Every finding on record at Grandview Healthcare Center

Based on clinical record review, staff and resident interviews, and facility policy review the facility failed to administer medication as ordered for one of four residents reviewed (Resident #1). The facility reported a census of 61 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had no cognitive impairment. Per the assessment, Resident #1 required total assistance from staff for transfers from one surface to another, dressing, and hygiene. The resident's Care Plan included the following focus dated 1/24/2025: Tube feeding related to Spinal Muscular Scoliosis, Dysphagia (difficulty with swallowing), and Gastroparesis (stomach empties foods slowly). The Care Plan included interventions: Enteral feeding - all nutrition received through this route. May have all medications at once through peg (percutaneous endoscopic gastrostomy, feeding tube placed through the abdomen into the stomach) tube unless otherwise ordered. Resident does not want to be woke up for medications and feedings. Wait until she wakes up naturally prior to 9 a.m. If she is not awake by 9 a.m. she would like us to wake her up close to that time as possible. The Physician Orders active on 2/5/2025 included: Atropine Ophthalmic Solution 1%. Give 6 drops sublingually (under the tongue) four times a day for increased secretions.The May 2026 MAR (Medication Administration Record) revealed staff failed to document administration of Atropine Ophthalmic Solution 1% on 5/2 at noon, 5/3 and 5/20 at a.m. and noon, and 5/22 at noon. The July MAR revealed staff failed to document administration of the Atropine Ophthalmic Solution 1% on 7/14 at a.m. and noon.During a resident interview on 8/12/2026 at 11:50 a.m. along with the resident's [family member] via phone, the resident reported staff failed to administer Atropine drops approximately 2 months prior. The resident indicated the facility had no drops available at the time.On 8/17/2026 at 9:00 a.m. Staff A, Director of Nursing reported via phone the facility had Atropine drops in the Emergency kit. There was a situation where they did not have it available. The nurse removed them from the kit and reordered the drops the very same day. Resident #1 had requested the drops. Staff A did not know if the resident missed any doses, but the drops were available.On 8/12/2026 at 3:56 p.m., Staff B, LPN (Licensed Practical Nurse) reported she did have to pull the Atropine drops from the Emergency kit when Resident #1 requested the drops. The drops were administered, she had to pull them and she told the resident she would get them as soon as she could. She was busy and she apologized. The order is four times a day and the resident did not appear to be in distress. She did not miss a dose, it was just late.On 8/13/2026 at 12:00 p.m., Staff C, LPN reported she had no concerns about the resident missing Atropine doses. The Atropine drops were always available.The facility Medication Administration - Medication Pass policy revised 5/2023 included:PURPOSE: To safely and accurately prepare and administer medication according to physician order and patient needsPROCEDURE:1. Position medication cart in full view outside patient room or dining room2. Perform hand hygiene3. Open EMAR (electronic medication administration record) to patient record and review physician medication order against medication label4. Read transcribed physician order on EMAR: patient name, medication name, dosage, route and interval ordered remove medication from cart compare EMAR with medication label for accuracy5. If medication is unfamiliar or physician order is questioned: read original physician order compare original physician order with EMAR for accuracy remove medication from cart compare EMAR with medication label for accuracy verify allergy status contact physician for clarification, if needed6. Read special medication administration instructions7. Obtain vital signs, if applicable, and record results on EMAR8. Prepare medications for administration

Based on clinical record review, staff interview, guidance from the 2025 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual and facility policy review, the facility failed to develop and implement a timely, comprehensive care plan for one of fifteen residents (Resident #33) reviewed. The facility reported a census of 59 residents. Findings include: The admission Minimum Data Set (MDS) Assessment of Resident #33, dated 3/9/26, documented an admission date to the facility of 3/2/26. The MDS triggered nine Care Area Assessment (CAA) categories. Of these, the facility identified six of those areas would be addressed in the Comprehensive Care Plan: Cognitive Loss/Dementia, Communication, Urinary incontinence, Behavioral Symptoms, Nutritional Status, and Psychotropic Drug Use. The MDS documented both a CAA completion date and a care plan completion date of 3/13/26. A record review conducted on 4/13/26 revealed only one of the six identified CAAs was documented on the Comprehensive Care Plan of the above indicated categories.Per the RAI manual guidelines, the IDT (interdisciplinary team) must develop a comprehensive plan that addresses the triggered CAA findings within 7 days of the CAA completion date.The required assessment summary in the RAI manual details the CAA completion date must be no later than the 14th calendar day of the resident's admission, and the Care Plan completion date must be no later than the CAA completion date + 7 calendar days. (21 days after admission to the facility, the Care Plan must be complete).On 4/15/26 at 8:25 am the MDS Coordinator stated she met with the MDS team regarding the missed care plan. She stated the team (herself, the kitchen manager, social services and the activities coordinator) has a virtual schedule accessible to everyone of when all MDS assessments need completed, reviewed and the care plan implemented or updated. She stated Resident #33 was somehow missed on this schedule and they are looking into how that happened.The MDS Coordinator further described their normal process as each member of the MDS team completing their portion of the assessment and then the care plan. When that is completed, the Activities Coordinator then sets up a care conference to discuss the care plan, the goals and interventions with the resident and/or their representative. She stated when Resident #33 was missed, the team initiated having a weekly meeting to rectify this and ensure no further residents are missed.On 4/15/26 at 9:12 am the interim Director of Nursing (DON) stated her expectation for care planning is to have a minimum of Activities of Daily Living (ADL), Fall Risk, High Risk Medications, Behaviors (if applicable), and Code Status included on the baseline care plan, and having that done within 48 hours of resident admission. She stated regarding a Comprehensive Care Plan, all of the same items and all needed additional items should be completed within 7 days of the admission MDS being completed. The facility policy titled Care Plan Policy revision date 3/2025 directed: 1. During admission, the facility will put in place baseline care plans within 48 hours to address resident's care.2. The baseline care plan at a minimum should include initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable. 3. The facility will provide the resident/representative a written summary of the baseline care plan by the completion of the comprehensive care plan. 4. After the comprehensive assessment (state/federal-required MDS) is completed, the facility will put in place person-centered care plans outlining care for the resident.5. These will be reviewed and revised by the interdisciplinary team after completion of MDS assessments when applicable and with changes that warrant a care plan revision.

Based on clinical record review, staff interview, and facility policy review, the facility failed to ensure that 1 out of 5 residents reviewed for unnecessary medications was provided with education regarding the risks and benefits of psychotropic medications (Resident #33). Additionally, the facility failed to offer alternative treatment options prior to the administration of the medications. The facility reported a census of 59 residents. Findings include: The admission Minimum Data Set (MDS) Assessment for Resident #33, dated 3/9/26, documented diagnoses that included late onset Alzheimer's Disease. The MDS recorded the resident's admission date to the facility was 3/2/26. Review of Resident #33's Medication Administration Record (MAR) dated March 2026 reflected the resident was ordered Escitalopram, an antidepressant medication, start date of 3/3/26, Quetiapine, an antipsychotic medication, start date of 3/2/26, Trazodone, an additional antidepressant, start date of 3/25/26, and Lorazepam, an antianxiety medication, start date of 3/4/26.A clinical record review of the Resident's Electronic Health Record (EHR) failed to reveal consent obtained for any of the medications prior to initial administration. Additionally, no progress notes or assessments were revealed of providing education of the side effects, risk vs benefits of psychotropic medications or offering of any alternative treatments prior to administering the medications.On 4/15/26 at 9:12 am the Interim Director of Nursing (DON) stated the facility staff were to contact the family and discuss the side effects before any new psychotropic medication was started. She added if a current resident had a medication that was increased or a new medication added, the staff was again to contact the family first to discuss the medication. For new residents to the facility, it was a priority along with completing the admission assessment to complete the education of medications prior to the resident receiving the first dose in the facility.The facility policy titled Usage for Psychotropic Medications Guidance, revision date 3/2025 directed:Prescribing New Medications and/or Increasing Dosage:-Before prescribing new psychotropic medications or increasing doses, document nonpharmacological approaches used and their outcomes.-Assess and document the benefits, risks, and treatment goals.-The facility will obtain informed consent from residents and/or their representatives before initiating or increasing psychotropic medication use. Inform the resident, family, or representative of the benefits, risks, and alternatives, including black box warnings, before initiating or increasing medication. -Provide educational materials to residents and/or their representatives from manufacturers or in collaboration with consultant pharmacists.

Based on clinical record review, policy review and staff interview the facility failed to follow physician orders by not giving medications within 1 hour before to 1 hour after the ordered time for 5 of 5 residents (Residents #1, #2, #3, #4, #5) reviewed. The facility reported a census of 58 residents. Findings include: Resident #1's admission Record documented an admission date of 4/7/25. The Order Summary Report included medications to be given up to 4 times per day. The Medication Administration Audit Report for November 1-15 revealed the resident had medications given outside of the 2 hour time frame it was to be given (1 hour before to 1 hour after the ordered time) for 15 out of 15 days reviewed. Resident #2's admission Record documented an admission date of 2/12/25. The Order Summary Report included medications to be given up to 3 times per day. The Medication Administration Audit Report for November 1-15 revealed the resident had medications given outside of the 2 hour time frame it was to be given (1 hour before to 1 hour after the ordered time) for 14 out of 15 days reviewed. Resident #3's admission Record documented an admission date of 6/17/25. The Order Summary Report included medications to be given up to 2 times per day. The Medication Administration Audit Report for November 1-15 revealed the resident had medications given outside of the 2 hour time frame it was to be given (1 hour before to 1 hour after the ordered time) for 13 out of 15 days reviewed. Resident #4's admission Record documented an admission date of 9/24/24. The Order Summary Report included medications to be given up to 4 times per day. The Medication Administration Audit Report for November 1-15 revealed the resident had medications given outside of the 2 hour time frame it was to be given (1 hour before to 1 hour after the ordered time) for 15 out of 15 days reviewed. Resident #5's admission Record documented an admission date of 10/6/15. The Order Summary Report included medications to be given up to 3 times per day. The Medication Administration Audit Report for November 1-15 revealed the resident had medications given outside of the 2 hour time frame it was to be given (1 hour before to 1 hour after the ordered time) for 15 out of 15 days reviewed. Facility policy titled Medication Administration- Medication Pass, last revised 5/2023, directs staff to administer medicaitons in accordance with frequency prescribed by physician- within 60 minutes before or after prescribed dosing time. During an interview on 12/1/25 at 10:48 AM, the Director of Nursing (DON) explained her expectation is medications are to be given within 1 hour before or after the scheduled time.

Based on observation, resident and staff interviews, the facility failed to place a barrier between the foot and the bed linen for a wound treatment to prevent cross contamination for 1 of 1 residents reviewed. The facility reported a census of 55 residents. Findings include: Resident #17's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14/15, indicating intact cognition. The MDS documented diagnoses of coronary artery disease, peripheral vascular disease, diabetes mellitus, and multi-drug-resistant organism (MDRO). The MDS documented Resident #17 had two unstageable pressure ulcers due to coverage of wound bed by slough (a layer of dead tissue separated from the surrounding or underlying tissue) and/or eschar (hardened, dry, black or brown dead tissue that forms a scab-like covering over deep wounds). The MDS documented Resident #17 had an infection of the foot. A review of the electronic health record (EHR) Orders tab, revealed two treatments for the left foot. The treatment for the left lateral foot (the outside of the left) with a start date of 4/4/2025 directed staff to: * Cleanse with wound cleanser or soap and water * Apply betadine to both wound bed * Cover with abdominal gauze pad (ABD), roll gauze and tape * Monitor for signs of infection, red area outlined with a black marker The treatment for the left medial foot (the inner side of the foot) with a start date of 4/4/2025 directed staff to: * Cleanse with wound cleanser or soap and water * Apply betadine to both wound beds * Cover with ABD pad, roll gauze and tape * Monitor for worsening signs of infection, any redness outlined with a black marker A review of the EHR Progress Note revealed a physician visit note dated 4/4/2025 at 1:00 PM that documented Resident #17 had been seen by the wound clinic on 4/3/2025. Resident #17 was started on Doxycycline for empirical treatment of infection to wounds. On 4/8/2025 at 2:08 PM, observed Staff F Licensed Practical Nurse (LPN) knock on Resident #17 door and donned a gown. Staff F, LPN washed her hands and donned gloves. The treatment cart had been pushed through the doorway and closed. Resident #17 had been positioned in bed with the head of bed raised to approximately 45 degrees. Resident #17 had a blanket across her legs. Staff F, placed a barrier on the surface of the treatment cart and placed the treatment supplies on the barrier. Staff F, removed the blanket and the blue cushioned boot from Resident #17's left foot. Staff F, placed a pillow under the left knee and calf. The left foot had been rotated outwards. Staff F, removed the roll gauze from the left foot. Staff F, held the left foot under the heal with her gloved left hand with the outer side of the foot parallel to the bed linen. Staff F, used her right gloved hand to remove the ABD pad from the outer and inner wound areas. A small amount of drainage had been observed on the ABD pad. Staff F, released the left foot allowing the left outer foot to touch the bed linen. Staff F, removed her gloves and donned new gloves. Staff F, used gauze sprayed with wound cleanser to wipe off the inner and outer wounds. Staff F, released Resident #17's left foot with the outer side of the foot on the bed linen. Staff F, placed her left hand under the heal of the left foot raising it off the bed linen and applied betadine to the inner and outer wound areas. Staff F, released the left foot allowing the outer side of the left foot to rest on the bed linen. There had been no odor noted. The wound area on the outer left foot appeared to be black in color approximately 2.5 inches by 2 inches. Staff F, placed the ABD on the wound areas and wrapped the left foot with rolled gauze. Staff F, placed the blue cushioned boot on the left foot and pulled the blankets across Resident #17's legs. Resident #17 did not show any distress, facial grimacing, or voice any concerns with pain during the treatment. Staff F, removed her gown and gloves and disposed of them in the biohazard bin. Staff F, washed her hands. During an interview on 4/8/2025 at 2:21 PM Staff F, LPN acknowledged a barrier should have been placed between Resident #17's left foot and the bed linen to prevent cross contamination to the wound area. During an interview on 4/8/2025 at 2:22 PM, the Director of Nursing (DON) acknowledged she observed no barrier had been placed between the bed linen and Resident #17's left foot during the treatment and observed the left outer foot directly on the bed linen. On 4/8/2025 at 4:43 PM, Resident #17, revealed her bed linens had not been changed after the wound treatment had been completed. During an interview on 4/9/2025 at 8:08 PM, Staff M, Certified Nursing Assistant (CNA)/Paid Nutritional Assistant (PNA) revealed bed linens are changed once per week. Staff M, CNA/PNA acknowledged Resident #17's bed linens had been changed during the morning on 4/8/2025. A review of the Skin Evaluation Pressure Wound assessment for Resident #17 completed on 4/9/2025 at 9:33 AM, documented the onset of the pressure wound to be 3/15/2025. The left outer foot had been identified as pressure and measured 2.7 in length, 2.3 in width and 0.1 in depth. The area is documented as a diabetic ulcer. A moderate amount of serosanguinous (fluid that contains clear, watery liquid and blood) drainage had been present. The Skin Evaluation Pressure Wound assessment noted Resident #17 is treated by the wound clinic. The Skin Evaluation Pressure Wound assessment had been completed by the DON and electronically signed. A review of the Infection Prevention and Control Program (IPCP) Guidelines with a revision date of 09/2022 directed staff to utilize standard precautions on all residents, regardless of the suspected or confirmed presence of an infectious agents. Potentially contaminated articles are stored and disposed of in appropriate containers. Enhanced barrier precautions (EBP) as an approach of targeted gown and glove use during high contact resident care activities. EBP may be applied to residents with any of the following: * Wounds - this generally includes residents with chronic wounds, not those with only shorter-lasting wounds, such as skin breaks or skin tears covered with a Band-aid or similar dressing. Examples of chronic wounds include, but are not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous status ulcers. The policy further states contaminated linen should be bagged at the time of use.

