Every finding on record at Good Samaritan - Holstein

Based on observation, resident interview, staff interview and policy review the facility failed to provide food at an appetizing temperature to 2 of 20 residents reviewed (Resident #21 and #51). The facility reported a census of 51 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status (BIMS) of 7 indicating severe cognitive impairment.On 4/6/26 at 3:10 PM Resident #21 stated the food was served cold at least once or twice a week. Resident #21 explained does not like cold food. 2. The MDS dated [DATE] revealed Resident #51 had a BIMS of 15 indicating no cognitive impairment.On 4/7/26 at 9:24 AM Resident #51 stated the food is frequently cool and would like it served warm. Resident #51 explained lunch and dinner were the meals that were served cold because his table was the last served. Continuous observation of lunch meal plates for the memory care unit revealed 1st tray placed in heated transport at 12:00 PM, sample plate placed on separate tray, heated transport taken back to the unit at 12:08 PM and 1st plate taken to the resident from heated transport at 12:10 PM. The temperature of food from the sample tray was: apple glazed pork loin 119 degrees, long grain and wild rice 122 degrees, and broccoli 116 degrees.Temperature obtained by Staff A, AM Shift [NAME] from the mechanical pork, on the steam table after lunch service, for the IDDSI (International Dysphagia Diet Standardization Initiative) 5 and ITSIY 6 diets was 117 degrees.On 4/8/26 at 12:50 PM the Staff B, Certified Dietary Manager (CDM) stated the pork for the IDDSI 5 and 6 should be warmer. The CDM stated the minimum temperature should be 135 degrees on the steam table. The CDM explained the food delivered to the resident on the memory care unit should also be a minimum of 135 degrees. On 4/8/26 at 3:37 PM the Administrator stated she would ask the CDM for the appropriate temperature of food on the steam table or served to residents on the memory care unit but knows the food should have been delivered to the residents above 120 degrees.Review of a policy proved by the facility reviewed 3/23/26 titled, Food Temperature Monitoring documented the proper holding temperature for hot food was greater than 135 degrees. Retake temperatures of the food on the steam table periodically throughout meal service to ensure foods are held above 135 degrees for hot food. Hot food should be served at 135 degrees or higher.

Based on observation, staff interview, and policy review the facility failed to prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal service to prevent cross contamination, to store food in accordance with professional standards by not dating open food items or disposing of expired food items. The facility reported a census of 51 residents.Findings include: An initial kitchen observation on 4/6/26 at 10:30 AM revealed the 2 door refrigerator had a 3.5 container of cottage cheese with an open date of 4/1/26 and a best by date of 3/26/26, a large plastic container of carrots in water dated 3/31/26, an 8 oz. container of parmesan cheese with a best by date of 11/25 open without an open date, a container of parmesan cheese with a best by date of 7/16/25 open without an open date, a container of barbeque sauce outside of a store bought container with an open date of 2/19/26, a container of strawberry syrup with a best by date of 12/25 open without an open date, and a 32 oz. container of chopped garlic open without an open date. The dry storage room had a bag of crotons, a bag of [NAME] noodles, a bag of egg noodles, 2 bags of spaghetti noodles open without a date of when the item was opened. One bag of spaghetti noodles was completely open to the air without a seal of cover. The 4 door freezer had these bags of food items open without an open date: a bag of French Fries, a bag of tater tots, onion rings and potato wedges. A four slot toaster on the counter top had brown and white debris covering the top with the crumb drawer on the left full and crumb drawer on the right half full of similar brown and white debris. On 4/6/26 at 12:28 PM Staff B, Certified Dietary Manager (CDM) stated the facility's expectation was that all food items that were open would have the date the food item was opened. The CDM stated she would expect the noodles to be closed and not open to air with a clip or a twist tie. The CDM stated she expected the toaster would not have all the debris on the top and the drawer would be empty. The CDM stated any food items with a best by date before today's date should have been thrown away and not used. An observation on 4/8/26 at 11:15 AM of Staff A, AM Shift [NAME] during lunch service revealed a piece of broccoli fell on the steam table where plates were being plated and hands were placed in-between serving the plates. Staff A picked the piece of broccoli up off the steam table with a fork and placed it back on the plate and served the plate.An observation on 4/8/26 at 12:15 PM of Staff A during the lunch service revealed Staff A obtained a hamburger bun from the bag with a paper towel in her ungloved hand, place the bun on the plate with the side the paper towel that was in her hand down on the plate, pulled the paper towel from under the bun, utilized tongs to place a hamburger on the bun, plate taken over to left side of the toaster to apply lettuce, top of bun fell onto the counter top where used utensils and other food debris was present, picked top bun up with ungloved hand, placed bun on the hamburger with lettuce and served to the resident. No hand hygiene was observed.An observation on 4/8/26 at 12:26 PM of Staff A during the lunch service revealed Staff A placed food on a residents plate with utensils in the steam table, handed the plate to staff to be served to the resident, walked from the steam table to 2 door freezer, opened the 2 door freezer with left hand, obtained a handful of French fries with right hand, placed the fries in the fryer and returned to the steam table to serve lunch. This same process was repeated 2 times with French fries and 1 time with tater tots. No hand hygiene was observed.On 4/8/26 at 12:50 PM Staff B, Certified Dietary Manager (CDM) stated hand hygiene should have been completed when the cook obtained any items from the freezer. The CDM stated she thought the deep fryer would kill all possible bacteria from cross contamination . The CDM stated tongs could have been utilized to obtain the frozen fries or tater tots. The CDM explained she would have liked to see the cook use tongs to obtain the hamburger bun as well, not a paper towel. The CDM stated the cook should not have picked the broccoli up off the steam table and placed it back on the resident plate. On 4/8/26 at 3:37 PM the Administrator stated tongs should have been used for the hamburger bun, french fries, and tater tots. The Administrator stated the cook should not have picked the broccoli up off the steam table and placed it back on the residents plate. The Administrator stated the open bags of food items should have dates when the food item was opened. The Administrator stated the food items with best by dates before today's date should have been thrown away. Review of a policy provided by the facility reviewed on 6/6/25 titled, Hand Washing and Glove Use-Food Nutrition Services documented employees do not touch any food with bare hands- ready -to-eat or otherwise. Employees must wash hands before handling food, when switching tasks, and after performing any activity that could contaminate hands.

Based on observation, Electronic Health Records (EHR) review, policy review and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube, that was on Enhanced Barrier Precautions (EBP) for 1 of 1 reviewed (Resident #9) and with missed opportunities for hand hygiene when personal cares were completed for 1 of 3 reviewed (Resident #21). The facility reported a census of 51 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS documented Resident #9 had a feeding tube in place.Review of Resident #9's EHR titled, Order Summary Report documented a physician's order to flush PEG tube with 200cc of tap water daily to maintain patency. Review of Resident #9's EHR titled, Care Plan documented Resident #9 required EBP related to peg tube placement with an initiation date of 3/12/26. The intervention for EBP on Resident #9's Care Plan documented to don a gown and gloves when performing high contact care activities including dressing, transferring, providing hygiene, repositioning, checking and changing. Observation on 4/8/26 at 9:30 AM of EBP sign outside of Resident #9's room that required the use of gown and gloves during high contact resident care activities such as dressing, transferring, providing hygiene, changing briefs, assisting with toileting and device care for feeding tubes.An observation on 4/8/26 at 9:38 AM of Staff C, Certified Nurse Assistant (CNA) and Staff D, CNA completed a transfer to the toilet and personal cares on Resident #9. Observation revealed Resident #9 was in bed lying down, Staff C and Staff D applied gloves, neither staff applied a gown, removed Resident #9's pants, removed Resident #9's brief, lift cloth applied, mechanical full body lift driven by Staff D, and Staff C guided Resident #9 to the commode, Staff D removed gloves, Staff C removed gloves, hand hygiene completed by both staff, gloves applied by both staff, Staff D applied socks, removed gloves, completed hand hygiene, returned to the lift, Staff D did not apply any gloves, Resident #9 sat on the commode until ready to transfer back to bed to get dressed. To the resident, both Staff C and Staff D applied lift cloth to full body mechanical lift, Staff C with gloves gave Staff D with no gloves the lift remote, Staff C assisted resident with lift cloth and assisting with directions, Staff D directed the full body lift, Staff C completed hand hygiene, applied gloves, Staff C pulled lift straps down between legs, Staff C obtained peri wash and peri wipes, Staff C utilized one wipe one swipe with care, Staff C removed gloves, Staff D applied brief, Staff C with no gloves fastened right side of the brief, Staff D fastened the left side of brief. Staff D removed gloves completed hand hygiene, both staff assisted Resident #9 with pulling pants up with no gloves on. Both Staff C and Staff D assisted in placing lift cloth into position. Staff C completed hand hygiene, Staff C applied gloves, Staff D without gloves applied the lift cloth to the lift, Staff D ran lift remote with no gloves. Staff C moved the wheelchair into position, Staff C assisted Resident #9 with positioning in the sling, Staff D ran the lift remote, moved the lift into place, Staff C assisted Resident# 9 into the wheelchair, both staff placed foot rests in place. Staff C removed gloves, Staff C applied gloves, completed the cleansing process with sanitizing wipes on the full body mechanical lift. Staff D completed hand hygiene and wheeled resident down to the therapy room.On 4/8/26 at 3:26 PM the Director of Nursing (DON) stated there could have been more hand hygiene and more applications of gloves during Resident #9's cares. The DON stated Resident #9 had a PEG tube in place. The DON explained Resident #9 required EBP when personal care was completed. The DON stated the staff should have worn gowns when completing cares on Resident #9. 2. The Minimum Data Set (MDS) dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. The MDS documented Resident #21 required partial / moderate assistance with toilet hygiene. An observation on 4/7/26 at 3:36 PM of personal care provided to Resident #21 by Staff E, Certified Nurse Assistant (CNA) and Staff F, CNA. Resident #21 ambulated to the bathroom on her own with the use of a walker, hand hygiene completed by both Staff E and Staff F, gloves applied by both CNA's, wet wipes placed on the sink spread out by Staff E. Staff E removed the first yellow colored brief, the second pull up style brief remained, Staff E continued to wear the same gloves, provided personal care from the peri cloths resting on the bowl of the sink. Staff E pulled the yellow brief through the legs to the front, Staff E removed gloves, Staff E assisted in pulling up sweat pants, Staff E completed hand hygiene, Staff F removed gloves and completed hand hygiene. On 4/8/26 at 2:52 PM the Director of Nursing (DON) stated she would have expected hand hygiene with any change of gloves and after removal of Resident #21's brief. The DON stated after the personal care she would expect hand hygiene, with new gloves and when Resident #9's pants were pulled up. The DON stated they do not use 2 briefs on residents but it has been Resident #9's preference lately. Review of a policy provided by the facility reviewed 11/13/25 titled, Hand Hygiene documented the purpose of the policy was to guide compliance for hand hygiene with the Centers for Disease Control and Prevention (CDC) and the World Health Organization's Moments of Hand Hygiene recommendations. All employees in patient care areas will adhere to the 4 moments of hand hygiene and 2 zones of hand hygiene: Entering room, before clean task, after bodily fluid/glove removal, exiting room, and zones are patient zone and health-care zones. Staff will complete hand sanitization when entering the patient room, after removing gloves regardless of task completed, after contact with secretions, when moving from contaminated body site to a clean body site during patient care, when entering supply drawers and when exiting patient room.Review of a policy provided by the facility reviewed 7/7/25 titled, Standard Enhanced Barrier, and Transmission-based Precautions documented Enhanced Barrier Precautions (EBP) expand the use of personal protective equipment beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDRO) to staff hands and clothing. EBP are also used for residents with chronic wounds and residents with indwelling medical devices such as feeding tubes. The procedure indicated to post clear signage indicating the type of precautions and required PPE gown and gloves during high-contact resident activities required the use of gown and gloves.

Based on observations, document review, Electronic Health Record (EHR) review, family interviews, staff interviews and policy review.The facility failed to protect a resident from the use of a physical restraint that the resident could not consistently remove on their own for 1 of 2 residents reviewed (Resident # 9). The facility reported a census of 51 residents.Findings Include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #9 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment . The MDS reported Resident #9 utilized a trunk restraint in the wheelchair. The MDS also documented Resident #9 had diagnoses of anxiety disorder, bipolar disorder, impulse disorder and unspecified intellectual disability. Review of a document provided by the facility on 4/6/26 titled, CMS 802 (Resident Matrix) documented use of a restraint for Resident #9. Review of Resident #9's EHR titled, Care Plan documented the resident utilized a seatbelt for physical restraints related to fall risk with an initiation date of 3/12/26. Resident #9 will remain free of complications related to restraint use, including contractures, skin breakdown, altered mental status, isolation or withdrawal. Provide restraint free time during activities when possible to supervise closely and apply the seat belt when up in the wheelchair. Review of Resident #9 EHR titled, Progress Notes, Assessments, Care Plan, Tasks, MAR/TAR (Medication Administration Record and Treatment Administration Record) reported no documentation of monitoring for any complications related to the restraint, no documentation of restraint free time, the length of time the restraint is anticipated to be used, who may apply the restraint, how to apply the restraint, the time and frequency the restraint should be released, specific direct monitoring and supervision provided during the use of the restraint, on going re evaluation for the need for the restraint and interventions to prevent and address any risks related to the use of the restraint. Review of Resident #9's Physician Order dated 3/12/26 at 3:56 PM documented to fasten seat belt when up in wheelchair.Observations completed on 4/6/26 at 11:25 AM, 1:15 PM, 2:20 PM, revealed Resident #9 sitting in the common area in a wheelchair with the seatbelt present and fastened across the lap and sitting in front of the TV.Observations completed on 4/7/26 at 9:00 AM and 10:15 AM, revealed Resident #9 sitting in the common area in a wheelchair with the seatbelt present and fastened in front of the TV. Observations completed on 4/8/26 at 9:09 AM, 9:30 AM and 10:15 AM, revealed Resident #9 sitting in the common area in a wheelchair with the seatbelt present and fastened in front of the TV playing with her socks.On 4/8/26 at 9:37 AM Staff C, Certified Nurse Assistant (CNA) stated during care that Resident #9 will attempt to get out of the chair and that is why the resident has to have a seatbelt. On 4/8/26 at 10:14 AM Staff D, CNA stated she worked with Resident #9 frequently. Staff D acknowledged Resident #9 does not mess with her seat buckle and could not buckle or unbuckle the seat belt. Staff D stated the seat belt was in the wheelchair one day, so she just applied it. Staff D said she had not provided restraint free time when working with Resident #9 besides bathing or when repositioned to the bed. Staff D, denies knowing of any documentation that is the CNA's responsibility in regards to the seatbelt nor of any documentation that she is aware of that tells her that resident is to be wearing the seatbelt. Staff D, explained she just knows the resident is supposed to wear the seatbelt when up in her wheelchair.On 4/8/26 at 10:34 AM Staff G, Registered Nurse (RN) stated she did not know if the wheelchair was provided by the facility. Staff G said she had not seen Resident #9 manipulate the seat belt, buckle or unbuckle the seat belt. Staff G explained Resident #9 always has the seat belt on when in the wheelchair. Staff G explained it could be hard to get Resident #9 to reposition to the bed because she attempts to climb out of the bed. An observation on 4/9/26 at 12:13 PM revealed The DON (Director Of Nursing) asking resident #9 to remove the seatbelt that was over her lap in the wheelchair. Resident #9 was unable to follow commands to remove the seat belt and she repeatedly stated I can't I can't. On 4/9/26 at 12:30 PM Resident #9's Mother stated she did not recall being notified about consent for the seat belt. She explained that she first witnessed the seat belt in place when she visited the facility a few days after Resident #9 was admitted . Mother acknowledged that she thought Resident #9 would benefit from using the seat belt if the facility thought it was needed because Resident #9 could fall out of the wheelchair when being energetic. Mother stated that she has not witnessed Resident #9 removing the seat belt on her own. Review of Resident #9's document dated 3/12/26, titled, Restraint Consent documented a telephone consent from Resident #9's daughter on 3/12/26. Document also signed by DON and Assistant Director of Nursing (ADON). On 4/9/26 at 12:13 PM DON stated Resident #9 is inconsistent with being able to remove the seatbelt herself. On 4/9/26 at 1:32 PM the DON stated Resident #9's ability to unbuckle her seat belt is inconsistent. The DON explained Resident #9 would tell the staff that the belt is unbuckled and then buckle the seat belt herself. The DON stated on the first day Resident #9 was a concern for falling out of the chair and that was the reason for the use of the restraint. The DON and ADON said that they had contacted Resident #9's Mother over the phone for consent to use restraint with explanation of the pros and cons for use. The DON stated the mother was at the facility the day Resident #9 entered the facility and then returned about a week later since then she has been at the facility about twice a week. The DON stated the care plan should have length of time and when the seat belt was released. The DON explained when Resident #9 first came to the facility she would lunge forward in the wheelchair. DON stated that she would expect more documentation to be in place related to use of a restraint then what the facility currently had. The DON acknowledged that she had added tasks on 4/9/26 and added more detail to the care plan for example when to remove the restraints. The DON stated there were not any less restrictive measures put into place prior to using the seatbelt. DON and ADON denied doing an assessment for restraints prior to using the seatbelt or having an assessment since the seat belt had been in place. Review of Policy provided by the facility with review date of 3/30/26 titled, Physical Restraints/Psychotropic Medications Alternatives documented to provide non-pharmacological alternatives to the use of a physical restraint or psychotropic medications.

Based on observation, Electronic Health Records (EHR) review, resident interview, resident family interview, staff interviews and policy review the facility failed to provide dignity and respect to a resident when 2 briefs were applied for incontinency to 1 of 3 residents reviewed (Resident #21 ). The facility reported a census of 51 residents.Findings Include:1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status (BIMS) of 12 indicating moderate cognitive impairment. The MDS documented Resident #21 required partial / moderate assistance with toilet hygiene. Review of Resident #21's EHR titled, Care Plan documented no interventions for utilization of 2 briefs for Resident #21.Review of Resident #21's EHR titled, Progress Note documented no discussions with Resident #21 or Resident #21's Daughter about the use of 2 briefs. Progress Notes documented no indications of trial or previous alternative interventions.On 4/6/26 at 3:17 PM Resident #21 explained the staff put 2 briefs on her because she is incontinent. Resident #21 stated she can tell when she has to urinate. Resident #21 stated she does not like wearing 2 briefs because it is uncomfortable and felt like the staff just did not want to clean up once she had voided. Resident #21 stated sometimes she voids and can not get to the bathroom on time and it will go through onto the chair and onto the floor. Resident #21 stated she did not think the staff were treating her with respect by applying 2 briefs. An observation on 4/7/26 at 3:36 PM of personal care provided to Resident #21 by Staff E, Certified Nurse Assistant (CNA) and Staff F, CNA revealed Resident #21 ambulated to the bathroom on her own with the use of a walker, hand hygiene completed by both Staff E and Staff F, gloves applied by both CNA's, Staff E removed the first yellow colored brief, the second pull up style brief remained, Staff E provided personal care from the peri cloths resting on the bowl of the sink, Staff E pulled the yellow brief through the legs to the front, Staff E removed gloves, Staff E assisted in pulling up sweat pants, Staff E completed hand hygiene, Staff F removed gloves and completed hand hygiene. On 4/7/26 at 3:45 PM Staff F, CNA stated Resident #21 took herself to the bathroom and she turns on her call light if she needs a new brief. Staff F stated she will turn the call light on and go to the bathroom. Staff F explained if they are not quick enough to respond to the call light Resident #21 will go back to her chair and wait to have her pants pulled up. Staff F stated the staff recently started double briefing her because she voids very heavily and started double briefing her because it will get on her dressings. Staff F explained that she knew that Resident #21 required a double brief because there was a note hanging on the wall in the CNA room.On 4/7/26 at 3:50 PM an observation in the CNA room revealed a note on the wall that had written Resident #21 was to have 2 briefs and pad (brief first then pull-up).On 4/8/26 at 2:52 PM the Director of Nursing (DON) stated they do not use 2 briefs on any resident besides Resident #21. The DON explained the 2 briefs was Resident #21's preference lately. The DON stated Resident #21 would be incontinent at meals, there would be a large puddle and it would embarrass her. The DON stated she was made aware of the preference yesterday by the CNA after the surveyor observation. On 4/8/26 at 3:07 PM the Assistant Director of Nursing (ADON) stated the first day Resident #21 wanted to try the double brief she spoke with Resident #21's Daughter about it. The ADON explained she had spoken with the staff and put on the communication board that they were trialing the double brief. The ADON stated they had not put the double brief intervention on the care plan yet. The ADON explained Resident #21 stated she was fine with using 2 briefs. The ADON said she had talked to Resident #21 a couple of times and she thought that 2 briefs continued to be a good idea. The ADON acknowledged she had not made any documentation in Resident #21's EHR about the use of 2 briefs for Resident #21 or discussion with Resident #21 or Resident #21's Daughter. On 4/9/26 at 9:26 AM Resident #21's Daughter/POA stated the facility called her yesterday on 4/8/26 and told her they started to use 2 briefs for her mother's incontinence. Resident #21's Daughter explained yesterday was the first call she had received. Resident #21's Daughter stated the facility explained they had been working with the incontinent situation and that was the best option. Resident #21's Daughter stated she seen Resident #21 4/4/26 and Resident #21 did not have the 2nd brief at that time. On 4/9/26 at 11:58 AM Resident #21 stated she does not want to wear 2 briefs. Resident #21 stated it irritates her because she knows they do not want to care for her urinary needs appropriately. Resident #21 explained she would like somebody to pay a little bit of attention and the facility would like her to handle it herself. Resident #21 stated she did not feel the facility was providing her with dignity or respect by using 2 briefs. Resident #21 stated nobody at the facility had spoke to her about if she wanted to use 2 briefs or if she was okay with trialing 2 briefs.On 4/9/26 at 2:09 PM the ADON stated the facility had tried other alternatives for Resident #21 such as just pull ups and just the velcro brief style and she acknowledged they were not on the care plan or documented in the progress notes as they were just trials. The ADON stated it was placed on the CNA board and only talked to them during huddles. The ADON stated she should have entered the information of trials in Resident #21's EHR. The ADON explained the facility typically would call the first day of the trial to get the okay. The ADON explained that it was not applied to the care plan because they were trialing the 2 briefs but was now on the care plan. The ADON explained that there was a late entry that she had entered today that reflected the conversation with Resident #21 and Resident #21's family.Review of a policy provided by the facility with review date of 12/1/25 titled, Care Plan documented the care plan will be modified to reflect the care currently required/provided for the resident. The Resident/family or legal representative will have the opportunity to participate in the planning of his or her care to the extent practicable.

