Every finding on record at Happy Siesta Health Care Center

Based on observation, staff interview, and policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs by use of incorrect serving size portions for meals. The facility reported a census of 54 residents.Findings include:Observation on 7/22/26 at 9:30 AM Staff A cook placed 6 servings of blueberry crisp into a blender and added milk for the puree process. Staff A then added thickener to the puree mixture. Staff A was then observed to pour the pureed blueberry crisp into single serving bowls without measuring the amount that was pureed. Observation on 7/22/26 at 10:04 AM Staff A prepared 6 servings of Rueben casserole into the blender for the puree process. Staff A then added 2 cups of milk. Staff A again was observed adding thickener to the puree mixture. Staff A then poured the pureed casserole into the serving container without measuring.Interview on 7/22/26 at 10:18 AM with Staff A revealed that she has never used the puree chart. Staff A further revealed she was never taught how to use the chart to determine the correct serving size for puree diets. Interview on 7/22/26 at 11:47 AM with the Administrator revealed that she would expect the puree process, and servings to be completed appropriately. Review of a facility provided document titled, Puree Volume Technique with a date of 2020 indicated:1. Measure out desired number of servings into blender 2. Puree the food 3. Add any necessary thickener or liquid of nutritive value and flavor to obtain desired consistency (pudding texture preferred). 4. Measure the total volume of the food after it is pureed. 5. Divide the total volume of the pureed food by the original number of portions a. Refer to scoop chart

Based on observation and staff interview, the facility failed to prepare and serve food with professional standards for food service safety. The facility had a census of 50 residents. Findings include: During observation in the kitchen: a. On 6/11/25 at 9:45 a.m. Staff F, [NAME] wore gloves, handled utensils, obtained milk from the refrigerator, put her gloved hand in the bread bag, placed 4 slices of meat in the Robot coupe, and the 4 slices of bread tearing the bread with the gloved hands. b. At 10:30 a.m. Staff F started plating food for the special care unit. During the meal service Staff F wore gloves. She plated the hot food and the Dietary Manager (DM) who also wore gloves, picked up buttered bread and folded it with both hands and placed it on the plate. She touched the hot plate and pushed the tray over (on the counter top) with her left hand, then picked up another slice of bread and folded and put on the plate. She continued through plating the the unit trays, then changed gloves. c. At 11:02 a.m. Staff F wore gloves when plating food for the main floor. Staff let them know who was in the dining room (DR). Staff F touched the serving utensils, going through the utensil drawer several times. At the start of serving the main floor, Staff F used a utensil to pick up the bread and put on the plates. After plating several, Staff F started picking up the bread with the gloved hand. She reached in the bread bag to make sandwiches. Staff F changed gloves several times without washing her hands. At the end of meal service, Staff F stated she knew they shouldn't touch the food. She said she was doing it that way (using a utensil) awhile when she thought about it. The DM confirmed they should not touch food, if other surfaces were touched with gloves on. The FDA Food Code 2022, 3-304.15 gloves, use limitation, directed if used, single use gloves should be used for only one task such as working with ready to eat food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occurred in the operation.

Based on record review and staff interview, the facility failed to notify the physician in a timely manner of a change in condition for 1 of 15 residents reviewed (Resident #22). The facility reported a census of 50 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #22 had a Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Diagnoses included aphasia (language disorder affecting the ability to communicate), schizophrenia, and adverse effects of unspecified antipsychotics and neuroleptics. The Care Plan initiated 3/9/22 identified the resident used an opioid medication. The interventions included observing and reporting changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motion (ROM), withdrawal or resistance to care. The Care Plan dated 6/21/22 documented the resident took psychoactive medications related to schizophrenia, anxiety, and depression. The interventions included observing for and reporting as needed any adverse reactions to: Depakote; including lethargy. Antidepressant; including fatigue, appetite loss. Antipsychotic; including fatigue, loss of appetite. Antianxiety; including drowsiness, slow reflexes, The Progress Notes documented: a. On 5/29/25 at 1:17 p.m. the resident found to have lowered herself to the floor next to her bed and resting her head on the bed. She responded slowly and appeared sleepy. Resident's hands were warm to touch and cheeks flushed. Assisted the resident with removing her sweater. She had a temperature of 98.2. The resident requested to lay back down in bed. Assisted the resident to bed and rest with her eyes closed. b. On 5/30/25 at 3:06 p.m. the resident had been lethargic and weak during the shift. She said she didn't feel very good, but could not be specific about what didn't feel well. She required 2 assist with transfers on and off the toilet. She had a difficult time holding an upright position while on the toilet. Vital signs (V/S) were temperature (T) 97.6, pulse (P) 81 respirations (R) 20, blood pressure (BP) 91/53 oxygen (O2) saturation (sat) 93% on room air (RA). She had no coughing noted or signs and symptoms of shortness of breath (SOB). Her bilateral arms/hands had tremors at times and had a difficult time holding a glass of liquid. Staff assisted her with both meals. The resident laid down from 10 a.m. until 12:30 p.m. Staff assisted her to the bathroom and asked her if she was hungry and she nodded her head yes. Staff brought the resident out and assisted with lunch. No foul odor noted to urine. Unable to get the resident to take deep breaths to assess lung sounds effectively. The nurse reached out to the resident's Power of Attorney (POA) and updated her. At 3:18 p,m. unable to reach the resident's POA due to being out of the office until Monday. Would call her Monday. c. On 5/31/25 at 12:49 a.m. the resident continued to appear lethargic. She rested in bed and exhibited periods of apnea (temporary cessation of breathing). Her skin was cool to the touch and her room was also cold. She responded to verbal stimuli and was able to move all extremities, though her movements were slow. She was unable to take deep breaths for a proper lung assessment. The resident responded to a few questions when prompted. She denied experiencing cough, sore throat, or body aches. However, she was confused, consistent with her baseline due to dementia. VS B/P, 112/81, P 92, O2 95%, tympanic temp 97.6, R 18. d. On 5/31/25 at 1:42 p.m. the resident was lethargic and not very talkative that shift. Her vital signs were stable and the resident unable to verbalize if she was not feeling well. The resident pocketed food at meals, and appetite poor. She did not drink much fluids even when asked by staff. She did take medications without any incident. Resident not her normal self. e. On 6/1/25 at 10:20 a.m. the resident had been sleepy during the shift. She was helped in the morning with cares, and came out for breakfast, eating 50%. Vital signs within normal ranges. The resident did not complain of, or show signs of pain. f. On 6/1/25 at 8:48 p.m. the resident continued to be very lethargic, pale, and cool to the touch. with periods of apnea noted. Her eyes were open during the assessment. When asked her if she felt sick, she whispered yes. Vital signs taken. The resident did take her pills with much encouragement and drank about 2 ounces of water. The resident rested in her bed. Would continue to monitor. g. On 6/2/25 at 8:11 a.m. house supplement held due to lethargy. h. On 6/2/25 at 9:47 a.m. called and spoke with the POA about changes noted with the resident. The resident continued to be lethargic. She sat with eyes open during shower and responded very little. The resident unable to maintain an upright position on the shower chair and leaned to the right. Sent a fax to the physician updating him, and asking if he would advise any testing. i. On 6/2/25 at 12:50 p.m. the resident found to have lowered herself onto the floor next to her bed. Required assistance of 2 with a gait belt to get her up into her wheelchair and into the bathroom. The resident continued to have difficult time maintaining upright posture while sitting on the toilet, and was incontinent of urine. Incontinence cares provided. Urine continued with no foul odor. When asked if she was thirsty resident softly answered yes. Assisted the resident with a glass of water and a cup of pudding, eating almost all of the pudding and drinking about 3/4 of the water. While assisting her, the resident drooled a few times. The resident sat with her eyes open and didn't speak. Call placed to the physician's office about the fax sent that morning to make sure they received it. Left a detailed message on the physician's nurse's voicemail. j. On 6/2/25 at 2:17 p.m. the resident's medications held due to being lethargic. k. On 6/2/25 at 4:31 p.m. the resident lethargic and not taking fluids. l. On 6/3/25 at 9 a.m. telephone order (T.O.) received to hold medications if the resident lethargic and unable to take. m. On 6/3/25 at 9:15 a.m. fax received back (from the physician) with orders to obtain a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP) and Urinalysis (UA). T.O. received to obtain UA with microscopic via mini catheter. n. On 6/3/25 at 9:35 a.m. obtained samples for labs. The resident rested in bed. She continued to be lethargic, laying with eyes open and responding very little. Tried pudding and water and the resident let both run back out of her mouth. o. On 6/3/25 at 12:30 p.m. call received from the physician's nurse reporting a critical value on res blood work. Her sodium was at 175 (reference 136 to 145). The physician's nurse stated the resident's POA would need to decide if she would like the resident seen in the emergency room (ER) for possible treatment, or look at end of life care. Call placed to res POA and would like the resident evaluated at ER. The physician notified of the POA decision. T.O. received to have the resident transferred by ambulance to the ER for evaluation. p. On 6/3/25 at 8 p.m. call received from the hospital stating the resident would be admitted to the hospital. A Physician Communication Form dated 6/2/25 at 9:40 a.m. documented the res. showed a decline over the last week. She responded very little that day and was lethargic. Required 2 assist for transfers. VS remained stable. Had a small amount of clear nasal drainage early last week, and complained of not feeling well. No cough or cold symptoms. The resident would sleep significantly more for a few days, then return to normal self. They were not seeing any improvement. Asked if the physician would advise any testing. Urine clear without foul odor. Has ate and drank very poorly since 5/27/25. The physician responded CBC, CMP, UA with micro dated 6/3/25. The hospital History and Physical dated 6/3/25 documented the resident had shown a gradual decline in her clinical condition the previous few months, but a drastic change the past couple of days. The resident had been less active and talkative lately, but showed a dramatic change over the last couple of days. The nursing facility reached out about obtaining labs. Her white blood count (WBC) was slightly elevated at 12.9, hemoglobin 17.3, sodium 175, BUN 121 (reference range 7 to 18) and creatinine 4.75 (reference range 0.55 to 1.02). Calcium mildly elevated at 10.7 (reference range 8.5 to 10.1). The resident admitted for continued care while they worked with her guardian to determine final course of care. On 6/11/25 at 1 p.m. Staff A Licensed Practical Nurse (LPN) said on 5/30/25, a Friday, (she worked Monday through Friday) she knew the resident was sleepy, but she'd had that before, so waiting a day before doing anything, was appropriate at the time. When she returned to work on 6/2/25 she could see the resident had not improved from Friday, so she tried to get hold of the doctor. She sent a fax out and called the office 2 to 3 times. Staff A said if she had worked the weekend she would have gotten something going sooner. On 6/11/25 at 1:40 p.m. Staff G Certified Nursing Assistant (CNA) stated prior to the hospitalization the resident was lethargic, and seemed to be in pain. On 6/11/25 at 1:45 p.m. Staff E Certified Nursing Assistant (CNA) stated prior to the hospitalization she was declining from Thursday (5/29/25) on. The nurses on the weekends were not as familiar with the resident. She ate very little. They had to wake her, but she was drinking. She didn't seem to be in pain. On 6/11/25 at 2:05 p.m. Staff B CNA stated prior to the hospitalization she had not been herself. They were wondering if she may have bumped her head sometime when getting down on the floor. On 6/11/25 at 4:50 p.m. Staff C RN stated when she worked in the unit prior to the resident's hospitalization, she was fatigued and didn't feel good. On 6/11/25 at 4:58 p.m. Staff D CNA stated prior to the hospital, the resident was very sleepy and not eating or drinking. On 6/12/25 8:31 a.m. the resident's Physician stated ideally they would have reported sooner. If they had notified him sooner, caught (the hypernatremia) earlier, and successfully treated it, he thought she would have died within 6 months. He said the resident had some dehydration, but there could be other causes of hypernatremia. He could not specify at the time. On 6/12/25 at 9:42 a.m. the Administrator stated the doctor and the psych ARNP were on vacation that week. They also knew the resident had been having a gradual decline. On 6/12/25 at 10:10 a.m. the resident's Physician stated when is on vacation the facility can send a fax to the office and the nurse would pass it along to another provider as necessary. If it was after hours they would call the ER on call. He said they usually responded to faxes the same day unless it was sent late afternoon. The facility undated Notification of Change Policy included the facility nursing staff should be responsible in notifying the resident's physician of changes in a resident's condition.

Based on record review and staff interview, the facility failed to ensure staff implemented resident specific interventions for psychotropic medications for 1 of 6 residents reviewed (Resident #22). The facility reported a census of 50 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #22 had a Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Diagnoses included aphasia (language disorder affecting the ability to communicate), schizophrenia, and adverse effects of unspecified antipsychotics and neuroleptics. The Care Plan dated 6/21/22 documented the resident took psychoactive medications related to schizophrenia, anxiety, and depression. The interventions included observing for and reporting as needed any adverse reactions to: Depakote; including lethargy. Antidepressant; including fatigue, appetite loss. Antipsychotic; including fatigue, loss of appetite. Antianxiety; including drowsiness, slow reflexes, The Psych Advanced Registered Nurse Practitioner (ARNP) managed the resident's medications. An Outpatient Psychiatric/Mental Health Progress Note dated 5/14/25 documented the resident's medications included Divalproex (anticonvulsant), Risperdal (antipsychotic), Sertraline (antidepressant), and Lorazepam (antianxiety). Treatment recommendations and orders included increasing Lorazepam 0.5 mg 3 times a day, to Lorazepam 1 mg every morning and 2 p.m. and continuing Lorazepam 0.5 mg at bedtime. Discharge instructions included calling with concerns or questions. The Progress Notes documented : a. On 5/30/25 at 3:06 p.m. the resident had been lethargic and weak during the shift. She said she didn't feel very good, but could not be specific about what didn't feel well. She required 2 assist with transfers on and off the toilet. She had a difficult time holding an upright position while on the toilet. Vital signs (V/S) were temperature (T) 97.6, pulse (P) 81 respirations (R) 20, blood pressure (BP) 91/53 oxygen (O2) saturation (sat) 93% on room air (RA). She had no coughing noted or signs and symptoms of shortness of breath (SOB). Her bilateral arms/hands had tremors at times and had a difficult time holding a glass of liquid. Staff assisted her with both meals. The resident laid down from 10 a.m. until 12:30 p.m. Staff assisted her to the bathroom and asked her if she was hungry and she nodded her head yes. Staff brought the resident out and assisted with lunch. No foul odor noted to urine. Unable to get the resident to take deep breaths to assess lung sounds effectively. The nurse reached out to the resident's Power of Attorney (POA) and updated her. At 3:18 p,m. unable to reach the resident's POA due to being out of the office until Monday. Would call her Monday. b. On 5/31/25 at 12:49 a.m. the resident continued to appear lethargic. She rested in bed and exhibited periods of apnea (temporary cessation of breathing). Her skin was cool to the touch and her room was also cold. She responded to verbal stimuli and was able to move all extremities, though her movements were slow. She was unable to take deep breaths for a proper lung assessment. The resident responded to a few questions when prompted. She denied experiencing cough, sore throat, or body aches. However, she was confused, consistent with her baseline due to dementia. VS: 112/81, P 92, O2 95%, tympanic 97.6, 18. c. On 5/31/25 at 1:16 p.m. the aide came to get the writer to evaluate the resident's right foot and right hip due to bruising. The writer noted a purplish/gray, 6 cm x 6 cm bruise to the top of her right foot. Also noted purple/gray diffuse bruising to the right hip. Due to the residents condition, unable to get description of what happened. d. On 5/31/25 at 1:42 p.m. the resident was lethargic and not very talkative that shift. Her vital signs were stable and the resident unable to verbalize if she was not feeling well. The resident pocketed food at meals, and appetite poor. She did not drink much fluids even when asked by staff. She did take medications without any incident. Resident not her normal self. e. On 6/1/25 at 10:20 a.m. the resident had been sleepy during the shift, she was helped in the morning with cares, and came out for breakfast, eating 50%. Vital signs within normal ranges. The resident did not complain of, or show signs of pain. f. On 6/1/25 at 8:48 p.m. the resident continued to be very lethargic, pale, and cool to the touch. with periods of apnea noted. Her eyes were open during the assessment. The writer asked her if she felt sick and she whispered yes. Vital signs taken. The resident did take her pills with much encouragement and drank about 2 ounces of water.The resident rested in her bed. Would continue to monitor. g. On 6/2/25 at 8:11 a.m. house supplement held due to lethargy. h. On 6/2/25 at 9:47 a.m. called and spoke with the POA about changes noted with the resident. The resident continued to be lethargic. Sat with eyes open during shower and responded very little. Unable to maintain an upright position on the shower chair and leaned to the right. Fax sent to the physician updating him, and asking if he would advise any testing. i. On 6/2/25 at 12:50 p.m. the resident found to have lowered herself onto the floor next to her bed. Required assistance of 2 with gait belt up into her wheelchair and into the bathroom. The resident continued to have difficult time maintaining upright posture while sitting on the toilet, and was incontinent of urine. Incontinence cares provided. Urine continued with no foul odor. When asked if she was thirsty resident softly answered yes. Assisted the resident with a glass of water and a cup of pudding, eating almost all of the pudding and drinking about 3/4 of the water. While assisting her the resident drooled a few times. The resident sat with her eyes open and didn't speak. Call placed to the physician's office about fax sent that morning to make sure they received it. Detailed message left on the physician's nurses voicemail. j. On 6/2/25 at 2:17p.m. the resident's meds held due to being lethargic. k.On 6/2/25 at 4:31 p.m. the resident lethargic and not taking fluids. l. On 6/3/25 at 9 a.m. telephone order received to hold medications if res if lethargic and unable to take. m. On 6/3/25 at 9:15 a.m. fax received back with orders to obtain Complete Blood Count (CBC), Complete Metabolic Panel (CMP) and Urinalysis (UA) with microscopic. T.O. received to obtain UA via mini catheter. n. On 6/3/25 at 9:35 a.m. obtained samples for labs. The resident rested in bed. She continued to be lethargic, laying with eyes open and responding very little. Tried pudding and water and the resident let both run back out of her mouth. o. On 6/3/25 at 12:30 p.m. call received from the physician's nurse reporting a critical value on res blood work. Her sodium was at 175 (reference 136 to 145). The physician's nurse stated the resident's POA would need to decide if she would like the resident seen in the ER for possible treatment, or look at end of life care. Call placed to res POA and would like the resident evaluated at ER. The physician notified of the POA decision. T.O. received to have the resident transferred by ambulance to the ER for evaluation. p. On 6/3/25 at 8 p.m. call recieved from the hospital stating the resident would be admitted to the hospital. On 6/11/25 at 1 p.m. Staff A Licensed Practical Nurse (LPN) said on 5/30/25, a Friday, (she worked Monday through Friday) she knew the resident was sleepy, but she'd had that before, so waiting a day before doing anything, was appropriate at the time. When she returned to work on 6/2/25 she could see the resident had not improved from Friday, so she tried to get hold of the doctor. She sent a fax out and called the office 2 to 3 times. Staff A said if she had worked the weekend she would have gotten something going sooner. The clinical record lacked documentation the facility notified the psych ARNP of the resident's condition change after the increase in psychotropic meds. On 6/12/25 at 9:17 a.m. the psych ARNP stated she checked her record and she had not received notification about the resident in that timeframe. The facility undated Psychotropic Medication Monitoring policy documented the facility would administer psychotropic medications appropriately working with the interdisciplinary team to ensure the appropriate use, evaluation, and monitoring.

