Every finding on record at Golden Age Care Center

Based on observation, record review, resident interview, staff interviews, and the facility policy, the facility failed to provide adequate supervision to prevent the elopement of Resident #25. The resident has a history of falling, behaviors of persistent exit seeking and a history of elopements at the facility without staff knowledge. On 6/23/26 at approximately 4:15 PM the resident was found outside on the front patio. The door alarms had not sounded and the staff were unaware she was outside. The staff implemented the intervention 1 on 1 as needed. On 6/24/26 at approximately 6:30 AM Resident #25 was found outside again. She was on the facility property walking toward a gravel road that led to a busy highway 50 feet away. The staff were unaware she had left the building and were not aware how she got out of the building for 1 of 4 residents reviewed for inadequate nursing supervision (Resident #25). This deficient practice resulted in an Immediate Jeopardy (IJ) to resident health and safety. The facility reported a census of 39 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/5/26 at 4:10 PM. The IJ began on 6/23/26 at approximately 4:00 PM, the day Resident #25 eloped from the facility and staff were not aware the resident out of the facility and then again eloped from the facility on 6/24/26 at approximately 6:30 AM and staff were not aware resident out of the facility. Facility staff removed the IJ on 8/6/26 through the following actions: Resident #25 was assessed on 8/6/26 for elopement risk. The intervention for the elopement that occurred on 6/23/26 was to monitor resident closely and keep within eyesight. The intervention for the elopement that occurred on 6/24/26 was to implement 1:1 supervision. She has not had an elopement since that date. She currently has 1:1 supervision effectively in place since 6/24/26 and has been accepted to another facility with a locked unit (finances pending). Resident #25 will remain on 1:1 supervision until she is discharged to a locked unit. All other residents were assessed for elopement risk on 8/6/26. Residents who are at high risk have a wanderguard in place and is functioning 8/6/26. Residents will be assessed upon admission, quarterly, annually, and with a change of condition. The policy for elopement/missing resident was reviewed on 8/6/26. An addendum will be added to the emergency action plan regarding the use of door alarms for employees to reference along with the existing emergency action plan of elopement that includes responding to door alarms. These are kept in the emergency action plan binder, and they are located at each nurses station. Each department has a copy of the emergency action plan binder as well. The emergency action plan will be updated annually with the facility assessment and as necessary with changes. All door alarms were tested on [DATE] and are functioning. Door alarms are checked for functioning daily by the housekeeping/designee. Resident wanderguards were tested on [DATE] for placement and function. Resident wanderguards are checked for placement and function daily by the nursing department. All employees were re-educated about the elopement policy, emergency action plans including elopement and use of door alarms as well as responding to door alarms on 8/6/26. Elopement drill was completed on 8/6/26 with 100% pass rate. Elopement drills will be completed monthly by Administrator/designee. The scope lowered from J to D at the time of the survey after ensuring the facility's alarms were in working condition and staff educated on alarms and the policy and procedures on elopements and missing residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated cognition intact. The MDS indicated medical diagnosis for Cerebrovascular accident (CVA), TIA, or stroke. The MDS revealed resident did not use a wander/elopement alarm. The MDS assessment dated [DATE] revealed Resident #25 scored a 9 out of 15 on the BIMS exam, which indicated cognition moderately impaired. The MDS indicated the resident needed supervision or touching assistance with walking 150 feet. The MDS revealed walking 10 feet on uneven surfaces was not attempted due to medical condition or safety concerns. The MDS revealed the resident took an antianxiety, antidepressant, opioid, anticoagulant, and anticonvulsant medications. The N Adv-Elopement Evaluation dated 5/26/26 at 12:42 PM revealed a score of 3. A score value of 1 or higher indicates Risk of Elopement. The Electronic Medical Record (EMR) revealed Physician Orders:a. Check patency of wander guard Q (every)shift: every shift for Prevention / Intervention dated 5/26/26The Care Plan revealed a focus area dated 6/3/26 for resident is an elopement risk/wanderer r/t (related to) Impaired safety awareness with anxiety and progression of cognitive impairments, She has eloped outside facility 2 times and continues to attempt to elope often walking fast to exits resident's main goal is to leave facility. The interventions dated 6/3/26 indicated to distract resident from wandering by offering pleasant diversions such as food, tv, books, music and assisting to activities that she likes; and wanderguard on left wrist for placement and working order every shift. The interventions dated 6/23/26 revealed to provide 1:1 monitoring as needed. The intervention dated 6/29/26 indicated resident with elopement on 6/23/26 all alarms and wander guards checked for working order and Elopement mitigation. The interventions dated 7/10/26 revealed elopement mitigation PIP (performance improvement project) was initiated again. 6/24/26 PIP was initiated again and all alarms were checked again and functioning properly, Resident placed on 1:1 care, referrals made for locked units; witnessed attempt elopement on 6/24/26 1:1 care continues and may be supervised while in lobby in eyes site by nursing staff and will remain until alternate placement is made or significant change in circumstances.The Care Plan revealed a focus area dated 6/3/26 for the resident at risk for falls as can be unsafe and run when she sees an exit at times, Resident with history of x2 fx's (fractures) in both arms The interventions dated 6/3/26 revealed to ensure that the resident is wearing appropriate footwear (bedroom slippers, black non-skid socks) when ambulating. The Behavior Note dated 6/5/26 at 10:09 PM, revealed resident attempted to leave out of the courtyard door twice between 6 and 9 pm this evening. Redirected by staff and verbally reminded not to go out the door without a staff member with her.The Incident Note dated 6/6/26 at 9:27 PM (late entry), revealed resident exhibited increased anxiety throughout the shift, making two attempts to exit through the Hall 1 door, stating she needed to go to court. Resident appeared tense and difficult to redirect. PRN (as needed) pain medication administered as ordered with positive effect. Following administration, resident became calmer, sat in a recliner in the common area, and napped after breakfast. No further exit-seeking behaviors were observed until approximately bedtime, when resident again appeared restless and tense. PRN oxycodone was administered as ordered, after which resident relaxed and remained seated in the recliner in the common area. Resident appears to demonstrate increased exit-seeking behaviors and anxiety when experiencing pain and may have difficulty effectively communicating pain needs to staff.The Health Status Note dated 6/10/26 at 2:45 PM (late entry), revealed was at nurses station and wanderguard alarm went off to north courtyard and this RN (Registered Nurse) went and found resident had went out the door and was headed down the sidewalk towards gazebo and stated I need to get off this property. Gently redirected resident back into building and she sat in recliner.The Health Status Note dated 6/14/26 at 1:53 PM, revealed resident began pacing the facility at approximately 7:20 AM and was observed looking for a way to leave the building, stating she needed to go to court in Missouri. Staff attempted to reorient the resident, informing her that it was Sunday and that she was currently in Iowa. Resident refused reorientation and continued expressing the desire to leave. Shortly afterward, resident exited through the south lobby door but immediately returned inside, stating that it was cold outside. Approximately 10-15 minutes later, resident again exited through the south lobby door. [staff name redacted] followed resident outside and maintained continuous visual supervision. Resident was never out of staff's sight during either incident. Approximately 15 minutes later, resident attempted to exit through the north lobby door but did not leave the building and was easily redirected to the dining hall for breakfast. A few minutes later, resident made another attempt to leave via the back door. Staff remained in close proximity and successfully redirected resident back to her seat. During frequent visual checks, staff observed that resident had removed her sweater. Staff promptly approached resident and assisted her with putting the sweater back on. Resident was instructed to keep her sweater on while in the dining room due to the presence of other residents.At approximately 11:45 AM, resident attempted to exit through the front door but was successfully redirected to the dining hall for lunch, where she sat down at her usual place. Resident remained under frequent observation throughout the shift.The Incident Note dated 6/23/26 at 4:15 PM (late entry), revealed alerted per staff that we had an elopement occurred and resident found outside on front porch just sitting in a chair. Alarms did not sound as we had several visitors at this time and potentially could have walked out with them. Did check fencing in north courtyard and resident unable to get through any part of the fence. No injures noted and placed in recliner and then taken to evening meal.The Health Status Note dated 6/23/26 at 5:10 PM, revealed Health Status Updated Dr. (doctor) [name redacted] that resident got out of building unnoticed and no alarms went off. Found sitting on front porch. Took two staff to encourage her to return inside. Wanderguard in place on her ankle. Sister [name redacted] updated on the occurrence also and voiced understanding.The Incident Note dated 6/24/26 at 7:30 AM (late entry), revealed resident was discovered on lawn near gravel road beside building by night nurse as she was leaving for day. Resident coaxed back into building Resident sat quietly in chair. At 7:30 AM then attempted to leave building via the back exit Resident followed et (and) coaxed back into building never lost sight of resident ADON (Assistant Director of Nursing) notified et one on one care initiated. The Incident Note dated 6/24/26 at 9;25 AM (late entry), revealed Dr. (doctor) [name redacted] made aware at this time that she had another elopement and found off grounds but still near facility and that checking into locked unit for her safety.The Self Report dated 6/24/26 at 1:43 PM revealed the following information:a. Incident Summary: On 6/23/26 at approximately 5:15 PM, the Administrator informed a resident who at risk for elopement had gotten out the front door and was found seated in the covered patio area. On 6/24/26 at approximately 6:15 AM and 7:45 PM, resident had gone out back door used by staff. The first incident Resident #25 was located right off property grounds by a gravel street. The second incident Resident #25 was immediately followed and brought back inside. b. Corrective Action Description: Resident was immediately checked for injuries, provided reassurance and taken inside for supper. All staff was reminded on the need to keep her within eye sight. All wanderguards monitors were checked to ensure they are working and batteries are not nearing expiration. All wanderguard sensors were checked in two ways, one with device in a staff's shoe, and one while holding it in their hand. It was noted that not all sensors triggered when the resident was wearing the device on their ankle. An additional device was placed on her wrist. All at risk residents were checked to ensure they had a device on their wrists. This morning, the Administrator instructed nursing staff Resident #25 was on 1:1 supervision until placement can be secured in a more appropriate setting. The Timeline of Events signed by Administrator on 6/29/26 revealed the following events:a. 6/23/26 at 3:30 PM- resident observed sitting in recliner in the main common area by multiple staff, including the Administrator. At approximately 4:00 PM, Resident #25 no longer present in the common area. Staff K, Licensed Practical Nurse (LPN) immediately checked Resident #25 room and nearby resident's room and unable to locate her. Staff K then notified Staff I, LPN and a facility wide search initiated. Staff S, previous Director of Nursing (DON) then notified. At approximately 4:15 PM, Resident #25 observed sitting on the bench outside the facility's main entrance, and safety escorted back into the building. b. 6/24/26 at approximately 6:20 AM- Resident #25 observed sitting in the recliner in the facility's common area. After completing shift report and controlled substance counts, Staff L, Registered Nurse (RN) clocked out and exited the facility through the main entrance. While leaving the property, Staff L observed Resident #25 near the corner of the facility assisted living unit preparing to step into the parking lot. Staff L immediately stopped her vehicle, placed it in park, exited the vehicle, and ran to Resident #25. Staff L telephoned the facility to notify staff of Resident #25 location and calmly escorted Resident #25 towards the main entrance. Due to repeated exit-seeking behaviors, one-to-one supervision was initiated immediately. The Witness Statement dated 6/23/26 from Staff I, LPN revealed Staff I was coming up hall 1 after being in patient room other nurse Staff K was coming down hallway and asked if Staff I saw Resident #25 as she was trying to give her eve (evening) meds and stated she was not in her room or in common areas. We immediately started alerting staff and initiated search of building and grounds and notified DON. After few minutes of searching resident was located sitting on bench in front of building. I did not hear door or wanderguard alarm activate before this incident. Resident coaxed into building and one on one initiated. The N Adv-Elopement Evaluation dated 6/26/26 at 5:59 PM revealed a score of 8. The Witness Statement dated 6/26/26 for event on 6/24/26 from 6:00 AM-7:00 AM for Staff L, RN revealeda. where were you? nursing station giving report, counting controlsb. Did you hear WG (wanderguard alarm)? noc. Did you hear door alarm? nod. What did you do? After clocking out, I exited the main entry in the front of the building. Spotted Resident #25 at the corner of [facility name redacted] about to step onto parking lot. Placed vehicle in park, (door left open) immediately went to Resident #25. Called Staff I from cell phone to alert and escorted Resident #25 through front door into facility. The Witness Statement dated 6/26/26 for event on 6/23/26 from 4:00 PM-5:00 PM for Staff G, Certified Nurse Aide (CNA) revealeda. where were you? [name redacted] and [name redacted] were in room [ROOM NUMBER] getting a resident up for dinnerb. Did you hear WG (wanderguard alarm)? noc. Did you hear door alarm? nod. What did you do? as I was pushing resident in wheelchair to lounge, [name redacted] asked if I had seen [name redacted]. I immediately began searching the building, room to room, closets, restroom. She was locate safe in a few minutes. The Witness Statement dated 6/26/26 for event on 6/24/26 from 6:00 AM-7:00 AM for Staff M, RN revealeda. where were you? in resident's roomb. Did you hear WG (wanderguard alarm)? noc. Did you hear door alarm? noThe Witness Statement dated 6/29/26 for event on 6/23/26 from 4:00 PM-5:00 PM for Staff N, Dietary Aide, revealeda. Where were you? Kitchenb. Did you hear WG (wanderguard alarm)? noc. Did you hear door alarm? nod. What did you do? put away truckThe Witness Statement dated 6/29/26 for event on 6/23/26 from 4:00 PM-5:00 PM for Staff O, [NAME] revealeda. Where were you? Kitchenb. Did you hear WG (wanderguard alarm)? noc. Did you hear door alarm? nod. What did you do? nothingThe Witness Statement dated 6/29/26 for event on 6/23/26 from 4:00 PM-5:00 PM for Staff P, [NAME] revealeda. Where were you? on breakb. Did you hear WG (wanderguard alarm)? no, was on break 4:15-4:45c. Did you hear door alarm? no, was on break 4:15-4:45d. What did you do? wasn't thereThe Witness Statement dated 6/29/26 for event on 6/24/26 from 6:00 AM-7:00 AM for Staff Q, CNA revealeda. where were you? At nurses station, saw Resident #25 in recliner in lobby at 6:20 AMb. Did you hear WG (wanderguard alarm)? noc. Did you hear door alarm? nod. What did you do? met 2 nurses and resident at front door and assisted back into buildingThe Witness Statement dated 6/26/26 for event on 6/24/26 from 6:00 AM-7:00 AM for Staff R, Business Office Manager revealeda. where were you? officeb. Did you hear WG (wanderguard alarm)? noc. Did you hear door alarm? nod. What did you do? was not awareThe Witness Statement dated 7/16/26 at 1:55 PM revealed Staff S, previous DON found Resident #25 at the same time Staff I did and it took 2-3 minutes from the time the Staff S informed resident missing. During an observation on 8/4/26 at 9:14 AM, the resident laid in the recliner in the common area. No staff in the area at the time. Within 5 minutes, a staff member came and sat next to the resident. During an interview on 8/4/26 at 8:54 AM, the Administrator queried on the incidents of elopement with Resident #25. The Administrator stated Resident #25 had been a challenge. The Administrator stated the codes had not been changed in 20 years and were posted on the alarm. The Administrator stated she was convinced the staff didn't follow protocol and check when the door alarm went off and the Administrator didn't know how Resident #25 got out. The Administrator stated the facility thought she got out the front door and was gone for less than 5 minutes. The Administrator stated the first time Resident #25 eloped the staff found her sitting in the rocker on the patio and the second time Staff L, the night nurse thinks Resident #25 followed her out the front door when Staff L left the facility. The Administrator said she thought Resident #25 followed the sidewalk to the edge of the property and thought Resident #25 heard traffic so she turned and that was when Staff L saw Resident #25 and got out of her vehicle and approached Resident #25. The Administrator stated she never left the property. The Administrator stated some of the wanderguard alarms at the doors would not sound unless opened. The Administrator stated if a wanderguard was by the door, the door won't open for 5-15 seconds and then would release. The Administrator stated the wanderguard would alarm when the door opened with a different sound than the door alarm. The Administrator stated if Resident #25 went out with visitors, staff might have seen the visitors and shut off the alarm because the Administrator had been doing her own spot checking and the alarms were working. The Administrator stated she didn't think the staff wanted to admit they didn't check the door and shut off the alarm. During an observation on 8/4/26 at 9:00 AM, Administrator walked the sidewalk and explained where Resident #25 found. Highway 5 was located in front of the building and the speed limit changes from 35 miles per hour to 45 miles per hour at the intersection to the facility. The highway was approximately 50 feet from where the Administrator stated Resident #25 found. During an interview on 8/4/26 at 2:11 PM, Staff K, LPN stated she worked on 6/23 and was here when Resident #25 eloped. Staff K stated she was looking for Resident #25 to give her medications and staff found Resident #25 on the porch. Staff K stated she would check on Resident #25 every time Staff K walked through the common area because Resident #25 always sit in the same recliner and Staff K didn't think it was more than a few minutes Resident #25 was outside. Staff K stated the alarm didn't go off and the staff thought Resident #25 went out with visitors. Staff K stated the North exit to the common area was completely fenced in and the South lobby was open and could see through the windows. Staff K stated Resident #25 could of snuck out with the smokers, because staff temporarily shut off those alarms when residents were smoking. Staff K stated the wanderguard alarm was a different sound and the other alarm was loud and Staff K doesn't recall either alarm going off. Staff K stated they started 1:1 supervision that day. During an interview on 8/4/2026 2:27 PM, Staff T, CNA stated she heard an alarm in the morning around 6-6:30 AM. Staff T stated she was in the center room and was in a hall getting a resident up. Staff T stated she had not received training prior to the elopements on what to do. Staff T stated Resident #25 was not a 1:1 the morning she got out and Staff T didn't know anything about Resident #25 eloping until Resident #25 came back in and now they do a 1:1 with her all the time. Staff T stated she didn't know about the alarms having different sounds. During an interview on 8/4/26 at 2:38 PM, Staff I, LPN stated she was at the facility both times when Resident #25 eloped. Staff I stated she didn't hear any alarms, but a housekeeper thought they heard one. Staff I stated the first day, she found Resident #25 at the front of the building. Staff I stated the second time Resident #25 eloped, Staff L found her in the grass close to the driveway. Staff I stated the facility put Resident #25 on 1:1 immediately after she got out a second time. Staff I stated Resident #25 was really good at watching staff and taking an opportunity to leave. Staff I stated Resident #25 was concerned about getting to the court house those couple of days. Staff I stated the wanderguard should have gone off and the facility had issues with a courtyard door not going off with a resident every time. During an interview on 8/4/26 at 2:49 PM, Staff L, RN queried on the incident on 6/24 and Staff L stated she was giving report and doing narcotic count at the nurse's station and seen Resident #25 around 6-6:20 AM. Staff L stated she clocked out right after that and went out the front door and got into her car and maybe drove 100 feet and noticed Resident #25 walking towards the building on the South side and coming back towards the building. Staff L stated she put her car in park, grabbed her phone, and walked to Resident #25. Staff L then called the facility and staff met Staff L up front and took Resident #25 back inside. Staff L stated she doesn't remember hearing an alarm. Staff L stated prior to Resident #25 exited that morning, Resident #25 was not a 1:1. Staff L stated she knew Resident #25 got out the day before and they had Resident #25 on a closer watch. During an interview on 8/4/26 at 3:09 PM, Staff G, CNA stated she didn't hear any alarms. Staff G stated the only thing she can think of was the facility had one resident who smoked with a wanderguard and if they didn't face the alarm, the alarm would not trigger. Staff G stated she assumed that was what happened, was Resident #25 alarm didn't face the alarm on the door. Staff G stated there were no different sounds for the alarms. During an interview on 8/4/26 at 3:20 PM, Staff M, RN stated she worked the morning of 6/24. Staff M stated she was not aware Resident #25 left until staff told her. Staff M stated she didn't hear any alarms go off. During an interview on 8/4/26 at 4:47 PM, the DON queried on the two incidents Resident #25 eloped and the DON stated the first time she was here and staff couldn't find her. The DON stated she didn't hear any alarms go off. The DON stated she wasn't here the second time Resident #25 got out. The DON stated she didn't know if Resident #25 remembered the door alarm codes. The DON stated she tested the alarms by putting an alarm in her shoe and all the alarms worked. The DON stated the door alarms were louder than the wanderguard alarms. The DON stated to her knowledge, no one heard the alarms going off when Resident #25 eloped. The DON asked why Resident #25 had 2 wanderguards on and the DON stated because the facility thought the alarm might not have gone off. The DON stated the facility didn't change the code to the front door until these incidents occurred and Resident #25 used to volunteer at the facility. During an interview on 8/5/26 at 8:56 AM, the Administrator stated she was told the alarms were not going off and then she tested everything and the alarms worked. The Administrator stated she believes Resident #25 bolted for the door with the visitors and then staff turned off the alarms when they saw visitors. The Administrator asked about the wanderguard alarm going off and she stated staff would have cleared it too thinking it was an old building. The Administrator stated the facility was getting quotes for a new alarm system and cameras. The Administrator stated everytime they tested the alarms they were working, so it meant someone cleared them. The Administrator stated if she had one fail she could understand it, but until a fail, she believed someone heard them and turned them off. The Administrator asked why Resident #25 had two wanderguards and the Administrator stated to make sure the wanderguards were working. The Administrator stated the other residents' wanderguards checked and if on the ankle, another one placed on the wrist. During an interview on 8/5/26 at 9:09 AM, Staff N, Dietary Aide stated she didn't hear any alarms in the kitchen when Resident #25 eloped. During an observation on 8/5/26 at 11:53 AM, Staff V, Housekeeping Supervisor checked all the door alarms. Staff V stated the only door he had trouble with was the courtyard door for the smokers, the door had a beeping sound to it. Staff V stated he contacted the company Friday and filled out the paperwork to the company to come and look at the door. Staff V stated he thinks Resident #25 got out the courtyard door by the lobby where she sat. Staff V stated the door alarms were shut off behind the nurse's station and the wanderguard alarms were shut off with a key code. During an interview on 8/5/26 at 12:35 PM, the DON stated the facility had a wanderguard device that checked the battery and placement of the wanderguards and staff checked the wanderguards every shift. The DON stated there might of been a glitch at some point, but not sure and the facility was trying to figure it out. The DON asked how long they think Resident #25 outside and the DON stated everyone thought 10 minutes but no one really knows how long Resident #25 was standing in the yard. During an interview on 8/5/26 at 1:21 PM, Resident #25 stated she tried to leave the building through the door by her recliner (courtyard door). Resident #25 would not say how many times or if she heard an alarm when she exited the building. During an interview on 8/5/26 at 1:24 PM, the Administrator stated she didn't know which door Resident #25 got out of and with her timeline on June 23rd, Resident #25 could have been outside for 45 minutes. The Administrator stated staff seen Resident #25 at 3:30 PM, and then Staff K went to give Resident #25 medications at 4:00 PM and couldn't find her and then someone found her around 4:30 PM. The Administrator stated if it was only a few minutes after the Staff S was notified and found Resident #25, the Administrator thought may 32-33 minutes Resident #25 outside of the building. The Administrator stated when Resident #25 eloped on June 24th, staff spotted her around 6:20 AM in the building and Staff L clocked out at 6:28 AM, so 10 minutes at the most. The Administrator stated the alarms were working and staff shut them off. During an interview on 8/5/26 at 3:00 PM, Staff X, CNA stated she was there the morning Resident #25 exited the facility. Staff X stated the overnight nurse spotted her outside and she helped Resident #25 back into the building. Staff X stated it was around 6:40 AM. Staff X stated she assumed she walked through the dining room because Staff X heard an alarm go off by the kitchen door. Staff X stated sometimes the door in the back by the kitchen would not always trigger when you pushed the black button. Staff X stated she just assumed staff were trying to come into the building. Staff X stated she should of paid more attention to the alarm and Staff X thought it was 5-6 minutes between the time of the alarm and the overnight nurse finding Resident #25. During an interview on 8/5/26 at 4:42 PM, Staff O, [NAME] stated she worked the evening Resident #25 exited the building. Staff O stated and didn't hear anything. Staff O stated the back door alarm usually went off when you opened it, but if you enter the door and hold the button, the alarm will not go off. Staff O stated when the delivery people come in, they usually set off the alarm and you had to put in the code to shut it off. During an interview on 8/6/26 at 12:18 PM, Staff Y, LPN stated she wasn't here when Resident #25 eloped. Staff Y stated it should have never happened and the only alarm staff would turn off was the alarm for the smokers when they took them outside and brought them back in. During an interview on 8/6/26 at 2:07 PM, Staff Z, Certified Medication Aide (CMA) stated she was not here when Resident #25 exited the facility. Staff Z asked if they ever noticed issues with the alarms and Staff Z stated yes, there were residents who left with family for doctor's appointments and wore wanderguards and the alarm didn't go off. Staff Z stated they checked the wanderguard, so she didn't know if it was the front door. Staff Z stated it happened about 3 months ago. During an interview on 8/6/26 at 2:24 PM, Staff C, CMA stated she never noticed issues with the alarms. Staff C stated she shut of the alarms to the smoking doors when they took the smokers out. Staff C stated the smoking times were 9 AM, 4 PM, and 7 PM. During an observation on 8/10/26 at 10:06 AM, Staff V plugged in the wanderguard cord to the smoker's courtyard door and when he opened the courtyard door, it didn't alarm. Staff Y checked the alarm box in the nurse's station and stated the alarm switch was in the middle and not turned on. Staff Y then turned the alarm back on. Staff V took the surveyor over to the gate and a padlock was noticed on the outside of the gate, so Staff V was unable to open the gate. The courtyard was enclosed with a white privacy fence approximately 6 feet tall. Review of the Facility Elopement and Wandering Residents dated 6/24/26 revealed The facility is equipped with door Jocks/alarms to help avoid elopements.Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner.Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staffAdequate 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 (e.g. internal alert code).

