Every finding on record at Friendship Home Association

Based on direct observation, faciliy document review, staff interview, and facility policy review, the facility failed to perform regular temperature and sanitation chemical monitoring for their dishwashing unit. The facility reported a census 41. Findings include: During a direct observation on 07/27/2026 at 10:30 AM the Initial kitchen audit revealed the July 2026 Dishwashing temperatures and chemical sanitation testing log had not been completed since 07/17/2026. The chlorine chemical solution in the dishwasher was noted to be low but still present at the time of this inspection. Additionally, the log did not have documentation on 07/16/2026, 07/14/2026, 07/09/2026, 07/02/2026, and 07/01/2026. During a follow-up kitchen visit on 07/28/2026 at 10:54 AM, the chlorine-based dish washing unit failed three chemical sanitation strip tests. The chlorine sanitation container was noted to be empty. The Dietary Manager sought assistance from Staff G, Dietary cook, who was able to identify the chlorine sanitation container was empty and then replaced it. After replacing the container the dishwash passed the sanitation testing measures. In an interview on 07/29/2026 at 04:08 PM with Staff G, Dietary Cook, she stated the previous dietary management team was having them test chemicals and record washing temperatures daily, she noted it was missed because the previous management team quit very recently, leaving a skeleton crew to perform all kitchen tasks. She stated she knew it needed to be done, and the team was getting back into a new routine after having hired new staff members. In an interview on 07/29/2026 at 03:56 PM with the Dietary Manager, she stated it was her expectation the sanitation log is performed every shift. She stated she had just started and knew it was a problem coming into the job. Review of a facility provided document titled Cleaning Dishes/Dish Machine, with an unknown date of last review, it states the following: Staff will follow these procedures for washing dishes:Prior to use, verify proper temperatures and machine function. Confirm that soap and rinse dispensers are filled and have enough cleaning product for the shift.

Based on clinical record review, and staff interviews, the facility failed to ensure the completion of comprehensive discharge summaries-specifically the recapitulation of stay-for 3 of 3 residents sampled (Resident #43, #44, and #45). The facility failed to ensure that mandatory discharge elements, including a summary of diagnoses, course of illness, treatment, therapy, and pertinent diagnostic results, were generated and maintained in the medical record for residents upon discharge. The facility reported a census of 41 residents.Findings include:1.The MDS for Resident #43 dated 6/19/26 documented a discharge date of 6/19/26, with no return to the facility anticipated.The facility provided a transfer/discharge report for Resident #43; however, the clinical record lacked the required recapitulation of stay.2. The MDS for Resident #44 dated 3/31/26 documented a discharge date of 3/31/26, with no return to the facility anticipated.The Electronic Health Record (EHR) of Resident #44 contained a signed Discharge Instruction Form and a transfer/discharge report. A recapitulation of stay was not located in the record of Resident #44. 3. The MDS for Resident #45 dated 4/9/26 documented a discharge date of 4/9/26, with no return to the facility anticipated.The facility failed to produce any discharge paperwork other than a signed Discharge Instruction Form; a recapitulation of stay was not located in the record of Resident #45.On 7/29/26, the Administrator stated the EHR software was not configured to generate a recapitulation of stay and that the document was not an available option within the current system configuration. She stated the facility had contacted customer support to resolve the software issue. On 7/30/26, the Director of Nursing confirmed the EHR software vendor was currently correcting the issue and stated the facility also plans to provide staff education and include a resident signature on the completed summary.The Director of Nursing stated the facility does not have a policy regarding discharge documentation or recapitualtion of stay.

Based on clinical record review, staff interviews and guidance from the 2025 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately complete Section P (Restraints and Alarms) of the Minimum Data Set (MDS) for 5 of 5 residents sampled (Residents #1, #3, #7, #26, #35). Specifically, the facility erroneously coded the use of bed rails as physical restraints on the MDS assessments. The facility reported a census of 41 residents. Findings include: Section P of the Minimum Data Set (MDS), P0100, documents Physical Restraints as Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.1. The MDS Assessment of Resident #1 dated 5/13/26 documented a bed rail that was used daily as a restraint. The Care Plan of Resident #1 failed to document the use of bed rails or restraints.2. The MDS Assessment of Resident #3 dated 5/20/26 documented a bed rail that was used daily as a restraint. The Care Plan of Resident #3 failed to document the use of bed rails or restraints. 3. The MDS Assessment of Resident #7 dated 5/13/26 documented a bed rail that was used daily as a restraint. The Care Plan of Resident #7 identified turn rails on his bed for independence in bed mobility. The Care Plan failed to document the use of restraints. 4. The MDS Assessment of Resident #26 dated 7/15/26 documented a bed rail that was used daily as a restraint. The Care Plan of Resident #26 identified turn rails to aid in bed mobility. The Care Plan failed to document the use of restraints. 5. The MDS Assessment of Resident #35 dated 6/10/26 documented a bed rail that was used daily as a restraint. The Care Plan of Resident #35 identified turn rails bilaterally to aid in bed mobility and transfers. The Care Plan failed to document the use of restraints.On 7/27/26 at 1:58 PM the MDS Coordinator stated it is a question on the MDS assessment if there are side rails on the bed, so she documents yes. She stated every resident of the facility who utilizes side rails, approximately 15 residents, have been documented this way on their MDS Assessments. She stated the facility does not use any restraints or alarms. She stated she would adjust the assessments accordingly. On 7/29/26 at 12:35 pm, the Director of Nursing stated the facility has no residents who use restraints. She stated the MDS coding would be addressed. She also stated that all residents who have side rails have a yearly assessment for side rails and are only used per resident request. The RAI Manual states the intent of Section P: Restraints and Alarms as the following:The intent of this section is to record the frequency that the resident was restrained by any of the listed devices or an alarm was used, at any time during the day or night, during the 7day look-back period. Assessors will evaluate whether or not a device meets the definition of a physical restraint or an alarm and code only the devices that meet the definitions in the appropriate categories.The Director of Nursing stated the facility does not have a policy for the accuracy of the MDS Assessments.

Based on clinical record review, staff interviews, and policy review, the facility failed to fully inform the resident and/or representative of alternative psychotropic medication options by failing to identify target behaviors (TBs) or non-pharmacologic interventions (NPIs) on psychotropic medication (medications that affect a person's mental state, emotions, and behavior) for 1 of 5 residents (#13). The facility reported a census of 41 residents. Findings include:Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of non-Alzheimer's dementia with other behavioral disturbances and Parkinson's disease. It revealed the resident took antianxiety, antipsychotic, and antidepressant medications in the 7-day look-back period. It indicated the resident was independent with eating, oral hygiene, and bed mobility, required maximal assistance with toilet and personal hygiene, sit-to-lying, and sit-to-stand mobility, and required moderate assistance with all other mobility and Activities of Daily Living (ADLs).The Electronic Health Record (EHR) included a physician's order dated 4/13/26 for Haldol (antipsychotic) by mouth every 4 hours as needed for severe agitation and combativeness and another order dated 6/04/26 for Lorazepam (antianxiety) every two (2) hours as needed for anxiety/restlessness.Two (2) documents titled Consent For Use Of Psychotropic Medication (11/2010) were reviewed. The consent form dated 4/13/26 did not include the required NPIs for Haldol. A second, undated consent form did not include the required TBs or NPIs for Lorazepam.On 7/28/26 at 3:28 PM, Staff D, Licensed Practical Nurse (LPN) stated Resident #13 became aggressive, combative, and resisted cares during episodes of psychosis and became loud and used profanity in public areas when he was anxious. She also stated staff would stay calm, verify his needs, and reminisce as a NPI for his behaviors.On 7/30/26 at 1:31 PM, the Director of Nursing (DON) stated the date should have been completed on the consent forms but the staff perceived the consents at the time were completed because the form did not include areas that addressed NPIs.A policy titled Psychoactive Drugs revised 5/15/26 revealed the information about responsible prescribing of the medication should provide the resident or authorized representative with information about the potential benefits, risks, and alternatives to the medication.

Based on clinical record review, staff interview, and policy review, the facility failed to identify and consistently monitor target behaviors (TBs) or non-pharmacologic interventions (NPIs) for 1 of 5 residents (#13) who received Lorazepam (antianxiety) medication. The facility reported a census of 41 residents. Findings include:Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of non-Alzheimer's dementia with other behavioral disturbances and Parkinson's disease. It revealed the resident took antianxiety, antipsychotic, and antidepressant medications in the 7-day look-back period.The Electronic Health Record (EHR) included a physician's order dated 6/04/26 for Lorazepam (antianxiety) every two (2) hours as needed for anxiety/restlessness. It did not include what behaviors the resident exhibited related to anxiety.A document titled Consent For Use Of Psychotropic Medication (11/2010) was reviewed. The undated consent form did not include the required TBs or NPIs for Lorazepam.The June and July Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not nurse documented monitoring of TBs or NPIs.A Behavior Note Progress Note dated 7/05/26 at 5:09 PM indicated no behaviors experienced on this shift. resident remained calm and respectful, and thoroughly entertained with today's activities. There were no subsequent Behavior Note Progress Notes documented.On 7/30/26 at 1:31 PM, the Director of Nursing (DON) stated nursing staff should monitor for identified, resident specific behaviors.A policy titled Psychoactive Drugs revised 5/15/26 revealed all psychoactive drug use, including the indication, dose, and monitoring parameters, should be documented in the resident's medical record.