Based on record review and staff interview, the facility failed to complete assessment after incidents for 1 of 2 residents reviewed (Resident #22). The facility reported a census of 50 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #22 had a Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Diagnoses included aphasia (language disorder affecting the ability to communicate), schizophrenia, and adverse effects of unspecified antipsychotics and neuroleptics. The resident had 2 or more falls with no injury and 2 or more fall with injury since the previous assessment. The Care Plan initiated 6/21/21 identified a focus of Activities of Daily Living (ADL's). The interventions included the resident had a past history and current behavior of putting herself on the floor or ground. She was able to get herself up off the floor at times, but may need assistance getting up at times. The Care Plan initiated 7/5/21 identified the resident had cognitive impairment related to paranoid schizophrenia. The resident observed with behavior of putting self on the floor and crawling around, then getting herself to a standing position independently. The Care Plan initiated 11/2/23 identified the resident had impulsive and frequent position changes. She often declined assistance during these transfers. Safety awareness and spatial judgement was poor. Interventions included encouraging res to wear shoes during the day. The resident was noted to lower herself to the floor, usually in her bedroom, assure safety of the area, and free of objects that may cause harm, and encouraging her to sit in her recliner. On 5/29/25 at 1:17 p.m. the resident was found to have lowered herself to the floor next to her bed and resting her head on the bed. The resident was slow to respond to the writer and appeared sleepy. Her hands were warm to touch and cheeks flushed. The writer assisted the resident with removing her sweater. T-98.2. The resident requested to lay back down in bed. Assisted the resident to bed and rested with her eyes closed. On 5/31/25 at 1:16 p.m. the aide came to get the nurse to evaluate the resident's right foot and right hip due to bruising. The nurse noted a purplish/gray, 6 cm x 6 cm bruise to the top of her right foot, and purple/gray, diffuse bruising to the right hip. Due to the resident's condition, unable to get a description of what happened. On 6/2/25 at 12:50 p.m. the resident was found to have lowered herself onto the floor next to her bed. She required assistance of 2 with a gait belt to get her up into her wheelchair and into the bathroom. The resident continued to have a difficult time maintaining an upright posture while sitting on the toilet. On 6/11/25 at 1 p.m. Staff A Licensed Practical Nurse (LPN) said they usually saw the resident when she would put herself on the floor. It was usually out in the main area. If she put herself on the floor in her room it would be from the bed down to the floor, and usually she would get back up on her own. Staff A said if the resident was found on the floor, and no one could see that she had done it herself, that would be an incident report with the appropriate investigative management. She said she saw her going down to the floor as she walked by her room on 5/29/25 and 6/2/25. 6/11/25 at 1:45 p.m. Staff E, CNA stated they helped the resident up from the floor when she couldn't get up on her own. They didn't always see her get down. On 6/11/25 at 2:05 p.m. Staff B, Certified Nursing Assistance (CNA) stated if they found the resident on the floor they helped her up, if they witnessed it or not. On 6/11/25 at 4:50 p.m. Staff C, RN stated the resident put herself on the floor repeatedly. She said they were mostly witnessed. If they were witnessed, they didn't do an incident report. On 6/11/25 at 4:58 p.m. Staff D, CNA stated they helped the resident off the floor if they witnessed her putting herself on the floor or not. They didn't tell the nurse every time, because that's what she did. On 6/12/25 at 9:42 a.m. the Administrator stated the resident put herself on the floor continually. She would put herself down and get herself back up. It was a very unique situation. The Director of Nursing (DON) stated the bruising (5/31/25) could have been caused by her rolling around on the floor. The undated facility policy, Resident Safety, Accidents and Incidents identified the purpose to ensure all resident accidents and incidents were properly assessed and reviewed. The following data, as applicable, shall be documented in the Risk Management section of Point Click Care: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's attending Physician was notified h. The date/time the injured person's family was notified i. The condition of the injured person, including his/her vital signs; range of motion, pain, observable injuries and neuros for all falls with head injury, or if the fall was unwitnessed. j. Any corrective action taken k. Intervention to prevent reoccurrence is added to care plan l. Other pertinent data as necessary or required; and m. The signature and title of the person completing the report.

Based on clinical record reviews, staff interviews, hospital record reviews, facility investigation and policy review the facility failed to provide adequate nursing supervision for 1 of 3 residents reviewed (Resident #1) for falls. Resident #1 had a fall while riding in the facility passenger van, resulting in his wheelchair tipping over backwards, hitting his head and sustaining three lacerations to the back of his head. The fall required a transfer to the emergency room three weeks later which resulted in admission to the hospital for a C2 cervical fracture that required surgical intervention and placement of a halo brace (an orthotic support that helps immobilize and protect bones in the neck following an injury). The facility reported a census of 54 residents. Citation considered past noncompliance as the facility completed the following interventions prior to the surveyor entering the facility on 4/15/24: 1. Q'straint loops ordered for securement-4/3/24 2. Antitipper attached to both chairs-3/8/24 3. Van drivers retrained on Q'straint securement-4/3/2024 4. Safety inspection completed for van -3/11/2024 5. Pre-trip safety checklist for van transports -4/4/2024 6. Staff education provided on accident policy-4/3/2024 and ongoing 7. Inventory system for wheelchairs established- 3/8/2024 and ongoing Findings include: Resident #1' s Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicated severely impaired cognition. The MDS identified Resident #1 had signs and symptoms of delirium of disorganized thinking that fluctuates. The MDS identified Resident #1 required partial/moderate assistance of one person with transfers, toilet use and ambulation of 50 feet using a walker. Resident #1's MDS included diagnoses of cancer, benign prostatic hyperplasia, thyroid disorder, stroke, non-alzheimer's dementia, and unsteadiness on feet. Resident #1's Fall Risk Evaluation documented the following scores and fall risk: 1/27/24= 16- Total score of 10 or higher represents a high risk 3/8/24= 15- Total score of 10 or higher represents a high risk The Care Plan with target date of 3/15/24 documented Resident #1 was a fall risk. The care plan interventions included the following: a. Anticipate and meet Resident #1 ' s needs. b. Assist to bed when noted to be drowsy. c. Be sure Resident #1 ' s call light is within reach and encourage him to use it for assistance as needed. d. Encourage Resident #1 to participate in activities that promote exercise, physician activity for strengthening and improving mobility. e. Follow facility fall protocol. f. Get up in a wheelchair if awake and anxious in bed. g. Keep foot pedals off the wheelchair when not assisting Resident #1. i. Merry-walker will have a tray securely in place at all times when utilizing it. j. Use one cushion in the wheelchair. A Progress Note dated 3/7/24 at 1:31 PM revealed Resident #1 was out to the dining room for lunch leaning quite a bit to the left and unable to sit himself up. Resident #1 then sat in a merry walker, continued to lean and was unable to stand on command. Resident #1 was unsteady and leaning to the left side. The note documented Resident #1 right hand grip greater than left. Resident #1's wife notified of condition and reported Resident #1 was leaning to the right a little the day before. The note further documented that the wife did not want resident assessed and would like him to stay at the facility. The note revealed the wife believed Resident #1 had another TIA( (Transient Ischemic Attacks). Primary Care Physician notified via fax of condition and to keep at facility per wife request with no further aggressive treatments/evaluations. A Progress Note dated 3/28/24 at 1:34 PM titled Social Service Note documented a new Iowa Physician Orders for Scope of Treatment (IPOST) was filled out with Resident #1's wife and placed in Resident #1's medical record. A Progress Note dated 3/8/24 titled Incident Note at 2:25 PM revealed while on bus ride, staff reported Resident #1 fell backwards in his wheelchair. Upon returning to the facility, Resident #1 was noted to have 3 lacerations to the back of the scalp with blood drainage. Vital signs and neurological checks (neuro's) were initiated upon return to the facility. The neurological checks revealed the left pupil was sluggish and Resident #1 was leaning to his left. The note documented the neurological symptoms were present on 3/7/24 and Primary Care Physician (PCP) had been updated on 3/7/24. The note documented the PCP and wife were notified regarding the fall and the wife wished to keep resident at the facility. An Incident Report (IR) dated 3/8/24 at 2:45 PM identified a witnessed fall during a bus ride. The report revealed Resident #1 while on the bus ride fell backwards in his wheelchair and received lacerations to the back of his scalp. The intervention was to have the bus inspected by maintenance to ensure no malfunctions. The IR dated 3/8/24 documented a note on 3/11/24 that revealed upon further review of the incident, the interdisciplinary team determined Resident #1 had been on a facility sponsored bus ride with Staff A, Activity Director and Staff B, Activity Assistant. Staff A was driving the van and as she completed a right turn, she accelerated and Resident #1 ' s chair tipped backwards. Staff A stopped the vehicle and Staff A and Staff B sat Resident #1 back up and return to the facility. The bus was taken out of use pending safety inspection. Staff C, Maintenance director completed the inspection on the morning of 3/11/24. The inspection resulted in no system concerns and the bus was placed back in use. Staff A reported that she thought she had Resident #1 strapped in correctly. The report documented it was plausible that the straps had come loose during the turn or that the resident had tried to stand. A Progress Note dated 3/9/24 at 9:37 PM documented the CNA (Certified Nursing Assistant) reported Resident #1 was really painful with movements getting out of the merry walker ready for bed. The note documented Tylenol was given. A Progress Note dated 3/10/24 at 1:39 PM documented Resident #1 complained of pain in the back of neck. Resident #1's neck was stiff and would not lift neck straight up. The note revealed Resident #1 needed full assistance with eating and drinking solids and fluids. The note documented Tylenol was given for neck pain that morning and a heat pad was applied to the neck. A Progress Note dated 3/11/24 at 2:38 PM documented Resident #1 self propelled in the wheelchair. Resident #1 complained of neck pain and was unable to lift head straight up. The note documented his neck was stiff. The note documented Tylenol was given and effective. A Progress Note dated 3/12/24 at 9:19 AM documented a new telephone order was received for Resident #1 to have Physical Therapy evaluation and treatment for wheelchair positioning and neck stiffness. The note documented Resident #1's wife notified and agreed with treatment. A Progress Note dated 3/12/24 at 10:32 AM documented Resident #1 complained of neck pain and Tylenol was given and a warm pack provided. A Progress Note dated 3/13/24 at 3:01 PM documented Resident #1's lacerations remained on the top of the scalp with dried blood and without pain when touched. Areas were cleansed. Resident #1 complained of neck pain. The note documented pain score was 10 out of 10. The note revealed Resident #1 had a lot of tension to the back of the head area and grimaced when head palpated. Resident #1's chin almost touched his chest and he had a harder time eating. Resident #1 had to use a straw to drink fluid as he was not able to tilt head back due to pain and stiffness. A Progress Note dated 3/13/24 at 6:48 PM documented Therapy assessed Resident #1 and reported that he may benefit from a muscle relaxer. Resident #1's back of neck was stiff and tight since the fall. Heat and Tylenol had been given for the pain of 10 out of 10. The note revealed a fax was sent to the PCP and the wife updated. The wife reported she had noticed during visit on 3/12/24, Resident #1's head had been down more than usual. The note documented at supper on 3/13/24, Resident #1 was able to drink without a straw and lift head a little further than earlier that day. A Progress Note dated 3/14/24 at 11:50 AM revealed a fax had returned from PCP regarding neck pain and new orders were received to start methocarbamol (muscle relaxant) 500 mg (milligrams) three times a day as needed for 14 days. The note documented Resident #1's wife was aware of the new order. A Progress Note dated 3/17/24 at 5:26 PM documented Resident #1 was transferred with the mechanical stand and two staff members and did not tolerate it well. The note documented Resident #1 would use a mechanical lift with assistance of two staff members for staff and resident safety. A Progress Note dated 3/19/24 at 3:08 PM revealed Therapy requested soft collar to support Resident #1's neck. The note documented a fax was sent to the PCP requesting an order. A Progress Note dated 3/19/24 at 5:50 PM revealed a new order was received from PCP for a soft collar brace. The note documented Resident #1's wife was notified of the new order and did not want to pay for the brace if it was over $100.00. The wife reported she would check the medical store and let the facility know. A Progress Note dated 3/20/24 at 12:29 PM documented Resident #1's wife came to the facility with a soft collar brace. The wife voiced concerns with Resident #1 not eating lunch. The note documented staff assisted Resident #1 with lunch and he refused to eat. Methocarbamol was given as Resident #1's neck appeared to be more [NAME] and not able to lift the head. The note documented Resident #1 leaning more to the left and unable to take drinks without straws and presented with challenges during feeding. A Progress Note dated 3/20/24 at 1:19 PM documented a new telephone order received from PCP for soft collar on in the morning and off at hour of sleep as Resident #1 tolerated. A Progress Note dated 3/21/24 at 12:47 PM documented Resident #1's wife at the facility for lunch and was concerned with Resident #1's neck pain. The wife reported Resident #1 had never had stiffness this long before and reported Resident #1 seemed to be in a lot of pain when touched. The note documented muscle relaxer, Tylenol and heat had been applied and effective at times. The wife wondered if a Chiropractor would be effective or able to do x-rays. The note documented a Chiropractic Office was notified of the wife's request and the office requested to talk to the wife. Resident #1's wife returned to the facility after lunch and requested for Resident #1 to be seen at Urgent Care for x-ray of the neck per Chiropractor's recommendations. The note revealed Urgent Care was notified of the situation, paperwork was given to Resident #1's wife and Resident #1 transported via facility van to Urgent Care. The note documented Resident #1's wife reported that she did not want to prolong anything, she just wanted him to be comfortable. The note revealed Resident #1 had not been able to relax his head while sleeping at night the last couple of nights. A Progress Note dated 3/21/14 at 12:56 PM documented Resident #1's wife was aware of the neck pain and initially refused assessment by PCP. A Progress Note dated 3/21/24 at 2:55 PM revealed the facility received a phone call from a Nurse Practitioner reporting Urgent Care was not able to do the x-ray as Resident #1 was in so much pain when they tried to straighten the neck. A new order was received for a CT (computed tomography) scan but would need a prior authorization through insurance first. A Progress Note dated 3/27/24 at 12:55 PM documented Resident #1's CT scan was scheduled for Friday, 3/29/24 at 11:00 AM. The note documented Resident #1's wife was aware. A Progress Note dated 3/29/24 at 4:53 PM documented the facility received a call from ARNP (Advance Registered Nurse Practitioner) who reported she had received the CT scan results and Resident #1 had a C2 fracture. The ARNP voiced she had reached out to Orthopedics for further services and would get back to the facility with orders. The note documented Resident #1's wife was updated. A Progress Note dated 3/29/24 at 7:55 PM documented the ARNP gave new orders to transfers Resident #1 to hospital emergency roiagnom on [DATE] via facility vehicle for placement of hard collar for acute fracture of the C2. A Progress Note dated 3/30/24 at 7:09 AM documented Resident #1 was out of the facility via facility van for appointment at a hospital in Sioux City. A Progress Note dated 3/30/24 at 10:01 AM documented Resident #1 had a hangman break (break in one or two bones in the neck) and would be admitted for surgery on 3/31/24. The note documented Resident #1's wife was aware and a bed hold was received. A Progress Note dated 4/2/24 at 12:25 PM revealed Resident #1 returned to the facility from the hospital with a Halo brace in place. Review of the IPOST dated 3/8/24 revealed Resident #1 was a DNR/Do Not Attempt Resuscitation and Comfort Measures only (Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction, and manual treatment of airway obstruction as needed for comfort. Patient prefers no transfer to hospital for life sustaining treatment. Transfer if comfort needs cannot be met in current location). Review of the CT Scan completed on 3/29/24 revealed the following impression: 1. Acute fracture C2 involving the junction bilateral pedicle with vertebral body. Minimally displaced. C2 shows 2 mm (millimeter) anterolisthesis (the upper vertebral body is positioned abnormally compared to the vertebral body below it) relative to C3. 2. Wedge configuration anterior body C3 new compared to prior CT from 2/7/2020. Age indeterminate consistent with mild anterior column wedge compression fracture. A Hospital Consultation report dated 3/30/24 documented Resident #1's head was tilted to the left about 70 degrees with his left ear almost on his shoulder. Attempts to straighten them up produced severe neck pain. The consultation note documented Resident #1 had a hangman's type C2 fracture right rotation slight angulation anteriorly of C2. The note revealed the Physician recommended treatment with distraction under sedation anesthesia then stabilized in a halo thoracic brace. A Hospital Progress Note dated 4/1/24 documented Resident #1 appeared to be tolerating his halo well. The note revealed Resident #1 was stable and could go back to the nursing home and to follow up in the office in one month for x-rays. On 4/15/24 at 12:45 PM, Staff B, Activity Assistant reported the bus ride occurred between 2-2:30 PM. Staff B reported Staff A loaded the residents on the van. Staff B reported it was her first time going in the van. She stated Resident #1 sat in the back of the van in a wheelchair directly behind the bench seats. She stated she remembered Staff A bending over and hooking some things up on his wheelchair but apparently it was not everything. Staff B reported she was riding along as an extra staff member for the activity. Staff B stated she had not been trained on the van. She stated she has now done the computer training (after the incident). Staff B reported Staff A was driving and she was in the passenger seat. She stated when they got to LeMars, they toured a residential area, she stated Staff A slowed down for a corner then quickly accelerated and that was when she heard a noise. Staff B stated she turned around and saw Resident #1 had tipped over. Staff B stated Staff A stopped the van on the street, they both got out of the van and went around to the back. She stated Staff A opened the back door and put the lift down. Staff B stated Resident #1 was still in the wheelchair that had tipped over backwards, his head was resting on the floor of the van. She stated they got Resident #1 upright. She stated Resident #1 was alert and conscious the whole time. She stated when they sat him up they noticed the laceration on the back of his head. Staff B stated she did not recall if safety straps were in place prior or after the incident. Staff B stated she was more concerned at that time if Resident #1 was okay. She stated once he was sat back up she recalled Staff A putting hooks to the wheelchair and putting a front strap across him. Staff B stated she wondered if the front strap was not in place before. She stated after the incident they returned to the facility. Staff B stated when they got back, Staff A unloaded Resident #1 and took him into the facility. Staff B stated some of the nurses asked her what had happened and she stated she thought Resident #1 was not strapped in correctly but she did not know for sure as she had not been trained. On 4/15/24 at 1:15 PM, Staff A, Activity Director reported Staff B and herself loaded the bus with five residents. Staff A stated everyone was buckled in and they went on a bus ride. She stated she went around a corner, Resident #1 tipped over in his wheelchair. She stated Staff B and herself got Resident #1 upright in the chair, buckled back in place and then headed back to the facility. Staff A stated she was the one who loaded Resident #1 into the van. She stated she thought she had applied the Q'straints to the wheelchair to hold it in place on the bus. Staff A stated two Q'straints go on the front of the wheelchair and two Q'straints go on the back of the wheelchair. When asked if she had applied the front seat belt, she stated she did not think so. She stated she thought she had totally forgotten to put the front strap on. She stated unless it got unbuckled. Staff A reported she was not going too fast around the corner. She stated she accelerated too fast. She stated she stopped the van on the road. She stated Staff B and herself went to the back of the bus and opened the door. Staff A stated she observed Resident #1 had tipped over backwards in his wheelchair. She stated he was still in his wheelchair but his butt was off the seat. Staff A stated Staff B and herself assisted Resident #1 upright by taking ahold of the wheelchair and tipping Resident #1 and the wheelchair up at the same time. Staff A stated Resident #1's head was bleeding. She stated there was a laceration on the top of his head. Staff A stated she was not sure what he hit his head on. Staff A reported she used some gauze from the 1st aid kit to clean the laceration and wipe off the blood. She stated she applied the Q'straints to the wheelchair and placed the front seat belt on the way back to the facility. She stated she did not call the facility prior to returning. She stated, I just brought him back. Staff A stated Resident #1 was awake, smiling and denied any pain. She stated she took Resident #1 into the facility and talked to Staff C, RN (Registered Nurse) and Staff E, RN/DON (Director of Nursing). Staff A stated Staff C and Staff D took Resident #1 to evaluate him. Staff A reported after the incident she took a class on the computer regarding the Q'straints. She stated she was fired on Friday, April 5th due to safety concerns with the residents. She stated after Resident #1 had tipped over in the bus, she was not sure what had happened with the Q'straints. She stated the Q'straint by the door was all the way unrolled, it appeared it had been in place but had come off the wheelchair. She stated the Q'straint across from the door appeared as it had not been put into place as it was still rolled up the mechanism/mount and the two Q'straints back of the wheelchair were in place. On 4/15/24 at 2:13 PM, Staff D, RN reported she was the nurse on duty when Staff A brought Resident #1 back to the facility from the bus ride. She stated she had been told in the report that Resident #1 was having stroke-like symptoms the day before and the Dr. had been faxed. Staff D stated Staff A reported to her Resident #1 had fallen in the van in the wheelchair. Staff D stated she assessed him from the point when he had been brought back to the facility. She stated she started neuro's (neurological assessment) which were hard to assess as the neuro's had been abnormal the day before because of the stroke-like symptoms. Staff D stated his wife was aware of the symptoms. She stated Resident #1 had lacerations to the back of his head. She stated she cleansed the lacerations, dried them and left them open to air. Staff D stated Staff E, DON called Resident #1's wife to update her. Staff D stated Staff E reported Resident #1's wife did not want him sent for a further evaluation. She stated she sent a fax to the Dr to report the fall and lacerations. Staff D stated Staff A reported Resident #1 fell backwards in his wheelchair. Staff D reported that Staff A made a comment in front of Staff E and herself, Can we not chart he wasn't buckled in correctly as I don't want to lose my job. Staff D reported Staff E took Staff A straight to her office. She stated she was not sure what happened after that but the comment was made on 3/8/24. She stated the facility asked for a statement about Staff A's comment on 4/4/24 when Corporate was in the building. Staff D stated Resident #1's wife wanted him to go to the Chiropractor but the Chiropractor would not work on him without imaging. She stated x-rays could not be done because they could not straighten out his neck so they had to get a prior authorization to get a CT scan. She stated that it took a couple of days to get approved. She stated the ARNP called her and told her there was a C2 fracture and asked if he was wearing the soft collar. Staff D reported Resident #1 would wear the soft collar during the day and it would be removed at night. She stated the ANRP reported he was going to need a hard collar. She stated she called Resident #1's wife regarding the fracture. Staff D stated Resident #1's wife wanted him to be comfortable and wanted to correct his neck. She stated they went over the risk vs. benefit. On 4/15/24 at 3:35PM, the Administrator reported the facility did not have any van policies prior to Resident #1's incident. She stated policies were created after the incident. She stated the driver of the van (Staff A) had training prior to the incident. She reported all the drivers received training after the incident including Staff A. The Administrator reported Staff A no longer worked at the facility. On 4/15/24 at 3:39 PM, Staff E RN/DON reported she believed Staff B brought Resident #1 to the nurse station from the bus ride. Staff E stated Staff B reported Resident #1 had fallen out of the wheelchair on the bus. She stated Staff A and Staff B picked Resident #1 up and came directly back to the facility. She stated Resident #1 was calm and had four lacerations to the back of his head. Staff E stated she talked to Staff A after parking the bus and Staff A reported Resident #1 had tipped backwards and thought he had hit his head on the ramp behind him. She stated the lacerations were oozing so Staff D, RN cleansed the areas and completed the neuro's exam. Staff E stated one pupil was sluggish and one hand grip weaker which were the same findings as the day before. She stated Resident #1's wife reported Resident #1 had frequent TIAs and Resident #1 s symptoms had been consistent with previous TIAs. Staff E stated Resident #1's wife was at the facility the day of the bus trip and encouraged him to go. Staff E stated Staff A was going around a corner, when she accelerated, Resident #1 tipped back in his wheelchair. Staff E stated Staff A reported she had applied the Q'straints but could not verify she had tightened them. Staff E reported she did not recall Staff A making the statement about not charting Resident #1 wasn't buckled in correctly. She stated she took Staff A to the office to call the Administrator to tell her what had happened. Staff E stated she called the wife, and reported Resident #1 had fallen out of the wheelchair. She stated Resident #1's wife stated he had probably tried to stand up and pushed himself back. Staff E stated she told the wife that nobody saw the incident happen and the facility would do an investigation and check the Q'straints to make sure they were working properly. Staff E stated she reported the abnormal neuro's to the wife and the wife was not concerned regarding the findings. She stated the wife did not want any further evaluations or Resident #1 to be sent out. Staff E stated the wife commented about the TIA and was not concerned. Staff E stated she could not comment if the front seat belt was in place. She stated she was more concerned about the chair tipping backwards and if the chair was secured down with the Q'straints in the front. Staff E reported Resident #1's head tilted to the left and became more pronounced with the recent stroke symptoms. She stated the wife reported his neck issue would usually get better after a few days and it did not. She stated she called Resident #1 's PCP to get a Physical Therapy order for neck stiffness. Staff E stated Resident #1's wife was okay with the order for PT. Staff E stated Therapy suggested a soft collar which was ordered by the PCP. She stated Resident #1's wife obtained the soft collar and brought it to the facility. She stated Resident #1 wore the soft collar during the day and off at night. She stated his neck was straight when he laid in bed and did not have the tilt. She reported that his pain varied. He would wax and wean. She stated there were periods of time his pain was improving. She stated the soft collar did hold his neck up a little. She stated she was surprised with the CT scan results. On 4/15/24 at 4:19 PM, Staff A, Activity Director re-interviewed and asked if she had stated not to chart Resident #1 wasn't buckled in correctly as she couldn't afford to lose her job. Staff A stated she may have said it out of fear and worry. She stated she says a lot of stuff when she is not thinking. She stated sometimes she says things she does not mean. She stated she does not always think before she speaks. She stated it is a problem she has and something she would like to change. She stated she was in tears after the incident. She stated she cannot say for sure if she said it or not. On 4/16/24 at 8:00 AM, the Administrator reported the probable conclusion from the facility investigation was that the Q'straints were not applied properly. She stated if they were applied properly along with the seat belt the chair would have not tipped. She stated the facility does not know for sure as the driver, Staff A was not able to recall details and Staff B was an activity assistant that rode along for the activity and did not pay attention to the restraints. The Administrator reported Staff A had been trained previously. She stated the training did not change and the bus was the same. She stated after the facility learned of the severity of the injuries they did a deeper dive into the incident and did a reenactment. She stated at that time they concluded that Staff A was intentionally careless and was terminated on 4/5/24. She stated after the incident Staff A did not drive the bus. The Administrator stated if you look at Staff A's employee file there were other concerns related to carelessness. The Administrator stated she did not think Staff A intentionally tried to hurt someone. When asked if she thought Staff A was driving too fast, she stated no. The Administrator stated sometimes Staff A acts before thinking. The Administrator reported Resident #1's wife had reported his neck stiffness and posture was a symptom of his TIAs. She stated Resident #1 had a gradual decline and his wife wanted him to go see the chiropractor as she thought his poor neck posture was leading to his neck being stiff. She stated the x-rays and CT scan were needed for him to be able to see the Chiropractor. She stated they were not suspecting an injury and were surprised by the results. The Administrator reported the Q'straint posters were added to the bus after the incident occurred as an intervention and reminder to staff. She stated the expectations for the Q'straints had not changed, they were the same before and after the incident. The Administrator reported during the investigation the facility learned they had different wheelchairs and needed different attachments to be secured in the van correctly. She stated they ordered and recieved Q'straint loops. On 4/16/24 at 8:30 AM, Staff C, Maintenance Director reported he had assessed the van after the incident and did not find anything wrong with the Q'straints. He stated Q'straints were working appropriately. Staff C reported if the Q'straints were properly placed the wheelchair should not have tipped backwards. He stated after the incident he completed training and became certified. He stated after watching the training videos he identified the [NAME] in the van needed to be moved to ensure the Q'Straints were applied correctly and at the right angle. Staff C demonstrated inside the van how he moved the [NAME] and how to attach the Q'straints correctly along with the seat belt. Staff C also demonstrated where the [NAME] and wheelchair would have been during the incident/fall. He stated after doing the training the facility learned that with the tilt-n-space wheelchairs need additional equipment (Q'straint loop) to secure the chair appropriately and to have the straps at the right angle. Staff C demonstrated that the Q'straints do not retract on their own and that you have to push a red button for the strap to retract. He stated if the Q'straints are applied correctly and tightened, he did not think the restraints would be able to come off on their own. He verified that if the Q'strainst had not been pulled out from the mechanism (unrolled) then it had not been applied to the wheelchair. Staff C reported Resident #1 was now using a Care Foam Chair and showed surveyor Resident #1's tilt-n-space wheelchair that was in the therapy room. The Administrator came to the therapy room. The Administrator stated during the investigation the facility could not determine which wheelchair Resident #1 was in during the ride (tilt-n-space) or standard wheelchair. She stated Staff A or Staff B could not recall. She stated the facility applied anti-tippers to both of the chairs after the incident. On 4/15/24 at 9:35 AM, Resident #1's wife reported she thought he had a mini stroke. She stated his whole upper body would tip when he had a stroke. She said his head tilted more than normal but she thought it was from the stroke. She stated a week or two after the fall he started hurting. She stated his head was going down and he could not lift it. She stated before he would snap out of it and straighten out. She stated it didn't happen this time and his head kept falling down. She stated she was visiting on the day of the bus ride and she had asked that he go along as he enjoyed going on rides. She stated he was switched to a regular wheelchair so he could sit up and see better. She stated she asked the nurse about going to the Chiropractor because she thought sometime might be out of place. She stated her Chiropractor suggested doing an x-ray first. She stated it was a good thing we did. She stated the staff was giving pain pills and muscle relaxers and they were not helping him and not loosening him up. She stated the DR told her the CT scan showed a lot of little strokes. She stated he couldn ' t raise his head and if they tried to raise his head, he would say ouch. She stated his chin was on his chest. She stated she thought something needed to be done as he was having a hard time eating and had to use a straw to drink. She stated that after the fall and as time went on his head tipped more and more. She stated she had met him at Dr ' s appointments before and would see the staff load and unload him from the bus. She stated during those times, the wheelchair was secured in the bus. She stated the day of the bus ride she did not see him get loaded on the bus so she does not know if the wheelchair was secured or if he had the seat belt on during the ride. On 4/16/24 at 1:49 PM, Staff F, RN reported Resident #1 was ve [TRUNCATED]

