers could hear the conversation. On 4/18/2017 at 9:40 a.m., the Director of Nursing (DON), was interviewed and stated she became aware when Staff B reported the incident the following day. The DON stated Staff B observed Staff A on Instagram posting a live stream while at work. Resident #1's name plate could be seen and she mentioned Resident #2 by name and someone's grandma/grandpa. Staff A assisted Resident #1 to the bathroom and viewers could hear the conversation that included the resident telling Staff A that he/she soiled his/her sock and needed it changed. Later Staff A showed the resident's face while in bed. The DON stated the resident's family member requested her/his mother not know about the phone being turned on. During a phone interview on 4/18/2017 at 11:45 a.m., Staff B stated she worked 3/28/2017 from 12:30 - 7:00 p.m. At about 9:45 p.m., she received a Social Media notification that Staff A posted live video. Staff B knew that Staff A worked that evening. Staff B observed video that included Resident #1's name plate with room number. Staff B also heard Staff A mention Resident #2 by name and video of the resident's face after Staff B assisted the resident to bed. While Staff A assisted the resident to the bathroom, Staff B heard conversation that included the resident telling Staff A he/she soiled self and had a sore bottom. On 4/18/2017 at 11:00 a.m., Staff A, CNA, with mother present, reported on 3/28/2017, near the end of the shift she sat near the back dining room with her phone on Instagram, live video, a Social Media account with approximately 7 friends viewing. Staff A stated she thought she had paused the video and went to check if staff working in the front of the building needed help. Staff A went to Resident #1's room and asked Staff F if she wanted Staff A to answer Resident #2's call light. Staff A went to Resident #2's room and placed the phone on the dresser, not realizing the phone remained on. Staff A assisted the resident to the bathroom and they discussed Resident #2's relative whom Staff A knew. Staff A assisted the resident to bed. The resident asked Staff A to tell the nurse the resident needed foot wraps changed. Staff A stated she did not realize she had shown the resident's face while in bed. There were approximately seven friends following the live video streaming at the time including Staff B, Dietary Aide. After Staff A left the resident's room, she went to the break room, clocked out and left the facility. Staff A clicked the phone live again which meant starting the video again and not resuming it. Staff A indicated the facility terminated her due to privacy violation. Staff A worked at the facility since 2/15/2017 and signed the Corporate Compliance of Commitment to Standards and Ethics and the Social Media Policy on 2/15/2017. During a phone interview on 4/18/2017 at 12:30 p.m., Staff F, CNA, reported working the evening of 3/28/2017. Near the end of the shift Staff F assisted Resident #1 when Staff A came and asked if he/she could assist Resident #2 from the toilet to bed. Staff F agreed. When Staff F completed cares on Resident #1, she checked on Resident #2 and observed the resident in bed. The policy and procedures titled Social Media Policy, revised and effective 8/16/2016 included: Purpose: The purpose of this policy is to provide guidelines covering Social Media. Social Media: covered by this policy includes both internal Social Media viewable only by Covenant Care audiences and external Social Media visible to third parties. Policy: All employees and Contingent Workers are personally legally responsible for the content of the commentary they post using Social Media and can be held liable for unlawful actives. Such improper activities could also result in disciplinary action up to and including termination of employment. 2. Resident #1 had a MDS (Minimum Data Set) assessment dated [DATE]. The MDS identified Resident #1 had no cognitive impairments and required extensive staff assistance for transfers and did not ambulate. The MDS documented the resident had [DIAGNOSES REDACTED]. The Incident Tracking System reported on 3/28/2017 at approximately 9:30 - 9:45 p.m. indicated the resident's room number and name were displayed on social media. On 3/30/2017 the facility notified the resident and the resident's physician. During an interview on 4/13/2017, the resident stated the facility informed him/her of the incident and the resident voiced he/she had no concerns the room name plate was shown on social media. The policy and procedures titled Resident's Rights, revised 6/2015 included the following; Policy: It is the policy of Covenant Care and its subsidiaries to provide our residents with a comfortable, private and safe environment in which to live. Terms: A. Each resident must be treated with respect. Residents have the right to be free from all forms of physical, mental and verbal abuse. Employees are expected to protect the rights of each resident at all times. B. Each resident is entitled to their privacy. All medical and personal records must be kept confidential. Any unauthorized access or publicizing of personal, medical or confidential information is strictly prohibited. Residents have the right to approve or refuse to have their records released to anyone outside of the facility, except in transfer to another health facility, or as required by law or third-party payment contract. D. Covenant Care expects every resident to be treated with consideration and full recognition of dignity and individuality, including privacy in treatment and care of personal needs. E. Any infringement of the comfort, privacy and personal safety of a resident will result in disciplinary action up to and including termination. The policy and procedure titled, Abuse, Prevention, Intervention, Investigation and Crime Reporting, revised September, 2011 included: Policy: It is the policy that every resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment and involuntary seclusion. Any form of mistreatment of [REDACTED]. Note: On 3/3017, the facility provided inservice training about social media policy and procedures which were added to the abuse policy. The facility implemented a form titled Audit Tool. This tool will ensure audits are completed to ensure phones are not present on the staff during scheduled hours and staff are able to verbalize the Social Media Policy.

Based on clinical record review, staff and resident interviews the facility failed to develop and implement a comprehensive care plan for one of six residents reviewed. The facility reported a census of 70 residents. Findings include: According to the MDS (Minimum Data Set) dated 12/21/2016, Resident #5 had no cognitive impairment , required extensive assistance of two staff to transfer with a mechanical lift, and had [DIAGNOSES REDACTED]. The Care Plan dated 10/31/16, revised on 2/1/17, directed staff to observe for accidental injury related to smoking due to his/her [MEDICAL CONDITION]. The Care Plan further directed staff to educate and enforce smoking in designated areas only, observe/report unsafe smoking practices, provide safe receptacles for extinguishing ashes. The care plan directed the staff to take the resident to their designated smoking area and then return within 3-5 minutes to take the resident back into the facility. The Smoking assessment dated [DATE] determined Resident #5 could smoke without supervision. Incident tracking system reported Resident #5 had falls on 11/2/2016 when he/she attempted to reposition self in wheel chair, 11/15/2016 when he/she slid out of the wheelchair, and 1/25/2017 from the commode. Observation on 2/1/2017 at 12:50 p.m. revealed Resident #5 in his/her room in the wheel chair with a cigarette. The resident indicated he/she had permission to smoke outside. At 12:55 p.m.,Staff E, CNA (Certified Nurse's Aide) pushed the resident via wheelchair outside, left the resident to smoke and came back inside. During an interviews on 2/1/2017, the Director of Nursing (DON) indicated the facility allowed the resident to smoke outside, but needed to make sure staff were aware. On 2/2/2017 at 12:01 p. m. the DON reported she assessed the resident for smoking ability last fall, but Staff D, RN completed the smoking Care Plan on 2/1/2017. During an interview on 2/2/2017 at 9:30 a.m., Staff D, RN indicated he/she completed the Care Plan related to smoking supervision on 2/1/2017 and admitted they backdated the Care Plan to suggest it had been initiated on 10/31/2016. The facilty failed to have a care plan in place for Resident #5 to safely smoke from 10/31/16-February 1, 2017.

