Every finding on record at Good Samaritan - Forest City

Based on record review and staff interview, the facility failed to ensure a resident was free from abuse for 1 resident reviewed (Resident #2). The facility reported a census of 34 residents.The citation is considered past non-compliance.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 scored 13 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident depended on staff for toileting hygiene, shower/bathing, lower body dressing, and transfers. The resident's diagnoses included aphasia (a language disorder that affects a person's ability to communicate), stroke, and hemiplegia (paralysis) or hemiparesis (weakness on 1 side of the body). The Care Plan revised 6/11/25 identified the resident:a. Had impaired cognitive function and impaired thought processes related to cerebral infarction (stroke) evidenced by inattention, disorganized thinking, and behaviors.b. The resident had a communication problem due to expressive aphasia related to a history of strokes.Revised 3/11/25:c. The resident was adjusting to admission related to a recent stroke and needing 24 hour care.Revised 7/14/25:d. The resident had the potential to experience trauma related to abuse allegations and ongoing investigation.A facility Investigation documented on 7/11/25 at 9:30 a.m. the Social Worker (SW) was asked to assist Resident #2 to help him with his new phone that he received the day prior. He told her he was not sure he was receiving messages and asked her to help. He gave her the phone and his password. When the SW unlocked the phone in front of the resident, she saw that there was a text message thread with someone with the same 1st name as Staff A Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA), and because it was a unique name, she questioned if it was Staff A from work, and Resident #2 said no. The resident asked her to click on a text message thread to see if she could get a message to send. The SW scrolled up on the feed to see if any messages were sent. She saw a picture of Staff A and other messages. The SW was concerned by photos she had seen. The resident said it was a friend from another town. The resident then asked her to hold on to his phone for him so that she could work on it which he has done prior when his phone didn't work properly. She went into his messages to see the last time he received a message. When she clicked on the Staff A contact and saw that it said, Good Morning Love, I miss you, she had some concerns that it may be the employee that worked at the facility and scrolled back to see a picture of Staff A, and then saw a picture of male genitalia. At that point she put the phone down and called the Administrator. The investigation ensued and included obtaining an interview with Staff A and a report to police.In a statement written by Staff A, she documented she met Resident #2 when he first came to the facility. They hit it off immediately. They had always had a very good working relationship. A couple of months ago feelings between the two of them became more than just friends. They exchanged phone numbers and had conversations outside of work. The relationship was physical one time with a kiss. It was never her intention for this to happen. It sprung up on her. There had never been any ill intentions. It was consensual on both sides. There had never been any sexual contact. At work their relationship had been professional with the exception of the one kiss. She admitted she knew it was wrong, but her feelings got the best of her.The Police Incident Report dated 7/11/25 at 10:54 a.m. documented the incident occurred 5/9/25 through 7/11/25, and the offense dependent adult abuse. The Police Arrest History dated 7/14/25 documented Staff A arrested for dependent adult abuse.A review of images from Staff A's phone showed it contained inappropriate messages and pictures sent to Resident #2's phone.During an interview on 8/6/25 at 2 p.m. Staff A stated she was empathetic to the resident. She said she got to know Resident #2 when he came in the facility. She said he was hospitalized and several wondered where he went and how he was doing. When he came back to the facility he asked for her phone number, so if he went back to the hospital, he could let her know how he was doing. She gave it to him, but she did not get his. He initiated things by giving her very nice compliments. She said he started texting her, and she texted back, mostly memes. There were a few phone calls, but communication over the phone was very difficult. She did start to have feelings for him. Some of the memes had I Love You in them. She confirmed the resident sent texts with a male's genitals in them. She did not know where he obtained them. She also admitted the pictures of a woman in a bra and panties, and exposing a breast were of her sent to the resident. She said it was not physical except for 1 kiss. It was a consensual relationship, and she did not hurt anyone. She knew it was wrong because she was employed at the facility, but it was consensual, and no one was hurt. A review of Staff A's personnel file showed she completed the Iowa Department of Health and Human Services Dependent Adult Abuse Mandatory Reporter Training on 10/8/24.The facility provided training to staff on July 15, 2025 related to dependent adult abuse and boundaries.The Iowa Department of Health And Human Services, Dependent Adult Abuse, A Guide for Mandatory Reporters revised July 2024 documented Sexual Exploitation by a Caretaker meant any consensual or nonconsensual sexual conduct with a dependent adult, and included kissing. The facility policy Abuse and Neglect reviewed/revised 4/7/25 documented the purpose to ensure that residents/clients were not subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the individual, family members or legal guardians, friends or other individuals. The resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

Based on observation, staff interview, clinical record review, Centers for Disease Control and Prevention (CDC) recommendations and policy review the facility failed to provide appropriate catheter care for 1 of 1 resident reviewed (Resident #17). The facility reported a census of 34 residents.Findings include:Resident #17's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS identified Resident #17 was dependent on staff assistance for toileting hygiene. Residents #17 MDS included a diagnosis of benign prostatic hyperplasia (enlarged prostate gland). The MDS revealed Resident #17 had an indwelling catheter (tube inserted into bladder to drain urine).The Care Plan revised dated 07/03/25 identified Resident #17 had an indwelling catheter due to urinary retention (inability to completely empty the bladder). The care plan lack direction on where to place the catheter urine bag and tubing to prevent the bag/tubing from touching the floor.Review of the form titled Catheter Data Collection dated 07/23/25 documented resident education to keep the urine bag lower than the bladder and off the floor.On 08/04/2025 at 1:53 PM, observed Resident #17 lying in bed and his catheter urine bag was laying on floor next to the bed. The urine bag did not have a dignity bag in place.On 08/05/2025 at 10:18 AM, observed Resident #17 catheter urine bag attached to the bed rail with the bag touching floor. The urine bag did not have a dignity bag in place. On 08/06/2025 at 7:29 AM, observed Resident #17 catheter urine bag attached to the bed rail with the bag touching floor. The urine bag did not have a dignity bag in place.On 08/06/2025 at 9:02 AM, the Director of Nursing (DON) stated her expectation of the catheter urine bag placement was that the bag should not be touching the floor while attached to the bed.Review of the CDC Guidelines for Prevention of Catheter-Associated Urinary Tract Infections dated 2009 directed the catheter urine bag not to be rested on the floor.The facility policy titled Catheter: Care, Insertion/Removal, Drainage Bags, Irrigation, and Specimen revised 04/06/25 directed staff to keep the resident's catheter bag covered and catheter tubing should never be allowed to touch the floor.

Based on clinical record reviews, hospital record review, staff interviews and policy review, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 3 residents reviewed (Resident #87). The facility failed to provide the appropriate level of assistance during a transfer which resulted in Resident #87 being lowered to the floor and hospitalized with a fracture requiring surgical intervention. The facility reported a census of 35 residents. Citation considered past noncompliance as the facility completed the following interventions prior to the surveyor entering the facility on 9/3/24: 1. Staff A, CNA provided written disciplinary action for not following the plan of care transfer-4/22/24 2. Employee Huddles discussed the importance of following the kardex and assist levels with all transfers at all nursing huddles at 6 AM and 2 PM on 4/20, 4/21 and 4/22/24. 3. The DON and MDS Coordinator applied colored labels to each resident walker/wheelchair so the staff would know the proper assist level of each resident and made sure the colored labels match the kardex. Staff were provided education that they would have real time information on what the resident assist level was. The admission checklist was updated to place colored labels on the equipment and therapy was educated to change the labels immediately when the level of assist changed- 4/22/24 4. The DON met with therapy to discuss not having different assist levels at different times of the day, if there was a question, to defer to higher level of care.- 4/22/24 5. All nursing staff were provided face to face education with the Clinical Learning and Development Specialist regarding safe transfers. If staff did not attend one of the group meetings then they were provided 1:1 education.- 5/16/24 through 7/10/24 Findings include: The Minimum Data Set (MDS) assessment for Resident #87 dated 3/14/24 identified a Brief Interview for Mental Status (BIMS) score of 12, which indicated intact cognition. The MDS identified Resident #87 required partial/moderate assistance with bed mobility, and was dependent on staff for transfers, and toileting. The MDS included diagnoses of anemia, atrial fibrillation (irregular heart rhythm), hypertension (high blood pressure), deep venous thrombosis (blood clot in a deep vein), diabetes mellitus, and chronic kidney disease. The Care Plan dated 3/8/24 revealed Resident #87 had a ADL (Activity of Daily Living) self care performance deficit related to generalized muscle weakness, diabetes, hypertension, osteoarthritis, macular degeneration, edema and depression. The Care Plan directed the following: -Resident #87 required extensive assistance x 2 staff to get to and from the commode, with completion of toileting hygiene and continence product management. -Resident #87 required assist of one staff member for stand pivot transfers (transfers toward the right) only with use of gait belt and front wheeled walker during the day hours (6 AM to 6 PM), and assist of two staff members for stand pivot transfers during the night hours when more fatigued. A Physical Therapy Discharge Summary dated 4/16/24 documented Resident #87 amounts of assistance with transfers and standing tolerance varied from day to day. The summary documented Resident #87 required an assist of one for transfers during the day (6 AM to 6 PM) and an assist of 2 at night. A Fall Risk Evaluation dated 3/8/24 documented a fall risk score of 20 which indicated Resident #87 was at high risk for falls. An Incident Report dated 4/19/24 at 8:45 PM documented Resident #87 had a sudden loss of strength to her left knee and caused a loss of balance. Staff member assisted Resident #87 to the floor. Resident #87 reported her left knee twisted. The report documented it was undetermined if Resident #87's knee twisted prior to being lowered to the floor or as she was lowered by staff. Resident reported she lost her balance when her knee gave out. Resident reported she wasn't standing that long this time. A Progress Note dated 4/19/24 at 8:45 PM documented Resident #87 was transferring from the commode to her wheelchair. Staff was moving the commode and putting the wheelchair behind Resident #87, when she had a sudden loss of strength to her left knee/lower extremity which caused a loss of balance. Resident #87 was not able to regain balance or bear weight on her left lower extremity with staff assistance. Staff lowered Resident #87 to the floor. Staff reported Resident #87 left foot was hooked behind her right calf after being lowered to the floor. Resident #87 reported she had twisted her knee. A head to toe assessment was completed along with vital signs. The head to toe assessment and palpation revealed pain to both anterior and posterior left knee. Increased pain was noted to the left knee with slight movement. No immediate bruising or increased swelling noted. Call placed to on call Provider and new order received to transfer Resident #87 to the hospital for further evaluation. Resident #87's husband was notified of the fall and aware of the transfer to the hospital. A Progress Note dated 4/20/24 documented Resident #87 was admitted to the hospital. A Hospital Consultation Note dated 4/19/24 documented Resident #87 was admitted to the hospital for a management of left fibula periprosthetic fracture. The consultation note documented Resident #87 presented to the emergency room (ER) via Emergency Medical Services (EMS) after falling from the commode at the nursing home. Resident #87 was being assisted at the time and claimed her left knee gave out. A Hospital Operative Report dated 4/22/24 revealed Resident #87 had an open reduction and internal fixation with a lateral plate due to the left distal femur periprosthetic fracture. An untitled facility form dated 4/22/24 documented Staff A, CNA (certified nursing assistant) transferred resident to the bedside commode with assistance of one. This level of assistance did not follow the resident's care plan of having assistance of two with transfers during the night time hours. The resident was lowered to the floor during the transfer resulting in a fracture. The summary and expectation portion of the form documented Staff A would follow resident care plans for all transfers and for all care. Staff A to ask for assistance when needed. The form documented Staff A was required to be in compliance with the policies. The form was signed by Staff A, the Director of Nursing (DON) and the Administrator on 4/22/24. On 9/4/24 at 10:25 AM, the Administrator reported Staff A, CNA was given a written warning for not providing appropriate level of assistance per the care plan. The Administrator reported there were some inconsistencies in the care plan that had to be clarified with therapy. She stated there was education and training provided to all the nurses and CNAs on transfer techniques. On 9/4/24 at 10:30 AM, Staff B, RN (Registered Nurse) reported she was called into Resident #87's room after she was lowered to the floor by Staff A. Staff B stated she completed vitals and a head to toe assessment. She reported Resident #87 had left knee pain. She stated she did some gently passive range of motion to the left knee and stopped when Resident #87 complained of pain. Staff B stated she sent Resident #87 to ER for an evaluation. She stated both Staff A and Resident #87 reported she did not hit her head during the fall. Staff B stated Resident #87 reported she went down easy. Staff B verified Staff A was not providing the appropriate level of assistance during the transfer. Staff B stated Resident #87 was supposed to have assistance from two staff members after 6 PM. Staff B stated she asked Staff A if she was in the room by herself and Staff A responded that she could not remember when Resident #87 was an assist of one vs. assist of two. She stated she did not believe Staff A. Staff B reported she had a conversation with Staff A, educating and reminding her on assistance levels. Staff B stated she told the Administrator and the DON and they also followed up with Staff A. Staff B reported the CNAs are to look at the care plan for assistance levels. On 9/4/24 at 1:34 PM, Staff A, CNA reported Resident #87 call light was on and she went to answer the light. She stated Resident #87 wanted to use the commode. She stated she put the gait belt on Resident #87, stood her up, pulled the wheelchair out and put the commode in place. She said Resident #87 sat for a little bit and when she was done, she stood her up to complete peri cares, keeping the commode behind her. She stated Resident #87 sat back down and then stood up again to remove the commode. She stated before she could get the wheelchair in place, Resident #87 started going down so she let her down easily to the floor. Staff A stated she called for the nurse. Staff A reported it happened so fast. She reported she did not hear any pooping and there was no twisting. She stated Resident #87 complained of pain in her left leg and asked her to reposition it. Staff A stated she told Resident #87 she could not move her leg until the nurse evaluated her. She reported Resident #87's Care Plan directed an assist of one with transfers from 6 AM to 6 PM and an assist of 2 from 6PM to 6 AM. Staff A stated she was transferring Resident #87 by herself and was aware after 6 PM she required the assistance of two. She stated the level of assistance was on Resident #87's kardex. She verified and acknowledged she was given a written warning by the DON and Administrator regarding the incident and not following the care plan. She stated she was a rule follower and has had no incidents afterwards. A facility policy titled Fall Prevention and Management reviewed/revised 7/29/24 documented the purpose of the policy was the following: *To promote resident well being by developing and implementing a fall prevention and management program. *To identify risk factors and implement intervention before a fall occurs. *To give prompt treatment after a fall occurs. *To provide guidance for documentation A facility policy titled Care Plan reviewed/revised 11/1/23 documented the care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. It will address the relationship of items or services required and facility responsibility for providing these services.

Based on clinical record review, staff interview and policy review the facility failed to develop a care plan to address risk factors and interventions for 3 out of 13 residents (Residents #87, #8, #30) reviewed for comprehensive care plans.The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #87 dated 3/14/24 identified a Brief Interview for Mental Status (BIMS) score of 12, which indicated intact cognition. The MDS included diagnoses of anemia, atrial fibrillation (irregular heart rhythm), hypertension (high blood pressure), deep venous thrombosis (blood clot in a deep vein), diabetes mellitus, and chronic kidney disease. The MDS documented Resident #87 received an anticoagulant medication during the assessment period (last 7 days). Review of Medication Administration Records (MAR) for the months of March 2024 to June 2024 revealed Resident #87 received coumadin (anticoagulant medication) at various dosages for atrial fibrillation. Review of Resident #87's Care Plan initiated on 3/8/24 revealed the anticoagulant medication, potential side effects and what to monitor for while taking the high risk medication was not addressed on the comprehensive care plan. On 9/4/24 at 11:32 AM, the MDS Coordinator acknowledged and verified the coumadin was not addressed on Resident #87's Care Plan. A facility policy titled Care Plan reviewed/revised 11/1/23 documented each resident to have an individualized, person centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident ' s optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. The plan of care will be modified to reflect the care currently required/provided for the resident. 49056 2. The MDS assessment for Resident #8 dated 8/5/24 identified a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. The MDS included diagnoses of atrial fibrillation, heart failure, hypertension (high blood pressure), anxiety and depression. The MDS documented Resident #8 received the diuretic medication during the assessment period (last 7 days). Per the clinical Physician Order dated 3/19/24 directed staff to administer hydrochlorothiazide 12.5mg Capsule, give 1 capsule by mouth one time a day related to congestive heart failure. Review of Resident #8's Care Plan with an initiated date of 3/15/23 revealed the diuretic medication, potential side effects and what to monitor for, while taking the high risk medication was not addressed on the comprehensive care plan. 3. The MDS assessment for Resident #30 dated 7/23/24 identified a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. The MDS included diagnoses of anxiety, depression, post traumatic stress disorder, and schizophrenia. The MDS documented Resident #30 received a antipsychotic medication during the assessment period (last 7 days). Per the clinical Physician Order dated 3/29/24 directed staff to administer Abilify15mg, give 1 tablet by mouth daily, Quetiapine 25mg tablet, give 1.5 tablet by mouth two times daily, and Quetiapine 25mg, give 2 tablets by mouth daily. Review of Resident #30's Care Plan with an initiated date of 1/29/24 revealed the antipsychotic medication, potential side effects and what to monitor for, while taking the high risk medication was not addressed on the comprehensive care plan.