Based on observation, clinical record review, and staff interview the facility failed to follow the manufacturer's directions for use in priming an insulin pen and proper administration of the insulin pen for 1 of 1 residents sampled (Resident #109). The facility reported a census of 55 residents. Findings include: The Order Review History Report electronically signed by the Provider on 3/28/25 listed a physician order for Insulin Glargine Subcutaneous Solution 100 units (U) per milliliter (ML) inject 45 units subcutaneously two times a day for diabetes mellitus. During an observation on 4/08/25 at Staff L, License Practical Nurse (LPN) removed Resident #109's Lantus Glargine pen from the medication cart. Staff L checked the physician order on the April 2025 Blood Glucose/Insulin Administration Record and set the pen to 45 units without priming the pen with two units of insulin. Staff L injected the insulin pen into Resident #109's lower right abdominal quadrant, pushed the button to inject the insulin, then withdrew the insulin pen without holding for 10 seconds per the manufacturer recommendations. During an interview on 4/08/25 at 2:49 PM Staff F, Registered Nurse (RN) relayed she sets the dial on the insulin pen a few units and primes the pen until she sees insulin clear the needle. She then presses the insulin pen to the site and hits the button to injection the insulin. Interview on 4/08/25 at 2:55 PM Staff K, RN explained she applies the needle to the pen, sets the dial to one or two units to prime the pen, then dials the pen to the physician ordered amount of insulin. She holds the pen for a few seconds at the injection site to ensure the resident receives the insulin. During an interview on 4/08/25 at 3:15 PM the Director of Nursing (DON) reported she expects the nurses to follow the manufacturer directions to administer the insulin pens. The Medication Administration Injection Policy, revised 4/2024, under Insulin Pen directed to prime the insulin pen per the manufacturer's guidelines and to hold the pen (to the skin) during administration at the site for 6-10 seconds before pulling the needle out. The Lantus Insulin Glargine Injection Manufacturer's Directions Step-by Step guide to using the Lantus Solo Star Pen directed the following: a. After attaching the needle, take the outer needle cap off and save it. b. Remove the inner needle cap and dial a test dose to 2 units. c. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. d. If no insulin comes out, repeat the test 2 more times. e. If there is still no insulin coming out, use a new needle and do the safety test again. f. Always perform the safety test before each injection. g. Never use the pen if no insulin comes out after using a second needle. h. Keep the pen straight, insert the needle into the skin. Use the thumb to press the injection button all the way down, slowly count to 10 before removing. The dose window should return to zero.

Based on observation, clinical record review, and staff interview the facility failed to apply hand splints and complete a passive range of motion Restorative Nursing Program (RNP) per the therapy discharge recommendations for 1 of 1 residents reviewed (Resident #7). The facility identified a census of 55 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #7 in a persistent vegetative state/no discernible consciousness with functional impairments of the bilateral upper and lower extremities. The MDS identified Resident #7 as dependent in all self-care (eating, dressing, toileting, personal hygiene) and mobility. The MDS listed diagnoses of chronic respiratory failure, stroke, aphasia (a neurological disorder that affects the ability to communicate and understand language), and quadriplegia (a condition characterized by the partial or total loss of function in all four limbs and the torso). The MDS further documented Resident #7 received passive range of motion 1 out of 7 days of the assessment look-back period and received a brace/splint program 7 out of 7 days of the assessment period. The undated Care Plan Focus noted Resident #7 at risk for alteration in skin integrity related to the need of assistance for bed mobility. The Care Plan directed the staff to use palm protectors to both hands outside of the splints. The Care Plan lacked direction of a RNP and how/when to use the hand splints. A 12/06/24 Occupational Therapy (OT) Treatment Encounter Note signed by Staff A, Certified Occupational Therapy Assistant (COTA; a healthcare professional who works under the supervision of a Registered OT) documented Resident #7 as contracted in a fetal position. Staff B, Qualified Medication Aide (QMA) educated on passive range of motion (PROM) of all joints. Staff C, Licensed Practical Nurse (LPN), Staff D, Certified Nursing Assistant (CNA), and Staff E, CNA present for education on hand splints on 2 hours and off 2 hours. The CNA's reported this acceptable as they reposition the resident every two hours. The 1/28/25 OT Discharge Summary signed by Staff A included discharge recommendations, recommending PROM to the bilateral upper extremities (BUE) (shoulders, elbow, wrist, hands, fingers) and bilateral lower extremities (BLE) (hips, knees, ankle, foot, toes) daily. Resident #7 April 2025 Task Record directed the restorative staff to provide PROM to the BLE and BUE with stretch daily; hand splints two hours on/two hours off; program frequency three times a week and as needed. Observation on 4/06/25 at 10:05 AM, 11:43 AM and 1:09 PM revealed Resident #7 lying in bed with no white palm splints or rolled wash cloths in hands. Fingers were contracted into the palms of both hands. The blue hand splints lay on the window ledge. During an interview on 4/06/25 at 2:03 PM a family member expressed concerns as they had visited and never seen the hand splints in use. Observation on 4/07/25 at 7:35 AM revealed Resident #7 lying in bed with no rolled wash cloths, palm protectors, or blue hand splints in hands. During an interview on 4/07/25 at 1:04 PM Staff B reported Resident #7 wears the hand splints two hours on and two hours off. Resident #7 is to wear white hand rolls when the splints are not in use. The April 2025 Documentation Survey Report V2 Report documented 4/06/25 at 10 AM, 12 PM, 2 PM, and 4 PM a N to indicate resident #7 had not refused the restorative program and had the hand splints placed for 120 minutes for each of the recorded times were in use. Observation on 4/07/25 at 1:05 PM Staff G, CNA and Staff B performed Resident #7 BUE/BLE PROM RNP starting at 1:05 PM and ending the RNP at 2:40 PM. During an interview on 4/08/25 at 7:50 AM Staff A reported she recommended Resident #7 to have the PROM program every day due to his quadriplegia and contractures. Generally, she leaves the RNP frequency up to the MDS nurse to address, but in his case she gave more specific recommendations. On 4/08/25 at 9:19 AM Staff H, CNA reported Resident #7 used to use palm protectors when the hand splints were not on, but she didn't' know if he was using them currently. As far as she knows the splints are still in use and she has been putting them on. They document the use of the hand splints in the electronic medical record system. During an interview on 4/08/25 at 9:23 AM Staff I, QMA reported Resident #7 wears hand splints on two hours and off 2 hours. They document the use of the splints in the electronic health care record. She voiced in the restorative documentation screen a question pops up asking if the resident refused the RNP. They can choose yes or no. A no answer means the resident did not refuse the hand splints and then they document the number of minutes the resident used the splints, so two hours would be the 120 minutes. On 4/06/25 at 11:32 AM Staff B reported she is the main person responsible for completing Resident #7 RNP. She thought his RNP was to be completed five days a week. Other restorative programs are usually 3-5 days per week, but his is five days a week. She reported she had checked with OT before doing the RNP on 4/07/25 and OT told her to hold the stretch for 10 seconds versus the 5 seconds that she usually provides so it took her longer to do the program. Staff B explained she does Resident #7 RNP on the days she is scheduled to work and she works three days a week. She is not sure who is responsible to do the RNP when she is not scheduled to work. She places the blue hand splints on when she is finished with his RNP. She didn't know why she had not placed the blue hand splints on Resident #7 when she completed the RNP on 4/07/25. She further voiced it is pretty common that Resident #7 does not have his blue hand splints in use. She goes in first thing in the morning between 6-6:30 AM and the hand splints are usually not on. Observation on 4/08/25 at 12:53 PM revealed Resident #7 laying in bed with no splints on. The blue hand splints lay on the window ledge. The small white palm protectors lay on the residents bedside table. Observation on 4/08/25 at 2:45 PM revealed Resident #7 laying in bed with no hand splints on. The blue hand splints lay on the window ledge. Interview on 4/08/25 at 3:59 PM Staff F, Registered Nurse (RN) reported it is the responsibility of the restorative staff or the CNA's to put on Resident #7 hand splints for his hand contractures. The nurses also chart on the Treatment Administrative Record (TAR) that the hand splints are on. The aides report if the resident refuses the hand splints so that the nurse can document on the TAR. She reported she did not know how long Resident #7 was to wear his hand splints, but he also has small white palm guards that he wears when the blue hand splints are not in use. Resident #7 April 2025 TAR lacked documentation the nurses were signing off any use of the hand splits or palm protectors. Further review on 4/08/25 of the April 2025 Documentation Survey Report V2 revealed on April 2nd and 4th the record was blank indicating the resident did not receive the RNP hand splint program. The Documentation Survey Report V2 for April 1, 3, 5, 6 from 10 PM through 4 AM, the RNP was documented with a Y to indicate the resident refused the Restorative Nursing Program. During an interview on 4/08/25 at 5:11 PM Staff J, CNA reported she primarily works the night shift and does work with Resident #7. She reported Resident #7 does not refuse his hand splints. She has never been trained in how to put the hand splints on so she does not use them or the palm splints. Staff J voiced the problem with restorative charting is they can only answer yes/no if the resident did the restorative program or refused the program. Since she doesn't put the hand splints or palm protectors on, she marks the restorative documentation with a yes to indicate the resident refused the RNP. He really isn't refusing the hand splints, she just doesn't use them. She has reported this to the nurses in the past but couldn't remember which nurses she had reported to. During an interview on 4/09/25 at 6:54 AM Staff K, RN reported that she is responsible for the RNP's. She completes a review with the quarterly MDS assessment schedule and documents the RNP in the electronic medical record under the Restorative Program Evaluation Assessment. Staff K explained she doesn't look at the therapy discharge, she just gets a communication email from therapy. She stated the RNP is put in the CNA task record of the electronic medical record to communicate to the CNA's the frequency of the program. She reviewed Resident #7 and reported he is set up for three times a week and as needed on the task record. If OT wanted daily, then she must have misunderstood what therapy wanted. She usually just reviews hand splints quarterly to make sure the resident is still able to wear them and the splints are not leaving marks on the resident hands. On 4/09/25 at 7:02 AM Staff K reported she expects the staff to follow the therapy recommended RNP. If the RNP was supposed to be daily, then the splints should be used per the program. She thought splints were to be used during the night, but the RNP doesn't state that. She voiced the RNP should be (PROM) in the morning and then staff should alternate the hand splints 2 hours on/2 hours off with the white palm splints used in the hands when the blue hand splints are not in use. On 4/09/25 at 7:50 AM Staff K reported she had checked the assessment tab of the electronic medical record and Resident #7 had not had any RNP review by a nurse completed. On 4/09/25 Staff K provided an email dated 12/16/24 from Staff A to Staff K communicating Resident #7 was discharging from therapy. He required PROM to the BLE/BUE with stretch and (hand) splints on 2 hours, off 2 hours. Staff A indicated in the email to Staff K to let her know if she had any questions. A 4/09/25 review of the 2025 Documentation Survey Report V2 reports revealed: a. February 2025 for the RNP showed the 10 PM to 6 AM shift with eight days documenting a N to indicate Resident #7 did not refuse the RNP and the hand splits were in use. The RNP contained blank for no restorative documentation on February 1, 2, 4, 5, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 20, 22, 23, 24, & 27. The Report documented the Resident received the PROM exercise program on February 5,7,10, 17, 19, 20, 25, & 27 with all sessions between 15-20 minutes. b. March 2025 Report for the RNP showed the 10 PM to 6 AM shift with only six days documenting a N to indicate the resident did not refuse the RNP and the hand splints were in use. The RNP record had blanks for March 1, 2, 5, 12, 14, 15, 16, 17, and March 30th. The Report documented Resident #7 received the PROM program on March 3 for 15 minutes; March 7th for 20 minutes, March 26 for 20 minutes, and March 28 for 20 minutes. During an interview on 4/09/25 at 8:00 AM the Director of Nursing (DON) reported she had been confused as well as to how Resident #7 RNP went from daily to only three days a week. She stated therapy gives RNP recommendations upon discharge and the RNP's are put in the task record of the electronic medical record to communicate the RNP to restorative staff and the aides. She expects the RNP's to be completed per the therapy discharge recommendations and the RNP's followed or staff should be reporting in why the RNP cannot be completed. The DON stated the facility does not have a restorative nursing policy/procedure.