Based on record review, staff and resident interviews the facility failed to meet professional standards of quality services for five of nine residents reviewed. (Residents 1, 2, 3, 4, 9). The facility reported a census of 58 residents. Findings include: 1. According to the MDS (Minimum Data Set) dated 9/23/2016, Resident #1 had moderate cognitive impairment, required extensive assistance to transfer and did not ambulate. The resident had [DIAGNOSES REDACTED]. The Care Plan indicated Resident #1 had altered nutrition and hydration related to increased nutritional needs for healing initiated 6/16/2016. It directed staff to monitor weight and notify physician of significant weight changes. The Care Plan indicated the resident had pain related to current health history of fracture ankle and pressure ulcer initiated on 6/2/2016. It directed staff to assess pain, offer non-medicine approaches, notify physician of changes and the licensed nurse will monitory for side effects of current medication. The hospital transfer sheet dated 6/2/2016 included physician orders [REDACTED].#1 daily, follow red flag of heart failure sheet and [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg (for pain), one tablet every 8 hours as needed. The physician's orders [REDACTED]. The order directed staff to weigh daily, notify physician of 3 pound weight gain in 24 hours or 5 pounds in a week in the morning related to heart failure. The orders also included an order for [REDACTED]. The September MAR ( Medication Administration Record) reported no administration of the pain medication, ( [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg)/ [MEDICATION NAME]) Resident #1's Controlled Substance Proof of Use record showed six doses, signed off as given, of the prn pain medication. None of those doses were recorded on the MAR between 9/4 and 9/23/2016. The summary of weights and vitals revealed staff weighed Resident #1 upon admission on 6/3 with a recorded weight of 227 pounds while in the wheel chair. Staff weighed the resident on 7/1 and 7/5 with a recorded weight of 210 pounds (-10% change). On 7/12 staff recorded a weight of 226.8 pounds (+10% change). On 7/18 and 7/19 the resident weighed 198 pounds (-10% change). On 8/1 the resident weighed 199 pounds and 8/17 the resident weighed 213 pounds. The resident admitted to the hospital. Hospital records revealed Resident #1 admitted to the hospital on [DATE] with increased lower extremity [MEDICAL CONDITIONS] and a urinary tract infection. The [DIAGNOSES REDACTED]. During an interview on 10/25/2015 at 12:15 p.m., the DON (Director of Nursing) revealed Resident #1 admitted from the hospital on [DATE]. The transfer sheet physician orders [REDACTED]. Staff never implemented daily weights until 8/25/2016 after the resident returned from the hospital. 2. According to the MDS dated [DATE], Resident #2 had no cognitive impairment , required extensive assistance of staff to transfer with a mechanical lift and did not ambulate. The resident had [DIAGNOSES REDACTED]. The Care Plan identified Resident #2 had chronic pain related to refusal to get out of bed, reposition and spinal stenosis. The Care Plan directed staff to administer Tylenol and [MEDICATION NAME] as per orders and resident allows, initiated 10/21/2015. Evaluate the effectiveness of pain interventions given. The physician's orders [REDACTED]. The September MAR revealed Resident #1 received 5 doses of prn [MEDICATION NAME]. The Controlled Substance Proof of Use forms revealed staff signed out 8 prn doses for September. 3. According to the MDS dated [DATE], Resident #3 had no cognitive impairment, required extensive assistance of staff to transfer, dress and for hygiene. The resident had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. JP(Jackson-Pratt drain) draining - strip and drain all JP drains and record amount three times a day. [MEDICAL CONDITION] wraps, applied per therapy following dressing changes. The September TAR (Treatment Administration Record) revealed Staff failed to strip the JP drains and record the amount 8 of 18 times opportunities. The TAR failed to include the [MEDICAL CONDITION] wrap order. The hospital dismissal summary dated 9/20/2016 included: Diagnoses: [REDACTED]. Wound care: left thigh, daily - change xeroform to incision sites, cover with dry gauze or ABD pad, and compression wrap toe to thigh. During an interview on 10/11/2016, Resident #3 reported staff failed to apply the compression wrap to the leg on a Saturday. Facility staff informed the resident only therapy could apply the wrap. Also, staff bleed the drainage tubes three times a day as the physician ordered. During a interview on 10/25/2016, Staff B, Physical Therapist reported that Saturday, he/she failed to come to the facility to apply the compression wrap, so the resident's family member applied it. Nursing staff could have applied the wrap. Staff B came to the facility on Sunday and applied the wrap. During an interview on 10/21/2016 at 3:10 p.m., Staff A, RN (Registered Nurse) reported working the weekend Resident #3 had a concern regarding the [MEDICAL CONDITION] wrap. Staff A reported he/she had no knowledge of how to apply the wrap, only therapy knew. Therapy had indicated they would apply the wrap on Saturday, but failed to come. 4. According to the MDS dated [DATE], Resident #4 had no cognitive impairment, required extensive assistance of staff to transfer and dress and had [DIAGNOSES REDACTED]. The Care Plan identified Resident #4 had chronic pain and directed staff to document and anticipate pain, provide interventions, monitor signs and symptoms of pain, and monitor/record/report to Nurse resident complaints of pain and requests for pain treatment. The physician's orders [REDACTED]. The September MAR revealed one prn [MEDICATION NAME] recorded as administered from 9/9 - 9/30/2016. (9/21) The Controlled Substance Proof of Use sheet recorded 21 prn doses administered in September, 2016. The October MAR revealed no prn [MEDICATION NAME] recorded as administered. The facility failed to provide the Controlled Substance Proof of Use sheet from 9/29 - 10/16/2016, that also would have included the scheduled [MEDICATION NAME] administration three times a day. The October MAR revealed staff administered 48 doses of scheduled [MEDICATION NAME] between October 1 - 16, 2016 with no documentation on a Controlled Substance Proof of Use sheet. 5. According to the MDS, Resident #9 had no cognitive impairment, required extensive assistance to transfer and dress and had [DIAGNOSES REDACTED]. The Care Plan identified Resident #9 had chronic pain due to a history of fractures and required as need pain medication. The physician's orders [REDACTED]. The resident had an order for [REDACTED]. On 10/20/2016, the physician ordered [MEDICATION NAME] 1000 mg by mouth every morning and at bedtime for pain. The August MAR revealed staff administered 9 doses of one tablet and 8 doses of two tablets for a total of 25 [MEDICATION NAME]/[MEDICATION NAME] tablets. The Controlled Substances Proof of Use sheet documented staff administered 46 tablets. The September MAR revealed staff administered 5 doses of one tablet and 7 doses of two tablets for a total of 19 [MEDICATION NAME]/[MEDICATION NAME]. The Controlled Substances Proof of Use sheet documented staff administered 57 tablets. The October MAR revealed staff administered 5 doses of one tablet and 1 dose of two tablets for a total of 7 [MEDICATION NAME]/[MEDICATION NAME]. The Controlled Substances Proof of Use sheet documented staff administered 21 tablets from October 1 - 17, 2016. During a group interview on 10/18/2016 at 1 o'clock p.m., Resident #9 reported staff recently were not able to provide a prescribed pain pill because there were non available, staff had to borrow the medication to give to another. Staff offered the resident Tylenol. During an interview on 10/20/2016 at 9:30 a.m., the resident indicated he/she asked for a pain pill in the evening, but not every night, usually around bedtime, and usually took one, not two pills. Occasionally the resident requested a pain pill during the night. The resident knew he/she took [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]). The resident never reported it. A review of the September and October Controlled Count verification sheets for Station I and Station II documented directions for staff to count all controlled substances with two staff present at the change of shift. The forms revealed that staff failed to sign the count verification forms at all times at the change of shift. On 10/21/2016 at 8:00 a.m., the DON reported he/she kept discontinued narcotics in a safe under a desk in his/her office. Observation revealed a safe under the desk and the key to the safe in an unlocked drawer in the desk. The DON indicated he/she took the key with him/her when leaving the room. The DON attempted to open the safe with the key, but failed to do so. The DON had maintenance staff drill the lock on the safe to open the safe. The DON indicated he/she planned to implement a new procedure that kept discontinued narcotics in the cart with staff counting them at the change of every shift until they could be destroyed by the DON and a witness. The facility Operating Standard Pain Management Process form included: Practice: It is the responsibility of the licensed nurse to consistently assess, manage, and monitor pain for all residents. The results of the assessment, effectiveness of the pain intervention (s), and monitoring of behaviors are necessary components within documentation. *Need to reassess effectiveness after giving pain medication on MAR. The facility Safeguarding Controlled Substances policy included: Practice: Each facility will engage in safe and secure practices related to appropriately receiving, storing, administering, reconciling, and safeguarding controlled substances. Practice guidelines: I. Safeguarding Controlled Substances Only authorized nurses will and pharmacy personnel will have access to controlled substances. Controlled substances are to be appropriately stored under 2 separate locks as required. Completed accountability records are submitted to the DON and maintained in the nursing facility for length of time per state regulation. II Administration of Controlled Medication Following removal and administration, the nurse is to document on the residents MAR the date, time and reasons if prn a controlled substance had been given. III Discontinued Controlled Substances Nurses are to provide discontinued or unused controlled drugs to the DON with accountability record as soon as practical. The DON must have a designated lockable drawer or storage area for controlled substances awaiting destruction. No one else should have a key to this drawer. Double lock provisions apply. Narcotics can be kept inside a locked drawer in the DON's office as long as the door to the office is locked when occupied.

Based on observation and staff interviews, the facility failed to provide housekeeping and maintenance services necessary to maintain an orderly and comfortable interior. The facility census was 64 residents. Findings include: Observations throughout the annual survey and the environmental survey conducted on 6/29/16 between 9:00 a.m. and 10:48 a.m. with the maintenance supervisor and laundry and housekeeping supervisor revealed: 1. Tiled floor surfaces throughout the 5 main halls in the facility revealed multiple long and deep linear scratches, dark in color, with an overall dull finish. The linear scratches were visible from at least 60 inches away. 2. Several resident room doors, all painted or stained a dark brown color, had multiple linear scratches and scrapes that extended the width of the doors from wheel chair foot rest collisions. The edges of some doors, both on the hinged and latch sides with bare wood exposed and splintered, also the result of wheel chair and equipment collisions. The maintenance supervisor stated that the doors were painted last May or June and there was not a plan in place that addressed door and wall repairs on an ongoing basis. The housekeeping and laundry supervisor offered to create a schedule for the repairs to assist with maintenance. 3. An approximate 2 inch gap between the end bracket and hardware of the lower wall mounted metal heating vent in the R hall shower room. 4. The privacy curtain at the entrance of the R hall shower room with a dry brown stain, approximately 2 inches across and irregular shape, approximately 40 inches above the floor surface. 5. The lower walls, wainscot type, of the D hall dining room with multiple scrapes and visible areas of missing paint. The pedestals beneath the tables revealed splatters of white spots, approximately 3 to 5 millimeters in size, that extended from the floor level to at least 24 inches above the floor. 6. At least 2 lower wall tiles in the R hall shower room stall were buckled and completely detached from the wall. During the survey findings conference on 6/30/16, the facility administrator stated there was a schedule for floor maintenance and she would address dining room table conditions with staff.