Based on clinical record review, staff interviews, and policy review the facility failed to provide assessment and interventions necessary for the care and services, to maintain the residents' highest practical physical well- being for 1 of 13 residents reviewed (Resident #21). The facility failed to complete and document nursing assessments related to diuretic usage and increased edema (fluid retention). The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #21 dated 6/8/24 identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS included diagnoses of anemia, atrial fibrillation (irregular heart rhythm), heart failure (heart cannot pump blood well enough), hypertension (high blood pressure), and chronic kidney disease. The Care Plan with revision date of 4/5/24 revealed Resident #21 had altered cardiovascular status related to atrial flutter, congestive heart failure (CHF), hypertension, anemia and history of tobacco use. The Care Plan directed staff to apply and remove bilateral ted hose. The Care Plan focus area and interventions dated 9/4/24 directed staff to monitor/document/report to health care provider as needed of any signs and symptoms of CHF: dependent edema of legs/feet, periorbital edema, shortness of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles/wheezes upon auscultation of the lungs, orthopnea, weakness, fatigue, increase heart rate, lethargy and disorientation. A Physician Order dated 11/26/23 directed staff to apply knee high ted hose on in the morning and remove at bedtime. Review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June through September 2024 lacked documentation Resident #21 ted hose were being applied and removed per the Physician order. A Progress Note dated 8/8/24 revealed Resident #21 had a significant weight gain of 6.1% in the past 30 days. A Progress Note dated 8/8/24 revealed a fax was sent to the Physician that documented Resident #21 had a significant weight gain, 3+ edema bilaterally and lung sounds were clear. The note revealed Resident #21 was not prescribed any diuretic (fluid pill) medications. A Progress Note dated 8/13/24 documented the ARNP (Advanced Registered Nurse Practitioner) responded to please have Resident #21 seen and evaluated for concerns for heart failure. The noted documented a appointment to be made. Review of the Progress Notes from 8/9/24 to 8/21/24 lacked documentation of nursing assessments and interventions related to fluid retention. The notes also lacked follow up documentation regarding the appointment for Resident #21 to be seen regarding the concerns for heart failure. A Progress Note dated 8/21/24 revealed the Physician evaluated Resident #21 and new orders received for Lasix (diuretic medication) 20 mg (milligrams) every AM (morning) and to draw a BMP (Basic Metabolic Panel/lab work) in 2 weeks. A Physician Progress Note dated 8/21/24 revealed the Physician was asked to see Resident #21 because of a lot of edema in her lower extremities. The note documented Resident #21 had swelling all the way up to the thigh area. The swelling started 1-2 weeks ago with it gradually getting worse. Resident #21 ankles had 2 to 3+ pitting edema in the lower extremities and 2+ edema up into the thighs. The note documented the plan was to add Lasix 20 mg 2 tablets in the morning and to repeat a BMP in 2 weeks. The facility to notify the Physician if there was no improvement. Review of the Progress Notes from 8/22/24 to 8/25/24 lacked documentation of nursing assessments and interventions related to fluid retention and the diuretic usage that was started the morning of 8/22/24. A Progress Note dated 8/26/24 documented Resident #21 was started on a new medication lasix on 8/21 with daily weight being completed at sporadic times and not at set time/same clothes. The note revealed Resident #21 had been slowly climbing with weight and fluid. The note documented Resident #21 had no shortness of breath and lung sounds diminished bilaterally. The note documented Resident #21 was educated regarding the importance of daily exercise but does not put forth the effort. Resident #21 was scheduled for a BMP lab draw on 9/5 and appointment with the Physician on 9/10/24. The clinical record lacked a daily weight on 8/26/24 per order. A Physician Progress Note dated 8/28/24 documented nursing concerns of increased weight and fluid accumulation. No new orders documented on the Physician Progress Note regarding the weight or fluid accumulation. Review of the Progress Notes from 8/29/24 and 8/30/24 lacked documentation of nursing assessments and interventions related to fluid retention. A Wound Care Telemedicine Follow Up Evaluation dated 8/29/24 revealed Resident #21 had a full thickness venous wound to the right posterior thigh with duration greater than 3 days. The note documented the wound size (length x width x depth) was 5.0 x 17.0 x 0.1 cm (centimeters). The wound had moderate amounts of serous (clear fluid) drainage. The note revealed the treatment plan was to apply hydrocortisone cream 0.1 % twice a day until healed. Review of the Progress Notes on 8/29 and prior lacked documentation regarding the open area to the right posterior thigh. The notes lacked documentation Resident #29 was seen for a telemedicine visit on 8/29. Review of the August MAR revealed the Hydrocortisone cream was started on 8/31/24. A Progress Note dated 8/31/24 at 3:11 PM documented Resident #21 had 4+ edema to both legs, weeping with open areas and a rash behind the right knee. The note documented a RN (Registered Nurse) wrapped legs in the morning, covered open areas with ABD (abdominal pad) and coban (self adherent wrap). The note reported at 2:30 PM Resident #21 had a bath, legs were redressed with ABD pad, ace wraps and an ABD pad under the right knee. The clinical record lacked documentation of a Physician Order for the legs to be wrapped with ace wraps. A Progress Note dated 8/31/24 (Saturday) revealed a fax was sent to the Physician reporting Resident #21 had 4+ weeping edema to bilateral lower extremities, along with open areas present to the right leg and a rash on the back of the right knee. The note documented there were no present orders to treat and the staff implemented wrapping both legs with coban and/or ace wraps and using an ABD pad as a moisture barrier. Review of the Progress Notes from 9/1/24 and 9/2/24 lacked documentation of any further nursing assessments related to the fluid retention, open areas to lower legs, lungs sounds or shortness of breath. The notes lacked any further communication to the Physician regarding the change in condition to the lower legs. A Progress Note dated 9/3/24 documented the ARNP returned communication and directed to give Lasix 40 mg at 12 PM, check BMP now and in one week to monitor kidney function and electrolytes. A Progress Note dated 9/3/24 at 1:52 PM documented the one time dose of lasix was given to Resident #21 per order. The noted documented Resident #21 denied shortness of breath and showed no signs or symptoms of difficulty breathing. Resident #21 legs were wrapped as weeping was present, especially in the right leg. A Progress Note dated 9/3/24 at 3:03 PM documented Resident #21 legs wrapped with ace wraps and ABD pads on the sores. The sores on the right leg are growing in nature, and a rash was present and has an ABD pad on it. On 9/4/24 at 1:00 PM, the DON (Director of Nursing) reported she would expect assessments to be completed when a new medication (lasix) was started. On 9/4/24 at 1:30 PM, the DON acknowledged and verified she could not locate a weight for Resident #21 on 8/26/24. The DON reported the facility had been in contact with the Physician and would be receiving new orders. A Progress Note dated for 9/4/24 at 2:10 PM documented a call was received from the Physician to discuss patient status and skin concerns. The Physician directed the following new orders: 1. Start spironolactone (diuretic) 25 mg daily 2. Increase Lasix to 40 mg twice daily 3. BMP in one week 4. Continue hydrocortisone cream for the rash 5. For the open area, use aquacel ag with silver or any equivalent calcium alginate with silver and cover with either a foam pad or ABD. 6. Continue to treat at the facility. If Resident #21 develops shortness of breath, heart rate is consistently greater than 120 beats per minute, or systolic blood pressure reading drops below 100, call back for further directives. 7. Call back on 9/5/24 to follow up on how Resident #21 was tolerating the medication and if not improving, other options could be tried. On 9/4/24 at 3:18 PM, the DON acknowledged R#21 did not wear ted hose to her lower legs and was waiting on a clarification order from the Physician. On 9/4/24 at 3:49 PM, the DON acknowledged and verified she could not locate documentation for the ted hose for the past 60 days. She reported the Physician does not feel the ted hose are appropriate anymore and was going to discontinue the order. She stated Resident #21 wore the brown compression stockings and the stockings were stopped a couple of weeks ago due to the swelling and weeping in the legs. The DON stated she would expect when the wraps were started an order would have been obtained and the ted hose either put on hold or discontinued. On 9/5/24 at 8:48 AM, the DON reported she expected physician orders to be followed and documentation completed if the resident refused and/or if nursing felt the order was contraindicated and to notify the Provider. On 9/5/24 at 9:14 AM, the DON reported she expected the nurses to triage and use their judgment on whether a fax or phone call to the Provider was appropriate. She stated she expected nursing to continue to monitor the resident and document whether there were improvements or declines while waiting for the Physician to respond and if there were declines to follow up/notify the Provider. The DON acknowledge the documentation for Resident #21 was sparse and missing details regarding assessments and interventions. She stated she was working on educating the staff. A facility policy titled Change in Condition reviewed/revised on 4/1/24 documented the purpose of the policy was the following: *To improve communication between nurses and a provider when nursing was monitoring a change in condition. *To enhance the nursing evaluation of and documentation of a resident who has a change in condition. *To provide a standard format to collect pertinent clinical data prior to contacting the provider when there is a change in condition. *To standardize shift to shift communication about a resident change in condition. The policy documented nursing judgment should be used when determining the urgency of contacting the Provider and at what point to call the Provider. The policy directed that staff continue to monitor the resident and update the change of condition evaluation as appropriate. A facility policy titled Physician/Practitioner orders reviewed/revised on 4/1/24 documented the purpose of the policy was to provide individualized care to each resident by obtaining and processing appropriate, accurate and timely Physician/Practitioner orders.

Based on observations, staff interview, and policy review the facility failed to obtain food temperatures with a resident's meal substitutions and ensure the kitchen ice machine wiped down on a regular basis to reduce the risk of bacteria growth and foodborne illness. The facility reported a census of 35 residents. Findings include: During the initial tour of the kitchen on 9/3/24 at 10:40 AM, the ice machine examined. Upon opening the lid, a line of pink/yellow residue found along the rim just above the ice collection bin. Lunch service observed on 9/4/24 at 11:45 AM. A serving of tomato soup as well as an individual frozen portion of macaroni and cheese reheated in the microwave. When finished cooking, kitchen staff plated the items and sent out to the resident. Temperatures were not obtained for either item. During an interview on 9/4/24 at 12:15 PM, the Certified Dietary Manager (CDM) made aware of the temperature oversight. The CDM acknowledged that temperatures should have been obtained on both food items to meet food safety standards. During an interview on 9/5/24 at 8:40 AM, the CDM acknowledged the residue found during the initial kitchen tour. The CDM explained there is no scheduled spot checks or wiping down of the ice machine. Kitchen and maintenance staff will complete monthly deep cleaning which is tracked on a separate maintenance computer program. The CDM would expect staff to clean any visible dirt or residue immediately. The policy Food Temperature Monitor-Food and Nutrition Services dated 12/21/23, outlines a minimal cook-to temperature of reheated or cooked foods in the microwave to 165 . The policy Cleaning Schedule-Food and Nutrition Services dated 11/27/23 outlines staff to check kitchen equipment for cleanliness and that it's in good repair. Refrigerated units placed on a regular cleaning schedule to ensure removal of mold and mildew.

Based on observations, interviews, and record review, the facility failed to provide the correct texture of diets to at least 6 residents (Resident #4, #9, #24, #27, #35 and #91) for an extended amount of time. The facility had all residents evaluated by a Speech Therapist (ST) for the IDDSI (International Dysphagia Diet Standardization Initiative 2019) framework of diets in April and May of 2023. Residents diets were changed and ordered per the ST's recommendations. These 6 residents were evaluated and were to receive either a Diet Texture 5 Minced & Moist or a Diet Texture 6 Soft & Bite Sized and were to have their food altered according to their designated diets. The Certified Dietary Manager (CDM) stated they were not following the diets as she was told to follow the mechanical soft diet model (from the National Dysphagia Diet (NDD)), which is a more liberal diet that included soft breads. Residents #4, #9 and #24 were to be given pureed bread sticks for lunch service on 10/17/23. They were given whole breadsticks. Resident #27 was to be given pureed pears on 9/17/23 and was given sliced pears. Documentation revealed that she had a choking episode. Resident #35, who was on Diet Texture 5 was given a Honey Bun, without it being approved by a Speech Therapist. Resident #91's documentation revealed that he was to have a level 6 diet soft and bite sized per ST's evaluation on 4/12/23. On 5/11/23 it was documented that this resident had recent coughing episodes and was to be on a soft and bite sized diet. On 5/24/23, the CDM documented that Resident #91 was on a general diet with mechanical soft texture. The facility reported a census of 38 residents. On 10/18/23 at 11:30 AM, the Iowa Department of Inspections and Appeals and Licensing staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. This Immediate Jeopardy situation started on 9/17/23, the day Resident #27 was documented as having a choking episode. The facility staff removed the immediacy on 10/18/23 and decreased the scope to D, after the facility staff completed the following: Corrective Action: a. Success Center Course IDDSI training will be completed for all cooks and dietary aids by end of today 10/18/23 or by next shift. CDM will complete training on dietary spreadsheets with all cooks prior to next shift. A competency quiz will be issued to all cooks and dietary aids to validate understanding. b. Dietary Spreadsheets will be updated and match diet cards, care plans will be updated and match physician orders and diet cards by end of today 10/18/23. c. Nursing assessments will be completed on residents #4, #9, #24 and #27 by end of day today 10/18/23. Any concerns will be immediately communicated to physician. Family and physician will be notified by facility regarding resident #27's coughing episode by end of day today 10/18/23. d. QAPI meeting will be held today 10/18 to review current action plan. Identification of Others: e. All residents with altered diet orders medical records will be audited today (10/18/23) to ensure all diets are correct. Any discrepancies found will be immediately corrected. CDM or designee will monitor all meals x 7 days to monitor and ensure proper diet texture is provided to residents. Process/Systemic Change: f. Success Center IDDSI training course will be issued for all new dietary hires and completed annually. g. Facility will follow Policy & Procedure utilizing dietary spreadsheets for validation of correct texture. h. All new or changed diet orders will be reviewed weekly during weekly IDT meeting to ensure accuracy of diet textures. Monitoring: i. CDM or designee, will monitor meal services and validation of correct texture at meal service per spreadsheet every meal x 7 days, if no concerns noted will continue audits weekly x 4 and monthly x 2. Findings will be shared during QAPI x 3 months for further review and recommendations. Further auditing will be determined by QAPI committee. Completion Date: j. Please consider this IJ abatement plan as the facility action to address the immediate concerns of noncompliance. This plan will be implemented and completed on October 18th, 2023, by end of day. Findings Include: The following is information that is included in handouts from IDDSI dated January 2019: Level 5 Minced & Moist Food for Adults -Soft and moist, but with no liquid leaking/dripping from the food -Biting is not required -Minimal chewing required -Lumps of 4mm (millimeter) in size -Lumps can be mashed with the tongue -Food can be easily mashed with just a little pressure from a fork -Should be able to scoop food onto a fork, with no liquid dripping and no crumbles falling off the fork Examples of Level 5 Minced & Moist Food for Adults included: -Fruit served finely mashed or chopped to 4 mm lump size pieces (drain any excess liquid) -NO REGULAR DRY BREAD due to high choking risk! Level 6 Soft & Bite-Sized for Adults -Soft, tender and moist, but with no thin liquid leaking/dripping from food -Ability to 'bite off' a piece of food is not required -Ability to chew 'bite sized' pieces so that they are safe to swallow is required -Bite-sized pieces no bigger than 1.5 X 1.5 cm (centimeter) in size -Food can be mashed/broken down with pressure from fork -A knife is not required to cut this food EXAMPLES of Level 6 Soft & Bite-Sized Food for Adults included: NO REGULAR DRY BREAD due to high choking risk! 1. A Minimum Data Set (MDS) dated [DATE], documented Resident #4's diagnoses included dysphagia of the oral phase (the tongue collects the food or liquid and moves it around the mouth so it can be chewed) and oropharyngeal phase (the tongue moves the food or liquid toward the back of the mouth). A Brief Interview for Mental Status (BIMS), for Resident #4 revealed a score of 9 out of 15, which indicated moderately impaired cognition. This resident was independent with set up help only for eating. A Care Plan for Resident #4 with a Focus Area dated as revised on 9/1/22, documented that this resident had a potential nutritional problem related to history of weight loss, difficulty chewing (missing dentures) and vision impairment. Interventions directed staff that this resident received a general diet with soft & bite size texture, regular fluid consistency. It directed that she needed to be supervised at meal intakes at this time. A Therapy Daily/PRN (as needed) Documentation Note dated 4/18/23 at 9:48 a.m., documented that Staff A, Speech Therapist (ST), completed a speech screen on 4/12/23 for transition to IDDSI Diet Recommendation: Food Level:#6 (Soft & Bite Size). Liquid Level:0 (thin). Eat with Supervision. Dietary updated. A Doctor's Order for Resident #4 dated 4/28/23, directed that Resident #4 was to receive a regular diet #6 Soft & Bite-Sized texture. 2. A MDS dated [DATE], documented that Resident #9's diagnoses included non-Alzheimer's dementia, dysphagia (difficulty with chewing) and anorexia . A BIMS for Resident #9 revealed a score of 3 out of 15, which indicated severely impaired cognition. This resident required extensive assist of 1 for eating. A Care Plan for Resident #9 with a Focus Area revised on 11/10/22, documented that this resident had a potential nutritional problem related to obesity, CHF (congested heart failure), self-feeding difficulty, inappropriate food choices, and need for a mechanically altered diet. An undated intervention, directed staff that this resident had an order for a texture modified diet. General, soft & bite size. A Therapy Daily/PRN (as needed) Documentation Note dated 4/18/23 at 9:48 a.m., documented that Staff A, ST, completed a speech screen on 4/12/23 for transition to IDDSI Diet Recommendation: Food Level:#6 (Soft & Bite Size). Liquid Level:0 (thin). Eat with Supervision and tray set up. Encourage small bites, take small bites/sips, medications crushed. Dietary updated. A Doctor's Order for Resident #9 dated 4/28/23 and revised on 8/24/23, directed that this resident was on a #6 diet Soft & Bite Sized texture. Directions were to offer finger foods as appropriate. Do not give condiments on plate. Staff to supervise and provide cues as well as assist with condiments. 3. A MDS dated [DATE], documented that diagnoses for Resident #24 included non-Alzheimer's dementia. A BIMS for Resident #24 revealed a score of 7 out of 15, which indicated severely impaired cognition. This MDS documented that this resident was independent with set up help only for eating. A Care Plan for Resident #24 with a Focus Area dated as revised on 8/17/23, documented that this resident had a potential nutritional problem with decreased oral intake possibly related to complaint of mouth pain and/or medication side effect. She had a recent history of bowel impaction and carried diagnoses of obesity and diabetes mellitus. Intervention directed staff that resident had an order for a minced and moist diet with thin liquids-she was to be supervised with meal intakes. A Doctor's Order dated 5/22/23 and revised on 8/24/23, directed that Resident #24 was on a regular diet, #5 Minced & Moist with transitional foods texture. Directions included ground meat, per request. Provide cueing during meals. A Nutritional Status-Dietitian Assessment progress note dated 6/8/23 at 11:08 a.m., documented that Resident #24 was recently hospitalized with a bowel obstruction. This resident was followed by ST and now received a minced and moist diet without concern. A Nutritional Status-Dietitian assessment dated [DATE] at 10:22 a.m., documented that Resident #24 has had difficulty establishing bowel regularity since her bowel impaction last quarter. Resident reported constipation, following a documented period of loose watery stools. She complained of mouth pain due to a canker sore located on her right, lower gum, stating I can't chew or swallow anything without it hurting. She continues on minced & moist textures. Resident at nutritional risk with decreased oral food intake possibly related to bowel irregularity, medication side-effect, and/or mouth pain. Resident may benefit from oral exam to resolve oral discomfort and cueing with meals to help increase oral intake. 4. A MDS dated [DATE], documented that Resident #27's diagnoses included non-Alzheimer's dementia and malnutrition. Documentation for a BIMS read that it should not be conducted as resident rarely/never understood. This resident required extensive assist of 1 for eating. A Care Plan with a Focus Area dated as revised on 6/8/23, documented that this resident had potential for nutritional problems related to varied meal acceptance, self-feeding difficulty, and unintentional weight loss. An undated intervention directed staff that Resident #27 received a general diet with minced & moist textures and slightly thickened liquids. Doctor's orders for Resident #27 were ordered as follows: On 9/14/22, Regular diet, regular texture thin consistency. On 4/27 23, Regular diet #7 regular texture thin consistency. On 6/28/23, Regular diet #6 Soft & Bite-Sized texture thin consistency On 8/1/23, Regular diet #5 Minced & Moist texture, Slightly thick consistency. An Incident Progress Note dated 9/17/23 at 8:55 p.m., documented that Resident #27 choked in the dining room after eating a pear slice at approximately 6:00 p.m. This resident showed no signs of distress after this choking incident. Lung sounds clear at 7:30 p.m. An Incident Progress Note dated 9/18/23 at 3:16 a.m., documented that resident was resting quietly without any problems to note. The head of her bed is elevated some and call light is within reach. Skin was warm, dry and pink. There was no further documentation following/related to these 2 Incident Progress Notes until 10/18/23. A Health status Progress Note dated 10/18/23 at 1:19 p.m., documented the note was an addendum to the Incident Progress Note on 9/17/23 at 8:55 p.m. Resident had a coughing spell on 9/17/23 at approximately 6:00 p.m. following the consumption of pears. The staff assisting with the meal called this nurse (nurse documenting the entry) to come and assess the resident after the coughing spell. Resident was visually assessed and lungs assessed afterward to ensure no aspirating had occurred and lung sounds were clear. Lung sounds were re-assessed at 7:30 p.m., and remained clear. The previous Progress Note this writer incorrectly used the word choking for this coughing spell. Daughter notified of this coughing incident and physician notified as well. A Health Progress Note dated 10/18/23 at 1:27 p.m. documented the Provider's name and residents date of birth. It then documented that on 9/17/23 at approximately 6:00 p.m., during mealtime, resident had a coughing spell after consuming pears. Resident did not have any signs of distress after this and lung sounds were clear when checked immediately after and an hour and a half later when rechecked. 5. A MDS dated [DATE], documented that Resident #35's diagnoses included malnutrition. This resident's BIMS score was 12 out of 15, which indicated moderately impaired cognition. This resident was independent with set up help only for eating. A Care Plan with a Focus Area dated as revised on 9/22/23, documented that this resident was at nutritional risk with underweight status and unspecified protein-calorie malnutrition diagnoses. She had chewing difficulty likely related to acute illness with generalized weakness and potential for self-feeding difficulty with tender, swollen dominant hand. Interventions directed staff to monitor for weight loss, this resident was to eat a general diet with minced and moist textures, thin fluids. Doctor's Orders for Resident #35's diet were as follows: 9/12/23 Lactose Restricted diet, #5 Minced & Moist with Transitional Foods texture, thin consistency 10/19/23 Regular diet, #5 Minced & Moist texture thin consistency. 6. A MDS dated [DATE], documented diagnoses for Resident #91 included dysphagia of the oral phase and the oropharyngeal phase. Documentation for a BIMS read that it should not be conducted as resident rarely/never understood. Resident required supervision with set up help only for eating. A Care Plan with a Focus Area dated as initiated on 1/18/23, documented that this resident was at nutritional risk with unintended weight loss related to end-stage disease process with inadequate oral food intake. This resident had a history of dysphagia, weight loss and altered nutrition related labs. Interventions directed that this resident had an order for regular, soft & bite size, with regular fluids. A Therapy Daily PRN Documentation Note Progress Note dated 4/18/23 at 9:52 a.m., documented that Staff A, ST contacted, completed a Speech Screen on 4/12/23 for transition to IDDSI Diet Recommendation: Food Level: #6 (Soft & Bite Sized). Liquid Level #0 (thin). Resident was to Eat with supervision with tray set up. Alternate liquids with solids. Small bites/sips, pause between bites/sips, medications crushed. Dietary was updated. A Doctor's Order dated 4/28/23, directed that this resident was on a regular diet #6 Soft & Bite-Sized texture. Thin consistency. A Nutritional Status-Dietitian Assessment Progress Note dated 5/11/23 at 10:13 a.m., documented that Resident #91 had recent coughing episodes at meals. He at this time was to receive a soft and bite sized diet order. He was accepting nourishment throughout the day from staff. A Care Conference Note Progress Note dated 5/24/23 at 2:28 p.m., was documented by the CDM. It documented that Resident #91 was on a general diet with regular fluids, mechanical soft texture. Progress Notes dated 8/20/23 documented that Resident #91 had passed away. On 10/17/23 at approximately 10:30 a.m., observed Staff C, Cook puree the food for lunch. Staff C had stated that they have 3 residents on a puree diet and she purees 4 portions to have extra. Observed Staff C puree 4 bread sticks with milk. On 10/17/23 at 11:30 a.m., observation of lunch service began. During this lunch service Resident #4, Resident #9, and Resident #24 received a full bread stick. The CDM was asked if it was okay that they received the breadsticks and she stated that it was. Resident #35 requested the cheesecake dessert. Staff B, Cook, stated that she could not have the dessert because Resident #35 was lactose intolerant. Staff B and the CDM agreed that she could have a Honey Bun. After the service was finished, these residents' trays were checked in the dining room. The bread sticks had all been eaten. The CDM verified that Residents' #4, #9 and #24 received and ate the full bread stick as well as the fact that Resident #35 received and ate a Honey Bun. The CDM stated they follow a mechanical soft diet not the IDDSI diet so these foods were safe to serve to the IDDSI level 5 and level 6 diets. The lunch service ended at 12:10 p.m. A test tray was tasted directly after service. It was noted that the bread stick was hard on both ends and the middle was chewy and not soft. A Fall/Winter-therapeutics menu documented the following: - 3rd week Tuesday, Lunch Day:3: documented that Goulash, 1 breadstick, and carrots had been written in for lunch regular diet and goulash pureed, breadstick pureed, and carrots pureed had been written in for the pureed diet. The typed menu had been whited out with the above written on the whited out area. Easy to Chew, Soft & Bite-Sized, and Minced & Moist diets had a dash (-) under them. This is the menu for the day of the lunch observation. The supper menu documented that the Regular diet was cheese pizza and for the Soft & Bite Sized and Minced and Moist diets the residents would be served Beef Rigatoni Casserole -3rd week Wednesday, Breakfast Day:4: Blueberry Muffin for Regular Diet, Blueberry Muffin slurried for Soft and Bite Sized diet, and Blueberry Muffin pureed for Minced and Moist Diet. Supper for this day had diced pears for Regular diet and pureed pears for Minced and Moist Diet. - 3rd week Saturday, Lunch Day:7: documented that a Garlic Buttered Breadstick was to be given for a Regular diet. It documented that the Garlic Buttered Breadstick was to be pureed for the Soft & Bite Sized Diet and for the Minced & Moist Diet. This day showed [NAME] Toast for Breakfast for the regular diet. For the Soft & Bite-Sized Diet and for the Minced & Moist Diet the residents on these diets were to receive pureed cinnamon white bread. On 10/17/23 at 2:29 p.m., Staff C, Dietitian, stated that the residents on a 5 (Minced and Moist) and 6 level diet (Soft & Bite Sized) should have had a pureed breadstick. She stated that technically speech therapy should assess and document the level of diet that each resident should be on. Staff C stated that she had just started at the facility in August. The decision for the diet level could have possibly been made by speech. Staff C stated that technically the facility should be following the diets. Staff C stated that she normally did not work with the IDDSI diet and this home has the diet. Staff C stated that she typically did not recommend a change in diet she would have speech therapy look at it if she thought a change was warranted. Staff C stated that she was new to the this corporation and the protocols are a little different then the homes she had been working at. Staff C was unable to access the records off site. She stated she did not recommend any diets at this facility. I would not have recommended any diets, I started beginning of August. Resident #35's name does sound familiar to me. Unable to access records. I don't remember recommending a diet for her. I typically would go with the diet that was recommended from the hospital if that was where she came from, or from Speech Therapy. Staff C stated that she had gone over diets with the CDM. She stated she did approve a change to goulash and bread sticks as there was a day with ham sandwiches on the menu and the residents do not like the ham sandwiches. On 10/17/23 at 1:19 p.m., the CDM, looked over the menu spreadsheet. The breadsticks for the meal for the upcoming Saturday menu were to be pureed for residents that were to be served 6 soft and bite sized diet textures and 5 minced and moist diet textures. This CDM stated that they should have served pureed bread sticks for the residents on these diets. Reviewed the residents on these diets and 3 out of 6 residents that received either the soft and bite-sized diet or the minced and moist diet received a bread stick (Residents #4, #9 and #24). One resident, Resident #35, who was on a minced and moist diet did not receive a bread stick but she was given a Honey Bun snack instead of cheesecake as she was lactose restricted. The CDM stated that Resident #35 should not have had a whole Honey Bun. This CDM stated that Residents #4, #9, and #24 should not have had whole breadsticks, the breadsticks should have been pureed. The CDM stated the residents were not going to be happy about this. When asked about the meal for this day being whited out and written over, she stated Staff C and the CDM went over the menus. Lunch for this day was to be a ham sandwich. The CDM stated the residents do not like the ham sandwich option, so the Dietitian and the CDM changed it to goulash, a bread stick and carrots. She said they changed it on the day the menu was dated by the dietitian. The CDM stated that there is a Corporate Dietitian and the company has changed to the SNOW program. She stated they follow the IDDSI diets now. She said that they used to be able to serve the bread sticks on a mechanical soft diet. On 10/17/23 at 2:08 p.m., reviewed diet cards for the residents who were on 5 or 6 level diets. No exceptions were on the diet cards (ie may have bread stick, may have honey bun), nor were there any exceptions written in their doctor's orders. On 10/17/23 at 2:20 p.m., Staff D, Certified Nurse Assistant (CNA), stated she assisted Resident #24 to dine at lunch. Staff D stated she had to hold the breadstick for Resident #24 and would put it up to this resident's mouth and then this resident would take a small bite of it. Staff D stated Resident #24 ate the whole bread stick, she ate all of her lunch. Staff D also stated that Resident #24 had toast at breakfast. Staff D stated she often cuts the crust off of the toast for Resident #24 as this resident tends to have a hard time chewing it. Staff D stated that she adds quite a bit of jelly to this resident's toast as she tends to swallow it better that way. Staff E, CNA stated she assisted Resident #9 at lunch. Staff E stated that she had broken off pieces of Resident #9's bread stick and then put it in her mouth. Staff D stated that the pieces were about 1 inch sized chunks. Staff E stated she did not assist Resident #9 at breakfast this morning. Staff E stated that Resident #9 seemed to do okay with eating the bread stick. On 10/17/23 at 2:28 p.m., Resident #4, when asked how her lunch was today, stated it was good. When asked if she enjoyed the breadstick. She stated it was good and denied having any problems with chewing or swallowing. On 10/17/23 at 3:19 p.m., went over concerns of these residents receiving bread without it being pureed with the Director of Nursing (DON). The DON acknowledged concerns regarding the diets being changed. On 10/17/23 at 4:25 p.m., the Administrator stated she talked with their Head of Therapy. She stated that the Speech Therapist was busy and meeting with clients. The Administrator stated that the Head of Therapy said the IDDSI diets are liberal with bread and that it is one of the items that can be given with the different levels. She stated that the Speech Therapist saw all of their residents in April and May to evaluate them for the IDDSI diet. She stated that she and the CDM and a couple of other people went to training on the IDDSI diets as the corporation was going to this evaluation system. She stated the residents' diets were updated, however, the menus didn't start until a month or two ago when the facility changed over from their summer to fall menus. She repeated that she was happy to hear the Head of Therapy state that bread is one of those items that can be given whole with some of the levels in the IDDSI framework. The DON stated that Resident #35 was not evaluated by ST as she was admitted from the hospital and they used the diet order that the hospital had. The hospital also uses IDDSI diets. They both stated they would get the other ST evaluation that was requested of them along with the Corporate Dietitians phone #. A text was sent to the ST at this time requesting a time to talk in the a.m., as she was unavailable this afternoon/evening. On 10/17/23 at 4:53 PM, the CDM verified that tonight cheese pizza is on the menu but all residents who are to receive the 5 and 6 diets will not be getting pizza but will be getting the alternate of beef rigatoni. This CDM stated they will be following the #5 and #6 IDDSI diets as they are written on the menus from this point on. On 10/18/23 at 9:00 a.m., the CDM stated that the facility started the IDDSI diets in late September. She stated she does not keep the old diet spread sheets. She stated she would look for emails to see if she can find an old diet menu. This CDM stated that they used the the old diet spreadsheets up to late September when they started using the IDDSI spread sheets. The CDM stated the old spread sheets did not have the minced and moist or soft and bite-sized diet textures, it had the mechanical soft diet on it. The CDM stated that was where it gets gray. The minced and moist in her mind is pretty much the mechanical soft diet without the bread. This CDM stated the bread is the gray area. The IDDSI diets break down the bread differently and this also is in the gray area. When asked about breakfast that morning, the CDM stated they served slurried muffins to the residents with the soft and bite sized textured diets and they served pureed muffins to the residents with a minced and moist textured diets per the IDDSI menu. This CDM stated she had training on the IDDSI diets but nothing on how to implement the change over to them. She stated that they were told just to adjust the menus to what they knew. The CDM stated that they were serving bread without altering it and they were serving the old mechanical soft diets to the minced and moist diets. This CDM stated the mechanical soft diets were more liberal. She stated that the training was more about here is the information on the IDDSI diets. Not really an explanation on them. She said that Staff C and the CDM would just go over the menus and adjust what they needed to, because sometimes there would be 2 servings of vegetables for one meal service and then the next day they would have just spaghetti and meatballs or something like that without the vegetables. So, the dietitian and the CDM would adjust the daily menus but not necessarily to each specific texture of diet. On 10/18/23 at 9:35 a.m., the Corporate Dietitian, stated she was told that somebody was given a bread stick for a soft and bite sized diet and was asked if that was okay. She stated the resident should not have received the bread stick. The Corporate Dietitian stated that the bread stick would have been fine had the ST specified it would be okay. She stated that as a society (corporation) they went to the new diets. She stated that she was a bit baffled by why they didn't change the menus to the IDDSI diets when they had the residents assessed and changed their individual diets to meet the IDDSI parameters. She stated the diets should have been transitioned to the IDDSI spread sheets (menus). She stated that the spread sheets/the SNOW program are their menus and their diet extensions including minced and moist and soft and bite sized. They include therapeutics as well. When told about the CDM stating she was using the mechanical soft diet guidelines for breads, the Corporate Dietitian stated that the CDM was right that a mechanical soft diet would allow bread. The Corporate Dietitian stated that if the facility was not ready to transition to the IDDSI diets then that would have been okay to wait until they were ready, but the problem was the facility went ahead and changed all the diets for the residents and then did not follow the diet orders. She stated other facilities did wait to start. On 10/18/23 at 9:50 a.m., Staff F, Speech Therapist, stated that it wasn't her that did the evaluations of the diets. She stated she was not really in the facility. This ST stated she didn't know the residents or their diets as she had not evaluated any residents at this facility. Staff F stated she would agree that bread sticks would have to be cleared through an evaluation by a Speech Therapist for a resident on a level 5 or 6 diet to have a bread stick. On 10/18/23 at 10:12 a.m., the Administrator and the CDM, both reported/concurred that the menus were changed to the IDDSI diets on 9/3/23. The Administrator stated the only issue was yesterday with the bread. Otherwise she had talked to others and they were following the diets. CDM stated they had been following the mechanical soft diets not the IDDSI diets. Administrator said they had the IDDSI diets though since April/May. CDM stated the IDDSI diets were on the diet spreadsheet but they were told not to follow them. They were to follow the mechanical soft diets. An explanation of the concern was given to the Administrator and the CDM. It was explained that the issue was that the residents were evaluated for the IDDSI diets with some of the residents having a diet change to Diet Texture 6 or 5 in April and May. These residents were not given the recommended food textures for these diets. They were given a more liberalized diet to include breads without a Speech Therapist determining that bread or any other item was okay for the individual residents that were evaluated and put on the Diet texture 5 and 6 diets. The CDM acknowledged that they had been giving them bread all along. The CDM and the Administrator were told about Resident #27 choking on sliced pears on September 17th. She was on a Diet Texture 5 minced and moist and per the week of diets provided by the facility at the beginning of the survey, pears are to be pureed for residents that receive Diet Texture 5. The Administrator stated she did not know about the choking episode and they should have done an incident report. When told they did do an incident progress note and on the incident progress note it documented that Resident #27 was given sliced pears. The Administrator stated she would have reviewed it then as she reviews all incident reports. The Administrator and the CDM agreed that breads for Diet Textures 5 and 6 were to be altered either by slurry or by pureeing depending on the type of bread and per the menu breakdown of diet texture types. On 10/18/23 at 11:20 a.m., the CDM provided spring/summer menus that she got off of the web site that they would have used for the spring and summer. She stated she is unable to give what dates that they actually used them. She also stated these were not the ones signed by the dietitian as she does not have a copy of those menus. She stated that she is still looking for the menu week that would have included 9/17/23. On 10/18/23 at 11:30 a.m., Staff A, Speech Therapist, stated that right now there was not a full time ST for this facility. Staff A stated that the reason she went up to the facility was to evaluate 9 residents for the International Diet (IDDSI). This ST stated she did these evaluations on 4/12/23. All 9 that she looked at were on modified diets already. Staff A stated the facility wanted her to look at these residents who were already on modified diets and evaluate them for the more restricted IDDSI diets. Staff A stated that the national level kind has more or less 3 different diets. The IDDSI has technically 4 solid levels. The big question for her to eval [TRUNCATED]