Based on staff interview, clinical record review, and policy review, the facility failed to respect choice and rights related to smoking, for 1 of 5 smokers reviewed (Resident #1), failed to implement additional safety interventions and denied smoking rights despite smoking at the facility for several years. The facility reported a census of 39 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses for Resident #1 included medically complex condition, anxiety, diabetes, kidney and respiratory disease. The Brief Interview for Mental Status (BIMS) score as 12 out of 15, indicating moderate impaired cognition. Resident #1 choosing hospice services.The Care Plan focus dated 4/21/21 for Resident #1 included trauma included to encourage work on coping skills, identify triggers included, her children not coming to visit, not being able to smoke and to remind resident of psychiatry and therapy appointments. The focus area dated 4/8/22 revealed Resident is to be supervised by staff to smoke. Intervention added on 5/10/24 resident has asthma and continues to be a current smoker of nicotine. On 7/16/26 added Resident #1 to smoke one cigarette at smoke break and vape as needed.The Facility Nursing Smoke Assessment date 7/16/27 at 2:46 PM documented Resident #1 uses tobacco and vapes. Care plan interventions focus of education and interventions was not completed; Clinical suggestions category included safety/options was not completed. On 8/3/26 at 2:35 PM Resident #1 relayed has smoked cigarettes for 57 years and about two months ago the Administrator said, no more cigarettes, was not safe because dropped one and burned a hole in the cushion, was told could only vape and does not agree with the decision, felt it was more expensive and was worse than cigarettes in regard to health. Resident displayed frustration and disagreement with denial of choice to smoke cigarettes. Resident #1 relayed did continue to go outside with others that smoked was only allowed a vape.On 8/5/26 at 11:11 AM the Director of Nursing (DON) relayed there was a new smoking policy and the Administrator relayed Resident #1 was unsafe to smoke, the cigarettes were collected and she was provided with a vape. The DON stated completed another assessment yesterday and Resident #1 did not drop the cigarette, smoked half and it went out and no hazards viewed. Discussed interventions for safety. The DON relayed Resident #1 does wear the safety apron and thought other interventions perhaps a glove could be tried if needed for her safety and to allow her to continue to smoke. On 8/5/26 at 2:00 PM the Administrator relayed the former DON relayed Resident #1 cushion on the chair had to be replaced, was not sure how the burn hole would occur if Resident #1 was wearing the safety apron. The Administrator reviewed Resident #1 Care plan and relayed had thought it directed that Resident #1 could not smoke any longer but it was not updated to reflect the change. The Administrator reported the Interdisciplinary Team (IDT) determined Resident #1 could only use a vape. The Administrator voiced now understood Resident #1's rights were violated and would be corrected. The Administrator included perhaps other interventions such as holders for cigarettes to ensure safety was a possibility. In an interview with the Nurse Practitioner, Staff A on 8/6/26 at 9:43 AM relayed awareness Resident #1 had smoked for a long time, felt Resident #1 could make an informed decision about smoking. Staff A relayed had many conversations about quitting and NF chooses not to and is at end of life with comfort being the focus. Relayed Resident #1 is aware of the risks and chooses the right to smoke. The New Facility Policy dated 7/1/25 titled, Resident Smoking Policy documented, Prior to, or upon admission, and as needed, residents and Resident Representatives(s) shall be informed about any limitations on smoking, including designated smoking areas, and the extent to which the facility can accommodate. The Nursing staff shall perform a Smoking Assessment upon admission, quarterly and as needed. Nursing staff will consult with the Attending Physician and the Director of Nursing Services to share results of smoking assessment and determine restrictions on a resident's smoking privileges. Smoking restrictions may be imposed for the safety and well-being of the Resident, in the case of weather- related conditions. This determination will be made by the Administrator and/or Director of Nursing. The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, and/or Resident Representative(s). The staff will review the status of a resident's smoking privileges. A smoking Apron may be required to be used if Resident is determined to be unsafe and needs supervision. This facility may check periodically to determine if residents have any smoking articles in violation of our smoking policies, room and pocket searches. Staff shall confiscate any such articles and shall notify the Director of Nursing and/or Administrator of such observation or search.Policy titled Resident Rights dated 7/29/25 documented, The resident has the right to a dignified existence, self-determination. The right to receive the services and/or items included in the plan of care. The resident has a right to be treated with respect and dignity,

Based on observation, staff interviews, record review and the facility policy review the facility failed to keep all medications in a locked medication cart, inaccessible to unauthorized staff and residents. The facility reported a census of 40 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #1 entered the facility on 7/22/22. The MDS also documented a Brief Interview of Mental Status (BIMS) of 09 indicating moderate cognitive impairment. The MDS documented diagnoses of non-Alzheimer's dementia, diabetes, and depression. Review of Resident #1 physician orders revealed Hydrocodone-Acetaminophen (pain medication) tablet 5-325 mg. Give 1 tablet by mouth at bedtime for pain dated 9/5/24. The Care Plan for Resident #1 documented a focus area for pain related to history of back and leg pain at times and usually takes medication at bedtime, date Initiated 11/10/22.Review of document titled Controlled Drug Receipt/Record Disposition Form for Resident #1 for Hydrocodone-Acetaminophen tablet 5-325 mg revealed count of -1 tablet entry on 10/11/25 at 8:05 pm with a signature of Staff A, Licensed Practical Nurse (LPN). A review of the facility reported incident revealed Director of Nursing (DON) was notified an incident at the facility that occurred on 10/11/25 around 9 pm, Staff A reported leaving Hydrocodone medication for Resident #1 unattended in her room on the bedside table then stepping out of the room to attend to another task prior to observing Resident #1 swallowing the medication. While Staff A was out of Resident's #1 room she observed Staff B, Certified Nursing Assistant leaving Resident's #1 room. Staff A, LPN went back to Resident's #1 room but the Hydrocodone that was left in a pill cup on the bedside table was not there. After searching the room and trash bins, the medication was not recovered.In an interview with the Director of Nursing on 10/20/25 at 2:35 pm, she stated her expectations were that Staff A should have administered Resident's #1 Hydrocodone right after removing it from a locked medication storage. In an interview with Staff A, LPN, 10/21/25 at 1:31 pm, she stated she was supposed to administer the medication to Resident #1 and observe the medication being taken and not left unattended. In an interview with Staff B, CNA on 10/21/25 at 10:50 am, she denied seeing any medications in Resident's #1 room when she was observed leaving the room. A review of the facility provided policy titled Medication Administration Times updated 09/2025 documented the following: The policy of the facility is to provide medications to residents as ordered by the physician. The following medication administration times will be observed unless specifically ordered otherwise by the physician.

Based on clinical record review, facility policy review, Centers for Disease Control and Prevention (CDC) guidelines, resident and staff interview, the facility failed to offer the pneumococcal vaccine to 4 of 5 sampled residents reviewed for immunizations (Residents #4, #5, 26 and #27). The facility reported a census of 40 residents. On 7/31/2025 at 8:49AM, the Director of Nursing (DON) reported she had been in her role as the DON and Infection Preventionist (IP) since May 2023. The DON reported they should check the immunization status of residents upon admission and residents should be offered immunizations at that time. The DON reported she followed the Center for Disease Control and Prevention (CDC) guidelines for offering residents the pneumococcal vaccine. The DON reported being aware that there were residents eligible for the vaccine who had not been offered. The DON explained the facility's pharmacy representative just did an audit related to vaccines to determine which residents were in need of vaccines. The DON reported she had issues accessing her Iowa Immunization Registry Information (IRIS) account. The DON reported the hard chart and electronic clinical record contained current immunization status information for each resident; however, she maintained a separate file that might have more current information. Review of CDC guidelines, dated 10/2024, revealed the following recommendations:Administer Prevnar 20 (PVC20), Prevnar 21 (PVC21), or Vaxneuvance (PVC15) for all adults 50 years or older who have never received any pneumococcal conjugate vaccine, or whose previous vaccination history is unknown.If a person received just Prevnar (PVC13) at any age, administer PVC20 or PVC21 one year or greater after the administration of PVC13.If a person received PVC13 at any age and Pneumovax (PPSV23) vaccine at age [AGE] or older, administer PVC20 and PVC21 5 years or greater after the last dose of PPSV23. 1. Review of the clinical record for Resident #4 revealed the following:The Minimum Data Set (MDS) assessment, dated 6/5/25, identified an admission date of 3/1/24, the resident was over age [AGE], and had diagnoses that included diabetes, dementia and sleep apnea. The assessment identified a Brief Interview for Mental Status (BIMS) score of 2 out of 15 (indicated a severe cognitive impairment). On 7/30/25, review of the clinical record for Resident #4's immunization status revealed a lack of documentation on whether Resident #4 had ever been offered or received the Pneumovax (PPSV23) vaccine, or any of the pneumococcal conjugate vaccines, Prevnar 20 (PVC20), Prevnar 21 (PVC21), Vaxneuvance (PVC15) per CDC guidelines. 2. Review of the clinical record for Resident #5 revealed the following:The MDS assessment, dated 7/18/25, identified an admission date of 10/13/24, the resident was over age [AGE], and had a diagnosis of coronary artery disease. The assessment identified a BIMS score of 15 out of 15 (indicative of no cognitive impairment).On 7/30/25, review of the clinical record for Resident #5's immunization status revealed the resident had received Pneumovax (PPSV23), dated 3/14/2013, and an unidentified pneumococcal conjugate vaccine (PCV13, PCV15, PCV20, or PCV21), dated 10/21/2016. The clinical record lacked documentation facility staff had offered Resident #5 the PCV20 or PCV21 vaccine per CDC guidelines.On 7/30/2025 at 4:14 PM, Resident #5 reported that if the facility had offered, she would have taken the pneumococcal vaccine. She was unsure of the last time she received the pneumococcal vaccine and what type. 3. Review of the clinical record for Resident #26 revealed the following:The MDS assessment, dated 6/2/25, identified an admission date of 6/20/2019, the resident was over age [AGE], and had diagnoses of dementia and diabetes. The assessment identified a BIMS score of 3 out of 15 (indicative of a severe cognitive impairment).On 7/30/25, review of the clinical record for Resident #26's immunization status revealed the resident had received Prevnar 13, dated 9/5/2002, and PPVS23, dated 10/21/2002. The clinical record lacked documentation facility staff had offered Resident #5 the PCV20 or PCV21 vaccine per CDC guidelines. 4. Review of the clinical record for Resident #27 revealed the following:The MDS assessment, dated 6/21/25, identified an admission date of 3/17/22, the resident was over age [AGE], and had diagnoses of chronic obstructive pulmonary disease (COPD) and heart failure. The assessment identified a BIMS score of 12 out of 15 (indicative of a moderate cognitive impairment).On 7/30/25, review of the clinical record for Resident #27's immunization status revealed the resident had received Prevnar 13, dated 1/31/2017. The clinical record lacked documentation facility staff had offered Resident #5 the PCV20 or PCV21 vaccine per CDC guidelines. On 7/31/2025 at 10:20 AM, the DON confirmed that the identified residents in the sample (Residents #4, #5, #26 and #27) had not been offered or administered the pneumonia vaccine, and the residents were all past due. Review of the facility policy, titled Pneumococcal Vaccine Policy, dated 8/2017, revealed that all residents would be assessed for eligibility per CDC guidelines and offered the pneumococcal vaccine within 30 days of admission to the facility.

Based on clinical record review, policy review, and staff interviews, the facility failed to ensure thorough documentation of an assessment of a resident's ability to self-administer insulin (an injectable medication used to lower blood sugar) for 1 of 1 residents reviewed for medication self-administration (Resident #35). The facility reported a census of 40 residents. The Minimum Data Set (MDS) assessment tool, dated 5/6/25, listed diagnoses for Resident #35 which included diabetes, hypertension, and Parkinson's disease (a disease that caused difficulty with mobility). The MDS stated the resident took insulin and listed his Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. On 7/31/25 at 12:34 p.m., via phone, Staff H Licensed Practical Nurse (LPN) stated she drew up the resident's insulin and she handed it to him or the Certified Medical Assistant (CMA) sat it on his table. She stated the resident refused to have certain staff administer his insulin so they started doing this recently. On 7/31/25 at 12:43 p.m., the Director of Nursing (DON) stated Resident #35 administered his own insulin but she did not know if there was documentation of an assessment which determined that he could do this. She stated Staff K LPN sat with him and ensured he could do this and she would search for the documentation. A 6/4/25 untitled note, handwritten by Staff K LPN stated she had the resident self-administer his insulin and he did fine. The facility lacked additional details or assessments regarding the resident's self-administration of insulin including whether staff were required to observe him administer his insulin. The resident's Care Plan focus, the resident has diabetes mellitus and is insulin dependent, initiated 2/13/24 lacked documentation the resident was able to self-administer his insulin. The undated facility policy Self-Administration of Medications, stated if a resident requested to self-administer medications, the facility would assess the resident to determine if self-administration of medication was clinically appropriate.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to make prompt efforts to resolve concerns for 1 of 1 resident reviewed for grievances (Resident #34). The facility reported a census of 34 residents. The Minimum Data Set (MDS) assessment tool, dated 5/6/25, listed diagnoses for Resident #35 which included diabetes, hypertension, and Parkinson's disease (a disease that caused difficulty with mobility). The MDS stated the resident received insulin (an injectable medication used to lower blood sugars) and listed his Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The facility Resident Grievance Policy revised 3/31/23, stated the facility had a grievance system to resolve issues and respond to grievances as soon as possible. On 7/28/25 at 2:19 p.m., Resident #35 stated he had to sit in his own waste frequently and stated last Sunday (7/27/25), he had to sit in waste for 4-5 hours before anyone changed him. He stated this was humiliating. He stated 3 weeks ago on a Sunday the staff did not check his blood sugar or give him insulin. On 7/30/25 at 4:40 p.m., via phone, Staff F Certified Nursing Assistant (CNA) stated she worked with Resident #35 on 7/27/25 and he complained to her that staff sometimes left him in his brief soiled with fecal matter. On 7/31/25 at 10:47 a.m., Staff B Licensed Practical Nurse (LPN) stated Resident #35 told her that staff left him in his own excrement and she reported this to either the Director of Nursing(DON) or Staff I Social Services. On 7/31/25 at 11:22 a.m., Staff J CNA stated if a resident reported to her that staff did not change them, she would report this to the DON or the Assistant Director of Nursing(ADON). On 7/31/25 at 11:55 a.m., Staff G Certified Medication Assistant (CMA) stated the DON and Staff C Registered Nurse (RN) stood at their medication carts at lunch and talked about Resident #35's insulin. Staff G stated the DON stated she would write refused because the resident didn't like her. Staff G stated at supper time, the resident was very angry that he did not get his lunch insulin. Staff G stated she reported this to the night nurse (Staff H LPN) and the next day she reported it to the Assistant Director of Nursing (ADON). The facility lacked documentation of a grievance process carried out related to Resident #35's concerns. On 7/31/25 at 1:22 p.m., the Administrator stated she expected staff to report such complaints as residents not getting insulin or not being changed. She stated she was not aware of these issues and if staff reported this, they would carry out a grievance process.

Based on clinical record review, policy review, and staff interview, the facility failed to carry out interventions and ordered treatments to treat a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident #45). The facility reported a census of 45 residents.Findings include:The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers:Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister.Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar.Unstageable Ulcer: inability to see the wound bed.Other staging considerations include:Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.The MDS assessment tool, dated 3/6/25, listed diagnoses for Resident #45 which included humerus (upper arm bone) fracture, history of falling, and diabetes. The MDS stated the resident was at risk for pressure ulcers but had no unhealed pressure ulcers. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 10 out of 15, indicating moderately impaired cognition. The facility policy Skin Care Program, revised 6/14/20, stated the facility would ensure residents with pressure ulcers received treatment and services consistent with the goal of promoting healing. A 3/14/25 Care Plan entry stated the resident had potential/actual impairment to skin integrity. A 3/24/25 entry stated the resident had a purple, boggy blister to the right and left heels. A 3/24/25 Health Status Note stated the resident had deep purple, circular areas on both heels. The right heel measured 2 centimeters (cm) x 1.2 cm (length x width) and the left heel measured 1.2 cm x 1.2 cm. A 3/25/25 Skin/Wound Note stated the provider assessed the resident's heels and agreed it was suspected deep tissue injury. The April and May 2025 Treatment Administration Records (TARS) listed the following orders:a. Skin prep to discolored areas to heels twice daily. The entries for the morning shifts on 4/2/25 and 4/8/25 were blank and lacked staff initials to indicate the completion of the treatment.b. Cleanse areas to the heels with saline and dry, apply skin prep to both peri wounds, apply a nickel thick layer of Santyl (an ointment used to treat wounds) to both wound beds and cover with border foam gauze every day and as needed. Entries on 4/18/25, 4/21/25, and 4/22/25 were blank and lacked staff initials to indicate the completion of the treatment.c. Cleanse areas to heels with saline and dry, apply skin prep to both peri wounds, apply a nickel thick layer of Santyl and cover with Tegaderm (a type of dressing) every day. The entries for 4/30/25 and 5/11/25 were blank and lacked staff initials to indicate the completion of the treatment.A 5/13/25 Health Status Note stated the facility received an order for Physical Therapy (PT) for positioning for heel wounds. The facility lacked documentation of this order carried out. On 7/31/25 at 10:28 a.m., Staff C Registered Nurse (RN) stated due to staffing it was difficult to complete everything. She stated there were a couple of times when she had to report to the next shift that she did not get a dressing change completed. She stated when she returned to work, she realized no one completed the dressing change. On 7/31/25 at 10:47 a.m., Staff B Licensed Practical Nurse (LPN) stated there were times when patches were not changed over the weekend and she determined that by the date on the patch. On 7/31/25 at 12:12 p.m., the Director of Nursing (DON) stated staff should carry out treatments as ordered. She stated staff should carry out PT orders in a timely manner.