Based on clinical record review, staff interviews, facility record review and facility policy review, the facility failed to ensure residents at risk for elopement were unable to exit the facility unattended for 1 of 1 residents reviewed for elopement (Resident #1). The facility failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a total census of 52 residents. The facility State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of June 27th, 2023 on July 11, 2023. The Facility Staff removed the Immediate Jeopardy on July 11, 2023 through the following actions: 1. Staff education conducted on 6/28/23 for the elopement policy that included resident headcounts for unexplained alarms and elopement drills. The elopement drills occurred on each shift then four times weekly and monthly thereafter. 2. The facility reduced the alarm reactivation delay for security doors from 30 seconds to 15 seconds completed on 7/5/23. 3. The security on the Chronic Confused Dementing Illness (CCDI) unit doors changed from a push button entry to a coded entry completed on 7/5/23. 4. The keypad codes reset for the secured doors completed on 7/5/23. 5. The second North exterior basement door, by the activities area, secured on 7/11/23. 6. Additional education given to staff to visually monitor security doors as visitors and staff pass through to prevent residents from exiting the area before the door closes and the alarm reactivates completed on 7/11/23. 7. The facility made certain every staff member received elopement education and instructed to count each resident when a source of a door alarm cannot be determined completed on 7/11/23. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented their plan of action, performed observations to ensure staff entered and exited secured doors safely and that all doors were properly secured. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of dementia with other behavioral disturbances, cognitive communication deficit and other symptoms and signs involving cognitive functions and awareness. The MDS showed the Brief Interview for Mental Status (BIMS) score of 4 which indicated severe cognitive impairment. Review of Resident #1 ' s Progress Notes revealed the following: a. On 5/31/2023 2:31 PM Resident #1 is wandering and checking doors this PM. He is smiling but tells me that he is a little defeated. He explains he has 3 families running over him. I reassure him he can turn the situation around. He continues on his way. b. On 6/4/2023 at 12:19 PM Resident #1 wandered throughout this shift in and out of the resident's rooms. Removing items from one room and bringing it to others. He reports he is very busy. Pleasant and cooperative. c. On 6/27/2023 3:30 PM Upon return to CCDI, head to toe assessment and skin assessment completed. Vital signs: temperature 98.5, pulse 84, respirations 12, blood pressure 130/80 and oxygen saturation 96% room air. Alert to self only which is normal for the resident. Lung sounds clear all fields, no sign or symptoms (s/s) of respiratory distress exhibited. Respirations are easy and unlabored. Bowel sounds present x 4 quadrants, abdomen is soft, nontender with palpitation. The resident is able to move all extremities within normal limits, no discomfort noted. Skin assessed and no impairments noted. Ambulates with steady gait. Dependent edema noted bilateral ankles which is also normal for the resident. Hand grips equal, pupils are equal, round and reactive to light and accommodation in bilateral eyes, skin dry and intact. Mood pleasant and cooperative. Denies pain when asked. Demeanor is calm and smiling. No S/S of injury noted. In an interview on 7/11/23 at 10:29 AM, Staff A, Certified Nursing Assistant (CNA), reported while driving to work on 6/27/23 herself and Staff B, CNA, observed Resident #1 walking near a local business located beside a highway. After assisting the resident into the car they drove him back to the facility, located approximately six blocks away. In an interview on 7/11/23 at 10:51 AM, Staff C, CNA, reported that she assisted another resident to the bathroom when she heard the door alarm sound. Staff C then heard an unidentified staff member report on the radio that it was all clear. Staff C later learned Resident #1 was found outside. Staff C also revealed that she did not receive elopement education and did not participate in elopement drills that day or thereafter. In an interview on 7/11/23 at 10:51 AM, Staff E, CNA, reported that she assisted a weak resident from the shower when the door alarm sounded. Staff E checked the alarming door approximately four to five minutes after the alarm started. When Staff E arrived at the alarming door she looked in both directions, and looked around the side of the building, but could not determine who or what triggered the alarm. Staff E stated that she called an all clear because she could not find anyone near the alarming door. Staff E reported after the elopement she received elopement education and now knows if the source of the door alarm cannot be determined, staff need to count all the residents to determine if someone is missing. On 7/12/23 at 11:48 PM a facility tour completed with the Administration and Maintenance Supervisor (MS). During the tour the Administrator explained the facility investigation concluded Resident #1 followed a staff member through two secured doors before the doors completely shut. This allowed the resident to exit both doors without alerting staff. The resident then exited an exterior door located behind the CCDI unit. The alarm sounded, staff investigated and called an all clear on the radio. The Administrator reported the staff that investigated the alarm failed to follow protocol. A headcount of all the residents should have been obtained when the source of the alarm is undetermined. Later in the tour the second north exterior basement door, located by the activities area, found to open to the outside when pushed. The door failed to be secured with a lock or door alarm. When asked why the door wasn ' t secured, the Administrator stated, it has always been that way. When asked if a resident could exit through the door without staff knowing, the Administrator answered, yes. This unsecured door could potentially allow a resident to ambulate approximately one block North to a highway with a speed limit of 35 miles per hour. The Administrator stated, we identified this area during our QAPI (Quality Assurance and Performance Improvement) assessment as an area that needed improvement. When asked if there was a plan to secure the door, the Administrator reported a company is scheduled to come the next day to identify needs and create a plan to better secure the building. When further asked what the immediate plan was to secure the door, the Administrator replied, we could install a door knob lock. The Administrator then turned to the MS and instructed him to complete the task that day. At 11:03 AM the Administrator reported the completion of the installation of the door knob lock. During the conclusion of the tour the exterior door of the staff entrance found not to be locked or secured by an alarm. The inside door to the hall where residents reside found to be secured with a keypad push button lock located on the door handle. Upon exiting this area the inside door did not close independently thus leaving the door unlocked and unsecured. The MS pulled the door shut manually. The Wandering Risk assessment dated [DATE] showed Resident #1 a high risk for wandering and resided in the CCDI Unit. The Care Plan last revised 6/7/23 showed Resident #1 as a high risk for elopement and appropriate for the CCDI unit. The Resident Safety: Elopement Risk, Wanderguard and Door Alarm policy dated 2023 directed staff that if no resident is seen at a site of a door alarm, staff should immediately start the Missing Person Procedure. Door Alarms: Each exit door has a catch all alarm that will sound if the appropriate code is not entered prior to opening the door. Once at the engaged door staff should immediately look for a resident that has or is trying to exit the building. If there is no resident seen, staff should immediately start the missing resident procedure. If an alarm is discovered de-activated or not working, staff will perform an immediate head count to ensure all residents are accounted for. The Missing Person policy dated 2023 identified upon discovery of a missing resident: 1. Conduct a quick but thorough search of the until and logical places where the resident may have gone. 2. If a resident cannot be located, the nurse in charge of the area shall be responsible for notifying the administrator and page overhead code chickadee. This will alert all staff that a resident is missing. Immediate attempts shall be made to determine where the resident was last seen and what the resident was wearing. This information should be indicated on the Information on missing residents form and given to the commande On 7/12/23 at 5:19 PM the Administrator reported that staff need to ensure that residents do not exit out of a secured door with staff. Staff should wait to make certain doors are completely closed before leaving the area. The Administrator reported that if a resident or person can not be found at the alarming door, staff are required to complete a headcount of all residents.