Based on observations, interviews and record review, the facility failed to notify the family and/or the physician of incidents that occurred for 2 out of 16 residents reviewed (Residents #17 and Resident #27). The facility did not notify the family or physician when a cold sore developed on Resident #17's lip. The facility did not notify the family or physician when Resident #27 had a coughing/choking episode at supper until a month later. The facility reported a census of 38 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented Resident #17's diagnoses included Alzheimer's disease. A Brief Interview for Mental Status (BIMS) score for Resident #17 was 0 out of 15, which indicated severely impaired cognition. Resident #17 required extensive assist of 1 for dressing and personal hygiene. On 10/16/23 at 3:23 p.m., Resident #17's son stated his mother had a cold sore on her lip. He believed they were following up with it. He didn't know if they had ordered any ointment or treatment for the cold sore. On 10/17/23 at 10:00 a.m., Resident #17 was noted to have a black scab on her right upper lip. It was approximately the size of a pea. Review of Resident #17's records revealed there was no documentation of the cold sore or of notification to the physician or to the family. On 10/19/23 at 1:07 p.m., Staff K, Registered Nurse (RN), Wound Nurse, acknowledged there was nothing in the chart regarding Resident #17's cold sore. Staff K stated she went ahead and notified the physician and the family. When asked what should have happened, she stated it should have been charted on, the physician should have been notified, the family should have been notified, and she should have been notified as the wound nurse so she could have started an assessment on it. On 10/19/23 at 1:20 p.m., the Director of Nursing (DON), stated that staff should have reported the cold sore and it should have been reported to the doctor and to the family. The DON acknowledged lack of notification of physician and family. On 10/19/23 at 1:36 PM, Staff K stated that she wanted to let us know that the family and doctor have been notified. A Communication/Visit with Physician Progress Note dated 10/19/23 at 1:22 p.m., documented Resident #17 noted to have a cold sore to her upper lip on the right side. No raised blisters or drainage noted. Appeared with approximately 0.2 cm X 0.5 cm scab with epithelization forming to wound bed. Vaseline applied to wound to help prevent cracking. Education to resident on hand hygiene and not to pick at scab. Education provided to staff to keep area clean and assist resident to not pick at it. Family has been notified and voices understanding. Do you want to treat with anything besides PRN (as needed) Vaseline at this time? Please Advise. 2. A MDS dated [DATE], documented Resident #27's diagnoses included non-Alzheimer's dementia and malnutrition. Documentation for a BIMS read that it should not be conducted as resident rarely/never understood. This resident required extensive assist of 1 for eating. An Incident Progress Note dated 9/17/23 at 8:55 p.m., documented Resident #27 choked in the dining room after eating a pear slice at approximately 6:00 p.m. This resident showed no signs of distress after this choking incident. Lung sounds clear at 7:30 p.m. An Incident Progress Note dated 9/18/23 at 3:16 a.m., documented that resident was resting quietly without any problems to note. The head of her bed is elevated some and call light is within reach. Skin was warm, dry and pink. There was no further documentation following/related to these two Incident Progress Notes until 10/18/23. A Health status Progress Note dated 10/18/23 at 1:19 p.m., documented the note was an addendum to the Incident Progress Note on 9/17/23 at 8:55 p.m. Resident had a coughing spell on 9/17/23 at approximately 6:00 p.m. following the consumption of pears. The staff assisting with the meal called this nurse (nurse documenting the entry) to come and assess the resident after the coughing spell. Resident was visually assessed and lungs assessed afterward to ensure no aspirating had occurred and lung sounds were clear. Lung sounds were re-assessed at 7:30 p.m., and remained clear. The previous Progress Note this writer incorrectly used the word choking for this coughing spell. Daughter notified of this coughing incident and physician notified as well. A Health Progress Note dated 10/18/23 at 1:27 p.m. documented the Provider's name and residents date of birth. It then documented that on 9/17/23 at approximately 6:00 p.m., during mealtime, resident had a coughing spell after consuming pears. Resident did not have any signs of distress after this and lung sounds were clear when checked immediately after and an hour and a half later when rechecked. On 10/18/23 at 1:45 p.m., Staff G, Licensed Practical Nurse (LPN), stated that the night of the incident with Resident #27, Staff G's shift started right at 6 p.m. and it happened about 6:02 p.m. Staff G stated she heard over the walkie talkies I need a nurse right away. She stated it was Staff H, CNA that had called on the walkie talkie. Staff G stated that when she arrived to the dining room Staff H stated that she was sorry, Resident #27 was just coughing, coughing, coughing and Staff H gets scared when they start coughing so much. Staff G stated that Staff F stated she had just given Resident #27 a pear and it had a little juice in there, maybe the juice kind of went down her throat. Staff G stated she was thinking that she hoped Resident #27 did not aspirate. The pears were sliced in a little white bowl. Staff G stated the pears were cut up. Staff G stated because she was hoping Resident #27 didn't aspirate, Staff G wrote the note so that there would be follow up for a couple of days, just to make sure that nothing went down her lungs. Staff G did not know that Resident #27 should have had pureed pears. This incident didn't require the Heimlich. Staff G stated she didn't see the scene itself and it didn't appear to me that she had choked. Staff G stated it didn't seem like her eyes were watery and her face wasn't red. Staff G said that nothing came up from this resident's coughing. Staff G stated that she and this CNA agreed that maybe it was the juice. Staff G said that this resident was to have thickened liquid and Staff G saw juice in the pears, she had no idea she needed pureed pears. Staff G stated she felt like Resident #27 should be followed up on so she wanted the next one or two shifts to at least listen to her lungs to be sure she didn't develop pneumonia because she could have gotten aspiration pneumonia from liquid going down into her lungs. On 10/18/23 at 4:00 p.m., the DON stated that Staff G notified the physician on this day regarding the coughing incident with Resident #27. On 10/19/23 at 9:30 a.m., the DON stated that the change in diets for Resident #27 in June and in August were spurred on by the family's request. She said they are active in their mom's care. On 10/19/23 at 10:52 a.m., Resident #27's daughter, second emergency contact and Power of Attorney (POA) over health, was in her mother's room with her mother. This daughter stated she and her sister were very frustrated because they found out yesterday that their mother had had a choking incident, and they were not notified. She stated that her and her sister received different reports on this as well. She said that one nurse told the sister that their mother had choked on a pear and another nurse told a sister that their mother had choked on the juice. This daughter stated that she and her sister were glad today to see that they had a ST reevaluate their mother's diet and concurred that she was on the correct diet of minced and moist. She said that her sister who lives in town had requested a stricter diet back in June. She said that her sister had told them to not give bread to their mother. This daughter stated that around August she was at the facility and noticed that there was bread on her mother's tray. She called her sister and told her and her sister was upset because she had told the facility to not serve their mother bread, as their mother could not swallow it effectively. This daughter again said this was very frustrating. On 10/19/23 at 10:59 a.m., Resident #27's daughter and fist emergency contact, stated that she had received a call about an incident and was surprised. The incident was that her mother was choking at dinner and her mother got red and coughed a lot but that was back in September. This daughter told them it would be nice to have had an earlier response then this daughter believed at a care conference they discussed the possibility about her mom not having any more bread. This daughter said some of the buns can be really dry. Buns and rolls, bread sticks any kind of bread, so it was decided she would not have any more bread. This daughter stated that she usually was there from the time her mom gets up after her nap until supper time. This daughter stated that the girl that she talked to yesterday about the choking told the daughter it was just liquid not the pears. This daughter stated that they did not tell her that the pears should have been pureed. On 10/19/23 at 1:18 PM, the DON acknowledged that the family and provider should have been notified of the incident. A Notification of Change policy dated 11/29/22, directed staff the following: PURPOSE To identify when regulation requires notifications to occur. POLICY A facility must immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative(s) when there is: I. An accident involving the resident which results in injury and has the potential for requiring physician intervention 2. A significant change in the resident's physical, mental or psychosocial status 3. A need to alter treatment significantly - a need to discontinue or change an existing form of treatment or to commence a new form of treatment. When making notification to the physician, the facility must ensure that all pertinent information is available and provided upon request. When the facility transfers or discharges a resident under any of the circumstances specified, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving healthcare institution or provider.

