Every finding on record at Harmony Dubuque

Based on clinical record review, and staff, resident, and family interviews, the facility failed to ensure the safety of resident personal items for 2 of 7 resident clinical records reviewed (Resident #1 and Resident #4). The facility reported a census of 58 residents. Findings include:1. The Minimum Data Set (MDS) Assessment tool with 7/15/26 date of review revealed Resident #1 had diagnoses of diabetes, asthma, and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) cognitive assessment, which indicated intact cognition. During an interview on 8/18/26 at 12:10 p.m., Resident #1 stated the facility's laundry had lost a pair of her pants, two shirts, and two bras they were labeled with her name. The resident explained she'd reported it several times to laundry and nursing staff but didn't get the items back until recently when she learned there was a form she had to fill out. Once she did that, then the facility replaced the lost items. 2. The Minimum Data Set (MDS) Assessment tool dated 5/7/26 revealed Resident #4 scored 4 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, Resident #4 had diagnoses that included non-Alzheimer's dementia, diabetes, and post-traumatic stress disorder. The resident was dependent for transfers to and from bed or chair, and was frequently incontinent of bowel and bladder. The MDS assessment revealed Resident #4 weighed 250 pounds and was 6 foot 5 inches tall. During an interview on 8/19/26 at 3:02 p.m., the resident's family member and Power of Attorney (POA) stated the resident had at least two missing shirts and two missing pairs of pants. Resident #4's family member expressed she didn't understand how as there were signs in the resident's room that she washed the resident's clothes. [The facility] were not to send his clothes to their laundry, and yet they continued to do that. She told Laundry and Nursing staff about his lost clothes; she brought it up at a care conference and had told the Administrator. The items remained missing, not replaced by the facility. She had to special order some of the resident's clothes due to his height and hoped that the facility could either find or replace the items. One time one of the Certified Nursing Assistants (CNAs) went to where they kept the Lost and Found and did come back with one of his missing shirts. During another interview on 8/25/26 at 9:55 a.m., Resident #4's family member stated she was not aware of a form to complete to alert the facility of the resident's missing clothes and questioned why she wasn't informed of that on one of the times that she reported the missing clothes. During an interview on 8/25/26 at 8:49 a.m. the facility Administrator stated when a resident had a missing item, a concern form was filled out by the facility staff member made aware, whether they were made aware by family or the resident themselves. That concern form was then given to the housekeeping supervisor to search for the item and make the laundry attendant aware that an item was missing. If the item could not be located, the housekeeping supervisor would follow up and we could replace with a like item or exact item. The Administrator further explained had had family send facility the exact link to purchase a specific item. The Administrator explained would send the request via the online portal to get the approval for replacement and then the item got ordered by our online system.

Based on clinical record review, facility policy review, and staff interviews, the facility failed to ensure that staff maintained an accurate inventory of each resident's narcotic medications for 1 of 5 residents reviewed that received narcotic medication (Resident #7). The facility reported a census of 58 residents. Findings include:The Minimum Data Set (MDS) Assessment tool with reference date 6/3/26 revealed Resident #7 admitted to the facility 5/28/26 with Hospice services in place. Resident #7's diagnoses included malignant neoplasm of rectum (cancer) with colostomy status, traumatic brain injury, and other symptoms/signs of cognitive with cognitive function and awareness. The assessment revealed the resident had frequent pain. Per the MDS Assessment, Resident #7 took antianxiety and opioid medications.Review of the Nursing Care Plan revealed the following focus area for Resident #7, initiated on 5/28/26: Resident has complaints of pain described as Chronic > (greater than) 3 months related to rectal cancer with metastasis. The Intervention dated 5/28/26 revealed, Administer pain medication per physician orders. 1. Physician orders directed staff to administer Lorazepam (a controlled anxiolytic medication), 2.0 milligrams (mg) per milliliter (ml) concentration as follows:a.5/29/26: 0.1 ml oral 3 times daily and every 1 hour as needed (PRN) and 0.2 ml at bedtime, discontinued 6/2/26.b. 6/2/26: 0.1 ml oral every 1 hour PRN, discontinued 6/3/26c. 6/2/26: 0.2 ml oral daily, discontinued 6/3/26d. 6/2/26: 0.1 ml oral 3 times daily, discontinued 6/3/26 e. 6/3/26: 0.2 ml oral every 1 hour PRN, discontinued 6/4/26 f. 6/4/26: 0.5 ml oral every 4 hours, discontinued 6/7/26The resident's Lorazepam narcotic inventory control sheet revealed the following: a. On 6/2/26 at 11:57 a.m., 0.1 ml given with balance of 28.3 ml. The next entry on the control sheet dated 6/1/26 at 4:30 p.m. revealed the amount given and amount left were not recorded.b. On 6/4/26 at midnight, 0.2 ml given, remaining balance 26.7 ml. The next line entry on the log said, 24.5 ml actual count, with the initials of only one staff member without second nurse's signature or manager signature for the 2.2 ml difference. Review of the resident's inventory control sheet for Morphine (an opiate narcotic analgesic) revealed the following: a. On 5/31/26 at 7:55 p.m., 1.0 ml given with balance of 16.4 ml. The next entry, dated 6/2/26 at 7:57 a.m. revealed 0.8 ml given with balance of 16.4 ml.b. On 6/4/26 at 4:00 a.m., 1.0 ml given with balance of 5.0 ml. The next three entries recorded entries were dated 6/1/26 (at 8:00am, 12:00 p.m., and 4:00 p.m.), with 0.8 ml administered at each time by Staff R, RN. c. On 6/1/26 at 4:00 p.m., the amount left was documented as 2.6 ml. The next entry recorded revealed, 0.25 ml actual count, dated 6/4/26 at 7:10 a.m. This entry had been signed and verified by 3 nursing staff members for the destruction of the .25 ml (2.35 ml difference).On 8/24/26 at 7:54 a.m. Staff R, RN, stated If the narcotic count was off, the nurse had to call management, and first try to determine if a dose wasn't documented and the count wasn't really off. If the count was still off a manager had to be called. Two nurses were required to witness narcotic destruction, to verify correct count, and if there were missing narcotics the nursing manager/DON would have to address the issue. The nurse shouldn't continue to administer from that supply until the count was corrected by the manager.During an interview on 8/24/26 at 8:42 a.m., the Director of Nursing (DON) stated nurses were required to record narcotic medications administered on the narcotic inventory control sheet, and the Medication Administration Record (MAR) at the time of the medication administration. It was not an acceptable practice to record doses administered three days later, when there was a discrepancy in the count. If there was missing narcotic inventory, the DON or designee had to be notified and involved with investigation of the matter. It was not acceptable for one staff member to adjust a narcotic inventory county without a managers involvement with investigating the discrepancy.2. Physician orders in effect from the evening shift on 6/6/26 until the afternoon on 6/7/26 for Resident #7 directed staff to administer medications that included, but were not limited to: Haldol (an antipsychotic medication) every 4 hours for nausea, Lorazepam (an anxiolytic medication) every 4 hours for anxiety, and Morphine (a narcotic analgesic medication) every 4 hours for pain. These medications were scheduled at 4 a.m., 8 a.m., 12 p.m. 4 p.m. 8 p.m. and 12 a.m.The resident's June 2026 Medication Administration Record (MAR) revealed the resident's medications that were scheduled at 12:00 a.m. on 6/7/26 were administered by Staff J, RN that included Morphine, Lorazepam and Haldol. The Morphine and Lorazepam doses were not recorded on the narcotic inventory control sheet. The only other medication documented as administered on the 6/7/26 night shift was the same medications scheduled at 4:00 a.m. The narcotic inventory control sheet revealed the medications were signed out for administration at 4:45 a.m. by Staff I, LPN. On 8/25/26 at 9:01 a.m. Staff J, Registered Nurse (RN) stated he usually worked Station 2, in the back of the building when he was there. When it was explained that he'd signed the administration of the resident's Morphine and Lorazepam at midnight on 6/7/26, Staff J stated if he signed that he administered the medication he did. He did not document anything he did not do, but he really didn't remember that, or anything about that night with the resident.The facility's Controlled Medication Storage and Count Policy, dated October, 2023 revealed, Purpose: To maintain safe storage and an accurate count of Scheduled II controlled medications. The Procedure section revealed the following: 1. Narcotics are stored under a double lock system2. After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken3. After administration of the controlled medication, the nurse/medication aide will sign off the eMAR (electronic medication administration record)4. If the controlled medication needs to be wasted, a second nurse should witness the wasting of the controlled medication and both nurses will sign the medication sheet (a certified medication aide and licensed nurse can waste controlled medication)NOTE: 2 certified medication aides are NOT authorized to waste controlled medications5. Any narcotic count discrepancy will be immediately reported to the Director of Nursing6. Narcotic counts are completed at the beginning and end of each shift or at the time when there is an exchange of medication cart keys- Requires two nurses (or one nurse and one certified medication aide)- Oncoming nurse validates medication count on the medication card, off-going nurse validates medication count on the paper document- Both nurses are required to sign off on the shift-to-shift count record

Based on clinical record review and staff interview, the facility failed to ensure adequate supervision and coordination of care overnight for 1 of 7 residents reviewed (Resident #7). The facility reported a census of 58 residents. Findings include:The Minimum Data Set (MDS) Assessment tool with reference date 6/3/26 revealed Resident #7 admitted to the facility 5/28/26 from a nursing home. Resident #7 had Hospice services in place, and diagnoses included malignant neoplasm of rectum (cancer) with colostomy status, traumatic brain injury, and other symptoms/signs of cognitive with cognitive function and awareness. The assessment revealed the resident had frequent pain, rated as high as a 3 on a 0 to 10 pain scale (10 used for the worse possible pain). Per the assessment, the pain frequently impacted the resident's ability to sleep and participate in day-to-day activities. The assessment revealed the resident required partial/moderate staff support for bathing, otherwise was independent for transfers to and from bed or chair/toilet, dressing, toileting, and personal hygiene. The resident had an indwelling catheter and ostomy. A Nursing Care Plan focus area initiated on 5/29/26 revealed, Resident requires assistance with Activities of Daily Living (ADL's). The Goal initiated on 6/4/26 revealed, Resident will be assisted with ADL's as required. The Goal initiated on 6/4/26 revealed, All ADL's will be completed by daughter per her request while she is present. The Nursing Care Plan directed staff to provide interventions that included:a. Assist resident with shower/bathing per schedule, initiated 6/4/26. b. Bathing: Dependent with assist of 2 staff member(s) to complete this ADL, initiated 6/4/26. c. Bed Mobility Dependent with assist of 2 staff member(s) to complete this ADL, initiated 6/4/26. d. Cares in Pairs, initiated 6/7/26. e. Daughter to complete all ADL's, initiated 5/29/26. f. Daughter will Complete colostomy changes, initiated 5/29/26.g. Dressing & Grooming: Dependent with assist of 2 staff member(s) to complete this ADL, initiated 6/4/26. h. Eating: Dependent with assist of 1 staff member to complete this ADL, initiated 6/4/26. i. Oral Care: Dependent with assist of 1 staff member to complete this ADL, initiated 6/4/26. j. Prior to initiating an ADL task, staff will explain the task to resident, initiated 6/4/26. k. Provide sufficient time for completion of ADL tasks, initiated 6/4/26. l. Staff will allow resident independence to the best of their ability with ADL task completion, initiated 6/4/26.m. Transferring: Dependent with assist of 2 staff member(s) to complete this ADL, initiated 6/4/26. Review of the Interdisciplinary team (IDT) Meeting Notes dated 6/4/26 at 1:22 PM revealed the resident had a care conference on 6/4/26. The Note revealed, Hospice nurse reports that the resident is minimally responsive, only eating bites and sips throughout the day. Resident also has a foley at this time .Hospice explained that he likely only has less than a week left. Progress Notes dated 6/5/26 at 11:49 AM and 6/6/26 at 7:57 AM noted the resident was unable to swallow. Physician orders in effect from the evening shift on 6/6/26 until the afternoon on 6/7/26 directed staff to administer medications that included, but were not limited to: Haldol (an antipsychotic medication) every 4 hours for nausea, Lorazepam (an anxiolytic medication) every 4 hours for anxiety, and Morphine (a narcotic analgesic medication) every 4 hours for pain. These medications were scheduled at 4 a.m., 8 a.m., 12 p.m. 4 p.m. 8 p.m. and 12 a.m.The resident also had as needed (PRN) Lorazepam and Morphine ordered to be administered every hour PRN. The resident's June, 2026 Medication Administration Record (MAR) revealed his medications that were scheduled at 12:00 a.m. on 6/7/26 were administered by Staff J, RN that included Morphine, Lorazepam and Haldol. The Morphine and Lorazepam doses were not recorded on the narcotic inventory control sheet. The only other medication documented as administered on the 6/7/26 night shift was the same medications scheduled at 4:00 a.m. The narcotic inventory control sheet revealed the medications were signed out for administration at 4:45 a.m. by Staff I, LPN. Staff interviews revealed:On 8/13/26 at 2:51 p.m. Staff I, LPN stated she remembered caring for the resident on the night shift that started on 6/6/26, mostly because she received a call about his care the following morning. Staff I stated she was assigned to Station 1. In the shift-to-shift report from the off-going nurse, she did not get report on the resident. She was instructed that the nurse at Station 2 got report on him and had his medications to administer. She had not received any other directives about him. Later in the shift, she offered to help the Station 2 nurse as he was busier. He asked her to administer the resident's scheduled medications and was told at that time he was Hospice and transitioning. She went into his room at 4:45 a.m., and he was positioned on his back but leaning towards his left side a little. He sort of mumbled as she spoke to him. She was not able to understand what he was saying. She assessed him, looked at his ostomy, and that was when she saw his catheter had become disconnected between the tubing to the bag and the catheter tube. His bed was saturated with urine and needed to be changed. There was no one with him at the time. She went out of his room, gathered bedding and supplies, and and asked an aide for assistance. She waited for the Morphine to take effect. She changed the bedding and completed hygiene care with Staff H, Certified Nursing Assistant (CNA). She did not observe any reddened skin areas or concerns beyond the catheter tubing disconnection. The other nurse at Station 2 administered his scheduled medication at midnight, and he had not indicated there was anything unusual.On 8/13/26 at 11:21 a.m. Staff H, CNA, stated when the resident was first at the facility he walked to the bathroom, he was slightly unsteady and was supposed to have assistance, and he ate and drank. The resident asked for towels so he could get washed up. A week later, the resident could not get out of bed, and couldn't really ask for anything. The resident's family/POA provided his care and was very insistent on that, she usually stayed at night, and staff weren't supposed to provide care unless she asked them to. The family member emptied his catheter and ostomy bag, changed his ostomy bag, and turned him. If Resident #7's family member wasn't there, someone else came around 11 p.m. and usually left around 2 a.m. On the evening of 6/6/26 to night of 6/7/26 nobody told her that the family had left or that nobody was in his room, and that she was supposed to provide care to him until around 5 a.m. when the nurse asked her to help her change his bed. They were careful as they gently turned him to change the bedding and provide hygiene care. She did not observe any reddened areas when assisted the resident with the bed change. On 8/20/26 at 2:23 p.m. Staff O, CNA, assigned to the resident on the evening shift on 6/6/26 stated she remembered the resident because his family provided his care. When he was assigned to her she only did what his family asked. She thought she repositioned him once when his family asked, and not sure what night it had been. Staff O couldn't say if it was on 6/6/26 but she otherwise didn't go in the room because the family provided his care.On 8/25/26 at 9:01 a.m. Staff J, Registered Nurse (RN) stated he usually worked Station 2, in the back of the building when he was there. He had the 2 short and 2 long halls when he worked, and it was very busy with the resident conditions on those halls. When asked if he remembered Resident #7, assigned to Station 1 but located near Station 2, he only remembered him because he had family that stayed in his room at night. When asked if he remembered a time that the resident was assigned to him with Station 2, he really didn't remember that, it was a couple months ago. When it was explained that he'd signed the administration of the resident's Morphine and Lorazepam at midnight on 6/7/26. Staff J stated if he signed that he administered the medication he did. He did not document anything he did not do, but he really didn't remember that, or anything about that night with him. He couldn't offer any information about the resident's care on that night.On 8/13/26 at 9:29 a.m. Staff M, Registered Nurse (RN) from Hospice stated she was on-call on 6/7/26, that was the first and only time that she'd seen the resident until she was called back to the facility later the same day, because the family found a red area on his left lateral leg and a mark on his back. When she went back to the facility they had already examined him. She looked at his lateral hip/trochanter area. It was red, a little raised, not open, the resident was very thin, near death. She wasn't completely sure what caused the red area. There was redness around the tip of the penis. The facility nurse cleaned the drainage on the penis. The resident said they beat me up last night during the first visit. Upon her assessment during the first visit he was transitioning. She titrated his Morphine and Lorazepam doses and thought he looked more comfortable during the second visit, his pain was managed. On 8/13/26 at 11:35 a.m., the Director of Nursing (DON) stated the facility had the responsibility to provide care to the resident. The DON further explained even when the resident's family insisted on being his care provider, the facility still had the responsibility to ensure his needs were met, and that staff provided the care he needed.