Based on clinical record review, staff interview and facility policy the facility failed to update the resident ' s care plan to accurately reflect the resident for 3 of 3 residents reviewed (Resident #1, #2, and #4) The facility reported a census of 49 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnosis of heart failure, renal insufficiency, diabetes mellitus, and hypertension. The MDS showed a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. The MDS also indicated Resident #1 was in hospice care. Review of the clinical census indicated that Resident #1 was admitted into Hospice care on 3/8/25. Review of the Care Plan for Resident #1 with a date initiated as of 7/23/24 revealed the facility failed to update the care plan to reflect Resident #1 was admitted to hospice care. 2. The MDS assessment dated [DATE] for Resident #2 documented diagnosis of heart failure, renal insufficiency, peripheral vascular disease, and toxic liver disease with acute hepatitis. The MDS showed a BIMS score of 15 indicating intact cognition. Review of the Progress Notes for Resident #2 showed documentation of a fall for the following date 4/4/25 at 10:50 a.m. Review of the Progress Notes on 4/6/25 at 3:31 p.m. showed the intervention documented for this fall where Resident #2 stated it is easier to step off of the side of the lift platform/transition piece. Review of the Care Plan for Resident #2 with a date initiated 2/11/25 revealed the facility failed to place intervention of Resident #2 stated it is easier to step off of the side of the lift platform/transition piece on the care plan. 3. The MDS assessment dated [DATE] for Resident #4 documented diagnosis of Non-Alzheimer 's dementia, diabetes mellitus, anxiety, and obesity. The MDS showed a BIMS score of 12 indicating moderate cognitive impairment. The MDS also indicated Resident #4 had a weight loss of 5% or more in the last month. Review of the medical diagnosis indicated Resident #4 had type 2 diabetes mellitus. Review of the Physician Orders indicated that Resident #4 to have daily blood sugars completed every a.m. and as needed for signs and symptoms of hypoglycemia. The Physician Orders also indicate Resident #4 was prescribed diabetic medications that had side effects of weight loss. Review of the Care Plan with a date of initiated 8/9/24 revealed the facility failed to update the care plan to accurately reflect Resident #4's weight loss, diabetic medications and blood sugars. Review of the facility policy named Care Plan-R/S, LTC, Therapy and Rehab dated 12/2/24 revealed the purpose is 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. Residents will receive and be provided with 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 measurable goals and timetables directed toward achieving and maintaining the resident ' s optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Resident Assessment Instrument (RAI) and review of the physician's orders. This plan of care will be modified to reflect the care currently required/provided for the resident. The interdisciplinary team will review care plans at least quarterly. Care plans also will be reviewed, evaluated and updated when there is a significant change in the resident ' s condition. An interview on 5/29/25 at 3:30 p.m. with the Director of Nursing and the Assisted Director of Nursing stated the admission nurse does the baseline care plan and the expectation is if the intervention or care have changed it should be placed on the care plan at that time.

Based on direct observation, clinical record review, and staff interview, the facility failed to provide adequate oral cares for 2 of 2 residents reviewed (Resident #22, #24). The facility reported a census of 49. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #22, dated 12/9/2024, documented the resident's Brief Interview for Mental Status (BIMS) score as 00, indicating the resident was rarely/never understood. It documented the resident required substantial/maximal assistance to perform oral hygiene. The Care Plan for Resident #22, last revised 12/15/2024, documented the resident had his own teeth. It instructed staff to assist the resident with oral cares every AM and PM shift. Review of the Plan of Care Response History, printed 3/20/2025 at 10:08 AM, contained no documentation of oral cares performed in the last 30 days, the maximum look back period of the plan of care response history. 2. The MDS for Resident #24, dated 1/29/2025, documented the residents BIMS score as 03, indicating severely impaired cognition. It documented Resident #24 was fully dependent on staff to perform oral cares. The Care Plan for Resident #24, last revised on 7/22/2024, directed staff to provide oral cares twice daily or after each meal as recommended by the dental hygienist. In a direct observation on 3/18/2025 at 8:18 AM revealed Resident #24 to be missing several teeth, and the teeth that were visible were stained and appeared to have a layer of film on them. Review of the Plan of Care Response History, printed on 3/20/2025 at 9:39 AM, documented only three instances of oral hygiene performed within the 30-day lookback period. In the evening of 3/18/2025, the morning of 3/19/2025, and the evening of 3/19/2024. In an interview on 3/20/2025 at 11:07 AM with Staff I, Certified Medication Aide (CMA), she stated the only place they document oral cares is in the Electronic Health Record (EHR). She stated she documents cares like oral cares twice daily unless it indicates otherwise. In an interview on 3/20/2025 at 11:18 AM with Staff F, Certified Nurse Aide (CNA), she confirmed that oral cares are documented in the EHR, and that oral care documentation is typically required once per shift. She stated that if there was no documentation of oral cares, she would assume it was not done. In an interview on 3/20/2025 at 11:21 AM with Staff G, Registered Nurse (RN), she confirmed it is the CNAs responsibility to document oral cares as indicated in the EHR. She further stated that if it wasn't documented it wasn't done. In an interview on 3/20/2025 at 11:32 AM with Staff H, RN, she confirmed oral cares for Resident's #22 and #24 should be documented twice daily as indicated by their plan of care. In an interview on 3/18/2025 at 5:57 PM with the Director of Nursing (DON), she acknowledged there was no documentation of oral cares for Resident #24 or #22. She stated there had been a mistake made when entering the care tasks for the residents and they were entered to be documented as needed, instead of a scheduled task to be done daily.

Based on direct observation, staff observation, and facility document review, the facility failed to serve food to residents in a safe and hygienic manner. The facility reported a census of 49. Findings include: A direct observation on 3/17/2025 at 12:21 PM revealed Staff J, Registered Nurse (RN), assisting two residents simultaneously with eating assistance. There was no witnessed hand hygiene as she transferred from resident to resident. A continued observation on 3/17/2025 at 12:22 PM revealed Staff J appearing to touch their face before continuing to assist both residents with eating, no hand hygiene was performed. A direct observation on 3/18/2025 at 12:31 PM revealed Staff J, RN, offer eating assistance to two residents again. No hand hygiene was observed as she switched from resident to resident. A direct observation on 3/18/2025 at 12:39 PM revealed Staff K, Certified Nurse Aide (CNA), assisting a resident to take a bite of a cake. While assisting the resident to take a bite of the cake she appeared to make direct contact with the tines of the fork, and then assisted the resident in taking another bite of cake. In an interview on 3/20/2025 at 11:07 AM with Staff I, Certified Medication Aide (CMA), she stated the facility instructs them to not assist two residents with eating at the same time. If they do, they must sanitize or wash their hands in between each bite the residents take. In an interview on 3/20/2025 at 11:18 AM with Staff F, Certified Nurse Aide (CNA), she stated they are not supposed to feed two residents at the same time. She stated that they are not allowed to touch the tines of forks, and would need to replace it if she did. In an interview on 3/20/2025 at 11:21 AM with Staff G, Registered Nurse (RN), she stated the facility directs them not to feed two residents at the same time, but if she were to do so she would be required to wash or use hand sanitizer between helping each individual resident. She also stated if she made direct contact with the eating surface of a utensil she should replace it. In an interview on 3/18/2025 at 4:09 PM with the Director of Nursing (DON), she stated her expectation is for staff members to feed only one resident at a time or to cleanse their hands every time they switch between residents. She further stated that if direct contact were made with the eating surface of a utensil, such as the tines of a fork, a new fork would be required to be provided. Review of a facility provided document titled Infection Prevention and Control Program, last revised 12/02/2024, states the facility uses standard precautions for all residents, regardless of suspected or confirmed diagnoses, and that those standard precautions include proper hand hygiene.

Based on clinical record review, staff interview and facility policy review, the facility failed to complete a gradual dose reduction (GDR) for 1 out of 5 residents reviewed for unnecessary medications, (Resident #21). The facility also failed to include nonpharmacological interventions and targeted behaviors for which staff were to monitor and/or redirect for 1 out 5 residents (Resident #31). The facility reported a census of 49 residents. Findings include: 1. Resident #21's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 01, indicating severe cognitive impairment. The MDS identified Resident #21 was independent transfers and ambulation. Resident #21's MDS included diagnoses of Alzheimer's, non-alzheimer's dementia, seizure disorder, and psychotic disorder. The MDS documented Resident #21 was taking an antipsychotic medication during the 7 day look back period. The Care Plan with a target date 9/17/24 documented Resident #21 received Seroquel medication with FDA (Food and Drug Administration) boxed warnings (most serious safety warning issued for a prescription drug). The Care Plan directed staff to consult with pharmacy and healthcare providers to consider dosage reduction when clinically appropriate. A Physician Order dated 4/20/23 directed staff to administer Seroquel (antipsychotic medication) 50 MG (milligrams) two times a day related to adjustment disorder with mixed anxiety and depressed mood. Review of the clinical record lacked documentation that a gradual dose reduction (GDR) had been attempted for the Seroquel in the last year. The clinical record lacked documentation of a clinical rationale from a Physician on why the antipsychotic medication was continued without a GDR. On 3/19/25 at 6:45 PM, the DON (Director of Nursing) verified the facility had not done a GDR on the Seroquel since July 2023. On 3/20/25 at 7:53 AM, the DON reported the expectation of the facility was that upon initiating a psychotropic medication, a gradual dose reduction should be attempted within the first year in two separate quarters, at least one month separating the attempts. The DON reported that upon attempting a GDR, and the resident experiences increased symptoms, or the physician does not feel a GDR would be beneficial or would be contraindicated due to symptoms, that the Physician and the facility had documentation to support this including targeted behaviors being exhibited. A facility policy titled Psychotropic Medications date reviewed/revised 12/30/24 documented that the residents would be free of any chemical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. The policy directed gradual dose reductions must be done according to federal regulations. The policy documented the purpose of tapering medication was to find an optimal dose or to determine if continued use of the medication was benefiting the resident. Tapering may be indicated when the resident s clinical condition has improved or stabilized, the underlying causes of the original target symptoms have resolved and/or nonpharmacological intervention have been effective in reducing the symptoms. The policy indicated within the first year an antipsychotic medication was started, the facility must attempt a GDR in two separate quarters with at least one month between attempts, unless clinical contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated. The policy documented clinically contraindicated meant the following: a. The resident's target symptoms returned or worsened after the most recent attempt at a GDR. b. The Physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. 47079 2. The MDS dated [DATE] revealed a BIMS of 02 out of 15 which indicated severely impaired cognition. It included diagnoses of Chronic Kidney Disease (CKD), Diabetes Mellitus (DM), Non-Alzheimer's Dementia, unspecified dementia with agitation, and depression. It also revealed the resident sometimes felt lonely or isolated from those around him and received antipsychotic (AP) and antidepressant (AD) medications during the last 7 days. On 3/17/25 at 1:35 PM, Resident #31's spouse stated the resident took medication for behavior concerns. The Electronic Health Record (EHR) included a Physician's Order for an antidepressant medication dated 6/04/24, escitalopram oxalate 10 mg by mouth one time a day for depression. It did not identify the resident's target behaviors that required an antidepressant. The Progress Notes did not identify target behaviors for depression. The Mood Task did not include documented observations of any of the following listed components nor identify them as depression-related target behaviors. a) Trouble falling or staying asleep, or sleeping too much b) Feels bad about self or is failure; let self/family down c) Moving or speaking so slowly that other people notice d) Fidgety or restless; moving around more than usual e) States life is not worth living or wishes for death f) Attempts to harm self g) Being short tempered, easily annoyed h) Little interest or pleasure in doing things i) Feeling or appearing down, depressed or hopeless j) Feeling tired or having little energy k) Poor appetite or overeating l) Trouble concentrating (e.g. reading newspaper, watching tv) The Care Plan revised 2/12/25 included the resident's antidepressant medication use but did not include the resident's individualized target behaviors for staff to monitor nor the non-pharmacological interventions for staff to attempt if the behaviors were observed. On 3/18/25 at 3:44 PM, Staff A, Registered Nurse (RN) stated she believed the resident's target behaviors should be in the Care Plan. She was not able to locate the resident's antidepressant target behaviors nor any non-pharmacological interventions in the resident's Care Plan. On 3/18/25 at 3:53 PM, Staff B, Certified Nursing Aide (CNA) stated CNAs document resident behaviors in the EHR's Point-of-Care (POC) component. On 3/18/25 at 4:53 PM, the Director of Nursing (DON) stated the target behaviors for a scheduled anti-depressant should be documented in a Mood & Behavior titled Progress Note. She also stated the resident's target behaviors should be in the Indications for Use box. She further stated non-pharmacological interventions should be documented in the Progress Notes. On 3/18/25 at 5:22 PM, the DON was not able to locate exhibited behaviors in the POC documentation. A policy titled Psychotropic Medications - Rehab / Skilled revised 12/30/24 indicated Based on a comprehensive assessment of a resident, the location must ensure that: a) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. b) Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. It also indicated if the reduction committee determines that initiating a medication is warranted, then the committee nurse will ensure the following is completed: a) Contact the physician and describe the behavior, attempted interventions and behavior committee recommendations. b) Obtain an order for an appropriate medication, in an appropriate dose and corresponding diagnosis, as well as medical symptom from the physician.

Based on clinical record review, staff interviews, observations, and policy review, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 3 residents reviewed for falls (Resident #46). The facility also failed to ensure a wander guard (a monitoring bracelet with activated alarm when exiting) was working for resident safety on a daily basis for 1 of 1 resident reviewed for risk for elopement (Resident #49). The facility reported a census of 49 residents. Findings include: 1. Resident #46's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. The MDS identified Resident #46 required supervision/touching assistance with bed mobility and ambulation. The MDS identified Resident #46 required partial/moderate assistance for transfers. Resident #46's MDS included diagnoses of non-alzheimer's dementia, depression, hypothyroidism and other abnormalities of gait and mobility. The Care Plan dated 7/8/24 revealed Resident #46 had an ADL (activities of daily living) self care performance deficit related to dementia. The Care Plan directed staff to transfer and ambulate Resident #46 with one assistance and a gait belt. A Fall Risk Evaluation dated 7/6/24 documented Resident #46's fall risk score was a 20 which indicated he was at high risk for falls. A Progress Note dated 11/7/24 title Communication/Visit with Physician documented Resident #46 was unsteady with increased weakness at times and requested an order for Physical Therapy (PT) to evaluate and treat. Review of the clinical record revealed there was no follow up regarding the request and the order for PT was not obtained. A Progress Note dated 12/6/24 documented Resident #46 was very sleepy throughout the day, requiring assistance of two staff members at times due to lethargy. The clinical record lacked any further follow ups or assessments. A Progress Note dated 12/9/24 at 12:15 AM documented CNA (certified nursing assistant) summoned RN (Registered Nurse) to Resident #46's room. CNA reported she had assisted Resident #46 to the bathroom and had walked him to the closet to get new clothes when he became unsteady and she lowered him to the floor. CNA reported Resident #46 said his leg was broken. The note documented upon the nurse arrival, Resident #46 was lying on the floor, flat on his back parallel to the closet and dresser and head was behind the bedroom door. Resident #46's right leg was externally rotated and he was unable to point his foot up or pull leg up. Resident #46 complained of pain to the right hip. A pillow was placed under Resident #46's right knee/leg and behind his head for comfort. A Progress Note dated 12/9/24 at 1:43 AM documented Resident #46 was transported to the emergency department (ED) at 12:55 AM for evaluation. A Progress Note dated 12/9/24 at 2:55 AM documented the facility received a phone call from the ED reporting Resident #46 had a right femur fracture. The ED Triage Notes dated 12/9/24 documented Resident #46 was brought to the ED via ambulance after reporting right hip pain and being lowered to the floor. Staff from the nursing home reported Resident #46 was ambulating and had a sudden onset of severe right hip pain so was lowered to the floor. Staff reported slight shortening and rotation of the right leg. The Hospital x-ray of the right hip dated 12/9/24 documented the impression of a nondisplaced intertrochanteric fracture of the right femur. The Hospital History and Physical dated 12/9/24 documented Resident #46 was admitted due to the right femur fracture and would undergo surgery to repair the fracture. A handwritten statement from Staff C, CNA dated 12/9/24 documented she assisted Resident #46 to the bathroom then she walked him to the closet to get clean clothes and he became unsteady so lowered him to the floor. The facility 5 day Summary/Root Cause Analysis dated 12/13/24 documented Staff D, RN was summoned to the memory car unit by Staff C, CNA. Staff C reported Resident #46 wavered/lost balance while picking out clothes at the closet and she intervened by lowering Resident #46 to the floor. Staff D reported that during the fall investigation and further conversation with Staff C, Resident #46 had been complaining of pain to his right leg off and on throughout the shift, most recently as they ambulated from the bathroom, several feet to the closet. The investigation documented the root cause of the fall was Resident #46 had been complaining of right leg pain prior to fall. The facility investigation documented the following facility interventions: -Educate CNAs to report any resident complaints of pain to the charge nurse. -Educate the Nurses to assess any resident reports of pain and document their assessment, interventions, and new orders. -Educate nursing staff that if a resident was unsteady or complains of pain, assist the resident to a safe surface (chair or bed), then bring them outfits from the closet to choose from, rather than having the resident stand at the closet where space is limited. -Review with nursing staff the Safe Resident Handling Program Overview R/S, LTC Policy. -Review Nursing Related Assessments Policy with the Nurses Review of the facility 5 day investigation did not indicate how Staff C, CNA lowered Resident #46 to the floor or if a gait belt was used as directed on the care plan. On 3/18/25 at 3:45 PM, the Nurse Manager reported she received a call from Staff D, RN and she came to the facility. The Nurse Manager reported the staff did not move Resident #46 because he was in pain. She reported she observed him sitting on his bottom by the dresser/closet. She reported she did not recall if Resident #46 was wearing a gait belt or not. She reported she interviewed Staff C, CNA and she had made the motion with her two hands like she was holding on to something when she lowered Resident #46 to the floor so she had assumed Staff C was using a gait belt. When asked about the request for therapy orders on 11/7/24, the Nurse Manager reported that the Nurse Practitioner did not respond to the request until 12/10 and Resident #46 was in the hospital. On 3/18/25 at 3:45 PM, the DON was present with interview with the Nurse Manager and reported Staff C, CNA did not tell the charge nurse until after the fall that Resident #46 had complained of right leg pain. The DON reported the facility questioned if the pain contributed to the fall or if the fracture happened/caused the fall. The DON reported she was not sure if Staff C was using a gait belt or not at the time of the incident. The DON said she educated all nurses and CNAs on reporting and assessing pain. When asked if the Resident #46 had a history of right leg pain, she said not that she was aware of. She reported there had been no previous falls prior to 12/9/24. On 3/19/25 at 11:04 AM, Staff D, RN said she was out in the main area and Staff C CNA called for assistance due to Resident #46 had fallen. She said when she arrived to the room she couldn't get the door opened very far as Resident #46 was lying behind the door. She said Staff C and Resident #46 reported they were walking back from the bathroom to the closet to get clothes, Resident #46 complained of pain in his right leg and Staff C lowered Resident #46 to the floor (sat him down and then laid back). Staff D reported Resident #46 said he felt like something was broken and complained his right hip hurt. She said there was external rotation and he was not able to pick up his right leg or point his toes. She said she called for an ambulance and the Nurse Manager. She said the Nurse Manager came to the facility before the ambulance got there. When asked if Resident #46 was wearing a gait belt, Staff D reported she could not say for sure if he had a gait belt on or not. She said she did not recall taking the gait belt off Resident #46 when he was transferred onto the gurney. Staff D reported Resident #46 required assistance of one staff member and a walker for ambulation. Staff D reported the pain in the right leg was new for Resident #46 and started when he was walking from the BR over to the closet. She said the pain was not reported before the fall. Staff D reported there was not a lot of space between the bathroom and closet, probably about 10 steps. Staff D reported she felt like something happened prior to the fall, she said Resident #46 had pain, then became unsteady and then sat on the floor. She reported Resident #46 told her he sat on the floor as he was having pain while walking and that the pain started prior to being on the floor. On 3/19/25 at 11:49 AM, Staff C, CNA reported she was working the night Resident #46 broke his leg. She reported when she entered the room, Resident #46 was standing up with his walker. She said she asked him if he needed to go to the bathroom and he did. She reported she walked Resident #46 to the bathroom and he sat down on the toilet and urinated. She reported when he was done, she walked him to the closet to pick out new clothes and he got wobbly, so she lowered him to the floor using the back of his pants and his regular belt. Staff C reported Resident #46 did not have a gait belt on when she lowered him to the floor. Staff C reported Resident #46 would get up on his own sometimes and walk around. She reported Resident #46 was already standing up so she walked him to the bathroom and did not put on the gait belt. When asked why she did not put the gait belt on after Resident #46 was sitting on the toilet, she said she did not think about it but should have put the gait belt on him. She reported when she lowered Resident #46 to the floor it was gentle and not hard. Staff C reported she would have had to lower Resident #46 to the floor even if he had the gait belt on. She reported when Resident #46 sat down on the floor, he complained that his leg hurt. When asked if Resident #46 had voiced any complaints of pain prior to the fall, she said he may have but did not recall for sure. Staff C reported after the fall, she was educated if a patient wanted to change their clothes, to have them sit on the bed or chair then get the clothes and assist them that way. On 3/19/24 at 4:15 PM, the DON (Director of Nursing) reported she would expect the staff to follow the care plan when transferring or ambulating a resident. She reported if Resident #46 was already standing up, she would expect the staff to assist the resident and then attempt to apply the gait belt once the resident was in a safe place (sitting down). A facility policy titled Gait- Transfer Belt date reviewed/revised 5/2/25 documented the purpose of the gait belt was to safely stabilize a transfer, to ambulate with a resident and to aid residents in maintaining balance. The policy documented gait belts are used with assisted ambulation and are never used as a lifting device, only for stabilization. The policy further directed staff not to use the pants/slacks belt as a gait (transfer) belt as upward movement of the belt can cause male residents severe pain. 2. Resident #49's MDS dated [DATE] identified a BIMS score of 03, indicating severe cognitive impairment. The MDS identified Resident #49 was independent with bed mobility, transfers and ambulation. Resident #49's MDS included diagnoses of Alzheimer's, non-alzheimer's dementia, anxiety, depression, and post traumatic stress disorder. The MDS documented Resident #49 used a wander/elopement alarm daily. The Care Plan dated 9/5/25 revealed Resident #49 had behavioral symptoms related to wandering and a potential for elopement related to Alzheimer 's disease. The Care Plan directed the following interventions: -Check wander guard placement every shift. -Wander guard used to alert staff to resident's movements. -Check wander guard functionality every shift to ensure wander guard is in working order. -Educate families to use the sign in/sign out sheet at nurses station. -Ensure that exit door alarms are in working order. A Physician Order dated 9/6/24 directed staff to check Resident #49's wander guard bracelet function daily. An Elopement Risk assessment dated [DATE] documented Resident #49 was at risk for elopement. A Progress Note dated 3/3/25 documented Resident #49 was independent with mobility and usually steady when doing so. The note documented Resident #49 was followed by Psychiatric ARNP (Advanced Registered Nurse Practitioner) for behaviors and anxiety as she had been noted to put herself on the floor, continued with pacing, attempted to get out doors and hitting staff. On 3/17/25 at 11:46 AM, observed Resident #49 pacing hallway, walking up and down quickly with no assistive device, wander guard in place to right ankle. Resident #49 told staff that she hates it here. A Progress Note on 3/17/25 documented Resident #49 upset that she cannot leave the facility and go home. Resident #46 started becoming agitated by other residents around her and staff intervened to allow her to have space. Resident #49 began hitting the window attempting to get out repeatedly stating I want to leave. Let me out of here Resident #49 very difficult to redirect and pacing quickly up and down the hall. Review of the September 2024 to March 2025 MAR (Medication Administration Records) and TAR (Treatment Administration Records) lacked documentation Resident #49's wander guard was being checked for placement and function. On 3/18/25 at 11:30 AM, Staff E, RN (Registered Nurse) verified Resident #49's wander guard was not documented on the MAR or TAR. She reported the Physician Order was put in the electronic medical record incorrectly so the order was not pulling over to the MAR or TAR for signature. Staff E reported she would correct the order. On 3/18/25 at 2:40 PM, the DON reported it was an expectation for the staff to check and document the placement of the wander guard daily and functioning of the wander guard twice a day on the TAR. The DON reported the facility had extra bands and devices so if the battery was to die, the staff would get a new device and band. A facility policy titled Alarms- Bed, Chair and Door date reviewed/revised 9/25/24 documented bracelet alarms are to be checked daily to see if the alarm was functional and nursing was responsible for visually checking for placement of the alarm daily.

