Every finding on record at Harmony Davenport

Based on observations, clinical record review, resident banking financial statement review, security surveillance video review, medication dispensing card review, and staff and residents interviews, the facility failed to prevent the financial exploitation of 2 of 3 resident's financial resources reviewed (Resident's #2 and #9) by Staff A, former Social Service designee, and failed to prevent diversion for 4 of 6 resident's narcotic medications reviewed (Resident's #3, #4, #5 and #6) by Staff B, Licensed Practical Nurse (LPN), The facility reported a census of 70 residents. Findings include:The facility's Patient Protection Guidelines Abuse Prevention, Reporting, and Investigation policy, dated as revised September, 2025 directed staff: 1. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.2. Dependent Adult Abuse included misappropriation of resident property - the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a patient's belongings or money without the patient's consent.3. Dependent Adult Abuse included exploitation - taking advantage of a patient for personal gain through the use of manipulation, intimidation, threats, or coercion.4. This facility follows the state and federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations.5. Upon initial employment each employee will be educated on the facilities abuse guidelines and reporting requirements. Within six months of hire each employee shall be required to complete an initial 2-hour training course approved by Iowa Department of Human Services. Each employee will take a 2-hour training every three years thereafter.6. The Administrator is responsible for the investigating, reporting, and coordinating of the investigation process of any alleged or suspected abuse regardless of the source of the concern. The Abuse Prevention Coordinator interacts with the survey team to explain the center's abuse, neglect, exploitation, mistreatment, and misappropriation of patient property prevention process.7. Center staff are required to notify the charge nurse and Abuse Prevention Coordinator immediately for any suspicion of abuse, neglect, exploitation, misappropriation, injuries of unknown origin meeting both criteria listed, and any reasonable suspicion of a crime.8. Following completion of the facility investigation, if the facility concludes that the allegations of resident abuse are unfounded, the employee may be allowed to return to job duties involving resident contact, but the employee must maintain a separation and have no contact with the resident alleged to have been abused, by reassigning the accused employee to an area of the facility where no contact will be made between the accused employee and the resident alleged to have been abused. This separation must be maintained until the State Department concludes its investigation and issues the written results of its investigation.9. In response to allegations of abuse, neglect, exploitation, or mistreatment, injuries of unknown origin, or misappropriation the facility must:- Have evidence that all alleged violations are thoroughly investigated.- Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.- Report all allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections, Appeals and Licensing and any other required state agency if applicable (ie: law enforcement). Reports of abuse or if there is resulting bodily injury, facility should report immediately and not later than two (2) hours. Allegations of neglect, exploitation, misappropriate of resident property, or mistreatment to be reported not later than two (2) hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury. The facility's self-reported incident dated 6/2/26 described Resident #2 reported her bank card was missing, the card found on 5/26/26, when bank records reviewed their were multiple charges and ATM withdrawals in May, 2026 that the resident had not authorized. 1. The Minimum Data Set (MDS) Assessment tool with reference date 5/1/26 revealed resident #2 admitted to the facility on [DATE], scored 11 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated mild cognitive impairment, with symptoms of delirium present, usually able to make herself understood and usually able to understand others. The resident had diagnoses that included schizophrenia, non-Alzheimer's dementia, anxiety, depression and urinary tract infection. The resident required moderate staff support for bathing, transfers to and from bed and chair, dressing lower body and toileting, and staff touch assistance for dressing upper body and personal hygiene, the resident unable to ambulate and wheelchair used for mobility. During an interview on 7/1/26 at 7:55 a.m. the Administrator stated Resident #2 had a bank card that was kept in a locked safe that only she and the previous Social Service Designee (SSD) employee, Staff A, had access to, the safe located in Staff A's office. Staff A and Staff E, the Activity Director, had the bank card PIN number and purchased 1 carton of cigarettes at a time for the resident with her bank card when she requested them around every 3 weeks. The resident requested her card when she went out on pass, otherwise the card was kept in the locked safe. Staff A was terminated from employment on 4/15/26 for a witnessed egregious violation of professional conduct directed towards a resident. At that time of her termination the Administrator provided Staff A with education documents from her personnel file that she would need for employment elsewhere. In mid to late May, the new Social Service Designee, Staff F, reported Resident #2 requested cigarettes, her bank card was not in the safe. They searched through the resident's room and belongings and the facility's safe and were unable to locate the card. She went to the bank with the resident and requested bank statements, based on the May 2026 transactions they felt the charges were fraudulent. On 5/26/26, Staff A was observed in the facility by Staff G, the Human Resources Coordinator before 7 a.m. she did not have a legitimate reason to be in the building as she had been terminated on 4/15/26. Later in the morning on 5/26/26 Laundry staff found Resident #2's bank card in a hamper and brought it to the Administrator. The resident's December 2025 through May 2026 bank statements revealed a total of $4,200.93 in expenses that were not authorized by the resident between 12/30/25 and 5/25/26; the total included $1900.00 in ATM withdrawals, $24.50 for ATM fees associated to the withdrawals, and $2276.43 in purchases at grocery stores, box stores, gas stations and cigarette/liquor stores that were not associated with cigarette purchases for the resident. Video surveillance images obtained by Iowa DIAL revealed Staff A, identified by staff recognition and unique tattoos, used the resident's bank card at box stores and ATM machines, the resident not with her, and the unauthorized use of the bank card continued through 5/25/26, after Staff A was terminated from the facility on 4/15/26. The purchases included items the resident would have no use for, such as children's clothing, Easter baskets, an electric men's shaver, raw meat, a lavender colored metal thermal handled cup that staff reported Staff A regularly used at the facility, and the kind of soda that Staff A routinely drank. On 7/14/26 at 10:07 a.m., Resident #2 stated somebody took her bank card, took $800 out of her account and she hoped they figured out who did that, she needed her money back. The resident stated somebody had made a bunch of charges with her bank card, she never told anyone to buy anything for her other than cigarettes, or to take money out of her account. 2. The Minimum Data Set (MDS) Assessment with reference date 12/22/25 revealed Resident #9 was admitted to the facility on [DATE], scored 10 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated mild cognitive impairment without symptoms of delirium present, always able to make himself understood and always able to understand others. The resident had diagnoses that included congestive heart failure, osteoporosis, hip fracture and cognitive communication deficit. The resident required extensive staff assistance for transfers to and from bed and chair, repositioning in bed, bathing, dressing lower body, toileting and toileting hygiene, and limited staff assistance for dressing upper body and personal hygiene. The resident was unable to ambulate, and required a wheelchair for mobilization. During an interview on 7/8/26 at 12:14 p.m., the Administrator stated Resident #9 kept his bank card in the facility's safe, when she called the bank to check the status of the resident's account she was informed his account had been flagged for potential fraud. During an interview on 7/9/26 at 11:04 a.m. the Administrator stated she went to the bank with Resident #9, got copies of his statements, there were 2 ATM withdrawals in January, one for $200, one for $100, the resident denied that he took the money out or that he had directed anyone to take money out of his account and she contacted the resident's Power of Attorney (POA). The POA told her they were unaware of the withdrawals from his account and had not used the resident's bank card. The resident's January 2026 bank statement revealed $200 was withdrawn from his account on 1/14/26 and $100 was withdrawn from his account on 1/16/26. During an interview on 7/13/26 at 2:03 p.m. Resident #9 stated he never asked anyone to go to the bank to get money for him or take money out of his account. During an interview on 7/14/26 at 8:37 a.m. the resident's POA stated they had not used the resident's bank card, were unaware of ATM withdrawals from his account until informed by the Administrator, when they visited the resident at the end of January 2026 they asked the SSD for the resident's bank card and the SSD refused to give them the card. They asked the SSD for the number on the card in case they had to purchase something needed by the resident, the SSD refused to provide the card number, the POA did not trust the SSD and thought there was something off about the whole situation. During an interview on 7/22/26 at 3:30 p.m., Staff A, Social Service Designee (SSD) denied that she had used Resident #2's and Resident #9's bank cards and had not made any ATM withdrawals from their accounts. Staff A stated she put Resident #9's banking information on her phone so she could assist the resident establish a new PIN (Personal Identification Number) for his bank account. During an interview on 8/3/26 at 1:47 p.m. Staff D, Admissions Coordinator stated Staff A asked her about the phone app for Resident #9's bank account and Staff A put that on her phone around the time when the resident was admitted to the facility. Staff D knew Resident #9's banking information remained on Staff A's phone as recent as a few months ago because at that time Staff A told her that was how she got the resident's bank statements that she needed for his Medicaid eligibility. The facility's self-reported incident dated 6/17/26 described staff found several Oxycodone medication cards tampered during the morning narcotic count, the Oxycodone tablets diverted and replaced by over-the-counter allergy medication. 3. The Minimum Data Set (MDS) Assessment tool with reference date 6/11/26 revealed Resident #4 was admitted to the facility on [DATE], scored 12 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated minimal cognitive impairment with symptoms of delirium present, always able to make himself understood and usually able to understand others, and had diagnoses that included congestive heart failure, hypertension (high blood pressure), peripheral vascular disease, diabetes, insomnia and amputation. During the 5 days that preceded the assessment analgesics were administered on a scheduled and an as needed basis for frequent pain rated as high as 8 on a 0 to 10 pain scale with 10 assigned to the worst pain possible, the pain frequently impacted his ability to sleep and rarely or never impacted his day-to-day activities and ability to participate in therapy. The resident required partial/moderate staff assistance to dress his lower body and don shoes, limited staff assistance to transfer to and from toilet or chair and bathing, unable to ambulate and independent in his wheelchair used for his mobility. A Complaints of pain described as chronic, greater than 3 months related to status post amputation, left below the knee amputation problem initiated 5/28/2025 on the Nursing Care Plan identified a 9/23/2026 goal Will not have an interruption in normal activities due to pain, and directed staff to provide interventions that included, but were not limited to: 1. Administer pain medication per physician orders, initiated 5/28/2025.2. Encourage/Assist to reposition frequently to position of comfort, initiated 5/28/2025.3. Evaluate efficacy of pain management, initiated 5/28/2025.4. Evaluate pain level as ordered, initiated 5/28/2025.5. Monitor for factors / activities that precipitate or aggravate pain, initiated 10/4/2025.6. Environmental modification factors- decrease noise, decrease stimulation, lighting, temperature, initiated 5/28/2025.7. Offer to lay down and rest, initiated 5/28/2025.8. Notify MD if inadequate pain relief as indicated, initiated 10/4/2025. 9. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from my past experience of pain, initiated 10/4/2025. 10. Observe for non-verbal signs of pain, initiated 5/28/2025. Physician Orders included: 1. Administer Oxycodone (a strong opiate narcotic analgesic)10 milligrams (mg) oral every 6 hours as needed, initiated 10/22/25.2. Administer Gabapentin (an anti-convulsant medication used to treat nerve pain) 900 mg oral daily at bedtime, initiated 2/16/26.3. Administer Gabapentin 300 mg oral daily in the morning, initiated 2/7/26.4. Administer Gabapentin 300 mg oral daily in the afternoon, initiated 3/2/26.5. Administer Acetaminophen (Tylenol) 650 mg oral every 6 hours as needed, initiated 9/1/25.6. Assess pain level daily on the day shift, initiated 9/2/25. Pain levels assessed daily on a 0 to 10 pain scale, with 10 assigned to the worst pain possible and recorded on the June, 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR) between 6/1/26 and 6/17/26 revealed: 6/1/26 06/2/26 06/3/26 1 6/4/26 1 6/5/26 6 6/6/26 0 6/7/26 06/8/26 56/9/26 06/10/26 8 6/11/26 06/12/26 06/13/26 0 6/14/26 0 6/15/26 7 6/16/26 46/17/26 0 During the investigation, the Iowa Department of Inspections, Appeals & Licensing (DIAL) determined that Staff B, Licensed Practical Nurse (LPN) diverted 26 Oxycodone 10 mg tablets from the residents supply on 6/4/26 when she worked the evening shift assigned to the resident's hall. Inspection on 7/8/26 revealed all 30 compartments/doses of the resident's Oxycodone 10 mg tablet medication card delivered on 6/16/26 were tampered, Staff B, LPN, signed for receipt of the medication when she worked the evening shift on 6/16/26. An Oxycodone medication administration card dated 6/1/26 showed 3 tablets remained on the card, tampering to compartments labeled #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #21, #22, #23, #24, #25, #26 and #27 were tampered. The tampering was identical to that on the 6/16/26 medication card. Compartments #1, #2 and #3 each contained a white, circle shaped 10 mg Loratadine tablet with flat surfaces on both sides, 1 side stamped with 10, the other side stamped with a G and identical to the facility's stock supply of Loratadine 10 mg tablets dispensed by Procura. Facility staffing records and investigation related to the self-reported incident revealed Staff B, LPN, worked from 2 p.m. to 10 p.m. on 6/16/26, relieved by Staff H, LPN who worked from 10 p.m. on 6/16/26 to 6 a.m. on 6/17/26. Staff I, LPN arrived for her scheduled shift at 6 a.m. on 6/17/26, Staff H and Staff I discovered tampered Oxycodone medication cards when they counted narcotics on the shift-to-shift narcotic count that morning and notified the Director of Nursing (DON). During an interview on 7/7/26 at 1:08 p.m., Staff I, LPN, stated she had worked a double shift (days and evenings) on 6/15/26), it was a busy day, she thought the Oxycodone looked different and meant to go back later to check on it but the day got away from her. The next time she worked was day shift on 6/17/26, when she counted with Staff H, LPN that morning and told her she thought the Oxycodone looked different the other day, they both looked at the medication cards closely and that was when they noticed the cards with Oxycodone had been tampered with and the Oxycodone replaced by Loratadine 10 mg tablets that the facility kept in stock bottles on every medication cart. She notified the DON right away. During an interview on 7/7/26 at 6:40 p.m. Staff H, LPN, she hadn't noticed anything unusual when the narcotics were counted until the morning of 6/17/26 when she counted with Staff I, LPN and they found the Oxycodone cards had been tampered. Staff H stated she had just came back to work after she was hospitalized and off work for several weeks. Staff H questioned if the narcotics had been tampered previously as she identified a resident that normally slept through the night experienced pain during the night a few months before, it was unusual and wondered if that resident's medications had also been diverted. During an interview on 7/14/26 at 5:41 a Staff L, Registered Nurse (RN) stated she had concerns about the number of PRN narcotic analgesics that Staff B reported she administered over the last few months, to residents who rarely or seldom complain of pain. During an interview on 7/14/26 at 11:45 a.m., Staff J, RN, stated over the last few months she had concerns about Staff B, LPN because of the amount of narcotics she reported as given, to resident's who rarely or never asked for them otherwise. Staff B used to be calmer, now it was as if she had ADHD (attention deficit hyperactivity disorder), she couldn't focus and she'd be all over the place. When you got report from her you had to pay very close attention to what she said and know enough to ask about what wasn't said. Many times when doing the narcotic count with her at the change of shifts the count would be off and Staff B would say oh yeah, I forgot to sign that out. During an interview on 7/8/26 at 12:53 p.m. the Director of Nursing (DON) stated after narcotic count on the morning of 6/17/26 Staff I, LPN notified her she thought the Oxycodone had been tampered. When the DON examined the Oxycodone medication cards that morning she confirmed they had been tampered, notified the Administrator, they removed the tampered medication cards from the medication carts, they assessed all residents for pain/unrelieved pain and did not identify a concern for pain management. During an interview on 6/30/26 at 10:20 a.m. the Administrator stated the DON notified her that some of the Oxycodone medication cards had been tampered, discovered during the narcotic count on the morning of 6/17/26, she observed the conditions and the cards were removed from the med carts, the medications replaced by their pharmacy, they interviewed every resident for pain control and did not identify an issue with that. The Administrator initiated an investigation and had suspended both Staff B, LPN, and Staff H, LPN as she worked on the night shift that started on 6/16/26. As she completed her investigation there were no concerns identified related to Staff H, but nursing staff reported Staff B had administered several PRN (as needed) narcotic medications to residents who never or seldom reported symptoms of pain. The Administrator also noted the tampering signs on the medication cards dated back to when Staff H was hospitalized and off work, she was able to bring Staff H back to work while Staff B remained suspended and awaited the completion of investigation by DIAL. 4. The Minimum Data Set (MDS) Assessment tool with 5/27/26 reference date revealed the Resident #3 admitted to the facility on [DATE], scored 15 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated no cognitive impairment, the resident had symptoms of delirium present, always able to make herself understood and always understood others. The resident had diagnoses that included congestive heart failure, diabetes, anxiety, depression, non-Alzheimer's dementia and chronic pain. In the 5 days that preceded the assessment the resident received analgesics on both a scheduled and as needed basis for occasional pain rated as 5 on a 0 to 10 pain scale, with 10 assigned to the worst pain possible, the pain occasionally effected the resident's ability to sleep and participate in day-to-day activities and did not interfere with her ability to participate in therapy. The resident required moderate to extensive staff assistance to transfer to and from bed and chair, reposition in bed, dressing, toileting and bathing, the resident unable to stand or ambulate and wheelchair used for mobility. A Resident is at risk for pain related to pain in abdomen, hips, bilateral legs, back pain, joints, right shoulder evidenced by verbalization related to arthritis; intellectual disability with anxiety and depression problem initiated 3/22/24 on the Nursing Care Plan listed a 10/25/26 goal: Resident states that level of pain is tolerable or has relief with interventions directed staff to provide interventions that included, but were not limited to: 1. Administer pain medication per physician orders, initiated 3/22/24.2. Encourage/Assist to reposition frequently to position of comfort, initiated 3/22/24. 3. Evaluate efficacy of pain management, initiated 3/22/24.4. Evaluate pain level as ordered, initiated 3/22/24.5. Implement non-pharmacological interventions massage, relaxation techniques, counseling, warm/cool compress, positioning as indicated, initiated 3/22/24.6. Monitor for factors / activities that precipitate or aggravate pain, initiated 3/22/24.7. Notify MD if inadequate pain relief as indicated, initiated 3/22/24.8. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from my past experience of pain, initiated 3/22/24. Physician Orders included: Assess pain level using 0 to 10 pain scale daily on the day shift, ordered 9/2/25.Administer Oxycodone (a strong opiate narcotic analgesic) 5 mg oral twice daily, ordered 9/1/25.Administer Gabapentin (an anti-convulsant medication also used to treat nerve pain) 400 mg oral 3 times daily, ordered 9/1/25.Administer Tylenol 8-hour Arthritis formula 650 mg tablet oral 3 times daily, ordered 9/1/25.Administer Oxycodone 5 mg oral every 6 hours as needed, ordered 9/1/25. The daily pain level assessments recorded on the June, 2026 Medication Administration Record between 6/1/26 and 6/17/26 revealed: 6/1/26 06/2/26 06/3/26 06/4/26 06/5/26 06/6/26 06/7/26 06/8/26 06/9/26 06/10/26 06/11/26 06/12/26 06/13/26 06/14/26 06/15/26 56/16/26 56/17/26 0 During the investigation, DIAL determined that Staff B, Licensed Practical Nurse (LPN) diverted 52 Oxycodone 5 mg tablets when she worked on 6/10/26. Examination of two Oxycodone 5 mg medication cards on 7/8/26, each with 30 tablets received on 6/10/26, labeled as card 1 and card 2 revealed on card 1: compartments/doses #30, #29, #28, #24 and #23 were not tampered, and all other compartments/doses were tampered and contained Loratadine (an over-the-counter decongestant) 10 mg tablets. On card 2: all dose compartments tampered except #1, #3, #8, #23 and #25, the tampered compartments contained Loratadine 10 mg tablets. Additionally, when the 6/10/26 medications were delivered, the resident had a medication supply available that was delivered on 5/26/26, 3 tablets remained on the card when Staff B started to administer from the supply received on 6/10/26, and not per expected facility practice. During an interview on 7/8/26 at 2:46 p.m. Resident #3 stated she didn't have pain very often, maybe once or twice a week. If she had pain it was typically in the afternoon, usually in her leg. The resident couldn't recall the last time she requested a pain pill. 5. The Minimum Data Set (MDS) Assessment with 4/29/26 reference date revealed Resident #5 admitted to the facility on [DATE], scored 15 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated no cognitive deficits or symptoms of delirium present, always able to make herself understood and always able to understand others. The resident had diagnoses that included diabetes, anxiety, depression, post traumatic stress disorder (PTSD), acquired absence of right toes and chronic pain syndrome. In the 5 days that preceded the assessment she received analgesics on both a scheduled and as needed basis for frequent pain, rated as high as 7 on a 0 to 10 pain scale, with 10 assigned to the highest pain possible, the pain rarely interfered with her ability to participate in therapy and occasionally affected her day-to-day function and ability to sleep. He resident required moderate staff assistance for dressing, toileting, bathing and transfers to and from bed or chair, and minimal staff assistance to reposition in bed or personal hygiene, the resident unable to ambulate and wheelchair used for mobility. A Resident has complaints of pain related to wounds, chronic pain syndrome, low back pain, fusion of spine thoracolumbar region, neuropathy problem initiated 12/29/25 on the Nursing Care Plan listed a 9/28/26 goal Will not have an interruption in normal activities due to pain and directed staff to provide interventions that included, but were not limited to:1. Administer pain medication per physician orders, initiated 12/29/20252. Encourage/Assist to reposition frequently to position of comfort, initiated 12/29/20253. Evaluate efficacy of pain management, initiated 12/29/2025. 4. Evaluate pain level as ordered, initiated 12/29/2025. 5. Notify MD if inadequate pain relief as indicated, initiated 12/29/20256. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from my past experience of pain, initiated 12/29/2025. 7. Observe for non-verbal signs of pain, initiated 12/29/20258. Staff to observe any behavior changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion (ROM), withdrawal or resistance to care, initiated 12/29/2025. Physician Orders included:Assess pain level with 0 to 10 pain scale daily on the day shift, ordered 4/25/26.Administer Methadone (a very strong opiate narcotic analgesic) 5 mg oral twice daily, ordered 4/24/26.Administer Oxycodone (a very strong opiate narcotic analgesic) 5 mg oral every 6 hours as needed, ordered 4/23/26, the order discontinued on 7/1/26. The daily pain level assessments recorded on the June, 2026 Medication Administration Record between 6/1/26 and 6/17/26 revealed: 6/1/26 06/2/26 06/3/26 06/4/26 06/5/26 06/6/26 06/7/26 06/8/26 06/9/26 06/10/26 06/11/26 06/12/26 06/13/26 06/14/26 46/15/26 06/16/26 06/17/26 0 The narcotic inventory control sheet for the resident's Oxycodone delivered to the facility on 4/28/26 revealed Staff B, LPN recorded 6 of the 11 doses administered between 6/1/26 and 6/17/26, documented on 6/3/26, 2 doses on 6/13/26,and 1 dose on 6/14/26, 6/15/26 and 6/16/26. During an interview on 7/8/26 at 2:53 p.m. Resident #5 stated she used to have a lot of pain, she would only take the Oxycodone when the pain was really bad. Per her recollection it had been a month or maybe 3 weeks since she had taken any Oxycodone, she didn't need it anymore and the doctor discontinued it. When she did take the Oxycodone she estimated she asked for It 4 or 5 times a week when pain was at its worst back in March and April. After April she thought she might have asked for the Oxycodone once a week. During the investigation, DIAL determined that Staff B, Licensed Practical Nurse (LPN) diverted 9 Oxycodone 5 milligram (mg) tablets from the resident's supply when she worked the evening shift on 5/5/26. When observed on 7/8/26, the back of the Oxycodone 5 mg medication card dated 4/28/26 revealed compartments #1, 5, 9, 10, 12, 15, 18, 21 and 22 were tampered with by the same method observed on Oxycodone drug cards for the other 2 victims identified during the investigation. Staff B, LPN documented she administered the second dose from the Oxycodone supply at 3:00 p.m. on 5/5/26 that would have been from the compartment/dose labeled #25. The medication administered from compartment/dose #22 was administered 5/7/26. When the Oxycodone medication card was observed on 7/8/26, 5 doses remained on the card, the tampered #1 and #5 compartments/doses contained a white, circle shaped 10 mg Loratadine tablet with flat surfaces on both sides, 1 side stamped with 10, the other side stamped with a G and identical to the facility's stock supply of Loratadine 10 mg tablets dispensed by Procura. 6. The Minimum Data Set (MDS) Assessment tool with 4/23/26 reference date revealed Resident #6 admitted to the facility on [DATE], scored 11 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated mild cognitive impairment without symptoms of delirium, sometimes able to make herself understood and usually understood others. The resident had diagnoses that included congestive heart failure, diabetes, hip fracture, anxiety, bipolar disorder and respiratory failure with asthma. In the 5 days that preceded the assessment the resident had not received any analgesics, and reported no pain at the time of the assessment. Resident #6 required substantial to maximal staff assistance to reposition in bed, transfer to and from bed and chair, bathing, dressing, toileting and dressing. A Resident has complaints of pain described as acute related to femur fracture problem initiated 12/15/25 on the Nursing Care Plan had a 9/20/26 goal Resident states that level of pain is tolerable at zero or has relief with interventions, and directed staff to provide interventions that included, but were not limited to: 1. Administer pain medication per physician orders, initiated 12/15/25.2. Encourage/Assist to reposition frequently to position of comfort, initiated 12/15/25. 3. Evaluate efficacy of pain management, initiated 4/17/26.4. Evaluate pain level as ordered, initiated 12/15/25. 5. Monitor for factors / activities that precipitate or aggravate pain, initiated 12/15/256. Non-Pharmacological intervention- Environmental modification[TRUNCATED]