Based on observations, facility policy, and staff interview, the facility failed to maintain a clean kitchen with white particles in drawers and black substance adhered to the range vent, ensure hygienic practices were followed in the kitchen to include wearing hairnets, hand hygiene, correct use of face masks, covering exposed kitchen utensils and storing scoops inside food containers. The facility reported a census of 51 residents. Findings include: Observations on 3/21/22 at 11:06 AM include the following: a. White particles in 5 of the drawers along counter below the 3 pane window, on the shelf above the range, and on the snack cart. b. Range vent hoods with black adhered substance and the tops of the sprinkler pipes for the range unit had white loose particles. c. Scoop in the Thick and Easy container and the container brown sugar was stored in. d. The silverware [MEDICATION(S)] container was uncovered. e. Staff A, Dietary Aide, lowered her face mask exposing her nose and mouth at 11:21 AM in the kitchen while lunch was being served. Observations on 3/23/22 at 9:58 AM include the following: a. The scoop in Thick and Easy container and brown sugar storage container. The silverware [MEDICATION(S)] container was uncovered. b. Staff C, Occupational Therapist, entered the main kitchen area without wearing a hairnet. c. Staff B picked an item up from the floor while wearing gloves. Staff B then touched a bread and butter sandwich without performing hand hygiene or changing gloves. Staff B did not perform hand hygiene or change gloves throughout the remainder of lunch service including preparing soup for a resident. d. Staff A lowered her face mask to expose her nose and mouth while standing next to the steam table. The Policy for Dietary Department, undated, directed staff to wash their hands when visibly soiled and before handling food. The same policy directed hair restraints are to worn while in the kitchen area. The same policy revealed all food preparation equipment, dishes, and utensils must be maintained in a clean and sanitary manner. In an interview on 3/24/22 at 9:44 AM. the Dietary Manager (DM) reported she would expect the kitchen to be clean, the range vents to be clean, that scoops would not be stored inside food containers, kitchen utensils would be either covered or placed inside cupboards, that face masks would cover the nose and mouth while in the kitchen, that staff would perform hand hygiene after picking an item up from the floor during meal service, and kitchen staff would ensure that non-kitchen staff wore hairnets when they entered the main area of the kitchen.

Based on observation, staff interview and record review, the facility failed to update the resident's care plan to include the resident's usage of opioid pain medications for 2 of 13 reviewed (Residents #4 and #42). The facility reported a census of 51 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed the Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Review of signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] a. Order dated 12/31/21 for [MEDICATION(S)] 50 mg take 1 tablet by mouth 2 times a day as needed (PRN) for pain. b. Order dated 3/1/22 for [MEDICATION(S)] 50 mg take 1 tablet by mouth every morning and keep PRN dosage. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. January 2022, Resident #4 received 16 doses of PRN [MEDICATION(S)] in a 31 day period. b. February 2022, Resident #4 received 16 doses of PRN [MEDICATION(S)] in a 28 day period. c. March 2022, Resident #4 received 22 scheduled doses of [MEDICATION(S)] out of 22 days and received 4 doses of PRN [MEDICATION(S)] in a 22 day period. The Care Plan with a revised date of 3/16/22 lacked any documentation pertaining to the residents usage and side effects to watch for with opioid pain medications. The Care Plan lacked non-pharmacological interventions to help reduce pain. 2. The MDS assessment dated [DATE] for Resident #42 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed the BIMS score of 04, indicating severe cognitive impairment. The MDS revealed Resident #42 had taken opioid pain medication the last 7 out of 7 days. Review of signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] a. Order dated 1/7/22 with a start date of 1/8/22 for [MEDICATION(S)] 50mg three times a day for pain. The Care Plan with a revised date of 3/23/22 lacked any documentation pertaining to the residents usage and side effects to watch for with opioid pain medications. The Care Plan lacked non-pharmacological interventions to help reduce pain. Review of the facility provided policy titled Care Plan Development Process dated 2022 revealed the purpose is to provide a summary of the specific goals and care needs for each resident, and an outline of how the care team will address those needs. The policy continues on to state the care plan is to be reviewed and revised in accordance with state and federal regulations and professional standards of nursing. The MDS coordinator is responsible for ensuring that each portion of the care plan is up to date and the care plan is to be reviewed and updated by all staff providing care or services for the resident. The care plan will include a statement of the focus, goal and specific interventions. Interview on 3/23/22 at 3:09 p.m., with the Administrator revealed she would expect the opioid pain medication to be listed on the Care Plan.

Based on observation, review of policy and staff interview the facility failed to ensure food was stored under sanitary conditions by not dating food when opened. The facility reported a census of 57 residents. Findings include: During the initial tour of the kitchen at 9:43 AM on 3/9/20, observed two packages of opened diced green peppers in the walk-in freezer not dated when opened. In the stand-up refrigerator unit, observed 2 bottles of chocolate syrup, 1 bottle of strawberry syrup, 1 bottle of thickened juice, 1 bottle of thickened water, and 3 opened 1 liters of soda that were not dated when opened. In the dry storage room, observed 3 opened packages of dry noodles not dated when opened. Review of the document titled, Food storage, dated 2018, stated: beverages must be dated when opened and discarded after 24 hours, other opened containers must be dated and sealed and covered during storage. During an interview with the Dietary Manager at 9:43 AM on 3/9/20, she stated she would expect all items to be dated when opened.

Based on interviews and record reviews, the facility failed to report an altercation between two residents (Resident #37 and #15) of 15 residents reviewed. The facility reported a census of 57. Findings include: 1. The Minimum Data Set (MDS) completed for Resident #37 with an Assessment Reference Date (ARD) of 1/20/20, showed the resident had long-term and short-term memory problems. The resident had [DIAGNOSES REDACTED]. The resident showed physical and behavioral symptoms directed towards others for one to three days out of the seven days of the lookback period. The Provider Notification, dated 1/28/20, stated the resident was seen at the breakfast table that morning. During that time, the resident noted to grab another resident she was sitting by, and then also slapped the peer's right arm. The peer noted to have an abrasion to their right arm. The Incident Note, dated 1/28/20 at 8:45 AM, documented the resident had resident to resident contact with a peer at the breakfast table. The Certified Nurses' Aide (CNA) intervened immediately and separated the residents. An intervention put into place and the care plan updated. The Care Plan, dated 9/24/18, showed the problem of behaviors with the intervention dated 9/24/18 of aggression towards peers and staff. Staff to observe and intervene as necessary. The Care Plan, dated 10/25/19, showed the problem of communication with the intervention dated 1/28/20, the resident was to sit at a bedside table in the dining room. 2. The MDS completed for Resident #15 with an ARD of 12/9/19, showed the resident had short-term and long-term memory problems. The resident had [DIAGNOSES REDACTED]. The resident had physical and behavioral symptoms directed toward others for one to three in the seven day lookback period. The Provider Notification, dated 1/28/20, stated the resident was noted at the breakfast table that morning. A peer sitting by the resident grabbed the resident's right wrist and slapped the resident's right arm. An abrasion noted to the right wrist following the incident. An assessment of the resident's arm with no signs or symptoms of pain from the resident. The resident's Power of Attorney (POA) notified and interventions put into place. The Incident Note, dated 1/28/20 at 8:45 AM, stated the CNA reported the resident had resident to resident contact with another peer at the breakfast table. The CNA intervened immediately and separated the residents. The notification to the provider and POA completed with an intervention put into place. An abrasion noted to the right wrist-the information reported to the Director of Nursing (DON) and Administrator. The investigation completed by the DON, dated 1/28/20, stated Staff B, CNA, was with Resident #37 and Resident #15 in the Assisted Dining Room. Staff B observed Resident #37 reach and touched Resident #15's right arm. Resident #15 pulled her arm away from Resident #37, resulting in a small skin tear to the right wrist. Staff B responded by separating the two residents and alerting the nurse. The determination of the incident was that due to their dementia and Resident #37 having a tendency for mood fluctuation, an appropriate intervention was for Resident #37 to be seated at a tray side table away from peers at meals. During an interview on 3/11/20 at 8:58 AM, Staff B, CNA stated she remembered the situation but did not witness the incident. She stated all she saw was Staff A, CNA, telling the residents, oh no, don't do that. During an interview on 3/11/20 at 9:02 AM, Staff A, CNA stated she couldn't remember the situation too well as it was two months ago. Staff A said Resident #15 likes to take other resident's plates. Staff A believed Resident #15 had her fork on Resident #37's plate. Staff A remembered seeing Resident #37 squeezing Resident #15's arm aggressively and then slapped her arm. During an interview on 3/11/20 at 1:34 PM, the DON reported she lacked notification the resident had slapped the other resident. She stated if she had received the information that the other resident had slapped the other resident, she would have reported it. The DON then said she did not make the ultimate decision on reporting the incident. The Administrator decided about notifying DIA, and due to her surgery, she would not be able to comment on the situation. During an interview on 3/12/20 at 8:45 AM, the Director of Clinical Coordination stated the facility was submitting a rapid improvement process for the failure to report. The policy, Resident Safety, dated 2020, reported residents would not be subject to abuse by anyone, including but not limited to: facility staff, other residents, consultants, volunteers, the staff of other agencies, family members, legal guardians, friends, or other individuals. Any such incidents will be investigated, and any findings will be reported to the Iowa Department of Inspections and Appeals (DIA) for such data in the Abuse Registry. All allegations of resident abuse shall be reported to the DIA not later than two hours after the allegations made. The document, Resident/System: Reporting Protocol, dated 3/11/20, stated the problem was on 1/28/20; an incident between two residents of the facility resulted in one resident receiving a small abrasion to her forearm. After an interview with the charge nurse, management did not feel that this was a reportable incident. During the annual survey, documentation reviewed and determination made that this should have reported to the DIA.

Based on observation, record review, facility policy and FDA food code and staff interview, the facility failed to assure hair covers were worn during 1 meal, food was reheated to the required temperature during 1 (one) meal, and proper dishwashing temperatures. The facility reported a census of 59 residents. Findings include: 1. During an observation on 03/11/19 7:12 a.m. the Dietary Manager (DM) served breakfast from a small table top steam table with no hairnet on. Policy: The undated facility policy Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices directed hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. The FDA Food Code (YEAR), 2-402.11 indicated food service employees should wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covered body hair, that were designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single use articles. 2. During an observation on 3/12/19, near the end of meal service, dietary staff ran out of potatoes and the mixed vegetables. The DM took leftover potatoes and carrots from the refrigerator. Staff A heated the carrots to over 170 degrees on the stove. The DM heated the mashed potatoes in the microwave. He stated when he pulled them out they registered 150 in 1 place and 170 in another. He sat the potatoes near the steam table uncovered and Staff A Cook served the potatoes to residents. Policy: The undated facility Nutrient and Heat Retention of Foods policy directed hot food should be reheated to an internal temperature of 165 degrees for at least 15 seconds before it could be re-served to residents. The FDA Food Code (YEAR), 3-403.11 indicated foods that were cooked, cooled, and reheated for hot holding should be reheated so all parts of the food reached a temperature of at least 165 degrees for 15 seconds. Food reheated in a microwave oven for hot holding should be reheated so that all parts of the food reach a temperature of at least 165 degrees and the food was rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. 3. During observation on 03/12/19 at 8:50 a.m. Staff B, Cook, placed a tray of dirty dishes into the dishwasher, started it and turned away to continue to prepare the next tray of dirty dishes. Observation of the dishwasher showed the temperature did not go higher than 96 degrees during the wash cycle, with the rinse temperature of 122 degrees during the first round. Staff B checked the chlorine levels with an Ecolab test strip to reveal chlorine levels of 50 parts per million (ppm). A second observation showed a wash temp maximum of 106 degrees through the wash cycle, and the rinse temperature started at 124 degrees and immediately dropped to 114 degrees. The Ecolab Strip revealed chlorine levels of 50 ppm. The (MONTH) Dishwashing Record - Low Temperature Chemical form showed temperatures documented at greater than 120 degrees. During an interview on 03/12/19 at 9:21 a.m. the DM stated he didn't know the wash temperatures needed to be 120 degrees. During an interview on 03/12/19 at 9:35 a.m., Staff C, dietary aide, reported she recorded temperatures on the rinse cycle because she was told to. The dishwasher label directed staff a minimum wash and rinse temperature of 120 degrees F required. Policy: The facility policy regarding dishwashing machine use (with no review date) directed the operator to check temperatures using the machine gauge with each dishwashing machine cycle, and record the results in the facility approved log. The operator should monitor the gauge frequently during the dishwashing machine cycle. Staff should report Inadequate temperatures to the supervisor and corrected immediately. If hot water temperatures or chemical sanitation concentrations did not meet requirements, staff should contact the appropriate vendor and ensure temperatures or concentrations were adjusted.

Based on observation, record review, and staff interview, the facility failed to follow the menu for 5 residents on pureed diets, and 40 residents on regular and mechanical soft diets on the main floor. The facility reported a census of 59 residents. Findings include: 1. The regular/no added salt diet and mechanical soft menu for Monday 3/11/19 included 1 (one) each bread and margarine. During observation of the noon meal service on 3/11/19 the residents did not receive bread and butter. During the service 1 (one) resident requested bread and butter. 2. The puree menu for Monday 3/11/19 included 1 (one) serving of pureed bread and butter. During observation on 3/11/19 at 9:50 a.m. Staff A Cook pureed food for the residents on a pureed diet. Staff A did not puree bread and butter. During an interview on 3/11/19 at 12:30 p.m. the Dietary Manager stated the residents did not get bread. He did not think it was on the menu.

Based on clinical record review, observation, and resident and staff interviews, the facility failed to provide ongoing assessment, care planning and current physician orders [REDACTED].#12). The facility reported a census of 59 residents. Findings included: The Minimum Data Set (MDS) assessment, dated 12/25/18, recorded Resident #12 had intact cognition, independent with ambulation in the room, and required limited staff assistance with bed mobility, transfers, and toileting. The MDS documented the resident's [DIAGNOSES REDACTED]. A Physician order [REDACTED]. (micrograms), 90 mcg base, 2 puffs inhaled orally every 4 hours when needed for shortness of breath. The resident's record lacked any type of assessment or evaluation of the resident's ability for safe self administration of medications and for keeping medications at the bedside. The resident's care plan lacked documentation the resident self administered medications. An observation 3/10/19 at 12:10 p.m., revealed an Ellipta Incruse inhaler and a bottle of Latanoprost eye drops on the table beside the chair the resident slept in. The resident stated he used both medications daily and staff allowed him to keep the medication in his room. During an observation 3/10/19 at 2:30 p.m., the Ellipta Incruse inhaler and Latanoprost eye drops remained on the same table. During an observation 3/12/19 at 12:10 p.m. the resident had a [MEDICATION NAME] (used to treat [MEDICATION NAME]) inhaler on the right side of the table beside the chair he sleeps in. The resident stated the [MEDICATION NAME] inhaler is his rescue inhaler. The Latanoprost bottle remained on the left side of the resident's chair and the Ellipta was not there. The resident stated the Latanoprost bottle empty and the staff removed the Ellipta inhaler. During an interview 3/12/19 at 10:10 a.m., the DON (Director of Nursing) stated the facility had never completed an assessment to evaluate resident's ability to safely self administer medications or provided a locked container for safe storage of the medications in a resident's room.

Based on observation, record review and interview the facility failed to obtain quarterly physician orders [REDACTED].#25). The facility reported a census of 59 residents. Findings included: 1. A Minimum Data Set (MDS) assessment tool, dated 1/21/19 ,identified Resident #25 with short and long term memory impairment, severely impaired cognitive skills for daily decision making, had total dependence on staff for bed mobility, transfers, personal hygiene, bathing, and toileting, and unable to balance or ambulate. The MDS documented the resident with upper extremity range of motion impairment on 1 side, bilateral lower extremity range of motion impairment, used a trunk restraint when in a chair or out of bed and a wheel chair for mobility. The MDS revealed the resident's [DIAGNOSES REDACTED]. A Fall Risk Assessment, dated 8/9/18, revealed the resident had a score of 14 and a score of 10 or above indicated the resident had a high risk for falls. The resident's care plan with a start date of 8/9/18, identified the resident used a seat belt when in the wheel chair. A goal date of 4/18/19 documented the resident would remain free from complications of restraint use. Interventions, dated 8/17/18 directed staff the resident used a seat belt when in the wheel chair to help maintain and upright position, prevent sliding down in the chair, staff to release the seat belt routinely, educate family on restraint use, continue to evaluate the need and effectiveness of the restraint, and therapy evaluations when needed. The care plan had an update on 3/12/19 directing staff to check the resident every 30 minutes and release the resident's restraint at least every 2 hours. Record review revealed the staff had documented 30 minute checks and the seat belt in place for no longer than 2 hours since admission. The record lacked monthly restraint assessments for the continued need for the seat belt restraint. Observations 3/11/19 at 7:53 a.m. and 3/12/19 at 8:07 a.m. and 1:00 p.m. revealed the resident sitting in a wheel chair with a seat belt restraint on. During an interview 3/12/19 at 3:30 p.m., the DON (Director of Nursing) stated she had been unable to find documentation of a physician order [REDACTED]. During an interview 3/12/19 at 3:42 p.m., the MDS nurse stated she had not been able to find a physician's orders [REDACTED]. During an interview 3/13/19 at 8:35 a.m. the DON stated the facility had not completed any type of assessments for the continued used of a physical restraint and the restraints effects on the resident. The facility undated Regulations State for restraints documented the use of a restraint not intended for discipline or convenience and the facility needed a systemic and gradual process to reduce restraint use.