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 21 residents (Resident #10, #16, #31) reviewed for comprehensive care plans. The facility reported a census of 49 residents. Findings include: 1. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Resident #10's MDS included diagnoses of diabetes mellitus, non-alzheimer's dementia, anxiety and depression. The MDS documented Resident #10 was taking insulin injections during the 7 day look back period. A Physician Order dated 9/25/24 directed staff to obtain a FSBS (Finger Stick Blood Sugar) daily in the morning related to type 2 diabetes mellitus. A Physician Order dated 10/14/24 directed staff to administer Basaglar Insulin 100 unit/ml (milliliter) to inject 14 units subcutaneously (fatty tissue below the skin) one time a day related to type 2 diabetes mellitus. Review of the Care Plan dated 9/12/24 lacked direction regarding the treatment and management of type 2 diabetes mellitus and insulin usage. The Care Plan lacked risk factors and interventions regarding blood sugar monitoring and parameters on when to report to the Physician, signs/symptoms to monitor for related to hyper/hypoglycemia (high/low blood sugars), and potential adverse reactions/complications. 2. Resident #16's MDS assessment dated [DATE] identified a BIMS score of 03, indicating severe cognitive impairment. Resident #16's MDS included diagnoses of non-alzheimer's dementia, seizure disorder, anxiety, depression, psychotic disorder and intellectual disabilities. The MDS documented Resident #16 was taking antipsychotic and antidepressant medications during the 7 day look back period. A Physician Order dated 4/24/23 directed staff to administer Sertraline HCL (antidepressant medication) 100 MG (milligrams) one time a day for depression related to emotional lability. A Physician Order dated 6/3/24 directed staff to administer Seroquel (antipsychotic medication) 50 MG three times a day related to delusional disorders. Review of the Care Plan with a target date of 10/29/24 revealed the antidepressant and antipsychotic medication, potential side effects and what to monitor for while taking the high risk medication was not addressed on the comprehensive care plan. On 3/19/25 at 4:15 PM, the DON (Director of Nursing) reported she would expect high risk medications and side effects to be addressed on the care plan. 47079 3. The MDS for Resident #31 dated 2/4/25 revealed a BIMS of 02 out of 15 which indicated severely impaired cognition. It included diagnoses of Chronic Kidney Disease (CKD), Diabetes Mellitus (DM), Non-Alzheimer's Dementia, unspecified dementia with agitation, and depression. It also revealed the resident sometimes felt lonely or isolated from those around him and received antipsychotic (AP) and antidepressant (AD) medications during the last 7 days. On 3/17/25 at 1:35 PM, Resident #31's spouse stated the resident took medication for behavior concerns. The Electronic Health Record (EHR) included a Physician's Order for an antidepressant medication dated 6/4/24, escitalopram oxalate 10 mg by mouth one time a day for depression. It did not identify the resident's target behaviors that required an antidepressant. The Progress Notes did not identify target behaviors for depression. The Care Plan revised 2/12/25 included the resident's antidepressant medication use but did not include the resident's individualized target behaviors for staff to monitor nor the non-pharmacological interventions for staff to attempt if the behaviors were observed. On 3/18/25 at 3:44 PM, Staff A, Registered Nurse (RN) stated she believed the resident's target behaviors should be in the Care Plan. She was not able to locate the resident's antidepressant medication target behaviors nor any individualized, non-pharmacological interventions in the resident's Care Plan. On 3/18/25 at 4:53 PM, the Director of Nursing (DON) stated the observed target behaviors for a scheduled anti-depressant should be documented in a Mood & Behavior titled Progress Note. She also stated the resident's target behaviors should be in the Indications for Use box. She further stated attempted non-pharmacological interventions should be documented in the Progress Notes. On 3/18/25 at 5:22 PM, the DON was not able to locate the antidepressant medication target behaviors in the Care Plan. A policy titled Care Plan - Rehab / Skilled & Long-Term Care, Therapy and Rehab revised 12/02/24 indicated Each resident will 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. It also indicated the plan of care will be modified to reflect the care currently required/provided for the resident.

Based on clinical record review, resident and staff interview, the facility failed to implement or follow through with advanced directives per resident directive upon admission for 1 of 21 residents reviewed (Resident #206). The facility reported a census of 49. Findings include: The entry Minimum Data Set (MDS) dated [DATE] indicated Resident #206 entered the facility on [DATE]. The Care Plan for Resident #206, implemented [DATE] did not document if the resident wanted cardiopulmonary resuscitation (CPR) should he require it. A review of clinical records and files on [DATE] showed they failed to document Resident #206 had a code status or advanced directive of any kind. His Electronic Health Record (EHR) lacked documentation the resident required CPR and did not indicate the resident was indicated as a do not resuscitate (DNR). In an interview on [DATE] at 3:54 PM with Resident #206, he was asked directly if he wanted CPR in the event he should need it. He was able to voice that yes, he wants CPR. In an interview on [DATE] at 4:09 PM with the Director of Nursing (DON), she stated she was unaware the resident's code status was not present in the EHR. She stated staff are instructed to check the EHR to determine code status should a resident require CPR.

Based on record, policy and video review, and interviews, the facility failed to report suspected abuse immediately, and failed to separate an alleged abuser from the residents immediately. A staff member witnessed a Certified Nurse Aide (CNA) with her hand covering the mouth of an agitated resident. She failed to report the suspicious activity for over 2 hours. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 29, 2024, on August 17, 2024 at 11:20 AM. The Facility Staff removed the IJ on August 17, 2024 through the following actions: a. Head to toe assessment on Resident #1 to include assessment for emotional distress. b. Abuse and Neglect education for all staff implemented through an online course. Team members instructed to review course prior to the next scheduled shift. Daily educational huddles completed daily for two weeks. c. Leadership supervision in memory care implemented to include daily oversight of behaviors, staff management and increased activities and interaction with residents. d. All residents interviewed to ensure they were feeling safe. e. Further education regarding dementia related behaviors, management of behaviors, resident rights, providing meaningful activities, follow-up quizzes, training videos to determine how behaviors may indicate unmet needs in dementia residents. f. Leadership perform Angel Rounding to include resident interviews and observations to ensure resident care needs are addressed. g. Administrator and Director of Nursing or designees will audit through observation while staff care for residents with behaviors for appropriate response and management. 5 team members randomly on all shifts daily for 10 days. h. Administrator and Director of Nursing or designees will audit through resident right questionnaire 5 team members randomly on all shifts daily for 10 days to ensure staff education on resident rights. i. Audits will be taken to QAPI for further review and recommendations. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 51 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficit). She required substantial assistance with dressing, hygiene, toilet transfers and was able to walk with partial assistance. Her diagnosis included cancer, anemia, hip fracture and Alzheimer's Disease. She was admitted to the facility on [DATE]. The Care Plan revised on 7/30/24, showed Resident #1 had impaired cognitive function/dementia related to Alzheimer's disease and required 24/7 supervision. The resident was able to understand consistent, simple direct sentences. Staff were to provide Resident #1 with simple cues, to stop and return later if she was agitated, and to monitor for physical/nonverbal indicators of discomfort or distress. The resident required supervision with ambulation in hallways and common area. She had behavior symptoms with verbal aggression, cursing, pushing and at times she was resistive with cares. According to a facility Incident Report dated 7/29/24 at 4:30 PM, Staff B, Activities Director witnessed Staff E, Certified Nurse Aide (CNA) with her hand over the mouth of Resident #1. The Director of Nursing (DON) reviewed a video tape of the memory care area and found that Staff E had also pushed the resident back down in to the chair, and pushed the chair up to the table when she was attempting to stand. Staff F, CNA was sitting at the same table during these events but failed to intervene or report the interactions. Staff F also braced the table with her feet when Resident #1 pushed it to get out of her chair. The resident was described as restless, anxious and confused. A summary of the facility investigation showed that on 7/29/242 at 4:30 PM, when the DON learned of the incident, Staff E had already left for the day, and Staff F was escorted out and suspended around 5:00 PM. Staff B, Staff E and Staff B were all placed on suspension. A review of the video from the memory care unit on 8/16/24 at 11:30 AM, revealed the following: a. At 1:32 PM, on 7/29/24, Staff E and Resident #1 were in the dining room and Resident #1 was sitting in a chair up to a round table. Staff E was standing behind the chair with her leg brace up against the back of the chair and was scrolling through her phone. A couple of minutes later, Staff E sat in a chair next to the resident and several times, the resident put her hands on the arms of the chair, pushed up, and attempted to stand. Each time, Staff E pushed down on the resident's shoulder to get her to sit down. The resident looked agitated and turned toward the staff member and said something. b. At 1:35 PM, Staff E pushed her down into the chair and the resident swung at the CNA. Staff E then grabbed the resident's wrists and hands and held them down. Staff F then entered the room with another resident and sat on the opposite side of the table from the residents. Resident #1 continued to try to stand and each time, Staff E pushed her back down into the chair. c. At 1:39 PM, once again, the resident swung at Staff E and the CNA grabbed the resident's arms and held them down against the arm rest of the chair. The two exchanged words, and at 1:40 PM, Staff E put her hand over the resident's mouth, the resident swung at her and the CNA grabbed her arms again. As they exchanged more words, Staff E took a blanket from the back of the chair and put it on the back of the resident's head. This increased her agitation and she pulled it back off. Resident #1 then tried to take her sweater off, she had it partially off of one arm when Staff E reached over and tried to force her to put it back on. d. At 1:41 PM, Resident #1 pushed her chair back from the table and the CNA responded by pushing the chair back until her torso was up to the table. Three more times, the resident tried to stand, and Staff E pushed her back down into the chair. Resident #1 put her head down on the table and looked to be crying, at 1:47 PM, Staff E looked at Staff F on the other side of the table and they snickered. Resident #1 then swung out at the CNA, and Staff E grabbed her hands and arms. Staff E then got up out of her chair and stood behind the resident's chair with her leg braced up against the back of the chair. With her hands on the table, the resident tried to push her chair back, but the table moved across the floor. Staff E lifted the resident's hand off the table, and with her body, she shoved the chair up to the table and pinned her against it. e. At 1:50 PM, the residents head was down and she looked to be crying. Staff E then picked up the resident's sweater and placed it on her head, Resident #1 got agitated and threw it off. At 1:52 PM, the resident looked to be yelling, Staff E kept her body firmly at the back of the chair and placed her hand over the resident's mouth. Resident #1 tried to push her chair back again but the table moved instead. Staff F then braced her feet at the base of the table so it wouldn't move as Staff E pushed the resident's chair up to the table again. f. At 1:53 PM, Staff E put her hand over the resident's mouth again and that was when Staff B entered the room. Staff E then backed away from the resident, allowed her to stand and walk around the room. The CNA followed the resident for a short period of time but then went and sat at the nurse's station. On 8/16/24 at 9:49 AM, Staff B said that on 7/29/24, she came down the hallway of the locked memory unit and she heard a resident screaming and yelling. She said that this was not unusual, as Resident #1 did tend to become more anxious in the afternoons. When Staff B entered the eating area, she saw Staff F sitting in a chair up at the table and Resident #1 was on the opposite side of the table. Staff E was standing behind Resident #1, with hand over the resident's mouth. The CNA quickly took her hand off of the resident and backed away. Staff B said that she went on with her activities over the next couple of hours. She said that she attempted to talk to the Director of Nursing (DON) sooner, but she thought it was not a big concern or cause for immediate action. She was able to connect with the DON around 4:30 PM. Staff B said that after watching the video from the memory unit, she came to understand that there were more concerning actions that had taken place, and she should have addressed it right away. On 8/17/24 at 10:00 AM Staff E, CNA said that on 7/29/24, Resident #1 was having a rough day, and they had tried different interventions to calm her. She said they had been taking turns caring for her but the staff member that was working with her, was short tempered and couldn't handle Resident #1 for very long. The resident was anxious, agitated, screaming, and yelling for attention she likes attention, good or bad. Staff E said the nurse had given the resident a medication to help calm her, and that tended to affect her gait so they were watching her close because she was a fall risk. The resident didn't want to get into the recliner, and she had been known to approach other residents at times, so Staff E thought a chair at the table was the safest option. Staff F was with her at the table, and some of the chairs don't have the grippers attached on the bottom of the legs. She said that she was afraid that when the resident pushed her chair back, it could tip backwards so that was why she stood behind her to prevent her from pushing it. Staff E said that this was better than letting her stand up and risk falling. Staff E said that at one point, the resident started hitting her, and she was taught that it was okay to place the resident's hands in their laps to keep you and the resident safe. She acknowledged that she put her hand on the resident's mouth several times to shush her. She said that had worked in the past. When asked to describe what a restraint looks like, she said you can't force them to stay in bed, you can't restrict their motion unless they are a harm to you or themselves. When asked about pushing the chair up to the table and trapping the resident, she said that this was a better plan than letting the chair tip backwards. Staff E said that her training on caring for dementia residents included watch videos, and following another CNA on the floor for about a week. She said they really didn't have hands-on training or competency tests to determine if they had learned the skills. Staff E said that she should have probably tried some different repositioning when Resident #1 continued to escalate. She said that they didn't have many staff in the unit and she still felt the safest option for Resident #1 was to keep her from standing and pushed up to the table. She thought the shushing would help, but when it didn't, that's when she decided to give the resident some space and let her walk. On 8/16/24 at 12:20 PM, Staff F, CNA said that she had been suspended from work because her coworker covered a resident's mouth and she didn't have a chance to report it. The resident was yelling out, so Staff E put her hand over the resident's mouth. She said that it wasn't very forceful and said that she told her to stop but she didn't know if she heard her, because the resident was yelling so much. When asked about not allowing the resident to get up out of the chair, Staff F said that was the case and she was pushing her back into the chair. She said that the resident had been swinging at Staff E but she did not see her holding down the resident's arms. When asked if she had seen anything that she would describe as a restraint, Staff F said that when the residents chair had been pushed against the table, that was probably a restraint. She did not know why she braced the table when the resident pushed it, trying to get up. I just wasn't thinking very clearly. Staff F acknowledged that by preventing the resident from getting up and walking around, her agitation and yelling had increased. Staff F said that she didn't have a chance to intervene or to report the incident. She said that they are provided on-line training on how to handle residents with dementia and agitation. She didn't remember much about it or any of the specific techniques that were taught. On 8/17/24 at 7:50 AM Staff H, Assistant Director of Nursing (ADON) said that she had watched the video and acknowledged that holding the resident's chair up against the table was a restraint. No staff or residents had ever come to her with concerns about Staff F or Staff E. She said they do random observations of staff interactions with residents. If they see concerns, or something that could be done differently, they take that opportunity to do education with them. On 8/16/24 at 11:30 AM Staff D, Quality Assurance (QA) nurse acknowledged that the pinning of the chair against the table and the holding down of arms and hands would be described as a restraint. She also acknowledged that staff had no reason to be on the phone while caring for the residents. According to the facility policy titled: Abuse and Neglect dated 7/22/24, the purpose of the policy was to ensure that employees were knowledgeable regarding the reporting and investigative process of abuse and neglect allegations. To ensure that the facility had an effective system in place that prevents mistreatment, neglect exploitation and abuse of residents. Resident have the right to be free from abuse .this includes freedom from corporal punishment and involuntary seclusion. Alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin would be reported immediately to the administrator.