Based on clinical record review, staff interviews, and guidance from the 2025 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete and transmit a Signifcant Change in Status Minimum Data Set (MDS) Assessment following resident enrollment in hospice for two of two residents reviewed for hospice (Res # 15 and Res #3). The facility reported a census of 41 residents.Findings include:1. The Census Line portion of the Electronic Health Record (EHR) of Resident #15 documented the resident enrolled in hospice care on 1/15/26. The Alert Note dated 1/16/26 documented the resident admitted to hospice care on 1/15/26. The Significant Change MDS of Resident #15 documented an Assessment Reference Date (ARD) of 2/18/26. Page 59 of the MDS documented a completion date of 2/24/26, 40 days after hospice enrollment. 2. The Census Line portion of the EHR of Resident #3 documented the resident enrolled in hospice care on 5/6/26. The Health Status Note dated 5/6/26 documented the resident admitted to hospice care on 5/6/26. The Significant Change MDS of Resident #3 dated 5/20/26 documented a completion date of 5/22/26, 16 days after hospice enrollment. According to the 2025 RAI Manual, a Significant Change in Status Assessment (SCSA) for the MDS must be completed no later than 14 calendar days after determining a significant change in a resident status (Determination Date + 14 days). The manual also states that a SCSA is required when a terminally ill resident enrolls in a hospice program. Therefore, the official determination date is the day of hospice enrollment. On 7/29/26 at 2:47 pm, the MDS Coordinator acknowledged that the Significant Change assessment for Resident #15 was not completed timely. She noted that her employment start date was 1/26/26 (11 days following Res #15's hospice admission) and attributed the failure to complete the assessment to the facility's previous staff.The Director of Nursing stated the facility does not have a policy regarding timely completion of the MDS.

Based on clinical record review, staff interview, and policy review, the facility failed to develop a personalized Care Plan that included resident specific target behaviors (TBs) or non-pharmacological interventions (NPIs) for 2 of 5 residents (#1, #13) who received psychotropic medications (medications that affect a person's mental state, emotions, and behavior). The facility reported a census of 41 residents. Findings include:1.Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of anxiety, depression, and psychotic disorder. It revealed the resident received antianxiety, antidepressant, antipsychotic, and hypnotic medications during the 7-day look-back period.The Electronic Health Record (EHR) included six (6) physician's orders for a) an antipsychotic medication for delusional disorder dated 5/21/25; b) an anticonvulsant medication for anxiety disorder dated 5/22/25; c) an atypical antipsychotic medication for major depressive disorder, with severe psychotic symptoms dated 5/22/25; d) an antidepressant medication for major depressive disorder, severe with psychotic symptoms dated 8/27/25 and an increased dose dated 10/21/25; and e) a hypnotic medication for insomnia dated 4/30/26.The July 2026 Medication Administration Record (MAR) revealed Resident #1 consistently received the six (6) scheduled psychotropic medications throughout July 2026.The Care Plan revised 5/18/26 included psychotropic medication use, but did not include any of the resident's psychotropic medication TBs or NPIs for staff to attempt.2. Resident #13's quarterly MDS assessment dated [DATE] identified a BIMS score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of non-Alzheimer's dementia with other behavioral disturbances and Parkinson's disease. It revealed the resident took antianxiety, antipsychotic, and antidepressant medications in the 7-day look-back period.The EHR included a physician's order dated 6/04/26 for Lorazepam (antianxiety) every two (2) hours as needed for anxiety/restlessness. It did not include what behaviors the resident exhibited related to anxiety.The July MAR revealed the resident received the Lorazepam on 7/26/26.The Care Plan revised 6/04/26 did not include Lorazepam, antianxiety medication use, or associated TBs or NPIs.On 7/30/26 at 1:31 PM, the Director of Nursing (DON) stated drug classes and not specific drug names should be listed on the care plan and the TBs and NPIs should be separated by drug class.A policy titled Updating Care Plans Timely dated 1/07/21 directed the MDS Coordinator to:Review MDS Schedule for CP due datesComprehensive scheduled for 1 week after admission MDS due dateUpdate after initial and quarterly care conferences & PRN (as needed)Print previous day new and DC'd (discontinued) resident ordersUpdate care plans for pertinent changes if they have not already been updatedMedication changes (bleeding risk, black-box warning, diuretics, psychotropics, etc)New or DC'd treatmentsDiet changesVaccinationsTherapy ordersAny changes in transfer/bowel/bladder status or other categories identified in CAAIn the absence of the MDS Coordinator, a specific nursing team member will be assigned this audit

Based on clinical record review, resident and staff interviews, facility reported incident documentation, and facility policy review, the facility failed to conduct a thorough investigation following a resident's fall with injury for 1 of 3 residents reviewed for falls (Resident #3). Specifically, the facility neglected to analyze the circumstances of the incident or interview the involved staff, resulting in an incomplete root cause analysis, hindering the facility's ability to prevent future falls. The facility reported a census of 41 residents. Findings include:The Care Plan of Resident #3 identified a Focus Area of history of falls due to impaired mobility. The Care Plan detailed an intervention stating Fall on 7/10/26 - Staff to assist the resident back to his room after meals, toilet, then chair or bed. The Care Plan failed to identify any toileting schedule or routine of Resident #3 prior to the intervention for a fall on 7/10/26.The facility's incident summary noted that Resident #3 fell in the bathroom on 7/10/26, hitting his head on the wall. He was sent to the hospital and subsequently diagnosed with a brain bleed. The facility document titled Accident Investigation Report detailed the fall was unwitnessed and staff responded immediately upon hearing the fall. It included that the bathroom floor was inspected and found to be dry and free of clutter and that no equipment malfunction or environmental issue was identified as contributing to the fall. The Report Section titled Root Cause Analysis included likely contributing factors of:Resident's underlying fall risk and mobility statusUnwitnessed transfer/ambulation in the bathroomNo environmental hazards were identified that directly contributed to the incidentThe opened but incomplete Risk Management Report (Incident Report) failed to document critical investigative information, including staff statements, resident footwear, the time the resident was last visualized, and incontinence status - some items necessary for a complete and accurate root cause analysis.On 7/28/26 at 9:08 am, Resident #3 stated that he thought the fall was a long time ago and he was unable to recall how it happened. On 7/28/26 at 3:20 pm, the Administrator provided the previously submitted Accident Investigation Report and a copy of the Progress Note detailing the fall. When the State Surveyor requested any further documentation of investigative details, the Administrator stated the only witness to hearing the fall was the nurse that wrote the progress note and opened the Risk Management Report. The Incident Note dated 7/10/26 detailed the following: The resident fell in the bathroom and hit his head on the wall. Staff A, Licensed Practical Nurse (LPN) author of the note, detailed that he was several doors down and heard a loud thud. Upon entering the resident's room, the resident was sitting on the floor with his head up against the shower wall of the bathroom. Per the note, the resident stated the only thing hurting was his head and that he did hit his head. Two small skin tears were found on his elbow. Following the nurse's assessment, staff assisted the resident to stand and then to sit in his wheelchair. The resident then was unable to state where he was or his spouse's name, the day of the week, and several times reported that his head hurt. On 7/28/26 at 3:52 pm, Staff B, Certified Nurse Aide (CNA) stated the fall happened just after her shift started. She stated she had not yet rounded on the resident or seen him that day. She stated she did receive a report from the offgoing staff, but could not recall who that staff member was.Review of the resident's clinical record revealed that Staff C, CNA had cared for Resident #3 on the shift prior to the fall. On 7/28/26 at 4:10 pm, Staff C, CNA stated she was unable to recall the specific shift of 7/10/26 but stated she frequently is assigned to the hall which Res #3 resides on. She stated the resident falls a lot and that fall happened after she had left so she was unable to give any specific details. She was able to describe the normal routine of Resident #3. She described that he comes out for meals (eats them in the dining room rather than in his room). She stated after meals, staff will transfer him to his recliner, and place his wheelchair next to him. She stated the staff usually will take him to the toilet prior to meals but if not, then will take him after meals. She stated usually between 4:30 and 5:00 pm is when residents are taken to the dining room for the evening meal, so toileting is normally in that time frame. She said residents are usually done eating by 6:00-6:15 but added that Resident #3 eats fast and he is often done by 5:30 or so and returns to his room at that time. On 7/29/26 at 12:18 pm, the Director of Nursing (DON) stated this was her first time managing a resident fall with a major injury while acting in her current role as DON. She reported that on the night of the incident, Staff A, LPN called her and she instructed him to make the required notifications to the resident's family and physician. Later that night, the DON received a second phone call from Staff A, during which she was informed of the resident's diagnosis. In the days following the incident, the DON, the Administrator, the Social Services Representative and the MDS Coordinator met to discuss Resident #3's routine, the fall, and interventions that could be put in place to prevent future falls. The DON voiced they reviewed the Progress Note written by Staff A and did also speak to Staff B. When the DON spoke to Staff B, she reported she had not yet seen the resident, as the incident occured at the beginning of her shift. The DON acknowledged that she did not document her conversation with Staff B, nor did she interview Staff C regarding the fall. On 7/29/26 at 2:27 pm, Staff A, LPN stated he had been in the room next to Resident #3's room and heard a thud and ran in. He stated the resident was in the bathroom, but had not taken his walker with him. The resident was sitting up on the floor. He thought the thud he heard was the resident hitting his head. When asked what footwear the resident was wearing, he stated he thought he had been barefoot as the resident has a habit of removing his shoes and socks. He stated he thought the CNAs had toileted him before he was helped to his recliner, but he did not witness this. He added the resident is care planned to be toileted both before and after meals. He was unable to state with certainty if the resident was incontinent at the time of the fall but did not think he was. The facility policy titled Falls, revision date 5/15/26 detailed the following: Point 7: Document in the progress notes the following information:Date and timePerson reporting the event (What alert staff to event - noise, call light, etc.)Was the event witnessed? Describe what the staff member saw.Location of the event. Be specific.Physical description of the resident, position on floor, position of extremities.Assessment for injury.Vital signsHead injury.Assess for cause:Statements by the residentEnvironmental issuesPersonal care issues: Last toileted, shoes on; shoes need repair; don't fit, wheelchair unlocked, etcAdaptive Equipment - Was equipment on and in place, was the resident using it; using it appropriately.Point 9: Determine potential causes for the fall and add teaching and/or interventions to the plan of care to prevent another fall from occurring.

