Every finding on record at Estherville Community Care Center

Based on observation, record review, and staff interview, the facility failed to ensure resident's individualized interventions were in place to prevent falls for 4 of 4 resident's reviewed (Resident #1, #2, #3, and #4). Resident #1 had an alarm to alert staff if she got up so they could assist her. Resident #1 stood up, walked a few steps and fell fracturing her left hip. The resident's alarm did not sound. Resident's #2, #3, and #4 had alarms that failed to sound and alert staff to assist them.The facility reported a census of 36 residents.Findings include:1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 demonstrated long- and short-term memory problems and severely impaired skills for daily decision making. The resident required substantial/maximal assist to transfer and partial/moderate assist to ambulate. Resident #1's diagnoses included primary osteoarthrosis of the right knee, age related physical debility, and unspecified fall, subsequent encounter. The resident used a bed alarm and chair alarm daily.The Care Plan with a goal target date of 5/14/26 identified Resident #1 at risk for falling related to repeated falls, unsteadiness, and abnormality of gait and mobility. Interventions included Resident #1 had a bed and chair alarm, approved by a family member dated 1/22/25, staff re-educated on wearing gripper socks daily dated 10/27/25.The Progress Notes dated 10/24/25 at 8:23 p.m. documented staff heard Resident #1's alarm sound and found Resident #1 on the floor next to her bed with the wheelchair behind her. The resident said she tried to get herself into the recliner. The nurse assessed the resident. Range of motion (ROM) within normal limits for the resident, hip alignment normal. The resident denied pain, and no injuries noted.The Progress Notes dated 12/15/25 at 5:50 p.m. documented the nurse was on west hallway when heard a woman scream for help. The writer walked into this resident doorway and witnessed resident sliding out of the recliner chair. Resident #1 slid onto her bottom with her feet out in front of her. Resident did not have proper footwear on. No injuries or c/o pain at the time (per the care plan staff reeducated on wearing gripper socks daily, dated 10/27/25. The Progress Notes dated 3/25/26 at 4:04 p.m. documented the writer received notification by a staff member Resident #1 was on the floor. Resident #1 laid on the floor in the east hallway on her right hip, with her head facing east and her feet facing west. Her wheelchair was in the hallway against the north side of hall facing east. The alarm did not sound. Witness stated Resident #1 used the railing to walk and then tipped over. VS- 97.4, 125/78, 66 heart rate, 18 and 98%. Resident yelling out in pain, initially stating her back hurt. Resident #1 adjusted to evaluate and continued to yell out in pain. Resident #1 carefully placed in wheelchair by multiple staff. Resident #1 stated her hip caused her pain. Call placed to the physician for orders. Ice and Tylenol administered. Resident #1's alarm replaced.The Progress Notes dated 3/25/26 documented receiving a call from the physician stating the resident had a right intertrochanteric hip fracture. He had spoken with the resident's family and they were considering what route to take with resident. The physician told them surgery probably wasn't the best option with her health/age, and again, talked about hospice. The physician would admit the resident to the hospital for pain control until the family decided what they would like to do.A hospital History and Physical report dated 3/25/26 documented Resident #1's assessment included a fall with a closed intertrochanteric fracture of the right femur. The resident had some steady decline over the past several months with poor oral intake, weight loss and frequent falls secondary to generalized weakness. Given the nature of fall and frailty, CT of the head along with x-rays of the hips/pelvis ordered. Mildly comminuted right intertrochanteric fracture noted. Resident would be given morphine 2 mg every 2 hours and Ofirmev 1 gm every 6 hours as needed.On 6/10/26 at 9:08 a.m. The Director of Nursing (DON) showed the different alarm boxes they had available. The alarm Resident #1 had could be turned off/on with a switch. She currently used a blue box that had to be squeezed after the resident no longer sat or laid on it to silence the alarm (then it would activate when the resident sat on it). The DON confirmed she wrote the statement about the 3/25/26 fall. She had taken the resident from the dining room to outside the room where the Podiatrist and his assistant were trimming resident's toenails. They saw Resident #1 get up, walk a couple steps and fall. The DON said the alarm did not sound. She did not know if the alarm was turned on, only that it didn't sound. She said the resident did restorative and could walk with assistance. She said the alarm alerted them if she was getting up so they could assist her.On 6/10/26 at 12:15 p.m. Staff A Certified Nursing Assistant (CNA) said she didn't work with Resident #1 that much except with transfers. She said it was a hectic day. She thought she and Staff B CNA got her up before lunch and then Staff A went to lunch. When she got back from lunch she went to talk to the DON and she said Resident #1 fell and the alarm was not turned on. Staff A said she thought Resident #1 had an alarm you could turn off and on. She said you turned it off when you transferred a resident and then you turned it back on so it was ready when the resident sat/laid on the pressure pad. She said then you would get a beep when they sat back down on it. She could have sworn it was on that day.On 6/10/26 at 2:03 p.m. Staff B stated she did work the day Resident #1 fell and fractured her hip. She said she thought it was just her and Staff A getting people up for lunch. She said she would normally shut the alarm off and then when she was off it, turn the alarm back on so it was ready the next time she was on it. She said she thought the alarm was on, but after Resident #1 fell she was told the alarm was off. She said it's really hard to be sure because there are so many alarms there. 2) According to the MDS assessment dated [DATE], Resident #2 scored 11 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required substantial/maximal assistance with transfers and depended on staff for ambulating. Resident #2's diagnoses included diabetes, non-Alzheimer's dementia, and cellulitis of his right lower limb. The Care Plan identified Resident #2 at risk for falls/injuries with the goal Resident #2 would remain free from fall related injuries through nursing/therapy interventions by next review date of 7/21/26. Interventions included a personal alarm while up in the chair/bed dated 4/17/26.The Progress Notes dated 4/8/26 at 6:15 p.m. documented Resident #2's roommate alerted staff to the resident on the floor in the west hallway, between the dining room and his room, directly in front of his wheelchair. The resident laid on his right side with his feet under his foot pedals. His head to the west and his feet to the east. Resident #2 wore a gripper sock on the left foot and cast shoe to his right foot at the time of the incident. Resident #2 attempted to propel himself back to his room when noted leaning forward prior to the fall. Resident #2 denied pain, no injuries noted, denied hitting head but neuros initiated and within normal limits (WNL). An Unwitnessed Fall Report dated 4/8/26 at 6:15 p.m. documented a chair alarm would be in place when up in the wheelchair.The Progress Notes dated 4/11/26 at 5:57 p.m. documented Resident #2 was in the dining room in his wheelchair. The writer saw the resident tipping forward out of his wheelchair. The writer attempted to reach the resident. Resident #2 tipped forward out of the wheelchair and hit his head on the floor and landed on his head and knees. Resident #2 assessed no injuries or pain at the time. The left side of the wheelchair wheel got caught on a walker and the wheelchair was unable to move. Clutter removed from the dining room and aides educated. The Progress Notes dated 5/1/26 at 3:50 p.m. documented the writer was notified by a CNA that Resident #2 was on the floor. Upon entering room the resident was in the fetal position lying on his left side. Resident #2's wheelchair at the end of his feet. Resident #2 stated he bent over to pick something up off of the floor. Resident #2's alarm did not sound and the alarm box changed to one that could not be turned off. No complaints of pain or discomfort at the time. The Progress Notes dated 5/15/26 at 6:05 p.m. documented a CNA came out to inform staff Resident #2 was on the floor. The writer found the resident on the floor with his head under the bed, back towards the wall and his legs beside the bed pointing towards the door. The resident verbalized he tried to reach his bedside table and fell out of bed. Did obtain a 1.7 x 1 cm skin tear to his left upper arm which was cleansed and Steri-strips applied. Scratch noted above the left eye measuring 4 x 0.1 cm.An Unwitnessed Fall Report dated 5/15/26 documented bed alarm applied. The Care Plan dated 4/17/26 documented chair/bed alarm.The Progress Notes dated 5/25/26 at 2 p.m. documented the nurse called to Resident #2's room as he fell out of his wheelchair. The resident was laid with his back against his bathroom door on his left side and his head right by his sink cupboard. Both boot and shoe were being worn at time of fall. Resident #2 stated he dropped his ring and was leaning over to grab it off the floor and fell, catching himself with his hands. Checked over for injuries with none noted. The alarm was not switched on after returning from dialysis. The alarm box was changed to one that sets itself to try to avoid this from happening again (the Progress Notes dated 5/1/26 documented the alarm box changed to one that could not be turned off). 3) According to the MDS assessment dated [DATE], Resident #3 scored 15 on the BIMS indicating no cognitive impairment. The resident was independent with transfer and ambulation. Diagnoses included heart failure, disorientation and repeated falls.The Care Plan identified Resident #3 at risk for falling related to difficulty in walking, history of falling, lack of coordination, abnormalities of gait and mobility, and unsteadiness on feet. Interventions included a new bed alarm box and pad was put onto her bed on 2/13/26. Resident #3 needed assistance with a.m. cares, assist with toilet use at 5:30 a.m. 2/25/26, staff and resident educated the resident must wear gripper socks when not wearing nonskid shoes 7/20/25.The Progress Notes dated 1/27/26 at 8 a.m. documented an aide called nurse to resident #3's room. Resident #3 sat on her suitcase at the end of her bed between the bed and a piled up tote and a box. Her legs were hanging off the suitcase pointing towards the west without any gripper socks on. Resident was hanging on to the foot board of her bed with her right arm and her left arm sitting on the suitcase. Resident's alarm was not sounding, as it was not working. Resident's walker was over by her closet facing the complete opposite way, so would assume she was not using it as she is supposed to. Resident assessed for injuries and none noted. Box and tote were moved to the basement and her suitcase was put into her closet. New bed alarm box and pad were put onto her bed.The Progress Notes dated 2/23/26 at 10:43 a.m. documented the writer called to Resident #3's room at 6:20 a.m. Resident #3 laid in the prone position with her head pointing west and her feet facing east in front of the bathroom door. Her walker was in front of the bed to the right hand side of the resident and several feet in front of her. Resident had bare feet. The bed alarm was not sounding. Resident stated that she went to the bathroom and when she finished she tried to pull her pants up and lost balance. Resident #3 rated pain 5/10. She had a bruise to left forehead, 5cm X 5cm with a small abrasion.An unwitnessed Fall report dated 2/23/26 identified the predisposing situation factors included bed alarm, transfer unassisted and improper foot wear. The immediate action taken to assist the resident to the toilet at 5:30 a.m. The report failed to address why the alarm didn't sound and why the resident did not wear gripper socks.The Progress Notes dated 3/30/26 at 7:30 a.m. documented Resident #3 noted laying on her left side, head against the bottom of the bed. Reported she was getting clothes out of the closet, stumbled backwards et fell. Alarm not sounding, on not working when checked. Alarm noted in reach of the resident. Alarm box moved out of the reach of this resident to avoid possible stopping the alarm. The Progress Notes dated 4/14/26 at 10 p.m. documented the resident found sitting on the floor with her legs out in front of her facing the bathroom door. Resident stated that she attempted to walk backward with her walker, her feet stuck to the floor, she lost her balance and fell hitting the other bed in the room. Resident #3 verbalized that the left side of her back hurt but able to ambulate without difficulty. An Unwitnessed Fall report dated 4/14/26 at 10 p.m. documented the above information and included the predisposing situational factors of bed alarm and during transfer (self/unassisted). The report failed to document if the alarm sounded at the time of the incident.On 6/9/26 at 8:50 a.m. Resident #3 in her room in her chair. She admitted having some falls. She said she walked around her room and in the hall with her walker. She said they had an alarm at night so if she got up it made a sound and they came running.On 6/10/26 at 9:08 a.m. the DON stated they put the bed alarm on the resident's bed because she would get up at 5:30 a.m. and fall while getting ready. 4) According to the MDS assessment dated [DATE] Resident #4 scored 11 on the BIMS indicating moderate cognitive impairment. The resident partial/moderate assistance with transfer and supervision/ touching assistance with ambulation. Diagnoses included arthritis, a stroke, and Parkinson's disease.The Care Plan identified Resident #4 at risk for falls/injuries related to a history of falling, with a goal the resident would remain free from fall related injuries through nursing/therapy interventions by the review target date of 7/8/26. Interventions included a bed alarm at night dated 5/9/26. The Progress Notes dated 5/9/26 at 11:05 p.m. documented finding Resident #4 on the floor beside his bed on his right side, feet towards the bathroom door and the top of his head towards his roommate. He verbalized he sat on the side of his bed and slid off onto the floor. An Unwitnessed Fall Report dated 5/9/26 at 11:05 p.m. documented the fall, and a new intervention for a bed alarm at night.The Progress Notes dated 5/16/26 at 3:20 a.m. documented finding Resident #4 on the floor face down in a pool of blood, feet towards the bathroom, top of his head pointing towards his roommates bed. Resident #4 obtained a 4.5 x 1 cm laceration above his right eye. Resident #4 sent to the Emergency Department (ED) for evaluation and sutures.An Unwitnessed Fall Report dated 5/16/26 at 3:20 a.m. documented the same fall information and predisposing situation factors included bed alarm and ambulating without assistance. The report failed to identify if the alarm sounded.The Progress Notes dated 5/31/26 at 10:50 p.m. documented called to the resident's room by the CNA. The resident was on the floor beside his bed, his head faced towards the door and partially under the bedside table, feet towards the bed. An Unwitnessed Fall Report dated 5/31/26 at 10:50 a.m. documented the fall and staff education on the bed alarm and ensuring it was in place and turned on.On 6/8/26 at 4:20 p.m. Resident #4 sat in his room in the wheelchair. He said he'd had some falls. He said he had to get stitches after 1 of them. He said they put something on the bed that made noise so they knew when he got up, so they could help him. He said he used his walker in his room, but someone had to be with him when he walked in the hall. He didn't know if the alarm sounded the night he fell and needed stitches.On 6/10/26 at 9:08 a.m. the DON stated they started documenting alarm checks on the treatment sheets after another resident's fall in March. She said she knew there were still issues with the alarms after they started the checks. The undated facility Accidents and Supervision policy documented the resident environment would remain as free of accident hazards as was possible. Each resident would receive adequate supervision and assistive devices to prevent accidents, including: a. Identifying hazards and risks, the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. b. Evaluating and analyzing hazards and risks, the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. Evaluations also look at trends such as time of day, location, etc. c. Implementing interventions to reduce hazards and risks, using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: 1. Communicating the interventions to all relevant staff, 2. Assigning responsibility, 3. Providing training as needed. 4. Documenting interventions, 5. Ensuring that the interventions are put into action, 6. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice. d. Monitoring for effectiveness and modifying interventions when necessary. Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: 1. Ensuring that interventions are implemented correctly and consistently, 2. Evaluating the effectiveness of interventions, 3. Modifying or replacing interventions as needed, 4. Evaluating the effectiveness of new interventions.