Based on observation, clinical record review, resident and staff interviews, the facility failed to administer a treatment as the physician ordered for one of three residents reviewed. (Resident #1). The facility reported a census of 53 residents. Findings include: The MDS (Minimum Data Set) dated 7/30/2024 reported Resident #1 had no cognitive impairment, required total assistance of staff to transfer from one surface to another, and had bowel and bladder incontinence. The resident had diagnoses including diabetes, anxiety, morbid obesity, and lymphadenitis (inflammation of the lymph nodes). The Care Plan identified the resident required assistance with ADL's (Activities of Daily Living) and directed staff to don size D tubi-grip (compression sleeves) from fingers to elbow first thing in the morning, and don size J tubi-grip from elbow to shoulder in the morning. Remove both at hour of sleep (HS). She may need them pulled back up during the day. If skin becomes sore/irritated remove and tell therapy. Refuses this treatment most of the time. The Physician Order dated 6/27/2024 directed staff to don size D tubi-grip from fingers to elbow, the hole is for thumb, and size J tubi-grip from elbow to shoulder first thing in the morning. Staff were to remove both at HS (hour of sleep). The resident's September MAR/TAR (Medication Administration Record/Treatment Administration Record) documented the resident refused the tubi-grip sleeves eleven out of thirty days. The October MAR/TAR revealed the resident refused the tubi-grip sleeves sixteen out of twenty-eight days. The resident's Progress Notes included nursing entries on September 5, 11, 19, 21, 22, 23, and 27 that documented staff did not observe the tubi-grips on the resident's arms, had no knowledge of, and/or the resident stated she had no tubi-grips. Observation on 10/28/2024 at 9:55 A.M. revealed the resident in bed on her left side with no tubi-grip sleeves on. On 10/28/2024 at 1:30 P.M. Staff A, CNA and Staff B, CNA (Certified Nurse's Aide) revealed they were unaware the resident had an order for tubi-grips. Staff C, co-DON (Director of Nursing) handed the surveyor a copy of the resident EMAR (electronic Medication Administration Record) that indicated the resident had refused the tubi-grips on that day, 10/28/2024 signed by Staff D, CMA ( Medication Aide). When asked, Staff D indicated she had not gone in the resident's room, but documented the resident refused the tubi-grips that morning. At 1:40 P.M., the resident reported she did not have the tubi-grips since some time in August, when the facility changed therapy companies. Staff D checked the resident's order, went to the therapy room and retrieved size D tubi-grip for the resident's lower arms. The facility failed to have Size J for the upper arms in stock. Staff D indicated they would have to place an order and would apply size K tubi-grip on the upper arms in the meantime. At 2:05 P.M., Staff E, CMA indicated she knew the resident had an order for tubi-grip and said she rarely had them on. Staff E left a note for therapy letting them know she needed it about a month prior. Staff E revealed she would ask the aides if the resident had them on and if not, she usually put the resident refused. At 2:10 P.M., Staff F, CNA reported she made the resident new tubi-grips. The resident indicated she had lost them and needed new ones. At times the resident refused. On 10/28/2024 at 2:15 P.M., Staff C and Staff G, co DON's were interviewed in the shared director of nursing office. Staff C revealed the tubi-grip order was on the TAR and therefore nurses/medication aides were to apply them, not the nurse's aides. Therapy had recommended the tubi-grip and the physician ordered it. Staff G indicated the the resident had the tubi-grip ordered due to her edema. On 10/29/2024 at 9:25 A.M., Resident #1's physician via his nurse reported if the resident had the order for tubi-grip, therapy saw a reason for it and staff should be putting them on. On 10/29/2024 at 9:40 A.M., Staff H, Physical Therapist reported she cut new lengths of tubi-grip for the resident that morning, applied them and ordered size J for the upper arms.

Based on clinical record review, document review, policy review, and staff interview the facility failed to serve the correct puree portion size for 2 of 6 residents sampled (Resident #26 and #19). Resident #26 and #19 were both documented as significant weight losses in the past six months (a significant weight loss is a 10% or greater weight loss in 6 months). The facility identified a census of 51 residents. Findings include: 1. Resident #26 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive loss, with long and short-term memory impairment. Resident #26 could not recall the current season, location of his room, or staff names and faces. The MDS listed diagnoses of Non-Alzheimer's Dementia, unspecified psychosis, and required supervision or touching assistance (the helper sets up or cleans up; resident completes the activity. The helper assists only prior to or following the activity) for eating. The MDS documented Resident #26 with a significant weight loss (a significant weight loss is defined as a loss of 5% or more in the last month or loss of 10% or more in last 6 months) and receiving a mechanically altered diet (a required change in texture of food or liquids (e.g., pureed food, thickened liquids). Section K0300 Weight Loss, signed as complete on 5/28/24 by the contracted Dietician, for significant weight loss documented, Yes, not on a prescribed weight loss regimen. Resident #26 Medication Order Review signed by the Provider on 4/02/24 listed a physician order for a pureed texture general diet. Resident #26 Weight Summary Record documented the following weights: a. 11/16/24 231.4 pounds (#) b. 5/15/24 209.8# (weight on 5/21/24 MDS assessment) c. 6/26/24 206.5# (weight loss 24.9#) A 6/28/2024 12:40 PM Significant Weight Change Progress Note documented a weight warning with a weight of 206.5# as of 6/26/24 with an MDS significant weight change of 11.4% weight loss in 180 days. The Progress Note lacked documentation of new interventions placed for Resident #26 weight loss. 2. Resident #19 MDS assessment dated [DATE] showed a BIMS score of 9 indicating moderate cognitive loss. The Resident required setup/clean up assistance with eating. The MDS listed diagnoses of aphasia and paranoid schizophrenia. The MDS documented Resident #19 required a mechanically altered diet and a therapeutic diet. Resident #19 Medication Review Report signed by the Provider on 6/25/24 ordered to serve a general pureed texture diet. Resident #19 Weight Summary Record documented the following weights: a. 12/28/23 264.5# b. 6/27/24 231.1# (weight loss 33.4#) A 6/28/2024 10:22 AM Significant Weight Change Progress Note documented a weight warning with a 6/27/24 weight of 231.1 pounds. The Progress Note noted a 11.9% weight loss over 180 days. A week 4 Monday Menu approved by the corporate registered dietician 7/01/24 listed the main entree for the lunch pureed diet menu as 1 serving of a grilled ham and cheese sandwich. The Diet Type Report provided by the facility on 6/30/24 identified six residents on physician ordered pureed diets (Residents #2, #19, #26, #39, #42, and #46). A Pureed Diet is a texture-modified eating plan that consists of foods with a soft, pudding-like consistency. It's often recommended for people who have difficulty chewing or digesting solid foods, such as those with difficulty swallowing or other digestive issues. The goal of a pureed diet is to prevent malnutrition by making a variety of foods safe to eat. During an observation on 7/01/24 at 9:28 AM Staff B, [NAME] reported she would prepare six servings of the ham and cheese sandwich as she had six residents on pureed diets. Staff B placed six ham and cheese sandwiches into the Robo Coupe blender. Staff B continued to add milk to obtain a puree consistency. The total puree food volume measured 6 3/4 cups of a very thin pureed product. Staff B utilized the Pureed Diet Portion Sizes/Scoops, Total Cups of Pureed Food chart to obtain a correct serving size for each resident. The Chart directed to find the number of persons that you pureed food for along the left-hand column of the table, then find the total cups of pureed food that you prepared along the top row of the chart. Follow both the row and column to where they meet and you will find the correct scoop to portion for the pureed food item. Staff B identified the six servings in the left-hand column and the total volume of puree along the top of the chart. She followed the chart to get a serving size of A #8 scoop x 2 (indicating to serve two of the #8 scoop) and a #30 scoop. Staff B located the #8 and the #30 scoop and set up for the dietary aide to serve. On 7/01/24 at 11:55 AM Staff C, walked to the steam table, reached in and picked up the #8 (4 ounce) scoop and placed 1 scoop of the pureed ham and cheese sandwich puree into a red bowl for Resident #26. Staff C failed to serve the second #8 scoop per the puree chart. The black #30 scoop (1 ounce) lay right next to the gray handled # 30 scoop, but was not utilized. Staff C then placed one #8 scoop serving of the pureed ham and cheese sandwich for another resident, who was not included in the sample. Observation on 7/01/24 at 11:56 revealed Staff D, Dietary Aide grabbed the #30 scoop and put one scoop of the pureed ham and cheese into a bowl that was served out to Resident #19. At 11:57 Staff C placed Resident #26 lunch and another random resident's lunch on a cart and wheeled the cart to A wing to serve the meals. At 12:04 PM Staff C returned the meal cart from A wing to the kitchen. The #30 scoop lay unused next to the steam pan of pureed ham and cheese sandwich on the steam table. At 12:05 PM the black scoop fell down inside the steam table well. On 7/01/24 at 12:53 PM Staff D reported she had only utilized one (#8) scoop serving size to serve out the pureed ham and cheese sandwiches. She did not use the #30 scoop. Observation revealed the steam pan of pureed ham and cheese sandwich with a half inch of dried puree at all four corners of the steam pan with a 1/2 inch of the puree in the bottom of the pan and over a 1/2 of the mixture still in the #8 scoop. During an observation on 7/01/24 at 12:15 PM Resident #26 finished the last bite of his pureed ham and cheese sandwich from the red bowl. Resident #26 continued to scrape the empty red bowl and lick his spoon repeatedly. Staff E, Certified Nursing Assistant (CNA) looked at Resident #26 and verbalized, Oh! You're all done. The resident continued to scrape his empty red bowl and lick his empty spoon a few more times. The Staff did not offer him more of the pureed ham and cheese sandwich. Observation on 7/01/24 at 12:17 PM revealed Resident #19 had eaten 100 percent (%) of her pureed ham and cheese sandwich. The bowl was scraped clean. On 7/01/24 at 12:46 PM Staff B reported she communicates to the serving dietary aide (Staff D) the scoop sizes that are required after she purees the food. She lays out the scoops for the dietary aide to use. Staff B visualized the #30 scoop laying inside the steam table, reporting and nodding the #30 scoop had not been used. Staff B went to the pureed serving size chart and reviewed the serving for six servings with 6 3/4 cups total volume of the pureed ham and cheese sandwich and voiced the serving size was two of the #8 scoops and one of the #30 scoop. She verbalized only the #8 scoop had been utilized. The facility failed to serve Resident #26 and #19 over a 1/2 cup portion (0.625 cup) of the required entree serving. During an interview on 7/01/24 at 12:48 PM Staff F, Dietary Aide reported she expected the staff to serve the correct pureed portion size according to the Pureed Diet Portion Size/Scoop Total Cups of Pureed Food Chart. During an interview on 7/01/24 at 12:49 PM the Certified Dietary Manager (CDM) reported she has talked with Staff C and Staff C admitted she had only given Resident #26 one (#8) scoop of the pureed ham and cheese sandwich. She admitted she had not followed the appropriate serving size. The Procedure for Determining Portion size of Puree Foods, undated, provided by the facility directed the following: 1. Review the recipe and/or spreadsheet to verify the portion required for the regular portions. 2. Prepare the liquids to be used during the puree process. 3. Verify the number of residents requiring a puree diet and plan for one extra portion. 4. Sandwiches: puree the entire sandwich with condiments together or layered pureed bread, puree protein, and puree bread can be made also. 5. Puree food without added liquid at first and add liquid gradually so that the Robo Coupe can work naturally to blend up food. 6. Measure the total volume of the final pureed product and divide by the number of servings added (including the extra).

Based on record review, staff interviews, and policy review the facility failed to ensure 2 of 4 residents Pre-admission Screening and Resident Review (PASRR) was submitted for review (Residents #19 and #22). Resident #19 was approved for a short term 60 day stay in 2018 and new diagnoses were documented in her medical record the facility failed to resubmit for review of needed services. The facility failed to accurately complete the PASRR for Resident #22 prior to admission, omitting diagnoses and medications. The facility reported a census of 51 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #19 dated 8/10/2023 documented a Brief Interview for Mental Status (BIMS) of 13 indicating she was cognitively intact. The MDS documented diagnoses of depression, psychotic disorder, and paranoid schizophrenia. Review of a document titled, Notice of Level of Care Determination Criteria Met for Short Term Stay at Skilled Nursing Facility dated 4/17/2018 for Resident #19 documented she was approved for 60 days and needed to be resubmitted by 6/16/2018. During an interview on 7/2/24 at 1:50 PM with Staff A, Social Worker, Staff H, Licensed Practical Nurse (LPN), and the Administrator revealed they did not know about Resident #19 Short Term 60 day stay PASRR. Staff A on 7/3/24 at 10:22 AM revealed they received Resident #19 new PASRR and was dated 7/3/24. Review of a policy provided by the facility titled Baseline Care Plan Guidelines last revised 12/10/2018 instructed to the facility to implement PASRR recommendations, if applicable into the Care Plan. 42134 2. The admission MDS dated [DATE] for Resident #22 documented an admitted [DATE]. The Electronic Health Record (EHR) medical diagnoses included major depressive disorder and psychotic disorder with delusions, both noted as present on admission. The Physician Orders in the EHR included quetiapine (an antipsychotic medication), Namenda (for dementia) and lorazepam (an antianxiety medication) all ordered on admission. The PASRR Level 1 completed on 8/31/23 for Resident #22 was coded with no mental health diagnosis being known or suspected. Medications included on the PASRR were lorazepam and Namenda. During an interview on 7/2/24 at 1:47 PM Staff H, LPN explained she does not check PASRRs for accuracy with diagnoses and medications.