Based on observation, staff interviews, and policy review, the facility failed to prevent cross-contamination by failing to prevent a resident in a wheelchair from self-propelling through a resident's incontinent urine puddle in the dining area. The facility reported a census of 41 residents.Findings include:Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of non-Alzheimer's dementia with other behavioral disturbances, Parkinson's disease, high blood pressure, enlarged prostate, and diabetes mellitus. It indicated the resident was independent with eating, oral hygiene, and bed mobility, required maximal assistance with toilet and personal hygiene, sit-to-lying, and sit-to-stand mobility, and required moderate assistance with all other mobility and Activities of Daily Living (ADLs). It also revealed the resident was frequently incontinent of urine.The Care Plan initiated 4/08/26 indicated the resident requires maximum assist by 1 to 2 staff for toileting. He is incontinent of urine and wears a pull up.During a continuous observation on 7/27/26 at 12:17 PM, Resident #13 was seated at the dining room table eating lunch. Liquid was observed flowing from under his wheelchair seat to the floor and puddling behind his wheelchair. Staff immediately transported Resident #13 back to his room.At 12:21 PM, Staff E, Dietary Aide (DA) looked at the puddle and turned her head toward other staff.At 12:23 PM, another resident self-propelled through the urine puddle in her wheelchair.At 12:33 PM, Staff D, Licensed Practical Nurse (LPN) approached Staff E and asked her if she saw the water on the floor where Resident #13 had been. Staff E informed Staff D that the liquid was urine. Staff D immediately left the dining room and returned at 12:35 PM, performed hand hygiene, and began assisting other residents.At 12:36 PM, Staff F, Certified Nurse Aide (CNA) arrived with a housekeeping mop and bucket. She cleaned up the urine.On 7/30/26 at 1:45 PM, the Director of Nursing (DON) stated staff should have immediately notified a nursing staff member and they should cover the area and clean it.A policy titled Environmental Cleaning Procedures updated 9/14/23 directed staff to clean spills of blood or body fluids immediately.

Based on Electronic Health Records (EHR) review, observation, document review, Medication Administration Record - Treatment Administration Record (MAR-TAR), staff interview and family interview the facility failed to notify the resident's representative / family / Power of Attorney (POA) for a new physicians order and change in condition when a wander guard was placed on the resident for 2 of 3 residents (Residents #2 and #3) reviewed. The facility reported a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 2 indicating severe cognitive impairment. The MDS also documented Resident #2 had diagnoses of dementia with psychotic disturbances and Alzheimer's disease with late onset. Review of Resident #2's undated EHR titled, Clinical Resident Profile documented Resident #2 had a POA.Observation on 9/3/25 of Resident #2 with a wander guard placed on the right lower leg.Review of Resident #2's MDS dated [DATE] documented utilization of a wander guard.Review of Resident #2's EHR titled, Clinical Physician Orders documented a physician's order started 8/14/25 to check wander guard placement every day and night shift. EHR titled, Orders also documented a physician's order started 8/14/25 to check wander guard function at bedtime.Review of Resident #2's MAR-TAR documented a physician's order started 8/14/25 to check wander guard placement every day and night shift. The MAR - TAR also documented a physician's order started 8/14/25 to check the wander guard function at bedtime.Review of Resident #2's document titled, Elopement Evaluation documented evaluation was faxed to physician with statement that Resident #2 was at risk for elopement due to wandering. Could the facility replace a wander guard device on the resident to prevent elopement with a reply from Resident #2's physician of yes dated 8/14/25.Review of Resident #2's EHR titled, Progress Report documented no notification of new order for wander guard to Resident #2's representative / Power of Attorney (POA).On 9/3/25 at 3:03 PM Resident #2's POA stated he was not aware that Resident #2 had a wander guard placed. Resident #2's POA stated he had not been notified in the last month of any wander guard placement. 2. The MDS dated [DATE] documented Resident #3 had a BIMS of 11 indicating moderate cognitive impairment. The MDS also documented Resident #3 had diagnoses of mild intellectual disabilities, major depressive disorder and generalized anxiety. Review of Resident #3's undated EHR titled, Clinical Resident Profile documented Resident #3's sister as her POA.Review of Resident #3's MDS dated [DATE] documented utilization of a wander guard.Review of Resident #3's EHR titled, Clinical Physician Orders documented a physician's order started 9/2/25 to check wander guard placement every day and night shift. The EHR titled, Orders also documented a physician's order started 9/2/25 to check wander guard function at bedtime.Review of Resident #3's MAR-TAR documented a physician's order started 9/2/25 to check wander guard placement every day and night shift. The MAR-TAR also documented a physician's order started 9/2/25 to check the wander guard function at bedtime.Review of Resident #3's fax dated 9/1/25 documented a request for an order for a wander guard with a physician's response of yes, may use wander guard dated 9/1/25.Review of Resident #3's EHR titled, Progress Report documented no notification of new order for wander guard to Resident #3's representative / Power of Attorney (POA).On 9/3/25 at 2:06 PM Resident #3's POA stated she knew that Resident #3 had a wander guard because Resident #3 talked to her about it. Resident #3's POA stated she was not notified by the facility staff that Resident #3 had a wander guard placed on her. Resident #3's POA stated Resident #3 had talked to her on the phone and was upset about the wander guard. Resident #3's POA explained that was how she found out Resident #3 had a wander guard placed. On 9/4/25 at 4:04 PM Staff A, Licensed Practical Nurse (LPN) stated she had applied a wander guard to Resident #3 because on 9/1/25 Resident #3 was trying to leave with her sister out the double doors. Staff A explained she requested the order for the wander guard from the physician and did not notify the residents representative / POA of new order or placement of the wander guard. Staff A acknowledged she should have notified Resident #3's representative / POA.On 9/3/25 at 3:11 PM the DON stated Resident #2 had a wander guard on and it was removed. The DON explained she had left it to Staff B to notify Resident #2's family. The DON acknowledged there was no documentation for family/representative/POA notification for wander guard use on Resident #2 or #3. The DON stated she would expect that there would be family notification of the wander guard placement as well as any new order for a resident at the facility. On 9/4/25 at 11:36 AM the Administrator stated the facility's expectation was the resident's family / POA would be notified of new orders, change in orders, medication changes, or incidents. The Administrator explained there would be an order from a physician for the wander guard use. The Administrator acknowledged she would expect notification to the resident's family / POA of the wander guard application. On 9/4/25 at 9:00 AM the DON explained the facility had no policy with family/POA notification of change in condition, new orders, change in orders or application of wander guard.

