Every finding on record at Good Shepherd Health Center

Based on observation, clinical record review, facility policy review, family, and staff interviews the facility failed to do a timely assessment on 1 of 3 residents reviewed (Resident #1). Resident #1 had a bruise on the right inner/outer thigh and hip area. The facility staff knew about the bruise on 2/13/26, and 2/14/26, which no staff assessed the area until 2/15/26 when the resident started to complain of pain. The facility reported a census of 150 residents.Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate impaired cognitive decisions. Resident #1 could understand others and others understood them. They had adequate hearing, and vision. Resident #1 required total staff assistance with toileting and substantial to maximal assistance with hygiene and dressing. The MDS included diagnoses of hypertension (a condition where blood consistently pushes hard against artery walls), Alzheimer's Disease, anxiety, depression, low back pain and history of falling.The Care Plan Focus initiated dated 2/4/25, indicated Resident #1 had a risk for skin breakdown and/or impaired wound healing related to age. The Interventions instructed the following:Observe skin with cares on shower days. Notify nurse/provider of concerns.Pressure reduction mattress to bed.Please assist Resident #1 with AM cares between 6:00 AM-7:00 AM every morning.Hip protectors to be worn at all times, may remove for cares, due to decline in health and bruising to right hip, Resident #1 is not wearing hip protectors at this time.The Risk Management form dated 2/15/26 at 10:40 AM, documented the staff called the nurse to Resident #1's bathroom. Resident #1 had a dark purple bruise extending from the right upper inner thigh to her right buttock. Resident #1 indicated they had discomfort when they transferred from the toilet to their wheelchair.The Health Status Note dated 2/15/26 at 10:40 AM, documented the staff called the nurse to Resident #1's bathroom. Resident #1 had a dark purple bruise extending from the right upper inner thigh to her right buttock. Resident #1 indicated they had discomfort when they transferred from the toilet to their wheelchair.The Incident Note labeled Late Entry dated 2/15/26 at 10:42 AM, documented, the nurse received a call from charge nurse, requesting them to come to Resident #1's room to see a bruise to their upper right thigh. Upon entering Resident #1's bathroom, they sat on the toilet, the staff stated they noticed the bruising and questioned if the bruise happened from a recent fall. A large bruise noted to the right upper thigh in various shades of purple, brownish outer parameters, and faded yellow on the top edges. The bruise extended from the upper thigh to the groin and around to the buttocks with some speckled bruising to the posterior right thigh. The top of the left thigh area had faint faded yellow bruising. The Incident Note labeled Late Entry dated 2/15/26 at 2:01 PM, documented the staff the nurse about Resident #1 in bed. Upon entering their room, observed Resident #1 in bed lying on her back. Once positioned it appeared Resident #1's right foot is approximately 2 inches shorter than the left and with the right knee turned outward. The thigh and knee had non-pitting edema present. When the nurse attempted gentle passive range of motion to Resident #1's right leg, they winced. The nurse stopped and gently placed leg back to their previous position.The Facsimile dated 2/15/26, with no time, documented the staff noted a large bruise to Resident #1 right thigh when doing cares. The bruise had various stages of healing with yellowish and brownish purple edges, possibly from recent falls. Noted the right leg looked several inches shorter than the left as well on the right kneecap slightly facing outward. The note indicated the family knew. When offered to send Resident #1 for x-rays, the family declined, and stated they always had one leg shorter than the other. They didn't feel Resident #1 was not a candidate for further intervention and requested to just keep them comfortable at the facility.The untitled facility investigation file recorded on 2/15/26 at 10:42 AM, indicated Resident #1 had a large bruise to their right upper thigh in various shades of purple, with the outer parameters brownish, and the top edges faded a yellow color. The bruise extended from their upper thigh to the groin and around to the buttocks with some speckled bruising to the posterior right thigh. There is very faint faded yellow bruising to the top of the left thigh area. When staff assisted Resident #1 to stand, they said ow. The staff did a pivot transfer with 2 staff to their wheelchair. Resident #1 didn't have complaints of pain once in wheelchair. The file documented an interview with Staff A, Certified Nursing Assistant (CNA), on 2/19/26. Staff A stated on 2/13/26, Resident #1 had purple/green swelling on the side of her hip and also under her buttocks. Staff A described them as noticeable but not too big or too small. The facility's interview with Staff B, CNA, stated, when they worked on 2/14/26, they told the nurse about the bruises at 8:45 AM. Resident #1 didn't have any signs of pain. On 2/15/26, Staff B went into the room with another staff member, Resident #1 yelled every time they attempted to move her to transfer. They called the nurse to verify what they saw and Resident #1's emotional state. The interview with Staff C, CNA, documented, they worked on 2/13/26. Staff C reported it took 2 of them and a gait belt to transfer her to the restroom. While in the bathroom, Staff C explained they noticed a bruise. The interview with Staff D, Licensed Practical Nurse (LPN), stated on 2/15/26, Staff B, mentioned Resident #1 had a bruise and they went to look at it on 2/15/26. Staff D admitted they didn't look at the bruise on 2/14/26, as it slipped their mind.On 2/17/26 at 4:30 PM, observe a bruise, in multiple stages, on Resident #1's right hip area, extending from the thigh/hip area down behind the right knee.On 2/17/26 at 2:30 PM, Resident #1's family member said they saw the bruising on 2/15/26 from the top of Resident #1 right hip/thigh area, across her buttocks and down behind the right knee. On 2/24/26 at 12:30 PM, the Assistant Director of Nursing (ADON), acknowledged Staff D failed to assess the bruise on Resident #1 right thigh/hip area on 2/14/26 when was the staff first alerted them. The ADON reported they expected the licensed staff to follow through with any change in resident conditions, bruising, falls, or anything out of the norm and do an assessment.On 2/24/26 at 1:30 PM, the Director of Nursing (DON) stated they expected the nursing staff to follow the procedure/policies for unusual occurrence and do an assessment as warranted.The Skin Program reviewed 2/13/26, instructed staff to use risk management for identification of skin issues. A member of the administrative skin team would complete a follow-up observation and initiate measures to prevent further skin issues. Weekly skin/wound progress notes will be completed until the area is resolved.

Based on observation, clinical record review, staff interviews, and facility policy and procedures, the facility failed to implement interventions to prevent weight loss and implement adequate hydration for 1 of 3 residents reviewed for weight loss and hydration (Resident #2). The facility identified a census of 150 residents.Findings include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE], identified short- and long-term memory problems with severely impaired decision-making abilities. Resident #2 required supervision for eating/drinking. The MDS listed Resident #2 at 230 pounds with no weight loss. The MDS included diagnoses of Alzheimer's Disease, Parkinson's and depression.The Care Plan Focus initiated dated 4/13/23, indicated Resident #2 had an activity of daily living (ADL) self-care performance deficit related to Alzheimer's/Parkinson's. The Interventions instructed the following:a. If you notice Resident #2 not eating or distracted at meal times, please sit with them and offer to assist them.b. Avoid over eating. Provide small frequent meals rather than 3 large ones.c. Provide house supplement as ordered.d. Registered Dietician to evaluate and make diet change recommendations as needed.e. Weigh weekly or as directed. The Electronic Health Record for the weight summary, revealed the following weights for Resident #2:a. On 10/27/25, weighed 234.5 poundsb. On 11/3/25, weighed 231.5 poundsc. On 11/10/25, weighed 229 poundsd. On 11/17/25, weighed 222.1 poundse. On 11/24/25, weighed 220.5 poundsf. On 12/1/25 weighed 218.5 pounds, a 5% weight declineg. On 12/11/25 weighed 217.4 pounds, a 5% weight declineThe Behavior Note dated 10/28/25 at 1:16 PM, documented as Resident #2 sat at the assisted table, they refused to have staff fill liquids in two handled cups and pushed glasses away from him and taking their tablemate's glass of water. After the staff poured Resident #2 liquids, they took half of the liquids, went to his room, and he poured them on the floor and the table. When the staff attempted to assist Resident #2, he refused assistance and fed himself. The Behavior Note dated 11/12/25 at 10:05 PM, documented, Resident #2 refused his house supplement. He only ate bites for supper and refused to allow staff to assist him with feeding. Resident #2 pushed the staff's hand away during any attempt to help him.The Behavior Note dated 11/26/25 at 10:12 PM, documented Resident #2 refused his afternoon house supplement. At supper, he refused all food offered to him. When the staff offered Resident #1 the casserole, he clamped his mouth shut. When offered a meat sandwich, he refused it.The Health Status Note date 11/30/25 at 1:07 PM, documented the staff attempted to assist Resident #2 at breakfast and noon meal. Resident #2 pushed his food away and pushed himself back in the wheelchair. Resident #2 refused to open their mouth and dumped his liquids on the floor.The After Visit Summary dated 12/11/25 at 10:51 AM, instructed Resident #2 needed 2 liters of water per day. In addition, he would need one-to-one (1-1) assistance for water intake as well as for diet orders.Resident #2's Electronic Health Record reviewed 2/18/26 at 4:03 PM revealed from 12/11/25 - 2/18/26, the Point of Care Response History for fluids received, lacked documentation Resident #2 received 2 liters of water per day. On 2/17/26 at 2:00 PM, observed Resident #2 sitting in a wheelchair, lips, gums, tongue appeared moist with no dryness noted.On 2/18/26, observed the noon meal from 11:15 AM - 11:55 AM, Resident #2 had a double handled mug filled with a clear liquid and another double handled mug filled with a brown liquid. Staff assisted Resident #2 with eating and drinking. At 12:30 PM, noted Resident #2 drank most of his liquids and left a few bites of lunch on the plate.On 2/19/26 at 11:01 AM, the Director of Nursing (DON) acknowledged Resident #2's clinical record lacked documentation of him receiving 2 liters of water every day. They added the 2 liters of water to the Treatment Administration Record for the nurses to document his intake of water.On 2/24/26 at 1:40 PM, the DON confirmed the clinical record lacked documentation of appropriate interventions to keep Resident #2 from an unintended weight loss.The Policy and Procedure for Interventions for Unintended Weight Loss dated 5/21/23, indicated the facility would identify and monitor unintended weight loss or gradual weight loss, so the staff could implement appropriate and individualized interventions. Th policy reflected it was appropriate for individuals who have unintended weight loss and/or a malnutrition diagnosis.

Based on observation, record review, and staff interviews the facility failed to ensure the windows for 2 of 2 bird aviaries were maintained in between routine cleanings and kept free of excessive bird feces. The facility reported a census of 145 residents. Findings include: Observation on 12/11/25 at 10:45 AM the Memory Care bird aviary consisted of 8 windows. All windows had multiple areas with white bird feces on it. Observation on 12/11/25 at 10:40 AM the Dining Room bird aviary consisted of 8 windows. All windows had multiple areas with white bird feces on itReview of the Aviary Service Checklist dated 7/30/25 documented the Memory Care aviary and Dining Room aviary last cleaned on 7/30/25.In an interview on 12/11/25 at 11:53 AM with the Administrator revealed the facility has a contracted a company from another state that provides quarterly cleaning to the aviaries. She informed in-between quarterly cleanings no one cleans or goes inside the aviary unless something urgent need to be done.

Based on record review, staff interview, and policy review the facility failed to ensure the Medical Director attended the Quality Assessment and Assurance (QAA) meetings quarterly. The facility reported a census of 145 residents. Findings include:The Quality Assurance (QA) Meeting Records provided by the facility revealed the Medical Director attended the QA meetings on 5/21/25 and 7/28/25 but not on the 1st quarterly meeting (3/20/25) or the 4th quarterly meeting (10/15/25). The facility failed to have the required members present at least quarterly for the facility's QA meetings.In an interview on 12/11/25 at 12:00 PM the Administrator reviewed the Quality Assurance Meeting Records and acknowledged that the Medical Director was not present at the 3/20/25 and 10/15/25 QA meetings. On 12/11/25 at 12:00 PM the Administrator stated that she is familiar with the QA committee meeting quarterly and the need for members to be present. In an interview on 12/11/25 at 12:00 PM the Director of Nursing (DON) reviewed the Quality Assurance Meeting Records and acknowledged the Medical Director didn't attend the QA meetings on 3/20/25 and 10/15/25.On 12/11/25 at 12:15 PM the Director of Nursing (DON) stated she expected the Medical Director to be present during the quarterly meetings. Review of the Annual Quality Assurance Performance Improvement (QAPI) Plan dated 2025, directed the QAPI Committee meets minimally bi-monthly with their Medical Director and will include and address any facility care concerns. The QAPI Committee may decide to meet on a quarterly basis rather than bi-monthly, or monthly. The DON or designee will be responsible for the maintaining of meeting minutes and activity.

Based on record review, staff interview and policy review, the facility failed to notify resident's representative in advance of the risks and benefits of a psychotropic medication, the treatment alternatives or other options and was able to choose the option the representative prefers for 1 of 5 residents reviewed (Resident #1). The facility reported a census of 145 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 0, indicating severely impaired cognition. The MDS included diagnoses of dementia, diabetes and respiratory failure. Physician order dated 11/17/25 for quetiapine (antipsychotic medicine that works in the brain) by mouth once daily as needed for aggression and agitation. Resident #1's Electronic Health Record (EHR) lacked documentation of notifying the resident's representative in advance of the risks and benefits of the medication, treatment alternatives or other options and let them choose the option they prefer prior to administering the medication.Resident #'1's Medication Administration Record (MAR) for November 2025 documented Resident #1 received the quetiapine 5 times that month. The MAR for December 2025 documented Resident #1 received quetiapine once. On 12/11/2025 at 10:18 AM the Director of Nursing (DON) reported they facility didn't do a consent with the family for quetiapine prior to giving. The DON reported staff are to speak with the family about risks vs benefits and document it.The undated facility policy titled Antipsychotic Medication Used lacked direction on notifying the resident or resident representative in advance of the risks and benefits of a psychotropic medication, the treatment alternatives or other options and was able to choose the option the resident or representative prefers.

Based on record review, staff and family interviews, and policy review the facility failed to ensure 1 of 2 residents personal belongings were retained in the facility and returned to the family after their death (Resident #159). The facility reported a census of 145 residents.Facility staff implemented immediate interventions on [DATE] and completed on [DATE] through the following actions:a. Discussion with facility staff on where the missing items went and identifying a miscommunication occurred with facility staff.b. Offered the family to replace the items at the facilities expense.The deficient practice was identified as past non-compliance singular event as of [DATE], the items were thrown away due to miscommunication prior to the survey, and financial compensation was offered to the family. Findings include:The Facility Death Record for Resident #159 documented she died on [DATE] at 1:50 PM.The Communication - with family/NOK/POA note dated [DATE] at 11:34 AM indicated the family hadn't finished with the room. The Social Worker read the note wrong and alerted housekeeping to clean the room. The family planned to come back to get other belongings. Unfortunately, the facility cleaned the room and removed the belongings. The Administrator and Social Worker apologized to the daughter.The Communication - with family/NOK/POA note dated [DATE] at 11:51 AM reflected Resident #159's Daughter called and expressed concerns of Resident #159's items being thrown before family could go through them. In an interview on [DATE] at 2:56 PM Resident #159's Daughter reported the facility Social Worker and Housekeeper had a misunderstanding and threw away the following things of her mom's personal items before they could come and pick them up:1. Family Picture in frame2. Pictures of when she was young on a tackboard3. Knitted last name doily4. Clothing5. Wall hanging with a saying on it6. Tie fleece blanket mauve and blue with [NAME] In an interview on [DATE] at 11:54 AM the Administrator explained they informed Resident #159's Daughter on [DATE] they would replace and pay for anything the facility accidently destroyed. She also reported they do not complete an inventory list as they are hard to keep up to date when families bring in or take-home items routinely throughout their stay at the facility. In an interview on [DATE] at 12:13 PM the Director of Nursing (DON) verbalized they offered financial compensation to the family, but they haven't heard anything. Review of an untitled and undated statement by the facility's Pastor reported he spoke with Resident #159's family on [DATE] at approximately 4:00 PM and expressed apologies for accidently throwing away personal items and reiterated the facility would provide financial compensation for the items. Review of an untitled statement dated [DATE] by the facilities Chief Executive Officer indicated on [DATE] he gave the directive to staff the facility would reimburse the family for whatever items they intended on keeping. Review of an undated Personal Property policy instructed the following: A representative of the admitting office advises the resident, prior to or upon admission, of the types and amount of personal clothing and possessions that the resident may keep in his or her room.The facility promptly investigates any complaints of misappropriation or mistreatment of resident property.

Based on clinical record review, staff interview and policy review, the facility failed to submit a Preadmission Screening and Resident Review (PASRR) for 1 of 2 residents with new mental health diagnoses (Resident #22). The facility reported a census of 145 residents.Findings include:Resident #22's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of anxiety, depression and psychotic disorder.The Electronic Health Record (EHR) listed a generalized anxiety disorder diagnosis added 5/14/19. In addition, an unspecified moderate dementia with other behavioral disturbance and unspecified psychosis diagnoses added 10/9/23.The Physician's Orders indicated that quetiapine (an antipsychotic medication) 25 milligrams two times daily started 2/7/23.Resident #22's Level I PASRR dated 10/21/18 lacked diagnoses of generalized anxiety disorder, unspecified moderate dementia with other behavioral disturbance and unspecified psychosis.Resident #24's clinical record lacked a PASRR after 10/21/18. In an interview on 12/10/25 at 2:43 PM Staff D, Social Worker (SW), stated that the last PASRR Level I was done for Resident #22 on 10/21/18. She would submit a new PASRR if significant medication changes or mental wellbeing would change. When asked about a new diagnosis of generalized anxiety disorder that was added 5/14/19, she stated she should have done one. When questioned about a new antipsychotic medication quetiapine on 2/7/23, she stated it would be on a case-by-case basis. When questioned about new diagnoses of moderate unspecified dementia and unspecified psychosis on 10/9/23, she again stated it would be on a case-by-case basis. She then added that based on or conversation that she would be doing a new one now.In an interview on 12/11/25 at 9:30 AM the Assistant Director of Nursing (ADON) stated that they do not have a policy on PASRR, and they follow the guidelines.In a document titled Iowa PASRR Program revised on 2/19/25, it indicated the PASRR evaluation must occur prior to admission, whenever a prior approval is expiring, and whenever a resident experiences a significant change in status.