Based on clinical record review, observation, staff and resident interview, along with facility policy review, the facility failed to provide a call light system within reach for which the call light was caught in the hinge of the side rail and was not able to be triggered when pulled for 1 of 3 residents (Resident #5) reviewed. The facility reported a census of 38 residents. Findings include:Resident #5's Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 for which indicated intact cognitive decisions, was able to be understood and understand others. The MDS addressed the resident as dependent for toileting, hygiene, showers/bathing, lower body dressing, sit to lying, sit to standing and transfers. The MDS included diagnosis of hypertension (when the pressure in your blood vessels is too high) anxiety, depression, after-care following replacement of total knee, weakness and need for assistance of personal cares. The Care Plan Focus with no date, indicated Resident #5 was at risk for falls related to recent hospitalization. Interventions include to have call light with in reach, resident room rearranged to put phone within reach of resident. Bed placed on other side of room to prevent call light/cord from being entrapped within bed, and I sleep in my chair rather than my bed.The Incident Note dated 2/15/26 at 10:23 AM, documented writer was standing at the medication cart in the dining room when a resident was heard calling out for help down east hall. Upon investigation, resident was sitting with her back against the south room door with feet out in front facing north. Resident stated she was attempting to get her cell phone to call for help. Residents call light was within reach but call light cord was caught in hinge of bed rail and was unable to be triggered when pulled. Phone was sitting on the sink counter. Bed placed on other side of room to prevent call light cord from being entrapped with in bed. Resident with no injuries at this time.The Health Status Note dated 2/16/26 at 8:15 AM, documented 24 hour follow-up from fall. No new injuries or marks noted to skin. Complains of lower back pain related to fall.The Facility Self Report dated 2/18/26 at 2:19 PM, documented that on 2/15/26 at approximately 8:15 AM, staff could hear someone calling out for help down the east hall. Resident was sitting with her back against the south room door with her feet straight out in front of her, facing north. It appeared as though residents call light was within reach of resident (while she was sitting in her recliner), however, the cord of the call light had fallen down and was caught under her bed grab bar preventing her from being able to pull it. After the resident attempted to pull her call light/cord for assistance to the bathroom, she got up out of her recliner and walked to her dresser area to get her cell phone (which was charging) to call the facility for assistance. Resident was not ambulating with the use of her walker at the time of incident. Resident had no injuries following fall. Bed was moved to the other side of room to prevent the call cord from getting caught in the bed rail anymore. Resident is also getting a longer phone cord to be able to plug her phone in near her recliner.Observation on 3/11/26 at 4:15 PM, revealed Resident #5 cell phone was across the room on a table underneath the north window, long cord attached to the cell phone, however, the cell phone was not with in reach.On 3/13/26 at 10:50 AM, Resident #5 stated that on the morning of her fall, 2/15/26, about 8:10 AM, she attempted to put her call light on, but the cord was wrapped around the top of the side rail and fell down and she was not able to reach it, and she needed to go to the bathroom. Resident #5 decided to get out of bed and walk to the sink where the cell phone was plugged in, then the left leg buckled and down on the floor she went. Resident #5 stated that she had no injuries from that fall, and feels that the fall at the physician office on 2/17/26 was the culprit on the ruptured quad left tendon, not the fall at the facility.On 3/19/26 at 10:10 AM, the facility Director of Nursing, acknowledged that the expectation from all staff are to make sure that call lights are with in reach and the call light cords are not wrapped around the bed rails. On 3/19/26 at 3:00 PM, the facility Administrator did not think they had a policy on call lights being with in reach, but stated that the expectation of all staff are to be aware of the call lights being with in reach and call light cords not wrapped around the bed rails.The facility policy statement with no date, documented that all resident call lights are accessible, functional, and answered promptly to maintain resident safety, dignity, and well being. Every resident must have a working call light within reach at all times.