Based on clinical record review, Long Term Facility Resident Assessment Instrument 3.0 User's Manual version 1.18.1 Dated October 2023 (RAI), and staff interview the facility failed accurately complete the Minimum Data Set (MDS) for 3 of 5 residents (Residents #5, #8 and #45). The facility failed to accurately code anticoagulant medications and Pre-Admission Screening and Resident Reviews (PASRR). The facility reported a census of 51 residents. Findings include: The MDS dated [DATE] for Resident #45 documented the resident was taking anticoagulant medication. The physician orders lacked an order for an anticoagulant medication. The orders did include an order for clopidogrel, an antiplatelet medication. During an interview on 7/1/24 at 2:10 PM Staff I, Registered Nurse (RN), Co- Director of Nursing (DON) confirmed there was no anticoagulant medication ordered for the resident. The RAI page 1-4 documents the RAI process has multiple regulatory requirements. Federal regulations at 42 CFR (Code of Federal Regulations) 483.20 (b)(1)(xviii), (g), and (h) require that the assessment accurately reflects the resident's status. During an interview on 7/2/24 at 12:14 PM Staff G, RN Resident Care Coordinator, explained they do not have an MDS policy. She further explained they follow the RAI. She continued to explain they have an MDS Drug Class Index they use for medications. She confirmed the guide listed clopidogrel as an antiplatelet medication and it should not have been coded as an anticoagulant. 42133 2. Ascend Management Innovations (Ascend) is under contract with the Iowa Department of Human Services, Mental Health and Disability Services, to perform PASRR evaluations. PASRR evaluations are federally required to help decide upon the best placement and services for persons who have disabilities. The 1/17/19 PASRR for Resident #5 under Mental Health documented Resident #5 met the criteria for having a diagnosis of mental illness as defined by PASRR. The PASRR included an Axis 1 primary diagnosis of schizoaffective disorder, bipolar type. Resident #5 Annual Minimum Data Set (MDS) assessment dated [DATE], under Section A 1500 Level II PASRR for the question is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition was marked no. The MDS Section Z0400 Signature of Persons Completing the Assessment contained the following statement: I certify that the accompanying information accurately reflects resident assessment information for this resident and that I collected or coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable Medicare and Medicaid requirements. I understand that this information is used as a basis for ensuring that residents receive appropriate and quality care, and as a basis for payment from federal funds. I further understand that payment of such federal funds and continued participation in the government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and that I may be personally subject to or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false information. I also certify that I am authorized to submit this information by this facility on its behalf. Staff A Social Worker at Z0400 signed she completed section A on 2/13/24. On 7/02/24 at 12:38 PM Staff G explained Section A of the MDS is usually completed by the Social Worker and the MDS Coordinator. During an interview on 7/02/24 at 12:40 PM Staff A reported she reviews the PASRR document from Ascend. If the PASRR is a level II and marked for a mental illness, she would mark yes on the MDS (at A 1500). Staff A reviewed the MDS and confirmed she had not completed section A1500 correctly. Staff A reported the facility utilizes the RAI (manual) to code the MDS. The MDS RAI User manual, Chapter 3, page A-32 directs to code 1, yes if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. The services to be provided by the nursing home and/or specialized services provided by the State that are specified in the Level II PASRR determination and the evaluation report should be addressed in the plan of care. 3. The 9/11/15 PASRR under Mental Health documented Resident #8 met the criteria for having a diagnosis of mental illness as defined by PASRR. The PASRR included an Axis 1 Primary Diagnosis of bipolar I disorder single manic episode and Axis I Secondary Diagnosis as major depressive disorder, single episode/severe/psychotic features. Resident #8 Significant Change in Status (SCSA) MDS dated [DATE], under Section A 1500 Level II PASRR for the questions is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition was marked no. Section I documented a diagnosis of bipolar disorder, but lacked documentation of major depression. The MDS 3.0 Section A - Identification Information page showed Staff A signed A1500, Level II PASRR conditions as completed on 1/23/24.

Based on clinical record review, Long Term Facility Resident Assessment Instrument 3.0 User's Manual version 1.18.1 Dated October 2023 (RAI), and staff interview the facility failed to complete Significant Change in Status (SCSA) Minimum Data Set (MDS) assessments in the required time frame for 2 of 2 residents reviewed for hospice (Residents #22 and #29). The facility reported a census of 51 residents. Findings include: 1. Physician orders for Resident #22 included an order to refer to hospice dated 4/29/24. The MDS dated [DATE] was coded as a significant change assessment for hospice services. The MDS was signed off as complete on 5/21/24, 21 days after the determination of a significant change. The RAI Page 2-17 directs the MDS completion date is no later than the 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). Page 2-25 directs An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. During an interview on 7/2/24 at 12:14 PM Staff G, Resident Care Coordinator, explained they do not have an MDS policy. She further explained they use the RAI for direction. She confirmed the hospice order date and the MDS completion date. 42133 2. The Electronic Census documented Resident #29 admitted into hospice care services on 6/11/24. A Hospice Election Statement dated 6/11/24 showed the family signed Resident #29 into hospice care. A 7/01/24 review of the MDS 3.0 Summary Page showed a Significant Change in Status MDS assessment with an assessment reference date of 6/21/24. The MDS 3.0 Summary page showed section V Care Area Assessment highlighted in yellow documenting in progress. The Complete MDS box highlighted in yellow directed to complete the MDS by 7/05/24. The MDS had not been signed, finalized, and locked to show completion of the assessment in the required time frame by 6/24/24 (14 days). During an interview on 7/02/24 at 2:49 PM Staff G verbalized she didn't understand the time requirements regarding the significant change completion date from the date of determination regarding hospice care from the RAI manual

Based on clinical record review, observation, policy review, and staff interview, the facility failed to report an allegation of resident abuse within 24 hours and to separate the resident from the alleged abuser for 1 of 4 residents sampled (Resident #1). The facility reported a census of 48 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 with a long/short term memory problem and severely impaired daily decision-making ability. The Resident exhibited inattention (difficulty focusing attention, being easily distractible or having difficulty keeping track of what was said) and disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) that fluctuated (comes and goes/changes in severity). The MDS documented no behaviors during the seven day look back period and no change in the behaviors from the prior assessment. The Resident required limited assistance of one staff member for transfer, walking in the room, corridor and off the unit. The MDS identified diagnoses of Non-Alzheimer's Disease and anxiety. A Facility (Investigation) Summary dated 8/04/23 detailed Staff A Certified Medication Aide (CMA) reported to Staff B Co-Director of Nursing (CDON) on 8/01/23 at approximately 11:30 PM Staff C Certified Nursing Assistant (CNA) was assigned to the dementia unit. Staff A stated Resident #1 was gait-belted to the chair's arm rest while in the dementia unit nurse's station. Staff A left the area and reported to Staff D Licensed Practical Nurse (LPN). The Summary detailed Staff D went to the dementia unit. She took Resident #1's blood pressure and noted Resident #1 sitting in a chair with the gait belt around her waist, but not around the chair. Staff E CNA had been assigned to the area from 2 p.m. to 10 p.m. with Staff C on 8/10/23. The gait belt was not present when she left at the end of her shift. The Summary further detailed Staff C had not worked since her scheduled shift on 8/01/23. Staff C had been suspended from work pending outcome of an investigation. The Summary detailed the following: a. 8/03/23 The facility electronically reported the allegation to the Department of Inspection, Appeals and Licensing. b. 8/03/23 The facility notified Resident #1's daughter. c. 8/04/23 The facility provided education to employees on Abuse Allegation reporting. A Review of Resident #1 Progress Notes and Assessments in the electronic record from 7/29/23 - to current revealed no documentation of the incident from 8/01/23. No documentation appeared in the Progress Notes until the Administrator documented on 8/03/23 the daughter was notified of the FRI (Facility Reported Incident) at 5:24 p.m. and Staff F, LPN, documented the completion of a head to toe assessment on 8/03/23 at 5:29 PM. A DIAL Intake Submission Form documented the following information regarding the facility on-line reporting: a. Submission Date and Time: 8/03/23 at 4:59 PM a. Submission Date: 08/03/2023 16:59:06 b. Entity Name: Grandview Healthcare Center c. Entity Type: Free Standing Nursing Facility/Skilled Nursing Facility d. Reporting Type: Allegation of Abuse e. Date/Time Occurred: 08/01/2023 f. Perpetrator Name: Staff C (CNA) g. Resident Name: Resident #1 h. Incident Summary: Staff member states they observed resident sitting in a chair gait belted to the chair's arm rest. Corrective Action Description: Staff member immediately reported to the charge nurse. The charge nurse investigated and noted the gait belt was around the resident but was not around any part of the chair. Charge nurse interviewed the CNA assigned to the area. CNA denied that the gait belt had been around the chair's arm rest. CNA is place on suspension pending completion of the facility investigation. The Facility Investigation File contained the following written statements: a. A Witness Statement signed by Staff A on 8/03/21 detailed on 8/01/23, Tuesday night, third shift approximately between 11 PM and midnight, they did not have any chocolate milk so the resident asking for it asked her to go to A wing (CCDI unit, a licensed chronic confusion or dementing illness unit (CCDI) which provides 24-hour supervised care) to look for some. When she went back there, Staff C came out of a (resident's) room quickly and acted strangely toward her. Staff C rushed her out of there by pouring the chocolate milk for her. She looked down at the resident sitting in the nurses' station with a blanket over her lap. The Resident leaned to the side and she could clearly see the resident gait-belted to the chair's armrest. Staff C told Staff A she had issues with behaviors and couldn't get anything done. Staff A left the unit and immediately told the charge nurse. Staff D, Licensed Practical Nurse (LPN) went back to observe the situation, but the gait belt was no longer wrapped tightly around the Resident and was laying loosely on the chair. b. A Witness Statement signed by Staff D dated 8/04/23 documented Staff D believed it was the night of August 1st when she worked 10 PM to 6 AM. Staff A came out from the CCDI (Unit) and stated she thought Staff C had Resident #1 tied in a chair with a gait belt. Staff D went back to the unit and took Resident #1's blood pressure. Resident #1 sat in a dining room chair inside the nurses' station with Staff C. The Resident had a gait belt around her waist but it was not around the chair. Staff D moved the lap blanket so she could visualize the whole belt. Staff D documented she asked Staff C if she had her hooked to the chair by way of the gait belt and Staff C told her no. Staff C told her the resident had been restless so she had her sitting by her for that reason. c. A Witness Statement signed by Staff E on 8/03/23 documented she worked form 4 PM to 10 PM on A wing (CCDI Unit) on 8/01/23. She worked with Staff C from 6 PM to 10 PM. They had Resident #1 sitting in a chair that wheels around to be able to move her more easily to observe her while doing cares with other (residents). At no point was a gait belt, sheet, or blanket or any other restraining used on Resident #1. She had tucked a blanket over Resident #1 but not as a restraint. d. A Witness Statement signed by Staff C on 8/04/23 documented on 8/01/23 Resident #1 was unsteady on her feet and took two-assist to move her so she moved her with her room to room as she took care of other residents so she could keep a visual eye on her. At shift change she took her with her to the nurses' station. She had a gait belt on her off and on for stability when she would get up and she had a blanket on her. Staff C had tried Resident #1 in her bed but Resident #1 didn't like it and wouldn't stay there. Resident #1 takes cat naps as long as Staff C sits beside her. During the shift Staff A came back for chocolate milk. Staff D came in to take Resident #1's blood pressure. Staff G came back and let Staff C go out for a break. The gait belt was only around her and at no time around the chair. During the shift, Staff C had to use a wheelchair to take Resident #1 to the bathroom. During an interview on 11/08/23 at 10:56 AM Staff C reported they suspended her after they called her in and asked her side of the story on Thursday, August 4th sometime in the afternoon. Staff D came back to the unit to take Resident #1 blood pressure. Staff D never asked her about the gait belt that night. Staff D didn't send her home that night. She finished working her shift. Staff C verbalized she had Resident #1 in the nurses station with her. At no time did she have the gait belt around the chair. She was just trying to keep the resident safe. A Time Card provided by the facility on 11/08/23 revealed Staff C worked 8/01/23 from 6:00 PM to 6:30 AM; total time 12 hours as the CCDI Unit CNA. The Time Card revealed Staff C had been suspended from duty on 8/04/23. On 11/07/23 at 2:14 PM Staff A reported Resident #1 would get up and wander around. Staff would have to fall in line and walk with her. It was rare for Resident #1 to have behaviors. The Resident probably did have behaviors, but she just didn't see it. Staff A reported the incident occurred on 8/01/23. She couldn't find any chocolate milk that a resident wanted. She went to the A wing (CCDI Unit). As she was coming around the corner to the doorway of the nurse's station, Staff C came quickly out of a room. Staff A could tell Staff C didn't want her to go back in the nurses' station. Staff C seemed like she was in a panic. Staff C poured the chocolate milk for her like she didn't' want her in there. Staff A verbalized she looked down at Resident #1 and said saw her seated in a dining chair positioned at an angle toward the trash can. The Resident had a small 3 foot by 3-foot lap blank on her lap. Staff C voiced gosh with the behaviors back here she couldn't seem to get anything done. At that time, it seemed like all the residents were sleeping. Staff A explained Resident #1 slept in the dining room chair with a gait belt around her waist and the left arm of the dining room chair. Staff A further explained she was less than a foot away from the left side of the dining room chair where the resident sat. She could clearly see the gait belt buckle just above the left arm rest of the chair going around the resident's waist. She wasn't able to recall the color of the gait belt, but she did see the gait belt was around the left arm rest of the chair and around the resident's waist. Staff A verbalized she didn't say anything to Staff C that night, but she was pretty sure Staff C knew she saw the gait belt as she was starring right at it before she left the nurses station. She went and got Staff D, the nurse. Staff D went to the unit to see what was going on and came back saying the gait belt hung around the chair, not the resident. On 11/07/23 at 1:53 PM Staff D reported Resident #1 would get up a lot on her own. She wasn't a hard resident to take care of, but she was pretty quick when she got up. Resident #1 had been independent, then she changed to an assistance of 1 staff and required the use of a gait belt. The Staff provided total care to her. She never saw Resident #1 get agitated too easily, but she didn't redirect very easy and she was up during the night a lot. They have 1 CNA on the CCDI unit at night. The aides use a walkie to call if they need more help back in the unit. On 8/01/23 Staff A reported to her around 1 AM she had gone back to the CCDI Unit and Staff C had the gait belt wrapped around the chair with Resident #1 in it. Staff D verbalized she asked Staff A if she was sure of what she had seen. Staff A responded pretty sure. Staff D explained she found it hard to believe. It was a few minutes before she went back to the unit, but not very long. She had to go back and take Resident #1 blood pressure. Staff D verbalized she went to the CCDI unit and moved Resident #1 lap blanket and the gait belt was around the resident's waist, not around the chair. She asked Staff C if she had the gait belt around the chair and Staff C said no. Staff C said she had Resident #1 sitting in the nurses' station to keep an eye on her because she kept getting up and down. Staff D reported it was possible that Staff C had time to remove the gait belt and replace the belt around the Resident's waist. During an interview on 11/08/23 at 11:55 AM Staff D verbalized she did not call the Director of Nursing (DON) or the Administrator at that time to let them know what was going on. When she had gone to the CCDI Unit that night Resident #1 had been awake and kind of restless but she has seen her worse. Resident #1 rocked back and forth in the chair like she was trying to get up. Staff D verbalized if there had been a gait belt tied around the chair it would have prevented Resident #1 from doing that motion. She explained she did not fill out an incident report and it is not usual for a staff member to say that a resident has been tied down in a chair. Resident #1 could not have removed the gait belt on her own if it had been bucked to the chair. She is to notify the administrator and DON if there is an allegation of abuse. If there is an allegation of abuse they have 24 hours to report the allegation to the State from when the incident occurred. Staff D explained she should have filled out an incident report that night for Resident #1 and separated Staff C from Resident #1, then called the Administrator or one of the DON's. During an interview on 11/08/23 at 12:39 PM Staff H CDON reported she became aware of the incident the following day, 8/03/23, at approximately 10 AM or 2 PM when Staff D came into work and reported the incident in. Staff A reported she had walked back to the unit and Staff C had a gait belt around Resident #1 and the chair. Staff A did not tell her how Staff C had Resident #1 buckled to the chair. Staff H thought the Administrator and Staff B had talked with Staff A about that. She immediately told the Administrator so that they could get it reported to the State. She thought it may have been more around 2 PM since it wasn't reported until 4:59 PM. They started their investigation on 8/03/23. Staff H verbalized it is considered abuse for a resident to be gait belted into a chair. The nurse should have separated the staff member from the resident, assessed the resident and filled out an incident report. She should have notified the Administrator and one of the CDON right away. They should have reported into the Department of Inspection Appeals and Licensing (DIAL) within 2 hours. They failed to report timely. The nurse failed to do the appropriate documentation. The Nurse failed to follow the policy for separating the resident from the staff member. During an interview on 11/08/23 at 12:50 PM the Administrator reported the staff are required to wear badges that state they are mandatory reporters. The Mandatory Reporter Cards state what the staff are supposed to do - separate, maintain safety, report immediately. Do not wait any time to report something. The Administrator emphasized they had provided training after the incident and as part of the staff training staff have to also report suspected abuse (i.e. resident stating ouch, sound through a door, screams). Everyone is to be wearing the updated badges. Every staff member has his phone number and he can be reached 24 hours a day. At 12:53 PM the Administrator reported a staff member reported to the charge nurse. The charge nurse failed to report timely. Once management found out about it, they reported to DIA and investigated the incident. The Abuse Prevention, Training and Investigations Policy, revised 12/30/20 provided by the facility directed the facility has a comprehensive system of practices and procedures designed to: a. Prevent occurrences of mistreatment, abuse, neglect and/or misappropriation of resident property; b. Monitor, identify and investigate injuries of unknown source and any allegation of suspected abuse, and; c. Insure that reasonable suspicions are reported to the appropriate law enforcement and regulatory oversight agencies. The Policy under Identification directs employees are required to report incidents - anything unusual or unexpected at the time of the occurrence to their supervisor or person in charge of the facility for further investigation, regardless of whether the incident results in obvious or visible injury. Employees are required to immediately intervene to distract, halt and/or prevent harm to the extent that they can do so without placing themselves at risk of injury if they observe what they suspect is abuse or other criminal behavior to be occurring. They are required to report allegations or suspicions of mistreatment, abuse, or other crimes perpetrated by any person - including a staff member or caregiver immediately and without hesitation directly to the person in charge of the facility at that time. If that person is not the Administrator, the employee is also required to report the allegation to the Administrator within 1 hour of first becoming aware. The Policy under Reporting directs the ABCM Reportable Occurrences Decision Tree may be used to assist the Administrator to determine whether an occurrence is reportable as either suspected dependent adult abuse under Iowa law, mistreatment, abuse or other criminal activity under federal law; and/or is reportable under other state or federal rules or regulations. When utilized for this purpose, the document should be included with the attorney/client work paper file. If the allegation does fall within the definition of a reportable occurrence, see the Mandatory Reporting Policy. The Mandatory Reporting of Dependent Adult Abuse, Crimes and other Notification Policy, revised 4/03/17 provided by the facility defined the following: a. Caretaker means a person who is or was a staff member of a facility who provides or provided care, protection or services to a dependent adult voluntarily, by contract, through employment or by the order of the court. b. Dependent Adult a person eighteen years of age or older whose ability to perform the normal activities of daily living or to provide for the person's own care or protection is impaired, temporarily or permanently. c. Unreasonable confinement means confinement that includes but is not limited to the use of restraints, either physical or chemical for controlling behavior or for the convenience of staff. The Reportable Occurrence Decision Tree under Allegations of Dependent Adult Abuse directed the staff in the following: #7. A Mandatory Reporter has a reasonable belief that any of the following has occurred by a caretaker: a. Willful misconduct b. Gross negligence c. Reckless act or omission AND #8 That behavior results in: a. physical injury involving a breach of skill, care and learning ordinarily exercised by a caregiver in similar circumstances. b. Unreasonable confinement or unauthorized use of a chemical/physical restraint. c. Unreasonable punishment an action or statement intended to punish, agitate, confuse, frighten or distress including threats, harassment, or false/deceptive statement. d. Assault by a caretaker an act that is intended to cause pain or fear or is insulting/offensive. e. Sexual offense or sexual exploitation meaning any consensual or nonconsensual sexual conduct including but not limited to kissing; touching of the clothed or unclothed inner thigh, breast, groin, buttock, anus, pubes, or genitals; or taking, transmitting or displaying electronic images of unclothes breast, groin, buttock, anus, pubes or genitals. f. Neglect the deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care of other care necessary to maintain the dependent adult's life or physical or mental health. Neglect can occur when there is an immediate or potential danger of the dependent adult suffering injury or death and includes, but is not limited to the failure of a caregiver to make a reasonable effort to protect the dependent adult from abuse. g. Exploitation - see Mandatory Reporter Policy for definition. h. Personal Degradation - see Mandatory Reporter Policy for definition. AND #9 a. There is an identified caregiver who is allegedly involved. If boxes 7, 8, and 9 are checked, notify DIAL within 2 hours if the allegation involves abuse or serious bodily injury. If B, C, F, G, H and no serious bodily injury report within 24 hours.