Based on observation, clinical record review, resident and staff interview, the facility failed to ensure residents were offered a snack at bedtime for nine of nine residents reviewed. (Resident #2, #5, #8, #9, #10, #18, #13, #19 & #20) The facility census was 64 residents. Findings include: 1. During group interview on 6/27/16 at 1:35 p.m., three of four residents in attendance stated they were not offered a snack before bedtime. One resident stated diabetics got a snack if they asked staff for one. Another resident stated the facility was supposed to have a snack cart that aides brought around. Another resident stated the residents never see the snack cart come around. 2. During interview on 6/29/16 at 10:20 a.m., Resident #5 stated she/he did not get a bedtime time snack and if they do bring snacks around it was always candy bars. 3. During interview on 6/28/16 at 7:20 a.m., Resident #10 and Resident #18 stated they did not get offered a bedtime snack the evening of 6/27/16 or 6/28/16. 4. During interview on 6/29/16 at 3:07 p.m., Resident #13 stated he/she did not get offered a bedtime snack. 5. During interview on 6/29/16 at 7:27 p.m., Resident #19 stated he/she did not get offered a bedtime snack nor did the resident whose room he/she was visiting in this evening get offered a snack. The resident stated he/she knows where the snacks are kept so they go help themselves. Observation on 6/29/16 at 7:30 p.m., Staff I, certified nurse aide, CNA walked by with a clear tote of granola bars. Resident #19 identified that as the snack bin. Resident #19 asked if Staff I was passing snacks and Staff I said yes. Resident #19 stated snacks were getting passed tonight, but usually are not. 6. During interview on 6/29/16 at 7:22 p.m., Resident #20 stated he/she was not offered nor received a bedtime snack and stated he/she had to ask for a snack to get one. Review of the facility policy/procedure for Nourishments and HS (hour of sleep) snacks dated 2008 states bed time snacks will be offered to all residents unless contraindicated. During observation on 6/29/16 at 7:20 p.m. to 8:15 p.m., the snack bin was not sitting on the front nurse's station desk where it was visible during the day. Several resident room doors were closed or half open with resident rooms dark and residents observed to be in bed. At 7:27 p.m., Staff I, CNA, pulled a clear tote half full of snack bars out from under the back nurse's station desk and walked down the C and D halls. At 7:45 p.m., observation revealed Staff H, licensed practical nurse, LPN, with three granola bars laying on the medication cart. Observation at 7:50 p.m., revealed Staff K, CNA, coming out of the back main kitchen door with a replenished tote full of snack bars containing Rice Krispie Treat bars. Staff K walked down the A hall and turned left to go to the R hall. During interview on 6/29/16 at 7:42 p.m., Staff I stated she had offered a snack to one resident in the A hall who refused it and stated several residents were asleep already so she gave a bunch to Staff H, to hand out with the medication pass. At 7:45 p.m., Staff H stated she had given out snacks to four residents already with medications and had three left on her med cart. Interview with Staff I at 7:45 p.m., revealed the selection of snack bars to be Lorna Done cookies, Nutri grain bars and granola bars. During interview on 6/30/16 at 11:00 a.m., the director of nursing stated it is an expectation that staff pass bedtime snacks to all residents that are able to consume them. 7. During interview on 6/28/16 at 6:05 a.m., Resident #2 reported there was a container of snacks at the nursing desk. The resident reported staff did not pass bedtime snacks, you have to go up to the desk and get them yourself. The resident replied not going to get a snack for himself/herself very often. Resident #2 minimum data set (MDS) assessment dated [DATE], showed the resident scored 15 of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. 8. During interview on 6/28/16 at 8:25 a.m., Resident #8 reported getting a bed time (HS) snack at night some of the times, maybe 2 times out of the week. The MDS assessment dated [DATE], showed Resident #8 scored 15 of 15 on the BIMS, indicating intact cognition. 9. During interview on 6/29/16 at 8:45 a.m., Resident #9 stated they did not get a bedtime snack. The MDS assessment dated [DATE], showed Resident #9 scored 15 of 15 on the BIMS, indicating intact cognition.

Based on observation, clinical record review, staff and resident interviews, the facility failed to follow proper infection control techniques when providing resident care for three of thirteen residents reviewed. (Resident #3, #1 & #13) The facility census was 64 residents. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] showed the resident had [DIAGNOSES REDACTED]. The MDS showed the resident had a skin application of an ointment/treatment and a dressing for skin treatment. The physician's orders [REDACTED]. Observation on 6/27/16 at 1:15 p.m. revealed Staff A, Registered Nurse, performing wound cares to the resident's right lower leg. After cleansing the wounds, applying [MEDICATION NAME] cream, and a dry dressing, Staff A wrapped the area with Kerlix. Staff A finished wrapping the lower leg, removed scissors from her uniform pocket, did not cleanse them and proceeded to cut the clean gauze and secured it with tape. An interview on 6/30/16 at 10:40 a.m. the Director of Nursing (DON/Registered Nurse), reported scissors coming out of a staff person's uniform pocket, should be cleansed before using. The DON noted the uniform pocket is considered a dirty environment. 2. Resident #1's MDS assessment dated [DATE] showed the resident had a score of 15 out of 15 in the Brief Interview for Mental Status (BIMS), indicating no memory loss. The assessment showed the resident had a catheter for urinary functions. The resident had [DIAGNOSES REDACTED]. The Care Plan dated 6/6/16 identified the resident at high risk for urinary tract infection related to an indwelling catheter needed for urinary retention. An intervention included to empty the Foley catheter every shift and as needed. Observation on 6/28/16 at 1:30 p.m. Staff B, Certified Nursing Aide, emptied the resident's catheter bag. Staff B placed 2 paper towels on the floor and placed the cylinder container on top. While draining the urine into the container, small amount of urine fell on to the paper towels, soaked through the 2 paper towels, onto the floor. Staff B wiped the floor with the same paper towels that were soiled. During cares two staff members observed wearing pants that dragged onto the floor, walking onto the soiled area. No staff person had sanitized the floor area. An interview on 6/28/16 at 2:30 p.m., the resident reported no one from housekeeping had come into the room to clean the floor since the morning. An interview on 6/29/16 at 12:15 p.m. the MDS Coordinator, Registered Nurse, reported staff should have cleansed off the tip of the tubing before placing into the holder the first time. She reported Staff A should have sanitized the floor after the small urine spillage. During an interview on 6/30/16 at 10:49 a.m. the DON stated she expected staff to sanitize the floor after a urine spillage. 3. During observation of housekeeping cleaning Resident's #13 room on 6/29/16 at 12:35 p.m. the following was noted: a. The resident is in Contact Isolation. A sign on the door directs visitors to report to the nurse's station for instruction. The sign is color coded to indicate[DIAGNOSES REDACTED] or other stool infection. The sign also directs visitors to wash hands, wear gloves, wear a gown, and wear a mask as needed. b. Staff L, Housekeeper, was noted to be in the resident's room cleaning. Staff L was not wearing a gown but did have gloves on. Staff L was wiping down all surfaces in the room with a Clorox bleach solution. The resident was watching TV in her room and visiting with Staff L as she cleaned. c. The isolation cart outside of the resident's room contained gloves, masks, a blood pressure cuff, gait belt, and stethoscope but no gowns. d. Staff M, housekeeper, swept the resident's room with a dry dust mop and then set it on the cleaning cart. She wet mopped resident's room and placed the mop back in the bucket of mop water in the hallway. Removed her gown in the hallway and placed it in the trash bag attached to the cleaning cart. Staff M, housekeeper, did not remove her gloves or wash her hands. She proceeded to push the cleaning cart and mop bucket down the hall to the C hall housekeeping closet. Staff M set the dry dust mop on the floor outside of the housekeeping closet. She wrung out the wet mop head, removed it from the mop handle and dumped the dirty mop water in the floor sink. Staff M placed the dry mop head and the wet mop head in a basin together and took them to the washing machine in the laundry room touching the door code key pad to enter the laundry room hallway. She started the washer and removed her gloves. Staff M was not observed to wash her hands before leaving the laundry room and proceeding back out into A hall. An observation from 2:25 p.m. to 3:05 p.m. on 6/29/16 revealed Staff T, Physical Therapist (PT), Staff U, PT Student, and Staff W, Certified Orthopedist (CO), present in the resident's room along with the resident's husband. No one was observed to have a gown or gloves on. Staff W, CO, was noted to be placing the resident's prosthetic leg on her for fitting. Staff V, Occupational Therapist (OT) stopped at the door and donned a gown and gloves before entering the room and closed the door behind her. Staff T and Staff U came out of the room and put on a gown and gloves, then re-entered the room closing the door behind them. All four staff members exited the room at 3:05 p.m. Observation at 9:03 a.m. on 6/30/16 Staff X, CNA, and Staff S, CNA, opened the door to Resident #13's room with gowns and gloves on Both CNA's exited the room after removing protective wear but neither washed their hands with soap and water before leaving the room and continuing down the hall. An interview with Staff D, at 2:42 p.m. on 6/29/16 stated that the color coding on the sign on the door of Resident #13 indicates what type of isolation it is and what all staff and visitors should use as protection to enter the room. During an interview with Staff M, Housekeeper, at 12:50 p.m. on 6/29/16 she stated she used Clorox Bleach Cleaner for wiping down all surfaces and Momentum Oxidizing Cleaner with Hydrogen Peroxide to mop Resident #13's floor. Both cleaning solutions were on the housekeeping cart.