Based on clinical record review, staff and family interview along with policy/procedure review, the facility failed to ensure that discharge instructions were documented in the residents medical record with the necessary information to the resident/resident representative that is easy to understand in a written form and language for 1 of 4 residents reviewed (Resident #1). The facility identified a census of 38 residents. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognitive decisions, is able to be understood and understand and no behaviors present. The MDS addressed that the resident is independent in the facility with all activities of daily living (dressing, personal hygiene, transfers, ambulation) and a walker is used for mobility. The MDS included diagnoses of cerebrovascular accident (damage to the brain from interruption of its blood supply), hemiplegia (paralysis of one side of the body, resulting from brain damage) anxiety, depression and Schizophrenia. The MDS revealed no active discharge plan for the resident to return to the community with no referrals wanted.The Care Plan Focus with no date indicated Resident #1 wishes to return home when appropriate. Interventions include to establish a pre-discharge plan with resident/family/caregivers and evaluate progress and revise plan as needed, evaluate and discuss the prognosis for independent or assisted living, discuss limitations, risks, benefits and needs for maximum independence and the residents motivation to return to the community.Health Status Note dated 11/6/25 at 3:05 PM, documented: During activities for several days now, 3 other residents are asking Resident #1 if he's going home soon and he replied Yes I think so I'm just not sure when and talks to them about his apartment. Answer every time it is asked replies Yes. This writer heard that a conversation has been held with family and Administrator and Director of Nursing (DON) and that No he is not going home. Writer placed a call to family to hear from the decision maker is this still a possibility. Family said yes absolutely it's still a possibility. Family is still working on getting resident back home and that it's not off the table yet and feels I don't feel Resident #1 should have to live in a nursing home for the rest of his life.Care Conference Note dated 12/16/25 at 11:35 AM, documented care conference held with resident and family, discussed returning home and family would like to re-evaluate in the spring.Care Conference Note with late entry dated 1/26/26 at 11:30 AM, documented that the resident came into my office to ask if I had spoken to his brother about residents discharge home in March of 2026. Re-educated the resident that the last care conference held on 12/16/25, with the family that the goal was to return home in the spring of 2026. Discussed that the next care conference is on March 18, 2026 and would discuss discharge in that care conference. Resident stated ok and left my office.Elopement Evaluation dated 2/4/26 at 10:46 AM, documented resident verbally expressed the desire to go home.Care Conference Noted dated 2/4/26 at 11:53 AM, documented discussed returning home and family would like to re-evaluate in the spring. The resident came to my office to ask if I had spoken to the brother about the residents discharge home in March 2026. I re-educated the resident that the last care conference with the family that they had anticipated the residents return home in the spring of 2026. Communication with Provider dated 2/24/26 at 6:40 PM, documented received orders for resident to discharge to home on 2/28/26.Health Status Note dated 2/28/26 at 2:22 PM, resident discharge from the facility.On 3/11/26 at 4:30 PM, the residents family member stated that no discharge instructions or orders were reviewed or given to the family or Resident #1 when family came to the facility on 2/28/26 to take the resident home.On 3/18/26 at 1:45 PM, the facility Administrator confirmed and verified that Resident #1's brother called on 2/24/28 and informed that Resident #1 was going to be discharged home on 2/28/26. Resident #1's family stated that they have taken care of Resident #1 before and they can do it again.On 3/18/26 at 2:50 PM, the facility DON, stated that she went over the discharge instructions with Resident #1 prior to being discharged on 2/28/26 and the discharge instructions were not signed by Resident #1. The DON confirmed and verified that the discharge instructions were mailed to Resident #1 on 3/3/26 to sign and return back to the facility and the facility has not received the signed discharge orders.On 3/18/26 at 3:30 PM, Staff A, Registered Nurse (RN) stated that no discharge paperwork was given to Resident #1 or family/representative when discharged on 2/28/26. Family came in the afternoon packed up all the belongings and left the facility.The facility policy statement with no date, documented, that all required information will be communicated to the receiving provider, and residents will receive proper written notice consistent with federal regulations. The Discharge planning must: Address the resident's ability to care for themselves, Assess caregiver availability, capacity, and capability, Ensure the receiving location can meet the resident's needs and preferences, and Include documentation of all planning activities.

Based on clinical records, facility policy and staff interviews the facility failed to provide a safe environment free from financial exploitation of dependent adult abuse for 3 of 3 residents reviewed (Resident #32, #41 and #43).The facility reported a census of 33 residents. Findings include:A. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #41 documented diagnoses of cancer, anxiety disorder and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment.The Clinical Census report for Resident #41 documented a discharge date of 4/4/25.In an interview on 9/16/25 at 2:08 PM, the son of Resident #'41 reported several months after the resident transferred from the facility, Resident #41's bank notified him of fraudulent charges to a debit card account. The charges started during the time Resident #41 resided at the facility. The fraudulent charges totaled over $13,000. The son reported Resident #41 had a debit card on her person while at the facility. The son stated, both mom and dad couldn't have used the card, they were too far out of it at the time.In an interview on 9/25/25 at 10:48 AM, a local law enforcement officer confirmed criminal charges filed against Staff A, Certified Nursing Assistant (CNA) in relation to fraudulent purchases made to Resident #41's debit card account in the approximate amount of $1,500 in part by using the numbers from the debit card in a phone application to make purchases online. The officer reported additional criminal charges were pending further evidence with an approximate total of $8,500 in fraudulent charges to Resident #41's debit card account. In an interview on 9/24/25 at 1:26 PM, the Administrator reported no knowledge of fraudulent charges to Resident #41's debit card account. The Administrator reported terminating Staff A on 8/18/25 due to in April law enforcement removed Staff A from the facility for unknown reasons and because of recently learning of another resident's missing money and a debit card. The Administrator stated, I looked Staff A up on Iowa Courts Online and found criminal charges for Theft 2nd degree against older individuals, fraudulent practices and unauthorized use of a credit card.B. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #43 documented diagnoses of bipolar, spinal stenosis and muscle weakness. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. The MDS indicated discharge home occurred on 6/20/25.The undated Incident Report for Resident #43 recorded the following: Husband came in with a credit card statement showing charges on their account, didn't know if it happened at the facility while she stayed here. The charges occurred in June, local law enforcement notified 8/7/25 when statements were brought in. There is an ongoing investigation at this time with local authorities, who will update the facility when they are able to. Incident Report showed staff read and reviewed financial abuse policy on 8/8/25. All cognitive residents were interviewed on 8/11/25 and all residents were educated on a lock box option 8/11/25. In an interview on 9/17/25 at 8:26 AM, Resident #43 reported discharging from the facility on 6/20/25. After leaving the facility Resident #43 stopped at a department store where she discovered the debit card missing from her purse. Resident #43's husband went to the bank on approximately 6/24/25 and found several fraudulent charges in the amount of almost $900. Resident #43 reported she kept the debt card in her purse at the facility which she kept in the closet of her room. Resident #43 reported to be absent from her room every morning while she attended physical therapy. Resident #43 stated, staff would have known I was at therapy. Resident #43 reported when her husband notified the facility, the Administrator had a hunch about who did it. Resident #43 stated, the Administrator said a certain person had taken odds and ends from the nursing home and they had taken care of it. Review of Resident #43's bank statement showed the first fraudulent charge attempted on 6/19/25 with the last transaction for this timeframe occurring on 6/24/25. The fraudulent charges occurred for online purchases and at the gas station. In an interview on 9/24/25 at 1:26 PM, the Administrator reported when the family reported the credit card charges the facility notified law enforcement, educated staff and interviewed residents. During interviews the facility discovered another resident with missing cash and possibly a missing or stolen credit card, the resident and husband couldn't confirm if the resident lost the card or if it was stolen. The Administrator stated, I know it was abuse, and I know there's an abuse tag coming. We've done all the education. The Administrator also indicated Staff A no longer worked at the facility.In an interview on 9/25/25 at 10:48 AM, a local law enforcement officer reported evidence obtained of Staff A, CNA attempting to withdraw money from Resident #43's bank account at a drive through window at a bank. The officer confirmed charges filed against Staff A. The officer could not provide further details as the investigations are ongoing and evidence of further fraudulent charges are expected to be obtained. C. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #32 documented diagnoses of cancer, need for assistance with personal cares and reduced mobility. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The Incident Report dated 8/11/25 for Resident #32 indicated the resident's husband reported $40 to $50 in cash and possibly a credit card missing. The Administrator reported the incident to law enforcement and the husband planned to go home to look for the missing card and to check for fraudulent charges. In an interview on 9/24/25 at 10:26 AM, Resident #32 reported money taken from a pink canvas cross body purse that she kept in a dresser at the foot of her bed. Resident #32 reported her husband would know more about how much money was taken as he usually handled the finances. Resident #32 reported the missing money to the facility but could not recall further details. In an interview on 9/24/25 at 12:17 PM, Resident #32's husband reported he placed cash in the resident's pink purse for a haircut. The husband placed bills of $20 x1, $10 x2, $5 x1, and $1 x2-3. The husband stated, someone took everything except the $5 and $1 dollar bills. The husband reported the purse to be located in the bedside table. After the money went missing he moved the purse to the dresser. The husband reported cash went missing the second time when he left money in the resident's purse for a funeral. The husband placed bills of $10 x1 and $1 x5-6. The next time they looked the $10 bill was gone along with a credit card. The husband reported he immediately reviewed his bank statement and didn't have any fraudulent charges and successfully closed the account before any charges could be made. The husband surmised about $40-50 in total missing. The husband reported the resident told him she wasn't sure if she placed the credit card back in her purse as she was attempting to make a purchase or may have left the card in a magazine or within the bedding. In an interview on 9/24/25 at 1:26 PM, the Administrator reported no further missing money, cards or other items since Staff A last worked at the facility. The Administrator reported reimbursing Resident #32 in the amount of $50. The Reporting Abuse to Facility Management last reviewed in August 2026 defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy also identified abuse and misappropriation of a resident's prosperity is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on clinical record review, staff interviews and the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately document and submit an accurate resident Minimum Data Set (MDS) Assessment for 2 of 2 residents reviewed (Resident #7 and #18). The facility reported a census of 33 residents. Findings include: 1. Resident #7's MDS assessment dated [DATE] documented a BIMS score of 13, indicating intact cognition. The MDS included diagnoses of bilateral primary osteoarthritis of knee, colon cancer, anemia, chronic obstructive pulmonary disease, and atrial fibrillation. The MDS further documented the bed rails used as a physical restraint (any manual method, physical, or mechanical device, material or equipment attached or adjacent to the resident's body the individual cannot remove easily which restricts freedom of movement or normal access to one's body). Resident #7's Care Plan documented that she could go from lying to sitting on the edge of bed independently. The intervention documented Resident #7 requested a transfer assist rail for the right side of the bed so she may maintain independence and mobility. On 9/17/2025 at 10:50 AM MDS Coordinator reported she just found out she marked it wrong but hadn't got to do a modification yet. The MDS Coordinator reported she did mark it as a siderail on the MDS. She further verbalized it does not restrict Resident #7's movement. The MDS Coordinator reported it is not a restraint then it should not be coded on the MDS. The RAI manual dated October 2025 documented in Chapter 3 page P-6 that bed rails are used with residents who are immobile. If the resident is immobile and cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present, the bed rails do not meet the definition of a physical restraint. 2. According to the MDS assessment dated [DATE] Resident #18 demonstrated long and short term memory problems and severely impaired skills for daily decision making. Diagnoses included non-Alzheimer's dementia, anxiety disorder, depression, and psychotic disorder. The MDS identified the resident took an antipsychotic and antidepressant medication. The MDS did not indicate the resident took antianxiety medication. CMS's Resident Assessment Instrument (RAI) Version 3.0 Manual included a section for high risk drug classes, their use and indication. The instructions included checking the box if the resident took any of the medications during the last 7 days. The Care Plan dated 1/11/23 identified the resident used anti-anxiety medication (Buspar) related to an anxiety disorder. The Medication Administration Record's for June and July 2025 documented the resident took Buspirone (Buspar) 5 mg 2 times a day related to dementia with anxiety, including the lookback period (7 days) for completing the MDS. On 9/17/25 11:17 a.m. the MDS Coordinator stated she didn't know why the Buspar didn't get on the MDS. She would have to check it. At 11:35 a.m. the MDS Coordinator stated she fixed MDS related to the residents use of Buspar. A modification MDS for 7/2/25 made a change to antianxiety use to yes dated 9/17/25.