Based on observation, clinical record review, staff interview, and facility policy/procedure review at the time of the investigation, the facility failed to intervene timely for a resident who needed had a change in condition following a fall on 2/3/25 for 1 of 4 residents reviewed (Resident #2). At Resident #2's admission in December 2024, he came to the facility with a repaired fractured right hip due to a fall at home. Due to his cognition, he frequently forgot he previously had a hip fracture and would frequently transfer by himself. On 2/3/25, he had an unwitnessed fall. When the nurse assessed him, he reported pain to his right hip. After the nurse's assessment, 2 Certified Nurse Aides (CNAs) assisted Resident #2 from the floor and back into bed. Despite Resident #2's recent surgical repair of his right hip, the nurse faxed the physician instead of sending him for evaluation. Resident #2 continued to report pain during the nurses' assessments to his right hip and needed assistance of 2 staff for transfers. On 2/5/25, the nurse contacted the Orthopedic provider about Resident 2's pain to his right hip. Despite Resident #2's decline in condition, the facility failed to intervene with emergency services until a nurse sent him to the emergency room (ER) for evaluation on 2/8/25. The ER evaluation reflected Resident #2 received treatment for a right pubic rami fracture (fracture of pelvis), hypoxia (low blood oxygen levels), and COVID-19. The facility identified a census of 151 residents. Findings include: Resident #2's Minimum Data Set assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. Resident #2 displayed verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, or verbal/vocal symptoms like screaming, disruptive sounds). Resident #2 required substantial to maximal assistance with all activities of daily living (ADL) including ambulation and transfer. The MDS listed him as frequently incontinent of bladder and bowel. The MDS included diagnoses of benign prostatic hyperplasia (BPH), diabetes mellitus, arthritis, recent hip fracture, and mild cognitive impairment. The Care Plan Focuses: a. Revised 2/17/25 identified Resident #2 required assistance with activities of daily living related to his right hip fracture with surgical repair and a right pubic rami fracture. The Interventions reflected the following: i. Revised 12/30/24: Physical Therapy (PT) and Occupational Therapy (OT) evaluate and treat as ordered by the physician. ii. Resolved 2/12/25: Transfers/walking: Per therapy alert 12/27/24: Transfer assist of 1 with gait belt and front wheeled walker. Ambulation with gait belt, front wheeled walker, and assist of 1. Encourage Resident #2 to walk outside of the room at least twice per day. iii. Revised 2/17/25: Resident #2 lived at the facility due to his impulsivity and attempts to self-transfer without waiting for assistance. He doesn't remember to use his call light or that he fractured his hip in the past. iv. Revised 2/17/25: Resident #2 required assistance from 2 staff and a standing mechanical lift. Resident #2 didn't like the use of the gait belt and would slap the staff hands away when they tried to apply a gait belt. When staff educated the reason for the gait belt, he usually allowed them to use it. Resident #2 didn't walk and used a wheelchair for all mobility. Resident #2 didn't walk and used a wheelchair for all mobility. b. Revised 12/10/24: Resident #2 had unspecified arthritis. The Interventions directed the following: i. Daily range of motion (ROM) exercises both active (moved by self) and passive (moved by someone else) as tolerated. ii. Monitor/document/report to medical doctor as needed signs/symptoms or complications related to arthritis: joint pain, joint stiffness, usually worse on waking, swelling, decline in mobility, decline in self-care ability, contracture (stiffness in a body part that restricts movement usually in a bent position) formation/joint shape changes, crepitus (creaking or clicking with joint movement), pain after exercise or weight bearing. Resident #2's February 2025 Medication Administration Record included an order dated 12/9/24 for acetaminophen (Tylenol) 500 milligrams (MG), take 2 tablets (1000 MG) by mouth twice daily as needed (PRN) for pain or fever greater than 100.4 degrees Fahrenheit (F). Do not exceed 4000 MG in 24 hours. Documentation reflected Resident #2 received the following dose of acetaminophen on: a. 2/3/25 at 6:54 PM, for pain level 6 (on a 0 to 10 pain scale), indicating moderate pain. b. 2/4/25 at 7:36 AM, for pain level 5, indicating moderate pain. c. 2/4/25 at 6:26 PM, for pain level 8, indicating severe pain. d. 2/5/25 at 8:29 AM, for pain level 4, indicating moderate pain. e. 2/6/25 at 7:43 PM, for pain level 6, indicating moderate pain. f. 2/7/25 at 12:08 PM, for pain level 8. g. 2/8/25 at 9:30 AM, for pain level 8. h. 2/8/25 at 1:41 PM, for pain level 9, indicating severe pain. The Behavior Note dated 2/3/25 at 4:37 AM, Resident #2 got up five times and moved on their own. They proved hard to guide and sometimes acted aggressive. The Incident Note dated 2/3/25 at 7:47 PM, the CNA told the nurse they saw Resident #2 on the floor in the bathroom. The CNA contacted the house supervisor because of the nurse being busy at the time. The house supervisor completed an initial assessment and helped transfer Resident #2 from the floor to the bed. The nurse later conducted a follow-up fall assessment. Resident #2 laid awake in bed when the nurse entered. When asked what happened, Resident #2 said, I'm being stupid. I tried to get up when I shouldn't have. Resident #2 denied hitting their head, but reported pain in their right hip when the nurse checked their range of motion (ROM). He couldn't rate the pain due to his altered mental status. The nurse administered acetaminophen for pain, but Resident #2 refused other pain treatments. Resident #2 remained at baseline, oriented to person but not time or place. The nurse couldn't check Resident #2's pupils because he refused. Resident #2's speech remained clear. He had decreased lung sounds in both lower lungs but stayed clear otherwise. He had equal grip strength felt on both sides. No sign of complications in the right hip repair appeared during the assessment. Resident #2 refused a skin check, saying, I'm fine. Just leave me alone. The fall went unwitnessed. The nurse completed a neurological assessment, still in progress, with no concerns noted at the time. The Incident Note dated 2/3/25 at 7:50 PM, the nurse received a call to Resident #2's room, where the CNA found him on the bathroom floor. Resident #2 laid on his back with his feet in front of the toilet, wearing socks. Resident #2 stated he needed to urinate but was in bed. The call light sat within reach but remained off, and the urinal rested by the bedside. Resident #2 wore loose pajama pants that slid down when he walked, requiring him to hold them up with one hand. The draw straps on the pants got tightened to prevent them from falling down easily. No internal or external hip rotation or leg shortening appeared. Resident #2 complained of discomfort in his right posterior thigh, where some muscle stiffness showed. 2 staff members assisted him to his feet and helped him walk to his bed with a gait belt and walker. The assessment identified no red areas, bruising, or crepitus (popping noise heard when moving joints). The nurse reminded Resident #2 to use the call light and urinal. The N Adv - Neurologic Focused Evaluation dated 2/4/25 at 12:24 AM, Pain Issue: New location in Resident #2's right hip. Pain score reached 7. Described as aching and non-radiating. Pain occurred intermittently. Resident #2 refused non-medication interventions, and these didn't provide relief. The nurse provided an as-needed (PRN) medication. Pain indicators included protective body movements, facial expressions, and vocal complaints. Resident #2 showed signs of disorientation, confusion, and disorganized thinking. Short-term memory loss appeared. Resident #2 remained oriented to person, made themselves understood, and understood others. Resident #2 also showed signs of agitation. The N Adv - Post Fall Evaluation dated 2/4/25 at 12:32 AM identified Resident #2 fell unwitnessed, in the bathroom. Resident #2 tried to use the bathroom alone at the time of the fall. The staff determined the cause of the fall as Resident #2 attempted to use the bathroom by himself without a cane or walker as instructed. The assessment reflected no injury from the fall. Resident #2 had the following indicators of pain: verbal, non-verbal sounds, and facial expressions. He rated his pain score a 3 on a 10-point scale (0 equals no pain and 10 equals the worst pain). The Evaluation indicated this as a change for Resident #2. A Nursing Facsimile (fax) form dated 2/4/25 at 12:36 AM, documented on 2/3/25 identified at 7:40 PM, the CNA found Resident #2 on the bathroom floor. Resident #2 laid on his back with his feet in front of the toilet, wearing socks. Resident #2 said he needed to urinate but was in bed. The call light sat within reach but stayed off, and the urinal rested by his bedside. Resident #2 wore loose pajama pants that slid down when he walked, so he had to hold them up with one hand. The draw straps on the pants got tightened to keep them from falling down. The assessment revealed no internal or external hip rotation or leg shortening. Resident #2 complained of discomfort in his right posterior thigh, where it had some muscle stiffness. 2 staff members helped Resident #2 to his feet, used a gait belt, and a walker to assist him back to bed. The Health Status Note dated 2/4/25 at 9:14 AM indicated a follow-up assessment of Resident #2 after his unwitnessed fall. He had an occasional nonproductive cough with a soft, non-tender abdomen. Resident #2 complained of right hip pain and needed 2 people to help with transfers. Resident #2 received PRN Tylenol for pain. The Health Status Note dated 2/4/25 at 11:58 PM reflected Resident #2 had an unwitnessed fall. Resident #2 complained of pain to his right hip and needed 2 people to help him transfer. Resident #2 received PRN Tylenol for pain. The Health Status Note dated 2/5/25 at 9:59 AM reflected a follow-up assessment of Resident #2's unwitnessed fall. He could complete an active and passive range of motion within normal limits. Resident #2 needed 2 people to help him transfer due to right hip pain. The Health Status Note dated 2/5/25 at 12:11 PM, reflected the nurse called Ortho (bone doctor) and left a message to ask if Resident #2 needed an x-ray or appointment for his right hip pain. The Health Status Note dated 2/6/25 at 1:43 AM, identified the nurse monitored Resident #2 after his unwitnessed fall. Resident #2 denied pain, but the nurse noticed him moaning with facial grimacing. Resident #2 refused pain relief, and despite being educated on options, raised his voice, saying, I don't need anything. The nurse observed Resident #2 transferring himself and they had difficulty redirecting him. The Health Status Note dated 2/7/25 at 1:12 AM, indicated the nurse completed post-fall monitoring for Resident #2. Resident #2 denied pain, but the nurse noticed him moaning with facial grimacing. The nurse gave him PRN Tylenol, but it seemed ineffective. Resident #2 refused other pain relief and proved difficult to redirect. The Health Status Note dated 2/7/25 at 5:40 PM reflected Resident #2 continued to need 2 people to transfer and complained of right hip pain. The nurse gave him PRN Tylenol for the pain. Resident #2 had an Ortho appointment scheduled for the next week. The Health Status Note dated 2/8/25 at 2:20 PM, indicated the CNA told the nurse that Resident #2 became extremely difficult while using the standing mechanical lift. Resident #2 complained of pain in both hips and the back, refusing to stand. The staff didn't feel safe transferring him that way. The nurse gave him PRN Tylenol, and the staff transferred Resident #2 to a wheelchair with a 2-person assist pivot (movement without twisting or rotating the spine or back). The staff felt they bore more of his weight than he did. Resident #2 picked at breakfast and wanted to use the bathroom. The staff asked the nurse to supervise since Resident #2 refused to stand while getting off the toilet. The staff used the standing mechanical lift, and Resident #2 became tearful during the transfer, saying his hips and back hurt. Afterwards Resident #2 rested in the recliner before the noon meal. The pivot transfer proved difficult, and Resident #2 refused to eat, saying he wanted to lie down. Due to his intense pain, the staff couldn't get Resident #2 up from the lying position. The nurse supervisor got notified. The nurse hadn't seen Resident #2 since the fall earlier in the week, and the situation marked a significant decline in his ability to transfer. The Health Status Note dated 2/8/25 at 2:38 PM, reflected the charge nurse notified the nurse Resident #2 couldn't bear any weight and complained of severe pain and he didn't have relief from the 1000 MG of PRN Tylenol. The nurse called Resident #2's wife, who agreed to send Resident #2 to the hospital if the doctor recommended it. The nurse received telephone orders to send Resident #2 to the emergency room (ER) for evaluation. The Health Status Note dated 2/9/25 at 6:52 AM, indicated the nurse called the ER for an update on Resident #2. The hospital reported they admitted Resident #2 for hypoxia and COVID-19. His X-rays showed a new fracture in the pubic rami. The Transfer/Discharge Report dated 2/8/25 at 2:40 PM, reflected the nurse documented Resident #2 felt restless and couldn't walk. Normally, Resident #2 could transfer with standby assistance from one person but couldn't do so that time. Resident #2 complained of severe pain in his lower back, both hips, and couldn't bear weight. Resident #2 stayed very restless and couldn't tolerate sitting on the toilet. Resident #2 fell last week. The History and Physical dated 2/8/25 at 8:40 PM identified Resident #2, went to the ER with complaints of lower back pain and right hip pain. Resident #2 didn't provide a clear history. According to the ER records, Resident #2 fell a week ago. For the last few days, the pain in his lower back and right hip worsened. He couldn't get up, transfer, or stand, though he usually could walk on his own. Due to the significant pain in his lower back and right hip, the staff eventually transferred him to the ER for evaluation. An X-ray of the hip showed acute (comes on suddenly and is usually caused by an injury or sudden illness)/subacute (a condition passed the acute phase but not quite long-term or chronic yet) fractures through the pubic rami (pelvis) on the right. On 3/6/25 at 2:30 PM, observed Resident #2 sitting in a reclining Geri chair (an extra cushioned wheelchair that allows a deeper recline allowing comfort, support, and adjustable features) with a red and yellow blanket over him, wearing glasses. He sat by the first-floor northwest nurses' station, with a staff member behind the station. Resident #2 had his feet elevated on the footrest of the reclining chair. On 3/10/25 at 5:30 PM, observed Resident #2 sitting in the television lounge with his feet elevated in a recliner. He couldn't remember the fall on 2/3/25. Interview on 3/10/25 at 2:55 PM, Staff D, CNA, stated that on 2/3/25, they found Resident #2 on the bathroom floor with no witnesses. When Staff D and Staff E, CNA, helped Resident #2 off the floor, they tried to assist him back to his bed using a gait belt, Resident #2 said, it hurts, it hurts. Staff D explained that before the 2/3/25 fall, Resident #2 could transfer from the wheelchair to a couch in front of the fish tank on his own. After the fall, Resident #2 needed more help with transfers and complained of more pain in his hip and back. Staff D said the staff told the facility nurses about his increased need for assistance and the rise in pain. Interview on 3/10/25 at 3:15 PM, Staff E stated that on 2/3/25, someone found Resident #2 in the bathroom with no witnesses. When Staff E and Staff D helped Resident #2 off the floor with a gait belt and tried to assist him back to his bed, Resident #2 said, it hurts, it hurts. Staff E and Staff D laid Resident #2 down in bed. Staff E explained they worked with Resident #2 all week and noticed more facial grimacing and moaning when they tried to help him walk. The staff told the charge nurses about Resident #2 having more pain and needing more help with transfers and walking, but they told the staff to give Tylenol for the pain. Staff E felt Resident #2 should have gone to the hospital on 2/3/25 after his fall, since he kept saying it hurt to walk. Interview on 3/10/25 at 4:15 PM, Staff F, Licensed Practical Nurse (LPN), stated on 2/3/25, the staff found Resident #2 on the bathroom floor with no witnesses. Staff D and Staff E placed a gait belt around Resident #2 and tried to help him walk after they completed an assessment. Staff F said Resident #2 complained of pain in his back and posterior thigh area, saying it hurts, it hurts. Staff F didn't feel Resident #2 needed to go to the ER for an evaluation at that time. Staff F added they didn't work again until 2/7/25, and no one reported Resident #2 needed more assistance or experienced more pain with transfers. If Resident #2 had more pain and needed more help with transfers and pain medication on 2/5/25, Staff F confirmed that Resident #2 should have gone for an evaluation. Interview on 3/10/25 at 4:45 PM, Staff G, Registered Nurse (RN), stated after Resident #2 fell on [DATE], he complained of more pain in his right hip. However, Staff G didn't think it felt any different from the pain Resident #2 had when he admitted with his prior hip fracture. Staff G didn't feel Resident #2 needed to go out for an evaluation because of the increased pain or need for more help with transfers. Staff G said the House Supervisor needed to make that decision, not the floor charge nurse. Interview on 3/11/25 at 10:00 AM, Staff H, LPN, stated on 2/5/25, the floor staff told them Resident #2 needed more help with transfers, as he wouldn't transfer from the wheelchair to the couch, and complained of more pain in his right hip. Staff H said they informed the House Supervisor, who told them to call the orthopedic department to let them know Resident #2 had more pain and needed more help with transfers and ask if an x-ray might be helpful. Staff H finished their shift and didn't get a response from the orthopedic department. Staff H confirmed they should have insisted on sending Resident #2 to the ER for an evaluation due to his change in condition on 2/5/25. Staff H also mentioned that before the 2/3/25 fall, Resident #2 could transfer independently from the wheelchair to the couch. Interview 3/11/25 at 10:30 AM, Staff I, RN, stated that on 2/8/25, Resident #2 went to the ER because staff reported he needed more help with transfers and pain medication than usual. Staff I said the staff mentioned Resident #2 complained of pain while he sat on the toilet and grabbed his lower back and right hip. Staff I notified the house supervisor on call that day, and they sent Resident #2 out. Staff I added Resident #2 should have gone to theER on [DATE] or 2/5/25 when he needed more pain medication and extra help with transfers. Interview on 3/10/25 at 2:20 PM, Staff J, RN, stated that on 2/8/25 around 2:40 PM, the charge nurse reported Resident #2 needed a standing mechanical lift to transfer and he complained of more pain in his right lower back and right hip. They decided to send Resident #2 to the ER for an evaluation. Staff J confirmed that before 2/3/25, Resident #2 could transfer from the wheelchair to the couch in the front lobby on his own. Interview on 3/12/25 at 4:15 PM, the Assistant Director of Nursing (ADON) confirmed Resident #2 should have gone to theER on [DATE] after he complained of pain in the right side of his back and hip while he walked. Interview on 3/13/25 at 10:50 AM, the Director of Nursing (DON) and ADON confirmed after they reviewed Resident #2's clinical record that he needed to go to theER on [DATE] due his change in condition, as he required more pain medication and extra help with transfers. The Resident Accident or Incident policy from October 2022 stated that the facility's policy aimed to ensure the safety and well-being of all residents. Due to unexpected events, accidents, or incidents, a resident's well-being could get affected. All employees at the facility had the responsibility to respond properly and report the events.

Based on clinical record review, Resident [NAME] of Rights, facility investigation, staff interview, and review of policy and procedures, the facility failed to report an allegation of abuse to the Department of Inspection and Appeals and Licensing (DIAL) for 1 of 3 residents reviewed (Resident #2) within the required 2-hour timeframe. Staff A, Certified Nurse Aide (CNA), alleged the witnessed Staff B, CNA, hit Resident #2 on 3/7/25. Staff A failed to report the incident to the facility until 3/8/25, after the 2-hour window when they witnessed the alleged incident. The facility reported a census of 151 residents. Findings include: Resident #2's Minimum Data Set assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition., documented diagnoses for which included Benign Prostatic Hyperplasia (BPH), diabetes mellitus, arthritis, recent hip fracture and mild cognitive impairment. The MDS revealed Resident #2 with a Brief Interview for Mental Status (BIMS) score of 5 for which indicated severe memory impairments, is able to be understood and understand by others, and displayed verbal behavioral symptoms directed toward others, (threatening others, screaming at others, cursing at others) other behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, or verbal/vocal symptoms like screaming, disruptive sounds) and substantial to maximal assistance with all activities of daily living (ADL) including ambulation and transfer, and frequently incontinent of bladder and bowel. Resident #2's Incident Report dated 3/8/25 at 12:00 AM, identified Alleged Abuse: Staff A, Certified Nurse Aide (CNA), approached the nurse and told them about an incident that happened the previous night on 3/7/25, involving Staff B, CNA, and Resident #2. Staff A stated Resident #2 began to yell at them again a few moments later and hit Staff B. Staff B then smacked Resident #2's left hand 3 times and said you do not hit me. Resident #2 became more agitated and yelled at Staff B calling her a stupid bitch. Staff B responded back to Resident #2 saying NO, you are a stupid bitch. Resident #2 then said shut up and Staff B said No you shut the fuck up? Staff A and Staff C didn't alert the nurse of the incident immediately. Staff C went home sick soon after the incident. Resident #2 couldn't give a description. The nurse notified the supervisor and immediately called the Director of Nursing (DON) and Staff B's employment agency. The nurse notified Staff B their contract ended effective immediately. The nurse filled out the Incident Report and did an assessment of Resident #2. The undated Facility Summary identified on the evening of 3/8/25 Staff A, reported to the nurse that on the previous evening, 3/7/24, they witnessed an incident of Staff B struck Resident #2 on the back of the hand 2 3 times. The facility reported the incident to the House Supervisor, the DON and the Administrator. Staff B worked at the time of notification and was immediately sent home. The facility completed the following: a. Dismissed accused individual. b. Educated the reporting individual on the importance of timely reporting. c. Facility provided education at hire and at annual in services on dependent adult abuse, reporting and response d. Contract staff had dependent adult abuse education of file. The Incident Note dated 3/8/25 at 11:30 PM indicated Staff A, Certified Nurse Aide (CNA), approached the nurse and told them about an incident that happened the previous night on 3/7/25, involving Staff B, CNA, and Resident #2. Staff A explained Staff B, Staff C, CNA, and themselves entered Resident #2's room because he pressed his call light and stated he needed to go to the bathroom. As the CNAs got him in the standing mechanical lift when Resident #2 started to become agitated asking what they were doing, they explained they were assisting him to the restroom as he requested. Resident #2 accepted the explanation. As they assisted him to use the toilet, he became agitated, the nurse entered the room at that time and told Resident #2 to please not yell at the aides that tried to help him. He told the nurse he just wanted to know why his leg hurt, the nurse explained to Resident #2 he came to the facility because he broke his hip. He calmed down and replied okay he just wanted to know what was going on. The nurse exited the room at that time to attend to another resident. Staff A stated Resident #2 began to yell at them again a few moments later and hit Staff B. Staff B then smacked Resident #2's left hand 3 times and said you do not hit me. Resident #2 became more agitated and yelled at Staff B calling her a stupid bitch. Staff B responded back to Resident #2 saying NO, you are a stupid bitch. Resident #2 then said shut up and Staff B said No you shut the fuck up? Staff A and Staff C didn't alert the nurse of the incident immediately. Staff C went home sick soon after the incident. After reporting the incident to the Nursing Supervisor, they directed the nurse to assess Resident #2. The assessment of Resident #2's hands and wrists identified a reddened area to his left wrist that measured 2 centimeters (CM) by 1.2 CM, in the area Staff A reported Staff B hit. Additionally, the nurse noted 2 bruises on his top right hand and wrist measuring 3 CM by 2.1 CM on the hand with a 3 CM by 3 CM on the wrist. Interview on 3/10/25 at 9:30 AM, the facility Administrator confirmed the facility failed to notify DIAL of the incident between Resident #2 and Staff B within the 2-hour time frame. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated December 2022, instructed all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegation of abuse to the Administrator, or designated representative. All allegations of resident abuse shall be reported to the Iowa Department of Inspections and Appeals no later than 2 hours after the allegation is made.

Based on clinical record review, policy/procedure review, and staff interview the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 3 resident reviewed. (Resident #2). The facility identified a census of 151 residents. Findings include: Resident #2's Minimum Data Set assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition., documented diagnoses for which included Benign Prostatic Hyperplasia (BPH), diabetes mellitus, arthritis, recent hip fracture and mild cognitive impairment. The MDS revealed Resident #2 with a Brief Interview for Mental Status (BIMS) score of 5 for which indicated severe memory impairments, is able to be understood and understand by others, and displayed verbal behavioral symptoms directed toward others, (threatening others, screaming at others, cursing at others) other behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, or verbal/vocal symptoms like screaming, disruptive sounds) and substantial to maximal assistance with all activities of daily living (ADL) including ambulation and transfer, and frequently incontinent of bladder and bowel. The Care Plan Focus initiated 12/10/24 reflected Resident #2 required assistance with activities of daily living (ADLs) due to a right hip fracture, pubic rami fracture (2/13/25) with surgical repair. The Care Plan Interventions directed the following: a. Initiated 2/4/25: Resident #2 required assistance from 2 staff and a standing mechanical lift. Resident #2 didn't like the use of the gait belt and will slap staff hands away when trying to apply the gait belt. Educate the reason for the gait belt and he would usually allow. Resident #2 didn't walk and used a wheelchair for all mobility. allow. Resident #2 didn't walk and used a wheelchair for all mobility. b. Revised: 2/12/25: Resident #2 required assistance of 2 staff with toilet use. He wore protective undergarments and needed assistance with perineal cares. The Care Plan Focus initiated 12/10/24 indicated Resident #2 had a risk for elopement and wandering due to a diagnosis of dementia/Alzheimer's disease. He has a history of attempting to leave the facility unattended and wanders aimlessly. The Interventions instructed to anticipate his wants and need as he may not always verbalize them. Resident #2's Incident Report dated 3/8/25 at 12:00 AM, identified Alleged Abuse: Staff A, Certified Nurse Aide (CNA), approached the nurse and told them about an incident that happened the previous night on 3/7/25, involving Staff B, CNA, and Resident #2. Staff A explained Staff B, Staff C, CNA, and themselves entered Resident #2's room because he pressed his call light and stated he needed to go to the bathroom. As the CNAs got him in the standing mechanical lift when Resident #2 started to become agitated asking what they were doing, they explained they were assisting him to the restroom as he requested. Resident #2 accepted the explanation. As they assisted him to use the toilet, he became agitated, the nurse entered the room at that time and told Resident #2 to please not yell at the aides that tried to help him. He told the nurse he just wanted to know why his leg hurt, the nurse explained to Resident #2 he came to the facility because he broke his hip. He calmed down and replied okay he just wanted to know what was going on. The nurse exited the room at that time to attend to another resident. Staff A stated Resident #2 began to yell at them again a few moments later and hit Staff B. Staff B then smacked Resident #2s left hand 3 times and said you do not hit me. Resident #2 became more agitated and yelled at Staff B calling her a stupid bitch. Staff B responded back to Resident #2 saying NO, you are a stupid bitch. Resident #2 then said shut up and Staff B said No you shut the fuck up? Staff A and Staff C didn't alert the nurse of the incident immediately. Staff C went home sick soon after the incident. Resident #2 couldn't give a description. The nurse notified the supervisor and immediately called the Director of Nursing (DON) and Staff B's employment agency. The nurse notified Staff B their contract ended effective immediately. The nurse filled out the Incident Report and did an assessment of Resident #2. The undated Facility Summary documented Resident #2 resided at the facility since 12/10/24. He had diagnoses of a fracture of his right femur neck (prior to admission), diabetes, dementia with mood disturbance, and osteoarthritis. He had a BIMS of 3. He required the use of equipment and 2 staff for transfers. Resident #2 received Tylenol for pain. He had no safety awareness, and repeatedly attempted to transfer himself without asking for assistance or using his call light. He became agitated at attempts to help him with cares and would hit, curse, and bite staff. Resident #2 had a long history of falls at home. On the evening of 3/8/25 Staff A, reported to her nurse that on the previous evening, 3/7/24, they witnessed Staff B strike Resident #2 on the back of his hand 2 3 times. The nurse elevated the Incident to the House Supervisor. The staff made notifications to the DON and Administrator. Staff B was present at the time and was immediately sent home. The investigation included staff statements and the DON contacted Staff B for a statement via telephone. The facility reported to the DON and Administration Resident #2 didn't have a bruise on their hand. There is documentation describing Resident #2's combative behavior in the time leading up to this incident. There are episodes in the nursing documentation for 3/1/25 and 3/4/25, where Resident #2 hit staff. One can expect that during a hitting motion, Resident #2 could receive bruising on inside of arms/wrists. The facility completed weekly skin checks. a. Dismissed accused individual. b. Educated the reporting individual on the importance of timely reporting. c. Facility provided education at hire and at annual in services on dependent adult abuse, reporting and response d. Contract staff had dependent adult abuse education of file. The Behavior Note dated 3/1/25 at 1:54 PM indicated Resident #2 yelled at staff when instructed to wait a moment, due to waiting on another staff member to assist as he required 2 staff for assistance. Resident #2 pushed, spit, and hit staff during incontinent care and transfers. The staff unable to successfully redirect him. The Communication - with Physician Note dated 3/4/25 at 1:32 PM reflected the staff reported Resident #2 continued to be combative with cares. The staff reported he hit, kicked, scratched, and bit them. The Incident Note dated 3/8/25 at 11:30 PM indicated Staff A, Certified Nurse Aide (CNA), approached the nurse and told them about an incident that happened the previous night on 3/7/25, involving Staff B, CNA, and Resident #2. Staff A explained Staff B, Staff C, CNA, and themselves entered Resident #2's room because he pressed his call light and stated he needed to go to the bathroom. As the CNAs got him in the standing mechanical lift when Resident #2 started to become agitated asking what they were doing, they explained they were assisting him to the restroom as he requested. Resident #2 accepted the explanation. As they assisted him to use the toilet, he became agitated, the nurse entered the room at that time and told Resident #2 to please not yell at the aides that tried to help him. He told the nurse he just wanted to know why his leg hurt, the nurse explained to Resident #2 he came to the facility because he broke his hip. He calmed down and replied okay he just wanted to know what was going on. The nurse exited the room at that time to attend to another resident. Staff A stated Resident #2 began to yell at them again a few moments later and hit Staff B. Staff B then smacked Resident #2s left hand 3 times and said you do not hit me. Resident #2 became more agitated and yelled at Staff B calling her a stupid bitch. Staff B responded back to Resident #2 saying NO, you are a stupid bitch. Resident #2 then said shut up and Staff B said No you shut the fuck up? Staff A and Staff C didn't alert the nurse of the incident immediately. Staff C went home sick soon after the incident. After reporting the incident to the Nursing Supervisor, they directed the nurse to assess Resident #2. The assessment of Resident #2's hands and wrists identified a reddened area to his left wrist that measured 2 centimeters (CM) by 1.2 CM, in the area Staff A reported Staff B hit. Additionally, the nurse noted 2 bruises on his top right hand and wrist measuring 3 CM by 2.1 CM on the hand with a 3 CM by 3 CM on the wrist. Interview on 3/11/25 at 4:30 PM, The facility Director of Nursing (DON), verified they expected all staff to treat residents with dignity and respect per the policy/procedure. Interview on 3/12/25 at 10:00 AM, the Facility Administrator confirmed all residents are to be treated with respect and dignity from staff at all times. The Resident Rights dated October 2017, documented the resident had the right to a dignified existence, self determination, and communication with and access to persons and services inside and outside the facility. a. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promoted maintenance or enhancement of his or her quality of life, recognizing each resident individuality. The facility must protect and promote the rights of the resident.