Based clinical record review, staff interview, and resident interview, the facility failed to ensure individualized interventions were implemented timely to meet the resident's behavioral health needs after a resident with a documented history of history of suicidal ideation expressed suicidal ideation on 8/11/26 to a facility staff member for 1 of 3 residents reviewed for behavioral health (Resident #3). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 7/22/26 revealed Resident #3 had diagnoses that included diabetes, anxiety, depression, post traumatic stress disorder(PTSD), and dissociative and conversion disorder. The assessment revealed the resident scored 13 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, which indicated intact cognition. The assessment revealed the resident had hallucinations and delusions, and did not have behaviors. The MDS Assessment further revealed Resident #3 was able to make herself understood and understood others. The resident scored 24 points on the Personal Health Questionnaire of the assessment (PHQ9), an assessment used to evaluate depression based on the person's self-assessment, with 27 as the highest possible score. The assessment revealed the resident required substantial/maximal assistance to transfer to and from bed or chair. Resident #3 used a wheelchair for mobility. The resident's MDS assessment dated [DATE] revealed the resident scored 17 points on the PHQ9 assessment. The MDS assessment with reference date of 2/16/26 revealed the resident scored 11 points on the PHQ9 assessment.Review of the resident's Nursing Care Plan focus area initiated 12/8/25 revealed, Resident has a mood state disturbance related to anxiety and major depressive disorder. Goals per the care plan revealed the following:a. Depression: Will identify resources and strengths towards recovery of depression (date initiated 12/8/25)b. Anxiety: Will demonstrate increased control over anxious behavior (date initiated 12/8/25)c. Suicidal Ideation: Will share thoughts and feelings concerning fears of self-harm or a plan of self-harm (date initiated 5/18/26)d. Frequent Complaints: Will share concerns/complaints and work with staff to resolve issues in a reasonable manner (date initiated 7/21/26)e. Hallucination/Delusions: Will maintain a safe and therapeutic environment to minimize distress associated with hallucinations/delusions (date initiated 7/21/26)f. History of self-harm as evidenced by resident stating they have scratched and used hands to hit head (date initiated 8/19/26)The care plan directed staff to provide interventions that included:a. Complete PHQ 2-9 interview (initiated 12/8/25) b. Distraction techniques include taking outside to get fresh air, taking her to an activity, talking with a friend on the phone, or taking her for a walk (initiated 8/19/26)c. Encourage resident to attend activity of choice (initiated 12/8/25) d. Encourage resident to identify strengths and positive coping skills (initiated 12/8/25) e. Encourage resident to outline factors that contribute to depression and assist to identify personal self-improvement goals (initiated 12/8/25)f. Encourage to communicate feelings (initiated 12/8/25) g. Frequent check-ins with social worker throughout the week (initiated 8/20/26)h. Listen to concerns and assure resident that concerns are validated. Work cooperatively with resident to resolve complaint (initiated 12/8/25) i. Medication as ordered (initiated 12/8/25)j. Notify practitioner of significant changes in mood or behavior (initiated 12/8/25).k. Offer frequent positive affirmations (initiated 12/8/25)l. Resident had appointment with psych ARNP, on 8/20/2026 who made medication adjustments to this resident's medications (initiated 8/20/26)m. Resident was moved to another station, where she will have less contact with the staff she views as stressors (initiated 8/21/26)A Preadmission Screening and Resident Review (PASRR) assessment (an assessment used to determine if a person's mental health conditions can be appropriately addressed in long-term care facilities, or determine the appropriate type of care facility for the person's mental health needs) dated 7/22/26 revealed the resident had a history of having thoughts and attempts to end their own life. The Level II PASRR document required the resident to receive ongoing treatment by a psychiatrist or psychiatric Advanced Practice Registered Nurse Practitioner (ARNP) for medication management of the resident's mental health conditions.A Social Worker (SW) note dated 8/11/26 at 11:31 a.m. stated, This social worker was informed by the Human Resources (HR) director who this resident requested to speak with that she was having suicidal thoughts. Resident would not inform HR director if she had a plan or not. This social worker attempted to speak with resident regarding these thoughts. Resident refused to talk to this social worker. The resident's psychiatric Advanced Practice Registered Nurse Practitioner (ARNP) and the resident's counselor were notified. A SW note dated 8/11/26 at 12:35 p.m. revealed, Director of Nursing (DON) notified. This social worker left a voicemail for resident's responsible party. Awaiting return call.The Encounter Note dated 8/12/26 at 12:00 a.m., signed by the Nurse Practitioner on 8/12/26 at 11:00 a.m., revealed the resident was reported yesterday, 8/11/26, to have suicidal ideation. At that time, she refused to speak with others, including her psychiatric provider, and also declined to contact an available resource. This was documented when she reported feeling this way. Today, she appears back to her baseline, smiling and laughing, and denies concerns. Provider notes this is a recurring issue for her. She does see a psychiatric provider and will continue to be monitored. The Plan section revealed the following per Moderate Major Depressive Disorder: Stable, chronic illness, situationally worse currently. Denies any suicidal thoughts Monitor for depression signs, behaviors or adverse events. If having behaviors, monitor for possible causes such as: medical conditions, medication side effects, pain, cognitive impairment, poor sleep, sensory changes, fear, boredom, or feelings of loss of control. Behavioral Interventions if needed: Providing education and support, enhancing communications with the patient, creating meaningful activities for patient, simplifying tasks, ensuring safe environment changing stimulation environment as needed, Keep follow-up with mental health provider. On 8/18/26 at 10:11 a.m., during an interview, Resident #3 stated a staff member made a comment to her about a month ago that was very upsetting to her. it wasn't true, she believed the staff thought she was a liar because of it and that was even more upsetting to her. The resident thought her high score on the last depression assessment was related to that, The resident was tearful throughout the interview and stated she felt hopeless that the situation with what she believed the staff said would improve. She admitted to thoughts of self-harm at times but denied that she had a plan. The resident verbalized that she had the phone number for the Suicide Hotline and was comforted by thoughts of her supportive family and friends.Staff interviews revealed:On 8/18/26 at 12:36 p.m. the facility Social Worker (SW) stated the resident had suicidal ideations on 8/11/26, went into the Human Resource (HR) director's office and told her the world would be better without her. She was notified of this, went the HR Director's office where the resident was located, and the resident refused to allow her in the office. The resident told the HR director she didn't want to be in this world anymore, and refused to speak to the SW about it. The HR director informed the SW of what the resident said, and the SW notified the resident's psychiatric ARNP, her counselor, the DON and the resident's responsible party. When asked about actions by facility staff related to this, the SW stated the aides would check on her (referred to Certified Nursing Assistants, or CNAs). When asked about the PHQ9 score on the last MDS assessment, she stated she tried to keep track of that and informed the psychiatric ARNP of that. The SW stated the resident had not had prior suicide attempts, she had moved the resident to different rooms at least twice, and there were no suicide threats in her room. The SW stated the resident's biggest barrier was the voices that she heard. On 8/19/26 at 8:50 a.m. the Director of Nursing (DON) stated she didn't know the resident told the HR Director she didn't want to be in the world anymore, nobody made her aware of that. They should have assessed the resident and put interventions in place as appropriate to the resident's risk level, including a psychiatric assessment at the hospital if indicated. The DON was certain she was not informed of this and she should have been. The only thing she had heard recently was there was a comment by staff over the weekend and the resident did not want the staff member in her room/contact with the staff member as a result. The DON stated she would meet with her team to address the resident's care needs and update her care plan with appropriate information and changes. Review of the Follow Up Note by the resident's psychiatric ARNP dated 8/20/26 who determined her increased depression and anxiety symptoms were the result of situational discord at that time. Per the note, the resident's depression and anxiety had really spiraled out of control. The Note referenced the resident had a long history of trauma, the resident said had days where she felt down, depressed, irritable, and hopeless. The resident stated her anxiety was always elevated, stated she had been trying to do better with her moods, and she did not really have any concerns with anger or irritability. She was able to fall asleep however would wake up because of nightmares. Per the note, the resident did have passive suicidal ideations but she had no plan and no intent. The Tests/Screening section revealed the client's current suicide risk was low.

Based on clinical record review, staff interview, and facility policy review, the facility failed to ensure staff reported an allegation of staff to resident abuse timely to the facility Administrator and to the Iowa Department of Inspections, Appeals, and Licensing for 1 of 7 residents reviewed (Resident #4). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 5/7/26 revealed Resident #4 had diagnoses that included non-Alzheimer's dementia, diabetes, anxiety, depression, and post traumatic stress disorder. Per the assessment, Resident #4 scored 4 out of 15 points on a Brief Interview for Mental Status (BIMS) exam, which indicated severe cognitive impairment. The assessment revealed the resident was usually able to make himself understood and usually understood others. Per the MDS, Resident #4 had verbal behaviors directed towards others that significantly impacted the resident's care from 1 to 3 days of the 7 days that preceded the assessment. The resident was dependent (helper does all of the effort) for transfers to and from bed or chair, to shower/bathe self, and for tub/shower transfer. The Nursing Care Plan focus area dated 3/4/26 revealed, Resident requires assistance with Activities of Daily Living (ADL's). The Goal, target date 11/9/26, revealed, Resident will be assisted with ADL's as required with staff anticipation of an increase in need for staff assistance related to terminal illness. The Interventions initiated on 3/4/26 directed staff to, Assist resident with shower/bathing per schedule, and prior to initiating an ADL task, staff will explain the task to resident. Review of a written interview Statement for Staff B, CNA dated 8/19/26 for date of incident 8/15/26 revealed, in part, the following: [Staff B] was asked for a statement regarding an incident that was brought to our attention by the [State Agency] that occurred on 8/15/26 during 1st shift with [Resident #4, Room number redacted] and [Staff A, CNA] and [Staff C, CNA]. [Staff B] stated she did not hear or see any physical harm done to [Resident #4]. She stated that [Staff A] threaten to bend fingers back on [Resident #4] due to him being combative. She stated no physical touches occurred outside of normal CNA duties. [Staff B] stated [Resident #4] told her that [Staff A] and [Staff C] Man Handled him in the shower and they hurt him. When asked if there were physical marks on [Resident #4] or signs of abuse, she denied there were any. When asked which nurse she made the report to, she stated she did not report the incident to a nurse. [Staff B] said [Resident #4] told her this information while [Staff A] and [Staff C] were downstairs gathering a sling. Review of a typed document, unsigned, titled Phone Conversation with [Staff A] on 08/18/2026 revealed, in part, .Human Resources (HR) then moved on to ask about the shift on 08/15/2026 .[Staff A] went to assist with [Resident #4's] shower and asked [Staff C] for assistance .[Staff A] then stated that [Staff C] did not assist with the shower as [Redacted] pulled her into the office. HR asked [Staff A] what occurred after the shower was completed and regarding the yelling in the hallway. [Staff A] stated there was no yelling in the hallway. HR then again, asked did you state I am never doing his shower again while wheeling him down the hallway, then entering his room and slamming the door-she denied this occurred. [Staff A] was then asked while assisting with the dressing process for [Resident #4], did she make a comment regarding bending back his fingers after she had been hit in the shoulder. [Staff A] denied these claims. Staff interviews revealed:On 8/19/26 at 12:58 p.m. Staff A, CNA stated, in part, she was under investigation for abuse. Staff A explained she was told Resident #4 said she'd abused him in the shower and bent his fingers backwards. She transferred the resident to the shower chair with Staff C, CNA. He was combative as they transferred him, and remained combative in the shower room. He leaned forward in the shower chair, not positioned correctly, she hurried as she feared he would fall out of the chair. She transferred the resident to bed with the mechanical lift with Staff B, and Staff C. Staff A stated she and Staff C were sent home after that. Per Staff A, the Scheduler, Staff E, told them they were overstaffed that day and why they were sent home at the time. Five minutes after they left they said, Staff B said she'd abused the resident and why she was sent home.On 8/19/26 at 2:53 p.m. Staff B, CNA, stated she helped Staff A, CNA and Staff C, CNA, transfer Resident #4 to bed with the lift after a shower on Saturday. When the two aides left the room for to get a new sling, while they were out of the room the resident said he'd been handled rough in the shower. Per Staff B, had not heard the resident say anything like that before. Around 45 minutes later he was in the hall in the wheelchair, and continued to say they'd been rough with him in the shower. Staff B stated she reported it to the nurse, said she didn't see any marks on him when they got him dressed after his shower. Staff B stated she had worked at the facility for 2 months through agency. During a second interview on 8/24/25 at 11:07 a.m. Staff B, CNA, stated on the day of the shower Resident #4 said they told him they were going to bend his fingers back if he didn't stop hitting her. Resident #4 was going back and forth with Staff A, CNA. Staff B didn't hear the resident say that at the time, she heard the resident say it later and then Staff A talked about it after the shower. She had not heard the resident say anything like that before either.On 8/19/26 at 3:27 p.m., the Administrator stated she wasn't aware of an allegation of abuse for Resident #4 on the past weekend. The Administrator explained she was aware that two aides, Staff A and Staff C, yelled in the hall on Saturday, completely inappropriate, and they were sent home related to their conduct. The Administrator stated she would initiate an investigation.On 8/20/26 at 8:33 a.m., Staff D, Licensed Practical Nurse (LPN) stated she worked over the past weekend and nobody said anything to her about suspected abuse of Resident #4. On 8/20/26 at 8:14 a.m. the Administrator stated she spoke to Staff B yesterday, who stated the resident said they had been rough with him in the shower. She didn't see any marks on him other that the wounds on his legs that were currently treated. She got busy answering call lights after that and did not tell the nurse about the allegation. On 8/20/26 at 8:38 a.m. Staff E, Scheduler and CNA, stated on the past Saturday Staff A, CNA looked frazzled as she wheeled Resident #4 in the hall to the shower, and in a loud manner said She was never going to give him a shower again. Staff E wasn't aware of any comments about staff being rough with the resident. On 8/24/26 at 8:42 a.m. the Director of Nursing (DON) stated they provided staff education on dependent adult abuse, who to report concerns to at the facility, and in the process of a plan to ensure agency staff were aware who to report concerns to.The facility's Patient Protection Guidelines Abuse Prevention, Reporting, and Investigation policy, dated last reviewed September, 2025 directed staff, in part, 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.The Reporting/Response section revealed, All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. If the person in charge is the alleged abuser, the staff member shall directly report the abuse to the Administrator immediately .In response to allegations of abuse, neglect, exploitation, or mistreatment, injuries of unknown origin, or misappropriation the facility must 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 shall 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.