Based on clinical record review, policy and staff interview, the facility failed to submit a Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 2 residents reviewed with a new mental health diagnosis (Resident #3). The facility reported a census of 33 residents. Findings Include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnosis of depression, anxiety, Psychotic Disorder and Post Traumatic Stress Disorder (PTSD). Resident #3's Level 1 PASRR dated 6/19/24 lacked a diagnosis of Psychotic disorder and PTSD. Resident #3's clinical record lacked a PASRR after 6/19/24. On 9/17/2025 at 10:30 AM, the Director of Nursing (DON) verbalized she submitted PASRR submissions. She reported she did not complete a new one for Resident #3 because the doctor keeps changing her medications around. She was not aware of the PASRR lacked the diagnoses of Psychotic Disorder and PTSD. The facility policy titled Pre-admission Screening and Resident Review revised 11/2016 lacked direction with a resident with a newly identified mental health diagnosis.

Based on record review, staff interview and policy review, the facility failed to provide trauma informed care with PTSD (Post Traumatic Stress Disorder) and was not assessed for potential triggers that could cause re-traumatization for 1 of 1 residents reviewed (Resident #3). The facility reported a census of 33 residents. Findings include: Resident #3's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS included diagnoses of anxiety, depression, PTSD, and psychotic disorder. Resident #3's behavioral health psych visit notes documented the resident had childhood trauma and history of suicidal attempts in the past. It further documented Resident #3 was grieving the loss of her husband who died a year ago. Resident #3's Care Plan lacked documentation of PTSD, history of suicidal history and loss of her husband. It further lacked potential triggers that could cause the re-traumatization and possible triggers that would cause her suicidal ideations. The Care Plan lacked goals, triggers and interventions for the mental health diagnoses. On [DATE] at 10:32 AM the MDS Coordinator reported she reviews the medications a resident is on and then puts together the care plan based on the medications. She reported she does not get the psych notes to know what is on it. She reported the facility is lacking on that part to make sure things are on the care plan and triggers are documented. She verbalized she was not aware trauma needed to be assessed and care planned. The facility policy for comprehensive care plans last revised 4/2025 documented trauma informed care incorporates knowledge about trauma into care plans and practices to avoid re-traumatization.

Based on record review and staff interview, the facility failed to ensure residents were offered and received the pneumonia vaccine for 1 of 5 residents reviewed (Resident #3). The facility reported a census of 33 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #3 scored 15 on the Brief Interview for Mental Status indicating no cognitive impairment. The MDS documented the resident was not up to date with the pneumonia vaccine, and it was not offered. The Clinical-Immunizations page lacked an entry for a pneumonia vaccine. A Pneumococcal Vaccine Consent dated 6/28/24 documented the resident e-signed that she had been educated on the risks and benefits of the pneumonia vaccine and gave permission for receiving the vaccine. The clinical record lacked documentation the resident received the pneumonia vaccine. According to the MDS assessment dated [DATE] the resident was not up to date with the pneumonia vaccine, and it was not offered. On 9/17/25 at 2:34 PM the Infection Preventionist stated she could not find anything on the pneumonia vaccine for the resident. On 9/18/25 at 10:44 a.m. the Director of Nursing stated when they did the admission packet they did not tell her the resident consented to the pneumonia vaccine. The facility Vaccination of Residents, Including Influenza, Pneumococcal, RSV and Covid-19, Reporting of documented residents would be offered flu, pneumovax and Covid-19 vaccinations per the CDC and CMS guidelines, based upon availability to the community.

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (July 1 - September 30) review, facility staffing reports review, employee time cards review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 36 residents. Findings include: The PBJ Staffing Data Report with run date 12/4/24 triggered for failing to have licensed nursing coverage 24 hours/day - 4 or more days within the quarter with <24 hours/day licensed nursing coverage with specific infraction dates. The report reflected 7 dates with failure to provide 24 hour/day nursing coverage during August and September. Review of the Nurse Schedule for the infraction dates revealed nursing shifts covered by the Director of Nursing (DON), Staff C, Licensed Practical Nurse (LPN), Staff D, LPN, Staff E, Registered Nurse (RN), Staff F, RN, and Staff G, RN for 7/7 dates. Review of time cards for the infraction dates revealed nursing services were provided for 24 hours/day. On 12/11/24 at 2:19 PM the Business Office Manager (BOM) stated she submitted the missed punches to Weblock, then uploaded them into a folder in Teams and then the Corporation would handle it from there. On 12/12/24 at 8:55 AM the Administrator stated during this quarter July 1 - September 30 their previous Corporation took care of submitting hours to PBJ. The Administrator acknowledged that during this period their own staff hours were not being transferred correctly to be submitted to PBJ and the Corporation was aware of this and looking into it.

Based on record reviews, staff interviews, and policy review, the facility failed to complete comprehensive assessments within required time frames for 7 of 7 residents (Residents #4, #7, #8, #15, #18, #189, and #190). The facility reported a census of 36. Findings include: On 12/10/24 at 9:31 AM, multiple record reviews revealed seven (7) past-due Comprehensive Assessments (Minimum Data Sets - MDS) and were documented as follows: 1) Resident #4's MDS included an Assessment Reference Date (ARD - last day of observation period) of 11/04/24 with an in-progress status. It indicated 22 days past due. 2) Resident #7's MDS included an ARD of 10/07/24 with an in-progress status. It indicated 50 days past due. 3) Resident #8's MDS included an ARD of 11/05/24 with an in-progress status. It indicated 22 days past due. 4) Resident #15's MDS included an ARD of 10/14/24 with an in-progress status. It indicated 41 days past due. 5) Resident #18's MDS included an ARD of 10/03/24 with an in-progress status. It indicated 54 days past due. 6) Resident #189's MDS included an ARD of 10/29/24 with an in-progress status. It indicated 28 days past due. 7) Resident #190's MDS included an ARD of 10/03/24 with an in-progress status. It indicated 54 days past due. It also included five (5) other past-due, in-progress MDS assessments with ARDs of 11/06/24, 11/11/24, 11/18/24, and 11/24/24. The Resident Assessment Instrument (RAI) indicated a resident's MDS assessments must be completed within 14 days from the ARD. A policy titled Comprehensive Assessment revised 08/22 indicated the Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: a) Within fourteen (14) days of the resident's admission to the facility; b) When there has been a significant change in the resident's condition; c) At least quarterly; and d) Once every twelve (12) months. On 12/12/24 at 8:01 AM, the Administrator stated she expected Comprehensive Assessments to be completed in a timely fashion.

Based on record review, staff interview, and policy review the facility failed to notify the Long Term Care (LTC) Ombudsman of a transfer to a hospital for 1 of 2 residents (Resident #190) reviewed. The facility reported a census of 36 residents. Findings include: Review of Resident #190's Clinical Census in the Electronic Health Record (EHR) revealed Resident #190 had a hospital unpaid leave from 10/30/24 to 11/6/24. Review of the facility document, Notice of Transfer Form to Long Term Care Ombudsman, for the month of 10/24 revealed there was no notification for the Resident 190's hospitalization beginning on 10/30/24. During an interview on 12/11/24 at 1:42 PM the Administrator acknowledged Resident #190 was neither on the Discharge Report nor the Notice of Transfer to Long Term Care Ombudsman Report. The Administrator stated the resident had been missed on his transfer to the hospital. The Administrator indicated she completed the Ombudsman notifications. On 12/12/24 at 8:00 AM the Administrator stated the expectation was for residents transferred to acute hospitals to be on the Ombudsman Report. The facility policy titled Transfer and/or Discharge, Including Against Medical Advice last revised 10/22 revealed a copy of the transfer or discharge notice should be sent to the Long Term Care Ombudsman and noted in the record. The facility provided document, The Iowa Health Care Association Protocols for Use and Issuance of Nursing Facility Transfer Notices dated 9/19, revealed copies of notices for emergency transfers must be sent to the Ombudsman, but may be included on a monthly summary.