Based on record review, resident, and staff interviews the facility failed to catheterize residents only when they had an order for 1 of 1 resident reviewed (Resident #46). The facility reported a census of 159 residents. Findings include: Resident #46's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #46 needed substantial/maximal assistance from staff with toileting hygiene. Record review of an untitled disciplinary action for Staff I, Registered Nurse (RN), dated 6/20/24 documented she catheterized a resident without an order for a catheter (Resident #46). During an interview on 10/28/24 at 3:36 PM Resident #46 explained earlier that year a new nurse put a catheter in her when she was not supposed to and she didn't have an order. She said she yelled at the nurse to stop it. She then reported she made a big issue with upper management at the facility and the nurse ended up getting fired. She explained it really bothered her and was not happy the nurse did not listen to her. She added maybe she should have asked more questions but figured the nurse knew what she was doing. On 10/30/24 at 2:25 PM the Director of Nursing (DON) reported she hired a new nurse (Staff I) earlier in the year. While still in orientation, someone told her to catheterize a resident but she mixed up the residents and catheterized Resident #46 (the wrong resident). She explained Staff I made an error and no longer worked at the facility. She added she spoke with Resident #46 multiple times and resolved the issue. During an interview on 10/31/24 at 11:08 AM the Administrator and DON said no one should catheterize a resident unless they had an order for it. In relation to when the nurse catheterized Resident #46, Staff I made an error and the facility chose to terminate her shortly after the incident occurred.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to implement adequate infection control prevention practices. While passing medication to a resident, the Certified Medication touched the resident's medication with their bare hands for 2 of 4 resident observed (Residents #213 and #26). The facility identified a census of 159 residents. Findings include: On 10/29/24 at 7:30 AM observed Staff E, CMA, compare the Electronic Medication Administration Record (EMAR) with the medication pack and punch 1 tablet of Resident #213's methylphenidate (attention deficit hyperactive disorder medication) 10 milligrams (MG) into her left hand, before placing it pill in a plastic med cup. At 7:32 AM Staff E shook two Vitamin D 1000 International Units (IU) tablets from the bottle into the lid, then with her left hand picked up one of the Vitamin D tablets, and placed it in the plastic medication cup. Staff E took the medication cup over to Resident #213, who took the medication. On 10/29/24 at 7:35 AM witnessed Staff E review Resident #26's EMAR orders. Staff E removed a stock bottle from the bottom drawer of the medication cart, shook 1 tablet of Certavite (multivitamin medication) tablet with antioxidants from the bottle into the lid, took the pill out with her right hand, placed it in a plastic medication cup, and then administered the medication to Resident #26. On 10/30/24 at 12:30 PM Staff F, Licensed Practical Nurse (LPN), reported no one should touch the medications with their bare hands. Staff F added they should use a tongue depressor or spoon to handle the medication. On 10/30/24 at 1:48 PM Staff G, LPN, reported no one should touch pills with their bare hands during medication administration. She indicated she would shake the pill into the lid of the bottle or use a new glove if she had to touch a pill. During an interview on 10/30/24 at 2:20 PM the Director of Nursing (DON) reported she expected the nurses and CMAs to use a clean glove if they need to touch an oral pill during medication administration. The nurse shouldn't touch oral pills with their bare hands. The Medication Pass Policy/Procedure revised 10/30/24 directed the staff to follow established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for the administration of medications, as applicable.

Based on observation, clinical record review and staff interview, the facility failed to provide services to treat or prevent reduction in range of motion for 1 of 1 resident sampled (Resident #134). After finishing Occupational Therapy, Resident #134 received specially modified palm guards to protect her hand from her contractures. Multiple observations revealed Resident #134 didn't have palm guards. Interviews determined, she didn't have them for a while and no one contacted therapy about getting replacements. The facility identified a census of 159 residents. Findings include: Resident #134's Minimum Data Set (MDS) assessment dated [DATE] identified they have short/long term memory impairment and severely impaired decision-making ability. Resident #134 had a functional loss in range of motion (ROM) on one side of the upper (shoulder, elbow, wrist, hand) body. The MDS included diagnoses of cerebral palsy and dementia. The MDS lacked documentation Resident #134 received restorative nursing services. Resident #134's Provider signed an order on 5/31/24 for Occupational Therapy (OT) to evaluate and treat as indicated to fit for a brace for the left-hand contracture. An OT Evaluation and Treatment Plan, start date 6/10/24, documented a treatment code for contracture of muscle, left hand. The Musculoskeletal System Assessment reflected Resident #134 had impaired left upper extremity ROM of the following: a. Thumb contracture - Do not treat (DNT) contracture b. Index finger contracture - DNT contracture c. Middle finger contracture - DNT contracture d. Ring finger contracture - DNT contracture e. Little finger contracture - DNT contracture The LUE strength indicated Resident #134 had impaired strength of the shoulder, elbow, and wrist. Resident #134's August 2024 Treatment Administration Record (TAR) included a Physician Order dated 7/15/24 to make sure the left palm guard is in place during the daytime. Place a rolled gauze in the hand during the night. Two times a day for splint wear. The Therapy Discharge Notification signed by the Occupational Therapist on 7/28/24 indicated Resident #134 met their goals. They provided Resident #134 with two palm guards for her left hand. OT services scheduled to end 8/5/24. An OT Discharge Summary dated 8/5/24 listed Discharge Recommendations and Status as Resident #134 required 24-hour assistance and continue her palm guard. They established and trained the staff regarding Resident #134's Restorative Splint and Brace Program to wear her palm guard on during the day, hand wash, and hang to dry. The Care Plan Focus dated 12/11/23 indicated Resident #134 had an activities of daily living (ADL) self care performance deficit related to cerebral palsy, kyphosis (bend of the spine) and fracture of her right tibia (lower leg bone). The Interventions directed the following: a. 3/21/24: Please make sure you are cleansing the left hand every day and allowing to air dry. Please put a rolled-up wash cloth or gauze in the palm to keep fingers from pressing into the palm. Please do this every shift and apply a clean wash cloth or gauze in the hand every shift until evaluated by occupational therapy. b. 7/15/24: Resident #134 had two left palm guards. Hand wash and air dry them daily. Do not throw them away! She is to wear the palm guard during the day. At night place rolled up gauze in the hand. Wash and dry hand guards daily and dry thoroughly! Resident #134's September 2024 TAR included a 9, indicating to see the progress notes for the AM shift on 9/16/24, 9/25/24, 9/26/24 and the PM shift on 9/23/24. The remaining entries reflected nursing had the palm guard in place to her left palm or a wash cloth/gauze rolled up in the left palm as ordered by the physician. The Orders - Administration Note dated 9/16/24 at 6:06 AM indicated the staff couldn't find Resident #134's splint. The Orders - Administration Note dated 9/23/24 at 10:08 PM reflected Resident #134 didn't have her palm guard in place. The Orders - Administration Note dated 9/25/24 at 11:01 AM listed Resident #134 didn't have her splint available. The Orders - Administration Note dated 9/26/24 at 12:18 PM indicted Resident #134 didn't have her palm guard available. On 10/29/24 at 12:57 PM observed Resident #134 lying in bed on her left side in a low bed. The observation showed Resident #134 without her palm guard or wash cloth in her left hand. Resident #134's middle finger and ring finger appeared to dig into her left palm. During an interview on 10/29/24 at 12:58 PM Staff A, Certified Nursing Assistant (CNA), reported she didn't have her palm guard in her left hand. Staff A added she is supposed to have a left-hand guard, but God only knows where they went. They've been gone for a long time. On 10/29/24 at 1:35 PM witnessed Resident #134 lying in bed on her left side without a palm guard, wash cloth, or gauze in her left hand. On 10/29/24 at 4:38 PM observed Resident #134 sitting in a wheelchair across from the 1 Southeast nurses' station. Resident #134's left wrist had a contracted hand with her fingers digging into her palm. Resident #134 didn't have her left-hand palm guard in place. On 10/30/24 at 7:51 AM Resident #134 sat in the wheelchair at the dining room table. Resident #134 middle finger and ring finger dug into her left palm. She had no palm guard, rolled wash cloth or gauze in her left palm. On 10/30/24 at 11:26 AM witnessed Resident #134's left hand without a palm guard, rolled wash cloth, or gauze to her left palm while she sat in the wheelchair. Her middle finger and ring finger appeared to dig into her left palm. Resident #134's October 2024 TAR included a 9, indicating to see the progress notes for 20 out of 58 times, indicating she didn't have her left palm guard available. The other 38 staff signatures reflected they followed the physician's order. A 10/30/24 review of the October 2024 Progress Notes documented not available on the 5, 6, 17, 21, 22, 25, and 27. On 11, 12, 15, 16, 18, 25, 26, 28, and 29 Resident #134 didn't have her palm guard in place. On 10/30/24 at 12:48 PM Staff B, Certified Occupational Therapist Assistant (COTA), reported Resident #134 received two palm guards. The guards had to be specially fitted due to the contractures of her hands. They told the staff to hand wash the splint, hang it to dry, and when to put them on. Staff B reported no staff requested new palm guards for Resident #134. Staff B recalled the recommendations instructed to put the palm guards on the left hand during the day and to put rolled up gauze in the left palm at night. Staff E reiterated Resident #134 had a very tight left palm, they had to cut the double layer of sheepskin in the palm guard and sew it back because of it being too thick for her palm. They had to specially fit the left-hand palm guards for Resident #134. Interview completed on 10/30/24 at 1:19 PM Staff C, CNA, voiced she only started working at the facility one month before. Resident #134 didn't have any palm guard to put in her left hand since she worked at the facility. On 10/30/24 at 1:20 PM Staff D, Licensed Practical Nurse (LPN), reported Resident #134 had 2 or 3 of the palm guards, but people didn't have the intelligence to understand they are supposed to hand wash them and hang them to dry, as the staff kept throwing out her hand guards. Staff D stated he charted the left-hand guards as not available for some time. Someone needed to go up to therapy and see if therapy could provide more hand guards. Staff D stated he was going to go up to therapy at that time to check on new hand guards. During an interview on 10/30/24 at approximately 2:25 PM the Director of Nursing (DON) reported if Resident #134's palm guards went missing, she expected the nurses to check with therapy on getting new palm guards. The Restorative Nursing Services Policy revised 10/30/24 directed residents will receive restorative nursing care as needed to help promote optimal safety and independence. The Policy documented restorative goals and objectives are individualized and resident centered, and are outlined in the resident's plan of care. The Policy further specified restorative goals may include but are not limited to supporting and assisting the resident to maintain physiological and psychological resources.

Based on observations, interviews, and record review, the facility failed to reassess blood pressures for one of one resident reviewed (Resident #67). Resident #67 had high and low blood pressures that didn't get reassessed. The facility reported a census of 159. Findings include: Resident #67's September and October 2024 Treatment Administration Record (TAR) included an order dated 4/18/24, that directed staff to obtain blood pressure and temperature every shift. The Weights and Vitals Summary review on 10/30/24 at 10:29 AM related to blood pressures listed the following results: a. 9/29/24 at 2:08 PM: 62/41 mm/Hg (measurement of pressure) (Lying r/arm)(Resident was lying down and blood pressure was taken on the right arm) diastolic bottom number of the blood pressure reading)(measures the pressure in the artery walls between heart beat)(pressure in the arteries when the heart beats) low of 60 exceeded, systolic (top number of blood pressure reading) low of 90 exceeded. b. 9/29/24 at 8:28 PM: 53/49 mmHg (Lying l/arm)(Resident was lying down and blood pressure was taken on the right arm) diastolic Low of 60 exceeded systolic low of 90 exceeded c. 9/30/24 at 3:49 AM: 75/49 mmHg (Lying r/arm) diastolic low of 60 exceeded systolic low of 90 exceeded d. 9/30/24 at 1:07 PM: 72/47 mmHg (Lying l/arm) diastolic low of 60 exceeded systolic low of 90 exceeded e. 10/5/24 at 11:24 AM: 187/129 mmHg (Sitting r/arm)( (Resident was sitting up and blood pressure was taken on the right arm) diastolic high of 89 exceeded systolic high of 139 exceeded f. 10/6/24 at 6:37 PM: 54/31 mmHg (Lying l/arm) diastolic low of 60 exceeded systolic low of 90 exceeded g. 10/10/24 at 10:14 AM: 60/45 mmHg (Lying l/arm) diastolic low of 60 exceeded systolic low of 90 exceeded On 10/ 29/24 at 3:17 PM, Staff J, Licensed Practical Nurse (LPN), stated she used a wrist cuff when she took Resident #67's blood pressures. When asked what she considered a low blood pressure, Staff J responded it depended on the resident. Staff J stated Resident 64's blood pressure ran low sometimes. Staff J stated she took blood pressure's on Resident #64 before that have been low. Staff J said that typically Resident #64 is lying down when Staff J takes their blood pressure and that's why her blood pressure runs low. When shown the October 2024 TAR Staff J acknowledged she should have rechecked Resident #64's blood pressures on the 10/5/21, 10/6/24 and 10/10/24. She stated on 10/5/24 she had too high of blood pressure readings and on too low on 10/6/24 and 10/10/24. On 10/29/24 at 4:21 PM, the Director of Nursing (DON), stated Staff J talked with them about the blood pressures. The DON went over blood pressure readings and they acknowledged the nurse should have done a recheck of Resident #67's blood pressures with a blood pressure cuff. She acknowledged they should have notified the charge nurse and the physician. The DON stated she would look into the situation further related to Resident #67's low blood pressures on the 9/29/24, 9/30/24, 10/6/24, and 9/30/24. She acknowledged they should have rechecked the blood pressures. She acknowledged Resident #67 had a high blood pressure on 10/5/24 that they should have rechecked. This DON stated she expected if a resident continued to have a low or high blood pressures after rechecking, then that would warrant further assessment and intervention. The DON stated the blood pressure on 9/29/24 at 8:28 PM, of 55/49 didn't even make sense. On 10/30/24 at 12:19 PM, the DON stated she didn't find any further rechecks for the blood pressures on the above dates. The DON stated she updated Resident #67's physician's order that all of Resident #67 blood pressures would from this point on be taken with a pediatric cuff, not the wrist cuffs. A Blood Pressure, Measuring Policy revised 10/30/24, defined blood pressure as to measure the pressure exerted by the circulating volume of blood on the walls of the arteries, veins and chambers of the heart. A blood pressure reading is represented as a ratio or fraction. The top number (the systolic pressure) measures the blood pressure during the contractions of the heart (systole). The bottom number (the diastolic pressure) measures the pressure of the blood while the heart is at rest (diastole). The blood pressure is generally defined as normal when the systolic pressure is in the range of 101 to 129 mm/Hg (milliliters of mercury) and the diastolic pressure is in the range of 61 to 84 mm/Hg. Borderline hypertension is typically defined as a systolic pressure of 130 to 139 mm/Hg and the diastolic pressure of 85 to 89 mm/Hg. Hypertension is usually defined as blood pressure over 140/90 mm/Hg (although the elderly often have recorded several readings taken at different times of the day. Staff should note any pertinent medications and/or recent changes of condition when reporting to the physician. hypotension is defined as blood pressure less than 100/60 mm/Hg. orthostatic (postural) hypotension is defined as a 20 mm/Hg (or greater) decline in systolic blood pressure or a 10 mm/Hg (or greater) decline in diastolic blood pressure upon standing. Post prandial hypotension is defined as a 20 mm/Hg decline in systolic blood pressure (or a 10 mm/Hg) drop if the baseline is less than 100 mm/Hg) within two (2) hours after eating a meal. New onset hypotension should be reported to the physician. Staff should record several readings throughout the day, including before and after meals.

Based on record review and staff interviews the facility failed to ensure the Facility Assessment evaluated each resident's need for activities of daily living (ADL's), bowel, bladder, mental ability, skin integrity, special care, treatment, and medications. In addition, the facility failed to evaluate their ability to meet their needs. The facility reported a census of 159. Findings include: Record review of the facility's current Facility assessment dated [DATE] lacked an assessment and evaluation of the facility's current residents that include but not limited to: a. ADL status for each resident and equipment that may be needed b. Bowel/bladder status and supply needs c. Mental abilities of residents and services to support cognitive function d. Skin integrity including type of treatments and supply needs e. Special care (such as palliative, hospice, therapy, oxygen) f. Treatments needed and suppliers g. Medications needed and suppliers. On 10/30/24 at 2:06 PM the Director of Nursing (DON) reported she assisted with reviewing the Facility Assessment but reported the Administrator as the person in charge of it. During an interview on 10/31/24 at 11:08 AM the Administrator and DON explained the facility used to have a process with a form in place for their Facility Assessment to address each resident's care areas but their current electronic health record (HER) didn't longer use that form anymore, so the facility didn't currently have a system in place for assessing resident specific needs.

Based on record review, observation, policy review, staff, and resident interviews, the facility failed to ensure a resident had their call light within reach at all times for 1 of 3 residents reviewed for recent falls (Resident #17). The facility reported a census of 159 residents. Findings include: Resident #17's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS listed Resident #17 as independent with bed mobility, walking, sitting, and toilet use. On 10/28/24 at 12:49 PM Resident #17 reported she had her call light sitting on the foot of her bed approximately eight (8) feet from her recliner she sat in. She had a sling to her right arm. She explained she recently fell in her bathroom and fractured her arm. On 10/30/24 at 2:34 PM the Director of Nursing (DON) reported she expected all residents have their call lights within reach when they are in their room including in bed, recliner, and toilet. During an interview on 10/31/24 at 11:08 AM the Administrator and DON reported they expected residents have a call light within their reach at all times when in their room. The Call Lights policy, reviewed 10/30/24 instructed to have a call light within reach of a resident while in their bed or confined to chair.

Based on clinical record view, staff interview, and the Resident Assessment Instrument (RAI) Manual, the facility failed to transmit 1 of 1 Minimum Data Set (MDS) assessments for the facility within the required timeframe (Resident #34). The facility reported a census of 159 residents. Findings include: The Discharge Summary dated 6/26/24 at 1:00 PM reflected Resident #34 discharged to home. The Clinical - MDS reviewed on 10/29/24 at 12:37 PM listed the MDS' completed on 6/1/24 and 6/26/24 as completed, indicating they didn't get transmitted yet. The previous MDS' indicated accepted, indicating the facility transmitted them. During an interview on 10/29/24 at 1:16 PM, Staff H, Registered Nurse/Care Plan Nurse, reported she completed Resident #34's discharge MDS. She reported she didn't submit the MDS to the Centers of Medicare and Medicaid Services (CMS) and she should have. On 10/29.24 at 3:29 PM, the Administrator reported the facility didn't have a policy for MDS submissions. She reported the facility followed the RAI Manual. The current RAI Manual dated October 2023 instructed to submit a discharge return not anticipated MDS no later than 14 days after the MDS completion. The facility should complete the MDS within 14 days after the discharge date .

Based on record review, staff interviews, and policy review the facility failed to ensure 1 of 3 residents (Resident #1) did not fall when getting off of the facility van. The facility reported a census of 153 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 13, indicating he intact cognition. The MDS listed Resident #1 as independent with transfers, walking, personal hygiene, and using the toilet. The MDS included diagnoses of cancer, hypertension (high blood pressure), and malnutrition (inadequate nutritional intake). Resident #1 received hospice services within the lookback period. The Fall with Injury Incident Report dated 9/2/24 at 12:32 PM reflected the receptionist called the staff to report a resident who fell in the driveway. Resident #1 complained of tenderness of his right wrist a few minutes after returning to his room. He could move it freely and had no deformity. Despite encouragement to go to the ER for evaluation, Resident #1 and his family declined to go. The untitled and undated investigation completed by the facility for Resident #1's fall on 9/2/24 indicated Resident #1 fell in his room during a self-transfer. Following the fall, he went to the emergency room (ER) and received sutures (stitches) above his left eyebrow. After returning to the facility, the facility van driver accidentally left the van lift in the ground level position. As the van driver walked backwards off the van, he fell backward to the lift, pulling Resident #1 out of the van to the ground with him. As the driver attempted to get up, he slowly tipped Resident #1 to the left side, causing him to slide out of the wheelchair into a lying position. Resident #1 reported he felt fine and did not hit his head. Later in the day, Resident #1 complained of wrist pain, when facility offerred to take him to the hospital, he declined to go for an evaluation and his family who witnessed the incident declined as well. The Plan indicated the facility terminated the van driver on 9/2/24. The facility updated their policy to add a requirement for any transports to have the driver and one additional person standing by for the loading and unloading of the van to ensure safety on 9/2/24. The facility reeducated the staff who operate the facility van on the new process on 9/3/24. The facility planned to give the policy to all new hires who drive the van on 9/3/24. Record review of a document titled Quality Assurence (QA) Meeting, dated 9/3/24 documented education to all van drivers employed by the facility. During an interview on 9/6/24 at 2:15 PM the Administrator reported Resident #1 fell by accident and they reeducated all employees on how to use the van. The facility policy, Post Fall Protocol dated 8/24/24 revealed the facility followed their policy and procedures related to Resident #1 fall on 9/2/24.