Based on clinical Medication Administration Records - Treatment Administration Records (MAR-TAR), Electronic Health Records (EHR) review, document review, family interview, staff interview, and policy review the facility failed to provide adequate nursing supervision when a resident left the facility from a Chronic Confusion or Dementia Illness (CCDI) unit and walked outside into the back yard of a neighboring resident unknown to the staff for 1 of 3 residents (Resident #1) reviewed. The facility reported a census of 42. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. The MDS documented utilization of a wander guard and wandering behavior had occurred 1-3 days reviewed for the MDS.Review of Resident #1's EHR dated 8/4/25 at 7:15 PM by Staff A, Licensed Practical Nurse (LPN) titled, Progress Notes documented that Resident #1 was found outside across the back parking lot on a private lot where a man was mowing his yard. Review of Resident #1's document dated 8/4/25 titled, Risk Management entered by Staff A documented Resident #1 went outside and was brought back in by Staff C, Registered Nurse (RN). Body assessment completed, no injuries were noted. Document further documented Staff C and Staff D came and asked Staff A if all the residents were accountable for the CCDI unit. Staff went into every room and were unable to locate Resident #1. Document continued with Staff C found Resident #1 outside, stated Resident #1 was in the yard where a man was mowing and he told Staff C that Resident #1 wanted to get on the lawn [NAME]. Reported by the man that Resident #1 had a fall.On 9/3/25 at 10:17 AM Staff D, LPN stated 8/4/25 was the first night she had ever worked at the facility and she was orientating. Staff D stated she was orientating with Staff C the night of 8/4/25. Staff D stated she was orientating upstairs at the facility. Staff D stated she was passing medications with Staff C. Staff D stated she heard an alarm going off. Staff D stated another staff told Staff C the alarm was going off downstairs on the CCDI unit. Staff D stated when she was done passing medications to the resident they were on, both of them went downstairs. Staff D stated Staff C yelled up to the nurse and CNA on the CCDI unit asking if all the residents were present or accounted for. Staff D stated Staff C then went to the right and out the door that way. Staff D stated once she was at the end of the hall she went down and she could see Staff C outside with Resident #1. Staff D explained it was a CNA that was upstairs that told them the alarm was for downstairs but did not remember which CNA. Staff D stated she did not know which door Resident #1 went out. Staff D explained Staff C brought Resident #1 back in from outside. Staff D stated Staff A was working the memory care unit on 8/4/25 as the nurse and she completed the assessment. Staff D stated when Staff C and Resident #1 was walking back; they were not on the other side of the water gutter. Staff D acknowledged the alarm went off for about 5 minutes before they responded. On 9/3/25 at 12:47 PM Staff C, RN acknowledged she worked for the facility. Staff C acknowledged that she worked upstairs the night of 8/4/25. Staff C stated she was doing the medication pass and around 6:30 PM the alarm on the CCDI unit went off. Staff C explained she went to the control box and noticed it was the wander guard alarm for the CCDI unit. Staff C acknowledged she waited a bit to see if the alarm would be responded to by the staff in the CCDI unit. Stated passed medications to a resident and when she exited the residents room a second alarm went off. Staff C explained it was a door alarm. Staff C stated she went downstairs and looked in the hallway and saw some residents walking inside the CCDI unit. Staff C acknowledged she shut the wander guard alarm off outside the double doors of the CCDI unit. Staff C explained she started walking to the door that was alarming and it had shut off. Staff C stated she then went to the CCDI unit and looked for the residents in the room and noticed Resident #1 was not in the room. Staff C explained she asked Staff E, Certified Nursing Assistant (CNA) if Resident #1 was down in the day room and Staff E said she thought Resident #1 was the resident who got out and sent Staff D down wing 5. Staff C explained she went to the employee entrance and the wing 6 alarm was going off again. Staff C stated she looked out the door and saw Resident #1 walking. Staff C stated Resident #1 had already walked across the back parking lot and onto the grass. Staff C stated when she found Resident #1 her shirt was inside out and her left arm was outside the sleeve and was missing a sock. Staff C stated she asked Resident #1 what she was doing and she told her that she wanted to get on the ride. Staff C stated the guy on the riding lawn [NAME] told her that Resident #1 had fallen. Staff C stated then Staff F, Dietary [NAME] was at the employee entrance. Staff C stated Staff F was waving at us and she brought Resident #1 back to the facility with her. Staff C stated Staff F met her at the end of the parking lot. Staff C stated Resident #1 was past the gutter in the blue house's back yard. Staff C stated Staff F helped Resident #1 with her across the gutter. Staff C stated that was when Staff A met them outside and asked if she had slipped out with Staff F on the unit and Staff F told Staff A no she had just got on the unit when she was gone. Staff C stated she called the DON and told them what was going on and to chart everything and had everyone write a statement. Staff C stated Staff A was told what to do on the unit after the elopement. Staff C stated to Staff A what the witness said and to complete an unwitnessed fall assessment on Resident #1. Staff C stated later on that day they found out that the magnetic lock was not turned on so the lock was reset for the double doors on the CCDI unit. Staff C explained when the alarm was going off everyone was supposed to respond. Staff C acknowledged she might have let the ball drop because she did not respond when she first heard the alarm. Staff C stated Staff E was standing in front of the nurses station on the CCDI unit and Staff A was standing behind the nurses station. Staff C stated when you are on the CCDI unit you could not hear the alarm for the wander guard because it was outside the double door. Staff C stated emails were sent out with education about responding to every alarm immediately after that elopement. Staff C stated there was a box placed over the switch for the magnetic lock. Staff C stated she did not direct the CNA's upstairs to respond. Staff C stated once Resident #1 was back she had staff do a head check hourly on the resident with a wander guard upstairs. Staff C stated the wander guard alarm was going off for about 3 minutes before she went to respond. Staff C explained the wander guard alarm was very loud upstairs. On 9/4/25 at 4:04 PM Staff A, LPN acknowledged she was at the facility on 8/4/25. Staff A stated she was working the CCDI unit on 8/4/25. Staff A stated she went to work and was passing pills. Staff A stated she saw 2 nurses coming up and told her the alarm was going off. Staff A stated she did not hear an alarm going off on the unit. Staff A stated the alarm was not working. Staff A stated there were 2 other staff working on the CCDI unit. Staff A stated Staff E was working on the CCDI unit with her. Staff A stated once Resident #1 returned Staff E said she heard a faint alarm. Staff A stated she asked Staff E why did you not tell me you heard an alarm?. Staff A stated Staff E did not tell her why she did not tell her about the alarm. Staff A stated Staff E appeared teary eyed as if she did something wrong. Staff A stated she told Staff E she needed to always tell her right away when she heard an alarm. Staff A stated there was only one hallway on the CCDI unit and all the resident rooms were on that hallway. Staff A stated she was in a resident's room passing medications at the time. Staff A stated some of the residents take their medications at 6PM and those were the medications she was passing. Staff A stated she did not see any resident leave or hear the double doors shut. Staff A stated the CNA's were taking care of residents at the time she thought. Staff A stated she completed the assessment on Resident #1. Staff A stated Resident #1 did not have any injuries. Staff A stated she started neuro checks and door checks. Staff A stated Resident #1 went out through the double doors. Staff A stated she did not think the double doors were locked with a magnet. Staff A stated Staff G, CNA told her that the alarm panel upstairs the magnetic lock was shut off. Staff A stated Resident #1 had made it off the unit and outside. Staff A stated she thought it would take Resident #1 about 5 minutes to get to where she made it outside. Staff A stated when the alarm went off staff should have responded immediately. Staff A stated there were 2 nurses upstairs and one of them was orientating. Staff A stated Staff C was orienting Staff D. Staff A stated Staff C stated the alarm was going off but did not tell her how long. Staff A explained that when 2 nurses were upstairs one of the nurses should have come downstairs immediately to check on the alarm. Staff A stated there were 13 residents on the CCDI unit 8/4/25. On 9/3/25 at 3:24 PM Staff E, CNA stated she was working on the CCDI unit at the facility on 8/4/25. Staff E stated she was familiar with Resident #1. Staff E stated she was talking to the nurse at the nurses station just after returning from break and she remembered an alarm but was very faint. Staff E explained she looked down the hall and saw the double doors closing. Staff E realized someone just went out the doors. Staff E stated she had heard the wander guard alarm before and just before she got to the double doors Staff C told her the alarm was going off. Staff E explained she started looking to see if all the residents were accounted for. Staff E stated Resident #1 was exit seeking that day. Staff E stated Staff C found Resident #1 out door #6 and the alarm was going off down hall 6. Staff E stated Staff C returned Resident #1 to the CCDI unit. Staff E stated she was working with Staff A on the CCDI unit that day with another CNA. Staff E stated Staff A and herself were at the nurses station talking when Staff C entered the CCDI unit looking for a missing resident. Staff E stated they were standing just outside of the nurses station at that time. Staff E stated she did not know where the other CNA was at that time. Staff E stated she did not hear anyone call down on the phone. Staff E stated the light at the nurses station was always red. Staff E acknowledged if the light would be green then the magnetic door would not be locked. Staff E explained she noticed it was green after the incident. Staff E stated usually you can hear the door alarm but not the wander guard when you are in a residents room or at the nurse station. Staff E explained the only alarm she heard was very faint. Staff E stated when an alarm goes off the staff are supposed to check rooms to ensure the residents are present. On 9/3/25 at 2:45 PM Staff F, Dietary [NAME] acknowledged she was working on 8/4/25. Staff F stated she was familiar with Resident #1. Staff F stated she was just finishing up her shift and was taking the laundry down to the laundry room. Staff F stated she was talking to Resident #1 and when the elevator door closed Resident #1 was in her room. Staff F stated about 3-5 minutes later the upstairs nurse came down and asked where Resident #1 was and told her she was just in her room. Staff F stated the nurse ran through the door. Staff F stated she put up the cart and went out the back door because she figured that she would recognize her. Staff F stated Staff C had found Resident #1 and she was in a neighbor's lawn. Staff F stated Staff C started bringing Resident #1 back. Staff F stated Resident #1 had grass on her shirt but did not appear to have an injury. Staff F explained they walked her back up to the building and then Staff A came out and they all returned Resident #1 to the CCDI unit. Staff F stated Resident #1 was on the other side of the water gutter when she came outside. Staff F stated she helped Staff C and Resident #1 cross the water gutter on the way back. Staff F stated she did not hear the alarm going off. On 9/3/25 at 11:15 AM Staff H, CNA acknowledged she was working at the facility on 8/4/25. Staff H stated she worked 6pm - 6am. Staff H stated she was working upstairs at the facility that night. Staff H stated she was on hall 1 that night and the alarm was going off and saw that it was downstairs. Staff H stated she kept trying to call them and nobody answered the phone. Staff H stated she went downstairs and Staff F told her that Resident #1 ended up getting out the door. Staff H stated the alarm was continuously going off when she came up the hall. Staff H stated she was in a resident's room at that time. Staff H stated she could not hear the alarm in the residents room. Staff H stated she was on her way with Staff I, CNA and the alarm shut off before they got in the elevator. Staff H stated she did not go downstairs. Staff H stated Staff I went downstairs. Staff H stated she did not know if any of the upstairs nurses went downstairs. On 9/3/25 at 1:39 PM Staff I, CNA stated he was down hall 2 for the evening of 8/4/25. Staff I stated he did not hear the alarm when he was in a room with a resident. Staff I stated the rule was if you are attending or completing care on a resident was to stay with the resident and then respond. Staff I stated he stayed with the resident because the resident was in a compromising situation. Staff I stated once the resident was no longer in a compromising situation he responded but other staff had already responded. Staff I stated the other staff upstairs were taking care of their own residents. Staff I stated he could hear the alarm in the room but the resident was in a situation where they could not be left. Staff I stated he knew the alarm was from downstairs. Staff I stated the alarm was going off for about 5 minutes or 10 minutes. Staff I acknowledge the alarm went off for a while before it was responded to. On 9/3/25 at 4:44 PM Staff G, CNA stated she was working on 8/4/25 upstairs at the facility. Staff G stated she knew who Resident #1 was. Staff G stated she was in a residents room when the alarm went off. Staff G stated when she made her way to the nurses station she was told by Staff H that the charge nurse had gone downstairs to answer the wander guard alarm on the CCDI unit. Staff G stated she could not hear the alarm from the residents room she was in. Staff G stated she did not know how long the alarm had been going off. Staff G stated she was not aware of any of the CNA's checking on the alarm. Staff G stated the charge nurse was trying to find out why the doors were not locking. Staff G stated she was the staff that saw that the switch was green and that was what shut off the door locks on the magnetic doors. Staff G explained the alarms are supposed to be checked promptly to determine if a resident had left. On 9/3/25 at 3:11 PM the DON stated during the investigation of Resident #1's elopement on 8/4/25 the main concern was with the response from staff. The DON stated the concern was that there was not an immediate response to the alarm. The DON stated immediate education was provided about the response. On 9/4/25 at 11:36 AM the Administrator stated during the investigation of the elopement there were concerns with the system being outdated and/or if it was working properly. The Administrator stated the nurse could have paged through the phone but if the staff were in rooms they would not have heard the page from the phone. The Administrator explained that the chances of both the wander guard alarm being faint and the magnetic lock on the double doors to the CCDI unit being deactivated was very slim but that was what occurred during the incident on 8/4/25. The Administrator explained the facility's determination was that the magnetic lock shut off button probably was hit by the monitor on the medication cart that is usually parked in front of the button. The Administrator explained now there was a clear box over the button like you would find on a thermostat. Review of Policy revised 8/5/25 titled, Friendship Home Elopement/Wandering documented the purpose was to ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents. Adequate supervision will be provided to help prevent accidents or elopements. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol. Review of undated procedure titled, Staff Education: Responding to Elopement Alarms documented the purpose was to ensure all staff respond immediately and appropriately when an elopement alarm sounds (e.g. wander guard or door alarm). Every second counted to keep the residents safe. Licensed nursing staff should respond to the origin of the alarm if known and call code wander using the overhead page or other communication tools. CNA / direct care staff should stop current tasks and immediately begin search unless a resident would be left unattended in unsafe conditions.