Based on observation, clinical documentation review, policy review, resident and staff interview the facility failed to ensure the urinary catheter collection bag remained off the floor and out of trash cans for 2 of 3 catheters reviewed (Resident #6 and #27). The facility reported a census of 43 residents. 1. Resident #6's Face sheet documents the resident was admitted to the facility on [DATE]. The Minimum Data Set (MDS) dated [DATE] documented Resident #6 had diagnoses including renal insufficiency, depression, and diabetes mellitus. The MDS documented the resident required extensive assistance for bed mobility, transfers, and toilet use. The Treatment Administration Record (TAR) documented Resident #6 had a urinary catheter inserted on 3/14/23. The clinical record documented a physician order dated 3/20/23 for Cefuroxime Axetil (an antibiotic) 250 milligrams (mg) twice a day for a urinary tract infection. During an observation on 3/27/23 at 2:28 PM the urinary catheter collection bag was in the trash can near the footrest of the recliner. There was no dignity bag or other barrier on the collection bag. There were used tissues in the trash can with the urine collection bag. During an observation on 3/27/23 at 4:14 PM the urine collection bag remained in the trash can with the used tissues. During an observation on 3/28/23 at 2:28 PM the urine collection bag was laying directly on the floor near the footrest of the recliner. There was no dignity bag or other barrier on the collection bag. During an observation on 3/29/23 at 9:45 AM the urine collection bag was hanging on the footrest of the recliner. The bottom of the bag was resting on the floor. There was no dignity bag or other barrier on the collection bag. During an interview on 3/29/23 at 3:19 PM Staff E, Registered Nurse (RN)/ Co-Director of Nursing (DON) explained she would not expect the urine collection bag to be in a trash can or on the floor. She further explained she would expect the urine collection bag to hanging from a walker, chair or bed frame, not having any contact with the floor and in a dignity bag. 42133 2. The Minimal Data Set (MDS) dated [DATE] for Resident #27 showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The resident received total assistance of two staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS listed diagnoses of neurogenic bladder, cerebrovascular accident (CVA, stroke), quadriplegia (a symptom of paralysis that affects all of a person's limbs and body from the neck down) and identified the use of an indwelling catheter. A Medication Review Report signed by the Advanced Registered Nurse Practitioner (ARNP) on 3/07/23 documented the following physician orders: a. Suprapubic catheter (a suprapubic catheter is a hollow flexible tube that is used to drain urine from the bladder. It is inserted into the bladder through a cut in the tummy, a few inches below the navel (tummy button) change monthly and as needed 20 French 10 cubic centimeters (cc's) balloon one time a day every 1 month(s) starting on the 28th for 1 day(s). Instill 10 cc's of sterile water in the balloon, start date 12/28/20. b. Suprapubic catheter change monthly and as needed, 20 French 10 cc balloon as needed, start date 12/28/2022 c. Treatment to the left posterior buttock wound: cleanse, lightly fill with 1/2 inch Dakin's (Dakin solution is a strong topical antiseptic widely used to clean infected wounds and ulcers) soaked gauze tape, do not over pack, cover with an ABD (type of thick dressing) pad and tape. Start date 3/28/23 d. Calazime Skin Protectant Paste, apply to peri-rectal topically every morning and at bedtime for rash. Start date 9/17/21. A review of the Care Plan on 3/29/23 detailed a Care Plan Focus dated 12/19/19 which documented Resident #27 had an indwelling suprapubic urinary catheter because of neurogenic bladder, quadriplegia, and urinary tract infections (UTI's) were expected. The Care Plan goal identified Resident #27 would not have greater than 1 UTI per quarter. The Care Plan directed the staff to maintain the catheter as a patent closed system, to change as needed for leakage, occlusion or other break in it and to observe for sign of symptomatic UTI: confusion or nausea and vomiting. Staff should report to the primary care physician if urinalysis results indicated a culture and sensitivity (a culture is a test to find germs (such as bacteria or a fungus) that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection) were necessary. The March 2023 Medication Administration Record (MAR) documented Resident #27's suprapubic catheter had been changed by Staff D, Licensed Practical Nurse (LPN) on 3/28/23. On 3/29/23 at approximately 9:05 a.m. observation revealed Resident #27's laying in bed with the urinary drainage bag hanging from the lower right bed frame by the foot of the bed uncovered. During an observation on 3/29/23 at 10:27 a.m. Staff A, Certified Nursing Assistant (C.N.A.) entered Resident #27's room, completed hand washing, wrapped a urinary collection hat with a plastic bag, donned a pair of gloves and proceeded to the resident's bedside setting the collection hat down on the floor by the foot of the bed. Resident #27 laid in bed supine with the urinary drainage bag hanging from the right lower bed frame by the foot of the bed. Staff A took multiple alcohol prep pads from her right uniform pocket with her right gloved hand. She dropped two alcohol prep pads on the floor. She picked the two alcohol prep pads up from the floor with her right gloved hand and placed back into her right uniform pocket. Using the same gloves Staff A opened the drainage tube on the urinary drainage bag and emptied the urine from the catheter bag into the urinary hat placed on the floor. Staff A closed the drain tube on the urinary drainage bag and using the same gloves cleansed the urinary drain tube with alcohol. She failed to change gloves and perform hand hygiene after picking the alcohol prep pads up off the floor. Staff A opened the closed urinary drainage system with dirty gloves potentially exposing Resident #27 to a risk of infection. During an observation on 3/29/23 at 10:54 a.m. Resident #27 laid in bed on his back with his head of bed elevated. The Resident's urinary drainage bag lay on top of the mattress level with his bladder at the lower right foot of the bed. Staff A using the bed control remote lowered the head of the bed, then Staff A and B, (LPN) assisted the resident to turn on his right side so Staff B could perform a wound treatment on the Resident's left buttock. At 11:01 a.m. Staff B called out on the walkie-talkie that she needed Calmoseptine Ointment. Staff B left Resident #27's room to go out to the cart to check on the Calmoseptine Ointment. Staff B returned to the Resident's room walking by the urinary drainage bag which laid on the floor by the lower right foot of the bed. Staff A walked around the foot of the bed by the urinary drainage bag laying on the floor. Staff B completed the wound treatment. At 11:06 a.m. Staff A picked up the urinary drainage bag from the floor and hung the bag back on the right side of the lower bed frame. Staff A did not place the urinary drainage bag inside the privacy cover on the bed. The Progress Notes 3/28/23 - 3/29/23 at 4:15 p.m. lacked documentation Resident #27's urinary drainage bag had been changed after the urinary drainage bag had been on the floor during the observation of the wound treatment at 11:01 a.m. A Review of the March 2023 MAR on 3/29/23 at 4:16 p.m. lacked documentation the urinary drainage bag had been changed after the urinary drainage bag had been observed on the floor at 11:01 a.m During an interview on 3/29/23 at 4:20 p.m. Resident #27 reported his catheter and urinary drainage bag had been changed 3/28/23. His urinary drainage bag had not been changed since his treatment earlier today. An interview conducted on 3/29/23 at 4:25 p.m. with Staff C, Registered Nurse (RN) revealed the resident had his catheter changed on 3/28/23. She reported he had not had his urinary drainage bag changed since 3/28/23. During an interview on 3/29/23 at 4:51 p.m. Staff E, RN, Co-Director of Nursing (DON) reported she would expect the urinary drainage bags to be up off the floor. During an interview on 3/29/23 at 7:09 a.m. Staff E reported she would expect staff to change their gloves after picking items up off the floor before opening a urinary drainage bag. The Appropriate Use of a Drainage Bag, Belly Bag, and Leg Bag Policy, adopted 5/02, provided by the facility, listed a Purpose to control odor, reduce odor, prevent contamination and cross-contaminating the urinary drainage system. The Policy on Page 2 under When a Drainage Bag and a Leg bag are Alternating directed the staff in the following: a. Hang the drainage bag below the level of the resident's bladder. b. The drainage bag should never touch the floor. c. A cover should be used at all times over the drainage bag to protect the dignity of the resident. The Appropriate Use of an Indwelling Catheter Policy, adopted 12/05, provided by the facility documented a resident will receive appropriate care and services to prevent urinary tract infections while utilizing an indwelling catheter.