Based on clinical record review, facility policy review, staff interview, Nurse Practitioner (NP) interview, physician office staff interview, resident interview, and resident family member interview, the facility failed to ensure a resident received effective pain management interventions that included the administration of analgesic and other medications that enhanced pain control as ordered and directed by the physician for 1 of 4 residents reviewed for pain management (Resident #9). This deficient practice resulted in the resident experiencing sleep disturbance due to pain. On 2/16/26 Resident #9 called 911 themselves for transfer to the hospital for pain management when the resident experienced pain at level 10 out of 10. The facility reported a census of 55 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 admitted to the facility on [DATE] from the hospital. The resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) cognitive assessment, which indicated intact cognition. Resident #9's diagnoses included arthritis, anxiety, depression and encounter for other specified surgical aftercare. Per the MDS assessment, the resident reported the worst pain over the last five days as level eight on a zero to ten scale, with zero being no pain and ten as the worst pain [the resident] could imagine. Per the assessment, the pain frequency was almost constant, and it frequently impacted his sleep. The assessment further revealed pain occasionally impacted his day to day function and rarely impacted his ability to participate in therapy. Per the MDS assessment, the resident required partial/moderate staff support and assistance to transfer to and from bed or chair, to dress their lower body, for toileting hygiene, and for ambulation of 10 feet or less on a level surface.A Hospital Discharge summary dated [DATE] and Hospital Records for date of service 1/29/26 revealed the resident had an L4-L5 (4th and 5th disc of lumbar spine) anterior interbody fusion with microdiscectomy and placement of intervertebral cage (hardware used for stabilization), and an L5-S1 (5th lumbar disc and 1st sacral disc area) anterior interbody fusion with radical discectomy. Per the hospital documentation, the procedures were completed by 2 different surgeons on 1/26/26. Resident #9 had 2 different incisions, one on the anterior right lateral lower flank area, and the other from the left posterior lateral sacral area. The hospital documents detailed the resident's transfer to the facility with therapy orders and continued care by the neurosurgeon with follow-up appointment scheduled on 2/10/26 at 8:30 a.m. Pain management medication directed by the neurosurgeon that included:1. Oxycodone (a very strong opiate narcotic analgesic) 5 milligrams (mg) tablet, 1 administered oral every 4 hours as needed for moderate pain, ordered 1/30/26.2. Oxycodone 10 mg (two 5 mg tablets) administered oral every 4 hours as needed for severe pain, ordered 1/30/26.3. Methocarbamol (known as Robaxin, a strong skeletal muscle relaxant medication) 750 mg administered oral every 6 hours as needed, ordered 1/30/26.4. Tylenol 325 mg, with directions to take one to two tablets (325-650 mg total) administered oral every 4 hours as needed, ordered 1/30/26.5. Lidoderm (a topical numbing medication) 5% patch applied topical daily, ordered 1/31/26.6. Lyrica (a prescription medication used to treat neuropathic pain) 75 mg administered oral twice daily, ordered 2/3/26. The resident's Nursing Care Plan included the following focus area initiated on 1/31/26: Resident has complaints of pain described as Acute related to post surgery spinal infusion. The goal initiated on 1/31/26 revealed the resident would not have an interruption in normal activities due to pain. Interventions per Resident #9's Nursing Care Plan included: a. Administer pain medication per physician orders, initiated 1/31/2026.b. Encourage/Assist to reposition frequently to position of comfort, initiated 1/31/2026.c. Evaluate efficacy of pain management, initiated 1/31/2026.d. Evaluate pain level as ordered, initiated 1/31/2026.e. Monitor for factors / activities that precipitate or aggravate pain, initiated 2/12/2026.f. Notify MD (Medical Doctor) if inadequate pain relief as indicated, initiated 2/12/2026.g. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from my past experience of pain, initiated 2/12/2026.h. Observe for non-verbal signs of pain, initiated 1/31/2026.i. Refer to Therapy as needed, initiated 2/12/2026.j. Staff to observe any behavior changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM (range of motion), withdrawal or resistance to care, initiated 1/31/2026. Orders transcribed by the facility's Nurse Practitioner (NP), not the resident's surgeon, included:1. Lorazepam (an anti-anxiety medication that is a controlled medication) 0.5 mg administered oral every 4 hours as needed, ordered 2/5/26.2. On 2/12/26 at 2:05 p.m., discontinued Oxycodone 10 mg order.3. On 2/12/26 at 2:15 p.m., administer Tramadol (an opioid narcotic analgesic used for moderate pain) 50 mg oral every 6 hours as needed.4. On 2/12/26 at 8:45 p.m., re-ordered Oxycodone 10 mg oral every 4 hours for severe pain, because facility could not access Tramadol at that time.5. On 2/13/26 at 10:29 a.m., discontinued Oxycodone 10 mg order.6. On 2/13/26 at 10:30 a.m., Oxycodone 5 mg administered oral every 4 hours as needed for moderate pain. A Physician's Progress Notes and orders from Resident #9's surgeon's office dated 2/10/26 following the appointment that day revealed, Patient states it is difficult to get pain meds as ordered. Having significant pain .Give meds as ordered (Oxycodone, Robaxin, Lyrica and Tylenol). Ok for heat application. Staff B, Registered Nurse (RN) noted the document on 2/11/26 (indicated acknowledgement of receipt and review).The resident's February 2026 Medication Administration Record (MAR) revealed the resident received Oxycodone 10 mg at the following dates/times, with the following pain assessment score documented from 0 to 10 on the MAR:2/6/26:a.1:06 a.m., pain score 8b. 5:28 a.m., pain score 9c. 9:53 a.m., pain score 7d. 3:02 p.m., pain score 7e. 8:32 p.m., pain score 82/7/26: a.12:41 a.m., pain score 8b. 6:10 a.m., 9 (Oxycodone 10 mg was administered after Tylenol given at 4:16 a.m. that morning)c. 10:16 a.m., pain score 7d. 3:59 p.m., pain score 7e. 9:00 p.m., pain score 72/8/26: a.1:22 a.m., pain score 7b. 6:05 a.m., pain score 7d. 4:46 p.m., pain score 7 (Oxycodone 10 mg was administered after Tylenol 650 mg given at 11:25 a.m. that morning)e. 8:47 p.m., pain score 82/9/26:a.12:59 a.m., pain score 10b. 5:00 a.m., pain score 9 (Oxycodone 10 mg was administered after Tylenol 650 mg given at 4:09 a.m. that morning)c. 9:22 a.m., pain score 6d. 1:49 p.m., pain score 7e. 6:10 p.m., pain score 7 f. 11:31 p.m., pain score 72/10/26:a.3:35 a.m., pain score 7b. 10:45 a.m., pain score 7 c. 2:59 p.m., pain score 7 (Oxycodone 10 mg was administered after Tylenol given at 1:27 p.m. that afternoon)d. 7:30 p.m., pain score 8 (After the administration of Oxycodone 10 mg, resident given Tylenol 650 mg at 11:11 p.m.)2/11/26: a.7:45 a.m., pain score 7 (After the administration of Oxycodone 10 mg, Tylenol 650 mg administered at 4:05 p.m.)b. 11:04 p.m., pain score 82/12/26: a.8:02 a.m., pain score 7b. 1:36 p.m., pain score 5The resident's pain scores revealed on 2/12/26 at 4:29 p.m., the resident's pain score of 6. On 2/12/26 at 8:46 p.m., the resident's pain score was 9. On 2/13/26, Oxycodone was administered at the following times, with the corresponding pain assessment score documented from 0 to 10 on the MAR:a. 6:07 a.m., pain score 8 (Oxycodone 10 mg)b.12:37 a.m., pain score 7 (Oxycodone 5 mg)c. 10:24 a.m., pain score 8 (Oxycodone 5 mg was administered after Tylenol given at 7:30 a.m. that morning)d. 2:42 p.m., pain score 7 (Oxycodone 5 mg)e. 7:29 p.m., pain score 9 (Oxycodone 5 mg)The Progress Note dated 2/13/26 at 12:00 AM by the Nurse Practitioner (NP) revealed the resident was at the facility for skilled therapies post lumbar fusion. The resident was on 1-2 tablets of oxycodone 5 mg every 4 hours PRN for pain. He took it around the clock, every 4 hours. The Progress Note revealed it was unsafe to send someone home on that much medication, and discussion was had with the resident on weaning this medication. The Progress Note further revealed the resident was on board, saw Dr. [Name Redacted] the day prior, and changed him (resident) to 5 mg of oxycodone every 4 hours as needed and 50 mg of Tramadol every 6 hours as needed. The facility had not received the Tramadol yet. The order was then put back in for the 5-10 mg of oxycodone every 4 hours as needed. The Progress Note further revealed unsure where order came from, but NP adjusted it back to the 5 mg of Oxycodone every 4 hours as needed and sent in the script for the Tramadol order. Per the Progress Note, the resident needed to wean off the oxy before discharge. On 2/14/26, Oxycodone 5 mg and Tramadol 50 mg were administered at the following times, with the corresponding pain assessment score documented from 0 to 10 on the MAR:a.12:01 a.m., pain score 8 (Oxycodone 5 mg administered)b. 1:29 a.m., pain score 7 (Tramadol 50 mg administered)c. 5:00 a.m., pain score 8 (Oxycodone 5 mg administered)d. 9:48 a.m., pain score 6 (Tramadol 50 mg administered)e. 2:59 p.m., pain score 8 (Oxycodone 5 mg administered)f. 7:38 p.m., pain score 8 (Tramadol 50 mg administered)g. 9:54 p.m., pain score 7 (Oxycodone 5 mg administered)On 2/15/26, Oxycodone 5 mg and Tramadol 50 mg were administered at the following times, with the corresponding pain assessment score documented from 0 to 10 on the MAR: a. 2:52 a.m., pain score 8 (Tramadol 50 mg administered)b.8:29 a.m., pain score 7 (Oxycodone 5 mg administered)c. 2:11 p.m., pain score 6 (Tramadol 50 mg administered)b. 8:47 p.m., pain score 7 (Oxycodone 5 mg administered, with Tylenol administered prior at 2:14 p.m.)On 2/16/26 at 3:15 a.m., Tramadol 50 mg was administered for a documented pain score of 10. A Patient Care Record from [City Redacted] Fire/EMS (Emergency Medical Services) for Resident #9 dated 2/16/26 detailed arrival to facility at 4:30 a.m. Per the Patient Care Record, the resident with complaints of back pain rated 10 on a 0 to 10 pain scale with 10, and the resident was transported to a hospital Emergency Room. Per the Narrative section, the patient appeared to be in a mild amount of stress due to pain in the back. The back pain was caused by a spinal fusion performed at [Name Redacted Hospital] approximately three weeks ago. The hospital Emergency Department [ED] Provider Note dated 2/16/26 revealed the resident was treated for acute bilateral low back pain with bilateral sciatica, pain rated at 10 out of 10 upon his arrival, and required medication administration that included:1. Robaxin 1000 mg given intravenous (IV) at 5:50 a.m.2. Tylenol 1000 mg oral at 5:51 a.m.3. Methylprednisolone (a steroid used for acute pain management) 40 mg IV at 5:53 a.m.4. Toradol (a very strong non opioid, non-steroidal anti-inflammatory drug or NSAID) 15 mg IV at 5:53 a.m.5. Zofran (a medication for nausea) 4 mg IV at 5:53 a.m.6. Dilaudid (a very strong opiate narcotic) 0.5 mg IV at 6:51 a.m.On 3/4/26 at 7:40 p.m., Resident #9's family member stated the facility staff were not good about giving the resident his pain medication as prescribed by the surgeon. Per the family member, the resident had to constantly ask, then wait. Resident #9's family member explained that made the pain worse and increased their (resident's) anxiety. Some of the nurses were good about getting his medication to him, but there was a couple, especially one on the night shift that didn't want to give him his pain medication. The family member explained they reported that to the facility and were told that the nurse had been fired. On 3/9/26 at 10:08 a.m., the resident stated he had a very difficult time getting the pain medication that his doctor ordered after his surgery. He had severe pain from the surgery, and Oxycodone 10 mg was ordered as often as every 4 hours. Per Resident #9, it did provide some relief but did not completely relieve his pain. The resident explained there was a nurse on the night shift (the resident identified Staff A by name) that would not give him his pain medication when he asked for it. He would sit in his wheelchair by the Nurse's Station, wait for her to get done with her work on the computer and ask her if he could have his medication. The resident explained she acted like she didn't see him or hear him. Resident #9 further explained he would continue to ask for it and she would tell him that it was too soon, or that he couldn't be in that much pain, and he would have to wait longer before she administered the medication. The last night he was there he had horrible pain, and they had reduced the amount of pain medication he could have. The resident explained his pain level had been at 10 for several hours and couldn't take it anymore, and wanted to go to the hospital. Resident #9 explained the nurse didn't call the doctor until 4:20 a.m., after he had already called 911 because the nurse hadn't called the doctor about his pain. They treated his pain in the emergency room and he did get relief from the medications that were given there.On 3/4/26 at 12:29 p.m. and during a follow up interview on 3/9/26, Staff A, Licensed Practical Nurse (LPN) stated she worked at the facility on the 6 p.m. to 6 a.m. night shift. On the evening of 2/15/26 the resident was asleep when she arrived for her shift and difficult to arouse. He woke up and wanted his Oxycodone shortly after she got there and she administered it. Staff A explained the resident usually asked for the medication every 4 hours, often earlier than when it could be administered. The resident complained of increased pain and it was not normal to have as much pain as what he said he had 2 weeks after surgery. Later that evening the resident requested the Oxycodone again, she checked his blood pressure (BP) to administer his diltiazem (heart and BP medication) at that time, his BP was 90 over something and she held the medication, also concerned about analgesic administration with low BP. She checked his BP again about a half hour later when he asked for pain medication again, his BP was lower, 86/63, and she instructed the resident she could not give the pain medication when his BP was that low. Staff A stated the resident reported severe pain of 10 at that time, and kept begging her to give his Oxycodone. Staff A stated she administered Tramadol to him at 3:15 a.m. against her better judgement, as his BP was low, the resident wanted his Oxycodone, said he couldn't take the pain anymore and wanted to go to the hospital. Staff A stated she tried to call the provider a couple of times that night, they didn't answer and she left a message. The resident asked if he could call 911 to go to the hospital, when the provider called her back the resident had already called 911 and the ambulance was on the way there. The resident was upset with her because he didn't understand what a time-consuming process it was to contact the provider and get an order for him to go to the hospital.On 3/4/26 at 10:28 a.m. Staff B, RN, stated the resident asked for pain medication early, before 4 hours since the last administration. She only gave the medication every 4 hours because given early, that set a precedent that made it worse for staff. On 2/10/26 he had a doctor appointment and transported by bus at 7:30 a.m. He last received the Oxycodone at 3:35 a.m. and she would not administer the medication 5 minutes too early, she did not administer any pain medication before he went to the appointment. On 3/4/26 at 5:02 p.m. Staff C, RN stated he worked on the 6 p.m. to 6 a.m. night shift, the resident had back surgery and was in a lot of pain, often complained of pain at 7 to 10 level and required Oxycodone 10 mg about every 4 hours. The resident could function when he received the analgesics, mobile in his wheelchair, but he had non-verbal signs of pain such as grimacing, guarding his back and slow body movements. Staff C was certain the resident had severe pain, he was not acting or drug-seeking. Staff C stated he was not aware of a time the resident's BP or pulse was low, or a contraindication to administer his analgesics when needed.On 3/4/26 at 3:18 p.m. Staff D, Certified Nursing Assistant (CNA), stated he worked the night shift assigned to the resident's hall. Per Staff D, the resident had a lot of pain and was often up during the night several times because of the pain. The night of 2/15/26 that ended 2/16/26, the resident complained of a lot of pain, said he couldn't take it anymore and wanted to go to the hospital. He heard Staff A tell the resident his BP was low and it was not safe to give him pain medicine, she had to call the doctor to get an order to send him to the hospital and the resident asked if he could call 911. To his recollection the resident had been up most of the night between 11 or 12 a.m. and 4 a.m. and it seemed like the resident had a lot of pain because he was unable to sleep or lay in bed that night.On 3/6/26 at 9:32 a.m., Staff F, Supervisor at the facility's physician provider group stated there were only 2 calls from the facility between 9 p.m. on 2/15/26 and 5 a.m. on 2/16/26. A call from the facility at 4:09 a.m. went to voicemail, but there was no message left. The second call was at 4:17 a.m., and the nurse spoke to the on-call provider. A note timed at 4:30 a.m. summarized the call and they directed the nurse to send the resident to the hospital for assessment of increased pain and low BP.On 3/9/26 at 12:41 p.m. Staff E, Office Manager stated she was responsible for transportation arrangements for medical appointments and had made the arrangements for the resident's appointment on 2/10/26. Staff E stated it could take as long as an hour after the appointment for the transport service to pick up the resident. Per Staff E, she had a few calls because he was at the wrong door and hadn't been picked up, and the resident called her about 20 minutes after his appointment, told her he had not been picked up. The resident said he was in a lot of pain/needed to get back to the facility to get his pain medication. On 3/4/26 at 11:03 a.m. the Director of Nursing (DON) stated the resident asked for pain medication every 4 hours and set an alarm clock so he woke up during the night to ask for it, and usually asked for it early before 4 hours was up. The DON explained she spoke to Staff A, LPN, about the resident's call to 911 and treatment in the emergency room on 2/16/26. Staff A stated in her professional opinion the resident was drug-seeking, he wasn't in that much pain, and due to that she didn't have to contact the MD about his pain or other symptoms. The DON stated that was unacceptable, it was the nurse's responsibility to notify the MD if a resident had increased complaints of pain, it was not consistent with their corporation's policy, and as a result Staff A was not allowed back to the facility. The DON stated she would have expected Staff B to assess the resident's pain before he left for the doctor appointment on 2/10/26, medications including narcotics could be administered up to an hour early per their company policy and it was not acceptable to send the resident to the doctor's office without pain management provided. During another interview on 3/5/26 at 10:06 a.m. the DON stated the nurse should have notified the doctor when the resident had complaints of increased pain and she wasn't comfortable giving the analgesic due to low BP, and should have contacted the doctor when his BP was under 90 for further directions. On 3/5/26 at 10:45 a.m. the facility's NP stated staff should report a resident's increased pain or unrelieved pain at the time that it occurred. She further explained should notify the provider if medications were withheld due to altered vital signs and cause for other concern at that time, unless parameters were specified.On 3/12/26 at 1:43 p.m. Staff G, RN at the resident's neurosurgeon's office stated staff at the facility did not want to administer his medication as ordered, and they sent a note the resident had a complicated spinal surgery that required the installation of hardware around the resident's spine that made the resident 1 and 1/2 inches taller as a result after the surgery. The resident had severe pain after the surgery, that was normal and was expected for several weeks. She called the facility several times to instruct the nursing staff that the resident needed to have his pain medication, because the resident called her nearly daily, in severe pain and told her that the staff wouldn't give him his pain medication. One call was 25 minutes long, she spoke to nursing staff and the Director of Nursing about the issue. She saw the resident in the office on 2/10/26, he was in excruciating pain because he had not had anything for pain for several hours, and the provider sent orders to the facility that directed them to give his pain medication as ordered. Staff G stated the facility had not contacted their office about reducing his pain medication, the neurosurgeon was the physician of record and the facility should have consulted with them about his pain management if there were concerns.On 3/9/26 at 2:30 p.m., the facility's Administrator stated she was not sure and would have to check when asked if the resident's pain had been addressed by their IDT (interdisciplinary team) team, as directed in their pain management policy. During another interview on 3/10/26 at 3:23 p.m., the Administrator stated the resident's pain had been addressed by the IDT team, the recommendation was the resident be assessed by their provider, and did not provide the date his pain was addressed at their meeting. The facility's Pain Quick Reference Guide, dated as last reviewed March 2025 and provided as their pain management policy directed staff: 1. If pain is 5 or greater 2 times in a 7-day period, or a single episode of 10, report to medical practitioner for possible treatment adjustment and review during IDT meeting process.2. Goals: Improve quality of life, increase function and mobility, reduce the degree to which pain interferes with activities, relieve psychological stressors and minimize risk of opioid misuse, abuse and addiction.3. Staff to:a. Advocate pain management for residentsb. Avoid labeling and judging residentsc. Treat pain early as delays can make pain more difficult to control