Based on observations, clinical record review, staff interviews, and policy reviews the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens during mealtimes, catheter management, and laundry delivery. The facility reported a census of 36. 1) On 12/09/24 at 12:11 PM, Staff A, Certified Nurse Aide (CNA) put on a pair of gloves, picked a fork off the floor with her right hand, and placed it on the table. She walked behind a resident (Resident #34) seated in a tilt-chair, repositioned the resident to face the right side of the table, sat down to the right of the resident, and began feeding the resident. She wiped the resident's mouth with a napkin in her right gloved hand, picked up the resident's milk cup from the top with her gloves, and gave the resident some milk. She did not perform hand hygiene or change gloves throughout the process. A policy titled Handwashing/Hand Hygiene revised 10/22 indicated employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under conditions which included before and after assisting a resident with meals. On 12/12/24 at 8:30 AM, the Director of Nursing (DON) stated staff should not pick utensils off the floor then assist a resident to eat. 49628 2) The Minimum Data Set (MDS) quarterly assessment with completed date 7/9/24, documented Resident #10 had a Brief Interview for Mental Status score of 10/15 indicating moderate cognitive impairment. The MDS documented diagnoses that included hemiplegia for unspecified cerebrovascular disease affecting the right dominant side, diabetes, and a Stage 3 Pressure Ulcer. The assessment section entitled Functional Abilities and Goals (GG) revealed Resident #10 required substantial/extensive assistance with activities of daily living (ADLs), mobility, and transfers. The resident had an indwelling catheter. Resident #10's Care Plan revealed approaches for staff to follow including the resident having a catheter, following Enhanced Barrier Precautions, taking care of catheter equipment, and monitoring of signs/symptoms for urinary tract infections. Observation on 12/10/24 at 12:36 PM revealed Resident #10 self propelling her wheelchair with the catheter bag and tubing dragging on the floor. The facility provided document, Indwelling Urinary Catheters, revealed the catheter tubing and drainage bag were to be kept off the floor. On 12/12/24 at 8:25 AM the Infection Preventionist (IP)/Director of Nursing (DON) stated the expectation would be for catheter bags/tubing to be kept in dignity bags and not on the floor. The Administrator on 12/12/24 at 8:00 AM stated the expectation would be for catheter tubing and drainage bags to be kept off the floor. 3) Observations on the following dates and times of laundry carts being moved by Staff B, Laundry Aide: On 12/9/24 at 1:46 PM observed Staff B delivering resident laundry in an uncovered cart. On 12/10/24 at 11:35 AM observed Staff B transporting uncovered dirty clothes from the [NAME] Hallway across the serving area and outer dining area to the North Hallway. On 12/10/24 at 11:40 AM observed Staff B transporting an empty laundry cart from the North Hallway to the East Hallway. The staff picked up dirty clothes and moved the uncovered laundry cart from the East Hallway to the North Hallway. On 12/10/24 at 1:41 PM observed Staff B transport uncovered clean linens and slings from the North Hallway to the [NAME] and East Hallways. On 12/10/24 at 1:55 PM Staff B stated she should cover the laundry cart when delivering laundry. The staff stated they had forgotten to cover the laundry as there was too much going on, and that she typically covers it. Staff B further stated she was unaware that dirty laundry needed to be covered prior to transporting through the facility. The facility provided document, Handling of Clean Linen and Linen Distribution, revealed that clean laundry should be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. The document further revealed the cart should be covered once it is filled and distributed to the units. On 12/12/24 at 8:15 AM the IP/DON stated laundry should be covered at all times when transported in the facility. On 12/12/24 at 8:00 AM the Administrator stated it was the expectation that laundry be covered during transportation whether clean or dirty.

Based on record review, staff and resident interviews and facility policy review the facility failed to provide residents with the ability to have access to their funds when requested for 2 out 4 residents reviewed (Resident #2 & #4). The facility reported a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of anxiety disorder, anemia and arthritis. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment. Interview on 10/15/24 at 2:44 p.m., with Resident #2 revealed she is unable to get money on the weekends if she asked for it. Resident #2 explained the facility always is waiting for a check to come to the facility and then they have to go get the money before they can give it to us. She has had to wait a couple of days to be able to get her money. 2. The MDS assessment dated [DATE] for Resident #4 documented diagnoses of anxiety disorder, hypertension and neurogenic bladder. The MDS showed the BIMS score of 11, indicating moderate cognitive impairment. Interview on 10/15/24 at 2:24 p.m., with Resident #4 revealed he had asked the Administration in the facility a couple weeks ago for $50 and has not received his funds. Resident #4 explained he was told the facility had to check the mail for a check to come and their check was coming. Resident #4 explained he was told there was no money in the building to honor his request. He stated he always has to wait for the facility to get more money when he asks for it. Review of facility provided policy titled Resident Trust Fund with a revision date of 6/12/24 revealed residents have access to their funds 24 hours a day, 7 days a week, 365 days a year. Interview on 10/16/24 at 12:41 p.m., with the Administrator revealed the facility was out of petty cash and did have to wait for the check to come from the corporate office which takes 2 days to process. She explained the check had just come and all resident requests have been fulfilled but they did have to wait for their funds. The Administrator confirmed Resident #4 had asked for funds and did have to wait for the facility check to arrive. The Administrator explained she is going to be working with the corporate office to find a solution for residents.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to provide adequate nursing supervision to prevent a fall for 1 of 3 residents reviewed (Residents #3). The facility reported a total census of 30 residents. Findings include: Resident #3's clinical record documented diagnoses of anxiety disorder, abnormal weight loss and adult failure to thrive. The Brief Interview for Mental Status (BIMS) score of 15, indicating severe cognitive impairment. Review of facility provided Incident Report dated 9/5/24 at 5:30 p.m. revealed under incident description staff heard someone yelling help help help. Staff ran to the direction of the screaming. Resident was laying down supine on the floor by the ice machine in the hallway. Resident's head was laying on the floor on the right side of the ice machine. Head towards the north wall with her right leg straight out towards the south of the hall. Resident's left leg was rotated out. Resident was screaming in pain that her left hip hurt so bad. Resident description revealed I slipped. Review of resident Progress Notes dated 9/5/24 at 5:40 p.m., revealed fall details. Date and Time of Fall: 9/5/24 at 5:30 p.m Fall was not witnessed. Fall occurred in the hallway. Activity at the time of fall: slipped on water in front of the ice machine. Reason for the fall was evident. Reason for fall: slipped on ice in front of the ice machine. Did an injury occur as a result of the fall: yes. Injury details: left hip fracture. Did fall result in an emergency room (ER) visit: yes. ER visit/hospitalization details: Resident transported to Emergency Department (ED). hospitalized in local hospital for left hip surgery tomorrow morning. Review of Facility Self Report dated 9/5/24 at 7:54 p.m., revealed Resident had just finished her supper and was walking up the northeast hallway to go back to her room. Nursing staff heard someone yelling help help help. Nursing staff ran to the area they heard someone yelling for help to find this resident lying on the floor, in a supine position. Resident complained that she couldn't move her left leg and that she hit her head when she fell . There was a quarter size amount of water on the floor near the area where the resident fell . Resident did have shoes on at the time of the incident. Resident stated I slipped. Resident is independent with ambulation without the use of an assistive device. Resident sent to the local ER for evaluation of left hip pain. Review of ED Note dated 9/5/24 revealed patient reports here today via Emergency Medical Service (EMS) from a local nursing home after slipping on some ice and landing on her left hip. She reports severe pain with movement of her left leg hip. She denies hitting her head, neck pain or headache. Patient's left leg is externally rotated and shorter than the right. Incident occurred just prior to coming to the emergency room . Patient's x-ray did confirm an intertrochanteric femur fracture. Interview on 9/6/24 at 12:47 p.m., with Staff A, Certified Nursing Assistant (CNA) revealed they were passing trays and heard someone yelling help me I fell . She went running over to where the sound was coming from and found the resident by the ice machine. Staff A asked Resident #3 what had happened. Resident #3 revealed she had slipped on water and fell . Staff A had the other aide got the nurse and the nurses handled it from there. Interview on 9/6/24 at 12:50 p.m., with Staff B, CNA revealed the fall happened when getting supper trays passed. She heard a scream and stopped what she was doing and went running to where the screaming was coming from. She did not have any tread on her shoes. Resident #3 didn't know the water was on the floor and slipped and fell and hit her head. Staff B got the nurse and she came running over right away. Interview on 9/6/24 at 1:55 p.m., with Staff C, Licensed Practical Nurse (LPN) revealed she was at her medication cart working on passing medications when she heard a different type of yell that is hard to explain for help. She took off running and found Resident #3 laying on the floor by the ice machine. Staff C asked Resident #3 what had happened. Resident #3 explained that she had slipped on a little puddle of water. Staff C confirmed she saw a puddle of water no bigger than a quarter on the floor. Resident #3 was holding her left hip and leg area and was stating she was in terrible pain. Resident was transferred to the ER for an evaluation. Interview on 9/6/24 at 2:29 p.m., with the Director of Nursing (DON) revealed she was just getting back with another resident from an appointment and the staff had asked which door the ambulance came to and she told them and asked why. Staff had told the DON Resident #3 had fallen by the ice machine. The DON went directly to the area and seen staff working with Resident #3. Resident #3 told the DON she had slipped on water on the floor. The DON revealed her left leg was visibly noted to be rotated outward and the ambulance was on their way. The DON further revealed the resident had on a pair of shoes that did not have any tread on the bottom of them and they would be getting her a new pair of shoes. Review of facility provided policy titled Fall Management Standard with a revised date of 8/2021 the evidence points to the following conditions as potentially modifiable risk factors in both community dwelling and nursing home residents including environmental hazards including wet floors. The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program. Residents are assessed for the fall risk factors. The interdisciplinary team works with the residents and family to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Interview on 9/6/24 at 3:06 p.m., with the DON revealed staff should clean up any spilled ice by the ice machine right away and make sure the floor is dry.

Based on record review, interview, and facility policy the facility failed to have the Director of Nursing Services, Medical Director and Infection Preventionist at quarterly meetings for their quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 28. Findings include: Review of the facility document titled Quality Assurance Process Improvement (QAPI) Committee: a. Document dated 11/3/22 lacked the signature of the Director of Nursing Services. b. Document dated 1/2023 lacked the signature of the Medical Director, Director of Nursing Services and Infection Preventionist. Review of the facility provided policy titled Quality Assurance Process Improvement Management dated January 2023 revealed the Administrator of this facility shall be the chairperson and shall appoint all representatives to the QAPI Committee. Additionally, any vacancies occurring on the committee shall be filled by the facility's Administrator. According to the Federal OBRA nursing home guidelines [S483.75(o)(l)(i-iii)], the QAPI Committee must include the Director of Nursing Services, a physician designated by the facility and at least 3 other members of the facility's staff. New regulations include nursing staff such as licensed nurses and certified nursing assistants. Interview on 10/4/23 at 1:18 p.m., with the Administrator revealed the facility did not have an infection preventionist in January of 2023.

Based on document review and staff interview the facility failed to verify professional nursing licensure prior to hire for 1 of 2 staff members reviewed (Staff A). The facility reported a census of 28 residents. Findings include: Review of Employee New Hire Report revealed Staff A, Registered Nurse (RN) documented a hire date of 1/7/23. Review of Employee Termination Report revealed Staff A was terminated on 4/19/23 with a hire date of 1/7/23. The personnel file for Staff A revealed a nurse license verification report was completed with a date and time of 10/26/22 at 12:40 p.m Review of Staff A personnel file lacked a license verification report dated prior to rehire date. Review of facility provided policy titled Freedom From Abuse, Neglect and Exploitation Policy with a revision date of August 2022 revealed when a potential new employee is considered for hire, each of the following steps should be taken to assure that the applicant is suitable for hire. Verification of License/Certificate - Verification of licensure or certification and identification of previous disciplinary actions or restriction on licensure/certification will be obtained for all applicable positions. A file with the license or certification will be kept for each applicable employee. Interview on 10/4/23 at 10:26 a.m., with the Administrator revealed Staff A did not have a licensure check completed on rehire.