Based on observation, clinical record review, facility policy review, family, physician, emergency medical personnel, and staff interview, the facility failed to implement interventions in a timely manner for a resident following a fall for 1 of 3 residents reviewed (Resident #3). The facility failed to intervene after Resident #3 fell and complained instantly of new pain to his ribs. Despite, the family's frequent questioning about Resident #3's situation, the facility failed to send him to the hospital for 2 hours and 36 minutes following his fall. The facility's policy requires someone from nursing management to assess a resident following an incident. It took the nursing supervisor approximately 1 hours after Resident #3 fell for the nursing supervisor assessed Resident #3. Following the nursing supervisor's assessment requested by Resident #3's family, the nursing supervisor attempted to contact the physician for an order to send him to the hospital. Resident #3 transferred to the hospital approximately 2 hours and 36 minutes following his fall, and approximately 1 hour after the nursing supervisor determined to send him. Once Resident #3 arrived at the emergency room , the staff found he suffered from a punctured lung, multiple rib fractures, and injuries inconsistent with the reported fall. Once at the hospital, the staff intubated Resident #3 and admitted him to the intensive care unit (ICU). After the hospital staff determined the extent of Resident #3's injuries and visited with his family. At that time, the decided to remove the intubation and transition to comfort measures on hospice on 8/15/24. The hospital records indicated Resident #3 passed away on 8/17/24. The delay in treatment for Resident #3 resulted in an immediate jeopardy situation. The facility identified a census of 165 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on August 23, 2024 that began as of August 13, 2024. The Facility Staff removed the Immediate Jeopardy on August 23, 2024 through the following actions: a. Revised post-incident protocol to include the following provisions to all nursing staff that in the instance of a suspected injury or change of condition: i. If the house supervisor is not available the charge nurse can and should contact emergency personnel and arrange transportation to the emergency department (ED) if the situation is deemed emergent or urgent. ii. If the physician does not respond within 60 minutes to a phone call to request to transfer to ED, that the supervisor or designee should call emergency response and arrange for transport. This should be followed with continued efforts to contact the physician to notify of the transfer. iii. Should include a review of resident's medications to determine what factors those medications could potentially have upon the assessment of the resident and potential outcomes. b. The facility provided immediate reeducation to House Supervisors and charge nurses to include the above. c. Summary will be placed on the electronic communication board on 8/23/24 for all clinical staff to read. d. The facility placed the policy at each nurses' station on 8/23/24 for staff signature. The facility tracked the signatures against their staff roster to ensure all nurses received the education prior to their next shift. e. New staff, agency, and contract staff orientation will include the revised policy prior to their first shift. The scope lowered from a J to G at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 165 residents. Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] indicated he had highly impaired vision. The MDS identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Resident #3 required substantial to maximum assistance from staff with sit to stand transfers and partial to moderate assistance from staff with ambulation. The MDS included diagnoses of a wedge compression fracture of lumbar vertebra (the front of the vertebral body collapses but the back portion did not), age-related osteoporosis, low back pain, muscle weakness, spinal stenosis (spaces inside the bones of the spine became too small) in the lumbosacral (mid to lower back) region, primary osteoarthritis, and diabetes mellitus (DM). The assessment reflected Resident #3 had occasional pain with the highest rating of a 5 on a scale of 0-10 (10 being the highest amount of pain) which occasionally interfered with his day-to-day activities. Resident #3 took as needed (PRN) pain medication in the lookback period. The Care Plan included the following Focus areas: a. 4/11/24: An activities of daily living (ADL) self-care performance deficit related to (r/t) low back pain and essential tremors. The interventions directed: i. Dependent ambulation assistance from 2 staff members, gait belt (GB) and front wheel walker (FWW) with a wheel chair (w/c) to follow. Dated 4/10/24 and revised 6/20/24. ii. Partial/moderate transfer assistance from 1 staff member with a GB and FWW, may use 2 staff members PRN. Initiated 4/10/24 and revised 6/20/24). b. A Pacemaker (device that sent electrical pulses to the heart for maintenance of a normal heart rate and rhythm). Initiated and revised 4/10/24. c. High risk for falls r/t low back pain r/t age related osteoporosis with a current pathological fracture (bone fracture caused by weakness of the bone structure) of the vertebrae and meniere's disease. Initiated 4/10/24 and revised 4/16/24. The Interventions directed Resident #3 required prompt response to all requests for assistance. Initiated 4/10/24. d. Chronic pain r/t lumbar (lower back) compression fractures, spinal stenosis of the cervical and lumbar regions. Resident #3 used PRN pain medication. Initiated 4/10/24 and revised 6/4/24. e. Impaired visual function r/t Glaucoma (increased pressure in the eyes that affects vision). Initiated 4/10/24. The Fall Risk Evaluation dated 7/16/24 reflected a score of 11, identifying Resident #3 at risk for falls. Resident #3's August 2024 Medication Administration Record (MAR) reflected he received the following Physician orders: a. Oxycodone 5 milligram (mg) tablet one (1) by mouth (po) every six (6) hours PRN for pain dated 6/19/24 at 11 PM. i. Documentation on 8/1/24, 8/2/24 and 8/4/24 thru 8/12/24 indicated he received a dose, due to a pain range of 2 to 5. ii. Documentation reflected he received a dose on 8/13/24 at 6:33 PM for pain rated at a 7, indicating a moderate amount of pain. b. Isosorbide Mononitrate (medication used to dilate the vessels, making blood flow easier) tablet 60 mg extended release (ER) 1 tablet once a day in the morning (AM) for hypertension (HTN - high blood pressure), atherosclerotic heart disease of the coronary artery with angina pectoris (a form of heart disease that can cause pain) dated 4.9.24 at 11 PM. Give in the morning (AM). c. Losartan Potassium tablet 25 MG tablet by mouth (po) every 12 hours for HTN dated 4.9.24 at 11 PM. Give at 8 AM and 8 PM The Fall with Injury report dated 8/13/24 at 5:15 PM identified as the certified nurse aides (CNA's) walked down the hall to help the residents to dinner, they found Resident #3 lying on the floor as his wife asked for help. The CNA's alerted the Registered Nurse (RN) of Resident #3 fell . Resident #3 had a pillow under his head with his wheelchair positioned in front of the recliner and his walker on its side. Resident #3 complained of rib pain when he moved his shoulder joint, but had no change in his level of consciousness (LOC). The staff noted a pink mark on his left torso from the arm of the wheel chair (w/c). The staff applied a gait belt (GB) assistive device and with the assistance of 2 staff, they helped him stand and positioned him into his w/c. Resident #3's left-hand sustained skin tears across his knuckles as well as his left upper forearms. The nurse cleansed the skin tears, rolled the skin over the open areas, and applied steri strips. Then the nurse covered the area with a non adherent pad (dressing that shouldn't stick) to the left forearm and wrapped with a kling wrap (type of gauze wrap). At 5:55 PM Resident #3's spouse returned from dinner and asked him if he felt hungry. At which time he responded yes and wished to go to dinner. Resident #3 used the urinal independently, coached to cough, respirations even, and non labored at 20-22 breaths per minute. He complained of discomfort during the cough and deep breathing requests. As Resident #3 transferred himself from the recliner to the w/c with the use of a walker, he remembered the w/c had the brakes locked. As he turned and sat down in the w/c the spouse attempted to help him. She moved the w/c, this resulted in him missing the w/c. He fell , striking his left torso and right axilla. The Injuries Observed at Time of Incident section indicated he had no injuries at the time of incident. During an interview on 8/22/24 at 12:22 PM Staff A, CNA, indicated around 5:00 to 5:10 PM, as she walked back from the dining room, she heard Resident #3's wife scream for help. When she entered their room, she observed Resident #3 positioned on the floor in front of the recliner, on his back, with his head under the desk area. Resident #3's wife already placed a pillow under his head. Staff A observed Resident #3's w/c shoved into the recliner and the walker right beside him in a standing position but they didn't know if the wife sat it up post fall or not. (Resident #3's wife had a BIMS score of 7, indicating severely impaired cognition). Resident #3 reported his ribs hurt, Staff A described this as a new complaint because he only complained of back pain. At that time, he called out to get him off the floor a couple times. The charge nurse arrived and assessed Resident #3, however she didn't know for sure if the nurse performed range of motion. The nurse then made the call to stand him. The nurse positioned herself on 1 side, a certified medication aide (CMA) on other as Staff A stood at his back side, while another unknown staff member maneuvered the w/c. When the staff stood him, Staff A said she wanted to say yes, he cried out in pain. The staff positioned him in his w/c until around 7 PM when he wanted to get in his recliner. The staff decided to use a lift device for the transfer process and for provision of more support for the resident. When the staff moved him forward in the w/c for placement of the sling device the resident made an ugg sound. The staff transferred Resident #3 with the lift device and positioned him in his recliner, where he appeared content after they got him situated. Staff A indicated around 8 PM she walked around the corner of the hallway and observed the Emergency Medical Service (EMS) as they arrived approximately 3 hours after his fall. The staff member stated, I wished they would have sent the resident out right way. During an interview on 8/22/24 at 12:36 PM Staff B, Registered Nurse, (RN) indicated at the time of Resident #3's fall, she performed blood sugar checks on a couple residents and gave insulin as the 2 aides who worked her area assisted other residents to the dining room. A little after 5:00ish PM Resident #3's wife stopped 1 CNA in the hall. One of the staff members reported to Staff B that Resident #3 fell . When Staff A responded, she found him on his back in his room with a pillow under his head as he complained of pain to the left side of his ribs. As Staff B assessed Resident #3, she noted him upset as he pointed at his wife and yelled she moved his w/c. The staff members placed a GB and noted a red mark that resembled the arm of the w/c on Resident #3's left side. The staff stood on each side of Resident #3 while 1 stood to his back and got him up and positioned him in the w/c. Resident #3 presented as real upset with his wife, so Staff B asked her if she wanted to go to dinner and she agreed. Staff B said she saw Resident #3's w/c brakes locked at that time. Staff B described Resident #3's vitals as stable and he never complained of shortness of breath (SOB) rather he just complained of his ribs hurting. Staff B reported she failed to assess Resident #3's lung sounds. Staff B indicated she got everything checked out and asked what happened. Resident #3 stated he sat in his recliner and he had his w/c positioned in front of him. As he stood up his wife moved his w/c to what she felt a better position and as he sat down his left axilla (arm pit) got caught on the arm rest and he just sat down on the floor. The arm of the w/c would have been the level of his arm. As Resident #3 sat in the w/c he still complained of of rib pain. Staff B contacted Staff E, RN/House day Supervisor, on the day shift at approximately 5:30 PM or within 10 minutes. Staff E indicated she didn't know when she could get down there, so Staff B stayed with Resident #3 until around 6 PM when his wife returned to the room. At that time, she felt comfortable enough to leave him alone. Staff B indicated she felt she needed to stay with Resident #3 until Staff E arrived and/or when she felt he had been safe. Staff B indicated she called the house supervisor again. At that time Staff D, RN/house night supervisor, came down to Resident #3's room right way and he assessed him. Following the assessment, Staff D felt Resident #3's situation didn't warrant a hospitalization , although she wasn't present during the assessment. Staff B indicated the decision to send Resident #3 to the emergency room (ER) happened because the daughter requested the transfer. During an interview on 8/22/24 at 1:15 PM Staff B confirmed she didn't call Resident #3's family, but she reported Resident #3 complained of rib pain to Staff E. During an interview on 8/22/24 at 11:47 AM Staff C, Certified Medication Aide (CMA), indicated at the time of Resident #3's fall, she been in the dining room, when 1 of the CNAs reported Resident #3 fell . Staff C asked if she reported the incident to the nurse at which time she said yes. Staff C went to Resident #3's room and observed Staff B already present with Resident #3 lying flat on the floor between the table/dresser and closet with his head positioned underneath the desk area with a pillow under his head and his feet stretched out towards his recliner. Staff C noted his w/c parked by the window but didn't have any recollection of the position of his walker. Staff C indicated she felt the fall didn't seem too bad. Staff D assessed Resident #3, including range of motion (ROM), wrapped the skin tears on his elbow, and knuckles on his left arm/hand. Staff C confirmed Resident #3 complained that his ribs hurt and before his fall, he only complained of back pain but she found nothing unusual with her own visual assessment at the time. Following the assessment 4 staff members assisted Resident #3 off the floor with the use of a GB and positioned him in his w/c. During the transfer Resident #3 complained of pain again in his rib area. When Staff C asked Resident #3 if the pain felt like his normal back pain, he responded no, it felt new. Staff C then left Resident #3's room. Staff C indicated all of the incident occurred about 5-5:30 PM, but she returned to Resident #3's room around 6:30 PM. As he sat in his w/c, he acted per usual except his rib pain, she reported it as the only abnormal thing. As she administered his evening pills he requested to move to his recliner, as 2 CNA's walked by Resident #3's room so they took over. When asked how come they didn't send him to the emergency room (ER) right away r/t his new complaints of rib pain she stated the nurse made that call. During an interview on 8/22/24 at 3:47 PM Staff E confirmed she received a call close to 6 PM maybe even right at 6 PM, however, she had to deal with all the incidents from her shift making her busy. When Staff D arrived for his evening/night shift, she reported to him Resident #3 fell and sustained skin tears to his elbow. Staff E denied receiving report r/t Resident #3's complaint of rib pain. She asked Staff B if Resident #3 was OK, she responded yes. When asked about the facility's falls policy and procedure, Staff E replied the nurse assessed Resident #3 and called the Nursing Supervisor immediately. In the event the Nursing Supervisor had been busy with another resident or situation the nurses could call the Director of Nursing (DON). Staff E indicated a lot of times the Physician's failed to return call to the facility in a timely manner and the facility required a Physician's order to send a resident out to the ER. During an interview on 8/22/24 at 12:59 PM Staff D indicated during the evening in question he didn't receive report from Staff E until 6 6:30 PM due to her being in the middle of a report pertaining to Resident #3. Resident #3's daughter called and expressed concern about her father's left arm pain. Staff D understood Resident #3 fell around 5:15 PM, and the charge nurse assessed him. The report Staff E received reflected Resident #3 sustained a skin tear but no other injuries, so she reported she didn't assess him. Staff D indicated as a practice the Nursing Supervisors performed the fall follow-up assessments but had times they couldn't do it with 1 Nursing Supervisor for 165 residents so they had to triage. Staff D indicated when he got off the phone with the daughter he went to Resident #3's room and observed him as he sat in his w/c. Staff D performed ROM exercises but Resident #3 appeared to move everything just fine and without distress. Resident #3 presented a bandage the nurse used to cover the skin tear on his left arm, but she failed to secure the skin flap. Staff D rewrapped the area and also noted he had 0.2 centimeter (cm) by (x) 0.2 cm open areas on each knuckle of his left hand. Staff D then offered when he performed ROM exercises to Resident #3 he complained of upper left-sided rib pain which he rated a 5 out of 10. Resident #3 grimaced a bit after lifting his left arm but didn't have SOB or anything like, but Staff D failed to assess Resident #3's lung sounds. After the assessment Staff D called Resident #3's daughter and told her he had rib pain. When Staff D asked if she wanted Resident #3 sent to the ER, she responded due to his previous back fractures she wanted him sent out. Staff D called the on call Physician and received orders to send him to the ER but had to call 2 times that night which sometimes happened. Staff D confirmed he would call the family first to ask them what they wanted done and then he'd called the Physician. Staff D thought Resident #3 called his family himself and notified them of his fall. Staff D indicated Staff B gave him no indication of an emergent situation and when he first assessed Resident #3 he showed no signs of emergent pain. However, when he transferred to the EMS gurney he guarded his left side and his O2 sats went down so the EMS crew requested him to deep breath and applied oxygen. During an interview per facility request on 8/27/24 at 9:58 AM Staff D indicated generally, he arrived to work at 6 PM and received report. That day, he took over for Staff E who ran behind so he received report closer to 6:30 PM. Staff E reported Resident #3 fell and sustained a skin tear to his left elbow however she did not get a chance to have performed a follow-up assessment. About half-way through their report, around 6:40 PM, Resident #3's daughter called and reported her dad fell and complained of left arm pain. Staff D told the daughter he planned to go down to Resident #3's room after they finished report. Staff D received a call from the Pharmacist who reported they entered the building with medications close to 7 PM. Staff D went to Resident #3's room as Staff E assisted the Pharmacist. When Staff D entered Resident #3 room, he sat in his w/c almost straight up but off to the side close to his recliner. When question how he felt by Staff D, Resident #3 replied OK but his arm hurt. Staff D performed ROM but when he got to his left arm he reached around and grabbed just under his axilla area adjacent to his breast. Staff D palpated the area and felt no crackling, protrusions, bruising or swelling. Resident #3 reported as he sat in his lift chair he used his walker to stand and attempted to transfer to his w/c with his wife's assistance rather than the staff. When asked how they performed the transfer, Resident #3 replied he had his walker positioned in front of him in his easy chair while his wife stood to his back and side. His wife pushed on his back as he turned with his walker and in the process his wife turned the w/c so as he sat down his left side ran down the right arm rest of the w/c and his axilla slammed into the arm rest. Staff D noticed the nurse wrapped his left elbow with gauze but she didn't reattach the skin flap so he rewrapped the area. Staff D again asked Resident #3 how he felt as Resident #3 complained his ribs hurt on the left upper side. The entire assessment took about a half hour. Staff D left and called Resident #3's daughter who verbalized concerns because he fell a lot at home. She said he didn't use his call light because no one answered it and it took up to 1 hour for response. Staff D indicated their phone call lasted about 20 minutes as he offered apologizes. When asked if she wanted him sent out for evaluation, she replied yes. After Staff D prepared the required paperwork, he went downstairs as the EMS crew arrived. They all went to Resident #3's room as Staff D noted the staff transferred him to his lift chair while he worked upstairs. After Resident #3 answered the EMS' questions, the paramedics put down his foot rest and raised his lift chair to the point his seat sat at a 30-degree angle. At that time Resident #3 used his left arm and guarded the left side. When he did that he started to hold his breath and took little wincing breaths due to (d/t) pain. At that time, he guarded his left side as he held his breath so his O2 saturation (sat) dropped to 87%. The paramedic encouraged him to take deep breaths which caused him discomfort, but rose his O2 sat to 95%. The paramedics brought the gurney in front of Resident #3's lift chair across the knees at which time Staff D offered to get the lift device and they said no we can get him. At that point, each of the crew members grabbed under Resident #3's arms and lifted him up as he yelled out in pain it hurts, it hurts. The crew said we know it hurts but we have to do it to get you to the hospital. They got him up and pivot transferred him to the gurney. They lifted his legs and applied O2. Staff D indicated the whole time he observed Resident #3 until the paramedics lifted him up he didn't observe any respiratory issues. Staff D indicated when the crew lifted him up, he noted a small little bruise that presented as a shading type area and/or the start of a bruise. The crew then left the facility with Resident #3. Staff D again reiterated he didn't witness Resident #3 with any immediacy until the ambulance crew transferred Resident #3 to the gurney. During an interview on 8/22/24 at 2:23 PM one of Resident #3's daughter voiced frustration that her father sat there so long in pain. Review of Resident #3's daughter's call logs revealed the following telephone calls to and from the facility and/or her mom and dad on 8/13/24 as specified and dated: a. Mom called daughter at 6:24 PM and reported the fall. Daughter spoke with her father who reported his side hurt. b. Daughter called the facility at 6:42 PM for 1 minute and again at 6:44 PM for 3 minutes. c. Daughter called Staff F, Social Worker, at 6:29 PM for 6 minutes. d. The facility called Resident #3's daughter at 7:01 PM for 4 minutes. e. Daughter called Staff D at 7:07 PM for 8 seconds, again at 7:07 PM for 9 seconds, and again at 7:08 PM for 4 seconds. According to an EMS/Fire Department report dated 8/13/24 the facility called EMS at 7:56 PM, they dispatched (sending someone to a destination or purpose) at 7:57 PM, enroute to the facility at 7:58 PM, on scene at 8:02 PM, and with Resident #3 at 8:03 PM. They departed from the facility at 8:19 PM and arrival at the hospital at 8:25 PM. The ambulance crew's assessment/documentation included the following: a. Injury to the Thorax (upper chest) from a slip, trip or stumble. b. Acute pain d/t blunt trauma to the left ribs. c. Blood on the left side. d. Moderate distress. e. At 8:04 PM Resident #3 presented with left sided anterior and posterior pain during inspiration and expiration, left upper and lower lobes to his lungs with decreased breath sounds, a contusion (bruise) to his left upper abdomen f. Vitals at: - 8:07 PM included a pulse (P) of 64, respirations 16, and an oxygen sat of 87% at room air with pain identified at a 10 level. - 8:17 PM Resident #3's blood pressure (b/p) of 144/89, pulse 60 and an oxygen saturation rate 96%. - 8:24 PM Resident #3's B/P registered at 136/81, P at 68 and an oxygen saturation rate of 92%. g. The narrative documentation included the following: Resident #3 alert and oriented x 3 (person, place and time) but unsure of the day or month. Resident #3's nurse stated he fell from a standing positioning forward onto the arm of his wheel chair. Resident #3 complained of extreme pain to his left ribs and had some minor bleeding from his left arm. Resident #3's wife stated she tried to help him into the wheelchair when he fell . Resident #3 stated his experienced pain just he sat and breathed. The initial oxygen sat registered at 85% at room air. Resident #3's wife stated his face looked puffy but both Resident #3 and the nurse said his face looked normal. Post assessment the crew placed Resident #3 on 2 liters of oxygen per nasal cannula, assisted him out of his chair, onto the cot, and transferred him to the local hospital. During an interview on 8/23/24 at 2:00 PM 2 EMS supervisors, EMS 1 and EMS 2, arrived at the facility on their own accord and requested a conversation with the Surveyor. When asked why they failed to use lights and sirens when they transported Resident #3 to the ER, EMS 1 suggested due to extensive studies lights and going fast are more detrimental to the patient and the use of sirens cause more accidents. During the meeting they called EMS 3, Paramedic, who responded to the transfer she indicated upon arrival Resident #3 sat in his recliner chair. EMS 3 confirmed she and her crew member, EMS 4, Paramedic, stood Resident #3 and pivot transferred him to his gurney however he showed no signs of substantial pain with the transfer process. EMS 3 described Resident #3's O2 sats registered in the 80's on their initial arrival but with coaching and O2 sats bounced back to within normal limits (WNL), or greater than 90% oxygen level. EMS 3 indicated Resident #3's wife kept saying his face looked puffy. When she asked Staff D he downplayed it and said the puffiness presented as Resident #3's norm. So, without knowing Resident #3, they maintained his stability for the short transfer to the ER. During another interview on 8/28/24 at 10:46 AM EMS 1 confirmed the medics transferred Resident #3 by placing their arms under Resident #3's arms. Their standard of practice directed this when a resident/patient assisted with the transfer process but that wouldn't cause the punctured lung. The Hospital's History and Physical form dated 8/14/24 at 2:16 AM documented by the Physician, they felt Resident #3 had inconsistent injuries with the stated cause of his injuries. The facility notified Resident #3's daughter her father fell . She then requested the facility to transfer her father to the ER for evaluation. The staff described Resident #3 as fine and felt an evaluation in the ER unnecessary. Then Resident #3's second daughter became involved, she too expressed concern, and asked the staff to transfer her father to the ER. A hospital's Discharge Summary *Final Report* form printed on 8/18/24 at 4:41 PM included the following: Resident #3 admitted to the hospital for a left pneumomediastinum (air present in the mediastinum, area between the lungs) s/p (following a procedure) a chest tube (chest tube used to treat a collapsed lung), pneumopericardium (rare condition that occurred when air or gas accumulated in the pericardial sac (tissue sac that surrounded the heart often caused by a blunt or penetrated chest trauma) and multiple fractures. He sustained a left skin tear of his forearm and had a 11/10 left sided rib pain. Patient arrived to the emergency room awake and alert as he talked appropriately and moved all extremities. He presented in respiratory distress and intubated (a tube placed in the trachea for maintenance of an open-air way and a means for facilitation of ventilation to the lungs which included a mechanical ventilation device). A noncontrast head and C spine test revealed an apical pneumothorax (collapsed lung near the apical zone of the lung otherwise known as an area above the 1st rib). Other imaging revealed bilateral subcutaneous emphysema (trapped air) throughout the neck, moderate sized left pneumothorax, mildly displaced fracture of the left lateral clavicle, nondisplaced fracture of the left acromion (broken bone in the shoulder blade), displaced fractures of the left posterior 2nd through 8th ribs, minimally displaced fractures of the left 1st thru the 5th ribs anteriorly, nondisplaced fractures of the right posterior lateral 1st and 2nd ribs, left lower lobe consolidation and acute fractures of the L1 and L2 vertebral bodies. The family decided to terminally extubate Resident #3 and transition him to comfort measures. The form indicated Resident #3 passed away on 8/17/24. During an interview on 8/22/24 at 11:10 AM a hospital Case Manager explained she had concern with the delayed response for the care and treatment of Resident #3. She understood the facility had contact with their provider and the family wanted him out. The facility told the family they had to get prior permission before they could send him to the ER. During an interview on 8/23/24 at 12:55 PM Resident #3's primary Physician confirmed he expected the staff to send Resident #3 to the ER per family request and his acute situation with left rib pain, considering his comorbidities (multiple diagnoses) even if they couldn't initially correspond with him and/or the Physician on-call.