Based on record review and staff interview the facility failed to report a diagnosed Major Mental Illness and/or Mental Disorder on a Level 1 Preadmission Screening and Resident Review (PASRR) upon admission to the facility for 1 of 4 residents reviewed for PASSR (Resident #57). The facility reported a census of 59 residents. Findings included: A Minimum Data Set (MDS) assessment dated [DATE], identified the resident's admission to the facility as 2/3/17. Review of a Medical [DIAGNOSES REDACTED]. A Level 1 PASSR form, completed by the faciliity Director of Nursing (DON) on 2/3/17, included 2 sections. One titled Major Mental Illness and the other titled Mental Illness. The same sections directed staff to document the resident's major mental illness such as delusional disorder or a mental disorder such as depression. Further review of the PASSR form revealed the DON documented the resident had no major mental illness and no mental disorders. Review of the PASSR reviewers response (ASCEND) with a review date of 2/3/17, revealed the resident had been assessed with [REDACTED]. 03/12/19 10:48 AM During interview on 3/12/19 at 10:48 A.M., the DON confirmed she missed the resident's delusional disorder and [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The DON stated the facility lacked a PASSR policy and procedure.

Based on record review and staff interview the facility failed to develop and implement a comprehensive person centered care plan for 1 of 16 residents reviewed, (Resident #45). The facility reported a census of 59 residents. Findings include: The Minimum Data Set with assessment reference date of 2/6/19 showed Resident #45 took an anticoagulant medication seven out seven days during the assessment period. The resident had [DIAGNOSES REDACTED]. The resident scored 15 on the Brief Interview for Mental Status indicating no cognitive impairment. The Medication Administration Record [REDACTED] A review of the written summary of the baseline care plan completed on 1/9/19, documented the resident's family had requested telling the resident what as on his plate during meals or snacks because he struggled seeing objects close to him. In the continued summary it documented the resident had a history of [REDACTED]. The resident's Comprehensive Care Plan did not include use of Eliquis and potential adverse side effects. The care plan did not include the resident's family request to tell the resident what was on his plate during meals or snacks. The care plan did not include the resident's history of laryngospasm, or the procedure should it occur. During an interview on 3/12/19 at 8:38 a.m., the Director of Nursing reported she would expect the care plan to include those directives/requests but they do not care plan Eliquis.

Based on observation, record review and staff interview, the facility failed to assure a resident at risk for skin breakdown received care to prevent the development of a pressure sore for 1 of 3 residents reviewed with pressure ulcers (Resident #3). The sample consisted of 16 residents and the facility reported a census of 59 residents. According to a [DIAGNOSES REDACTED].#3's [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE], revealed the resident had difficulty with short and long term memory and moderately impaired decision making skills. The MDS indicated the resident required extensive assistance from staff with bed mobility, transfers and ambulation and identified the resident as at risk for pressure ulcer development. Staff recorded the resident as having no pressure ulcers at the time of the MDS assessment. A Braden form dated 12/10/18, identified the resident at risk for skin impairment. Resident #3's Care Plan (not dated), with a target date of 2/11/19, included a problem for being at risk for pressure ulcer/skin development and a goal for the resident to not sustain a pressure ulcer. The same care plan included the following interventions: gripper socks at bedtime protective ointment to the groin ROHO cushion in recliner Staff will reposition routinely The care plan lacked intervention to prevent pressure ulcer development on the resident's heels. Review of a New Skin form dated 2/13/19, revealed staff noted a 3.6 centimeter(cm) by 2 cm., un-stageable pressure ulcer to the left heel. Staff documented the resident spent much time in a living room recliner and noted the foot rest on the recliner the resident sat in, had minimal cushion. Staff documented the wound likely occurred from a combination of friction and pressure on the recliner footrest. Review of a care plan with a problem date of 2/13/19 revealed a new problem for a pressure ulcer to her left heel. Not until the development of the resident's heel ulcer, did staff provide the following interventions: provide a pillow under the resident's feet in a recliner alternating air mattress to the resident's bed On 2/15/19 staff provided Prevalon Sage boots (pressure relieving) to the resident's bilateral lower extremities. Review of Wound/Skin Healing Record forms revealed the following descriptions and measurements of the resident's left heel ulcer: 2/13/19 - 3.6 cm by 2 cm in size and described the wound bed as black/eschar. 2/20/19- 2.5 cm by 1.1 cm in size and described the wound bed as black/eschar. 2/27/10 - 2.5 cm by 1.9 cm in size and described the wound bed as yellow in color 3/6/19 - 2.5 cm by 1.0 cm in size and described the wound bed as pink in color. Review of a W[NAME] (Wound Ostomy Continent) Nursing Flowsheets, revealed the following documentation: 2/13/19- The W[NAME] documented the resident sat in a recliner with her feet elevated on a foot rest on a pillow. The W[NAME] noted the resident frequently sat and slept in a recliner due to agitation and reportedly rested better in a recliner. She noted the current recliner the resident sat in had a firm ridge on the edge of the foot rest which could have caused the wound. The W[NAME] documented not being able to stage the wound due to being covered with an encrustation. She noted the etiology of the wound as caused from pressure, complicated by shear and friction when the resident had been restless with her feet up on the footrest. The W[NAME] recommended the resident sit in a different recliner and provide pressure redistribution boots to offload the heels. 2/21/19 - The W[NAME] documented part of the wound crust on the resident's left heel as lifted, needed to remove the crust to prevent the crust from catching on something and being pulled off. She identified the peri wound (wound under the crust) as pink and healthy. 2/27/19- The W[NAME] identified the wound base with a yellow cover and unknown if the wound base continued to be healthy or would again form a crust. Observation on 3/12/19 at 10:05 A.M., revealed the resident sat in a recliner in living room with bilateral prevalon heel protector boots. The resident's heels in the boots rested directly on the recliner foot rest. During interview on 3/12/19 at 10:06 A.M., Staff D - Certified Nurse Aid (CNA), confirmed prior to the development of the resident's left heel pressure ulcer, the resident either sat in a recliner in the living room with the foot rest up, or was in bed. Staff D confirmed prior to the resident's heel boots, her heels rested directly on the recliner foot rest. During interview on 3/12/19 at 10:30 A.M., Staff E, CNA, described a typical day for the resident prior to the development of her left heel ulcer, as being transferred to a recliner in the living room after breakfast, transfer back to a wheelchair for lunch and back to a recliner after lunch. Staff E stated the resident typically wore gripper socks and her heels rested directly on the recliner foot rest. Observation on 3/12/19 1:25 P.M., revealed the resident laid in bed in her room. Staff G, Registered Nurse (RN), partially removed the resident's left heel pressure ulcer dressing. Observation revealed a yellow and white open area in the middle of the pressure ulcer, with a small amount of serosanguinous drainage on the dressing. The resident displayed no signs of pain during the dressing removal. Staff G reported the pressure ulcer had been scheduled to be measured again on 3/13/19. During interview on 3/12/19 2:40 P.M., the DON described the resident as being restless when she sat in a recliner. The DON reported staff repositioned the resident routinely, but lacked documentation of repositioning. During interview on 3/12/19 at 2:55 P.M., Staff F, CNA confirmed she worked the evening shift. She described a routine afternoon/evening for the resident as being in a recliner when she arrived to work until approximately 2:00 -2:30 P.M. She stated staff toileted the resident prior to supper, transferred the resident to a wheelchair for supper, toileted the resident after supper and transferred the resident back to her recliner until approximately 8:00 P.M. At approximately 8:00 P.M., staff prepared the resident for bed. Staff F reported the resident always wore gripper socks and stated sometimes her heels rested directly on a recliner foot rest. Observation on 3/13/19 at 7:55 A.M., revealed Staff H, RN, changed Resident #3's dressing on her left heel. Staff H measured the pressure ulcer at 1.2 cm by 1 cm in size. During the dressing change, the resident displayed no signs of pain.

Based on record review and interview the facility failed to adequately supervise 1 resident of 2 residents reviewed for falls (Resident #25). The facility reported a census of 59 residents. Findings included: 1. An admission Minimum Data Set (MDS) assessment tool, dated 8/17/18, identified Resident #25 with short and long term memory impairment, had total dependence on staff for bed mobility, transfers, and toileting, and unable to balance or ambulate. The MDS documented the resident with upper extremity range of motion impairment on 1 side, bilateral lower extremity range of motion impairment, and used a trunk restraint when in a chair or out of bed. The MDS revealed the resident's [DIAGNOSES REDACTED]. A Fall Risk Assessment, dated 8/9/18, revealed the resident had a score of 14 and a score of 10 or above indicated the resident had a high risk for falls. The resident's care plan identified the resident at risk for falls (no start date). A goal date of 4/18/19 documented no serious injuries would result from the falls. The care plan interventions, dated 8/17/18, directed staff to anticipate and meet the resident's needs and the resident had a low bed with a mattress on the floor. The resident's care plan with a start date of 8/9/18, identified the resident used a seat belt when in the wheel chair. A goal date of 4/18/19 documented the resident would remain free from complications of restraint use. Interventions, dated 8/17/18 directed staff the resident used a seat belt when in the wheel chair to help maintain and upright position, prevent sliding down in the chair, staff to release the seat belt routinely, educate family on restraint use, continue to evaluate the need and effectiveness of the restraint, and therapy evaluations when needed. A nursing Progress Notes entry, dated 9/5/18 at 6:10 p.m., documented a CNA (Certified Nurse's Aide) reported the resident found on the floor on his back without any injuries or pain. Staff assessed the resident and used a full body lift to transfer the resident back into the wheel chair. An un-witnessed form #366, dated 9/5/18 at 6:10 p.m., documented no predisposing environmental, physiological, situational factors contributed to the incident. Form #366 documented the resident had been at therapy using a stand aid, the CNA's removed the resident from the stand aide band had not applied the resident's seat belt, resulting in the resident sliding out of the wheel chair shortly after. During an interview 3/12/19 at 1:37 p.m., the DON (Director of Nursing) verified the resident had slid out of the wheel chair because the staff had not put the resident's seat belt on.

Based on observation, record review, facility policy and staff interview the facility failed to identify a weight loss for 1 of 1 Residents reviewed, (Resident #1). The facility reported a census of 59 Residents. The findings include: The Minimum Data Set (MDS) with an assessment reference date of 2/25/19 assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The resident had [DIAGNOSES REDACTED]. The MDS documented the resident did not have a weight loss of 5% or more in 1 month or 10% or more in 6 months. The Weights and Vitals record indicated the resident had a significant weight loss, with the following weights recorded: a. 2/4/19 at 1:23 p.m. 110.4 pounds, b. 3/5/19 at 1:04 p.m., 103.0 pounds (a 7.4# or 6.6% loss), c. 3/7/19 at 3:13 p.m., 102.2 pounds (an 8.2# or 7.4% loss). The Nutrition/Snacks record documented the resident accepted a snack six times in the last 30 days. A Dietitian note completed on 2/22/19 showed the Dietitian completed a quarterly assessment. The resident weighed 110 pounds, stable over 30 days, and down 1% in 180 days; not significant changes. The resident consumed a regular diet and fed herself. Oral intake equaled 25-75%, and labs from 1-7-19 noted. The resident took med pass 4 ounces three times a day for weight management. Weight stable overall, and nutrition needs met. Would continue with plans and monitor ongoing. The monthly assessment completed on 3/11/2019 at 1:01 p.m., showed the resident weight on 3/7/19, 102.2#, weight on 9/17/18, 111.2#. The resident had a poor appetite. She received 4 ounces of Medpass at each meal and needed frequent prompting to drink it. Snacks were offered at each snack pass. During observation on 3/11/19 at 7:36 a.m., the resident finished the entire meal on the plate for breakfast. The care plan identified the resident at risk for significant weight loss with a goal of maintaining her weight through her next review. The interventions included she did better with meals when her spouse joined her, supplements per order, encourage the resident to take time with meals, and weight per routine. During an interview on 3/12/19 at 8:38 a.m. the Director of Nursing reported the facility did have a weight protocol and policy. She stated she would follow the policy regarding weight management. Policy: The facility policy regarding weight management reviewed on 7/19/18 directed residents would have body weight measured at least monthly. Residents identified with a significant gain or loss would have their weights checked weekly. Newly admitted residents would have their weights obtained weekly times 4 weeks to determine baseline. The procedure indicated the following: a. The nursing assistant would obtain weights and report to the charge nurse for documentation. b. The Charge Nurse/Dietician/Director of Nursing would review weights and identify significant changes. Significant change will be determined by a loss or gain of 5% in one month, 7.5% in three months, or 10% in six months. The formula for determining the percentage of gain/loss: previous weight minus current weight divided by previous weight. c. If there was a discrepancy of 5 or more pounds gain/loss noted from the previous weight, and the resident weighed exactly the same method (clothed vs unclothed, same time, same scale, etc ) this would indicate the need to reweigh the resident. d. Should the reweight not establish a variance, the reweight would be documented. e. The Charge Nurse would notify the Doctor, Dietitian, Dietary Service Manager, Director of Nursing and the resident's family about the weight loss/gain.