Based on observations, interviews and record review, the facility failed to assess and provide interventions for 2 out of 16 residents reviewed (Residents #17 and Resident #27). The facility did not assess or provide interventions when a cold sore developed on Resident #17's lip. The facility did not do follow up assessments and interventions for Resident #27 with the exception of an assessment by the following shift's nurse,Staff I, Registered Nurse (RN), after Resident #27 had a coughing/choking episode at supper until a month later. Staff G, Licensed Practical Nurse (LPN), initially assessed this resident and reported it on to Staff I. No further assessments were documented. The facility reported a census of 38 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented that Resident #17's diagnoses included Alzheimer's disease. A Brief Interview for Mental Status (BIMS) score for Resident #17 was 0 out of 15, which indicated severely impaired cognition. Resident #17 required extensive assist of 1 for dressing and personal hygiene. On 10/16/23 at 3:23 p.m., Resident #17's son stated his mother had a cold sore on her lip. He believed they were following up with it. He didn't know if they had ordered any ointment or treatment for the cold sore. On 10/17/23 at 10:00 a.m., Resident #17 was noted to have a black scab on her right upper lip. It was approximately the size of a pea. Review of Resident #17's records revealed there was no documentation of the cold sore or of notification to the physician or to the family. On 10/19/23 at 1:07 p.m.,Staff K, Registered Nurse (RN), Wound Nurse, acknowledged there was nothing in the chart regarding Resident #17's cold sore. Staff K stated she did go ahead and assess the cold sore. She stated it looked like it was pink and healing. When asked what should have happened, she stated it should have been charted on, the physician should have been notified, the family should have been notified, and she should have been notified as the wound nurse so she could have started an assessment on it. On 10/19/23 at 1:20 p.m., the Director of Nursing (DON), stated that staff should have reported the cold sore and it should have been reported to the doctor and to the family. The DON acknowledged lack of assessment and intervention. A Communication/Visit with Physician Progress Note dated 10/19/23 at 1:22 p.m., documented Resident #17 noted to have a cold sore to her upper lip on the right side. No raised blisters or drainage noted. Appeared with approximately 0.2 cm X 0.5 cm scab with epithelization forming to wound bed. Vaseline applied to wound to help prevent cracking. Education to resident on hand hygiene and not to pick at scab. Education provided to staff to keep area clean and assist resident to not pick at it. Family has been notified and voices understanding. Do you want to treat with anything besides PRN (as needed) Vaseline at this time? Please Advise. 2. A MDS dated [DATE], documented Resident #27's diagnoses included non-Alzheimer's dementia and malnutrition. Documentation for a BIMS read that it should not be conducted as resident rarely/never understood. This resident required extensive assist of 1 for eating. An Incident Progress Note dated 9/17/23 at 8:55 p.m., documented Resident #27 choked in the dining room after eating a pear slice at approximately 6:00 p.m. This resident showed no signs of distress after this choking incident. Lung sounds clear at 7:30 p.m. An Incident Progress Note dated 9/18/23 at 3:16 a.m., documented that resident was resting quietly without any problems to note. The head of her bed is elevated some and call light is within reach. Skin was warm, dry and pink. There was no further documentation following/related to these two Incident Progress Notes until 10/18/23. A Health status Progress Note dated 10/18/23 at 1:19 p.m., documented the note was an addendum to the Incident Progress Note on 9/17/23 at 8:55 p.m. Resident had a coughing spell on 9/17/23 at approximately 6:00 p.m. following the consumption of pears. The staff assisting with the meal called this nurse (nurse documenting the entry) to come and assess the resident after the coughing spell. Resident was visually assessed and lungs assessed afterward to ensure no aspirating had occurred and lung sounds were clear. Lung sounds were re-assessed at 7:30 p.m., and remained clear. The previous Progress Note this writer incorrectly used the word choking for this coughing spell. Daughter notified of this coughing incident and physician notified as well. A Health Progress Note dated 10/18/23 at 1:27 p.m. documented the Provider's name and residents date of birth. It then documented that on 9/17/23 at approximately 6:00 p.m., during mealtime, resident had a coughing spell after consuming pears. Resident did not have any signs of distress after this and lung sounds were clear when checked immediately after and an hour and a half later when rechecked. On 10/18/23 at 1:45 p.m., Staff G, Licensed Practical Nurse (LPN), stated that the night of the incident with Resident #27, Staff G's shift started right at 6 p.m. and it happened about 6:02 p.m. Staff G stated she heard over the walkie talkies I need a nurse right away. She stated it was Staff H, CNA that had called on the walkie talkie. Staff G stated that when she arrived to the dining room Staff H stated that she was sorry, Resident #27 was just coughing, coughing, coughing and Staff H gets scared when they start coughing so much. Staff G stated that Staff F stated she had just given Resident #27 a pear and it had a little juice in there, maybe the juice kind of went down her throat. Staff G stated she was thinking that she hoped Resident #27 did not aspirate. The pears were sliced in a little white bowl. Staff G stated the pears were cut up. Staff G stated because she was hoping Resident #27 didn't aspirate, Staff G wrote the note so that there would be follow up for a couple of days, just to make sure that nothing went down her lungs. Staff G did not know that Resident #27 should have had pureed pears. This incident didn't require the Heimlich. Staff G stated she didn't see the scene itself and it didn't appear to me that she had choked. Staff G stated it didn't seem like her eyes were watery and her face wasn't red. Staff G said that nothing came up from this resident's coughing. Staff G stated that she and this CNA agreed that maybe it was the juice. Staff G said that this resident was to have thickened liquid and Staff G saw juice in the pears, she had no idea she needed pureed pears. Staff G stated she felt like Resident #27 should be followed up on so she wanted the next one or two shifts to at least listen to her lungs to be sure she didn't develop pneumonia because she could have gotten aspiration pneumonia from liquid going down into her lungs. On 10/18/23 at 4:00 p.m., the DON stated that Staff G notified the physician on this day regarding the coughing incident with Resident #27. On 10/19/23 at 9:30 a.m., the DON stated that the change in diets for Resident #27 in June and in August were spurred on by the family's request. She said they are active in their mom's care. On 10/19/23 at 10:52 a.m., Resident #27's daughter, second emergency contact and Power of Attorney (POA) over health, was in her mother's room with her mother. This daughter stated she and her sister were very frustrated because they found out yesterday that their mother had had a choking incident, and they were not notified. She stated that her and her sister received different reports on this as well. She said that one nurse told the sister that their mother had choked on a pear and another nurse told a sister that their mother had choked on the juice. This daughter stated that she and her sister were glad today to see that they had a ST reevaluate their mother's diet and concurred that she was on the correct diet of minced and moist. She said that her sister who lives in town had requested a stricter diet back in June. She said that her sister had told them to not give bread to their mother. This daughter stated that around August she was at the facility and noticed that there was bread on her mother's tray. She called her sister and told her and her sister was upset because she had told the facility to not serve their mother bread, as their mother could not swallow it effectively. This daughter again said this was very frustrating. On 10/19/23 at 10:59 a.m., Resident #27's daughter and fist emergency contact, stated that she had received a call about an incident and was surprised. The incident was that her mother was choking at dinner and her mother got red and coughed a lot but that was back in September. This daughter told them it would be nice to have had an earlier response then this daughter believed at a care conference they discussed the possibility about her mom not having any more bread. This daughter said some of the buns can be really dry. Buns and rolls, bread sticks any kind of bread, so it was decided she would not have any more bread. This daughter stated that she usually was there from the time her mom gets up after her nap until supper time. This daughter stated that the girl that she talked to yesterday about the choking told the daughter it was just liquid not the pears. This daughter stated that they did not tell her that the pears should have been pureed. On 10/19/23 at 1:18 PM, the DON acknowledged that follow up assessment and interventions were not done thoroughly for this resident after the nurse deemed it necessary to do follow up after a coughing episode to evaluate the possible development of complications from aspiration. The DON stated that she felt the nurses should have done an assessment every shift x 3 days. The facility provided the following policy for assessment and intervention of the resident: A Nursing Documentation Guidelines, Timelines-Rehab/Skilled dated as reviewed/revised on 4/26/23, directed the following: When a change in condition is identified in a resident, the nurse will use the elNTERACT Change in Condition Evaluation - UDA (CICE) to collect the data prior to communicating with the medical provider. The CICE is the progress note and does not require the information to be re-written. If more information is collected than will fit on the CICE, PN - Health Status may be used. Incidental Charting - day-to-day type documentation of specific occurrences will be completed by a licensed nurse in the appropriate progress note determined by the content of the note. For the purpose of generating reports, it is important to document information in the most appropriate progress note. In the case that documentation could fit into more than one progress note type, the nurse should determine the key content and document in the progress note type that is most appropriate.

Based on observation, clinical record review, emergency room report, staff interview and facility policy review, at the time of the investigation, the facility failed to promptly identify and intervene for an acute change in a residents condition related to increase pain/swelling/bruising in the resident right upper arm for which resulted in a diagnosis of a right humerus fracture for 1 of 4 residents reviewed with a condition change, (Resident #7). The facility identified a census of 35 residents. Findings include: 1. A Quarterly Minimum Data Set (MDS) assessment form dated 11/2/2022, documented Resident #7 had diagnosis that included Hypertension, Non-Alzheimer's Dementia, anxiety, depression, and muscle weakness. The assessment documented the resident with short and long term memory problems, severely impaired for decision making abilities, needing extensive assistance of two staff members with bed mobility, transfers, and extensive assist of one staff member for locomotion on/off the unit and a wheelchair as mobility device and no ambulation. The assessment also documented the resident with no limitation of upper extremity range of motion and absent of any pain. A Care Plan with a focus area dated 9/20/2018, documented the resident has chronic pain/discomfort related to left knee arthritis, generalized weakness, and pain during ambulation. Interventions included the following: *Notify health care provider if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. *Observe/record/report to Nurse any signs/symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); vocalizations (grunting, moans, yelling out, silence); mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); eyes (wide open/narrow slits/shut, glazed, tearing, no focus); face (sad, crying, worried, scared, clenched teeth, grimacing) body (tense, rigid, rocking, curled up, thrashing). *Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, withdrawal or resistance to care. Observation on 4/17/23 at 1:15 p.m., Resident #7 was sitting in a broda chair with a pillow underneath the right arm and hand on top of the residents abdomen. The Progress Notes documented the following on these dates and times: *11/19/2022 at 8:15 a.m., This nurse was called to residents room by CNA (Certified Nursing Assistant) as resident was not bearing any weight to right side. Upon assessment noted minimal facial dropping to right side, limp right arm, tense right leg and not bearing any weight to it. Resident with facial wincing when repositioning arm, scheduled Tylenol given. We do have PRN (as needed) morphine on hand and will use as needed. ROM (range of motion) WNL (with-in-normal limits) for residents left side. Resident was unable to voice her needs and was orientated to self only, per her usual. On call Doctor notified of happenings and that resident was DNR and on hospice. Doctor stated no need to send her out, just keep comfortable. Family and Hospice notified as well. *11/19/2022 at 2:57 p.m., Incident, Late Entry: This nurse and another nurse were called to resident room approximately 9:30 p.m., this evening. Staff noted resident with a large swollen area to upper right arm. Assessed decreased ROM to right arm. Some non-verbal signs/symptoms of pain/discomfort. Staff hoyer assisted to bed. Encouraged elevating arm. Applied cool packs approximately 20 minutes. Update sent to primary physician and hospice notified. No orders to send to hospital as resident is Hospice and comfort cares were provided as ordered. Staff education provided for resident positioning and transfers with hoyer only. Physician, family and Hospice have been notified. Instructed to provide comfort cares to resident. Added to daily documentation. *11/19/2022 at 3:29 p.m., Health Status, Note Text: Resident continues with slight facial droop to right side, limp right arm/ contracted hand, and tensed right leg. Appears comfortable at this time and is resting quietly in bed. *11/19/2022 at 10:32 p.m., Administration Record (Default Note) Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 2 hours as needed for Pain-Moderate; Pain-Severe;Shortness of Breath given for comfort d/t facial grimacing and stating Oh, oww. as the CNAs were assisting with cares. *11/20/2022 at 5:25 a.m., Communication/Visit with Physician Note Text: As staff were assisting resident in completing cares, it was noted resident had an area on the upper outer/ inner arm. Right upper arm: Irregular shaped bright red/ light purple red in color measuring approximately 10.3 cm (centimeters) by 11 cm. A mobile nodule noted toward the inner upper arm, closer to armpit region, measuring approximately 6.0 cm in diameter per wound measuring guide circular grid. Resident does not complain of pain upon assessment of the area, though when right arm slightly moved for cares, states, Oh, Ow. accompanied with facial grimacing. 3 interventions attempted, repositioning, elevation of extremity, one on one consoling, reduced stimuli. Resident was given a PRN dose of Morphine 0.25 ml to aid in comfort orders. Staff encouraged to take extra precaution during cares, slight elevation of extremity encouraged as well for comfort. *11/20/2022 at 7:12 a.m., Administration Record (Default Note) Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 2 hours as needed for Pain-Moderate;Pain- Severe;Shortness of Breath *11/20/2022 at 10:42 a.m., Communication - Other Note Text: Hospice on-call nurse notified of swollen right arm and bruise/nodule found yesterday evening. *11/20/2022 at 12:55 p.m., Health Status, Note Text: Resident was bearing weight to right leg this morning and by the afternoon no longer was. Morphine given due to facial grimacing per PRN orders. Red and bruise/swollen area to right arm continues with minimal pain. Vitals WNL for resident, no SOB (shortness of breath) noted. CNA stated she is eating slower than normal but no further troubles noted. She is currently resting in bed, arm propped for comfort. *11/20/2022 at 5:48 p.m., Administration Record (Default Note) Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 2 hours as needed for Pain-Moderate;Pain-Severe;Shortness of Breath. Morphine given due to wincing and shaking for comfort. *11/21/2022 at 7:16 a.m., Administration Record (Default Note) Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 2 hours as needed for Pain-Moderate;Pain-Severe;Shortness of Breath. Administered for pain prior to transfer out of bed. *11/21/2022 at 4:04 p.m., Health Status Note Text: Resident continues with bruising to right arm and limited movement. Resident given Roxanol this morning prior to getting transferred from bed to wheelchair. Resident drank this morning, but didn't eat anything. Resident rested in recliner in TV area for awhile. No signs or symptoms of pain. Resident's niece and hospice nurse here today to see resident. Resident resting quietly in bed at this time. *11/22/2022 at 11:19 a.m., Health Status Note Text: Resident continues with bruise to right arm, now down into forearm and with limited movement. She was resting comfortably this morning and slept in later than usual. Staff using hoyer to transfer at this time. Took morning medications without concern. *11/22/2022 at 2:46 p.m., Communication/Visit with Physician Note Doctor, Update on right arm; swelling to upper arm has gone down, bruising now noticed in forearm and hand. Swelling noted now in right hand as well, geri sleeves applied, sling in place to keep arm elevated as she is not able to do so herself. Ice packs and PRN morphine also being used for pain control. Will notify hospice. *11/22/2022 at 5:02 p.m., Transfer to Hospital: Reason(s) for Transfer: Pain (uncontrolled) Other (specify) - right upper arm. Bruise/swelling, Decreased ROM. Increase pain. *11/22/2022 at 5:17 p.m., Health Status Note Text: This nurse received call back from hospice transport for an X-ray of the right arm. Paperwork sent with resident. She is being transported by facility van and accompanied by the driver. This nurse called hospital to speak with ER. *11/22/2022 at 8:30 p.m., Health Status Late Entry: Resident returned in facility van with staff member from hospital. Diagnosis with Humerus fracture to be treated with immobilization. Orders state Leave in posterior splint with shoulder sling. Have follow up in 2 weeks for re-X-ray and examination. Contact hospice if further pain medication needed. Hospital form included the following: -the humerus is the large bone in the upper arm-a broken humerus is often treated by wearing a cast, splint or sling -Wear a splint or sling as told by your doctor. Remove it only as told by your doctor. -Move fingers often. A phone call was made to hospice message left with triage nurse updating on diagnosis. *11/22/2022 at 10:30 p.m., Health Status Late Entry: Resident given PRN dose of Roxanol prior to hoyer transfer into bed. Splint and sling remain in place and cover arm all the way to right wrist. Right hand is very swollen and completely black and blue. Resident paperwork states move finger often when communicating with resident and showing her, writers moving fingers she was able to move them on the right hand. Hospice nurse also arrived and assessed resident, no new orders at this time. Will attempt to control pain with PRN med's already ordered from hospice. *11/23/2022 at 4:50 a.m., Communication/Visit with Physician Note Text: Resident returned from ER visit at 10:30 p.m., on 11/22/22 was diagnosed with a closed displaced segmental fracture of shaft of right humerus with malunion. They applied posterior splint with shoulder sling and state to leave on. Have follow up in 2 weeks for re X-ray and exam. Contact hospice if further pain medication is needed. Return to ER for new or worsening symptoms. Residents right had is very swollen and completely covered in dark purplish bruising. Staff is elevating with pillow on her lap. Can we get orders for: Gel ice pack on for 15 minutes - 30 minutes up to hourly PRN? Thank You The Skin Observation form dated 11/19/22 at 10:30 p.m., documented, right upper arm: irregular shaped bright red/ light purple red in color measuring approximately 10.3 cm x 11 cm. A mobile nodule noted toward the inner upper arm, closer to armpit region, measuring approximately 6.0 cm in diameter per wound measuring guide circular grid As staff were assisting resident in completing cares, it was noted resident had an area on her upper outer/ inner arm. Resident does not c/o pain upon assessment of the area, though when right arm slightly moved for cares, states, Oh, Ow. accompanied with facial grimacing. Resident was given a PRN dose of Morphine 0.25 ml to aid in comfort per orders. Staff encouraged to take extra precaution during cares, slight elevation of extremity. encouraged as well for comfort. The Pain Level Summary form with these dates and times, documented the residents level of pain, from the 1-10 level scale of pain, (1 lowest level of pain, 10 being the highest level of pain): *11/19/2022 at 3:28 p.m., 2 *11/19/2022 at 10:00 p.m., 3 *11/19/2022 at 10:30 p.m., 6 *11/20/2022 at 7:12 a.m., 5 *11/20/2022 at 8:43 a.m., 3 *11/20/2022 5:48 p.m., 5 *11/21/2022 at 7:16 a.m. 4, *11/22/2022 at 3:55 p.m., 5 *11/22/2022 at 4:33 p.m., 2 The Medication Administration Record (MAR) for November 2022, instructed staff to administer Morphine Sulfate (Concentrate) Solutions 20 MG/ML, give 0.25 ml by mouth every 2 hours as needed for Pain, (moderate-severe) and for shortness of breath. The MAR documented the morphine given on these dates and times. *11/19/22 at 10:32 p.m. *11/20/22 at 7:12 a.m., and 5:48 p.m. *11/21/22 at 7:16 a.m. *11/22/22 at 3:55 p.m., and 10:25 p.m. *11/23//22 at 10:33 a.m., and 3:40 p.m. The emergency room Final Report dated 11/22/22 at 7:53 p.m., documented, the patient presents with right arm injury. The onset was 3 days ago. The course/duration of symptoms is constant. Type of injury is unknown. The character of symptoms is pain. The degree of pain is moderate. The degree of swelling is moderate. The exacerbating factor is movement. The relieving factor is non. The patient can give no history and does not speak. According to staff, 3 days ago they thought she had a stroke because she was not using her right arm. The staff started to have to use a Hoyer lift to move her. There is no known fall or injury but the patient started to have right arm bruising so was brought into the emergency room for evaluation. Review of symptoms: *Skin Symptoms=bruising right arm *Musculoskeletal symptoms= pain with movement of right arm *Musculoskeletal= proximal upper extremity, right arm, tenderness, swelling, ecchymosis *Findings=right mid shaft humerus fracture with significant displacement *Patient was given morphine 2 MG IM, Patient had posterior long arm splint applied and placed in a shoulder sling Diagnosis= Closed displaced segmental fracture of shaft of right humerus with malunion. Interview on 4/20/23 at 9:00 a.m. Staff A (Licensed Practical Nurse) stated was notified that Resident #7 was not acting right. Staff A went into the room and noticed that the resident had a right sided facial droop, and some right sided weakness. Staff A did range of motion on the right side and noticed that Resident #7 did have some wincing when range of motion was completed. Staff A confirmed and verified that the resident had a change in condition with the limited movement during range of motion to the right upper arm and that Resident #7 needed to be sent out for evaluation. Interview on 4/19/23 at 3:30 p.m., Staff B, LPN, heard about about the bruising/swelling on 11/19/22 around 10:00 p.m., when the evening shift aides were getting Resident #7 ready for bed. Staff B and Staff C (Registered Nurse)proceeded to go into the resident room to assess the right arm/shoulder area. Staff B confirmed and verified that there was bruising/swelling and a notable bump on the inner part of the right arm. Staff B confirmed and verified that the resident had a change in condition and that further assessment/intervention needed to have been completed. Interview on 4/20/23 at 10:00 a.m., Staff C, RN, confirmed and verified that Staff B came and got her to look at Resident #7 upper right arm area. Staff C noticed that there was a lump on the inner right side by the arm pit, but does not recall if any range of motion or assessment was completed. Interview on 4/19/23 at 1:30 p.m., Staff D, LPN, stated they worked on 11/21/22 and seen the bruising/swelling on Resident #7 upper right arm area and limited range of motion to that area. Staff D confirmed and verified that Resident #7 had a change in condition and that the expectation of the nurses is to do a thorough assessment and if needed to have the resident seen. Interview on 4/19/23 at 2:00 p.m., Staff E, RN, worked on 11/22/22 and got report from the previous nurse that Resident #7 had bruising/swelling on the upper right are/forearm/and hand, and that there was a lump/bump by the upper arm. Staff E explained that they called the facility physician and hospice and received an order to send the resident out for x-rays due to the resident having pain and limited range of motion in the right arm. Interview on 4/19/23 at 3:00 p.m., the Physician confirmed and verified that it is the expectation of the nursing staff to have a resident evaluated at a hospital if there is a change in condition. Interview on 4/20/23 at 11:00 a.m., the facility Administrator confirmed and verified that the nurses are expected to do an assessment on the resident and if a change of condition is seen and warranted to call the doctor to inform of the change and condition and the need to send out of the facility for an evaluation. The INTERACT-Change In Condition Evaluation Policy dated 3/29/2023, documented the purpose is to improve communication between nurses and a provider when nursing is monitoring a change in condition, to enhance the nursing evaluation of and documentation of a resident who has a change in condition, to provide a standard format to collect pertinent clinical data prior to contacting the provider when there is a change in condition and to standardize shift to shift communication about a resident change in condition. The Procedure: *Nursing judgement should be used when determining the urgency of contacting the provider. In the even the situation requires calling 911, the change in condition evaluation would not be used. *Check with other staff members who have regular contact with the resident to obtain an accurate picture of the change in condition. Staff members who can provide useful information about the situation include the nursing assistant, rehabilitation staff members, social workers and activity staff members.