Based on personnel file review, facility policy review and staff interview the facility failed to provide dependent adult abuse training within 6 months of hire for 1 of 5 employees reviewed (Staff B). The facility identified a census of 28 residents. Findings include: Review of Employee New Hire Report revealed Staff B, Certified Nursing Assistant (CNA) documented a hire date of 3/22/23. Review of Staff B personal file revealed a Dependent Adult Abuse Training certificate dated 10/2/23. Review of Staff B time card dated 9/17/23-9/30/23 revealed Staff B worked on 9/23/23, 9/27/23, and 9/28/23. Review of time cared dated 10/1/23-10/14/23 revealed Staff B did not work. Review of facility provided policy titled Freedom From Abuse, Neglect and Exploitation Policy with a revision date of August 2022 revealed to create an educated awareness of resident abuse, the facility standard of Freedom of Abuse, Neglect and Exploitation covers types of abuse, abuse reporting and abuse investigation. This information shall be reviewed during orientation with each new employee and reviewed with staff on an annual basis. Interview on 10/4/23 at 2:52 p.m., with the Administrator revealed Staff B was unable to work until her Dependent Adult Abuse Training was completed.

Based on personnel file reviews, staff interviews, and facility policy review, the facility failed to ensure all employees had an Iowa Criminal Background check and dependent adult/child abuse registry check completed prior to working in the facility for 1 out of 5 employees reviewed (Staff A). The facility reported a census of 28 residents. Findings include: Review of Employee New Hire Report revealed Staff A, Registered Nurse (RN) documented a hire date of 1/7/23. Review of Employee Termination Report revealed Staff A was terminated on 4/19/23 with a hire date of 1/7/23. The personnel file for Staff A revealed documention of an criminal background check and dependent adult and child abuse registry check was completed on 1/27/23 at 3:56 p.m The file lacked documentation of the Iowa Criminal Background Check and dependent adult/child abuse registry check prior to hire. Review of facility provided policy titled Freedom From Abuse, Neglect and Exploitation Policy with a revision date of August 2022 revealed the Criminal Background Check/Nurse Aid Registry Check - In states where Criminal Background Checks are required; all employment candidates are required to authorize the facility to conduct a background check for conviction of crimes. Background screens are submitted after a conditional offer is extended and must be received within the appropriate time frames per state requirements. Interview on 10/4/23 at 10:26 a.m., with the Administrator revealed Staff A did not have a background check completed on rehire.

Based on record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for 3 of 12 residents reviewed (Resident #4, #8, and #11). The facility reported a census of 28 residents. Findings include: 1) According to the MDS assessment dated [DATE] Resident #4 scored 9 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident's diagnoses included depression and schizophrenia. The MDS indicated the resident was not considered to have a mental illness by the state Level 2 Preadmission Screening and Record Review (PASRR) process. The resident admitted to the facility on [DATE]. A facility referral from the hospital dated 8/17/23 documented the PASRR would be faxed once completed, it was under review. A Notice of PASRR Level 1 Screen Outcome dated 8/17/23 documented the resident needed referral for a Level 2 screen onsite. On 10/3/23 at 2:40 p.m. the DON stated they had not had the Level 2 done. The hospital should have had that done. She did not know if it had been done. On 10/4/23 at 5:15 p.m. the DON had the resident's Level 2 dated 8/20/23. She said she got it from the PASRR site. A Notice of PASRR Level 2 Screen Outcome dated 8/20/23 documented the resident had a Level 2 approved with a time limit. The resident met inclusion for PASRR based on a mental health diagnosis of schizophrenia, an unspecified intellectual disability, and Down Syndrome. 2) According to the MDS assessment dated [DATE] Resident #8 scored 7 on the BIMS indicating severe cognitive impairment. The resident's diagnoses included non-Alzheimer's dementia. The MDS documented the resident received no diuretic in the 7 day look back period. The current Clinical Physician's Orders documented the resident had an order for Lasix 20 mg once daily for hypertension with a start date of 12/9/23. The August 2023 Medication Administration Record (MAR) documented the resident received Lasix 20 mg daily in the 8/16/23 MDS 7 day look back period. On 10/4/23 at 5:07 p.m. the MDS coordinator stated she did not identify the diuretic on the resident's MDS assessment, and verified that was an error. 49056 3. The MDS assessment dated [DATE] for Resident # 11 included diagnosis of anxiety disorder and unspecified mood disorder. The MDS showed a BIMS score of 13 indicating no cognitive impairment. Review of the MDS revealed Resident #11 took anti-anxiety medication for 7 out of 7 days in the lookback period. Review of the July and August Medication Administration Record (MAR), lacked administration of anti-anxiety medication. Review of the Medication Review Report for the month of July signed and dated 7/6/23 failed to show an anti-anxiety medication. Interview on 10/4/23 at 03:00 PM, with the MDS Coordinator agreed that it was coded inaccuratley. She voiced at the time of doing the MDS dated [DATE] when she looked at the MAR for the month of August it showed underneath the medication seroquel, the dx is unspecified mood (affective) disorder and generalized anxiety disorder, she had seen the generalized anxiety disorder and coded it on the MDS. She also stated that she sent in a correction after it was brought to her attention.

Based on clinical record review and staff interview, the facility failed to give 2 day notification of the Notice of Medicare Non-Coverage (NOMNC) Centers of Medicare & Medicaid (CMS)-10123 for 1 of 3 sampled residents. (Residents #184). The facility reported a census of 28 residents. Findings Include: Record review for Resident #184 revealed form CMS 10123-NOMNC with a services end date of 5/10/23. Resident #184 signed 5/9/23. Centers for Medicare and Medicaid website titled, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 visited on 10/4/23 at 12:56 p.m., revealed the NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Interview on 10/4/23 at 1:14 p.m., with the Administrator revealed it should be a 2 days notice unless they waive it.

Based on observation, clinical record review, resident representative interview, staff interviews, facility policy, and facility record review, the facility failed to ensure residents at risk for elopement were unable to exit the facility unattended for 1 of 2 residents reviewed for elopement (Resident #35). The facility failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a total census of 29 residents. Findings include: Observations of the switch turned to the off position for the front door alarm for the following dates and times: a. 08/01/22 at 01:18 PM b. 08/02/22 at 07:43 AM c. 08/03/22 at 03:56 PM In an interview on 08/02/22 at 07:32 AM, one of Resident #22's representatives reported that the switch is always turned off to alarm the front door when she visits the facility. In an interview on 08/04/22 at 11:56 PM Staff F, maintenance, reported he does not know how to check door alarms since he just started working at the facility. The Maintenance Log for August 2022 revealed Staff F marked that he checked door alarms and wander guard alarms for the first 3 days of the month. The Maintenance Logs from January to May had illegible years. In an interview on 08/04/22 at 12:57 PM, the Maintenance Director reported he was unable to locate the maintenance log for July 2022. The Social Service Progress Note dated 12/09/20 revealed Resident #35 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The History and Physical dated 12/04/20 signed by a physician revealed the resident was diagnosed with confusion, recurrent severe [CONDITION(S)], type 2 diabetes mellitus, anxiety, weakness, altered mental status, decreased concentration, and joint pain. The Initial Nursing assessment dated [DATE] revealed the resident walked with the assistance of a walker and 1 person, she was confused, had memory problems, was an elopement risk as the resident reported it would be easy to walk out of the facility. The Elopement Risk assessment dated [DATE] revealed the resident was at risk for elopement. The Skilled Daily Nurse's Note dated 12/10/20 revealed the resident removed the screen to her window and the window unlocked. The Skilled Daily Nurse's Note dated 12/12/20 revealed the following: a. The resident had disorganized thinking. The resident was also restless, fidgety, and anxious. b. An entry at 08:30 PM, the resident reported she wanted to leave. c. An entry at 09:40 PM, the resident was found missing from her room. The resident was last seen at 09:30 PM. d. At 10:10 PM, the local police arrived at the facility and reported that they took the resident to a family member's home. They asked Staff C , License Practical Nurse (LPN), if the person they transported was a resident of the facility. The county 911 Command Log printed on 08/04/22 revealed on 12/12/2020 law enforcement officers were notified of a woman pulling a suitcase on a road across the highway from the facility 4 blocks from the facility. Officers transported the resident to a residential address and then arrived at the facility. In an Email, the state climatologist reported the wind chill on 12/12/20 was 15 degrees Fahrenheit. An untitled document dated 12/12/20 revealed the resident reported that a lady pushed the yellow button by the service entrance and that was how she eloped from the facility. The Baseline Care Plan dated 12/09/20 revealed the resident was at risk for elopement with interventions that a tabs alarm was placed and the resident would have frequent checks. The clinical record lacked documentation that frequent checks of the resident occurred prior to her elopement from the facility on 12/12/20. The Elopement Management policy dated 2021 revealed the following: a. The licensed nurse and the Interdisciplinary Team are responsible for evaluating each risk factor and its related causes, completing a root cause analysis to a behavior and implementing preventive strategies as applicable. b. Centers for Medicare and Medicaid (CMS) definition: Unsafe Wandering or Elopement. Wandering is a random or repetitive locomotion. This movement may be goal oriented such as the person seems to be searching for something, like an exit, or it may be non-goal directed and aimless. Non-goal directed wandering requires a response in a manner that addresses both safety issues and an evaluation to identify a root cause to the degree possible. Moving about the facility aimlessly may indicate the resident is frustrated, anxious, bored, hungry, or depressed. c. Clinical process that addresses a resident's risk of elopement from the premises or a safe area without authorization and/or necessary supervision to do so. d. Identification and implementation of individualized approaches to provide the resident with a safe and secure environment. e. Evaluation of the resident's individualized plan of care and validation of effectiveness of interventions. The Investigation packet supplied by the facility contained the following: a. Log of checks of the resident after the resident's elopement. b. A typed statement dated 12/13/20 from an employee of the incident. c. An Investigation Statement Summary with an incident date of 12/12/20 unsigned and incomplete. d. An Investigation Statement Summary dated 12/13/20 complete and signed by only the employee. The Accidents and Incidents Investigating and Reporting Event Management policy dated 06/17 revealed the following: a. The following equipment and supplies will be necessary when performing this procedure: 1. Incident Investigation Report Form 2. Page 1 Resident Incident Report 3. Page 2 Resident Incident Report Follow-Up 4. Page 3 Narrative of Event 5. Page 4 Summation - *must use form provided in manual (contains signature lines for Administrator, Medical Director and Committee Members) 6. Employee Witness Statement Forms - *Must use blank forms provided in the manuals. Employees' statement, in their own words, will be written in narrative form by interviewer. The employee will then review/sign statement. Employees are not to write their own statements. The Investigation packet provided by the facility lacked the following: a. Incident Investigation Report Form b. Resident Incident Report c. Resident Incident Report Follow-Up d. Narrative of Event e. Summation - *must use form provided in manual (contains signature lines for Administrator, Medical Director and Committee Members). f. Employee Witness Statement Forms - Employees' statement, in their own words, will be written in narrative form by interviewer. The employee will then review/sign statement. Employees are not to write their own statements. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 08/04/2022 at 01:05 p.m. and provided the IJ template. Facility staff removed the Immediate Jeopardy through the following actions: a. A lock box has been installed covering the control panel of the alarm system, completed 8/4/22. b. A secondary control entrance alarm button was installed that will have to be pushed on the outside of the door before entering, or the alarm will sound, completed 8/4/22. c. Facility wide elopement assessments with wander guards placed if appropriate and clinical records updated, completed 8/4/22. The facility's Plan of Correction was amended 08/08/22 through the following actions: a. Staff education on elopement. b. Residents with wander guards will be brought to the front door to check their alarms until the new wander guard unit was installed. c. A new wander guard unit was ordered. The Immediate Jeopardy was corrected on 8/8/22. At the time of exit the scope and severity was lowered to an E after verification of staff's implementation of correction plan.