Based on observation, interview and record review the facility failed to ensure that residents were free from abuse for 1 of 1 resident reviewed. Staff F, Certified Nurse Aide (CNA), and Staff E, CNA, used punitive restrictions and restraints to control Resident #1 preventing her from moving about. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 29, 2024, on August 17, 2024 at 11:20 AM. The Facility Staff removed the IJ on August 17, 2024 through the following actions: a. Head to toe assessment on Resident #1 to include assessment for emotional distress. b. Abuse and Neglect education for all staff implemented through an online course. Team members instructed to review course prior to the next scheduled shift. Daily educational huddles completed daily for two weeks. It was identified during survey Staff I worked 9 times prior to taking course and Staff J worked 12 times prior to taking course. c. Leadership supervision in memory care implemented to include daily oversight of behaviors, staff management and increased activities and interaction with residents. d. All residents interviewed to ensure they were feeling safe. e. Further education regarding dementia related behaviors, management of behaviors, resident rights, providing meaningful activities, follow-up quizzes, training videos to determine how behaviors may indicate unmet needs in dementia residents. f. Leadership perform Angel Rounding to include resident interviews and observations to ensure resident care needs are addressed. g. Administrator and Director of Nursing or designees will audit through observation while staff care for residents with behaviors for appropriate response and management. 5 team members randomly on all shifts daily for 10 days. h. Administrator and Director of Nursing or designees will audit through resident right questionnaire 5 team members randomly on all shifts daily for 10 days to ensure staff education on resident rights. i. Audits will be taken to QAPI for further review and recommendations. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 51 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficit). She required substantial assistance with dressing, hygiene, toilet transfers and was able to walk with partial assistance. Her diagnosis included cancer, anemia, hip fracture and Alzheimer's Disease. She was admitted to the facility on [DATE]. The Care Plan revised on 7/30/24, showed Resident #1 had impaired cognitive function/dementia related to Alzheimer's disease and required 24/7 supervision. The resident was able to understand consistent, simple direct sentences. Staff were to provide Resident #1 with simple cues, to stop and return later if she was agitated, and to monitor for physical/nonverbal indicators of discomfort or distress. The resident required supervision with ambulation in hallways and common area. She had behavior symptoms with verbal aggression, cursing, pushing and at times she was resistive with cares. According to a facility Incident Report dated 7/29/24 at 4:30 PM, Staff B, Activities Director witnessed Staff E, Certified Nurse Aide (CNA) with her hand over the mouth of Resident #1. The Director of Nursing (DON) reviewed a video tape of the memory care area and found that Staff E had also pushed the resident back down in to the chair, and pushed the chair up to the table when she was attempting to stand. Staff F, CNA was sitting at the same table during these events but failed to intervene or report the interactions. Staff F also braced the table with her feet when Resident #1 pushed it to get out of her chair. The resident was described as restless, anxious and confused. A summary of the facility investigation showed that on 7/29/242 at 4:30 PM, when the DON learned of the incident, Staff E had already left for the day, and Staff F was escorted out and suspended around 5:00 PM. Staff B, Staff E and Staff B were all placed on suspension. A review of the video from the memory care unit on 8/16/24 at 11:30 AM, revealed the following: a. At 1:32 PM, on 7/29/24, Staff E and Resident #1 were in the dining room and Resident #1 was sitting in a chair up to a round table. Staff E was standing behind the chair with her leg braced up against the back of the chair and was scrolling through her phone. A couple of minutes later, Staff E sat in a chair next to the resident and several times, the resident put her hands on the arms of the chair, pushed up, and attempted to stand. Each time, Staff E pushed down on the resident's shoulder to get her to sit down. The resident looked agitated and turned toward the staff member and said something. b. At 1:35 PM, Staff E pushed her down into the chair and the resident swung at the CNA. Staff E then grabbed the resident's wrists and hands and held them down. Staff F then entered the room with another resident and sat on the opposite side of the table from the residents. Resident #1 continued to try to stand and each time, Staff E pushed her back down into the chair. c. At 1:39 PM, once again, the resident swung at Staff E and the CNA grabbed the resident's arms and held them down against the arm rest of the chair. The two exchanged words, and at 1:40 PM, Staff E put her hand over the resident's mouth, the resident swung at her and the CNA grabbed her arms again. As they exchanged more words, Staff E took a blanket from the back of the chair and put it on the back of the resident's head. This increased her agitation and she pulled it back off. Resident #1 then tried to take her sweater off, she had it partially off of one arm when Staff E reached over and tried to force her to put it back on. d. At 1:41 PM, Resident #1 pushed her chair back from the table and the CNA responded by pushing the chair back until her torso was up to the table. Three more times, the resident tried to stand, and Staff E pushed her back down into the chair. Resident #1 put her head down on the table and looked to be crying, at 1:47 PM, Staff E looked at Staff F on the other side of the table and they snickered. Resident #1 then swung out at the CNA, and Staff E grabbed her hands and arms. Staff E then got up out of her chair and stood behind the resident's chair with her leg braced up against the back of the chair. With her hands on the table, the resident tried to push her chair back, but the table moved across the floor. Staff E lifted the resident's hand off the table, and with her body, she shoved the chair up to the table and pinned her against it. e. At 1:50 PM, the residents head was down and she looked to be crying. Staff E then picked up the resident's sweater and placed it on her head, Resident #1 got agitated and threw it off. At 1:52 PM, the resident looked to be yelling, Staff E kept her body firmly at the back of the chair and placed her hand over the resident's mouth. Resident #1 tried to push her chair back again but the table moved instead. Staff F then braced her feet at the base of the table so it wouldn't move as Staff E pushed the resident's chair up to the table again. f. At 1:53 PM, Staff E put her hand over the resident's mouth again and that was when Staff B entered the room. Staff E then backed away from the resident, allowed her to stand and walk around the room. The CNA followed the resident for a short period of time but then went and sat at the nurse's station. On 8/16/24 at 9:49 AM, Staff B said that on 7/29/24, she came down the hallway of the locked memory unit and she heard a resident screaming and yelling. She said that this was not unusual, as Resident #1 did tend to become more anxious in the afternoons. When Staff B entered the eating area, she saw Staff F sitting in a chair up at the table and Resident #1 was on the opposite side of the table. Staff E was standing behind Resident #1, with hand over the resident's mouth. The CNA quickly took her hand off of the resident and backed away. Staff B said that she went on with her activities over the next couple of hours. She said that she attempted to talk to the Director of Nursing (DON) sooner, but she thought it was not a big concern or cause for immediate action. She was able to connect with the DON around 4:30 PM. Staff B said that after watching the video from the memory unit, she came to understand that there were more concerning actions that had taken place, and she should have addressed it right away. On 8/17/24 at 10:00 AM Staff E, CNA said that on 7/29/24, Resident #1 was having a rough day, and they had tried different interventions to calm her. She said they had been taking turns caring for her but the staff member that was working with her, was short tempered and couldn't handle Resident #1 for very long. The resident was anxious, agitated, screaming, and yelling for attention she likes attention, good or bad. Staff E said the nurse had given the resident a medication to help calm her, and that tended to affect her gait so they were watching her close because she was a fall risk. The resident didn't want to get into the recliner, and she had been known to approach other residents at times, so Staff E thought a chair at the table was the safest option. Staff F was with her at the table, and some of the chairs don't have the grippers attached on the bottom of the legs. She said that she was afraid that when the resident pushed her chair back, it could tip backwards so that was why she stood behind her to prevent her from pushing it. Staff E said that this was better than letting her stand up and risk falling. Staff E said that at one point, the resident started hitting her, and she was taught that it was okay to place the resident's hands in their laps to keep you and the resident safe. She acknowledged that she put her hand on the resident's mouth several times to shush her. She said that had worked in the past. When asked to describe what a restraint looks like, she said you can't force them to stay in bed, you can't restrict their motion unless they are a harm to you or themselves. When asked about pushing the chair up to the table and trapping the resident, she said that this was a better plan than letting the chair tip backwards. Staff E said that her training on caring for dementia residents included watch videos, and following another CNA on the floor for about a week. She said they really didn't have hands-on training or competency tests to determine if they had learned the skills. Staff E said that she should have probably tried some different repositioning when Resident #1 continued to escalate. She said that they didn't have many staff in the unit and she still felt the safest option for Resident #1 was to keep her from standing and pushed up to the table. She thought the shushing would help, but when it didn't, that's when she decided to give the resident some space and let her walk. On 8/16/24 at 12:20 PM, Staff F, CNA said that she had been suspended from work because her coworker covered a resident's mouth and she didn't have a chance to report it. The resident was yelling out, so Staff E put her hand over the resident's mouth. She said that it wasn't very forceful and said that she told her to stop but she didn't know if she heard her, because the resident was yelling so much. When asked about not allowing the resident to get up out of the chair, Staff F said that was the case and she was pushing her back into the chair. She said that the resident had been swinging at Staff E but she did not see her holding down the resident's arms. When asked if she had seen anything that she would describe as a restraint, Staff F said that when the residents chair had been pushed against the table, that was probably a restraint. She did not know why she braced the table when the resident pushed it, trying to get up. I just wasn't thinking very clearly. Staff F acknowledged that by preventing the resident from getting up and walking around, her agitation and yelling had increased. Staff F said that she didn't have a chance to intervene or to report the incident. She said that they are provided on-line training on how to handle residents with dementia and agitation. She didn't remember much about it or any of the specific techniques that were taught. On 8/17/24 at 8:23 AM, a family member for Resident #1 said that the resident did not like to be touched and any attempts to redirect her by putting hands on, would only escalate her. They advised the staff to just walk with her and try not to touch her. She said that at times, the staff would try to talk her into sitting down, and that did not work. She understood that Resident #1 was a fall risk, but trying to force her just made things worse. On 8/17/24 at 7:50 AM Staff H, Assistant Director of Nursing (ADON) said that she had watched the video and acknowledged that holding the resident's chair up against the table was a restraint. No staff or residents had ever come to her with concerns about Staff F or Staff E. She said they do random observations of staff interactions with residents. If they see concerns, or something that could be done differently, they take that opportunity to do education with them. On 8/16/24 at 11:30 AM Staff D, Quality Assurance (QA) nurse acknowledged that the pinning of the chair against the table and the holding down of arms and hands would be described as a restraint. She also acknowledged that staff had no reason to be on the phone while caring for the residents. According to the facility policy titled: Abuse and Neglect dated 7/22/24, the purpose of the policy was to ensure that employees were knowledgeable regarding the reporting and investigative process of abuse and neglect allegations. To ensure that the facility had an effective system in place that prevents mistreatment, neglect exploitation and abuse of residents. Resident have the right to be free from abuse .this includes freedom from corporal punishment and involuntary seclusion. Alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin would be reported immediately to the administrator.

Based on interviews, video, record and policy review, the facility failed to ensure staff displayed competent dementia care and safe interventions for 1 of 1 resident reviewed. Staff F, Certified Nurse Aide (CNA), and Staff E, CNA, used punitive restrictions and restraints to control Resident #1 preventing her from moving about. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 29, 2024, on August 17, 2024 at 11:20 AM. The Facility Staff removed the IJ on August 17, through the following actions: a. Head to toe assessment on Resident #1 to include assessment for emotional distress. b. Abuse and Neglect education for all staff implemented through an online course. Team members instructed to review course prior to the next scheduled shift. Daily educational huddles completed daily for two weeks. c. Leadership supervision in memory care implemented to include daily oversight of behaviors, staff management and increased activities and interaction with residents. d.All residents interviewed to ensure they were feeling safe. e. Further education regarding dementia related behaviors, management of behaviors, resident rights, providing meaningful activities, follow-up quizzes, training videos to determine how behaviors may indicate unmet needs in dementia residents. f. Leadership perform Angel Rounding to include resident interviews and observations to ensure resident care needs are addressed. g. Administrator and Director of Nursing or designees will audit through observation while staff care for residents with behaviors for appropriate response and management. 5 team members randomly on all shifts daily for 10 days. h. Administrator and Director of Nursing or designees will audit through resident right questionnaire 5 team members randomly on all shifts daily for 10 days to ensure staff education on resident rights. i.Audits will be taken to QAPI for further review and recommendations. The scope lowered from a K to E at the time of the survey after ensuring the facility implemented their policy and procedures, and staff education. The facility identified a census of 51 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficit). She required substantial assistance with dressing, hygiene, toilet transfers and she was able to walk with partial assistance. Her diagnosis included cancer, anemia, hip fracture and Alzheimer's Disease. She was admitted to the facility on [DATE] The Care Plan revised on 7/30/24, showed Resident #1 had impaired cognitive function/dementia related to Alzheimer's disease and required 24/7 supervision. The resident was able to understand consistent, simple direct sentences. Staff were to provide Resident #1 with simple cues, to stop and return later if she was agitated, and to monitor for physical/nonverbal indicators of discomfort or distress. The resident required supervision with ambulation in hallways and common area. She had behavior symptoms including; verbal aggression, cursing, pushing and at times she was resistive with cares. According to a facility Incident Report dated 7/29/24 at 4:30 PM, Staff B, Activities Director, witnessed Staff E, Certified Nurse Aide (CNA) with her hand over the mouth of Resident #1. The Director of Nursing (DON) reviewed a video tape of the memory care area and found that Staff E had also pushed the resident down into the chair when she tried to get up, and pushed the chair up to the table to prevent the resident from standing. Staff F, CNA was sitting at the same table during these activities, but she failed to intervene or report the interactions. Staff F also restricted the resident by holding her feet on the base of the table to prevent it from moving. The resident was described as restless, anxious and confused. A review of the video from the memory care unit on 8/16/24 at 11:30 AM, revealed the following: a. At 1:32 PM, on 7/29/24, Staff E and Resident #1 were in the dining room and Resident #1 was sitting in a chair up to a round table. Staff E was standing behind the chair with her leg brace up against the back of the chair and was scrolling through her phone. A couple of minutes later, Staff E sat in a chair next to the resident and several times, the resident put her hands on the arms of the chair, pushed up, and attempted to stand. Each time, Staff E pushed down on the resident's shoulder to get her to sit down. The resident looked agitated and turned toward the staff member and said something. b. At 1:35 PM, Staff E pushed her down into the chair and the resident swung at the CNA. Staff E then grabbed the resident's wrists and hands and held them down. Staff F then entered the room with another resident and sat on the opposite side of the table from the residents. Resident #1 continued to try to stand and each time, Staff E pushed her back down into the chair. c. At 1:39 PM, once again, the resident swung at Staff E and the CNA grabbed the resident's arms and held them down against the arm rest of the chair. The two exchanged words, and at 1:40 PM, Staff E put her hand over the resident's mouth, the resident swung at her and the CNA grabbed her arms again. As they exchanged more words, Staff E took a blanket from the back of the chair and put it on the back of the resident's head. This increased her agitation and she pulled it back off. Resident #1 then tried to take her sweater off, she had it partially off of one arm when Staff E reached over and tried to force her to put it back on. d. At 1:41 PM, Resident #1 pushed her chair back from the table and the CNA responded by pushing the chair back until her torso was up to the table. Three more times, the resident tried to stand, and Staff E pushed her back down into the chair. Resident #1 put her head down on the table and looked to be crying, at 1:47 PM, Staff E looked at Staff F on the other side of the table and they snickered. Resident #1 then swung out at the CNA, and Staff E grabbed her hands and arms. Staff E then got up out of her chair and stood behind the resident's chair with her leg braced up against the back of the chair. With her hands on the table, the resident tried to push her chair back, but the table moved across the floor. Staff E lifted the resident's hand off the table, and with her body, she shoved the chair up to the table and pinned her against it. e. At 1:50 PM, the residents head was down and she looked to be crying. Staff E then picked up the resident's sweater and placed it on her head, Resident #1 got agitated and threw it off. At 1:52 PM, the resident looked to be yelling, Staff E kept her body firmly at the back of the chair and placed her hand over the resident's mouth. Resident #1 tried to push her chair back again but the table moved instead. Staff F then braced her feet at the base of the table so it wouldn't move as Staff E pushed the resident's chair up to the table again. f. At 1:53 PM, Staff E put her hand over the resident's mouth again and that was when Staff B entered the room. Staff E then backed away from the resident, allowed her to stand and walk around the room. The CNA followed the resident for a short period of time but then went and sat at the nurse's station. On 8/16/24 at 9:49 AM, Staff B said that on 7/29/24, she came down the hallway of the locked memory unit and she heard a resident screaming and yelling. She said that this was not unusual, as Resident #1 did tend to become more agitated in the afternoons. When Staff B entered the eating area, she saw Staff F, CNA sitting in a chair up at the table and Resident #1 was on the opposite side of the table. Staff E was standing behind Resident #1, with her hand over the resident's mouth. The CNA quickly took her hand off of the resident and backed away from her. Staff B said that she was concerned that Staff F was not engaged with the residents as she had a picture or something in her hand and was not paying attention. On 8/17/24 at 10:00 AM Staff E, CNA said that on 7/29/24, Resident #1 was having a rough day, and they had tried different interventions to calm her. She said they had been taking turns caring for her but the staff member that she was working with her was short tempered and couldn't handle Resident #1 for very long. The resident was anxious, agitated, screaming, and yelling for attention she likes attention, good or bad. Staff E said the nurse had given the resident a medication to help calm her, and that tended to affect her gait so they were watching her close because she was a fall risk. The resident didn't want to get into the recliner, and she had been known to approach other residents at times, so Staff E thought a chair at the table was the safest option. Staff F was with her at the table, and some of the chairs don't have the grippers attached on the bottom of the legs. She said that she was afraid that when the resident pushed her chair back, it could tip backwards so that was why she stood behind her to prevent her from pushing it. Staff E said that this was better than letting her stand up and risk falling. Staff E said that at one point, the resident started hitting her, and she was taught that it was okay to place the resident's hands in their laps to keep you and the resident safe. She acknowledged that she put her hand on the resident's mouth several times to shush her. She said that had worked in the past. When asked to describe what a restraint looks like, she said you can't force them to stay in bed, you can't restrict their motion unless they are a harm to you or themselves. When asked about pushing the chair up to the table and trapping the resident, she said that this was a better plan than letting the chair tip backwards. Staff E said that her training on caring for dementia residents included watch videos, and following another CNA on the floor for about a week. She said they really didn't have hands-on training or competency tests to determine if they had learned the skills. Staff E said that she should have probably tried some different repositioning when Resident #1 continued to escalate. She said that they didn't have many staff in the unit and she still felt the safest option for Resident #1 was to keep her from standing and pushed up to the table. She thought the shushing would help, but when it didn't, that's when she decided to give the resident some space and let her walk. On 8/16/24 at 12:20 PM, Staff F, CNA said that she had been suspended from work because her coworker covered a resident's mouth and she didn't have a chance to report it. The resident was yelling out, so Staff E put her hand over the resident's mouth, but she told Staff F to stop but she didn't know if she heard her because the resident was yelling so much. When asked about not allowing the resident to get up out of the chair, Staff F said acknowledged that Staff E was pushing the resident back into the chair. She said that the resident had been swinging at Staff E, but she did not see her holding down the resident's arms. When asked if she had seen anything that she would describe as a restraint, Staff F said that when the resident's chair was pinned up to the table, that was probably a restraint. She said that they have on-line training on how to handle residents with dementia and agitation. She didn't remember much about it or any of the specific techniques that were taught. Staff F acknowledged that by preventing the resident from getting up and walking around, her agitation and yelling had increased. Staff F said that she didn't have a chance to intervene or to report the incident. She wasn't sure why she didn't intervene and said she wasn't thinking clearly that day. On 8/16/24 at 12:30 PM, Resident #2 (BIMS of 15) said that there wasn't much interaction between staff and residents. She said that she'd had several roommates that were totally dependent on staff and the only time they would interact with them was to put them to bed or get them up for meals. They didn't get much stimulation. On 8/17/24 at 8:23 AM, a family member for Resident #1 said the resident did not like to be touched and any attempts to redirect her by putting hands on, would only escalate her. They advised the staff to just walk with her and try not to touch her. She said that at times, the staff would try to talk her into sitting down, and that did not work. She understood that Resident #1 was a fall risk, but trying to force her just made things worse. On 8/17/24 at 7:50 AM Staff H, Assistant Director of Nursing (ADON) said that she had watched the video and acknowledged that Staff E was holding the chair up against the table and she would consider that as a restraint. She said that the staff have online trainings but no direct observations or competency testing. She said they just randomly observed staff interacting with the residents, and if they saw any concerns or something that could be done differently, they would take that opportunity to do education with them. On 8/17/24 at 4:00 PM, Staff D Quality Assurance (QA) nurse, said that the staff had online trainings, but they did not have quarterly in-services for the staff that worked in the memory unit. According to the facility policy titled: Employee Training-Special Care Unit. The special care unit employee would receive quarterly scheduled in-service education to: review information learned during initial training. Keep abreast of new information regarding Alzheimer's disease and other dementias. Improve skill training regarding caring for resident with Alzheimer's disease and other dementias.