Based on record review, observation and staff interviews, the facility failed to provide adequate supervision to protect 1 of 4 residents from hazards. Staff interviews and record review revealed Resident #1 eloped from the facility on 5/27/17 without staff's knowledge and another resident alerted the facility staff Resident #1 had been outside. Observation of the area where staff caught up to Resident #1 showed a nearby highway (20 feet away) with a speed limit of 45 miles per hour. Staff interviews revealed when they found Resident #1, he/she had been persistent in wanting to talk with the nearby police officer who was on the highway. Record review revealed Resident #1's judgement and thought process impaired with delusions and paranoia. The findings constitute an immediate jeopardy to the resident's health and safety. The facility identified a census of 52 current residents. Findings include: 1. According to review of the clinical record, Resident #1's Minimum Data Set ((MDS) dated [DATE] identified [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs (brief interview for mental status) score of 13 which indicated intact cognition. Documentation in Resident #1's MDS indicated he/she had psychosis of delusions (misconceptions or beliefs that are firmly held, contrary to reality). Review of the facility plan of care dated 3/16/17 identified Resident #1 will make delusional statements and frequently wants to contact Law enforcement regarding delusions. The care plan identified the resident can be difficult to redirect at times and directed staff to allow alone time and discuss the Iowa Hawkeye's. On 5/27/17 the care plan update to include the following directions: a. 15 minute checks for whereabouts. b. Wander guard applied to the right ankle. Review of the Elopement Risk assessment dated [DATE] revealed the resident moved to the main unit and adjusted well. The resident used a Wanderguard without problems. On 12/19/16 the Elopement Risk revealed Resident #1 had no further need for a Wanderguard and no wandering risk. Review of the physician progress notes [REDACTED].#1 had been upset about living at the nursing home and had been court ordered for some time now. Resident #1 had reported feeling like he/she was in prison and did not deserve to be in a nursing home. Review of the Behavioral Health note dated 5/4/17 revealed Resident #1 had been irritable to the point where he/she felt as though he/she needed to get a lawyer to get him/her out of the nursing home. The note identified Resident #1 does have a history of being very territorial and this continued in addition to paranoia. The documentation revealed Resident #1 had significant periods of sundowning primarily in the evenings and becomes increasingly confused and more difficult to redirect. Resident #1 had a history of [REDACTED]. The note revealed Resident #1 had been at his/her current placement (nursing home) since 9/8/14 and his/her thought process are delusional and paranoia. Resident #1's judgement and thought content is confused. The note documented Resident #1 reported he/she had been receiving nebulizer treatment and he/she had been brought to the nursing home by the cops against (his/her will). Review of the Physician Communication For dated 5/27/17 at 6:30 PM identified the resident eloped at 4:10 PM from the facility to the outdoors. Staff caught up with the resident and redirected him/her back to the inside in the wheel chair. By 4:15 PM the resident sat in the wheelchair and calmed down. The resident had stated earlier I need to get to the police station. Notified spouse after a head-to-toe assessment done and he/she had no injury and no fall. Review of the Incident/Accident Report dated 5/25/17 at 4:10 PM revealed the resident had an elopement to the outside. The resident agitated. The incident report identified the certified nursing assistant (CNA) used a wheelchair for the resident when he/she returned to the facility. The nurse notified and staff initiated 15 minute checks and placed a Wanderguard on his/her right ankle. Review of the sign posted near the front door alarm key pad instructed residents/staff/visitors to please enter: 1 2 3 4 before leaving. Review of the Physician order [REDACTED]. Review of the Physician Communication Form dated 3/6/17 revealed the order for tessalon pearls 100 mg 3 times a day as needed. Review of the Physician Communication Form dated 4/27/16 revealed the order for mucinex 1 to 2 tablets every 12 hours as needed. Review of the MAR(medication administration record) dated May 2017 revealed on 5/27/17 Q-tussin 10 ml administered at 8:56 AM. No other cough medication documented administered on 5/27/17. Review of the Charting Notes dated 5/27/17 at 7:30 p.m. revealed at 4:00 p.m. the resident walked to the nurse's station requesting cough syrup. Staff told Resident #1 he/she had to wait until done helping another resident. A CNA (certified nursing assistant) got him/her a chair to sit in and wait at the nurses station. At 4:10 p.m. another resident had stopped staff and stated the resident sitting in the chair had went outside and walked down the street. The CNA went outside and called for help over the walk-ie (talkie) (hand held radio). The note identified the alarm wasn't going off until staff ran to get the resident and opened the door and activated the alarm. Staff notified at 4:12 p.m. by another CNA and went outside. (When staff caught up with Resident #1), the resident sat in the wheelchair after walking down the street toward Highway 3. (An orange pole on the opposite side of the street marked the location where he/she walked too.) The notes identified there had been a police car pulling a car over on Highway 3 at the time of the incident. The CNA transported Resident #1 back to the nursing home, he/she kept saying he/she needed to talk to the police because he/she was sick of waiting around. The resident had stated that he//she had pushed the numbers (code posted) to get out (side). The resident returned inside with no injuries. The charge nurse and the DON (Director of Nursing) were notified. The resident 1st refused his/her medications and then took the medication after getting cough syrup. Resident put on 15 minute checks and Wander guard placed on his/her right ankle. During observational tour of the area Resident #1 had been seen on the street (Lincoln Street) next to the curb showed: Highway 3 with a speed limit of 45 miles per hour approximately 20 feet from the location where staff caught up with the resident (marking of orange pole on the opposite side of the street). An untitled document (statement from witness Resident #2) dated 5/31/17 documented the following: When asked about the incident when Resident #1 went out the front door, Resident #2 reported : that man/woman went out through the doors. He/she had not asked anyone for the code that he/she could recall. Resident #2 thought Resident #1 was going for a short walk but when he/she did not return, Resident #2 became afraid that he/she was heading for the highway and alerted staff. During an interview with Staff M, CNA on 6/2/17 at 9:15 AM she stated the resident came to the nurse's station and had been shaky. He/she asked Staff N for cough medicine. She asked him/her to wait and had been in the middle of medication pass for another resident. Staff M went to another resident's room to assist to the dining room. A resident (Resident #2) had been in the dining room looking out the window and told her a resident had been outside. She looked and noticed the resident (Resident #1) had been a ways away. She called on the walkie-talkie for help and ran outside. When she caught up to the resident, he/she wanted to get the Police and there had been a police officer on the highway. On the way back to the facility she asked the resident about the alarm and he/she stated I pushed the code. Staff M reported the resident had not had other attempts to leave. During an interview with Staff F, CNA on 6/1/17 at 1:10 PM she stated the resident had been in the resident pretty independent. She stated the resident came up to the nurses station and asked for cough medicine. He/she had been upset at the time. She told Staff N and she said she would get it in a little bit. The resident then sat at the nurse's station and stated It's going to be years before I get any. I'll be waiting for that as long as I wait for Christmas. Staff F went to break at 4:07 PM and approximately 4 minutes later, a call came over the walkie-talkie (radio) that a resident was by Highway 3. The resident had his/her walker and had been approximately 20 feet from the highway and stated I want to talk to the Police. She stated there had been a Police car stopped on the highway. Staff got a wheelchair and wheeled the resident back to the facility. During an interview with Staff K, CNA on 6/1/17 at 4:00 PM she stated around 3:45 PM the resident pulled the call light and asked for cough syrup. She told Staff N when she went up to the desk. The resident walked up to the nurses desk with his/her walker and wanted cough syrup. Staff went to him/her and got a chair so he/she could sit down. Staff N said I will get it in just a minute. Staff K then clocked out at 4:06 PM for a break. Staff K heard over the walkie-talkie (radio) the resident had been outside by Highway 3. She ran outside with Staff F and heard no alarm sound. Staff M had already been with the resident. Staff K went back in the facility to get a wheelchair. She further stated the resident stated I want to talk to the cops, I want to talk to the cops. Police were on the highway. Staff talked the resident into sitting in the wheelchair and returned to the facility at 4:15 PM. During an interview with Staff N, CMA on 6/2/17 at 9:45 PM she stated the resident ambulated to the nurse's station and said wanted cough syrup. She told him/her, OK I'll get it as soon as I can. She further stated no one had told her prior to this he/she asked for cough syrup. During an interview with Staff I. CNA on 6/1/16 at 3:00 PM she stated she had heard the resident state on a previous day if he/she didn't get their cough medicine, he/she was busting out of here and going to the Doctor him/herself. During an interview with Staff C, CNA/CMA (certified medication assistant) on 6/1/17 at 12:15 p.m. she stated the resident gets coughing spells. He/she stated he/she did not want to be here because we don't do enough for him/her. Staff C stated staff give the resident cough medication after coughing spells. Staff C reported Resident #1 had stated this is a prison and did not want to be here. During an interview with Staff A, CNA on 6/1/17 at 11:45 AM she stated the resident brings up the Police when he/she is worked up. Staff A stated coughing spells get him/her worked up and upset when not able to have cough medicine. She stated she remembers 2 to 3 times the resident upset and wanted to talk to Police. Staff A reported there are no other resident that wander. During an interview with Staff O, LPN (licensed practical nurse) on 6/2/17 at 11:15 AM she stated she had been in the unit downstairs and informed over the walk-ie radio the resident walked out of the facility. He/she used the code to silence the alarm. When Resident #1 returned she did an assessment around 6:00 PM and the resident had been real sleepy and just stated he/she had been OK. Staff O stated a Wanderguard and 15 minute checks were being done. An interview with the Administrator revealed the facility took the following measures and corrected the IJ: During an interview with the Administrator on 6/1/17 at 10:30 a.m., she stated the resident exited the facility through the front door on 5/27/17. She further stated the door had a sign directing instructions to enter 1 2 3 4 at the time of the elopement. The Administrator stated Resident #1 appeared to enter the code to bypass the alarm. On 5/30/17, the Administrator reported the sign to alert the code was removed on Tuesday (5/30/17). She stated the front door had a Wanderguard alarm but Resident #1 did not use a Wanderguard at that time. After the incident, a Wanderguard was added on 5/27/17 (and 15 minute checks). She further stated she had been in the building in her office on 5/29/17 and watched the front door from 9:00 AM to 5:15 PM. The Administrator stated an all staff in-service was held on 5/30/17 which included re-education on elopement prevention. A review of the Staff Education form titled Resident Elopement Prevention Agreement directed all staff to do the following: Effective May 30, 2017 - Codes posted at the doors have been removed. a. All exit doors are equipped with alarm device's that sound when the door is opened unless the proper bypass code is entered at the door. b. These door alarms are to be kept activated at all times except when one staff member is exiting and another staff member is physically at the alarm panel and prepared to reactivate the alarm immediately after the other staff member exits. c. No staff member shall deactivate am alarm and then exit the building through the door that has been deactivated. d. No staff member shall turn off or reset an alarm that is sounding unless that staff member has personally verified by visual inspection, or has been told by another staff member who has done such as visual inspection, that there has not been an unauthorized departure from the building by a resident e. Any employee's failure to comply with these requirements may result in disciplinary action up to and including termination. f. I have received a copy of the procedure to be implemented when a resident has been determined to be, or is thought to be, missing from the building.

Based on record review, staff interview and review of the facility policy/procedures, the facility failed to ensure each resident received adequate supervision and assistance devices to ensure against hazards from self for 2 of 11 residents reviewed (Resident #8 and #7). The facility reported a census of 45 residents. Findings include: 1. A Minimum Data Set (MDS) assessment tool dated 5/30/16, revealed Resident #8's [DIAGNOSES REDACTED]. The MDS identified the resident's cognition as severely impaired, required extensive assistance from staff with transfer and ambulation (walking) and identified his/her balance as unsteady with walking but able to stabilize with staff assistance. A Fall Risk assessment dated [DATE] identified the resident as at high risk for falls. A Care Plan dated 6/1/16, directed the staff to provide assist of 1-2 staff for ambulation with cares. A facility Gait Belts policy included direction encouraging staff who provide direct resident care, to utilize a gait belt whenever hands on assistance is needed for transfer and/or ambulation unless otherwise contraindicated, to ensure a resident's safety. The policy explained the gait belt could serve as a handle for the resident to grasp if the resident began to fall, which could help prevent the fall or control the resident ' s descent. A Fall Assessment Form dated 1/22/16 at 7:45 A.M., revealed Resident #8 stood up from a dining room chair, lost his/her balance and fell to the floor. Staff documented the resident incurred no injury. A Fall Assessment Form dated 6/10/16 at (no time documented) revealed Staff B, Certified Nurse Aid (CNA) escorted Resident #8 from his/her living area across a hallway to a shower room. Staff documented Staff B opened the shower room door and while she opened the door, the resident fell to the floor. The assessment form and clinical record lacked an investigation into Staff B's use of a gait belt and/or if Staff B had a physical hold on the resident at the time of the fall. A Nurse's Note dated 6/10/16 at 8:15 A.M., revealed staff notified Staff C, Registered Nurse/RN, the resident fell . Staff C went to the room and saw that the resident lay on the floor on his/her left side, with his/her face in the carpet. Staff C noted a laceration on the resident's left eyebrow that bled, and documented the resident was very restless and appeared uncomfortable, as his/her elbow was wedged under him/her. Staff C also documented due to the resident's memory loss and diagnosis, staff had been unable to reason with the resident, and 2 staff held the resident's hands in an attempt to calm the resident and supported his/her head for comfort. Staff transferred the resident to an emergency room via ambulance. The documentation lacked information regarding an investigation into the use or non-use of a gait belt at the time of the resident's fall. An emergency room (ER) Visit Note dated 6/10/16 revealed a Physician documented the resident presented to the ER with a 2 centimeter (cm) laceration on the left forehead. The Physician described the area as a skin tear plus a laceration, and identified the skin as torn back with the underlying dermis (second layer of skin) torn as well. The Physician placed 3 sutures to close the laceration. Observation on 9/21/16 at 10:00 A.M., revealed Staff A, CNA, stood at Resident #8's side and they both ambulated through the resident's bedroom door. The resident ambulated with a shuffling gait. Closer observation revealed no gait belt around the resident's waist. During the same observation, Staff A confirmed she had no gait belt on the resident and reported she didn ' t always place a gait belt on the resident when assisting the resident with ambulation. During interview on 9/21/16 at 10:25 A.M., the facility Director of Nursing (DON) stated staff needed to use a gait belt when they assisted Resident #8 with ambulation. During interview on 9/21/16 at 11:05 A.M., Staff C stated staff should use a gait belt when assisting Resident #8 with ambulation. During a telephone interview on 9/21/16 at 4:00 P.M., Staff B confirmed she escorted Resident #8 from his/her living area, across a short hallway to a shower room. Staff B stated she had no gait belt around the resident's waist, but held the resident's hand until they arrived at the shower door. Staff B stated she let go of the resident's hand in order to use a key to open the shower room door, turned her back on the resident, and the resident fell to the floor. Staff B stated she never used a gait belt when she assisted Resident #8 with ambulation. 2. According to the MDS dated [DATE], Resident #7 had [DIAGNOSES REDACTED]. The MDS identified the resident ' s cognition as severely impaired and revealed he/she required extensive assistance of one staff with bed mobility, transfers and ambulation in his/her room. The MDS documented the resident as only able to stabilize with assistance from staff when moving from a seated to a standing position and walking. A Fall Risk assessment dated [DATE] identified the resident as at high risk for falls. A Care Plan with a start date of 5/3/16 included a category for safety/falls and devices. The Care Plan directed staff to provide assist of 1 staff with bed mobility and noted the resident was able to make significant changes in position in bed, and also documented the use of a high/low bed, a personal alarm when not in a wheelchair, and a seat belt alarm. An undated facility Accidents/Incidents Investigations and Reporting Policy and Procedure defined a fall as resident found on floor or an unwitnessed accident or injury. A Fall Assessment Form dated 11/21/15 at 1:50 P.M., revealed staff heard the resident say I fell . Staff found the resident laying on the floor in his/her room. Staff documented the resident's seat belt alarm had not been in use at the time of the fall. The resident sustained [REDACTED].M., revealed staff documented the resident had been in his/her wheelchair in his/her room prior to the fall). Review of Nurse's Note dated 7/25/16 at 1:00 P.M., revealed staff documented the resident's alarm sounded, and the resident had scooted him/herself from their low bed onto the floor. Staff documented this was not considered a fall as the resident had not changed planes intentionally and sustained no injury. The record lacked an investigation related to how the resident found their way to the floor, although the record revealed staff had not witnessed the resident moving from his/her bed to the floor. The documentation failed to contain information regarding how the resident had been found, such as on his/her buttocks, side, back etc. Review of a Nurse's Note dated 7/27/16 at 7:50 P.M., revealed staff documented the resident scooted him/herself to the floor from his/her low bed, but this was not considered a fall. Staff documented the resident sustained [REDACTED]. The documentation also failed to contain information regarding how the resident had been found, such as on his/her buttocks, side, back etc. During an interview on 9/20/16 at 9:25 A.M., the DON confirmed she had not considered staff finding the resident on the floor on 7/25/16 and 7/27/16 falls, and no investigation was completed regarding the same. During an interview on 9/20/16 at 12:50 P.M., the DON confirmed she could not be certain how the resident ended up on the floor as described above and confirmed no staff witnessed the event. During an interview on 9/21/16 at 7:32 A.M., Staff D, CNA stated if she found a resident on the floor, she needed to notify someone (such as a nurse), right away, as the resident may have fallen.

Based on record review, observation and staff interviews, the facility failed to provide adequate supervision and assistive devices in order to prevent accidents for 4 of 7 residents reviewed. ( Resident #3, #4, #5 & #6 ) The facility identified a census of 44 current residents. Findings include: 1. Resident #4 had a MDS with a reference date of 11/19/15. The MDS identified the resident ' s [DIAGNOSES REDACTED]. The MDS identified the resident with a BIMS score of 9. A score of 9 identified the resident with a moderate cognitive impairment. The MDS identified the resident required total dependence with bed mobility, transfers and toilet use. The Care Plan indicated the resident required the use of a wheelchair. The Care Plan dated 11/25/16 directed staff to transfer the resident with a Hoyer lift (mechanical lift). The Care Plan also directed staff to provide cues with eating and assistance as needed. The resident required a pureed diet with nectar thickened liquids. The Nurse ' s Notes dated 2/7/16 at 11:00 p.m. identified 3 blisters on right thigh and 1 blister had ruptured on left thigh. The note indicated the resident told staff he spilled hot coffee on self the previous night (2/6/16). An investigation report titled Bruise/Abrasion Investigation dated 2/8/16 at 2:00 AM indicated the resident had a popped blister on the left thigh and 3 intact blisters to the right thigh. The left thigh 2 by 1 cm (centimeters) and the right thigh 3 by 1 by 1 cm, 2 by 1.5 by 1 cm and 0.5 by 2 cm. The resident stated he/she spilled a hot cup of coffee on legs Saturday night (2/6/16). The new intervention included to not give hot drinks unless supervised by staff or family member. Review of the Non-Pressure Skin Condition Report dated 2/7/16 identified the left thigh had a popped blister that measured 2 by 1 cm. The Non-Pressure Skin Condition Report dated 2/7/16 revealed the right thigh had 3 intact blisters that measured 3 by 1 by 1 cm, 2 by 1.5 by 1 cm and 0.5 by 2 cm. Review of the facsimile to the physician dated 2/7/16 reflected the resident had 4 new blisters located to the bilateral inner thighs by the groin area. The resident stated he/she spilled a hot cup of coffee on his/her lap. The blister to left inner thigh popped and no longer intact. Three blisters to the right inner thigh all intact and fluid filled. Areas currently covered with 2 by 3 inch Telfa adhesive dressing. The new physician's order [REDACTED]. Review of the MAR (medication record review) dated 2/1/16 through 2/29/16 reflected an order to apply Silvadene (cream) to all burns when Silvadene arrived. The treatment started on 2/9/16 on shift 3 (2 days for treatment). On 2/18/16 at 11:00 a.m. the resident ' s spouse was interviewed and stated the resident spilled the hot coffee during the supper meal. The resident used a regular coffee cup and stated the resident ' s hands shake. The resident ' s left hand is worse than the right hand for shaking. The spouse described the resident as having shaky hands and mostly of the left hand. On 2/12/16 at 10:50 a.m., Staff I RN (Registered Nurse) was interviewed and stated the resident's spouse informed her that Resident #4 had spilled coffee. The spouse had not said anything more so Staff I stated she didn ' t ' think it would amount to anything. Staff I stated the facility did not know when the resident spilled the coffee. On 2/12/16 at 12:30 p.m., Staff B (cook) was interviewed and stated the dietary manager told her on Wednesday that the resident should not have coffee and did not know when the resident spilled the coffee or even had coffee. During an interview with the Interim Administrator on 2/12/16 at 1:30 PM she stated that the facility had just switched providers for the coffee maker. She called the new company today and they will come to the facility and check the temperature of the coffee maker. On 2/23/16 at 2:45 p.m., the Dietary Aide (Staff N) stated the resident did have coffee during evening meals. Staff N stated she always thickened the coffee to nectar consistence but had not been aware the resident spilled the coffee. Observation on 2/10/16 at 11:00 AM revealed Staff E, CNA pushed the resident in the wheelchair from the resident's room to the dining room approximately 86 feet. The wheelchair did not have pedals in place. Observation on 2/10/16 at 12:00 PM revealed staff E, RN pushed the resident in the wheelchair from the dining room table to the nurses ' station. The wheelchair did not have pedals in place. The resident had been sleeping in the wheelchair and not eating. Staff pushed the wheelchair and the resident had his/her eyes closed and appeared to be sleeping. The resident's feet scraped on the floor. 2. Resident #3 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 1/11/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident required limited assistance with bed mobility, transfers and ambulation. According to the MDS, the resident required the use of a walker. The MDS identified the resident had a BIMS (Brief interview for Mental Status) score of 3. A score of 3 determined the resident as severely cognitively impaired. The Care Plan dated 11/4/15 directed staff to assist the resident with a front wheeled walker for ambulation. Review of the Fall Risk assessment dated [DATE] indicated a total score of 18. A total score above 10 represented a high risk for falls. Observation on 2/10/16 at 12:45 PM reflected Staff M, CNA (Certified Nursing Assistant) pushed the resident from the dining room to the lounge area in the wheelchair. The resident did not have wheelchair pedals on the wheel chair. 3. Resident #5 had a MDS assessment with a reference date of 12/16/15. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had short and long term memory problems and had severely impaired cognitive skills for daily decision making. According to the MDS the resident required total dependence with bed mobility, transfers and eating. The MDS identified the resident required the use of a wheelchair. The Care Plan dated 9/22/15, directed staff to assist the resident with the wheelchair. Observation on 2/9/16 at 9:20 AM revealed Agency CNA wheeled the resident in the wheelchair from the front lounge area to the resident ' s room. The wheelchair did not have wheelchair pedals and the resident's toes touched the floor. 4. Resident #6 had a quarterly MDS assessment with a reference date of 1/11/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMS score of 4. A score of 4 identified the resident with a severe cognitive impairment. According to the MDS, the resident required extensive assistance with bed mobility, transfers and toilet use. The MDS identified the resident required the use of a wheelchair. The Care Plan (not dated) indicated the resident had a problem with self- care deficit due to dementia with behavioral disturbances, depressive disorder, hypertension and insomnia. The Care Plan indicated the resident self- propelled the wheelchair. Observation on 2/10/16 at 11:10 a.m. revealed a nursing assistant pushed the resident from the lounge area to the dining room table, a distance of approximately 30 feet. The wheelchair had no wheelchair pedals and the resident ' s feet, covered with socks (no shoes) were noted to have a slight bounce on the floor. On 2/12/16 at 7:40 a.m. The Director of Nursing was interviewed and stated the expectation of the staff in the dementia unit are to only push residents with wheelchair pedals on or cue to move self. It had not been addressed off of the unit.