Based on observation, resident, and family interview, the facility failed to answer resident call lights in a timely manner and within the regulated 15-minute time frame for 3 of 5 residents reviewed (Resident #3, #4 and #5). The facility reported a census of 165 residents. Findings include: 1. On 8/23/24 at 11:53 AM observed Resident #4's call light on. According to the call light monitor at the nurse's station on the 1 [NAME] hallway the call light had been on for 16 minutes and counting. On 8/23/24 at 11:54 AM Staff G, Licensed Practical Nurse (LPN), entered the room. Staff G brought in a nutritional drink and Resident #4's pain patch. Staff G became defensive when she spoke with Resident #4 and his daughter. She spoke in a derogatory tone, rolled her eyes, and made negative facial expressions. Resident #4's family member (RR #4) asked if the surveyor saw that and reported Staff G always addressed her mother and/or herself that way. During observation, Staff G failed to address Resident #4's call light to see if someone helped her or if she still needed help. On 8/23/24 at 12:05 PM 2 unknown Certified Nurse Aides (CNAs) entered the room and shut off her call light. During that timeframe, observed Resident #4 feeling unwell with a flat facial expression. On 8/23/24 at 12:10 PM Resident #4's daughter reported the facility planned to send Resident #4 to the hospital due to having a temperature and potential dehydration after the nurse assessed her. 2. During an interview on 8/22/24 at 2:23 PM Resident #3's daughter reported the facility failed to answer Resident #3 call lights in a timely manner. Which at times took up to one (1) hour which caused frustration for him so he self-transferred. This daughter offered that she visited her parents 1 2 times a week for at least 4 hours and no staff member came in to check on them. The daughter confirmed she witnessed her father put on his call light while she visited. Although she never timed how long it took the staff to answer his call light, she knew it caused him frustration as he sat in clothing soiled with urine. The Communication with Family/NOK/POA on 8/13/24 at 7:29 PM reflected as the facility discussed Resident #3's fall with his daughter, she voiced frustration that he came to the facility due to falls at home and he had 2 falls since his admission. Resident #3's daughter reported in the past Resident #3 had to wait well over an hour for assistance when he turned on his call light and that's why he transferred himself. The note indicated the writer explained if that is correct that that is a concern to them and they would speak to the staff about the importance of answering call lights in the timeliest fashion, however Resident #3 stated he did not call for assistance because he and his wife live together and she can take care of his needs. Resident #3's daughter stated she talked to him about it in the past and she would like to follow-up with the care plan and a social worker to come up with a plan to prevent this. 3. During an interview on 8/27/24 at 4:03 PM Resident #5 explained she timed having call light on for up to 45 minutes, as she used the clock on the wall. This caused pain when they left her on the commode. Resident #5 declared the call light issue occurred on every shift. 4. On 8/27/24 at 12:14 PM observed room [ROOM NUMBER]'s call light on. According to the call light monitor at the nurse's station on 1 [NAME] hallway the call light had been on for 17 minutes and counting. The Resident Rights document provided by the facility dated October 2017 instructed the resident had the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, clinical record review, staff, physician and family interview, the facility failed to protect a resident against burn hazards from the heating elements in their rooms by placing a residents bed parallel to the heater in their room for 1 of 5 residents reviewed (Resident #3). On 1/26/23 Resident #3 rolled out of low bed and was found by staff with body on top of the heater with the skin of the right ear, neck and upper thigh touching the heater. The facility identified a census of 159 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 11/30/22 indicated Resident #3 had diagnoses that included Non-traumatic brain dysfunction, Non-Alzheimer Dementia, cataracts, glaucoma, muscle weakness and age-related physical debility. The MDS documented the resident with minimal difficulty with hearing, has clear speech, and usually understands and understood by others, and with vision impairment with corrective lens. The assessment documented the resident with a Brief Interview for Mental Status (BIMS) score of 1 (which indicated severe impairment with daily decision making abilities), required extensive assistance of two (2) staff with bed mobility and transfers and as non-ambulatory with no limitations to upper or lower extremities, and being not steady for surface to surface transfers. The assessment documented the resident with no skin issues and no complaints of pain. A Care Plan initiated 5/1/17, documented the resident had focus areas that included: *The resident has an activities of daily living (ADL) self-care performance deficit related to senile degeneration of brain. *The resident has a communication problem related to hearing deficit. Hard of hearing in the left ear. *The resident has impaired cognitive function/dementia and senile degeneration of brain. *The resident is risk for falls related to dementia, poor safety awareness, and abnormality of gait. The approaches included the following: * Ensure I have a warm blanket or double blanket to keep me warm throughout the day. * Please make sure I have a bedspread on my bed daily. * The resident transfers with hoyer and assist of 2 staff for all transfers. * Resident is able to let staff know my needs at this time. * Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Large paddle call light now in use and needs to be pinned directly to my night clothes. * Body pillow placed in front of resident while lying in bed. * Ensure low bed is in locked position when resident in bed. * I have a lipped air flow mattress to prevent me from slipping out of bed. Mattress does not keep me restrained in bed. If necessary, I can roll over the side of my bed. Lipped mattress keeps me from slipping out of bed if I get to close to the edge. * I received an airflow mattress from hospice d/t risk of impairment to skin. Please ensure I am positioned in the center of the bed to prevent slips out of bed as the mattress is higher than my previous mattress. * Low bed with fall matt in place. * My bed has been moved in my room, my bed is not to be near heat register. * I have a specialty cushion in wheel chair with gripper matt above and below cushion & specialty mattress ordered from hospice. * I prefer to lay on left side when in bed. I have a reddened area to my left hip. Complete treatment as ordered. * Provide daily treatment to right thigh/calf, see electronic medical administration record, (SEE EMAR) A Morse Fall Scale Assessment form dated 8/16/22, documented the resident at a high risk for falls. An Incident Report form dated 1/26/23 at 8:55 p.m., noted as this nurse entered residents room, resident said Ma'am, can you help? Noted resident was between her bed and radiator. Resident was on her right side with the right side of the neck resting on the radiator, right thigh noted to be resting on top of the radiator. Called Certified Nursing Assistant (CNA) to call the supervisor immediately and tell her where the resident was. This nurse yelled out for CNA to come to residents room. CNA was supporting residents head while CNA was holding residents right leg off the heat register. Nursing supervisor arrived and resident was assisted to her bed with CNA's holding her legs while the nursing supervisor and myself was holding residents torso gently lifted resident and rolled her back onto the bed Once resident was back in bed she started pinching/grabbing at staff/sticking her tongue out and hitting staff per residents normal behaviors. Resident moves all extremities (MAE) without difficulty or discomfort. Resident has multiple burns to the right side of her neck, right anterior thigh-right lateral thigh, a reddened area just above her right lateral and a reddened area to right lateral upper hip. Areas described as: *Burn, Right thigh (front) anterior thigh measures 22 centimeters by 3 centimeters, right lateral thigh measures 3.2 centimeters by 12 centimeters. *Burn, Neck measures on right side, 14 centimeters by 6 centimeters The Progress Notes dated and documented the following: On 1/27/2023 at 12:43 p.m., communication with Family/next of kin/power of attorney, Call placed to daughter to let her know about the bed being moved to the adjoining wall so that she is away of the heat register. Daughter informed about prior abrasion and blister the occurred on Monday. Daughter stated that she feels as though this was a freak accident and thanked me for everyone's due diligence with immediately following up and intervening. On 1/26/2023 at 10:59 p.m., Incident Note Text: At 9:00 p.m., CNA reported resident was found by charge nurse lying on the heat register. Upon entering room, resident was lying on the register on her right side, with right shoulder between the register and the mattress. CNA was holding resident head up off the register, another CNA was holding legs up from the register and Charge Nurse was kneeling on the bed assessing situation. I removed the blankets from the bed, then gently lifted slightly and rolled resident off the the register and into the bed. Resident was moving all extremities per her usual baseline, and attempting to hit,pinch,yell at staff per usual behaviors. Resident was sticking tongue out as areas were being assessed resident skin. Areas to right neck, shoulder, thigh, right back/hip, back of right thigh all measured. I left Staff to turn bed away from register and do cares. On 12/8/2022 at 00:14 a.m., Incident Note Text: follow up on resident found on floor mat next to bed on 12/7/22 at 5:10 p.m.,temperature 97.6. Resident refused vital signs and tried to pinch this nurse. Resident sleeping quietly at this time. Bed is in low position with fall mat. No signs or symptoms or complaints of pain from resident continue to monitor. On 12/6/2022 at 5:23 p.m., Incident Note Text: Notified resident was on the mat beside her bed. On assessment resident sitting in her wheel chair at the nurses station. She does not know how or why she was on the mat. She did bump her right cheek on the garbage can and has a small skin tear to her cheek. Grips firm and equal bilat. Alert to self per usual. MAE to the best of her ability with range of motion (ROM). No deformities noted. No internal or external rotation of lower extremities. Doctor and daughter informed of incident. Will monitor neuros x 72 hrs. On 12/6/2022 at 5:10 p.m., Incident Note Text: Called to resident room by CNA for report of resident on fall mat. Resident was observed in bed less than 10 minutes ago. Resident was lying face down on fall mat with head resting on garbage can that was in between mat and wall. Resident was assisted to sitting position on fall mat with two staff. There it is was noted that there was and open area to right cheek. Area measures 0.4 centimeters x 0.2 centimeters. Area is not actively draining. Area cleansed, no drainage noted at this time. Left open to air to dry. Resident is able to move extremities per norm. Resident was transferred to bed where they were cleaned and changed due to incontinent of bowel. Then assisted with hoyer to wheel chair. No signs of pain observed or vocalized by resident. Alert and orient to self, per norm for resident. Will continue to monitor. Supervisor called and came to unit to assess. On 12/2/2022 at 9:10 p.m., Incident Note Text: Housekeeper reports resident fell out of bed. Noted Resident on fall mat beside her bed lying on her right side. No noted head strike. VS 97-93-15-96/53. Resident voices no discomfort. No noted internal/external rotation of hips. Resident assisted back into bed with staff via hoyer. Nurse Supervisor present and notes right shoulder abrasion. During observation on 2/9/23 at 2:45 p.m., Resident sitting in a broda chair in the lounge by the nurses station. Blanket over her with tennis shoes on. Hair combed, glasses on, hoyer sling underneath her while in the broda chair. Dressed in slacks, long sleeve shirt. No redness noted on resident right ear or right side of neck. Upon observation, area on right outer thigh/leg area with no redness or scabbed areas. Resident not able to recall the incident. Resident denies any sign/symptoms of pain. Observation of resident room revealed resident bed not against the heat register. Fall matt against the wall. Interview on 2/14/23 at 5:35 p.m., Staff A, Licensed Practical Nurse (LPN), went into Resident #3's room to attend to the roommate and heard Resident #3's voice say ma'am, please help me, ma'am please help me. Staff A said that she pulled back the privacy curtain and saw Resident #3 lying on her right side facing the wall. Staff A said that she called in the hallway for staff to come and assist with Resident #3, Staff B was right outside the room so he came in. Staff A went to the middle of the bed and Staff B went to the head of the bed and another staff member went to the bottom of the bed. Staff A said that when she found Resident #3, her right arm was wedged between the bed and the heat register, her right neck was against the edge of the heat register, her right ear on top of the heat register, her right leg on top of the heat register and her left leg on top of her right leg. Staff A said that by then Staff D came into assist with moving Resident #3 to the middle of the bed. Staff A and Staff D started to do an assessment on the areas on the neck, ear, and her right outer leg. Staff A said that there was no body pillow in front of the resident. Staff A and Staff D started to look at all the areas neck/ear/right outer leg/thigh area. It was decided then to transfer Resident #3 to the emergency room for evaluation. Staff A said that there was an air mattress on the residents bed and that the resident can make changes in her position. Interview on 2/14/23 at 2:00 p.m., Staff B, Certified Nursing Assistant (CNA), stated that he went into Resident #3's room at 8:20 p.m., and Resident #3 was lying in bed on her right side with her face facing the west wall and her butt facing the east towards the hallway. Staff B said that around 8:40 p.m., Staff A came out into the hallway and asked for help due to Staff A seeing Resident #3 is lying on the heat register. Staff B went into the residents room and saw that the resident had her right arm wedged between the low bed and the heat register with her neck on the edge of the heat register, her right ear on the top of the register, her right leg on the top of the heat register and her left leg on top of her right leg. The fall matt was on the floor and there was at least a foot between the head of the bed and the north wall and at least 4 1/2 inches between the bed and the heat register. Staff B held the residents head up off the heat register. No body pillow was in place, and the wheels on the low bed were not locked. Staff B said that the resident is able to move herself in bed. Interview on 2/14/23 at 6:22 p.m., Staff D, Licensed Practical Nurse (LPN), got a call that Resident #3 was wedged between the bed an the heat register with the residents right ear, side of neck and right outer thigh/leg area on top of the register. When Staff D got to the room, Staff B was at the head of the bed holding up the residents head so that it was not resting on the register, another staff member was at the foot of the bed holding up the right/left leg and thigh area. Staff D said that there was no body pillow in front or in back of the resident. Staff D said that there was an air mattress on the bed. Staff D said that Resident #3 is capable of moving herself around in bed. The areas on the neck and ear were red and felt warm when touched. It was decided to send the resident to the emergency room for evaluation due to the areas on the outer right leg/thigh area and with the right shoulder being bruised. Interview on 2/14/23 at 2:00 p.m., Staff C, (Quality Assurance Nurse) received a phone call by the facility Director of Nursing (DON) some time around 8:45 p.m., that the facility had called that Resident #3 was found on top of the heat register in her room. Staff C, arrived to the resident room, Resident #3 was already off the heat register and Staff A and Staff D were doing a skin assessment on the right ear, neck and right outer thigh/leg area. Staff C went to touch the resident right leg and she would not let me touch it, she would attempt to pinch/hit. Staff D assessed her neck/ear/right outer leg, it was determined that the resident would be sent out of the facility to the ER for evaluation of the right thigh/ear/neck. The right shoulder was discolored and it would be a good idea to have that area looked at. Staff C, completed an internal investigation, it was determined that the body pillow was not in place and that the wheels on the bed were not locked. It was then decided to rearrange Resident #3 room so that the bed was not parallel to the heat register. Interview on 2/15/23 at 3:30 p.m., Staff F, LPN, confirmed and verified that the resident care plan says that their needs to be a body pillow in front of the resident and that the wheels on the bed need to be locked. Interview on 2/16/23 at 12:30 p.m., the resident family member met Resident #3 at the ER. The ER physician confirmed and verified that the areas to her right neck and ear were a burn but no treatment was necessary for those areas. The family member stated happy that the facility moved the residents bed away from the heat register. Interview on 2/20/22 at 3:50 p.m., the emergency room Physician, confirmed and verified that the neck and ear were definitely first degree burns. Interview on 2/20/23 at 3:30 p.m., Staff E, Registered Nurse (RN), confirmed and verified that the body pillow needed to be positioned in front of the resident and that the wheels on the bed needed to be locked at all times.

Based on observation, clinical record review, staff and senior center staff interview, facility video footage review and facility policy review, the facility failed to ensure staff maintained a safe and secure environment for 1 of 4 residents reviewed who were at an elopement risk, (Resident #1) which resulted in immediate jeopardy to resident health and safety. On 1/14/21 at 11:22 am Resident #1 left through door 4 on the 2nd floor, went down 2 flights of cement stairs and left the building out of door 1 on the 1st floor. The door alarm on the 2nd floor did not sound as it was shut off. The door alarm on the 1st floor sounded but the alarm panel showed door 3. One staff member responded to door 3, opened the door and briefly loooked North, South and East but did not see anyone so she silenced the alarm and performed a head count for her assigned area on the 1st floor and all residents were accounted for. The staff member got busy and failed to notify the charge nurse about what had occured. The local senior center called the facility to let them know a resident arrived at their building between 11:40 am - 11:45 am approximately one block from the facility. The facility staff failed to monitor the functionality of the door alarms as the 2nd floor exit door 4 was de-activated and had been for at least 2 days per observance of the camera footage by management staff which put 30 residents at risk. The facility identified a census of 163 residents. Findings include: Review of the facilities video footage dated 1/14/21 revealed the following observations as timed: a. 11:22:19 a.m.- Resident at door with a velcro stop sign across the door. The resident wore a red sweatshirt, pants, shoes and no socks. b. 11:22:58 a.m. - Resident still at the door, door opened with a stop sign still across the door and intact. c. 11:22:58 a.m. - The resident ambulated through the door and released the velcro'd stop sign. d. 11:23:03 a.m. - The resident ambulated out the door and shut the door behind her. Review of the video footage 1/22/21 at 11:15 a.m. revealed the resident wore gray colored, flat, slip on shoes with a rubber soul but no socks and her pants were short which revealed the residents bilateral ankle area. During an interview at the same time the Director of Nursing (DON) confirmed the observation. A Minimum Data Set (MDS) assessment form dated 12/4/20 indicated Resident #1 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severely impaired cognitive status, wandered one (1) to three (3) days in the look back period (1 week), required extensive assistance of staff with transfers and locomotion on and off the unit and ambulated in her room and in the corridor with limited staff assistance. Resident #1's Care Plan identified the following focus areas and interventions as dated: a. Impaired cognitive function/dementia or impaired thought processes related to (r/t) dementia and long and short term memory deficits. (revised 11/27/20) 1. Wander guard placed on right ankle with staff to have checked placement two times a day (BID). (initiated 1/15/21, after the elopement) b. An activities of daily living (ADL's) self-care performance deficit r/t dementia, limited mobility and a recent hospitalization with Covid-19. (revised 11/27/20) 1. The resident self-transferred with supervision. (initiated 11/27/20) c. At risk for falls r/t confusion, gait/balance problems and weakness. (initiated 11/27/20) A Wandering Risk Assessment form dated 11/27/20 at 1:55 p.m. identified the resident as at a moderate risk to have wandered. A Morse Fall Scale dated 11/27/20 at 1:52 a.m. identified the resident as at a high risk to have fallen. Review of the facilities Progress Notes revealed the following entries as dated: a. 1/14/21 at 1:10 p.m. - Received a call the resident had been in the process of being brought back to the facility with the Director of Nursing (DON). The resident went out the Northwest door of the 2nd floor of the facility without the door alarm having sounded. Following a facility investigation the alarm had been shut off. Staff returned the resident to the facility without difficulty. The resident denied discomfort and stated she just wanted to go home. The resident ate her noon meal and tolerated it well. The resident went back to her room and staff performed a skin assessment with no areas of discoloration or injuries related to her elopement. The resident continued to state she wanted to go home. b. 1/13/21 at 10:54 p.m. - The resident paced the halls most of the shift as she looked for ways out of the facility. The resident attempted to have opened exit doors a few time and described as not easily directed as she told Certified Nursing Assistants (CNA's) she would break a window to get out of there. c. 1/13/21 at 1:46 p.m. - Moved the resident to the secured unit. (located on the 2nd floor of the facility) d. 1/13/21 at 6:47 a.m. - Staff checked on the resident's husband and observed the resident as she packed her belongings and said they planned to go home. e. 1/12/21 at 12:13 p.m.- The resident wandered that shift and yelled at her husband Lets go, I gotta get out of here, We are leaving, where are the keys? f. 1/12/21 at 7:12 a.m. - Staff described the resident as very confused and agitated on and off from approximately 9:00 p.m. until 2:00 a.m. as she stated she wanted to go home. g. 1/11/21 at 12:44 p.m. - The resident packed up her and her husband's things and told him they planned to go home and their kids would get them. The resident cried and told staff that her children had been home alone and they needed to get there to take care of them because they had been little children. The resident spoke with her daughter and following the call told staff she planned to just walk to her children. The resident walked away from the nurse's station, down the hallway towards the 2 West area of the building and stated that she planned to leave to the staff. h. 1/8/21 at 11 p.m. - The resident wandered the hallways as she looked to go home. i. 1/8/21 at 7:37 a.m. - At 2 a.m. the resident woke her husband and when staff checked on the residents they had been packed to leave. When asked where they planned to go the resident laughed and stated home!. j. 1//5/21 at 4:57 p.m. - The resident wandered the halls, cried and stated I just want to go home. After staff interventions the resident continued to cry and looked for a way out of the facility. k. 1/4/21 at 10 p.m. - The resident wandered and looked for a way home. When staff asked the resident where home had been she stated Oklahoma. The staff told the resident the weather had not been good and she said I guess I will have to start walking then. l. 1/4/21 at 5:24 p.m. - The resident looked for a way home and stated I just want someone to take me home. An Elopement Incident Report Form dated 1/14/21 (no time) documented the Administrator and DON was notified by the Senior Center because the resident had been located at their facility at 11:30 a.m The staff members obtained a wheel chair and cloak and drove a facility vehicle to the Senior Center located a block North of the facility. When the staff entered the Senior Center the resident sat at a banquet table with 2 of the Senior Center staff. The staff members had placed a coat around the resident and gave her a cup of coffee. The resident wore a red sweatshirt, slacks and shoes. Her skin had been warm and dry with pink color tones to her face. The resident presented as flustered and embarrassed but happy for assistance as she had not realized where she came from. The resident's clothes appeared dry (the streets had been damp from melted snow). The resident stood easily as she assisted the facility staff with placement of a fleece cloaked hoodie. Staff assisted the resident into a wheel chair, transferred into the bus and returned to the facility at 11:40 a.m. A typed statement from the facilities Administrator (not dated) included the following documentation: On the morning of 1/14/21 at 11:15 a.m., the resident had been in the memory care dining room as she prepared for lunch. Staff reported that she became angry, demanded to go home and insisted that her family were coming to get her. Staff observed her as she stood and gathered her beverages. Staff B, LPN instructed the aides that the resident had been care planned for staff to have reproached her at a later time when she became upset. Staff H, CNA asked the resident for the drinking glasses so they wouldn't get spilled. The resident handed the glasses to Staff H and then left the dining room. At 11:24 a.m. the resident exited the 2 NE exit through door number 4. (confirmed upon camera review during the investigation) Staff on duty at the time reported that no alarm sounded. The resident pushed on the magnetic locked door enough times to disengage that system, which had a 15 second delay before it unlocked. She then exited through the door, pulled the velcro stop sign from the door as well. The alarm connected to the magnetic lock had an intermittent beeping sound and would possibly not have been audible in the dining room where staff prepared to serve meals and the nurse dispensed medications. The overhead door alarm bell did not sound. The resident then descended the stairs to the first floor and exited to the outdoors in a Northward direction which set off the door alarm on the first floor. Staff D, CNA on 1 NE responded to that downstairs door alarm and searched the immediate area. She did not observe the resident or any other residents. A head count had been conducted on the first floor per protocol and all residents on that unit were accounted for. At approximately 11:35 a.m. the facility received a phone call from the Senior Center, located at the North end of the facility campus. They reported to the Administrator they had a lady, (Resident #1) with them and that she had a cup of coffee at their center. She had been dressed that day in a shirt, sweatshirt, slacks and walking shoes. The weather had been 37 degrees Fahrenheit and damp with misting precipitation. The Administrator and DON took the facility van and a wheel chair to collect the resident. She cooperated fully, allowed staff to position her in the van per the wheel chair and she returned to the facility at about noon. A nursing assessment had been completed with no injuries noted. When asked where she had been going the resident reported that she tried to find her family, who came to pick her up in their car. An investigation had been initiated immediately. The magnetic lock door was tested and observed to have been functioning appropriately. After review of the alarm system located at the 2 NE (memory care/upstairs) nurse's station, the staff discovered the overhead alarm toggle connected to door number 4 (upstairs) had been in the off position. All other alarm toggles were in the on position. Staff knew in the memory care unit that some residents liked to be busy and would tinker with objects and occasionally played with the alarm panel. A plastic cover protected the alarm panel which allowed only to a silence button through a small hole, about finger-width in diameter. The toggle switch to door #4 had been accessible through that hole and could have been switched to the on or off position without having removed the plastic cover and using only a finger or another object such as a pen. During an interview on 1/21/21 at 2:17 p.m. the Director of the Senior Center stated the resident entered the center at about mid- morning and he believed the receptionist acknowledged her. The resident seemed disoriented, knew her name but had not worn a coat. The Senior Center staff gave her a coat and the cook gave her a cup of coffee. The staff then put 2 and 2 together and called the nursing home and they came right to the Senior Center. The Director thought it had not been snowing that day but described the weather as fairly cold and kinda windy. During an interview on 1/22/21 at 9:30 a.m. the receptionist at the Senior Center confirmed she worked the day the resident arrived at the facility at around 11:45 a.m. The resident wore a sweatshirt, pants and shoes (she could not recall her shoes but she thought they were tennis shoes) but no coat. The receptionist first observed the resident as she walked in the parking lot of the Center with a steady gait. The resident entered the facility and appeared cold. The cook asked the resident if she felt cold and the resident said yes so they gave her a coat and a cup of coffee. The resident said she wanted to go home,( named a different town) and wanted the cook to call her son which the cook had not done. The receptionist said the cook felt the resident appeared confused. During interview on 1/22/21 at approximately 9:45 a.m. the cook arrived at the Senior Center and confirmed the resident arrived sometime between 11:40 a.m. and 11:45 am and she knew that because that had been the time of day she usually left the Senior Center for the day. The cook first observed the resident as she stood at the reception desk and looked out the front window of the Senior Center and observed the resident as she walked across the street in front of the Senior Center, with no cars on the road, ambulated across the parking lot of the Senior Center and entered Center. The resident stood by the reception desk as she held her own hands in front of her body across her chest. The cook asked the resident if she felt cold and she said yes so the cook gave her a spare coat they had at the Senior Center and a cup of coffee. After the Senior Center staff thought about the situation they thought the resident either lived at the senior living facility across the street or at the nursing home (both owned by the same organization) so they called the Administrator and told her they thought they had one of her residents. The Administrator and DON arrived shortly thereafter and took the resident back to the facility. During an interview on 1/21/21 at 1:50 pm Staff A, Certified Nursing Assistant (CNA) indicated on the day of the elopement the staff prepared the residents for lunch and pharmacy staff had been present to vaccinate the residents for COVID-19 also located in the dining area. The resident became upset and wanted to leave so the staff planned for her to walk off her agitation. The resident ambulated down the hallway and the staff member got busy with vaccines and lunch and could not hear an alarm at all. The staff member stated if an alarm sounded on any of the doors it registered on a dining room rectangle thing (monitor posted on the dining room wall ) that told staff what door alarm sounded. Staff returned the resident to the facility around 11 a.m. something but she had been unsure of the exact time because staff still served lunch. The staff member knew the resident wore a sweater with birds, regular slacks and her regular tennis shoes with socks. When the resident returned the staff member described the resident as cold and confused but they had a blanket around her so she was covered up and curled up in a wheel chair. The staff member confirmed the resident even described herself as cold. The staff member confirmed the resident as not having worn a wander guard alert device because she dressed the resident that morning and the device had not been present. During an interview 1/21/21 at 2:23 p.m. Staff B, Licensed Practical Nurse (LPN) confirmed she had been the charge nurse the day of the elopement with no other nurse's or Certified Medication Aides (CMA's) with 29 total residents. The staff member stated Staff C, Care Plan Nurse came up to the floor and asked if she had been aware the resident left the floor and facility and ambulated to the Senior Center. Staff C asked Staff B if she heard any alarms and she said no. The 2 staff members looked at the camera footage and observed the resident as she exited the floor thru door #4. The staff members noticed when they looked at the camera footage the alarm for door 4 had been shut off and no residents tampered with the alarm box. Prior to elopement the Resident had been in the dining room with pharmacy staff present for the resident's COVID-19 vaccinations so she became agitated. The resident gave staff members her chocolate milk glass and a water glass and said I am getting out of here however the staff just thought she meant the dining room. The staff member thought she had probably observed her right before she left the floor and facility at around 11:30 a.m. The staff member confirmed she never looked at the alarm box at the nurse's station and did not think to check to see if the alarm switch had been on or off because the alarms have been covered with a box type security device. The staff member stated when the resident returned to the facility she wore a sweatshirt, pants, socks and shoes. The DON brought her to the floor and she had not looked cold. The resident then ate lunch. After lunch the staff member took the resident to her room and performed a head to toe assessment and observed no skin problems but failed to have looked at the resident's clothes in case she would have fallen. The staff member described the weather as cold outside and stated the resident had not worn a wander guard alert device. During an interview 1/22/21 at 11:29 a.m., Staff D, CNA stated at approximately 11:15 a.m. to 11:30 a.m. the alarm on the 1st floor went off. She went to the panel at the nurse's station and it said door 3 had been opened so she went to door and looked both ways and did not see anybody outside. The staff member got distracted but performed the head count for the residents who lived on the 1st floor Northeast area and accounted for all of the residents. The staff member told her co- workers the door registered all clear and she shut off the alarm. A call light went off so she answered the light and forgot tell the supervisor that she accounted for all of the residents. The staff member later heard about the elopement on the 2nd floor thru door 4 on that floor. The staff member confirmed no camera's as present on the 1st floor. During an interview 1/22/21 at 1:32 a.m. Staff E, CNA confirmed she heard the 1st door alarm however she had been in the dining room so by the time she responded Staff D stated all clear and she had shut off the door alarm. During an interview 2/3/21 at 10:06 a.m. the Chief Executive Officer (CEO) indicated when he reviewed the video footage following the elopement he placed residents and staff in the area of the alarm box (located on the East wall at the nurse's station) however due to the angle of the camera's he had been unable to tell if anyone reached into the hole located in the middle of the alarm security box cover and switched the alarm toggle for door 4. During an interview 1/22/21 at 12:05 p.m. the DON confirmed the staff should have placed a wander guard tracking device when the resident resided on the 1st floor as she had been known to wander and exit seek but there had been no formal policy. During an interview 1/22/21 at 1:48 p.m. Staff F, LPN confirmed when resident displayed behaviors of exit seeking and displayed a safety issue with elopement and wandering a wander guard device should have been placed. During an interview 1/22/21 at 1:50 p.m. Staff G, LPN confirmed if you observed residents as they wandered and you knew they had a history and verbalized they wanted to leave and get out of the facility a wander guard device should have been placed. The facilities Resident Elopement policy form revised 12/2019 included the following procedures: a. Residents who posed a threat for their safety by wandering may be provided a room in secured areas. b. Resident identified as at risk for elopement will be provided with a code alert transmitter (wander guard device) or transferred toa more secure area in the facility. c. Door alarms: 1. All doors and stairwells throughout the facility alarmed. The monitor/indicator is located at the respective nurse's station. 2. Exit doors and/or stairwells located on the 2nd and 3rd floors of Cornerstone and Breezeway exit on the 1st floor of the health center have sound indicators at the doorway as well as at the monitor located at the nurse's station. d. Activation/Deactivation of alarms: 1. When a door alarm sounds, staff are directed to proceed to the respective nurse's station to determine what door is alarming. Each door is marked with a number that corresponded with the number on the panel. 2. NO ALARMS SHALL BE TURNED OFF until person at alarm hears Door ____ is clear. It is the responsibility of the person shutting off the alarm to make sure door number and alarm number matched. e. Staff response to exit door alarm/code alert alarms. 1. When an exit door alarm is activated all staff will report to the nurse's station to determine what door alarming. Each door marked with a number that corresponds with a number on the panel. If the door activated has an alarm at the door, the employees of that area will go to that exit immediately. Abatement: The facility was notified of the Immediate Jeopardy on 1/22/21 at 3:15 pm and given the IJ template on 1/27/21 at 1:00 pm. The facility abated the immediate jeopardy on 1/14/21 by taking the following actions: 1. On 1/14/21 placed protective gaurds within all door alarm panel covers to prevent anyone from accidentally switching overhead door alarm toggles to an off position. 2. On 1/14/21 immediately performed testing of all door alarms within the building. 3. On 1/14/21 completed elopement drills on all 3 shifts. 4. Elopement education provided on 1/15/21. 5. Inservices on Elopement for all departments on 1/18/21 at 11:00 am and 1:00 pm and 1/20/21 at 6:00 am and 1:00 pm. The situation is considered past noncompliance as the facility had corrective measures in place prior to our entrance into the facility.