Based on observation, interview and record review the facility failed to ensure accurate accounting of Scheduled II medications for 2 of 6 residents (#3 and #4). The facility also failed to ensure that medications were securely locked in the cart and storage room. The facility reported a census of 57 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 2 (severe cognitive deficit). The resident was totally dependent on staff for eating, toileting, dressing. Her diagnoses included cancer, anemia, anxiety disorder, secondary malignant neoplasm of brain, adult failure to thrive. The Care Plan updated on [DATE] showed Resident #3 had alteration in gastrointestinal status related to malignant neoplasm on the abdomen. She had communication problem related to difficulty forming words and self-care deficit related to weakness. The resident was on high risk medications prescribed for pain, depression and anxiety. The following orders were found on the Medication Administration Record (MAR): a. An order dated [DATE] at 12:15 PM for morphine tablet 15 milligram (ml) give 1 tablet every 2 hours as needed for pain. b. An order dated [DATE] at 3:45 PM for 0.5 of Ativan to use as needed (PRN) for anxiety. c. An order dated [DATE] at 5:00 PM for a scheduled 0.5 mg Ativan 4 times a day. According to the Individual Resident Narcotic Record (IRNR) showed from the 27th of May through 31st of May the tabs were administered 18 times, the MAR showed in the same timeframe that the medication was administered just 14 times. Staff used the same IRNR sheet for the scheduled and the PRN Ativan. On [DATE]th, the IRNR showed that the Ativan used 4 times and the MAR showed that it was used 5 times. 2) The MDS for Resident #4, dated [DATE], showed a BIMS score of 14 (intact cognitive ability). The resident was independent with eating, toileting and dressing, transfers and walking. Diagnoses included anemia, anxiety, depression and Chronic Obstructive Pulmonary Disease (COPD). The Care Plan updated on [DATE] showed the resident had altered cardiovascular status and at risk for potential fluid imbalance overload. She had sleep disturbance and insomnia and often had difficulty falling asleep. She had chronic pain syndrome. Resident #4 had an order dated [DATE] at 8:00 PM for lorazepam 0.5 mg twice a day for anxiety, and an order dated [DATE] at 4:00 PM for Pregabalin 200 mg two times a day related to rheumatoid arthritis. According to the IRNR, on [DATE] at 7:34 PM Resident #4 had 3 Ativan tabs remaining. The IRNR for Pregabalin 200 mg showed on [DATE] that there was 1 tab remaining. On [DATE] at 7:58 AM, Staff D, Nursing Supervisor said that she was unsure why there were left over pills for Resident #4 and when there was a changeover with a refill of pills, she investigated when the count was off and would destroy the extra. On [DATE] at 9:42 AM the Director of Nurse stated that she witnessed the medications being destroyed and that it was their process to destroy left over medications so they could start a new narcotic sheet with the number of tabs that were delivered. She acknowledged the 3 Ativan tabs and 1 Pregabalin tab were destroyed and she witnessed that process. 3) In an observation on [DATE] it was discovered the Controlled Drug Count Record for June, (used to verify that all narcotics had been counted at shift change) lacked two nurse initials on the 3rd, 6th and 11th of June. Staff A, Licensed Practical Nurse, had pre-signed for the beginning of her shift at 11:00PM, and the end of her shift at on [DATE]. 4) On [DATE] at 5:30 AM, Staff B, Certified Nurse Aide (CNA) was gathering laundry in the 300 hallway. The medication cart was sitting near the nurse's station with a key attached to a ring of other keys was in the narcotic drawer. The medication room door was propped open. There were no staff in the area supervising the medication cart or room. According to the facility policy titled: Medications: Acquisition Receiving Dispensing and Storage reviewed on [DATE]. An employee would be responsible for receipt of medications and once medications are received, they would be secured in the appropriate storage areas. Medications would be stored in locked medication cart. Staff would routinely check for expired medication and necessary disposal would be done in accordance with state/pharmacy regulations. Controlled drug would be reconciled at least daily through appropriate system of records of recipe and disposition.

Based on facility record review and staff interviews, the facility failed to ensure the facility's Dietary Service Manager had the required qualifications in the absence of a full-time dietitian. The facility reported a census of 57 residents. Findings include: On 12/20/2023 at 11:30 a.m., the Dietary Manager (DM) reported she did not have her Certified Dietary Manager certification. The DM explained she enrolled in a class that starts on 1/8/24. The DM reported she worked with the facility and recently transitioned into the DM role on 9/24/23. The Director of Nursing (DON) explained the facility could not find a policy regarding Dietary Manager. On 12/21/2023 at 12:00 p.m., the DON verified the DM's registration to take an Iowa Food Manager Certification Course. On 12/20/2023 at 3:00 p.m., the Administrator confirmed that the DM enrolled for the class on 1/8/24.

Based on interviews with staff and administration, and policy review the facility failed to provide training or orientation to temporary nursing staff for 2 of 2 staff reviewed (Staff M and N). The facility reported a census of 57 residents. Findings include: On 12/21/23 at 11:28 AM, Staff M, Licensed Practical Nurse (LPN), said that she worked for an agency and had worked at the facility since November on a full-time basis. She said that she did not get orientation when she started, and they just put her on the floor with a full load of residents. She said that she worked at other facilities that provided some orientation and that did help her to transition better. On 12/21/23 at 3:14 PM, Staff N, Certified Nurse Aide (CNA), said that he worked for an agency and had a contract with the facility. He said that he did not get formal training or have an orientation checklist completed before the facility expected him to work independently with the residents. On 12/20/23 at 3:45 PM, the Director of Nursing (DON) said that she did not know they needed to have an orientation checklist for agency staff, but she would investigate that requirement. The Orientation of Contingent Labor (independent contractors or agency staff) Responsibilities, dated 2/12/21, directed the facility to have a plan for orientation and training of contingent labor upon initial hire and annually thereafter. The facilities had the responsibility to provide training based on the duties expected of the contingent labor role.

Based on observations, interviews, record, and policy review the facility failed to keep residents safe from preventable accidents and hazards for 5 of 6 residents reviewed (Residents #49, #31, #50, #22, and #9). Resident #49 required two persons with the use of a mechanical lift for transfers. On two occasions, as one staff member assisted Resident #49, he fell from the lift as they transferred him. Resident #31 had a fall from her wheelchair when staff put her in the wrong wheel chair and failed to secure a safety belt. An observation revealed Resident #50 smoking a cigarette with her oxygen tank nearby. An observation revealed the staff transferring Resident #22 without the use of a gait belt, and Resident #9 sustained a skin tear to her hand when an unleashed dog jumped up into her lap unexpectedly. Findings include: 1. Resident #49's Minimum Data Set (MDS) dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive deficit. The resident had limited impairment of his lower extremity and used a wheelchair for mobility. He required total dependence for bed to chair transfers and for toilet transfers. The MDS included diagnoses of heart failure, anemia, diabetes mellitus, dementia, Parkinson's disease, and muscle weakness. The Care Plan initiated 11/2/23, reflected Resident #49 had communication problems with difficulty speaking and tremors. He had activity of daily living (ADL) self-care performance deficits and needed assistance with all ADLs. Resident #49 required the assistance of 2 for transfers. The Interventions directed the staff to monitor for changes in gait, lower extremity joint function, standing, and sitting balance. The Communication/Visit with Physician note dated 9/1/23 7:39 PM, reflected that as staff transferred Resident #49 with the sit-to-stand mechanical lift, Resident #49's right foot or knee gave out, possibly slipping from the base of the stand. When his leg bent, he went down onto his right knee. The assessment revealed he sustained a skin tear on his right shin. The Incident note dated 10/6/23 at 9:10 PM indicated Resident #49 became weak while hooked up to the sit-to-stand and began to slip down. The staff lowered him to the ground and called for help. The assessment revealed he sustained a skin tear to the right leg below his knee. According to a Sit-Stand-Walk Data Collection tool dated 8/21/23 at 12:06 PM and on 11/27/23 at 9:14 PM, Resident #49 could not bear weight on at least one leg. The tool indicated staff should use a total lift to transfer him. On 12/20/23 at 9:28 AM, the Physical Therapist (PT) said she remembered Resident #49 admitted as a total full-body mechanical lift (Hoyer lift). When he got stronger, they transferred him to a sit-to-stand. She said the facility policy instructed to use the assistance of two persons with all mechanical lifts. On 12/20/23 at 12:02 PM, Staff G, Registered Nurse (RN) said that she worked when Resident #49 fell from the sit-to-stand. She said that Staff I, Certified Nurse Aide (CNA), transferred Resident #49 by herself. She heard Staff I call for assistance because Resident #49 fell . Staff G said she completed an assessment to determine his need for the mechanical lift. At that time the nurses and PT had a difference in opinion on his ability to bear weight on his legs. On 12/20/23 at 2:00 PM Staff I, CNA, said that when Resident #49 first came to the facility he transferred with a sit-to-stand lift but then he required the Hoyer due to his weakness. She said as she transferred him to sit, he started leaning, and slowly lowered down. She said she received training to use two people for mechanical lift transfers. She didn't know why she hadn't waited for help when she transferred Resident #49. She said while he stood with the sit-to-stand lift, she turned away from him for a minute, and when she turned around she saw him sliding down, so she braced him until help came. On 12/21/23 at 10:45 AM, the Director of Nursing (DON) said she expected staff to use two with a sit-to-stand transfer, especially with a known unstable resident. The Safe Resident Handling policy dated 8/1/23, instructed to identify the resident's most appropriate method of transfer, use a Sit Stand Walk Data Collection Tool. 2. Resident #31's MDS dated [DATE], identified a BIMS score of 4, indicating severe cognitive deficit. Resident #31 required total dependence from two staff for transfers, dressing, locomotion, and hygiene. She used a wheelchair for mobility. The MDS the use of a restraint to prevent her from sliding from the wheelchair. The Care Plan updated 12/4/23 indicated Resident #31 had a traumatic brain injury with limited mobility, she was chair fast, did not ambulate, and required the use of a full-body mechanical lift (Hoyer lift) for transfers. She used a wheelchair with a seatbelt in place. On 12/20/23 at 11:49 AM, observed two Certified Nurse Aides (CNAs) transfer Resident #31 from bed to the wheel chair with the use of a Hoyer lift. They fastened a lap belt around her waist after she sat in her chair. The Incident Report dated 10/13/23 at 4:50 PM, indicated a visitor alerted staff of Resident #31 sliding from her wheelchair. By the time staff got to her, she fell on the floor. On 12/20/23 at 1:05 PM, Staff J, CNA, said that on the day Resident #31 slid from her chair, she and Staff H, CNA, transferred her into a wheelchair from just outside her room in the hallway. They found out later that the wheelchair belonged to a different resident and she didn't remember seeing a seat belt. They wheeled her to the chapel where Resident #31 liked to sit. She acknowledged that she should have taken steps to ensure Resident #31 sat secure in her chair. On 12/20 at 12:02 PM, Staff G, Registered Nurse (RN), said she worked the day Resident #31 slid from her wheelchair. The two aides grabbed a similar looking wheelchair with a seat belt that belonged to another resident. Due to Resident #31 weighing more, they couldn't buckle the seat belt. A family member saw Resident #31 sliding down out of the chair and went to get staff. By the time staff got to her, she had slid onto the floor, but she did not have any injuries. 3. Resident #50's Minimum Data Set (MDS) dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 14, indicating no cognitive impairment). Resident #50 used a walker and/or a wheelchair for mobility with all transfers. The MDS indicated that she could walk independently for 150 feet. The MDS listed Resident #50 as independent with eating, oral hygiene, toilet hygiene, shower/bathing, upper and lower body dressing, and personal hygiene. The MDS included diagnoses of chronic obstructive pulmonary disease (chronic lung disease), hypertension (high blood pressure), and anxiety disorder. Resident #50 had shortness of breath with exertion (walking, bathing, transferring), and used supplemental oxygen therapy. The Care Plan updated on 9/12/23 showed that Resident #50 had ineffective gas exchange, used continuous oxygen therapy at 3 liters (L) per nasal cannula, and used tobacco products. The Interventions directed the staff to remove Resident #50's oxygen prior to smoking, store her cigarettes and lighter at the nurse's station. Staff were to provide an extension tubing or portable oxygen apparatus. A Tobacco Assessment completed on 9/21/23 showed that Resident #50 wished to smoke 4 times a day. The cognitive status section listed her as independent with smoking. Resident #50 had physical limitations that interfered with her ability to get outside and back into the center independently; the document lacked descriptions of those limitations. Resident #50 received oxygen therapy, but she did not have a physician order allowing her to remove her oxygen for smoking. The Medication Review Report dated 11/9/23 included an order for continuous oxygen at 3 L per nasal cannula via an oxygen concentrator and/or a tank. The chart lacked a physician's order for smoking. On 12/20/23 at 11:20 AM, observed Resident #50 walk independently with a front wheeled walker down the hall with a portable oxygen tank attached to the front of the walker. Staff B, Certified Nurse Aide (CNA), assisted Resident #50 with the first set of double doors into a breezeway (small room between a doorway and the main portion of a building). Resident #50 grabbed her coat from a hook, put it on independently, entered a digital code to disengage the door alarm, and exited the building. An unidentified staff member assisted her with the door to the outside. Resident #50 sat in a chair outside the door and proceeded to light a cigarette. With the lit cigarette in her mouth, and nasal cannula in her nose, Resident #50 leaned over the portable tank to adjust the tank and turn the top key. When Resident #50 finished her cigarette, she bent over, put it out on the ground, and disposed of it in the smoking canister. Resident #50 adjusted the key and side dial of the portable oxygen tank, then remained seated outside. Several unidentified staff walked by Resident #50 at various times while she sat outside. An unidentified staff entered the building and assisted Resident #50 with both sets of doors. Resident #50 independently removed her coat and hung it on a hook between the doors. Afterwards, she walked to the dining room using the front wheeled walker with the portable oxygen tank attached and sat down at her table. The portable oxygen tank revealed her setting at1L. In an ongoing observation throughout the noon meal and back to her room, the oxygen remained at 1 L. Resident #50's lips had a blue tint. This observation with the use of the portable oxygen tank usage ended at 12:51 PM with no staff verifying the setting of the portable oxygen tank while in use. On 12/20/23 at 11:20 AM, Staff B said that Resident #50 could smoke independently. On 12/20/23 at 12:52 PM, Resident #50 said that during the day, she kept her cigarettes and lighter inside the zipped pocket of her coat. At night, she kept them in the nurses' station. She said that the facility kept her carton. Resident #50 said that she could enter the code to disengage the door alarm but if it took too long, an alarm would go off, and then she would need to re-enter the numbers. She said that other residents had ankle monitors which caused the alarm to go off when they got too close to the door. Resident #50 stated that while outside, she pushed the walker with oxygen away from her, turned the key, and watched the dial. She would then remove the nasal cannula and place it on the walker. On 12/21/23 at 8:28 AM, Staff A, Registered Nurse (RN), said that Resident #50 shouldn't smoke with an oxygen tank. She said that they instructed Resident #50 to use a concentrator when smoking. Staff A said the staff had concerns that Resident #50 was non-compliant regarding smoking safety. She described the facility as a smoke free facility, with only 1 resident grandfathered in for tobacco use. Staff A did not know why the facility now allowed smoking and when they started to allow residents to smoke. On 12/21/23 at 9:27 AM, Staff C, Director of Nursing (DON), said that Resident #50 had no set time for smoking, and came to the facility as a smoking resident. Staff C indicated that the staff had some confusion regarding Resident #50's oxygen usage and whether she should use a tank or concentrator. Staff C stated that the physician indicated that if Resident #50 smoked, it would be better to use a concentrator. Resident #50 previously smoked in the courtyard with a receptacle available. Staff C indicated the facility kept the smoking supplies at the nurses' cart. Resident #50 would notify the staff when she went out to smoke and could ask for assistance as needed. When asked about following up with Resident #50's oxygen tank settings upon completion of smoking, Staff C stated their facility didn't have a policy or protocol in place to ensure the resident received the correct oxygen setting. On 12/21/23 at 10:20 AM, Staff D, RN, said the doctor gave approval for Resident #50 to smoke independently. The facility provided education to Resident #50 regarding the use of oxygen and safety with a reverse demonstration. Resident #50 demonstrated to staff how to turn her oxygen off and on using the side knob and top key, along with pushing her walker out to the side or in front. Staff D couldn't give an exact distance for Resident #50 to keep the walker away to ensure safety while smoking. Staff D stated that she hadn't witnessed any unsafe practices when Resident #50 smoked. The facility didn't have procedures in place to check/monitor Resident 50's oxygen settings or saturations after she finished smoking. On 12/21/23 at 10:45 AM Staff C reported Resident #50 received education at various times. Resident #50's chart lacked documentation related to the training. The Tobacco Free Policy, described the facility as a Tobacco Free Building or Tobacco Free Facility. The policy indicated if the facility continued to have grandfathered in residents on July 1, 1994, such tobacco use spaces must be readily visible for employee observation, must be free of hazardous materials, and provide adequate ventilation. The space must be physically separate from the common areas used by non-tobacco users. Residents who smoke must not pose a safety hazard to themselves or others. 4. Resident #22's MDS dated [DATE], identified a BIMS score of 5, indicating severe cognitive deficit. Resident #22 required substantial assistance to sit from the side of the bed. The Care Plan dated 1/11/19 reflected Resident #22 had an intellectual disability and required assistance with decision making. The Interventions directed the staff to provide a safe environment and ensure call light within reach. Transfers between surfaces required 1-2 staff assistance. On 12/18/23 at 11:56 AM, observed Staff K, CNA, go into Resident #22's bedroom where she sat on the edge of the bed. Resident #22 said she wanted to get into her wheelchair next to the bed. Staff K approached Resident #22, put her arms under Resident #22's arms and lifted her with a bear hug from the bed to the wheelchair. On 12/21/23 at 10:45 AM, the DON said they directed the staff to use a gait belt with all transfers. 5. Resident #9's MDS dated [DATE] identified a BIMS score of 0, indicating severe cognitive deficit. Resident #9 used a wheelchair for mobility. The MDS listed Resident #9 as always incontinent of bowel and bladder. The Care Plan revised 6/9/21 reflected Resident #9 had impaired cognitive function related to dementia with difficulty expressing herself and had difficulty understanding others. The Intervention revised 8/15/18 instructed that Resident #9 enjoyed holding a baby doll. On 12/19/23 at 2:31 PM, observed Resident #9 sitting in her wheelchair with a baby doll in her hand with some bruising on the top of her right hand. She did not respond to questions. The Incident Note dated 11/28/23 at 1:15 PM labeled Late Entry indicated as Resident #9 sat in her wheelchair in the living room, a visitor's dog jumped up into her lap, causing a skin tear to her right forearm and right hand. On 12/19/23 at 2:27 PM, Staff L, Licensed Practical Nurse (LPN), reported she observed when the dog jumped into Resident #9's lap. She saw the dog several times and always without a leash. Resident #9 didn't startle, appear afraid, appear in distress. The dog did not stay in her lap very long. Staff L said the dog belonged to a staff member. On 12/21/23 10:11 AM, the DON said the dog who jumped into Resident #9's lap belonged to the Activity Director. She said the planned to have the dog on a leash. Another incident happened in October where the dog scratched a different resident, the owner planned looking into getting some protective shields to put on his toe nails. The Animals in Long Term Care policy, reviewed 2/10/23 reflected the facility would provide procedures to promote the safety of building occupants when animals were present.

Based on observation, interview and record review the facility failed to notify the physician when a resident did not get her scheduled medication for 1 of 4 residents reviewed (Resident #50). Resident #50 had an order for Lexapro daily, when she ran out of her pills, the staff failed to replenish the supply. In addition, the facility failed to notify the phsyician regarding a significant change in weight for 1 of 2 residents reviewed (Resident #55). Resident #55 had a significant loss in weight in 6 months (greater than 10%) of 11.2%. Findings include: 1. Resident #50's Minimum Data Set (MDS) dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 14, indicating no cognitive impairment). Resident #50 used a walker and/or a wheelchair for mobility with all transfers. The MDS indicated that she could walk independently for 150 feet. The MDS listed Resident #50 as independent with eating, oral hygiene, toilet hygiene, shower/bathing, upper and lower body dressing, and personal hygiene. The MDS included diagnoses of chronic obstructive pulmonary disease (chronic lung disease), hypertension (high blood pressure), and anxiety disorder. Resident #50 had shortness of breath with exertion (walking, bathing, transferring), and used supplemental oxygen therapy. The Care Plan updated on 9/21/23 showed that staff were to consult with the pharmacy and health care provider regarding her psychopharmacological medications. The Clinical Orders listed an order dated 9/12/23 at 7:15 AM for Escitalopram (Lexapro) 20 milligrams daily (medication used for treatment of depression and anxiety). A review of the Medication Administration Record (MAR) revealed that the medication was not available for 15 days, in October and 3 days in November. Progress Notes Review a. On 10/17/23 at 11:04 AM the facility called the pharmacy regarding no Lexapro delivered. The pharmacy stated they never filled the medication before. b. On 10/28/23 at 12:43 PM, Resident #50 complained of not feeling well, laid in bed and refused her meals. In addition, she reported symptoms of a urinary tract infection (UTI). c. On 11/2/23 at 9:53 AM a staff member discussed with Resident #50 about the missed medication and her change in habits, including staying in bed more and skipping meals. They explained the missed doses of Lexapro could cause the symptoms. d. On 11/2/23 at 12:55 PM, a staff member discovered Resident #50 did not have a card of Lexapro. Resident #50 appeared to sleep more and stayed in bed most of the day. On 12/20/23 at 11:21 AM, Staff E, Certified Medication Aide (CMA), said that any time the Medication Administration Record (MAR) displayed a scheduled medication, it needs administered. If the medication is not present, she would notify the nurse and document on the missing medication. The chart lacked physician notification until Resident #50 missed 16 doses of her Lexapro. On 12/20/23 at 12:52 PM, Resident #50 said that after her surgery she had lots of changes made, and she did not know all of them. She knew about recent changes in her antibiotics related to a urinary tract infection. She said that she felt down, but she had many losses and changes during the past year. The Medications: Acquisition Receiving Dispensing and Storage policy dated 3/2/23 directed licensed nursing employees as responsible for ordering from the pharmacy and checking all new orders of medications from the physicians' orders. The licensed nurse and or medication aides had the responsibility for reordering of medication per their pharmacy system. Staff are to report discrepancies and omissions promptly. 49056 2. Resident #55's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. The MDS included diagnoses of Alzheimer's disease, anxiety, depression. The Weight and Height Policy dated 9/18/23 directed the licensed nurse to notify the Director of Food and Nutrition (DFN) within 24 hours regarding any significant weight change. The policy defined a significant weight change five percent in 30 days, 7.5 percent in 90 days, and 10 percent in 180 days. The licensed nurse should immediately notify the medical provider regarding any significant weight change. The facility should weigh residents at nutritional risk weekly. The location will immediately inform the, consult with the resident's physician and, if known, notify the resident's legal representative when they have a significant change in weight. Review of Resident #55's clinical record reviewed the following information: On 6/16/23, Resident #55 weighed 191.8 pounds. On 9/27/23, Resident #55 weighed 181 pounds which is a -6.1% Loss On 6/16/23, Resident #55 weighed 191.8 pounds. On 11/9/23, Resident #55 weighed 178 pounds which is a -11.2% Loss. Resident #55's undated Care Plan lacked information regarding weight loss or interventions in place to prevent further weight loss. Resident #55's clinical record lacked physician notification regarding their significant weight loss. On 12/21/23 at 8:25 a.m. the Director of Nursing (DON) revealed the nurse should notify the physician of a significant weight loss. They are trying to put new processes into place.