Based on observation, record review and family and staff interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 4 of 5 residents reviewed. Resident #1's platform was in disrepair and the recliner chair that sat on the platform was not secured. The resident fell when the chair came forward over the area of the platform that was not repaired and sustained a hip fracture and died . The facility knew of the platform needing repaired approximately one month prior to the fall. Resident #1, #2 and #3 sustained falls when one staff worked on the unit and were busy with other residents before they could assist Resident #1, #2 and #3. Resident #2 received a dislocated fractured finger. Resident #3 fell and did not receive injury but the surveyor had to assist the one staff on duty lower the resident safely to the ground. Resident #5 disconnected the alarms and fell without injury. The facility knew the resident manipulated alarms prior to the fall but did not change alarm placement until after the fall. Two observations revealed the alarm in reach and beside the resident's arm. The Care Plan did not contain directives on alarm placement. The facility identified the facility census as 39 residents. Seventeen residents resided in the CCDI (Chronic Confusion Dementing Illness) unit. Findings include: 1. Resident #1 had an annual Minimum Data Set (MDS) assessment with a reference date of [DATE]. The MDS assessed Resident #1 with a brief interview for mental status score of 3. A score of 3 identified the resident as severely cognitively impaired. The assessment reflected the resident was sometimes understood by staff and the resident sometimes understood others. The resident had the following indicators of delirium: inattention and disorganized thinking. The MDS identified that the resident was fidgety and restless and that caused the resident to move around a lot more than usual in the previous 2 weeks. The resident required extensive assistance of staff with bed mobility, transfers, walking in room and corridor, dressing, toileting, personal hygiene and bathing. A balance during transitions and walking test identified the resident as not steady and only able to stabilize with staff assistance in all areas of testing. The resident had functional limitations in range of motion on one side of the upper and lower extremities. The resident used a walker for ambulation. The resident was frequently incontinent of bladder and not on a toileting program. The resident had [DIAGNOSES REDACTED]. The resident had one fall without injury in the previous assessment period. On [DATE] at 11:12 a.m. the social worker, who competed the mood section of the MDS, confirmed the resident as restless and fidgety in the 2 weeks prior to the MDS assessment. A fall risk assessment, completed on [DATE], identified the resident with a score of 16. A score of 10 or above represented the resident at a high risk for falls. A Care Plan Conference sheet dated [DATE] identified the nursing department documented it would be alright (OK) to use a baby monitor. The Care Plan in place when the [DATE] fall occurred (undated but with evaluation date of [DATE]), did not identify the resident at risk for falls or contain any directive to staff regarding supervision of the resident since the family refused alarms. The Care Plan did not contain the baby monitor intervention. The surveyor was unable to review the nurse aide care plan that was in place at the time of the incident. On [DATE] at 9:11 a.m., the Director of Nursing stated she does not save the old nurse aide care plans. She does them in "Word" and just deletes what was in place when she updates it. An Incident/Accident Report dated [DATE] at 10:35 p.m. identified Staff A (nurse aide) called for a nurse aide to come to the CCDI due to Resident #1's recliner chair tipped off of the platform that it sits on. The incident report identified the resident had pain in the left hip and could not move the left extremity as usual. When staff touched the left hip/leg, the resident screamed in pain. Staff B (charge nurse from temp agency) telephoned the ambulance which arrived at 11:15 p.m. to transport the resident to the hospital. The Fall Assessment Form, dated [DATE] at 10:35 p.m. identified the nurse aide reported the resident's chair tipped off of the platform. When Staff B evaluated the resident, she observed the resident's left leg flexed. Staff could not perform range of motion due to extreme pain when just touching the leg. Staff B documented the resident as already in bed when she arrived to the room. The resident could not stand. There were no direct witnesses to the incident. When Staff A entered the room, she observed the resident's chair tipped off the platform. Staff B notified the resident's daughter of the fall and the daughter identified that the chair platform needed repaired prior to the incident. A hospital history and physical dated [DATE] identified the resident as relatively healthy in fairly good health except for dementia. The resident fell last night coming down on the hip resulting in a markedly displaced intertrochanteric fracture if the left hip. The resident was admitted to the hospital for orthopedic surgery. An x-ray of the left hip showed a fracture of the left femoral neck, subcapital. The x-ray showed override and displacement with the femur displaced 2 centimeters superiorly. The hospital Discharge Summary dated [DATE], identified the resident underwent [REDACTED]. The Discharge Summary identified the resident remained in poor condition during the postoperative period due to not responding as well as anticipated. The resident did not appear very responsive or talkative and did not eat well. The family agreed to the use of Hospice and "let nature take its course" without insertion of a feeding tube. The resident writhed in pain from the surgery and appeared more comfortable with the use of medications. The resident was on comfort care and Morphine (narcotic) a few days prior to the resident's passing. The resident expired [DATE] at 11:05 a.m. surrounded by family. A funeral home copy of the death certificate dated [DATE] identified the immediate cause of death as: Senile Dementia of 7 years, due to or as a consequence of: Left Hip Fracture of 12 days and Hypertension of [AGE] years. In the "other significant conditions" area of the death certificate, the physician documented the resident fell at the nursing home causing fracture to the hip. The resident could not awaken appropriately to manage pain and allow resident to eat. The manner of death was: natural. A facility refusal of medical release, dated [DATE] identified the resident's responsible party did not want the facility to utilize alarms or merry walker assistance devices. A Care Conference dated [DATE] (difficulty determining date) identified the Care Plan team phoned the resident's responsible party on [DATE] (difficulty determining date) at 10:20 a.m. The Care Plan team identified the resident was up and down often. The resident's gait was unsteady and the resident required assistance with activities of daily living (ADLs). A Care Conference dated [DATE] identified the responsible party attended via phone. The care team notes identified the family agreed to the use of a baby monitor in the resident's room but continued to decline other alarms. The Nurse ' s Notes dated [DATE] at 9:30 p.m. identified the resident self- rose once that shift. The Nurse ' s Notes dated [DATE] at 8 p.m. revealed the resident self- rose several times and appeared restless. The Nurse ' s Notes dated [DATE] at 2 a.m. identified the resident as restless and up several times. Staff placed the resident in the recliner with a blanket and the resident appeared content watching television. The Nurse ' s Notes dated [DATE] at 8:30 p.m. revealed the resident self- rose four times that shift and appeared very restless. Staff took the resident to his/her room and elevated the foot rest and the resident appeared content. The Nurse ' s Notes dated [DATE] at 7 p.m. revealed the resident was very restless. Staff gave the resident a project but the resident continued to self- rise and wander the unit. The Nurse ' s Notes dated [DATE] at 11 p.m. identified staff came out of a resident ' s room and heard the resident say, "Oh Lord". Staff observed the resident wrapped in a blanket and lying face down on the floor beside the bed. The resident received a skin tear on the right knee 1.5 centimeters (cm.) by 1.5 cm. and a 2 cm. by 2 cm. skin tear to the left elbow. Staff observed no other injuries. The Nurse ' s Notes dated [DATE] at 8:30 p.m. identified the resident as very busy. The resident self- rose several times. The Nurse ' s notes dated [DATE] at 10:35 p.m. revealed the charge nurse was called to the atrium (CCDI). The resident was in the chair when it tipped over on platform. The resident was already back in bed when the nurse entered the room. The resident screamed in pain when touched and range of motion was not normal. The resident transported to the hospital via ambulance on the same date at 11:15 p.m. Staff That Worked When the Incident Occurred: On [DATE] at 5:08 a.m., Staff A stated the resident didn't want to go to bed for the 2 p.m. to 10 p.m. shift so he/she was in his/her room in the recliner. Staff A looked over and saw the resident go down to the floor with the recliner chair off the platform about 2 inches. Staff A observed the resident wedged between the wall and chair. Staff A identified the raised edge as not present on the front of the chair which allowed the chair to slide over the edge of the platform. The chair went sideways and over the platform edge. Staff A stated she thought if the raised edge was present; it would have made a difference and may have prevented the chair going over and across the platform. Staff A stated Staff C (evening charge nurse) knew about the missing raised piece and Staff C said she informed the maintenance person. The chair was not secured on the platform. She stated there were many times that she had to scoot the chair back on the platform because it was coming off the forward edge where the raised piece should have been. If the chair wasn't far enough back on the platform, it would slide because the platform didn't have the raised edge. Staff A stated she could hear the resident's walker rattle when the resident got up and then she would go in and help the resident. When asked if the baby monitor was in place when the fall occurred, Staff A stated it didn't work. The monitor was too static sounding and staff couldn't hear anything. She stated the charge nurses knew it didn't work. Staff A stated when the incident occurred she was caring for the two residents in the front room and alarms were going off. When she finished helping the other residents, she glanced in the room and saw the resident go down. She didn ' t know how long the resident stood there before going down. Staff A was alone in the unit at the time and that is why she called the main floor and asked Staff F to assist her with the resident. On [DATE] at 6:18 a.m. Staff F (nurse aide) stated he worked upstairs. Staff A called to see if he could help with Resident #1. When he got there, he observed the resident sitting in front of his/her recliner. He assumed the resident slid out of the recliner so he helped Staff A stand the resident and when the resident went to take his/her initial step, he/she complained of pain so they sat the resident down. He stated he agreed with Staff A's account of how the recliner was on the platform. On [DATE] at 3:22 p.m. Staff B (temp staff registered nurse) stated she became aware of the incident when she received report from another temp nurse. That temp nurse told her to finish report before assessing the resident. She stated Resident #1 was a resident that would get up without assistance. She assumed the resident rolled out of bed. After report and not more than 5 minutes since she first became aware of the resident's fall, Staff B went to the unit to assess the resident. The resident was in bed and holding his/her hip and in pain. Staff B realized the resident needed to be sent to the emergency room for examination. She stated she didn't look at the chair or the platform; she just focused on the resident. She just went by what Staff A said, that the chair tipped off the platform. Staff B notified the resident's responsible party of the incident and they said the platform had been in disrepair for months prior to the incident and previously asked staff to fix it but they did not fix it. Other staff: On [DATE] at 10:38 a.m., the Minimum Data Set (MDS) Care Plan Nurse was interviewed and stated she investigated the incident and made the initial report to the State agency. She stated she spoke with Staff B who told her the incident occurred while she was getting report. Staff B sent a nurse aide down. When Staff B got to the unit, the resident already laid in bed. Staff B assessed the resident and felt the resident should go to the emergency room for examination. She asked Staff B what she knew about the platform. Staff B didn't look into the cause. Staff B was a temp nurse so she just took care of the resident. She stated she didn't find out about the platform issue until she spoke with Staff A and Staff F and found out that probably played a part in the fall. Two days after the incident, she spoke with Staff F who told her he worked in the main area upstairs and Staff A asked him to come and help get the resident up. Staff F just complied and did as Staff A asked. She stated 3 other residents had platforms under their chairs and the facility checked those after the incident. All 3 chairs are secured to platforms. She stated she didn't know why Resident #1's chair was not secured to the platform. During the investigation, the surveyor attempted to contact and was unable to reach the maintenance person, who was no longer employed by the facility. On [DATE] at 1:20 p.m. Staff L (registered nurse) stated there was no maintenance log available. On [DATE] at 11:38 a.m. the Director of Nursing stated the resident used a recliner chair with arms. It sat on top of a wooden platform. Each edge of the platform should contain a raised edge. Resident #1's platform did not contain a raised front edge. It was missing. The night of the incident, the resident wanted to get up and took the chair and scooted to the front and fell in-between the TV stand and wall. The recliner chair was off the platform and turned so the chair was off the front of the platform a few inches. The DON stated she did not know how long the platform piece was missing. The DON stated she just found out about it after the incident. The DON heard staff knew about the missing edge but didn't know which staff. Staff B talked to the family who stated they told staff about it before the incident. She stated the resident's room was by the nurse ' s station and staff would keep the resident out by the nurse ' s station as much as possible. Staff toileted the resident routinely and made frequent observations of the resident. There was no set schedule for the observations. On [DATE] at 3:30 p.m., the DON stated the facility did not have a policy regarding the use of platforms. On [DATE] at 4:30 p.m., she stated she didn't know why the chair wasn't secured to the platform. On [DATE] at 2 p.m., Staff C (licensed practical nurse) stated the family insisted that the resident use the platform. The resident had problems getting up without the platform. The family brought the platform. Staff C stated one of the edges of the platform came off so she turned the side with the missing piece to the back of the platform and the family turned it so the missing piece area was at the front of the platform. Staff C stated every time staff placed the resident in the chair, they situated the chair on the platform. Staff C stated staff would hear the resident's walker and then they would run to the resident. The resident's room was across from the nurse ' s station and whenever they went by, they would look in the room. They also tried to distract the resident with activities when he/she became restless. Staff C stated she didn't know if the resident used a baby monitor the night the incident occurred. Staff C stated she discussed the platform with maintenance but she didn't follow up with maintenance. She told the maintenance person verbally. She stated the chair would shift side to side on the platform but she had never seen it come off. This happened every time the resident sat in the chair. Staff would then position it on the platform. She stated the family informed her of the missing platform piece about 3 weeks prior to the incident and she told the maintenance person right after that. On [DATE] at 1:10 p.m. Staff J (nurse aide) was interviewed and stated the chair would move back on the platform but staff would just push it forward. Staff would check the resident often. The room was by the nurse ' s station. The family didn't want alarms because they thought alarms would scare the resident. On [DATE] at 12:25 p.m. Staff L (registered nurse) was interviewed and stated the resident's chair sat on a platform and that made it easier for the resident to get up Staff L spoke with the family once about removing the platform to make it harder for the resident to get up since he/she didn't use alarms. The family said no. A lot of times the resident would be up by the time staff realized the resident got up. The resident was unsteady. Staff L stated she listened for the resident's walker. She stated there was a danger in that because staff couldn't always hear the walker. Staff L stated she learned that one of the raised edges on the platform was broken. She stated she knew about it before the fall. She observed it broken in the back but then Staff L took the resident to the bathroom one day and observed a raised edge present on the back of the platform so she thought it was repaired. She didn't know it was still broken in the front because she didn't see the front. She later found out the family wanted the broken edge in the front because they were afraid the chair would fall off the back of the platform. Staff L stated she had no knowledge it was still broken. 2. Resident #2 had a MDS assessment with a reference date of [DATE]. The MDS reflected Resident #2 had the impaired ability to understand others and others sometimes understood the resident. The resident had a brief interview for mental status (BIMS) score of 4 which identified severe cognitive impairment. The resident had the following signs and symptoms of delirium: inattention and disorganized thinking. The resident had a behavior of wandering 1 to 3 days out of 7. The resident required limited staff assistance with bed mobility, transfers, ambulation in and out of room, dressing, toileting and personal hygiene. A "balance during transitions and walking" test identified the resident as not steady and only able to stabilize with staff assistance in all areas of testing. The resident used a wheelchair for mobility. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident with 2 falls with injury since the previous assessment. A Fall Risk assessment dated [DATE] identified the resident with a score of 20. A score of 10 or above identified the resident at high risk for falls. The Care Plan with a problem date of [DATE] identified the resident at risk for falls and injury. A Physical Therapy Discharge Summary dated [DATE] revealed the resident required standby assistance with bed mobility, transfers and ambulation and contact guard assistance for ambulating in confined spaces such as the bathroom. A Fall Assessment Form (incident report) dated [DATE] at 6:30 p.m. identified the resident with a fall in the bedroom. The resident self- rose and fell into the wall. The resident put his/her hand out to catch self and dislocated the left 3rd finger. Staff sent the resident to the hospital for the physician to put the finger back in place. The summary of the incident identified that the resident was in his/her room in the wheelchair when he/she tried to self- transfer. The personal alarms sounded and when staff answered they observed the resident on the floor. The resident appeared to have landed against the wall. The resident noted injury to the left third finger. A major injury determination form dated [DATE] at 12 p.m. identified the injury sustained as NOT a major injury. On [DATE] at 12:15 p.m. Staff E (nurse aide) stated on the evening of Resident #2's incident, she was in a room with another resident when she heard an alarm sound. She stated she was the only staff on the unit at the time because the other staff went to break. The resident she was with also used an alarm so she couldn't leave the other resident to get the alarm. Staff E stated she got the other resident in a safe location and then went to the resident whose alarm she thought sounded but it wasn't that resident. She then realized it was Resident #2's alarm. She stated it didn't take over a couple minutes before she got to Resident #2. The resident's door was half open and when she entered Resident #2's room, she observed him/her lying on the floor by the wall opposite the bed. The resident was pulling on his/her finger saying, "We've got to get this straight". Staff E stated the resident was in bed when she came on duty and remained in bed until Staff E found the resident on the floor with an injured finger. The resident stated he/she was going to the bathroom when he/she fell . Time cards reflected Staff E punched in at 6 p.m. that night (30 minutes prior to the fall). On [DATE] at 12:27 p.m. Staff D (registered nurse) stated she left the unit when Staff E arrived. She assisted the resident to the toilet after supper around 5:15 p.m. and the resident laid down. The resident did not appear restless on her shift. The Emergency Department (ED) Hospital records dated [DATE] identified the resident with finger dislocation and fracture of finger. The resident's left mid-finger had a joint dislocation with a chip fracture. The physician reduced the injury and applied a splint and taped the finger to the fourth finger. On [DATE] at 11:25 a.m. observation revealed the resident in his/her room with Staff J (nurse aide). The resident stood by self and tucked his/her pants in and sat in the wheelchair. The wheelchair contained a raised cushion. The resident used 2 alarms in the wheelchair. Observation reflected, on [DATE] at 5:05 a.m., the resident in bed with a personal alarm in place and sensor floor mat by the bed. 3. Resident #3 had an MDS assessment with a reference date of [DATE] which identified the resident had a BIMS (brief interview for mental status) score of 6. A score of 6 reflected the resident had a severe cognitive impairment. The resident had the following indicators of delirium: inattention and disorganized thinking. The resident required extensive assistance of two staff with bed mobility and transfers. The resident was nonambulatory. The resident had [DIAGNOSES REDACTED]. The resident did not have a history of falls. The resident was on Hospice care. On [DATE] at 5:15 a.m. observation revealed one staff person working in the CCDI unit. While Staff A (nurse aide) worked with a resident in another area of the unit, the surveyor was at the nurse ' s station and heard Resident #3 yelling for help. The surveyor entered the resident's room and found the resident sliding out of bed. She placed her leg against the resident's leg to prevent further sliding from the bed and yelled for Staff A. Staff A arrived and the resident began sliding out further. To prevent a fall, the surveyor assisted Staff A to lower the resident to the floor. Staff A then called the charge nurse from upstairs and she came and assessed the resident. There was no injury. After the incident, on [DATE] at 5:50 a.m. Staff A stated incidents have occurred before when she is with a resident that she can ' t leave and another resident needs help. 4. A Minimum Data Set (MDS) with assessment reference date of [DATE], assessed Resident #5 with a brief interview for mental status score of "13" (no cognitive impairment) The MDS identified the resident with delusions. The resident required limited staff assistance with transfers and supervision with ambulation. A "balance during transitions and walking" test identified the resident as not steady but able to stabilize without staff assistance in all areas of testing except when turning around and facing the opposite direction while walking. While turning around, the resident was not steady and only able to stabilize with staff's help. The resident used a walker while ambulating. The resident had [DIAGNOSES REDACTED]. The resident had one fall without injury since the previous assessment. A falls CAA (care area assessment) dated [DATE] stated the resident fell on [DATE] due to self- rising from bed. The resident was at risk for falls due to imbalance and use of psychoactive medications. The resident used personal alarms at all times due to chronic self- rising. A fall risk assessment completed on [DATE] identified the resident with a score of 15. A score of 10 or above represented high fall risk. A fall assessment form dated [DATE] at 6:30 a.m. reveled the resident self- rose and lost his/her balance. The resident stated he/she slid down the wall to the floor. The fall summary identified that Staff I (licensed practical nurse) heard the resident yelling "help me". The resident attempted to get self- ready for the day. The alarm did not sound. The resident's walker was in reach but the resident did not use the walker. The resident did not wear footwear when the fall occurred. Staff Interviews: On [DATE] at 1:27 p.m. Staff I stated she was going down the hall around 6 a.m. when she heard the resident calling for help. She saw the resident sitting on the floor by the wall. The resident stated he/she walked to the bathroom and slid down the wall. The resident laughed about the incident. Staff I stated no alarm sounded when the incident occurred. The resident used 2 alarms and the cords from both alarms were detached from the alarm boxes. Staff I stated she knew the resident could turn alarms off but she never knew the resident to detach the cords from the alarm boxes before. Staff I stated that now staff keeps the alarm at the end of the resident's bed when the resident is in bed and behind the chair when the resident is in the chair. The alarms are kept out of the resident's reach. On [DATE] at 6:18 a.m. Staff F (nurse aide) stated he knew of the resident disabling alarms prior to the [DATE] fall but not to pull the cords out of the alarm boxes. On [DATE] at 12:53 p.m. Staff K (nurse aide) stated the resident shut alarms off in the past and now staff places the alarms where the resident can ' t reach them. On [DATE] at 1:45 p.m. Staff H (licensed practical nurse) stated she knew of the resident turning alarms off prior to the fall. On [DATE] at 11:38 a.m. the Director of Nursing stated the resident's BIMS score was good but the resident gets mixed up. The resident disconnected alarms so staff placed the alarm boxes under the bed or behind the wheelchair. Observation showed on [DATE] at 4:30 p.m., the resident seated in his/her recliner with the alarm box in reach directly beside the resident's right elbow. The surveyor notified the Director of Nursing. Observation on [DATE] at 7:24 a.m. revealed the resident seated in his/her recliner with the alarm box directly beside the resident's left arm. On the same date at 7:35 a.m. Staff D (charge nurse) sat by the resident giving the resident medication and the alarm box remained in the same position. The current undated Care Plan with evaluation dated of [DATE] did not identify the resident with a risk for falls and did not alert staff that he/she could disable alarms or that staff should place them out of reach.