Based on clinical record review, facility policy review, and staff and resident interviews, the facility failed to ensure that residents were able to choose sleeping and waking schedules per their preference for 4 residents (Resident #11, Resident #16, Resident #24 and Resident #25) when an intoxicated resident (Resident #8) frequently woke the residents during the night due his being loud and argumentative with staff. The facility reported a census of 71 residents.Findings include:Review of Resident 8's Minimum Data Set (MDS) assessment tool dated 5/28/26, revealed Resident #8 scored 7 out of 15 points possible on the Brief Interview for Mental Status (BIMS)score of 7 out of 15, indicating a severe cognitive impairment. The diagnoses list included alcohol dependence, tobacco dependence, alcohol abuse, and COPD (chronic obstructive pulmonary disease) with dependence on supplemental oxygen. The assessment indicated Resident #8 demonstrated verbal behaviors, other behaviors not directed towards others and rejected care from 1 to 3 days of the 7 days that preceded the assessment.Review of Resident #8's Care Plan dated 3/18/26, revealed a Focus area to address Resident has a mood state disturbance related to anxiety, alcohol use; refusal of cares, refusal of assessments, poor compliance; restlessness, fatigue, difficulty concentrating, irritability, easily annoyed and sleep problems, derogatory or yelling behavior towards staff, refuses to follow safe food storage, refusal and/or poor compliance with prescribed plan of care. Interventions initiated on 3/18/26 included, in part:a. Encourage adequate rest periods.b. Evaluate causative factors contributing to mood disturbance.c. If resistive to care, attempt to reapproach at a later time.d. Notify practitioner of significant changes in mood or behavior.e. Psych evaluation as needed as patient wishes.f. Utilize relaxation techniques such as exercise, music, low lighting, going outside etc.g. Approach/speak in a calm manner.f. Communicate clearly and assertively what behaviors are unacceptable and inappropriate.h. Document behaviors and response to intervention.i. Remove resident from situation and take to alternate location as needed.j. Staff to maintain respect for resident rights to make own lifestyle choice.Review of the electronic health record (EHR) revealed the following:a. On 4/4/26 at 4:59 PM: Resident consumes more than the allotted dosage of alcohol, Resident is very intoxicated and yelling out being belligerent singling out staff and yelling at staff member. Resident behaviors have a negative effect on other residents causing disruption to other residents here on the floor. Some of the other residents are becoming upset with this resident and yelling and threatening physical violence towards this resident which causes this resident to use foul language and yell even louder to other residents on the floor. Resident is unable to be redirected by staff, unable to move resident from the area he is sitting in, resident gets louder with yelling at staff and other residents. b. On 5/9/26 at 6:00 AM: Resident out to nurses' station, yelling loudly, cursing at staff and other residents. Disruptive, waking other residents, yelling loudly down the hallway. Many attempts to redirect resident without success. Cursing at staff yelling shut the fuck up Res called 911 stating this nurse was not providing cares and he needed help. When asked Resident what he needed help with he said I don't know, not a damn thing, just do your job Continued difficulty with redirection. Refusing to go to his room as other residents complaining. 0500 this am as staff assisting others, Resident sitting by patio door inside, in his wheelchair with oxygen in place and lit a cigarette. As nurse came around corner Resident threw cigarette on the ground and stomped it out. Resident educated on fire and explosion risks with smoking and oxygen with Resident stating that wasn't me I don't care I don't know what you are talking about Continued to be loud, cursing at staff and other residents. On call nurse notified of residents behavior. c. On 5/11/26 at 7:54 AM: Resident highly intoxicated this Am shift. Resident out to nurses station, yelling loudly, cursing at staff and other residents. Disruptive, waking other residents, yelling loudly down the hallway. Many attempts to redirect resident without success. Resident refusing to go to his room as other residents complaining. Resident sitting by patio door inside, in his WC with oxygen. Resident playing music on his phone and is loud and is heard on entire floor and refused to turn down and or off. d. On 5/17/26 at 9:11 PM: Resident got up out of bed and into his wheelchair, has a bottle of alcohol on him. Resident sitting at the nurses station by the patio door waiting to go outside and smoke, is very loud when speaking and other residents are becoming upset and coming out to the nurses station to tell him to quiet down. Other resident is verbally making physical threats but not acting on threat towards this resident. This resident then went outside to smoke, resident could be heard from inside nurses station yelling when talking outside. Staff reported residents got into a verbal altercation and this resident reports another resident pushed him, put his fingers in this resident's face causing this residents to call the police. e. On 5/25/26 at 9:06 PM: Resident continues to consume large amounts of alcohol resulting in obnoxious behaviors which is disturbing to other residents on the floor. Resident loud yelling out during conversations causing other residents to awaken and become upset with him related to behavior, management aware of behaviors. f. On 5/25/26 at 11:07 PM: Monitoring of Substance Use Disorder. signs and symptoms related to substance use and potential overuse. See nurses notes if symptoms are present, notify provider and complete documentation every shift related to ALCOHOL ABUSE WITH INTOXICATION, UNSPECIFIED.Was a behavior observed? YES resident is inebriated being loud, rude and obnoxious to staff and other residents. g. On 5/29/26 at 6:55 AM: Resident sitting at nurse station in his wheelchair and appears to be intoxicated. Resident yelling outward at staff and toward co-residents. Resident expressing verbal outburst toward staff, resident was and unable to redirect. h. On 6/3/26 at 12:49 AM: Monitoring of Substance Use Disorder. signs and symptoms related to substance use and potential overuse. See nurses notes if symptoms are present, notify provider and complete documentation every shift related to ALCOHOL ABUSE WITH INTOXICATION, UNSPECIFIED.Was a behavior observed? YES resident being loud, rude and obnoxious to staff and other residents.i. On 6/4/26 at 12:13 AM: Monitoring of Substance Use Disorder. signs and symptoms related to substance use and potential overuse. See nurses notes if symptoms are present, notify provider and complete documentation every shift related to ALCOHOL ABUSE WITH INTOXICATION, UNSPECIFIED.Was a behavior observed? YES resident returned from the neighbors with 5 beers and a bottle of liquor being loud and obnoxious. Attempted to send multiples of beer with the neighbor, resident very loud and refused to allow. j. On 6/18/26 at 6:34 AM: Sitting at nurses station this Am and appears to be intoxicated. Speech slurred and leaning in his wheelchair. Sitting in his wheelchair with a bottle of alcohol and drinking at intervals. Resident declined to give bottle to staff for safety. Resident talking in loud tone which indicates he has signs/symptoms of obnoxious behaviors. Resident continues to use derogatory words and not easily redirected. When asked to lower his voice and or calm down he gets louder. Resident continues to talk, yell outward in loud tone. Will continue with plan of care. k. On 6/29/26 at 6:00 AM: Resident has been drinking alcohol, black bag sitting behind resident in his wheelchair. Refuses to give to staff. Resident yelling loudly, slurred speech, eyes glossed over, yelling/cursing loudly and demanding towards staff to assist with cares. Sitting at nurses station coughing, spitting mucous/secretions on the floor despite having tissues and asked multiple times to not. Resident waking other residents, unable to redirect, states I don't give a fuck Monitored frequently. Verbal altercation with another resident on patio, yelling, cursing, derogatory statements regarding nationality. Unable to redirect. Continued behaviors. On call supervisor informed of difficulty with residents behavior. Will continue to monitor and call for support if continued. Resident returned to his room around 0330. In his chair resting at this time. During an interview on 6/25/26 at 9:36 AM, Resident #24 stated she had been woken up in the middle of the night quite a few times by another resident yelling and causing problems, the last time was around a week or so ago. Resident #24 identified the resident yelling as Resident #8. The staff tried to calm him down but that just made things worse with him. She preferred to sleep through the night if she could. A MDS dated [DATE], indicated Resident #24 had intact cognition based on a BIMS score of 15 out of 15. During an interview on 6/25/26 at 9:44 AM, Staff B, Licensed Practical Nurse (LPN), stated Resident #8 has been inebriated on her shift before, but it's usually on the evening or night shift that they have the problems with him and his drinking. When he's inebriated, he's unreasonable, he can't be redirected and he just doesn't care. They try to redirect him to his room or away from the other residents, sometimes he will go out to smoke but they usually have to get the other residents away from him. If they try harder to get him to his room or out of the common area and away from other residents, he becomes argumentative, yells, curses at staff and they can't really control what he says/does when he's that way. During an interview on 6/25/26 at 10:55 AM, Resident #25, stated he had been woken up in the middle of the night many times by a resident yelling. The staff can't make him stop yelling, when they yell at him that makes it worse and he yells more. Resident #25 identified the resident yelling as Resident #8. Resident #25 stated he would rather sleep through the night without someone yelling like that. A MDS dated [DATE], indicated Resident #24 had intact cognition based on a BIMS score of 15 out of 15.During an interview on 6/25/26 at 1:32 PM, Resident #16 stated he had been woken up in the middle of the night several times by a resident who gets very loud, yells, curses and it's not pleasant at all. Resident #16 identified the resident who has woken him up yelling as Resident #8. A MDS dated [DATE], indicated Resident #24 had intact cognition based on a BIMS score of 15 out of 15. During an interview on 6/25/26 at 1:47 PM, Resident #8 stated he got the care he needed, staff usually treated him with dignity but there were too many rules. Resident #8 stated he's always been a night owl, he's up at night and slept during the day, they don't like that but that was their problem, not his and he's not going to change. He's going to go outside and smoke when he wants to, he can drink alcohol, he's an adult and can do that when he wants to, but the staff want to argue with him about thatDuring an interview on 6/25/26 at 2:05 PM, Staff J, LPN stated when Resident #8 has been intoxicated, he yells at the nurse's station, wakes other residents, and there is nothing staff can do to make him stop yelling or acting that way. She stated Resident #8's leaves the facility, usually late evening between 10:00 PM and 11:00 PM and returns anytime between 12:00 AM and 2:30 AM. Staff J stated she usually documents the time, and the resident has to sign the in and out book. Staff J stated the resident will not let anyone touch his wheelchair or search him for alcohol, and he starts yelling and cursing if attempted. Staff J added Resident #8 wakes up other residents when returns intoxicated. Staff J stated she has called the manager on call when this happens and the decision has been if the resident is not hurting himself or others to leave him be, keep everyone safe, no other actions taken. During an interview on 6/25/26 at 2:12 PM, Resident #11 stated he had been woken up several times during the night by a resident that goes out, gets drunk and then yells and argues with the staff when he comes back in the middle of the night. This has happened a lot, the last time was the night before last. Staff tried to help the resident but he doesn't want their help and curses at them. Resident #11 identified the resident yelling as Resident #8. Resident #11 stated he preferred to sleep through the night and didn't want to listen to that. A MDS dated [DATE], indicated Resident #24 had intact cognition based on a BIMS score of 14 out of 15. During an interview on 6/25/26 at 3:38 PM. Staff K, Registered Nurse (RN) stated Resident #8 frequently leaves the facility during the late evening/night shift, and when he returns, he is often drunk. She stated when he is drunk, he yells, curses, becomes argumentative and wakes up other residents. She stated despite closing room doors, some residents still woke up. Staff K described one night when Resident #8 demanded she call his debit card company to check his balance. She stated there was a call light going off at the time, and he didn't want to wait. Staff K stated after she told him the balance, he demanded that she put the phone on speaker because he didn't believe her. Staff K stated when she told Resident #8 she had to answer the call light he called 911. During an interview on 6/30/26 at 8:10 AM, the Administrator stated she looked closer at Resident #8's conditions, found his BIMS at 7, spoke to him about safety and he was not safe to leave the facility given the nature of his cognition. She spoke with him about alcohol treatment to which he said he did need to do something about the alcohol. He went out over the weekend, came back with alcohol and intoxicated, the nurse tried to take his alcohol but he refused and became more agitated. She called an inpatient alcohol detox/treatment center to inquire about a referral and hoped to hear from them with a decision later that day. She spoke to staff yesterday and directed them they were not to let Resident #8 leave the building without someone signing him out. Review of the facility policy titled Dignity and Respect policy, dated 4/2024 revealed a Purpose statement with declared: To lay the foundation for treating all residents with dignity and respect and maintaining and enhancing his or her self-esteem and self-worth.The Procedure section directed, in part: 1. Each Resident has the right to considerate and respectful care and to be treated with honesty, dignity, respect and with reasonable accommodation of individual needs except where the health, safety, or rights of the resident or other individuals in the facility would be endangered.2. Each Resident has the right to be free from physical, verbal, sexual or mental abuse, corporal punishment, involuntary seclusion, and any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms.3. Each Resident has the right to retain and use personal possessions, including furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.4. Each Resident has the right to participate in their own care and treatment.5. Each resident has the right to manage their own finances.6. Each resident has the right to file grievances.7. Each resident has the right to access their own information.8. Each resident has the right to have visitors.9. Each resident has the right to be free of discrimination and reprisal from the facility in exercising his/her rights.10. Each resident has the right to equal access to quality care regardless of diagnosis, severity of condition, or payment source11. Each resident has the right to exercise his/her rights of the facility as citizen/resident of the United States.

Based on observation, clinical record review, resident and staff interview, the facility failed to ensure resident safety by not storing smoking materials in a safe location for a resident using oxygen and ensuring a resident's feet are on the foot pedals during a wheelchair transport for 2 of 5 residents (Resident #6 and Resident #22) reviewed for safety. The facility reported a census of 71 residents.Findings include:1. Review of the Minimum Data Set (MDS) dated [DATE] identified Resident #6 as cognitively intact with a Brief Interview for Mental Status score of 14 out of 15. The list of diagnoses included chronic diastolic congestive heart failure, multiple sclerosis and COPD (chronic obstructive pulmonary disease). The MDS identified Resident #6 required supervision/touch staff assistance with most activities of daily living and required oxygen therapy. Review of Resident #6's Care Plan revealed the following Focus areas: a. Resident is at risk for ineffective breathing.date Initiated: 5/9/25. Intervention included, in part: Administer oxygen per order. b. Tobacco Use, date initiated: 3/29/26. Interventions included, in part: Independent Smoker: Must keep smoking accessories secured when into in use (via lockbox or in control of facility staff). Review of the most recent Smoking assessment dated [DATE] identified Resident #6 as an Independent Smoker.Resident is considered a safe smoker and May use/access smoking materials consistent with facility policy. Staff is not required to remain in attendance while resident is smoking. RESIDENT AGREES TO FOLLOW SMOKING RULES During an observation with interview on 6/3/26 at 9:38 AM, Resident #6 stated he kept his pack of cigarettes and his cigarette lighter on him. Resident #6 then pulled put each from his shirt pocket. Resident #6 using continuous oxygen via oxygen concentrator (a machine that pulls in room air, separates out the nitrogen and delivers concentrated oxygen) set at 4 liters per minute via nasal cannula. During an interview on 6/4/26 at 7:44 AM, Staff B, Licensed Practical Nurse (LPN) stated she was not sure if residents were allowed to keep cigarette lights in their room with use of continuous oxygen. She stated it was not a safe practice, however, if the resident was alert, then it should be safe. During an interview on 6/4/26 at 10:39 AM, the Assistant Director of Nursing (ADON) reported residents who have continuous oxygen should not have their cigarette lighters kept in the same room. During an interview on 6/4/26 at 12:01 PM, the Director of Nursing (DON) reported it is not safe for a resident to keep a cigarette lighter in a room where there is continuous oxygen running. Review of the facility policy titled Smoking Policy revised January 2024, revealed a Purpose section which declared: To establish and maintain safe resident smoking practices and determine if a resident is an Independent or Dependent smoker prior to the resident exercising the privilege to smoke. Facilities, at their discretion, may choose to not allow smoking on their premises, may allow smoking only when the resident requires no supervision to smoke, or may offer smoking times and supervised smoking only The Guidelines section for Smoking Facilities directed, in part: Residents determined to be an Independent Smoker may smoke without assistance or supervision. Independent Smokers must follow smoking guidelines including keeping smoking accessories secured when not in use (via lockbox or in control of center staff), smoking only in designated areas/designated times (unless resident is able to independently get to and from the designated smoking area). 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #22 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 14 and had the following diagnoses: Epilepsy, Anxiety Disorder and COPD (Chronic Obstructive Pulmonary Disease). The MDS also identified Resident #22 required supervision/touching assistance from staff with showers and required set up or cleanup assistance with showers and toileting. The MDS also identified Resident #22 has had two or more falls since admission, however, none which resulted in injury. An observation on 6/3/26 at 2:15 PM revealed the Assistant Director of Nursing (ADON) who pushed Resident #22 in a wheelchair in the hallway without foot pedals and feet skimming the floor. The ADON informed Resident #22 don't forget to lift up your feet Resident properly positioned and appeared comfortable. On 5/21/26, the Care Plan identified Resident #22 to be at risk for unavoidable falls related to seizures, impatient, impulsive, does not wait for supports. The Care Plan failed to identify intervention to ensure foot pedals are on the wheelchair prior to transporting the resident. During an interview on 6/4/26 at 7:31 AM, Staff A, CNA, reported when transporting a resident in a wheelchair, she would need to put the foot pedals on the wheelchair first then place the resident's feet on the foot pedals. If this isn't done, the resident could flip out of the wheelchair if their feet get caught. She also stated Resident #22 has a history of falls. During an interview on 6/4/26 at 7:44 AM, Staff B, LPN reported before staff transport a resident in a wheelchair, they should make sure there are foot pedals on the wheelchair and make sure their feet are placed on the foot pedals. If this isn't done, the resident could fall out of the wheelchair. During an interview on 6/4/26 at 10:39 AM, the ADON reported staff should make sure the foot pedals are on the wheelchair and put the resident's feet on the foot pedals before transporting them and if they forget to, the resident could flip out of the wheelchair. She verified she pushed Resident #22 in her wheelchair without the foot pedals as she is usually independent and self-propels on her own. She also admitted she did have a history of falls and that it was her mistake. During an interview on 6/4/26 at 12:01 PM, the DON reported before staff transport residents in a wheelchair, she would expect them to place the foot pedals on the wheelchair and feet should be placed on the foot pedals. If this is not done, residents could fall out of the chair and fracture something. Upon request for a facility policy which addressed safe wheelchair transport, the Administrator reported the facility did not have one.