Based on clinical record review, and staff interviews, the facility failed to obtain a urine analysis (UA) per physician order for 2 of 4 resident reviewed (Resident #5 and Resident #8) and additionally failed to apply ted hose per physicians orders for 1 of 4 resident reviewed (Resident #5). The facility reported a census of 35 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], for Resident #5 identified a Brief Interview for Mental Status (BIMs) score of 8, indicating moderately impaired cognition. The MDS identified Resident #5 was requiring extensive assist of one for toilet use and personal hygiene and frequently incontinent of urine. The MDS included diagnoses for which included heart failure, hypertension, renal insufficiency, renal failure, diabetes mellitus and Alzheimer disease. The Plan of care with an initiated date 5/27/2021, the resident has bladder incontinence related to Alzheimer's Disease, History of UTI , Impaired mobility, diuretic use. Interventions include: *Encourage resident to drink more fluids during morning and afternoon and limit fluids in the evening/night. *Monitor/document for s/s UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status. *Resident uses incontinence product: pull up brief *Resident prefers to use the toilet during the day and a bedside commode on the right side during the night. The Progress Notes dated 9/23/2021 at 10:22 a.m., documented, that the family wonders if a urine analysis (UA) should be collected as she has more confusion. Patient has no other UTI symptoms. A facsimile sent to the facility on [DATE] included an order that instructed staff to do a UA. The facsimile was signed and dated by the physician on 10/1/21. The facsimile was not noted by the facility until 10/4/21 at 7:32 AM. The Progress Notes dated 10/4/2021 at 7:31 a.m., documented received a new order from physician to collect a UA. Charge nurse notified. TAR order entered. The Progress Notes dated 10/4/2021 at 7:36 p.m., informed family of UA order that was received, stated sample had already been obtained and sent to lab. The Clinical Record lacked any documentation of the UA being collected on 10/1/21, per the physicians order. 2. The Quarterly MDS assessment dated [DATE], for Resident #8 identified a BIMS score of 12, which indicated impaired cognition. The MDS identified Resident #8 was requiring extensive assist of 1 for toilet use and supervision with set up help for personal hygiene and frequently incontinent of bladder. The MDS diagnoses included heart failure, hypertension, diabetes mellitus, anxiety and depression. The Plan of Care with an initiated date 4/23/2019, identified the resident had bladder incontinence related to diuretic use, cognitive impairment, impaired mobility, generalized weakness, history of recurrent urinary tract infections. Interventions included: *Encourage resident to drink more fluids throughout the morning and afternoon and encourage her to limit fluids in the evening/night. *Monitor/document for signs or symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. *Encourage & assist Resident #8 with washing her hands following toileting, before meals. The Progress Notes dated 4/11/2023 at 12:09 p.m., documented the physician in facility for rounds this morning. Visit with resident. Reviewed medications and diagnosis. Resident complained of urinary pain/discomfort. 1. Orders to straight catheter UA received. The Progress Notes dated 4/13/2023 at 6:44 a.m., documented, did attempt a straight catheter UA this morning. Only got a few drops and not enough for the sample. Resident then told this nurse I just went before you came in. Resident was incontinent of urine. The Progress Notes dated 4/14/2023 at 5:25 a.m., documented urine sample obtained at this time by straight catheter using sterile technique The Clinical Record lacked any documentation of the UA collected on 4/11/23 as ordered by the physician. 3. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], for Resident #5 identified a Brief Interview for Mental Status (BIMs) score of 8, indicating moderately impaired cognition. The MDS identified Resident #5 was requiring extensive assist of one for toilet use and personal hygiene and frequently incontinent of urine. The MDS included diagnoses for which included heart failure, hypertension, renal insufficiency, renal failure, diabetes mellitus and Alzheimer disease. The Progress Notes dated 10/14/21, documented provider also asked if resident would benefit from TED hose to bilateral lower extremities, on each a.m., and off at hour of sleep. Physician signed and dated OK on 10/15/2021. The Clinical Record lacked any documentation of the TED hose applied as ordered. Interview on 4/25/23 at 10:00 a.m., the facility Administrator and the facility Director of Nursing confirmed and verified that the clinical record lacked any documentation of the orders being followed and it is the expectation of the staff to follow the physicians orders.

Based on resident interview, record review, policy review and staff interviews, the facility failed to document changes to Dietician approved menus, notify residents of the changes to the menus, and notify the Dietician of the menu changes prior to the changes being made. The facility reported a census of 35 residents. Findings include: 1. Review of facility form titled, Menu Substitution Log, revealed changes to the menu were made 2/7/22 and 2/10/22. The Dietitian acknowledged the changes 2/10/22 by initialing the Menu Substitution Log form. During an interview on 2/9/22 at 4:27 PM a Dietary Manager (DM) who works at a different facility revealed meals are sometimes substituted. The DM revealed if she needs to make a change to the menu approved by the Dietician, the Dietician will approve the changes after the change has been made when the Dietician comes to the facility. The DM revealed she will sometimes call the Dietician to get approval. During an interview on 2/10/22 at 10:29 AM, the Dietician revealed when there are changes to the menu the changes are documented on the white board in the dining room for residents to view. The Dietician further revealed she is notified each Thursday when she is at the facility of any changes that have occurred to the menu and she reviews and signs the substitution log. The Dietician further stated the Administrator or the Cook is currently making the decision to make changes to the menu and they sometimes have to use their best judgment in regards to menu changes. During an interview on 2/10/22 at 10:40 AM, Staff A, RN revealed she was unable to locate any menu substitution logs since October 2021 after requested for review. The Dietician revealed changes have been made to the menus however she did not recall signing menu substitution logs since October 2021. During an interview on 2/10/22 at 1:09 PM, the Director of Nursing (DON) revealed menu changes are not documented or kept on file with original posted menus as expected after requested copies of menu changes since October 1, 2021. 2. Interview on 2/10/22 at 12:16 PM with Resident #15 revealed the facility has a rotating schedule of meals and about half the meals every week has had changes. She stated since she eats in her room she doesn't know about the changes till she gets her tray. Resident #15 also revealed the Administration at the facility are not ordering things on time so the cooks have to make due with what they have on hand. Review of facility policy titled, Menu Substitutions-Food and Nutrition Services with a review date 4/27/21 revealed the following: a. All substitutions are documented and kept on file with original posted menu. Document the following: the date, changed from, changed to, reason for change and the initial of the person making the substitution on the day of use. Substitutions are recorded either on the menu or on the menu Substitution Log (GSS #296). The dietician will review and initial the substitutions with each visit where required. b. When possible the cook will check with the director of food and nutrition before making changes/substitutions. c. Menu changes are to be kept to a minimum. d. The change to the posted menu should be made as soon as the decision has been made to change the menu. e. If another department is responsible for announcing the menu, food and nutrition employees will ensure that they are notified of the change in a timely manner so as not to confuse the residents. f. Special events, holiday menus and resident Meals of the Month will be noted on the menu or substitution list.

Based on clinical record review, staff interview and policy review, the facility failed to notify the Long Term Care (LTC) Ombudsman for 1 of 4 residents reviewed that transferred and discharged to the hospital, ( Resident #6). The facility reported a census of 35 residents. Findings include: 1. Review of Census History revealed Resident #6 transferred to the hospital 10/8/2021 and readmitted to the facility from the hospital 10/11/21. The Census History further revealed Resident #6 transferred to the hospital 10/19/21 and readmitted to the facility from the hospital 10/21/21. Progress Notes revealed Resident #6 transferred to the hospital 10/8/21 and 10/19/21. Review of facility protocol titled Admission, Transfer and Discharge Team with a review date of 8/11/21 documented admissions, transfers and discharges will be conducted according to state and federal regulations. The clinical record for Resident #6 lacked LTC Ombudsman notification of the transfers to the hospital 10/8/21 and 10/19/21. During an interview on 2/8/2022 at 3:48 PM, the Administrator acknowledged the Ombudsman was not notified in regards to Resident #6 being discharged to the hospital on either of the two occasions in October 2021.

Based on record review and facility staff interviews the facility failed to have a current contract with 1 of 2 hospice providers reviewed (Hospice #1). Review on [DATE] of Hospice #1 contract with the facility revealed the contract terminated 5 years after [DATE] ([DATE]). The facility reported a census of 35 residents. Findings include: Record review on [DATE] at 11:59 AM of the facilities contract with Hospice #1 titled, Hospice and Nursing Facility Services Agreement revealed the policy documented it went into effect on [DATE]. The policy directed the agreement shall be effective for a term of one (1) year, commencing on the effective date, unless earlier terminated in accordance with the provisions of the agreement. The contract went on to instruct the agreement shall automatically renew for four (4) additional one (1) year terms unless the agreement otherwise terminates according to other terms and conditions. Record review of the facilities Detailed Census Report dated [DATE] documented two residents received hospice services from Hospice #1 who's contract expired [DATE]. Resident #101: [DATE] to [DATE] Resident #3: [DATE] to present Interview on [DATE] at 10:27 AM with the facilities Senior Corporate Council revealed the facility does not have a current contract with Hospice #1 and it was expired in [DATE]. He revealed a contract was requested by the Administrator at the facility on [DATE] and the local hospice provider has not signed after multiple attempts. He revealed it would be the Administrators responsibility to ensure the contract is signed.

Based on clinical record review, observation, staff interview and facility policy review, the facility failed to utilize appropriate infection control practices during resident care for 1 of 5 residents reviewed (Resident #5). The facility reported a census of 32 residents. Findings included: The Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognitive functioning. The MDS stated she required limited assist of 1 staff with transfers and walking and required extensive assist of 1 staff with bed mobility, dressing and toileting. The MDS included [DIAGNOSES REDACTED]. Observation on 6/16/20 at10:31 a.m. revealed Staff A- Licensed Practical Nurse (LPN) performed wound care and dressing changes on Resident #5. Staff A knocked and entered the room. Staff A washed her hands at sink with soap and water, shutting the faucet off with the soiled paper towels she had just dried her hands with. Staff A stated she had never done Resident #5's leg treatments before and had printed the orders out to look at while she did the treatments. Staff A placed the papers onto the bed and a towel on top of the bedside stand. Staff A opened the closet and removed 3 bins of wound supplies and placed 2 bins on the bedside stand and 1 bin on the residents bed. Staff A applied gloves and pulled a folding chair out of the closet and sat down on it in front of Resident #5. Staff A did not perform handwashing or hand hygiene prior to applying her gloves. Staff A removed stockinette from right lower leg and removed dressing from resident's right shin and from resident's right lateral foot. Staff A discarded the old dressings into the garbage. Staff A removed and discarded her gloves and applied new gloves. Staff A did not perform hand hygiene or handwashing prior to applying her new gloves. Staff A used 4 x4 gauze pads from the bins, wet them with NS and cleansed the open area on right shin, discarded the gauze and proceeded to do the same to the right lateral foot and discarded the gauze. Staff A removed her gloves and looked at the papers she had placed onto the bed. Staff A stated she could not find an order for [REDACTED]. Before she left the room, Staff A applied gloves and applied a gauze dressing to the area on resident right lateral foot and then stated she would be right back. The right shin area was left open to air. Nurse then removed her gloves and left the room. Staff A did not wash her hands before leaving the room. During an observation of wound care on 6/16/20 at 11:30 a.m., DON and Staff A knocked and entered the room. Both staff washed their hands and applied gloves. The DON had Staff A remove the dressing on the right lateral foot. Staff A then removed some [MEDICATION NAME] gauze from the top of the bottle, and cut a small section to pack the wound on right lateral foot per order. Staff A dropped the [MEDICATION NAME] gauze piece on the floor and as the nurse reached down to pick up the gauze from the floor, the DON immediately told her to not use that piece since it had been on the floor. Staff A discarded the piece that had fallen onto the floor and cut a new piece of the [MEDICATION NAME] gauze. Staff A applied the small piece into the wound on Resident #5's right lateral foot and covered it with a gauze dressing and used cling gauze to secure the dressing. Staff A then removed her gloves and started to apply new ones and DON stated to Staff A that she must wash her hands or use a hand sanitizer in between all glove changes. Staff A did stand up and walk over to the hand sanitizer dispenser in Resident#5's room and sanitized her hands. Staff A applied clean gloves, and cleansed the right shin wound site again with a 4 X 4 gauze and normal saline. Staff A then applied a gauze dressing and cling gauze to secure dressing. Staff A noted to use the same scissors from earlier and did not clean them in between uses with the resident's dressing changes. The DON assisted Staff A to hold up Resident#5's right leg and at 11:48 a.m. Staff A applied stockinette to residents right lower leg and proceeded to wrap the right leg from toes to knee with a compression bandage. Staff A then went to the sink and washed her hands with soap and water, shutting off the faucet with the wet paper towels. Staff A applied new gloves and removed stockinette from left lower leg and removed the old cling gauze to expose the dressings to the leg which included the wound vac dressing to Resident #5's left lateral heel area, a dressing to the left 5th plantar toe, and the left lateral ankle. Staff A attempted to remove the old dressing on the left ankle and DON again reminded Staff A to remove her gloves and hand sanitize before putting new gloves on again. DON noted the wound on Resident #5's left 5th plantar toe was healed and skin was flush with a scab like appearance. DON instructed nurse to cleanse site and cover with a gauze dressing and the physician would be notified today that area was healed and no longer needed packed with gauze. Staff A then removed the old dressing from Resident #5's left outer ankle dressing and then began looking through the supply bins on the table with her contaminated gloved hands. DON immediately prompted nurse to wash her hands before touching things and after she removed soiled dressings. Staff A washed her hands at sink with soap and water and applied new gloves. Staff A cleansed the left outer ankle wound with a 4 X 4 gauze soaked with normal saline. Staff A removed gloves and used the hand sanitizer in resident's room. Staff A applied new clean gloves and applied the medicated ointment to resident's left outer ankle per physician's orders [REDACTED]. Staff A then removed and re-applied a dressing to cushion the wound vac tubing that was coming from the left lateral heel area. Staff A then wrapped the entire foot and shin area with cling gauze and tape using the scissors to cut the tape. Staff A applied the stockinette over the top of all of the dressings on Resident #5's left lower leg and wrapped the left leg with a compression bandage from the toes, to just below the knee. Staff A removed her gloves after completed all of the treatments at 12:25 p.m. Staff A then used her bare hands to put all of the supply bins back into the closet and then went to the sink and washed her hands with soap and water and again shut off the water with the wet/soiled paper towels. Staff A did not disinfect the scissors before, during or after any of the treatments she completed. During interview on 6/17/20 at 8:51 a.m. the DON stated Staff A should have removed her gloves and sanitized her hands after the removal of old dressings, after picking up items from the floor and with all glove changes. DON further stated she expected nurses to clean and disinfect the scissors in between uses when caring for multiple wounds. DON stated Staff A should have removed her gloves and washed hands before touching the clean items in the wound supply bins, before and after she had touched the papers while in the room. DON stated she expected all nurses employed at the facility to follow basic infection control practices when they completed dressing changes. Review of the facility's Hand Hygiene Handwashing Policy, revised 4/14/20, stated the purpose of the policy was to ensure appropriate hand hygiene technique for clinical use. The background of the policy was regular handwashing with soap and warm, not hot water is one of the best ways to remove germs. Avoid getting sick and prevent the spread of germs to others. The goal of handwashing and glove use for patient care was to prevent the spread of infection between residents. Handwashing and changing gloves occurs after care is delivered to prevent the spread of organisms to other residents. Sanitizers are used in patient care areas. The facility's procedures during patient care included: 1. Wash hands with plain soap and water or with an anti-microbial soap and water: a. If hands are visibly soiled. b. If hands are visibly contaminated with blood or bodily fluids. c. Before eating. d. After using the restroom. e. When a build-up of [MEDICATION NAME] (moisturizers such as ointments, lotions or creams) is felt on hands (usually after five to ten applications of a gel). 2. If hands are not visibly soiled or contaminated with blood or bodily fluids, use an alcohol based hand rub for routinely cleaning hands: a. Before having direct contact with residents, patients and children. b. After having direct contact with another person's skin. c. After having contact with bodily fluids, wounds or broken skin. d. After touching equipment or furniture near the resident/patient. e. After removing gloves. 3. Alternatively, hands may be washed with an antimicrobial soap and water in clinical situations described above.

Based on clinical record review, resident and staff interviews, and policy review the facility failed to appropriately care plan the use of a Wound Vac device, the care and dressing changes required for the wound vac use and the care the resident was receiving at the wound clinic for several chronic [MEDICAL CONDITION]. The facility also failed to initiate a discharge plan on the care plan for 1 of 5 residents reviewed. (Resident # 5). The facility reported a census of 32 residents. Findings Included: A Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 was admitted to the facility on [DATE]. The Brief Interview for Mental Status (BIMS) score of 15, indicated intact cognitive functioning. Resident #5 was independent with decision making and was her own responsible party. The MDS included [DIAGNOSES REDACTED]. Review of Resident # 5's June Treatment Administration Record (TAR) revealed resident had a wound vac device attached to her left heel due to a [MEDICAL CONDITION]. The TAR documented the facility's nurse changed the wound vac dressings on Mondays and Saturday's and the Wound Center changed the dressings on Thursday's during her weekly appointments. Review of Resident #5's comprehensive Care Plan with a revision date of 6/11/20, revealed it lacked documentation for the use of the wound vac, the care the nurses were providing to the wound vac site and that resident was receiving care at a wound center, on a weekly basis. The Care Plan also revealed there was no discharge plan listed. Interview with Resident #5 on 6/16/20 at 10:31 a.m., revealed she was concerned that she wanted to leave the facility but no one at the facility was listening to her nor had they discussed her discharge plans with her. The resident did not know who she needed to talk to in order to voice her needs and request a referral to another facility. Interview with Staff D- Social Service worker (SSW) on 6/16/20 at 10:50 a.m., revealed she was not aware of Resident #5's wish to have a referral to move to another facility. Staff D stated she had just started in her position in May 2020 and had not yet completed any discharge plans or completed a care plan due to her still receiving her orientation to the SSW role. Staff D stated she was aware Resident #5 had wanted to leave the facility and go home once her wounds were healed but had not realized Resident #5 wanted to move to a different nursing facility as soon as possible. Interview with Staff C-Activity Director on 6/17/20 at 9:13 a.m., revealed she had assisted in the SSW department when Resident #5 admitted to facility on 5/6/20. The facility did not have a SSW employed at the facility until mid-May 2020, so Staff C had been asked to help complete the social service assessments until a new SSW was hired. Staff C verified she had completed the initial social services admission assessment, but did not document the discharge plan on the care plan. Staff C stated she was not aware that a discharge plan should be included on the care plan. Interview with the Director of Nursing (DON) on 6/17/20 at 8:51 a.m., revealed she was not aware Resident # 5's Care Plan had no discharge plan included on it. She reported they did not have a SSW at the facility when Resident #5 was admitted to the facility. The DON also stated she was not aware the care plan did not include the use of the wound vac daily, the 3 times per week dressing changes, and that Resident #5 was going out to the wound center weekly on the facility van. The DON stated she did not know why these items were not listed on Resident #5's Care Plan but stated she did not think that information really needed to be on it. The facility's Care Plan Policy, with a revision date of December 2019, stated the purpose was to develop a comprehensive care plan using an interdisciplinary team approach, and to provide guidance to the interdisciplinary team in developing the initial care plan. The Care Plan Policy defined a comprehensive care plan should include: Measureable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The policy stated residents would receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. Each resident will have an individualized, person centered, comprehensive plan of care that will include measureable goals and timetables directed towards achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial and educational needs. The plan of care will be modified to reflect the care currently required/provided for the resident. The care plan will emphasize the care and development of the whole person ensuring the resident will receive appropriate care and services. It will address the relationship of items or services required and facility responsibility for providing these services.