Based on clinical record review, observations, physician, staff, and resident interviews, the facility failed to assure that each resident was free from a significant medication administration error for 1 of 4 residents reviewed (Resident #1). On 1/7/22, Staff A, Licensed Practical Nurse (LPN), gave Resident #1, Resident #4's medications that included three diuretics, or a medication that is used to decrease excess fluid that can decrease blood pressure, and one blood pressure medication used to decrease the resident's blood pressure. Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Following the administration of the medications, the resident required an intravenous (IV - a tube inserted into the vein to provide fluids) of fluids to [MEDICATION(S)] (reduce the effect) the significantly dangerous side effects of the medications. The facility reported a census of 37 residents. Findings include: According to the annual Minimum Data Set (MDS) dated [DATE], Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident had a Brief Interview for Mental Status score of 3 which indicated severe cognitive impairment. The resident required extensive assistance with eating. The resident required limited assistance of one staff for transfers, walking, and dressing. The resident required extensive assistance of one staff for toilet use and eating. Resident #1 had bladder incontinence and occasional bowel incontinence. The resident did not use diuretics in the seven-day lookback period. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan updated on 8/29/21 revealed Resident #1 needed assistance with her activities of daily living due to shortness of breath, pulmonary emboli in both lungs, acute [CONDITION(S)] with [CONDITION(S)], increasing confusion, depression, vascular dementia, [CONDITION(S)] and anxiety. The care plan directed staff to provide a seat pad alarm on her chair or bed due to history of falls, ambulate with 1 staff with a wheeled walker, provide assistance for incontinence episodes, dressing, hair care, and gripper strips in front of her bed to prevent slipping. Review of the Order Summary Report (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] tablet 100 milligrams (MG) once daily for Plasmablastic [CONDITION(S)] for 7 days from 12/31/21-1/7/22. b. [MEDICATION(S)] tablet 0.25 MG twice daily for anxiety. c. [MEDICATION(S)] capsule 200 MG twice daily for [CONDITION(S)]. d. [MEDICATION(S)] 250 MG once daily for urinary tract prophylaxis. e. [MEDICATION(S)] eye drops 0.2-0.5% for [CONDITION(S)]. f. [MEDICATION(S)] solution 2% three times a day for vision. g. [MEDICATION(S)] Suspension 50 micrograms twice daily for allergies. h. [MEDICATION(S)] HCL tablet 5 MG three times daily for low blood pressure. i. [MEDICATION(S)] tablet 50 MG once daily for Plasmablastic [CONDITION(S)] for 7 days from 12/31/21-1/7/22. j. [MEDICATION(S)] 22.5 MG once daily for depression. k. [MEDICATION(S)] HCL 50 MG once daily for depression. l. [MEDICATION(S)] tablet 50 micrograms once daily for elevated [CONDITION(S)] stimulating hormone. The Progress Note labeled Incident Report dated 1/4/22 at 5:43 PM revealed Resident #1 had a fall in her room then complained of head and back pain. The note continued to indicate that the staff obtained an order to transfer the resident to a local emergency room . The Communication - with Outside Vendor Note dated 1/5/22 at 12:32 AM documented that the resident admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hospital Discharge Summary dated 1/6/22, the resident had an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Health Status Note dated 1/6/22 at 11:15 AM documented the resident returned to the facility. The Progress Notes labeled Communication - with physician dated 1/7/22 at 10:40 AM revealed the facility notified the physician of the medication error. The physician indicated they would call back and directed the staff to monitor the resident's vitals until the call was returned. The Communication - with Family/Responsible Party dated 1/7/22 at 11:00 AM documented that the resident's daughter received notification of the medication error. The daughter requested to ask the physician for intravenous (IV) fluids when they call back. The Health Status Note dated 1/7/22 at 2:40 PM recorded that the nurse successfully started an IV for the resident with fluids running at 125 milliliters per hour (ML/hour). The Progress Notes dated 1/7/22 at 7:59 PM documented that the staff will take the resident's vital signs every hour. The Progress Notes dated 1/7/22 at 10:42 AM labeled Incident Report - Medication Error revealed Resident #1 received another resident's medications in error at 10:40 AM The resident received the following medications in error: a. [MEDICATION(S)] (medication to treat high blood pressure) 25 MG b. [MEDICATION(S)] (progestin hormone) 10 MG c. [MEDICATION(S)] (medication to treat high blood pressure and is a diuretic, or a medication that is used to decrease excess fluid) 50 MG d. Calcium/vit D (a dietary supplement) 600/200 e. [MEDICATION(S)] (medication used to thin blood) 2.5 MG f. [MEDICATION(S)] (diuretic) 20 MG g. Potassium (essential mineral supplement too high of a level can cause an irregular heart rate) 40 micrograms. h. [MEDICATION(S)] (medication to treat high blood pressure and diuretic) 2.5 MG Review of an Order Recap Report dated 1/7/22 directed the staff to complete the following orders: a. Draw a basic metabolic panel (BMP) one time only for medication error. b. IV therapy using Sodium Chloride Solution 0.9%, use 125 ML/hour intravenously one time only for dehydration. c. IV therapy using Sodium Chloride Solution 0.9% use 125 ML/hour for 5 hours for prevention of dehydration until 1/7/22 for accidental diuretic dose. During an interview with Staff E, Licensed Practical Nurse (LPN)/Agency nurse, she commented that she felt that Staff A, LPN/Agency nurse, had needed more training. Staff A was given a cheat sheet with resident information, but about one week before, Staff A made other errors. She failed to do the morning blood sugars or insulins for about six residents. Staff E reported telling the Director of Nursing (DON) about a week before that incident that she didn't feel Staff A was safe. Staff E added that the DON said they would get Staff A more training. During an interview on 2/7/22 at 11:00 AM, the Assistant Director of Nursing (ADON), stated there was an incident regarding Resident #1 on 1/7/22. A nurse gave Resident #1 another resident's medications during the morning medication pass. The ADON called the PCP who ordered staff to monitor the resident's vital signs every hour and to start an IV then monitor her for dehydration as the resident recently returned from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff C stated the resident received IV fluids on 1/7/22 and 1/8/22. During an interview with Staff B, RN, on 2/8/22 at 2:30 PM, Staff B stated she arrived to work at 2:30 PM for the evening shift. When she arrived, she was asked to place an IV in Resident #1 due to a medication error earlier in the day. Staff B stated that when she started the IV for the resident, she was lethargic and confused. During an interview on 2/9/22 at 8:16 AM, Staff A stated she no longer worked at the facility. Staff A reported that as she prepared medications for Resident #4, a Certified Nurse Aide (C.N.A) approached her and asked her a question about Resident #1. After she looked up the requested information related to Resident #1, she mistakenly added Resident #1's minerals and vitamins to Resident #4's cup of medications, rather than returning to Resident #4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #1. Staff A reported the error immediately and reported it to the ADON, who helped make the necessary phone calls and notifications. During an interview on 2/9/22 at 9:45 AM, Resident #1's Primary Care Provider (PCP) stated Resident #1 experienced a fall on 1/4/22, transferred to a local emergency room where she admitted to the hospital for urinary tract infection and dehydration. The resident returned to the facility on [DATE]. The PCP stated on the morning of 1/7/22, the nursing home called and reported that Resident #1 received Resident #4's medications. Those medications included medications for high blood pressure and diuretics. The PCP ordered staff to closely monitor the resident's vitals and ordered to infuse at 125 ML every hour. The IV fluids were put in place to [MEDICATION(S)] the blood pressure lowering medications and diuretics. The PCP stated the resident just got out of the hospital the day before (1/6/22) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/9/22 at 1:00 PM, the DON stated the facility did not have a policy specific to medication administration but expected the nurses to give the correct medications to the residents.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to follow accepted infection control practices for two of three residents reviewed. (Resident #28 & #25) The facility census was 54 residents. Findings include: 1. Resident #28 had a sign on her door to check with the nurse before going in with gloves and masks located in a holder on the door on 2/17/20 and 2/18/20. The facility reported placing the resident on transmission based precautions for influenza. The care plan for Resident #28 stated the facility placed the resident on respiratory isolation precautions for Influenza A. The Infection Prevention and Control Program Guidelines Policy revised 11/2017 stated facial protection is necessary and a mask will be used when staff are within 3-10 feet of a resident on droplet precautions. On 2/17/20 at 11:05 a.m., Staff D, Certified Nurse Aide, CNA entered the resident's room without a mask and handed a portable telephone to the resident prior to exiting. On 2/17/20 at 12:15 p.m., Staff E, laundry aide, and Staff F, laundry aide entered the resident's room without masks, stood at resident's bedside within 3-10 feet of the resident and conversed for a minute prior to leaving the room. On 2/17/20 at 12:17 p.m., Staff E and Staff F reported not knowing about any transmission based precautions for the resident. On 2/19/20 at 9:00 a.m., the ADON (Assistant Director of Nursing) reported the facility communicates with staff on transmission based precautions through PCC (Point Click Care), the electronic health care records system, as well as by a sign on the resident's door. Nursing staff and department heads have access to PCC. On 2/17/20 at 12:35 p.m., the Director of Nursing (DON) stated she expects staff to wear a mask when entering a room for a resident on transmission based precautions for influenza. 2. During observation on 2/18/20 4:18 p.m., Staff B, Respiratory Therapist [MEDICAL CONDITION] for Resident #25. Staff B failed to remove his soiled gloves and went into the bathroom, picked up a washcloth, went tot he sink and turned on the water to wet the washcloth. Staff B returned to bedside and wiped the resident's right eye and without changing surfaces of the washcloth wiped the residents left eye and the right eye again before handing the resident their glasses. Staff B took the washcloth back to the resident's bathroom and removed his gloves and washed his hands. 2/19/20 12:40 PM During interview on 2/19/20 at 12:40 p.m., the ADON stated she did notice Staff B had on the same gloves used to suction the resident and clean the residents eyes.

Based on observation, clinical record review and staff interview, the facility failed to ensure proper technique was utilized when checking placement of a feeding tube for two of three residents observed. (Resident #11 & #41) The facility census was 54 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #11 had [DIAGNOSES REDACTED]. The MDS documented the use of a feeding tube for nutrition. During observation on 2/18/20 at 4:06 p.m., Staff A, Registered Nurse, RN used a stethoscope and injected air into the feeding tube (auscultation) to check for correct placement of the tube. Staff A did not withdraw any residual to check for correct placement. Staff A was asked at that time if she was using the air bolus to check for placement and she said yes. 2. The MDS assessment dated [DATE] for Resident #41 listed [DIAGNOSES REDACTED]. On 2/19/20 at 11:26 a.m., Staff C, Licensed Practical Nurse, LPN used a stethoscope and injected air into the feeding tube (auscultation) to check for placement of the tube. Staff C did not aspirate any stomach contents to check residual for correct placement. Review of the facility policy on Enteral Feeding and Medication Administration with a revision date of 2/2019 revealed placement of the feeding tube to be done prior to medication administration, feedings, and flushes by aspiration of stomach contents. Placement by auscultation is no longer considered appropriate clinical technique. On 2/9/20 at 11:50 a.m., the DON (Director of Nursing) stated she expects nurses to follow current standards of practice and the facility policy by checking placement of feeding tubes with aspiration of stomach contents.