Based on clinical record review, policy review, and resident and staff interviews, the facility failed to ensure 1 of 6 residents (Resident #35) reviewed for medications was free of a significant medication error due to the omission of insulin (an injectable medication used to lower blood sugar). The facility reported a census of 40 residents. The Minimum Data Set (MDS) assessment tool, dated 5/6/25, listed diagnoses for Resident #35 which included diabetes, hypertension, and Parkinson's disease (a disease that causes difficulty with mobility). The MDS stated the resident took insulin and listed his Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. A 12/5/24 Care Plan entry stated the resident had diabetes and was dependent on insulin. The undated facility policy Recording of Physician Orders directed staff to ensure physician orders were accurate and to avoid medication errors. On 7/28/25 at 2:19 p.m., Resident #34 stated 3 weeks ago on a Sunday the staff did not check his blood sugar or give him insulin. The May and July 2025 Medication Administration Records (MARs) directed staff to check the resident's blood sugar in the evening at 4:00 p.m. and listed an order for Novolog (a type of insulin) per sliding scale three times per day. The entries for insulin on the evening shifts of 5/4/25 and 7/6/25 were blank and lacked initials to indicate staff administered the insulin. The entry for the blood sugar check on 7/6/25 was blank and lacked staff initials to indicate the completion of the blood sugar check.The resident's Progress Notes lacked documentation the resident received or refused insulin on the evenings of 5/4/25 and 7/6/25On 7/31/25 at 11:55 a.m., Staff G Certified Medication Assistant (CMA) stated the Director of Nursing (DON) and Staff C Registered Nurse stood at their medication carts and talked about Resident #35's insulin. Staff G stated the DON stated she would write refused because the resident didn't like her. Staff G stated at supper time, the resident was very angry that he did not get his lunch insulin. Staff G stated she reported this to the night nurse (Staff H Licensed Practical Nurse (LPN) and the next day she reported it to the Assistant Director of Nursing (ADON). On 7/31/25 at 11:13 a.m., Staff D CMA stated Resident #35 complained to her that he did not get his insulin.On 7/31/25 at 12:12 p.m., the DON stated if a resident refused insulin, they should document why and notify the physician. She stated the only time she documented the resident refused was when he did refuse.

Based on observation, staff interviews, resident interviews and policy review, the facility failed to provide a proper functioning call system to ensure resident timely access to staff for 2 of 16 residents reviewed (Resident #3, Resident #22). The facility reported a census of 40. Findings include: 1) The Minimum Data Set (MDS) dated [DATE] for Resident #3 listed diagnoses to include traumatic brain injury, heart disease, renal insufficiency, neurogenic bladder, urinary tract infection, anxiety chronic pain, reduced mobility. The resident was coded to need substantial/maximus assistance with transferring from bed or chair, or to the toilet. The MDS section for Brief Interview of Mental Status (BIMS) scored 13 out of 15 indicated intact cognitive function. The Care Plan initiated 3/25/24 for Resident #3 documented impaired balance, assistance of two staff with stand lift, noted to put on call light to use bed side commode or to be changed. 2) The MDS dated [DATE] for Resident #22 listed diagnoses to include diabetes, depression, vision deficits and heart disease. Resident coded for using a walker and had a BIMS score of 10 indicating moderate cognitive impairment. The Care Plan dated 4/29/24 for Resident #22 documented the resident needs prompt response to all requests for assistance.On 7/28/25 at 2:45 PM Resident #3 relayed it can take a half hour to forty-five minutes at times to get staff assistance and believes the long wait time is related to the system not functioning correctly, relayed all other lights can be seen and or heard from the nurse's station call light board except for this room. On 7/28/25 at 2:47 PM Resident #22 relayed awareness Resident #3 could not transfer independently and was uncomfortable waiting a long time when needing to use the bathroom. Resident #22 relayed is able to walk with her walker and had gone looking for staff to assist Resident #22. Resident #22 relayed is aware that their room call light cannot be heard or seen at the nurse's station call light board. Resident #22 stated only if staff is walking by and see the overhead light on would they know assistance is needed and felt the malfunction contributed to long wait times. On 7/28/25 at 2:55 PM the Certified Nursing Aide (C.N.A.), Staff B relayed they thought the call light would show up on the nurse's station board. Agreed to test the system, the call light button was pushed and verified, no sound or light at the nurse's station call light board. On 7/28/25 at 2:58 PM the Licensed Practical Nurse (LPN) Staff B relayed they felt sometime the call light will be activated on the board, and is unpredictable. Staff B stated the entire call system is an old system and needs work.On 7/31/25 at 10:20 AM Registered Nurse (RN), Staff C relayed 100, 200 and 300 halls call systems do not have sound, hall four is only hall that had sound. On 7/31/25 at 10:25 AM CNA Staff D, relayed call light system is really old and heard had trouble getting parts, stated all call lights use to have sound, sound was turned off related to malfunctioning, not certain where the sound was coming from and or it was going off for no reason. Staff D stated 400 hall will sound at the nurse's station but the other halls will only light up. Relayed a room in 100 hall will not sound or light up at the nurse's station and staff are only aware if they view the light from the overhead door. Agreed if did not view the overhead light directly could cause a longer wait time for those residents. On 7/31/25 at 10:27 AM with CNA Staff E relayed the call light system is old and needed repaired often and had heard management was looking into another system. On 7/31/25 at 10:30 AM the Administrator acknowledged the call light in R#22, R#3 room does not function properly. Discussion of the call system included Administrator awareness the system is old and is repaired often for various issues. Relayed the system is costly and ongoing work is in process to get a replacement. The facility policy titled Call Light Policy, not dated documented aims to ensure prompt and effective communication between residents and staff to meet their needs and ensure their safety and well-being, each resident room shall be equipped with a functioning call light system, be inspected and maintained to ensure proper functionality.

Based on staff and resident interview and clinical record review, the facility failed to provide restorative activity as planned for 1 of 1 resident reviewed. (Resident #3) The facility reported census was 38. Findings include: According to a Minimum Data Set (MDS) with a reference date of 2/3/25, Resident #3 had a Brief Mental Status (BIMS) score of 15 indicating an intact cognitive status. Resident #3 required moderate assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #3 was coded as having a catheter and occasional incontinent bowel functioning. Resident #3's diagnosis included atrial fibrillation, renal insufficiency, neurogenic bladder, and diabetes mellitus. According to the Nursing Restorative Care Program from January 28, 2025 through March 14, 2025, Resident #3 has the following restorative tasks which all are to be performed 3-6 times per week: 1. Active range of motion to both upper extremities: trunk flex pulling/pushing tabletop therabar 1x15 reps seated rows across the blue bands 1x15 reps. 2. 2# ankle weights: ankle pumps LAQ's, hip flexion, hip abduction HS curls. 3. Continuous cycling 10-15 minutes 2# resistance alternative forward rotation and backward rotation every other day. 4. Nu-Step for both upper extremities and both lower extremities: 10-15 minutes at 2# resistance- 1x15 table slides side to side forward/back with 2# wrist weights applied. 5. STS 3-5 reps at hallway rail or parallel bar and hold as long as possible. 6. Cone reaching crossing midline seated. Documentation of restorative tasks completed indicated: January 2025: tasks 2, 5 and 6 were not worked on that month February 2025: tasks 1, 4, 5 and 6 were not worked on that month. March: 2025 tasks 2, 4, 5 and 6 were not worked on that month. In an interview on 3/17/25 at 11:20 a.m. Staff C, Rehab Director, was queried regarding Resident #3's involvement with therapy services. Staff C stated Resident #3 had been in therapy services on and off for over a year. Their goals have always been to increase his mobility. Early on they discovered he had some loose screws in his hip which limited his weight bearing. In between formal physical and occupational therapies, they developed a plan for a restorative aide to continue with therapy. At one point the restorative aide had Resident #3 walking in the hall, but was unsure when and why that stopped. Resident #3 just started back receiving physical therapy 3 times per week today. In an interview on 3/19/25 at 11:20 a.m. Resident #3 was queried about therapy. Resident #3 stated he broke his hip in February 2024 and had a rod placed in his leg. His original goal was to be walking by April 2025. Resident #3 stated he had therapy that was altered due to loose screws in his leg. Resident #3 stated once that healed he returned to therapy and then a restorative aide (Staff O) took over, but she might only show up once a week, if that. Resident #3 stated he was frustrated that he was not progressing like he would have liked and blames some of that on a lack of restorative therapy. In an interview on 3/19/25 at 1:00 p.m. Resident #3 was shown his monthly restorative recorded activity and asked if he felt the activity recorded was accurate. Resident #3 stated February and March seemed to be the months in which the restorative aide was pulled to the floor and unable to provide restorative tasks. In an interview on 3/19/25 at 12:40 p.m. the Assistant Director of Nursing (ADON) was asked who the restorative nurse was. The ADON stated in the future they are wanting herself and another nurse to track and ensure programs are being followed, but right now she does not know who would be responsible for that. The ADON stated she has been involved with updating plans and providing monthly forms to track the services. The ADON was queried as to why restorative tasks for Resident #3 were not completed in January, February and March 2025. The ADON stated the restorative aide will sometimes do what the resident prefers, but noted Resident #3 had always prioritized improving his ambulation.

Based on clinical record review and staff interviews, the facility failed to ensure residents are appropriately assessed and provided interventions to maintain their optimal health and well-being for 1 of 3 residents reviewed. (Resident #3) The facility reported census was 38. Findings include: According to a Minimum Data Set (MDS) with a reference date of 2/3/25, Resident #3 had a Brief Mental Status (BIMS) score of 15 indicating an intact cognitive status. Resident #3 required moderate assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #3 was coded as having a catheter and occasional incontinent bowel functioning. Resident #3's diagnosis included atrial fibrillation, renal insufficiency, neurogenic bladder, diabetes mellitus. According to a Progress Note dated 1/26/25 at 7:07 a.m. written by Staff G, Registered Nurse, Resident #3 was agitated and complaining of a sore groin and peri area. Staff G indicated the area was reddened and tender to touch. Staff G stated she would check on getting something, but noted doctors do not come in on Sundays and staff must have an order for creams. (No skin sheet was produced related to Resident #3's redness and tenderness in his groin area) The Progress Note dated 1/26/25 at 12:07 p.m. written by Staff G, Registered Nurse, a request for a cream to apply on Resident #3's groin area was placed in the PCC folder at the nurse's station. The Progress Note dated 1/26/25 at 2:03 p.m. written by Staff G, Registered Nurse, Resident #3 continues to voice discomfort in his groin area and frustration of not being able to get the discomfort under control. Staff G reminded Resident #3 that an antifungal powder was applied that morning. (There was no order for an antifungal powder to be used for Resident #3) The Progress Note dated 1/28/25 at 4:54 p.m. written by Staff H, wound nurse. Weekly skin assessments completed. (No skin sheet was produced related to Resident #3's redness and tenderness in his groin area) The Progress Note dated 2/4/25 at 2:52 p.m. written by Staff H, wound nurse. Weekly skin assessments completed.(No skin sheet was produced related to Resident #3's redness and tenderness in his groin area) The Progress Note dated 2/6/25 at 3:45 p.m. written by Staff N, Licensed Practical Nurse, indicated the Nurse Practitioner ordered PeriGuard (barrier cream) twice daily to bilateral peri area and groin. (8 days after Resident #3 first complained of groin discomfort due to irritation) According to Resident #3's January Treatment Administration Record (TAR), there was no order for an antifungal powder to be used on Resident #3's peri and groin area. Also there were two barrier related creams that were available as needed for peri rectal excoriation had Staff G thoroughly reviewed the TAR. In an interview on 3/17/25 at 4:12 p.m. Staff G, Licensed Practical Nurse, was queried regarding an incident involving Resident #3 complaining of excoriation in his groin area. Staff G stated Resident #3 was complaining of excoriation and discomfort in his peri area (1/26/25). Staff G stated she assessed Resident #3 and he was a little red and tender. Resident #3 stated he had been complaining for 3 days to get some cream and no one had done anything. Staff G stated Resident #3 was disrespectful and threatened to take Staff G's license. Staff G explained it wouldn't be possible on a weekend (Sunday) to get the cream. Staff G consulted with other nurses and they agreed using a fungal powder until a cream could be obtained was reasonable. Staff G put a request in to order cream and used the powder that morning. Staff G understood this to be the process when dealing with nonemergent situations. Staff G was asked if she had reviewed the January 2025 Treatment Administration Record (TAR) for Resident #3 and seen that there were actually two orders which may have helped relieve Resident #3 s discomfort. One was for Dermaseptin topically twice daily as needed to peri rectal area as needed for wound treatment and the other Cavilon Emollient External Cream applied to reddened peri rectal area topically as needed for excoriation twice daily as needed until healed. Both are barrier creams. Staff G stated she must have missed seeing those orders. Record review noted there were no orders for Nystatin powder. In an interview on 3/17/25 at 1:20 p.m. the Director of Nursing (DON) was queried regarding the process when a resident has a complaint of pain, discomfort or illness. The DON indicated she would assess the resident and if deemed necessary, she would contact the physician for consultation and orders as necessary. When asked about on weekends, the DON stated the only difference may be to contact the on-call physician.

Based on clinical record review, staff interviews, family interview and provider interview, the facility failed to notify a physician and family representative upon discovery of a blistered area on a resident's left foot. (Resident #1) The facility reported census was 38. Findings include: According to the Minimum Data Set (MDS) with an assessment reference date of 5/3/24, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, indicating an intact cognitive status. Resident #1 required dependent to maximal assistance with transfers, mobility, dressing, toilet use and personal hygiene needs and was frequently incontinent of bladder and occasionally incontinent of bowel. Diagnosis included lymphedema, congestive heart failure, renal insufficiency, diabetes mellitus, and morbid obesity. Clinical record review found on a 7/3/24 skin assessment, a new blister was identified on the left foot of Resident #1 measuring 6 centimeters (cm) long by 3.5 cm wide. Staff A indicated in her progress note dated 7/3/24 at 9:56 a.m. a large, dark, elongated intact blister was observed. Staff A wrote she covered the blister area with Xeroform and secured it with cling and noted the physician was updated. In an interview on 7/16/24 at 11:08 a.m. Staff A, Registered Nurse, stated on 7/3/24, she discovered a large, dark, elongated blister on the arch of Resident #1's left foot. Staff A stated she covered the area with Xeroform and cling wrap, notified the primary care physician and noted Resident #1 was aware of her condition and the power of attorney (POA) was not required to be contacted of changes in the resident's condition. In a follow up interview on 7/16/24 at 2:30 p.m., Staff A queried whether she contacted a physician upon the discovery of the blister on Resident #1's left foot on 7/3/24 and she stated no. Staff A queried whether Resident #1's POA was contacted of the change in condition, Staff A stated no. In an interview on 7/16/24 at 11:08 a.m. Staff A, Registered Nurse, stated on 7/10/24, Resident #1's wounds were assessed and the blister on her left foot had grown (8 cm x 7.5 cm) and remained firmish soft, dark in color and intact. Staff A stated she changed the treatment to a non-stick telfa and covered it with cling wrap. In a follow up interview on 7/16/24 at 2:30 p.m., Staff A queried whether she contacted a physician upon the progression of the blister discovered on 7/3/24 and she stated no. Staff A queried whether Resident #1's POA was contacted of the change in condition, Staff A stated no. In an interview on 7/16/24 at 12:13 p.m. the Advanced Practice Nurse Practitioner (ARNP), stated she was not initially aware of the new blistered area on Resident #1's left foot on 7/3/24, as she was on vacation during that time, but was made aware of it upon her return. In an interview on 7/16/24 at 1:01 p.m. Resident #1's power of attorney (POA) stated she visited her mother on 7/13/24 and noted a strong odor in her room. She mentioned it to staff and staff indicated it was from her wounds. The POA stated she was aware of the blistered area at some point, but had not been informed of it's severity.

Based on clinical record review, staff interviews, and provider interview the facility failed to obtain treatment orders for a resident identified with new wounds. (Resident #1) The facility reported census was 38. Findings include: According to the Minimum Data Set (MDS) with an assessment reference date of 5/3/24, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, indicating an intact cognitive status. Resident #1 required dependent to maximal assistance with transfers, mobility, dressing, toilet use and personal hygiene needs and was frequently incontinent of bladder and occasionally incontinent of bowel. Diagnosis included lymphedema, congestive heart failure, renal insufficiency, diabetes mellitus, and morbid obesity. Clinical record review found on a 7/3/24 skin assessment, a new blister was identified on the left foot of Resident #1 measuring 6 centimeters (cm) long by 3.5 cm wide. Staff A indicated in her progress note dated 7/3/24 at 9:56 a.m. a large, dark, elongated intact blister was observed. Staff A wrote she covered the blister area with Xeroform and secured it with cling and noted the physician was up dated. In an interview on 7/16/24 at 11:08 a.m. Staff A, Registered Nurse, stated on 7/3/24, she discovered a large, dark, elongated blister on the arch of Resident #1's left foot. Staff A stated she covered the area with Xeroform and cling wrap, notified the primary care physician and noted Resident #1 was aware of her condition and the power of attorney (POA) was not required to be contacted of changes in the resident's condition. In a follow up interview on 7/16/24 at 2:30 p.m., Staff A queried whether she contacted a physician upon the discovery of the blister on Resident #1's left foot on 7/3/24 and she stated no. Staff A queried whether she received an order for the Xeroform dressing on 7/3/24 and she stated no. When queried whether Resident #1's POA was contacted of the change in condition, Staff A stated no. In an interview on 7/16/24 at 11:08 a.m. Staff A, Registered Nurse, stated on 7/10/24, Resident #1's wounds were assessed and the blister on her left foot had grown (8 cm x 7.5 cm) and remained firmish soft, dark in color and intact. Staff A stated she changed the treatment to a non-stick telfa and covered it with cling wrap. In a follow up interview on 7/16/24 at 2:30 p.m., Staff A queried whether she contacted a physician upon the progression of the blister discovered on 7/3/24 and she stated no. Staff A queried whether she received an order for the non-stick telfa dressing on 7/10/24 and she stated no. When queried whether Resident #1's POA was contacted of the change in condition, Staff A stated no. In an interview on 7/16/24 at 12:13 p.m. the Advanced Practice Nurse Practitioner (ARNP), stated she was not initially aware of the new blistered area on Resident #1's left foot on 7/3/24, as she was on vacation during that time, but was made aware of it upon her return. ARNP stated Resident #1 had multiple comorbidities, lymphedema, poor circulation, diabetes and morbid obesity which all contributed to her lower extremity skin issues. ARNP stated skin breakdown resulting in stasis wounds would be expected.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to carry out infection control measures for 1 of 7 residents observed during the medication pass (Resident #21). The facility also failed to develop and implement a plan to prevent the growth of Legionella(a bacteria) in water systems. The facility reported a census of 37 residents. Findings Include: 1. The Infection Prevention and Control Program policy, reviewed 5/19/22, stated the facility would provide a safe environment to help prevent the development and transmission of disease and infection and stated the facility would ensure compliance with State and Federal Regulations. The Minimum Data Set(MDS) assessment tool, dated 1/8/24, listed diagnoses for Resident #21 which included heart failure, urinary tract infection, and pain. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 8 out of 15, indicating moderately impaired cognition. A 2/7/24 Health Status Note stated the resident's eyes were red and swollen with drainage. On 2/7/24 at 8:10 a.m., Resident #21 sat at the breakfast table with 2 other residents. Resident #21 had a white substance in both corners of both of his eyes. Staff F Licensed Practical Nurse(LPN) administered the resident's eye drops while she wore gloves. She then took a tissue and wiped the resident's eyes multiple times while he sat at the table, removing some of the white drainage. Both residents at the table looked at Resident #21 as this was done. Staff F initially placed the used tissues directly on the table but then discarded them. As Staff F wiped the resident's eyes, she stated to Staff G Certified Medication Aide(CMA) that his eyes needed more than the eye drops and Staff G stated they obtained a culture. Staff F did not sanitize the table after she walked away. A 2/8/24 Health Status Note stated the resident's eyes remained reddened and staff applied antibiotic drops in both eyes. On 2/8/24 at 11:09 a.m., the Director of Nursing(DON) stated the resident's eyes should not be cleaned out at the breakfast table. 2. The facility Legionella Policy and Procedures , reviewed 9/2023, stated the facility would reduce the potential for infections caused by biological agents in water systems and stated the Maintenance department and the Infection Control Preventionist would monitor the facility's water system for the Legionella bacterium. The policy directed staff to run water in empty rooms at a minimum of weekly. On 2/8/24 at 10:45 a.m. Staff J Maintenance Assistant stated that he did not know what Legionella was and that his focus with the water in the facility was to decrease the amount of heavy metals. He stated they did not flush water lines in empty rooms. When queried as to what measures the facility carried out to assess for and prevent the risk of Legionella disease, he did not name any but stated he would like to obtain more information regarding Legionella. The facility lacked documentation of the following: a. An Assessment of (e.g., description of the building water systems using text and flow diagrams) where Legionella and other opportunistic waterborne pathogens grow and spread. b. Measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems that is based on nationally accepted standards such as visible inspections, disinfectant, and temperature control. c. A way to monitor measures in place (e.g., testing protocols, acceptable ranges), and established ways to intervene when control limits not met. On 2/8/24 at 11:47 a.m., the Administrator stated the facility was new to Legionella. She stated Staff J's last day will be Friday and they have a new Maintenance Supervisor who will go through the Life Safety Code(LSC) and will implement a plan.

Based on observation, record review, policy review, and staff interview, the facility failed to serve diets at the appropriate consistency for 5 of 5 residents receiving a mechanical soft diet (a soft diet consisting of finely chopped, blended, or ground foods). The residents received diced chicken instead of ground chicken at a meal. The facility reported a census of 37 residents. Findings include: The 12/7/23 facility Diet List revealed 5 residents on a mechanical soft diet. During the noon meal service on 2/7/24 at 11:56 a.m., Staff H Cook served 5 residents on a mechanical soft diet diced chicken with pieces approximately 1 centimeter in size. On 2/7/24 at 2:45 p.m., via phone, Staff I Speech Therapist, stated diced chicken would not be acceptable for residents on a mechanical soft diet and stated chicken should be ground. On 2/7/24 at 3:15 p.m., the Dietary Manager stated they sometimes used diced chicken for mechanical soft diets but stated she had wondered herself if this was appropriate. The undated policy Therapeutic and Mechanically Altered Diets stated a mechanically altered diet required specific preparation to alter the consistency of food in order to facilitate oral intake. The policy stated the facility would prepare all mechanically altered diets as planned.