Based on clinical record review, physician and staff interviews and facility policy review, the facility failed to immediately notify the physician in order to obtain prompt treatment for [REDACTED].# 17). The facility reported a census of 46 residents. Findings included: According to a Minimum Data Set (MDS) assessment dated [DATE], Resident #17's [DIAGNOSES REDACTED]. The MDS identified the resident's Brief Interview Mental Status (BIMS) as 7, indicative of severely impaired cognition. The MDS revealed the resident as independent with bed mobility, transfers, dressing and had a steady balance and required the use of a urinary catheter. Resident #17's care plan included a focus, initiated on 7/31/18, for an indwelling catheter related to an enlarged prostate and history of [MEDICAL CONDITION]. The care plan included an intervention for staff to monitor, record and report to a health care provider any signs and symptoms of pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature (temp), urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns. Review of Resident #17's nursing Progress Notes revealed the following information: On 10/15/18 at 2:03 P.M., Resident #17 had a Foley (urinary) catheter draining straw colored urine (straw colored urine is considered normal color). On 10/15/18 at 5:42 P.M. - (Note- Staff documented this note as a Communication/Visit with Physician) - The resident displayed increased confusion, a low grade fever of 99.8 degrees Fahrenheit (F), abdominal tenderness at times, purulent green discharge in his catheter bag. Other vitals: Pulse (p)- 96 beats per minute (bpm), Respirations (r) -18 per minute, blood pressure (BP) 140/84. Staff requested a UA (urinalysis). On 10/15/18 at 8:40 P.M. - Staff described Resident #17 as confused and he refused supper. The urine in his catheter had increased odor, purulent drainage and at times he stated he had abdominal pain. Staff documented a low grade temp of 99.8 degrees F and sent a fax (facsimile) to the physician to inquire about a UA (even though a previous fax had been sent after office hours). On 10/15/18 at 8:01 P.M. - Staff documented a 'Change in condition, symptom or signs called about' note regarding Resident #17's altered mental status and fever. Staff documented the resident's vital signs as: t- 99.8, p-96 r-18. (Note- even though the progress note states called about, no phone call had been made to a physician, other than a fax to a physician's office after hours). Review of a Change in Condition Evaluation form dated 10/15/18 at 8:01 P.M., revealed staff documented Resident #17 had an altered mental status, fever and the following vital signs: BP- 140/84, t-99.8, p- 96, r-18. Staff described the resident with increased confusion, an abrupt significant change in cognitive function, symptoms or signs of pain, abdominal distension or tenderness, occasional labored breathing and documented the resident's symptoms as worse since the initial change in condition occurred. The evaluation form included a notification section with guidance to notify a medical doctor, nurse practitioner or physician assistant immediately in regards to the resident's general weakness, abdominal pain, increased confusion and memory loss (the record review revealed staff failed to notify a Medical Practitioner in regards to the resident's ongoing symptoms). On 10/16/18 at 12:05 A.M. staff documented Resident #17 complained of being cold and shivering and administered Tylenol 650 milligrams (mg). On 10/16/18 at 10:24 A.M. - Staff documented the resident as very weak and lying naked across his bed this morning. He sat up with the assistance of two staff and a nurse needed to help him get dressed. The resident walked to a recliner with his walker with a slow unsteady gait. The resident complained he had not felt well and wanted to return to bed after breakfast. Staff described the resident's urine in his drainage bag as thick milky white in color. Staff documented the resident's daughter had been in the facility and aware of the resident being ill. On 10/16/18 at 1:20 P.M. staff documented calling a physician to report an elevated temperature of 103.6 degrees F, p-112 and described the resident's urine as dark in color and milky. Staff documented the physician ordered the resident to be sent to a hospital emergency room (ER). Review of a pain level summary report form revealed the resident had no complaints of pain between 10/1 - 10/14/18. On 10/15/18 at 5:41 P.M. the resident rated his pain at 5 ( on a scale of 0 -10, 10 being the worse pain). On 10/16/18 at 8:53 A.M., the resident rated his pain at 4. In an Emergency Department Provider note dated 10/16/18 at 2:18 P.M., the physician documented Resident #17 presented to the ER with fever and confusion. The physician documented a septic workup had been initiated and described the resident's urine as a thick purulent liquid and because of the urine and the indwelling catheter, the resident'[MEDICAL CONDITION] was probably due to the catheter. The physician diagnosed the resident with a bladder infection [MEDICAL CONDITION]. A History and Physical note dated 10/17/18 at 5:49 P.M. documented the resident with acute [MEDICAL CONDITION]. Review of a Procedures -Encounter Notes, dated 10/22/18 at 8:01 P.M., revealed the resident required the insertion of a PICC (peripheral inserted central catheter) line. Review of a Discharge Summary form, with an admission date of [DATE] and discharge date of [DATE], revealed a discharge [DIAGNOSES REDACTED]. The physician's brief history description of the resident's course of illness documented Resident #17 became lethargic and subsequently transferred to the hospital. At that time of arrival to the ER the resident's temperature measured 102.2, BP -88/51 and a blood sugar of 500. The physician described the resident as quite sick. According to a nurse Progress Note dated 10/23/18 at 11:50 A.M., the resident returned to the facility following his hospitalization . According to a nurse Progress Noted dated 10/23/18 at 6:30 P.M., staff documented the resident required the assistance from 2 staff and the use of a platform walker from transfers. A facility Policy for Notification of Change, dated 11/16, included the following: A facility must immediately inform the resident's physician and the resident's representative of a significant change in a resident's physical, mental or psychosocial status. During interview on 1/29/19 at 1:20 P.M., the Director of Nursing (DON) stated there was no copy of the fax sent to the resident's physician on 10/15/18 at 5:40 P.M. She stated if the doctor does not respond, they don't keep the fax. The DON stated she expected a nurse to notify the doctor directly if a resident had thick purulent drainage in their catheter bag, abdominal tenderness, increased confusion and a low grade temp. The DON expected the nurses to follow the assessment tool the facility uses. The DON stated the nurse did a change in condition assessment on 10/15/19, but then did nothing with it regarding physician contact. The nurse should have notified a doctor with the beginning of significant changes on 10/15/18. During telephone interview on 1/29/19 at 3:11 P.M., the resident's physician confirmed staff needed to contact a physician at the time Resident #17 began to have symptoms of purulent green drainage in his catheter bag, abdominal pain, confusion, etc. The physician confirmed in the event there are concerns after office hours, there is always a physician available at a local ER.

Based on observation, record review, resident and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision or assistance devices to prevent accidents for 2 of 6 residents reviewed (Resident #6 & Resident #3). Facility census was forty-eight (48) residents. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 ' s brief interview for mental status (BIMS) score of 0. Resident #6 speech was unclear and notations of rarely understands others and rarely makes his/herself understood. Resident #6 ' s cognition was identified as severely impaired and exhibited short and long term memory issues. Resident #6 exhibited wandering behavior 4 to 6 days out of 7. According to the MDS Resident #6 independently transferred and ambulated with supervision in the corridor. A balance during transitions and walking test identified the resident as not steady but able to stabilize without staff assistance. Resident#6 ' s [DIAGNOSES REDACTED].#6 was 60 inches tall and weighed 85 pounds. The MDS identified Resident #6 experienced no falls since the prior assessment. Resident #6's care plan with target date of [DATE] identified the resident exhibited behavior symptoms related to dementia and anxiety as evidenced by increased confusion and easily agitated behavior. The care plan directed staff to intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Resident progress notes identified Resident #6 admitted to the facility on [DATE] from another facility. A social service progress note dated [DATE] at 6:53 p.m. revealed Resident #6 admitted to the CCDI (chronic confusion and dementing illness) unit following an elopement at the previous facility. Resident progress notes contained the following information regarding Resident #6's: [DATE] 4:36 a.m. Wandering at 3:30 a.m. and woke residents up that slept in recliners [DATE] at 8:15 p.m. Ambulating up and down hallway attempting to enter other resident rooms [DATE] at 12:59 p.m. Ambulating in hall and entering other resident rooms. [DATE] at 5:12 p.m. Wanders daily looking for a way out of the CCDI as well as looking for parents. [DATE] at 3:10 a.m. Wandered unit with another resident. [DATE] at 3:28 a.m. Resident wandering up and down hall opening and closing doors. [DATE] at 7:59 p.m. Found lying in another resident's bed. [DATE] at 12:30 a.m. Pacing floor and knocking on CCDI door. [DATE] at 5:08 a.m. Pacing up and down halls wanting to leave the CCDI. An incident description dated [DATE] at 1:39 p.m. identified an incident occurred in the hallway. Resident #6 wandered and shut doors of resident rooms. One of the resident rooms had an open window. The pressure from the open window caused the door to quickly slam shut with Resident#6's fingers caught in the door. Resident #6 received a laceration and abrasion to the back of the left hand. The nursing progress notes dated [DATE] at 1:28 p.m., identified the left hand pointer finger and middle finger with open areas (no sizes listed). Staff cleansed the areas and applied band aides. An incident description report dated [DATE] at 6:05 p.m., identified an incident occurred in the hallway. Staff A certified medication aide (CMA) sat at the nurses station outside the CCDI unit. Staff A heard a loud bang from the CCDI unit. When Staff A entered the CCDI unit, she observed Resident #6 seated on the buttocks on the floor of the hallway with legs extended in front of the resident. Resident #6 held onto the right hip. Staff A summoned the nurse and Resident #6 was transported to the emergency room (ER) with a suspected fracture of the right hip. The incident description report identified a resident to resident incident in which physical contact was made. A nursing progress note dated [DATE] at 9:26 p.m., revealed Resident #6 sustained a right hip fracture and was transported to a hospital in Sioux City. A hospital history and physical (H & P) dated [DATE] revealed Resident #6 was admitted to the hospital [DATE]. The H & P identified Resident #6 in his/her usual state of health with a habit of shutting doors when someone took hold of the door resulted in Resident #6 losing his/her balance. Resident #6 fell around 6:00 p.m. A local hospital identified a right intertrochanteric fracture and transferred to a larger hospital for further management. Resident #6 admitted to the surgical floor. A hospital discharge summary dated [DATE] identified Resident #6 underwent IM nailing for the right intertrochanteric hip fracture. The summary revealed complications with the hospital course by Resident #6's negligible oral intake. The family declined feeding tubes and Resident #6 transferred back to the nursing home. A nursing progress note dated [DATE] at 1:50 p.m., identified Resident #6 returned from the hospital after surgical repair of the hip fracture. Resident #6 exhibited facial grimacing and moaning. Resident #6 used oxygen at 3 liters per nasal cannula. Resident #6 unable to answer questions. On the same date at 3:00 p.m., the physician assistant (PA) ordered Fentanyl 25 micrograms per hour for pain control. Assessment identified Resident #6 with a wound on the right hip with bruising from the mid back around the right side of the right posterior hip, thigh and outer thigh with knees purple to blue in color. The PA gave permission to consult with Hospice and admit to hospice. The nursing progress note dated [DATE] at 2:36 p.m. revealed the admission to Hospice. Family notified by the hospice staff. A nursing progress note revealed Resident #6 expired on [DATE]. A death certificate identified the immediate cause of death as congestive heart failure of 7 days, due to or as a consequence of hip fracture of 7 days, with underlying cause of dementia. Staff Working When the Incident Occurred: On [DATE] at 3:00 p.m. Staff C CNA stated she heard a call for help and went to assist in the CCDI for a few minutes. Resident #6 was on the floor. Resident #6 never said what occurred while Staff C was there. On [DATE] at 3:30 p.m. Staff D CNA identified herself as on light duty and stated Resident #3 didn't like it if anyone barged in the room. Resident #6 wandered the hall and opened and shut doors as he/she went. Resident #3 told Resident #6 to stay out of his/her room before. Staff D heard other staff talk about Resident #3 not liking Resident #6 in the room before. Staff D stated she thought Resident #6 would stumble if someone tried to interfere with his/her walking. On [DATE] at 6:10 p.m. Staff E LPN stated she was on dinner break off facility property when the incident occurred. She got a call on her mobile phone from Staff A telling her to return to the facility. A nurse from another area of the building remained with the resident until Staff E arrived. Staff E observed Resident #6 seated on his/her bottom with his/her legs in front of him/her outside Resident #3's room. Later in the shift Staff E asked Resident #3 what occurred and Resident #3 told her that Resident #6 was in his/her room. Resident #3 could not finish the sentence due to speech issues. Resident #3 denied pushing Resident #6. Staff E stated she did not know of Resident #3 ' s being protective of his/her room. She stated Resident #6 did wander the hall and closed and opened doors and peeked in rooms. On [DATE] at 2:10 p.m. Staff B CNA stated she was in a resident room bagging laundry and when she left the room, she observed Resident #6 on the floor crying. Staff B went to Resident #6 and she/he stated they were mad and pushed Resident #6. Not even 30 seconds later, Resident #3 opened his/her room door and stated he/she just pushed Resident #6 a little and that Resident #6 was fine. Staff B stated Resident #6 weighed only about 82 pounds so it would be easy for him/her to be thrown off balance. Staff B stated staff members knew Resident #3 got angry when others tried to go in his/her room without knocking. Resident #3 didn't like people in his/her room. In the past, Resident #1 kept poking his/her nose in Resident #3's room so Resident #3 shoved a chair under the door knob to keep him/her out. The resident did that a few times. On [DATE] at 3:10 p.m. Staff A CMA stated she sat at the desk on the computer outside the CCDI unit. She heard a big boom and a scream that came from inside the unit. She locked the computer and entered the unit and saw Resident #6 on the ground. Resident #6 stated he/she fell , grabbed the right hip and stated it hurts. Staff M LPN (licensed practical nurse) assessed Resident #6 and Staff B CNA (certified nursing assistant) arrived and sat with Resident #6. At that time Resident #6 stated that a man pushed him/her. Resident # 3 then opened his/her door. Staff members asked Resident #3 if he/she saw anything and Resident #3 replied that he/she just wanted Resident #6 out of his/her room. Staff A stated she also observed Resident #1 in the hallway when she observed Resident #6 on the floor and then Resident #3 opened his/her door. On [DATE] at 8:42 a.m. Staff M LPN stated she was the charge nurse for the other unit. Staff members called her to the CCDI because Staff E LPN was on a break. Resident #6 sat with his/her back to the wall. While assessing Resident #6, Staff M LPN assessed shortening and rotation of the extremity for Resident #6. Other staff: On [DATE] at 11:40 a.m., the Director of Nursing (DON) stated she received a call at home that Resident #6 fell . She went to the facility and observed Resident #6 on the floor at an angle from Resident #3's doorway. Staff A stated she heard a noise and scream and entered the CCDI to find Resident #6 on the floor. Resident #6 stated to staff that Resident #3 pushed him/her. Resident #3 said he/she shut the door. The DON didn't know if Resident #6 fell back when the door shut. Resident #3 stated Resident #6 came in and he/she shut the door. An hour or so later the DON asked Resident #3 what happened. At that time, the resident stated he/she put his/her hand on Resident #6's shoulder to get him/her out of the room. Resident #3 put his/her hand on the DON's shoulder to demonstrate and gently pushed the DON out of the room. The DON stated if Resident #3 touched Resident #6, that Resident #6 might startle and get off balance or if turning to go out, Resident #6 could get off balance. Resident #6 went up and down the hallway closing doors. One time Resident #6's finger got slammed in a door when he/she closed a door. After the [DATE] incident, Resident #6 went to the hospital and returned and expired shortly after that. The DON identified Resident #3 as a loner who left his/her room to attend meals. The DON never heard Resident #3 had problems with residents entering his/her room other than Resident #1. Resident #1 stopped at Resident #3's room and Resident #3 told the other resident to leave. On [DATE] at 2:17 p.m., Staff L CNA stated Resident #6 would open resident doors and go in and mess around. On [DATE] at 2:27 p.m., Staff G CNA stated Resident #6 liked to open doors and peek in. Resident #3 appeared territorial so he/she would jump up and shut the door when that occurred. Staff G stated Resident #3 pushed staff out of the room before. Resident #3 stated no and tried to get staff out of his/her room. Staff G stated the resident barricaded the entrance to his her room with chairs and other items in the past. Resident #3 unable to explain why he/she did it due to speech problems. On [DATE] at 4:30 p.m., Staff N MDS (Minimum Data Set) nurse stated no one witnessed the incident, it was just heard by a door shutting and a scream. On [DATE] at 12:12 p.m., Staff H CNA stated Resident #3 occasionally got mad when people went in his/her room. Resident #3 gets mad and slams the door. 2. A MDS assessment dated [DATE] identified Resident #3 ' s BIMS score of 3 that indicated severe cognitive impairment. Staff usually understood Resident #3 but had difficulty communicating some words or finishing thoughts. The MDS identified other behavioral symptoms directed at others 1 to 3 days out of 7. Resident #3 ambulated independently in the room and with supervision in the hallway. The MDS listed Resident #3 ' s [DIAGNOSES REDACTED]. The resident measured 70 inches tall and weighed 185 pounds. Resident #3 Nursing progress notes: [DATE] at 12:49 p.m. Staff observed Resident #3 push another resident's wheelchair from the front when the other resident approached Resident #3. [DATE] at 8:14 p.m. Resident #3 barricaded room door with chair. Resident #3 stated he/she didn't like that guy when asked about the door barricade. [DATE] at 8:05 p.m. After the evening meal Resident #3 commented that another resident was out to kill him/her. Resident #3 then partially barricaded door with small chair. [DATE] at 9:00 p.m. Resident #3's door remained partially barricaded. Resident #3 informed a nurse aide that another resident entered his/her room twice that evening. [DATE] at 3:52 p.m., Resident #3 made needs known. Resident #3's behaviors fluctuated with refusal to leave the room and barricading his/her door. A physician encounter form dated [DATE] identified the ARNP (advanced registered nurse practitioner) last observed Resident #3 on [DATE] and was prescribed Buspar (antianxiety) 2.5 milligrams (mg.) morning and supper due to Resident#3 ' s complaint of feeling more anxious on a daily basis particularly with any activity involving other people. The ARNP documented that if Resident #3 went in his/her room, Resident #3 did fine with anxiety. Since the ARNP last saw Resident #3, he/she appeared happy and smiling. The ARNP documented Resident #3 did get stressed when a lot of people were around. Resident #3 did need to go to his/her room to de-stress. Sometimes Resident #3 even put things by the room door blocking the entrance, so others would leave Resident #3 alone. Staff reported residents wandered into Resident #3's room uninvited if Resident #3 didn't block the entrance. Resident #3 acknowledged that he/she needed alone time. Resident #3 liked people but when Resident #3 felt the need for a break, others need to leave Resident #3 alone. Nursing progress notes dated [DATE] at 9:37 p.m., revealed staff entered Resident #3's room at bedtime to assist Resident #3 with cares. Resident #3 told the nurse aide that he/she didn't want her or anyone else in his/her room ever again and that he/she didn't need help with care. A physician encounter form dated [DATE], identified the ARNP last observed Resident #3 on [DATE] with no concerns identified since that visit. Resident #3 continued to prefer alone time for the most part and got agitated when exposed to a lot of noise and activity on the unit. Nursing progress notes dated [DATE] at 12:53 p.m. revealed staff informed Resident #3 ' s physician staff members located Resident #6 on the floor in the hallway across from and diagonal to Resident #3's doorway. Resident #3 told staff about pushing Resident #6 a little. On the first interview, Resident #3 said Resident #6 came into his/her room and Resident #3 closed the door. The second interview, Resident #3 stated he/she pushed Resident #6 away and demonstrated by placing his/her hand on staff nurses left shoulder and guiding staff away from the doorway and closing the door. On [DATE] at 11 a.m. the surveyor knocked on Resident #3's door. A motion sensor mounted at the top of the door failed to alarm when the surveyor entered the room. Resident #3 answered the door and let the surveyor come in. Resident #3 stated things are pretty bad at the facility and started to say we don't get . and could not finish the sentence due to speech issues. Resident #3 stated other residents used to come in his/her room but they don't anymore. Resident #3 stated a lot of different residents used to come in the room and he/she didn't like it. Resident #3 stated it disturbed him/her. When asked if he/she ever pushed anyone out of the room Resident #3 stated, Not really. Resident #3 did say that he/she touched the other resident to get him/her out. Resident #3 stated he/she could not show the surveyor what he/she did when the incident occurred. Resident #3 stated that Resident #6 entered his/her room in the past, but left when told to get out. Resident #3 stated he/she didn't touch any other residents to get them out of the room. The surveyor asked Resident #3 about a buzzer sounding on his/her door when he/she left the room. Resident #3 said yes and attempted to demonstrate. At that time, Resident #3 exited the room and the alarm failed to sound. Closer observation by the surveyor revealed the alarm in the off position. On [DATE] at 2:17 p.m. Staff L stated laundry left Resident #3's clothes elsewhere because Resident #3 didn't like laundry staff in his/her room. Resident #3 got angry and yelled at them to get out. Resident #3 placed a chair in front of his/her door before to keep people out. On [DATE] at 9:55 a.m., the social service director stated Resident #3 liked his/her space and did not appear sociable. The resident normally came to meals and then back to his/her room routine. The resident had [DIAGNOSES REDACTED]. Staff knew the resident did not like people in or around his/her room. The resident considered that area his/her personal space. The resident goes to the door and shuts it. The resident appeared alarmed if someone just walked in. The social service director stated she did not think the resident would intentionally hurt anyone. On [DATE] at 11:47 a.m., Staff O the nurse manager stated Resident #3 barricaded the entrance to his/her room before. Other than that, she didn't know of the resident having issues with others going in his/her room On [DATE] at 12:12 p.m., Staff J LPN stated Resident#3 tried to keep laundry staff out of his/her room so laundry staff delivered laundry to the shower room. The CCDI staff put the laundry in Resident #3's room. Resident #3 yells at the laundry staff. On [DATE] at 3:32 p.m., Staff I LPN stated Resident #3 didn't like staff to go in his/her room. Resident #3 would get angry and wave at staff to tell them to get out. If the door was shut, Resident #3 would get up and push staff back out by closing the door on them. Review of Resident #3's care plan dated [DATE] failed to identify Resident #3's need for privacy and alone time to de-stress until after the [DATE] incident occurred. The care plan failed to identify that others and noise caused stress for Resident #3. After the incident, the care plan contained a new problem dated [DATE] that Resident #3 had a psychosocial problem related to bipolar disorder evidenced by Resident #3 disliking others in his/her personal space. A behavior symptom problem contained an addendum dated [DATE] that directed staff members to apply a motion sensor above Resident #3 ' s doorway to alert staff of Resident #3's coming and going and in relation to other residents, staff and visitors.