Based on record review and staff interviews, the facility failed to ensure two of ten residents reviewed for falls (Residents #5 and #2) received adequate supervision from hazards and failed to ensure the necessary safety care plan provisions were implemented. The facility identified a census of 44 residents. Findings include: 1. A quarterly Minimum Data Set (MDS) assessment tool dated March 14, 2011 documented Resident #5 with signs and symptoms of delirium with disorganized thinking that fluctuated with changes in severity (characterized by incoherent rambling or irrelevant conservation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). The assessment revealed the resident required one staff limited assistance with bed mobility, transfers, and toilet use; and required extensive staff assistance of one staff with ambulation, personal hygiene, and bathing. The MDS identified the resident ' s balance during transition and walking as not steady, only able to stabilize with human assistance when moving from a seated to standing position, when walking, when turning around, when moving on and off the toilet, and when completing surface to surface transfers (transfer between bed and chair or wheelchair). The MDS revealed the resident had no limitations in range of motion. The MDS documented the resident had one fall with no injury and one fall with a non major injury since the prior MDS had been completed. A quarterly MDS dated [DATE] documented Resident #5 with signs and symptoms of delirium with disorganized thinking that fluctuated with changes in severity ; and signs and symptoms of delirium with inattention (characterized by being easily distracted, out of touch or difficulty following what was said.) The assessment revealed the resident required extensive staff assistance of two or more staff with bed mobility, transfers, ambulation, dressing, and toilet use, and required extensive staff assistance of one with personal hygiene, and bathing. The MDS documented the resident had frequent bladder and occasional bowel incontinence. The MDS identified the resident's balance during transition and walking as not steady, only able to stabilize with human assistance when moving from a seated to standing position, when walking, when turning around, when moving on and off the toilet, and when completing surface to surface transfers (transfer between bed and chair or wheelchair). The MDS revealed the resident had no limitations in range of motion. The MDS documented the resident had two falls without injury, one fall with a non-major injury, and one fall with a major injury since the prior MDS assessment completed March 14, 2011. The June 2011 Medications Flow-sheet documented the resident's [DIAGNOSES REDACTED]. Fall Risk Assessment sheets dated December 17, 2010, March 14, 2011, March 22, 2011, and April 29, 2011 documented the resident had a score of 16, and an assessment sheet dated June 6, 2011 documented the resident had a score of 21. The sheet directed a score of ten or above indicated the resident had a high risk for potential falls and directed staff a prevention protocol needed initiation immediately and to document on the resident's care plan. A Resident Admission Record sheet documented Resident #5 had been admitted to the facility December 17, 2010. A Care Plan with a problem start date of December 17, 2010 documented the resident had a problem with Falls related to Alzheimer's, osteoporosis, anxiety, and depression, and a fall history prior to admission while the resident resided at an assisted living facility. Approaches included personal alarm on at all times, ensure the resident wore adequate footwear, therapy evaluations as needed, and encourage walker use (had not used prior to admission). A problem start date of December 17, 2010 documented the resident had a problem with activities of daily living and approaches included the resident required the assistance of one staff member when ambulated and transferred. An Incident/Accident Report and Falls Investigation Worksheet dated January 7, 2011 at 4:10 p.m. documented Resident #5 had sat at a dining room table, stood and tried to take a step, and fell to his/her knees. The report documented the resident had a clip alarm attached that had not sounded. The Falls Investigation Worksheet documented the string on the personal alarm was too long and had been shortened to allow for earlier notification when the resident attempted to self rise. An Incident/Accident Report dated February 9, 2011 at 3:55 p.m. documented the resident sat at a table eating a snack with a personal alarm on and stood and fell . The report documented the resident had dementia and confusion and the physician had been notified to obtain a merry walker order. A Falls Investigation Worksheet dated February 9, 2011 at 3:55 p.m. documented a merry walker had been implemented to assist with ambulation due to the resident's balance concerns. A facsimile Physician Assistant sheet dated February 9, 2011 directed staff to place the resident in a merry walker as needed for his/her safety. An Incident/Accident Report dated March 19, 2011 at 10:20 a.m. documented Staff H3 had ambulated the resident, the resident had been unsteady, tripped and fell , and no injury occurred. A Falls Investigation Worksheet dated March 19, 2011 at 10:20 a.m. documented an assistive device had not been used by the resident at the time and directed staff to use a gait belt when the resident ambulated. An undated Gait Belts Standard directed all employees that provided direct resident care had been required to utilize a gait belt whenever hands on assistance was required for resident transfers and ambulation unless otherwise contraindicated. During interview June 23, 2011 at 10:12 a.m. Staff O2 stated Staff H3 had not used a gait belt when the March 19, 2011 at 10:20 a.m. fall occurred. Staff H3 stated Resident #5 required staff assistance with ambulation at the time of the fall and Staff H3 expected staff to use a gait belt at all times when a resident required staff assistance with ambulation. Staff O2 read the Gait Belts Standard and verified again Staff H3 needed to use a gait belt when she had ambulated the resident. An Incident/Accident Report March 22, 2011 at 5:30 p.m. documented the resident stood up while at the dining room table, personal alarm sounded, the resident side stepped, fell on buttocks went back and hit his/her head on the floor. The resident sustained [REDACTED]. The Falls Investigation Worksheet dated March 22, 2011 at 5:30 p.m. documented the resident had been eating supper and a nurse witnessed the fall and had been unable to reach the resident in time to prevent the fall. The same sheet documented a new intervention that directed staff to sit with the resident at meal times and position the resident in a merry walker when the staff had to be away from the table. An Incident/Accident Report dated April 29, 2011 at 5:30 p.m. documented the resident stood at the supper table, lost his/her balance, and fell to the floor. The Incident/Accident Report documented the resident had been alert and confused and had a red elbow after the fall. The same report documented steps taken to include prevention of recurrence included one to one supervision during feeding time and transfer the resident back to the adult walker immediately after eating. A Falls Investigation Worksheet dated April 29, 2011 at 5:30 p.m. documented the resident had been restless, located in the dining room, the fall had been unwitnessed, and the resident had not been injured. A Nurse's Notes entry dated April 29, 2011 at 5:30 p.m. documented the resident had full range of motion to all extremities after the fall, the resident had soreness of the left elbow when pressure had been applied, the elbow had been visibly pink, monitor for possible bruising, and the resident denied any other pain or discomfort. The next Nurse's Notes entry dated April 30, 2011 at 2:00 a.m. documented the resident had been resting quietly without any ill effects from the recent fall and the resident's temperature had been 97.2 degrees Fahrenheit, pulse 74/minute, and respirations 20/minute. The entry lacked any documentation of the appearance of the resident's left elbow. The next Nurse's Notes entry dated April 30, 2011 at 2:15 p.m. documented the resident had "great pain" in the left elbow, the physician's nursing supervisor had been notified, an x-ray had been ordered, the resident's family had been notified, and the resident had left the facility with a family member to see the physician at 2:50 p.m. The entry lacked any documentation of the appearance of the resident's left elbow. Record review revealed the resident had not received any medication for left elbow discomfort after the fall prior to leaving to see the physician April 30, 2011 at 2:50 p.m. A hospital left elbow Radiology Report dated April 30, 2011 documented the resident had sustained an oblique fracture through the olecranon, with effusion (swelling), and nondisplaced. A facility Referral Form documented physician orders [REDACTED]. Clinical record review of a Treatment Flowsheet dated 4/1/11 to 4/30/11 documented may use merry walker as needed. The treatment sheet lacked any signatures for the entire month. A May 3, 2011 physician consultation report documented the resident had a long arm splint at approximately 90 degrees of flexion, no proximal or distal tenderness, without neurovascular concerns, and follow up in one week. A May 10, 2011 physician consultation report documented the resident's splint had been intact, the fracture remained non displaced, continue the splint another 2 1/2 weeks, and then probably begin range of motion exercises. A May 26, 2011 physician consultation report documented the resident's fracture had healed, splint removed, and the resident had loss of range of motion in flexion and extension but well within functional range. The physician ordered therapy for range of motion and no strengthening at the current time. During interview June 22, 2011 at 2:22 p.m. Staff D2 stated she had forgotten to put a personal alarm on Resident #5 in the dining room prior to the April 29, 2011 5:30 p.m. fall. Staff D2 stated this was the first she had forgotten to put an alarm on a resident. Staff D2 stated she and Staff J had been working together than evening and it had been one of the first evenings staffing had only one nurse and one aide on the floor. Staff D2 stated Staff J was out of the dining room area assisting another resident and she (Staff D2) had left the dining room area to assist another resident. Staff D2 stated she heard a thud, went back to the dining room, and saw Resident #5 on the floor. Staff D2 stated she had not been aware of an intervention initiated March 22, 2011 to place the resident in a merry walker when the resident was left unattended in the dining room. Staff D2 stated she had received a verbal and written warning for not applying the resident's personal alarm. During interview June 22, 2011 at 1:15 p.m. Staff J stated she and Staff D2 worked together April 29, 2011 when Resident #5 fell at 5:30 p.m. Staff J stated another resident had not been doing very well, she had left the dining room area to toilet the resident, D2 had been in the dining room. Staff J stated she heard a resident fall and did not heard an alarm sound. Staff J stated she had been aware Resident #5 needed supervision at all times at meal time. Staff J stated she informed Staff D2 she had to write a warning for lack of alarm use. During interview June 22, 2011 at 1:30 p.m. Staff O2 stated the nursing staff used a one page care plan with the 17 Atrium residents names listed on the front and back and with interventions listed for each resident. Staff O2 presented the current undated sheet with the residents names listed and interventions for each resident listed under the heading as follows: nutrition needs, bowel/bladder, ambulation/transfer/ADL's (activity of daily living), safety, sensory devices/dentures, cognition, skin status, and other special instructions. Staff O2 stated the one page care plans had been updated periodically and the previous care plans had not been saved. Staff O2 stated she had been unable to remember if the March 22, 2011 intervention that directed staff to sit with the resident at meal times and if staff needed to be away from the table the resident needed to be moved to the merry walker had been on the one page care plan. During interview June 23, 2011 at 10:12 a.m. Staff O2 read the care plan intervention dated March 22, 2011 that directed staff to sit with the resident at meal times and if staff needed to be away from the table the resident needed to be moved to the merry walker. Staff O2 verified the intervention and stated the intervention had not been reasonable. Staff O2 stated the memory care unit (Atrium) usually had one nurse and one aide present. Staff O2 stated the 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. shifts had been staffed with one nurse and one aide per shift. Staff O2 stated a second aide occasionally worked in the Atrium from 10:00 a.m. to 2:00 p.m. and assisted with two person baths and other cares and a second aide worked two to three days a week from 4:00 p.m. to 8:00 p.m. to assist with cares. Staff O2 stated the Atrium never had a second day or evening aide on weekends. Staff O2 stated one aide worked from 10:00 p.m. to 6:00 a.m. in the Atrium and the nurse or the aide that worked the nursing floor upstairs went to the Atrium to assist at times. Staff O2 stated new interventions related to resident care had been written in a communication book for all staff to read and be aware of. Staff O2 stated the March 22, 2011 intervention to not leave Resident #5 unattended in the dining room at meal time unless moved to a merry walker had been added to the communication book and Staff D2 had not initialed that she had read the intervention. Staff O2 stated all nursing staff had been responsible for knowing the information in the communication book even if the staff had not initialed that the intervention had been read. 2. Record review of the MDS, dated [DATE] for Resident # 2 revealed the following Diagnoses: [REDACTED]. The Brief Interview for Mental Status revealed a score of 13 which signified a moderate impairment in cognition. The MDS documented the resident had limitations on 1 side for the arm, hand, and leg. The MDS, with an assessment date of 10/21/10, 1/9/11, and 3/21/11 revealed the resident required extensive assistance of 1 staff for transfers. The MDS, dated [DATE] documented the resident had 1 fall with no injury and 1 fall with injury (except major) since admission or prior assessment. Record review of the Care Plan, with a problem start date of 3/9/06 revealed the resident at risk for falls and injuries from falling due to history of falls and use of psychotropic drugs. Staff were to ensure the resident wore adequate footwear, keep the resident's room and hallway clutter free, observe for orthostatic hypotension, encourage the resident to wear shoes at all times when ambulating and wear socks and pull up all the way. Staff were also to instruct the resident to call for assist with picking items up off the floor, provide non skin strips in front of bed, ensure a personal alarm on at all times and bed alarm at night. Staff were to ensure the resident wore a seat belt alarm on when in the wheelchair, ensure the resident in a low bed position, and provide a sign in the room to remind to call staff for help. Staff were also to remind the resident to use a call light, ensure resident to remain in dining room until staff able to assist the resident to bed. Record review of the Fall Risk Assessment revealed: a. On 11/12/10 a score of 20: a score of 10 or above represented a high risk for falls. b. On 12/11/10 a score of 20. c. On 1/2/11 a score of 20. d. On 5/11/11 a score of 22. Record review of the Incident/ Accident Report revealed: a. On 11/5/10 at 5:45 PM the resident found on floor of his/her room lying flat on the stomach. The resident trying to get up off the floor without help. The resident incontinent of urine and a glass of water on the floor. Documented steps to prevent recurrent falls were to toilet the resident after finished with supper and watch television in the living area until bedtime cares provided. b. On 1/2/11 at 6:30 PM the resident stood at the wheelchair trying to remove his/her shirt out of the closet. The resident fell backward when the wheelchair rolled behind him/her because the brakes were not locked. Steps take to prevent recurrence documented the resident would not be in the resident's room until staff could provide bedtime cares. c. On 1/26/11 at 6:15 PM staff found the resident on the floor, in a sitting position, leaning against the closet door. The resident received a 7 centimeter (cm) x 0.3 cm scrape on the left mid back. The new intervention put into place: to escort the resident front the dining room to his/her room after meals. Further interventions by the Director of Nursing (DON) included to continue the seat belt alarm, assist the resident with Activities of Daily Living (ADL'S), and to place a sign in the resident's room to remind the resident to call staff for assistance. d. On 6/14/11 at 5:50 PM the resident observed sitting on the floor in front of the wheelchair with no clothes on. The resident trying to provide his/her own. The new intervention put into place to prevent further falls were to keep the resident at the assisted dining table until all resident's were finished eating, then staff were to assist the resident to the room and assist the resident with bedtime ADL'S. Staff interview on 6/23/11 at 2:00 PM revealed the resident had been in his/her room at the time of each fall. Staff should of provided ADL's to the resident and not make the resident wait in the room. The resident had been in a serious accident and received a severe head injury. When staff would attempt to redirect the resident, the resident would have behaviors.