Based on observations, clinical record review, facility policy review, resident and staff interviews, the facility failed to implement the infection control practices of hand hygiene and use of Enhanced Barrier Precautions during wound care treatment and the cleaning of a g-tube insertion site for 4 of 6 residents (Resident #1, Resident #2, Resident #5, Resident #64, and Resident #) reviewed for infection control. The facility reported census of 68 residents. Findings include:1. Review of the Minimum Data Set (MDS) assessment for Resident#2, dated 12/30/25 revealed a list of diagnoses which included diabetes mellitus, high blood pressure and schizophrenia. The MDS indicated the resident dependent for personal hygiene, bath/shower and transfers. The MDS cognitive assessment for Resident#2 showed short- and long-term memory problems and severely impaired decision daily decision making. Review of Resident #2 Care Plan, dated 3/17/26, revealed a Focus area to address at risk for alteration in skin integrity related to impaired mobility diabetes, incontinence, morbid obesity.Interventions included, in part: a. Administer medications as ordered. Date Initiated: 3/17/26. b. Administer treatments per physician orders. Date Initiated: 3/17/26. c. Facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 3/17/26. Review of the April 2026 Treatment Administration Record (TAR) revealed an order (L – left) inner elbow: Cleanse wound NS (normal saline)/wound cleaner. Dry thoroughly. Apply double layer of xeroform to wound. Change dressing twice daily and as needed (PRN).Start Date: 3/20/26. During an observation on 04/02/2026 at 7:28 AM, Resident #2 in bed. Enhanced Barrier Precaution (precautions taken in an effort to reduce the spread of multidrug resident organisms (MDROs) supplies include gloves and gowns) supply caddy present and hung over the room door. Staff K, Licensed Practical Nurse (LPN) in room. He washed his hands, and donned (put on) gloves. Staff K did not don a gown. Staff K removed the old dressing from the residents left elbow placed it in the trash can. Without a change of gloves and completing hand hygiene, Staff K cleaned the wound. Without a change of gloves and completing hand hygiene, Staff K applied a new dressing to Resident #2's left elbow. During an interview on 04/02/2026 at 7:33 AM, Staff K, LPN stated he did not use the gown for EPB, and he did not change gloves or complete hand hygiene during wound care. During an interview on 4/2/26 at 3:30 PM, the Administrator stated she expects staff to wear gloves and a gown for EBP, and to change gloves and complete hand hygiene between tasks. 2. Review of Resident #64's MDS, dated [DATE], revealed a list of diagnoses which included stroke and osteomyelitis (bone infection). The MDS identified the resident with a Stage III pressure ulcer (a full-thickness loss of skin, in which subcutaneous fat may be visible) and a Stage IV pressure ulcer (a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer), and pain. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated intact cognition. During an interview on 3/30/26 at 11:38 AM, Resident #64 stated he had three wounds on his buttocks. Resident #64 stated he had to wear a depend (incontinence brief) instead of the commode to defecate and occasionally the feces got in his pressure sore and that hurt. Review of Resident #64 Care Plan, dated 12/23/24 revealed a Focus area to which addressed resident at risk for alteration in skin integrity.Interventions included, in part: a. Administer medications as ordered. Date Initiated: 4/02/26. b. Administer treatments as ordered. 4/02/26. c. Facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 4/02/26. d. Treat/assess pain as per orders prior to treatment/turning to ensure resident's comfort. Date Initiated: 4/02/2026. Review of the April 2026 TAR revealed an order Coccyx wound - cleanse with normal saline, pat dry. Apply lidocaine ointment 5% topically. Apply primary dressing aquacel Ag advantage and gauze sponges. Cover with ABD pad/tape. Change dressing BID and PRN every day and eve. Start Date: 3/26/26. During an observation on 4/01/2026 at 1:07 PM, Staff N, LPN and Staff R, LPN donned gowns and gloves from the EBP supplies. Staff R placed the dressings, saline, tape and medicated dressings on the sheets of Resident #64's bed. Staff N repositioned Resident #64, and opened the incontinence brief which had been soiled. Without removing the brief, Staff R cleaned the large wound. Without a change of gloves or completing hand hygiene, Staff R patted the wound dry and applied lidocaine cream. Staff N rolled Resident #64 two times to remove the soiled brief, and without a change of gloves or completing hand hygiene applied a clean dressing and attempted to secure with tape. Staff N placed the soiled brief on the resident's bed. Without a change of gloves or completing hand hygiene, Staff N repositioned Resident #64, and Staff R placed tape over the dressing, and put a clean incontinence brief on the resident. Staff N and Staff R removed their gloves, and without putting on new gloves or completing hand hygiene threw away the soiled brief and without a change in linens covered Resident #64 with the bed sheet. 3. Review of Resident #1 MDS, dated [DATE] revealed a list of diagnoses which included diabetes mellitus, gastric reflex disease, and respiratory failure, The BIMS score of 15 out of 15 indicated intact cognition. During an interview on 3/31/26 at 12:22 PM, Resident #1 stated the staff do not use his feeding tube for medications or feedings. Review of Resident #1's Care Plan, dated 11/26/25 revealed the follow Focus areas: a. EBP (Enhanced Barrier Precautions) related to Urinary Catheter, Feeding tube). Interventions included, in part: EBP Precautions: Staff to wear a gown and gloves while performing high-contact care activities (High Contact Care Activities to include: Bathing/showering, Transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, caring for or using an indwelling medical device (central venous catheter/PICC, urinary catheter, feeding tube care, tracheostomy/ventilator care), Performing wound care) Date Initiated: 11/26/2025 Review of the April 2026 TAR revealed an order to Cleanse enteral tube feeding site with normal saline and apply dry dressing every day shift. Start Date: 11/25/2025. During an observation on 4/01/2026 at 1:54 pm, an EBP sign noted on the door to Resident #1 door, with gowns and gloves available. Staff N, LPN entered Resident #1's room that and placed treatment supplies on the residents stand without first cleaning the stand or placing a barrier down. Staff N donned gloves without washing her hands prior, and without donning began the treatment process. Resident #1 pulled off the soiled split gauze from around the g tube insertion site and handed it to Staff N. Without a change in gloves or completing hand hygiene, Staff N cleansed around the G -tube with gauze and normal saline and assessed the site. Without a change in gloves or completing hand hygiene, Staff N prepared a syringe with 25 milliliters of water and flushed it into the G-tube. Staff N then removed her gloves and threw them away with the used supplies. Staff N did not wash her hands prior to leaving the room. 4. Review of Resident 5's MDS, dated [DATE], revealed a list of diagnoses which included stroke, obstructive uropathy (urine flow obstructed), and diabetes mellitus. The MDS identified the resident dependent for transfers, and lower body tasks. The MDS indicated Resident #5 had pressure ulcer/injury care, which included the application of non-surgical dressings, and ointments/medications; and utilized an indwelling catheter. Review of Resident #5's Care Plan, dated 5/2/25, revealed the following Focus areas: a. At risk of alteration in skin integrity.Interventions included, in part: Administer medications as ordered. Date Initiated: 05/05/2025; Administer treatment per physician orders; Follow facility policies/protocols for the prevention/treatment of skin breakdown Date Initiated: 05/05/2025. b. EBP (Enhanced Barrier Precautions) related to urinary catheter. Interventions included, in part: EBP Precautions: Staff to wear a gown and gloves while performing high-contact care activities. Date Initiated: 05/05/2025. Review of the April 2026 TAR revealed an order for Left heel apply skin prep daily every day shift for skin protection. Start Date: 3/20/26. During an observation on 4/1/26 at 8:05 AM, EBP sign noted on resident's door, and supplies available in a caddy. Staff C, LPN donned gloves and without putting on a gown, performed the treatment to Resident's #5's left heel. During an interview immediately following the 4/1/26 treatment to Resident #5 heel, Staff C stated Resident #5 had EBP due to having a urinary catheter. Upon reviewing the EBP posted on the door, Staff C acknowledged she should have donned a gown prior to performing the treatment to the left heel. During an interview on 4/1/26 at 8:10 AM, the Director of Nursing stated Resident #5 had EBP due to a urinary catheter. The DON acknowledged gloves and gown should be worn when providing wound care. Review of the EBP poster used in the facility directed providers and staff to: 1. Wear gloves and gown for the following high-contact resident care areas: a. Dressing b. Bathing/showering c. Transferring d. Changing linens e. Providing hygiene f. Changing briefs or assisting with toileting g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy h. Wound care: any skin opening requiring a dressing Review of the policy titled, Dressing Change, revised 11/2023 revealed a Procedure section which directed, in part: a. Evaluate patient's need for pain reducing interventions, administer if indicated and allow time for intervention to achieve effectiveness. b. Set up the area by placing a clean or sterile barrier on the over bed table then place hand sanitizer and supplies on top of barrier. Sanitize the over the bed table after treatment completed. c. Perform hand hygiene and apply gloves before and after remove soiled dressing, cleansing of wound, preparing supplies, anytime a soiled item is touched, and after procedure. The Policy titled Enhanced Barrier Precautions (EBP) are implemented to minimize the transmission of novel or targeted multi-drug-resistant organisms (MDROs) during high-contact resident care. These precautions supplement, rather than replace, standard or transmission-based precautions. a. Presence of wounds (e.g., pressure ulcers, diabetic foot ulcers, unhealed surgical wounds) or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, or tracheostomies/ventilators). b. PPE Requirements: Staff must wear gowns and gloves during high-contact care activities, such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, toileting, or performing device/wound care. c. Duration: EBP is generally intended for the duration of a resident's stay or until the wound resolves or the indwelling medical device is discontinued.

Based on clinical record review, policy review and staff interview the facility failed to maintain accurate Advance Directive decisions for 1 of 16 residents reviewed (Resident #43). The facility reported a census of 68.Findings include:The Minimum Data Set (MDS) assessment for Resident #43, dated [DATE], documented a Brief Interview for Metal Status (BIMS) score of 8 out of 15, which indicated a moderate cognitive impairment. The MDS listed diagnoses of coronary artery disease, Alzheimer's disease, and non-Alzheimer's dementia. Review of Physician Orders in the electronic health record (EHR) revealed a Full Code order dated [DATE].The Care Plan Report initiated on [DATE] included a Focus are to address Advance Directives. Facility staff are directed to:1. Document the advance directive on the Physician Orders sheet in the EMR system.2. Educate resident and or representative about their options addressing life sustain care.3. EMR chart to identify code status. Review of the paper chart for Resident #43, revealed an undated red piece of paper with black bold print Do Not Resuscitate (DNR). The red piece of paper was located in the same plastic sleeve as the Iowa Physician Orders for Scope of Treatment (IPOST). The front page of the IPOST indicating cardiopulmonary resuscitation (CPR or Full Code) faced the back of the red paper. The physician signed the IPOST on [DATE].On [DATE] at 3:51 PM, the Administrator stated the IPOST documents are not uploaded to the EHR. The Administrator indicated the red paper in the paper chart indicated DNR. The Administrator indicated staff are to follow code status in the EHR. On [DATE] at 8:32, Staff C, Licensed Practical Nurse (LPN) verbalized she would look in the paper chart for a residents code status in the event of an emergency. ON [DATE] at 8:37 AM, the Director of Nursing (DON) stated there are several places code status is listed. The DON explained the first place staff are to look is the paper chart. The DON acknowledged the EHR listed Resident #43 as a full code. The DON acknowledge the paper chart had a red paper with DNR in front of the IPOST. The DON stated staff would look at the red paper versus pulling out the IPOST in an emergency. The DON acknowledged the IPOST listed CPR. The DON reported Social Services places red papers in each chart for DNR and [NAME] papers for CPR. The facility policy, the Code Status Identification and CPR revised on [DATE], Code Status Identification section directed: a. Physician's orders related to a resident's code status and/or DNR/limited treatment documentation is completed by the licensed nurse or social services director/designee and entered into electronic medical record (EMR).b. Direct care staff with [name of electronic medical record brand redacted] access are educated during orientation and as needed on system identification of patient code status.c. If center has an EMR failure or utility loss, follow back up procedures and EMR failure plan. Code status is then identified on the paper MAR/TAR.The Procedure section directed, in part:1. Upon determination that a resident is in cardiopulmonary or respiratory arrest, CPR will be immediately initiated by nursing staff and 911 called for advanced cardiac life support unless one of the exceptions applies:a. When the resident or resident representative has indicated that resuscitation is not desired, and the attending physician has issued a written do not resuscitate (DNR) order that is maintained in the facility's clinical record; orb. When there is the presence of obviously clinical signs of irreversible death (rigor mortis or dependent lividity)2. Each resident's resuscitation status will be maintained in the clinical record and identified as described above (Code Status Identification).

Based on observations, facility policy review, and resident and staff interview and facility policy review the facility failed to maintain a homelike environment due broken wall tiles in the shower room, stained and crumbling ceiling tiles in a resident's room, window curtains unable to be completely closed to provide privacy, and maintaining mouse traps in timely manner. The facility reported a census of 68 residents.Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #8 dated 4/24/26, listed diagnoses of anemia, high blood pressure, and arthritis. The MDS showed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated a moderate cognitive impairment. During an observation on 03/30/2026 at 2:07 PM, Resident #8 sat in his room, and reported having seen mice in his room every day. A black mouse trap, next to the resident's recliner, observed to contain a dead mouse. The trap remained in this condition when observed on 3/31/26 at 12:19 PM, on 4/1/26 at 12:16 PM, and on 4/2/26 at 9:19 AM. During an interview on 4/2/26 at 9:21 AM, Resident #8 stated a Certified Nursing Assistant (CNA) told him about the dead mouse in the trap earlier on this morning. During an interview on 04/02/2026 at 9:21 AM, Staff G, Housekeeper stated she checked the mouse traps one time a week. Staff G said she planned to remove the dead mouse yesterday but got busy and forgot. 2. During an observation on 04/01/2026 at 12:21 PM, broken wall tiles found in the 2nd floor Central Bath/Shower room. The were tiles located in the left corner of the room, approximately 2 feet inside the door, and 2 to 3 feet up from the floor. On 04/01/2026 at 12:38 PM, Staff I, CNA reported the tiles on the wall at the corner in the 2nd floor Central Bath/Shower room broke a few weeks ago. Staff I stated a work order in place and they are getting the parts to fix the corner. On 04/02/2026 at 11:29 AM, Staff J, Registered Nurse (RN) reported the broken tiled felt sharp and he wanted to cover the edges. During an interview on 04/02/2026 at 1:25 PM, Staff I, Maintenance Director stated he did not know about the broken wall tiles in the 2nd floor Central Bath/Shower room. Staff I said the staff don't fill out the work orders, they tell him in the hall and he can't remember everything. When queried about emptying mouse traps, Staff I stated he goes every day and checks the glue traps for the mice. He reported he did not know of the mouse in Resident #8's room or that Staff G, Housekeeping saw the mouse in the trap on 4/1/26 and the trap had yet to be removed. 3. Review of Resident #55's MDS assessment, dated 2/26/26 revealed a list of diagnoses which included coronary artery disease, bipolar disorder and schizophrenia. The BIMS score of 13 out of 15 indicated intact cognition. Review of the census records documented Resident #5 moved to room [ROOM NUMBER] on 3/4/26. During an observation on 3/31/26 at 8:29 AM, room [ROOM NUMBER] noted to have a two panel curtain with a gap of approximately 16 inches between the panels. The panels were not attached to the rod to allow for complete closure, leaving a view into the residents room. The ceiling noted to have a stain which started at the corner of the doorway and reached over the first bed. The stained ceiling area appeared bubbled. During an interview on 4/1/26 at 2:18 PM, Staff D, CNA acknowledged the curtains could not be closed all of the way. Staff D stated she attempted to hang them up, but was unable to get them to close and stated maintenance needed to help. Staff D stated the ceiling looked bad and didn't know how long it appeared that way. On 4/1/26 at 2:26 PM, Staff E, RN entered room [ROOM NUMBER] and stated he did not know how long the curtains were unable to be closed. Resident #55 laid in his bed, and stated the curtains had been unable to be closed all of the way since he moved into the room. During an interview on 4/1/26 at 2:50 PM, Staff M, Maintenance reported he had not received any work orders for room [ROOM NUMBER] until this day. Staff M explained that work orders are to be entered into an electronic work order tracking program. Staff M walked into room [ROOM NUMBER] and acknowledged he hadn't known about the curtains or ceiling discoloration and bubbling texture. Staff M acknowledged the room had not been maintained as a homelike environment. During an interview on 4/1/26 at 3:21 PM, the Administrator viewed room [ROOM NUMBER] and acknowledged the room had not been maintained as a homelike environment. On 4/2/26 at 7:08 AM, the Administrator provided the electronic work order tracking report. The Administrator reported there were no work orders submitted for room [ROOM NUMBER] prior to 4/1/26.

Based on clinical record review, facility record review and staff interview, the facility failed to notify the the Long-Term Care Ombudsman of a discharge for 1 of 3 residents (Resident #77) reviewed. The facility reported a census of 68 residents.Findings include:Review of the electronic health record (EHR) Clinical Census information for Resident #77 revealed an entry of STOP BILLING effective 1/24/26.A Progress Note dated 1/24/26 at 7:19 PM, documented Resident #77 discharged against medical advice (AMA). Review of the Action Summary report dated 3/30/26 did not list Resident #77 as discharged . Review of the Notice of Transfer From to Long Term Care Ombudsman did not list Resident #77's 1/24/26 discharge. During an interview on 4/2/26 at 12:17 PM, Staff B, Social Services reported Resident #77 had not been included on the Notice of Transfer From to Long Term Care Ombudsman as he did not appear on the Action Summary report. Staff B acknowledged Resident #77 left AMA on a weekend. During an interview on 4/2/26 at 12:29 PM, the Administrator stated it is her expectation the LTC Ombudsman office is notified of discharges. In an email on 4/2/26 at 12:40 PM, the Administrator revealed the facility does not have a policy which directed the notification of discharges to the LTC Ombudsman.

Based on clinical record review, staff interview and the 2025 Resident Assessment Instrument (RAI) manual, the facility failed to transmit Minimum Data Set (MDS) Assessments within the Federal Guidelines timeframe for 1 of 24 residents (Resident #31) reviewed. The facility reported a census of 68. Findings include:The discharge MDS of Resident #31 was dated for his discharge date of 11/25/25. The MDS was signed as completed on 12/9/25. The clinical record revealed that the MDS assessment was never transmitted to the Centers for Centers for Medicare & Medicaid Services (CMS) as required.On 4/1/26 at 9:07 am, the MDS Coordinator stated she would unlock the MDS and transmit it. She was not aware of why the assessment had not been transmitted. She stated she does run reports on missing assessments but Res #31 had not been included on any of the reports and she had not been aware the assessment had not been transmitted. She stated she would transmit the assessment immediately.On 4/1/26 at 10:54 am, the administrator stated, via email, that the facility does not have an MDS policy and they utilize the RAI manual. The 2025 RAI manual states the MDS must be transmitted (submitted and accepted into the iQIES [Internet Quality Improvement and Evaluation System] ) electronically no longer than 14 calendar days after the MDS Completion date.

Based on clinical record review, facility policy review and staff interview, the facility failed to accurately list known mental health diagnoses on a Pre-admission Screening and Resident Review for 1 of 2 residents reviewed (Resident #15) for Pre-admission Screening and Resident Reviews. The facility reported a census of 68 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #15, dated 1/10/26 revealed a list of diagnoses which included depression, post-traumatic stress disorder (PTSD-a mental health condition triggered by experiencing or witnessing terrifying events), and adjustment disorder with mixed anxiety and depressed mood. The MDS identified 1/5/16 as the admission date to the facility.Review of the electronic health record (EHR) revealed Resident #15 had an initial admission to the facility on 9/27/25 for skilled care after a hospitalization. Resident #15 discharged to home on [DATE] with no expectation with return. Resident #15 had a new admission to the facility on 1/5/26. Review of the EHR Medical Diagnosis section revealed the following mental health diagnoses:a. Adjustment disorder with mixed anxiety and depressed Mood. Date: 9/29/25.b. Anxiety disorder, unspecified. Date: 3/6/26.c. Major depressive disorder, recurrent severe without psychotic features. Date: 10/15/25.d. Post traumatic stress disorder, unspecified. Date: 9/29/25.Review of the Pre-admission Screening and Resident Reviews (PASARR - a federal requirement ensuring individuals with serious mental illness or intellectual/developmental disabilities area not inappropriately placed in nursing facilities) revealed:a. PASARR dated 9/22/25 with determination No Level II Required - No SMI/ID/RC (serious mental health, intellectual disability, related conditions). Mental Health Diagnoses submitted: Major depression, current; Anxiety disorder, current.b. PASARR dated 1/03/26 with determination No Level II Required - No SMI/ID/RC. Mental Health Diagnoses submitted: No mental health diagnoses is known or suspected.During an interview on 4/2/26 at 8:58 AM, Staff B, Social Services reported the nurse liaison reviewed the PASRR prior to admission. Staff B, reported she reviewed the PASRR once admitted and is responsible for submitting updated PASRR when needed. Staff B, acknowledged the PASRR completed prior to admission lacked accurate diagnoses for Resident #15. Staff B, acknowledged Resident #15 hadn't been evaluated for [NAME] II PASRR (an in-depth, person-centered evaluation triggered when a Level I screen indicates a potential serious mental illness (SMI), intellectual disability (ID), or related condition).During an interview on 4/2/26 at 9:07 AM, the Administrator stated the Administrator and Social Services are responsible for reviewing the Notice of PASRR Level I prior to/at admission. The Administrator stated someone with a diagnosis of PTSD would need to be evaluated for Level II PASRR. The Administrator acknowledged the Notice of PASRR Level I needed updated for Resident #15. Review of the facility undated facility policy, titled PASRR Process QRG directed the following:1. admission staff member validate PASRR completion prior to admit2. All Level II PASRR's and renewals are monitored and manage by Social Services3. Psychotropic medication changes and new or updated diagnosis should be discussed as part of the daily inter disciplinary team (IDT) meetings. Social Services would then update PASRRs with the information necessary.

Based on clinical record review, family representative interview, resident and staff interviews the facility failed to develop comprehensive Care Plans for 3 of 8 residents (Resident #1, Resident #19, and Resident #30) reviewed for Care Plans. The facility reported a census of 68 residents.Findings include: 1. Review of the Minimum Data Set (MDS) for Resident #1, dated 2/26/26 revealed diagnoses of diabetes mellitus, gastric reflex disease, and respiratory failure. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated intact cognition. The MDS did not identify Resident #1 utilized a Gastric tube (G-tube) for medications or tube feedings. During an interview on 3/31/26 at 12:22 pm, Resident #1 stated the staff no longer use his feeding tube for medications or feedings.Review of Physician Orders revealed the following orders:a. Regular diet, Regular texture. Thin liquids consistency. Start date: 2/3/26.Review of the Care Plan for Resident #1, dated 11/26/25, revealed a Focus area to address Tube feeding related to dysphagia. Interventions included, in part: Provide enteral nutrition as ordered. The Medication Administration Record (MAR) dated March 2026 for Resident #1 revealed the last medication administration through the Gastric-tube was 3/4/26. The medications are administered oral since 3/4/26.During an interview on 4/01/2026 at 8:06 am, Staff N, Licensed Practical Nurse (LPN) stated Resident #1 took his medications orally and did not use the G-tube anymore. Staff N stated the G tube was to be flushed and the site was to be cleaned and the dressing changed daily.2. Review of the MDS for Resident #19, dated 3/20/26 list of diagnoses revealed end stage renal disease, diabetes mellitus and a special procedure of hemodialysis via AV fistula. The BIMS score of 15 out of 15 indicated intact cognition. Review of Resident #19's Care Plan, dated 3/30/26 revealed a Focus area to address Resident requires dialysis related to Diagnosis of End Stage Renal Disease. HD (hemodialysis) device (AV or arteriovenous - a surgical created access for dialysis created by joining an artery directly to a vein) left arm, IJ device (dialysis access in the neck via internal jugular managed by the HD unit). Interventions listed in the Care Plan did not include directions to complete a daily assessment of the AV site for pulse, listening for bruit (a swishing noise heard by stethoscope), palpation of the AV site for the feel of a thrill (a vibration) to assure adequate blood flow, assessment of the extremity for bruising, vein distention, or pain. 3. Review of the MDS for Resident #30, dated 2/19/26 revealed a list of diagnoses which included end stage renal disease and identified received a special treatment of dialysis. The BIMS score of 14 out of 15 indicated intact cognition. Review of Resident #30's Care Plan, dated 12/1/25 revealed a Focus area to address Resident requires dialysis related to Diagnosis of End Stage Renal Disease. AV fistula left upper extremity, pt often declines to go to dialysis proving various rational for refusals. The Interventions listed in the Care Plan did not include directions to assess the AV site for site for thrill, bruit and pulse.During an interview on 4/06/2026 at 10:53 AM, Staff M, Registered Nurse, and MDS & Care Plan Coordinator stated Care Plans are completed by the Interdisciplinary Team (IDT). Staff M stated the IDT also revised the plans, or a floor nurse could also make a change in their scope of practice.

Based on observations, clinical record review, resident and staff interviews, the facility failed to assist dependent residents with shaving, nail care and toothbrushing for 2 of 4 residents (Resident #6 and Resident #40) reviewed for activities of daily living. The facility reported a census of 68 residents.Findings include:1. Review of the Minimum Data Set (MDS) assessment for Resident #6, dated 12/30/25, revealed a list of diagnoses which included diabetes mellitus (DM), and non-Alzheimer's dementia. The Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicated a moderate cognitive impairment. The MDS identified Resident #6 dependent for toileting, bathing and showering; and required substantial to maximal assistance for personal hygiene. During an observation on 03/31/2026 at 2:44 PM, Resident #6 sleeping in bed. His hair appeared greasy, fingernails long with a brown substance underneath the nail. Review of the Care Plan, dated 2/19/24, for Resident #6 revealed a Focus area which addressed ADL (activities of daily living) Resident requires assistance with ADL's needed, related to DM.Interventions included, in part: a. Assist resident with shower/bathing per schedule. Date Initiated: 2/19/24. b. Dressing & Grooming with assist of 1. Date Initiated: 2/19/24. Review the electronic health record (EHR) Response History for Did the resident take a shower, bath or bed bath revealed a 30 day look back period which documented Resident #6 bathed on 3/5/26 and 3/12/26, with refusals documented on 3/16/26, 3/19/26, and 3/23/26. During an interview on 04/01/2026 at 12:00 PM, Resident #6 stated gets a bed bath, and staff do not clean his finger nails or cut them much. Resident #6 added they get his hair washed at times. During this interview Resident #6 hair looked oily and unkempt, and nails remained long and had a black/brown resident under the nail. During an interview on 4/2/26 at 3:30 PM, the Administrator stated if a resident refused a bath or cares the Certified Nursing Assistant should tell the nurse. Review of the EHR revealed a lack of communication regarding Resident #6 refusals of assistance with activities of daily living. 2. Review of the MDS assessment for Resident #40, dated 1/8/26, revealed diagnoses of stroke and arthritis. A BIMS score of 13 out of 15 indicated intact cognition. The MDS identified Resident #40 dependent on staff for oral care and hygiene needs. Review of Resident #40's Care Plan, dated 1/21/26 revealed a Focus area which addressed At risk for Oral/Dental health problems related to own natural teeth. Interventions included, in part: a. Encourage/assist to perform oral hygiene. Date Initiated: 1/21/26. Another Focus area addressed Resident requires assistance with ADL's related to disease process.Interventions included, in part: a. Oral Care with assist of 1. Date Initiated: 1/21/26. b. Grooming: with assist of 1. Date Initiated: 1/21/26. During an interview on 3/31/2026 at 12:42 PM, Resident #40 stated he did not think the staff had brushed his teeth in a month. A Resident Representative present during the interview stated the family had voiced concern with the residents' teeth not getting brushed, and also the resident not getting assistance with shaving. During this interview, Resident #40 had noticeable beard growth. During an observation on 4/1/26 at 11:42 AM, Resident #40 had noticeable beard growth. During conversation, Resident noted to have bad breath and debris stuck in his teeth. During an interview on 4/01/2026 at 11:35 AM, Staff I, Certified Nursing Assistant (CAN) stated the Care Plan provided direction for ADL care. Staff I added she had not been assigned to care for Resident #40 on this date. During an interview on 4/01/2026 at 11:37 AM, Staff N, Licensed Practical Nurse (LPN) stated the staff have a schedule for shaving, no resident was shaved every day, and Resident #40's family will shave him. During an interview on 4/01/2026 at 11:39 AM, Staff H CNA stated she shaved men on their shower day. Staff H stated she brushed Resident #40's teeth a little this morning but staff have been very busy. During an interview on 4/01/2026 at 3:12 PM, Staff O, CNA stated she used the mouth swap for Resident #40 when his tooth hurt. Staff O stated he had bad breath and white stuff on his tongue that won't come off even after you brush. Staff O stated Resident #40 was to get shaved on shower day and thought his mom shaved him a few days ago in the dining room. Staff O stated Resident #40 had a shower yesterday and was unsure why he did not get shaved and she would go shave him.