Based on observation, record review, and staff interview, the facility failed to assure the provision of side rails in compliance with safety guidelines to reduce the resident's risk of entrapment for 1 of 7 residents reviewed (Resident #27), which resulted in an immediate jeopardy to resident's health and safety. The facility also failed to attempt to use appropriate alternatives prior to installing a side or bed rail, review the risks and benefits of bed rails with the resident or resident representative, and obtain informed consent prior to installation for 7 of 7 residents (Resident #27, #9, #15, #180, #5, and #7). The facility reported a census of 31 residents. Findings include: The undated, Sample Policy and Procedure for Side Rail Usage, documented partial side rails would be analyzed for safety and prevention of entrapment utilizing the guidelines of the U.S. Food and Drug Administration for the Prevention of Entrapment/Hospital Bed System Dimensional Assessment Guidance to Reduce Entrapment issued (MONTH) 10 2006. The areas of entrapment would be checked when the bed was in the flat position and the partial rails upright including: a. The open spaces within the rail would not exceed more than 4-3/4 inches. Any assessment findings that did not meet the guidelines for the prevention of entrapment would require immediate corrective action including removal of the bed from the resident care area. 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #27 demonstrated a persistent vegetative state. The resident depended on staff for activities of daily living. The resident's [DIAGNOSES REDACTED]. The resident received nutrition through a feeding tube. A Side Rail assessment dated [DATE] documented side rails recommended for resident safety. The resident moved her extremities freely and occasionally rolled in the bed. The assessment lacked any alternative interventions attempted, review of the risks and benefits with the residents representative or informed consent. The current Care Plan edited 7/30/18 identified the resident at risk for falls due to involuntary muscle movements of arms and legs. The interventions included 1/2 side rail for boundaries/repositioning. The Nurse's Notes dated 12/16/18 at 1:15 a.m. documented upon entering the resident's room, the Licensed Practical Nurse (LPN) observed the resident at the lower half of the bed, with both feet over the left side, and the feeding tube disconnected from the pump. The resident had the tube in her hand and pulling on it, and appeared restless. The resident appeared to have rail indentations on her outer left thigh. Staff repositioned the resident and placed 2 pillows in front and 2 in back. During an observation on 5/5/19 at 11:00 a.m. the resident laid in bed in her room. The resident had bilateral 1/2 bed rails with large gaps between the vertical rails (5 vertical bars with 4 gaps) measuring greater than 7 inches. During an interview on 5/5/19 at 1:00 p.m. Staff A Certified Nursing Assistant and Staff F Registered Nurse (RN) stated the resident moved around in the bed, thrashed around and described her as a wiggle worm. During an interview on 5/5/19 at 1:30 p.m. when notified the facility needed to intervene, the Director of Nursing (DON) stated they must have been old side rails they found when the resident came in. She stated the family wanted her to have side rails. She stated she understood the side rails in use had the potential for entrapment. She stated the resident moved about in the bed and they tried to keep pillows around her to keep her safe. During an observation on 5/5/19 at 4:10 p.m. the bed with side rails had been removed from the room. The resident had a high low bed with a scoop type mattress, in low position with the bed up to the wall on one side and a mat on the floor on the other side. During an interview on 5/6/19 at 11:30 a.m. the Maintenance Man stated he had checked the measurements of side rails about a year ago, and the resident admitted after that. He did not measure her side rails. He said when they started talking about the state coming, he eyeballed her rails and thought they were probably okay. He did not measure them until he was called in the day before to remove them and he stated they measured well above the acceptable range. The facility abated the immediate jeopardy on 5/5/2019 by removing the side rail for resident #27. 2. According to the MDS assessment dated [DATE], Resident #9 scored 9 on the BIMS indicating cognitive impairment. The resident required extensive assistance with bed mobility. The resident's [DIAGNOSES REDACTED]. The current Care Plan edited 8/7/18 identified the resident at risk for falls. The interventions included; okay for 1/4 side rails for positioning. During an observation on 5/7/19 at 8:20 a.m. the resident had 1/4 bilateral padded siderails. A Side Rail assessment dated [DATE] documented the resident expressed a desire to have side rails raised while in bed for safety or comfort. The assessment lacked alternative interventions attempted, review of the risks and benefits with the residents representative, or informed consent. 3. According to the MDS assessment dated [DATE] Resident #15 scored 10 on the BIMS indicating cognitive impairment. The resident required extensive assistance with bed mobility. The resident's [DIAGNOSES REDACTED]. The current Care Plan edited 4/27/19 identified the resident at risk for falls. The interventions included 1/4 side rail for positioning. During an observation on 5/7/19 at 9:00 a.m. the resident sat in bed with bilateral 1/4 side rails. A Side Rail assessment dated [DATE] documented the resident expressed a desire to have side rails raised in bed for safety or comfort. The assessment lacked alternative interventions attempted, review of the risks and benefits with the residents representative, or informed consent. 4. The Baseline Care Plan for Resident #180 noted the resident had been admitted to the facility on [DATE]. The resident required assist of one to two staff for bed mobility. An intervention of 1/4 side rail for positioning was added on 4/29/19. The Side Rail Assessment completed on 4/27/19 indicated the grab bar would be sufficient for repositioning per the resident. 5. The MDS completed with ARD of 4/19/19 indicated Resident #5 had a BIMS score of 15, intact cognition. The resident had [DIAGNOSES REDACTED]. The care plan edited 4/27/19 included the intervention for a 1/4 side rail or turn bar for positioning. An observation on 5/5/19 at 2:44 p.m. showed bilateral rails to the resident's bed. 6. According to the MDS with ARD of 2/13/19 Resident #7 had a BIMS score of 14, indicating cognition intact. The resident had the [DIAGNOSES REDACTED]. The care plan edited 4/29/19 included the intervention for 1/4 side rails for positioning. Observation on 5/5/19 at 1:44 p.m. noted a rail to the left side of the resident's bed. Resident #7's Side Rail Assessment, with blank completed date, noted side rails not indicated unless resident requested them. Orders received on 4/29/19 for repositioning bar per nurse request following assessment. During an interview on 5/6/19 at 4:12 p.m. the Director of Nursing (DON), reported the facility did not complete side rail consents.