Based on staff interviews, facility record review and facility policy review the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in repeated deficiencies cited on the current survey that were cited in previous surveys. The facility reported a census of 57 residents.Findings include: The Centers for Medicare and Medicaid Services (CMS) 2567 form dated 10/24/24 reflected deficiencies identified for the QAPI program (F865), and infection control (F880) . The current survey conduction 1/5/26 though 1/14/26 also identified the above concerns. In an interview on 1/12/26 at 3:52 PM, the Administrator reported that the Infection Preventionist developed interventions for the past deficiency of F880. A review of the interventions which the Infection Preventionist implemented included, in part, the following: Medication Pass Audits which include watching hand washing, blood sugar checks, cleaning of the glucometers, Insulin administration, eye drops and inhalers. Treatment Audits which include hand washing, barrier technique, changing of gloves after removing old dressing and applying new dressing. Also includes EBP (Enhanced Barrier Precautions). A review of the facility's QAPI Plan dated 10/23/25 had documentation of the following: The QAPI Plan addresses the element of systemic analysis and systemic action using the following processes and systems: root cause analysis, use of a continuous cycle to evaluate the effectiveness or performance improvement initiatives, communication of performance improvement project efforts and re-evaluation of the center's QAPI Plan annually.

Based on observation, record review and staff interviews, the facility failed to don isolation gowns while providing cares to two of three residents in Enhanced Barrier Precautions (Resident #5 and Resident #35). The facility also failed to use proper hand sanitation during an observation of a Medication Pass on 1/7/26. The facility reported a census of 57 residents. Findings included:1.The Minimum Data Set (MDS) dated [DATE] identified Resident #5 as cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 03 out of 15. The MDS also identified Resident #5 as always incontinent of urine and bowel, and had one Stage IV pressure ulcer and one unstageable pressure ulcer. Observations of Resident #5 revealed the following: On 1/5/26 at 10:39 AM, the resident was asleep in bed, covered with a bath blanket from waist to feet. On Resident #5's door there was a caddy for PPE (Personal Protective Equipment ) and a sign for Enhanced Barrier Precautions (EBP). On 1/7/26 at 1:55 PM, Staff E, CNA (Certified Nursing Assistant)/CMA (Certified Medication Aide) and Staff C, RN (Registered Nurse) both entered room, donned gloves, however, did not don isolation gowns. At 1:57 PM, neither staff member donned an isolation gown before removing the blanket and unfastening incontinent brief. At 1:58 PM, neither staff member donned an isolation gown before they repositioned Resident #5 up in bed. At 1:59 PM, Staff E removed her gloves and washed her hands then used Alcohol Hand Rub ( AHR) and donned new gloves, however did not don an isolation gown before she cleansed the resident's perineal area. At 2:02 PM, Staff E did not don an isolation gown before she turned resident to lie on her right side. At 2:03 PM, Staff C removed her gloves, used AHR, and donned new gloves. At 2:04 PM, Staff C removed her gloves, washed her hands and donned new gloves, however she did not don an isolation gown before she cleansed the pressure ulcer. At 2:07 PM, Staff C then removed her gloves, washed hands and opened up the foam dressing. She donned new gloves, however neither Staff C or Staff E donned isolation gowns for the remainder of the wound care. In an interview on 1/12/26 at 1:14 PM, Staff E, CNA reported she thought the type of isolation Resident #5 should be in would be precautions. She also reported before providing cares for Resident #5, staff should wear a mask, isolation gown and gloves. When she provided cares on Resident #5 on 1/7/26, she admitted she did not don an isolation gown during cares. She usually did not work that hallway. She also reported she would know a resident is on EBP if there was a sign posted on the door. In an interview on 1/12/26 at 1:25 PM, Staff C, RN reported Resident #5 should be in contact isolation and staff need to don isolation gowns and gloves when providing cares. She also reported Resident #5's room did have a caddy for PPE with a sign on her door. When she and Staff E provided cares for her on 1/7/26, she verified they both forgot to don isolation gowns. Staff C acknowledged it was an oversight on her part. 2. The MDS dated [DATE] identified Resident #35 as cognitively impaired with a BIMS score of 9 out of 15. The MDS also identified Resident #35 had an indwelling urinary catheter, incontinent of bowel frequently, and had one unstageable (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer. An observation of Foley (catheter) and incontinence care revealed the following on 1/7/26 at the following times: At 9:12 AM, Staff B, CNA entered room to assist Staff D, CNA. Staff D did not don an isolation gown before she provided cares after Resident #35 was incontinent of BM (bowel movement). There were sheets soiled with BM on the floor beside the bed. Staff B left the room to obtain more clean towels and cloths. At 9:14 AM Staff D, did not don an isolation gown before she used disposable wipes to cleanse Resident #35's groin. At 9:15 AM, Staff B returned to room and wore a face shield, isolation gown and gloves. Staff D did not don an isolation gown. After she removed her gloves, Staff B did not use hand sanitizer or wash her hands before she donned new gloves. Staff D pulled the incontinent brief into place with BM still noted on the brief. When asked to recheck the brief, Staff D pulled it back and noted BM still on the brief and reported he constantly oozes BM. At 9:18 AM, Staff B removed the soiled brief and placed it in a plastic bag, removed her gloves, used AHR and donned new gloves. and removed fitted sheet and placed new sheet underneath the resident. At 9:20 AM after Staff B changed the linens on the bed, Staff D did not don an isolation gown before she assisted Resident #35 to turn to his side. At 9:24 AM, Staff D placed the soiled sheets in a plastic bag in trash can, removed her gloves, however, she did not wash hands or use AHR before she donned new gloves. Then both aides secured the brief into place. At 9:26 AM Staff D removed her gloves, did not use AHR or wash her hands before she donned new gloves. She did not don an isolation gown before she handled soiled linens and gown and placed all in a plastic bag. In an interview on 1/7/26 at 1:26 PM, Staff D, CNA reported when providing cares to a resident with pressure ulcers or a urinary catheter, staff should wear an isolation gown and gloves. When she provided cares today on Resident #35, she did not don an isolation gown and could not remember why. She admitted she placed the linens with BM on the floor when she should have placed them in a plastic bag. She reported she did see BM on his bottom when she went to secure his brief into place but he was constantly oozing BM. She admitted she should have made sure to clean it all off completely as his pressure sores could become infected. In an interview on 1/7/26 at 1:42 PM, Staff B, CNA reported residents with pressure ulcers or an indwelling catheter should be placed in Enhanced Barrier Precautions and staff should don an isolation gown, gloves and face mask when providing cares. She also reported when she walked into Resident #35's room on 1/7/26 she did see linens on the floor that were soiled with BM and they should have been placed in a plastic bag. When she assisted Staff D with incontinence cares, she verified there was still BM on the brief after Staff D had placed it on him, however he is constantly oozing BM all the time. Staff B explained should try to make sure to clean off the BM off the wounds to his bottom as it can worsen the wounds, or he can develop new wounds or get an infection. In an interview on 1/13/26 at 2:31 PM, the Director of Nursing (DON) reported Residents #5 should be placed in Enhanced Barrier Precautions and she would expect the staff to don gloves, gown and mask when providing cares. She also verified had a PPE caddy, however was unsure if had a sign on the door. A review of the Facility Policy titled: Enhanced Barrier Precautions dated as last revised March 2024 revealed, in part, the following: For residents whom EBP are indicate; gowns and gloves should be used during high contact resident care activities that provide opportunity for MDROs (Multi-Drug Resistant Organisms) to be transferred to staff hands and clothing. High contact resident care activities include: Dressing, Bathing/Showering , Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use urinary catheter .Wounds care: any skin opening requiring a dressing 3. On 1/7/26 at 7:23 AM during observation of medication administration Staff F, RN administered eye drops to Resident # 30 and did not wash hands before or after she administered medication. She then pushed another resident to the dining room and came back to the medication cart. Staff F, RN did a blood sugar on resident and did not wash hands or use hand sanitizer. On 1/7/26 at 7:35 AM Staff F, RN completed a blood sugar on Resident #3 and did not wash hands or use hand sanitizer. She drew up the residents insulin and administered it and then sanitized hands after she administered the medication. On 1/07/26 at 3:22 PM Staff C, RN stated with medication pass you should wash hands between each resident. She also indicated before checking a residents blood sugar you should wash hands or use hand sanitizer in between residents. On 1/08/26 at 12:52 PM the DON stated when staff are doing medication pass they should use hand sanitizer in between residents. She would expect stuff to do the same thing before or after blood sugars, and to use gloves while obtaining the blood sugar and then sanitize hands and change gloves between residents. The facility provided the Infection Control Practice Guide, revised 9/2023, which revealed, Hand hygiene has been proven to reduce the risk of infections.

Based on observation, record review, resident and staff interviews, the facility failed to ensure dignity was maintained for one of four residents observed during cares (Resident #35). The facility reported a census of 57 residents. Findings include: The MDS dated [DATE] identified Resident #35 as moderately cognitively impaired with a BIMS score of 9 out of 15. The MDS also identified Resident #35 had an indwelling urinary catheter and was incontinent of bowel frequently. The Care Plan initiated 10/7/25 identified Resident #35 required assistance with activities of daily living. In an observation of incontinence care on 1/7/26 at 9:22 AM, the Facility Nurse Practitioner entered the room without knocking on the door and asked CNAs (Staff B, CNA and Staff D, CNA) to help her in a different room when they were finished. When she entered the room, the privacy curtain was not pulled around the bed and Resident #35 was not covered with a sheet when she entered. The resident's gown was pulled up above his waist, exposing his lower abdomen and groin area. In an interview on 1/7/26 at 1:26 PM, Staff D, CNA reported before entering a resident's room, staff should knock on the door first, wait for staff in the room to say resident care, ok to come in. When providing cares on Resident #35 on 1/7/26, she verified she didn't think she heard the Nurse Practitioner knock on the door before she walked into the room during cares. In an interview on 1/7/26 at 1:42 PM, Staff B, CNA reported before any staff enters a resident's room, they should knock on the door first. She also verified the Nurse Practitioner did not knock on the door before she came in when she provided cares on Resident #35 on 1/7/26. In an interview on 1/12/26 at 1:25 PM, Staff C, RN reported before entering a resident's room, staff should knock on the door first. In an interview on 1/13/26 at 2:31 PM, the interim DON (Director of Nursing) reported when staff are ready to enter a resident's room when the door is closed, she would expect them to knock on the door first, if the staff says cares and wait for staff to say it would be alright to enter. A review of the Facility Policy titled: Resident Rights - Dignity and Respect dated as last reviewed April 2024 revealed, 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, police reports, interviews, facility investigation documentation, and policy review the facility failed to protect residents from being taken advantage of financially for 2 of 3 residents reviewed (Residents #2 and Resident #11). An employee took one resident's bank card information and paid personal bills with it, and accepted $25 from another resident. The facility reported a census of 57 residents.Findings include:1. The Minimum Data Set (MDS) for Resident #2 dated 11/26/25 documented diagnoses of amputation, cancer, depression, and malnutrition. The resident scored 15/15 on the Brief Interview for Mental Status (BIMS) assessment which indicated intact cognition.On 1/05/26 at 3:06 PM observed Resident #2 in his bed and talking with his [family member] who was seated in a chair near the foot of the bed. The resident's phone rested on his chest, and it had an attached sleeve on the back to hold cards. He pointed to it and slipped his identification out to show how it worked. His debit card was under the phone on his chest. He confirmed that was the bank card information that was stolen. At this time Resident #2 and his [family member] were interviewed together. The resident's [family member] stated while reviewing their bank statement she noticed charges she did not believe were theirs. She learned one was to a water company in another state and one to an electric company. She noted a third attempted charge for $330 was declined by the bank. Resident #2 added that his phone and cards were with him unless he was sleeping, and he thought someone must have removed the bank card or copied the numbers while he slept. His [family member] said the water department provided her with a last name for the billed account. The electric company would not provide information. She reported this information to the police and told the nursing home administrator about the report so they knew an officer was coming to talk to Resident #2. The administrator told her they would start an internal investigation at that time. Resident #2 stated the officer interviewed him for 30-45 minutes and he thought the investigation was ongoing. Review of a Concern Form dated 12/11/25 and Investigation Summary provided by the facility indicated the last name given by the water company matched that of a Certified Nurses Aide (CNA), Staff K, who worked in the facility the day of the charges. The follow up included suspension of the CNA and interviews with other residents. The interview process determined that a second resident gave Staff K $25.00 in cash.A document titled Daily Schedule dated 12/8/25 documented Staff K was a CNA in the facility on that day.A police report dated 12/11/25 at 7:58 PM documented the unauthorized use of Resident #2's card on 12/8/25 with a total loss estimated at $297. It documented the resident did not give anyone permission to use his card and identified a facility CNA who worked the day of the charges had the same last name as the accounts charged. It included an address and and invoice number tied to the water department billing. The last 4 numbers of the card used matched the last 4 numbers of the resident's card.The address listed in the police report as part of the water department billing invoice was determined to be a business address. On 1/7/26 at 2:56 PM the human resources department of that business revealed Staff K was a former employee. They were not aware she was using their address for any purpose.On 1/7/26 at 3:32 PM the city manager for the water department verified that the name, home address, phone number, and account number paid with Resident #2's card belonged to Staff K.2. The MDS for Resident #11 dated 10/29/25 documented diagnoses of Parkinson's disease, non-Alzheimer's dementia, depression, and anxiety. The resident scored 15/15 on the BIMS assessment which indicated intact cognition.During an interview on 1/8/26 at 8:44 AM Resident #11 confirmed he gave Staff K $25.00. He reported Staff K told him she went to the bathroom and someone stole her bank card while she was in there. He stated he gave it directly to her for a cab ride home. He denied putting it in a Christmas card and repeated that he just gave it to her. He indicated she didn't ask for it but implied she needed money to get home. A document titled Course Completion History indicated Staff K attended abuse and resident rights related trainings on 10/27/24, 11/14/24, and 6/30/25.During an interview with Staff K on 1/7/26 at 12:28 PM she stated she was terminated from the facility because she was told she stole from one resident (Resident #2) and took money from another. She denied stealing a bank card or banking information. Staff K stated that was stupid and who would do something like that. She reported she did tell Resident #11 that someone stole her money out of the break room, and said he gave her a Christmas card with money in it. Staff K said she did not tell anyone about the money or bring it back, and that if that was taking money from a resident 'I guess I did.'On 1/8/26 at 2:42 PM the Administrator reported she led the investigation into the theft from Resident #2 which led to learning about Staff K accepting money from Resident #11. Once she learned of the charges to Resident #2's card, she determined Staff K was in the building and immediately pulled her from the floor. Staff K was interviewed and denied responsibility for the charges. She was escorted out of the building and suspended pending investigation. At the resident's request the Administrator witnessed the interview with the police officer. She reported the water company gave some information but the electric company would not. The Administrator directed the facility Assistant Directors of Nursing (ADON) to interview their residents to determine if there were any other victims. Resident #11 told them he did not want to get Staff K in trouble but he felt bad for her and she said she needed money. The Administrator stated she reassured the resident that his safety was more important and the facility reimbursed him. She provided documentation that staff were educated about not accepting gifts or money from residents, and reinforced policy. A policy titled Patient Protection Guidelines Abuse Prevention, Reporting, and Investigation revised 9/25 documented exploitation as taking advantage of a patient for personal gain through the use of manipulation, intimidation, threats, or coercion. Misappropriation of resident property included the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a patient's belongings or money without the patient's consent. Training included recognizing signs of exploitation and misappropriation of resident property and how to report suspicions or allegations.