Based on personnel document review, facility document review, staff interview, and policy review the facility failed to implement the abuse and neglect policy by not completing background checks prior to staff employment. The facility reported a census of 40 residents. Findings include: Review of background check for Staff E revealed the background check was completed 2/13/24. Review of an untitled document with staff phone number and hire dates provided by the facility revealed a hire date for Staff E of 11/30/23. During an interview 7/30/24 at 11:46 AM with the Administrator revealed that Staff E had worked at the facility prior to her being rehired 11/30/23. The Administrator further revealed she thinks that the background check got missed upon rehire and was completed again 2/13/24. The Administrator then revealed that her expectation would be for background checks to be completed prior to working at the facility. Review of a facility provided policy with a subject of background checks dated 1/29/21 documented: a. Background checks will be completed on all new hires per state regulation on the single contact repository (SING).

Based on facility document review, observations, staff interview and policy review the facility failed to ensure that residents were served the food as listed on the menu, and failed to accurately measure the pureed food items for 3 of 3 residents reviewed. The facility reported a census of 40 residents. Findings include: According to the Week at a Glance Menu for Week 5; the lunch meal on 7/30/24 included ham loaf with pineapple sauce, potato, broccoli, bread/margarine, ice cream and milk. The pureed meal would include pureed bread with margarine. On 7/30/24 at 10:00 AM Staff A, Dietary Aide/Cook, prepared the broccoli for 3 residents that required pureed foods. She used a small hand-held mixer and said that she had added water earlier to aide in the pureeing process. After getting the vegetable to the desired consistency, she put it in the dish, covered it with tin foil and put it in the oven. Staff A then got the ham loaf out of the oven and said she had 6 mechanical soft and 3 pureed to prepare. She dished out 7 servings for mechanical soft and put that in the heating dish. She then took 4 servings of the ham loaf and placed them in the mixer. As she was mixing, she added water several times. Without measuring the volume, she put the pureed meat in the heating dish. When asked about measuring for volume so she could determine the size of serving scoop, she said that she just uses a 4-ounce (oz) scoop for the vegetables and for the meats. She said she had worked in many different places and she did not see the need to measure the volume or use the chart to determine scoop size. Staff A failed to put any bread in the pureed items, and she did not puree bread with margarine. On 7/30/24 at 11:20 AM, Staff A failed to include bread and margarine on the plates for residents in the Chronic Confusion or Dementing Illness (CCDI) unit. According to the Resident Matrix, the CCDI unit included 13 residents. On 7/30/24, none of the CCDI residents were served bread with margarine. On 7/30/24 at 11:00 AM, the Dietary Manager (DM) said that she taught staff to prepare one more serving than needed when making pureed foods. She said that they should measure the volume after pureeing to figure out the serving size. The DM said that she had talked to Staff A about using water for the pureed foods and that they were taught to use thinning fluids with nutritional value rather than water. The DM said that Staff A should have followed the menus and serve bread when it's on the menu. According to the [NAME] Brother's Puree Process (posted on the refrigerator in the kitchen): Step 1. Measure out desired number of servings into container for pureeing. Step 2. Puree the food. Step 3. Add any necessary thickener or appropriate liquid of nutrition value and flavor to obtain desired consistency. Step 4. Measure the total volume of the food after it is pureed. Step 5. Divide the total volume o the pureed food by the original number of portions. (See Puree Scoop Chart). Step 6. Heat or chill the pureed food to safe serving temperatures. According to the undated facility policy titled: Food and Nutrition Services. The dining experience would enhance each individuals quality of life through person centered dining: providing nourishing, palatable, and attractive meals that meet the individual's daily nutritional needs and food and beverage preferences.

Based on observations, staff interviews and policy review the facility failed to ensure that open containers of food had been dated. Staff failed to provide safe hand hygiene procedures during meal service. The facility reported a census of 40 residents. Findings include: In an observation of the walk-in refrigerator with the Dietary Manager (DM) on 7/29/24 at 9:45 AM, it was discovered that there were three large bags of shredded cheese and a bag of shredded lettuce that had been opened and half-used. The bags did not have a date written on them to indicate when they were opened. At the front of the walk-in, there was a tray cart on wheels that contained a tray of individual cups of pudding, uncovered and undated. On the top shelf, there was an opened bag of cubed cheese that had been opened, with no open date. As the DM lifted the bag, it was revealed to have some mold spots on a couple cheese cubes at on the bottom of the bag. The DM said that she expected staff to enter the open date on the bags and to pay attention to outdates. In the freezer, an open bag of what looked to be cubed meat was found on the bottom shelf. The DM said that it was cubed turkey and she acknowledged that there was no open date on the package. The walk-in freezer also had 4 bags of frozen vegetables on the top shelf, opened and not dated. She grabbed all of them to dispose of them. On 7/30/24 at 10:00 AM, in an observation of the pureed food preparation, Staff A, Dietary Aide got a ham loaf out of the oven and placed it on the counter. She failed to conduct hand hygiene. The meat had been cooking on a sheet of parchment paper and had stuck to the paper. She had difficulty getting it off the paper so she used her bare hand to pull it off and placed it in the mixer. In an observation of the lunch meal service on 7/30/24 at 11:20 AM, Staff A put a glove on her left hand, she grabbed the bag of bread to open it, and with the same gloved hand grabbed a piece of bread out of the bread bag, held the bread with that hand, buttered it and placed it on a resident's plate. She then removed the glove. Staff A performed the same process at least 4 more times through the meal services. Staff A grabbed a stack of cheese slices from the refrigerator with a glove on her left hand only, with both hands she unwrapped the plastic wrap and then reached in and grabbed a slice of cheese. Throughout the meal services, Staff A touched different surfaces and wiped her hands on her scrub top. She completed serving at 11:45 AM and failed to conduct hand hygiene throughout the entire serving. On 7/30/24 at 11:00 AM, the DM said that she found glove use to be a detriment in the kitchen because staff tended to think they can touch anything with the gloved hands and then touch the food. She preferred that staff would use tongs or unwrap the food first and then use a clean glove to touch food items. An undated facility policy titled: Food and Nutrition Services; Bare Hand Contact with Food and Use of Plastic Gloves. Gloved hands were considered a food contact surface that could get contaminated or soiled. If used, single use gloves should be used for only one task, used for no other purpose and discarded when damaged or soiled. Hands were to be washed when entering the kitchen and before putting on the single use gloves and after removing single use gloves. An undated facility policy titled: Food and Nutrition Services undated, indicated that when a food package was opened, the food item should be marked to indicate the open date. This dated would be used to determine when to discard the food. Leftovers were to be used within 72 hours or discarded.

Based on clinical document review, staff interview, and policy review the facility failed to have the correct documentation of residents choice related to advanced directives for 1 of 5 residents (Resident #27) reviewed. The facility reported a census of 40 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #27 dated [DATE] revealed Resident #27 was admitted to the facility [DATE]. Review of a document titled, Iowa Physician Orders for Scope of Treatment (IPOST) dated [DATE] revealed there was a selection for Cardiopulmonary Resuscitation (CPR). This document further revealed the IPOST was signed by the Physician and Resident #27 ' s representative. Review of the Electronic Health Records (EHR) on [DATE] revealed a document titled, Clinical Physician Orders that revealed an order for Full Code status with a start date of [DATE]. Review of Resident #27 ' s Care Plan with a revision date of [DATE] revealed that Resident 27 ' s family requested DNR status. During an interview [DATE] at 8:15 AM Staff D revealed she would look in the front of the resident's chart for code status. Staff D further revealed that if a resident is a full code status there would be a heart above the bed in the resident ' s room. Staff D then revealed that Resident # 27 does not have a heart sticker above her bed. During an interview [DATE] at 9:02 AM with the Director of Nursing (DON) revealed that her expectation would be for the IPOST and the physician orders to match as to code status. Review of a facility provided policy titled, Advanced Directives dated ,d+[DATE] documented: a. Review all advance directives / IPOST to determine if there are any apparent omissions or inconsistencies so they may be cleared up with the resident.