Based on observation, record review and staff interviews, the facility failed to plan for and direct nursing services to ensure residents received adequate supervision from hazards for three (3) of four (4) residents reviewed (Residents #2, #3 and #1). Resident #2 fell from the whirlpool chair lift when staff raised the seat without applying the safety belt and turned away from the resident. Resident #2 sustained humeral and nasal fractures, lacerations and bruising. Resident #3 had a hip fracture and needed staff to assist with transfers. Staff were aware Resident #3 made attempts to get up him/herself and took no action. Resident #3 self transferred and ambulated with a fall and sustained a jaw fracture with dislocation. Resident #1 fell while being assisted by staff. Staff let go of the gait belt and Resident #1 fell and fractured his/her hip. The facility reported a census of 55 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment, dated [DATE], Resident #2 had been unable to complete the Brief Interview for Mental Status cognitive test. Resident #2 demonstrated long and short term memory problems and severely impaired skills for daily decision making. Resident #2 required extensive assistance with ADL's including dressing, toilet use, personal hygiene, and bathing. Resident #2 ambulated independently. Resident #2's [DIAGNOSES REDACTED]. Resident #2 had no pain the previous 5 days. Resident #2 had no falls the previous assessment period. The Comprehensive Care Plan dated [DATE] identified Resident #2 with impaired cognitive skills and behavioral symptoms related to [DIAGNOSES REDACTED]. The interventions included: a. Provide step by step instructions while providing ADL's to manage resident's confusion/paranoia and prevent behaviors. The care plan identified periods of impaired mood and psychosocial well being related to [DIAGNOSES REDACTED]. The interventions included: b. Resident #2 did yell with cares such as pericare and shower. Use kind but firm approach, he/she did not like these cares but they must be done for dignity. An Incident Details report dated [DATE] at 4:15 p.m. documented Resident #2 was in the whirlpool chair and held onto each side of the whirlpool. When lowered Resident #2 yelled louder than usual and the CNA saw his/her right forearm caught between the whirlpool chair and the whirlpool. Resident #2 sustained an 8.1 by 1.7 centimeter (cm) bruise. The report lacked an intervention to prevent the incident from happening again. The Comprehensive Care Plan lacked an intervention related to the incident. An Incident Details report dated [DATE] at 7:20 p.m. documented Resident #2 fell out of the whirlpool chair while elevated 34 inches from the floor. Resident #2 was scheduled to have a whirlpool bath. Resident #2 sat in the whirlpool chair and Staff F CNA raised it to the high position, with no safety belt on. The battery didn't work and staff attempted to change it with Resident #2 still up in the chair. Staff G CNA stated Resident #2 launched out of the chair while up in the air. Resident #2 had bruises and lacerations; not measured. Resident #2 went to the emergency room (ER). The Emergency Department (ED) report dated [DATE] documented Resident #2 fell from a shower chair lunging forward hitting his/her face on the tub, bounced and hit the tub's surrounding ledge. Resident #2 fell from a height of 3 to 5 feet with impact on a hard surface. Resident #2 lost a moderate amount of blood. The point of impact was the head, with moderate pain in the head. Resident #2 had multiple facial lacerations with swelling and bleeding. The physical exam revealed active bleeding from both nares, a 1.5 cm laceration to the right outer cantus of the eye, a 4 cm laceration above the right eye, a 0.5 cm laceration to the bridge of the nose, and a 1.5 cm laceration to the left side of the nose. Resident #2 had pain with movement of the right arm, new bruising on the medial upper humerus, with muscle spasms noted. Resident #2 had lacerations repaired with sutures to the right eyelid times 2, the nose times 2, and the left small finger. Resident #2 had a splint with an ace wrap applied from his/her shoulder to his/her wrist. A Radiology Transcription Report dated [DATE] documented 2 views of the right humerus for a fall with obvious arm deformity, showing an acute mid shaft humeral fracture with prominent over riding and impaction of fracture elements of at least 7 cm. In addition it had an oblique spiral course along the diaphyseal aspect and at least 1 cm distraction of fracture elements. The fracture appeared unstable with surrounding hematoma. Follow up through reduction and repair process recommended. Of note, at the fracture apex was at least 20 degrees of angulation A report regarding head and neck trauma identified an acute left nasal bone fracture with mild fluid in the dependent portion of the maxillary sinuses and ethmoid sinuses. The Interdisciplinary Progress (IDP) Note dated [DATE] at 10:15 a.m. documented Resident #2 returned to the facility per van accompanied by the Administrator. Resident #2 pushed to his/her room per wheelchair and transferred to a recliner per 2 staff with a gait belt. Resident #2 complained of pain with gentle movement of the right arm to put the gait belt on. At 2:00 p.m. Resident #2 had discomfort with movement of the arm, though did not attempt to move per self. At 5:30 p.m. Resident #2 had been up with assist of 2 in the wheelchair and to supper. Resident #2's right arm had a splint and ace wrap. He/she complained of pain when moving his/her right arm. The Interdisciplinary Progress (IDP) Note dated [DATE] at 1:50 p.m. documented Resident #2 cried frequently and yelled for help at times. Wound Flow Sheets documented Resident #2 had the following skin impairments on [DATE]: a. A 4 cm laceration to the bridge of the nose with 3 sutures and bruised surrounding skin. b. A 0.7 by 0.6 cm scabbed area to the left elbow. c. A 0.5 by 0.2 cm scabbed area to the right knee. d. A 0.4 by 0.1 cm scabbed laceration of the left lateral side of the eye. e. A 4 cm laceration above the right eye with 8 sutures. f. A 2.3 by 4.4 cm red bruise to the right upper arm. g. A 3 by 4 cm bruise to the right knee. h. A 6 by 3 cm bruise of the left elbow. i. A 14.5 by 8 cm bruise of the left hand from the proximal joint of the pinky and around wrist. A Wound Flow Sheet dated [DATE] documented a 4.1 cm laceration of the left pinky with 6 sutures A Clinical Monitoring/Acute Care Flow Sheet dated [DATE] documented Resident #2 had facial bruising to his/her bilateral eyes, left cheek, and jawline. The Interdisciplinary Progress (IDP) Note dated [DATE] at 12:30 a.m. documented Resident #2 complained of right arm pain with movement and increased anxiety with attempts to ambulate. During an observation on [DATE] at 10:40 a.m. Resident #2 sat in a recliner. Resident #2 had sutures above his/her right eye/eyebrow area, and nose. Resident #2 had yellowing under both eyes and bruising extended to the left side of his/her mouth, and left arm. Resident #2's right arm had a wrap. At 12:09 p.m. staff put a gait belt on Resident #2. He/she cried when they moved his/her arm to apply the belt. Staff assisted Resident #2 to stand. He/she cried please, please. At 2:00 p.m. staff put the gait belt on Resident #2, and he/she cried, and said owe, owe, owe when staff put their arm under Resident #2's right arm to take a hold of the gait belt. During an observation on [DATE] at 9:10 a.m. staff put a pillow under Resident #2's right arm and he/she yelled help, help, help. In a written statement dated [DATE], Staff F CNA wrote she took Resident #2 into the shower room in order to do his/her whirlpool bath. Resident #2 did not like being bathed or showered and started to whine and cry, while refusing, saying no. Resident #2 usually refused all cares. Staff F then proceeded to help Resident #2 take her pants off. Resident #2 then sat in the whirlpool chair. The safety belt was not applied. Staff F noticed there were no bath towels so she called on the walkie for an aide to bring some. Staff G CNA came in to the room as she realized the battery died , with Resident #2 up in the air. The reason Staff F put Resident #2 up all the way was because he/she had a tendency to grab the sides of the whirlpool and has been pinched so she wanted to prevent that from happening again. Staff G entered the room while Staff F turned and went to grab a new battery to lower Resident #2 down, since the chair wouldn't move. Staff F heard Staff G say oh my god, and Staff F turned around quickly to see Resident #2 hit his/her head on the bottom of the tub and immediately called for a nurse. During an interview on [DATE] at 1:56 p.m. Staff F, CNA stated she had Resident #2 in the whirlpool room. She got Resident #2 ready and sat him/her in the whirlpool chair. She had removed Resident #2's clothing for the bath. She had the whirlpool chair up against a shelf with the brakes locked. She raised Resident #2 in the whirlpool chair. As she raised the chair, she called over the walkie for bath towels. Staff F raised the chair to its highest position. She thought that was a little too high so she tried to lower it a little bit and it would not move. That's when she determined the battery died . She removed the battery from the chair lift, turned, and walked toward the replacement battery. She had her back to Resident #2, and Resident #2 was in the whirlpool chair in the high position. Staff G, CNA came into the whirlpool room when Staff F walked toward the replacement battery. Staff F heard Staff G say oh my god, and turned to see Resident #2 hit his/her head on the corner of the whirlpool and the ground. Staff F immediately started calling for the nurse. Staff F said she did not have the safety belt on Resident #2. She said she usually did. She said she raised Resident #2 high in the chair because if she didn't, Resident #2 grabbed onto the sides of the whirlpool and pushed, and had an incident of getting his/her arm pinched in the past. If high enough Resident #2 couldn't grab the sides. She said the battery had died before when she had a resident in the chair, but they were not as high, and she usually had the safety belt on. On [DATE] at 11:57 a.m. Staff F stated she could not remember if she watched a video on the use of the whirlpool lift. She didn't remember being trained on the use of the whirlpool. She didn't know if she received training when the whirlpool was new. She said she had been very stressed since the incident occurred. During an interview on [DATE] at 11:31 a.m. Staff G, CNA stated the day Resident #2 fell out of the bath chair, she just happened to walk in the whirlpool room when it happened. Staff F had called for towels and Staff G didn't want her (Staff F's) partner to have to leave the unit so she replied she would bring them. Staff G had her hands full of towels when she walked in the whirlpool room. When she walked in Staff F was several feet away from Resident #2, and was turned with her back to Resident #2. Resident #2 jumped from the whirlpool chair and Staff G said oh my god. Resident #2 hit the whirlpool. Staff G said Resident #2 did not have a safety belt on and was high up in the chair. Staff G said she is 5' 3 " and Resident #2's legs were at least as high as her (staff G's) shoulders. Resident #2 fell a ways. Staff G said she had always used a safety belt when she gave a whirlpool, but she had never given a whirlpool in the unit. During an interview on [DATE] at 8:52 a.m. Staff M Registered Nurse (RN) stated the eve Resident #2 fell from the whirlpool chair, there were 2 CNAs, and her in the unit. She knew Resident #2 got a bath that eve, but didn't know they were doing it that moment. She was busy with her duties when she heard a page for help. She was with another resident and she responded to find Resident #2 on the floor of the whirlpool room. Someone said he/she fell from the whirlpool chair. Resident #2 had obvious injuries with blood from his/her mouth and nose. Resident #2 had a laceration above his/her right eye and his/her little finger. Staff M called over the walkie for another nurse to call 911. They did not move Resident #2. Staff M asked Staff F if she had the safety belt on Resident #2 and she flat out said no. When she asked why, Staff F started crying and didn't answer. She asked Staff F why she had Resident #2 so high up. Staff F said because of the incident a few months earlier when Resident #2 got his/her arm pinched. Staff M didn't know previously, this was Staff F's procedure. Staff M said they should always use the safety belt. She said she didn't know anyone wasn't using it. During an interview on [DATE] at 2:05 p.m. Staff N CNA stated she worked the weekend package, Friday, Saturday, and Sunday, from 6:30 p.m. to 7:00 a.m. She worked the evening Resident #2 fell out of the whirlpool chair lift. When she came to work, Staff F said there were still some baths to do. Staff N asked Staff F if she wanted her to do the baths. Staff N did not like to do baths for personal reasons so she said Staff F could do them. Staff N said Staff F took Resident #2 in first and the accident happened. Staff N asked Staff F after if she should do the rest of the baths. Staff F was crying, but said she would do them. She said they did a reenactment that evening with the DON in the whirlpool chair raised to the high position. When the DON asked what could have been done differently, Staff N asked if wasn't it required to use the seat belt and the DON said yes. This made Staff F cry even more. Staff N asked Staff F why she didn't use the seat belt and she said this one time she didn't have the seat belt on and this happened. Staff N said everyone knew you were supposed to use the seat belt. During an interview on [DATE] at 1:52 p.m. Staff O CNA stated she gave baths in the unit and gave Resident #2 baths quite often. She said Resident #2 was typically Alzheimer's, and didn't always like things. Resident #2 didn't like the lap belt, but she would explain he/she needed it for safety. When she put it on him/her, Resident #2 would say oh great, now I can't get out. Staff O told Resident #2 it would keep him/her safer. Staff O said she would raise Resident #2 just enough to get his/her feet over the threshold of the whirlpool tub. She said the only time she raised the bath chair to it's highest position was when the tub didn't drain quick enough and she needed to get the resident out over the side of the tub. She said sometimes Resident #2 would try to hold on to the side of the whirlpool. Staff O would just remind Resident #2 to put his/her hands in his/her lap and he/she complied. She had the battery go dead when trying to raise the whirlpool chair lift. She always had the safety belt on, so she could walk backwards and grab the replacement battery while still keeping her eye on the resident, and they were secured in the chair with the safety belt. She was not there when the whirlpool was new and maintenance demonstrated it. She had no formal training in it's use. The Unit Manager asked her if she needed training, but she said she had been an aide for [AGE] years and familiar with it. During an interview on [DATE] at 2:30 p.m. Staff D, CNA stated she did whirlpools sometimes. She said sometimes the battery to the chair did go dead with the resident raised. She said if that happened, she would stay with the resident and call for help on the walkie. She didn't know when she learned this, but she thought it was common sense. She thought they had been told to stay with them. She said she always used the safety belt in the whirlpool chair. During an interview on [DATE] at 3:18 p.m. Staff E, CNA stated she did whirlpools at times. She said the chair had stopped when raising a resident in it. She called on the radio for help. She said the battery was by the sink and not even within reach. She said they are supposed to use the safety belt, but she had not always used it; depending on who she was giving a bath to. She said after the incident she used it all the time. During an interview on [DATE] at 10:23 a.m. Staff L, CNA stated she only used the whirlpool on the main floor, not in the unit. She said she used the safety belt unless the resident refused. During an interview on [DATE] at 10:30 a.m. Staff K, CNA/activities stated she used the whirlpool in the unit 1 time. She said Staff E showed her how to use it, and to use the safety belt. The battery was charged and did not go dead that day. She said she didn't know what to do if the battery went dead. During an interview on [DATE] at 3:55 p.m. the staff development coordinator stated staff watched a video on the use of the whirlpool when they started at the facility. She said in July of 2013 they had a skills fair and reviewed the steps in the use of the whirlpool and lift/chair. She did not have a check off sheet for this. During a Concerns and Findings meeting on [DATE] at 12:11 p.m. with the Administrator, Director of Nursing, and Unit Supervisor, they agreed that they had a different whirlpool since the skills fair [DATE], in the unit. At 12:35 p.m. the same staff stated not knowing if the previous whirlpool (in the unit) had a safety belt on it, but they didn't use it often because it leaked. At 12:39 p.m. the Administrator stated the new whirlpool shipped [DATE] and would have been installed some time that week. At 12:45 p.m. the DON stated they did not do a formal training of the (new) whirlpool when they got it, but they had everyone who was there come in and the maintenance person demonstrated it. She did not have a sign in sheet showing who observed this. At 12:50 p.m. an observation of the previous whirlpool in the unit revealed the seat was part of the whirlpool, not a separate chair lift. During an interview on [DATE] at 10:25 a.m. the Maintenance Supervisor stated he taught some of the staff about the new whirlpool. He didn't specifically remember who, or specifically what he covered. He said he would have covered the battery for the whirlpool chair lift and how to raise and lower it. He would not have covered the safety belt use. During an interview on [DATE] at 12:34 p.m. a representative from the Penner Patient Care, Inc. (whirlpool lift chair company) stated the seat (elevated) 34 inches from the floor would be pretty close to it's highest point. He said you have to use one safety belt otherwise someone could fall out of the chair. During a viewing of the Penner Cascade Premier DVD dated [DATE] on [DATE] at 9:31 a.m. the narrator stated all whirlpool chairs came with a seat belt, and it was mandatory to place it around a resident's waist. The Penner Manufacturing, Cascade Patient Transfer Lift System, Safe Operation and Daily Maintenance Instructions guide dated [DATE] page 9 warned that failure to secure the resident properly with the seat belt could result in injury to the resident or operator. A Corrective Action Notice/Final Warning dated [DATE] documented on [DATE] Staff F CNA failed to follow policy and procedures and secure the safety belt used when transferring a resident in the whirlpool bath. 2) According to the MDS assessment, dated [DATE], Resident #3 had been unable to complete the BIMS cognitive test. Resident #3 demonstrated long and short term memory problems and severely impaired skills for daily decision making. Resident #3 demonstrated inattention and disorganized thinking. Resident #3 required two staff assistance with ADL's including bed mobility, transfers, ambulation, dressing, eating, toilet use, personal hygiene, and bathing. Resident #3 was not steady when moving from a seated to a standing position, walking, turning around, moving on and off the toilet, and surface to surface transfer. Resident #3's [DIAGNOSES REDACTED]. A Falls Data Collection Tool dated [DATE] scored Resident #3 at 21, with a score of 12 or more equaling a high risk for falls. An Incident Details report dated [DATE] at 6:40 p.m. documented Resident #3 found sitting on the floor with his/her feet straight out facing the windows. Resident #3 had a laceration to the left temporal area and a swollen left upper cheek. An Incident Details report dated [DATE] at 12:45 p.m. documented Resident #3 sat at the table in the dining room eating lunch with a CNA standing by him/her assisting him/her with fluids. The CNA walked away from the table about 6 to 7 feet and heard a loud noise. They observed Resident #3 in a chair lying on his/her left side, with the arm rests on the chair at the site of Resident #3's pain. Resident #3 grabbed his/her hip when up. Resident #3 went to the hospital via ambulance. A hospital Discharge Summary dated [DATE] documented Resident #3 admitted after a fall with a hip fracture. Resident #3 had a history of [REDACTED]. Resident #3 had orthopedic surgery with hemiarthroplasty of the left hip. The Comprehensive Care Plan dated [DATE] identified Resident #3 with cognitive impairment with potential moods and behaviors related to dementia and depression manifested by increased confusion and requiring a need for a secured unit. The interventions included: a. Provide step by step explanation of cares being provided to prevent increased confusion. The care plan identified a potential for injury status [REDACTED]. The interventions included: a. Pad alarm in bed. b. Ensure pathways clear. c. Eva walker and assist of 2 for transfers. A Daily Skilled Note dated [DATE] at 1:40 p.m. documented Resident #3 a fall risk due to post hip fracture, unsteady gait and weakness. At 7:00 p.m. Resident #3 ambulated with steady gait with 1 staff assist. Resident #3 did try to stand alone after supper, with staff there to intervene. A Daily Skilled Note dated [DATE] at 2:05 p.m. documented Resident #3 a fall risk due to post hip fracture, unsteady gait and weakness. A Daily Skilled Note dated [DATE] at 2:55 p.m. documented Resident #3 had an unsteady gait, weakness, and impaired decision making. At 7:50 p.m. Resident #3 had a bed alarm for safety. A Daily Skilled Note dated [DATE] at 9:30 a.m. documented Resident #3 had an unsteady gait and weakness. An Incident Details report dated [DATE] at 7:45 p.m. documented Resident #3 found on the floor lying on his/her right side in the unit in a room doorway with his/her head near the door frame. Resident #3 had bleeding from the left ear canal and injury to his/her mouth and chin. Resident #3 transferred by ambulance to the ER. A Daily Skilled Note dated [DATE] at 8:00 p.m. documented a nurse was called to the unit per the charge nurse. Resident #3 laid on the floor in the doorway. Staff stated finding Resident #3 lying there. They noted blood from the right ear, mouth, and a laceration on the chin. Resident #3 did not respond well. Resident #3 transferred to the ER. A head CT without contrast dated [DATE] documented Resident #3 had a left mandibular (jaw) subcondylar fracture with temporomandibular joint (TMJ) dislocation. A Major Injury Determination Form dated [DATE] documented Resident #3 had multiple facial lacerations (chin and upper and lower lips), a fracture of the left side of the mandible with dislocation, and bleeding from the left ear. After reviewing the circumstances, injury, and prognosis of the patient, the physician believed the injury sustained was a major injury. An Inpatient note dated [DATE] documented Resident #3 admitted observation through the emergency department on the 11th after evaluation for a fall. Findings at the time were left subcondylar mandibular fracture with TMJ dislocation. They consulted a physician with the conclusion of conservative management due to Resident #3's inability to be conscious enough or alert enough to cut the wires if he/she ever had vomit, as wiring his/her jaw would be the usual treatment. Further work up on the 12th found urinary tract infection which may be a precipitator of the fall. A Daily Skilled Note dated [DATE] at 11:50 a.m. documented Resident #3 had no anxious behaviors prior to self ambulating. They would revise the care plan on readmit. They did remind staff to prioritize tasks based on resident risk. A hospital Discharge Summary dated [DATE] documented Resident #3 admitted to skilled care on the 22nd after being admitted acute on the 13th with a urinary tract infection, left subcondylar mandibular fracture and TMJ dislocation. Resident #3 also found on the 25th to have a right wrist subtle impacted fracture of the metaphysis of the radius. Resident #3's course in the hospital without improvement. Resident #3 received intravenous (IV) antibiotics, fluids, and total parenteral nutrition (TPN). Medications were adjusted to hopefully improve his/her overall level of cognition, with little result seen. Resident #3 had a poor prognosis. An Inter-facility Transfer to Nursing Facility admission orders [REDACTED]. Resident transferred nothing per os (nothing by mouth, NPO). Resident #3 to wear a soft neck brace at all times for support of his/her jaw. A Transfer Lift Assessment for Residents dated [DATE] documented Resident #3 on total bedrest, staff to reposition. A Funeral Home report documented Resident #3 died on [DATE] at 1:25 a.m. with an immediate cause of death of dehydration. In an undated written statement Staff B CNA wrote Staff I CNA and she were in another resident's room at the time of the incident (7:45 p.m.) transferring the resident who needed 2 assist. They heard crying and Staff I ran out and found Resident #3 on the floor. Resident #3 had a large amount of blood from both ears. Staff I immediately called Staff A (the nurse) and she responded immediately. Staff B felt like this could have been prevented. The unit was unpredictable and should always have 3 people. In a written statement dated [DATE] Staff A wrote she was called to the unit at approximately 7:45 p.m. due to a fall. She had been on the 200 hall doing med administration on her portion of the 200 hall residents. Upon entering the unit, Staff A noted Resident #3 lying on his/her right side in the doorway of room 107. Resident #3 had bleeding in his/her mouth, left ear canal and a laceration underneath his/her chin. Staff did not move Resident #3. Resident #3 did not cooperate with pupil checks or hand grips. During an interview on [DATE] at 3:46 p.m. Staff B CNA stated she only worked the unit every 3rd weekend (Friday, Saturday, Sunday) and if needed during the week. She said Resident #3 fell on a Friday. She said they started getting people up around 3:30 p.m. Resident #3 was one of the last, so she probably went to the dining room around 4:30 p.m. and supper is around 5:00 p.m. Resident #3 sat in a regular dining room chair. Resident #3's spouse came and was there when they started taking people back to their rooms. Resident #3's spouse left about 7:15 p.m. Resident #3 dozed in the chair, but would rouse and take a drink of juice now and then. They took another resident to his/her room that needed 2 assist, to the commode. They were in with the other resident maybe 10 minutes when they heard crying. Resident #3 was on the floor by the room next to where they were working with the other resident. Staff B stated they need 3 people in the unit, so if 2 are assisting a resident in the room, someone could supervise the other residents. They only had 2 at the time of the fall. During an interview on [DATE] at 3:26 p.m. Staff I CNA stated she worked the evening Resident #3 fell . She said they would have walked Resident #3 to the dining room around 4:00 to 4:30 p.m. They toileted Resident #3 sometime before supper which is around 5:00 p.m. At some point Resident #3's spouse came to visit. She didn't know when the spouse left, but he/she was gone before she and the other CNA took another resident to their room to get them cleaned up and put on the commode. When they were assisting the other resident Staff I heard a noise and looked out to see Resident #3 on the floor in the hallway, bleeding. They called for the nurse. Staff I stated after Resident #3 fell and fractured his/her hip, he/she would try to get up on his/her own. She said she reported to the nurse manager 2 to 3 times and they did nothing. Staff I stated the fall was preventable. They knew he/she tried to get up and did nothing. She said she put her resignation in prior to this incident because she feared something like this might happen, but they wouldn't listen. She said when there were only 2 CNA's in the unit and they had to assist a resident, there was no one to supervise the other residents. She said several residents in the unit needed assist of 2 and others needed more supervision. During an interview on [DATE] at 10:17 a.m. Staff A RN stated there were 2 CNAs working in the unit the eve Resident #3 fell , and she had shared duties in the unit and the 200 hall. The eve of the fall she went out of the unit between 7:00 and 7:15 p.m. She did not recall Resident #3's spouse being there then. Staff called for her about ,[DATE] hour later. Resident #3 laid on the floor down the hall from the dining room. Staff A stated she knew Resident #3 had actually gotten up from the wheelchair, but not when it occurred. She did not know Resident #3 stood up at the dining room table days before the fall, with staff intervening. She said she only worked back there every other weekend. She didn't know the policy for supervising residents in the great room of the unit. She said when they had 3 nurses on she could stay in the unit, and she would not leave the dining room when both other staff were assisting residents out of the dining room. She said she had told administration they need 3 nurses for the shift and 3 staff in the unit. During an interview on [DATE] at 11:07 a.m. the Administrator stated they had a census of 16 in the unit on [DATE] prior to Resident #3's fall. During an interview on [DATE] at 1:30 p.m. Staff C Licensed Practical Nurse (LPN) stated Resident #3 tried to get up 2 times prior to his/her last fall. She said 1 time Resident #3 sat in the dining room eating dinner. Resident #3 used his/her feet to scoot back and then tried to stand up. Staff C intervened. She said another time prior, about 2 weeks, she saw Resident #3 standing in the doorway of his/her room. Staff C walked Resident #3 to his/her recliner. Staff C found out Resident #3's spouse had visited and left without telling anyone. Resident #3 sat in the wheelchair when the spouse left. Staff C didn't know if she documented these events. During an interview on [DATE] at 2:30 p.m. Staff D CNA stated one day Resident #3's spouse left him/her in the room and she got up and walked. Staff D stated Staff C told her. Staff D stated she had not witnessed Resident #3 try to get up or told that he/she did. She received no directive after (found up walking). During an interview on [DATE] at 3:18 p.m. Staff E CNA stated she did not witness Resident #3 up walking, but Staff C told her. Staff E said Resident #3 would attempt to stand but would not succeed. She said Resident #3 needed supervised when in the chair or wheelchair. She said they would let someone know if they were both going to be in a room to assist a resident so the residents would be supervised in the great room. She said they used the restroom at the nurse's station so they could stay close to the great room. She said it helped to have the 3rd person back in the unit. During an interview on [DATE] at 1:56 p.m. Staff F CNA stated she had personally seen Resident #3 try to get up 2 times prior to his/her last fall, and she reported it to her supervisor. During an interview on [DATE] at 8:25 a.m. Staff M RN stated Resident #3 started trying to get up a couple of weeks prior to the fall. She didn't know of anything they did diff