Based on clinical record review, staff interview and facility policy review, the facility failed to follow up on a wound culture of resident's left foot done on 5/21/20 that resulted in a [MEDICAL CONDITION] (MRSA) infection. (Classified as a Multi-Drug Resistant Organism) (MDRO). The resident did not receive appropriate antibiotic treatment and follow up within the facility's Antibiotic Stewardship Program as required per regulation for 1 of 5 residents reviewed. (Resident #5). The facility reported a census of 32 residents. Findings included: A Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 was admitted to the facility on [DATE]. A Brief Interview for Mental Status (BIMS) score of 15, indicated intact cognitive functioning. The resident required limited assist of 1 staff with transfers and walking and required extensive assist of 1 staff with bed mobility, dressing and toileting. The MDS included [DIAGNOSES REDACTED]. Clinical record review on 6/16/20 of Resident #5's chart revealed a Wound Center Note dated 5/21/20, that instructed nursing home staff of a wound culture taken from resident's wound on her left lateral foot. The wound clinic also sent a signed physician's orders [REDACTED].-125 mg. 1 tablet, twice per day for 7 days. The [MEDICATION NAME] order and wound culture information was documented in a Progress Note by the charge nurse upon resident's return to the facility on [DATE] at 5:01p.m. Per further chart review, there was no wound culture report found in Resident #5's chart from 5/21/20. Resident #5's Medication Administration Record [REDACTED]. twice per day for 7 days for [DIAGNOSES REDACTED]. During an interview on 6/16/20 at 4:00 p.m., the Director of Nurses (DON), provided a faxed copy of the 5/21/20 wound culture report. The facility had received the report on 6/16/20 at 3:47 p.m. per the DON's request. DON stated the wound culture was positive [MEDICAL CONDITION] infection. Reviewed Resident #5's wound culture report and noted [MEDICATION NAME] was not listed on the report as an effective antibiotic to treat resident'[MEDICAL CONDITION] infection. DON stated when she had done her antibiotic tracking reviews as the facility's Infection Preventionist, she had missed that the wound culture had been done at the wound center. DON stated she would have to be more careful when doing her antibiotic reviews going forward. Review of the facility's Antibiotic Stewardship Program revised on 12/2019, stated in part the purpose of the policy was to provide guidance to the organization's facilities for antibiotic stewardship plans and also to decrease the incidence of multi-drug resistant organisms.(MDRO). The policy stated the background of the policy was to improve the use of antibiotics to protect residents and reduce the threat of antibiotics as both a national and organizational priority. The policy defined the Antibiotic Stewardship Plan as a set of commitments and actions designed to optimize the treatment of [REDACTED]. (CDC definition). The facility failed to appropriately monitor, follow up on and treat Resident #5'[MEDICAL CONDITION] infection

Based on observation, record review and staff interview the facility failed to provide incontinent/catheter care in a manner to prevent infection for 4 of 6 residents reviewed, (Resident #18, #31, #1, and #32). The facility reported acensus of 35 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment, dated 8/13/19, Resident #18 scored 5 on the Brief Interview for Mental Status (BIMS), indicated severe cognitive impairment. The resident required extensive assistance with activities of daily living including toilet use and personal hygiene. The MDS revealed resident had an indwelling catheter. The current Care Plan, revised 8/23/19, identified the resident had a suprapubic catheter related to history of [MEDICAL CONDITION]. The Care Plan identified a problem, resident will show no signs and symptoms of urinary infection. During an observation on 10/8/19, at 9:34 AM, with Resident #18 staff performed catheter care. Staff A, emptied urine into a plastic disposable graduate that had been dated 4/1/19, which indicated when last changed. Interviewed Staff A and verified the date on the graduate was 4/1/19. During an observation on 10/8/19, at 9:37 AM, the Director of Nursing verified the date on the plastic disposable graduate was 4/1/19. Interviewed the Director of Nursing at this time regarding the policy for changing the graduates and she stated she would have to check but it should have been changed since April. The form titled, Clinical Laboratory, dated (MONTH) 19, 2019, revealed Resident #18 urine culture had positive flora and resident was started on [MEDICATION NAME] (antibiotic) for 10 days. Record review of Medication Administration Record [REDACTED]. 2. The MDS, dated [DATE], for Resident #31, documented the resident was frequently incontinent of urine and always incontinent of bowel. The resident needed extensive assistance of 2+ persons for toilet use and was not on a toileting program. The resident had a BIMS of 3, indicating severe cognitive impairment. During observation on 10/8/19 at 10:15 AM, Staff A and Staff H entered Resident #31's room. Staff A and Staff H performed hand hygiene and assisted resident to bed using the mechanical lift. Staff A and Staff H rolled the resident side to side to pull pants down. Hand hygiene was performed and applied gloves. The brief was unfastened and pushed down between the resident's legs by Staff H. Frontal Peri care was completed wiping front to back by Staff H. The resident was rolled on to his left side. Staff H wiped front to back between the buttocks. Buttocks were not cleansed. Right and left hips were not cleansed. During interview on 10/8/19, at 1:19 PM, Staff H stated resident was incontinent of urine at the time peri care was done at 10:15 AM. Staff H acknowledged she did not cleanse resident's hips. During interview on 10/8/19, at 1:23 PM, the Director of Nursing stated she would expect complete peri care to be completed on a resident incontinent of urine. She further stated complete peri care would include cleansing of buttocks and hips. 3) According to the MDS assessment, dated 9/17/19, Resident #1 scored 3 on the BIMS, indicating severe cognitive impairment. The resident required extensive assistance with toilet use and personal hygiene, The resident had frequent bladder incontinence and [DIAGNOSES REDACTED]. During an observation on 10/08/19 at 7:05 a.m., Staff E, Certified Nursing Assistant (CNA) washed her hands and applied gloves. Staff F, CNA used hand sanitizer and applied gloves. Staff assisted the resident to sit on the side of the bed and put on her shoes and socks. Staff assisted the resident to the bathroom and removed the wet incontinent pad. Staff F changed gloves with no hand hygiene. Staff [NAME] changed gloves and washed her hands. Staff F removed the residents shoes and then applied the resident's deodorant and bra. Staff F wiped her nose with her right gloved hand and then combed the resident's hair. Staff F pulled out disposable wipes from the packet (wearing same gloves she handled the shoes and wiped her nose with). Staff F applied the gait belt and assisted the resident to stand, then wiped the resident's anal area and buttocks 3 times with different wipes. Staff F removed the right glove, applied a new one with the contaminated glove and pulled up the resident's new incontinent pad and pants. Staff F removed her gloves, took the soiled linen out of the room, handling the bathroom door handle, the room door handle, and the utility room door with no hand hygiene. 4) According to the MDS assessment, dated 8/27/19, Resident #32 demonstrated long and short term memory problems and severly impaired skills for daily decision making. The resident required extensive assistance with bed mobility, transfer, ambulation, dressing and personal hygiene. The resident had frequent bowel and bladder incontinence. The resident's [DIAGNOSES REDACTED]. During an observation on 10/8/19 at 9:05 a.m., Staff F and Staff [NAME] walked the resident to the bathroom. Staff F sanitized hands and applied gloves and Staff [NAME] applied gloves. The resident sat on the toilet. Staff F turned the water on in the sink wearing gloves then removed disposable wipes from the packet wearing the same gloves. Staff F wiped under her nose with her right gloved hand. The resident voided and had a bowel movement. After standing the resident, Staff F wiped the resident with disposable wipes with her left hand, then changed the left glove with the contaminated right gloved hand and pulled up the resident's pad and pants. Staff F used hand sanitizer before leaving the room. During an interview on 10/9/19 at 12:05 p.m., the interim Director of Nursing stated she expected staff to change gloves and do hand hygiene when gloves were contaminated. Hand hygiene and clean gloves should be applied prior to doing pericare. She expected staff to wash hands after providing perineal care, before leaving the room. The facility policy, Hand Hygiene and Handwashing, revised 1/18, directed during patient care wash hands with plain soap and water or with antimicrobial soap and water after using the restroom. If hands were not visibly soiled or contaminated use an alcohol based hand rub for routinely cleaning hands after removing gloves.

Based on clinical record review, observation, staff and resident interviews, the facility failed to ensure appropriate treatment and services to 3 of 8 residents reviewed, (Resident #28, #11, and #1) to prevent further decreases in mobility. The facility reported a census of 35. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] revealed Resident #28 had impairment of bilateral lower extremity Range of Motion (ROM). The resident had a [DIAGNOSES REDACTED]. Resident #28 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. During initial screening on 10/7/19 at 1:02 PM, Resident #28 stated he gets restorative exercises once in a while. Resident #28's Care Plan, dated 11/15/18, showed a focus: the resident had a need for restorative intervention due to ADL (Activities of Daily Living) self-care performance deficit/limited physical mobility related to [MEDICAL CONDITION] (Chronic [MEDICAL CONDITION] Obstructive Disease), [MEDICAL CONDITIONS] and obesity. Evidenced by Activity intolerance, fatigue, SOB (Shortness of Breath) and weakness. The Care Plan documented a goal of resident will participate in restorative services 3 times weekly. The interventions included; Nursing Rehab #1: Active range of motion: Upper extremities: See Restorative therapy worksheet, 10-15 reps & 2-3 sets, 1 time/day 2-3 days per week. Lower extremities: See Restorative therapy worksheet, 10-20 reps & 1-3 sets, 1 time/day, 2-4 days /week. Interview with the DON, on 10/9/19 at 1:58 PM, revealed the Restorative therapy worksheets are the forms titled, PT Restorative Therapy Alert and OT Restorative Therapy Alert. The PT Restorative Therapy Alert, not dated, documented a frequency per week: 2-4 times as tolerated. The OT Restorative Therapy Alert, dated 11/14/18, documented a frequency per week: 2-3. Review of the Documentation Survey dated (MONTH) 2019 showed Intervention/Task: Nursing Rehab #1: Active range of motion: Upper extremities: See Restorative therapy worksheet, 10-15 reps & 2-3 sets, 1 time/day 2-3 days per week. Lower extremities: See Restorative therapy worksheet, 10-20 reps & 1-3 sets, 1 time/day, 2-4 days /week. The documentation for the week of: a. (MONTH) 11-17 restorative was received 1 day b. (MONTH) 25-31 restorative was received 1 day Review of the Documentation Survey dated (MONTH) 2019 showed Intervention/Task: Nursing Rehab #1: Active range of motion: Upper extremities: See Restorative therapy worksheet, 10-15 reps & 2-3 sets, 1 time/day 2-3 days per week. Lower extremities: See Restorative therapy worksheet, 10-20 reps & 1-3 sets, 1 time/day, 2-4 days /week. The documentation for the week of: a. (MONTH) 1-7 restorative was received 1 day. b. (MONTH) 8-14 showed restorative was received no days. 2. The MDS, dated [DATE], revealed Resident #11 had impairment of bilateral lower extremity ROM. The resident had a [DIAGNOSES REDACTED]. Resident #11 had a BIMS score of 3, indicating severe cognitive impairment. Review of the Care Plan, dated 11/7/17, showed focus of: the resident had a need for restorative intervention due to ADL self-care performance deficit/limited physical mobility related to activity intolerance. Evidenced by need for staff assist with ADL's. The Care Plan documented a goal of: resident will participate in restorative services 3-5 times weekly. The Care Plan documented intervention of: Nursing Rehab #1: Active range of motion: Upper extremities: See Restorative therapy worksheet, 12-20 reps & 1-3 sets, 1 time/day 3-5 days per week. Lower extremities: See Restorative therapy worksheet, 15-20 reps & 1 set, 1 time/day, 3-5 days /week. The Care Plan included intervention of Nursing Rehab #2: Walking: See Restorative Therapy Worksheet: Sit to Stand using FWW (Front wheeled Walker) &/or in parallel bars Interview with DON on 10/9/19 at 1:58 PM, revealed the Restorative therapy worksheets are the forms titled PT Restorative Therapy Alert and OT Restorative Therapy Alert. The PT Restorative Therapy Alert dated 4/12 /19 documented a frequency per week: 3-5. The OT Restorative Therapy Alert dated 4/12/19 documented a frequency per week: 3-5. Review of the Documentation Survey, dated (MONTH) 2019, showed Intervention/Task: Nursing Rehab #1: Active range of motion: Upper extremities: See Restorative therapy worksheet, 10-15 reps & 2-3 sets, 1 time/day 2-3 days per week. Lower extremities: See Restorative therapy worksheet, 10-20 reps & 1-3 sets, 1 time/day, 2-4 days /week. The documentation for the week of: a. (MONTH) 4-10 restorative was not received. b. (MONTH) 11- 17 restorative was received 2 days c. (MONTH) 18-24 therapy was received 2 days The Intervention/Task: Nursing Rehab #2: Walking: See Restorative Therapy Worksheet: Sit to Stands using FWW (Front wheeled Walker) &/or in parallel bar had documentation for the week of: a. (MONTH) 4-10 restorative was not received b. (MONTH) 11-17 restorative was received 2 days c. (MONTH) 18-24 restorative was received 1 day d. (MONTH) 25-31 restorative was received 1 day A review of the Documentation Survey dated (MONTH) 2019 showed Intervention/Task: Nursing Rehab #1: Active range of motion: Upper extremities: See Restorative therapy worksheet, 10-15 reps & 2-3 sets, 1 time/day 2-3 days per week. Lower extremities: See Restorative therapy worksheet, 10-20 reps & 1-3 sets, 1 time/day, 2-4 days /week. The documentation for the week of: a. (MONTH) 1-7 restorative was not received. b. (MONTH) 8-14 restorative was received 2 days c. (MONTH) 15-21 restorative was received 2 days d. (MONTH) 22-28 restorative was received 2 days The Intervention/Task: Nursing Rehab #2: Walking: See Restorative Therapy Worksheet: Sit to Stands using FWW (Front wheeled Walker) &/or in parallel bar had documentation for the week of: a. (MONTH) 1-7 restorative was not received b. (MONTH) 8-14 restorative was received 1 day Restorative services were not received for 19 consecutive days between (MONTH) 10 and (MONTH) 28. During interview with the Director of Nursing (DON), on 10/9/19 at 2:54 PM, she stated she would expect the Care Plan to be followed. During interview with the DON, on 10/9/19 at 9:04 AM, stated she needs to revamp the entire restorative program. 3) According to the MDS assessment, dated 6/18/19, Resident #1 scored 3 on the BIMS, indicating severe cognitive impairment. The resident required limited assist with bed mobility, transfer, toilet use and personal hygiene and supervision with ambulation. The resident experienced limitation in functional range of motion of both lower extremities. A P.T. (Physical Therapy) Restorative Therapy Alert dated 6/4/18 directed the resident's plan included exercises 2-3 times a week, 15 repetitions, 2-3 sets, standing and seated exercises. The current Care Plan revised 7/20/18 identified the resident had a need for restorative intervention due to limited physical mobility related to right [MEDICAL CONDITION]/replacement and bilateral knee replacement. The goals included the resident would maintain the current level of function and would participate in restorative 2-3 times weekly. The interventions included active range of motion lower extremities: See Restorative Therapy Worksheet, 15 reps & 2-3 sets, 1 time/day, 2-3 days/week, revised 6/12/2019. The Documentation Survey Report, documented the resident received active range of motion of the lower extremities: a. 0 times the week of 7/14-20/19. b. 1 time the week of 7/21-27/19. c. 0 times the week of 7/28-8/3/19, refusing 1 time. d. 1 time the week of 8/4/10/19. e. 1 time the week of 8/11-17/19, refusing 1 time. f. 0 times the week of 8/18-24/19, refusing 1 time. g. 1 time the week of 8/12-31/19, refusing 1 time. During an observation, on 10/08/19 at 7:05 a.m., Staff E, Certified Nursing Assistant (CNA) and Staff F, CNA assisted the resident to sit on the side of the bed. Staff applied a gait belt and assisted the resident to stand. The resident could not take steps. Staff assisted the resident in sitting down and then transferred her to the wheelchair. During an interview, on 10/8/19 at 11:17 a.m., Staff G, Restorative Aide stated she did not know what the gaps in the program were. 4) According to the MDS assessment, dated 7/9/19, Resident #8 scored 15 on the BIMS, indicating no cognitive impairment. The resident required extensive assistance with bed mobility. The resident's [DIAGNOSES REDACTED]. The current Care Plan, revised 4/19/18, identified the resident had a need for restorative intervention due to ADL self-care performance deficit and limited physical mobility. The interventions included active range of motion upper extremities, see Restorative Therapy Worksheet, 15 reps and 2 sets, 1 time/day, 3 days/week and lower extremities, see Restorative Therapy Worksheet, 10-20 reps and 1 set, 1 time/day, 2-3 days/week. The Documentation Survey Report documented the resident received active range of motion of the upper extremeties and lower extremeties: a. 1 time the week of 7/1-6/19. b. 1 time the week of 7/28-8/3/19. c. 1 time the week of 8/11-17/19. d. 1 time the weerk of 9/1-7/19. e. 1 time the week of 9/8-14/19. f. 1 time the week of 9/22-28/19.

Based on record review and staff interview the facility failed to ensure code status in the electronic health record and the Iowa Physician order [REDACTED]. (Resident #31) The facility census was 35. Findings include: According to the Minimum Data Set with assessment reference date of 8/27/19, Resident #31 had admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The residents Brief Interview of Mental Status showed a score of 3, indicated severe cognitive impairment for daily decision making. Resident # 31's record included an IPOST form dated 3/3/19. The form showed a code status of Do Not Resuscitate (DNR). The IPOST showed Resident #31 wanted comfort measures only: use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of [REDACTED]. Patient prefers no transfer to hospital for life sustaining treatment. Transfer only if comfort needs cannot be met in current location. The IPOST showed no artificial nutrition by tube. The active orders as of 10/7/19 revealed a [DIAGNOSES REDACTED]. The active orders showed an order for [REDACTED]. Use oxygen, suction and manual treatment of [REDACTED]. Use medical treatment, cardiac monitor, oral/IV (intravenous) fluids and medications as indicated. an order for [REDACTED]. (MONTH) consider less invasive airway support ([MEDICAL CONDITIONS]). (MONTH) use vasopressors. Transfer to hospital if indicated, may include critical care and an order for [REDACTED]. During an interview on 10/7/19 at 4:03 p.m. the Director of Nursing stated Resident #31's IPOST did not match the Active Orders. She stated she would expect them to match.