Based on observation, interviews, and records review the facility failed to treat resident with dignity for 1 of 8 reviewed for dignity (Resident #3). Resident #3 was moved to the feeding table for assistance abruptly, expressed embarrassment and humiliation with being fed at the feeder table. The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) scored 14, which indicated no cognitive impairment. The MDS coded Resident #3 for eating, ability to use suitable utensils to bring food and liquid to the mouth, and swallow once the meal is placed before the resident. Diagnosis included cerebral infarction, dysphagia following cerebral infarction, viral hepatitis, cirrhosis, lung disease, hemiplegia (left side paralysis) depression, and bipolar. The Care Plan documented a Focus Area with initiated date of 9/4/2118 that the Resident had an Activities of Daily Living (ADL) self-care deficit related to status post stroke, that affected her left upper and lower extremities. The Care Plan directed staff as follows; a. the resident is independent with eating, but required set up assistance from staff b. the resident needed a plate guard at each meal, small portions, mechanical soft, with regular meat finely cut. The Progress Note dated 1/31/24 at 10:40 AM revealed increased coughing with eating and drinking. Staff has been assisting Resident #3 last couple of days, request for speech therapy to evaluate. Observation 2/5/24 at 12:15 PM Resident #3 in specialized wheel chair at feeding assist table in the main dining room, two staff seated at the table with other residents being fed. In in interview on 2/6/24 at 9:38 AM with Resident #3 stated wanted to lose weight, expressed is pleased with recent seven (7) pound weight loss. The Resident reported she, was put at the feeder table as a result and now they are poking food down me. Resident expressed she missed her best friend and her Aunt at her regular table. Relayed embarrassment at the feeder table, wanted to lose weight and felt punished. In an interview on 02/06/24 02:38 PM with the facility contracted dietician, relayed no weight concerns, confirmed resident lost seven pounds but no concerns or significant weight loss. Relayed every Tuesday visits the facility and updates are provided by the Director of Nursing (DON) or from her assistant. Relayed she was not aware resident was moved to the feeding assistance table, relayed she would expect to be informed about that change. In an interview on 2/6/24 at 2:55 PM with the Director of Nursing (DON) confirmed resident moved to assistance with feeding table not sure of the exact date, relayed resident having difficulty feeding self, not getting food to mouth. Relayed is pending a speech evaluation and was not aware resident felt she was moved to the feeding assist table because she lost weight. DON acknowledged, did not have a conversation with resident about the change. She did not know if there was a policy or process directing resident inclusion with decision making. Agreed to look for a policy on the process. On 2/7/24 at 09:59 AM, the DON relayed further information, stated the Certified Nursing assistant (CNA) felt Resident #3 was having more difficulty feeding self so she ensured a therapy communication note for assessment and moved the resident from her usual table with peers to the feeding assist table. The DON did not reveal any inclusion of resident for information or involvement. In an interview on 2/8/24 at 8:50 AM with CNA, Staff C confirmed had moved resident #3 to the feeding table last week. In an interview on 2/8/24 at 8:55 AM with CNA, Staff D acknowledge resident had received assistance if needed at her own table where she sat with her friend and a relative when there is enough staff. Stated any staff can move a resident to the feeder table if they need help and if there is not enough to help feed at their own table. In an interview on 2/8/24 at 8:58 AM with CNA, Staff B acknowledged she did assist with residents move to the feeder table last week and she did continue to stay at the feeder table last week and again this week. Speech Therapy Evaluation and Plan of Treatment form dated 2/6/24 reviewed, Assessment summary section documented resident is frustrated wanting to sit with her friend and her aunt in adjacent table. Reported felt embarrassed at the feeder table, Resident #3 wanted to self-fed, reported was placed at the feeder table due to weight loss. Resident #3 reported coughing and choking once in a while with chewy foods. Facility provided employee handbook, revised September 2023, directed under Resident Rights section, all residents must be treated with consideration, respect and full recognition of their dignity and individuality. Staff members are strongly encouraged to show respect when speaking, caring for or talking as an affirmation of their individuality and dignity.

Based on employee file review, policy review, and staff interview, the facility failed to complete a criminal background check to include a record check evaluation for 1 of 6 staff members reviewed (Staff A). The facility reported a census of 37 residents. Findings include: 1. The 7/1/23 Single Contact License and Background Check (SING), for Staff A Certified Nurses Assistant (CNA) documented further research was required for the criminal history background check and directed to await the final response for criminal history. A W-4 form for Staff A, CNA listed a first date of employment as 7/21/23. An Iowa Record Check Request Form S, dated 7/26/23, stated Staff A's criminal history was attached and listed a 5/9/22 arrest for operating while under the influence and an 8/7/22 arrest for driving while license denied or revoked. The facility lacked documentation of a Record Check Evaluation to determine if Staff A may work in the facility. The facility Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, updated October 2023, stated the facility would conduct criminal record checks for potential employees. On 2/7/24 at 3:12 p.m., the Administrator reported she could not locate a record check evaluation for Staff A but stated she expected this to be completed.

Based on observation, interview, and record review, the facility failed to thoroughly investigate concerns with staff treatment towards residents and failed to separate residents from an alleged perpetrator after staff had become aware of an allegation for three of four residents reviewed for abuse (Resident #14, Resident #15, Resident #22). This resulted in an immediate jeopardy to residents health and safety. The facility reported a census of 36 residents. Findings include: 1. The Significant Change Minimum Data Set (MDS) assessment for Resident #15 dated [DATE] documented the resident scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment for Resident #22 dated [DATE] documented the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, the resident required the extensive assistance of two plus persons for bed mobility and transfer. 2. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on [DATE] at 11:02 AM revealed Resident #22 seated in a recliner chair in the common area of the facility, did not respond verbally to questions asked, and nodded or shook their head in response. On [DATE] at 7:17 AM, when queried if she had been aware of any staff abuse, neglect, or name calling towards residents, Staff C, Certified Nurse Aide (CNA) Supervisor, explained she had not, or they would be in big trouble. On [DATE] at 10:19 AM, when queried if they had been aware of staff having been mean, rude, or calling residents names, Staff D, CNA, acknowledged there had been one individual. Staff D explained they had been transferring Resident #22 one day, the walker had hit the other staff member's (later identified as Staff B, CNA's) leg or knee, and Staff B had said if that leaves a bruise I'm coming back down here and kicking you in the [testicles]. Staff D further explained that Staff B called the resident an idiot, and maybe dumb [a*s]. Per Staff D, she had written papers on Staff B, and further explained she did not believe anything had been said to Staff B. When queried when the incident that involved the walker had occurred, Staff D replied maybe a month ago. When queried if she (Staff D) had directly witnessed the incident, Staff D responded they had, and just herself and Staff B had been present. On [DATE] at 10:19 AM, when queried about the statements they had written, Staff D explained they just put it on printer paper, and the statement would be written and signed. Staff D explained they had went and told Staff C. When queried which incidents had been turned in to the CNA Supervisor (Staff C), Staff D explained the incident where the walker had hit the staff. Staff D explained it had been hard to remember, and she believed she had handed in more than one paper. When queried if the concerns had ever been directly brought to the Director of Nursing (DON) or Administrator, Staff D explained she did not think so, and she had brought it to the CNA Supervisor. When queried when the incident that involved the walker had occurred, Staff D explained maybe a month ago. When queried if she (Staff D) had directly witnessed the incident, Staff D responded they had. Per Staff D, it had just been herself and Staff B. On [DATE] at 10:49 AM, when queried if they had been aware of staff having been mean, rude, or calling names, Staff E, CNA, identified one individual (Staff B). Staff E explained Staff B would say fat [a*s] (later clarified as to Resident #22), and explained she had witnessed that. When queried about the situation, Staff E explained the resident would not stand, and they had been trying to lift him. Staff E also explained Staff B told a resident (later identified as Resident #15) one time that her son had died . Staff B acknowledged she had witnessed this event. Staff E further explained that Resident #15 always said, Jesus Oh Lord, please help me, and would call for her son [Name Redacted]. Per Staff E, this had been when Staff B had said [Son's Name] can't help you he died . When queried about Resident #15's response, Staff E explained the resident had been like, oh really. Per Staff E, Resident #15 had taken it like this had occurred. When queried about an incident time frame, Staff B explained this had occurred about a month to a month and a half ago. On [DATE] at 10:49 AM, when queried as to what she had done, Staff E explained she had told someone, explained she did not know if it had been Staff C, CNA Supervisor, or she could not remember. Staff E explained she had been pretty sure she had made a statement. Staff E further explained she had made a couple of statements. When queried as to who she would give the statements, Staff E replied to Staff C or the Director of Nursing (DON). When queried as to whether she had done a statement pertaining to Resident #15, Staff E responded she thought she had done so, and she was not one hundred percent sure. On [DATE] at 10:49 AM, when queried as to how Resident #22 had responded when the resident had been called the name, Staff E responded the resident had not had a reaction. Staff E also explained the resident had been told, If you don't stand up I'll cut your [testicles] off. Per Staff E, the resident had not assisted with the cares, had been capable of doing so, and really only did so (not assist with the cares) with Staff B. Per Staff E, if other staff worked with Resident #22 he would assist with the care. Staff E acknowledged a couple of times they had not written statements. During an observation on [DATE] at 10:51 AM, Staff D CNA and Staff Q CNA rolled Resident #15 over in order to perform perineal cleansing. When staff assisted her to roll from side to side, the resident repeatedly stated oh my god. On [DATE] at 11:24 AM, when queried if she had encountered staff who treated residents rude, mean, or called them names, Staff F, CNA responded yes. Staff F, CNA explained she had heard her (Staff B), tell one resident he (Resident #22) was stupid, and Staff F also mentioned the word [Ret*rded]. Staff F acknowledged she had witnessed both events for Resident #22. When queried as to Resident #22's reaction, Staff F explained the resident had not had a reaction. Staff F explained the situation as trying to get the resident to stand, and something had been said like, Quit being [Ret*rded]. On [DATE] at 11:24 AM, Staff F explained the following pertaining to Staff B and Resident #15: Staff F explained Resident #15 liked to yell for God a lot, and Staff B would tell Resident #15 that God died of Covid, had gone to haven, was resurrected, and died . When queried further about the situation, Staff F explained Resident #15 would be yelling out God help me, and she would come off with that. When queried about Resident #15's response, Staff F explained the resident had not had a response. On [DATE] at 11:24 AM, when queried about what had occurred after the incidents happened, Staff F responded we've reported it, and explained she did not know if anything had ever been said as Staff B had still been working at the facility. When queried who she had reported it to, Staff F responded Staff C. When queried if she had reported to anyone else, Staff F responded, I really don't remember. When queried if she had ever heard of any follow up about the situation, Staff F responded no. Staff F also acknowledged she had never written a statement. When queried if the Administrator or Director of Nursing (DON) had asked her about any of the incidents, Staff F acknowledged this had not occurred. When queried as to the time frame the incidents involving Resident #15 and Resident #22 had occurred, Staff F explained it had been within the last year. During an observation on [DATE] at 11:44 AM., Staff C CNA Supervisor and Staff D assisted Resident #15 to transfer from the bed to the wheelchair using the mechanical lift. During the transfer, the resident repeatedly stated oh my god. On [DATE] at 12:34 PM, when queried about the duties included in their job role, Staff C, CNA Supervisor, explained the workers would come to her and would report things. Per Staff C, she would report to the DON and the QA (Quality Assurance).When queried about staff statements about concerns with care provided, Staff C mentioned Staff B. When queried how Staff B's name had come up, Staff C explained they came up to her and told her that she (Staff B) is not physical, but her mouth. Staff C explained it had been told to her that Staff B told Resident #22 to stand your fat [a*s] up, you need to grow up and not be a baby, and explained she could not remember all of it. Staff C explained this information had been communicated by CNAs, around three of them. Staff C then further explained there had been four (staff), but one was not at the facility. Per Staff C, all four had said that Staff B had made those type of statements, one staff would not fill out a paper as they had not wanted to get involved, and the other three staff had filled out statements. On [DATE] at 12:34 PM, when queried about written documentation of care concerns that a CNA notified her about, Staff C explained she would give this information to the DON after if had been given to her. When queried as to when CNAs would be instructed to write a statement, Staff C acknowledged this would occur when there had been harm to one of the residents, or a complaint from the resident it needed to be written down on a concern paper. Staff C acknowledged it would explain the concern and who it had been from. When queried if Staff C had kept a copy of those, Staff C responded no. On [DATE] at 12:34 PM, when queried about staff statements of concerns with care provided, Staff C mentioned Staff B. When queried how Staff B's name had come up, Staff C explained they had come up to her and told her that she (Staff B) was not physical, but her mouth. Staff C explained it had been told to her that Staff B told Resident #22 to stand your fat [a*s] up, you need to grow up and not be a baby, and explained she could not remember all of it. Per Staff C, this information had been communicated by CNAs, around three of them, then explained four but one was not at the facility. Per Staff C, all four had said that Staff B had made those type of statements, one staff would not fill out a paper as they had not wanted to get involved, and the other three staff had filled out statements. When queried as to where the statements had gone, Staff C explained they had gone to the DON. On [DATE] at 12:34 PM, Per Staff C, she explained the DON had told her (Staff C) that she was going to talk to Staff B, and see what for sure had went on. Per Staff C, she had not witnessed it, and it (information) had been persons coming to her. Staff C explained she had gone into Resident #22's room and and had asked the resident if he thought he had been abused. Per Staff C, she did not think the resident had understood, and had asked the resident if someone had called him names that hurt his feelings. Per Staff C, the resident told Staff C no. When queried as to what had occurred after that, Staff C responded they did not think anything, and further explained the had not heard anything for awhile. When queried about the time line of when the incidents had occurred, Staff C responded a few months ago, maybe three or four months. When queried if there had been follow up after statements had been given to management, Staff C responded no. On [DATE] 12:34 PM, when queried if Staff B had been taken off of the schedule, Staff C, who also did CNA scheduling, responded not that she had been aware of. Staff C explained the following communication with Staff B: Per Staff C, Staff B had said that she had not meant nothing by it but it had slipped out. When queried what had slipped out, Staff C explained she could not remember specifics. Staff C then explained that she had told her (Staff B) that had been abuse and it could not slip out. Staff C explained she had told Staff B how would you feel if someone said something to you [family member], and explained that had been what Staff B had to think of. Per Staff C, the DON had been going to speak with Staff B as well. On [DATE] at 12:56 PM, when queried about concerns with staff treatment towards residents by staff, Staff B, CNA denied concerns. When queried who she would notify if she had witnessed concerns, Staff B explained she would tell the Charge and go up the chain of command. When queried about Resident #22's participation in cares, Staff B explained sometimes he participated and sometimes he did not. When queried about concerns caring for Resident #22 and Resident #15, Staff B denied concerns. On [DATE] at 1:06 PM, when queried as to the process for communication of CNA concerns of staff treatment to residents, the Director of Nursing (DON) explained staff could come to any of the team leaders. Per the DON, staff had concern papers available to actually write down what they had observed/heard, and they could hand to them for follow up from there. The DON acknowledged anyone could take concern papers. When queried about statements from Staff C, the DON explained she would bring them to the Administrator or the DON. Per the DON, if it was an immediate situation, staff would go immediately to the Charge Nurse if she was not in the building. On [DATE] at 1:06 PM, the DON denied statements of concerns of how staff had treated residents in the last year, and also denied concerns with Resident #22 in the last year. The DON then explained Staff C had come to her a little bit ago and had told her some things that had happened. The DON explained she had been unaware of them until that point. The DON clarified a little bit ago as today ([DATE]), and explained a discussion had occurred because abuse education had occurred many times. The DON explained there had been no written concerns for Resident #22 in the last year, nor Resident #15. On [DATE] at 1:24 PM, when queried if they had knowledge of staff treating residents in a concerning way, the Administrator explained they did not think they had heard of anything in the last year. When queried if they received statements of staff concerns with treatment to other residents, the Administrator explained they had forms where staff to staff or staff to residents could be written. When queried about communication of staff concerns pertaining to how another staff treated residents, the Administrator explained this information would be brought to the DON or Administrator. When queried if it would be appropriate to bring this information to the CNA Supervisor, the Administrator responded it would not, and would be brought to the DON or Administrator because they would initiate the investigation. When queried about investigations and/or statements/incidents for Resident #15 and Resident #22, the Administrator responded she knew she did not have any because when they got them they would be addressed. On [DATE] at 2:17 PM, the Director of Nursing (DON) explained she did not have any staff concern papers. Review of the Facility Policy titled Dependent Adult Abuse Prevention, Identification, Investigation and Reporting Policy, review date [DATE], documented, in part, the following per the investigation section: All allegations of Resident abuse shall be reported immediately to the Administrator or designated representative. The employee reporting the abuse or suspected abuse shall complete a thorough written account of the incident. Should an incident or suspected incident of Resident abuse (as defined above) be reported or observed, the Administrator or his/her designee will designate a member of management to investigate the alleged incident. The administrator or designee will review documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident. 3. The Annual Minimum Data Set (MDS) assessment tool, dated [DATE], listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS listed the resident's BIMS(Brief Interview for Mental Status) score as 15 out of 15, indicating intact cognition. An [DATE] Care Plan entry directed staff to discuss with the resident her concerns and fears. A [DATE] Care Plan entry stated the resident had mood/depression episodes and a cycling pattern of highs and lows. The Residents' Bill of Rights, reviewed [DATE], stated the facility must treat each resident with respect and dignity and must protect and promote the rights of the resident. During an interview on [DATE] at 1:36 PM, the resident stated Staff N Former Administrator told her to quit (expletive) calling here. During an interview on [DATE] at 3:40 PM, Staff O Social Worker stated she remembered she assisted the resident to report her complaint about Staff N to the State Agency. She stated she could not locate any additional information related to the complaint. The facility lacked any additional documentation or investigation of the resident's complaint regarding Staff N. The facility lacked documentation they separated Staff N from residents after the allegation. During an interview on [DATE] at 9:20 AM, the Director of Nursing (DON) stated she did not know about the resident's complaint related to Staff N until just the other day. During an interview on [DATE] at 8:23 AM, the Administrator stated the facility had no disciplinary issues with Staff N. She stated she did not know of any complaints coming from residents regarding Staff N. During an interview on [DATE] at 9:40 AM, Staff C CNA(Certified Nursing Assistant) Supervisor stated Staff N was rude to residents and staff. She stated 2 residents(one who was Resident #14) would call the nursing station and Staff N picked up the phone and hung up on them. She stated after this occurred, Staff N continued to work at the facility. The facility lacked documentation they reported the allegation to the State Agency. During an interview on [DATE] at 1:22 PM, the Administrator stated she had no file on Staff N. She stated he began employment at the facility in [DATE] and his last day was [DATE]. During an interview on [DATE] at 3:41 PM, the DON stated staff should not state they would take resident phones away. It was the resident's right to have a phone. She stated she did not hear about the complaints related to Staff N until the time of the survey. She stated the facility should investigate and report such things and separate the residents from the staff member. During an interview on [DATE] at 8:54 AM, the Administrator stated she was not aware that Staff N hung up on the resident. During a follow-up interview on [DATE] at 8:12 AM, Staff C stated Staff N told her and other staff to go down to the resident's room and take her phone away. Staff C stated she informed Staff N she could not do that. She stated she witnessed Staff N hang up the phone on Resident #14 several times. The IJ template was provided to facility on [DATE] at 10:30 a.m. The IJ was removed on [DATE] after the facility implemented the following corrective actions. -The facility re-educated management staff on the abuse policy/reporting/investigating abuse -A complete head to toe assessment was completed on involved residents -Abuse will be reported /investigated per policy -Employee was suspended -Staff were re-educated on the abuse policy/reporting/investigating -An audit was completed to ensure all employees have the Dependent Adult Abuse required training -An audit was completed to ensure no other potential abuse has occurred in the building -Audits to be completed periodically -Bring results to QAPI meeting The scope and severity of a K level has been lowered to E level deficiency as the facility will need to ensure staff complaisance with abuse policy.