Based on clinical record review, facility policy review, family representative and staff interviews, the facility failed to treat each resident with dignity and respect when a staff member made a resident condition statement in the presence of a family member for 1 of 9 resident records reviewed (Resident #7). The facility reported a census of 64 residents.Findings include:Review of the electronic health record (HER) revealed Resident #7's admitted to the facility on [DATE] with diagnoses that included pulmonary fibrosis, chronic respiratory failure with oxygen dependence, adult failure to thrive, peripheral vascular disease, diabetes and dementia, and hospice services in place. A Nursing Care Plan problem initiated 6/25/25, included a Focus area to address Resident has complaints of pain described as chronic > (greater than) 3 months, related to osteoarthritis, peripheral vascular disease and wounds. Interventions directed staff to, in part: a. Administer pain medication per physician orders, initiated 6/25/25.b. Encourage/assist to reposition frequently to position of comfort, initiated 6/25/25.c. Evaluate efficacy of pain management, initiated 6/25/25.d. Evaluate pain level as ordered, initiated 6/25/25.e. Observe for non-verbal signs of pain, initiated 6/25/25.f. Non-pharmacological intervention - encourage socialization or time alone, initiated 6/25/25.g. Non-pharmacological intervention - family visits, initiated 6/25/25.During an interview 9/30/25 at 5:24 p.m., a family member of Resident #7's stated when she was in the hallway near the Nurse's Station she heard Staff A, Licensed Practical Nurse (LPN) say to the staff present go check on her [NAME] to see if he was alive. The family member stated at the same time she observed another employee motion to Staff A to stop talking, a family member was present, then the family member told Staff A they were the resident's family member. The family member stated the remark was completely unprofessional, unkind, and the residents there shouldn't have to tolerate that.During an interview 10/2/25 at 12:08 p.m., Staff A, LPN, stated she thought she was relating to the Certified Nursing Assistants (CNA's) on duty when she referred to the resident as a [NAME], asked them to check on the resident, didn't realize any family was present, what she said was disrespectful and she shouldn't have said it. She felt horrible when she realized the family heard what she said and reported it to the on-call manager (Staff B, Registered Nurse) right away. Staff A stated she made arrangements for the other nurse on duty to take care of the resident before she called the manager on-call, Staff B supported that action and counselled her at that time about professional conduct and respectful care of the residents. During an interview 10/2/25 at 11:50 a.m. Staff B, RN and Unit Manager stated when she was the manager on-call she received a call from Staff A, LPN who reported she said something she shouldn't have in front of a family member, thought she was speaking to the aides, didn't realize anyone else was around, Staff B counselled and educated Staff A on professional conduct, not to make inappropriate remarks about the resident's that they care for and to always treat residents and their family's respectfully. Staff A had already arranged for the other nurse on duty to assume care of the resident, Staff B contacted the resident's responsible party to address the matter and they were satisfied with change of staff assignment and staff education related to the incident.The facility's policy, titled Resident Rights - Dignity and Respect, dated 4/2024 included a Purpose statement, which declared To lay the foundation for treating all residents with dignity and respect and maintaining and enhancing his or her self-esteem and self-worth. The Procedure section directed, in part:a. Each Resident has the right to considerate and respectful care and to be treated with honesty, dignity, respect and with reasonable accommodation of individual needs except where the health, safety, or rights of the resident or other individuals in the facility would be endangered.

Based on observation, clinical record review, and staff interview, the facility failed to ensure a resident with a history of poly substance overuse smoked safety when under the influence for 1 of 1 (Resident #1) residents reviewed for smoking safety. The facility reported a census of 70 residents. Findings include: Review of the Minimum Data Set (MDS) assessment tool dated 4/10/25 revealed Resident #1 admitted to the facility on [DATE]. A score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicated intact cognition. The MDS list of diagnoses included anxiety, asthma and respiratory failure. Review of the document Smoking Program assessed the following areas to determine if a resident is an unsafe smoker of cigarettes. Per the instructions the assessor to evaluate or observe the resident in the following areas. Any check will make the resident unsafe smoker using a cigarette: a. Unable to comprehend facility-smoking policy? b. Smokes in unauthorized areas? c. Careless with smoking materials? d. Burn holes observed on clothing or wheelchair? e. Inappropriately extinguishes cigarettes or matches? f. Provides smoking materials to others? g. Unaware of surroundings? h. Poor judgement or decision-making skills? i. Inability to control movements or maintain control of cigarette? j. Inability to follow instructions? k. Unable to safety light cigarette? l. Falls asleep while smoking? m. Other physician limitations or behaviors that interfere with safe smoking? n. None of the above. Review of the Smoking Program assessments completed on 4/16/25 and 6/3/25 revealed no areas checked. The section Program Independent Smoking Program listed a Focus area: Tobacco use, with the Goal: Resident will adhere to smoking policy. Intervention: Independent Smoker: May smoke without assistance. The 6/3/25 assessment added the Intervention: Independent Smoker: Must smoke only in designated areas/designated times (unless able to independently get to and from the designated areas). The Smoking Program assessments completed on 4/16/25 and 6/3/25 did not address if Resident #1 unsafe smoker using cigarettes when under the influence. Review of the Care Plan, dated 4/2/25, revealed a Focus area to address Tobacco Use. Interventions included, in part: a. Independent Smoker: May smoke without assistance. Date Initiated: 4/17/25. b. Independent Smoker: Must smoke only in designated areas/designated times (unless able to independently get to and from the designated areas). Date Initiated: 6/3/25. Review of the Care Plan, dated 6/3/25, revealed a Focus area to address History of poly substance overuse that may impact psychosocial functioning. Interventions did not address general safety or safety when smoking. Review of a facility self-report, dated 5/31/25 at 8:21 AM revealed, in part: The morning of 5/31/25 at approximately 7 am DON [name redacted] was called to this facility as the police department was contacted due to a noise complaint related to residents on the smoking patio. When DON arrived at facility approximately 7:15 resident [name redacted, Resident #1] was on the smoking patio being very loud and belligerent. During an interview on 6/12/25 at 2:43 p.m., Staff A, Registered Nurse (RN) stated on the evening of 5/30/25 Resident #1 left with his family and returned between 10:15 p.m. - 10:30 p.m. Staff A stated when he first returned he was pleasant and did not act that intoxicated. She stated as the night progressed he became increasingly belligerent, extremely loud, and uncooperative. Staff A stated he was drunk, and demanded to smoke. She explained he was out on the smoking patio for several hours during the night shift. She stated she had gone out to check on him, at least 3 times, encouraged him to come inside so she could check his oxygen levels. She stated he allowed her to check one time between 3:30 a.m. and 4:00 a.m. Staff A stated Resident #1 was loud and yelling when out on the patio, despite her asking him to keep it down and lower his voice. She stated the resident was unable to be reasoned with. While on the patio Resident #1 had a can of beer, which he surrendered when she requested. Staff A stated there was less than an ounce of beer left in the can. She stated around 5 a.m., a neighbor called the facility and reported a resident was yelling loudly outside and asked if there was anything the facility could do to make the resident stop yelling. Staff A stated she notified the Director of Nursing (DON) at that time, and the police did come to the facility. During an interview on 6/19/25 at 3:10 p.m., Staff D, Licensed Practical Nurse (LPN), stated she did not think the resident was safe to smoke independently when he was intoxicated. Staff D stated but try telling him that, he does whatever he wants. Staff D state had not observed Resident #1 dropping a cigarette when outside or burning a hole in clothing, but had heard this had happened. During an observation on 6/19/25 at 3:18 p.m., Resident #1 in his room with two staff members. Resident #1 had returned to the facility after a family outing. Resident #1 yelled loudly, speech appeared slurred, and demanded to go outside to smoke. The staff were unable to calm the resident or get him to lower his voice. During an interview on 6/19/25 at 3:20 p.m., the Administrator stated the Smoking Program assessments reflected one point in time. She stated a resident's condition could vary, someone who could smoke independently today may not be able to smoke independently tomorrow if their condition changed. When asked if she thought Resident #1 should smoke independently in his current condition per the observation at 3:18 p.m., the Administrator stated she would have to assess further and went to the resident's room During an interview on 6/19/25 at 4:51 p.m., Staff A, RN stated Resident #1 was under the influence he was not safe to smoke. She stated when he is intoxicated there is no reasoning with him. Staff A stated there were times when he was intoxicated that he would let the cigarette burn down to his fingers, she wasn't aware of any injury from that. She heard that he burned a hole in one of his jackets when smoking outside and he probably needed to wear a smoking apron (a fire-retardant garment worn to protect clothing from burning ashes/cigarettes). During another interview on 6/23/25 at 8:07 a.m., the Administrator stated that she put a new plan in place for Resident #1. She explained he would be supervised when smoking at all times, and there was a staff member assigned on each shift to do so.

Based on the Center of Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (for October 1st to December 31, 2024) review, facility staffing assignments review and staff interview, the facility failed to submit accurate agency staffing data for the PBJ Staffing Data Report. The facility reported a census of 66 residents. Findings include: The PBJ reported for the first fiscal year (FY) 2025, triggered for Excessively Low Weekend Staffing. The Daily Nursing Staffing Schedule for 9/2024, showed a consistent number of staff from the week and the weekends. The Daily Nursing Staffing Schedule for 10/2024, showed a consistent number of staff from the week and the weekends. The Daily Nursing Staffing Schedule for 12/2024, showed a consistent number of staff from the week and the weekends. Review of the Audit for PBJ 10/2024 through 12/31/2024, revealed 20 agency staff not submitted to the BPJ. On 3/19/25 at 3:43 PM, the Administrator reported the data submission for the PBJ and staffing reports were completed by the corporate office. On 03/20/2025 at 8:45 AM, the Administrator revealed she identified twenty nursing staff from agencies that were not included in the PBJ data. On 3/20/25 at 11:52 AM, the Administrator reported the facility failed to use a policy or procedure for the PBJ process.

Based on observations, record review and staff interviews, the facility failed to label and date opened food items in the refrigerator, freezer and dry storage areas in an effort to prevent foodborne illness. The facility reported a census of 66 residents. Findings Include: During the initial kitchen tour with Staff G, [NAME] on 3/16/25 at 10:10 AM, observations included: a. In the cooler, apple sauce, cheese, cabbage, and ranch dressing observed open. No label present or open date indicated. b. In the ice freezer, breadsticks, biscuits and slider rolls observed open. No label present or open date indicated. c. In the 3-door freezer, waffle fries and breaded fish fillets observed open. No label present or open date indicated. d. In the 2-door freezer, two packages of vegetables observed open. No label present or open date indicated. e. In the dry storage room, a box of fruit flavored cereal and bag of toasted flake cereal observed open. No label or open date indicated. When queried about storage of opened food items, Staff G stated food items that had been opened should have been labeled and dated. During an interview on o 3/19/25, the Dietary Manager stated any food item opened should be labeled and dated. He stated this it is his expectation that kitchen staff indicate the name of a food item and date opened is clearly written on the packaging. Review of the facility policy titled Labeling and Dating, revised on 12/2023 included a Purpose statement which declared To ensure foods stored will be properly labeled according to guidelines. Procedures included, in part: Date Marking for dry storage food items: 2. Once a case is opened, the individual food items from the case are dated with the date the items was received into the facility and placed in/on the proper storage unit . Date marking for refrigerated food items: 3. Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date. Date marking for freezer storage food items: 3. Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date .

Based on observations, clinical record review, facility policy review and staff interviews, the facility failed to ensure urinary catheter bags and tubing placed off the floor to minimize the risk of urinary tract infections for 2 of 4 residents reviewed (Resident #37 and Resident #121) with indwelling catheters. The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14 out of 15 for Resident #37, which indicated intact cognition. The MDS listed diagnoses included: neurogenic bladder (lose of control of bladder function due to nerve damage) and urinary tract infection. The MDS assessed Resident #37 dependent on staff for all activities of daily living with the exception of eating. The MDS indicated the resident had an indwelling urinary catheter. Review of the Care Plan, Date Initiated: 5/8/24 revealed a Focus area to address Resident requires the use of a indwelling catheter related to neurogenic bladder. Interventions included, in part: Ensure dignity bag remains in place, monitor tubing for kinks and leaks and ensure tubing remains off the floor. Date Initiated: 5/8/24. Review of a Discharge Summary from the Internal Medical provider, dated 12/23/24 Reason for Admission: Septic Shock Secondary to Urinary Tract Infection. During observations: a. On 3/16/25 at 11:21 AM, Resident #37 laid in bed with the dignity cover flap and tubing of the urinary catheter bag resting on the floor. b. On 3/16/25 at 2:06 PM, resident sitting up in bed, watching television with catheter bag and tubing resting on the floor. Staff D, Certified Nursing Assistant (CNA) in room and then exited without repositioning the bag and tubing. sat up in bed watching television. Foley bag and tubing remained on floor, Staff D, CNA left the room without repositioning bag and tubing. c. On 3/17/25 at 7:30 AM, the resident lying in bed with the collection bag, with a dignity cover, resting on the floor. d. On 3/17/25 at 7:37 AM, the Director of Nursing (DON) left the room after bringing the resident water. The collection bag remained on the floor. e. On 3/17/25 at 8:18 AM, Staff B, CNA entered the room with breakfast tray. Staff B exited the room without repositioning the collection bag off the floor. 2. Review of the Admission Record for Resident #121 revealed an admitted [DATE]. Review of the Medical Conditions listed on the March 2025 Medication Administration Record included, in part: type 2 diabetes mellitus, benign prostatic hyperplasia (BPH, meaning an enlarged prostate), and obstructive and reflux uropathy (blockage of urinary tract that hinders urine flow). Review of the Care Plan, Date Initiated: 3/7/25 revealed a Focus area to address Resident requires use of a (indwelling, catheter related to BPH w/Obstructive Uropathy. Intervention included, in part: Endure dignity bag remains in place, monitor tubing for kinks and leaks and ensure tubing remains off the floor. Date Initiated: 3/7/25. During observations: a. On 3/16/25 at 11:35 AM, while Resident #121 in bed, catheter bag and tubing rested on the floor. b. On 3/17/25 at 7:30 AM, while resident slept in be, the catheter bag and tubing rested on floor. c. On 3/18/25 at 6:15 AM, while resident slept in bed, catheter bag and tubing rested on the floor. During an interview on 3/18/25 at 10:10 AM, Staff D, CNA stated if she saw a resident's catheter bag and/or tubing on the floor, she would report it to the nurse so the nurse could change the bag and tubing. During an interview on 3/18/25 at 2:08 PM, Staff A, Registered Nurse stated if a staff member saw a resident's catheter bag or tubing on the floor, she would expect them to pick it up off the floor, perform catheter care and if needed change the bag out. Staff A stated CNAs can change the bag. During an interview on 3/18/25 at 3:46 PM, the Director of Nursing reported if a nurse or CNA found a resident's catheter bag or tubing on the floor, he would expect them to pick it up off the floor and inform the nurse. A review of the facility policy titled: Catheter Care: Indwelling Catheter, reviewed on December 2023 directed staff to: a. Check that tubing is not kinked, looped, clamped, or positioned above the level of the bladder b. Validate drainage bag is off the floor and in a dignity bag.

Based on observation, record review and staff interviews, the facility failed to utilize proper infection control methods during the change of a resident's colostomy bag/wafer (Resident #2) for one of one residents reviewed with a colostomy and during wound care for one of three residents reviewed for wound care (Resident #37) and failed to initiate and follow precautions for one of four residents reviewed for Enhanced Barrier Precautions (Resident #121). The facility reported a census of 66 residents. 1. The Minimum Data Set (MDS) dated [DATE] for Resident #2 revealed a diagnosis of paraplegia identified a colostomy. The Brief Interview for Mental Status (BIMS) score was 15 that suggested an intact cognition. The Care Plan for Resident #2 directed staff to utilize Enhanced Barrier Precautions (EBP) by wearing a gown and gloves while performing high-contact care activities such as colostomy care due to colonized multidrug-resistant organism (MDRO). A Physician Order, dated 1/19/25 for Resident #2 revealed a colostomy bag and to change the pouch twice a week and as needed (PRN). The General Progress Note, dated 3/14/25 for Resident #2 revealed the resident was noted to have a right abdomen urostomy patient with clear colored urine and noted to have on the left side, a colostomy with brown, semi soft stool. During an interview on 3/17/25 at 1:32 PM, Resident #2 stated the colostomy bag had come off and the nurse was to change it. During an observation on 3/17/25 at 3:02 PM, Staff K Licensed Practical Nurse (LPN) entered Resident #2's room and put on personal protective equipment (PPE), a gown and gloves, and proceeded to gather supplies out of the resident's bed side stand to change his colostomy wafer and bag. Staff K removed the towel covering the colostomy to Resident #2's left abdomen. The previous colostomy wafer was partially pulled away for the resident's stoma (an artificial surgical opening into the body for the purpose of waste removal or drainage) and a small amount of soft bowel movement was coming out. Staff K removed the old wafer and bag and placed in the trash, then pulled wipes from a bag to wipe away the bowel movement. Staff K removed the gloves and put new gloves on then proceeded to place a new wafer on. Staff K then proceeded to replace the urostomy bag (surgical opening to the divert urine from the kidneys to an external bag). Staff K failed to hand hygiene before putting on the PPE, after changing gloves during the procedure, or after securing the colostomy bag and adherence of the ostomy bag. A document titled Treatment Administration Record dated March 2025 for Resident #2 revealed the colostomy bag was marked as changed on 3/17/25. During an interview on 3/17/25 at 4:02 PM, The Director of Nursing (DON) stated his expectation was that the nurse would perform hand hygiene before, during and after procedures such as colostomy cares. 25855 2. The Minimum Data Set (MDS) dated [DATE] identified Resident #37 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 14 and had the following diagnoses: neurogenic bladder (lose of bladder control due to nerve damage), septicemia (blood infection), and urinary tract infection. The MDS also identified Resident #121 had an indwelling urinary catheter. Review of Resident #37 Order Summary Report, dated 3/16/25 revealed an order for Gentamacin Sulfate External Ointment 0.1% (Gentamicin Sulfate (Topical)). Apply to left ischium topically every day and evening shift for Ischial Wound Cleanse with NS (normal saline), paint peri-wound betadine, apply gentamicin to wound bed, cover with alginate AG, cover with gauze dressing, secure with tape. Start Date 1/9/25. During an observation of wound care on 3/17/25 at 1:56 PM, Staff A, Registered Nurse (RN ) cleansed the wound to the left ischium, and dabbed with gauze. Without completing hand hygiene or changing gloves, Staff A then used a betadine swab to paint the wound. Staff A then open a package of cotton applicators, and without completing hand hygiene or changing gloves applied gentamicin ointment to the applicator and applied to wound. During an interview on 3/18/25 at Staff A, RN stated when performing wound care she would complete hand hygiene and change gloves in between cleaning the wound bed and applying treatments. Staff A stated she did not do this during the wound care observation on 3/17/25 with Resident #37. During an interview on 3/18/25 at 3:46 PM, the Director of Nursing (DON) stated completing wound care he would expect nursing staff to complete hand hygiene and change gloves when going from cleansing wound and then applying the prescribed treatment, or when going between two different wounds. A review of the facility policy titled: Dressing Change, reviewed November 2023, included a Procedure, which directed, to complete hand hygiene and apply (or change) gloves after: setting up area with supplies and assisting resident to a comfortable position, removing soiled dressing, preparing dressing if needs to be cut to use, after cleaning wound, and after completing the treatment. 3. Review of the Admission Record for Resident #121 revealed an admitted [DATE]. Review of the Medical Conditions listed on the March 2025 Medication Administration Record included, in part: type 2 diabetes mellitus, benign prostatic hyperplasia (BPH, meaning an enlarged prostate), and obstructive and reflux uropathy (blockage of urinary tract that hinders urine flow). Review of the Care Plan, Date Initiated: 3/7/25 revealed a Focus area to address Resident requires use of a (indwelling, catheter related to BPH w/Obstructive Uropathy. Intervention included, in part: Endure dignity bag remains in place, monitor tubing for kinks and leaks and ensure tubing remains off the floor. Date Initiated: 3/7/25. During an observation on 3/16/25 at 7:30 AM, a lack of a sign on door or within the room to indicate the need for Enhanced Barrier Precautions noted. Gloves noted to be available in the room. Lack of protective gowns outside or inside room noted. During an observation on 3/17/25 at 7:43 AM Staff B, Certified Nursing Assistant (CNA) and Staff C, CNA entered Resident #121 with mechanical lift to transfer the resident from his bed to his wheelchair. Neither staff donned a gown prior transferring the resident. During an observation on 3/16/25 at 2:07 PM, Staff D, CNA entered Resident #121 room. Staff D completed hand hygiene and donned gloves prior to emptying Resident #121 urinary catheter bag. Staff D did not don a gown prior to emptying the bag. During an interview on 3/18/25 at 10:10 AM, Staff D, CNA stated that Enhanced Barrier Precautions (EBP) should be in place for anyone who has catheters. She stated EBP required the use of gown and gloves when providing care. Staff D stated no on reported to her that Resident #121 would require gowns and gloves for cares. During an interview on 3/18/25 at 3:46 PM, the Director of Nursing stated EBP should be used for any resident that has a direct line for infection, such as larger wounds, intravenous access, and catheters. He stated should be aware of the need for EBP if they saw a blue caddy on the door with PPE and a sign. A review of the facility policy titled: Enhanced Barrier Precautions, last reviewed March 2024 included a Purpose statement, which declared: To minimize risk of transmission of novel or targeted Multi-Drug Resistant Organisms (MDROs) during high contact resident care activities for residents requiring enhanced barrier precautions (EBP). Procedure directed: 1. EBP will be used in conjunction with standard precautions for residents with any of the following (if/when Contact Precaution requirements are not in place): a. Infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply; b. Wounds and/or indwelling medical devices (even if the resident is not known to be infected or colonized with a targeted MDRO). NOTE: Wounds generally include chronic wounds including but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. This would not include shorter-lasting wounds, such as skin breaks/tears covered with an adhesive bandage or similar dressing. NOTE: Indwelling medical devices include: central lines/PICC, urinary catheters, feeding tubes, tracheostomy/ventilator (a peripheral intravenous line would not be considered indwelling device for purpose of EBP).