Based on observation, clinical record review, staff and resident interviews, and policy review the facility failed to ensure residents received care and services that allowed for a dignified existence and communication with friends and family for 3 of 4 residents reviewed for resident rights (Residents #1, #2, and #3). Resident #1 was left in the dining room leaning sideways in her wheelchair and spoken to disrespectfully by staff, Resident #2 reported being incontinent waiting for a call light to be answered, and Resident #3 was denied phone calls with family. The facility reported a census of 47 residents.Findings include: 1. The Minimum Data Set (MDS) for Resident #1 dated 8/20/25 documented diagnoses of pneumonia, Multiple Sclerosis (MS), Chronic Obstructive Pulmonary Disease (COPD), and Post Traumatic Stress Disorder (PTSD). The Brief Interview for Mental Status (BIMS) score totaled 14/15 which indicated intact cognition.The Care Plan (CP) for the resident with an admission date of 10/4/24 indicated she agreed to sit at an assisted table in the dining room for all 3 meals. She required assistance of 2 staff and a lift for transfers and used a custom tilt and space wheelchair with lateral supports, a head rest, and roho cushion. The CP directed staff that if the resident was leaning she should be repositioned in the wheelchair and to tilt the chair. If she continued to lean hard to left she needed to be laid down in bed secondary to her declining postural control.A document titled Physical Therapy Discharge Summary signed on 9/4/25 included the following discharge recommendations: Reposition frequently in the wheelchair and offer to tilt in space. If Resident #1 was falling over to the left side of the chair, staff needed to lay her down.During an observation on 11/13/25 at 12:38 PM Resident #1 was sitting alone at a table near the dining room door leaning over the left side of her chair. She appeared unable to reach her food. The nurses station was in view of the resident. At 12:46 PM Resident #1 was observed in the same position. Her right hand was holding the edge of the table, her knuckles white. Her right arm was sitting on a pillow. Her left arm was hanging over the side of her wheelchair with her hand grasping the wheel. Her body was leaning far to the left with her head below the level of the arm of the chair. Her right foot was on a pedal and her left foot was between the two pedals. She attempted to lift her foot up and was unable to. Two dining staff were present cleaning tables and did not assist or find a Certified Nurses Aide (CNA) to assist. At 12:52 PM Resident #1 was able to lift her head enough to get a cup and straw to her mouth for a drink. She was unable lift her body higher and put the cup back down. At 12:56 PM Resident #1 was observed using her right hand on the table and left hand on the wheel of her wheelchair to try to rock the chair back from the table. At that time she did not have the strength to do so. At 12:58 PM a CNA came in the dining room and spoke to the resident. She asked her why she moved her pillow and said that was why she was leaning over. The CNA asked again why the resident moved the pillow, said don't do that, asked the resident how she thought she could sit up without it, and asked the resident what she thought she was doing. After the CNA repositioned the pillow she firmly told the resident not to do that again and wheeled her out of the dining room.At 12:48 PM on 11/13/25 Staff A, Dietary was asked if Resident #1 usually sat alone. She stated a resident usually sat at the table with her but not staff.Interview with Resident #1 on 11/13/25 at 3:44 PM revealed she leaned to the left a lot due to her diagnosis of MS. She was observed sitting in her recliner leaning to her left with no pillow propped under her left side for support. Her call light was on her bed and not in reach. When asked how she would get help she indicated that she 'would be screaming.' She reported that she was not left like that in the dining room a lot but it had happened before. Resident #1 indicated that some staff got on her if the pillow moved but she couldn't help it. She stated she hated her wheelchair because it did not provide enough support for her and staff were supposed to keep her propped with pillows.During an interview on 11/13/25 at 4:11 PM the Director of Nursing (DON) stated she expected staff to give residents their call light buttons wherever they were in their room and staff were frequently educated and reminded about call lights. She expected staff to know what positioning requirements were needed for Resident #1 because it was on the kardex they used for care and the information came directly from the care plan. She confirmed both facility and agency staff had access to that information. She stated the resident's provider and insurance were aware of the resident's concerns about the wheelchair and that the resident's posture control continued to decline. She confirmed that the resident would be unable to sit herself up on her own or prop herself up independently with the pillow. 2. The MDS for Resident #2 dated 8/27/25 documented diagnoses of anxiety and depression, constipation, osteoarthritis, and repeated falls. The BIMS assessment was 14/15 which indicated intact cognition.The CP for the resident with an admission date of 5/21/25 indicated she required contact guard assist of 1 staff and a 4 wheel walker for transfers and ambulation to the bathroom. Staff were directed to allow time to complete the task. The resident was documented as at risk for falls and experienced chronic pain related to arthritis.An interview with Resident #2 on 11/13/25 at 1:09 PM revealed she felt able to make her needs known but had to get to the right person. At the time of the interview she had her call light on waiting for a CNA to help her use the bathroom. She mentioned she dealt with long call lights and within the past two days had an incontinence episode that wet through to her pants. The resident reported she left the building at 7:30 AM this morning for an appointment and came back around 12:30 to find her bed had not been made, and indicated this happened often. She stated she did not feel staff respected her schedule and gave the example that staff made her get in bed between 9:00 PM and 9:15 PM even if she wanted to stay up. Resident #2 said she was a grown woman and should be able to make that decision for herself. She reported incidents like these made her feel disrespected and wondered about residents who could not speak for themselves.An interview with Staff C, CNA on 11/13/25 at 2:44 PM confirmed that the resident was incontinent waiting for a call light. She stated that when she arrived for her shift that day the resident was very upset. Staff C confirmed call lights were expected to be answered within 15 minutes and speaking for herself did the best she could to meet that goal. She had heard complaints here and there from other residents as well.On 11/13/25 at 2:55 PM Staff E, Licensed Practical Nurse (LPN) stated that she heard complaints about call lights almost every day.During an interview on 11/13/25 at 4:11 PM the Director of Nursing (DON) stated she expected staff to answer call lights in 15 minutes or less and frequently educated and reminded staff about call lights. She had heard complaints about all shifts, lights longer than 15 minutes, and reviewed call light procedure forms with staff when there was a complaint. She reported that questions about call lights and personal care were addressed with staff as early as the interview process. 3. The MDS for Resident #3 dated 8/9/25 documented diagnoses of anxiety, depressive episodes, and syncope and collapse. The BIMS assessment was 10/15 which indicated moderate cognitive impairment.A Social Service Note dated 11/6/25 at 12:33 PM indicated the resident scored 14/15 on the BIMS which indicated intact cognition.The CP for the resident with an admission date of 1/18/20 indicated she was at risk for changes in mood related to anxiety and depression, and was on medication for depression. A focus area regarding discharge indicated the resident was unable to discharge to the community and directed staff to support the resident, family, and representatives as needed.An interview with Resident #3 on 11/13/25 at 12:59 PM revealed family visits and phone calls were very important to her. The resident reported a family member told her more than once that she tried to call the resident on the facility phone but had not been able to talk to her. Another family member reported not being able to speak to the resident by phone for 2 weeks in spite of repeat calls, mostly in the evening. Staff told the family member the resident was eating or sleeping and could not come to the phone. The resident stated if that family member called for her, no one told her and she would have taken the call. When asked if she called her family, Resident #3 stated no one had ever told her she could use the facility phone to do that.On 11/13/25 at 2:14 PM Staff B, Office Manager stated that until 8:00 PM all calls came through one line and after that when directly to the nurses stations. To get calls to residents the caller would be placed on hold. The calls were announced on the speaker system. There were 2 cordless phones at each nurses station and any staff should take the phone to the resident, take it off of hold, and let the resident talk in private. Otherwise residents could be brought to the nurses station if they wished. If a resident was eating or sleeping her process was to tell the caller and let them decide if they wanted to wake them or interrupt their meal, call back, or have the resident call them when they were done. When asked if residents were always given a choice about whether or not to take the call, Staff B stated it depended on if the caller was the Power of Attorney.On 11/13/25 at 2:55 PM Staff E, LPN stated 99 percent of the time residents took calls from loved ones if they knew they were on the phone.On 11/13/25 at 4:37 PM the Administrator stated she had only been there a month and was not aware of concerns about family calls getting through. She expected all staff to be responsible for ensuring residents could speak with their loved ones.A policy titled Resident Rights - Dignity and Respect revised 4/2024 documented the purpose of the policy was to lay the foundation for treating all residents with dignity and respect and maintaining and enhancing his or her self-esteem and self-worth. Residents had 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. Residents also had the right to be free from involuntary seclusion, to manage their own care, to have access to visitors, and the right to exercise his/her rights of the facility as a citizen/resident of the United States.

Based on clinical record reviews, staff and resident interviews, policy review, and observations the facility failed to notify a resident's physician of a change in condition in a timely manor for 1 of 6 residents reviewed (Resident #6). The facility reported a census of 59 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #6 had diagnoses which included fractured left femur neck, Parkinson's disease, and sepsis. The MDS revealed the resident had a Brief Interview for Mental Status score of 11, which revealed the resident had moderate cognitive impairment and may need extra help for daily tasks. The resident had a history of falls. The resident required supervision or touch assistance with transfers and partial to moderate assistance with walking. Review of the resident's Care Plan dated 12/10/23 directed the staff to assist the resident with ambulation and transfers as needed and on 3/27/2024 the Care Plan directed the staff to place a sign in the resident's room to remind him to use his call light. Review of the Nurses Progress Notes dated 1/16/25 at 5:49 pm the staff found the resident lying on the floor of his room, next to his roommates bed, complaining of left hip pain. The resident complained of his hip hurting and rated the pain as 3 on a scale of 0-10. The nurse called the on-call provider at 6:35 pm and gave a status report. The on-call provider ordered a mobile x-ray of the resident's left hip. The Nurse's Progress Notes revealed the mobile x-ray unit arrived at the facility at 11:00 pm and completed the ordered x-ray. The results of the x-ray were printed off and placed on the Primary Care Providers desk in the facility at 3:00 am for her to review on rounds the morning of 1/17/25. Review of the portable x-ray report dated 1/17/25 indicated Resident #6 had an acute mildly displaced subcapital left femoral neck fracture. During an interview with Staff B-RN on 1/29/25 at 12:15 pm, Staff B stated she was the Primary Nurse responsible for Resident #6 on 1/16-1/17 am. She reported he fell at change of shift on 1/16 at approximately 6:00 pm. On initial assessment he denied pain but at about 7:30-8:00 pm he complained of pain in his left hip. The nurse called the on-call provider to report the fall with pain. An x-ray was ordered and obtained at 11:00 pm. The facility received a phone call from the mobile x-ray provider between 1:30 and 2:00 am on 1/17/25 directing them to refer to the residents electronic health record. Staff B-RN stated at about 3:00 am they read the results and noted the resident had a fractured left hip. The resident was sleeping at the time so she decided to copy the results and placed them on the Nurse Practitioner desk to review when she came in that morning. Staff B stated she received a 1:1 In-service re-education from the Assistant Director of Nurses as directed by the Administrator. She stated she should have called the on-call physician when she noted the results of the fractured hip as soon as she read the results. Review of the One on One In-service Record dated 1/17/25, stated that on 1/16/25, Staff B-RN received an x-ray report on a patient which showed a fractured left hip. Staff B re-educated when she receives an x-ray report or critical lab result and its after hours, Staff B must call and report the findings to the on-call provider and not to wait until the following day. During an interview with Staff D-Administrator on 1/29/25 at 11:03 am. Staff D stated she did the investigation regarding the fall. She became aware the staff failed to call the provider with the fractured hip report. Staff D stated the staff should have called the provider immediately upon learning of the resident's fractured left hip. During an interview 1/29/25 at 11:35 am with Resident #6's Nurse Practitioner regarding the fractured hip the resident sustained on 1/16/25 fall. The on-call provider working the evening of 1/16 ordered a portable x-ray which was completed at 11:00 pm. The results returned to the facility on [DATE] around 3:00 am but the staff failed to call the on-call provider to report the findings. The Nurse Practitioner would have expected the staff to call the on-call provider to alert them of the resident's fractured hip and not to wait until the next morning when she was expected to make rounds to review the results. Hospital records dated 1/17/25 revealed the resident arrived at the emergency room with a diagnosis of left hip fracture. The resident underwent surgical repair of the left hip and returned to the facility on [DATE]. Review of a Notification of Change of Condition policy dated June 2023 directed the facility staff they must immediately consult with the resident's physician when an accident occurs which result in an injury and has potential for requiring physician intervention, a change in the resident's condition, a need to alter treatments or a decision to transfer or discharge a resident.

Based on Payroll Based Journal (PBJ) Data, schedule review, and staff interview the facility failed to submit complete and accurate payroll data to CMS during the third quarter of the 2024 fiscal year. The facility reported a census of 52 residents. Findings include: A document titled PBJ Staffing Data Report for Fiscal Year 2024 Quarter 3 (April 1-June 30) documented the facility triggered for excessively low weekend staffing. On 10/22/24 at 8:12 PM the Administrator stated she became aware there was an issue with the PBJ data the day before. She had already reached out to their main office for a report of what was submitted and to try to learn what caused the facility to trigger for low staffing. She reported they were the ones who submitted PBJ data for the facility, and she was not aware of any days with excessively low staff. On 10/23/24 the Administrator provided paper copies of staff schedules for the months of April, May, and June. They documented hours worked by nurses, certified medication aides, and certified nursing aides for three shifts each day and included staff who called off or did not show for their shift. The documentation included both facility and agency staff. On 10/24/24 at 10:17 AM the Administrator reported she had not received an email response with the report, apologized, and said she would have to try to reach someone again.

Based on observation, staff interview, and record review the facility failed to label and date food appropriately to prevent a food borne illness during initial tour of the kitchen. The facility failed to serve food in a way that prevents food borne illness for 1 out of 1 meals observed. The facility reported a census of 52 residents. Findings include: 1. ) During the initial tour of the kitchen on 10/21/24 at 9:20 AM the following items were observed in a refrigerator across from the stove not labeled or dated: - meat sandwiches - tater tot casserole - sliced cheese open to air in original package - sliced cheese and bologna stored together in a plastic container - tomato juice in a pitcher - box of bacon open to air and not dated - large container of strawberries - large container of barbeque pork During an interview on 10/21/24 at 9:45 AM Staff D, cook, stated everything should be labeled and a use by date on it that is stored in the refrigerator. On 10/21/24 at 9:50 AM the dietary manager stated the items would need to be tossed because no date on them. She said all food should be labeled and dated when opened and stored in the refrigerator. The facility provided a policy titled: Labeling and Dating, with a revision date of 12/2023 it directed staff 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 manufacturers expiration date. 2.) During a continuous meal observation on 10/22/24 from 11:29 AM to 12:40 PM Staff D, cook, during meal service used her gloved hands to touch the quiche and cake she was serving to residents on plates. She changed her gloves multiple times but would touch the counter, the lids to serving pans, and the serving utensils then would use a spatula to scoop up the cake or quiche and use her other gloved hand to remove them from the spatula onto the plate. During an interview on 10/23/24 at 10:54 AM Staff D, stated she does have the Serve Safe certificate for food handling. She stated she should not have used her gloves to touch the food during meal service. I am supposed to use tongs or other utensils to serve the food. On 10/23/24 at 1:21 PM the Dietary Manager discussed the cooks practice of food handling the prior day at lunch and she stated she noticed how she served the food - not proper food handling. She stated she even attempted to hand her tongs and she did not use them correctly. The changing of the gloves and touching all the food is not correct food handling, she should have used the tongs. I would expect her to use tongs and utensils and not touch the food. The facility provided a policy titled: Food Handling, with a revision date of 10/23 it directed Purpose: To adhere to the food safety standards described in the local Food Code and as per Center for Medicare Services (CMS) food safety standards for long-term care Procedures: 1. Employees must perform hand hygiene prior to handling food and maintain safe food handling practices. 2. Employees wear approved hair restraints and clean uniforms. 3. Ready-to-eat food must not be touched with bare hands.