Based on observation, clinical record review, and staff interview, the facility failed to failed to administer the correct medication dose for 1 of 2 residents reviewed taking potassium(Resident #15), failed to ensure properly qualified staff assessed and administered insulin for 1 of 4 residents observed during medication administration(Resident #21), failed to ensure qualified staff assessed and administered oral medications for 1 of 17 residents in the sample(Resident #16), and failed to ensure qualified staff assessed and administered nebulizer treatments for residents as a general practice in the facility. The facility reported a census of 36 residents. Findings: 1. The Significant Change Minimum Data Set (MDS) assessment tool, dated 6/6/22, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 6/21/22 order written on the resident's Hematology report directed staff to decrease the resident's potassium to 20 mEq(milliequivalents) daily. The resident's June 2022 MAR(Medication Administration Record) displayed a 6/21/22 order for potassium 20 mEq/15 ml(20 mEq) twice daily. The resident's July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A 7/30/22 Progress Note stated the resident received the wrong concentration of potassium since 6/21/22. A pharmacy Packing Slip stated the pharmacy provided the resident with potassium chloride solution 20%(40 mEq/15 ml) on 6/21/22. During a telephone interview on 8/4/22 at 12:55 p.m., Staff K Pharmacy Technician stated that potassium 20% was equivalent to 40 mEq/15 ml. He stated the pharmacy should have sent the 10% concentration. During a telephone interview on 8/4/22 at 1:00 p.m., Staff L Pharmacist stated they should have sent the 10% potassium or should have sent direction to give 7.5 ml. She stated they would turn that into their QA(Quality Assurance) because it was a medication they had on high alert. Stated they should have put the mEq/ml on the label. During an interview on 8/3/22 at 2:00 p.m., Staff I Certified Medication Aide (CMA) stated she discovered the resident received the wrong concentration of potassium and she informed the nurse. During an interview on 8/9/22 at 3:41 p.m., the Director of Nursing (DON) stated if a medication was incorrect, staff should return it from the pharmacy. She stated Staff I discovered the error and the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 2. The Quarterly Minimum Data Set (MDS) assessment tool, dated 6/23/22, listed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 7/27/22 at 12:16 p.m., Staff I (CMA) obtained Resident #21's blood sugar and stated she planned to administer the resident's insulin. Staff I retrieved the resident's [MEDICATION(S)](a type of insulin) pen from the cart and stated she intended to administer 8 units. The surveyor asked Staff I to clarify her credentials and she stated she was a CMA. She stated she administered insulin at the facility since she became a medication aide and stated that was 2 years ago. The surveyor suggested they speak with the Director of Nursing (DON). The surveyor and Staff I went to the DON and she stated CMA's administered insulin at the facility and did so at her former facility as well. The DON stated she would check into it and stated Staff A RN(Registered Nurse) would administer the insulin. The surveyor observed Staff A administer Resident #21's insulin. During an interview on 8/2/22 at 10:48 a.m., the DON stated the instructor of the medication aide course taught the course incorrectly and educated students that CMAs were able to administer insulin. She stated she completed education with Staff I and reviewed her job description. The CMA Job Description, reviewed 8/1/22, stated Medication Aides could administer oral, topical, and rectal medications. A Performance Improvement Plan, dated 8/1/22, stated CMAs could not draw up or administer injectable's such as insulin The MDS assessment tool, dated 6/23/22, listed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 8/1/22 at 12:16 p.m., Staff I CMA(Certified Medication Aide) obtained Resident #21's blood sugar and stated she planned to administer the resident's insulin. Staff I retrieved the resident's [MEDICATION(S)] pen from the cart and stated she intended to administer 8 units. The surveyor asked Staff I to clarify her credentials and she stated she was a CMA. She stated she administered insulin at the facility since she became a medication aide and stated that was 2 years ago. The surveyor suggested they speak with the DON(Director of Nursing). The surveyor and Staff I went to the DON and she stated CMA's administered insulin at the facility and did so at her former facility as well. The DON stated she would check into it and stated Staff A RN(Registered Nurse) would administer the insulin. The surveyor observed Staff A administer Resident #21's insulin. During an interview on 8/2/22 at 10:48 a.m., the DON stated the instructor of the medication aide course taught the course incorrectly and educated students that CMAs were able to administer insulin. She stated she completed education with Staff I and reviewed her job description. The CMA Job Description, reviewed 8/1/22, stated Medication Aides could administer oral, topical, and rectal medications. A Performance Improvement Plan, dated 8/1/22, stated CMAs could not draw up or administer injectable's such as insulin. 3. The Significant Change MDS assessment tool, dated 6/13/22, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The July 2022 Routine Medications report included the following medications administered to Resident #16: [MEDICATION(S)](for constipation) 100 mg(milligrams) one capsule by mouth every other day, [MEDICATION(S)](for depression) 100 mg by mouth daily, and [MEDICATION(S)](a narcotic pain medication) 5/325 mg by mouth four times a day. During an interview on 8/9/22 at 10:05 AM, Staff E CNA(Certified Nursing Assistant) stated she observed a staff nurse set up medications for Resident #16 and hand them to Staff B CNA. Staff B then took the resident down to Resident #16's room and closed the door. Staff E stated she was not sure which nurse did this. During an interview on 8/9/22 at 10:50 AM., Staff F CNA stated she observed 2 staff nurses setting up medications for Resident #16 and Staff B CNA took the medications down to Resident #16's room and closed the door. During an interview on 8/9/22 at 11:13 AM., Staff A RN stated CNAs could not administer medications. 4. During an phone interview on 8/10/22 at 10:37 a.m., Staff S CNA stated the nurses gave them the liquid nebulizer medication and she placed the medication into the nebulizer machine. She stated all of the nurses did this and the nurses were not present when she gave the nebulizer medication. During a phone interview on 8/10/22 at 10:42 a.m., Staff R CNA stated the nurses placed nebulizer medication into the resident's nebulizer and when the resident was ready to take the medication she turned the machine on and off. She stated she did not observe the nurses placing the medication into the nebulizer as they did this earlier in the shift. The facility policy Administering Medications, revised December 2012, stated only persons licensed may administer medications. The policy stated staff should administer medications in accordance with the orders and directed staff to check the medication label 3 times to verify the correct dosage. During an interview on 8/9/22 at 3:41 p.m., the DON(Director of Nursing) stated she did not hear of CNAs administering medications. She stated if other staff witnessed this, they should report it.

Based on clinical record review, policy review, resident interview, and staff interview, the facility failed to ensure staff treated residents with dignity and respect for 1 of 5 residents reviewed for dignity(Resident #14). The facility reported a census of 36 residents. Findings: 1. The Annual Minimum Data Set (MDS) assessment tool, dated 6/3/22, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. An 8/23/13 Care Plan entry directed staff to discuss with the resident her concerns and fears. A 6/11/18 Care Plan entry stated the resident had mood/depression episodes and a cycling pattern of highs and lows. The Residents' Bill of Rights, reviewed on 6/2/22, stated the facility must treat each resident with respect and dignity and must protect and promote the rights of the resident. On 8/1/22 at 1:36 PM, the resident reported Staff N Former Administrator told her to quit (expletive) calling here. On 8/3/22 at 3:40 PM, Staff O Social Worker stated she remembered she assisted the resident to report her complaint about Staff N to the State Agency. She stated she could not locate any additional information related to the complaint. The facility lacked any additional documentation of the resident's complaint regarding Staff N. During an interview on 8/8/22 at 9:20 AM, the Director of Nursing (DON) stated she did not know about the resident's complaint related to Staff N until just the other day. During an interview on 8/9/22 at 8:23 AM, the Administrator stated the facility had no disciplinary issues with Staff N. She stated she did not know of any complaints coming from residents regarding Staff N. During an interview on 8/9/22 at 9:40 AM, Staff C Certified Nursing Assistant (CNA) Supervisor stated Staff N was rude to residents and staff. She stated 2 residents(one who was Resident #14) would call the nursing station and Staff N picked up the phone and hung up on them. She stated after this occurred, Staff N continued to work at the facility. The facility lacked documentation they reported the allegation to the State Agency. During an interview on 8/9/22 at 1:22 PM , the Administrator stated she had no file on Staff N. She stated he began employment at the facility in January 2020 and his last day was 12/11/20. During an interview on 8/9/22 at 3:41 PM, the DON stated staff should not state they would take resident phones away. It was the resident's right to have a phone. She stated she did not hear about the complaints related to Staff N until the time of the survey. She stated the facility should investigate and report such things and separate the residents from the staff member. During an interview on 8/10/22 at 8:54 AM, the Administrator stated she was not aware that Staff N hung up on the resident. During a follow-up interview on 08/11/22 at 8:12 AM, Staff C stated Staff N told her and other staff to go down to the resident's room and take her phone away. Staff C stated she informed Staff N she could not do that. She stated she witnessed Staff N hang up the phone on Resident #14 several times.

Based on clinical record review, observations and staff interviews the facility failed to provide care consistent with professional standards of practice, to prevent a pressure ulcer from developing for 1 of 1 sampled (Resident # 3). The facility reported and census of 49. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident # 3 had a Brief Interview for Mental Status (BIMS) of 6 indicating severe cognitive impairments. The MDS indicated Resident #3 required extensive assistance of 2 staff for bed mobility, transfers, walking in room, dressing and toileting. The MDS included [DIAGNOSES REDACTED]. Resident #3 had a risk of developing pressure ulcers and had a surgical wound. The MDS revealed Resident #3 readmitted to the facility on [DATE]. The Care Plan updated 2/6/20 identified a skin impairment to Resident #3's left heel and directed staff to ensure gel protectors on both wheel chair pedals. The Care Plan updated 2/17/20 directed the staff to utilize a pressure relieving mattress, heel protectors while in bed or recliner, float heels to protect the skin while in bed and weekly treatment documentation for each area of skin breakdown (width, length, depth, type of tissue and exudate and any other notable changes or observations). The Care Plan updated 2/17/20 identified a left hip repair related to a fall and directed staff to reposition as necessary to prevent skin breakdown. The Braden Scale for Prediction Pressure Sore Risk sheet dated 1/27/20 revealed Resident #3 scored a 14 indicating a moderate risk. The Wound/Skin Healing Record provided the following Descriptions of Stages for Arterial, Diabetic, Vascular and Pressure Ulcers: a. Stage I - An observable pressure -related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameter; skin temperature (warmth or coolness), tissue consistency (firm or boggy), sensation (pain, itching) and or a defined areas of persistent redness in light pigment skin, whereas in darker skin tones the ulcer may appear with persistent red, blue or purple hues. b. Stage II - Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. c. Stage III - Full thickness loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. d. Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts also may be associated with Stage IV. The Nurse's Admission assessment dated [DATE] identified Resident #3 had the following skin issues: a. Multiple bruises on the left hand from an intravenous site. b. Multiple bruises on the right hand from intravenous site. c. A bruise to the left hip that measured 14 centimeters (cm) by 10 cm to the left hip. d. A surgical incision to the left hip that measured 17 cm by 0.5 cm with 25 staples. The Skilled Flow Sheet dated 2/6/20 revealed during a shower the staff identified Resident #3's left heel had a red area measuring 3.5 cm by 4.2 cm with a black center measuring 2.4 cm by 2 cm. The Nurse applied skin prep to the area. The fax notification sheet dated 2/6/20 revealed the staff notified the physician Resident #3 had an area of the left heel that measured 3.5 cm by 4.2 cm with red outer edge and a black center that measured 2.4 cm by 2 cm. The staff reported they applied skin prep and requested to continue with the treatment. The Physician approved the treatment. The Skin Condition Report for Non-Pressure Sore Skin Conditions dated 2/6/20 documented Resident #3's heel area first observed on 2/6/20. The area measured 3.5 cm (length) by 4.2 cm (width) with a 2.4 cm by 2 cm black center. The black center not open and no odor or drainage. The staff applied skin prep and notified the physician. On 2/12/20, the area measured 3.3 cm by 3.5 cm, not open, with a 1.8 cm by 2 black center, no drainage, and continue initial treatment. On 2/19/20, the area measured 3.3 cm by 3.6 cm, not open, and red/purple edges with black center. The February Treatment Record revealed an order started on 2/7/20 to apply skin prep to Resident #3's left heel every day. The Skin Care Program policy revised 2/28 revealed a commitment to provide a comprehensive pressure ulcer prevention and management program to ensure that residents do no develop pressure ulcers unless the individual's clinical condition demonstrates they are unavoidable. Any resident with a pressure ulcer will receive treatment and services consistent with the resident goals of treatment. Typically, the goal will be one of promoting healing and preventing infection unless resident preferences and medical condition necessitate palliative care as the primary focus. The policy directed for a Braden score of 13 - 16 to completed weekly skin checks, place a cushion in the wheelchair, heel protectors, float heels/ elbows with pillows, foot cradle if needed, and consider supplements and vitamin therapy. Observation on 2/18/20 at 9:08 a.m. Resident # 3 wearing bilateral cushioned boots. Observation on 2/18/20 at 3:51 p.m. Resident #3 sitting in her wheelchair with cushioned boots on bilateral feet out in the day room watching TV. Observation on 2/19/20 at 10:35 a.m., revealed Staff A (Licensed Practical Nurse) applied skin prep to Resident # 3's left heel. Staff A used hand sanitizer and donned gloves. Staff A wet 2 wash clothes and removed Resident #3's cushioned boot, gripper sock and pulled up the support stocking. Staff A cleansed Resident #3's left heel with soapy water, rinsed with a wet wash cloth and dried the area. The left heel had a white color over a pink center with dark edges. Staff A explained it looked worse since yesterday. Staff A applied skin prep in a circular motion, then pulled the [MEDICAL CONDITION] wear down and put the gripper sock on then the cushioned boot. Staff A took off right cushioned boot and gripper sock off and looked at right foot it looked clear no issues. Staff A then put the gripper sock and cushioned boot back on. Resident #3 had a gel pad in her seat cushion, gel pads taped to the wheelchair pedals, the left foot peddle the gel cushion had moved up about an inch and the hard metal wheelchair pedal exposed. Observation and Interview on 2/19/20 at 1:29 p.m., revealed Staff B (Registered Nurse/Wound Nurse) entered Resident #3's room. Staff B washed her hands and donned gloves. Staff B removed the cushioned boot, gripper sock and pulled up the compression stocking on Resident #3's left foot. Staff B measured the left heel wound. The area measured 3.3 cm by 3.6 cm. Staff B reported pressure as the source of the wound. Staff B reported she failed to document the wound as pressure because the Physician had to make the determination. Staff B reported the Physician had knowledge of the area but had not seen the area. Staff B removed her gloves and washed her hands. Staff B pointed out a wound/shin healing record form in the medication room. The record had pictures and explanation of stages of ulcers. Staff B reported Resident # 3's heel looked like or worse then the photos of the Stage 1 pressure ulcer. Resident #3 had a gel pad in her seat cushion and gel pads taped to the wheelchair pedals. The gel on the left foot pedal had moved exposing the metal foot pedal. During an interview on 2/20/20 8:36 a.m., the Director of Nursing (DON) confirmed the facility failed to implement interventions to prevent the wound. The DON reported she expected interventions due to Resident # 3's history of skin issues and recent hip surgery. The DON reported the facility implemented the cushioned boots the day they found the area on 2/6/20. During an interview on 2/20/20 at 10:43 a.m., with the DON reported the previous Administrator directed the staff not to document the type of ulcer until the physician determined the source. The DON acknowledged the Physician had not seen Resident #3 heel yet. During an interview on 2/20/20 at 10:52 a.m., the DON asked Staff B (Wound Nurse) if she talked to Resident #3's Physician. Staff B reported no. Staff B explained she faxed the Physician when the staff identified the area.

Based on observation, record review and staff interviews, the facility failed to prevent the development of unavoidable pressure ulcers and failed to provide timely interventions to promote healing. The sample consisted of 3 residents and the facility reported a census of 45 residents. Resident #3 had a history of [REDACTED]. On 4/23/17, the resident developed another pressure ulcer on the coccyx area. The facility added interventions on 4/27/17 (during the investigation) which consisted and included a referral to an occupational therapist regarding an ill-fitting wheelchair, placement of an alternating air mattress on the bed, and removal of a soaker pad and overlay on the mattress. Findings include: Resident #3 had a MDS (Minimum Data Set) assessment with a reference date of 1/20/17. The MDS indicated Resident #3 had short and long term memory deficits and severely impaired cognitive abilities for daily decision making. Resident #3 required total dependence on care givers for mobility, transfers, dressing, toilet use and personal hygiene needs. The MDS identified the resident as always incontinent of bowel and had a suprapubic catheter (tube in abdomen that removes urine from bladder). Resident #3's [DIAGNOSES REDACTED]. The MDS described the Stages of pressure ulcer as the following: Stage I-An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness), tissue consistency (firm or boggy), sensation (pain, itching; and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues). Stage II-Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. Stage III-Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. Stage IV-Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The Care Plan identified the resident at risk for impaired skin integrity due to incontinence, impaired mobility and poor nutritional status with recurrent history of pressure ulcers on 1/29/14 and revised on 2/8/17. The interventions included and directed the staff to lay the resident in bed between each meal to relieve pressure, keeping head of bed at 30 degrees and use a soaker pad or turn sheets when repositioning. Addendum dated 4/27/17 indicated Resident #3 is provided a continuous alternating air mattress for bed to reduce pressure, Resident #3 is to be last resident up and first resident to lie down for meals. The interventions directed staff to turn the resident side to side so the resident remained off of coccyx/sacral area and a body pillow to provide positioning support. The interventions dated 4/27/17 (during the investigation) had interventions to continue to use an alternating airflow mattress on the bed for pressure reduction and to not use a soaker pad on the bed. The intervention directed the staff to use a sheet folded in half with a disposable chux pad. The interventions included to leave the area open to air; without a brief and have therapy evaluate for positioning in the wheelchair. The Braden Scale-for the prediction of pressure sore risk dated 2/2/17 identified the resident at a moderate risk. On 4/27/17, the scale increased to high risk for the development of pressure ulcers. The form titled Wound/Skin Healing Record noted on 4/10/17, an onset of a pressure ulcer, Stage II, on the left lower buttocks (ischial tuberosity). The record identified the nurse monitored the pressure ulcer weekly. The TAR (Treatment Administration Record) identified the pressure ulcer treated daily. On 4/10/17 the area measured 1 cm (centimeters) by 1 cm by 1.5 cm. On 5/1/17, the area measured 1 cm by .5 cm. The Wound/Skin Healing Record indicated the staff identified a coccyx pressure ulcer on 4/23/17. On 4/24/17, the assessment determined the area to be a Stage III and measured 2 cm by .8 open area and 3 by .5 cm purple area. The Occupational Therapy Plan of Care dated 4/28/17 indicated Resident #3's reason for referral was evaluation due to an ill- fitting wheelchair. Initial assessment found the resident's current wheelchair too narrow, causing the development of coccyx ulcers and have further skin breakdown. An identified goal was to obtain a new custom wheelchair in order to reduce skin breakdown and increase the resident's quality of life. On 4/27/17 at 2:15 p.m. and again on 5/1/17 at 2:20 p.m. the Director of Nursing (DON) was interviewed and stated Resident #3 has a history of recurrent pressure ulcers which have typically healed with treatment. DON stated the resident currently has an ulcer on his/her left lower buttocks and coccyx area. The DON stated on 4/18/17, the treatment team had discussed evaluating Resident #3's positioning in his/her wheelchair as a potential contributing cause. An Occupational therapy evaluation was completed 4/27/17. The DON stated she had not seen the results to date. The DON stated on 4/27/17 she moved Resident #3 into a room with a continuous alternating air mattress and the Care Plan updated. The DON stated she believed Resident #3 developed pressure ulcers due to poor positioning. The DON stated residents should be repositioned every hour while in a chair and every two hours while in bed. During an observation on 4/27/17 from 8:00 a.m. until 12:24 p.m. Resident #3 remained in his/her wheelchair the entire time with no observations of staff attempting to reposition him/her or off load pressure areas from the wheelchair. In an interview on 4/27/17 at 1:30 p.m. Staff A, certified nurse aide, stated Resident #3 was assisted up and cared for early that morning and brought to the dining room. Resident #3 would usually be taken back to his/her room after breakfast, but remained in the wheelchair due to needing to see the podiatrist. Resident #3 remained in the wheelchair all morning. Staff A stated she was not involved with any other cares with Resident #3, until assisting his/her to bed at 1:30 p.m. In an interview on 4/27/17 at 1:40 p.m. Staff B, certified nurse aide, stated she assisted with getting Resident #3 up this morning and took him/her to breakfast. Typically Resident #3 would be taken to bed after breakfast, but today waited to see the podiatrist and remained in his/her wheelchair. Staff B stated she repositioned Resident #3 one time while in his/her wheelchair around noon by shifting him/her on the seat pad. Staff B could not recall whether she utilized a pillow to support Resident #3. Staff B stated she and Staff A put Resident #3 to bed around 1:30 p.m. and provided incontinence cares at that time. On 4/26/17 at 2:30 p.m. the nurse changed the resident's dressings on the left lower buttocks and coccyx. Observation identified both wounds as Stage II. The staff positioned the resident onto the right side.

Based on clinical record review, facility policy, staff and resident interviews the facility staff failed to provide mechanical lift transfers for Resident #8 in a manner to prevent resident injury. The facility reported a census of 47 residents. Findings included: The Minimum Data Set (MDS) assessment for Resident #8, dated 8/18/14, indicated the resident with a BIMS (brief interview for mental status) of 15 which indicated intact cognition. Resident #8 required extensive assist of two or more staff members for bed mobility, transfers and hygiene cares. The MDS indicated the resident required a wheelchair for mobility. [DIAGNOSES REDACTED]. Resident #8's plan of care with a goal date of 12/03/14 instructed staff to transfer Resident #8 with two staff members and the use of a mechanical lift for transferring. The care plan directed staff members to make sure Resident #8 has shoes on during transfers. On the fall risk assessment sheet dated 02/21/14, 05/27/14 and 08/28/14 staff documented a score of 11 that indicated Resident #8 to be at high risk for a fall. On 09/09/14 at 2:00 p.m. during a resident interview, Resident #8 stated that he/she had received a fracture to one of his/her toes during a transfer. The resident noted that although it was an accident, it probably should not have happened. Review of the clinical record revealed an entry on 04/09/14 at 4:10 p.m. documented at approximately 3:20 p.m. two certified nursing assistants were transferring the resident from bed to wheelchair. During the transfer the resident's great right toe became caught on the wheelchair pedal causing the toe to become overextended. The documentation noted that although the toe had range of motion the resident complained of increased pain to the top of the foot and toes. The resident primary care provider had been notified and orders received for radiology of the right foot by mobile radiology. On 04/10/14 at 3:30 p.m. the staff documented the resident's great toe with swelling and light purple bruising noted with the resident complaining of pain and discomfort to the area. The staff documented the radiology report revealed a non-displaced fracture at the base of the first proximal phalanx. On 04/11/14 at 11:45 a.m. the staff documented a new order received to repeat the x-ray in two weeks and to place an ice bag to the right foot two times a day as needed. On 04/25/14 the staff documented the repeat x-ray revealed soft tissue swelling of the foot predominantly the dorsum of the foot with a non-displaced fracture seen at the base of the 1st proximal phalanx. On 06/23/14 a radiology report noted soft tissue swelling of the foot predominantly the dorsal aspect of the foot, with a healing fracture at the base of the proximal phalanx of the right great toe. The facility document for Mechanical lift transfer procedure instructed the staff to: Assemble necessary equipment, two staff must be present, explain procedure to resident, provide privacy, wash hands, move obstruction from under the transfer area, including wheelchair pedals, place lift sling under the resident, set lift legs to widest position, keep the resident centered between legs of the base and facing toward the person operating the lift, lower the lift and place hooks in the appropriate holes of the sling, cross the resident's arms over chest, lock wheelchair brakes, raise resident with appropriate lever, guide the resident to surface of transfer, protecting legs and feet from contact with the object and lower resident slowly to bed or chair, unhook the sling after the resident is seated, position the resident comfortably with call light in reach and wash hands. Interview with Staff C, certified nursing assistant (CNA) on 09/09/14 at 3:00 p.m. revealed that on 04/09/14 Staff C and Staff D had been transferring Resident # 8 from the bed to wheelchair with a mechanical lift. Staff C indicated he had been running the lift and Staff D had been holding on to the back of the sling. Staff C stated he had a hold of the resident's legs and as he lowered the resident into the wheelchair, the resident's foot got caught under the wheelchair pedal. Staff C stated they failed to remove the wheelchair pedals, even though they had been trained to do so, because they just forgot. Staff D, CNA, had terminated her employment with the facility had not been available for an interview. On 09/11/14 at 9:20 a.m. the facility director of nursing (DON) stated that she would have expected the staff to follow the facility policy and remove the wheelchair pedals from the wheelchair. The DON stated the facility did not submit a self-report to the Department of Inspections and Appeals because the former administrator did not consider the incident a major injury because it did not change the resident's level of care.