Based on observations, maintenance record review, resident and staff interviews the facility failed to provide dignified care to residents when the water temperature unpredictably changed from a comfortable temperature to a cold temperature for 6 of 6 resident reviewed for dignity. The facility reported a census of 66 residents. Findings include: During interview on 11/19/24 at 2:40 p.m., the facility Administrator stated she became aware shower water temperatures were not hot enough on 11/12/24 when a resident informed her of the concern. She contacted a local plumbing company at that time for service. The Administrator stated the plumbing company was on site the same day, and identified the 2nd floor central shower required a new cartridge. She stated the plumbing company returned on 11/15/24 and replaced the cartridge. On 11/20/24, the State Agency took water temperatures from the identified location with the following results: a. At 9:57 a.m., the 2nd floor central shower measured at 107.8 Fahrenheit (F). b. At 10:59 a.m., the 1st floor central shower measured at 109.7 F. c. At 11:30 a.m., the 1st floor central shower measured at 112.4 F. d. At 11:34 a.m., the 2nd floor west shower measured at 62.8 F, the shower room floor was wet upon entry, used towels and wash cloths were in the hamper (indications the room was recently in use). e. At 11:39 a.m., the 2nd floor central shower measured at 111.5 F. A review of the facility's water temperature log completed by Staff E, Maintenance Director, revealed water temperatures recorded throughout the 1st floor on 10/22/24, 10/29/24, 11/5/24 and 11/15/24 revealed a temperature range of 110 F to 115 F. Water temperature for the 2nd floor were not recorded. During an interview on 11/20/24 at 11:34 a.m., Staff F, Licensed Practical Nurse (LPN) stated they had warm water today so they were able to do a few showers. She stated other days they could not get showers done if the water didn't get warm enough. During an interview on 11/20/24 at 11:56 a.m., the Administrator stated after speaking to maintenance staff she had been told you had to run both the sink and the shower at the same time in the 2nd floor west shower to get the temperature up. During an observation on 11/20/24 at 12:04 p.m. Staff E, Maintenance Director and the Administrator took water temperatures of the 2nd floor west shower room. While running the sink and shower at the hottest possible setting the first temperature taken measured at 89 F, then 93 F, then 97.9 F, then back down to 94.1 F within a 2-minute time period. Staff E stated because it was upstairs you had to leave the water run for a while to get the temperature up. During an interview on 11/20/24 at 11:49 a.m., Resident #2 (BIMS of 15 out of 15, intact cognition) stated water in the showers was never warm enough. The resident stated he had refused too many showers to count over the last 3 to 4 months due to the water temperatures. Resident #2 stated he has been in the shower when the water cools down and had staff hurry to finish as there was no assurance that the water temperature would get warmer again. During an interview on 11/20/24 at 6:11 p.m., a family member and Power of Attorney for Resident #1 stated the water in the sink in the resident's room has been cold since she was admitted to the facility 5 weeks ago. The family member stated the water never got warm or hot, and they spoke to different staff about it since the resident was admitted . They stated the standard response was we are working on it, but nothing changed. The family member stated Resident #1 had refused several showers because the water was cold, and she had a hard time to get warm after that. During an interview on 11/21/24 at 9:44 a.m., Resident #5 (BIMS of 15 out of 15, intact cognition) stated he received his shower in the 1st floor central shower room and there has been a problem for several months with the water not being hot enough to shower. The resident stated had to wait 20 minutes while in the shower for the water to get warm enough again to continue. During an interview on 11/21/24 at 9:50 a.m., Resident #7 (BIMS OF 15 out of 15, intact cognition) stated they have to run the water for a while to get it warm enough. He explained they can't have showers when the dishwasher is running. He stated the water has cooled down during his shower a couple of times, that wasn't comfortable and he hoped they could fix the problem. During an interview on 11/21/24 at 9:52 a.m., Resident #8 (BIMS of 13 out of 15, intact cognition) stated he had been in the shower when the water got cool. He stated staff had to flush the toilet to make it warmer but it still was not warm enough. Resident #8 stated it seemed like they were having problems with the water temperatures for a while. During an interview on 11/21/24 at 10:12 a.m., Resident #6 (BIMS of 15 out of 15, intact cognition) stated they had problems with the water temperature in the shower for at least a few months. She stated the water isn't hot enough and will cool down during the shower. Resident #6 stated when you are all lathered up they have to finish and rinse that off with cool water and it was uncomfortable. Everyone here knows there is a problem with the water temperature in the shower. Resident #6 stated she has refused showers when the water isn't warm enough at least 3 to 4 times in the last couple months. During an interview on 11/21/24 at 10:02 a.m., Staff H, Certified Nursing Assistant (CNA), stated the hot water had to run for 10 to 15 minutes to get it warm enough for resident showers, the sink water had to be running at the same time to help get the temperature up. Staff H stated when she worked on the evening shift they couldn't do showers after supper because when the dishwasher ran it took all the hot water. During an interview on 11/21/24 at 10:36 a.m., Staff E, Maintenance Director when asked where the 2nd floor water temperatures were recorded for the 10/22/24 and 11/15/24 time period, stated he had given the log to Staff G, Maintenance staff that worked on the weekend to complete. He stated the temperatures he recorded on the form was after the water had ran for 10 to 15 minutes because that is what he had to do to get the temperature as hot as it would get. Staff E stated the water temperatures had been an issue since he started working there in January [2024]. Staff E stated he had consulted with the corporation about service providers and when there are water temperature issues at the facility it is more of an immediate need and difficult to get providers at the time to address the issue. During an interview on 11/26/24 at 6:56 a.m., Staff I, CNA, stated the hot water/shower temperatures had been a problem for a while. She stated there had been different companies there to try to fix it but the water temperatures continued to be low. Staff I stated the best time to shower a resident with the best chance for warmer water was right before breakfast She stated you have to keep the sink on when you give the shower, has been in the middle of a shower when the water temperature drops, it could be 15 minutes before the water temperature gets high enough to resume the shower so you have to cover the resident and wait for the water temperature to go back up, there wasn't anything else you could do. On 11/26/24, the State Agency, with the Director of Nursing present obtained the following water temperatures from the shower on the 1st floor west shower after the sink and shower faucets turned to the highest hot water setting, while running at the same time: a. 7:10 a.m. 56.5 F b. 7:14 a.m. 76.1 F c. 7:16 a.m. 75.4 F d. 7:17 a.m. 83.4 F e. 7:19 a.m. 81.7 F f. 7:21 a.m. 78.4 F g. 7:24 a.m. 96.0 F h. 7:27 a.m. 97.2 F i. 7:29 a.m. 96.1 F j. 7:30 a.m. 92.2 F The hot water in the Therapy Room (located near the 1st floor central shower room) on 11/26/24 at 7:35 a.m. revealed hot water at the sink at 117.9 F within 1 minute of turning the faucet on, the water as high as 119.0, and fluctuated between 116.3 F and 119.0 F without loss of hot water temperature. During an observation on 11/26/24 at 7:40 a.m., the 1st floor central shower room steamy upon entrance, had a shower temperature measurement of 117.2 F. During an interview on 11/26/24 at 7:04 a.m., Staff G, Housekeeping and Maintenance, stated he has never taken a water temperature at the facility. Staff G stated he had not been instructed to take water temperatures, and did know about the water temperature logs.

Based on observations, maintenance record review, and resident and staff interviews the facility failed to maintain essential equipment in acceptable operating condition to maintain water temperatures in resident showers between 110 degrees Fahrenheit (F) and 120 degrees F as required. The facility reported a census of 66 residents. Findings include: During interview on 11/19/24 at 2:40 p.m., the Administrator stated on 11/12/24 a resident informed her the shower water temperatures were not hot enough on 11/12/24. She stated she contacted local plumbing company A at that time for service. She stated the repair company was on site the same day. The plumber identified the central shower on the 2nd floor required a new cartridge. The cartridge was replaced on 11/15/24. The Administrator stated maintenance staff monitored water temperatures. She stated the facility had 1 boiler and 2 water heaters in use. During an interview on 11/20/24 at 11:34 a.m., Staff F, Licensed Practical Nurse (LPN) stated the facility had warm water today so they were able to do a few showers. During an interview on 11/20/24 at 11:56 a.m., the Administrator stated after she spoke to the Maintenance staff, she had been told to get the water temperature up on the 2nd floor, west shower room both the sink and the shower had to be ran at the same time. During an observation on 11/20/24 at 12:04 p.m., Staff E, Maintenance Director and the Administrator took water temperatures on the 2nd floor, west shower room. While running the sink and shower at the hottest possible setting the first temperature taken measured at 89 F, then 93 F, then 97.9 F, then back down to 94.1 F within a 2-minute time period. Staff E stated because it was upstairs you had to leave the water run for a while to get the temperature up. A review of the facility's water temperature log completed by Staff E, Maintenance Director, revealed recorded temperatures for the 1st floor showers recorded on 10/22/24, 10/29/24, 11/5/24 and 11/15/24 revealed a temperature range of 110 F to 115 F. Water temperatures for the 2nd floor showers were not recorded in the log. During an interview on 11/21/24 at 10:36 a.m., Staff E stated the water temperatures had been an issue since he started working there in January [2024]. Staff E stated he had consulted with the corporation about service providers and when there are water temperature issues at the facility it is more of an immediate need and difficult to get providers at the time to address the issue. During an interview on 11/21/24 at 11:20 a.m., the Administrator stated local plumbing company A had returned to assess the hot water at the facility. She stated the facility is getting estimates on a new boiler a few weeks ago as a local plumbing company B informed her the boiler leaked and required replacement. The hot water in the Therapy Room (located near the 1st floor central shower room) on 11/26/24 at 7:35 a.m. revealed hot water at the sink at 117.9 F within 1 minute of turning the faucet on, the water as high as 119.0, and fluctuated between 116.3 F and 119.0 F without loss of hot water temperature. During an interview on 11/21/24 at 10:02 a.m., Staff H, Certified Nursing Assistant (CNA), stated the hot water had to run for 10 to 15 minutes to get it warm enough for resident showers, the sink water had to be running at the same time to help get the temperature up. Staff H stated when she worked on the evening shift they couldn't do showers after supper because when the dishwasher ran it took all the hot water. During an interview on 11/21/24 at 9:50 a.m., Resident #7 (BIMS OF 15 out of 15, intact cognition) stated they have to run the water for a while to get it warm enough. He explained they can't have showers when the dishwasher is running. He stated the water has cooled down during his shower a couple of times, that wasn't comfortable and he hoped they could fix the problem. On 11/26/24, the State Agency, with the Director of Nursing present obtained the following water temperatures from the shower on the 1st floor west shower after the sink and shower faucets turned to the highest hot water setting, while running at the same time: a. 7:10 a.m. 56.5 F b. 7:14 a.m. 76.1 F c. 7:16 a.m. 75.4 F d. 7:17 a.m. 83.4 F e. 7:19 a.m. 81.7 F f. 7:21 a.m. 78.4 F g. 7:24 a.m. 96.0 F h. 7:27 a.m. 97.2 F i. 7:29 a.m. 96.1 F j. 7:30 a.m. 92.2 F During an interview on 11/26/27 at 1:00 p.m., the Administrator stated local plumbing company B is scheduled to return to further diagnosis the issue with maintaining hot water temperatures on the 2nd floor.

Based on observations, clinical record review, resident and staff interviews, the facility failed to follow physician orders for wound care and positioning for 1 of 3 resident records reviewed for wound care (Resident #2). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 9/20/24, revealed Resident #2 diagnoses listed included osteomyelitis (infection of the bone) of the vertebra, sacral and sacrococcygeal region, hypertension (high blood pressure), peripheral vascular disease (restricted blood flow), paraplegia (paralysis of the lower body), and hemiplegia (paralysis of one side of the body). Resident #2's Brief Interview for Mental Status score of 15 out of 15 indicated intact cognition. The MDS assessed the resident dependent on staff to roll left and right, and for a chair/bed-to-chair transfer. The MDS indicated the resident at risk for developing pressure ulcers. The MDS identified Resident #2 with two Stage 4 pressure ulcers. A review of the electronic health record Medical Diagnosis list indicated Resident #2 diagnosed with: a. Pressure ulcer of left lower back, Stage 4 on 3/22/23. b. Pressure ulcer of sacral region, Stage 4 on 3/22/23. The Care Plan, date initiated 7/22/24, included a Focus area to address SKIN: At risk for alteration in skin integrity related to impaired mobility, pvd (peripheral vascular disease), refusal of repositioning. Non-compliance with preventative measures, dry skin, hld (high cholesterol), vit([NAME]) d deficiency, h/o (history of) cachexia (condition that causes loss of muscle and fat mass); healing prognosis is poor, h/o and risk of malnutrition, anemia, edema. Interventions included, in part; Administer treatment per physician orders, date initiated 1/11/24. A Wound Care Progress Note dated 11/12/24, Plan directed, in part; a.Limit time in chair to 1 hour (or less as tolerated by patient0, and reposition every 30 minutes while in chair. b. Use betadine to the peri wound (skin around the wound), gentamicin ointment, silver alginate covering with gauze and tape to the sacrum and left ischium ulcers changing twice daily and as needed with the assistance of facility nurses. Topical lidocaine 4% to aid in pain relief twice daily and as needed with dressing changes. Saline or wound cleanser of choice with dressing changes. Continue dressing orders until next office visit. A review of Physician Orders in the resident's electronic health record revealed an order transcribed 11/21/24 by Staff A, Registered Nurse (RN) and the facility's Wound Nurse, directed staff to apply Gentamicin Sulfate 0.1 percent ointment to the left ischium wound topically twice daily. Apply Betadine to peri wound, apply Gentamicin ointment to wound bed, cover with alginate, cover with gauze, secure with tape and apply to left ischium topically as needed for wound care if loose or soiled. The November, 2024 Treatment Administration Record (TAR) revealed the resident had no documented wound care of the left ischial pressure ulcer from 11/13/24 through 11/20/24 (7 days without treatment), and the physician directive to limit the resident's time up in chair to 1 hour or less at a time was not listed in the treatment orders. When reviewed on 11/25/24, the resident's Kardex (a brand name for an informational system that is used as a quick reference for nursing staff) directed staff to Encourage resident to minimize time up in wheelchair. Wound clinic recommends no longer than 2 hours 3 times a day. During an observation on 11/20/24 at 12:57 p.m., Resident #2 in bed, with the door to the room open. The door to the room closed at 1:10 p.m. Staff C, Certified Nursing Assistant (CNA) opened the door at 1:14 p.m., and Resident #2 seated in his wheelchair. During an interview on 11/2024 at 1:44 p.m., Resident #2 while in his wheelchair, stated he was supposed to go to bed, and was not to be up for more than 30 minutes. He stated he could not access his call light from his current position. The call light was activated, and Staff D, CNA responded at 1:47 p.m. Staff D stated she was unaware the resident had a restriction on how long he could be up in his wheelchair, her coworker Staff C, CNA, was currently on break and she would return with Staff C when she was back from break to lay the resident down. At 2:05 p.m., the resident remained seated in his wheelchair in his room, Staff D in the hall near the Nurse's Station and stated they (Staff D and Staff C) had just completed care on another resident and would lay Resident #2 down next. During an interview on 11/20/24 at 1:22 p.m., Staff A, RN, and facility Wound Nurse, stated Resident #2's current physician orders for the left ischial wound was to apply Betadine to the peri wound, Gentamicin ointment to the wound bed, followed by a calcium alginate wafer, covered with a 4 inch by 4-inch gauze dressing secured with tape, or a border gauze dressing, applied twice daily. Staff A stated the physician's recommendation was the resident was not to be up in a chair for more than 2 hours at a time. Staff A stated either she or the nursing staff on duty normally transcribed the Wound Center's physician orders upon the resident's return from the appointment, and as the facility Wound Nurse, she reviewed the Wound Center physician progress notes and assessed and measured resident wounds at least weekly. During an interview on 11/25/24 at 11:06 a.m., Staff A stated she realized the 11/12/24 physician orders for the left ischial wound care had not been transcribed when she was interviewed on 11/20/24, and entered the physician orders in the computer at that time.

Based on clinical record review, observations, staff interviews, and review of the facility's Falls Practice Flow Chart, the facility failed to prevent a fall with serious injury for one of three residents reviewed for supervision (Resident #10). The facility reported a census of 59 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #10 with moderate cognitive status with a Brief Interview for Mental Status (BIMS) of 12 out of 15 points and had the following diagnoses: Cancer, Cerebrovascular Accident (stroke) and Non-Alzheimer's Dementia. The MDS also identified Resident #10 required extensive staff assistance with most activities of daily living (ADL's) and had a history of falls one month prior to admission to the facility. The Incident Report dated 6/8/23 at 7:20 PM, documented the following: Resident #10's roommate stated he was on the floor. Resident #10 found sitting on the floor with legs crossed, stated he stood to use urinal, floor got wet and he fell . He was using a bedside table to walk in the room. Resident #10 able to stand with assist of 2, then stated his left leg hurt. Emergency Medical Services (EMS) notified and arrived at 7:35 PM. Resident #10 transferred from bed to gurney with assist of 4 then taken to the hospital. Injury: possible fracture left trochanter. A review of the Nurse's Notes revealed the following: a. On 6/8/23 at 7:20 PM, Resident #10 found on the floor, range of motion normal without complaints of pain. After staff assisted the resident to stand and transfer him to bed, he complained of pain to his left upper outer thigh area. Resident #10's Power of Attorney (POA) and Physician notified. Orders received to send to the Emergency Department for evaluation and treatment. EMS transported the resident to the hospital at 7:35 PM. b. On 6/9/23 at 5:04 PM, Resident #10 returned from the hospital after hospitalized for left hip fracture after a fall. Family decided to leave untreated and continue with Palliative Care. c. On 6/13/23 4:22 PM, Resident #10 found unresponsive without heart rate or lung sounds. The Major Injury Determination Form had documentation of the following: a. Date and time of injury: 6/8/23 (no time documented). b. Description of injury: left femoral neck fracture, mild proximal migration of left femoral shaft. c. Circumstances of incident causing injury: up to use urinal, stood, slipped and fell next to bed. d. Resident's previous functional ability: supervision and cueing for transfers. Completed by DON (Director of Nursing) on 6/9/23 at 11:09 AM. Response by the facility to Medical Director on 6/19/23 at 11:00 AM. On 6/16/22 the Care Plan identified Resident #10 with the problem of ADL's - Self-care deficit and directed staff to transfer with supervision/ as needed (PRN) assist with a walker. During the investigation survey, observations of the Resident #10 lying in bed on his back with continuous oxygen maintained at 2 liters per nasal cannula per concentrator on the following dates and times: a. On 6/19/23 at 11:51 AM, at 12:42 PM, at 3:45 PM, and at 3:48 PM. b. On 6/20/23 at 7:47 AM, and at 9:29 AM. c. On 6/21/23 at 8:01 AM, at 10:08 AM, at 12:36 PM, and at 12:42 PM. d. On 6/27/23 at 3:00 PM. Resident #10 made no attempts to get up out of bed on his own. In an interview on 6/28/23 at 11:17 AM, Staff I, Certified Nurse Aide (CNA) reported before Resident #10 fell on [DATE], he was independent with transfers, but sometimes the staff would need to monitor him closely because his feet would swell and would not sit still. In an interview on 6/28/23 at 11:35 AM, Staff J, CNA reported before Resident #10 fell on [DATE], he was independent in his room with his walker. In an interview on 6/28/23 at 12:54 PM, Staff K, Registered Nurse (RN) reported before Resident #10 fell on [DATE], he was to be transferred with the assistance of one staff member with a gait belt, however, he was non-compliant and would use his bedside table and push that around. The staff should have made rounds on him at least every 15 or 30 minutes because of his history of getting up on his own. In an interview on 7/3/23 at 10:10 AM, the DON (Director of Nursing) reported before Resident #10 fell on [DATE], he was to be transferred with the assistance of one staff member to provide standby assistance, that he had been pretty impulsive and had a history of falls prior to this one. A review of the facility Falls Practice Flow Chart revealed a process to include assessment, plan, implementation and evaluation.

Based on clinical record review, resident and staff interviews, the facility failed to ensure a resident's pain control during wound care was maintained for two of five residents reviewed (Residents #3 and #9). The facility reported a census of 59 residents. Findings Include: 1. The Minimum Data Set, dated dated dated [DATE] identified Resident #3 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 of 15 points and had the following diagnoses: Cancer, Peripheral Vascular Disease and Malnutrition. The MDS also identified Resident #3 required extensive staff assistance with most activities of daily living (ADL's) and with one Stage 2 pressure ulcer and four venous/arterial ulcers. In an interview on 6/19/23 2:15 PM, a nurse from the Veteran's Administration (VA) reported the following: The VA Nurse and Physician observed the dressing change. The VA Physician informed the Facility Nurse that Resident #3 should be premedicated prior wound care. The resident received Morphine earlier, however, it was short acting, and by the time the Facility Nurse did the dressing, an hour had passed and by then Resident #3 was in agony and the VA Doctor directed the Facility Nurse to give Resident #3 pain medication. The VA Nurse reported, even after the Floor Nurse had medicated the resident again and he still looked like he was in pain. A review of the facility Nurse's Notes revealed the following: a. On 5/11/23 at 11:04 AM, Rates pain as 10 out of 10. b. On 5/12/23 at 11:29 PM, Give as needed (PRN) Ativan (medication to treat anxiety) and PRN Morphine (medication to relieve pain). Resident #3 is crying and grimacing. Hospice notified. c. On 5/16/2/23 at 5:47 PM, Reported pain for MDS assessment. d. On 5/26/23 at 12:50 AM., Resident #3 reported pain to both legs and rated as a 10 on a scale of 0 to 10. Multiple entries of administration of Morphine, Lorazepam, Trazadone documented daily. 2. The MDS dated [DATE] identified Resident #9 as severely cognitively impaired with a BIMS score of 0 out of 15 points and had the following diagnoses: Dementia, Coronary Artery Disease and Benign Prostatic Hyperplasia. The MDS failed identify the resident with pressure or venous stasis ulcers. On 5/5/22 the Care Plan identified Resident #9 with the problem of chronic wounds to his left foot related to plasmocytic perivascular spongiotic dermatitis to the left heel, foot and toes. The left great toe callus (scab off and treated 6/20/23). The Care Plan failed to direct the staff to offer the resident analgesics (used to relieve pain) prior to wound care. A review of the June 2023 Medication Administration Record (MAR) and Physician Order Summary revealed an order dated 3/17/20 for Acetaminophen (Tylenol) 325 mg tablet, give 2 tablets orally every 4 hours as needed for pain related to right foot. The MAR lacked documentation to show any doses had been administered for the entire month. During an observation/interview on 6/19/23 at 11:30 AM, Resident #9 sat up in bed with the air mattress inflated and Prevalon boots to both feet (to relieve pressure and help prevent ulcers). Resident #9 reported when the nurses change his dressings and touch a spot on his left heel, it causes a lot of pain and none of the nurses offer to medicate him prior to the dressing changes. During an observation of wound care on 6/20/23 at 1:01 PM, Staff B, Licensed Practical Nurse (LPN) and Staff D, Certified Nurse Aide (CNA) both washed their hands, donned gloves and assisted Resident #9 to turn to his left side. After Staff B removed the dressing to Resident #9's coccyx area, he yelled Ow! I tell you what! At 1:18 PM, as Staff B wrapped a dressing around Resident #9's left foot, the resident flinched with a facial grimace of pain when Staff D lifted his leg. At 1:21 PM, when Staff B left the room for more dressings, Resident #9 reported he was not given any pain medication prior to the dressing change and rated his pain level as 9 In an interview on 6/28/23 at 9:37 AM, Staff E, CNA reported he had helped nurses turn Resident #9 during wound care and 9 times out of 10 Resident #9 looked like he was having pain and will let the staff know this when they turn him. In an interview on 6/28/23 at 10:12 AM, Staff H, CNA reported she helped nurses turn Resident #9 during wound care and observed him complain of pain when the staff are too rough when turning him. In an interview on 6/28/23 at 10:29 AM, Staff B, LPN reported Resident #9 did not like being turned over on his side too long and had complained that she took too long to clean him up during wound care. When asked if there was a reason why he was not being pre-medicated prior to his wound care, she reported she never thought of it. In an interview on 6/28/23 at 2:33 PM, Staff A, RN reported Resident #9 complained of pain when they clean his wound. When asked if he was being pre-medicated prior to his wound care, she said no, however, that is a great idea. She also reported she thought the intervention of pre-medicating Resident #9 prior to wound care should be addressed on his Care Plan and felt the Nurse Practitioner (NP) should consider writing an order to pre-medicate. In an interview on 7/3/23 at 10:10 AM, the Director of Nursing (DON) reported Resident #9 had complained during wound care when repositioned or when staff lifted his leg. When asked why he was not being pre-medicated prior to wound care, the DON reported Resident #9 will say he did not want it, the nurse will ask and he will refuse. She also reported they should be documenting when he refuses. She also reported she felt the need to offer to pre-medicate did not need to be addressed on the Care Plan. The facility policy titled: Pain Quick Reference dated November 2021, documented the following tips for nurses to advocate pain management for your patients: a. Avoid labeling and judging patients. b. Ask Is there anything we can do to make you more comfortable? c. Consider age, culture, religion, and previously used successful intervention when creating a Plan of Care. e. Treat pain early - delays can make pain more difficult to control. f. Non-pharmacological interventions are a key 1st step in pain management. g. Consider analgesics (medications to treat pain) for continuous pain or cognitive impairment with regular signs of pain. i. Regularly evaluate the effectiveness of the Pain Management Plan.