Based on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies forms, the facility Quality Assessment and Performance Improvement (QAPI) Plan, and staff interview the facility failed to carry out Quality Assurance (QA) activities to ensure effective measures had been taken to correct deficiencies and prevent their ongoing prevalence. The facility reported a census of 52 residents. Findings include: The CMS 2567, dated 10/20/22 listed, in part, the following concerns: F880 The CMS 2567, dated 11/07/23 listed, in part, the following concerns: F677, F812 The current survey, conducted 10/21/24-10/24/24 also identified the above concerns. In an interview on 10/24/24 at 10:48 AM the Administrator explained the QAPI Committee monitors improvement projects for 4-6 weeks depending on what the issue is. After that, they review things monthly and then every other month if there is consistency. She acknowledged she was not aware of the repeat deficiencies. The facility policy titled QAPI Plan, updated 8/16/24 instructed the following: The QAPI Committee is responsible and accountable for: 1. Identifying and prioritizing problems based on performance indicator data; 2. Including patient, patient representative, and staff input into the process; 3. Ensuring corrective actions are effective; 4. Analyzing QAPI program performance to identify and follow up on areas of concern or opportunities for improvement. Method of Monitoring Multiple Data Sources: Regulatory outcomes are monitored and trended at the center level. Regulatory outcomes include licensure survey results, certification survey results, life safety survey results, complaint survey results, and additional focused survey results. The QAPI Committee directs these activities and reviews these data sources for the identification of trends, comparison to available benchmarks, and identifying and monitoring additional performance improvement projects (PIP) needed. Identifying Change as an Improvement: Areas of opportunity identified in the QAPI Assessments are corrected through the PIP. Completion of the Investigation stage and review of those findings should demonstrate that process improvement initiative implemented in the initial stage have been sustained and the focus area has not been re-identified in the investigation stage.

Based on clinical record review, observation, staff interview, and facility policy review the facility failed to maintain proper infection control practices to prevent cross contamination and potential infection of residents. During medication administration staff touched medication with their bare hands. While in community areas of the building Resident #3's catheter dignity bag and tubing dragged on the floor. The facility reported a census of 52 residents. Findings include: 1. The Minimum Data Set for Resident #3, dated 9/16/24, documented diagnoses of cancer, obstructive uropathy, and non-Alzheimer's dementia. The Brief Interview for Mental Status Assessment revealed a score of 10, which indicated moderately impaired cognition. Resident #3's Care Plan, with a focus area dated 5/30/24, indicated the resident required the use of an indwelling Foley catheter related to urinary retention due to obstructive uropathy. A goal with the same date was to remain free of complications related to catheter use. Interventions also dated 5/30/24 documented the use of a catheter securement device, ensuring the dignity bag remained in place, monitoring tubing for kinks and leaks, and keeping the tubing off of the floor. During a meal observation on 10/21/24 at 12:14 PM the resident was eating in the dining room. The blue dignity bag holding the catheter bag rested on the floor below his wheelchair, near the left wheel. On 10/22/24 at 07:46 AM observed the resident enter the dining room. Staff reminded him not to put his brakes on and to use the wheels and his feet to propel himself. Resident #3's catheter bag was in a dignity bag under his wheelchair and dragged along the floor near the right wheel as he moved toward a table. On 10/22/24 at 05:58 PM observed the resident leaving the dining room after dinner. His catheter tubing dragged along the floor between the two wheels, with visible urine stopped in the tube. As he used a combination of his feet and hands to move himself forward, his right foot hit the tubing twice. The catheter bag was in a dignity bag, and it skidded along the floor near the left wheel. An interview with Staff E, Registered Nurse (RN) on 10/24/24 at 9:08 AM revealed she had not seen the resident's bag or tubing dragging on the ground. She stated the resident did try to self transfer at times and the bag or tubing hanging low or dragging would be a good indicator that he tried. She stated the CNAs have to check that and make sure it is secured. During an interview with the Infection Preventionist on 10/24/24 at 09:14 AM she confirmed CNAs were responsible for making sure the bag and tubing were off of the floor. She stated the dignity bag was supposed to be strapped up with clips and the tube tucked so it didn't hang that low. She stated she would have to look into why both were dragging on the ground and said the way it was supposed to be positioned should ensure it did not do that. A policy titled Catheter Care: Indwelling Catheter, documented as Rev. 12/2023, noted the purpose was to provide hygiene for patients with indwelling catheters. Numbers 12-14 of the procedure section documented to secure the catheter to the patient's leg using a securement devise or Velcro leg strap to prevent tension on the urethra. Check that tubing is not kinked, looped, clamped, or positioned above the level of the bladder. Validate drainage bag is off the floor and in a dignity bag. 2. During observation of a medication pass on 10/22/24 at 6:49 PM Staff E, Registered Nurse (RN) took a stock bottle of acetaminophen from the medication cart drawer for Resident #52. She removed the lid, emptied out two pills, and put them in the medication cup with ungloved fingers. When each of the resident's medications were in the cup, she administered them. At 7:46 PM on 10/22/24 observed Staff E prepare medications for Resident #8. She prepared the resident's acetaminophen, senna plus, and melatonin by shaking them out of the bottles and putting them in the medication cup with ungloved fingers. When each of the resident's medications were in the cup, she administered them. On 10/22/24 at 07:57 PM the Administrator was seated at the nurses station. When asked how medications should be administered from the bottle, she said the nurse should pour the stock meds into the cup and not touch them. During an interview on 10/23/24 at 2:16 PM the Director of Nursing stated she expected staff to gel in and gel out with medications administration. She expected they would not touch the medication itself and would work with one resident at a time. On 10/24/24 at 8:59 AM the Infection Preventionist stated staff should not be using their bare hands to administer medication, and they should put medications in the lid and then put in the med cup. They also should be washing their hands. She reported they would provide in-services and education regarding both medications and catheter care. On 10/24/24 at 9:08 AM Staff E stated she was an agency nurse and did not receive medication administration training at the facility. She was trained as part of her education and had 'extensive' training through her agency. A policy titled Medication Administration - Medication Pass, documented as Rev. 5/2023, indicated the purpose was to safely and accurately prepare and administer medication according to physician order and patient needs. The general instructions section documented staff should not touch medication or inside of the medication cup. The tablets/capsules section noted if the medication was obtained from a bottle, it should be transferred to the cap and then into the souffle cup.

Based on record review, resident and staff interviews, and policy review the facility failed to provide showers as scheduled for 1 of 2 residents reviewed (Resident #2). The facility reported a census of 52 residents. Findings include: The Minimum Data Set (MDS) report dated 10/02/24 for Resident #2 indicated a Brief Interview for Mental Status (BIMS) score of 15/15, indicating no cognitive impairment. The MDS further indicated diagnoses including: acute and chronic respiratory failure, mild intellectual disabilities, and other specified disorders of muscle. It documented the resident as fully dependent on staff for assistance with showering/bathing. The Care Plan revised 7/10/24 instructed staff to assist the resident with shower/bathing per schedule. The Station 1 Shower List, updated 10/03/24 listed Resident #2 shower days as Tuesday and Friday. The Follow Up Question Report compiled 10/22/24 revealed the resident missed showers on the following dates in the last three months: 8/6, 8/20, 8/27, and 9/27. In an observation on 10/21/24 at 9:54 AM Resident #2's hair appeared greasy and matted, his shirt had food stains on it, and there was a moderate smell of body odor emanating from him. In an observation on 10/22/24 at 8:02 AM the resident remained in the same clothing as the prior day. There were additional food stains on the shirt and shorts, his hair remained matted and greasy, and body odor was present. In an interview on 10/21/24 at 9:54 AM Resident #2 reported he gets a shower once per week and would like an additional shower or two. In an interview on 10/22/24 at 11:11 AM Staff A, Certified Nursing Aide (CNA) and Staff B, CNA reported they fill out a shower sheet and chart showers in the Electronic Medical Record (EMR). The sheets are given to the nurse to sign off and then the Unit Manager files them. They reported Resident #2 got showers twice per week in the afternoons on Tuesdays & Friday. They explained the shower schedule was posted at the CNA desk. In an interview on 10/22/24 at 12:14 PM the Unit Manager, Station 1, explained if the shower reports are not there on paper they would be in the EMR where the CNA's chart. In an interview on 10/22/24 at 1:20 PM Staff C, CNA confirmed the resident is supposed to get a shower twice per week. She noted it could be a staffing issue. There are not enough staff to get showers done during the day. In an interview on 10/22/24 at 1:23 PM Staff B, CNA reported there were times where there were not enough staff to get all the showers in for the week. In an interview on 10/22/24 at 1:24 PM Staff A, CNA explained they have Sundays as a make-up shower day in case they couldn't do it another day. In an interview on 10/23/24 at 12:03 PM the Director of Nursing explained she expected residents to be offered a shower twice a week. She further explained showers have to be documented by the CNA's on the shower sheets and then the nurse signs off on it. The Unit Managers double check everything and then give it to her. She reported she was not aware of residents not getting offered a shower twice a week. The facility policy titled Hygiene- Bathing/Showering, revised 3/2024 failed to indicate a frequency for baths/showers to be offered to residents.

Based on observation and staff interview, the facility failed to provide housekeeping services in a manner to maintain a clean, comfortable, and homelike environment. The facility reported a census of 62 residents. Findings include: Facility observation on 7/1/2024 at approximately 10:30 - 11:30 A.M. included: Rooms 163, 164, 165, and 172 had floors with heavy dirt and grime. Rooms 163, 166, 169 and 171 had bathrooms with a dark substance on the floors and toilets. Observation of the kitchen revealed heavy dark grime along the perimeter of the floor and base boards. The floor also had used gloves, a coffee cup, food debris, a red food storage lid, and heavy dirt and food particles under the food storage shelves. The stainless steel food prep tables had a moderate amount of grime and food particles. The gas stove had heavy food particles and the floor area was covered with a brown substance. The refrigerator exteriors had a moderate amount of fingerprints and a sticky substance. Staff A, housekeeping revealed the facility had two housekeepers on duty, and the previous floor maintenance staff no longer worked at the facility. Staff B, housekeeping indicated the facility had one housekeeping staff on weekends. Staff C, dietary supervisor revealed she recently became the supervisor and had worked as the cook for 2.5 years. Staff C reported she needed to complete her classes and tests.

Based on observation and resident and staff interviews the facility failed to follow the menu and offer food choices according to the residents' requests. The facility reported a census of 62 residents. Findings include: Observation on 7/1/2024 at 11:30 A.M. revealed dietary staff serving lunch. Staff C, Dietary Aide indicated they switched Monday and Wednesday's menus due to the holiday. Staff C indicated they prepared enough food according to the menu most of the time. Resident #5 sat at a dining room table and reported not always being served what she requested. The resident indicated the facility runs out of food. On 7/1/2024 at approximately 11:00 A.M., Resident #1 reported he eats meals in his room and occasionally does not get what he orders. The previous night the menu included soup, sandwich and salad. The resident failed to receive a salad for dinner as he requested, and the food is not always hot when the food tray arrived. On 7/2/2024 at 12:15 A.M., Resident #6 reported she eats meals in her room and occasionally does not get what she orders from the menu. The kitchen occasionally fails to send milk, coffee, and dessert and food is not always hot when it arrives. A review of the Food Temperature Log book revealed staff failed to consistently document food temperatures prior to serving at each meal, a test tray entree on 7/1/24 tested at 154 degrees. On 7/2/2024 at 11:40 A.M., Staff E, RDLD reported 154 degrees was not an acceptable temperature in order for the room trays to be served hot and expected residents to receive menu items they request. The concern had been addressed and they had a plan in place.

Based on clinical record review, facility policy review, and staff interviews the facility failed to follow physician orders for three of three residents reviewed. (Residents #2, #3, #6). The facility reported a census of 59 residents. Findings include: 1. The MDS (Minimum Data Set), an assessment tool dated 3/20/2024 revealed Resident #2 had moderate cognitive impairment, transferred from one surface to another with staff assistance. The resident received scheduled pain medication for occasional pain rated at a score of 6 on a 0-10 pain scale. The resident had diagnoses including muscle disorder, history of falls, seizure disorder, and cognitive deficit. The Care Plan identified the resident had a risk for pain related to osteoarthritis and amputation of toes. On 3/26/2024, the Care Plan directed staff to administer pain medication as ordered by the physician and evaluate effectiveness of pain management. The current Physician Orders included an order for Hydrocodone/Acetaminophen 5/325 mg (milligrams), one tablet three times a day. On 3/6/2024 the order instructed staff to administer the medication two times a day. The March, 2024 MAR (Medication Administration Record) revealed staff failed to administer the Hydrocodone/Acetaminophen on March 30, March 31 and April 1, 2024 due to the unavailability of the medication. 2. The MDS dated [DATE] revealed Resident #3 had intact cognitive abilities, transferred from one surface to another with staff assistance and had diagnoses including PTSD (Post Traumatic Stress Disorder), depression , diabetes, and COPD (Chronic Obstructive Pulmonary Disease). The Care Plan identified the resident had PTSD and had a risk for changes in mood, had cardiac disease, edema, respiratory impairment, and urinary incontinence. It directed staff to administer medication as ordered by the physician. The April and May Physician Orders, and MAR included: Prednisone, 5 mg every day for four days from 4/12 - 4/16/2024, for inflammation. No dose administered on 4/15/2024. Quetiapine 50 mg table two times a day, for PTSD. No morning dose administered on 4/19/2024. Hydrochlorothiazide tablet 25 mg, give one tablet one time a day, every other day for COPD. No dose administered on 4/1/2024. Allegra Hives 24 hour oral tablet, 180 mg. Give one tablet by mouth one time a day. No dose administered on 5/11/2024. Incruse Ellipta Inhalation Aerosol. Inhale orally one time a day for COPD. No dose administered on 5/2 and 5/3/2024. Saw Palmetto oral tablet. Give one tablet by mouth one time every day for supplement. No dose administered on 5/26, 5/27, & 5/28/2024. 3. The MDS dated [DATE] revealed Resident #6 had severe cognitive impairment, transferred from one surface to another with staff assistance, had a colostomy and diagnoses including aftercare following surgery, diabetes, colon cancer, and dementia. The Care Plan identified the resident had a colostomy initiated on 5/13/2024 and directed staff to monitor and provide care as needed. The Care Plan identified the resident had diabetes and it directed staff to administer medication as ordered by the physician and monitor effectiveness and side effects. The Physician Orders included an order for Glipizide 10 mg orally two times a day for diabetes to begin on 5/10/2024. The resident also had an order for Loperamide 2 mg four times a day for high ostomy (opening in an organ of the body, colostomy) output to begin 5/10/2024. The May MAR revealed staff failed to administer the Glipizide and Loperamide on 5/10/2024. On 6/3/2024 the Administrator and Director of Nursing indicated they were aware of the medication concern, have educated staff regarding documentation and pharmacy notification, and have implemented a performance improvement plan. The facility Medication Administration - Medication Pass policy dated 5/2023 included: Purpose - To safely and accurately prepare and administer medication according to physician's order and patient's needs.