Based on clinical record review and staff interview, the facility failed to ensure one of eight resident reviewed received adequate supervision and assistance to prevent accidents. (Resident #1) Findings include: 1. Resident #1 entered the facility on 6/7/17, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had severe cognitive impairment, required extensive staff assistance with transferring, bed mobility, ambulation, bathing and toilet use and required limited assistance with personal hygiene. The facility developed Home Therapy Program dated 4/9/19, directing staff to ambulate the resident to and from meals and activities with a front wheeled walker, gait belt and the assistance of two staff. The individual plan of care identified a focus area of activities of daily living (ADL's) indicating the resident required assistance with personal cares and mobility related to [DIAGNOSES REDACTED]. The plan of care directed staff to ambulate the resident to/from meals and activities with front wheeled walker, gait belt and assistance of two staff. Nurse notes dated 5/19/19 at 8:45 p.m., documented a nurse was called to the resident's room and found the resident laying on their back with their feet towards the window and head towards the door. The resident was holding their right wrist complaining it was broken and hurt really bad. The resident was alert but confused. Upon asking the CNA (certified nurse aide) what happened, the CNA stated they were walking back to the bed when all of a sudden the resident yelled whoa and fell backwards. The CNA stated their hand slipped from the gait belt when the resident fell . The CNA was able to prevent her from hitting her head but unfortunately not the fall. The CNA stated the resident was steady when she was walking the resident to the restroom and back to bed. Nurse notes dated 5/20/19, indicated the resident sustained [REDACTED]. The resident was sent to the hospital for surgical repair of the right wrist. During interview on 8/20/19 at 10:10 a.m., Staff A, CNA stated the resident was in bed and requested to use the restroom. Staff A stated the resident did not have slipper socks on so she put slipper socks on prior to ambulation and assisted the resident to the restroom and the resident did not have any difficulty with ambulation. Staff A stated she and the resident were almost to the bed when the resident said whoa and fell backwards. Staff A stated at the time of the incident she was unaware the resident was to be assisted by two staff. Staff A stated she was unaware of the home therapy sheet or how to access the resident care plan on the I-pad until after the incident. Staff A stated she went by what other CNA's told her about the resident's and they all indicated the resident was a one person assist to transfer. During interview on 8/20/19 at 9:14 a.m., Staff B, CNA stated she was aware the resident had been changed to a two staff transfer just shortly prior to the fall, (maybe just a few days before). Staff B stated she was aware because the careplan coordinator alerted and informed staff working that day. During interview on 8/20/19 at 9:31 a.m., Staff C, licensed practical nurse, LPN stated she thought the resident required one staff to assist with transfers prior to the fall. During interview on 8/20/19 at 9:40 a.m., Staff D, registered nurse, RN stated the resident required two staff assistance with transfers prior to the fall. Staff D stated this information would have been on the resident's care plan in the room and it was the staffs responsibility to check the care plans. During interview on 8/20/19, the Administrator stated reminders were put in the staff newsletter for at least four days following the incident reminding staff that resident ambulation and transfer status can change and should be verified on the care plans. The director of nursing stated on 5/20/19 one on one education was provided with staff that worked on the wing where the resident resided. In addition, all staff were educated on how to access transfer status on any resident in the facility. The director of nursing indicated changes in a resident's care was passed along in report and available on Point Click Care for all staff to access and added the facility has about ten I-pads for staff to use and update themselves on the resident's plan of care. This is considered past non compliance as the facility placed corrective actions in place on 5/20/2019 and no current concerns were identified.

Based on observation, clinical record review and staff interview, the facility failed to assess for the use of bed rails and failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to the installation date on 4 of 14 residents. Findings include: 1. A Minimum Data Set (MDS) with the Assessment Reference Date of 11-29-2018 for resident #29 documents under the heading Comatose, this resident is in a persistent vegetative state/no discernible consciousness. This resident is totally dependent on 2 staff for bed mobility, transfer, dressing, toilet use, personal hygiene, bathing and requires assist of one staff for locomotion on and off unit and eating (tube feeding). Resident's [DIAGNOSES REDACTED]. Observation on 1/28/19 during initial walk through revealed the resident lying in her bed with full padded bed rails up on both sides of the bed. A care plan, dated as last reviewed on 8/21/18 directed staff: The resident is to have two quarter rails on each side of bed, further directed to pad bed railings. In an interview on 1/30/19 at 8:20 AM the ABCM Nurse Consultant confirmed the facility had not completed assessments for grab bars. The Nurse Consultant further stated they were unaware assessments were required for grab bars but confirmed, after reading the regulation, understanding that an assessment is required for all residents who have grab bars. The Nurse Consultant acknowledged the resident's bed rails are more than grab bars and constitute full side rails. The Nurse consultant acknowledged they had failed to contact the family and had failed to care plan the side rails for this resident. 2. According to the MDS (Minimum Data Set) assessment tool, dated 10/18/18, Resident #12 had [DIAGNOSES REDACTED]. The MDS documented the residents BIMS (Brief Interview for Mental Status) as 15 out of 15, indicating intact cognition. The MDS stated the resident had no falls since the previous assessment. A care plan with a revised date of 10/19/18, failed to indicate bed rails are used. Observation on 1/29/19 at 11:53 AM, revealed the resident transferred from bed to the shower chair with the assistance of two (2) staff. The resident positioned self with staff assistance in a sitting position at the side of the bed with the assistance of metal grab rails that were attached to the bed frame. The Facility failed to provide an assessment for the use of bed rails, and failed to provide documentation of informed consent for use of bed rails. In an interview on 1/29/18 at 4:30 PM, the ABCM Nurse Consultant and the Assistant Director of Nursing stated unable to provide documentation of assessment or discussion of risk for Resident #12. The Nurse Consultant further stated unaware of the requirement to complete assessment and obtain consent for grab rails and stated will review the regulation. Confirmed failed to complete assessment or obtain consent for grab rail (bed rail) for any residents at facility. 3. The MDS assessment tool for Resident #43 with a completion date of 12/20/18, identified [DIAGNOSES REDACTED]. The MDS documented the resident totally dependent on the assistance of two (2) staff for bed mobility, transfer, dressing and toilet use. The MDS documented the resident's BIMS (Brief Interview for Mental Status) as 15 out of 15, indicating intact cognition. The MDS documented the resident had no falls since the previous assessment. On 1/29/19 at 10:08 AM, observation revealed the resident in bed with side rails on the top half of both sides of the bed. During the observation the resident did not use the rails for positioning. A care plan with a revision date of 7/2/18, did not indicate the use of bed rails. Review of the clinical record failed to provide an assessment for the use of bed rails, and failed to provide documentation of informed consent for use of bed rails. 4. The MDS assessment tool for Resident #32 with a completion date of 12/6/18, identified [DIAGNOSES REDACTED]. The MDS documented the resident was totally dependent on the assistance of two (2) staff for bed mobility and transfers. The MDS documented the resident's BIMS as 9 out of 15 indicating moderate cognitive impairment. The MDS documented the resident had no falls with injury since the previous assessment. On 1/29/19 at 1:50 PM observation revealed the resident's bed with hand rails on the top half of both sides of the bed. During the observation the resident grabbed the rails to assist in positioning on the right side. A care plan with a revision date of 1/14/19, did not indicate the use of bed rails. Review of the clinical record failed to provide an assessment for the use of bed rails, and failed to provide documentation of informed consent for use of bed rails. A facility policy dated 1/2000, titled Side Rail Use directed: Side rails to be used only when assessed for a specific medical condition or treatment. The policy further directed a Side Rail Assessment Tool be completed by the facility and a Shared Negotiated Risk Statement signed by the resident and/or family.

Based on observation, record review and staff interview, the facility failed to ensure appropriate perineal care after an incontinence episode for 1 of 6 residents reviewed (#32). The facility reported a census of 56 residents. Findings include: The Minimum Data Set (MDS) for Resident #32 with a completion date of 12/6/18 listed [DIAGNOSES REDACTED]. The MDS documented the resident needed extensive assistance of two (2) staff for bed mobility and toileting. Transfers and ambulation did not occur during the observation period. The MDS documented the resident is always incontinent of both bowel and bladder. The MDS documented the BIMS (Brief Interview for Mental Status) as 9 out of 15, indicating moderate cognitive impairment. The MDS documented the resident is at risk for skin breakdown. During an observation of incontinence care on 1/29/19 at 1:50 PM, Staff C and Staff D, both CNA's (Certified Nurse's Aide) washed their hands and donned gloves. Staff C performed incontinence care using disposable wipes. Staff C cleansed down both leg creases, across the abdomen, down the central urethral area, and front of thighs. Staff C removed her gloves, sanitized hands, donned new gloves, rolled resident to the right hip. Staff C removed a urine saturated incontinence brief and wound dressing from the left buttock. Cleansed the left buttock and hip with wipes, removed her gloves, donned new gloves, and placed a clean brief under the resident. Staff D, removed gloves, donned new gloves and rolled resident to the left hip. Staff C failed to cleanse the right hip or buttock. During an interview with Staff C on 1/29/18 at 2:05 PM the CNA stated they were trained to wash all areas where urine would touch including buttocks, hips, and upper thighs. During an interview with the Director of Nursing (DON) on 1/31/19 at 8:20 AM she stated her expectation for incontinence care is that all areas on the resident where urine would have come into contact with skin would be cleansed including hips, buttocks, thighs. The DON stated the facility does not have a perineal care policy but they train and audit staff based on professional standards for nursing care.

Based on record review, staff interviews and review of the facility policy/procedures, the facility failed to utilize a safety device to protect a resident from harm for one of one residents reviewed that sustained an injury during a fall (Resident #3). The sample consisted of 13 residents. The facility identified a census of 63 residents. Findings include: Resident #3 had a MDS (Minimum Data Set) assessment with a reference date of 7/23/15 for a significant change in condition. The MDS reflected the resident had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of one staff person for bed mobility and transfers. A facility policy/procedure titled Transfer/Gait Belts/Ambulation and Use of Safety Straps/Belts, revised on 11/08, directed the staff will use gait belts on residents who require assistance with transfers and/or ambulation when mechanical lifting devices are not used. The policy/procedures included directives (#7) to always keep one hand on the resident ' s gait belt and the other hand on the resident ' s walker until the resident has reached the standing position. For assisting the resident with ambulation, follow Procedure #7 to reach the standing position (the gait belt may require adjusting at this time to allow for approximately one finger's space between the belt and the resident). Once the resident establishes his/her balance, grasp the gait belt firmly with one hand and walk about a half step behind the resident, allowing the resident to set the pace. You may have to stand beside the resident and assist him/her with advancing the walker or steering a wheeled walker if the resident has difficult with these tasks. Safety straps/belts during bathing: Ambulate or transfer resident to shower or whirlpool chair following applicable guidelines listed above. The staff are to ambulate or transfer the resident to the shower or whirlpool chair following applicable guidelines. The Care Plan initiated on 11/27/13, included a problem with the resident being at risk for falls, history of falls and unsteady during transitions. The problem included the following interventions: a. Be aware the resident may become unsteady when transferring to the shower chair. b. History of having had a fall recently, recurrent falls would be expected to occur for resident. Tell the provider and family of any falls and/or injuries. c. Ensure the resident wears appropriate footwear when transferring and mobilizing in wheelchair. d. The resident is able to use call light to summon assistance but (staff) may also check on resident for safety and to anticipate and needs resident may have. e. Lipped mattress to be on bed. f. The resident has cataracts removed and only need to wear glasses to read fine print now. g. Resident has Hi-Lo bed. Please assure that it is in the lowest position. h. Call light should be clipped to the body pillow. i. Place personal items as close to the resident as possible when in room. j. Observe for signs and symptoms of problematic side effects of Cymbalta (anti-depressant: sleep disturbances, suicidal thoughts, blurred vision, gastrointestinal changes, dysuria, [DIAGNOSES REDACTED], muscle cramps, increased sweating). Report to physician if observing adverse side effects from Cymbalta. k. Remind resident to ask staff for assistance when needed instead of asking roommate. l. The consultant pharmacist may review medications every month and make recommendations. A gradual dose reduction may be done only on physician order with close monitoring of status by staff nurses, reporting of effect on my mentation. m. Monitor blood pressures per usual routing and tell provider if blood pressure drops significantly. An incident report dated 7/10/15 at 6:40 a.m., documented the nurse had been called to C wing shower room and found staff with resident. Resident was supine on the floor with head at the door and feet pointing to the shower area. Resident was awake, alert and responding to the nurse in an appropriate fashion. The resident admitted to striking the posterior aspect of the parietal part of the head. The resident stated they had no pain in or about the head. Staff lifted resident up into the shower chair and voiced the only complaint of lower back hurting. The resident did have a small reddened area on the right upper back but the resident had no complaints about that area. The Certified Nurse Aide (CNA) with the resident reported she had moved the resident close to the whirlpool and stood the resident up, using the gait belt. The resident was holding on to the whirlpool edge and the CNA let go of the resident to bring the shower chair underneath the resident ' s bottom. As the CNA moved the shower chair, the resident fell back wards onto the floor into the position described above. The incident report documented the resident was showered and ate breakfast. The physician was notified and the facility transferred the resident to the local emergency room for x-rays and other assessments. Neurological checks were immediately started along with every 15 minute vital signs (pulse, respirations, blood pressure) until transferred to an emergency room . The Progress Notes dated 7/10/15 at 8:24 a.m., documented a nurse called another health facility and spoke to the physician ' s nurse. Discussed residents fall and requested x-ray of back due to back pain and informed that resident hit head and facility doing neurological checks and what they were. The nurse directed the facility to send the resident to the emergency room . An x-ray report of the lumbar spine for back pain status [REDACTED]. The facility Quality Assurance (QA) Nurse was interviewed on 10/29/15 at 8:15 a.m. and stated they (the facility) would have expected the CNA to hold on to the resident ' s gait belt when in the shower room and if unable to do that, radio for assistance. The QA nurse stated all staff are to carry walkie-talkies and staff can use this device if they need help with a resident. On 10/29/15 at 10:15 a.m., Staff A was interviewed and stated she had let go of the resident ' s gait belt to move a shower chair in the way and the resident fell . Staff A stated she knew she should not have let go of the gait belt but the resident had been walking with no difficulty.