Based on clinical record review and staff interview, the facility failed to follow physician orders [REDACTED]. (Resident #2) The facility census was 64 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] showed Resident #2 had [DIAGNOSES REDACTED]. The MDS showed the resident had frequent pain and rated the pain intensity at a level of 5 from a scale of 1 to 10, with zero being no pain and ten as the worst pain. A Physician order [REDACTED]. A Physician order [REDACTED]. Narco consists of [MEDICATION NAME] 5 milligrams and Tylenol 325 milligrams. The Resident's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED] 6/2/16: 3 times-receiving a total of 3,575 milligrams. 6/3/16: 2 times-receiving a total of 3,250 milligrams. 6/7/16: 3 times-receiving a total of 3,575 milligrams. 6/8/16: 3 times-receiving a total of 3,575 milligrams. 6/10/16: 2 times-receiving a total of 3,250 milligrams. 6/24/16: 2 times-receiving a total of 3,250 milligrams. 6/25/16: 5 times-receiving a total of 4,225 milligrams. The Resident's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED] 5/2/16: 2 times-receiving a total of 3,250 milligrams. 5/3/16: 2 times-receiving a total of 3,250 milligrams. 5/9/16: 2 times-receiving a total of 3,250 milligrams. 5/10/16: 2 times-receiving a total of 3,250 milligrams. 5/11/16: 2 times-receiving a total of 3,250 milligrams. 5/12/16: 3 times-receiving a total of 3,575 milligrams. 5/13/16: 3 times-receiving a total of 3,575 milligrams. 5/15/16: 2 times-receiving a total of 3,250 milligrams. 5/17/16: 3 times-receiving a total of 3,575 milligrams. 5/18/16: 2 times-receiving a total of 3,250 milligrams. 5/21/16: 2 times-receiving a total of 3,250 milligrams. 5/22/16: 2 times-receiving a total of 3,250 milligrams. 5/23/16: 3 times-receiving a total of 3,575 milligrams. 5/25/16: 2 times-receiving a total of 3, 250 milligrams. 5/26/16: 2 times-receiving a total of 3, 250 milligrams. 5/27/16: 2 times-receiving a total of 3, 250 milligrams. 5/28/16: 2 times-receiving a total of 3, 250 milligrams. 5/29/16: 2 times-receiving a total of 3, 250 milligrams. 5/31/16: 3 times-receiving a total of 3, 575 milligrams. The Resident's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED] 4/2/16: 2 times-receiving a total of 3,250 milligrams. 4/19/16: 3 times-receiving a total of 3,575 milligrams. 4/27/16: 2 times-receiving a total of 3,250 milligrams. 4/28/16: 3 times-receiving a total of 3,575 milligrams. During interview on 6/29/16 at 1:15 p.m., the Director of Nursing (DON) and Staff D, Licensed Practical Nurse agreed the resident received Tylenol exceeding the dose limit set by the physician.

Based on observation, clinical record review and staff interview, the facility failed to follow the care plan for one of four residents reviewed. (Resident #4) The facility census was 64 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #4 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], recorded the resident had a history of [REDACTED]. The plan of care initiated on 4/8/15, indicated the resident as at risk for falls and injuries related to a history of falls and self transfers without assistance. An entry on 5/25/16 instructed staff to change from a tab alarm to a pad alarm. The care plan instructed staff to monitor the resident for unsteady gait and balance. During observation on 6/27/16 at 1:13 p.m., the resident was seated in a wheelchair in the independent dining room. There was no chair alarm on the resident's wheelchair. At 1:20 p.m., the resident had a pad alarm in place on the recliner in resident's room while the resident was sitting in the wheelchair. At 3:00 p.m., the resident had no pad alarm under him/her while sitting by the front main entry desk in a wheelchair. During observation on 6/28/16 at 6:49 a.m., the resident was sitting in a recliner in his/her room playing with an I Pad. There was no chair pad alarm underneath the resident. Observation at 4:45 p.m., revealed the resident was seated on the loveseat in the main entry common area without an alarm pad. The resident had a walker in front of him/her and stood to ambulate without assistance. Staff responded to assist with ambulation. During interview on 6/28/16 at 8:19 a.m., Staff Z, certified medication aide, CMA, and Staff AA, certified nurse aide, CNA, stated the resident was to have a strip/chair alarm on the wheelchair, bed, and recliner at all times. During interview on 6/29/16 at 7:15 a.m., the director of nursing, DON, stated the resident was to have a chair pad alarm underneath him/her at all times.

Based on observation, clinical record review and staff interview, the facility failed to ensure fall interventions were in place as planned for one of four residents reviewed. (Resident #4) The facility census was 64 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #4 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], recorded the resident had a history of [REDACTED]. The plan of care initiated on 4/8/15, indicated the resident as at risk for falls and injuries related to a history of falls and self transfers without assistance. An entry on 5/25/16 instructed staff to change from a tab alarm to a pad alarm. The care plan instructed staff to monitor the resident for unsteady gait and balance. During observation on 6/27/16 at 1:13 p.m., the resident was seated in a wheelchair in the independent dining room. There was no chair alarm on the resident's wheelchair. At 1:20 p.m., the resident had a pad alarm in place on the recliner in resident's room while the resident was sitting in the wheelchair. At 3:00 p.m., the resident had no pad alarm under him/her while sitting by the front main entry desk in a wheelchair. During observation on 6/28/16 at 6:49 a.m., the resident was sitting in a recliner in his/her room playing with an I Pad. There was no chair pad alarm underneath the resident. Observation at 4:45 p.m., revealed the resident was seated on the loveseat in the main entry common area without an alarm pad. The resident had a walker in front of him/her and stood to ambulate without assistance. Staff responded to assist with ambulation. During interview on 6/28/16 at 8:19 a.m., Staff Z, certified medication aide, CMA, and Staff AA, certified nurse aide, CNA, stated the resident was to have a strip/chair alarm on the wheelchair, bed, and recliner at all times. During interview on 6/29/16 at 7:15 a.m., the director of nursing, DON, stated the resident was to have a chair pad alarm underneath him/her at all times.

Based on record review and staff interviews, the facility failed to request and receive registry verification of a Certified Nurse Aide (CNA) eligibility to work as a CNA prior to employment, and in lieu of registry verification of CNA eligibility, failed to notify the Direct Care Worker Department that the CNA to be currently employed at the facility for 1 of 1 reviewed (Staff E). The facility census was 64 residents. Findings Include: 1. Review of personnel files revealed Staff E hired as a CNA on 1/19/16. The facility performed criminal history and abuse registry checks on 12/17/15 but did not complete the nurse aide registry check with those inquiries. Review of the CNA Roster dated 5/11/16 provided by the Direct Care Worker (DCW) Department revealed that Staff E not included as an active CNA employed at the facility. During an interview on 6/29/16 at 10:30 a.m., the Administrator reported learned that the Business Office Manager at the time of hiring Staff E did a check with the DCW to see if an active CNA or not, but never entered Staff E as an employee of the facility. The Administrator stated Staff D, Nurse Manager remembered checking the eligibility of Staff E on January 2016 and she was an active CNA. The Administrator also reported she had contacted the DCW this day and talked to the staff and had Staff E added to the CNA Roster for the facility and informed Staff E still an eligible CNA. The Administrator then presented a form from the DCW dated 6/29/16 that indicated Staff E eligible. During interview on 6/29/16 at 3:31 p.m. with Staff Y from the DCW indicated had been contacted by the facility in regards to Staff E this day. Staff Y further reports when reviewing Staff E noticed the facility failed to complete a Single Contact License & Background Check (SING) check on Staff E to verify CNA status prior hiring Staff E on 1/19/16. Staff Y did report had now entered Staff E in the DCW system as employed at the facility and as eligible. Review of the facility's Abuse Prevention, Intervention, Investigation & Crime Reporting Policy revised 12/2012 directed staff under the procedures section for Screening that nurse assistants and licensed nursing staff will be screened prior to hire and regularly monitored for active, unencumbered licensure and/or certification verification.