Based on clinical record review, facility policy review, and staff interviews the facility failed to provide the assistance required to prevent falls for 2 of 5 residents reviewed for falls (Resident #8, and Resident #223). The facility reported a census of 72 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 8/30/23 , listed diagnoses for Resident #8 that included: Type 2 diabetes, dysphagia (difficulty swallowing), severe intellectual disability, and fracture of lower right leg. The MDS assessed the resident required extensive assistance of one staff for: bed mobility, transfers, and walking in the room and the corridor; and supervision with set up help only for eating. The MDS did not list the resident's Brief Interview for Mental Status (BIMS) score. The Care Plan revealed a focus area of at risk for falls due to history of falls, impaired balance/poor coordination initiated on 5/27/21. A Progress Note dated 8/20/23 revealed the resident incurred a witnessed fall after using the bathroom. The fall did not result in an injury. A Fall Risk Assessment complemented on 8/20/23 lacked a completed conclusion/narrative summary. A Progress Note dated 8/23/23 revealed the resident had a witnessed fall in the bathroom. Due to not being able to tolerate standing, the resident transferred to the local hospital and an x-ray confirmed a right ankle fracture. A Fall Risk Assessment complemented on 8/23/23 lacked a completed conclusion/narrative summary. The resident remained hospitalized until 8/26/23, when she discharged back to the facility. The clinical record lacked a Fall Risk Assessment upon readmission. The Care Plan revealed a focus area of at risk for falls due to history of falls, impaired balance/poor coordination initiated on 5/27/21. Interventions listed in the Care Plan included providing assistance to transfer and ambulate as needed initiated on 5/27/21. During an interview on 11/1/23 at 3:36 PM, Staff P, Certified Nursing Assistant (CNA) stated she assisted the resident to the bathroom on 8/23/23. Staff P stated the resident got out of bed, and walked to the bathroom with her walker. Staff P stated she walked behind the resident to ensure safety. Staff P stated she was unsure if she used a gait belt to assist the resident. Staff P stated the resident's walker blocked her from being able to sit on the toilet. Staff P stated she reached over the resident to move the walker, while the resident reached for the grab bar. Staff P stated the resident then fell to her knees. During an interview on 11/1/23 at 3:57 PM, Staff Q, Registered Nurse (RN) stated she did not witness the residents fall, but assessed the resident after the fall. Staff Q stated when she entered the residents bathroom, she found the resident resting on her knees. Staff Q stated the resident could not tolerate standing so she transferred to the local hospital for evaluation. Staff Q stated Resident #8 did not have a gait belt on when she came to the bathroom to assess. Staff Q stated the CNA should have used a gait belt as the resident has a history of falls and can be unsteady. During an interview on 11/6/23 at 4:02 PM, the Director of Nursing (DON) stated she expects staff to use a gait belt when assisting any resident who has a fall history. The facility policy, with a revised date of 11/2023, titled Fall Occurrence Purpose indicated the purpose of the policy is for the facility to ensure that residents are evaluated for fall risks and interventions implemented to minimize risk for falls and/or risk for injury from falls. Procedure #1 of the policy directed staff to complete a Fall Risk Assessment upon admission, readmission, and as necessary. Procedure #2 of the policy directed staff to implement Care Plan interventions to be based on the assessment. 2. The Minimum Data Set (MDS) assessment tool, dated 9/11/23, listed diagnoses for Resident #223 that included Metabolic encephalopathy (chemical imbalance in the brain), cirrhosis, and adult failure to thrive. The MDS assessed the resident required extensive assistance of two staff for bed mobility, and toilet use. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The Care Plan, initiated on 9/13/23, included a focus area for risk of falling due to impaired mobility. A Physical Therapy discharge summary, dated 9/8/23, Functional Assessment for bed mobility indicated the resident is dependent to roll left and to the right. A Progress Note, dated 10/9/23 at 7:55 PM, documented the resident rolled out of bed while a CNA (Certified Nursing Assistant) changed the resident. The initial assessment revealed a large skin tear to the left inside of the resident upper arm, and a large laceration on the outside of the upper arm. The resident transferred to the local hospital for evaluation and treatment. A Progress Note, dated 10/9/23 at 11:10 PM, documented the resident returned to the facility. A Progress Note, dated 10/10/23 at 12:10 AM, documented the resident had the left forearm laceration sutured with 11 stitches, and a left humerus fracture. The Facility Investigation Witness statements revealed on 10/9/23 Resident #223 transferred to bed with the use of a Hoyer lift and assistance from two CNA's. One CNA left the room, the other resident assisted the resident with incontinence care. While rolling the resident towards the window, the aide was unable to stop the resident and the resident fell off the bed to the floor. An Employee Warning Notice, dated 10/11/23, issued to an agency CNA due to Violation of Policy and Procedure. The notice documented: On the evening of 10/9, a resident sustained a fall with injury due to staff not having proper staff assistance. During an interview on 11/6/23 at 3:19 PM, the Administrator stated the staff involved in Resident's #223 fall had been an agency staff and is no longer able to work at the facility. The Administrator stated two staff transferred the resident with a Hoyer, but only one staff assisted with incontinence care. The Administrator stated both staff should have stayed with the resident until after all care tasks had been completed. The Administrator stated since this fall, the facility has changed their policy now requiring two staff to assist with bed mobility if the resident required two staff for a transfer.

Based on observation, clinical record review, document review, resident and staff interviews, the facility failed to prevent an injury of unknown origin on 6/10/23 which resulted in a hematoma and facial bruising for 1 of 3 resident's sampled (Resident #6) and failed to utilize a gait belt per the therapy recommendations for safety for 1 of 3 residents reviewed (Resident #20). The facility completed an investigation for injury of unknown origin to assure resident safety from abuse from 6/10/23 - 6/15/23. The facility reported a census of 65 residents. Findings include: 1. Resident #6's MDS dated [DATE] showed Resident #6 with long/short term memory impairment and severely impaired decision making. The Resident exhibited fluctuating symptoms of inattention (easily distractible or having difficulty keeping track of what was said); disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject); and an altered level of consciousness (startles easily to any sound or touch; lethargic - repeatedly dozes off when being asked questions, responds to voice or touch; stuporous - very difficult to arouse and keep aroused for an interview; comatose - not being able to arouse). The Resident required extensive assistance for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), dressing, toileting, and personal hygiene. The MDS listed diagnoses of atrial fibrillation, hypertension, peripheral vascular disease, diabetes mellitus, depression, anxiety, cognitive communication deficit, and weakness. The MDS identified the Resident had not fallen since the last assessment. The Care Plan dated 10/04/21 documented Resident #6 at a risk for falls due to impaired mobility, weakness, and repeated falls. The Care Plan directed staff to use body pillows when in bed and encourage to transfer and change positions slowly. An Order Review Report signed by the Provider on 6/06/23 showed Resident #6 received Eliquis 2.5 milligrams (mg) 1 tablet orally twice a day for chronic atrial fibrillation. Eliquis is a prescription anticoagulant, or blood thinner, used to lower the risk of strokes and blood clots in people with an irregular heartbeat known as atrial fibrillation. The medication carries of risk of bleeding. A Progress Note dated 6/10/23 at 7:30 a.m. entered by Staff H, RN documented a CNA reported the Resident almost rolled out of bed at 4:00 a.m. on rounds during incontinence care. The first shift CNA reported the Resident had a bruise on her forehead measuring 4 centimeters (cm) x 7 cm. The facility notified hospice. Vital signs and neurological checks were done. All were within normal limits. As needed pain medication had been administered to the Resident. A Facility Investigation Brief Description of the Incident completed by the Director of Nursing (DON) with an incident date of 6/10/23 documented at approximately 6 a.m. Staff F, CNA and Staff G, CNA went into Resident #6's room to get her up for the day. Upon entering the room and turning on the lights, they noted the Resident had a big bump and bruise on the right side of her head. Staff F and Staff G reported this to Staff H Registered Nurse (RN). The Resident's room, upon entering, was set up with a bedside night stand on the Resident's left and an over-bed table on the Resident's right, perpendicular to the bed. Staff H administered the Resident as needed pain medication and notified hospice who came up to see the Resident and the family, who also joined hospice at the facility. An interview of the staff that worked that night was conducted. It had been noted that Staff N and Staff O, CNA's, entered the Resident's room about 5:30 a.m. to check and reposition the patient for the last time on their shift. They both reported the Resident did not have any bumps or bruising on her face upon entering the room. During this time the bed was raised to working level. Staff O was on the Resident's left side and Staff N was on the Resident's right side. Staff N placed an incontinence brief on the Resident. The Resident was on her left side facing Staff O and he assisted in supporting and rolling the Resident. The Resident unexpectedly rolled forward more causing her feet to slide off the bed. At that time, Staff N went to the left side of the bed to help Staff L get the Resident's legs back in bed. Staff O was supporting the Resident's upper body while Staff N placed the Resident's legs back in bed. They did this without further incident, finished up cares and made the Resident comfortable in bed. Both CNA's stated they did not see or hear the Resident hit their head. They both said they were focused on getting her legs back in bed so they were looking in that direction. Both CNA's agreed it was possible her head hit on the bedside table but neither saw this happen and the Resident did not call out in pain or call out at all. Both CNA's stated when they left the room about 10 minutes after entering, the patient had nothing visible on her face or head and did not say anything about her face or head. The Type of Injury documented a right frontal and periorbital (the area around the eyes)/premolar (the permanent teeth located between the molars in the back of your mouth and your canine teeth, or cuspids, located in the front) soft tissue contusions (bruising caused by a direct blow to the body that can cause damage to the surface of the skin and to the deeper tissues) without underlying fracture (broken bone) identified. The Facility Investigation detailed the following immediate actions taken on 6/10/23: a. 6:00 a.m. large bump noted upon entering the room on the Resident's head. b. 6:15 a.m. as needed morphine given for pain and the on-call hospice nurse notified. c. 7:40 a.m. as needed morphine given again for pain. d. 8:55 a.m. hospice called for an in-person visit. e. 9:25 a.m. hospice arrived. f. 11:00 a.m. family arrived. g. 12:30 p.m. a decision was made to send the Resident to the emergency room and the Resident was transferred out. h. 3:00 p.m. call from the hospice nurse stating everything is negative and the Resident would be returning. i. 4:00 p.m. call from the hospice nurse stating the Resident would not be returning and had been admitted to the hospital. The Facility Investigation Disposition documented the Resident had been sent to the emergency room following bruising and a hematoma to the right side of the face with unknown origin. The Resident admitted to the facility on [DATE]. She had a primary diagnosis of chronic atrial fibrillation. The Resident is dependent for all activities of daily living (ADL's) and transfers with assist of two staff with a hoyer lift. The Resident at times needs assistance with feeding, but is able to feed self at times. Upon admission her BIMS was a 7 (10/09/21); BIMS of a 4 (11/24/21) and by March of 2022 she was not able to participate successfully to complete a BIMS. The Resident had recently been placed back on hospice at the beginning of June 2023. She did not have a strong fall history. The facility was unable to interview her on the incident as she had no short-term memory recall. She could answer simple yes/no questions but not with 100 percent accuracy. The Resident called out when she wanted to lay down, get up, or have a drink. She spent most of her days in bed at her request, but did get up for meals. The family decided to send her to the emergency room (ER). The ER nurse called the hospice nurse, who called the facility around 3 p.m. that same day and stated there were no injuries found. The computer tomography (CT) scan (a CT scan is a diagnostic imaging exam that uses X-ray technology to produce images of the inside of the body) and x-rays were negative. The Resident would get a liter of fluid and return to the facility. About 1 hour after that the ER nurse called the hospice nurse who call the facility and said the Resident would not be returning and had been admitted with a diagnosis of a concussion. A head to toe assessment had been done and there were no further new injuries. The Resident's roommate had a BIMS of 9 and could not be interviewed. All residents with a BIMS of 13 or above were interviewed on 6/10/23 in regard to abuse. All residents with a BIMS below 13 had skin checks conducted. There were no verbal reports or concerns identified and no physical new areas of concern identified. Staff N's Witness Statement dated 6/10/23 documented last night on rounds about 5:30 a.m. she had been helping Staff O with Resident #6's. She was on the right side of the bed. She cleaned the Resident up and the Resident faced the wall where Staff O stood. Staff N tucked the pad under the Resident who was resisting some and pushing back on her. She tried to calm her down by talking to her and telling her what she was doing and that it would be okay. Suddenly the Resident stopped resisting and when she did her whole body moved forward and the lower part of her legs fell off the side of the bed. Staff O was on that side of the bed holding her upper body from falling. She went to the other side of the bed to help him put her legs back in the bed. Staff P CNA was coming into the room at this time to see if we needed help and Staff N shut the door, Staff P went down and told Staff H the nurse that they may need help. Staff H came into the room and asked if everything was okay. By that time, they had her legs back in bed and she was okay. They finished her cares by fastening her brief, getting her centered in the bed, comfortable, put her bed down to the ground, gave her the call light, covered her and left. The Resident did not have any injury when she left the room. She did not see her hit her head but assumed that it might have happened as her head was toward the edge of the bed and the table was right next to the bed. She had been focused on her legs and getting her them back in bed. The Resident did not say anything that would have indicated she hit her head. She did not call out in pain. Staff O's Witness Statement dated 6/10/23 at 8:55 a.m. given by a company representative documented he and another aide were in the process of changing the Resident. They had her rolled toward him and her feet slipped off the bed. He stated she was close to the edge. He held her up while the other aide went to get her legs back on the bed and stabilize her. He stated he didn't notice any injuries or bumps anywhere. He stated his main concern was for her to not fall on the floor as she was high up due to being changed. He said that when she slipped she may have hit her head on the table by her bed as that was the side he was trying to hold her up on. He had let the supervisor know and if there were more questions, someone would reach out to him. Staff P's Witness Statement dated 6/10/23 documented he did not provide cares to the Resident that night. After his last rounds he could hear the Resident yelling, which was not abnormal because she yelled a lot with cares but he went to her room anyway to check if she was yelling for help or if someone was in the room and needed help. He got to the door of the Resident's room and started to open the door and Staff N pushed the door back in his face. He stood outside the door for about 1-2 minutes then Staff H came down and went into the room so he figured they were okay and walked away. Later Staff N and Staff O informed him that the Resident's legs had fallen out of bed and Staff N had pushed the door back on him because she was running over to help put the Resident's legs back in bed and the door was in the path of that. He didn't actually go into the resident's room at any point that night. Staff F's Witness Statement dated 6/10/23 documented when she came in and got report nothing was mentioned about the Resident. At 6:00 a.m. she went into the Resident's room with Staff G, they immediately noticed a big bump on her head. They proceeded to get her dressed and ready for the day. As they were rolling her the Resident shouted, don't drop me again! She was shouting for a doctor as well. They finished getting her up and reported what had happened to the nurses. Staff G's Witness Statement dated 6/10/23 documented when she and Staff F entered the Resident's room, they noticed a red swollen bump on her head. They continued to dress her and get her up for the day. She brought her out to the nurse's station and asked Staff H and Staff Q, RN if anything had been reported. Neither knew about any injury. Nothing had been reported. While getting her dressed she kept yelling, don't drop me again. Staff H Witness Statement, undated, documented during the early morning medication pass on 6/10/23, Staff O and Staff N were doing final round check and changes. They changed Resident #6 at approximately 5:20 p.m. Afterwards Staff O stated to him that the Resident had almost fallen out of bed during incontinence cares, but he was able to keep her from falling. He described she was close to rolling off the edge of the bed, but a fall was narrowly missed. The day shift nurse at 6:00 a.m. was a no show. At 6:15 p.m. Staff H notified management of the no show. Shortly thereafter, the day shift CNA's brought Resident #6 out to the hallway by the nurse's desk. The Resident was agitated and had an obvious bruise above her right eye extending into her hairline. The short hall day shift nurse, Staff Q, administered as needed morphine and called the hospice after hours answering service. He was aware that the Unit Manager was on his way to relieve him. The hospice on call nurse returned a call and stated to continue to treat for pain, do vital signs and neuro checks, and apply ice if needed. The hospice staff would be in to assess. He administered her scheduled medications, because they included Tylenol and lorazepam. Her vital signs and neurological checks were within normal limits. Her pupils were equal and reactive. Her right eye was not swollen shut. No changes in mentation were noted. When the Unit Manager arrived, he instructed me to enter it under risk management and skin issues since a fall was not reported but still under risk management. Hospice would be in to assess and issue orders from there. At that time the bruise measured 4 centimeters (cm) by 7 cm long. When he left, the Resident had been sitting in the wheelchair in the hallway. The Unit Manager was the nurse on the hallway and hospice was coming in to assess. The DON's Written Statement dated 6/10/23 documented she had been notified by the Unit Manager who was working as a floor nurse that day. The Resident had a rather large bump on her head and hospice had been called and was coming in. Staff were unclear about what had happened. She was scheduled to work on the floor following the Unit Manager midday. She arrived to work and went to the Resident's room first. The Resident's son, daughter, daughter's husband and the hospice nurse were in the room. The hospice nurse told her she was discussing options with the family as far as sending her to the ER. She had explained what would happened with her hospice care both ways. She also explained the risks and benefits of being seen. All other options were explained to the family. She joined in the conversation supporting the hospice nurse. At that time, she only knew the Resident was bruised with a bump. She had not talked with all staff. She assured the family they would conduct an investigation and the incident would be turned into the State of Iowa (Iowa Department of Inspection and Appeals, DIA) for further review. Around 12:30 p.m. the hospice nurse approached her and said the family was going to send the Resident to the ER and she had called for transport. She gathered the paperwork needed and called report to the ER nurse. She informed the ER Nurse of the situation and that her next steps were to do a formal report to DIA. A Second Witness Statement with Staff O dated 6/10/23 completed by the DON documented she wanted to clarify the incident with Staff O. Staff O repeated he did not see the Resident bump her head. The Resident did not call out in pain and he did not hear anything. When he left the room, the Resident was resting in bed and nothing was on her face. He stated he was a bit shook up because he was worried she was going to fall and was very glad that a fall from bed had been prevented. He stated he had told the nurse about the near fall incident after leaving the room. The Unit Manager's Witness Statement dated 6/12/23 documented on Saturday 6/10/23 when he arrived to work to relieve the 3rd shift nurse (Staff H), the Resident was sitting in the hallway against the wall in her wheelchair. During report Staff H informed him that the Resident had a large goose egg to her forehead above her right eye. Staff H stated that nothing had been reported to him until the day shift CNA's got her up for the day. He proceeded to do his skin protocol and stated the hospice nurse was aware of the situation. The Resident talked at the time and was taken down to the dining room for breakfast. Around 8:30 a.m. the Resident came back to her room and was placed in bed. At 8:50 a.m. the Resident was lying in bed. Her goose egg had swollen and her right eye was starting to swell shut. Per nursing judgment ice was placed and hospice was notified to come see the Resident at 8:55 a.m. Hospice arrive to see the Resident at 9:25 a.m. Hospice started to make their calls and notifications. He continued with his medication pass and treatments as scheduled. Hospice informed him the family was going to be coming to see the Resident and would decide what they would like done. The Family arrived around 11:00 a.m. and met with hospice. The hospice nurse asked for Tylenol and Lasix to see if she would take her medication which she did. The DON relieved him at 12:00 p.m. The DON took over the situation from there. During an interview on 6/26/23 at 2:09 p.m. Staff Q reported he had picked up a four-hour shift on 6/10/23. When the aides on first shift brought Resident #6 out to breakfast, she had a red lump on her head. Bruising had started on her right forehead but wasn't very pronounced at that point. He stated by 10:15 am judging from time how fast it started to swell and bruise, he thought something had probably happened on the last rounds between 4-5 a.m. The night shift had one agency aide, Staff O and two other aides, Staff N and Staff P. He gave the Resident morphine around 6:15 am. On 6/27/23 10:57 a.m. The Hospice Patient Care Director reviewed the Resident's medical record and reported a call first came through their triage around 6:43 a.m. The nurse returned a call to the facility within 2 minutes. Staff H reported the Resident had a goose egg on the right side of the forehead measuring 4 cm x 7 cm. A CNA reported she had almost rolled out of bed, but didn't. At 8:46 p.m. the Unit Manager called triage to notify the area was getting larger and requested a hospice visit. The Unit Manager reported the Resident did not receive her morning insulin as she didn't eat breakfast. When the hospice nurse arrived, the Resident lay in bed with her eyes closed. She opened her left eye and said her name, but wouldn't answer any other questions. The facility should have notified the family as it took them a long time to get to the facility. The hospice nurse called the son within about 10 minutes of getting to the facility. The family was very distressed at what had happened at the facility. The POA questioned if they dropped her on her head or hit her in the head with something. The hospice nurse went through options with the family. They decided to have to go to the ED due to using Eliquis and potential for a brain bleed. Two aides reported the Resident had been unable to eat that morning. She acted like she didn't know how to chew. They took food out of her mouth and took her back to room and laid her down. The facility staff denied a fall or injury. The hospice nurse followed up with the hospital staff in the afternoon. She had a soft tissue contusion. The x-rays showed no fractures. She stayed at the hospital per family request until they could find another facility. On 6/10/23 at 4:17 p.m. the hospice nurse called to report the Resident had been admitted to the hospital unable to eat or drink and with concussion. On 6/27/23 at 3:34 p.m. The Hospice RN Case Manager reported she got to the facility and the Resident lay in bed with a hematoma and bruising to her right forehead and along the top of her hairline. The bruising had started to move downward on her forehead. The right eye was swollen and looked like it had water injected into it. It was starting to turn black. She was on Eliquis (blood thinning medication) 2.5 mg. As she had walked to the Resident's room, the Unit Manager stood there and said they found her with a bump on her head and they were not sure what had happened. The resident did not say anything to her while she was at the facility. She asked her questions but she did not get answers the questions. By what the family said, she could answer yes or no questions, but couldn't carry on a conversation. When she examined her head it seemed like the injury impact happened on the top of her head and the swelling was settling more on the forehead. She could not speculate about the injury. She said the facility thought she had rolled and hit her on the nightstand. She didn't see that as a viable option, she feels there would have been a laceration or an abrasion to the side of the head and the hematoma probably would be smaller. It seemed like there was a direct impact with the top of her head. It would make sense if someone rolled her she could have rolled out of bed onto her head but that is speculation only. She contacted the daughter who was in shock. She wanted to know what happened to her mom. She told her the facility didn't know at that point what had happened. She asked her to come to the facility so they could make decisions on if the Resident needed to stay in the facility or transfer out. At first the family thought she was on hospice and it seemed like they were not going to send her out. The son got agitated since there were no answers on what happened, so he wanted her sent to the hospital so he knew what the extent of the injuries were. She reported she followed up with the hospital on 6/10/23 at 15:15 p.m. there were no brain bleeds and no fractures to the face and the hospital was sending her back to the facility. Then 16:20 p.m. hospital called and said she had a bad concussion and couldn't eat or drink so they were going to keep her. During an interview on 6/27/23 at 5:27 p.m. Staff O reported he had been coming to the facility for approximately 1 month. He didn't recall a crashing sound, or the Resident calling out for help. He didn't notice any injuries while they were in the room. He was on his way home from work when Staff H called and asked him what had happened as the Resident had a knot on the side of her head. He had assisted Staff N with incontinence cares on the Resident. The Resident lay in the first bed as you entered the room. The room layout was her bedside stand, the bed, the space between the two roommates, her roommate's recliner, then her roommates' bed. He had been on the left side of the bed. She had been hollering out earlier in the night and they had said she does that when she is wet. They went in the room and by then she had calmed down and had her eyes closed. She was pretty out of it at that time, sleeping. They did a check and change and her legs rolled off the bed and she came toward him so fast. He supported her body weight. Her feet never hit the floor but her left arm was the only thing on the bed. The rest of her body was laying on him. He was trying to keep her from hitting the floor. They had put the bed height up so that they could do the check and change. She just rolled off the bed with her legs going to the left. She was laying on her arm with her belly and body across him. Her left arm was still on the bed. Her legs were hanging off the bed and her head was hanging off the bed. The rest of her body was laying on him. He didn't want her to hit the floor. Staff N grabbed her legs and rolled her back over onto the bed. He never heard a bang or heard the resident yell out to indicate that she had hit anything with her head. Once they got the check and change completed he went out in the hallway to get some linens and told Staff H she almost rolled off the bed. The nurse stated as long as she didn't hit the floor, it was okay. The nurse didn't even go in to see her at that time. The resident never said anything. He was holding almost all of her body except the arm that was touching the bed. Her legs were off the side of the bed and her head was hanging off the bed. He did not hear a bang or anything or hear her say ouch. The bedside stand was up next to the bed. She could have hit that with her head but he didn't see it. It had happened so fast. He doesn't recall if the bed was higher than the bedside stand. He didn't remember where her head was but it was hanging off the bed. She did not have any side rails up on her regular size bed. He guessed she had been a little too close to the edge of the bed. They should have moved her over in the bed before rolling her to her side so that it would not have happened. He was not meaning for her to get hurt. He was trying to keep her off the floor, but she got hurt anyway. He thought the way her legs went over so fast and she came out of the bed so fast, they should have moved her over in the bed before rolling her. On 6/28/23 at 10:22 a.m. Staff F reported she had asked if anyone had fallen during the night as part of report that morning. There had been no falls. They always get the Resident up right after report in the morning around 6:06 a.m. Staff G had walked in the Resident's room right after her and the Resident lay in bed with a large bump on the right side of her head that looked like a cone head. Staff G went to talk to the nurse and she stayed with the Resident. The Resident stated her head hurt and to please don't drop me again. They got her up via hoyer lift. She was in her normal disposition when they hoyered her into her chair. She yelled out her head hurt and to take her to the doctor, she kept repeating that over and over until they took her out for breakfast for about an hour. She kept checking in with the Unit Manager to see where they were with things. The Unit Manager said they were waiting on hospice. She took her out to breakfast and tried to feed her. The Resident just let food sit in her mouth. She wouldn't chew or swallow. It was frustrating to her as the resident clearly was not okay. Around 9:00 - 9:30 a.m. she and Staff G took the Resident back to her room and laid her down. They put the head of the bed up. At that point she was developing more swelling on the right side of her face and trailing down from the bump on her forehead. Her bruising was more pronounced. It looked like she was bleeding out of her pores. Hospice came shortly after and put ice on her head. They were trying to make her comfortable. A review on 6/28/23 of the Emergency Department to Hospital Admission records from 6/10/23 for Resident #6 documented Resident #6 as a [AGE] year old female with a history of dementia, insulin dependent diabetes, congestive heart failure, atrial fibrillation and presented to the emergency department via emergency medical services for evaluation of facial swelling. The nursing home reported the patient had been found to have swelling and pain over her right forehead and around her right eye. She was sent to the ED for further evaluation. The nursing home was unable to determine what had happened during the night to cause this injury. The Resident presented in the emergency room with a blood pressure of 168/92, heart rate of 72 beats per minute, respirations of 22 breaths per minute, temperature of 97.3 degrees, and an oxygen saturation rate of 92%. On Physical Exam she did not exhibit any acute distress and had tenderness and swelling to the superior aspect of the right orbit and lateral orbital region of the right eye. Swelling noted to the right upper eyelid. The Comprehensive Metabolic Panel showed an abnormally high sodium level of 151 (normal range 136-145). Further lab results showed a Protime (A prothrombin time (PT) test measures how long it takes for a clot to form in a blood sample) of 15.8 high (normal range 9.4 - 12.5) and an elevated INR (An INR (international normalized ratio) is a type of calculation based on PT test results. Prothrombin is a protein made by the liver. It is one of several substances known as clotting (coagulation) factors) of 1.3 (normal range 0.8 - 1.2). The Resident admitted to the hospital with a diagnosis of injury to head, dehydration, hypernatremia, and type 2 diabetes mellitus with other specified complication, with long-term current use of insulin. During an interview on 6/28/23 11:19 a.m. The Discharging Hospital Doctor of Osteopathic Medicine reviewed the Resident's sodium level from the emergency room records and reported Resident #6 was severely dehydrated and her electrolytes were off. He stated the family had stated she had been eating a banana and candy bars two days prior to the incident. He couldn't state that the dehydration was caused by the facility versus a result of a very recent head injury that caused her to quit eating and drinking. She had been hospice prior to the hospitalization and they were talking to the family about hospice again. They were going to send her back to the facility but then she was admitted for dehydration. He remembered the family did not want her to go back to the nursing home. She responded very well to the IV fluids treatment, woke up, was eating, talking, and discharged to a nursing home on hospice care. On 6/28/23 at 11:56 a.m. Staff G reported they went into the Resident's room around 6:00 a.m. She saw the lump and asked Staff F if she had seen it. She had a goose egg on her right side of her head by the hairline. They got her ready and took her out to the nurse's station. She asked Staff Q and Staff H if there were any falls or incidents and they both said no. They turned on the hallway lights and took a look at her. They took vital signs on her and started calling the CNA's to see what had gone on. They put her back in bed after breakfast. When they were rolling her in bed she screamed please don't drop me again. She repeated it again and again. She thought she probably went head down onto the floor and they picked her back up and didn't realize how bad it was. The Resident didn't say anything at the breakfast table she was very disoriented at the breakfast table. When at the nurse's station she had been asking to see a doctor. The nurses were really not paying attention to her. There were no actual cuts that she could see, but it looked like she was bleeding out of her pores by 9:30 a.m. The Unit Manager requested they start putting ice packs on her head when they laid her back down. She always used two aides to reposition her in bed. She was really stiff and if she went over too far, you would not be able to keep her from going down on the floor from the bed. To her knowledge night shift did not get her up with the hoyer that night. On 6/28/23 at 12:34 p.m. Staff N reported Staff O needed help just finishing rounds on his side. Resident #6 was worked up. She was on the Resident's right side of the bed and Staff O was on the left side of the bed. They rolled the Resident toward the wall and she was providing cares to her. She had one hand holding her by her hip a little bit, Staff O was holding her on her side as well. She cleansed her bottom and the Resident pushed back and was resisting care. The Resident didn't say anything, she was just really worked up. All of a sudden, the Resident stopped resisting and the counter pressure of her hand on her hip the resident went forward out the edge of the bed and her feet went off the bed. She kind of rolled over and Staff O was