Based on clinical record review, staff, physician interview and facility policy review, the facility failed to provide the necessary assessments for 3 of 4 residents reviewed with a condition change, (Resident #2, #3 and #4) which resulted in an immediate jeopardy to resident's health and safety. The facility identified a census of 46 residents. Findings include: According to a typed statement dated 6/4/19 at 11:02 a.m. the Administrator indicated the nursing staff should have assessed and documented on residents with a change of condition a minimum of 3 days. According to a Nursing Documentation Guidelines/Timelines form revised 5/17 the purpose included the following: a. To have systematically and continuously collected information about the health status of the resident. b. To have ensured appropriate documentation as completed in a timely manner. The guidelines included the following: a. Skilled nursing documentation a completed on the Daily Skilled Note by licensed nursing employees each shift. 1. According to a Minimum Data Set (MDS) assessment form dated 4/30/19 Resident #2 had [DIAGNOSES REDACTED]., Depression, Athersclerotic [MEDICAL CONDITION] and [MEDICAL CONDITION]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3, severely impaired cognitive skills for daily decision making. The resident required extensive assistance of staff with most activities of daily living (ADL's). Review of a Care Plan printed 5/21/19 failed to reveal any documentation that addressed the resident's respiratory status and/or the oxygen utilization. Review of the facility's Progress Notes for Resident #2 revealed the following entries as dated: On 5/15/19 at 2:33 p.m. - Resident #2's vitals were assessed two times today. The resident had been lethargic. Denied feeling ill or having pain. The resident said she felt tired. Resident #2' skin was pink, warm and dry, mucous membranes moist. She refused meals and drank sips of water. A urinalysis obtained which resulted in positive reading for leukocytes and had been sent to the clinic for a culture. The resident rested quietly. No signs and symptoms of pain or distress. The Progress Notes lacked documentation the facility had notified the resident's physician related to her lethargy/change in condition. On 5/16/19 at 4:03 a.m. - The resident rested in bed with eyes closed. No coughing noted. The residents lungs clear. Oxygen on at 2 liters a minute with a oxygen saturation level at 92 percent and afibrile. On 5/16/19 at 3:20 p.m. - The resident continued with a decreased appetite and decreased oxygen saturation. Vital signs were within normal limits. She had a pleasant affect. The Progress Notes lacked documentation the residents physician had been notified of her decreased appetite and decreased oxygen saturation level. On 5/17/19 at 3:50 p.m. - Resident rested in bed with eyes closed. No cough noted. Lungs clear. Oxygen on at 2 liters a minute with an oxygen saturation (Spo2) level at 90% and afibrile. On 5/17/19 11:27 p.m. - The resident remained lethargic and slept most of the last shift and now. Encouraged fluids when awake. Oxygen saturation at 92%with oxygen on at 2 liters (L) and respirations easy. On 5/18/19 at 1:54 p.m. - Resident more alert. Resident #2 had oxygen on at 2 L with Spo2 level of 93%. No cough noted, lung sounds diminished, respirations easy. Appetite fair and fluids encouraged. On 5/19/119 at 12:28 a.m. - Resident more alert that evening. The resident had some congested cough, no sputum. Oxygen at 2 L with a Spo2 level of 92%. The Progress Notes lacked documentation the residents physician had been notified of her congested cough. On 5/20/19 at 11:41 a.m. - Resident up for breakfast and ate with verbal cues and assistance. Resident alert, talkative and in good spirits. No lethargy noted, fluids encouraged and drank water well. On 5/25/19 at 2:04 p.m. - The resident had a large amount of yellow sputum. Lungs clear to auscultation. Oxygen saturations checked x 2 that shift. Resident removed O2 occasionally. Instructed the resident to keep the O2 canula in place for better oxygen levels. The Progress Notes lacked documentation the physician was notified of the large amount of yellow sputum. 2. According to a MDS assessment form dated 2/27/19 Resident #3 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 5, severely impaired cognitive skills for daily decision making. The resident required extensive assistance of staff with most ADL's. A Care Plan with a printed date of 5/21/19 failed to address the residents [MEDICAL CONDITION], functional decline and shortness of breath. Review of the facility's Progress Notes for Resident #3 revealed the following entries as dated: On 3/18/19 at 10:31 p.m. - The resident had some dyspnea and audible wheezing noted with ambulation. The residents breath sounds had crackles noted halfway up both lungs posteriorly. Resident #3's ankles had 3 plus (+) [MEDICAL CONDITION] noted bilaterally. A facsmilie including the residents medication list sent to the physician. The note did not include appropriate physician notification for after office hours and did not include notification of the resident's family/representative. On 3/19/19 at 9:12 a.m. - The resident had increased respirations at 32 per minutes. The resident denied shortness of breath. Her Spo2 at 78% on room air and lungs sounded adventicious through out. The resident had been shaky with a temperature of 99.8 degrees. Resident #3 was alert and oriented per usual. Her skin pale warm and dry. She had 2+ [MEDICAL CONDITION] to her bilateral lower extremities. The resident's blood pressure (B/P) 142/81, pulse (P) 133 and slightly irregular. She stated she felt fine. Standing orders for O2 initiated, Tylenol administered and called her daughter to update. The note did not include physician notification of the residents change of condition. On 3/19/19 at 9:48 a.m. - Resident #3's family returned call and requested the resident sent to the hospital. On 3/19/19 at 9:49 a.m. - Phone call made to the resident's physicians nurse and updated on the residents condition, vital signs and family request to be sent to the hospital. The nurse to update the physician and would call the facility back. On 3/19/19 at 9:53 a.m. - A Change in condition , symptom or signs called about included: [MEDICAL CONDITION] (new and/or worsened), fever functionally declined (worsened function an/or mobility), SOB (started on 3/19/19) and [MEDICAL CONDITION] (new or worsened). The residents vital signs were B/P 142/81 (on resident's arm as she sat), P 133, irregular and chronic, R 32, T 99.8 on her temporal artery, O2 saturation 78% on room air (all taken at 9:11 a.m.) and a weight of 124.6 on 3/13/19 (on a standing scale). On 3/19/19 at 10 a.m. - The Physician returned call with order to transport the resident to the emergency room (ER). On 3/19/19 at 10:38 a.m. - The local ambulance service arrived and transported the resident to the ER. On 3/19/19 at 4:52 p.m. - Phone call made to the daughter for an update on Resident #3. The resident had been admitted to the hospital as they thought the resident had aspirated. 3. According to a MDS assessment form dated 2/12/19 Resident #4 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 14, cognitively intact skills for daily decision making. The resident required extensive assistance of staff with ADL's. A Care Plan printed 5/21/19 failed to address the resident's bilateral lower extremity [MEDICAL CONDITION] or weeping skin condition. Review of the facility's Progress Notes for Resident #4 revealed the following entries as dated: On 2/15/19 at 11:12 a.m. - The resident continued with 2+ [MEDICAL CONDITION] to her left lower extremity (LLE) and 1+ [MEDICAL CONDITION] to her right lower extremity (RLE). She wore her TED socks and staff encouraged elevation of BLE with in the recliner. No cough or SOB noted and denied SOB when asked. The facility awaited a return fax from the Physician. The note did not include a thorough nursing assessment which would have included lung sounds and vital signs. On 2/15/19 at 1:58 p.m. - A facsmilie returned from the physician with an order to increase the resident's [MEDICATION NAME] from 20 milligrams (mg's) to 40 mg's 1 by mouth (po) every morning for 5 days followed by a report. On 2/16/19 at 4:03 a.m. - The resident continued on increased [MEDICATION NAME] dose related to [MEDICAL CONDITION] and weeping [MEDICAL CONDITION] with no adverse reactions noted. On 2/16/19 at 2:03 p.m. - The resident had some ankle [MEDICAL CONDITION]. The resident started on [MEDICATION NAME] 40 mg today. No weeping noted today. No adverse effects noted thus far. On 2/16/19 at 3:39 p.m. - Resident #4's lungs clear but slightly diminished. The resident denied SOB. Her oxygen saturation at 92% on room air. The resident had 2+ [MEDICAL CONDITION] to the RLE and 1+ [MEDICAL CONDITION] to the LLE. Her bilateral lower extremities were elevated in a recliner. On 2/17/19 at 12:02 p.m. - No real change in the ankle [MEDICAL CONDITION] yet, no weeping noted. Resident stated she felt well. No adverse effects noted so far. On 2/17/19 at 5:35 p.m. - The resident denied shortness of breath. Her lung sounds clear but slightly diminished. She had 2+ [MEDICAL CONDITION] to the RLE and 1+ [MEDICAL CONDITION] to the LLE. Elevated BLE when in the recliner. On 2/17/19 at 10:51 p.m. - [MEDICATION NAME] DM syrup 10 milliliters (ml) po every 6 hours as needed (PRN) for a cough administered per the resident's request. On 2/18/19 at 12:09 p.m. - Resident continued on the increased dose of [MEDICATION NAME] at 40 mg daily. Denied SOB, lungs sounded clear but diminished at the bases. The resident had 2+ [MEDICAL CONDITION] to the LLE and 1+ [MEDICAL CONDITION] to the RLE. Resident encouraged to elevate legs when able too. The note did not include a through assessment including vital signs and cough status. On 2/19/19 at 10:16 a.m. - The resident had 1+ [MEDICAL CONDITION] to her BLE which had improved. No complaint of SOB, Spo2 at 93% on room air. Lungs clear but slightly diminished. On 2/20/19 at 11:15 a.m. - The Physician conducted rounds and documented the 20th as the last day of the increased dose of [MEDICATION NAME]. From 2/20/19 through 2/25/19 the facility staff failed to have assessed the resident's medical condition. On 2/26/19 at 2:49 p.m. - The resident had increased [MEDICAL CONDITION] to BLE with 2+ [MEDICAL CONDITION] present to BLE. The family and resident reported the increase. The RLE had been weeping a moderate mount of fluid from a small opening near her ankle The resident recently had a increase in [MEDICATION NAME] up to 40 mg x 5 days on 2/16/19 then returned to the original dose of 20 mg QD. Meplix applied to the right outer ankle and the legs elevated in the recliner and with pillows. Called the physician and gave an update on the resident and recent medical history.Also requested an order for [REDACTED]. On 2/26/19 at 4:15 p.m. - Received a return call from the Physician's nurse who requested information faxed to the office. A fax sent related to increased [MEDICAL CONDITION] and weeping from the RLE. On 2/27/19 at 5:25 a.m. - The resident requested [MEDICATION NAME] DM syrup 10 ml for a cough. On 2/27/19 at 12:02 p.m. - The resident continued with [MEDICAL CONDITION]. Meplix remained intact. The resident denied SOB. Encouraged to have her legs elevated when in the room. On 2/27/19 at 10:21 p.m. - No change in [MEDICAL CONDITION]. The resident kept her legs elevated and wore her TED hose. Weeping area covered with [MEDICATION NAME]. No medication changes thus far. On 2/28/19 at 12:26 p.m. - The resident requested [MEDICATION NAME] DM syrup 10 ml for a cough. On 3/1/19 at 4:04 p.m. - No [MEDICAL CONDITION]. [MEDICATION NAME] intact. No complaints of SOB, legs elevated in the recliner. On 3/1/19 at 7:45 a.m. - B/P at 158/81, P 71, R 18, Spo2 at 86% and T of 97.6 degrees. On 3/1/19 at 9:38 a.m. - B/P at 169/91, P 62, R 16, Spo2 at 97% and a T of 98.2 degrees. On 3/1/19 at 2:11 p.m. - Resident #4's vitals assessed with [REDACTED]. Lungs sounds were diminished through out. The resident admitted to a productive cough at times. She said the phlegm had been clear. The resident's skin was pink, warm and dry with 2+ [MEDICAL CONDITION] to the BLE. The resident was encouraged to elevate her BLE more as she had not elevated them high enough. She voiced understanding. Fluids were encouraged. The resident wanted to eat meals in her room and only wanted broth and liquids Denied any nausea or vomiting. On 3/2/109 at 12:26 a.m. - The resident had increased secretions with a productive cough. Resident appeared to have became weaker and asked for medications crushed r/t difficulties swallowing. The resident was able to talk normally with no signs of cyanosis or airway obstruction noted. The staff asked if the resident would like to go to the ER for evaluation, she declined and said she would let the writer know if she felt the need to go and then go to the ER. The resident asked for Sprite and was provided one. Her Spo2 was at 93% on r/a with lungs sounds diminished and slight wheezing noted. Her skin was warm and dry to the touch, T 97.6, R 16 even and non-labored. Will Continue to monitor. The note lacked physician and family notification of the change in condition. On 3/2/19 at 9:38 a.m. - The resident had been sent to the hospital for respiratory infection at 9:38 a.m. with the vital signs documented from 3/1/19. On 3/2/19 at 10:21 a.m. - The resident's color remained pale. Her oxygen saturation on room air was 86% so oxygen was started at 2 L per nasal canula. Resident felt better after that intervention. Respirations were 18 per minute. Lung sounds diminished bilaterally halfway up posteriorly. She had been unable to expectorate much but the sputum appeared greenish-brown. The resident was afebrile but weak and unable to stand or walk with a walker. She asked to have medications crushed that morning because she had been unable to swallow them. Her daughters present and requested transfer to the hospital. The resident consented to the transport. The Physician was notified and orders obtained for transportation to the ER by the local ambulance service. At the time of the note the resident had already been sent to the hospital and no thorough assessment had been completed by the nursing staff. A Certificate of Death form indicated Resident #4 passed away on 3/4/19 at 1:50 p.m. due [MEDICAL CONDITION] as a consequence of Pneumonia. During an interview with the Physician on 5/30/19 at 11:53 a.m. the Physician confirmed she would have expected a thorough nursing assessment with any change in condition which included vital signs, lung sounds, cough and etc. and any sudden changes should have been called to her immediately and that she would have wanted the resident sent to the hospital right away and for the facility staff not to have waited. During an interview 5/30/19 at approximately 1:45 p.m. the Administrator confirmed no further assessments had been documented and she would have expected thorough assessments with [MEDICAL CONDITION] would have included lungs sounds, cough, temperature and etc The facility abated the immediate jeopardy on May 31, 2019 by staff education, implementation of walking rounds every two hours by Nurses and CNA's, the Interdisclipinary Team will review High Risk Alerts daily, audits will be completed and reported to QAPI committee and two Nurses were terminated related to care practicies.

Based on observation, clinical record review, staff, resident, family and Physician interview, the facility failed to ensure staff maintained a safe and secure environment for 1 of 5 residents reviewed, (Resident #5). The facility identified a census of 46 residents. Findings include: According to a Minimum Data Set (MDS) assessment form dated 4/5/19 Resident #5 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status score of 12, moderately impaired cognitive skills for daily decision making. The resident required extensive assistance of staff with transfers, ambulation and locomotion. A Care Plan with focus areas dated 4/22/19 indicated Resident #5 had an activities of daily living (ADL's) self care performance deficit related to (r/t) weakness, impaired visual function r/t [MEDICATION NAME] degeneration and a risk for falls r/t oxygen use, required ADL assistance and weakness. The resident also had a focus area dated 4/2/19 with a potential for an activity deficit r/t weakness, difficulty seeing; a pursuit of independence as evidenced by required staff assistance; continuous oxygen use and legally blind. The approaches included the following: a. The resident required assistance of one staff member, a gait belt and walker with ambulation and transfers. b. A fall on 4/18/19 with no injury and intervention of caution sign placed on her walker. c. A fall 4/23/19 with no injury and intervention resident will be moved to another room closer to the nurse's station. d. A fall 4/25/19 with no injury and intervention scheduled toileting at night around 1 a.m. On 5/2/19 the schedule changed to toileted at 12 a.m. with the resident's consent. e. A fall 4/27/19 with no injury and intervention moved to Center hall room. f. A fall 4/30/19 times (x) two (2) with no injuries and interventions to fax the physician to solicit ideas and following the second fall an e-Care consult (which involved a remote consult with a Physician). g. A fall 5/4/19 with no injury with intervention that included re-education of staff to prompt toileting. h. A fall 5/11/19 with no injury with intervention of a urine dip stick, to check for a urinary tract infection. Review of Fall Tool forms revealed the following fall risks as dated: a. 3/31/19 at 1:23 p.m. - High risk. b. 4/18/19 at 3:10 p.m. - Low risk. c. 4/22/19 at 4:41 p.m. - High risk. d. 4/23/19 at 1 a.m. - Medium risk. e. 4/25/19 at 9:45 p.m. - High risk. f. 4/30/19 at 4 a.m. - Medium risk. g. 4/30/19 at 5 p.m. - Medium risk. h. 5/3/19 at 11 p.m. - Medium risk. i. 5/11/19 at 8:45 p.m. - High risk. j. 5/16/19 at 12:15 p.m. - Medium risk. k. 5/16/19 at 1:01 p.m. - High risk. l. 5/20/19 at 9:45 p.m. - High risk. Review of the facilities Progress Notes for Resident #5 revealed the following entries as dated and timed: On 5/20/19 at 9:45 p.m. - The nurse and certified medication aide (CMA) walked by the resident's room when they heard help me. The CMA checked on the resident and found her on the floor in the door way of the joining bathroom as her feet faced to the East (away from the bathroom). The resident stated she needed to go to the bathroom. The nurse completed a head to toe assessment with no injures noted. The residents range of motion (ROM) within normal limits (WNL), blood pressure (B/P) 105/54, pulse (P) 84, respirations (R) 18 and neuro checks initiated. Two staff assisted the resident off of the floor. On 5/21/19 at 7:33 a.m. - The resident continued on skilled level of care. Vital signs (VS) WNL and bowel sounds active time four quadrants. The resident had fallen last night and had complained of pain r/t the fall. The pain was located on the left hip and left wrist. Some swelling noted on the left wrist in addition to bruising. The nurse notified family, Administrator and Director of Nursing (DON) of the resident's status and transfer. On 5/21/19 at 7:55 a.m. - Staff sent the resident to the hospital via the local ambulance service. On 5/21/19 at 4:33 p.m. - The hospital notified the facility the resident sustained [REDACTED]. An Emergency/Urgent Care form dated 5/21/19 at 3:41 p.m. documented the resident sustained [REDACTED]. During an interview on 5/31/19 at 8:36 p.m. Staff L, CMA indicated she punched out for the night when she heard someone who yelled. She asked Staff D, Licensed Practical Nurse (LPN) who yelled and Staff D stated, Oh it is just Resident #5. Staff F went and checked on the resident who had been positioned on the floor right out of the bathroom door as she sat on her buttocks with her feet aimed into the bathroom. Because she had already punched out of the facility for the night she had been unaware if she could have cared for the resident so she requested assistance. During an interview on 5/29/19 at 4:18 p.m. Staff F, Agency Certified Nursing Assistant (CNA) indicated herself and Staff D, LPN entered the resident's room and found her positioned on her left side in the doorway of her bathroom as if she had ambulated from the bathroom. The resident stated she had to go to the bathroom. Staff D checked the resident's vital signs, performed ROM and checked the resident's body for any deformities. The staff then placed a gait belt around the resident's waist as Staff F and Staff D stood the resident and positioned her in the wheel chair. As the resident sat down she complained of leg pain. The staff members then propelled the resident to the television lounge area and Staff D stayed with the resident as Staff F proceeded back down the hallway to assist other residents. During an interview on 5/31/19 at 8:25 a.m. Staff F indicated Staff L came and informed her the resident had been on the floor because she had already punched out. Staff F confirmed when she entered the room the resident had the oxygen tubing wrapped around her feet and complained of pain to her hand and left leg. The staff member reconfirmed the resident laid on her left side on the floor. When Staff D performed ROM the resident said ouch. The staff members then placed a gait belt and stood the resident up but at first she had been unable to stand so the staff rocked her back and forth, the resident placed her hand on the rail in the bathroom and they stood her and positioned the resident in the wheel chair and propelled her to the television lounge area. During an interview on 5/30/19 at 3:22 p.m., Staff D indicated on 5/20/19 she had been called to the resident's room by Staff F, CNA. When she entered, the resident sat on her buttocks between the bathroom and her room as she faced the bathroom with an unknown CNA present. When she entered the room she also observed the foot rest of the recliner in an up position with her walker beside the chair. The resident had been bare footed and had her oxygen tubing wrapped around both of her legs. Staff D assessed the resident's VS which she described as normal, untangled the resident's legs from the oxygen tubing, performed ROM exercises as the resident sat on the floor. Because the resident sat on the floor Staff D just had her bend her legs a little bit at the knees at which time the resident had not complained of pain. The resident then squeezed the hand of Staff D. The resident complained of left wrist discomfort however the wrist had not been swollen but rather a little red and discolored. The staff placed a gait belt, utilized 2 staff assistance, stood the resident and sat her in the wheel chair. The staff members attempted to position the resident in the wheel chair but she became to restless so the staff members took the resident to the television lounge area to keep an eye on her. At around 10:30 p.m. to 10:45 p.m. the resident became tired so Staff D and Staff F put the resident to bed with the use of a gait belt, however, before the staff transferred the resident she complained of lower back pain. Staff D stated she assessed the area however she failed to have documented her findings. The staff member then indicated she could not have recalled if the resident complained of any other pain at that time as she went onto say, when they lifted the residents legs up onto the bed she thought the resident said ouch and grabbed her stomach but again could not recall the resident having said anything else. After the resident had been positioned in bed, Staff D indicated she checked the resident for bruising and warmth and she stated she had checked the resident's legs as she ran her hands down the legs, which included the hips, to see if the resident complained of pain with palpation. The staff member stated she failed to have assessed the length of the legs or for any abduction and adduction of the bilateral lower extremities. At that point the staff placed the bed in the low position, placed the fall mat beside the bed, gave the resident her call light, covered her up and tucked her into bed. The staff member indicated she returned later around 11:15 p.m. as the resident slept. Staff D indicated either herself and/or the CNA checked on the resident throughout the night but she personally had not ever repositioned the resident. The nurse indicated no staff member on the 2nd or 3rd shift ever asked her if the resident should have been sent to the hospital. The staff member again confirmed the resident complained of wrist and back pain and she failed to call the physician and/or family. When asked why, Staff D stated she had no clue and she had no good answer for that question but hindsight she should have notified both the physician and family. During an interview on 5/30/19 at 5:50 p.m. the Administrator stated Staff D told her she contacted the family of the resident at 6 a.m. and she also told her they transferred the resident to bed at 11:30 p.m. The Administrator stated she had not been told and/or aware the resident's oxygen tubing had been wrapped around her ankles and that observation had not been documented in the resident's medical record. Staff D also documented on the incident report she left a message on the Administrator's and the DON's telephone however she had not. During an interview on 5/29/19 at 2:31 p.m. Staff C, CNA indicated she had been called into the resident's room after the fall and she thought Staff D and Staff E had already been present. When she entered the resident had been in the doorway of the room into the bathroom on her back as Staff E held her head and Staff D assessed the resident. The staff member could not recall if the resident verbally complained of pain however her face had been all scrunched up (as if in pain). Staff C indicated she had not observed Staff D as she performed ROM exercises and/or felt around the resident's body for any abnormalities. The staff members then placed a gait belt and stood the resident up and the resident said ouch. During an interview on 5/29/19 at 4:02 p.m. Staff E confirmed she worked the evening of the resident's fall, however, she had not assisted the resident following the fall. The staff member indicated later that evening/night she observed the resident positioned in a wheel chair in the television lounge area at a time unknown. The resident showed no signs of pain and eventually staff assisted the resident to bed. The staff member indicated she also worked the night shift following the resident's fall and herself and Staff G questioned Staff D if the resident should have been sent to the hospital. During an interview 5/31/19 at 8:02 p.m. Staff G, CNA indicated she received report on 5/20/19 when she arrived for the night shift. She observed the resident positioned in the wheel chair in the television lounge area and was told the resident had fallen on the evening shift. Staff G stated at around 10:20 p.m. the resident wanted to go to bed so she propelled the resident to her room. As she stood the resident, the resident was unable to bare weight on her left leg and complained of pain. The staff member went and retrieved Staff D and they both stood the resident who informed them she could stand because of the pain. Staff G asked Staff D if she wanted an EZ stand lift device and she said yes so they transferred the resident to the bathroom with the EZ stand lift device. The resident stood flat footed without any real complaints of pain. The staff sat the resident on the toilet the resident moved her left foot so it aimed inwards towards her right foot with a facial affect the represented pain as she cringed. When the staff members stood the resident up she stated it hurt it hurt but failed to have said where. The staff members sat the resident on the edge of the bed, lifted her feet and as they held her left leg she complained of pain. Staff D failed to intervene because she had already performed ROM and she had been okay. Staff G said to Staff D but she hurt now when positioned in bed. The second time Staff G told Staff D about the resident's pain, approximately 2 hours later after she observed the resident moaned, rubbed her leg and stated she hurt all over. The third time she informed Staff D about the resident's pain had been around 3:30 a.m. and Staff D just rolled her eyes and walked away. The resident then seemed to settle down and she slept the rest of the night. During an interview on 5/30/19 at 2:03 p.m. Staff I, CNA confirmed she worked 6 a.m. until 2 p.m. on 5/21/19. When she received report that morning she had been told the resident fell the night prior at around 9 p.m. but the rest of the report had been vague. Because the resident appeared content that morning Staff I provided morning cares for other residents. Later when she assisted the resident with morning cares and lifted her left foot a little bit to place the resident's sock she yelled ouch, pointed to her left leg and said it hurt and turned her foot out right away. The staff member described the resident as in pain. The staff member then lifted the resident's right leg with no complaints of pain. The resident then complained of wrist pain but stated it had not been that bad. The wrist had been swollen but the the resident had been able to move the area. Staff I informed Staff H, LPN who assessed the resident and directed her to keep the resident in bed and she sent her to the hospital for an evaluation and treatment. During an interview on 5/29/19 at 3:27 p.m. Staff H confirmed she worked 5/21/19 and was informed in report the resident had fallen the night prior but not that she had been in any pain out of ordinary and that her ROM had been okay. Staff H stated that right away in the morning a CNA informed her the resident complained of pain and they had not wanted to move her. When Staff H entered the resident's room the resident had been in a lot of pain and pointed to her left hip. Staff H indicated she barely got her hand under the resident's foot and she screamed in pain but there had been no bruising or swelling to the site. Staff H also noted swelling and bruising to the resident's left wrist however she moved the wrist without difficulty. Staff H asked the resident how she fell and she said on her left side. The resident denied having reported pain the night before just that everything hurt when a person fell . The nurse asked the resident if she wanted anything for pain and she stated if she had not moved there had been no pain. The nurse then proceeded with getting things going and sent her to the hospital. During an interview on 5/30/19 at 1:43 p.m. Staff H indicated the resident had been positioned in bed with her left wrist swollen to the middle of her hand approximately 4 inches but with no bruising or deformity to the area. The resident moved the wrist and winced but had no verbal complaints of pain. Staff H looked at the resident's hip and noted something had been wrong by the way she favored the area. When Staff H asked the resident to move the hip she had not been able to do so. Staff H thought she gave the resident a glass of water, explained what had been going on and they prepared her for transfer. Staff H called the resident's son and informed him of the complications from the fall the previous night and he said what fall, no one told me and said he planned to arrive at the facility right away. During an interview on 5/30/19 at 12:11 p.m. the resident's son confirmed he had not been informed of the resident's fall until the following morning. When he entered the resident's room following the telephone call he immediately noticed her arm had been broken, her shoulder had been swollen and the nurse on duty told him she had observed her leg as one had been shorter than the other. The family member indicated his mom may not have been alive currently following the fall with injury however she should have been sent out to the hospital for at minimum pain control. During an interview on 5/30/19 at 11:53 a.m. the resident's physician confirmed having moved the resident's leg could have changed the alignment. For example, while she had been positioned on the floor no visible deformity had been present but when the staff positioned her in the wheel chair the leg/hip could have moved the bones further out of alignment and the resident would have complained of pain. The physician agreed herself or the physician on call should have been informed of the fall at the time of the incident or closely thereafter. During an interview on 5/30/19 at 12:28 p.m. the Administrator confirmed she would have expected the staff to have called and reported the fall to the Physician earlier than the following morning.