Based on observations, clinical record review, staff, Provider and resident interviews the facility failed to prevent the development of a facility acquired pressure ulcer for 1 of 1 residents (Resident #43) sampled. The facility reported a census of 57 residents. Findings Include: The MDS (Minimum Data Set) Assessment identifies the definition of pressure ulcers as follows: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). May be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. 1. The Minimum Data Set (MDS) Assessment Tool, dated 1/3/2023, listed diagnosis for Resident #43 included: Dependence on renal dialysis (severe kidney disease), congestive heart failure, and Type 2 diabetes mellitus. The MDS assessed the resident required extensive assistance of two staff for transfers, and extensive assistance of one staff for bed mobility. The MDS, dated [DATE], revealed the resident did not have a pressure ulcer on admission, and assessed the resident at risk of developing a pressure ulcer. The MDS listed the Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating Intact cognition. The 12/30/22 Admission Evaluation Clinical Integumentary (skin) Evaluation noted the resident's skin integrity issues to be an arterial wound on the right inner ankle. No pressure ulcers noted being present on admission. The 12/30/22 Baseline Care Plan on the Admission Evaluation focused on the resident being at risk for alterations in skin integrity, with an intervention to encourage repositioning as needed, and use assistive devices as needed. The facility Skin Alteration Record started on 1/20/23 for a friction/moisture alteration. Wound information for the left ischial (buttock area) area: a. On 1/20/23 a measurement of 2 centimeters (cm) x 1 cm red area. b. On 1/26/23 a measurement of 3 cm x 5 cm x 0.2 cm, with slough. c. On 2/1/23 a measurement of 3 cm x 4.5 cm x 0.2 cm, the area described as intact with moderate serous (clear) drainage and surrounding skin appearing swollen. Wound information for the right ischial area: a. On 1/20/23 a measurement of 4.3 cm x 3 cm, the area described as intact and dark. The report also noted a 1 cm x 1.5 cm open area in the center of the wound. b. On 1/26/23 a measurement of 3 cm x 6.6 cm, the area noted to have slough, and eschar to the lateral aspects. Scant serous (clear fluid) drainage noted with surrounding skin reddened. c. On 2/1/23 a measurement of 3 cm x 6.4 cm x 0.2 cm, the area noted to have eschar with serous drainage. The surrounding area was described as reddened. A review of the clinical record revealed a 1/24/23 Nursing Communication to the residents provider stating the resident left Dialysis early due to his butt being too sore. A 1/26/23 Skin note documented the residents right and left ischial areas noted to have increased discoloration and open areas. The facility notified the Provider and received a new order to cleanse the area with normal saline, apply Dakins 1/4 strength soaked gauze with alginate and foam adhesive daily. Review of the January 2023 Treatment Administration Record (TAR) revealed no treatments administered to the identified unstageable pressure ulcers to the right and left ischial areas until January 27, 2023, seven days after first documented the areas discovered on 1/20/23. The resident started on-site Wound Clinic care for the left and right ischial areas. Per the Wound Clinic notes: For left ischial wound: a. On 2/1/23: Stage 4, measuring 3 cm x 1.5 cm x 0.3 cm with moderate serous drainage with 100% granulation tissue. b. On 2/7/23: Stage 4, measuring 3.5 x 2 x 0.5 with moderate serous drainage and 100% granulation tissue. Wound progress described as improved. For right ischial wound: a. On 2/1/23: Stage 4, measuring 6 x 3 x 0.3 with moderate serous drainage, and 50% black necrotic tissue and 50% granulation. Surgical excisional debridement required. b. On 2/7/23: Stage 4, measuring 6.5 x 4.5 x 0.3 with moderate serous drainage, and 50% black necrotic tissue and 50% granulation. Surgical excisional debridement required. Wound progress described as deteriorated. Surgical excisional debridement required During an interview on 2/7/23 at 10:07 AM, the resident stated he has a very sore bottom due to sores. The resident stated the night staff have told him they will not transfer him in and out of bed during the night. The resident explained he has a wound on his right foot that hurts, and feels better when he gets out of bed. During an observation of wound care on 2/7/23 at 10:30 AM, the resident informed the provider the night staff told him they will not get him in and out of bed all night. During an interview on 2/7/23 at 10:38 AM, the resident's Provider stated the right ischial wound has deteriorated and he is concerned to hear the resident stated that staff will not get him in and out of bed during the night. The provider stated off loading is important for the resident. On 2/8/23 at 9:00 AM the resident observed out of his wheelchair, resting in bed. On 2/8/23 at 4:40 PM the resident observed out of his wheelchair resting in bed. On 2/9/23 at 1:00 PM the resident observed out of his wheelchair resting in bed. During an interview on 2/8/23 at 12:24 PM, Staff D, Certified Nursing Assistant (CNA) stated the resident has told her that the night staff does not like to get him in and out of the bed during the night. Staff D stated the resident has refused to transfer from his wheelchair to his bed; however when re-approached he often agrees to the transfer. During an interview on 2/8/23 at 1:38 PM, Staff A, Registered Nurse stated several residents have complained to her that the night staff will not get them up. During an interview on 2/8/23 at 4:16 PM, Staff E, CNA stated when she worked nights, the resident has asked if she is going to make him stay in bed all night. Staff E stated she assisted the resident in and out of bed multiple times during the night on 2/7/23. During an interview on 2/14/23 at 2:41 PM, the Director of Nursing (DON) stated the resident had a decline in condition from time of admission to the time he developed pressure ulcers. The DON stated the resident is a new dialysis patient at the time of his admission. The DON agreed the patient did not have pressure ulcers at the time of his admission on 12/30/22 until 1/20/23 when first noted on the skin alteration records. When asked what changed, the DON did not provide an answer. The DON stated she had not heard that night staff are refusing to transfer patients in and out of bed during the night, The DON stated she would expect the staff to transfer people in and out of bed as many times as requested. The facility policy, dated 6/2021, titled Wound/Skin Condition Procedure Section stated the licensed nurse conducts a wound/skin evaluation within 24 hours of move-in. A weekly progress note is documented in the residents health record.

Based on clinical record review, Advance Registered Nurse Practitioner (ARNP) and staff interviews, the facility failed to ensure one of four residents reviewed remained free of a significant medication error, which resulted in an immediate jeopardy to resident health and safety. (Resident #1) The facility census was 75 residents. Findings include: 1. The Admission Record Report printed (MONTH) 8, (YEAR), documented Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], documented the resident required extensive assistance with bed mobility, transfers, toilet use and personal hygiene and had short and long term memory problems. The Plan of Care directed staff to administer medications as ordered by the physician. An Incident Report dated 10/26/18 at 5:30 a.m., revealed the resident was administered another resident's medications at 5:30 a.m., resulting in lethargy, altered mental status and further evaluation at the emergency room was required. The Medical Practitioner Progress Note dated 10/26/18 at 12:26 p.m., revealed the resident was seen for sudden onset of drowsiness, slurred speech and unable to understand words (which was not normal). The resident was unable to keep their eyes open during the examination, had increased weakness and decreased strength on the left side. The nurse reported the resident ate all of their breakfast and appeared fine at that time. The pulse saturation level was initially 85 to 86% on room air. Oxygen was applied at 2 Liters and the pulse saturation was up to 94%. During the examination the nurse reported the resident mistakenly received the wrong medications. Further investigation revealed the resident did not receive their own medications. During the assessment and chart review the resident became more lethargic, was unable to respond to questions, was responsive to painful stimuli only, had increased drooling and was unable to hold their head up or control their oral secretions. The resident was transported to the emergency room with the medication list and a list of wrong medications ingested. The resident ingested Resident #2's medication on 11/7/18. Resident #2's medications included: a. [MEDICATION NAME] (antianxiety) 150 milligrams (mg) one tablet. b. Citrus Calcium 200 mg - Vitamin D 3 250 mg tablet. c. [MEDICATION NAME] (antipsychotic) 100 mg tablet. d. [MEDICATION NAME] one tablet. e. Magnesium Oxide one tablet. f. [MEDICATION NAME] 25 mg tablet. g. [MEDICATION NAME] 20 mg tablet. h. Therems vitamin one tablet. i. Vitamin D3 1,000 units one tablet. The Discharge Summary revealed the resident was hospitalized from [DATE] to 10/28/18 for toxic [MEDICAL CONDITION] and possible urinary tract infection. The summary revealed the resident took inappropriate medications and had subsequent unresponsiveness. On Medics arrival the resident responded to painful stimuli, did not answer questions or open their eyes. On arrival to the emergency room the resident had stable vital signs, was somnolent but spontaneously opened their eyes. Laboratory tests revealed the resident had mild lactic acidosis of 2.8 and a Sodium level of 130 (perhaps chronic). Several hours later, the resident was fully conscious and alert and unable to provide history. The resident remained nothing by mouth until mentation improved and the resident was alert. No infectious etiology identified except the resident had positive urine cultures and was treated with [MEDICATION NAME]. The resident was afebrile and without leukocytosis or symptoms. During interview on 11/8/18 at 8:16 a.m., Staff B, licensed practical nurse, LPN reported Staff A, LPN reported she left Resident #1's medications in the resident's room and still needed to administer them before she left. Staff B reported she found medications in a cup on the rail in the hallway. Staff B did not know who the medications belonged to and discarded them. Staff B reported Staff C, certified nurse aide, CNA exited the resident's room and reported finding pills in the residents room. Staff B told Staff C to tell the resident to take the medications. After breakfast Staff C reported to Staff B the resident was not acting right. Staff B reported the resident was alert but not acting right. Staff B had the Nurse Practitioner check on the resident. Then Resident #2 reported they did not receive their morning medications. Staff B reported Staff A should have administered Resident #2's medications. Staff D, registered nurse, RN called Staff A to inquire about Resident #1's medications. Staff B reported she made a poor decision by having the resident take the medications that were left in the room without checking them. During interview on 11/8/18 at 8:39 a.m., the ARNP stated she was with the resident about 20 minutes when asked to examine her. She applied oxygen and was unable to hold her head up and was declining rapidly so she made the decision to send the resident out. During interview on 11/7/18 at 2:43 p.m., Staff D, RN reported calling Staff A to inquire about Resident #2's medications. Staff A reported she left Resident #2's medications in Resident #1's room. Staff D reported that was when they realized what was going on with Resident #1. Staff D reported Staff B reported finding medication on the rail in the hall and threw them away. Staff D reported the pills found in the hall were likely Resident #1's medications. During interview on 11/7/18 at 8:56 a.m., Staff C, CNA reported finding medications in Resident #1's room and told Staff B. Staff B directed Staff C to tell the resident to take the pills. Staff C reported she went back in the room and told the resident to take the medications. Staff C reported the resident took the medications. Staff C reported after breakfast the resident was not acting right and reported the behavior to the nurse. During interview on 11/7/18 at 7:27 p.m., Staff A reported Resident #1 yelled out for help as she was about to deliver Resident #2's medications. Staff A entered Resident #1's room with Resident #2's medications and set the medications down on a tray table. Staff A told Resident #1 to wait a minute and she would be back. Staff A remembered she needed to obtain a laboratory specimen for another resident and left the room. Staff A forgot to pick up Resident #2's medications and reported she did not recall setting up Resident #1's medications. The deficiency will be considered past non-compliance as the facility corrected the deficient practice on (MONTH) 26, (YEAR) when they completed an all staff one-on-one skills inservice regarding medication administration. Education included do not leave medications at bedside, do not have someone else give your medications and give medications to the resident that is prescribed the medications. The facility reinforced the Medication Administration policy dated 3/2010, to ensure staff knew to take the medication to the resident, call the residents name, check the residents identification, look at resident photo, describe the medications and what the medication is for to the resident, administer the medication as physician ordered, remain with the resident until the medication is taken and document on the medication administration record.

Based on record review, observation and staff interviews, the facility failed to provide adequate supervision and safely transfer 1 of 5 residents according to the facility policy (Resident #1). Resident #1 fell from the sit to stand lift and sustained a fractured clavicle. The facility reported a census of 75 residents. Findings include: Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 7/28/16. The MDS identified Resident #1 had no cognitive impairments and required extensive assist of two staff members with bed mobility, transfers and toilet use. The Care Plan dated 7/25/16, directed the staff to transfer Resident #1 with a sit to stand lift and with the assistance of two staff members The Incident Report sheet dated 8/3/16 2:30 p.m. revealed the nurse heard yelling, entered Resident #1's room and observed Resident #1 on the floor. Resident #1 had the sit to stand lift in front of him/her and the wheelchair behind him/her. The nurse aide reported Resident #1 blacked out and went down and the resident yelled out in pain and held the right shoulder. The reported indicated the resident was transferred to the hospital for an evaluation. The Radiology Report dated 8/3/16 at 4:05 p.m. identified Resident #1 had a right midclavicular fracture. On 9/28/16 at 1:09 p.m. Staff D (certified nursing assistant) reported Staff G assisted with transferring Resident #1 to the toilet with the sit to stand lift. Staff D stated Resident #1 refused to allow the staff to secure the leg and waist straps. Staff D stated she encouraged Resident #1 to use the belts but Resident #1 refused. Staff D stated she left Resident #1 hooked to the lift with the one brake locked and left the room. On 9/29/16 at 8:51 a.m. Staff B (certified nursing assistant) was interviewed and stated she answered Resident #1's call light. Staff B stated Resident #1 had the lift hooked without the waist and leg straps secured. Staff B secured the waist straps. Staff B lifted Resident #1 and pulled him/her away from the toilet. Staff B started to perform cares and Resident #1 had a blank face. Staff B decided not to lower Resident #1 back onto the toilet because of pipes behind the toilet. Staff B pushed the lift out of the bathroom and attempted to get to the bed. Resident #1 started to fall out of the lift and woke up at the same time. Staff B reported the lifts require two staff members. Staff B reported she lifted Residents in the past to complete cares and lowered them back down and found a second staff for the transfer. The Lift Program Skills Check-Off Sheet Stand Assist Mechanical Lifts sheet received 9/28/16 directed the staff to fasten the safety belt around the patient ' s waist. The facility policy and procedure titled Mechanical Lift, revised on 1/2014, directed the staff to verify the clips and straps are secure prior to lifting the patient. The Use of Lifts and Friction-Reducing Devices sheet revealed the number of employees required when operating the lift. Although one person can operate most models of hydraulic lifts, it's advisable to have two staff members present to stabilize and support the patient. As such, a two person lift is required when using lift equipment. On 10/6/16 at 3:14 p.m. the DON (Director of Nursing) was interviewed and stated the staff need to have two staff members present if they are going to move the resident in the lift. On 9/28/16 at 3:26 p.m. observation of the sling used during the incident (verified by the Director of Nursing) on 8/3/16 identified a green mesh sling. The sling had no visible defects. The Arjo Sara 3000 Lift #2 used during the transfer had a weight limit of 440 pounds. The Arjo Huntleigh sling color/size sheet directed a green sling weight range of 154 to 264 pounds and a blue sling weight range of 308 to 440 pounds. According to the Minimum Data Set assessment dated [DATE] Resident #1 weighed 348 pounds. An interview on 9/28/16 at 3:58 p.m. the DON reported she thought the staff used the correct size sling.

Based on observation, record review, and staff and family interviews, the facility failed to provide adequate supervision to prevent accidents that resulted in a fracture hip injury to 1 of 5 resident's reviewed with fall histories (Resident #6). The facility reported a census of 73 residents. Findings include: Resident #6 had a MDS (Minimum Data Set) assessment with a reference date of 4/15/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident scored a 9 out of 15 for the BIMS (Brief Inventory of Mental Status. A score of 9 identified the resident had problems with cognitive status. The MDS indicated the resident had symptoms of delirium, sometimes able to make self- understood and sometimes able to understand others, required corrective lenses for vision, extensive assistance by 2 or more staff members for transfers to and from the bed and chair, bathing, toileting and personal hygiene, occasional urine and frequent bowel incontinence and without a toileting program in place. The Care Plan included a problem with a risk for falls and identified on 8/7/15. The risk was due to potential medication side effects, history of falls, and non-compliance with use of assistive devices. The Care Plan interventions included and directed the staff to do the following: 1. Commonly used articles (place) within easy reach, initiated 8/17/15. 2. Administer medications per physician order, initiated 8/31/15. 3. Provide assist to transfer and ambulate as needed, initiated 8/31/15. 4. Report development of pain, bruises, change in mental status, ADL function (activities of daily living), appetite or neurological status per facility guidelines post fall, initiated 8/31/15. 5. Therapy evaluation and treatment per orders, initiated 8/31/15. 6. Encourage and offer toileting through the night with rounds, initiated 9/6/15. 7. Reinforce need to call for assistance, initiated 11/1/15. 8. Low bed, initiated 2/6/16. 9. Supervised toileting, initiated 3/1/16. 10. Body pillows place to remind bed perimeters, initiated 5/6/16. 11. Early morning, first thing, and frequent checks to assist with toileting, initiated 5/6/16. 12. Utilize non-slip footwear, initiated 5/6/16. Another nursing Care Plan problem, initiated 2/10/16 was identified as resistive/noncompliant with care, waiting for assistance related to cognitive impairment, with interventions that included: 1. Allow for flexibility in ADL routine to accommodate mood, preferences, and customary routine, initiated 2/10/16. 2. Evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic medications, initiated 2/10/16. 3. Provide non-care related conversation proactively before attempting ADL's, initiated 2/10/16. 4. If resists care, leave and return later if safe to do so, initiated 2/10/16. 5. Anticipate needs and cue, initiated 5/6/16. Resident #6's fall history included: On 9/6/15 at 2:15 a.m., the staff found the resident on the floor at the end of the bed in room. The nurse identified no injuries. On 11/1/15 at 3:00 a.m., the staff observed the resident roll off the bed and onto a body pillow on floor as they entered the room. The nurse identified no injuries. On 2/16/16 at 9:50 a.m., the staff found the resident on floor, on left side by bed, yelled for help, bed in low position. The nurse identified no injuries. On 3/1/16 at 2:30 p.m., The staff found the resident seated on the floor and leaned against wall, had attempted to transfer to wheel chair from toilet, wheel chair brakes were locked, tennis shoes on. Resident reported mild back pain, no worse than usual, skin abrasion to left posterior thigh. On 5/6/16 at 6:15 a.m., the staff found the resident on the floor positioned on side next to bed. The resident stated he/she had toileted and attempted to return to bed. The resident received skin tears (2) on bilateral knees, dressings applied, no other injuries identified. On 5/6/16 at 4:10 p.m., the staff found the resident on the floor next to the bed and positioned on right side. When the staff positioned the resident on back, the resident stated he/she had pain in the back. The right thigh pain was not severe when leg straightened with no abnormalities identified and resident assisted to bed. A hospital history and physical document transcribed at 6:12 p.m. on 5/6/16 indicated Resident #6 required surgery for [REDACTED]. Observation in Resident #6's room on 5/16/16 at 9:38 a.m. indicated the room at the end of the hall, approximately 65 to 70 feet from the nurse's station. Observation reflected the resident positioned in a low bed with body pillow positioned on the resident's left side, a sign posted on the closet door (across from the foot of the bed) and a sign on the wall above the call light outlet (same side of room as the head of the bed) that instructed the resident to call for assistance to get up. On 5/17/16 at 8:10 a.m., the resident's family member was interviewed and stated the resident has dementia and was initially admitted to the facility's first floor. The facility staff moved the resident to 3 different rooms on the first floor, and then moved the resident to a room at the end of a hall on 2nd floor, against their objections due to the resident's dementia. The resident ' s increased confusion with the room changes, placed the resident at increased risk for falls. The family member stated the resident did not use the call light and with dementia, did not understand their limitations. The resident would not know to call for assistance and would attempt to ambulate or transfer to the bathroom if they thought they had to go. The family member stated the Administrator told her the staff would check on the resident every 15 minutes after the move to 2nd floor, but did not believe the staff performed the checks based on their observations during their daily visits. The facility investigated the incident and provided Quality Assurance Committee statements from employees with the Director of Nursing Present. A statement indicated Staff Z had just returned after a break and he went to the resident's room to ask what time he/she wanted a shower. Staff Z found the resident on the floor. Staff Z obtained the nurse right away and then they rolled the resident to their back. The resident voiced the hip and leg hurt. Staff G and Staff Z used a gait belt and assisted the resident. The resident had attempted to get up to go to the bathroom prior to the fall. During an interview on 5/16/16 at 3:51 p.m., Staff G, registered nurse (RN) stated residents were toileted every 2 hours. Resident #6 had a history of [REDACTED]. Staff G stated interventions used to prevent the resident's falls included frequent checks, the resident kept in line of vision when not in bed, toilet frequently or ask resident if they needed to go to the bathroom, and thought there were signs in the resident's room to call for help when they needed to get up. Staff G was the nurse on duty on the evening shift on 5/6/16, when the resident fell and broke the right hip. When asked about her assessment of the resident after that fall, Staff G stated she was summoned to the room by a CNA (Staff Z). Resident #6 laid on their right side on the floor and complained his/her back hurt a little bit. The staff rolled the resident on to his/ her back. The resident seemed okay with legs slightly bent but didn't want to straighten legs because it hurt. The resident voiced it ached a little and didn't say they had severe pain. The resident didn't appear to be in severe pain and neither leg looked shortened or rotated. Staff G stated she didn't think the hip was broken at the time and they assisted Resident #6 back to bed with a gait belt. Staff G stated she tried to assess the legs and hip further once in bed and the resident still wouldn't straighten their legs and said it hurt to move. The resident had no shortening or rotation of the legs when in bed. Staff G stated she contacted the doctor and obtained an order to send the resident to the emergency room . The resident had a fractured hip. A facility document related to the investigation of Resident #6's fall with fracture identified Staff O, CNA, worked the evening shift on 5/6/16. Staff O stated she had not seen Resident #6 prior to the fall. The resident wasn't assigned to her but she answered call lights if they were on. Resident #6 had not used the call light. Staff O informed the DON another CNA came out of the resident's room and said the resident had fallen. During an interview on 5/11/16 at 3:11 p.m., Staff F, CNA, stated residents were toileted every 2 hours. Staff F stated she worked the evening shift on 5/6/16 and when she returned from break, she heard the resident fall. The paramedics arrived and transported the resident to the hospital. Staff F stated the last time she saw the resident was at 2:15 p.m. lying in bed. The resident was assigned to a different CNA that day and other CNA's told her the resident would get up. Staff F stated that is why there were reminders in the resident ' s room to ask for help before she/he got up. During an interview on 5/18/16 at 4:20 p.m., Staff M, CNA, stated the resident did not use the call light reliably when on the 1st floor and had not used the call light on the 2nd floor. The resident was in a low bed with bumpers on both sides of the bed, and he/she had climbed over the bumpers in the past. Staff M stated the resident's room was located at the end of the hall and staff would check on the resident when they could and when the resident was in his/her room. During an interview on 5/11/16 at 10:41 a.m., Staff B, CNA, stated she attempted checks on the resident every hour because the resident would forget they required assistance and got up on their own to go to the bathroom. The resident was care planned for 1 to 1 assistance with a gait belt for transfers. There are signs in the resident's room on the closet door to call for assistance and not to get up on own without assistance. The facility put a sign in the bathroom to call for help when finished. During an interview on 5/11/16 at 11:04 a.m., Staff D, licensed practical nurse (LP), stated staff were supposed to toilet the residents before and after meals and as needed, Resident #6 was Care Planned for 1 to 1 assistance with gait belt for transfer, wheel chair utilized and no walker prior to the 5/6/16 fall with fracture. Staff D stated she worked the day shift on 5/6/16 when the resident fell unattended upon their return from the bathroom at 6:15 a.m. The resident had a history of [REDACTED]. The resident became more alert and active after they started the Remeron (antidepressant medication). During an interview on 5/11/16 12:29 p.m., Staff E, CNA, stated residents were toileted every 2 hours or sooner if requested. The resident ' s Care Plan directed staff for one staff person assistance with a gait belt for transfer and no walker. The resident had a wheelchair. Staff E worked the day shift on 5/6/16 and stated she last saw the resident in bed at 6:00 a.m. and around 6:30 a.m. one of the CNA's took off running, she followed her to the resident's room and found him/her with t-shirt, shorts and socks but no shoes as he/she laid on the floor between the bed and bathroom. The resident stated he/she was trying to get to bed after gone from the bathroom. The resident complained of knees hurt, they were both scuffed, there was a small amount of blood on his/her wrist and forehead looked a little red, the resident said they hit head with the fall and the redness went away later, they took vitals and told the nurse. Staff E stated the resident required constant reminders to call for assistance, there were signs in the bathroom and above the call light to call for help before getting up, the resident didn't have alarms but did have a body pillow in bed to prevent falls. During an interview on 5/18/16 at 4:10 p.m., Staff I, licensed practical nurse (LPN) stated Resident #6 did not use the call light, required assistance of 1 or 2 staff for transfers but the resident attempted self-transfers and staff had to check on the resident frequently. The resident ' s room was located at the end of the hallway and it would have been better if the resident ' s room was closer to the nurse's station, however, a room was not available. During an interview on 5/19/16 at 8:02 a.m., the Director of Nursing (DON) stated staff are to notify their manager of resident falls or incidents for interventions to initiate at that time. The nursing staff could enter the interventions on the resident's computer Care Plan. The DON stated the facility had attempted to get rid of all alarms and utilize other interventions for fall prevention and staff are to check frequently. When asked to define frequently the DON stated between every 15 minutes to no greater than 2 hours between checks.