Based on observation, staff interview, and policy review, the facility failed to provide food served by a method to maintain a safe and appetizing temperature. The facility reported a census of 43. Findings include: During a continuous observation on 11/7/23 beginning at 11:15 AM, Staff A, Dietary Cook (DC), obtained the temperatures of 10 menu items prior to serving residents lunch. The temperature of the pureed coleslaw measured 50.2 degrees Fahrenheit (deg F). Staff A covered the pureed coleslaw and placed it in the refrigerator. All other menu items' temperatures were within required range. At 11:30 AM, Staff A removed the pureed coleslaw from the refrigerator and check the temperature which measured 49.2 deg F. She stated it would just have to be written up. It was served to the resident at that temperature. At 11:55 AM, Staff A took the temperatures of the remaining menu items. Observed 3 menu items outside of the acceptable holding temperature: a. French Fries - post-serving temperature of 131.1 deg F b. Carrots - post-serving temperature of 107.4 deg F c. Coleslaw - post-serving temperature of 42 deg F. At 12:00 AM, Staff A reported that due to the heat level in the serving area, they had difficulty with maintaining the cold items. An undated policy titled General HACCP Guidelines for Food Safety instructed that hot holding food temperatures should be above 135 deg F; otherwise, reheat to 165 deg F for a minimum of 15 seconds. An undated policy titled Handling Cold Foods for Tray Line indicated cold food items should be chilled to less than or equal to 41 deg F and temperatures will be taken halfway through service to assure foods' temperature is maintained less than or equal to 41 deg F. On 11/8/23 at 9:50 AM, the Dietary Manager stated they expected the staff to follow the policy for food safety.

Based on observation, document review, staff interview, and policy review the facility failed to store food and follow proper sanitation to prevent cross contamination and the spread of illness in accordance with professional standards. The facility reported a census of 43 residents. Findings include: 1. An initial kitchen tour on 11/6/23 at 10:15 AM - 10:45 AM revealed: a. Walk in refrigerator had items open without open dates that included a bag of toffee bites, a bag of sliced American cheese, a bag of shredded parmesan cheese, a bag of cheddar cheese, a bag of mixed vegetables, a bag of carrots, a bag of lettuce, and a 20 oz. bottle of soda pop. b. Dry storage had items open without open dates that included a 25 lbs. bag of rice, 1 gallon of syrup, a bag of croutons, a bag of crispy onions, 2 bags of dry noodles, a bag of spaghetti noodles, and a bag of crushed crackers. c. Walk in freezer had items open without open dates that included a bag of frozen noodles, a bag of mixed vegetables, a bag of corn, a bag of raspberries, a bag of diced green peppers, a bag of carrots, and a bag of cubed potatoes. During the initial kitchen tour observed a printed sign hung outside of the walk-in refrigerator that directed to cover, label, and date all items. Review of undated document titled, General Food Preparation and Handling revealed leftovers must be dated, labeled, covered, cooled and stored in a refrigerator. On 10/6/23 at 10:47 AM the Certified Dietary Manager (CDM) stated that all open food items should be dated when opened. The CDM stated that all open items without a date would be discarded at that time. On 11/9/23 at 12:58 PM the Administrator stated she expected the staff to follow the outlined materials and education provided to them in the policy and procedures. The Administrator stated open items of food should have an open date when opened. 47079 2. On 11/7/23 at 9:43 AM, observed Staff A, Dietary Cook (DA), clean the food preparation counter with a detergent soaked rag, then they wiped the same counter with a rag soaked in a sanitizing bucket. She performed a sanitizing solution check. She took one strip from the Hydrion QT-40 sanitizer test strip container and dipped it into the sanitizing solution. She removed the strip and noted the strip was orange. She compared it to the manufacturer's strip guide and the sanitizer concentration measured 0 parts-per-million (PPM). Staff A stated that the sanitizing solution had not been changed since the early morning. She changed the sanitizing solution but did not sanitize the food preparation counter. She then placed two plastic serving bowls on the food preparation counter and placed a serving scoop inside one bowl. The bowl turned on its side and she picked up the bowl and used it for a resident's pureed cole slaw. On 11/7/23 at 11:25 AM, Staff A used a pizza cutter to divide sandwiches and placed the cutter on the counter attached to the front of the steam table. Staff A's shirt rubbed against the blade of the cutter 4 times while she plated residents' food. She picked up the cutter and used it to finish cutting sandwiches. At 11:40 AM, Staff A grabbed a can of tomato soup with a gloved left hand and stabilized it while she opened it with the ungloved right hand. She poured the soup into a bowl and placed it in the microwave with her right hand. She returned to the steam table with the gloved left hand and placed a turkey sandwich on a resident's plate. Staff A did not perform hand hygiene or change the glove. At 11:45 AM, observed Staff A's shirt in direct contact with the top surface of the counter attached to the front of the steam table. Staff A placed a sandwich directly on the counter and used the pizza cutter to divide the sandwich. She picked up the two portions of the sandwich and placed them on the resident's plate. The counter had not been sanitized between the staff member's shirt and touching the sandwich. At 11:34 AM, Staff B, Dietary Aide (DA) served a resident tray in the dining room with ungloved hands and then returned to the serving counter. Staff B picked up a resident's plate and grabbed a gelatin bowl from the cold food holding table. She placed the bowl on the resident's plate and the bowl slid into the resident's cole slaw. At 11:50 AM, Staff A picked up hot plates with a clean dish towel and placed the towel on the counter where her shirt frequently contacted. No one sanitized the counter during the meal service. On 11/8/23 at 9:50 AM, the Certified Dietary Manager stated they expected the staff to follow the facility policy for kitchen safety and sanitation. An undated policy titled Food Safety and Sanitation directed employees to wash their hands just before they start to work in the kitchen and after smoking, sneezing, using the restroom, handling poisonous compounds or dirty dishes, and touching face, hair, other people or surfaces or items with potential for contamination.

THE FOLLOWING DEFICIENCIES RELATE TO THE IOWA ADMINISTRATIVE CODE (IAC) CHAPTER 58. VA State Rule 58.12(1)l Within 30 days of a resident's admission to a health care facility receiving reimbursement through the medical assistance program under Iowa Code chapter 249 A, the facility shall ask the resident or the resident's personal representative whether the resident is a veteran and shall document the response. If the facility determines that the resident is a veteran, the facility shall report the resident's name along with the names of the resident's spouse and any dependent children, as well as the name of the contact person for this information, to the Iowa department of veteran's affairs. Where appropriate, the facility first shall seek reimbursement from the identified payor source before seeking reimbursement from the medical assistance program established under Iowa Code chapter 249A. This REQUIREMENT is not met as evidenced by: Based on document review, and staff interview, the facility failed to inquire about Veterans Affairs (VA) eligibility within 30 days of admission for 3 of 3 residents reviewed (Residents #38, #40, and #41). Findings include: On 11/6/23, the Administrator reported they completed a self-report due to the facility's missed VA eligibility registry entries. 1. Resident #38's Minimum Data Set (MDS) assessment dated [DATE] listed an admitted [DATE]. The MDS identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. Resident #38's Admission Application reflected her spouse as a veteran on 5/8/23. 2. The admission MDS for Resident #40 dated 9/14/23 revealed an admitted [DATE] and a BIMS score of 10 out of 15, indicating moderately impaired cognition. Resident #40 Admission Application reflected her spouse as a veteran on 7/6/23. 3. The admission MDS for Resident #41 dated 10/7/23 revealed an admitted [DATE] and a BIMS score of 15 out of 15, indicating completely intact cognition. Resident #41's undated Admission Application reflected her spouse as a veteran. On 11/8/23 at 3:30 PM, the Administrator explained that they hired and trained Staff B in January 2023. She stated that the trainer did not ensure Staff B thoroughly understood the VA eligibility process. The Administrator reported that the resident self-identifies their VA eligibility via a self-identification on the resident's admission paperwork. She stated a record audit on 11/6/23 of all residents admitted since July 2022 revealed 7 residents who self-identified as VA eligible who were not added to the registry. Of the 7 residents, she stated 2 were ineligible due to not meeting marriage requirements and 1 passed away on hospice care within 72 hours after facility admission. She stated 1 of the 4 remaining self-identified residents (Resident #40) utilized a VA medication benefit but the facility did not add them to the registry. She stated almost all the VA eligible residents only used the medication VA benefit but recently began using another medication benefit source due to supplier problems. An undated document titled IDVA Resident Eligibility (Iowa Department of Veteran's Affairs) indicated residents who confirmed positive veteran status on the admission form were to be added to the IDVA Resident Eligibility.

Based on record review and staff interview, the facility failed to ensure the required members attended the Quality Assessment and Assurance committee (QAA). The required members included: 1. The Nursing Home Administer (NHA) or representative; 2. Director of Nursing (DON); 3. The Medical Director (MD) or representative; 4. The Infection Preventionist; and 5. two other members of the facility's staff present on a minimum of a quarterly basis. The facility reported a census of 43. Findings include: A facility document titled QAA Committee Minutes, dated 12/6/22 for the 4th quarter lacked attendance signatures for the Infection Preventionist. A facility document titled QAA Committee Minutes, dated 3/2/23 for the quarter December 2022 - February 2023 lacked attendance signatures for the Infection Preventionist. A facility document titled QAA Committee Minutes, dated 5/18/23 for quarter March 2023 - May 18, 2023 lacked attendance signatures for the Infection Preventionist and two (2) other staff members. A facility document titled QAA Committee Minutes, dated 8/10/23 for quarter 5/18/23 - 8/17/23 lacked attendance signatures for the Administrator or designee. It indicated the Director of Nursing (DON) also served as the facilitator. On 11/8/23 at 2:59 PM, the Administrator reported that she did not know the complete list of required QAA meeting attendees until the 11/8/23 interview. She also stated the Minimum Data Set Coordinator (MDS Coordinator) should have been her designee. An undated document titled QAA Committee Members indicated the committee members were the Medical Director (or her representative), Administrator, Director of Nursing (DON), Infection Preventionist (IP), Consultant Pharmacist, Registered Dietician, Therapy Representative, Social Services, Maintenance/Environmental, Dietary, and Activities.