Based on observation, staff interview and record review, the facility failed to prevent the development of heel ulcers and failed to provide services to promote healing for 1 of 4 residents reviewed with pressure ulcers (Resident #11). The facility reported a census of 192 residents. Findings include: The Medication Administration Record [REDACTED]. Resident #11 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 2/1/16. The assessment indicated the resident to be at high risk for the development of pressure ulcers. The assessment identified the resident did not have pressure ulcers and the facility used a pressure reducing device for the chair and bed. The resident received nutrition and hydration intervention to manage any skin problems. The facility did not have a turning/repositioning program. The resident depended upon 2 or more staff for transfers and toilet use. The resident required extensive assistance of 2 or more staff for bed mobility, dressing and personal hygiene. The resident did not ambulate during the 7 day assessment period. Another quarterly MDS, with a reference dated 4/11/16 continued to have the functional status with bed mobility transfers, ambulation, dressing and toilet use as the previous MDS of 2/1/16. The MDS continued to indicate the resident at risk for the development of pressure ulcers and did not identify any pressure ulcers. The MDS identified the resident had an infection of the foot and open [MEDICAL CONDITION] on the foot. The facility continued to have the pressure relieving devices present on the chair and bed but no turning/repositioning program. The resident received treatments and dressings to areas other than to the feet. Resident #11 had a MDS (Minimum Data Set) for with a reference date of 6/20/16. The MDS indicated the resident at risk for the development of pressure ulcers and currently had a pressure ulcer. The resident had a Stage 2 pressure ulcer with the oldest ulcer being 2/18/16 (not identified on the April MDS). The resident had a pressure ulcer with Eschar (black, brown or tan tissue that adhered firmly to the wound bed or ulcer edges). The MDS identified the resident needed extensive assistance of one or two persons for bed mobility, transferring, dressing, toilet use, and hygiene. The BIMS (Brief Interview for Mental Status) dated 6/20/16 indicated Resident #11 had a score of 12. A score of 12 identified the resident had a moderate cognitive impairment. The Progress Notes dated 4/10/16 documented an initial identification of black spots on the back of each heel. The left heel area measured 2.2 centimeters (cm) by .9 cm. and black (eschar). The area on the right heel measured 1.7 cm by 1.0 cm and black (eschar). The nurse documented to monitor. The Progress Notes dated 4/11/16 at 10:25 a.m. indicated the back of the left heel had 3 cracked, black areas. A 2 cm black slit to the back of the ankle (not heel) and a dark black scabbed area to the left outer heel that measured 2 by 1.6 cm. The nurse documented the areas seemed to be from dry skin on feet and she educated the staff to lotion the feet twice a day, wear socks when up and to wear Prevalon boots when in bed. The nurse documented she would have the wound clinic assess the areas. The Progress Notes of 5/19/16 at 10:15 a.m. identified the left heel wound and no further description of the right heel wound assessment. The following measurements and observations were documented by facility staff nurses in the Progress Notes regarding the left heel wound: 1. 4/14/16 - 1.5 by .5 cm 2. 4/20/16 - 1.6 by .5 cm 3. 4/21/16 - 1 by 1 cm with superficial depth but no drainage. 4. 5/12/16 - 2 by 1 cm with dry flaky skin surrounding and treatment of [REDACTED]. day 5. 5/19/16 - 3 by 2 cm with dark brown scab 6. 5/22/16 - Left heel with open area where scab fell off, 7. 5/23/16 - physician's orders [REDACTED]. The wound clinic ordered [MEDICATION NAME] to the base of the left heel wound, 8. 5/30/16 - 2 by .8 by .3 cm with pink tissue inside continue with [MEDICATION NAME] dressing, 9. 6/1/16 - Resident returned from wound clinic with no new orders, 10. 6/2/16 - 2 by 1 cm and .3 cm depth, yellow drainage noted on old dressing, area looks Cleaner and less drainage since last week. 11. 6/9/16 - 3 by 2 by .4 cm depth, moderate amount of yellow drainage, foul smell noted 12. 6/11/16 - 3 by 2 by .4 cm with serosanguinous drainage and black perimeter 13. 6/16/16 - 3 by 1.8 by .5 cm depth with large amount of yellow/red drainage noted, foul smell noted, continues to be followed by wound clinic with treatment completed per wound clinic orders, no shoes, uses blue pressure relieving boots on feet. 13. 6/22/16 - 2.5 by 2.5 by .5 depth without granulation 14. 6/23/16 - 4 by 3 cm with yellow center, pink edges, moderate amount of yellow/red drainage, foul odor, followed by wound nurse, no changes to Care Plan or treatments at this time 15. 6/29/16 - Resident complained of severe pain to left foot, 16. 6/30/16 - 3 by 3 by .3 cm with large amount yellow/red drainage and foul odor detected, 17. 7/7/16 - 3 by 3 cm with large amount of yellow/red drainage, foul odor, pink perimeters and yellow center 18. 7/11/16 - 2.9 by 2.8 by .5 cm with yellow red drainage, foul odor, black around opening and able to see some bone 19. 7/14/16 - Did not assess left heel wound today as treatment to area and measurements were completed by wound nurse 7/13/16, 20. 7/16/16 - physician's orders [REDACTED]. The clinical record contained a document from Advance Wound Center dated 6/1/16 documented the left heel wound measured .8 centimeter (cm) by 1.5 cm with .3 cm depth. The recommended treatment was to change the dressing every day, apply [MEDICATION NAME] dressing directly to wound base and cover with gauze. Observation on 7/19/16 at 7:00 a.m. revealed Staff P (LPN) removed the dressing from Resident #11's left heel wound. The dressing contained copious tan colored drainage with a strong foul odor. No measurements were taken. Blue padded boots were applied. The Care Plan dated as last reviewed on 7/20/16 lacked directions to staff for the application of the padded boots. The May MAR indicated [REDACTED]. On 5/23/16 the order was changed to [MEDICATION NAME] directly to wound base, cover with gauze and secure with cling. The treatment had not been changed since 5/23/16. The Advance Wound Center dated 6/22/16 indicated the left heel wound measured 2.5 cm by 2.5 cm by .05 cm depth. The recommended treatment was to change dressing every day, apply [MEDICATION NAME] dressing directly to wound base and cover with gauze. The Advance Wound Center documentation dated 7/11/16 documented the left heel wound measured 2 cm by 1.8 cm by .1 cm depth. On 7/20/16 at 4:30 p.m. Staff N was interviewed and stated the Care Plan nurse was responsible to monitor the wounds, update measurements and Care Plans. At this time staff were unable to identify which staff member was responsible for communication between the facility and the wound clinic nurse to collaborate on treatments. The facility provided documentation on 7/21/16 that Resident #11's left heel wound measured 2.4 by 2.1 by .1 cm with small amount of yellow drainage noted on old dressing, wound bed is pink and dry, odor is less than two weeks ago. A facsimile was sent to wound clinic with this assessment.

Based on observation, record review and interviews with police, physician and staff, the facility failed to ensure Resident #1 and Resident #12 received adequate supervision in order to protect against hazards from self. Resident #1 exited the unit via the second floor northeast (2 NE) stairwell causing an alarm to activate. Staff reset the alarm without looking at the alarm panel which identified the door opened. The resident fell down the 2 NE stairwell's concrete stairs face first, landing at the bottom of the steps with a Merry Walker on top of the resident. The medical examiner identified the resident's death as accidental due to blunt force trauma to the head due to the fall down the stairs. Resident #12 was left unattended while in the bathroom. The Care Plan directed staff to not leave the resident unattended while on the toilet. The facility identified the census as 197 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of [DATE] which reflected the resident had impaired long and short term memory and severely impaired decision making skills. The MDS identified the resident's admitted as [DATE]. The resident had the following signs and symptoms of delirium: inattention and disorganized thinking. The resident had no behavior symptoms identified, including wandering. The resident required extensive assistance of staff with bed mobility, transfers, ambulation, dressing, eating, toileting, personal hygiene and bathing. A "balance during transitions and walking" test identified the resident as unsteady and only able to stabilize with staff assistance when moving from seated to standing position, walking, moving on and off toilet and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. The resident had 2 falls without injury since the previous assessment. A cognitive loss care area assessment (CAA) dated [DATE], identified the resident used a Merry Walker (specialized walking aide with seat and supportive bars to help support the resident). The resident also had hearing and vision losses. A physical restraint CAA dated [DATE] also identified the resident used a Merry Walker. The resident did not make attempts to get out of the Merry Walker and appeared content using it (the device). The resident enjoyed rising and sitting back down while in the Merry Walker. A physician visit preliminary report from [DATE] identified the resident with severe dementia. The resident no longer recognized his/her family. The resident had occasional falls without significant injury and the facility protected the resident. The resident continued to use the Merry Walker and the Merry Walker seemed to provide enjoyment to the resident. The physician identified the plan for the resident as supportive care and to keep the resident safe. A Care Plan dated [DATE], identified the resident with an anticipated fall due to poor safety awareness with gait and lack of insight to his/her needs. The resident utilized a restraint (Merry Walker) to reduce the fall risk. A documentation survey report identified Staff G (nurse aide) last viewed the resident on [DATE] at 6:18 a.m. An incident/accident report dated [DATE] at 6:45 a.m. revealed Staff G (nurse aide) looked for the resident and could not find the resident on the unit. Staff D (licensed practical nurse) and Staff H (nurse aide) opened the Northeast (NE) stairwell door and found the resident face first at the bottom of the stairwell with the Merry Walker on top of the resident. When found, the resident did not have a pulse or respirations. Staff D notified Staff C (registered nurse). Staff C documented on the incident report that staff summoned her to the floor at 6:50 a.m. She observed the resident at the bottom of the NE stairwell with his/her head on the landing and Merry Walker on top of the resident and the resident's feet on the last 2 steps. The resident laid in a pool of blood without a pulse or respirations. The Director of Nursing (DON) documented on the form that the resident's skin appeared pale and cool to the touch. Staff removed the Merry Walker and rolled the resident onto his/her back. The resident had no pulse, respirations or blood pressure. The DON arrived to the scene at 7:00 a.m. The NE door alarm functioned properly when she checked it (door alarm). On [DATE] at 10:18 a.m. the Chief Executive Officer (CEO) of the facility stated on [DATE] around 6:20 a.m. Staff I (licensed practical nurse) exited the unit and found out (realized) he forgot his car keys on the unit. Staff I returned to the unit and entered around 6:35 a.m. While on the unit, the alarm sounded and he thought he set the alarm off. He told other staff he caused the alarm to activate. Staff G came to the alarm panel and Staff D told her to go ahead and reset the alarm because it activated due to Staff I entering the unit. Staff G turned the alarm off. Approximately 10 minutes later, Staff G looked for Resident #1. Staff searched rooms and didn't find the resident. Staff then began to open doors and saw the resident at the bottom of the steps still in his/her Merry Walker. The CEO stated Staff I pushed the code to enter the unit. He thought the door didn't latch causing the alarm to activate. After finding the resident, staff called the ambulance. The ambulance arrived and instructed staff to notify the police. The police arrived and determined there was no foul play. The police instructed the facility to call the medical examiner. The medical examiner arrived and stated there would be an autopsy that afternoon. The first thing the CEO did was check the doors and the alarm system. He stated the incident occurred through no fault of the system. The fault came into play when the nurse took the word of another employee who turned the alarm off without checking as the procedure directs staff to do. He stated no one else had exited the facility. The CEO stated he began reeducating staff immediately. The DON went ahead and educated staff so they all know the alarm response and everyone knew the policy. The facility conducted alarm drills and they are still in the process of drills and education. The CEO stated the maintenance personnel checked every door in the facility and found no issues. On [DATE] at 11:20 a.m., the police officer that investigated the incident stated he looked at the surveillance footage of the incident. The resident went down to the end of the hall and pushed on the door long enough that it opened and the resident went through the door. The resident accidentally went down the stairs head first. The alarm to the door activated but an employee that left thought it was him (staff nurse). The alarm activated between 6:30 a.m. to 6:40 a.m. The facility called for the ambulance at 7:11 a.m. The resident received a skull fracture in the incident which was the cause of death. He stated the resident remained strapped in the Merry Walker and staff cut the strap to get the resident out of the Merry Walker. Staff checked for signs of life and found none. When the policeman arrived there was no rigor (rigidity of muscles). The resident laid in a pool of coagulated (clotted) blood. The police officer documented in the police report he measured the distance of the stairwell as 11 feet 8 inches. On [DATE] at 11:35 a.m. the medical examiner that was at the facility following the incident, stated staff last saw the resident between 6:15 a.m. to 6:30 a.m. When found, the resident "had not been down long". He described the resident as confused and used a Merry Walker. The Administrator described to the medical examiner how the resident went through the door's safety mechanism. The mechanism held the door closed for 15 seconds before opening. He stated there was a delay before the door opened so residents could not casually go through the door. Residents needed to make an effort to get through the door. The resident tumbled down steel and concrete stairs and sustained a fatal injury. The resident received a skull fracture. Staff found the resident at the bottom of the steps face down. He stated the resident's death was accidental due to blunt force trauma to the head due to the fall down the stairs. The medical examiner stated another physician performed the autopsy. On [DATE] at 11:38 a.m. the physician that performed the autopsy was interviewed and stated the resident had a laceration to the front left side of the head that had a lot of bleeding. Underneath the laceration, she could see a left frontal bone fracture that extended deep into the skull through the ethmoid bone and into the frontline. At the tip of the frontal lobe of the brain was a contusion. A coup lesion was present and a contrecoup lesion was present in the right cerebellum and that was the cause of death (When the head strikes a fixed object, the coup injury occurs at the site of impact and the contrecoup injury occurs at the opposite side.) The physician stated she would look at the heart closer for infarction but at the initial observation, she did not see any signs of infarction. The physician stated the resident was probably pretty healthy. The resident's brain was shrunk and had atrophy. The resident had dementia. Staff present on 2 Northwest (NE) unit when the alarm activated were interviewed: On [DATE] at 2 p.m. Staff I (licensed practical nurse) stated the resident was up and awake in the Merry Walker all night. When his shift ended, he gave report to Staff D. He then left the unit and went to the parking lot when he realized he forgot his keys on the unit. He went back up to the floor and put the code in the keypad to the southwest (SW) door. He asked Staff D for the keys to get into the medication room where his car keys were. After he got his keys, he went to Staff D to return the medication room keys. She stepped out of the dining area and got the keys. At that time, they heard a door alarm sound. He was at an angle to the LED sign that tells staff which door is open. He did not look at it. Staff D told the aides to see what alarm went off but he did not know if they looked. He stated he did not know if Staff D checked the alarm panel. At the time he thought he caused the alarm to sound and stated, "I wonder if that was me". Staff I stated during the night he reset the alarm to the SW door a couple times. The light would appear red at the nurses ' station and then when he flipped the maglock reset switch at the nurses ' station it was green. Staff I stated when the light was green then the door was alarmed. Staff I thought maybe the door was not shutting. He stated he was confused about the lights. When asked how the incident could have been prevented, he stated if he would have checked the alarm panel to see which door tripped the alarm it may have prevented the incident. He did not know if anyone checked the panel. He stated the resident would try and leave and would also go in other resident rooms. On [DATE] at 12:33 p.m. Staff D (licensed practical nurse) stated she came on duty at 6 a.m. the day the incident occurred. Staff I left around 6:20 to 6:25 a.m. Staff D worked in the dining room where there is a camera surveillance screen where she can see what is going on in different areas on the unit. She stated about 5 to 10 minutes later, Staff I came back in the unit and around that time an alarm went off. She stated typically there are a lot of alarms going off around that time. She looked at the camera surveillance screen and could not get a good visual on the stairway door. She stated the sun blinded her from seeing the resident. She started to go towards the door, when Staff I said not to worry; he set the alarm off because the door did not latch. She said sometimes the main door doesn't reset because it is not completely latched. Even if it ' s not completely latched, the alarm will still sound when it ' s opened. Staff D sent Staff G (nurse aide) to silence the alarm. She stated as Staff D came up the hall to the panel to turn the alarm off, Staff G did not see anyone and she would have a straight visual shot down the hall. She stated the resident had to hold the bar on the exit door for 15 seconds before it opened. Ten minutes later Staff I left and Staff G looked for Resident #1. Everyone started looking for the resident. They held the northeast (NE) exit door for 15 seconds and opened it finding the resident on the floor at the bottom of the stairs. Staff D saw the resident down face first with the Merry Walker on top of the resident in a pool of blood. Staff D stated the resident was not a fast mover. Staff D stated no one else got out past the alarms. The alarms were always fool proof and required someone to hold the door for 15 seconds before opening. The normal procedure when an alarm is activated is to check the cameras and check the alarm panel. She stated she listened to Staff I saying he tripped the alarm. She did check the cameras but didn't see anything. She stated she had not seen the resident yet that day. On [DATE] at 9:40 a.m. Staff G (nurse aide) stated at 6:20 a.m. she checked on the resident. At that time, the resident sat in the Merry Walker in the dining room. She then got a resident up and assisted another staff with a resident transfer. At approximately 6:35 a.m. a door alarm went off and she went to the panel. Staff D told her to turn the alarm off. Staff G did not check the panel to see what door alarm lit up because Staff D told her to turn it off because Staff I said it was him (staff nurse). Staff G stated the door that Staff I went through is not the door staff uses to enter and exit the unit. Around 6:40 a.m. she then attempted to locate Resident #1. She went room to room and as she saw other nurse aides, she would ask if they saw the resident. Staff went to the NE stairway door and it operated like it should. When they got the door open, they saw the resident at the bottom of the stairs with the Merry Walker on top of the resident. Staff notified the Director of Nursing (DON) and Staff C (registered nurse). Staff G stated there was a lot of blood. Staff G stated she should have looked to see where the alarm activated and then went to that area. Staff G stated the resident normally opened doors and then would get trapped in doorways and staff would turn the resident around. Resident #1 walked at a normal pace and got along well in the Merry Walker. On [DATE] at 10:08 a.m. Staff H (nurse aide) stated she arrived at work a 6 a.m. She saw the resident in the hallway by the nurses ' station roaming around in the Merry Walker. Staff H went in a room to assist a resident and then she heard the alarms go off. She sat the resident in a chair and went out to check the alarm. Staff H stated they did check the alarm and didn't see anything. Everything was clear and staff said it was the night nurse that came back in. She had just seen Resident #1 roaming in the hall just past the nurses ' station. They continued getting residents up for breakfast. Resident #1 normally goes in and out of rooms. Staff could not find the resident at that time. They checked rooms and exit doors. During a check of exit doors, they found the resident. The resident laid at the bottom of the stairs face first. The Merry Walker laid on top of the resident. They got Staff C (registered nurse) and the DON. Staff H stated normal procedure when an alarm activates is to go to the panel and look at which door activated the alarm. Staff then goes to check to see if they see anyone. Staff H did not know anyone that failed to follow this procedure. Staff received training prior to the incident and since the incident, the facility conducted drills. Staff H stated she saw the resident 5 to 10 minutes before the incident down the NE hall but not by the exit door. On [DATE] at 11 a.m. Staff F (nurse aide) stated she came to work at 6 a.m. and went to the nurses ' station and got report. Around 6:15 a.m. she went to a resident's room and while in that room, an alarm activated. Staff F couldn't leave the resident she was with and when she could leave, the alarm was silent. She knew if the alarm no longer sounded then everything was OK. It means it is taken care of. She went to a second resident and heard a staff person scream. She placed the resident in a wheelchair and they both went to the hallway. She heard Resident #1 expired. She opened the stairwell door to look and did not recall what she saw. Staff E became very emotional during the interview recounting the information about what she visualized. She stated the normal practice is to go to the panel and find out what door is opened. Staff then goes to the door and check for residents and will go beyond the door is necessary before the alarm is silenced. She stated staff received training prior to the incident. She stated the resident would go to other resident's doors. Sometimes staff would get the resident and other times, the resident would come out on his/her own. On [DATE] at 10:35 a.m. Staff E (nurse aide) stated she got report at 6 a.m. and they all went to their assigned areas. She went to a resident room and had a resident on the toilet when she heard a door alarm. She finished caring for that resident and peeked out the door. Staff I and Staff D were in the hallway and they said it was all clear. Shortly after that, Staff G could not find the resident. Staff E told her she saw the resident in the lobby. The resident is not a fast mover. Staff G stated she would look in rooms because the resident goes in rooms. She came back and said she still could not find the resident. Staff E said they all better start looking. Just a second after that, she heard Staff H and Staff G say oh my God the resident is at the bottom of the stairs. Staff E went to the stairs and Staff D told her to call people. Staff E went back and called the DON's cell phone. She also called Staff C and she arrived immediately. Staff D stated to keep calling people to see how many they could get there. Staff E stated she did not know what happened regarding the alarms. The resident would open room doors not necessarily trying to leave. Staff E saw the resident by the window near the NE exit during report and she did not see the resident again. On [DATE] at 1 p.m. Staff A (nurse aide) stated around 6 a.m. she went to a resident room and came out to get gloves. Resident #1 faced west to the nurses ' station. After that, she finished care on a resident and assisted that resident to the dining room. She did not notice where the resident was at that time. As she got the resident into the dining room, she heard an alarm sound so she went to the nurses ' station. When she arrived at the nurses ' station she saw Staff G reset the alarm at the panel. Staff G said Staff I set the alarm off. Staff A then went to a resident room. While she was in the room, Staff G came in and said she could not find Resident #1. Staff A said the resident might be in a room. Shortly after that, Staff A heard the resident got down the stairs. Staff A peeked and saw the resident at the bottom of the stairs. Staff A stated the resident walked slowly in the Merry Walker. On [DATE] at 1:22 p.m. Staff C (registered nurse) stated she received a call at 6:50 a.m. from Staff E who told her they needed her right now. Staff C could hear panic in Staff E's voice. Staff C went to the area and found out the resident fell downstairs. Staff C observed the resident face forward in a pool of blood with the Merry Walker on top of him/her. The resident's feet laid on the bottom 2 steps. The resident remained strapped into the Merry Walker. The resident's head bled and his/her skin appeared pale cool and clammy. Staff C took a pulse and determined the resident did not have a pulse or respirations. They rolled the resident over and cut the strap on the Merry Walker to remove the resident from the Merry Walker to further assess him/her. Staff C stated she knew the Director of Nursing was on her way and once she arrived, she called the direct number for the ambulance, the resident's physician and the resident's spouse. The ambulance arrived about 7:20 a.m. Staff C got papers ready for the transfer. Staff C asked Staff D when they last saw the resident. Staff D indicated she wasn't sure when staff last saw the resident. Staff D told her a nurse came in and they thought the nurse caused the alarm to activate. Staff checked the alarms the stairwell and they worked appropriately. On [DATE] at 2:35 p.m. the Director of Nursing (DON) stated she arrived to work around 6:50 a.m. and was in her office when her cell phone rang around 7 a.m. Staff E told her to come to 2 NE immediately. She went to the unit and it seemed quiet. She saw Staff H crying. Staff C informed her that the resident was at the bottom of the first flight of stairs of the NE stairwell. The door operated properly when the DON went to the stairwell. She observed the resident in the Merry Walker face down with a pool of blood around his/her head. The DON performed a brief assessment and there was no breathing and no pulse. The DON asked when the staff last observed the resident and they told her 6:15 a.m. The ambulance arrived and the DON briefed them. The police came and then the coroner. The DON stayed on the unit until the resident left. After everything occurred, she spoke with all the staff. She began collecting data and the education process. Staff checked the door alarms multiple times after the incident and everything functioned properly. They walked through exactly what happened and determined there was a breakdown in procedure. The DON stated she didn't think staff visualized the alarms and they made an assumption which was unfortunately the wrong one. When asked what may prevent the incident, the DON stated "visualizing the alarm panel". She stated staff is educated on this. There have been no prior issues with staff not checking the panel. The DON stated she did not think staff fully understood the door alarms. She stated normal procedure when an alarm activates is to identify which door it is and then respond. Let staff know which door it is and follow as far as necessary even to street level until they can say it ' s clear. Staff needs to perform a head count and notify the supervisor that the count is correct. Review of video surveillance of the unit recorded during the time the incident occurred revealed at 6:37 a.m. staff went to the alarm panel, at 6:43 a.m. staff appeared to search for the resident by looking into rooms, at 6:48 a.m. staff gathered at the end of the hall by the exit entrance which identified they located the resident at the bottom of the stairs and at 6:51 a.m. Staff C (registered nurse) is seen on the unit heading towards the exit door area. On [DATE] at 2:10 p.m. the CEO identified the distance from the nurses station to the exit as 90 feet. Facility policy: The resident elopement policy dated ,[DATE] identified when an alarm activated, staff would not turn off the exit door alarm monitor unless staff notified the charge nurse of the door location, reason and duration. Staff will not turn the alarm off until staff checked the door exit and staff accounted for all residents. When an exit door alarm activated then all staff should report to the nurses ' station to ascertain which door activated the alarm. The Administrator stated on [DATE] at 12:30 p.m. that the facility revised the policy after the incident. They removed the sentence about notifying the charge nurse and revised it to state: NO ALARM SHALL BE TURNED OFF until the person at the alarm hears "Door ---is clear". It is the responsibility of the person shutting off the alarm to make sure the door number and alarm match. Door Alarm Checks: On [DATE] at 11:42 a.m. the surveyor and CEO checked all exit alarms and code alerts for function. All alarms functioned appropriately. At 10:40 a.m. the CEO and surveyor went to the Memory Care Unit 2 NE. At that time, the CEO stated just prior to the incident, staff saw the resident at the window at the end of the hall by the 2 NE exit. Observation revealed the location of the windows as directly by the 2 NE exit. When testing the 2 NE door, the CEO held the door panel for 15 seconds with alarm sounding before the door opened. The CEO stated on the day of the incident, staff didn't look at the door panel before they shut the alarm off. The nurse told Staff G it was Staff I and to go ahead and turn the alarm off. He stated Staff G should have checked to see what door alarm activated. Review of door alarms/code alert door checks performed by maintenance revealed weekly checks of the alarms were performed since [DATE]. Note: At the time of the complaint investigation, the complaint was coded at a "J", immediate and serious jeopardy. By [DATE], the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the "D" level. The Company Executive Director provided in-services for the proper procedures when an alarm activates. The CEO revised the facilty policy to reflect no alarm shall be turned off until the person at the alarm hears the door is clear and the person shutting off the alarm ensures the door number and alarm match. As of the [DATE] exit conference, the facilty continued to need to: .Continue to in-service all employees regarding the revised policy/procedure for alarm activation. .Monitor staff to assure compliance with the facility policy/procedure when a door alarm activates. 2. Resident #12 had a Minimum Data Set (MDS) assessment, with a reference date of [DATE] which identified [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance for transfers, and toilet use. The MDS also documented the resident had a brief interview for mental status (BIMS) score of 8. A score of 8 reflects the resident to have moderately impaired cognitive status. The resident's care plan initiated on [DATE], directed staff to transfer resident with assistance of 2 (staff) using the EZ-stand (mechanical stand lift). The care plan also established the resident as not to be left unattended on the toilet. During an observation on [DATE], at 8:47 am Staff R, Certified Nursing Assistant (CNA), and Staff T, CNA, assisted Resident # 12 to the toilet using an EZ-stand. During the observation at 8:52 Staff R and T left the Resident hooked up to the EZ-stand. Staff R had given Resident the call light cord. Both Staff left the room and left the Resident unattended on the toilet. At 9:00 am Staff T returned to the room along with another CNA to assist the Resident off of the toilet. On [DATE], at 1:40 pm, Staff R acknowledged that they should not have left the Resident alone on the toilet earlier in the day. On [DATE], at 2:15 pm, Staff T acknowledged they should not have left the resident's room and left the Resident alone on the toilet. Staff T explained the Care Plan stated the Resident is not to be left alone on the toilet and he/she had been wrong to leave the Resident on the toilet alone.