Based on clinical record review, staff interviews, physician interview, and family interviews, the facility failed to provide nursing provisions with accurate assessment and timely interventions for two residents (Resident #6 and Resident #5) who experienced an adverse change in his/her physical condition. Resident #6 had a decline in his/her physical condition and decrease in fluid intakes, resulting in hospitalization with dehydration and a critical sodium level of 174 (normal range 136 to 145). Record review and staff interviews identified Resident #6's intake was low and the resident was declining. The resident's physician reported the facility staff did not notify her of Resident #6's declining condition, or that the resident was not eating or drinking. The facility reported a census of 54 residents with six residents reviewed. Findings include: 1. According to the quarterly Minimum Data Set (MDS) assessment with a reference date of [DATE], Resident #6 scored 7 on the BIMS (Brief Interview for Mental Status) test. A score of 7 indicated the resident had severely impaired cognition skills for daily decision making skills.The MDS indicated the resident demonstrated independence for all activities of daily living (i.e., eating, dressing, bathing, personal hygiene, bed mobility, transfers, and walking.) The MDS indicated the resident had an unsteady balance but could steady self without staff assistance and had no functional limitations. The resident's [DIAGNOSES REDACTED]. The assessment identified the resident had no swallowing, nutritional problems, or dehydration conditions, with a weight of 113 pounds at 62 inches tall. The care plan with team conference date of [DATE] instructed staff to encourage the resident to stand slowly, report changes in balance, provide assistance of one staff as needed if resident appeared unsteady. The care plan indicated the resident had a fall on [DATE] and interventions would be added when the resident returned from the hospital. A incident/accident report dated [DATE] at 7:25 a.m. indicated the resident had been found sitting on the floor next to the right side of the bed on buttocks with knees pulled up to chest. Assessment revealed the resident had full range of motion to all extremities while on the floor and resident denied discomfort. The report indicated that after two staff assisted the resident from the floor, and proceeded to ambulate to the dining room the resident began complaining of pain to the right leg/groin, placed in a wheelchair and taken to nurses station. The nurses notes dated [DATE] at 7:50 a.m. indicated the physician had been notified of the fall and orders received to transfer the resident to the emergency room . At 11:25 a.m. Staff F contacted the hospital for an update and noted the resident had been admitted for a right [MEDICAL CONDITION]. On [DATE] Staff B, LPN contacted the hospital for a condition update and documented the resident's surgery had been postponed due to an elevated troponin level and abnormal EKG. On [DATE] at 5:10 p.m. Staff A, RN documented the resident had returned to the facility from the hospital. The nurses notes dated [DATE] at 10:30 p.m. Staff H, LPN documented the resident had been found lying on the floor beside the bed with the call light on the bed. The side rails were up on both sides of bed. The resident did not know how he/she fell , denied hitting head, assessment revealed neuro checks normal, range of motion to all extremities intact and resident denied pain. Staff H documented the resident had been covered up on floor, oxygen reapplied and notified the physician and POA (power of attorney). The resident had been transferred to the emergency room for evaluation. The nurses notes dated [DATE] at 00:30 a.m. the emergency contacted facility nurse and stated the X-ray revealed no fractures and the resident would be returned to the facility. The resident returned to the facility at 1:00 a.m., placed into bed by ambulance crew and repositioned to right side. Facility staff placed pin alarm and call light on resident, assessment completed, toilet offered and declined. The resident was left to rest. At 4:30 a.m. the resident attempted to get out of bed by self to use the bed side commode, the call light had been within reach. The resident assisted to the commode by three staff, then back into bed. The call light and bed alarm were reattached to resident. On [DATE] at 7:40 a.m. Staff A, RN documented the physician notified nurse that the X-ray had been read incorrectly and the resident did have a fractured left hip. The resident had been transferred back to the emergency room and then transferred to a Des Moines hospital. At 4:30 p.m. Staff A documented the receiving hospital reported the resident had a [MEDICAL CONDITION] infarction (MI) ([MEDICAL CONDITION]). A readmission assessment with a reference date of [DATE] indicated the resident demonstrated impaired short and long term memory deficits and moderately impaired cognitive skills for daily decision making. Resident #6 required extensive assistance with physical assist of two staff with bed mobility, transfers, dressing, eating, bathing and personal hygiene needs. Resident #6's [DIAGNOSES REDACTED]. An admission care plan dated [DATE] indicated the resident required total assistance for activities of daily living, was non weight bearing and no range of motion. The care plan instructed staff to use a bed alarm when the resident was in the bed, to keep call light within reach and to encourage use of call light. The dietary progress notes identified the resident had a fluid restriction of 1200 milliliter (mL) on [DATE]; and on [DATE] the diet order for puree diet with nectar thick liquids, and a readmission weight of 104 pounds. The skilled daily nurses notes dated [DATE] at 2:30 p.m. Staff T, RN documented the resident returned to the facility, head to toe assessment completed and revealed an irregular heart rate. The skilled daily nurses notes dated [DATE] at 5:00 p.m. Staff B, LPN documented the resident had been taking only small amounts of food and fluids with weight change fax sent to the physician. The skilled daily nurses notes dated [DATE] (no time documented) Staff B documented the staff had offered food, fluids and resource supplement but resident continues taking only small amount of nourishment. Staff B documented the resident showing periods of confusion, talking to and seeing people that were not there. On [DATE] at 2:45 a.m. Staff F, LPN documented fluids encouraged. At 12:00 noon Staff S, RN documented the resident alert but confused. At 10:30 p.m. Staff T documented the resident ate bites of supper with much encouragement and cueing. On [DATE] at 1:30 p.m. Staff C, RN documented the resident continuously removing the oxygen cannula from nose and placing it in the mouth. Staff C documented that fluids were encouraged and taken poorly. The skilled daily nurses notes dated [DATE] at 7:30 p.m. Staff H, LPN documented the resident ate bites of supper and sips of fluids, but unable to feed self or own activities of daily living. A nutritional assessment dated [DATE] documented the resident had shown a 15.8% weight loss in 30 days. The oral intake record identified the following: 1). On [DATE] at 7 am to 3 pm, 200 mL; from 3 to 11 pm., 120 mL; and 11 pm to 7 am, 240 mL. 2). On [DATE] at 7 am to 3 pm, 120 mL; from 3 to 11 pm., 60 mL; and 11 pm to 7 am, 120 mL. 3). On [DATE] at 7 am to 3 pm, 60 mL; from 3 to 11 pm., nothing charted; and 11 pm to 7 am, 50 mL. 4). On [DATE], nothing charted on the intake record for the entire day. 5). On [DATE]: at 7 am to 3 pm, 200 mL; from 3 to 11 pm., 50 mL; and 11 pm to 7 am, nothing charted. 6). On [DATE]: at 7 am to 3 pm, 220 mL; from 3 to 11 pm., 50 mL; and 11 pm to 7 am, 45 mL. 7). On [DATE]: at 7 am to 3 pm, 180 mL; from 3 to 11 pm., 50 mL; and 11 pm to 7 am, 50mL. 8). On [DATE]: at 7 am to 3 pm 400 mL; from 3 to 11 pm., 250 mL; and 11 pm to 7 am, nothing charted. 9). On [DATE] at 7 am to 3 pm, 180 mL; from 3 to 11 pm., nothing charted; and 11 pm to 7 am, 120 mL. 10). On [DATE] at 7 am to 3 pm, 180 mL; from 3 to 11 pm., 25 mL; and 11 pm to 7 am, 60 mL. 11). On [DATE] at 7 am to 3 pm, 90 mL; from 3 to 11 pm., 0 (zero) charted ; and 11 pm to 7 am, 60 mL. 12). On [DATE], at 7 to 3, " sips " ; nothing charted from 3 to 11pm and 11 pm to 7 " REF " (refused). (In comparison, an average 12 fluid ounces drink contains 355 mL.) The dietary progress notes dated [DATE] identified the resident's weight down to 96 pounds. The staff documented the resident intakes bites of puree/ nectar thick liquids. The staff documented the resident's weight loss was related to recent hospitalization and [MEDICAL CONDITION] repair X2 (times two). The dietary note identified the resident eats in the assisted dining room. The note recommended the following: [MEDICATION NAME] for increase in appetite and fragile skin; 4 ounce 2 Cal (three time a day) to boost the resident's calorie and protein; a multivitamin, and iron for increase nutrition. The skilled daily nurse's notes dated [DATE] at 12:00 noon Staff F noted the resident had eaten in room and taken ,[DATE]% of meal, being fed by friend or staff. At 4:00 p.m. Staff documented the dietitian recommended an increase in the supplement to 4 ounces three times a day. The skilled daily nurses notes dated [DATE] at 1:00 a.m. Staff H, LPN documented that staff encouraging fluids but intake continues to be poor. At 1:00 p.m. Staff F, LPN documented the resident ate about 70% of breakfast, assessment within normal limits. At 6:00 p.m. Staff I, LPN, documented the resident took only 15% of supper. The skilled daily nurses notes dated [DATE] at 9:30 a.m. Staff D, LPN documented the resident had been offered fluids and took sips of fluids. The staff indicated the resident ate a few bites at breakfast. At 9:30 a.m. Staff F, LPN documented the resident did not take any fluids or food due to difficulty swallowing. At midnight Staff H, LPN documented the resident had been demonstrating increased difficulty with swallowing. On [DATE] at 12:30 p.m. Staff A, RN documented the resident demonstrated unclear speech, only oriented to name, shallow respirations, dusky nail beds, finger tips purple/blue, cold to touch and the resident's feet dark purple and cold. Staff A documented the resident's irregular pulse rate with oxygen saturation between 84 to 91%. Therapy indicated the resident had difficulty swallowing thickened liquids. Staff A documented the resident had been provided oral care for a dry mouth and that resident only consumed a couple of sips at lunch due to coughing. Staff A stated the resident's POA notified of assessment. Staff A documented the resident medication had been held due to difficulty swallowing. On [DATE] and [DATE] staff continued to document that the resident refused drinks of fluids, mouth and lips remained dry and refused to take any medications. According to the nurse's notes on [DATE] at 8:30 p.m. Staff I, RN documented the facility received a telephone call from the resident's granddaughter for a condition report and wandering why the resident had not been taken to the emergency room . Staff I noted that she explained the POA wanted the facility to provide comfort measures. The granddaughter stated that the two granddaughters had obtained a new guardianship and wanted the resident sent to the hospital. Staff I stated she requested the granddaughter send the paperwork, who did so. The resident was then transferred to the hospital on [DATE] at 9:11 p.m. The hospital admission history and physical dated [DATE] noted the resident had been admitted hypotensive with dementia, would open eyes to stimulation but could not communicate, the orthopharynx extremely dry and lethargic. Laboratory test revealed an elevated troponin level equivocal for acute MI ([MEDICAL CONDITION]), a critically high sodium level of 174 (normal ,[DATE]) and BUN of 72 (normal ,[DATE]). The hospital discharge summary dated [DATE] documented the resident had been admitted to the hospital with [REDACTED]. During the hospitalization , the resident had been rehydrated and sodium corrected down to 153. The resident's mental status improved but the resident remained weak and malnourished. On the morning of [DATE] the resident developed a wide complex [MEDICAL CONDITION] apparent [MEDICAL CONDITION] at 190 beats per minute. Resuscitation efforts were unsuccessful and the resident expired at 7:50 a.m. on [DATE]. The discharge summary listed the final [DIAGNOSES REDACTED]. On [DATE] at 2:30 p.m. Resident #6's physician stated she would have expected the facility staff to notify her of the resident's declining condition. The physician stated she had been unaware that the resident had not been eating or drinking and shown a decreased mental status. The physician noted that the resident's severe dehydration, critically increased sodium level of 173 (174), and urinary tract infection led to admission to the hospital. The physician stated that the second [MEDICAL CONDITION] within a month contributed to the resident rapidly declining health condition along with the MI ([MEDICAL CONDITION]) after each [MEDICAL CONDITION]. The physician noted that after being rehydrated the resident did perk up, but then suffered another acute MI which the resident could not overcome. On [DATE] at 7:45 a.m. Staff I, LPN stated she had been told in report on [DATE] that the resident had stopped eating and drinking and the POA wanted comfort measures. Staff I stated she confirmed with the POA on the phone that this was what she wished. Staff I noted that she received a telephone call later that evening from the resident's family member who claimed that she had acquired a POA (guardianship) and requested that the resident be sent to the emergency room for evaluation and treatment. Staff I stated she requested a copy of the POA (guardianship) be faxed to the facility. As soon as she received the paperwork, Staff I stated she transferred the resident to the emergency room . Staff I stated she then notified the family member of the transfer and admission to the local hospital. (The resident's clinical record lacked an order for [REDACTED]. On [DATE] at 8:00 a.m. Staff D, LPN stated that she had taken care of the Resident #6 on [DATE] and at that time the resident had been having problems with eating and drinking. Staff D stated the resident would awaken when talked. She stated the resident would answer questions appropriately.Staff D stated that when a resident showed a decline in condition the doctor and family would be notified. Staff D acknowledged the doctor had not been notified on her shift and stated she should have checked to make sure the physician had been notified. On [DATE] at 8:35 a.m. Staff P, CNA stated that prior to the first fall in October (2012) the resident had been totally independent. After the fall the resident had been confused about using his/her call light. Staff P stated she always offered the resident a drink of water every time she entered her room and stated sometimes the resident would drink and sometimes not. When the second fall occurred Staff P stated she heard Staff N, CNA call for assistance and found the resident on the floor. Staff P stated she did not hear the alarm sounding. Staff P stated the nurse came in and assessed the resident and got the resident ready to send to the emergency room . After the resident had been brought back from the emergency room Staff P noted she assisted to toilet the resident and placed the resident back into bed. Staff P stated she came back to work the next night and learned the resident had been sent back to the hospital with a [MEDICAL CONDITION]. Staff P stated when the resident came back to the facility; the resident had been moved to another hall closer to the nurse's station. On [DATE] at 9:30 a.m. Staff R, CNA stated that prior to the first fall the resident did everything independently and would ask if anything was needed. The first fall the resident had been found sitting on the floor by another CNA. The resident had been sent to the hospital and had been gone for 2 weeks. After the second fall the resident had been moved to another hall closer to the nurse ' s station. On [DATE] at 10:15 a.m. Staff N, CNA stated she had just come into work on [DATE] and was passing supplies when she heard someone calling out for assistance. Staff N stated she found Resident #6 on the floor beside the bed. Staff P stated she did not hear the alarm sounding but the resident sometimes would take it off. Staff P stated she paged the nurse who came with the other CNA. Staff N stated the nurse assessed the resident and called the physician and POA. Staff N stated the resident had been sent to the emergency room but returned the same night. Staff N stated the resident became more confused after the second fall and fracture. On [DATE] at 10:50 a.m. Staff H, LPN stated that prior to the first fall the resident had been totally independent but when the resident returned from the hospital Staff H stated she noted some increased confusion. Staff H stated the resident required total cares on the night shift. Staff H stated on [DATE] she had been paged to the residents room by the CNA who stated she had found the resident on the floor. Staff H stated the alarm had been removed and the resident did not recall what happened. Staff H stated she assessed the resident but did not move the resident because of the first fracture and called the physician and ambulance to transport the resident to the emergency room . Staff H stated the ambulance crew did not place the resident on a back board as she requested, just picked the resident up and placed on the cart. Staff H stated the resident returned to the facility the same night with a report of no fracture. Staff H stated she found out the next night the resident had fractured the other hip. Staff H stated when the resident returned from the hospital she noticed a condition change, the resident not taking fluids during the night, taking the oxygen off, required total care and had increased confusion. On [DATE] at 11:50 a.m. Staff A, RN stated prior to the first fall the resident had been alert, talkative, friendly, and helpful to all the other residents. Staff a stated the resident had been independent with all cares and ambulated. Staff A stated the resident required reminders for meals, activities and had been forgetful at times. On [DATE] one of the CNAs notified the nurse that the resident had fallen and was on the floor. When entering the room the other staff had the resident sitting up. Staff A stated the resident denied pain; the assessment revealed no signs of injury but after getting the resident up from the floor and attempting to ambulate the resident complained of pain in the right hip. Staff A stated the staff placed the resident into a wheelchair and taken to the nurses station. Staff A stated she informed the resident's nurse that the resident had been complaining of hip pain. The resident was sent to the emergency room and admitted to the hospital. The resident had an abnormal EKG and elevated troponin levels as well as the [MEDICAL CONDITION]. On [DATE] the resident had been readmitted to the facility and assisted to the bed. Staff A stated when she did the admission assessment she noted the resident to be sleepy but answering questions appropriately. Staff A stated that they were unable to get an accurate pulse oximetry reading due to poor circulation. Staff A stated on [DATE] the facility received a telephone call from the resident's physician who stated the resident's radiology report had been read incorrectly. The resident did have a fractured left hip and she gave an order to send the resident back to emergency room . Staff A stated on [DATE] the resident had been declining with swallowing/eating/drinking. The resident's circulation was poor with purple skin returning. Staff A stated the further treatment was discussed with the POA and the facility social worker and the POA chose to keep the resident at the facility. Staff A stated that the change of guardianship had not been mentioned during the discussion, just that the granddaughters were planning on going to court [DATE]. On [DATE] at 2:30 p.m. Staff B stated that the resident used to come to visit the facility prior to becoming a resident. Staff B stated the resident had been ambulatory and independent with cares. When the resident entered the facility Staff B stated the resident required cueing. After the second admission the resident became more confused to time and place and would only take small amounts of fluid without choking. Staff B stated on [DATE] the resident became frail and the POA remained at the resident's side. Staff B stated the POA mentioned she had been in touch with the resident's family daily. On [DATE] at 3:30 p.m. Staff E stated the resident had been very independent prior to the first fall, had been independent for cares and made needs known. After the first fall the resident's mental status changed, was unable to make needs known, and would yell out when he/she needed something. Staff E stated the resident would not use the call light when instructed. Staff E stated after the second fall, the resident's mental status changed again. The resident would barely speak when spoken to, and had been unable to make needs known. Staff E stated the resident would eat small amounts when fed by someone, and would take small amounts of fluids. Staff E stated [DATE] was the last day she had cared for the resident and at that time the resident did take some fluids and small amounts of food. Staff E stated the resident would speak when spoken to. On [DATE] at 5:15 p.m. Staff F, LPN stated the resident had been independent with ambulation prior to the first fall. She stated the resident would sit in the lobby looking at books or sleeping. Staff F stated at time the resident would be disoriented but easily redirected. On the morning of the first fall, Staff F stated she was receiving report and counting with the off going nurse when the CNA informed her that the resident had been found sitting on the floor. Staff F stated she and Staff A completed and assessment of the resident and determined that the resident had no injury and the resident denied discomfort/pain. Staff F stated the resident had been assisted back to bed. After the CNA assisted the resident to dress, and began to ambulate the resident to the dining room. The resident began to complain of discomfort. The resident had been placed in a wheelchair. The doctor had been notified and resident sent to the emergency room . Staff F stated they tried to notify the POA of the resident's fall prior to transfer but had been unable to reach. Staff F stated when the resident returned from the hospital, he/she had slurred speech and poor appetite. Staff F stated after the second fall, the resident had returned to the facility the resident condition had changed to extensive assist, continued to have slurred speech. The resident remained alert and oriented to self and place, but needed to be reoriented one or two times. Staff F stated the staff needed to assist the resident to eat. Staff F stated the staff provided care every two hour for the resident. Staff F stated the resident had stopped swallowing, food and liquids would run out of the resident's mouth. Staff F stated she had been under the impression the resident's change of condition had been reported to the physician. 2. According to the Minimum Data Set (MDS) assessment with a reference date of [DATE], Resident #5 scored 10 on the BIMS (Brief Interview for Mental Status) test, which revealed the resident's cognitive skills for daily decision making skills were moderately impaired. Resident #5 required limited assistance of one staff for bed mobility, transfers, dressing, bathing and personal hygiene needs. Resident #5's [DIAGNOSES REDACTED]. The resident's care plan with a goal date of [DATE] instructed staff to administer medications, provide treatments and obtain laboratory testing as instructed. The care plan instructed the staff to assist the resident with activities of daily living as needed. Review of the nurses notes from [DATE] through [DATE] revealed staff documented the resident had been receiving an antibiotic for a urinary tract infections. On [DATE] at 12:00 noon, a family member reported to Staff S, Registered Nurse (RN) that the resident had a non-productive cough and requested a cough medication. Staff S documented that the resident had been assessed, noted lungs sound clear, and oxygen saturation was 90% on room air. Staff S documented the physician had been notified and [MEDICATION NAME] DM, 1 teaspoon every four hours as needed had been ordered. From [DATE] to [DATE] the staff continued to document the resident had an occasional cough, but lungs clear and oxygen saturations remained 94 to 95% on room air. On [DATE] at 9:30 a.m. Staff F, Licensed Practical Nurse (LPN) documented in the nurses notes a family member requested that the resident be sent to the physician's office because of the cough. An assessment revealed the resident's vital signs were with in normal limits and oxygen saturation at 90% on room air. Staff F noted the resident's lungs to be clear in the upper lobes but slight wheezes in the lower lobes and resident exhibited an occasional non productive cough. Staff F contacted the physician's office and obtained an appointment for [DATE]. At 4:40 p.m. the family member requested the resident be sent to the emergency room , the physician again notified and order given to send the resident to the emergency room . At 8:00 p.m. Staff H, LPN documented the resident had returned from the emergency room with orders [MEDICATION NAME](antibiotic) 500 milligrams two times daily and to increase [MEDICATION NAME] (diuretic) to 20 milligrams twice a day for a [DIAGNOSES REDACTED]. Staff H documented the resident had no cough but wheezes throughout the upper and lower lung fields. On ,[DATE] at 10:15 a.m., Staff B, LPN documented in the nurse's notes the physician had been notified of the resident ' s condition and received an order to obtain a chest x-ray which had been obtained with the resident's family transporting the resident to the local hospital for the test. On [DATE] the radiology report noted improving right sided infiltrate when compared to the previous [DATE] report (from [DATE] emergency room visit). The report also documented [MEDICAL CONDITION] congestion noted. The staff continued to document the resident had an occasional cough with diminished lungs sounds. Nurse ' s notes dated [DATE], documented by Staff B, LPN revealed the resident continued with an occasional cough and family noted the resident to have a poor appetite for breakfast. The physician was notified per family request, ordered laboratory tests and [MEDICATION NAME], 1 gram per intramuscular injection (IM) for 10 days and [MEDICATION NAME] pack. On [DATE] at 10:45 a.m. Staff F, LPN documented in the nurse's notes the resident's lung sounds diminished but no noted cough. On [DATE] at 2:00 a.m. Staff I, LPN documented in the nurse's notes the resident with diminished lung sounds and slight wheezing noted in the right lower lobe. The resident had received the [MEDICATION NAME] 1 gram per IM with no adverse reactions. At 2:00 p.m. Staff B documented the resident's lungs clear but diminished in all four lobes, and the resident appeared more alert. Staff B had noted the physician had examined the resident at 1:00 p.m. and had no new orders. At 9:00 p.m. Staff H, LPN documented the resident's lungs to be diminished with slight wheezing noted, no cough and resident denied discomfort. Staff H noted the resident had received the [MEDICATION NAME] IM per order. The nurse ' s notes dated [DATE] at 7:00 a.m. Staff B, LPN documented the resident's lungs were clear. At 11:00 a.m. Staff B documented the resident's family requested cough medication for the resident, and although the resident had no cough, lungs clear but diminished, the cough medication was provided. At 9:00 p.m. Staff H, LPN noted the resident continued on the antibiotic, lungs clear to auscultation and no cough noted. On [DATE] at 2:00 p.m. Staff E, LPN documented in the nurses notes the resident's lungs to be clear but diminished, the respirations even and unlabored and resident denied shortness of breath. According to the nurses notes dated[DATE] at 7:00 p.m. Staff A, RN noted the resident's lungs had cleared, the resident had denied cough and stated she/he had been feeling better. Staff A notified the physician of the resident's improved condition and antibiotics had been completed per fax. The nurse ' s notes from [DATE] through [DATE] contained no further documentation concerning the resident's cough or lung assessments. On [DATE] at 1:30 p.m. Staff F, LPN documented in the nurses notes a family member alerted her that the resident was breathing heavy. Upon assessment the nurse noted the resident's vital signs to be within normal limits, except the respirations which were at 24 breaths per minute (normal respirations are considered to be 16 to 20 breaths per minute). Staff F noted the resident to be taking shallow breaths. The nurse instructed the resident to pursed lip breathing to assist in slowing respirations which the resident did with the results that the respirations slowed to 18 breaths per minute. Staff F noted the resident's lungs to be clear to ausculation throughout all fields. At 2:20 p.m. Staff F documented the resident in bed with eyes closed, resting quietly with no labored respirations. On [DATE] at 2:00 p.m. Staff C, RN documented in the nurses notes the residents respirations to be even and unlabored at 18 breaths per minute and resident showed on adverse affects from medication change. At 5:00 p.m. Staff D, LPN documented the resident to be in lying bed with eyes opened. Staff D noted resident coughing and denied wanting to eat supper. Staff D noted the resident took evening medications and cough medication. On [DATE] at 00:30 a.m. Staff H, LPN documented the resident resting quietly in bed with eyes closed, respirations even and unlabored at 18 breaths per minute, oxygen saturation at 96%, and lungs clear to auscultation on both sides. At 7:45 a.m. Staff C, RN noted the resident to be up in the front lobby in the wheelchair. Staff C documented the resident's respirations at 18 breaths per minute, and no signs or symptoms of shortness of breath. Staff C noted the resident had taken morning medications without difficulty. At 8:00 a.m. Staff C documented a family member notified her the resident had complained of nausea. Staff C documented the oxygen saturation checked because the resident's respirations appeared fast and labored at 28 breaths per minute. With the oxygen saturation reading of 80 to 89% obtained. Staff C documented she applied oxygen at 2 liters per minute per nasal cannula with the oxygen saturation increasing to 96% on the 2 liters/minute. Staff C documented she attempted to contact the resident's physician at the clinic, per cell phone and then at the hospital. Staff C noted she then called the on-call physician and obtained an order to transport the resident to the emergency room for assessment. Staff C documented the resident was sent to the emergency room per ambulance and admitted to the hospital. The family notified the facility the resident expired at the hospital on [DATE]. Review of the emergency room notes from [DATE] at 9:00 a.m. revealed the resident arrived in severe respiratory distress with shallow, rapid respirations at 52 breaths per minute, and oxygen saturation at 91% on 2 liters/minute of oxygen per nasal cannula. The resident showed decreased mental status, non-responsive to questions except with moans. Review of the resident's hospital admission history and physical dated [DATE] revealed the resident had been admitted