Based on record review and staff interview, the facility failed to provide notification to the resident or responsible party of the impending discharge from skilled services for 1 of 3 resident records reviewed (Resident #16 ) The facility census was 64 residents. Findings include: 1. Resident #16 received skilled Medicare services from 11/14/15 through 12/21/15. The facility could not provide documentation that the resident or RP was notified of the facility's determination that Medicare funded services would end effective 12/22/15. During interview on 6/30/16 at 9:30 a.m., the business office manager and social worker (SW) stated the SW began employment in January, 2016 and assumed responsibility for Advanced Beneficiary Notification (ABN) sometime after that.

Based on record review, observation and staff, resident and family interviews, the facility failed to provide residents with adequate supervision and assistive devices to protect and ensure against hazards (Resident #1, #3, and #4). The facility reported a census of 79 residents. 1. Resident #1 had a MDS (Minimum Data Set) assessment, with a reference date of 10/29/2013 which revealed Resident #1 had [DIAGNOSES REDACTED]. The MDS reflected Resident #1 required extensive assistance of one staff person with transfers, and had moderately impaired decision making capabilities. The Care Plan dated 10/31/2013 identified the resident had a problem with self -care deficit and needed assistance with activities of daily living. The approach directed staff that the resident required assistance of one (person) and a front wheeled walker to ambulate, a wheelchair for mobility; propelled by self or staff, and to provide a hazard free environment for safety. The Elopement assessment dated [DATE] identified Resident #1 as not generally at risk for an elopement if self- mobile by wheel chair or ambulation. The Elopement assessment dated [DATE] identified (a change) the resident at risk for elopement with a score of 12 points. A score of 7 or above reflected a risk for elopement. According to the Nurse ' s Notes dated 11/10/2013 at 2:30 a.m., Resident #1 heard an alarm from the A wing door. A nursing assistant observed the resident gout out the door. The nursing assistant saw the resident standing outside by the door. The resident stated she needed fresh air. The Elopement Risk Care Plan was not implemented until 11/18/13. A Report of Incident Form dated 11/18/2013 at 11:40 p.m. documented Resident #1 went outside by self and staff found the resident at the end of A Wing exit door by the parking lot. Staff found the resident in a wheelchair. The document revealed the resident ' s vital signs were: Temperature 90 degrees Fahrenheit (normal 98.6), Pulse 60 (normal 60-100), blood pressure 148/80, and respirations 24 (normal 16-20). Staff applied a Wander Guard bracelet to left wrist; staff provided 15 minute checks and notified the physician and family. An IDT Post Occurrence Assessment and Plan Review reflected on 11/18/13, Resident #1 exited the building after signing self out, found in front of building in wheel chair by staff and returned to the building. The resident stated he/she wanted fresh air. An assessment identified the resident had no injuries noted and blood sugars within normal limits. The staff implemented fifteen minute checks applied a wander guard (bracelet) and offered a room change closer to nurse's station but the resident declined. The Nurse ' s Notes on 11/21/2013 at 3:00 p.m., an addendum for 11/17/2013 at 11:30 p.m. entry noted resident not available for blood sugar check. The nurse telephoned the resident ' s power of attorney and left a message requesting the resident be returned to the facility since it was noted the resident signed self out after supper The Nurse ' s Notes on 11/21/2013 at 3:20 p.m., Addendum for 11/18/2013 at 12:40 p.m., reflected the resident inside facility, responds appropriate and the family coming to the facility. The AccuNurse documentation for 11/17/2013 revealed staff transferred Resident #1 to the chair at 3:30 p.m. At 5:30 p.m. the resident ate 100% of dinner (supper). On 11/18/2013 staff transferred the resident to the bed at 1:00 a.m. On 11/26/2013 at 2:50 p.m., observation revealed Resident #1 sitting in his/her recliner, reading with feet elevated and wearing glasses. The resident had no memory of going outside the evening of November 17, 2013. The resident resided in a room near A Wing exit, at the end of the hall. A Mandatory In-Service Training/Attendance Record revealed the facility had staff training regarding elopement, door alarms and meal completion on 11/20/2013. During an interview on 12/2/2013 at 4:10 p.m., Resident #1's family member reported having his/her phone turned off the night of 11/17/2013 and so didn ' t receive the call from the facility until the next morning. The family member stated the resident would not go out on his/her own, and the family had not taken the resident out since June, when the resident had an allergic reaction to a medication. In April the family took the resident to a family wedding, and family always signs the resident out when leaving the facility. A family member did take the resident out recently for Thanksgiving. The family member stated the resident has confusion; one minute has a normal conversation, and the next talks of events a long time ago. On 11/26/2013 at 9:00 a.m. the Director of Nursing (DON) reported Resident #1 had signed his/her self out on 11/17/2013 at 4:00 p.m. however another resident signed out before him/her at 4:15 p.m. The DON stated the staff and other residents also observed the resident at supper time. Staff D, registered nurse, administered medications at supper time and was in and out of the dining room. No staff heard the resident mention leaving, and no staff observed the resident exiting the building. Around 7:30 p.m., Staff A, registered nurse, looked for the resident to administer medications and failed to find the resident. Staff saw that the resident had signed his/her self out in the Sign Out book kept at the front nurse's station. Now the facility keeps the sign out book on the medication carts. All families have been notified of the new procedure. The staff began calling the resident's family around 11 to 11:30 p.m. The staff had felt the resident should have been returning. They searched the grounds and found the resident seated outside near the A Wing exit, at the end of the ramp near the parking lot at approximately 12:30 a.m. The resident stated he/she was going to the Dollar Store. Staff assessed the resident and notified the physician via facsimile. They checked all the door alarms and found they all worked appropriately. The DON Stated The resident knew to push the red button at the front door exit; he/she used to sit near the exit prior to the recent renovation. It used to upset the resident when people walked out without pushing the button and it caused the alarm to sound. The maintenance man does weekly door alarm checks, and night shift checks all the door alarms. The DON felt the resident exited the front door since the STOP sign remained intact at the A Wing exit door, and no staff reported responding to the door alarm. The DON stated the Sign Out book was kept at Station I, on the counter. The resident ' s family had only signed the resident out once in the last year (April or May). The resident never signed self out prior to 11/17/2013. The resident had physician appointments but the facility did not require residents to sign out for appointments. Since the incident, the facility required residents to sign out for appointments. On 11/26/2013 at 3:30 p.m., the Administrator was interviewed and reported the facility used A Wing exit during the renovation. Since completion on 10/31/2013, the facility used the front entrance with an alarm and Wander Guard system. The facility added additional alarms on Exits A, B, E, R. Each exit has a minimum of 2 alarms. All alarms functioned correctly at the time Resident #1 exited the facility. On 11/10/2013 the resident exited the A Wing exit door, the alarm sounded and staff immediately responded. On 11/27/2013 at 1:30 p.m., and 12/2/2013 at 2:05 p.m., Staff A, RN reported working second shift on 11/17/2013, in charge of A, B and C Halls. At approximately 4:00 p.m. Staff A administered a treatment to Resident #1. At approximately 7:15 p.m. Staff A started the evening medication pass (administration of medications to residents), failed to find the resident in his/her room and looked for the resident with Staff I, CNA. They saw the resident signed his/her self out at 4 p.m., but knew that was not correct. The resident had previously gone out during second shift. The STOP sign remained on A Wing exit, and the door alarm never sounded. When the resident failed to return by 10 o'clock p.m. they thought it unusual. They started calling family around 11 p.m., but had problems reaching family. The third shift nurse, Staff F, RN found the resident outside. The resident's blood sugar was 123 and the resident voiced complaints of being cold. Staff A stated now the resident sign out book is on the medication cart, the resident has fifteen minute checks and they have applied a Wander Guard device On 11/26/2013 at 3:50 p.m., Staff I, certified nursing assistant, reported working second shift on 11/17/2013 on A Wing. Around 4 p.m. Resident #1 came out of his/her room and Staff I assisted residents in the assisted dining room; Resident #1 ate in the independent dining room. Staff I stated around 7 p.m. she looked for the resident and saw he/she signed his/her self out. The resident never spoke of her/his intention to leave but had no concern. At 10:30 p.m. Staff I's shift ended, he/she reported to the next shift that the resident had gone out. Staff I heard they found the resident at the end of the A wing sidewalk, where it ends, in his/her wheel chair. On 12/2/2013 at 8:00 a.m., Staff F, RN was interviewed and reported working the night shift on 11/17/2013, arrived at work at 10:30 p.m. Staff A reported Resident #1 signed his/her self out at 4 p.m., and family usually had the resident back by then. Staff A started calling family and waited for someone to return the call. Finally she spoke with a family member and realized the family had no knowledge of the resident going out. They checked the A Wing exit door, opened it, looked out but failed to see the resident, out of view. Staff F went outside and found the resident seated in the wheelchair, at