Based on clinical record review and staff interviews, the facility failed to plan and direct nursing care and services to ensure one (1) of four (4) residents received adequate supervision from hazards. Resident # 1 slid out of his/her wheelchair on 12/23/13 without injury. The care plan coordinator noted an intervention on the incident report to not leave the resident unattended in his/her room when sitting in the wheelchair, however this directive had not been made available to the staff providing the services. On 1/1/14 Resident #1 had been left unattended in his/her room and fell from his/her wheelchair sustaining injuries not limited to nasal fracture and a massive nosebleed that resulted in his/her death. Interviews revealed staff had not been informed of the directive. The facility reported a current census of 199 current residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 5 on the Brief Interview for Mental Status (BIMS) test revealing severe cognitive impairments. The assessment identified Resident #1 had [DIAGNOSES REDACTED]. The assessment indicated the resident required assistance of 2 staff members with bed mobility, transfers, dressing and toilet use; and assistance of 1 staff member with locomotion on and off the unit. The assessment identified Resident #1 was non-ambulatory and as only able to stabilize himself/herself with staff assistance when moving from a seated to standing position, moving on and off the toilet and during surface to surface transfer. The resident had impairments on both sides of his/her upper and lower extremities. A Care Plan with a goal initiated and revised on 9/23/13, indicated the resident with an impaired physical mobility/potential for falls related to an unsteady gait and poor balance. The interventions directed staff to do the following: a. 1/2 side rail times 1 (by the wall), low bed and a fall mat. b. Have a cordless phone in bag on edge of bed during waking hours, have a phone on hoot at night to chance, ensure phone had been in reach when in bed. c. Restorative ambulation and exercise programs to have been initiated by therapies. d. Transfer with 2 assist, gait belt and a walker and/or a stand-eze lift device and 2 staff assist as needed (PRN). e. Use a wheel chair for general mobility and a specialty cushion in chair. f. Gripper pad dated 12/23/13. According to a Fall Assessment Tool and Guidelines For Use form dated 9/23/13, the resident scored a 12. (10 or more indicated a risk for falling). A Negotiated Shared Risk Agreement For Falls form signed by the staff and resident 10/2/13 documented the following: a. The cause for concern: thickened liquids as the resident requested regular liquids. b. The probable consequences of the resident's choice: coughing, choking, aspiration, pneumonia and death. c. The final agreement: the resident may have what he/she wanted to drink within the fluid restriction. Review of Good Shepherd Health Center, Inc. Incident/Accident Report forms revealed the following: a. 12/20/13 at 5:45 a.m., the resident had been hollering for help. A Certified Nursing Assistant (CNA) went into the room and found the resident on his/her knees facing the bed and holding onto the side rail, the fall mat had slid away from the bed. The intervention dated 12/23/13 directed the staff to continue the fall mat. b. 12/20/13 at 7:25 p.m., Staff A, CNA and Staff B, CNA assisted the resident with bedtime (HS) cares/undressing. The resident became uncooperative with undressing and slid from his/her wheelchair. Staff caught the resident and lowered him/her to the floor. The intervention dated 12/23/13 directed the staff to continue with assistance. c. 12/23/13 at 4:45 p.m., the resident had been found lying on the floor on his/her right side facing the door and stated he/she had slid out of the wheelchair with no visible injuries and/or complaints. The resident requested to go to bed so staff assisted him/her with the process. The intervention dated 12/23/13 documented a gripper pad placement between the cushion and the wheelchair by the charge nurse. Another intervention dated 12/24/13 directed the staff not to leave the resident alone in the wheel chair in his/her room rather position him/her in the bed or recliner. This entry had been crossed through however no date and time had been placed to identify when the staff had been directed to discontinue the intervention. Facility Nursing Notes revealed the following documentation: a. On 1/1/14 at 10:15 a.m. Staff C, Licensed Practical Nurse (LPN) documented the following: During breakfast the resident started coughing which resulted in coughing up some breakfast so the staff took the resident back to his/her room at approximately 8:30 a.m. At 8:50 a.m. the resident fell out of the wheel chair landing on his/her stomach with the right side of the head on the floor, bleeding from the nose, mouth and possibly the temple area. The resident had been placed on his/he right side due to coughing up excessive amounts of blood. When staff asked the resident if he/she hurt the resident stated "just my face" vital signs included a blood pressure of 166/73, pulse of 80, respirations 24, temperature of 97.7 and an oxygen saturation level at 85 %. Due to the resident bleeding from the nose and mouth staff placed the oxygen cannula by the resident's mouth which increased the oxygen level to 96%. The supervisor had been notified and paramedics called. During an interview 1/29/14 at 8:40 p.m., Staff C, (LPN) indicated the resident had been known to cough and choke a lot. During breakfast on 1/1/14 the resident started coughing and spit up phlegm and food but she could not remember if there had been medication present. At 8:30 a.m. the staff member directed a CNA to take the resident back to his/her room but could not remember who the CNA had been. At about 8:40 a.m. she went by the resident's room and observed him/her facing the television and asked the resident if he/she had been OK and the resident said yes. As she had been in another resident's room Staff F told her to come to the room of Resident #1. When she entered the staff member observed the resident on the floor, face first next to the night stand in a pile of dark red blood. Staff G, CNA rolled the resident over and noticed "1/2 of a banana" sized dark black/red clots and blood coming out of the resident's mouth and nose. The staff member asked the resident if he/she hurt anywhere and the resident said "my face". Because the resident had been making gurgling sounds and so much blood had been coming out of his/her mouth the staff member positioned the resident on his/her side, checked vitals and "cranked" up the oxygen to raise the saturation levels. Staff H, CNA entered the room so she directed her to go and get Staff D. Staff D arrived and called the paramedics as well as Staff I, LPN who took over for the staff member so she could complete the charting and finish her morning tasks. The staff member indicated there had been nothing on the floor, she was pretty sure the cushion had been in the wheel chair (but not 100 %) but she had not been sure about the gripper pad. The staff member indicated staff soaked up 10-15 hand towels of blood after the resident fell while she had been with the resident. The staff member confirmed she had not been aware of the directive not to leave the resident in his/her room unattended until after the incident when she gave Staff J, LPN report and the staff member informed her. The staff member indicated she asked Staff K, RN the next day about the directive who confirmed the directive as true but she had not told the other staff members about the intervention yet, that it was part of the new care plan (still) on her desk. Staff C stated no one knew until Staff J said something and asked the care plan coordinator (Staff K). Facility Nursing Notes revealed the following documentation: b. On 1/1/14 at 10:15 a.m. a late entry for 8:50 a.m., Staff D, Registered Nurse (RN) documented the following: Notified of the resident's fall. The resident had been laying supine on the floor of the room with his/her head towards the door to the room and feet towards the window. The resident had been alert per usual. Answered "yes" to the nurse calling his/her name. When questioned about pain the resident stated "my face and head". Noted to have a large amount of sanguineous drainage noted on the face, in the mouth and on the clothes. The nose had been swollen and lacerations noted to the upper lip and nose. Facility Nursing Notes revealed the following documentation: c. On 1/1/14 at 10:30 a.m. a late entry for 8:50 a.m., Staff D documented the following: the fire department/ambulance at the facility, body and head stabilized by the emergency medical service (EMS). The resident continued with a lot of sanguineous drainage from the mouth and face. The resident able to cough blood out of mouth and the EMS staff also wiped the blood out of the mouth. The resident left via the ambulance service for the hospital emergency room (ER). During an interview 1/28/14 at 2:20 p.m., Staff D, (RN) indicated she arrived to the resident's room and observed him/her positioned just outside the closed bathroom door and that staff moved him/her somewhat because he/she had been bleeding bad and she knew the resident required hospitalization . The staff stabilized the resident as he/she had been bleeding profusely from the bridge of his/her nose, the nose, appeared to have bitten the lip and the resident complained of his/her head hurting. When the ambulance arrived it appeared the resident had been bleeding more profusely from his/her mouth with clots but she could not describe the clots as she stepped back and the ambulance crew assumed primary care and treatment. The staff member had been unaware where the cushion of the wheel chair had been positioned. The staff member indicated she had been informed the resident coughed up his/her breakfast and medications at breakfast but that had not been unusual for the resident as he/she had dysphasia which had been a constant on going situation. The staff member confirmed after the fall Staff C informed her there had been a directive not to leave the resident unattended in his/her room. According to a Transfer/Discharge Report form dated 1/1/14 at 9:15 a.m., the resident fell face first out of the wheel chair at 9 a.m. and received lacerations and/or injuries to the nose, mouth and potentially the ear AD (right ear). Staff E, CNA came to the nurse's office to notify her of the fall and stated I saw him/her reaching to the floor then he/she fell face first out of the wheel chair. A call had been placed to the physician and family notified. According to a Nursing Notes form dated 1/1/14, Staff E documented the following information: She (Staff E) walked down the north east hall toward the resident's room to get Staff F, CNA to help with another resident. When I had been about 12 feet away from the resident's door I noticed he/she had been leaning over in his/her chair, not sure if he had been reaching over to grab something. I bee lined toward the resident but within 2-4 feet of my moving toward him/her I watched him/her fall forward and out of the chair. Immediately I had been at his/her side and yelled for help. Staff F had been just outside walking with another resident so she ran in and then yelled for Staff C. I sat with the resident and reassured him/her that we had been getting help. Staff C came in and asked me to call the house supervisor. I could not get through the phone line as it had been busy so I ran upstairs and told Staff D quickly what happened and she ran downstairs with me. The resident's phone had not been ringing, his/her cushion had been in the chair and there had been nothing in my view that he/she had been reaching for on the floor. An Iowa EMS Report form dated 1/1/14 documented the following information: a).Called via telephone by Good Shepherd Health Center requesting a non-emergent transport for a patient who had fallen out of his/her wheel chair and now had a bloody nose. Upon arrival staff directed us to the patient ' s room and told us that he/she lost a lot of blood. Staff stated that it had been a witnessed fall out of his/her wheel chair and that the patient had not lost consciousness at all. Staff stated that they believed the patient had a broken nose and possibly a laceration on the side of his/her face/head but they had not been able to find one (source) due to all of the blood. Attending RN showed up and stated that the patient had been a dialysis patient and had been scheduled to go for treatment on that date. Staff stated the patient had bled a lot from his/her nose since the fall. The patient grunted when asked questions and when asked if anything hurt he/she stated "face" and that had been it. b).Upon arrival we found a patient laying on his/her right side with a pillow under his/her head and two towels by his/her mouth that had quite a bit of blood soaked into them. Obvious blood noted in the patients nose but it had not been bleeding. The patient had been spitting blood out of his/her mouth. No laceration had been found on the patients head. No active bleeding had been coming out of the patient ' s nose but the patient had been spitting large blood clots and blood out of his/her mouth. Vitals had been taken with noted findings. c). A C-collar applied and the patient log rolled onto the gurney and secured with straps and a head bed. Once on his/her pack the patient started coughing up and spitting large blood clots out of his/her mouth. The patient had been tilted to his/her right side she he/she could clear his/her airway. The patient spit many blood clots with blood out of his/her mouth during transport. Approximately 400 cubic centimeters (cc's) of blood had been suctions from the patient during transport. According to a Provisional Autopsy Report dated 1/1/14, the resident's immediate cause of death had been a massive epistaxis (nosebleed). The basic cause of death had been nasal trauma due to a fall from a wheel chair, landing on his/her face. The findings included the following: a. Palpably fractured nasal cartilage with intranasal blood and blood in the stomach. b. No visible skull fracture noted. During an interview 1/29/14 at 9:40 a.m., upon review of the Provisional Autopsy Report a Physician confirmed the cause of death as a nose bleed and blood loss. During an interview 1/28/14 at 1:20 p.m., Staff H, (certified nurse aide)/CNA indicated she and Staff L, CNA transferred the resident utilizing an EZ stand lift device to a wheelchair, assisted the resident with morning cares and one of the staff members propelled the resident to the dining room for breakfast. While at the dining room table the resident coughed up all his/her food, medication and everything. The staff member cleansed the resident and transported the resident back to his/her room around 8-8:15 a.m. with the assistance of Staff C and maintained the resident positioned in the wheel chair in case he/she aspirated and/or threw up. The next time she observed the resident he/she had been positioned on the floor by the night stand in a puddle of blood and bleeding from his/her nose. The staff member indicated the wheel chair cushion as positioned on the floor by the wheel chair with a gripper pad on top of the cushion and no other items on the floor. The staff member indicated the resident as known to lean to either side or sometimes forward while positioned in the wheel chair. The staff member indicated she had not been directed not to leave the resident unattended in his/her room and never heard that directive after the fall either. On 1/29/14 at 10:19 a.m. the staff member called the surveyor crying and apologized for not sharing the truth the day prior during the interview. The staff member went onto confirm she found out about the directive not to leave the resident unattended in his/her room after the fall, Staff K placed it on the care plan however no one knew and after the fall the directive had been removed. During an interview 1/28/14 at 10:45 a.m., Staff L, CNA indicated she and Staff H assisted the resident with morning cares, transferred the resident with an EZ stand lift device to a wheel chair and left him/her unattended in the room. The resident propelled himself/herself to the dining room and ate breakfast at her table without any difficulties however required encouragement. After the resident finished eating he/she started coughing and spitting out food which the resident had been known to do at times. At around 8:20 a.m. either herself or Staff H took the resident back to his/her room. While walking another resident she heard a call for help, entered the resident's room and observed the resident face first on the floor by the night stand around a lot of bright red blood, coughing but not talking. When the nurse entered the staff member left the room to get towels. When she returned the resident had been positioned on his/her back, with a bloody face, swollen eyes and blood coming out of his/her mouth. The staff member confirmed the resident as known to lean forward and to the right when positioned in the wheel chair, with the cushion on the seat of the wheel chair after the fall, with nothing present on the floor after the fall and leaving the resident unattended in his/her room as acceptable. During an interview 1/28/14 at 11:20 a.m., Staff M, CNA indicated she entered the resident's room as several staff members had been present and resident had been laying on the floor by the night stand, on his/her back in a pool of dark blood, with blood clots coming out of his/her nose, coughing up blood and making a gurgling noise. Staff positioned the resident on his/her right side as the resident coughed up a golf ball sized blood clot with bubbles in it. She then left the room and returned as the ambulance crew loaded the resident. The staff member confirmed the resident had not self-propelled himself/herself in the wheel chair recently, the resident as a fall risk, the resident "slouched" in the wheel chair, the cushion as positioned on the seat of the wheel chair, could not recall if there had been a no skid pad present, no items on the floor and the staff had not been made aware of the intervention not to leave the resident unattended in the room until Staff J told staff after the fall. During an interview 1/28/14 at 12 p.m., Staff G, CNA confirmed she observed the resident cough up phlegm and dry heaving as she walked up to the breakfast table and asked Staff H and Staff L to assist the resident back to his/her room. At 8:55 a.m. she heard commotion and someone say the resident's name. The staff member went to the room, observed Staff E and Staff F in the room with the resident face down on the floor by the night stand in a pool of dark red blood. The resident had been making a gurgling noise and coughing up blood and big clots described as "hockey puck" size. Staff C arrived and rolled the resident onto his/her back at which time the resident began gurgling and choking more so the staff member positioned the resident on his/her right side while blood poured out of the mouth. When the resident coughed more clots came out of his/her mouth. The staff asked the resident 3-4 times how he/she felt and the resident always said my face hurts. The staff member described the nose as double in size and looked smashed. Staff D arrived and said there had been to much blood and called the ambulance while Staff C checked the resident's vital signs. The resident seemed to go in and out of responsiveness/consciousness because staff had to say his/her name several times and raise their voice to arouse the resident. The staff member stayed with the resident until the ambulance personal arrived and then assisted to transfer the resident to the gurney. The staff member confirmed there had been no items present on the floor, the resident as a known fall risk, the resident self-propelled himself/herself in the wheel chair, the resident had been getting weaker and slumping forward in the wheelchair, the cushion as present in the wheelchair and the nonskid pad present under the cushion. The staff member confirmed she had not been told not to leave the resident unattended in his/her room until after the resident fell when she heard Staff J shares that information. During an interview 1/28/14 at 1:30 p.m., Staff K, care plan coordinator/register nurse confirmed she made the entry on the resident's incident report dated 12/24/13 not to leave the resident unattended in his/her room but when the Director of Nursing (DON) reviewed the intervention deemed it inappropriate and removed the directive however the staff member could not recall when the intervention had been removed but knew it had not been on 12/24/14. The staff member recalled documenting the intervention on the resident's quick reference form (carded/mini-care plan) but had been unaware of where that form had been presently located. The staff member also stated she informed Staff J of the care plan change as well. During an interview 1/28/14 at 3:43 p.m., Staff J, license practical nurse (LPN) indicated she could not recall if she had been aware if the resident was not to have been left unattended in his/her room. During an interview 1/28/14 at 2:07 p.m., the DON indicated she had been unable to locate the quick reference form Staff J referenced in her interview and she had not known when the intervention to not leave the resident unattended in his/her room had been remove but she knew it had not been on the care plan on 1/1/14 because she reviewed the care plan when she arrived at the facility to investigate the fall to make sure all the interventions had been in place.