Based on observation, record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing suprapubic catheter cares for 1 of 2 residents (Resident #26). Findings include: Resident #26's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Resident #26 had an indwelling catheter. The MDS included diagnoses of obstructive uropathy, diabetes mellitus, and benign prostatic hyperplasia with lower urinary tract symptoms. During a continuous observation 11/8/23 at 7:15 AM observed Staff D, Certified Nurse's Aide (CNA), and Staff E, CNA, perform catheter care on Resident #26. During Resident #26's catheter care, Staff D got a new unpackaged catheter drainage bag, placed it on the bed sheet without a barrier, immediately picked it up, and asked Staff E to obtain a new barrier. Staff E then placed a new barrier down and they placed the previously new contaminated drainage bag onto the clean barrier. Staff D disconnected the previous catheter drainage bag and tubing, cleaned the connection port of the catheter with an alcohol swab and connected the new drainage bag. Staff D then placed a drainage sponge to the suprapubic catheter site and doffed gloves. Staff D then asked Staff E to get tape for the drainage sponge. Staff D donned new gloves and put Resident #26's underwear, pants, and shoes on. Staff D removed her gloves as Staff E returned with the tape. Staff D applied the tape with no gloves onto the top of the catheter drainage sponge to the skin. Afterwards, Staff D and Staff E assisted Resident #26 with pulling up his pants. During an interview 11/8/23 at 7:32 AM Staff D reported they always required a barrier pad for peri rags and catheter care. During an interview 11/8/23 at 9:18 AM the Director of Nursing (DON) explained that she expected staff to have a barrier placed, wear gloves at appropriate times for catheter care, and while applying tape to drainage sponges. Review of a facility provided policy titled, Urinary Catheter Care updated 11/3/23 instructed to: a. Clean the ends of the drainage bag tubing and catheter with an alcohol wipe and friction. Also, clean the tubing end of the replacement bag (if it is not a new sterile bag). Review of another facility provided policy titled, Suprapubic Cath Care with an updated date of 9/7/23, directed to: a. Apply dressing on top and secure with adhesive tape. b. Remove gloves, wash hands, thank Resident.

Based on observation, interview with staff and family, clinical record review and facility policy review the facility failed to provide adequate supervision to prevent accidents for 2 of 6 residents reviewed (Resident #6 and #1). Resident #6 had periods of restlessness and would attempt to get out of bed on his own. He had many falls and it was discovered that the fall mat next to his bed was a risk hazard. The fall mat was displaced upon one unwitnessed fall when he sustained a major injury. Resident #1 had a fall while on the fall mat next to her bed so the mat had been removed. Staff continued to put the mat next to her bed after the intervention had been discontinued. The facility reported a census of 43 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #6 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating a severe cognitive deficit. The MDS documented at that time, he was independent with bed mobility, transfers and walking in his room. The MDS documented he had diagnoses to incude anxiety disorder and vascular dementia. The MDS documented he wandered daily and had fallen. An MDS dated [DATE] documented Resident #6 had a change in condition and required extensive assistance with transfers, walking and toileting. The MDS documented he had internal bleeding and had fallen since last assessment. According to the Event Report dated 3/13/23 at 10:45 PM Resident #8 found sitting on the floor leaning back on the recliner next to his bed. Observed a golf ball sized raised and bleeding hematoma above his right eye and copious amounts of bright red blood around the resident on the floor and on the resident. The resident complained of a massive headache. Staff observed the resident asleep on the couch 15 minutes prior to being found on the floor. Family updated and resident sent out to the emergency room . The Emergency Department (ED) Notes dated 3/13/23 at 11:40 PM documented Resident #6 had a small traumatic subarachnoid hemorrhage to right temporal sulci. The ED Note dated 3/14/23 documented the ED does not accept intercranial bleeds and the resident was to be transferred to a local hospital. On 7/17/23 at 4:45 PM Certified Nurse Aide (CNA), Staff Q, stated she found the resident on 3/13/23 on the floor by the recliner. She said that he had been pacing a lot through the night, it was on the overnight shift and there was not a fall mat next to the bed at that time. On 7/18/23 at 7:30 AM Registered Nurse (RN) Staff A, stated the resident was sent back to the facility the next day (3/14/23) and he was not stable. When he returned, he required assistance with transfers but he continued to try to get up by himself because this was what he would do before. The Progress Notes dated 3/15/23 at 6:06 AM, documented staff found Resident #6 on the floor mat next to his bed on his right side at 5:25 AM. No injuries and denied pain at time of assessment. Resident toileted at approximately 3:30 AM and had been continent of bladder. The resident stated he was trying to get up and get a glass of water. The Care Plan for Resident #6 documented an intervention dated 3/14/23 to lower the bed and put a mattress on the floor by the bed. This intervention had been crossed through and noted that it was discontinued on 3/16/23, the changes were not timed. The Progress Notes dated 3/16/23 at 10:37 PM documented the resident had been assisted to bed by staff and exited the room at 8:49 PM. The residents call light went off at 9:01 PM and when staff entered the room found him laying on the floor, extended away from the bed on the bedside mat on his right side. It appeared as though the resident may have attempted to get out of bed and tripped over the mat edge along side of the bed and assisted in the fall. Significant bruise noted to right brow extending down to right cheekbone, purple in color and a large lump on the right frontal forehead. Resident stated he had pain in that area. Right eye swollen shut and swelling around the socket. The Event Report dated 3/16/23 at 9:01 PM showed that Resident #6 had been found on the floor with his feet under the bed. It appeared that the resident tried to get up on his own and may have tripped on the edge of the fall mat. The ED Provider Note dated 3/16/23 at 10:14 PM documented the resident presented to the ED after a fall onto his face with facial trauma and pupils 1 mm dialed bilateral. The results from a head CT documented the provider received a critical alert from radiology that the resident had sustained a traumatic hygroma (collection of cerebrospinal fluid located under [NAME] membrane of the brain) with mass effect. A Major Injury Determination form with physician signed date 3/17/23 at 3:31 AM indicated that the injury was determined to be a major injury traumatic subdural hygroma. On 7/17/23 at 3:40 PM Licensed Practical Nurse (LPN), Staff C, stated she was working on 3/16/23 when Resident #6 had a fall. She stated the resident had erratic behaviors and extreme outbursts for several days. Earlier in the day, there had been 2 aides and a nurse and the resident had required one on one supervision. He had been combative and even threw his phone across the room. At about 8:45 PM they tried putting him to bed, he had a call light touch pad in his bed that would go off if he moved around in bed and there was a floor mat next to the bed. It was about 20 minutes after they had put him to bed and his call light was going off so she sent the CNA back to check on him and that was when they found him on the floor. She stated his torso and arms were off the mat, and the bottom half of his body was on the mat. She stated she thought because of the position of his body, he would have been standing on the mat. She stated it didn't look like the mat had moved. On 7/18/23 at 9:02 CNA, Staff D stated she was the nurse on the overnight shift when the resident fell on [DATE]. She stated she found him on his right side on the fall mat. She stated that his bed had been moved to the dining room area by the nurse's station to keep a closer eye on him, it was just her and a CNA, and they had gone to help with another resident. When they came back to the dining room area, he was on the floor. She stated the fall mat had shifted, but his entire body was on the mat. On 7/18/23 at 1:20 PM the Director of Nursing (DON) and Care Planning (CP) nurse said that after the 3/13/23 fall, they requested a physical therapy evaluation. They acknowledged that on 3/14/23 there was a CP intervention to put a fall mat next to the bed. The CP nurse stated she hadn't added that intervention but someone must've thought it was a good idea. The DON agreed that since he was independent with transfers and was up and down a lot this wasn't a good intervention. She stated that the team must've thought that it wasn't such a good idea because it had been discontinued on 3/16/23. Since the intervention had not been timed, she didn't know for sure when it had been discontinued, but assumed that it would have been during business hours, which would have been before the 3/16/23 fall. She acknowledged that the mat should not have been next to his bed on 3/16/23. 2) According to the MDS dated [DATE], Resident #1 had a BIMS score of 0 out of 15 indicating severe cognitive deficit. The MDS documented she required extensive assistance with the help of 2 staff for bed mobility, transfers, walking and toileting. The MDS documented she was not steady, and only able to stabilize with staff assistance for all transfers and walking. The MDS documented she had diagnoses to include dementia. The MDS documented she had two or more falls with no injury since the last assessment and 2 or more falls with injury since the last assessment. The Care Plan for Resident #1 dated 9/16/22 documented a high risk for falls related to advanced dementia, wandering and history of falls. The Care Plan documented extensive assist of 1 or 2 with transfers. The Care Plan directed staff with the following interventions: a. On 3/6/23 the resident had a fall in her room with injury, slid from edge of the bed. Staff lowered the bed to the floor with fall mat next to the bed. b. On 3/17/23 recliner removed from the room and replaced with one that is more stable. c. On 3/24/23 direction to staff to check the resident every hour when she was in bed. d. On 5/2/23 fall with physical therapy (PT) and occupational therapy (OT) referral (head injury). e. On 5/17/23 fall with removal of blue mat at bedside as mat slides. f. On 6/19/23 fall with staff education to have all supplies at bedside prior to starting cares. g. On 6/20/23 sit to stand for transfers and grab bars removed from toilet. The Event Report dated 5/17/23 at 9:00 PM documented Resident #1 found lying on her stomach in front of the loveseat in her room. The report documented the bed was slid away, mat tested by nurse and easily slides when foot placed on mat. The report documented the Care Plan reviewed and removed the mat beside the bed as the mat slides when feet placed on it. The Event Report dated 6/19/23 at 8:28 PM documented Resident #1 fell head first onto the floor while an aide assisted resident to bed. The report documented the bed lowered with mat next to the bed. Staff sent resident out to the hospital due to changes in neuro exam and found to have a small subdural hematoma. Resident returned to the facility. On 7/19/23 at 2:37 PM, Registered Nurse (RN), Staff P stated she just noticed that the fall mat had been taken out of the room of Resident #1. On 7/19/23 at 3:39 PM CNA, Staff I, stated Resident #1 required assistance of two. She stated that she had a mat next to her bed up until a couple of days previously, and they had been using it. On 7/19/23 at 3:55 PM LPN, Staff F stated that she was the nurse on duty when Resident #1 fell on [DATE]. She stated she removed the mat after that fall, because it appeared to have slipped out of place. On 7/20/23 at 8:30 CNA. Staff E, stated the resident had a fall on 6/19 and the fall mat was not on the floor at the time, but it was still in the room and they were using it at night. She stated the resident would try to get up by herself and was very unsteady. On 7/20/23 at 10:44 AM the DON stated the floor mat should not have been used after it was discontinued on 5/17/23. A falls policy dated 9/22/21 documented the purpose of the policy was to ensure that if/when a resident falls a thorough assessment would be completed and appropriate documentation with interventions identified to prevent future falls. Determine potential causes for the fall and additional teaching and /or interventions to the plan of care to prevent another fall from occurring.