Based on observation, record review and staff and physician reviews, the facility failed to ensure one of four residents received adequate supervision to protect against hazards to self (Resident #1). The facility identified a census of 71 residents. Findings include: 1. According to a Minimum Data Set (MDS) assessment form dated 4/24/14, Resident #1 had [DIAGNOSES REDACTED]. The assessment documented the resident with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (No cognitive impairment), disorganized thinking as present and fluctuating, required extensive assistance of staff with transfers, ambulation in room, toilet use and as not steady and only able to stabilize self with staff assistance when moving from a seated to standing position, turning around, moving on and off the toilet and any surface to surface transfer and with one fall with no injury since admission to the facility. According to a Care Plan revised 4/21/14, the resident had been at risk for falls due to an adjustment disorder with mixed emotions, depression, anxiety, polymyalgia rheumatic (inflammatory disorder when muscles are painful and stiff), charcot-marie tooth disease with neuropathy (neurological disorder that effects peripheral nerves), [DIAGNOSES REDACTED] ([DIAGNOSES REDACTED] disorder when the signal from nerves to muscles are blocked. Muscles cannot move and become weaker) and ataxia (lack of muscle control). The resident received psychotropic medications and had a history of [REDACTED]. Additionally the resident required assistance with activities of daily living (ADL'S) The interventions included the following: a. Personal alarm utilized when in his/her room to alert staff of position changes. b. Assistance of one staff, gait belt and a wheeled walker for transfers and ambulation. c. Assistance of one staff for toileting. A Fall Risk Assessment form dated 3/19/14, reflected the resident as at a moderate risk for falls. According to the Progress Notes, the facility staff made the following entries: a. 3/21/14 at 11:10 p.m. - Called to the resident's room and upon arrival found the resident laying on his/her bottom with his/her knees slightly bent on the floor on the left side of the bed with no apparent injuries. b. 6/17/14 at 11:04 p.m. - The resident had been unusually confused today, out of his/her norm. He/she appeared weaker and required the assistance of 2 staff members for ambulation since he/she had been leaning heavily to the left. c. 6/27/14 at 11:21 p.m. - This writer had been at the medication cart looking through the Medication Administration Record (MAR) when I heard a crash and someone yell "help me". I found the resident on the bathroom floor. Vital signs included a blood pressure of 110/60, pulse 58 (normal 60-100), respirations 20 (normal 16-20). The resident had full range of motion (ROM) and had been able to walk to his/her bed but stated that his/her back hurt real bad. There had been no visible injuries noted. d. 6/27/14 at 11:30 p.m. - The resident had an unwitnessed fall. He/she had been walking out of the bathroom to bed and hit his/her back on the corner of the wall having caused the fall. He/she stated that he/she had not hit his/her head. A hospital Visit Summary report form printed 7/3/14, reflected the resident as admitted to the hospital on [DATE] at 9:48 p.m. with [DIAGNOSES REDACTED]. During an interview 7/16/14 at 2:11 p.m., Staff A, Registered Nurse (RN) stated the fall actually occurred between 9:27 p.m. to 9:30 p.m. per the facilities pager system and call light activity report form. The staff member stated she had been looking through the MAR/TAR (treatment administration record) positioned on top of a medication cart setting along the wall across from the nurses work area at the end of the hall close to the resident's room when she heard a crash. She went down the hallway and observed the resident's feet under the approximate 12 inch gap of the bathroom curtain and the floor which had been 1/2 to 3/4 shut. When she entered the bathroom she observed the resident on the floor in front of the toilet positioned on his/her bottom and a portion of his/her lower back requesting assistance. The resident had been wearing pajamas with the pants pulled up but the staff member could not recall if the resident had been wearing gripper sock and/or slippers. When the staff member asked the resident if he/she hit his/her head, the resident had been indignant that he/she had not hit his/her head. At that point, Staff B, Certified Nursing Assistant (CNA) entered the resident's room so she instructed her not to move the resident and that she had to retrieve assessment tools. The staff member returned, assessed the resident, the vitals had been within normal limits (WNL) however the resident complained of pain but not in/on any specific body area and had been able to perform range of motion (ROM) exercises without pain. The resident felt he/she had been able to get off the floor so the use of a gait belt the 2 staff members stood the resident and ambulated him/her to bed per normal and with no yelling out. The staff member assessed the resident's back when ambulating him/her to bed but observed no redness or swelling. The resident had been positioned in bed on his/her back with his/her feet up on a pillow per usual. The resident continued to complain of pain when the staff member touched various areas on the resident such as the legs, ribs and etc. The staff member gave the resident a pain pill and placed an ice pack to the resident's right lower back. The staff member confirmed the resident required a personal body alarm at all times and that the device had not been attached to the resident while he/she had been in the bathroom which had been the facilities policy and/or procedure if staff left a resident at a fall risk unattended. During an interview 7/16/14 at 3:23 p.m., Staff B, Certified Nursing Assistant (CNA) confirmed she left the resident unattended and not alarmed in the bathroom to answer another resident's call light which she should not have done. When she returned she observed the resident on the floor in the bathroom by the toilet and sink with Staff A present and assessing the resident. When Staff A asked the resident about pain he/she complained of pain and pointed to his/her rib area. Following the assessment the staff members along with Staff C, CNA assisted the resident back to bed and that is when she left the resident's room. The staff member confirmed the resident required a personal body alarm at all times which would have included if he/she had been left in the bathroom unattended and that she was wrong and made a mistake because she had been doing too much at one time. During an interview 7/16/14 at 3:55 p.m., Staff C stated he had finishing with cares for another resident as he ambulated past the resident's room and observed Staff A, B and another staff member in the resident's room while he/she had been sitting on the bathroom floor. He entered the room and assisted Staff A and B stand the resident and set him/her on the seat of a wheeled walker, take him/her to bedside and transferred the resident to bed while the resident complained of right sided back pain, however, the area had no bruising or redness at the time so he brought the resident an ice pack. The staff member confirmed it had been the facilities policy to not leave a resident at a fall risk and alarmed unattended and not alarmed when positioned in the bathroom. On 7/17/14 at 9:11 a.m., the physician was interviewed and stated he would have absolutely and without a doubt expected staff to not leave the resident in the bathroom unattended and/or not alarmed and absolutely without a doubt the fall could have been prevented.

Based on record review and physician and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and the environment and the health facility supervisor failed to supervise the implementation of the written health care plan to meet the needs of the resident (Resident #1). The sample consisted of 3 residents with fractures and the facility reported a census of 72 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 7/21/2012 which identified [DIAGNOSES REDACTED]. The care plan dated 5/28/08 identified a problem with Self Care Deficit in Activity of Daily Living (ADL) related to the [DIAGNOSES REDACTED]. The problem was manifested by the needing assistance with ADLs (Activities of Daily Living). An addition was added on 9/6/11 which documented a history of a fracture of the left femur. The interventions of the care plan directed staff to: a. Assistance of two staff with bed mobility (of the resident). Offer assistance to turn/reposition the resident every two hours. Cue the resident to use the half-rails on his/her bed to assist. b. Assist the resident as needed to complete ADL tasks, use cues as needed for resident to participate at highest practical level, allow rest periods as needed. c. Assist the resident as needed to keep eyeglasses clean and in good repair. d. Assist the resident to cleanse after incontinence episodes and utilize disposable products to manage incontinence. e. Explain cares before beginning and ask the resident if it is okay to proceed. If resistive to ADL cares, leave alone and re-approach later. f. Assist with personal hygiene cares, including oral cares two times daily and as needed. Be aware of old fracture right femur and limited range of motion of right leg during cares. Added on 9/6/11-and fracture of left femur. g. Encourage the resident to consume foods/liquids at meals and snack time. Feed the resident if he/she will not feed self. h. Do not sit the resident at the edge of bed or perform pivot transfers. i. Administer oxygen as ordered. Check oxygen saturation as ordered. Notify physician of any unrelieved dyspnea on oxygen. j. Transfer the resident with an EZ lift/assistance of two staff into rock and go chair. k. Be aware that resident does not want to participate in an exercise program for range of motion with staff. l. Check on resident for safety and anticipate any needs he/she may have. m. Refer to Physical Therapy home therapy plan for transfers. n. Refer to Occupational Therapy home therapy plan for geri-chair positioning. o. Assistance of 2 staff with all cares given in bed (added 8/4/11). p. Cleanse eyelids with baby shampoo and warm water as ordered (added 4/4/12). An incident report dated 8/4/11, documented a Certified Nurse aide, CNA had the resident on his/her right side buttoning clothing when the resident ' s feet and legs rolled off the bed and the resident continued to roll off the bed. Left knee had lavender bruise that measured 8.0 centimeters (cm) by 3.0 cm, an abrasion with lavender bruising 2.0 cm long by 1.2 cm wide to the left elbow, the lower left facial cheek had a 2.0 cm by 2.0 cm abrasion with light lavender bruising. Limited range of motion to the left leg (per usual). Functional range of motion of left arm and neck. Assisted up with EZ lift (mechanical lift) and 5 staff back to bed. The Interdisciplinary Progress Notes (IPN) dated 8/4/11 at 12:10 p.m., indicated the same as the incident report as well as temperature 98.4, pulse 72, blood pressure 180/92, oxygen saturation 95% with edema (swelling) 3+ of bilateral feet. The entry indicated a neurological assessment was started. The IPN dated 8/4/11 at 1:30 p.m., documented the resident ' s emergency contact was notified the resident rolled out of bed and a physician was notified by facsimile the resident rolled out of bed, with neurological assessment continued on another sheet. The IPN dated 8/4/11 at 8:30 p.m., documented staff attempted to do a dressing on the resident ' s hip and foot. The resident stated "Please don't touch me." When staff asked where the resident hurt the resident stated "all over". Staff again attempted to assess the resident for injury and the resident refused. A review of the facility investigation revealed a statement dated 8/4/11, signed by Staff G, CNA that documented the resident ' s bed was wet so his/her sheets were removed. Upon partially dressing the resident, Staff D who was present left the room. Staff G documented he/she wanted to snap the resident ' s clothing and prepare for a Hoyer (sling) sheet. Staff G documented when he/she rolled the resident to his/her right side the residents feet went off the side of the bed and the resident continued to slide off of the bed, landing on his/her left side and bumping his/her head on an oxygen concentrator. Staff G documented he/she went to the hall to get another staff person. Review of a counseling session dated 8/4/11, revealed the facility had counseled Staff G to plan tasks before starting which would allow for items/equipment to be within reach, and to communicate with partner to ensure procedures go smoothly, which may help to protect residents and employees. The IPN dated 8/5/11 at 1:00 a.m., documented the resident rested quietly in bed with no complaints or signs or symptoms of discomfort. The IPN dated 8/5/11 at 9:00 a.m., documented a dressing was changed to a wound with an assessment of the area. At 12:00 p.m., an entry of a 24 hour roll out of bed follow up, bruise to face larger, bruise to elbow same, bruise to knee same but slightly more swollen. The IPN included no other assessment or entry until 8/7/11. Nurse notes dated 8/7/11 at 3:30 p.m., documented the CNA reported the residents left knee was hurting. The entry indicated the writer had assessed the area and noted +2 edema, extreme tenderness on mild palpitation and very warm to touch. At 3:40 p.m., the writer paged a physician. At 4:00 p.m., the writer paged another physician who was on call. Clinical record review revealed an order was received at that time, to give as needed pain medications to control the residents pain, ice as needed to the left knee and portable x-ray on left total knee on 8/8/11. A portable x-ray result dated 8/8/11, documented the x-ray was done after pain and swelling status [REDACTED]. The IPN dated 8/8/11 at 9:55 a.m., documented a portable x-ray was completed of the left knee. An entry at 12:50 p.m., documented the x-ray results had indicated a fracture of the left distal femoral metaphysis. The entry at that time indicated the results were faxed to the physician. No further entry was made until 8/10/10 at 12:10, which documented the physician was notified via facsimile of increase in size to the bruise beneath the left jawbone, notified of current condition of the area. Updated on current condition and treatment of [REDACTED]. A review of the as needed medication administration sheet for August 2011, revealed the resident received an as needed Tramadol (pain medication) fifty-five times from 8/4/12 until 8/31/12, for reasons that included back, hip, leg and knee pain. During an interview on 9/4/12 at 8:15 a.m., Staff A, Director of Nursing stated the CNA involved in the residents fall and fracture was counseled and considered it an issue if one CNA repositioned or turned a resident in bed without the assistance of another staff person if the resident was care planned to have assistance of two for bed mobility. During an interview on 9/4/12 at 10:24 a.m., Staff D, CNA stated before the incident the resident was wet so he/she needed to leave the room and get a clean sheet. Staff D stated all he/she knew was that Staff G had met him/her at the door and said to get the charge nurse because the resident had fell out of bed. Staff D stated sometimes you could turn the resident by yourself but his/her mattress was wet and Staff G tried to turn the resident alone and the resident slipped off of the bed. Staff D stated the resident ' s care plan indicated the resident needed assistance of two for bed mobility. On 9/4/12 at 10:55 a.m., Staff G, CNA was interviewed and stated he/she and a partner had gone in to get the resident dressed and up on the day of the incident. Staff G stated his/her partner stepped out to get a Hoyer lift and he/she went ahead and continued to dress the resident, and when he/she rolled the resident over the resident fell off of the bed. Staff G stated he/she did recall the resident had no sheet on the bed with a wet mattress. Staff G reported at the time of the incident the resident could be turned with one person, but the resident was care planned to have assistance of two. Staff G stated the residents bed was in the high position with a grab bar up near the head of the bed and no side rails up when the fall occurred. On 9/4/12 at 12:15 p.m., Staff E, CNA stated a CNA should not turn a resident in bed without the assistance of a second person if the resident was care planned for assistance of two. During an interview on 9/4/12 at 12:20 p.m., Staff F, CNA stated he/she would never turn a resident without assistance if the resident was care planned to have assistance of two for bed mobility. A Major Injury Determination Form signed by a physician on 8/9/11 (5 days after the fall) at 12:00 p.m., documented the resident had a fracture of the distal femoral metaphysis sustained 8/4/11 at 12:10 p.m.. The form reviewed the circumstances of the incident to be the resident had been laying on their right side, staff were buttoning the back of a garment when the resident ' s legs slid off the bed causing the resident to roll out of bed. The form indicated the resident was totally dependent on staff for all mobility/transfers/meal assistance. The physician documented the prognosis for return to previous level of functioning was good, and a checkmark was placed indicating that after review of the circumstances, injury and prognosis, the injury sustained was not a major injury, and to the best of the physician ' s knowledge, he/she believed the patient would return to his/her previous functional status. The physician who signed the non-major injury determination form identified him/herself during interview on 9/4/12 at 12:26 p.m., as being the facility medical director but did not recall the resident or specifics of the incident. The physician stated the form was probably signed by him/her due to an absence of the resident ' s primary physician. The physician reported he/she did not recall seeing the resident after the injury but probably based the determination on the x-ray report.