Based on clinical record review and staff and resident interviews the facility failed to ensure residents are free of any significant medication errors. (Resident #1). The facility reported a census of 74 residents. Findings include: 1.According to the MDS (Minimum Data Set) dated 8/4/2018, Resident #1 had no cognitive impairment, required extensive assistance of two staff to transfer, [DIAGNOSES REDACTED]. The resident received scheduled and as needed pain medication that included opioid medication. The Care Plan identified the resident had functional mobility and transfers limited by back pain. It directed staff to apply diathermy, electrical stimulation, manual therapy, massage therapy, and exercise therapy. It documented the resident also had problem with pain related to back pain and a history of [MEDICAL CONDITION], hand pain, right ankle pain. It directed staff to administer medication per physician orders. The Physician orders [REDACTED]. [MEDICATION NAME] Patch 25 mcg (micrograms) per hour patch, change every third day. Diagnosis: [REDACTED]. The Progress Notes dated 9/5/2018 revealed staff observed Resident #1 difficult to arouse, oxygen saturation at 80% with oxygen on at 2 liters per nasal cannula, opened eyes and gives one word answers. Facility called 911 and sent the resident to the emergency room . The resident admitted to the hospital ICU (Intensive Care Unit). The hospital Emergency Department record dated 9/5/2018, revealed Resident #1 arrived from the nursing home because of decreased responsiveness, and reportedly less responsive over the past 2-3 days. Patient had a similar episode in the past that was associated with [MEDICATION NAME] overdose due to multiple [MEDICATION NAME]es being left on. On 9/5/2018, three [MEDICATION NAME]es were found on the patient. The patient should have had only one 25 mcg/hr patch. Clinical Impression: Intentional [MEDICATION NAME] overdose. The hospital History and Physical dated 9/5/2018 included: Patient found in nursing home with decreased responsiveness and brought in by ambulance. It is understood that the patient was found to have multiple [MEDICATION NAME]es, three were found. The patient is difficult to arouse, patient was given [MEDICATION NAME] and on Bi-Pap and working hard to breathe. Principal Problem: unresponsiveness, hypercarbic [MEDICAL CONDITION], acute [MEDICAL CONDITION], and overdose with [MEDICATION NAME]. Plan: Admit to ICU (Intensive Care Unit), level one, Bi-Pap, [MEDICATION NAME] drip. The hospital Discharge Summary dated 9/8/2018 included: Follow up issues: Monitoring pain medication side effects and confirming that only one [MEDICATION NAME] is being used. Hospital Course: admitted to ICU on Bi-Pap and [MEDICATION NAME] drip for [MEDICATION NAME] overdose. Three patches were found on his back, likely and oversight when they should have been removed prior to replacement every 72 hours. Patient eventually became alert and usual state of consciousness. Upon discharge, orders were carefully written to remove the patch prior to replacing it every 72 hours. The facility Incident Report included: Patient sent to emergency room (ER) for respiratory issues on the morning of 9/5/2018. It was reported per phone from the ER nurse that there were 3 [MEDICATION NAME]es found on the patient, one on the back dated 9/2/2018, and two on the chest area, one dated 8/27/2018 and one too smudged to make out the date. During an interview on 9/11/2018 at approximately 10:30 a.m., Resident #1 reported he went to the hospital because he/she had three patches on and it made him/her in la la land. In (MONTH) he/she had two patches on but he/she also had a urinary tract infection. During a phone interview on 9/11/2018 at 11:20 a.m., Resident #1's physician reported the July, (YEAR) incident where the resident went to the ER with two [MEDICATION NAME]es on, could have been attributed to the fact that the resident had a urinary tract infection. However, with regards to the (MONTH) 5 incident , the resident had nothing else going on and the symptoms were due to having on three [MEDICATION NAME]es. During an interview on 9/7/2018 at 10:50 a.m., Staff A, DON (Director of Nursing) revealed after the (MONTH) incident when Resident #1 went to the ER with 2 [MEDICATION NAME]es on, staff involved were educated. After the (MONTH) 5 incident, they educated all nursing staff and implemented a new policy where two nurses administer the patch, two nurses remove and destroy the old patch every 72 hours. The hospital informed Staff A the resident had two patches on his/her chest and one on his/her back. During an interview on 9/7/2018 at 12:05 p.m., Staff B, RN (Registered Nurse), Unit Manager reported being called to Resident #1's room on 9/5/2018 and observed the resident staring and difficult to get a response with an oxygen saturation of 82 %. They called 911 and sent the resident to the ER. Staff B observed the resident's back and saw one patch and did not check the resident's chest. The resident had a history of [REDACTED]. The facility Medication Administration: [MEDICATION NAME] Drugs policy included: Purpose: To administer medication for systemic or local effect by way of applying to skin. Procedure: 6. Examine patient's chest, back and shoulders for any residual medication patches. Remove previous patch and wipe away any remaining medication. Dispose of controlled substance medication patches by folding in half and discarding into sharps container. 7. Select and alternate placement site. 8. Label medication administration paper or disk with date, time and initials.