Based on record review and interviews the facility failed to ensure each resident received adequate supervision to protect against hazards in the environment for one (1) of four (4) residents reviewed. Record review identified Resident #8 cognitively impaired and used a Wanderguard bracelet for his/her safety. On 6/7/15, Resident #8 exited the facility and his/her Wanderguard device activated the door alarm which sounded to alert staff. Staff turned off the alarm and assumed the alarm had been for visitor(s) as staff could not distinguish the Wanderguard alarm sound from the door alarm sound. The nursing home later discovered they were unaware of Resident #8's whereabouts and called the local police. Resident #8 had walked over two (2) miles away from the nursing home with the outdoor temperature heat index of 91 degrees Fahrenheit (F). Staff interviews revealed multiple staff could not accurately distinguish the difference between the Wanderguard alarm and door alarms prior to Resident #8's elopement. In addition, staff did not search outside to determine whether any of the 16 Residents that used Wanderguards bracelets had exited the nursing home. The findings constitute an immediate jeopardy to residents' health and safety. The facility reported a census of 87 residents. Findings include: The hospital Discharge Summary dated 3/16/15 revealed the police found Resident #8 outside sleeping in cold weather and unable to recall where he/she lived. The resident had been court ordered for mental health treatment at the hospital and determined he/she would be admitted to a nursing home. According to the Admission Record Report printed on 6/8/15, Resident #8 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] revealed Resident #8 had moderately impaired decision making and delusions. The Care Plan dated 4/20/15 informed staff Resident #8 used a Wanderguard/alert bracelet due to his/her wandering. The care plan noted the resident with cognitive impairments and wanted to go outside to see his/her family. The care plan directed the staff to check for the presence and functioning of the alert bracelet per facility guidelines, provide directional cues to room and familiar places and redirect with conversations of movies, baseball, offer snack and offer to view truck/automobile. The Progress Notes dated 6/7/15 at 3:50 p.m. revealed friends at the facility to visit and unable to locate Resident #8. The staff initiated the missing person protocol with notification to the family and physician. The Incident Report dated 6/7/15 at 4:30 p.m. revealed Resident #8 eloped out the front door of the facility with a visitor. Upon return the staff completed nursing evaluation, pain evaluation, hydration evaluation and had pending lab work. The Police Narrative on 6/7/15 at 4:34 p.m. revealed dispatch received a 911 emergency call reporting Resident #8 wandered away from the facility and the facility looked for Resident #8 for an hour. The report noted a person in the community called 911 and reported Resident #8 appeared disoriented and did not have a cellular phone or any cash. Resident #8 requested a ride to Rock Island, IL. The police determined the description of Resident #8 matched the description from the community member. The police noted the resident had been wearing several layers of clothing. The Police Case Report revealed the Administrator reported according to the facility surveillance cameras Resident #8 left the facility with a church volunteer at 3:36 p.m. According to the Police report, the Administrator reported Resident #8 had been wearing a tee-shirt, a hoodie (sweatshirt) and brown pants. The Progress Note dated 6/7/15 at 5:30 p.m. revealed Resident #8 returned to the facility after looking for his/her family member. The staff completed a physical evaluation and no skin areas were noted. The Pain Assessment in Advanced Dementia Scale dated 6/7/15 revealed Resident #8 had normal breathing, no negative vocalizations, relaxed body language and no need to console. The Hydration Status Evaluation dated 6/7/15 at 5:45 p.m. revealed Resident #8 had exposure to environmental factors after eloping with church members. The staff offered and Resident #8 drank 2 - 7 ounce glasses of water with relief. Resident #8 had no increase in confusion and talked with friends. The Clinical Weights and Vitals sheet dated 6/7/15 at 5:53 revealed Resident #8 had a temperature of 98.2 degrees Fahrenheit. An interview on 6/9/15 at 9:28 a.m. the Climatologist reported a heat index of 91 degrees Fahrenheit on 6/7/15 at 3:52 p.m. at the Davenport Airport. The Exit Seekers sheet received on 6/9/15 revealed the facility had 16 residents with Wanderguard bracelets. An interview with the Police Officer on 6/8/15 at 2:20 p.m., revealed he had no idea what route Resident #8 took but the nursing home is located 2.7 miles from where the resident had been located. The officer mentioned the resident's face was red in color and staff took off the resident's sweatshirt and offered him/her water when he/she returned. Resident #8's friend that visited on 6/7/15 had been interviewed on 6/8/15 at 5:54 p.m., and stated they looked for Resident #8 and could not locate him/her. The friend stated Resident #8's attire had been dressed too warm on the day of the incident. During an interview with Resident #8 on 6/8/15 at 1:42 p.m., he/she reported going for a long walk yesterday (6/7/15) until the police pick him/her up. Resident #8 reported if he/she gets the chance, he/she will attempt to leave again and will not return. Resident #8 reported the police cannot stop the train and if you're careful, you won't get hurt. The surveyor observed the Wanderguard bracelet on Resident #8's left ankle and shared his/her expressed interest to leave again with the facility. An interview on 6/8/15 at 3:51 p.m. Staff A, certified nurse aide (CNA) stated she heard an alarm and had been by the nurse's station. Staff A reported she looked at the alarm panel (at the nurse's station) and it showed the front door had alarmed. Staff A stated she did not know if it was the door alarm or the Wanderguard alarm that sounded. Staff A reported the alarms sound the same. Staff A looked out the door and observed the church volunteers. Staff A did not go outside. Staff A did not ask the volunteers if they set the alarm off. Staff A reported she reset the alarm. Staff A reported later Resident #8's friend (with a teenager child) arrived and asked to see Resident #8. Staff A reported they could not locate Resident #8, and the Administrator called 911. An interview on 6/8/15 at 3:21 p.m. Staff B, CNA Staff B stated on the day Resident #8 eloped, Resident # 8 wanted to go to the bread store. Staff B stated later a visitor (and teenage child) arrived to see Resident #8. Staff B heard Staff A tell them to look in the TV room for Resident #8 and then Staff A and Staff B started looking for Resident #8. Staff B called Code Green to alert other staff of a missing resident. Staff B stated after the police were called, they located Resident #8 and brought him/her back to the nursing home. Staff B stated she heard the alarm go off twice at the end of the church and headed in that direction but the alarm had already been turned off. Staff B stated she thought Staff A responded to the alarm. Staff B stated the alarm was sounding a lot as the church members were leaving. Staff B stated she did not know which alarm sounded. Staff B reported at the nurse's station, staff cannot tell which alarm is sounding but as staff gets closer to the front door, she is able to distinguish the Wanderguard alarm from the door alarm. Staff B reported the Wanderguard makes a chirp sound and the door alarm is a constant beeping sound. During an interview with Staff H, Registered Nurse (RN) on 6/8/15 at 4:26 p.m., she reported Resident #8 moved him/her (self) from one room to another room the day of the incident. Staff H stated when staff could not locate Resident #8, they called code green. Staff H and the DON left the nursing home to search for Resident #8 at the bread store and then drove around. Staff H stated Resident #8 had been wearing two (2) sweatshirts, 2 t-shirts and sweatpants. When Resident #8 returned to the nursing home, he/she told Staff H he/she had gone to the bridge and got scared of heights and turned back. Staff H stated Resident #8 had not walked out with the church member as initially reported. An interview on 6/11/15 at 10:30 a.m. Staff C, License Practical Nurse (LPN) reported she cannot distinguish the door alarm sound from the Wanderguard alarm on the front door. Staff C reported the alarms sounded the same. An interview on 6/11/15 at 10:22 a.m. Staff D, CNA reported prior to the incident, she did not know how many alarms were on the front exit door. Staff D reported she could not distinguish the door alarm from the Wanderguard alarm on the front door. Staff D received training on 6/9/15 and now knows the difference in the sounds of the alarms. During an interview with Staff E on 6/16/15 at 3:15 p.m., she reported seeing Resident #8 around 3:15 p.m. and he/she had been talking about (going to) the bread store. Staff E reported at the time of the incident she could distinguish the difference between the front door alarm sound and the Wanderguard alarm. However, Staff E thought the front door alarm is a constant ring and the Wanderguard is a shorter higher pitched ring. During an interview with Staff F, CNA on 6/9/15 at 4:46 p.m., she reported at the time of the incident she could distinguish the difference between the front door alarm and the Wanderguard alarm. However, Staff F thought the front door alarm is a longer beeping sound and the Wanderguard is a shorter beeping sound. During an interview with Staff G, CNA on 6/16/15 at 9:21 a.m., she reported she does not work on the first floor but had worked the day of the incident. Staff G thought the alarms on the front door sounded the same. Staff G reported yesterday (6/9/15), the DON informed her the Wanderguard alarm had a longer sounding beep and the door alarm had a shorter sounding beep. During an interview with Staff I, LPN on 6/11/15 at 10:14 a.m., she stated prior to the incident she did not know the difference between the door alarm sound and the Wanderguard alarm sound. During an interview with the DON on 6/8/15 at 11:57 a.m., she reported Resident #8 ' s friend came to visit him/her and staff could not locate the resident. The DON reported she assisted with looking for Resident #8 and went to multiple locations until the Administrator called her and said the police had returned him/her to the nursing home. The DON stated when Resident #8 returned, staff gave him/her two glasses of water and a shower. The DON stated she assessed Resident #8 who had no injuries. The DON reported she was in the process of training staff how to respond to door alarms. The surveyor informed the DON on 6/9/15 at 2:40 p.m., that some staff reported the Wanderguard alarm makes a chirps/shorter sound and the door alarm is a constant sound. The surveyor informed the DON this is conflicting from the education they provided to staff. On 6/8/15 at 11:55 a.m., the Administrator showed the surveyor the video. The Administrator reported to turn off both alarms staff enter the code at the door location. The Administrator reported the facility had just completed an elopement drill on 6/5/15. (Staff A did not attend the 6/5/15 elopement drill.)The Administrator reported Staff A stated she had looked at the panel at the nurse's station and then went to the front door (main entrance).(Staff do not know by looking at the panel at the nurse's station whether the Wanderguard alarmed or door alarm sounded.) The Administrator stated he was going to add a special feature so the staff turning off the alarm would not turn off the Wanderguard alarm and a green code would be triggered. The Administrator later informed the surveyor he could not make changes to the alarm system in this manner. The undated Emergency Code indicated staff would call a green code if a resident cannot be accounted for and institute a search of the immediate area. If the resident is not located, staff would search the exterior of the building. The DON reported on 6/9/15 at 2:31 p.m., all staff had been retrained except the PRN (as needed) staff or staff that were out of town. The DON reported staff were not allowed to work unless they have been educated on the different alarm tones between the door alarm and Wanderguard alarm sound. The DON reported these staff would be re-educated to call code green for staff to initiate a missing resident the when door alarms to ensure residents did not walk out of the nursing home. The facility abated the Immediate Jeopardy on 6/9/15 when they provided training for 96 employees. The training consisted of the following: a. The training directed the staff when a resident is missing or they hear an alarm it may indicate that a resident left the facility, the staff member immediately conducts an internal or simultaneous external search of the immediate area to locate the resident. b. The training directed the staff to call a code green when doors alarm to ensure no resident walked out with a visitor or staff. c. The training reviewed the different tones for the alarm verses the Wanderguard alarm system. The facility educated staff the door alarm is a short beep sound, and the Wanderguard is a longer drawn out sounding alarm. d. The training informed the staff the door code alarms changed and not to give the codes out to residents, families, hospice staff, activity groups, agency staff, distributors and visitors. The Administrator reported an additional blue light louder alarm had been installed at the front door. The Administrator also increased the hours of the receptions working. On the weekends, the visitors use the intercom to enter the nursing home with staff allowing access to them. The facility tested all door alarms after the incident to ensure they all functioned. All residents wearing Wanderguard devices were tested and their care plan interventions were reviewed and revised if necessary. After the incident, the facility updated Resident #8's Care Plan which directed staff to provide 1:1 supervision and move to a room farther away from the exit doors. The scope and severity of the IJ was lowered from a K to an E as the facility had 19 untrained PRN (as needed) staff or staff out town, and these remaining staff would not be allowed to work until trained. These actions lowered the IJ from K to E with the need for ongoing monitoring of door alarms and staff's responses to ensure residents safety.

Based on clinical record review and staff interviews, the facility failed to complete an ongoing resident assessment when a resident had a condition change that warranted the assessment. The facility census was 85 residents. (Resident #11) Findings include: 1. An Admitting Record with a printed date of 5/22/13, documented Resident #11 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] revealed the resident had severe cognitive impairments and required extensive assistance with bed mobility, transfers and toilet use. The Care Plan directed staff to assist with fluids at night, transfer with a mechanical lift, ask questions requiring yes or no answers and check for incontinence frequently and provide incontinence care as needed. A Progress Note dated 4/22/13 at 9:54 p.m., revealed the resident as very tired in the morning and wanted to eat but fell asleep and did not take food or fluids. The resident returned to bed. Remains on [MEDICATION NAME] (antimicrobial) for [MEDICAL CONDITION] (bacterial intestinal disease-cause diarrhea). Will continue to monitor to see that all needs are met. A Progress Note dated 4/23/13 at 4:23 a.m., revealed the resident had medications without difficulty, fluids encouraged and accepted and sleeping quietly. The facility bowel records revealed the resident had continued loose stools two times on 6/23/13 during the day and evening shift and times one on 6/24/13 on the day and evening shift. The fluids offered sheet revealed on 4/23/13 at 1:47 a.m., 2:12 a.m. and 4:34 a.m., the resident accepted fluids. A Progress Noted dated 4/24/13 at 11:42 p.m., revealed at 7:00 p.m. the resident was non-responsive. The nurse was unable to obtain blood pressure, oxygen saturation or pulse. The resident was up in a wheelchair with his/her head tilted back and limbs flaccid. Staff notified the physician on call and received an order to send the resident to the hospital for evaluation. Hospital records revealed the resident presented to the Emergency Department with decreased responsiveness. The resident was admitted to the hospital with [REDACTED]. The laboratory results, obtained on 4/24/2013 at 8:10 p.m., identified the following abnormal tests: White blood test=24,000 (normal 4,000-10,000) Hemoglobin 17.1( normal 12-16) Hematocrit 50.9 (normal 37-47) Platelets 121 (normal 130-450 Sodium 160 (normal 136-145) Chloride 120 (normal 98-107) BUN 93 (normal 7-22) Creatinine, Serum 3.41 (normal .40-1.10) [MEDICATION NAME] 2.6 (normal 3.4-5.0) A hospital discharge summary dated 4/29/13 revealed the resident was admitted [MEDICAL CONDITION] that required treatment in the intensive care unit, [MEDICAL CONDITION] tube placement and intravenous antibiotics due to [MEDICAL CONDITION]. The resident ' s family decided to proceed with comfort measures and the resident transferred to hospice care. On 5/22/13 at 5:09 p.m., Staff Q (Certified Nursing Assistant) stated she worked 6:00 a.m. to 2:00 p.m. on 4/24/13, and reported the resident had loose stools, did not eat and would not open his/her eyes. Staff Q left the resident in bed for breakfast and put food and drink up to the resident's mouth and it fell back out. The resident did not eat any breakfast and Staff Q reported the resident was the same on 4/23/13 but drank a little better. Staff Q thought the resident was dying. On 5/22/13 at 4:47 p.m., Staff I (Certified Nursing Assistant) was interviewed and stated he worked 6:00 a.m. to 2:00 p.m. on 4/23/13 and assisted the resident out of bed for lunch. Staff I had to lay the resident back down because he/she was tired and weak. Staff I stated the resident shook his/her head back and forth when Staff I put food and fluid up to his/her mouth. Staff I reported the resident had two loose stools during the shift. The Progress Notes dated 4/30/2013 at 2:00 p.m. revealed the resident ' s family member picked up the resident ' s belongings at the facility. The family member reported the resident is on hospice at the hospital and is not expected to return.