Based on record review, staff interview and policy review the facility failed to provide adequate nursing supervision to prevent falls with injury for 4 of 4 current residents reviewed (Residents #1, #2, #3 and #4). The facility identified a census of 54 current residents. Findings include: 1. According to the MDS (minimum data set) dated 9/6/17 Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident scored 10 (out of 15) on the cognitive test Brief Interview for Mental Status (BIMS),which identified the resident had moderate cognitive impairments. According to the MDS the resident required extensive assistance with bed mobility, transfers, ambulation, dressing and toilet use. The MDS identified the resident experienced shortness of breath or trouble breathing with exertion, sitting at rest and lying flat. According to the MDS the resident required oxygen therapy during the last 14 days of the assessment period. Review of the Exam Report dated 7/6/17 revealed the resident had X-ray of the pelvis that identified the resident had osteopenia. The care plan dated 9/18/17 directed staff to do the following interventions to prevent falls (all initiated 7/20/17): a. 7/20/17 Educate resident/family about safety reminders and what to do if a fall occurs. b. Educate resident/family as to causes of fall. c. Remind resident not to bend over to pick up dropped items. Encourage use of grabber or to ask for assistance. d. Ensure that resident wearing appropriate footwear, hark sole shoes or gripper socks when ambulation or mobilizing in wheelchair. e. Avoid clothing that is falls risk too loose, slippery and or too long. f. Monitor resident for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function. Review of the Incident report dated 8/26/17 at 1:45 PM revealed the nurse called to the resident's room. The resident sitting on the floor on her bottom, leaning up against the bathroom door. The resident did not have her call light on and the foot part on the recliner still in the up position. The resident stated she had I had to go to the bathroom. Vitals, neuro checks and active range of motion assessed. Skin checked for injuries, none noted at this time. The resident denied pain and urine sample to be collected. Review of the Progress Notes dated 8/26/17 at 2:48 PM revealed the intervention to have staff assist the resident to the bathroom after meals and will encourage the resident to try and use the restroom even if she says she doesn't need to. Review of the Falls Tool dated 9/1/17 revealed the resident had a total score of 12 which indicated medium risk for falls. Review of the Incident report dated 9/1/17 at 8:15 AM revealed the nurse called to the resident's room by her roommate. The resident climbed out of her recliner and fell to the floor near the chair. The resident lying on her right side. Vital signs done and all within normal limits. The resident confused and hallucinating, oriented to herself only. Full range of motion to all extremities. The resident had a large bruise noted on the dorsum (top) side of the right hand and covered the dorsum of the forearm to the elbow and dark purple in color. She had been unable to articulate pain or describe what happened. On 9/2/17 the note added a deep purple bruise on the left great toe and entire top of foot, right great toe, right knee, right hip and right buttock noted. The resident transferred back in the chair using a lift. Review of the Progress Notes dated 9/6/17 at 9:40 AM revealed the proactive committee discussed the resident climbing out of her chair during the day and in the evening. Staff will have her sit in the lounge area instead of her room. The resident had moved rooms and into a bed, which had been beneficial with improvement in [MEDICAL CONDITION]. The resident not a morning person and likes to sleep until 10:00 AM. Staff will let her sleep until she wakes up and if it's after breakfast, can feed her in the kitchenette. Review of the Incident report dated 9/15/17 at 2:55 PM revealed the resident had been sitting in the TV room in the wheelchair on portable O2 (oxygen). The brakes on the wheelchair locked and tray table sitting in front of her with water and paper and pencil and she had been writing a list. The resident stood up with the foot pedals down and 1 hand on the tray table and 1 hand on the wheelchair. She stepped over the wheelchair pedals with her right foot and her left foot got caught on the foot pedals. She leaned on the tray table for support and the tray table slid out from under her and slid across the room causing her to fall to the floor landing on her right hip and shoulder hitting her head. The resident stated she was getting up to go on Holiday. The nurse completed an assessment the neuro checks were initiated and stable. Range of motion without pain, able to roll from right side and sit on her buttocks. No shortening or rotation noted to either leg. Assisted with 3 staff assist and total lift off the floor into the recliner. The resident sat in the recliner with O2 concentrator via nasal cannula. At 9:30 PM staff assisted the resident to transfer from the recliner to the wheelchair to go to the bathroom and she complained of right leg pain. She had difficulty bearing weight with maximum assist of 2. While sitting on the toilet the resident complained of no pain. Again during transfers to bed she had increased pain to the right leg. When lying flat in bed she appeared comfortable with no signs of pain during range of motion or palpitation. No shortening or rotation noted. No bruising or deformities to the right leg. The resident did have bruising to the right elbow with a small abrasion. Review of the Point of Care Audit Report dated 9/15/15 revealed the resident toileted at 12:18 AM, 5:00 AM, 10:24 AM and 9:59 PM. Review of the Progress Notes dated 9/15/17 at 9:46 PM revealed staff administered [MEDICATION NAME] 650 mg by mouth due to leg pain. At 11:58 PM the medication effective, the resident sleeping, no pain with passive range of motion. On 9/16/17 at 3:34 AM [MEDICATION NAME] 650 mg administered due to moaning in bed, when asked if she had pain she denied pain. Able to move bilateral lower extremities. At 4:11 AM the resident assisted with check and change. When nurse entered the room the resident was crying. Assessment and passive movement of the right leg had an increase in crying, moaning and she grabbed at her leg and winced. She had been given pain medication about 30 minutes prior to assessment due to moaning in her sleep. The resident repositioned and continued to be tearful but does not stated she had pain but her verbal signs indicated pain. Physician paged to notify. At 4:39 AM the physician updated on current assessment and pain. New order received to transfer for an evaluation. At 4:51 AM family notified of increase in pain and order to transfer to the emergency room for evaluation. At 5:11 AM The resident leaves that facility accompanied by ambulance staff. Review of the Exam Report dated 9/16/17 revealed the CT of the pelvis without contrast identified a comminuted fracture involving the right inferior pubic ramus. Review of the Medical Record revealed no new interventions placed following the fall of 9/15/17. Review of the MAR (medication administration record) dated 9/1/17 through 9/30/17 revealed staff administered [MEDICATION NAME] 650 mg (milligrams) to the resident on 9/15/17 at 9:46 PM and on 9/16/17 at 3:34 AM as needed for pain. During an interview with Staff A CNA on 2/20/18 at 1:05 PM she stated she saw the resident in the TV room sitting in the wheelchair writing a list. She talked to the Staff B, RN, turned around and saw the resident on the floor. She stated the wheelchair pedals were on and the resident's feet had been on the wheelchair pedals. She tried to stand and the tray table rolled across the room. Staff B assessed the resident and staff transferred her to the chair with the hoyer lift and applied oxygen. During an interview with Staff B, RN (Registered Nurse) on 2/20/18 at 3:20 PM she stated the off going nurse gave the resident a tray table. Staff B had been in the nurses station with Staff A. She saw the tray table go across the room and the resident fell to the floor. The resident tried to step over the wheelchair foot pedals and became tangled in the pedals. She further stated the tray table had the ability to lock at the wheels but the wheels were not locked. During an interview with the Director of Nursing on 2/20/18 at 5:00 PM she stated the facility had found the CNAs were not documenting all of the toileting for the residents. They knew the resident's were being toileted. Part of the intervention had been for staff now tracking toileting on paper as well as the computer. The DON stated education had been completed for all staff. She further stated Staff F, CNA (certified nursing assistant) had initially stated she offered toileting to the resident but she declined. She stated she expected staff to document resident refusals. 2. According to the MDS dated [DATE] Resident #2 had [DIAGNOSES REDACTED]. The MDS identified a BIMs score of 6, which indicated severe cognitive impairments. According to the MDS the resident required supervision with bed mobility, transfers and extensive assistance with dressing, eating and toilet use. The MDS identified the resident had 1 fall with a major injury since the last assessment period. The care plan dated 3/27/16 directed staff the resident independent with a front wheeled walker in the facility. Review of the Falls Tool dated 11/5/17 revealed the resident had a total score of 17 which indicated a high risk for falls. Review of the Incident report dated 11/5/17 at 8:40 PM revealed the resident found lying on the floor mat next to his roommates bed. The resident laid on his back with his hands behind his head, legs out straight. The resident had gripper socks on, the walker next to the mat, room lights not on but did have a night light on. The CNA had the resident in the bathroom and assisted him to get ready for bed 30 minutes prior to being found on the floor. The resident stated he thought this was his bed. The nurse completed an initial assessment and the resident's right wrist was tender however the range of motion revealed no pain. The resident could make a fist with his right hand but complained of pain when his wrist was rotated with the palm side up. The assessment revealed no swelling or discoloration of deformities noted to his right wrist. Staff applied ice and administered scheduled Tylenol at the evening medication pass. No open areas, discoloration, swelling or deformities were noted anywhere else. The resident assisted off the floor with 2 staff assisting as the total lift would not fit over the mat and the resident had been attempting to get up. Review of the Progress Notes dated 11/5/17 at 9:57 PM revealed at 8:40 PM the resident's roommate yelled for help. The resident found lying on the floor mat next to the roommate's bed. He had gripper socks on and walker next to the mat. The room lights not on nut did have a night light on. The CNA had been in the bathroom and assisted him to get ready for bed 30 minutes prior to him found on the floor. The nurse completed an assessment. Review of the Physician visit dated 11/7/17 at 9:45 AM revealed the resident had a closed [MEDICAL CONDITION] end of the right radius, unspecified fracture morphology. Review of the medical record revealed no evaluation of the causal factors to prevent further falls. 3. According to the MDS dated [DATE] Resident #3 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs score of 6 which indicated severe cognitive impairment. According to the MDS the resident required supervision of ambulation, eating, toilet use and hygiene and limited assistance for dressing and bed mobility. The MDS identified the resident had 1 fall with no injury since the last assessment period. The care plan dated 4/1/17 directed staff the resident independent with transfers and ambulation. The care plan directed to encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as exercise is fun and exercise games. On 2/7/18 the care plan updated to direct staff to remind the resident not to bend over to pick up dropped items. Encourage the use of a grabber or to ask for assistance. The care plan also included to ensure the resident wearing appropriate footwear: gripper sock/hard soled slippers/slip resistant shoes when ambulating. Review of the Falls Tool dated 1/5/18 revealed the resident had a score of 12 which indicated a medium risk for falls. Review of the Incident report dated 1/5/17 at 7:00 AM revealed staff heard the resident yell out and went to her room. The resident found sitting on her bottom with legs out in front, facing the doorway to her room. Her shoes and pajamas on and no clutter noted. The resident stated her walker got caught up. The CNA did state the resident's clothes that were set out for the day were laying to the left of her on the floor. Review of the Progress Notes dated 1/5/17 at 2:41 PM revealed staff heard the resident yelled out and went to her room. The resident lay on her left side in the middle of the room. The resident denied pain, range of motion assessed, vital signs and neuros assessed. She denied hitting her head and no injuries noted to her head but did have bruising to the left elbow. No other injuries noted. The CNA did state the resident's clothes that were set out for the day were laying to the left of her on the floor. Intervention included will have staff assist the resident to the bathroom prior to setting out her clothes and toiletries for the day. Review of the Incident report dated 1/27/18 at 7:00 PM revealed the resident getting up from the table at the same time as another resident sitting next to her. Staff witnessed both residents start to lose their balance. The resident fell to the floor landing on her buttocks. The other resident attempted to help her but had to stabilize herself. The resident did not hit her head. The resident assisted by 3 staff and total lift off the floor into the dining room chair. The intervention included encourage staff to adjust the spacing between residents once the 1st of 5 residents get up from the table. Review of the Progress Notes dated 1/27/18 at 11:30 PM revealed the resident had been getting up from the table the same time as another resident sitting next to her. Staff witnessed both residents start to lose their balance. The resident fell to the floor landing on her buttocks. The other resident attempted to help her but had to stabilize herself. Intervention included to encourage staff to adjust spacing between residents once the 1st of 5 residents gets up form the table. Review of the Incident report dated 2/12/18 at 7: 35 PM revealed the resident on the floor lying on her right side. A pillow put under her head. The CNA reported the resident had been walking with her walker. She heard the resident fall and heard her hit her head on the floor. The resident stated her head hurt and unable to tell how the fall happened. Review of the Progress Notes dated 2/12/18 at 7:35 PM revealed the resident lying on the floor on her right side with a pillow under her head. Staff stated the resident had been walking with her walker. She heard the resident fall and heard her hit her head on the floor. Review of the medical record revealed no evaluation of the causal factor/s for the fall on 2/12/18. 4. According to the MDS dated [DATE] Resident #4 had [DIAGNOSES REDACTED]. The MDS identified the resident had short and long term memory problems and modified independence with cognitive skills for daily decision making. According to the MDS the resident required extensive assistance with bed mobility, transfers, ambulation, dressing and toilet use. The MDS identified the resident had 2 or more falls with no injury and 2 or more falls with injury (not major). The care plan dated 11/30/17 directed staff to do the following: a. Educate resident/family amount safety reminders and what to do if a fall occurs. b. Remind resident not to bend over to pick up dropped items. Encourage use of grabber or to ask for assistance. c. Encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. d. Ensure the resident wearing appropriate footwear shoes or gripper socks. e. Modify to maximize safety. Remove clutter, keep door open, bedside table close so resident can easily reach items on the table. f. Use of floor bed with same height mattress next to bed to reduce fall risk. g. alternative soft touch call light. h. Review resident's history of recent or recurrent falls. Review of the Falls Tool dated 1/31/18 revealed the resident had a total score of 15 which indicated a medium risk for falls. Review of the Incident Report dated 10/1/17 at 1:35 PM revealed the resident found on the floor on his back with the wheelchair nearby and brakes off. The resident had been slipping out of the chair earlier and had been pulled up twice before. Intervention included had Physician address medications. intervention included to make sure the mattress pad down by the bed and if there had been a walk through between shifts, someone should have noticed the mattress pad not down. Review of the Incident Report dated 10/8/17 at 1:40 PM revealed the resident's roommate reported the resident fell . The resident found on the floor next to his bed. Review the Incident Report dated 10/25/17 at 6:45 PM revealed the resident found on the floor in his room in front of his bed. The resident appeared to have attempted to self transfer. Intervention included for automatic brakes to be placed on the wheelchair. Revision on 10/27/17 at 2:20 PM Automatic breaks to short the the resident's wheelchair. Will check to see if longer breaks can be ordered. Review of the Incident Report dated 11/6/17 at 7:35 PM revealed the resident found near the fireplace on the floor lying on his back. The cushion and sticky mat on the floor near the resident. The resident stated he had slipped out of the wheelchair. Review of the Incident Report dated 11/8/17 at 9:45 PM revealed the resident on the floor next to the mat, lying on his back with head facing south next to the bathroom. Socks on and the resident incontinent of soft stool. The resident last changed about 45 minutes prior to found on the floor. Staff did place the resident on the commode without adequate results. Review of the Incident Report dated 11/15/17 at 5:28 PM revealed the resident found on the floor next to his bed. The resident stated he tried to get into bed. Intervention included to educate CNA to ask if resident tired while sitting in wheelchair. During an interview with the Director of Nursing on 2/22/17 at 7:30 AM she stated the facility had been working on fall interventions and their placement on the care plan. She stated they have had improvement. Review of the Policy and Procedure titled Fall Prevention and Management dated 10/17 directed staff to do the following: a. On admission or readmission, review the applicable documents and any additional admit information documentation for fall risk factors. b. Complete the falls Tool for fall screening and identifying all risk factors. c. Care plan the appropriate interventions. d. Continue to monitor condition and the effectiveness of the interventions.

Based on clinical record review, facility record review, facility policy and staff interview, the facility failed to ensure one (1) of thirteen (13) residents remained free from abuse (Resident #12). The facility reported a census of 52 residents. Findings included: According to the Minimum Data Set with assessment reference date of 4/14/17, revealed Resident #12 had a Brief Interview of Mental Status (BIMS) score of 3 out of 15, which revealed the resident had severe cognitive impairments for making daily decisions. The resident required supervision with transfers and ambulation and extensive assist with dressing, eating, toilet use, personal hygiene and bathing. Resident #12's Progress Notes dated 5/1/17 included a note at 11:33 p.m Documentation showed the nurse had been notified of an incident with CNA (Staff A) and Resident #12 in the resident's room at 9:30 p.m Staff B reported that Staff A was found lying on bed kissing Resident #12. Both were fully dressed. Upon two nurses entering the resident's room after separation, found Resident #12 in bathroom on toilet, independently toileting. Full body assessment performed at this time with no physical findings or injuries. Resident #12 had been calm and questioned without a change of behavior. The resident denied pain. Staff assisted Resident #12 to lie in bed and vitals obtained. Resident was asked how things were going, responded with what. Repeated to resident is anything going on tonight, the resident responded, no. Staff A was removed from the Manor and any direct resident contact. During interview on 5/2/17 at 2:25 p.m. Staff B stated she had worked the evening shift in the special care unit on 5/1/17 with Staff A. Staff B stated she had left the unit at 8:30 p.m. to take the trash and laundry out and then answered a couple of resident call lights on her way back to the unit. When Staff B left the unit at 8:30 p.m. Staff A had gone to Resident #12's room to assist the resident with cares and help the resident to bed. When Staff B returned to the special care unit about 40 to 45 minutes later she looked for Staff A. Staff B went to Resident #12's room, knocked on the door there was no answer, she saw the privacy curtain pulled and thought she heard kissing sounds. When she looked around the curtain she saw Staff A laid back on the bed with Resident #12 on top of Staff A kissing. Resident #12 was fully clothed with pajama pants slightly pulled down with the top part of incontinent brief showing. Staff A was fully clothed. Staff B stated she thought Resident #12 had pinned the staff member down and asked her if she needed help, Staff A stated, No, I am okay. The Resident got up off Staff A, and Staff B left the room to go down the hall. Staff A called her over and wanted to sit down and visit. Staff B stated Staff A covered her eyes as she told her she wanted love and affection. Staff B stated she then left the unit and told the charge nurse what she had seen and what Staff A had told her. During interview on 5/2/17 at 1:50 p.m. Staff C stated she had worked the evening shift on 5/1/17. Staff C stated Staff B had reported to her what she had witnessed between Staff A and Resident #12 and what Staff A had told her. Staff C went to Staff A and told her to gather her things and go to the conference room. Staff C then went to Resident #12's room and completed an assessment. Review of the facility investigation of incident showed Staff A had been interviewed on 5/1/17 by the Administrator. When Staff A was asked to tell about the events that happened with Resident #12 tonight, Staff A responded she was drawn into it, had not gotten a lot of affection at home. She stated she knew it was wrong and it would not happen again. Staff A stated to the Administrator you will have to do what you have to do. Staff A was asked if she had kissed Resident #12 and she responded yes, and also reported, a few weeks ago Resident #12 kissed her and she gave in to it. The Administrator clarified with Staff A that she had said the resident had tried to kiss her a few weeks ago, and she kissed the resident back, Staff A said yes. When Staff A was asked if anything other than kissing had happened Staff A stated no. Staff A's Corrective Action Notice dated 5/1/17 revealed she was placed on suspension pending an investigation for an allegation of abuse. The Corrective Action noticed dated 5/2/17 revealed at approximately 9:10 p.m., a coworker witnessed Staff A kissing a resident (Resident #12). When witnessed, the resident was on top of her. Following the incident, Staff A admitted to kissing the resident. The notice revealed abuse of any form is not tolerated. On 6/19/14, Staff A signed Our Pledge which stated as a staff she pledged that she will have zero tolerance for abuse or neglect. The facility informed Staff A she was being terminated for Actual abusive treatment and to protect residents from abuse and neglect in any form. The Abuse Policy dated 10/15, identified employees are more apt to commit acts (of abuse) when they believe the quality of their work is not being monitored or that they need not be concerned with the consequences of their actions. The abuse policy defined willful as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy revealed the willful infliction of injury, or intimidation, or physical harm or mental anguish or deprivation by an individual including a caretaker that are necessary to attain or maintain physical mental and psychosocial well-being and these included verbal, sexual abuse or physical abuse and mental abuse. The policy revealed exploitation was defined as taking advantage of a resident for personal gain through the use of manipulation. The policy identified mistreatment meant the inappropriate treatment or exploitation of a resident.