the end of A Wing exit ramp. The wheel chair was stuck in a dip in the concrete. The resident wore slacks, shirt, shoes and a sweater and shivered from being cold. The resident had no knowledge of how long he/she sat outside and had a temperature of 89-90 degrees Fahrenheit when checked with an ear thermometer. Staff F stated since the incident, the staff received an in-service about resident elopements. On 12/02/2013 at 7:00 a.m., Staff H, nursing assistant, was interviewed and reported working the night shift on 11/17/2013. When she arrived to work at 10:30 p.m., Staff I reported Resident #1 apparently went out of the facility and failed to return at that time. Staff A stated the resident failed to return and Staff H suggested they call family to see if they intended on keeping the resident overnight. The facility found the resident was missing after calling quite a few people. Staff H thought it strange to find the resident not there at 10:30 p.m. They did a room search and Staff F found the resident outside with the wheel chair caught in a dip in the concrete. The resident was cold and said he/she was going home. The State Climatologist report verified on 11/17/2013, the area had a 44 degrees Fahrenheit temperature with a 35 degree wind chill at 4:00 p.m., 43 degrees with wind chill of 24 degrees at 6:00 p.m., 40 degrees with 31 degrees wind chill at 8:00 p.m. and 10 p.m., and 37 degrees with 26 degrees wind chill at 12:00 midnight. Note: At the time of the complaint investigation, the complaint was coded at a " J " , immediate and serious jeopardy. By 11/18/13, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the " D " level. The Administrator revised the policy for the location of the Sign Out book. The book no longer resides on the counter of Station I. The book is kept on the medication cart so staff are aware when a family member/resident signs the book when leaving the facility. The facility also assessed all the residents for the need of Wander Guards devices and performed in-service to staff about the revised policy and elopement of residents. As of December 2, 2013, the facility needed to: ? Continue to in-service employees regarding the location of the sign out book/policy. ? Continue to in-service employees about elopement and the policy/procedures. ? Monitor staff to assure compliance with the elopement policy and the location effectiveness with the sign out book. 2. Resident #3 had an MDS with a reference date of 10/11/2013. The MDS identified the resident had modified independence with cognitive skills for dailydecision making, and long and short term memory impairment, required extensive assistance of two staff to transfer, dresss, eat eatand use the toilet. The MDS reported the resident had [DIAGNOSES REDACTED]. behavior disturbance and hypertension. The MDSindicated the resident required staff assistance and balance when turning around, moving on or off toilet and transferring from one surface to another. The Care Plan dated 7/4/2013 and updated, revealed Resident #3 had a self care deficit and needed assist with activities of daily living. It directed staff to provide assistance with showers, pericare with incontience,toileting, and monitor for signs and symptoms of UTI's. It instructed staff to ambulate, transfer with assist of one and a front wheeled walker or hand held assist, and provide a personal alarm at all times. Observation on 11/27/2013 at 8:49 a.m. revealed Resident #3 in his/her room, on the toilet with Staff M. Staff M assisted the resident to stand and ambulated the resident without the use of a gait belt. The Fall Risk Evaluation revealed Resident #3 scored 18, indicating the resident had a high risk for falls. 3. According the MDS dated [DATE], Resident #4 had severely impaired decision making skills, required extensive assistance of one staff to transfer, ambulate, and personal hygiene. The resident had occasional incontinence of bowel and bladder. The MDS reportedthe resident had had steady times when turning round, moving off toilet and transferring from one surface to another, but able to stabilize without staff assistance. The Fall Risk Evaluation revealed Resident #4 scored 17 points on 11/11/2013 indicating the resident had a high risk for falls. Observation on 11/26/2013 at 2:50 p.m. revealed Staff O, CNA passing ice water to residents on A Hall. Observation from 2:50 to 3:02 p.m. revealed Resident#4 on the toilet. The resident had no staff present while on the toilet. The resident's roommate reported staff should remain with the resident while on the toilet. Staff entered the resident's room and assisted the resident with incontinence cares and then assisted the resident to ambulate to the bed with a walker and without a gait belt. Staff O assisted the resident to lay in bed and placed a clip alarm to the resident's slacks at the waist. The facility Gait Belt, Use of Policy included: Policy - It is the policy of this facility that staff will help control and balance (by using a gait belt)residents who require assistance with ambulation and transfer. During an interview on 12/2/2013 at 3:50 p.m. the DON stated the staff were to use gait belts with all residents who require assistance with transfers and ambulation.

Based on record review and family and resident interviews, the facility failed to accurately plan for and direct the nursing services so a resident ' s needs are met prior to and following eye surgery with the proper use of eye drop medications and failed to assess for pain and determine the need and effectiveness of [MEDICATION NAME]. The findings include: 1. The admission summary document indicated Resident #1 had the following Diagnoses: [REDACTED]. Resident #1 had an MDS (Minimum Data Set) assessment with a reference date of 12/8/2011. The assessment identified the resident had no memory problems and scored a 15 out of 15 on the BIMS (Brief Interview Memory Status). Review of the resident ' s record revealed conflicting orders for the administration of [MEDICATION NAME] 5 (treats eye swelling) cc (cubic centimeters) eye drops. The Nurse ' s Notes dated 11/8/2011 at 12:00 p.m. indicated the resident returned from seeing the eye doctor. The physician ordered [MEDICATION NAME] 5 cc (cubic centimeters) 1 drop to the left eye three times a day preoperatively and the resident was scheduled for left eye surgery on 1/10/2012. A physician's order [REDACTED]. The facility staff did not make the changes to the Physician order [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The staff administered the medication at 6:00 a.m., noon and at 4:00 p.m. The staff stopped the medication after the 6:00 a.m. dose on 1/9/2012. Review of the physician clinic notes revealed on 1/9/2012, the facility staff notified the clinic and informed the physician the resident had been receiving [MEDICATION NAME] three times a day since 1/1/2012. The clinic nurse reviewed the booklet for orders about the drops with the facility nurse. On 1/10/2012 the clinic gave an order for [REDACTED]. The Nurse ' s Notes dated 1/11/2012 at 8:30 a.m. revealed the resident went to surgery. At 1:00 p.m. the facility received a telephone call that the resident had a corneal bleed and had been transferred to Iowa City. The Nurse ' s Notes dated 1/12/2012 at 1:00 p.m. indicated the nurse received a telephone order for [MEDICATION NAME] (relaxes eye muscle to dilate the pupil) 1% to the left eye 1 drop three times a day and to increase [MEDICATION NAME] to 1 drop 8 times a day to the left eye. At 10:45 p.m. the nurse documented the physician signed the fax for the order. The MAR indicated [REDACTED]. The Nurse ' s Notes dated 1/17/2012 at 3:15 p.m. indicated a fax was sent to the physician requesting Loratab for pain relief. The physician ordered Loratab 5/500 1 tablet every 4 hours for break through pain regarding the cataract surgery (The resident had been receiving Tylenol as needed for pain). The PRN Medication document indicated on 1/24/2012 at 10:00 p.m. the resident was administered [MEDICATION NAME] 5/500 1 tablet for a headache. This first dose was 7 days after ordered by the physician. The staff indicated the pain was an " 8 " . The Nurse ' s Notes did not reflect an assessment had been performed prior to the administration of the medication for break through pain. At 12:00 a.m. the PRN Medication report indicated the [MEDICATION NAME] had been helpful for the pain, however, an assessment had not been performed to determine the effectiveness of the medication. The PRN Medication documented the resident received the medication on 1/25/2012 at 10:00 p.m. for pain at a " 7 " . Tylenol had not been administered. On 1/26/2012 at 8:00 p.m. the resident received the medication for general discomfort and again on 1/31/2012 at 8:00 p.m. for general discomfort. The record reflected no assessments had been performed when the resident displayed a change of condition and required the [MEDICATION NAME] medication. The Tylenol had not been given. On 2/7/2012 at 12:30 p.m. the resident ' s family member stated there were eye drops ordered that should have been given after the surgery but the facility did not receive the medication from the pharmacy. The family member noted of the need to call the local physician to get the eye drops. The local physician call the prescription to a drug store and the family member picked up the medication and took it to the facility to be given to the resident. The Nurse ' s Notes indicated on 1/17/2012 at 3:15 p.m. the resident returned from a post operative appointment with the physician. The physician ordered [MEDICATION NAME] (lowers inner ocular pressure) 1 drop in left eye twice a day. On 2/7/2012 at 1:50 p.m. Staff R (Transcriptionist) at the physician ' s office was interviewed and stated she had given the 2 page instructions to the facility and had spoken with the facility to confirm the instructions for pre and post operative orders. The facility had confirmed to her of receiving the instructions. The Physician was interviewed on 2/7/2012 at 4:06 p.m. and stated the medication [MEDICATION NAME] had been given incorrectly, too many days ahead of surgery. The Physician commented the medication had not caused the ocular bleed as the resident was at a high risk with very poor vision and a very dense cataract. The office did receive a phone call from the resident ' s family member regarding pain in the resident ' s eye after surgery and stated the facility had not received the eye medication which was ordered. The