Based on clinical record review, staff interviews and physician interviews the facility failed to provide nursing provisions with accurate assessment and timely interventions for Resident #4 who experienced an adverse change in his/her physical condition and was admitted to the hospital with [REDACTED]. Findings include: The annual MDS (Minimum Data Set) assessment,reference date of 1/23/2013, identified Resident #4 with severely impaired cognition and long/short term memory deficits. The MDS indicated the resident required total assistance for all activities of daily living including toileting, mobility, eating, drinking, grooming and personal hygiene. The MDS indicated the resident was always incontinent of bowel and bladder. The resident ' s [DIAGNOSES REDACTED]. The resident's individual plan of care, goal date 4/30/2013, identified the resident at risk for constipation. The approaches directed staff to check and change the resident on rounds and PRN (as needed), to check for bowel sounds and distention PRN, rectal checks as ordered to ensure adequate bowel elimination, record bowel movements (BMs), report signs and symptoms of constipation, encourage fluids, and give medications as ordered. A review of Nurse's Notes dated 2/10/2013 at 5:50 a.m. revealed Staff A, Licensed Practical Nurse (LPN) was called to the resident's room and found the resident lying on the bed with " CNA (Certified Nurses Aide) holding upper body up large dark black vomit coming from mouth. Vomit splattered on wall next to bed. Bowel sounds hyperactive , abdomen hard distended. CNA report large black BM." Continuing documentation stated the physician was notified and the resident was sent by ambulance to the local hospital emergency room (ER). Review of ER documentation dated 2/10/13 revealed the ER physician admitted the resident to the hospital for observation with [DIAGNOSES REDACTED]. The report stated the resident had " coffee-ground emesis " indicating questionable GI (gastrointestinal) bleed. Review of a abdominal radiology report dated 2/10/13 read "A large amount of retained stool with fecal impaction. No evidence of perforation, obvious organomegaly or mass [MEDICAL CONDITION]." Diagnosis: [REDACTED]. During an interview on 2/12/13 at 11:30 a.m. with the ER physician who admitted Resident #4 to hospital for observation he stated the resident presented to the ER "chock full of poop- had a marked ileus and had a lot of stool in {gender} colon/rectum." He stated he admitted the resident so aggressive laxative therapy could be initiated. He ordered tap water enemas and oral Magnesium [MEDICATION NAME] (a strong laxative which is administered to completely empty the bowel) to be administered to the resident. Review of facility Nurse's Notes from 12/25/12 to 2/10/13 revealed the resident had two prior episodes of emesis. On 12/25/12 a CNA reported the resident had an emesis after sticking his/her finger down his/her throat. On 1/12/13 Nurse's Notes documented the resident had vomited brown emesis that appeared to be digested meat. Nurse's notes review from 12/25/12 through 2/10/13 did not reveal any documentation of assessment of bowel sounds or abdominal distention during the nurse's notes review. Review of Resident #4 ' s facility Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident ' s MAR indicated [REDACTED]. Record review of the MAR for the month of February 2013 revealed the resident received the scheduled medications as ordered. The PRN medications had not been administered in February 2013. Bowel movement records for the month of January 2013 revealed the resident had 1-3 medium or large bowel movements (with an occasional small movement noted five times during the month) every 24 hours with the exception of four 24 hour periods where documentation revealed the resident did not have a BM (1/14/13, 1/1/137,1/28/13, and 1/29/13). The February 2013 BM records revealed the resident had the following BMs noted each 24 period: 2/1/13 -2 medium and one large BM 2/2- 3 large BM 2/3- 2 large BMs 2/4 -1 large BM 2/5- 1 medium BM 2/7- no BMs 2/8- 1 small B 2/10- no BM During an interview with the resident ' s primary physician on 2/12/13 at 8:45 a.m. she stated the resident had a history of [REDACTED]. She expected staff to initiate the PRN medications if the resident did not have a BM in 24 hours. She stated she would have expected the staff to consider the resident's pattern of 1-3 BMs a day and to administer one of the PRN medications after the resident did not have a BM on 2/7/13. She stated it is possible that the resident may not have become as constipated if a PRN medication had been given prior to the morning of 2/10/13 however she said it is impossible to know for sure. Review of the facility undated policy " Resident BM Schedule " revealed the policy stated : Day 1- monitor Day 2- Milk of Magnesia (MOM) Day 3 Suppository-monitor-notify physician if no results During an interview with Staff A, LPN, on 2/12/15 at 11:30 a.m. she stated she is the MDS nurse and also works as a floor nurse and cares for Resident #4. She stated if she had been the floor nurse for the resident on 2/9/13 she would have discounted the small BM (not assessing it as a " normal " BM) and would have initiated the PRN MOM on that day to the resident. She stated this is how she assesses BMs for this particular resident given his/her previous history. She stated she interpreted the physician ' s PRN order of a laxative " daily as needed " to mean the PRN medication could only be administered once a day. She stated she is unsure how the other floor nurses assess Resident #4 ' s BM habits and how other nurses would interpret the facility policy or the physician PRN orders. During an interview on 2/12/13 at 2:00 p.m. with the Director of Nurses (DON) and Staff A, LPN, the DON stated the night nurse is responsible for monitoring resident bowel movements and reports to the day nurse if a resident has not had a BM. The day nurse is responsible for initiating a PRN medication if warranted per policy. She stated the resident ' s pattern of not having a BM in January 2013 five times suggested the resident had a pattern of not having BMs every day and staff nurses should not have been alarmed on 2/9/10 when the resident had only had a small BM in 72 hours. However, conversely, the DON and Staff A both stated the resident ' s previous history of 1-3 BMs daily did not represent a pattern of " normal " BM habits that should be considered when assessing the resident ' s need for PRN laxative medication. During an interview with Staff B, LPN, on 2/12/13 at 3:00 p.m. she stated she follows the facility policy for administering PRN laxative medications. She stated she would administer MOM to a resident who had not had a BM in 2 days. She stated she would consider the resident ' s previous history of BM patterns when determining if the resident required a PRN laxative medication. She stated she does not care for Resident #4 as she works another hall. During an Interview with Staff C, LPN, she stated she does not routinely care for Resident #4. She stated she would administer PRN laxative medications as instructed by the facility policy. During an interview with Staff D, LPN, on 2/12/13 at 9:45 p.m. she stated as the night nurse one of her duties is to review the bowel movement records for all the residents. She stated she then reports to the day nurse which resident have not had a BM in 24 hours. She stated the day nurse is responsible for initiating PRN laxative medications. Review of the CNA record book revealed a communication 2/11/3 which was addressed to all nursing staff and stated " We are finding several holes in the BM sheets. This is very important that these be completed every shift ACCURATELY. Review of hospital documentation dated 2/12/13 revealed the resident was transferred from observation care to acute care for further tests. Review of a second abdominal X-ray performed 2/12/13 revealed " Interval improvement in the amount of fecal material suggestive of significant improvement in constipation " since prior exam.

The following deficiency relates to complaint -C: Based on record review and staff and family interviews, the facility failed to provide an accurate assessment and timely intervention when Resident #1 appeared distressed by a family member. The resident displayed adverse symptoms and staff did not assess the resident and provide timely suctioning as ordered by the physician. The sample consisted of 4 residents and the facility identified a census of 57 residents. Findings include: 1. Resident #1 had an MDS (Minimum Data Set) assessment with a reference date of 5/18/12 which reflected the resident had impaired short and long term memory deficits and severely impaired cognitive skills for daily decision making. The MDS identified Resident #1's [DIAGNOSES REDACTED]. A physician communication form dated 6/5/12 indicated the facility requested a physician order [REDACTED]. The Treatment Administration Record (TAR) for June 2012 indicated the last recorded time the suctioning performed was on 6/8/12 by Staff C. The Nurse's Notes dated 6/8/12 at 10:40 a.m. and written by Staff C, identified Resident #1 with a loose wet cough and staff suctioned thick clear phlegm from the resident. In an interview on 8/1/12 at 12:14 p.m. FM 1 (Family Member #1) indicated she arrived to the facility at 7:30 a.m. on 6/22/12 and heard Resident #1 calling out the family member ' s name. FM1 entered the resident ' s room and noticed food debris on the resident ' s lips and appeared to be in distress. FM 1 left the room and found Staff A (Licensed Practical Nurse- LPN) and informed the staff person that Resident #1 was in distress. Staff A came to the room, but noted she had eight other residents to care for. Staff A observed Resident #1 and told FM 1 he/she was pocketing food (keeping food in checks and not swallowing). Staff A attempted to wipe Resident #1's mouth. Staff A then left the room. FM 1 then left the room and found Staff F (Social Service/Licensed Practical Nurse) and inquired as to needing oral swabs (Toothettes) to wipe the inside of the resident ' s mouth). Staff F gave FM 1 the keys to the storage area and FM 1 obtained several swabs, returned the keys to Staff F and returned to Resident #1's room. FM 1 stated she was not out of Resident #1's room for more than 1 to 2 minutes. FM 1 stated that once back in the room, she was afraid of trying to wipe out Resident #1's mouth in fear she may choke the resident. Minutes later FM 1's sister, family member #2 (FM 2) entered the room and witnessed Resident #1 in distress. FM 2 informed FM1 she would find a nurse and she left the room. Minutes later Staff B (Certified Nurse Aide, CNA) entered the room and FM 1 indicated Resident #1 needed suctioned and she was unable to get Staff A to help. Together Staff B and FM 1 got Resident #1 up into his/her geriatric chair. Staff B then propelled Resident #1 to the assisted dining room area as FM 1 remained in the bedroom. Within minutes Resident #1 was propelled back into the bedroom accompanied by Staff C (Registered nurse, RN) and Staff D (Certified Nurse Aide). Staff C walked to the suction machine and stated, "It's not even put together". Someone (unknown) obtains the container and supplies as Staff C then attempts to get the suction machine together. FM 1 was saying "hurry". FM 1 indicated Staff C had begun suctioning Resident #1 for about two minutes when instructed by Staff C to get Staff G (Assistant Director of Nursing). FM 1 left the room and told Staff G, who was sitting in her office, that Resident #1 needed her now. Staff G responded to Resident #1's room. Staff G placed a stethoscope on Resident #1's chest while Staff C continued to suction. Staff G looked up at FM 1 and FM 1 stated, "Is that it?" Staff G responded, "Yeah, that's it". The suction container had an inch of brown fluid present in the container. The time Card for FM 1 identified FM 1 clocked in for work at 7:30 a.m. on 6/22/12. On 8/2/12 at 1:23 p.m. Staff A (Licensed Practical Nurse, LPN) was interviewed and stated on the morning of 6/22/12, she was approached by FM 1 and asked to come to Resident #1's room. Staff A and FM 1 walked to Resident #1's room. FM 1 told Staff A that Resident #1 had stuff in his/her mouth and apple sauce on his/her lips and may need suctioned. Staff A saw the dried apple sauce on Resident #1's face and asked Resident #1 to open his/her mouth. Staff A saw nothing in the Resident #1's mouth. Staff A looked for oral swabs in the room and saw none. The nurse again asked Resident #1 to open his/her mouth, but this time the resident refused. FM 1 told Staff A to go on, she would get Staff C. Resident #1 will open his/her mouth for Staff C. Staff A left the room and walked directly to the supply room and obtained some swabs and returned to Resident #1's room (less than 1 minute). Staff A then swabbed Resident #1's mouth out and noted nothing was observed on the swab. Staff A noted Resident #1's respirations were even and unlabored and he/she was not in any distress. Staff A informed Resident #1 that an aide would be in soon to get him/her up for breakfast and Resident #1 responded, "okay". Staff A indicated FM 1 was not in the room during this time. Staff A stated she returned to the floor and continued assisting others with getting residents up for breakfast. Staff A stated at around 8:15 a.m. she entered the assisted dining room to administer medications. Staff A heard a "rattling" sound and Staff C indicated it was Resident #1 and she was taking Resident #1 back to his/her room to try and suction. Staff A remained in the assisted dining room as Staff C took Resident #1 to his/her room. Staff A indicated FM 1 never made any statements about Resident #1 making sounds, being in pain or discomfort or of having any breathing problems. On 8/1/12 at 12:59 p.m. FM 2 (family member #2) was interviewed and stated on the morning of 6/22/12, she was in the lobby and could hear Resident #1 "gurgling". FM 1 sought out Staff C, who was assisting a resident into the dining room and told Staff C that Resident #1 needed suctioned now. FM 2 stated Staff C did not respond and continued to help residents. FM 2 stated she returned to the laundry room. On 8/1/12 at 11:20 a.m. Staff B (Certified Nurse Aide) was interviewed and stated on the morning of 6/22/12, she heard Resident #1 call out for FM 1 about three times and could tell Resident #1 needed help coughing up something. Staff B responded to Resident #1's room and FM 1 indicated she had tried getting Staff A (LPN), but Staff A didn't come. FM 1 wanted to get help from another nurse. Together Staff B and FM 1 got Resident #1 up into his/her geriatric chair. Staff B then preceded to try and get Resident #1 to cough up or clear his/her throat for about 1-2 minutes. Staff B was unsuccessful with getting Resident #1 to clear his/her throat so she took Resident #1 to the assisted dining room to be seen by Staff C (RN). Staff B indicated Resident #1 was "gurgling" as she arrived to the assisted dining room. Staff B informed Staff C that she was unable to get Resident #1 to cough up anything and was instructed by Staff C to try and give him/her a sip of tea. Staff B indicated Resident #1 took a sip but remained in distress. Within 1-2 minutes of being in the assisted dining room, Staff C and Staff D (CNA) took Resident #1 back to his/her room. Staff B stated from the very beginning that morning she felt Resident #1 was in need of being suctioned. In a statement written for the facility on 6/22/12, Staff B indicated she had sent FM 1 to get some swabs and FM 1 returned with 6 swabs. Staff B attempted to clean Resident #1's mouth and obtained a little amount. On 8/6/12 at 11:05 a.m. Staff C (Registered Nurse, RN) was interviewed and stated on 6/22/12 at around 7:00 a.m. she went into Resident #1's room to check for safety alarms. Resident #1 was in bed resting quietly without any signs or symptoms of discomfort. Staff C stated later that morning she was approached by FM 2 while working in Hall 1. FM 2 told her that Resident #1 was in need of suctioning and Staff A wouldn't help. Staff C stated she assumed Staff A, who was assigned to Resident #1, would get her if she needed help. Staff C stated at around 8:15 a.m. Resident #1 was brought into the assisted dining room by Staff B (CNA). Resident #1 was alert but gurgling. Staff B attempted to get him/her to cough up the phlegm without success. Staff C instructed Staff B to hold the food, but try to get Resident #1 a sip of tea. Within 2-3 minutes as the gurgling persisted, Staff A entered the assisted dining room and Staff C and Staff D (CNA) took Resident #1 to his/her room. The suction machine in the room was not set up for immediate use. Staff C had to leave the room to obtain a canister and returned to the room to find there was no tubing. Staff C went back to the supply room and obtained tubing. While setting up the canister and tubing, Resident #1 took two deep breathes and then stopped breathing. FM 1 left the room and got Staff G (ADON). Staff G entered the room and checked for a heartbeat and found none. On 8/2/12 at 2:40 p.m. Staff D (Certified Nurse Aide, CNA) stated on 6/22/12 at around 8:15 a.m. she was in the assisted dining room assisting residents with eating when Resident #1 was propelled into the assisted dining room by Staff B (CNA). Staff D stated she heard Resident #1 choking before he/she ever got into the assisted dining room. Resident #1 sounded like he/she was drowning. Staff D immediately questioned what was happening and Staff B indicated Resident #1 was pocketing. Staff D stated that was not pocketing and stated she would find someone to help. Staff C (RN) who was also in the assisted dining room stated she would help or Staff A (LPN) could help. At that time Staff A entered the assisted dining room. Staff D instructed Staff A to remain in the assisted dining room and Staff C and Staff D took Resident #1 to his/her room to be suctioned. Staff D stated Resident #1 was already turning gray as they left the assisted dining room. FM 1 met Staff C and Staff D in the main lobby and followed them into the Resident #1's room. As they prepared to suction the staff discovered not all the needed items were in the room. Staff C and Staff D left the room to get the needed supplies as FM 1 remained with Resident #1. Upon returning, Resident #1 was turning even grayer and Resident #1 was stating, "I'm sick, I'm sick, I'm sick". Staff C continued to work on the suction machine then proceeded to suction him/her, but it was too late. By this time Staff G (ADON), FM 1 and FM 2 were all in the room and Staff D left. Staff D indicated it was probably 5-7 minutes from the time she heard Resident #1 drowning to when he/she passed away. On 8/7/12 at 11:20 a.m. Staff E (Certified Nurse Aide, CNA) was interviewed and stated on the morning of 6/22/12, she was in the assisted dining room assisting with feeding residents when Staff B (CNA) brought Resident #1 into the assisted dining room. Resident #1 sounded like he/she was underwater when she talked. Staff D (CNA) asked Staff B if Staff A (LPN) had suctioned Resident #1. Staff B stated Staff A said she tried suctioning but she felt Resident #1 was pocketing saliva/mucous. Staff C (RN) instructed Staff B to try and give Resident #1 a drink of tea to get the food down, if he/she was pocketing. Staff E stated that Resident #1 did not drink anything. Staff E stated Staff C and Staff D had to wait until Staff A arrived to the assisted dining room before they could take Resident #1 back to his/her room to try to suction him/her. Within 3 minutes, Staff A walked into the assisted dining room and Staff C and Staff D took Resident #1 back to his/her room. Staff E stated after Resident #1 was taken back to his/her room, she asked Staff A if she had suctioned Resident #1 and Staff A stated she had tried, but Resident #1 was just pocketing the mucous. On 8/8/12 at 3:30 p.m. Staff F (Social Services/Licensed Practical Nurse) stated she was working in Hall 2 performing care duties on the morning of 6/22/12. FM 1 approached Staff F and asked who the nurse was for Hall 3. Staff F stated it was Staff A. FM 1 asked if she could get into the supply room for swabs because she thought Resident #1 needed suctioned. FM 1 was given the supply room keys, obtained the swabs and returned the keys within one minute, then took off to find Staff A. Staff F continued working. Several minutes later Staff F was standing in the dining room when Resident #1 was propelled by Staff C (RN) towards his/her room. Resident #1 was gurgling and Staff F asked if Staff C needed any help. Staff C indicated they were taking Resident #1 back to his/her room to suction him/her. Staff F continued to help residents from the dining room and approximately 5 minutes later was at the front of Hall 3 when Staff C yell get Staff G. Staff F stated, "I'm right here, can I help". Staff F entered Resident #1's room and walked to Resident #1 who was in his/her geriatric chair facing the window. Staff C was working with the suctioning machine. Resident #1 was blue around his/her mouth and Staff F asked if he/she was okay. Resident #1 did not answer, so Staff F did a sternal rub and got no pain response. Staff F felt for a pulse and asked if someone could get her a stethoscope. An aide returned with a stethoscope and upon listening Resident #1 was without a heartbeat. At this same time Staff G (ADON) walked in and took the stethoscope and checked for a heartbeat as well. Resident #1 was without a heartbeat. On 8/6/12 at 1:35 p.m. Staff G (Assistant Director of Nursing, ADON) was interviewed and stated she arrived to work at 8:15 a.m. on 6/22/12 and before she could even sit down, FM 1 approached her and said Resident #1 was in need of suctioning. Staff G accompanied FM 1 and walked to Resident #1's room. Upon entering, Resident #1 was in his/her geriatric chair with his/her back facing the door. Staff C, D and F were in the room. Staff G looked at Resident #1 as he/she took two deep breathes. Staff C opened a suction tubing package and Staff F was listening to Resident #1's chest. Staff F handed Staff G the stethoscope and Staff G listened for an apical pulse for about one minute. Staff C began suctioning Resident #1's mouth and got a scant amount of cloudy white fluid. Staff G felt for a carotid pulse for about one minute with no heartbeat or respirations detected. Staff G looked up at FM 1 and stated, "He's/She's gone". Staff D stated she had clocked in that morning at 8:15 a.m. and believed Resident #1 was pronounced dead by her at approximately 8:20 a.m. The time card for Staff G confirmed Staff G clocked in for work at 8:15 a.m. on 6/22/12. On 8/7/12 at 11:10 a.m. Staff H (Certified Nurse Aide, CNA) stated she was working the day shift on 6/22/12 and assigned Hall 2. Staff H stated she worked with Staff A (LPN) getting residents up when FM 1 came down the hall and informed Staff A that Resident #1 needed suctioned. Staff A went with FM 1 and Staff H continued working with residents living on Hall 2. On 8/6/12 at 2:20 p.m. Staff I (Minimum Data Set Coordinator/Licensed practical nurse) stated she was working the morning of 6/22/12 when Staff D approached her asking where she could find suction tubing, noting the one they are using isn't working. Staff I instructed Staff D to go to the storage room to get it. Staff I then walked to Resident #1's room to ask specifically what was needed. Staff G and Staff C was in the room and Staff C was attempting to suction Resident #1. Staff D came into the room with the equipment needed and Staff I left the room. On 8/8/12 at 10:00 a.m. Staff J (Licensed Practical Nurse, LPN) was interviewed and stated she was working the morning of 6/22/12 on Halls 1 and 4. Staff J stated she had no physical contact with Resident #1 that day or of having any knowledge of Resident #1 being in distress until Staff G (ADON) arrived. On 8/7/12 at 10:55 a.m. Staff K (Administrator) was interviewed and stated she arrived to the facility around 7:00 a.m. on 6/22/12 and was monitoring staff getting residents up for breakfast. At around 7:15 a.m. Staff K saw Resident #1 resting in bed and without any indication of being in distress. At around 8:15 a.m. Staff K was outside when Staff G (ADON) arrived. Staff K spoke to Staff G briefly before Staff G entered the facility. Moments later Staff K went into the facility and was sitting at the nurse's station when Staff D (CNA) told Staff K she needed to go to Resident #1's room. Staff K responded immediately (8:18 a.m.) Upon entering the room Staff K witnessed Staff C attempting to suction Resident #1 and Staff G pronouncing Resident #1's death. In an interview 8/6/12 at 6:55 p.m. Staff L (Licensed Practical Nurse, LPN) was interviewed and stated at times Resident #1 would not completely swallow foods or medication and he/she would require suctioning. Resident #1 would also have oral secretions and would sound gurgled. Suctioning was effective at clearing Resident #1's airways during these times. Note: At the time of the complaint investigation, the complaint was coded at a "J", immediate and serious jeopardy. By 8/8/2012 the facility had abated the situation and adequately addressed the jeopardy and the grid placement was lowered to the "D" level. The facility had educated staff for proper assessment for a resident with a significant change of condition. The facility began checking suction machines each day. Suction machines are now fully equipped and ready for use. The nurses were educated and demonstrated the skills for proper oral suction machine use. As of the 8/8/2012 exit conference, the facility continued to need to: . Continue to educate nursing staff about proper assessment and timely interventions when a resident has a significant change of condition and requires oral suctioning. . Continue to monitor and ensure the nurses can perform proper tecniques for oral suctioning. . Continue to monitor each day that the suction machines are checked, equiped and ready for use.