Based on clinical record review, staff, psychologist and resident interviews, the facility failed to provide adequate supervision to ensure against hazards from self and others and failed to revise the care plan as necessary for 10 of 13 resident (Resident #1, #2, #3, #4,#5 #7, #9, #10, #12 #13). The facility reported a census of 85 residents. Findings include: 1. An Admitting Record, with a print date of 5/7/2013, documented Resident #3 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], revealed the resident had a severe cognitive impairment and required extensive assistance with bed mobility, transfers and toilet use. The Care Plan directed staff to provide assistance of two staff with bed mobility, transfer with extensive assist of two staff, if resists care, leave (if safe to do so) and return later, inform of activity of daily living that is required ahead of time and give two options of times for it to be done, give choice and allow flexibility in routines, attempt to provide consistent routines/caregivers, reinforce need to call for assistance, low bed, fall matt, body pillows and scoop mattress. The Care Plan (not dated on 5/9/13), revealed the resident moved to a room closer to the nurses ' station for closer observation, medication review, reinforce need to call for assistance, provide assistance with transfers and ambulation as needed, laboratory test as ordered and therapy evaluation and treatment. An Incident Report dated 4/7/13 at 8:20 p.m., and 4/15/13 at 1:45 a.m. revealed staff found Resident #3 half on and half off the bed. An Incident Report dated 5/2/13 at 2:00 p.m., revealed staff found Resident #3 on the floor in the room. The resident attempted to self- transfer and did not put call light on for assistance. A Progress Notes dated 5/2/13 at 2:40 p.m.; revealed staff heard a loud thump and "ouch". Staff found Resident #3 lying on his/her left side (on the floor). Staff observed the resident in the wheelchair beside the bed 10 minutes prior to the incident. The resident complained of left leg pain and remained on the floor until medics arrived. A History and Physical dated 5/2/13 revealed the resident was unsupervised when staff heard a noise and found the resident on the floor. The resident sustained [REDACTED]. On 5/28/13 at 10:36 a.m., Staff H (Occupational Therapist) was interviewed and stated she assisted Resident #3 with therapy in the resident ' s room. Staff H left the resident in the wheelchair next to the bed watching television. Staff H reported the resident never attempted to get out of the wheelchair to her knowledge. Staff H stated when leaving the room, the resident's roommate asked for assistance. Staff H pulled the call light and informed nursing staff the roommate needed assistance. On 5/29/13 at 1:45 p.m., Staff I (Certified Nursing Assistant) recalled leaving that day at 1:45 p.m. and there was only one other aide (Staff J) working 1st floor. Staff I and Staff J both had to leave at 1:45 p.m. because they shared transportation. Staff I placed the resident in the lounge so that they could supervise the resident after lunch. Staff I reported the resident had attempted to get out of the wheelchair during a previous stay. Staff I left the resident in the room in the wheelchair at times. It depended on the resident's mood. Staff I reported a lot of times the resident laid down after meals. Staff I did not get a chance to ask the resident to lie down because he left early and it was hectic. On 5/28/13 at 2:56 p.m., Staff J (Certified Nursing Assistant) was interviewed and stated she had observed the resident attempt to self- transfer from the wheelchair. Staff J placed the resident in the lounge or nurses ' station when up in the wheelchair. Staff J reported the resident had confusion and did not use the call light but yelled out for help. Staff J reported they had two aides that day and normally there were three to four. They had to work together that day because there are so many (residents that require) two person transfers. On 5/28/13 at 3:58 p.m., Staff K (Certified Nursing Assistant) reported staff placed the resident in bed after meals unless the resident refused. Staff K reported the resident did not self- propel in the wheelchair and did not use the call light. Staff K only left the resident in the wheelchair in the room long enough to get another staff to assist with the transfer. Staff K observed the resident put his/her hands on the sides of the wheelchair and verbalize that he/she was going to stand up. Staff K placed the resident in the lounge or nurses ' station area if the resident wanted to stay up. Staff K reported the family told staff when they were leaving to ensure the resident was not left unattended in the room in the wheelchair. 2. The MDS assessment, with a reference date of 3/29/13, documented Resident #12 had [DIAGNOSES REDACTED]. The MDS assessment revealed the resident required extensive assistance with bed mobility and transfers. The Care Plan with an initiated date of 10/5/12 identified a problem with self-care deficit as evidenced by the need for assistance with some activities of daily living skills. The Care Plan directed staff to ambulate the resident in the room with a rolling walker and stand by assistance. The Care Plan with an initiated date of 10/5/12, directed staff to transfer the resident with a mechanical lift with a bariatric size sling and assistance of two staff members. An Incident Report dated 5/15/13 at 5:00 p.m., revealed the staff (member) called the nurse to the room. The nurse found Resident #12 lying on the floor in front of the wheelchair. Resident #12 reported he/she attempted to transfer from the wheelchair to the bed, started to turn and could not move and fell . A Hospital Discharge Summary dated 5/16/13, revealed the resident sustained [REDACTED]. On 5/29/13 at 2:50 p.m., Staff N (Certified Nursing Assistant) was interviewed and stated Resident #12 had to use the lift the days prior to the fall because he/she had breathing problems. Staff N tried to get Resident #12 to use the lift but refused. Resident #12 had heavy breathing and removed the oxygen. Staff N told Resident #12 it was not a good idea. Resident #12 always refused the gait belt. Resident #12 locked the wheelchair and stood the resident up to the walker and took 4 steps and said he/she could not move. Staff N moved the wheelchair behind the resident ' s legs and the resident caught the edge of the chair and slid to his/her left side onto the floor. Staff N summoned the nurse. On 5/29/13 at 9:41 a.m., Staff O (Certified Nursing Assistant) was interviewed and reported always using the total lift to transfer the resident. According to Staff O the Patient Information Worksheet directed staff to use two staff and a total mechanical lift. On 5/29/13 at 9:52 a.m., Staff P (Certified Nursing Assistant) was interviewed and reported she had transferred the resident with the total mechanical lift and in the past with standby assistance. Staff P reported the resident refused the gait belt. According to Staff P the Patient Information Worksheets directed the staff to use two staff and a total mechanical lift. On 5/29/13 at 1:53 p.m., Staff I only used the total mechanical lift to transfer the resident with another staff. Staff I reported the resident told Staff I they transferred from the chair to the bed with a rolling walker and stand by assistance because he/she did not want to wait for another staff person to help with the transfer. On 5/28/13 at 4:53 p.m., Staff K (Certified Nursing Assistant) was interviewed and reported the resident required assistance of two staff with a total mechanical lift for all transfers. Staff K felt it would not be safe to transfer the resident without the lift due to the resident's size. On 5/29/13 at 8:35 a.m., the Administrator verified the Care Plan at the time of the fall directed staff to transfer with assistance of two staff and a total mechanical lift or rolling walker and stand by assistance. 3. The Admitting Record with a print date of 4/25/2013, identified Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, with a reference date of 4/8/13, revealed Resident #2 had severe cognitive impairments and required extensive assistance of one staff with bed mobility, transfers, dressing, toilet use and personal hygiene. The Care Plan revealed Resident #2 had verbal aggression/agitation and directed staff to administer medications per physician orders, allow resident time to respond to directions or requests, approach slowly and slightly to the side, be cognizant of not invading personal space, gain attention before speaking or touching, give clear, concise explanation of anything about to occur and talk to in a low pitch, calm voice to decrease/eliminate undesired behavior. A telephone physician's order [REDACTED].#1 to the emergency room for an evaluation and treatment. A Progress Note dated 4/24/13 at 1:27 a.m. (late entry) revealed Resident #2 was upset with his/her roommate (Resident #1) at bedtime. Resident #2 wanted the roommate to turn the light off. The nurse informed the resident that he/she shared the room and needed to be polite and allow the roommate to keep the light on. The resident rolled away from the light and the nurse left the room. A Progress Note dated 4/24/13 at 1:00 a.m. (late entry), revealed Resident #2 had an altercation with the roommate (Resident #1). Resident #1 approached the nurse and reported Resident #2 hit him/her. Resident #1 had bleeding from the nose and mouth and the right eye was blood shot with swelling. A Progress Note dated 4/24/13 at 4:10 p.m., revealed Resident #2 returned from the hospital with a new order for Haldol (antipsychotic) 5 milligrams by mouth once at bedtime. The Care Plan for Resident #2 was updated on 4/23/13, and directed staff to provide 1:1 supervision and psychiatric consult. The Emergency Department Notes dated 4/24/13 revealed Resident #1 was seen for right subconjunctival (eye) hemorrhage and a contusion to the orbital ridge (eye). The resident returned to the facility and moved to a room on a different floor of the facility. Resident #1 was discharged from the Emergency Department at 1:50 a.m. (to the facility). On 5/7/2013 at 10:12 a.m., Staff T (Registered Nurse) was interviewed. Staff T stated another nurse (Staff U) brought Resident #1 downstairs to separate from Resident #2. Staff T stated Resident #1 ' s left temple had an open area bleeding and under the eye had redness and swelling present. The eye was bloodshot and the lower lip swollen. Staff T stated Resident #1 has a tendency to not regard others personal space. On 5/8/13 at 10:01 a.m., Staff F (Certified Nursing Assistant) was interviewed and stated she observed Resident #2 doing pushups (exercises) beside the bed around 7:15 p.m. Then around 7:25 p.m., Resident #2 approached Staff F and reported Resident #1 would not leave him/her alone. Staff F informed her supervisor. At 7:45 p.m. Staff F looked into the resident ' s room. Both residents were lying on their beds with the curtain pulled. Staff F had the television on as he/she always did. On 5/8/13 at 10:21 a.m., Staff G (Certified Nursing Assistant) was interviewed and reported Resident #2 approached him/her with a concern with Resident #1 touching the television. Staff G told Resident #2 that he/she would talk to Resident #1. Staff G went to the room and Resident #1 was not in the room. Staff G did not talk to Resident #1. 4. An Admitting Record with a print date of 5/13/13, documented Resident #9 had [DIAGNOSES REDACTED]. The MDS assessment with a reference date of 4/26/13, documented the resident had moderately impaired decision making skills and required extensive assistance with bed mobility, limited assistance with transfers and supervision with locomotion. The Care Plan initiated on 12/27/2010 identified the resident had a problem with wandering related to the cognitive impairment. The care plan directed staff to monitor location and complete visual checks frequently, observe and assist with safe decision making and may ambulate with a rolling walker. An Incident Report dated 5/12/13 at 4:00 p.m., revealed staff found Resident #9 performing oral sex on the resident ' s roommate (Resident #10). Staff separated the residents and placed both on 1:1 supervision. The Care Plan updated on 5/13/13, revealed Resident #9 had inappropriate sexual behaviors and directed the staff to avoid types of conversation that could encourage or initiate inappropriate behavior, distract if possible, provide privacy, provide supervision in social gatherings, provide 1:1 supervision, refer for psychological services, remain calm and avoid angry reactions if exhibits behavior. During an interview on 5/14/13 at 12:20 p.m., Staff M (Certified Nursing Assistant) stated she answered Resident #10's call light. Staff M found Resident #10 lying in bed and Resident #9 performing oral sex on Resident #10. During an interview on 5/14/13 at 6:20 p.m., the Psychologist reported Resident #10 wanted a new roommate and brought it up again at the next session. The Psychologist asked further on why Resident #10 wanted a new roommate. Resident #10 told the Psychologist that Resident #9 touched him/her at night. The Psychologist informed Staff L of Resident #10's allegation. The Psychologist did not know if Resident #10 was serious about the allegation. The Psychologist told Resident #10 to use the call light for help if it happened again. The Psychologist reported Resident #10 did not have complaints about the roommate until the last two sessions. The last visit was on 5/9/13. On 5/14/13 at 2:00 p.m., Staff L (Licensed Practical Nurse) confirmed the psychologist informed her of the allegation Staff L reported the Psychologist did not believe Resident #10 because the resident wanted a new roommate. Staff L did not tell anyone about the allegation. On 5/15/13 at 8:55 a.m., the Administrator reported as a result of the facility investigation, it was determined staff were normalizing behaviors. The facility planned to educate all staff regarding how to handle behaviors. 5. An Admitting Record, with a print date of 5/15/13, documented Resident #7 had [DIAGNOSES REDACTED]. The MDS assessment, with a reference date of 3/22/13, documented Resident #7 had no cognitive impairments and was independent with bed mobility, transfers and toilet use. The resident displayed verbal behaviors directed at others each day. The Care Plan indicated the resident verbalized understanding and remained noncompliant, used a cane per choice and provide psychological referral as needed, be cognizant of invading personal space, emotional support and counseling as needed, encourage to leave public areas when behavior is disruptive/unacceptable, talk in a low pitch, calm voice to decrease/eliminate undesired behavior, allow for flexibility in activities of daily living to accommodate mood, preferences, and customary routine, elicit family input for best approaches, if resists cares leave and return later, provide non-care related conversation proactively before attempting activities of daily living, easily annoyed when educated on effects of noncompliance, avoid type of conversation that could encourage inappropriate behavior, provide supervision in social gatherings/recreational activities, remain calm and avoid angry reactions if exhibits behavior, set limits for unacceptable behaviors, engage in conversation about occupation and hobbies and help to identify strengths and coping strategies to use in present situation. A Progress Note dated 2/20/13 at 12:34 a.m., revealed the nurse entered Resident #7's room at 6:00 p.m. Resident #7 began to yell using foul language to his/her roommate (Resident #13). Resident #13 had family present. Resident #7 became louder and louder. The nurse intervened and told Resident #7 that yelling, making verbal threats, and making others feel unsafe was unacceptable. Resident #7 used foul language and told the nurse to shut up and leave. Resident #13's family calmly asked the residents to respect each other and get along. Resident #7 told the family to " shut up " . Resident #13's family spoke to the nurse outside of the room. Resident #13's family requested the nurse contact administration as they did not feel it was safe for Resident #13 to stay in the room overnight. The Administrator arrived and spoke to Resident #7 and Resident #13. A Social Service Note dated 2/21/13 at 11:23 a.m., revealed a follow up from the incident the evening prior. The social worker interviewed both residents and concluded they did not want to live together. The facility moved Resident #13 to another room as Resident #13 and Resident #13's family did not feel he/she was safe around Resident #7. The police were called because both residents were threatening each other. The roommate was moved to another room on a different floor because the family did not feel the resident to be safe around Resident #7. A Progress Note dated 3/15/13 at 11:39 p.m., revealed Resident #7 threaten to hurt another resident and made derogatory ethnic comments. Staff intervened and removed Resident #7 from the area. A Progress Note for Resident #5 dated 3/21/13 at 5:29 p.m., revealed no negative statements made by Resident #5 after altercation with Resident #7. During interview on 5/8/13 at 10:20 a.m., Resident #5 reported Resident #7 threatened to knock Resident #5 out of the wheelchair and kick him/her in the head. Resident #5 commented he/she did not have any legs and knew Resident #7 could hurt him/her. Resident #5 reported the Administrator reported to the facility after the incident. A Progress Notes dated 3/22/13 at 12:06 p.m., revealed Resident #7 standing on the elevator making derogatory ethnic comments to other residents. Staff informed Resident #7 that the other residents were free to speak their language of choice. The other residents left the area. A Progress Note dated 3/23/13 at 12:22 p.m., revealed staff called the Social Worker to report to the facility due to Resident #7's behaviors all night and into the morning. While the Social Worker spoke to Resident #7 another resident passed by and Resident #7 began yelling, swearing and threatened to kill him/her. The police were contacted to diffuse the situation. The police encouraged the facility gather documentation and present it to the facility attorney to proceed with an order from a judge for other placement for Resident #7. A Progress Note dated 3/26/13 at 1:37 a.m., revealed Resident #7 returned from the hospital with an order to follow up with psychological services. Resident #7 was advised at the hospital to expect legal action if threatening or intimidating staff or other residents. The Deer Oaks Discharge Summary dated 4/4/13, revealed Resident #7 focusing rage/anger towards psychologist and refused to look or speak to psychologist. Resident #7 informed the Administrator that he/she no longer wanted services. A Progress Note dated 4/9/13 at 12:47 a.m., revealed Resident #7 returned from an appointment and stood at the nurses ' station screaming, yelling and banging his/her fists on the nurses ' station. The nurse called the Administrator to settle the issue. A Progress Notes dated 4/13/13 at 12:19 a.m., revealed Resident #7 in the front lobby making threats to Resident #4 and Resident #4's family. Staff separated the residents and contacted the police. A Progress Notes dated 4/9/13 at 12:30 p.m.; revealed Social Services spoke to Resident #7 regarding a concern with the resident touching female staff and making inappropriate comments. A Social Service Progress Note from 3/12/13 to 4/26/13, for Resident #4 had no entry regarding the incident between Resident #4 and Resident #7. A Progress Note dated 4/18/13 at 6:30 p.m., revealed the Director of Nursing and another nurse advised Resident #7 they needed to go to the hospital for an evaluation and upon return to the facility 1:1 supervision would be implemented. A Progress Note dated 4/25/13 at 11:03 a.m., revealed Resident #7 had a warrant for arrest and the police took them into custody. Staff notified Resident #7's family and the physician. The Emergency Involuntary discharge date d 4/26/13, revealed a notice to Resident #7 of an emergency involuntary discharge. The reason for the notice explained the resident's behaviors posed a threat and disruption of the welfare and well- being of other residents and staff. On 5/21/13 at 11:00 a.m. and at 12:38 a.m., the Administrator reported on 4/19/13, Resident #4's family spoke to him/her concerning Resident #7. A detective contacted the Administrator and informed them that Resident #7 would be arrested. The next day the detective called back and informed the Administrator that Resident #4's family obtained an order of protection. The Administrator reported a representative from the Department of Inspections and Appeals contacted him/her on 4/18/13 concerning Resident #7 and the facility placed Resident #7 on 1:1 supervision.

Based on record review, resident and staff interviews, the facility failed to implement intervention (s) to provide adequate supervision to prevent falls for one of eleven residents (Resident #2). The facility reported a census of 91 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool ((MDS) dated [DATE] the resident scored 14 out of 15 on the Brief Interview for Mental Status which indicated the resident cognitively intact. The resident required an extensive assist of 2 staff for bed mobility, transfers, and toilet use, extensive assist of 1 staff for dressing, eating and personal hygiene and totally dependent on 2 staff for bathing. According to the Routine Physician order [REDACTED]. Resident #2's Care Plan with an initiated date of 1/23/13 directed staff to provide assist with transfers. The care plan noted the resident had been at risk for falls due to impaired balance/poor coordination, his/her abnormal posture and due to CVA with left [DIAGNOSES REDACTED]. The resident's Care Plan initiated 1/22/13 and last updated 2/21/13 after the resident sustained [REDACTED]. Resident #2's Care Plan directed nursing staff to transfer the resident with a mechanical lift with a sling due to self care deficit related to left sided weakness from a stroke. The Care Plan initiated on 2/21/13 directed staff to use place floor matts on the floor as resident at risk for falls due to impaired balance/poor coordination and left sided weakness. Review of the Nurse's Progress Notes for Resident #2 revealed the resident had sustained a fall on 2/21/13 at approximately 12:15 p.m.. The note indicated the resident receiving cares before a scheduled appointment and rolled off the bed. The resident struck the left side of face which created a 2 centimeter in length laceration to the eyebrow area and a swollen left cheek. The doctor ordered the resident transferred to the local emergency room (ER). Noted an entry in the progress notes the resident returned to the facility from the ER at approximately 10:45 p.m. with no new orders and 5 sutures to the left eyebrow. The resident complained of pain to his/her face and rated the pain at a 6 out of 10. The Progress Notes dated 2/22/13 at 2:48 p.m., documented the resident still had swelling to his/her left cheek and eye. The Incident Report dated 2/21/13 also described the fall from 2/21/13 and noted the resident complained of a headache after the fall. The emergency room Physician Notes dated 2/21/13 identified Resident #2 had pain and bleeding from his/her nose. The resident complained of a headache and the head Computed Tomography (CT) results showed no evidence of changes. The Maxillofacial CT showed possible minimally-displaced right nasal fracture. During an interview on 2/26/13 at 8:13 a.m., Resident #2 reported his/her left eye hurt some. When asked what happened, the resident stated he/she rolled too far and rolled out of bed, guess was too far over to the edge. During an interview on 2/26/13 at 9:05 a.m., Staff H, Certified Nurse Aide (CNA), reported worked alone with Resident #2 on 2/21/13 at approximately 11:50 a.m. Staff H assisted the resident with personal cares after incontinent of bowel and bladder and the resident had a 1:45 p.m. appointment and to be picked up soon. Staff H reported she the only staff in the room to work with the resident and had done so in the past with no problems. Staff H reported if she recalled correctly, Resident #2 needed a 2 person assist prior to this fall. Staff H indicated she had rolled the resident back and forth already in bed to change the bed linens and did fine. Then Staff H rolled the resident to the left side so the resident's right side, non-affected from the stroke, was up. Staff H reported the policy at the facility was to have no side rails for residents on the bed unless necessary. Staff H stood behind the resident and reached to the side to get a clean incontinent brief out of the chair beside the bed. As Staff H turned for the brief then looked back and the resident's top half of the body had fallen out of the bed to the floor. The resident hit his/her head on the floor. Staff H reported the bottom half of the resident remained barely in the bed and Staff H hung onto the resident while moved around the end of the bed to the resident's side, proceeded to lower the resident to the floor and then call for help. Staff A, Licensed Practical Nurse, responded as the resident noted to be bleeding. The resident left the facility per ambulance to the local ER. Staff H revealed that the CNAs know how much assistance a resident requires by the Patient Information Worksheet (PIW). Each CNA expected to carry the daily PIW for the area of the facility worked. Staff H admitted she knew Resident #2 was a 2 person assist for cares and transfers. Staff H reported done cares for the resident by herself before with no problems. Staff H also admitted she had completed cares for the resident with another CNA present but not every time. Staff H stated she thought she could do cares by herself as no problem before, but knows better. Staff H reported a CNA training completed to enforce the need for 2 person assist at all times if a resident deemed so since Resident #2's fall. Staff H also reported training given to the CNAs on the PIW sheets and to follow the PIW directions. Staff H said she and was trying to save a step as other CNAs were busy serving lunch and thought she could do it alone. During an interview on 2/26/13 at 9:46 a.m., Staff A, LPN, reported the CNAs carry the PIW sheet with them to know what cares, assistance and how many needed to assist a resident. Resident #2 could be washed up by 1 CNA but when turned in bed or transferred a 2 person assist needed and required a Hoyer Lift for transfers form bed to chair. Staff A recalled on 2/21/13 around noon, Staff H called out for help from Resident #2's room while Staff A at the Nurse's Station passing medications. Staff A went to the resident's room and found the resident on the floor face down with the left side of the face toward the floor and had fell to the side of the bed towards the window. Next Staff A reported assessed the resident without moving the resident and the resident complained of no pain except for head and noted the bleeding minimal amount form area around the left eye in the eyebrow area. Staff A reported log rolled the resident to the resident's back along with assist form Staff A then another LPN, Staff J entered the room to assist. Staff A reported cleaned off the facial area of the resident and did not see blood anymore, but the area opened, also noted the resident's left cheek area reddened. Staff A reported the resident never lost consciousness and tried to raise self from the floor. Staff A indicated completed vitals assessment and neuro checks on the resident. Staff I Registered Nurse/Director of Care Delivery (RN/DCD) proceeded to call the doctor for orders to transport to the local ER for evaluation, completed the transfer paperwork and notified the family about the fall. Staff A reported an ice pack also applied to the left eye area for the resident. Staff A indicated Resident #2 remained a 2 person assist and reported thought Staff H gone to wash up the resident and would come to get assist to roll/turn the resident to get out of bed. Staff A reported everyone busy serving and assisting to feed residents lunch in the 2 West dining room. Staff A recalled not seen the resident rolled or turned without a 2 person assist, but not in the room all the time when CNA's providing cares. During an interview on 2/26/13 at 1:45 p.m., Staff K, CNA reported instructed when a resident needs a 2 person transfer assist, the resident needs a 2 person assist with cares such as bed mobility and rolling in bed. When asked about Resident #2, Staff K indicated the resident a 2 person assist in bed with cares and that is how understood before the resident rolled out of bed. During an interview on 2/26/13 at 2:00 p.m., Staff I, RN/DCD reported on 2/21/13 at approximately 12:15 p.m. the 2 West dining room full of people eating lunch and 1 CNA out of the dining room assisting a resident to eat in the resident's room and 1 CNA assisting residents to eat in the assisted dining room area. Staff I indicated knew Resident #2 had an appointment at 1:45 p.m. and unaware Staff H in the resident's room alone getting the resident ready for the appointment until heard Staff H holler for help. Staff I revealed responded to the resident's room with Staff A and saw the resident's bed in a high position, about waist high as Staff H cleaning the resident up. Staff I observed the resident lying on the floor between the bed and the window face down and Staff H at the resident's feet. Staff I instructed Staff A to assess the resident as saw swelling to the left eye/orbital area and blood and unsure of the severity of the head wound. Staff I reported the resident never lost consciousness and talked to staff. Staff I reported then went to the Nurse's Station to begin transfer paperwork and called the doctor to get the resident transferred to the local ER. Once the order received Staff I called the non-emergency phone number for the ambulance and notified the family of the resident's fall. Staff I also reported went back to check on the resident while waited for the ambulance and noted Staff H stayed with the resident and Staff A continued to monitor the resident's vitals and did neuro checks. Staff I reported the resident went to the local ER and returned later in the day and nursing staff continued to monitor the resident after returned. Staff I returned the next day and learned the resident received 5 stitches to the laceration in the left eyebrow area. Staff I reported the ER did lab work and a Computed Tomography (CT) Scan and no problems noted. Staff I indicated staff education completed after the incident on all residents who are 2 person assist with mechanical lifts for transfers. Staff educated if a resident is a 2 person assist for transfers, then 2 staff needed to assist with personal cares performed in bed especially if the resident to be rolled. Staff I revealed floor matts in place on either side of Resident #2's bed and a larger mattress applied to the bed. Staff I reported a facility policy in place for no side rails on a resident's bed except in exceptional cases. During an interview on 2/26/13 at 2:45 p.m., Staff J, LPN reported worked on 2/21/13 in the Central Area of 2nd floor. Staff J indicated at the Nurse's Station at lunch time when noted Staff A appeared coming out of Resident #2's room and asked for assistance. Staff J reported entered the resident's room and observed the resident on the floor between the bed and the window on the resident's back with Staff H in the room with the resident. Staff J noticed the resident bleeding moderately from an area in the left eyebrow area. The resident did not lose consciousness. Staff J asked the resident what happened and the resident responded rolled out of bed and laying here. Staff J left the room and got 4 x 4 gauze pads and normal saline to clean the area above the left eye and assess the how deep the wound was. Staff J and Staff A agreed ice needed to be applied to the left cheek of the resident as beginning to swell. Staff J indicated in and out of the resident's room to see if all okay and not present when the resident transported by ambulance to the local ER and not worked with the resident since that day. Staff J reported Resident #2 an extensive 2 to 1 assist and transferred per a Hoyer Lift. Staff J indicated when a resident an extensive 2 to 1 assist staff trained there should always be 2 staff attending to the resident's personal cares when provided in bed for bed mobility. During an interview on 2/28/13 at 7:54 a.m., the Director of Nursing (DON), reported worked 2/21/13 and knew of staff working with Resident #2 at approximately 12:15 p.m. and the resident falling out of bed after the fact. The DON reported did go to the resident's room to check on the situation and found the resident on the floor on the resident's back between the bed and the window. The DON noted Staff H and Staff A in the room assessing and caring for the resident. The DON indicated the resident alert and orientated and when asked what happened by the DON replied "I rolled out of bed." The DON reported observed a laceration above the resident's left eye in the eyebrow area bleeding, but not profusely and the peri-orbital area beginning to turn red and swell. The DON indicated the staff already cleansed the area and Staff I preparing the transfer paperwork and made all the appropriate phone calls to transfer the resident and family contacted also. The DON reported the resident went to the local ER and returned that evening after the DON had left the facility. The DON indicated did not return to the facility the next day as ill and the Administrator completed the necessary paperwork to notify State of the fall and an investigation started the day of the fall. The DON reported education of the CNA's started in regards to incontinence cares and turning residents in bed, did a one-on-one training with Staff H, and group education on extensive assist of 2 staff at all times when providing cares in bed. The DON stated the expectation of all the CNA's to know if caring for a resident who is an extensive 2 person assist for cares, bed mobility and transfers there should be 2 staff present, be it 2 CNA's, a CNA and a Nurse, or 2 Nurses. The DON indicated if a CNA had a one-on-one training in regards to an issue and continued to do what were trained on not to, the next step to be a disciplinary action steps and depends on the infraction as could lead to termination. The DON reported to best of knowledge Staff H had not been educated with an one-on-one on the particular issue with Resident #2. During an interview on 2/28/13 at 1:35 p.m., Staff L, CNA reported whenever staff work with a resident who is an extensive assist of 2 in bed mobility, transferring, or toileting there should always be 2 staff to assist. 2 staff needed when providing personal cares with a resident especially when needing to be rolled back and forth in bed. Review of the Incontinence Care Policy dated 12/09 and updated 12/12 directed the nursing staff to assist the resident to a side lying position turning towards caregiver, unless more than one caregiver present. If more than one caregiver present, one caregiver provides support of resident to maintain side lying position while the other caregiver completed the procedure. This policy presented by the DON as the material used when educated the CNA's in regards to residents who were extensive 2 person assist.