Based on review of the Facility Reported Incident (FRI), staff interviews, and clinical record review, the facility failed to implement a bedside fall mat to prevent an injury for one of three residents reviewed for falls (Resident #192). This failure resulted in harm, a subarachnoid hemorrhage (brain bleed), when Resident #192 fell from the bed onto the floor. The facility reported a census of 42 residents. Findings include: Review of the Face Sheet, located in the electronic medical record (EMR), revealed Resident #192 was admitted to the facility on [DATE] with diagnoses that included cerebral ischemia (stroke) and [CONDITION(S)] (poor circulation). Resident #192's Minimum Data Set (MDS) assessment dated [DATE] listed a Brief Interview of Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive impairment. The MDS indicated that Resident #192 required extensive assistance of two staff with bed mobility, transfers, and toilet use. The Care Plan Focus dated 3/3/21 documented that Resident #192 had a history of falls related to joint pain, medications and dementia. The Care Plan included the following fall intervention created on 10/14/19 directed to keep Resident #192's bed to be in the lowest position with the brakes locked and a floor mat next to her bed. The Event Report, provided by the facility dated 6/11/22, documented that at the time of the fall, Resident #192 lacked the use of adaptive equipment. The Major Injury Determination Form signed by the Advanced Registered Nurse Practitioner (ARNP) on 6/13/22 recorded that Resident #192 fell on [DATE] at 3:15 AM and received a subarachnoid hemorrhage. Resident #192's previous functional ability as mechanical lift assist for transfers, assist of one with all activities of daily living (ADLs) with advanced dementia. The ARNP indicated that after reviewing the circumstances, injury, and prognosis of the patient, they felt the injury sustained was a major injury pursuant to 481 Iowa Administrative Code 50.7(1)(a)(3). The FRI provided by the State of Iowa, Resident #192 fell on [DATE] which resulted in a brain bleed. The intake indicated that the agency Certified Nursing Assistant (CNA) failed to put the fall mat at Resident #192's bedside. When staff found Resident #192 on the floor, they noted the bed in low position without a fall mat. Resident #192 observed with a hematoma and bleeding to her forehead. The CNA and Registered Nurse (RN) applied pressure. The staff called for an ambulance to transport Resident #192 to the emergency room (ER). The hospital updated the facility that Resident #192's computerized tomography (CT) scan showed a brain bleed. After twelve hours Resident #192 returned to the facility in stable condition with seven sutures to her forehead. On 6/30/22 at 4:49 PM the Administrator reported that she remembered the incident well. On the day of the fall an agency CNA and an agency RN worked with Resident #192. The CNA did not put the fall mat beside Resident #192's bed and when she fell out of her bed she hit her head on the floor. The RN is the direct supervisor over the CNA. The RN and CNA were not available for interview. On 6/30/22 at 5:11 PM the Director of Nursing (DON) revealed that she provided the education for the agency nurse and CNA on Care Plans and where to find them after Resident #192 sustained her fall and injury. The DON stated she expected that Care Plans be followed, as that directed how to care for the resident's needs. The agency staff sometime miss things and this could have been prevented.

Based on observation, record review and interviews, the facility failed to plan for and direct nursing care and services to ensure Resident #1 received adequate supervision from hazards for one (1) of five (5) residents. Resident #1 sustained a hip fracture, bilateral subdural hematomas, a head contusion & facial injuries when he/she stood up and fell forward. Although the resident ' s care plan directed staff to use an alarm at all times, staff interviews identified Resident #1 had been known to remove his/her alarm. The director of nursing and or the facility failed to plan for and direct nursing services to ensure Resident #1 ' s received adequate interventions. The facility identified a census of 56 residents. Findings include: 1. According to the MDS (minimum data set) assessment dated [DATE] Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident with a Brief Interview for Mental Status with a summary score of 2, which indicated severe impairment. According to the MDS the resident required extensive assistance with bed mobility, transfers and toileting. The Fall Risk Evaluation dated 10/4/11 revealed Resident #1 scored 18 which indicated he/she had a high risk for falls. A total score of 10 or above suggested the resident at high risk for falls. The care plan dated 10/24/11 directed staff to provide a personal alarm to the resident at all times due to wandering attempts and fall potential. The Skilled Nurse's Notes dated 10/7/11 at 7:30 PM documented the resident found on the floor in the lounge area. The note identified that the resident had taken the personal alarm off and tried to walk unassisted. The resident transferred to the emergency room for examination. Review of the Nurse's Notes dated 11/12/11 at 1:00 PM documented the resident got up to the bathroom by his/her self. The resident had unhooked the alarm and stood up. The CNA (certified nursing assistant) immediately at the resident's side. Review of the Nurse's Notes dated 11//18/11 at 8:00 PM revealed at 7:50 PM revealed staff saw the resident standing at the end of hall 5 by him/herself. Staff unable to get to the resident and the resident fell over and hit his/her head hard landing on the right side. The resident unconscious, the nose bleeding and the right arm hyperextended behind him/her. The resident remained unconscious approximately 3-4 minutes and then complained of right hip pain. The resident noted to guard the right hip and the resident's right foot externally rotated. A large hematoma noted to the right eye. At 7:55 PM emergency Medical Technicians arrived. The resident then transferred to the hospital for an evaluation and treatment. Review of the Incident/Unusual Occurrence Report dated 11/18/11 revealed at 7:50 PM Resident #1 fell at the end of hall 5. The resident fell over and hit his/her head hard landing on the right side. Staff noted that the resident unclipped the personal alarm with the safety pin still attached. The report identified the facility would now use a pressure alarm upon the resident ' s return from the hospital. Review of the Radiology Report dated 11/18/11 revealed the resident with the following findings: a. Subcapital right femoral neck fracture. b. Bifrontal contusion and subarachnoid blood with additions small bilateral subdural hematomas. c. High-attenuation blood in the right maxillary sinus with small amount in the right greater than left ethmoid sinuses. Marked right periorbital soft tissue swelling. During an interview with the DON on 12/12/11 at 9:30 a.m., she stated Resident #1 passed away following hip surgery. The DON stated Resident #1 started having difficulty with eating at the hospital and the feeding tube kept going into the resident ' s lung. Observation on 12/12/11 at 3:15 PM revealed the distance Resident #1 ambulated from the recliner to the point of fall measured at approximately 98 inches (8 foot 2 inches). During an interview with Staff B, LPN (Licensed Practical Nurse) on 11/23/11 at 11:30 AM, she stated that she worked the day the resident fell and the night shift had reported to her that the resident had been unfastening the alarm. Staff B indicated the night shift reported that they had put a safety pin on. She had seen the alarm in place that day but unaware if the alarm had been attached with a safety pin or the clip. During an interview with Staff A, LPN on 12/12/11 at 11:45 AM, she stated that she knew the resident had been taking off the alarm. Staff A learned of Resident #1 taking off the alarm in report the night before his/her fall. Staff A stated the safety alarm attached to the clip and then pinned to the resident ' s clothing. Staff A stated that safety pins used for other residents in the past if able to remove the alarm and she did not think the elderly had the dexterity to unlatch the safety pins. During an interview with Staff D, LPN on 12/12/11 at 1:30 PM, she reported she had never seen the resident take the alarm off but on the weekend prior to the fall, staff had reported to her that Resident #1 had taken it off and the alarm had been pinned to the resident with a safety pin. During an interview with Staff E, LPN on 12/12/11 at 10:00 AM, she stated that she worked as the charge nurse the night the resident fell . She had seen the resident approximately 10 minutes prior to the fall and assisted him/her with their snack and to settle back into the recliner. The resident had been leaning forward and she saw that the alarm had then been attached to his/her shoulder. Following the fall she noticed the alarm off the resident on the recliner and the clip attached to a safety pin. Staff E stated the safety pin was in a closed position. Staff E stated the CNA ' s then reported to her that the resident could take the alarm off. Staff E stated she did not know the resident could remove the alarm. During an interview with Staff C, CNA on 12/12/11 at 1:45 PM, she stated that she had been told the resident had been removing the alarm and instructed to use the safety pin. She had taken the resident to the rest room after supper and then walked him/her to the recliner and remembered pinning the alarm with a safety pin. During an interview with Staff F, CMA (certified nursing assistant) on 12/12/11 at 3:00 PM, she stated that she saw the resident fall in hallway 5. She had seen the resident earlier in the recliner with the alarm on. She also stated that she knew the resident could take off the alarm and staff had found open safety pins in bed with the resident on rounds so they knew he/she could take the safety pins off too. During further interview with the Director of Nursing on 12/12/11 at 3:40 PM, she stated that staff had used large diaper like safety pins for personal alarm if the resident's took the alarm clips off. She also stated that she did not necessarily remember the use of the safety pins for the resident. During an interview with the Assistant Director of Nursing on 12/12/11 at 3:50 PM, she stated that she was not aware that the resident took off the personal alarm. During an interview with the Director of Nursing on 11/23/11 at 9:45 AM, she reported she started educating staff to ensure they communicated to the charge nurse; or nurses are to inform the care plan coordinator when residents are removing alarms. The DON stated she ordered a new type of personal alarm to replace the clip alarm.