Based on review of facility policy/procedures, observation, record review, and staff and family interviews, the facility failed to provide adequate supervision to ensure against hazards to self or elements in the environment and the health service supervisor failed to plan and direct the nursing care services so the resident ' s needs are met (Resident #1). The facility reported a census of 194 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment, with a reference date of 9/11/12, which identified [DIAGNOSES REDACTED]. The MDS assessment indicated the resident sometimes made self-understood, usually understood others, had short and long term memory deficits and required staff supervision when ambulating in the room and the corridor. The Care Plan dated 9/25/12 identified a fall risk problem due to impaired judgment and the use of psychotropic medication. The approaches directed staff to perform the following: a. Up ad lib without an assistive device. b. Provide cues/direction to locations as needed. The Care Plan identified a problem with altered thoughts with behavior manifestations due to a [DIAGNOSES REDACTED]. The approaches directed staff of the following: a. Resident may become upset when asked to do something. Give the resident space and time when needed, assuring his/her safety and that of others. b. Resident may become agitated when taken outdoors and had attempted to leave staff that had been with him/her. c. Code alert on at all times. An Incident/Accident Report form dated 10/22/12 at 3:50 p.m., documented the resident had eloped and staff assigned to the area were in the hallways and/or resident's rooms. The Assistant Director of Nursing, ADON documented Staff B (Registered Nurse) received a call from staff on the first floor informing him/her the resident was outside and they planned to bring him/her into the facility. Staff C (Certified Nursing Assistant) went downstairs and returned the resident back to the unit without incident. Fifteen minutes later when Staff D (Registered Nurse) arrived at the unit, the resident was not present. Staff D documented he/she received a call from Staff B, RN who informed them that at approximately 3:45 p.m., the resident exited the memory care unit unattended, that he/she was unsure what exit door the resident had utilized to exit because several alarms had been going off at the same time but the resident was returned to the unit. Staff D documented the resident was observed outside in the Northeast (NE) parking lot by a staff member and brought back to the unit. Staff D went to the unit to investigate the reported incident but could not find the resident in his/her room and/or on the unit following an entire search. The Incident Report indicated Staff D began a line 10 call (which alerted the entire facility that a resident had been missing). At that time a visitor reported to the facility staff that he/she had observed a resident outside of the facility in the NE parking lot. A staff member from 1st floor, Southeast (SE) hallway returned the resident back to the unit without incident and the resident was carrying clothes with him/her at the time. The resident was placed on a 1 to1 staff intervention with staff education and care planned. The Code Alert was on and all door alarms were checked and functional. On 10/26/12 at 10:40 a.m., Staff B was interviewed and stated she was unsure of when the resident had left the facility but thought it was when 2 alarms sounded at the same time. Staff B stated the first alarm sounded for the Northwest (NW) fire escape door. Staff B went to the door and observed 3 residents standing in the area with one of the resident's hands on the door handle so she assumed the resident had sounded the alarm. Staff B stated she did not check the stairwell. Staff B confirmed that when the second alarm sounded another staff member responded and just presumed the residents had sounded the alarms all of the time. Staff B was passing medications in the dining room when she received a call from the first floor staff informing her that a resident was outside of the facility and facility staff planned on returning the resident to the unit. Staff B sent Staff C, CNA to assist staff and the resident to the unit. Upon arrival the resident was returned to his/her room but not put on 15 minute checks and/or 1 to 1 interventions. Staff B paged the supervisor to inform him/her the resident had eloped. The supervisor began his/her investigation and found the resident was not present on the unit. The supervisor called a code 10. Staff B said a community/family member informed staff on the first floor that a resident was in the parking lot. Again, facility staff on the first floor responded along with Staff C. When the resident was returned to the unit the resident was placed on a 1 to1 status ratio status. On 10/26/12 at 9:00 a.m., Staff F (Certified Nursing Assistant) was interviewed and confirmed at approximately 3:00 p.m., when he worked on the first floor in the SE hallway, he heard an alarm bell sound somewhere on first floor (not on his/her hallway) which had been silenced immediately so he assumed another staff member had responded. Staff F stated approximately 25 minutes later he observed the resident ambulating down the NE hallway and carrying a photo album, 2 sweaters and a baby doll. Staff F stated he knew the resident resided in the memory care unit so he attempted to encourage the resident back to the unit without success. Staff F accompanied the resident to the SE hallway nurse's station where the resident laid down his/her belongings and left the facility via the SE exits doors, accompanied by Staff F. Staff F utilized his headset to alert staff of the situation. After he accompanied the resident on a walk they returned to the facility and he assisted the resident back to the memory care unit. Staff F stated not even 20 minutes later a person in the community informed Staff E (Certified Nursing Assistant) that the resident was outside of the facility. Staff E responded to the call however Staff F observed the resident carrying what looked like his/her entire closet of clothing draped over his/her arms. On 10/26/12 at 8:35 a.m., Staff E was interviewed and confirmed she was passing ice on the first floor in the SE hallway when a family member informed her that a resident who resided upstairs in the facility was outside. Staff E responded and observed the resident ambulating on the side walk, by the fence at the end of the parking lot and carrying clothing. Staff E confirmed staff ran to the resident and assisted the resident back to the unit reported the incident to the nurse, placed the resident's belongings in his/her room and then went back to their scheduled unit. On 10/26/12 at 2:30 p.m., the community/family members approached the surveyor. The community/family members confirmed they witnessed the resident ambulate across the NE parking lot, down the sidewalk that ran north and south on the east side of the building and through the grass in front of their truck which was parked in the SE parking lot. The community/family members confirmed the resident was carrying a load of clothing at that time so one of the members went into the facility and informed staff while the other stayed with the resident. The community/family members confirmed they were aware the resident resided on the memory care unit on the second floor as they witnessed him/her exit the unit earlier in the same week, sounding the alarm and carrying his/her belongings. The surveyor obtained photographs of the exit doors, stairwell and outside surrounding areas which included the rail road tracks and a vehicle parking area. On 10/26/12 at 11:20 a.m., Staff C (Certified Nursing Assistant) was interviewed and confirmed she had received a page from Staff F stating the resident was outside of the facility and requested assistance. Staff C responded and redirected the resident back to the memory care unit and into his/her room. Staff C confirmed the resident picked up the doll and was standing by his/her bed when she left the resident's room. Staff C confirmed the resident was not placed on 15 minute checks or 1 to 1 interventions but they encouraged other staff members to keep an eye on the resident. Staff C stated the second time the resident left the facility the NE stairwell door alarm sounded but another staff member responded to the alarm. At that time another resident was standing by the door so Staff C assumed that resident set off the alarm and escorted the resident away from the door. Staff C said immediately after that incident Staff D (Registered Nurse) requested the unit staff perform room checks on all of the residents at which time staff realized the resident was missing again. Staff D called a code 10 and shortly after a staff member called the unit and said he/she found the resident and returned Resident #1 to the unit. Review of the facilities Monthly Behavior Monitoring Flow sheet dated 10/12, documented the resident was out the exit doors on the following dates: a. 10/2/12 - 2 times on the evening shift. b. 10/3/12 - 1 time on the evening shift. c. 10/6/12 - 1 time on the day shift. d. 10/10/12 - 1 time on the day shift and 1 time on the night shift. e. 10/12/12 - 2 times on the evening shift. f. 10/16/12 - 1 time on the evening shift. g. 10/19/12 - 1 time on the evening shift. h. 10/20/12 - 2 times on the evening shift. i. 10/21/12 - 1 time on the day shift and 2 times on the evening shift. j. 10/22/12 - 2 times on the evening shift. Review of the facilities Monthly Behavior Monitoring Flow sheet dated 9/12, documented the resident opened the exit doors, stood by the elevator and attempted to leave on the following dates. a. 9/7/12 - 1 time on the day shift. b. 9/8/12 - 3 times on the evening shift. c. 9/9/12 - 4 times on the evening shift. d. 9/10/12 - 2 times on the day shift. e. 9/11/12 - 3 times on the day shift and 1 time on the night shift. f. 9/12/12 - 1 time on the day shift and 3 times on the night shift. g. 9/13/12 - 3 times on the evening shift. h. 9/14/12 - 2 times on the evening shift. i. 9/23/12 - 3 times on the evening shift. The Social Service Record dated 8/8/12, documented the resident as very energetic and staff had taken the resident out for walks but then the resident refused to return to the facility so it became unsafe for the resident. The form documented the resident had opened the alarmed doors, tried to get onto the elevators, had been hard to redirect at times and often required 1 to1 staff interventions. The Social Service Record dated 5/21/12, documented the resident as very active and had quite a bit of energy. The staff were working towards different activities to assist in keeping the resident busy such as, taking him/her outside for more walks. The form documented the resident packed his/her belongings and attempted to get on the elevator at times. A Treatment Administration Record (TAR) dated 10/1/12 through 10/31/12, documented the resident had a Code Alert transmitter on at all times and directed staff to check placement two times a day and as needed. Review of the TAR revealed the transmitter was checked as follows: a. 10/5/12 - 1 time. b. 10/8/12 - 1 time. c. 10/9/12 - 1 time. d. 10/13/12 - 1 time. e. 10/14/12 - 1 time. f. 10/22/12 - 1 time. Review of the facility Frequent Flyers List form documented residents pictured on the Frequent Flyer list that were at risk of leaving the building unattended. The resident's picture was present and dated 2/1/12. Review of the Resident Elopement policy dated 4/01, indicated it was the policy of the facility to provide a safe and secure environment for each resident. The procedure directed staff to: a. When an exit door alarm was activated all staff would report to the nurses' station to ascertain the door activated. If the door activated had an alarm at the door, the employees of that area would go to that exit immediately. b. When a Code Alert Alarm was activated, all staff would respond to the door with the activated alarm immediately. c. Staff would be alert to residents on both sides of the exit and assured that all residents were safely inside. d. Any resident observed leaving the facility and/or floor without authorization would be courteously returned to the building and/or floor of the residence. Observation on 10/25/12 at 10:50 a.m., revealed Staff A (Licensed Practical Nurse), testing the resident's code alert alarm which was not functional. Observation on 10/26/12 at 8:05 a.m. revealed the Director of Nursing (DON) tested a Code Alert Wanderguard device at the Southeast (SE) doorway just outside the main dining room on the first floor which was not functional. On 10/26/12 at 8:10 a.m., the DON was interviewed and confirmed the Maintenance Department planned to adjust the sensors for the SE doorway as they were aiming towards the hallway, not across the doorway. Observation at 8:15 a.m., revealed maintenance personnel repairing the sensors on the SE doorway. Review of an invoice dated 10/9/12, revealed an electrical company installed cameras on the new dementia unit. Review of a Code Alert policy dated 4/01 reflected the residents known to wander would be provided with an appropriate means of identification. The guidelines would be observed by nursing staff to ensure the comfort of the resident and the efficacy of the device. The guidelines included the following: a. Nurse to check the bracelet during their shift with the transmitter and record information on the resident ' s treatment record. Note: Att he time of the complaint investigation, the complaint was coded at a "J" immediate and serious jeopardy. By 10/31/2012, the facility had implemented emasures that adequately addressed the jeopardy and the grid placement was lowered to "D" level. The facility repaired the sensor located on the south east doorway, installed cameras on the north dementia unit and the Code Alert Policy guidelines and Elopement Policy were inserviced to staff. As of the 10/31/2012 exit conference, the faciltiy continued to need to: ? Continue to inservice staff to the Code Alert Policy and Elopement Policy. ? Monitor staff to assure compliance with the Code Alert Policy and Elopement Policy procedure.

Based on clinical and hospital record reviews staff interviews and review of facility policy/procedures, the facility failed to provide adequate supervision to ensure against hazards from self and failed to revise the health care plan to meet the needs of the resident (Resident #1). The sample consisted of 4 residents and the facility reported a census of 188 residents. Findings include: 1. The Admission record for Resident #1 included the following Diagnosis: [REDACTED]. Resident Admission assessment dated [DATE] included chief complaint: dizziness. Resident alert and cooperative. Trace edema to both legs. Resident gait: unsteady. Orientation to environment included: unable to use call light. The Minimum Data Set (MDS) assessment with an assessment date of 12/6/2012 identified Resident #1 had minimal recall difficulty. The resident required extensive assistance of two persons with bed mobility, transfer assistance, walking, dressing, toilet use and personal hygiene. The active [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. The Resident Care Plan dated 1/24/2012 reflected Resident #1 had a potential for falls related to impaired mobility and dizziness. The listed approaches directed staff the resident could be up ad lib in room and with the assistance of one staff person in the hallways. The approach identified the resident as Independent with an electric scooter. The Care Plan indicated the bed had 2 ? side rails for safety. A hospital History and Physical report dated 11/28/11 noted this resident's family member reported the resident had been complaining of dizziness chronically for the past [AGE] years. Physical examination revealed a standing blood pressure of 201/97 and a lying blood pressure of 180/89. The assessment included hypertensive emergency and dizziness. Physician recertification orders signed by the physician on 1/16/12 included: Meclizine Hydrochloride as needed for dizziness. The Nursing Notes indicated the following: a. On 2/14/12 at 1:45 a.m. staff answered the call light and found the resident sitting on the floor with back to the bed. The resident stated had slipped off the side of the bed when attempting to get into the bed. The resident ' s feet did not have gripper socks covering the feet. The staff reminded the resident to not remove the gripper socks. b. On 214/12 at 2:07 p.m. the nurse was called to the resident ' s room. The laid flat on floor with head by the north wall and feet towards the bed. The resident had eyes open but did not speak when spoken to. The resident had a small cut located on the back of the head with blood covering back of head. The staff assisted the resident to bed. c. On 2/14/12 at 2:20 p.m. the nurse documented the resident had shortness of breath and anxious. The note indicated the lung congestion and oxygen applied. The nurse contacted the physician and family and received orders to send to the emergency room . A Hospital Discharge Summary dated 2/18/12, identified Resident #1 was admitted to the hospital on [DATE] due to congestive heart failure and atrial fibrillation. The discharge [DIAGNOSES REDACTED]. The resident arrived to the hospital quite hypoxic. There had been also noticed large metastases in the liver which had been growing since the previous exam. The resident had 2 acute nondisplaced right rib fractures, and also there had been changes noted in the 2 left ribs which were new from the past in which the radiologist suspected metastatic disease. The family was informed the overall prognosis down the road would be poor. They also discussed Hospice services. The summary noted at the time of discharge he/she still needed help of two with walking. The hospital care plan during this hospitalization indicated the resident at high risk for falls. The staff used a sitter (person to sit with the resident) to supervise the resident at all times, bed alarms, nonskid footwear, side rails. The physician orders [REDACTED]. The nursing notes revealed the following: On 2/18/12 at 12:15 p.m. returned from hospital. Alert and confused. The resident ' s vital signs read temperature-98 (normal 98.6), pulse-88 (normal 60-100) and blood pressure -121/71 (improved). On 2/18/12 at 4:45 p.m. assessment documented included vital signs of pulse-64, temperature-98.2, and blood pressure 140/57. The nurse noted no edema present and the oxygen saturation at 92% (normal 92-100%). The resident denied pain. On 2/18/12 at 8:47 p.m. the CNA (Certified Nursing Assistant) called the nurse to the resident ' s room. The nurse found the resident lying on the floor in the middle of the room. Observation revealed the right ear bleeding from within and the hearing aids found on the floor away from the resident. The resident ' s vital signs revealed to be: blood pressure 192/114, pulse 98, respirations 18 and temperature 98. The resident did not have oxygen on. Four staff members physically lifted the resident and transferred to the bed. The resident did not verbally respond to questions. At 8:53 p.m., the nurse documented the resident ' s pupils were equal and reacted to light, hand grips equal but not strong and the resident did not verbally respond to staff questions. g. On 2/18/2012 at 9:20 p.m. the paramedics transported the resident to the hospital. On 2/18/12 at 9:25 p.m. addendum: resident's family member had been visiting with resident earlier today and returned at 6:30 p.m. The family stayed with the resident until 7:30 p.m. and told this nurse that the resident appeared to be asleep in bed and family was leaving. The family patted the nurse on the back and said, "Good Luck". On 2/19/12 at 12:20 p.m. the facility received call from the hospital emergency room . The resident did have a skull fracture with bleed and admitted to critical care. When interviewed on 3/6/12 at 9:50 a.m. Staff B (staff nurse) stated on 2/18/12, she had been informed in report of this resident's return/readmission from the hospital. The resident had returned with a new [DIAGNOSES REDACTED]. Staff B went to the resident's room, and assessed him/her. They assisted the resident up and into a wheelchair and took the resident to the dining room. The nurse did not chart this incident, she did not notify this resident's physician and/or family and she did not notify her supervisor as was protocol. The nurse stated she was just going to let it slid due to no known injury. Later the staff again told her the resident was on the floor. She went to the resident's room and found the resident on the right side with blood coming from the right ear. They then called 911 to summon an ambulance. The nurse stated she does not know if she had informed her supervisor of the first fall or if the supervisor would have instructed her to provide one on one supervision. The nurse stated she felt bad not knowing if they could have prevented the fall with injury, had she informed her supervisor of the first fall. When interviewed on 3/14/12 at 10:40 a.m. Staff D (Certified Nursing Assistant) stated on 2/18/12 Resident #1 returned from the hospital about lunch time. Staff D stated she assisted another staff member with getting this resident out of the car. Staff D noted this resident was not their normal self. The resident required total assistance of two persons for transfer and they were very weak. The resident was confused and antsy/restless. They took the resident to the dining room in a wheelchair. The resident's family sat next to the resident in the dining room. The resident kept trying to stand up from the wheelchair. They then assisted the resident from the dining room back to the resident's room. They assisted him/her to the bathroom and to bed. Again the resident was weak and required the assistance of two persons for all transfers. A resident's family member voiced concern about the resident and their risk for falls and asked if this resident could have an alarm placed. Staff D informed the charge nurse, Staff A about the family's concern and request for an alarm. Staff D stated the facility was trying to get away from using alarms. In place of alarms they normally used alternate interventions including seat belts in the wheelchairs, fall mats next to the resident's bed and the use of a low bed. Staff D stated these alternate interventions were not utilized for Resident #1. Staff D stated they were concerned on 2/18/12 about this resident's safety due to the resident's restlessness, confusion and determination to stand up. When interviewed on 3/14/12 at 9:30 a.m. Staff A (Licensed Practical Nurse) stated she was the charge nurse for Resident #1 on 2/18/12. Staff A stated the resident returned from the hospital about noon. She stated she did not do an assessment of the resident. Staff A stated she was orienting a new nurse that day and she had the new nurse go down and do an assessment of the resident. Staff A was in the dining room and did see the resident stand up from his/her wheelchair while at the table and the resident's family member told the resident to sit down. A CNA came to her and told her of the resident's family concern and request to use an alarm. The nurse stated she did not go to the family to discuss their concern; she did not go and assess the resident and/or the resident's risk for falls. Staff A told the C.N.A. to go back to the family and tell them the facility was trying to do away with the use of alarms. She did not tell her supervisor until the next day of the resident's family concerns and their request for the use of an alarm. When she went to leave the building she saw the resident's family member and she told the family the facility was trying not to use alarms. The family voiced their concerns and stated they hoped the resident would not fall. Staff A stated normally in place of alarms, Good Shepherd implemented other interventions to prevent falls, such as closer supervision and if the resident was restless they would place the resident in the lobby for closer supervision. She stated due to it was on a weekend, these interventions were not implemented. Staff A stated the resident was a little confused that day and he/she was a little restless in the dining room. Staff A stated she did not see the resident in his/her room to know if they were restless in his/her room or not. Staff A stated this resident's bedroom was at the end of the hall. In her written statement, Staff A documented a CNA told her this resident's family wanted an alarm on the resident. This nurse was busy with another resident and told the CNA to tell the family that this facility was getting away from alarms. When this nurse was leaving the building, the resident's family member was by the entrance and the nurse told her that Good Shepherd was not using alarms. On 3/14/12 at 10:30 a.m. Staff C (CNA) was interviewed and stated Resident #1 returned from the hospital totally different than when he/she went to the hospital. Staff C stated when the resident returned from the hospital he/she was like a wet noodle. The resident could hardly stand up. The resident was very weak. While in the dining room the resident was trying to stand up. The resident was restless. They took the resident from the dining room to the resident ' s bedroom and assisted the resident to the bathroom with the maximum assistance of two persons. They then put the resident to bed, applied gripper socks and oxygen. The bed was left at the normal height and it was not a low bed. They then went and assisted the resident from the bed to the recliner. The family asked her partner if they could use an alarm. The resident was restless. They told the second shift staff that the resident was restless. Staff C stated normally they utilize alternate interventions for residents at risk for falls, such as: fall mats next to the resident's bed, provide closer supervision, leave the resident's bedroom door open, use a low bed, check on the resident more frequently, and/or place the resident in a recliner instead of a wheelchair. Staff C stated the only new interventions they were informed of was to use two persons for all transfers. On 3/14/12 at 1:40 p.m., Staff E (Registered Nurse-Supervisor) was interviewed and stated on 2/18/12 she was the nurse supervisor until 6:00 p.m. Staff E stated normally at that time it was the responsibility of the charge nurse to assess the resident upon return from the hospital. It was the nurse supervisor's job to review the hospital records and to evaluate the care plan to see if new interventions were needed or if the care plan needed to be changed. On 2/18/12 when Resident #1 returned from the hospital, she reviewed the resident's hospital records and determined the resident required two person assist for all transfers. Staff E informed the staff of the need to use two-person assist. Staff E did not evaluate him/her for fall risk and she did not update this resident's plan of care to reflect their need for more assistance. Staff E stated the charge nurse did not inform her of this resident's family's concern for this resident's safety and did not inform her of their request for the use of an alarm. Staff E stated had the charge nurse informed her of the request she would have went down to this resident's room and visited with the family to see why they were concerned and why they wanted to use an alarm. Staff E stated she would have then evaluated the resident's condition along with the family's concern to evaluate if they needed to implement more fall risk interventions. She also stated she was on duty until 6:00 p.m. and she was not informed of this resident's first fall that evening. Staff E continued and stated had she been informed of his/her first fall she would have assessed the resident, filled out an incident report, called and reported the fall the resident's physician and family and evaluated the resident for any necessary changes to the care plan. She would have documented her findings. She stated it is never appropriate to not document a fall, even when there is no known injury. The Fall Identification and Prevention Policy and Procedure in effect at the time of this incident, revised in April of 2005 noted: It is the policy of Good Shepherd Health Center to ensure the safety of each resident. Procedure for assessing fall risk included: Administrative nursing will complete fall risk assessment, review fall history prior to admission, review medical [DIAGNOSES REDACTED]. ability. The Fall Risk Determined included: If fall risk is determined, preventative factors are initiated with review by staff, resident and family. Care plan to be developed indicating interventions: physician assessment of risk factors, therapy evaluation and treatment, resident and family education regarding safety measures, assistance with cares and transfers, equipment use, footwear and activity tolerance. When interviewed on 3/5/12 at 11:00 a.m. the Director of Nursing and the Assistant Director of Nursing stated Resident #1 fell on [DATE]. The Assistant Director of Nursing assessed the resident and found him/her to be unusually short of breath. At that time the care plan noted this resident was independent/up ad lib in the bedroom. The resident was admitted to the hospital and returned on 2/18/12. The resident's plan of care was not updated and continued to read up ad lib in room, even though the staff were informed the resident required the assistance of two persons for transfers. The resident's family spent the majority of the afternoon with the resident on the day of his/her return from the hospital on [DATE]. The resident fell about 8:47 p.m. and sustained a head injury. No alarms were in use or planned. This resident had a history of [REDACTED]. The nurse was terminated for her failure to follow their fall protocol. The facility has now implemented a new practice for a fall risk assessment to be completed on re-admissions and for the care plans to also be reviewed/updated on re-admissions. A hospital discharge summary dated 2/20/12 noted this resident was hospitalized from [DATE] through 2/18/12 for [DIAGNOSES REDACTED]with rapid ventricular response, acute or chronic diastolic heart failure and pneumonia. The resident sustained [REDACTED]. They say he/she was not making sense. They also noticed blood in the resident's ear. A CT of the head on 2/18/12 revealed 1) small left subdural hematoma with associated subfalcine herniation on the right of 7 mm, 2) moderate subarachnoid hemorrhage, and 3) right temporal bone fracture with fluid within the mastoid air cells and middle early cavity, disruption of the ossicular chain cannot be excluded on this exam. The family is insisting on no heroics being undertaken. They had initially talked with the family about hospice services due to worsening of overall condition. The patient also has some worsening of METS (metastasis) in the liver and possible new metastasis in the ribs. The patient will be made inpatient Hospice with comfort measures and end-of-life cares. A hospital Discharge Summary dated 2/20/12 listed discharge [DIAGNOSES REDACTED]. All of these falls were at home. The physician was consulted for appropriate level of hospice care. The physician noted the patient be admitted to inpatient hospice care for end-of-life care treatments for congestive heart failure and [DIAGNOSES REDACTED] due to acute SDH (subdural hematoma) and SAH (subarachnoid hemorrhage). The physician wrote, "Given (his/her) clinical condition at the time of my consultation, it was my medical opinion (he/she) will benefit from receiving excellent end-of-life treatments at inpatient hospice for management of (his/her) end-stage CHF (congestive heart failure). When the resident returned from the hospital on [DATE], a fall risk assessment had not been performed and a revised care plan had not been completed to prevent falls. The family provided supervision while at the facility, however, when family asked if an alarm could be used, the facility staff did not use additional and adequate methods to keep the resident safe.