Based on observation, record review and staff and pharmacist interviews, the facility administered multiple doses of a medication (antibiotic) in which the resident had a history of [REDACTED]. The sample consisted of 4 residents with a known medication allergy and the facility reported a census of 51 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 12/7/12, which revealed [DIAGNOSES REDACTED]. The Re-admission orders [REDACTED]. Review of the Interdisciplinary Progress Notes revealed: On 10/2/12 at 12:55 PM the facility received urinalysis results and faxed the results to the physician. On 10/3/12 at 1:20 PM the facility received an order for [REDACTED]. Review of the Laboratory Report dated 10/2/12 revealed an order for [REDACTED]. Review of the Medication Record, dated 10/1/12 revealed Bactrim DS initiated on 10/3/12 and given until 10/12/12 in the AM. The Interdisciplinary Progress Notes dated 10/12/12 at 1:15 PM identified the resident had a red lacey rash noted on the trunk of body and all extremities. The resident complained of itching. Staff called the physician and reported the resident started on Bactrim DS on 10/3/12 and B12 injection given on 10/10/12 with no other new medications started. The physician order [REDACTED]. [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The Drug Information Handbook for Nursing 2007 (8th Edition of Lexi-Comp ' s Drug Reference Handbook) identified Bactrim as an antibiotic/ sulfonamide used to treat urinary tract infections. The medication is contraindicated in patients hypersensitive to sulfonamides and the adverse reactions included [MEDICAL CONDITION] urticaria (like hives) and pruritus (itching). Review of the Interdisciplinary Progress Notes revealed: a. On 1/6/13 at 1:15 PM the resident had fowl smelling urine. Staff faxed the physician to request a mini cath urinalysis (UA) with culture and sensitivity (C & S) if indicated. b. On 1/7/13 at 1:30 PM the facility received an order for [REDACTED]. c. On 1/9/13 at 9:05 AM the facility received the C & S results and faxed the results to the physician. At 12:55 PM the facility received an order for [REDACTED]. Review of the Laboratory Report dated 1/9/13 revealed an order for [REDACTED]. d. On 1/11/13 at 10:00 PM the facility received an order to discontinue the Bactrim DS and change the antibiotic to [MEDICATION NAME] 500 mg by mouth every day x 7 days. The resident noted to have red, blotchy rash all over body. PRN's (give as necessary) given and resident "better". e. On 1/13/13 at 2:50 PM the resident's lips were swollen with small blisters on top lip. The physician was contacted and recommended to continue to use the [MEDICATION NAME] and monitor. [MEDICATION NAME] is an [MEDICATION NAME] used to treat allergy symptoms. At 6:45 PM the resident had 2 open blisters. f. On 1/14/13 at 11:30 AM the resident's lips swollen with sores noted on upper lip and lacey, red rash covered the resident's trunk area and bilateral arms. The resident's skin very warm to touch. The resident complained of stinging in the arms and 2 open areas noted on the resident's forearm. At 12:40 PM the facility spoke to the resident's family in regards to allergic reaction and the family requested intravenous medications for the resident to get the reaction under control. The facility contacted the physician and received an order to transfer the resident to be transferred to the emergency room to be evaluated. At 4:00 PM the resident returned to the facility with an order for [REDACTED]. The facility to contact the physician in 2 weeks if rash not resolved. g. On 1/15/13 at 11:30 a.m. the resident continued to have swollen lips and swelling to the tongue. Staff noted blisters on the upper and lower lips with rash to all extremities. The resident had decreased fluid and solid food intake. The physician notified and the resident to be seen in the office at 11:30 AM. At 2:00 PM the resident admitted to the hospital for fluid intravenous evaluation by family request for allergic reaction. Review of the Medication Record dated 1/1/13 revealed the resident received a total of 5 doses of Bactrim DS from 1/9/13 PM - 1/11/13 PM. Review of the emergency room Report dated 1/14/13 revealed a chief complaint of multiple abrasions in both arms and also abrasions and reddish discoloration in the upper lip. The history included the resident came to the emergency room (ER) because the resident received some doses of sulfa medication for a urinary tract infection and review of the chart revealed the resident apparently allergic to sulfa. Review of the Outpatient Observation Progress Note dated 1/15/13 revealed the resident presented in the office today with increased swelling, crusting to the lips, poor oral intake, some shortness of breath, a red lacey rash over his/ her body. The resident had an allergic reaction to a sulfa drug he/she had before. The resident had not been doing well with no oral intake. The resident admitted to the hospital for precautions for the [MEDICATION NAME] monitoring. The resident to receive Intravenous (IV) solu-[MEDICATION NAME] (a corticosteroid used to treat severe inflammation). Assessment included an allergic reaction with [MEDICAL CONDITION] to sulfa medications with dehydration. Review of the Discharge Summary dated 1/17/13 revealed the resident admitted to the unit for an anaphylactic reaction, an allergic reaction secondary to sulfa medication. The resident had significant [MEDICAL CONDITION] of the lips and tongue with ulceration and swelling. The resident unable to have good oral intake due to the [MEDICAL CONDITION]. Interview on 1/30/13 at 1:20 PM with Staff D Nurse Manager revealed she knew the resident had a previous reaction to Bactrim in October. The physician discontinued the Bactrim and ordered [MEDICATION NAME] for the resident. The resident had symptoms of a lacey, red rash on the trunk and arms. She said when she talked to the nurse at the physician's office, she questioned if the resident had an allergy to Bactrim. She said she did not specifically tell the pharmacist the resident had an allergy to Bactrim. She said she would assume the pharmacy would document the resident's allergy to Bactrim with an order for [REDACTED]. She said she reported this on Saturday. When she (Staff D) came to work on Monday the Bactrim had been discontinued on Friday night and [MEDICATION NAME] given. She said the resident's symptoms had increased with blisters on the lips, swelling to the lips, and scabbed areas on the lips. She said the resident's arms were red and hot to touch. The facility contacted the physician and sent the resident to ER. The resident returned to the facility with orders to continue the [MEDICATION NAME] and a cream for the body. The family came the next day and requested the resident be seen by his/her regular physician. The facility had the resident seen and later admitted to the hospital for the allergic reaction to the Bactrim. She stated resident's allergies are listed on the front of the chart on a sticker, the Physician order [REDACTED]. Interview on 1/29/13 at 11:00 AM with Staff B Licensed Practical Nurse (LPN) revealed she received an order for [REDACTED]. She said resident's allergies could be found on the inside of the chart on a sticker. She looked on the sticker and did not see Bactrim DS listed as an allergy. She said staff told her the stickers were not updated with noted allergies. She said the resident's allergy to Bactrim listed only on the Physician order [REDACTED]. She said she did not recall the resident's allergy to Bactrim until the Nurse Manager told her after the resident had the anaphylactic reaction. When she faxed the order for the Bactrim, the pharmacist never stated an allergy to Bactrim at the time of the order. The resident's symptoms were not noted until after approximately 5 doses of the Bactrim. She said the pharmacist or the physician were not aware of the resident's allergy to Bactrim until January 2013, after the resident had the reaction. An interview with Staff A LPN on 1/30/13 at 2:00 PM revealed she gave the resident 2 doses of the Bactrim DS and had not been aware of the resident's allergy to the Bactrim until after the resident's started to appear. She said the resident's symptoms started on Friday after the medication started on Wednesday. The overnight nurse told her on Friday the resident had a red rash allover his/her body. She said the physician discontinued the Bactrim and order [MEDICATION NAME]. On Saturday the resident's symptoms continued and the lips began to swell. She said she knew the resident's allergies were listed on the front of the chart, on the MARS, and physician orders. An interview with Staff C LPN on 1/30/13 at 2:00 PM revealed she gave the resident Bactrim and not aware the resident allergic to the medication. She said she did not look into the resident's chart to verify the resident's allergies before giving the resident the medication. She said she did look at the sticker on the chart and Bactrim not listed as an allergy. An interview on 1/30/13 at 1:05 PM with Staff E Pharmacist revealed the pharmacy did not have the knowledge of the resident's allergy to Bactrim until January 15, 2013. She said the resident had been a customer of the pharmacy prior to his/her admission to the facility and the Bactrim not listed as an allergy prior to the admission of the facility. An interview on 1/30/2013 at 2:20 p.m. with Staff G LPN, a nurse at the resident's physician office, revealed the facility informed to the resident's allergy to Bactrim and placed in the resident's chart on January 15, 2013. The office did not have documentation or concerns documented related to the resident's allergy to Bactrim prior to this date. The resident's [DIAGNOSES REDACTED]. An interview with the Director of Nursing on 1/30/13 at 1:40 PM revealed the physician's office and pharmacy were not notified of the resident's allergy to Bactrim until January 2013. They were not notified by the Nurse manager in October when the resident had his/her initial reaction to Bactrim. She said she now has implemented new fax notification papers to be used with any communication with the physicians. The communication listed all resident's allergies. The nurses all received an in service on where to look for allergies and how to implement any changes when a resident has an allergic reaction to medication. She said she faxed all new communication sheets to the physicians. She said a physician office actually returned a sheet with allergies listed the facility not aware of. The physician office did not make the facility aware of the resident's allergies until now. An interview on 1/3/13 at 9:30 AM with the resident's physician revealed when he saw the resident in the office, the resident had a lot of [MEDICAL CONDITION]. The resident in a severe reaction to the medication, Bactrim. The resident had stopped drinking due to the severity of the reaction. He stated he never orders a Sulfa medication before asking the staff or other if the resident has an allergy to sulfa. He stated he would have never ordered the medication Bactrim if allergic to Sulfa. He stated the situation frustrated him because when he ordered Bactrim DS for the resident, the facility did not inform him the resident allergic to Bactrim/Sulfa drugs. He further stated the facility in error because the facility needed to be aware of the resident's allergies and notify the physician and pharmacy of the allergy. According to the physician, the resident had shut down due to the [MEDICAL CONDITION], both in the mouth and throat. No doubt the resident would have ended in a more severe case in a few days if not treated in the hospital. He stated he made the facility aware of the allergy to Bactrim/ Sulfa drugs when contacted about the reaction/ rash in October 2012. He stated he ordered [MEDICATION NAME] for the allergic reaction. The facility should have notified the pharmacist and his office of the reaction so Sulfa would have been listed as a medication allergy. He strongly stated the facility is responsible with health chart and he and other physicians rely of the facility for important information such as medication allergies. They are all professionals and need to know the importance of medication allergies and their side effects. The failure to notify the physician and pharmacist in October put the resident at risk for an unnecessary risk of a severe reaction to the medication. This incident could have been prevented with the proper steps taken.

Based on observation, clinical record review, and staff interviews, the facility failed to plan and direct nursing services to ensure 1 of 8 residents reviewed received adequate supervision for fall prevention (Resident # 2). The facility reported a census of 51. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident # 2 dated 10/7/11 revealed [DIAGNOSES REDACTED]. The MDS documented the resident had a BIMS score of 4 which signified the resident had severe impairment of decision making skills. The resident required extensive assistance of 2 for more staff for transfers and bed mobility . Review of the Comprehensive Care Plan, dated 10/19/11 revealed the resident had a potential for injury related to [DIAGNOSES REDACTED]. The plan directed to ambulate the resident with the assistance of 2 and a 4 wheeled walker as able, provide the resident with non-skid slipper socks at night, position the bed in low position, implement a raised edge mattress on the bed, a personal alarm at all times, a non skid in recliner and a pressure alarm in bed. The plan directed to check the function of the alarms every shift. Review of the Falls Data Collection Tool dated 12/21/11 revealed the resident had a fall and a fall score of 21. A score of 12 or more indicated the resident a high risk for falls. Staff were to proceed with care plan approaches, review and revise as appropriate. Review of the Incident Details dated 12/23/11 at 7:40 PM revealed staff found the resident on the floor on his/her left side. The personal alarm was on but did not activate. The battery weak and the device set on low when the resident found by the CNA. The CNA placed the transferred the alarm from the wheelchair to the recliner and did not report the malfunction of the alarm. The CNA noted the alarm had a weakened battery but did not notify the charge nurse or change the alarm battery. The resident did not receive an injury. Interview with Staff C LPN (Licensed Practical Nurse) on 1/10/12 at 7:10 PM revealed the resident's alarm did not sound at the time of the fall. The string to the alarm had a long string and did not detach from the resident. She said they check the alarm and revealed the battery did not function and the box turned to low sound. She said they changed the batteries and turned the box to high before the alarm would function.