office contacted the hospital, received the medications name and dose and contacted the drugstore for the family member to obtain and take to the facility. The physician ' s office contacted the facility and questioned why the medication had not been given to the resident. The facility stated they had not received the prescribed dose for the eye medication for their pharmacy to dispense. The physician stated the resident would absolutely have eye pain without receiving the medication due to a built up of pressure in the eye. The packet for surgery instructions consisted of a front page with phone numbers. The remainder of the booklet consisted of 2 pages, one with instructions regarding eye drops before surgery and the second page with instructions for the night before surgery, the afternoon and evening after surgery and the morning after surgery instructions. On 2/9/2012 at 2:45 p.m., the Director of Nursing (DON) and Staff V (Nurse Consultant) was interviewed and stated they could not answer why the [MEDICATION NAME] was given incorrectly before surgery and why the medication was started on 1/1/2012 (9 days before surgery). The DON and Staff V could not answer why the record revealed no assessment performed for pain and for the effectiveness of the medication. The DON had confirmed an order for [REDACTED]. On 2/10/2012 at 8:00 a.m. the Pharmacy Consultant was unaware of the resident ' s medication [MEDICATION NAME] not delivered in a timely manner or that there was even a problem. On 2/10/2012 at 8:15 a.m., Staff R, Pharmacy Data Clerk was interviewed and stated there was no data entry for a prescription of [MEDICATION NAME] on 1/17/2012. The pharmacy did have an order for [REDACTED]. On 2/10/2012 at 11:18 a.m., Staff H, Licensed Practical Nurse (MDS Nurse) confirmed she had not given the medication identified on the telephone order form until the physician returned the signed order. Staff H stated the pain medication ([MEDICATION NAME]) which had been ordered on [DATE] for the resident would not be given until 1/23/2012 when the order was returned and signed by the physician. The physician ordered the medication on 1/18/2012 which directed the facility to administer the medication on 1/18/2012 and not wait until a signed order returned to the facility. The facility 2011 Nursing Drug Handbook identified [MEDICATION NAME] as used for inflammation associated with ocular surgery. The book noted the use to be after surgery for [REDACTED]. The handbook noted the drug not to be used for long term use and if used for 10 days or longer, to monitor intraocular pressure. The Nurse ' s Notes dated 1/27/2012 at 6:45 a.m. indicated the resident returned to the hospital for another appointment. The resident returned to the facility at 11:50 a.m. with discharge instructions. The physician wrote " Must follow instructions or the resident will go blind. "

Based on observation, record review and resident and staff interviews, the facility failed to implement a written health care plan to protect the resident when ambulating and transfers for Resident #1 and failed to have foot pedals on the resident ' s wheelchair when transporting the resident in a wheelchair (Resident #5). The facility identified a census of 75 residents. The physical therapist treatment notes identified Resident #1, needed to be assisted by 2 staff persons when transferring. The resident ' s care plan was updated on 8/2/2011 and directed the staff to transfer the resident with the assistance of 2 staff persons. The Communication book kept at the nursing station noted on 8/2/2011 directed the staff that the resident required 2 people to assist with transfers. On 8/7/2011 the resident was transferred by one staff person which resulted in the resident being lowered to the floor. Based on staff interviews, the staff did not know the current plan which directed staff to have an additional person when transferring the resident. Findings include: 1. An MDS (Minimum Data Set) assessment with a reference date of 6/13/2011, identified Resident #1 with a BIMS (Brief Interview for Mental Status) score of 10 out of 15. A score of 10 reflects moderate cognitive status impairment. The MDS indicated the resident exhibited verbal behaviors, required extensive assistance with one staff person for bed mobility, transfers, dressing, eating, bathing and toilet use. The MDS noted the resident's balance as not steady, but was able to stabilize without human assistance and had no limitation in range of motion. The assessment identified the following active Diagnoses: [REDACTED]. The Care Plan dated 06/14/11 identified the resident with impaired mobility with an approach to transfer with 1 staff person assist. An update on 08/02/11 revised the transfer and directed staff to transfer the resident with the assistance of 2 staff persons. The Physical Therapy Progress Report dated 07/21/11 noted the resident had stated "my balance is not so good". The resident also has decreased functional activity tolerance and shortness of breath. The Physical Therapy Daily Treatment Note dated 08/02/11 stated the resident was to be an assist of 2 staff persons at this time. The Physical Therapy Progress Report dated 08/04/11 noted staff was educated to provide assistance with 2 staff persons for transfers and to ambulate the resident to the bathroom due to a recent fall. The IDT (Interdisciplinary Team) Post-Occurrence Review dated 08/02/11 noted the resident needed to be a 2 person transfer for now per Physical Therapy recommendations related to increase pain. The Communication Book kept at the Nursing Station noted on 08/02/11 the resident as now a 2 person transfer due to difficulty with transfers. A Diagnostic Radiology report dated 08/08/11 concluded the resident had at least a fracture of the lateral malleolus (ankle). A Discharge Summary from the hospital dated 08/10/11 noted the resident had been admitted to the hospital on [DATE] after presenting in the emergency room with pain to the right ankle after sustaining a fall during a transfer. The Summary noted the admission [DIAGNOSES REDACTED]. The resident had secondary [DIAGNOSES REDACTED]. A Hospital Admission Consultant dated 08/09/11 noted the resident with multiple medical problems including chronic edema, venous stasis changes of the lower extremity, morbid obesity, chronic [DIAGNOSES REDACTED]on Coumadin and a mildly displaced commuted fracture lateral malleolus of the right ankle. A short walking leg non-walking cast was applied and would continue with no operative treatment. Observation on 09/20/11 at 8:00 a.m., revealed the resident sitting in a large wheelchair eating breakfast, with the right foot in a purple cast, slightly elevated up on the foot rest. Record review of the IDT Post-Occurrence Review and Post-Fall Documentation Flow Sheets indicated the following falls by the resident: On 02/19/11 at 10:15 p.m. the resident was observed in the room lying in front of the recliner, stated of believing the wheelchair was locked when trying to transfer self to the recliner. There were no injuries. The Change of Condition Report noted the post fall actions were to provide safety re-education and re-enforce the use of the call light. The Episodic Care Plan: Post-Fall, undated, noted additional intervention of using breaks when getting up. On 03/18/11 at 6:00 p.m. the resident's spouse witnessed the resident getting up from the wheelchair transferring self to the recliner and falling forward into the recliner. The resident was balancing with the elbows on the seat of the recliner and toes of the shoes still on the floor, thus did not hit the floor. There were no injuries. The Change of Condition Report noted the post fall actions were to provide safety re-education and re-enforce the use of the call light. On 03/19/11 at 12:35 p.m., the resident lost his/her balance while attempting to pick up a towel from the floor, fell against the wall by the doorway to the room with the legs out in front. A bruise was noted to the resident's left buttocks. The Change of Condition Report noted the post fall actions were to provide safety re-education and re-enforce the use of the call light. The Episodic Care Plan Post-Fall dated 03/21/11 noted an additional intervention to have a sign on the walker for visual cuing to help with ambulation/transfers. On 05/26/11 the resident had a fall on 05/25/11 at 10:40 p.m. staff noted the resident was sitting on the floor, on the buttocks, legs out in front with the knees bent to the right. The fall was witnessed and noted the resident bumped the head on the side of the bed, but had no apparent injuries. The Change of Condition Report noted the post fall actions were not addressed. The Episodic Care Plan Post-Fall dated 05/25/11 noted an additional intervention to encourage the resident to ask for assistance with transfers. The Nurse's Notes dated 05/25/11 stated after a call to the spouse regarding the fall, the spouse requested the resident be sent to the hospital due to the elevated blood pressure. The Nurse's Notes dated 05/26/11 noted the return of the resident at 1:35 a.m. with new orders for the [DIAGNOSES REDACTED]. On 07/30/11 at 6:10 p.m. the resident was on the floor in front of the wheelchair in the bathroom doorway. The wheelchair was unlocked and slid back when the resident went to sit down. There were no signs of injury. The Change of Condition Report noted the post fall actions were not addressed. The IDT Review noted recommendations to not place the wheelchair in front of the resident in the chair, put the walker locked in front of the resident and exchange sides of the room with the roommate. The Flow Sheet noted discontinuation of documentation due to another fall on 08/01/11 at 4:30 p.m. On 08/01/11 at 4:30 p.m., the resident was noted sitting on his/her buttocks on the floor with back toward the window and the feet toward the door with the knees bent at a 45 degree angle to the right. The resident was holding onto the dresser that was to the left side with the resident's relative holding the resident in a sitting position. Sixteen bruises were identified along the abdomen, buttocks and both arms. The Change of Condition Report noted the post fall actions were not addressed. The IDT Review noted recommendations of Physical Therapy working with the resident and them recommendable the resident is a 2 person transfer for now due to decreasing of transfers related to pain. On 08/07/11 at 8:15 p.m. the resident was found on the floor in a kneeling