Based on observation, record review and staff interview the facility failed to adequately supervise a resident at risk for falls resulting in a fall and fracture (Resident #4) and failed to secure a stove from cognitively impaired residents . The facility reported a census of forty residents. Findings include: Resident #4's July 12, 2011 Minimum Data Set (MDS) assessment documented the resident experienced periods of disorganized thinking, periods of altered consciousness. The resident also had thoughts that he/she would be better off dead or of hurting him/herself in some way. The resident required extensive assistance of two staff for transfers and did not ambulate. The resident was not steady and could not stabilize without human assistance when moving from seated to standing position, when walking, or when moving on and off the toilet and during surface to surface transfers. The resident's August 2011 Medication Administration Record documented [DIAGNOSES REDACTED]. The resident's Care Plan documented on April 3, 2009 staff added a pressure alarm to the bed and chair which was later discontinued and replaced with a clip alarm (personal safety alarm/PSA). The care plan intervention added on June 12, 2011 directed the PSA shall be on the resident at all times. Staff documented in the Nurse's Notes on July 29, 2011 at midnight the resident had been heard yelling from the room. Staff found the resident sitting on the side of the bed hallucinating (that the furnace was running and there were ashes floating in the air). The resident was determined to get up to turn off the furnace after his/her hallucination. Staff documented on Incident/Accident Reports the resident experienced falls as follows: On August 12, 2010 the resident fell forward out of the wheelchair. On December 27, 2010 the resident fell next to the bed trying to go to the bathroom. In the Nurse's Notes staff documented on August 6, 2011 at 6:45 a.m. staff found Resident #4 on the floor in front of the toilet. Staff noted the following injuries: a 2 centimeter (cm) skin tear on top of the right hand near the 4th digit with purple bruising 7 by 6 cm. around the wound; a 7 by 7 cm. purple bruise to the left elbow; a 4.5 cm. bruise to the right elbow; a 14 by 3 cm. pink bruise like area to the right mid back; and a 2 by 2 cm. abrasion to the right knee. On August 6, 2011 at 2:35 p.m. staff documented in the Nurse's Notes the resident complained of discomfort to the right hand, the grip of the right hand was slightly weaker and he/she had a new purple bruise to the middle of the palm of the right hand. On August 7, 2011 at 8:00 a.m. staff documented in the Nurse's Notes the right hand appeared 75% purple. On August 8, 2011 at 8:40 a.m. staff documented in the Nurse's Notes the right hand was edematous, dark purple, tender and noted the resident guarded the extremity at times. An August 8, 2011 X-ray Report stated Patient History: swelling, bruising, discomfort. Findings documented the resident had a fracture of the fifth metacarpal neck. During the initial tour of the facility on August 9, 2011 at 10:20 a.m. the Director of Nursing stated at the time of the fall, Resident #4 had been on the toilet and the CNA had stepped away to get a wash cloth. During interview on August 10, 2011 at 8:59 a.m. Staff F, CNA stated at the time of the fall she had stepped out of the bathroom to get a washcloth from the sink and heard the resident fall. She thought Resident #4 had leaned over and fell off the toilet. At 9:33 a.m. Staff F stated she had been taught not to leave the room when alarmed residents sat on the toilet. She wasn't sure if that meant not to leave the bathroom or not to leave the resident's room. She said she had also been taught to multitask, do other things while residents sat on the toilet. When asked if that included residents who used alarms she stated, "yes". During interview on August 10, 2011 at 8:46 a.m. the Director of Nursing stated they normally did not leave any resident who used an alarm alone on the toilet. During interview at 10:23 a.m. the DON stated they had no specific policy related to leaving alarmed resident's unattended on the toilet. When it was suggested that it didn't make sense to leave such a resident alone out of sight on the toilet without the alarm the DON stated, "I don't disagree with that." An employee warning notice dated August 11, 2011 regarding the August 6, 2011 incident, Staff F documented she had been instructed by the DON to place a resident on the toilet and go about other duties (multitasking) which is what she was doing. Observation on August 10, 2011 of the resident's room and bathroom showed the front of the resident's toilet sat three feet from the bathroom door; the center of the bathroom door to the floor in front of the center of the sink measured five feet. The toilet could not be seen from the sink. During observation on August 10, 2011 at 7:09 a.m. the resident sat in a wheelchair in the dining room. The resident had a splint wrapped with an elastic bandage over the hand and to the elbow. On August 9, 2011 at 12:15 p.m. staff wrote in the Nurse's Notes an appointment with the doctor to apply a cast to the arm on August 16, 2011 at 10:15 a.m. During interview on August 10, 2011 at 8:59 a.m. Staff J1 Restorative Aide stated the resident's Restorative Programs had been put on hold because of the fracture. At 8:30 a.m. on 8/11/11 the door to the kitchenette was unlocked and no staff were in the activity room attached to the kitchenette. The stove/oven in the kitchenette was able to be turned on. During the environmental tour with Staff G1 at approximately 9:15 a.m. the door remained unlocked with no staff around. This surveyor had been able to turn on a burner. Staff G1 stated the door is to be locked and the breaker for the stove is to be off. Staff G1 turned off the breaker at this time. During interview on 8/11/11 at 10:25 a.m. Staff A stated the key to turn the breaker on/off for the stove is kept on top of the refrigerator in the kitchenette. Staff A stated the stove had last been used Wednesday of last week (8 days ago) to bake monkey bread. The facility identified 9 residents with cognitive impairment that could get around the facility on their own.

Based on record review and staff interviews, the facility failed to provide nursing provisions with timely assessment and intervention for one of eight residents reviewed (Resident #1) with an onset of changes in physical condition. The facility reported a census of 44 residents. Findings Include: The Minimum Data Set, with an assessment reference date of 2/22/11, showed Resident #1 had long and short term memory problems with modified independence making decisions regarding tasks of daily life. The resident had required extensive staff assist for transfers, toilet use, and personal hygiene. Resident #1 required supervision, (oversight, encouragement or cueing) for eating. Resident #1's Nurses Notes, dated 2/18/11 at 3:00 a.m., noted upon entering the residents bathroom the resident was sitting on the floor with legs straight out in front of body and back against the wall. The resident ' s skin was pale, cool, and clammy and noted to have short periods of body shivers and dry heaving. The resident stated he/she had to go to the bathroom and began to not feel good and threw up. The resident complained of being tired and weak and stated, I feel like I am dead, leave me. Three staff assisted with a gait belt to transfer the resident to a standing position and into wheelchair. The notes described the resident tolerated minimal weight, unsteady and started to drop his/her weight and stated, I can't, I'm dying. The resident noted the resident incontinent of loose stools. At 4:40 a.m. Resident #1 vomited on self, still complains of nausea, clothes changed and resident put to bed. At 11:30 a.m. Resident #1's family visited and updated on illness and fall. The notes documented a message left at doctor ' s office. At 11:30 a.m. the resident ' s vitals read: temperature at 97.9, pulse at 80, respirations at 18, and blood pressure at 116/64, with his/her oxygen saturation at 96% (on room air). The note described the resident as very sleepy, pale skin, and had episode of emesis (water like color phlegm noted). The resident had fine crackles in and out to lower bilateral lobes. At 3:40 p.m. the physician responded with a physician's order [REDACTED]. The resident ' s family made aware and stated, let's see how he/she does tonight. At 11:00 p.m. a facsimile sent to the physician to notify that 5:00 p.m. and 8:00 p.m. medications held except scheduled Tylenol due to lethargy and vomiting. Resident #1's Nurse Notes, dated 2/19/11 at 3:05 a.m., documented the resident ' s vital signs and noted no emesis, and that the resident had loose stool. The note described the resident as continued to be weak and needed the assistance of two staff with a gait belt for toileting and transfers. No other entries for 2/19/11. Resident #1 had no entries in Nurse Notes on 2/20/11. Resident #1's Nurse Notes, dated 2/21/11, noted received a signed facsimile back from the doctor. The facsimile that had been sent to him on 2/18/11. No other entries in the Nurse Notes. On 2/22/11 Resident #1's Nurse Notes had an entry at 6:30 a.m., the resident ' s temperature at 98.5, pulse at100, respirations at 22, blood pressure reading of 142/80, and oxygen saturation at 97% (on room air). The note described the resident as pale in color, lethargic, refusing fluids, and moved all extremities slowly. The note documented Resident #1 did not respond verbally, and just opened his/her eyes and closed them. A phone call placed to family, they will come out to see if resident will drink for them. The resident had dark periorbital area. At 7:30 a.m. the resident had been sitting up in bed drinking for family. At 8:45 a.m. the resident was awake, smiling, and talked a little while, and took medication without difficulty. The resident consumed one half bowl of oatmeal, 240 cc's of supplement, 120 cc's of water and 120 cc's of apple juice. At 9:00 a.m. phone call to the physician, message left related to resident's weakness and consumption after family arrives. At 12:05 p.m. the notes described the resident continued to be very weak and needed extensive assistance of two staff with gait belt to pivot transfer to the toileting. The note documented that much stimulation was needed to get the resident to take medications and drink fluids. Staff placed a phone call to the doctor and left a message. The note documented apical pulse regular, strong 98 to 102 beats per minute. At 2:18 p.m. the resident ' s family member requested that Resident #1 be sent to the emergency room via ambulance. At 2:20 p.m. phone call to the emergency room and order received to send to the emergency room via ambulance. At 4:00 p.m. received phone call from the doctor, Resident #1 admitted to the hospital with [REDACTED]. A physician progress notes [REDACTED]. The resident still looks rather dry; he/she is more responsive than yesterday. Will increase the intravenous rate and give more fluids. The resident's potassium came up from 2/6 to 2.8 (normal 3.5-5.2), amylase is improved but still slightly elevated, creatinine has come down from 4 to 2.8 (normal 0.6-1.3). A History & Physical dictated 2/27/2011 at 7:22 a.m., documented the resident had been brought in from the nursing home with severe dehydration, a urinary tract infection [MEDICAL CONDITION], a questionable infiltrate on his/her chest x-ray and abdominal discomfort. The hospital admitted the resident to skilled nursing care for continued hydration and IV antibiotic therapy. The Discharge Summary, dated 3/4/11, noted under History of Present Illness, Resident #1 had been brought into the hospital for extreme dehydration, vomiting and diarrhea for several days. The summary documented the resident had been found unresponsive and lethargic. The Final [DIAGNOSES REDACTED]. The Nutrition Risk Assessment, dated 9/15/10, assessed Resident #1 total calories needs daily of 1620 and total fluid needs daily of 2130 cc's. The Dietary Intake for Resident #1 included the following: 1. 2/18/11 had refusal for food and fluid at breakfast. No entries for lunch or supper. 2. 2/19/11 there were no entries documented for food and fluid intake for breakfast, lunch, and supper. 3. 2/20/11 at breakfast the resident had 0-25% of food and fluid offered, at lunch had 26-50% of food offered and 51-75% of fluid offered, at supper had 0-25% of food and fluid offered. 4. 2/21/11 at breakfast and lunch the resident had no food intake and only sips of fluids, for supper the resident had 0-25% of food offered and 26-50% of fluids offered. 5. 2/22/11 Resident #1 had 0-25% of food offered and 100% of fluids offered, for lunch he/she consumed 0-25% and drank 26-50% of fluids offered. During interview on 5/20/11 at 9:40 a.m. Staff G stated if a resident had nausea and vomiting she would want an assessment done every shift to monitor how the resident is doing. The assessment would include food and fluid intake, and output. During interview on 5/20/11 at 10:25 a.m. Staff D1 stated she would expect staff would have done a head to toe assessment on Resident #1 each shift, because of the nausea and vomiting the assessment should include the residents intake and output. At 12:35 p.m. Staff D1 stated about 4 to 5 months ago the facility held a nursing in-service where assessment guidelines and helpful hints had been covered. During interview on 5/20/11 at 12:25 p.m. Staff E stated she would have taken a set of vital signs, check output, check if eyes were sunken in, check orientation, (with Resident #1 that is hard to assess as the resident fluctuates) would check if the resident is eating and drinking, any loose stools as those would decrease body fluids, how often bowels moving, any emesis, check lung sounds to ensure the resident is not aspirating. Staff E stated she had a very good clinical instructor who taught her to look at these things and know that they effect older people differently than someone her age.