Based on observations, record review, and staff interviews, the facility failed to provide adequate assessments and interventions for a resident with leg contractures and the inability to fully move legs for bowel incontinent skin cleansing (Resident #1) and failed to assess and provide interventions for bowel management (Resident # 8) and pain management (Resident # 3, #16). The facility reported a census of 59 residents. Resident #1 depended upon staff for activities of daily living needs due to contracture impairments of both legs (hips, knees, ankles and feet). An incident report and nurse ' s notes revealed on 4/29/2012, staff attempted to cleanse the resident after a incontinent bowel episode. The staff heard a pop by the resident ' s left knee and then saw the deformity of the foot bent upwards and towards the resident ' s face. The resident was sent immediately to the hospital and provided narcotic [MEDICATION NAME], cat scan (revealed the thigh fractured in 3 pieces) and transferred to a Des Moines Hospital for surgery to repair the fractures. Findings include: 1. Resident #1 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 03/09/12 which identified [DIAGNOSES REDACTED]. The MDS identified the resident required total dependence of two staff for toileting, bed mobility, and transfers. The MDS identified the resident with impairment of functional limitation in range of motion for both sides of the lower extremities (hip, knee, ankle, foot). The Nurse's notes dated 04/29/12 at 5:08 p.m. revealed the nurse was called to the resident ' s room. The nurse observed the resident lying on left side with left leg bent at the knee facing upwards, foot next to the resident ' s face. The resident ' s vital signs were obtained, physician notified and the resident transferred to the emergency room . The incident report dated 04/29/12 at 5:10 p.m. revealed a brief summary which revealed two Certified Nursing Assistants changed resident's brief and provided perineal care while the resident lay in bed. The CNA's heard a pop by the resident ' s left knee and then noted the resident ' s foot deformed and bent upward to his/her face. The local hospital emergency room report dated 04/29/12 documented the resident was brought in by EMS (Emergency Medical Services) and noted grossly dislocated left leg. The leg flexed upwards. Staff states they were rolling patient over to change attends (brief) and they heard a pop and the resident ' s leg became dislocated. Staff denied injury, face, or trauma. Patient has co-morbidities of [MEDICAL CONDITION] and unable to communicate. The document revealed the resident received [MEDICATION NAME] (narcotic [MEDICATION NAME]/pain medication) 4 milligrams at 6:05 p.m., 6:35 p.m. and 6:45 p.m. The record further documented additional pain medication of [MEDICATION NAME] 50 micrograms (narcotic [MEDICATION NAME]) administered at 6:50 p.m. and 7:13 p.m. A radiology report dated 04/29/12 revealed a computed tomography (CT exam) with findings of a complex comminuted [MEDICAL CONDITION] femur (thigh). There is angulation at the fracture site. Chronic [MEDICAL CONDITION] changes of the hip joint with chronic subluxation. SI joints and right hip are unremarkable. Changes of osteopenia. Resident #1 was transferred to another hospital for surgery in Des Moines Iowa and arrived at 8:50 p.m. on 4/29/2012. An orthopedist examined the resident and ordered 5 pounds of traction until an open reduction internal fixation surgery could be performed. The emergency room staff obtained photographs of the resident ' s leg. The Operative Report indicated the resident had surgery on 5/1/2012 for repair of the fractures. The report indicated the femur had 3 comminuted (fracture in pieces) fractures in 3 parts. The procedure consisted of an intramedullary nail fixation of the left subtrochanteric femur fracture with an open reduction technique. The hospital Patient Discharge & Transfer Form indicated the date of discharge to be 5/4/2012. The orthopedic physician had ordered physical therapy, weight bearing status from bed to chair. Change the dressing daily until dry and put [MEDICATION NAME] on the incision. Provide [MEDICATION NAME] (anticoagulant) 5,000 IU (international units) subcutaneously for 30 days after admission. The order directed the resident to return in 2 weeks for a follow up appointment. The resident ' s physician admission orders [REDACTED]. The physical therapy notification identified a discharge date of [DATE]. The therapist ordered passive range of motion to both upper extremities for 10 repetitions and passive range of motion to knees, ankles and toes for 10 repetitions. The therapist instructed staff to keep the arm support in the geriatric chair for the left side and keep an abduction wedge between thighs while monitoring for wincing for the pain level. Observation on 05/16/2012 at 8:04 a.m. revealed Resident #1 in bed and the bilateral lower leg extremities contracted in a scissor like position; left leg over the right crossed at knees. The resident had an incision along the left femur. During an interview on 05/22/12 at 1:10 p.m. Staff W provided a written statement: the resident was laying on his/her back and had a very large bowel movement. I was holding his/her left leg up so that Staff X could clean well between his/her legs. He/she was resisting and then I heard a pop and his/her left leg just fell to the head of the bed. I hurried and ran out and got charge nurse. During the interview, Staff W reported no education or special way to provide incontinence care for a resident with severely contracted lower extremities. On 05/22/12 at 2:00 p.m. Staff X was interviewed and provided a written statement: Staff W and I went to prepare for care and the resident had BM (bowel movement) up to his/her belly button. During cares I heard a snap/crack and Staff W looked and his/her foot was touching the forehead. I then told Staff W to go get the nurse. Staff X commented she had no education or special way to provide incontinence care for the resident. The care plan at the time of the incident did not identify the resident with limited physical mobility due to leg contractors (crossed) and how staff should provide activities of daily living (ADL) cares. The interviews and record review revealed the facility had not provided additional training to staff regarding how to care for the resident with lower leg contractures post injury. 2. Resident #3 had a Minimum Data Set assessment with a reference date of 04/05/2012 which identified Resident #3 with [DIAGNOSES REDACTED]. The medical record revealed the resident had a history of [REDACTED]. The assessment indicated the resident received a scheduled pain medication regimen and a PRN (as necessary) pain medication. A pain evaluation dated 7/6/2011 identified the resident had a [DIAGNOSES REDACTED]. The conclusion dated 10/20/11 indicated the resident received [MEDICATION NAME] 12 mcg/hr and changed every 72 hours. On 1/10/2012 the evaluation revealed no change. On 4/12/2012 the pain assessment identified the resident as restless and moans. [MEDICATION NAME] and PRN Tylenol to be continued. A monthly summary dated 5/21/2012 identified the resident had frequent pain. The summary did not identify indicators of pain (non-verbal sounds, vocal implants, facial expressions, protective body movements or postures). The care plan dated 04/18/2012 identified the resident had a difficult problem with making self understood, often restless, fidgety and words noted as garbled and hard to understand. An approach directed staff to observe for non-verbal signs of distress (guarding, moaning, restlessness and grimacing). Turn/reposition, communicate, provide pericare, assess for pain and provide liquids/food as needed. Observation on 05/14/12 at 5:13 p.m. revealed the resident in the front lounge sitting in a geriatric chair with sad facial expressions, frown brow, with grimacing noted, and crying. Registered Nurse attends to resident ' s side, holding hand. The nurse reported the resident gets " this way " at this time of day. Observation on 05/15/12 at 8:38 a.m. revealed the resident in his/her bed with sad facial expression. Observation on 05/15/12 at 3:10 p.m. noted the resident in the front lounge crying with frowned brow. A staff member provided the resident with a drink of water. Observation on 05/16/12 at 11:07 a.m. revealed two CNA's ambulating the resident with a gait belt from the bathroom to his/her geriatric chair in the front lounge. Observation revealed the resident with frowned brow, sad facial expression and making repetitive sounds. A nurse sent a facsimile on 4/11/2011 which identified the [MEDICATION NAME] 12 mcg (micrograms) had been changed the previous night and had fallen off. The patch could not be found. The nurse requested an order to replace the patch. On 4/11/2012, the physician gave approval. The physician progress notes [REDACTED]. The record revealed no documentation of a pain assessment or reason for the discontinuation of the narcotic [MEDICATION NAME]. The May Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 05/22/12 at 9:40 a.m. Staff GG, Licensed Practical Nurse, reported she thought the [MEDICATION NAME] was discontinued due to it falling off the resident. Staff GG stated the resident is given the Tylenol and [MEDICATION NAME] but the resident spits it out. Staff GG stated she had not noticed any changes in the resident but thinks the [MEDICATION NAME] Patch would give the resident more relief. (especially when the resident spit out the medication) 3. Resident #16 had an MDS assessment with a reference date of 2/16/12. The assessment documented the resident had [DIAGNOSES REDACTED]. The MDS documented the resident received scheduled pain medication. The MDS documented the resident as totally dependent on staff for cares and did not walk. The MDS documented the resident had long and short term memory loss as well as severely impaired decision making abilities. The care plan dated 2/29/12 documented the resident has behaviors of yelling out and [MEDICAL CONDITION]. The care plan documented the resident utilized Tylenol for pain control and had an order for [REDACTED]. During observation on 5/15/12 in the afternoon, the resident yelled and had [MEDICAL CONDITION] of people trying to kill her/him. Observation on 5/21/12 at 3:35 p.m. revealed the resident in bed yelling for help. The May 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the [DATE] documented staff failed to administer pain medication on 5/15/2012. Review of the MAR for April 2012 the resident received as needed pain medication three times and did not receive any as needed antipsychotic medication. Review of the MAR for March 2012 the resident received as needed pain medication three times and did not receive any as needed antipsychotic medication. Review of the MAR for February 2012 the resident received as needed pain medication once during the month. Review of the MAR for January 2012 the resident received as needed pain medication 5 times and did not receive any as needed antipsychotic medication. 4. A quarterly MDS assessment with a reference date of 3/29/12 identified Resident #8 with [DIAGNOSES REDACTED]. The assessment reflected toileting did not occur during the assessment period; however, the resident was identified as always incontinent of bowel and bladder function. The assessment indicated the resident did not have a toileting program. The Resident Care Plan dated 4/11/2012 identified a problem with the resident unable to perform any activities of daily living skills. The approaches directed staff to check and change at least every 2 hours for incontinence and not to let the resident go more than 2 days without a bowel movement. A physician order [REDACTED]. as needed for constipation, and Milk of Magnesia (laxative) 30 ml ( milliliters). The February Bowel Movement record revealed Resident #8 did not have a bowel movement 2/5/2012, 2/6/2012 and 2/7/2012. The resident had a large bowel movement on 2/8/2012. The resident went from 2/12/12 to 2/15/12 without a recorded BM, from 2/18/12 to 2/22/12 with an XS (extra small) BM recorded due to receiving a [MEDICATION NAME] suppository on 2/22/12 to aide in bowel evacuation. This is the only date according to the MAR indicated [REDACTED]. The March Bowel Movement record revealed Resident #8 had a large BM on 3/2/12 and didn't have a recorded BM until 3/9/12. According to the MAR indicated [REDACTED]. The bowel record documented the resident with a BM on 3/23/12 and a large BM recorded on 3/27/12. Again the resident went from 3/27/12 to 3/31/12 when staff documented a small BM. The March MAR indicated [REDACTED]. The April Bowel Movement record revealed the resident went from 4/1/12 to 4/5/12 without a recorded BM. On 4/5/2012 the resident had a large bowel movement. from 4/6/12 to 4/13/12 without a recorded BM, from 4/11/12 to 4/13/12, and 4/27/12 to 4/29/12 without recorded BM's. The April MAR indicated [REDACTED].

Based on record review, observation and review of the Quick Reference Guide for Clinicians, the facility failed to ensure one resident received appropriate interventions for repositioning off pressure ulcers and provide complete and accurate assessments of ulcers for 1 of 15 sample residents (Resident #2). Interventions were ineffective to prevent the occurrence of an avoidable additional pressure ulcer or were not implemented as directed on the care plan. The facility reported a census of 59 residents. Upon admission on 5/3/2012, Resident #2, facility staff identified 2 pressure sore areas located on the resident ' s left and right outer ankle, fifth right digit and anterior area of the right foot. On 5/4/2012 the facility staff identified a black area located on the resident ' s left heel. On 5/6/2012, the staff sent a facsimile to the physician for orders for an air mattress and heel protectors. The initial care plan dated 5/3/2012 and current care plan directed staff to use heel protectors to relieve pressure on the heels. The initial admission care plan approach directed staff to have an air mattress located on the bed. A facsimile to the physician on 5/14/2012 indicated the facility had identified another pressure ulcer located on the right heel which measured 2 centimeters (cm) by 2 cm and brown. The facsimile informed the physician the facility did not have a treatment order for the heels. On 5/14/2012 at 6:00 p.m., the physician ordered an " okay " for heel protectors and to keep the heels off of the bed. The wound assessment records determined on 5/14/2012, the left heel pressure ulcers had enlarged and an additional pressure ulcer had become present on the right heel. Observation revealed the heel protective boots not always on the resident ' s feet when the resident lay in bed on 5/15/12, 5/16/12, 5/17/12. Findings include: 1. Information from the Quick Reference Guide for Clinicians regarding pressure ulcer treatment includes the following: ? Stage I: Nonblanchable [DIAGNOSES REDACTED] of intact skin. ? Stage II: partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. ? Stage III: full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. ? Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures. ? Reassess pressure ulcers at least weekly. 1. The Minimum Data Set (MDS) Assessment Tool with a reference date of 05/10/2012 identified Resident #2 with [DIAGNOSES REDACTED]. The MDS reflected the resident required 1 staff person with limited assistance for bed mobility, transfers and ambulation. The MDS identified the resident at risk for developing pressure sores and identified the resident with two unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar. The largest unhealed wound at the time of the assessment documented the wound measured 1.5 centimeters in length and 1.0 centimeters in width with necrotic tissue (eschar - a black, brown, or tan that adheres firmly to the wound bed or ulcer edges). The MDS reflected the resident received pressure ulcer care, pressure reducing device for the bed. The MDS reflected the resident did not have a turning/repositioning program or pressure reducing devices for the feet The Braden Scale for Predicting Pressure Sore Risk dated 05/03/12 revealed a score of 18 with a score of 12 or less indicated a high risk for skin breakdown. The initial care plan dated 05/03/12 identified a concern for pressure sores/skin care with a goal to prevent/heal pressure sores and skin breakdown. Interventions listed: to follow the facility skin care protocol, preventative measures with use of heel protectors/air mattress, and report to charge nurse any redness or skin breakdown immediately. A skin condition report dated 05/03/12 revealed the following skin issues: a. The left outer ankle noted a brown scab that measured 0.4 centimeters by 0.4 centimeters (cm). b. The right outer ankle noted a 3 cm callous area with a 0.3 cm brown center. c. The top of the right foot noted a 1.0 cm by 0.4 cm reddish open area. d. The right outer 5th toe of the right foot noted a 0.3 cm by 0.3 cm black scab. A skin condition report dated 05/04/12 documented a left heel black scab like area that measured 1.5 centimeters in length. A facsimile (fax) dated 05/04/12 requested treatments for the skin concerns. A wound assessment dated [DATE] revealed the following measurements: a. The left heel revealed a dark scab that measured 1.0 cm by 1.0 cm. b. The left outer heel revealed a 0.3 cm by 0.5 cm scab and 1.0 cm by 3.0 cm callous. The assessment revealed a fax sent for treatment with an air mattress and heel protectors. A wound assessment dated [DATE] revealed the following measurements: a. The left heel revealed a scab that measured 1.5 cm by 1.0 cm (increased in size). b. The left outer heel revealed a 0.5 cm scab and 1.0 cm by 3.0 cm callous. c. The right heel revealed a wound that measured 2.0 cm by 2.0 cm with a wound bed as brown in color and intact (new area). The Treatment record for May 2012 revealed a treatment to monitor the following areas: a. Monitor left heel. b. Monitor left outer heel. c. Monitor left outer ankle. d. Monitor top of right foot, right outer pinky, and fourth toe (right) for ten days then weekly till healed. e. Float heels/heel protectors as resident allows. The Treatment record dated 05/14/12 revealed a treatment to the left and right heel of skin prep twice daily. Observations on the following dates and times revealed no use of the heel protective boots while the resident laid in bed. a. On 05/15/12 at 7:30 a.m. b. On 05/16/12 at 4:35 a.m. c. On 05/17/12 at 7:33 a.m. Observation on 05/17/12 at 10:30 a.m. revealed Staff Y, Registered Nurse, provided skin prep treatment to the resident's right and left heels. Observation revealed black wounds to the resident's right and left heel, 5th toe, and fourth digit. Staff Y completed the treatment and placed the resident's shoes on his/her feet. Record review lacked documentation of the refusals for wound treatments or education provided of the importance of care.