position with 2 staff persons holding the resident in an upright position, after the resident used the bathroom and was walking to the recliner. The resident was lowered to the floor. Verification of Incident Investigation/Administrative Summary dated 08/08/11 noted the resident was ambulating back from the bathroom with Staff A, Certified Nursing Aide, when the resident got to the side of the wheelchair, took the right hand off from the walker and leaned back onto the wheelchair and continued to lean. Staff A eased the resident into himself/herself while Staff J, Certified Nursing Aide, held onto the right front of the resident. The resident continued to lean forward with his/her knees. Staff eased the resident to the floor. The resident was assisted to stand and transferred to the wheelchair by 4 staff persons. The resident stated his/her knees hurt. The report's Follow-Up Actions Taken were noted as the resident was sent to the emergency room and kept for an urinary tract infection, weakness, increase in blood pressure and pulse, hyperventilating and to provide education. The relative informed the facility the resident's ankle was fractured. The record lacked any documentation of a care conference completed in regarding safety issues for the resident due to falls. During an interview on 09/20/11 at 8:29 a.m. the resident had no recollection of when or how the ankle was fractured. During an interview on 09/20/11 at 12:04 p.m., Staff J, Certified Nursing Aide, recalled being called to the room by yells of help from the resident. Staff A, Certified Nursing Aide, was holding onto the resident without a gait belt, who was leaning into Staff A's body with their knees toward the floor. The resident had gripped the arm of the wheelchair and wouldn't let go. Staff A removed the gait belt from his/her waist and placed it on the resident while Staff J supported the resident on the right side. The 2 staff persons tried to assist the resident to a standing position, but were unsuccessful. They lowered the resident to the floor, on the resident's knees. Staff J stated the resident was transferred by a stand by assist before this fall, not requiring a gait belt and noted the resident would put himself/herself into the bathroom without any calls for assistance or while waiting for a call light to be answered. During an interview on 09/20/11 at 4:45 p.m., Staff E, Registered Nurse and prior Director of Nursing (DON), stated the resident was a 2 person transfer only if the resident allowed it. Staff E remarked the resident refused to exchange sides of the room with the roommate (to be closer to the bathroom). Staff E noted personal alarms were attempted but the resident's anxiety caused the alarms to be discontinued. During an interview on 09/21/11 at 7:23 a.m., Staff G, Certified Nursing Aide, stated the resident was a 1 person assist with transfers before the fracture and if the staff didn't answer the call light quickly enough, the resident would get up and go alone. During an interview on 09/21/11 at 7:27 a.m., Staff B, Registered Nurse, stated staff could access their headphones (Accunurse computer system) and find out a resident's mode of transfer at anytime. The computer system would also give staff updates for a change of cares regarding a particular resident as their care plan changed. When a staff person logged into the system, it would inform them there was an update and asked if they wanted to review that update. During an interview on 09/21/11 at 7:34 a.m., Staff L, Certified Nursing Aide and Restorative Aide, noted Physical Therapy would write into the Communication Book of any new changes for a resident. The MDS Coordinator would place those changes into the computer which would place an update to the Staff when they logged into the computer system. It was noted the updates were done for only the residents on their Nursing Station. Staff on the front Nursing Station got updates for only the residents residing in the front station, not for residents in the back station and vice versa. Staff L stated Resident #1 was a transfer with the assist of 1 person before the fractured ankle. During an interview on 09/21/11 at 9:37 a.m., Staff F, Certified Nursing Aide, stated the resident was a transfer with 1 person assist before the fractured ankle. Staff F remarked of learning about new updates on residents by reading the Communication Book at each Nursing Station. Each staff member was responsible for reading the Communication Book every morning, but did not have to initial it off, to indicate of having read the notes. Staff F also noted changes were made known during shift report, by word of mouth. Another way to know about a change in cares for a resident was by receiving them on the computer system when you logged into the system. During an interview on 09/21/11 at 10:28 a.m., Staff M, Registered Nurse and MDS Coordinator, stated the resident had a change in transfers on 08/02/11 (Note: it was 5 days before the fractured ankle occurred). It was probably discussed in the daily morning meetings and would have been put into the computer system. Staff M was unaware if the computer system sends out the update only for that day and unaware if a staff person who logs into the system will receive an update when that staff person had been off for a couple days. Staff M was aware each staff person could ask for a resident's plan of care at anytime through the computer system. Staff M noted the Communication Book was expected to be read by every staff person every morning at each station and noted no one was required to initial it off, to indicate it was read. When asked how supervisors know if staff had read the Communication Book, Staff M, replied, they didn't know. During an interview on 09/21/11 at 11:30 a.m., the Facility Rehabilitation Director (FRD), Physical Therapist, stated the resident had been changed to a 2 person transfer upon their recommendation due to the resident's unsteadiness. The report noted staff education, written in their note, did not indicate an in-service was completed, but meant staff had been informed of the change. The FRD was unaware if alarms had been attempted on the resident for a safety intervention. The FRD noted the IDT Reviews would indicate what interventions were put into place for a resident after a fall incident. During an interview on 09/21/11 at 3:08 p.m., Staff A, Certified Nursing Aide, stated of answering a red call light (which indicates the resident is in the bathroom) for the resident. After bathroom cares were completed, the resident walked from the bathroom toward the wheelchair with the use of a walker, with Staff A following behind. The resident let go of the walker and placed the right hand onto the arm of the wheelchair and asked the relative who was sitting in the wheelchair, to get out of it. When Staff A asked the resident to let go of the wheelchair and place the hand back onto the walker, the resident couldn't do it and appeared to get weak. Staff A placed his/her arms around the resident and his/her legs under the resident's legs and the resident yelled for help. Staff J came into the room and held onto the resident's left arm. Staff A removed the gait belt from around his/her waist and placed it around the resident's waist. As both staff persons grabbed the gait belt, the resident went down and was sitting on Staff A's lap. When Staff A asked the resident to lean backward, the resident leaned forward and went to the floor with his/her knees. Staff A commented the resident normally walked around the room independently and was a transfer with a stand by assist in the room without the use of a gait belt. Staff would use a gait belt with the resident during ambulation in the hallways due to the resident's easy shortness of breath. During an interview on 09/21/11 at 3:45 p.m., the Director of Nursing(DON), Registered Nurse, stated of not being sure how the computer system works, how long new updates stay on it for staff to review, but would check with Corporate Headquarters. The DON recognized the new change, for a 2 person transfer for the resident had not been passed on or communicated to attending staff, for some reason. The DON commented of not knowing if personal alarms had been attempted for the resident as a safety intervention. The DON noted the investigation was handled by the prior DON. The facility's Incident and Accident Management Policy dated 03/2010 stated the purpose was to promptly acknowledge and manage facility incidents and accidents to ensure the medical needs of affected individuals are identified and addressed; to analyze contributing factors and environmental conditions that may be modified in order to provide a safe environment and reduce incidence of reoccurrence; to provide a process for tracking and trending incident data for improved quality of care and facility safety. 2. The History and Physical dated 09/02/11 identified Resident #5 with [DIAGNOSES REDACTED]. The Minimal Data Set(MDS)assessment with a reference date of 09/13/11 identified the resident with a score of 3 out of 15 for cognitive skills (severely impaired cognitively) and required extensive assistance of 1 staff person for bed mobility, transfers, locomotion, dressing, hygiene, bathing and toilet use. The MDS indicated the resident and no impairment with range of motion but was unsteady with changing positions and only stabilized with human assistance but could stabilize without human assistance with walking. The resident's Care Plan dated 09/14/11 noted impaired mobility with ambulation using a front wheeled walker and assistance of 1 staff person and to provide a wheelchair for mobility, propelled by staff and or self-propelled. Observation on 09/20/11 at 11:45 a.m., revealed the Speech Therapist, Staff O, pushing the resident done the hall from the front Nursing Station to the back Nursing Station (approximately 40 to 50 feet). The Therapist asked the resident to lift their legs while being pushed because there were no foot pedals/ rests on the wheelchair. As they got closer to the back station the resident's feet were hanging lower so the Therapists again asked the resident to raise the feet a little higher, which the resident did, as Staff O wheeled the chair around to park it at the nursing Station. During an interview on 09/22/11 at 11:10 a.m., the Director of Nursing and MDS Coordinator agreed standard protocol required staff persons to push a wheelchair with foot rests intact, with the resident's feet resting on the pedals.